Development and validation of a patient experience assessment questionnaire for evaluating hospital care in Iran

Abstract

Purpose

Understanding patient experience is crucial for advancing patient-centered care and improving hospital service quality. This study aimed to design and validate a Persian version of a patient experience assessment questionnaire to evaluate hospital services.

Methods

This descriptive-analytical study on tool development was conducted cross-sectionally during 2021–2022 in Iran. The study consisted of two stages: (1) In the first stage, a deductive approach and comprehensive literature review were employed to develop the initial questionnaire items, based on the framework from prior research titled "Developing a Model for Evaluating Patient Experience in Teaching Hospitals in Iran." (2) In the second stage, validation was carried out by assessing face validity, content validity (using expert panels to evaluate the Content Validity Index (CVI) and Content Validity Ratio (CVR)), and construct validity through confirmatory factor analysis. Sampling for the face validity stage included 30 randomly selected patients, while construct validity was assessed with a sample of 340 participants, of which 300 provided complete and valid data. Reliability was determined using internal consistency (Cronbach's alpha) and stability (intra-cluster correlation coefficient) measures.

Results

The initial questionnaire comprised 44 items. Following expert reviews and validation processes, 10 items were removed, resulting in a final version with 33 items. The confirmatory factor analysis confirmed the five-dimensional structure, with a Cronbach's alpha of 0.97 and an intra-cluster correlation coefficient of 0.89, indicating strong internal consistency and reliability.

Conclusion

This study successfully developed and validated a 33-item questionnaire for assessing patient experience in Iranian hospitals, ensuring cultural relevance and robust psychometric properties.

Patient or Public Contribution

This study was actively led by the involvement of patients and the public in its design and evaluation. Thirty patients were recruited for the face validity phase in order to assess items on the questionnaire in terms of relevance and comprehensibility. Their views had a direct impact on the modifications of the tool in terms of suitability and clarity. The examination also involved medical professionals with real-world hospitals to refine the content of the questionnaire and make sure it pegged crucial elements of patient experience. The final instrument is an efficient tool for the evaluation of quality care due to the integration of ideas from expert and patient perspectives on hospital care.

Introduction

Patient experience is acknowledged as a distinct aspect of healthcare quality, alongside clinical effectiveness and patient safety [1, 2]. The pursuit of quality serves as a significant catalyst for these widespread changes within the industry, influenced by evolving healthcare policies that link hospital and physician remuneration to patient experience metrics, an increased emphasis on patient engagement, and the rise of a consumer-oriented perspective [3].

Patient satisfaction is defined as meeting physical needs by performing professional care, psychological, social support, satisfaction of care and ensuring comprehensive and inclusive services to the patient [4]. However, since patient satisfaction, as a subjective and unique phenomenon, is very influenced by standards, different expectations, patient status and previous experience. Therefore, in order to recognize how to evaluate the performance of services, measuring the patient's experience can be a more appropriate method [5].

In this context, Bowling et al. conducted a study in 2012 aimed at assessing patients' satisfaction and their experiences of health services in the City of London. The results of this study showed that patient satisfaction is very influenced by age, gender, health status, ethnicity and race [6]. Responsiveness to patients means adequate recognition and appropriate response to patients logical expectations based on appropriate design of internal and external relationships [7]. In this context, Peltzer conducted a study in 2009 aimed at assessing patient experiences and accountability of the health system in South Africa. The results of this study showed that evaluating the patient experience provides more detailed and accurate information about the quality of health services than responding to it [8].

The "patient experience" includes a range of interactions that patients have with the healthcare system and hospital staff during the treatment process. In evaluating the patient experience, aspects of responding to the patient individual preferences, needs and values such as good communication with healthcare providers, easy access to information, timely receiving of health care are examined [9]. Understanding patient experience is a key step in moving towards patient-centered care [10, 11].

On the other hand, evaluating patient experience along with improving the quality of health care can improve clinical effectiveness and patient safety. For example, clear and accurate information, mutual communication, empathy with patients and respect for their beliefs and concerns by hospital service providers can increase patient awareness, participation in decision-making and their willingness to disclose information needed for their treatment. Ultimately, this leads to timely diagnosis and treatment, better clinical outcomes, improving patient safety and reducing the use of unnecessary health services [12, 13].

In different countries, various tools are used to assess patient experience, each responding to the specific needs and conditions of that country [14]. For example: In Sweden, patient experience assessment is typically conducted through national and local surveys that help collect data related to the quality of healthcare services [15]. In England, the NHS (National Health Service) uses tools such as the 'Patient Experience Survey' to gather patients' opinions about healthcare services [16]. In Norway also uses similar surveys and focuses on improving the quality of healthcare services and patient experience. In India, patient experience assessment tools may include local surveys as well as the use of digital technologies to collect feedback [16]. In Hong Kong, patient experience assessment is usually conducted through online surveys and face-to-face interviews. In Scotland, NHS Scotland also employs similar tools to assess patient experience and pays attention to collecting data for improving healthcare services. These tools help various countries enhance the quality of healthcare services and improve patient experiences [14].

Despite the increasingly important role that the patient experience occupies in health-care clinical practice, research, quality improvement efforts, and policies, there is the lack of a standardized tool to assess patient experience in Iran and many similar countries. There are several reasons for this, the patient experience is a multidimensional, multifaceted, and intimately connected concept with several subsections. Furthermore, framing definitions, even when concepts are well understood, is not a simple task [17].

Considering the important functions of patient experience evaluation in improving the quality, effectiveness and safety of healthcare services, patient satisfaction, responsiveness and other similar indicators, it is necessary to design a standard scale to evaluate patient experience in Iran.

To develop the current patient experience assessment questionnaire, this study was built upon prior research by Najib Jalali and colleagues, which established a comprehensive evaluation model tailored to the Iranian context. This foundational study identified 10 dimensions and 29 subcategories, considering the unique socio-cultural factors affecting patient experiences. By employing a deductive approach that integrated this model with a literature review, the current research developed questionnaire items to capture the specific needs and perceptions of Iranian patients, ensuring cultural relevance and methodological soundness. there for due to the lack of a suitable scale to measure it,Therefore, this study aimed to By examining the various tools available for assessing patient experience,design and validate the patient experience questionnaire from the services provided in the hospital as a developing country which can serve as a basis for other similar countries as well.

Methods

This descriptive-analytical study was conducted cross-sectionally from 2021 to 2022 to develop and validate a patient experience assessment questionnaire specific to the context of Iranian hospitals. The study design comprised two main stages: the development of the initial questionnaire and its validation.

Stage 1: Development of the Initial Questionnaire

In the first stage, a deductive approach was used, leveraging existing models and findings from prior research. The foundational framework for the questionnaire was based on the study by Najib Jalali and colleagues, titled "Developing a Model for Evaluating Patient Experience in Teaching Hospitals in Iran," which outlined 10 key dimensions and 29 subcategories of patient experience relevant to the local healthcare context [18]. To enhance the comprehensiveness of the tool, a literature review was conducted from 2018 to 2022. This review aimed to identify additional aspects of patient experience that might not have been covered in the original model and to update the content with recent developments in patient-centered care evaluation. The search included databases such as Google Scholar, Scopus, PubMed, Magiran, and ISI using keywords like "patient experience," "evaluation," "patient-centered care," "patient satisfaction," and "patient responsiveness."

This stage culminated in the production of 44 preliminary items for the questionnaire, covering various aspects of patient experience, including communication, service quality, emotional support, and the hospital environment.

Initial version of the Patient Experience assessment questionnaire It is attached as Appendix One.

Step (2) Validation of Patient Experience assessment questionnaire:

Validation of the questionnaire was conducted through several sub-stages, validates the developed questionnaire by assessing its face validity, content validity, structural soundness, internal consistency, and repeatability.

Face validity

This was assessed both qualitatively and quantitatively. A panel of 10 experts, including health services management faculty members, hospital administrators, and quality improvement managers, reviewed the questionnaire to provide feedback on clarity, difficulty, and relevance. To evaluate face validity quantitatively, the initial version of the questionnaire was administered to 30 randomly selected patients who met specific inclusion criteria, such as age over 18, literacy, and hospital stay exceeding 48 h. Items with an impact score above 1.5 were retained [19].

Content validity

Content validity was evaluated through both qualitative and quantitative methods. For the qualitative assessment, a panel of experts, selected during the qualitative face validity phase, provided their insights regarding the writing, distribution of items within their respective domains, and the significance of each item after thoroughly reviewing the research questionnaire. The Content Validity Ratio (CVR) was utilized to determine the necessity of each questionnaire item, while the Content Validity Index (CVI) ensured that the questions accurately reflect the relevant content and objectives. Ultimately, questions with a CVR score exceeding 0.62 were retained [20]. On the other hand, Bausell-Waltz content validity index was used to calculate CVI [21].

Construct validity

For assessing construct validity, the method of confirmatory factor analysis (based on the conceptual model at the time of creation of the bank items) and the results of the obtained factor loadings were used to analyze the questionnaire items. To test the model, indicators of chi-square ratio versus freedom, RAMSA, TLI and CFI were considered [22, 23]. For this purpose, cluster sampling was initially used and 6 hospitals were randomly selected It was then decided that 10 patients would be referred to selected hospitals for each point. Patients selected through available sampling based on the research team's selected criteria were included.

Reliability

To calculate the reliability of the questionnaire, the internal consistency and stability of the questionnaire were examined. Cronbach's alpha method was used to assess the internal consistency of the designed questionnaire. For this purpose, the same selected patients were interviewed at the face validity stage. According to the research team, a Cronbach alpha coefficient of at least 0.7 was acceptable in this study. In assessing the reliability of the designed questionnaire, ICC method and open test were used. Therefore, the designed questionnaire was administered to 12 patients who referred themselves to the studied hospitals and were selected using the available sampling method. Finally, in this study, the research team showed that the reliability coefficient of 0.8 or more showed satisfactory stability.

Inclusion and exclusion criteria for the patient included: literacy, age over 18 years, length of hospital stay over 48 h and full consciousness. Their exclusion was also due to reluctance to participate.

The inclusion and exclusion criteria for specialists included: health management faculty members with professional experience and related studies, hospital managers with at least five years of experience in educational hospitals and quality improvement managers in educational hospitals and its exclusion criteria was due to reluctance to participate in the study.

Sample size sufficiency

The sample size for the psychometric tests adhered to established guidelines, ensuring that the number of participants was sufficient for both CFA and reliability testing. The selected sample sizes (30 for face validity and 340 for CFA) met the criteria for robust psychometric evaluation, supporting the reliability and generalizability of the study findings.

Statistical analysis of the data was performed using Excel software assessment of face and content validity), SPSS version 16 (assessment of internal consistency, stability and descriptive statistics) and Amos version 20 (assessment of structural validity) and a significant value of 5% taken into account.

Results

A total of 344 items were collected. After removing duplicates, eliminating items with significant overlap, and discarding items that did not align with the objectives and target population, 44 items were selected for the validation process. These items were designed on a 5-point Likert scale, ranging from "completely satisfactory" to "completely opposite.

Face validity

For face validity, the expert panel reviewed item clarity and relevance, leading to minor adjustments. Quantitative assessment, involving 30 patients, resulted in impact scores above 1.5 for all items, as detailed in Table 1, confirming their appropriateness.

Table 1 CVR, CVI, Impact score and judgments for each of the questionnaire items

Content validity

For content validity, it is essential to rely on an expert panel to ensure the questionnaire accurately reflects its intended purpose. In this study, the expert panel included individuals with significant expertise: faculty members in health services management, hospital managers with at least five years of experience in educational hospitals, and quality improvement managers from these institutions. This diverse range of professionals provided a comprehensive evaluation of the content's relevance, clarity, and alignment with the study objectives.

At this stage of the study, 10 participants (balanced equally between male and female) were involved, with the majority being faculty members (60%), graduate students (70%), and professionals with 5–10 years of experience (55%). The study adhered to ethical guidelines approved by the Ethics Committee of Mashhad University of Medical Sciences (IR.MUMS.REC.1400.364). All participants provided informed consent prior to their participation. The qualitative content validity of the questionnaire was assessed, focusing on grammar, item clarity, and alignment with relevant domains. Quantitative content validity was then determined using Content Validity Ratio (CVR) and Content Validity Index (CVI) scores. As shown in Table 1, items with insufficient CVR and CVI scores were removed. The final questionnaire adopted a five-dimensional structure, encompassing communication with medical staff, service provision, information provision to the patient, comfort, physical environment and facilities, and emotional support. (Table 1).

Construct validity

Construct validity was assessed using confirmatory factor analysis (CFA) on data from 300 participants, as outlined in Table 2, confirming the questionnaire’s five-dimensional structure.

Table 2 Goodness of fit index of factor analysis model confirmatory research questionnaire before correction

Participant demographics showed an average age of 40.1 years, with a majority being female (56.3%), married (73%), and having at least a high school diploma (69%). Item 11 was removed from the questionnaire due to a low factor loading, with the confirmatory factor analysis (CFA) results for the adjusted model summarized in Table 2

Fig. 1

The initial diagram of the confirmatory factor analysis model of the research questionnaire with 34 items

After removing the first item of the second dimension, namely item 11, and readjusting the confirmatory factor analysis, the 5-dimensional structure of the questionnaire was confirmed (Fig. 1). Figure 2 and Table 3 provide more detailed information.

Fig. 2

The final diagram of the confirmatory factor analysis model of the research questionnaire with 33 items

Table 3 Goodness of fit index of factor analysis model confirming research questionnaire After Correction

Internal consistency and Stability (Repeatability) assessment

Reliability was confirmed with a Cronbach’s alpha of 0.97 for the total scale and values above 0.7 for each dimension, as shown in Table 3. Stability was assessed using the test–retest method, resulting in an intra-cluster correlation coefficient of 0.89 with a confidence interval of 0.43–0.97, indicating satisfactory stability for the questionnaire.

The final version of the primary tool consisted of 33 items, derived from an extensive review of existing patient experience evaluation models, particularly based on the framework developed in the study "Developing a Model for Evaluating Patient Experience in Teaching Hospitals in Iran" by Najib Jalali and colleagues. The items were refined and validated through a comprehensive process involving both expert panels and patient feedback​.

Final version of the Patient Experience assessment questionnaire It is attached as Appendix Two.

Informed consent to participate was obtained from all of the participants in Different phase of this study.

Discussion

This study’s findings on the development and validation of the Patient Experience Assessment Questionnaire (PEAQ) contribute to a growing body of research focused on assessing patient experience. By aligning key dimensions of patient experience with local cultural contexts, the PEAQ offers a tailored approach to understanding patient satisfaction within Iranian healthcare. This section compares the findings of this study with congruent and non-congruent results from similar research and provides arguments for the observed differences and similarities.

Congruent findings with international tools

High reliability and internal consistency

This study's Cronbach's alpha score of 0.97 demonstrates high internal consistency across the PEAQ dimensions, a finding that is consistent with studies such as the Patient-Reported Experience Measure for Care in Chinese Hospitals (PREM-CCH) by Wang et al. (2021), which also reported high reliability for communication, empathy, and professional competence dimensions. These findings underscore the universal importance of strong internal consistency in patient experience assessments [24]. Both studies’ high reliability scores suggest that comprehensive measures of communication, emotional support, and competence are crucial across different healthcare settings.

Emphasis on communication and service quality

Similar to the Picker Patient Experience Questionnaire (Jenkinson et al., 2002), which was designed to measure patient satisfaction in the UK, the PEAQ includes communication and service quality as central dimensions [9]. The similarity in dimensions highlights the universal importance of these elements in creating a positive patient experience, regardless of the cultural context. Effective communication, especially, is a key factor that appears across various tools and is well-supported by both this study’s findings and global research.

Non-Congruent findings reflecting cultural differences

Importance of emotional support and comfort in the Iranian context

In contrast to Western tools like the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which emphasizes autonomy and shared decision-making [25], the PEAQ prioritizes emotional support and comfort [26]. This difference likely stems from cultural expectations in Iranian society, where patients may place a higher value on empathy and holistic care than on personal autonomy. In Middle Eastern settings, emotional support may be more closely linked to patient satisfaction because healthcare interactions are often more personal and relationship-oriented [27]. This finding aligns with research by Oltedal et al. (2007) in Norway, where emotional support also contributed significantly to patient experience scores, suggesting that non-Western contexts may similarly prioritize empathy as a core component of patient satisfaction [28].

Lower emphasis on digital and technological aspects

In contrast, studies from technologically advanced healthcare environments, such as India and Hong Kong, often include dimensions related to digital interactions and telehealth services [29]. The PEAQ does not include these aspects, which may reflect the current technological capabilities and patient expectations within the Iranian healthcare system [27]. This difference highlights the need to adapt patient experience tools based on the available healthcare infrastructure, as tools emphasizing digital communication may not be relevant in settings with lower technological integration.

Supporting arguments for congruent and non-congruent findings

Argument for Universal Aspects of Patient Experience: The strong alignment in dimensions like communication and service quality between the PEAQ and international tools (e.g., PREM-CCH, Picker) suggests that certain aspects of patient experience are universally significant. Regardless of cultural context, patients generally expect clear, respectful communication and high-quality service from healthcare providers. This universality is further supported by high reliability scores across studies, suggesting that robust internal consistency for these dimensions is achievable across different healthcare systems.

Argument for Cultural Adaptations in Patient Experience Assessment: The differences observed in this study, such as the focus on emotional support and comfort, emphasize the role of cultural context in shaping patient expectations. Western tools like HCAHPS emphasize autonomy, reflecting cultural values of individual empowerment, whereas the PEAQ reflects a collectivist culture where interpersonal support and comfort are integral to patient care. Studies such as those by Bowling et al. (2012) show that patient satisfaction can vary significantly with demographics like age, gender, and cultural background, lending weight to the argument that patient experience tools must be adapted to local values and expectations to capture a true reflection of patient satisfaction.

Comparison with other regional tools and emerging trends

Similarities with the NORPEQ in Norway

The Norwegian Patient Experience Questionnaire (NORPEQ), validated by Oltedal et al. (2007) [28], shares several dimensions with the PEAQ, such as professional competence and empathy. Both tools also achieved high internal consistency, suggesting that patient experience tools in non-Western or culturally distinct regions may prioritize relational and supportive aspects of healthcare. This similarity may suggest a broader trend in non-Western countries to prioritize emotional support, comfort, and respect for cultural values in patient experience assessments.

Differences with tools in high-tech environments

Patient experience tools in settings where technology plays a prominent role, such as Hong Kong, reflect a shift toward integrating telehealth and digital communications. Studies like those by Webster et al. (2011) and Wong et al. (2013) [29, 30] highlight the inclusion of digital aspects in these environments, showing that patient experience tools are evolving to meet new patient expectations shaped by digital interaction. In contrast, the PEAQ’s lack of these dimensions indicates the importance of aligning patient experience assessment tools with the technological capabilities and patient preferences specific to the target setting.

In summary, this study's findings align with those of several global studies regarding the multi-dimensional structure of patient experience assessment tools. However, cultural and contextual factors introduce unique dimensions in the PEAQ, such as emotional support and comfort, which reflect local patient expectations within the Iranian healthcare system. These findings underscore the importance of adapting patient experience assessment tools to both universal and context-specific elements to ensure a comprehensive and culturally relevant understanding of patient satisfaction.

Methodological rigor

The methodology employed in the development of the PEAQ is a notable strength of the study. The two-step process—first designing the questionnaire based on a pre-existing framework and then rigorously validating it—ensures the reliability and relevance of the tool. The use of a cross-sectional study design for tool development and validation, including the confirmatory factor analysis (CFA) with a large sample (n = 300), significantly enhances the credibility of the findings. The study's decision to rely on CVI and CVR to eliminate redundant or unclear items demonstrates a commitment to ensuring the clarity and precision of the questionnaire items, further contributing to the tool's applicability in real-world hospital settings.

The study’s validation approach also parallels the methodological rigor seen in global studies on patient experience tools. For example, the widely used Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in the United States underwent similar phases of content and construct validity testing, confirming the universality of such validation processes [31]. However, one key distinction is the focus of the PEAQ on internal consistency (Cronbach's alpha = 0.97) and repeatability (ICC = 0.89), demonstrating both the stability and reliability of the tool, which is essential for its long-term application in healthcare settings.

Implications for practice

The results of this study have several practical implications. First, the PEAQ offers healthcare administrators in Iran and potentially other developing countries a validated tool for regular use in hospital settings. The ability to assess multiple dimensions of patient experience can help healthcare providers identify areas for improvement, especially in communication, service delivery, and emotional support. The five-dimensional structure of the questionnaire aligns with international trends in patient-centered care but also incorporates culturally relevant factors that may influence patient experiences in Iran, such as feelings of comfort and emotional support. This adaptability to local contexts is crucial for ensuring the effective implementation of patient experience assessments.

Furthermore, the successful validation of this tool emphasizes the importance of continuous patient feedback in healthcare improvement efforts. As Peltzer (2009) noted, evaluating patient experiences provides healthcare providers with detailed, actionable information that goes beyond traditional measures like patient satisfaction [32]. This information is critical for addressing patient concerns and enhancing the quality of care in a more nuanced and responsive manner.

Conclusion

This study successfully developed and validated a culturally relevant patient experience assessment questionnaire tailored for use in Iranian hospitals. The final tool, comprising 33 items across five dimensions, demonstrated strong construct validity, high internal consistency (Cronbach's alpha = 0.97), and excellent stability (ICC = 0.89). These results underscore the importance of adapting patient experience tools to reflect the unique cultural and operational context of a specific healthcare system. While the findings align with global research on multi-dimensional patient experience assessment, they highlight key culturally specific elements, such as emotional support and comfort, that are particularly significant in non-Western settings.

Although the validated tool is specifically designed for the Iranian context, its framework and methodological rigor may be adapted for use in other countries with similar cultural and healthcare structures. However, direct application in significantly different cultural settings may require modifications to ensure relevance, as patient expectations and healthcare interactions can vary widely. Future research should focus on regional adaptations within Iran and modifications for use in other cultures, incorporating emerging healthcare technologies and patient care practices to meet evolving global standards and expectations.