This paper describes the development and validation of the COPS-D for the measurement of patient satisfaction with day care in hospitals. Patient satisfaction is seen as an important indicator of quality of care [11–13, 23, 26–28]. This study meets the need of Dutch hospitals for a valid and reliable questionnaire for day care patients given the rising organisation of day care in recent years.
The day care questionnaire is based on the COPS, a well validated questionnaire to measure patient satisfaction for clinical and outpatient hospital care. It is adapted to the day care situation with two additional dimensions: Pre-admission visit and Operation room. Part of the day care patients will have surgery in the operation room and/or have an intake visit with a nurse. The importance of the pre-admission visit for day care is supported by the literature: it is associated with reduced anxiety and increased satisfaction [5, 6, 29–31]. The questionnaire was tested in a large sample of patients from five general hospitals in the Netherlands.
Construct validity and reliability
Based on the correlations being higher than 0.7, we concluded that the items ‘Personal attention surgeon’, ‘Information surgeon’ and ‘Transfer of information’ in the COPS-D measure the same construct as items in the COPS. It is reasonable to assume that the surgeon is the only doctor that the patient sees during the day care admission. We therefore deleted these redundant items from the dimension ‘Operation room’.
The factor analysis confirmed the relevance of the eight dimensions of the questionnaire. The extraction communalities were higher than the threshold, as were the MSA.
Cronbach’s α’s showed good internal consistency within the dimensions. The item internal consistency was higher than the threshold, as were the inter-item correlations. The item discriminant showed that all items correlated stronger with the dimension they fit in than with the other dimensions. The results of the item ‘Privacy’ were erratic. If this item is deleted from the dimension Autonomy, the Cronbach’s α slightly increases. One could argue that the item ‘Privacy’ is not that important for a one day visit to the hospital and that it therefore should be deleted from the questionnaire. However, this item has inter-item correlations higher than 0,45 (0,530 with ‘Self-sufficient’ and 0,557 with ‘Participation in treatment’), extraction communalities are higher than 0,45 (0,640) and the item internal consistency is also higher than 0,40 (0,589). Therefore we decided to keep this item in the questionnaire. It could be interesting to investigate the scores on this item after collecting data from more hospitals with different kinds of day care facilities.
Patients’ overall satisfaction showed strong correlations (Spearman’s ρ >0,5) with the eight dimensions. From the literature  we know that overall satisfaction rates most highly correlate with factors associated with patients interaction with the hospital staff. This study showed that the dimension with the highest correlation with overall satisfaction in day care was the dimension Information. These findings correspond for example with the results of patient satisfaction research on pre-assessment clinics, where the provision of information was also an important indicator of patient satisfaction [29, 33], and in day care for neurological patients, where patient satisfaction was not related to a new diagnosis or treatment, but rather to the amount of information and emotional support during the day care stay . Patient information has become crucial in health care because it is necessary to enable the patient to take part in medical decisions and the resulting care provision .
The items in the COPS-D with the strongest correlation with overall satisfaction were ‘Transfer of information between professionals’ (ρ = 0,58), ‘Reception at the day care department’ (ρ = 0,57) and ‘Information about further treatment’ (ρ = 0,57). Next in strenght were ‘Expertise’, ‘Attention’ and ‘Information of the nurses’ (ρ = 0,55) and ‘Doctors’ (ρ = 0,53).
Apparently, the procedural items are more important to day care patients than to clinical patients, for whom interaction and attention of the professionals were most strongly related with their overall satisfaction . Literature supports the finding that exchange of information between health care professionals and patients is essential, also because of time constraints and limited patient contact . This might be an interesting field of future research. Especially the consequences for organisation of and attitude of professionals in day care centres deserve attention.
External validity and known group differences
Although our sample involves less children (age 0–19 year) than the total Dutch day care population, the results of the two groups are comparable regarding gender and age. Therefore we assume that the results can be extrapolated to Dutch day care patients in general.
We found, as expected, that older and healthier patients are more satisfied with respect to all dimensions. We also found patients with lower education levels are more satisfied, except for the dimensions Pre-admission visit and Autonomy and that gender does not have a significant effect on satisfaction scores on all dimensions. These findings are in line with the literature [12, 22, 23].
Clearly missing values are to be avoided. Our analysis showed that one of the remaining 24 items in this questionnaire had over 10% missing values. There is no strict rule regarding the maximum number of missing values to be considered acceptable. The number of missing data may be affected by a number of factors: the nature of the variable, the specialty a patient visited or the patient’s treatment [24, 25].
The item ‘Transfer of information to external professionals’ clearly is not applicable to all patients. Twelve per cent of the day care patients did not answer this item on the questionnaire. This might depend on the specialty or treatment of the patient. Twenty per cent of the dermatology patients did not answer this item, as well as up to 7% of the patients coming for ear nose throat-surgery.
During our pilot study it appeared that day care organisation varied widely between Dutch hospitals. Day care centres differed in name, organisation of the department, employees and (medical) treatments or operations. For example, there are day care centres for surgery, for radiotherapy, psychiatric treatment, dialysis or diagnostics. Therefore, we suggest that this item is only added to the questionnaire if transfer to external professionals is indeed applicable. If this item is deleted, the Cronbach’s α still will be good (0,82 rather than 0,86). Another possibility for future research is to add the answering category ‘Not applicable’, because this might be the reason a relatively high percentage of patients did not answer the question.
As patient satisfaction is seen as indicator of quality of care and satisfaction may depend on the type of hospitalisation, it is reasonable to assume there is a difference in satisfaction between different kinds of hospital care [32, 35]. Day care patients receive a different kind of care than clinical patients. The logistics and atmosphere of day care departments are different in the inpatient clinic. In general, day care patients are in better health than clinical patients. Moreover, health status influences patient satisfaction [23, 32, 36], as do individual conditions, treatments and preferences . It can be expected that day care patients are more satisfied with day care facilities than clinical patients with inpatient care [30, 38, 39]. This corresponds with findings about patient satisfaction about day care admission for neurological second opinions or tertiary referrals . Because the Clinical COPS, Outpatient COPS and COPS-D contain several identical questions, a comparable study can identify possible differences between the three types of care. This is an interesting topic of future research.
A number of limitations of the study design must be mentioned.
First, we could not study the characteristics of the non-responders, because of anonymity. Although our response rate is reasonable [14, 40], extremely (dis)satisfied patients may not have returned the questionnaire. However, former research showed that the impact of non-response bias on satisfaction questionnaires of hospitalized patients is relatively small [34, 41]. Also the external validity results showed that although our sample involves somewhat less children than the population of day care patients in the Netherlands, the groups are comparable regarding gender and age. Therefore, we assume that our non-response bias is limited.
Secondly, although the COPS is entirely based on the needs of clinical patients , day care patients were not specifically involved in constructing the COPS-D. The adaption is based on suggestions of professionals in hospitals that provide day care. We have assumed that the six general dimensions of Admission, Nursing care, Medical care, Information, Autonomy and Discharge and aftercare were also important to day care patients. We indeed found high correlations between these dimensions and the day care patients’ overall satisfaction. Still, there might be other aspects of day care which are important but not yet covered in the COPS-D. In-depth interviews and focus groups could further establish the content validity of this questionnaire for day care patients.
One of the arguments against assessing patient satisfaction is the skewed score distribution found regularly [34, 42]: most patients are satisfied with the care they receive and only very few are dissatisfied. We indeed found a ceiling effect in our data: the highest percentage of the maximum score given addresses medical care (given by 30,4% of the patients). Nevertheless, high satisfaction figures do not mean that there is no room for improvement . In this study we also see differences in means between the dimensions: e.g., comparing the mean score for Admission (M = 4,22) and the mean score for Discharge (M = 3,72). Thus, there is still room for improvement.