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Dos and don’ts of visiting someone in the hospital

Author: Sean Ankrom, MD

• Health and Wellness

When a friend, family member or loved one is in the hospital, your first instinct is to visit them and show your respects, whether it be due to an illness, injury or accident. Stepping into the hospital environment can be intimidating and scary. Here are some things you should remember when visiting a hospital patient.

What are the most common things that hospital visitors do that they shouldn't?

It's very important to not overstay your welcome when visiting a hospitalized patient. Patients need rest during their stay, and hosting visitors for an extended period can be draining--both physically and emotionally. The length of the visit should be proportional to how well you know the patient, but I’d recommend limiting the visit to one hour or less. If a physician enters during your visit, it's polite to step outside of the room until the conversation is over.

When is the best time to visit someone in the hospital?

The best time to visit a hospitalized patient is in the early evening. The hospital is typically humming with activity throughout the day, when patients are often scheduled for tests, procedures and staff are frequently entering and exiting the room. Toward late afternoon, the hospital tends to slow down a bit. By visiting later in the day, you'll have a better chance of having an uninterrupted visit. Weekends are another great opportunity to visit, as the hospital is usually quieter.

What are a few important things visitors should do before/after visiting the hospital?

Before traveling to the hospital, call to check the visitation policy. Certain units have strict visiting hours and some have policies that restrict the number of visitors. It’s common for young children to be restricted from visiting. If you have any signs of illness, such as fever, runny nose, nasal congestion or cough, it’s recommended that you postpone your visit until you’re well. After arriving at the hospital, check in with the nurse before entering the room to see if any personal protective equipment is required to prevent communicable disease. Washing your hands or using hand sanitizer when you enter or exit a hospital room is one of the most important things you can do to prevent the spread of germs.

Is it OK to bring gifts?

Bringing gifts is a fantastic idea, but isn’t necessary. The presence of a familiar face is often the best present a patient can receive in the hospital. If you do choose to bring a gift, bear in mind that hospital rooms are often small and storage space is limited. A large bouquet of flowers or balloons may seem like a nice gesture, but it may end up making the room feel crowded. Before visiting, I recommend checking in with the patient or a family member to see if they have any gift requests. Maybe there’s a book they’ve been wanting to read, a new issue of a favorite magazine or newspaper, or a small item that reminds them of home that you can bring in. Coloring books, puzzle books and card games also make nice gifts. If you’re thinking about bringing in outside food, check with the nurse or physician first. Patients are often on specialized medical diets and may have certain dietary restrictions. Sean Ankrom is a hospitalist at The Ohio State University Wexner Medical Center.

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How to Prepare Yourself for Visiting Someone in Hospital

Last Updated: February 16, 2022 References

This article was medically reviewed by Jonas DeMuro, MD . Dr. DeMuro is a board certified Pediatric Critical Care Surgeon in New York. He received his MD from Stony Brook University School of Medicine in 1996. He completed his fellowship in Surgical Critical Care at North Shore-Long Island Jewish Health System and was a previous American College of Surgeons (ACS) Fellow. There are 8 references cited in this article, which can be found at the bottom of the page. This article has been viewed 36,215 times.

If you're planning on visiting someone in the hospital, you may be feeling anxious, confused, or helpless about that individual's condition. You may even be fearful of seeing that person in a state of illness or incapacity. All of these feelings are normal and can be managed with proper planning. Learning how to manage your emotions and figure out the logistics of a hospital visit can help you be as prepared as possible for this potentially upsetting situation.

Figuring Out the Logistics

• Call ahead with the name of the patient you wish to visit to confirm the location of the patient and the visiting hours for that ward.

• Some patients may not be physically or mentally capable of having visitors. This could be for a variety of reasons, and it's important to be respectful of those reasons.
• The person may be on isolation precautions, meaning you will have to take special steps before entering the room. Speak to a nurse to find out if you need to wear a mask, protective gown, gloves, or other protective equipment. The nurse will be able to provide you with these items and instruct you on proper use. It's important you follow directions exactly, to protect both the patient and yourself.
• Call the hospital and ask to speak with a nurse working on your patient's floor. Ask the nurse whether it would be okay to visit, and provide a rough time frame you'd like to visit.

• Check in with the patient or her family to see if she wants visitors while staying in the hospital.
• If the patient does not want visitors, be respectful of her wishes. You can always send a card or get-well package through the mail or ask the patient's family to deliver it for you.

• If you're ill, you are better off staying out of the hospital for both yourself and the patient. Consider a phone call or video chat instead.
• Even if you're healthy, you should wash your hands before and after visiting the hospital, in particular when you enter and exit the patient’s room. You could accidentally introduce bacteria or viruses to patients inside the hospital, or you could inadvertently carry a serious pathogen home with you when you leave the hospital.
• When you wash your hands, use soap and clean, running water for a total of 20 seconds. [4] X Trustworthy Source Centers for Disease Control and Prevention Main public health institute for the US, run by the Dept. of Health and Human Services Go to source You may also wish to use an alcohol-based hand sanitizer instead of washing your hands.

Feeling Emotionally Prepared

• Start out by only reading credible medical articles. You can find a wealth of information on websites run by hospitals, medical schools, and medical care centers, such as the Mayo Clinic or Medline Plus .
• You can also find endless information in print form. Check your local library for medical textbooks and journals, then research the condition or illness for which your friend or relative is being treated.
• Once you've read some credible medical information, it may be comforting to read some personal accounts that talk about that condition/illness. Look for memoirs or even personal online blogs that discuss that condition or illness. Online forums specific to the illness often have good discussions and information.

• Remember that everyone deals with crisis situations differently. You may be able to maintain your composure and handle the situation, or you may grow anxious, frightened, or even angry.
• These feelings may change as the patient's health improves, declines, or alternates between improvement and decline.

• You can speak with family and friends about any concerns you have, especially if those friends or relatives are also close with the patient you're going to visit.
• If you have deeper-seated emotional concerns, you may want to consider speaking with a therapist or a clergy member (if you are religious).

• You can write anything you want in your journal. You don't have to show it to anyone, and you can even destroy the page when you're finished.
• Try to be consistent in your journaling. Since your feelings may change as the days or weeks go on, it can be helpful to make a daily habit of reflecting and writing.
• You can buy any type of journal you want, from a simple spiral-bound notebook to an elegant leather-bound book of blank pages; however, you may want to consider portability and ease of access when you're deciding on a notebook.
• It may be easier for you to journal on your phone or tablet. There are many apps that allow you to keep a journal on your devices.

• Exercise regularly. This can help you burn off some energy or stress and stay healthy. Even walking around the hospital can help.
• Make sure you're eating a healthy diet. While vending machines are convenient, they mostly contain junk food and you'll need proper nutrition, including a balanced diet with fresh fruits and vegetables.
• Get adequate rest. Remember that most adults need at least seven to nine hours of sleep each night, while some adults may need even more sleep. [7] X Research source
• Do things to help you relax and deal with your stress. Even if you can't leave the hospital, bring books, magazines, crafts, and other things to keep yourself busy and take your mind off of things.

Making a Successful Visit

• Try to base your gift on the individual's tastes.
• Choose a gift that will cheer up the individual. For example, if you know the person is an avid hiker and camper who is eager to get back on the trail, you may want to bring something that will make her think of hiking or camping.
• Consider bringing something that will help the person pass the time, such as a book of crossword puzzles, magazines, a book, or some other activity.
• If you know an image or object might upset the patient, you should avoid bringing anything that might be a reminder of that image or object. For example, if the individual will never be able to walk or ride a bike again, bringing reminders of these activities could be upsetting.

• Anticipate that the patient may be feeling a range of emotions. She may be feeling hopeful, fearful, angry, or she may even be in denial.
• Never tell the individual how she should feel. Simply accept the way she's feeling without criticism or interrogation.
• Ask the individual if she wants to talk about what she is going through. Don't unload your grief or fear on the patient, as she has enough to deal with on her own.
• Let the patient know that you're available to talk anytime. Even if she doesn't want to discuss what she's going through now, that may change with time. Make sure she has your contact information so she can reach you in case she wants to talk later.
• If the patient has a chronic illness/condition or will be going through a prolonged recovery period, be sure that you continue to offer support over the long-term. Many people will be there at first, but your friend or relative will need support down the line.

• Talk to other friends or family members of the patient to coordinate schedules. Let each other know when you're available and what shifts would work best.
• Once you've worked out a schedule, let the patient know who will be staying in the hospital and when. Having a schedule in mind may help give the patient some sense of normalcy.

• Going for a walk, getting yourself some food or coffee, or simply stepping outside to talk on the phone can help give you a mental break from the stress of being in the hospital.
• Let the individual know that you'll be back, and try to provide a rough time estimate. This can help put an anxious hospital patient a bit more at ease.

• Don't point out that the patient looks ill, injured, or otherwise unwell. Likewise, avoid talking about the procedure/surgery unless the patient wants to talk about it.
• Focus on the patient's treatment and recovery. Try to remain positive so that the patient can keep a healthy, positive attitude.
• If the patient is feeling sad or hopeless, try to lift her spirits. Talk about fun or humorous memories and try to get her to think about the fun times you'll have in the future once she is feeling better.

Expert Q&A

• Be aware of what you say to the patient. Never say something like, "Gosh, you gave us all a fright!" This can create feelings of guilt in the patient at a time when they should be focusing on recovery. Thanks Helpful 1 Not Helpful 0
• Try to see the positive things about a hospital stay. Many patients are having babies, getting long awaited life-changing surgery or having treatments that will make them better in the long term. Thanks Helpful 1 Not Helpful 0

You Might Also Like

• ↑ https://www.betterhealth.vic.gov.au/health/servicesandsupport/visitors-in-hospital#lp-h-3
• ↑ https://www.betterhealth.vic.gov.au/health/servicesandsupport/visitors-in-hospital#lp-h-1
• ↑ https://www.betterhealth.vic.gov.au/health/servicesandsupport/visitors-in-hospital#lp-h-2
• ↑ http://www.cdc.gov/features/handwashing/
• ↑ http://med.stanford.edu/cfcenter/services/SupportingLovedOnes.html
• ↑ http://www.healthtalk.org/peoples-experiences/intensive-care/intensive-care-experiences-family-friends/emotional-impact-relatives-friends-icu
• ↑ https://sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need
• ↑ https://www.betterhealth.vic.gov.au/health/servicesandsupport/visitors-in-hospital

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Being Admitted to the Hospital

• Registration |
• What to Bring to the Hospital |
• After Admission |

Hospitals provide extensive resources and expertise that enable doctors to rapidly diagnose and treat a wide range of diseases.

However, a hospital can be a frightening and confusing place. Often, care occurs quickly and without explanation. Knowing what to expect can help people cope and actively participate in their care during their stay. Understanding more about what hospitals do and why they do it can help people feel less intimidated by their hospital experience, more in control, and more confident about their health when they are discharged.

People are admitted to a hospital when they have a serious or life-threatening problem (such as a heart attack). They also may be admitted for less serious disorders that cannot be adequately treated in another place (such as at home or in an outpatient surgery center). A doctor—the primary care doctor, a specialist, or an emergency department doctor—determines whether people have a medical problem serious enough to warrant admission to the hospital.

The main goal of hospitalization is

To restore or improve health so that people can be safely discharged

Thus, hospital stays are intended to be relatively short and to enable people to be safely discharged to home or to another health care setting where treatment can be completed.

For many people, hospital admission begins with a visit to the emergency department. Knowing when and how to go to an emergency department is important. When people do go to the emergency department, they should bring their medical information .

Children may require a parent or other caregiver to stay at the hospital most of the time.

Registration for Hospital Admission

The first step in admission is registration. Sometimes registration can be done before arriving at the hospital. Registration involves filling out forms that provide the following:

Basic information (such as name and address)

Health insurance information

Telephone numbers of family members or friends to contact in case of an emergency

Consent to be treated

Consent to release information to insurance companies

Agreement to pay the charges

People are given an identification bracelet to be worn on the wrist. They should check to make sure the information on it is correct and should wear it at all times. That way, when tests or procedures are done, staff members can make sure that they have the right person. In many hospitals, the identification bracelet has a unique, personal barcode that health care providers scan prior to giving medications or other treatments or doing tests to ensure the proper care is given to the right person at the right time.

In the United States, a federal law called the Health Insurance Portability and Accountability Act (HIPAA) applies to most health care institutions and clinicians. The act sets detailed rules regarding privacy, access to information, and disclosure of individually identifiable health information, referred to as protected health information.

What to Bring to the Hospital

Whether people are admitted to the hospital through the emergency department or by their doctor, they should bring their medical information.

The most important things people should bring are

A list of all medications they are taking and the doses of the medications (the list should include over-the-counter medications, prescription medications, and dietary supplements, such as vitamins, minerals, and medicinal herbs)

A list of any medication allergies

Any written instructions from their doctor

If people do not have this information or they are too ill to communicate, family members or friends should provide it if possible, and they should bring all bottles of medications they can find at home so that the hospital staff can make a list of those medications for the medical record.

People should also bring a copy of their most recent medical summary and records of recent hospital stays. However, many people do not have these records. In such cases, the hospital staff typically obtains the information from the primary care doctor, the hospital records department, or both.

Hospitals recommend that people also bring advance directives and any legal forms that indicate who can make medical decisions for them in case they cannot make decisions for themselves ( durable power of attorney for health care ).

People should give all of this information to the nurse responsible for getting them settled into a hospital room.

Personal items

People should also bring the following:

Toiletries, including a razor if used at home

Eyeglasses, hearing aids, and dentures (if they are used at home)

A CPAP (continuous positive airway pressure) machine to help with breathing (if they use one)

A few personal items, such as photographs of loved ones, to make them feel more comfortable, and, if they wish, something to read

Cell phone and cell phone charger

If a child is being hospitalized, parents should bring a comforting object, such as a favorite blanket or stuffed toy.

Because items often get lost in the hospital (especially when changing rooms), all personal items should be marked or labeled. Valuables (such as a wedding ring or other jewelry, credit cards, and large sums of money) should not be brought to the hospital.

Current prescription medications

Many people bring their own medications to the hospital so that they can use their own supply. However, to ensure patients are receiving the correct type and dose of medication, people are instead given the same or similar medications from the hospital's supply. If people bring medications to the hospital for the doctor or staff to review, the medications are usually returned home by a family member or friend after the medications are recorded in the medical record.

Therefore, in general, prescription medications should be left at home. Exceptions are expensive, unusual, or hard-to-obtain medications. These medications should be brought because the hospital may not be able to provide equivalent medications immediately. Such medications include rare chemotherapy drugs and experimental medications. In these cases, the medication is given to the hospital pharmacist who inspects and verifies it before it is given. During the person's hospital stay, the medication is kept in a storage area, and the nurse gives each dose of the medication to the person.

After Admission

After admission, people may be taken for blood tests or x-rays or go immediately to a hospital room. Before performing any invasive test or providing medical treatment, doctors must obtain permission from the patient or an authorized surrogate decision maker by explaining the potential harms and benefits of the tests and/or treatments. The process is known as informed consent . 

Hospital rooms may be private (one bed) or semi-private (more than one bed). Even in a private room, privacy is limited as staff members frequently go in and out of the room, and although they usually knock, they may enter before people can respond.

Various tests, such as blood or urine tests, may be done to check for problems. Staff members may ask questions to determine whether people are likely to develop problems in the hospital or to need extra help after discharge from the hospital. People may be asked about eating habits, mood, vaccinations, and drugs taken. They may be asked a standard series of questions to evaluate mental function (see table Mental Status Testing ).

Intravenous (IV) lines

An IV line is placed in almost every person who is admitted the hospital. An IV line is a flexible tube (catheter) inserted into a vein, usually a vein in the crook of the arm. IV lines can be used to give people fluids, medications, and, if needed, nutrients.

If people stay in the hospital for more than a few days, the IV line may have to be moved to a different place in the arm to avoid irritating the vein.

Preferences for resuscitation

All people admitted to the hospital are asked if they have a living will that documents their preferences for resuscitation and what their preferences for resuscitation are, even when they are in the hospital for minor problems and are otherwise healthy. Therefore, people should not assume that this question means they are seriously ill.

Resuscitation measures include the following:

Cardiopulmonary resuscitation (CPR)

Electric shocks to the heart

Use of certain medications

Insertion of a breathing tube in the throat (intubation) and use of a machine to help with breathing ( mechanical ventilation )

Insertion of a feeding tube into the stomach to give nutrition

The decision about resuscitation measures is very personal and depends on many factors, including the person's health, life expectancy, goals, values, and religious and philosophical beliefs and on family members' thoughts. Ideally, people should decide on their own after discussing the issues with their family members, doctors, and others. They should not allow others to make this decision for them.

People may decide against resuscitation if they are older and feel they have lived a full life or if they have a serious disorder with a short life expectancy or a disorder that makes their quality of life poor. Doctors may suggest that people consider deciding against resuscitation measures if they have a terminal disorder or a disorder that makes returning to an acceptable quality of life unlikely after resuscitation. If people decide against resuscitation, doctors write do-not-resuscitate (DNR) or do-not-attempt-resuscitation (DNAR) orders on their chart.

The decision against resuscitation measures does not mean no treatment. For example, people who have a DNR or DNAR order are still treated for all disorders they have until their heart stops or until they stop breathing. Comfort care and treatment for pain are always provided and become a primary focus for health care professionals as people near the end of life.

Did You Know...

If people indicate that they do not know how to answer, doctors assume that they want all resuscitation measures.

People can change their decision about resuscitation measures at any time by telling their doctor. They do not have to explain why they changed their mind.

Ideally, resuscitation measures would restore the body's normal functions, and assistance with breathing and other support would no longer be needed. However, in contrast to what is typically portrayed in the media, these efforts have varying degrees of success, depending on the person's age and overall condition. These efforts tend to be more successful in younger, healthier people and are much less successful in older adults and in people with a serious disorder. However, there is no sure way to predict who will have a successful outcome after resuscitation and who will not.

In addition, resuscitation can cause problems. For example, rib fractures can result from chest compressions, and if the brain does not get enough oxygen for a while before people are resuscitated, they may have brain damage.

If people indicate that they do not want to be resuscitated (a DNR or DNAR order), a plastic bracelet is applied to their wrist and kept in place during the hospital stay to indicate their preference. Also, a doctor fills out a form called a portable medical order or Provider Orders for Life-Sustaining Treatment (POLST) to indicate that they do not want to be resuscitated. People are given this form for their records. Then, after discharge, those who have a serious illness can post this form prominently at home (for example, on the refrigerator) in case they are found at home unconscious by medics. Formal POLST and similar programs do not exist in every state or community, but their development is spreading rapidly.

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How Hospital Visitation Policies Are Changing During COVID-19

Er Productions Limited / Getty Images

Key Takeaways:

• Since March, hospitals have implemented strict visitation policies, which have profoundly impacted patients and their families. 
• Now, hospitals nationwide are slowly relaxing their protocols and seeking feasible ways to manage the emotional needs of patients while preventing the spread of COVID-19.
• Restrictive hospital visitation can leave patients without an advocate and physical support from their loved ones. 

It was May 15 when Emily Schmitz's 78-year-old father was first admitted to the hospital for small bowel obstruction surgery. Despite her father testing negative for COVID-19, Schmitz says she and her siblings were not permitted to see him due to the hospital's strict visitation policies.

Schmitz, who owns a communications agency in Austin, Texas, tells Verywell that initially, her father was doing well, but he quickly deteriorated—showing signs of confusion—which concerned her and her siblings. Soon they were making countless phone calls to the hospital to ensure their father’s needs were met, including a request for water. 

"[My sister] asked every day to see him, especially when his mental and physical state was deteriorating, and they still would not allow her to see him and advocate for better care for him," she says. Eventually, on May 21, the hospital allowed Schmitz's sister to visit their father, but only for the day.

Growing more concerned about her father's condition, Schmitz flew in from Texas, but upon arriving at the hospital, she was denied visitation. She decided to take matters into her hands. “I took it all the way to the hospital administrator and it took that to have someone listen to us,” Schmitz says. “It was pretty frustrating.”

On May 29, the hospital finally allowed Schmitz and her siblings to visit their father, who at that point, was in critical condition in the intensive care unit (ICU). They wore masks and gloves and were only allowed to visit for 10 minutes.

Their father passed away the next day—alone—not from the small bowel obstruction for which he was originally admitted, but from severe sepsis with septic shock.

“Families know their loved one and know when something is not right,” Schmitz says. “So, not being able to have somebody there for the patient is where hospital systems are falling really short.”

After months of restrictive visitation policies, patients and their families are speaking out about COVID-19's emotional toll. Now, hospitals nationwide are responding by slowly relaxing their protocols, and implementing new strategies to keep families connected. 

What This Means For You

If you or your loved one needs to visit the hospital, check with your local hospital to review their updated COVID-19 visitation policies. Phone and video calls are good ways to stay connected, but your local hospital may have different resources to help families cope with the distance.

How Strict Are Visitation Policies Now?

At the beginning of the pandemic, most hospitals implemented strict no-visitor rules to curb the spread of COVID-19. A July study, published in The American Journal of Respiratory and Critical Care Medicine , found that out of 48 Michigan hospitals, 39% prohibited visitors without exception and 59% only allowed visitors under “certain exceptions.” These certain exceptions often meant end-of-life situations or the birth of a child. Hospital systems set their own individual policies, but federal organizations like the Centers for Disease Control and Prevention have released COVID-19 guidelines for healthcare facilities.

After several reports about the negative ways visitation policies have impacted patients and their families, some hospitals are beginning to loosen their restrictions, while still requiring visitors to take the necessary COVID-19 precautions like wearing masks. For example, for inpatient units, MedStar Health System, located in Maryland and Washington D.C., now allows patients one visitor per day, but only if that patient doesn't have COVID-19.

For Mothers and Babies

“Initially, we implemented a draconian approach, which was to almost completely shut down all visitors, except for the mother’s significant other,” Jorge E. Perez, MD , neonatologist and co-founder of Kidz Medical Services, tells Verywell.

According to Perez, who also serves as medical director of neonatal and newborn services at South Miami Hospital in Florida, the visitor would have to stay isolated in the mother’s room until the mother and baby were discharged. If the visitor left the hospital, they would be unable to return.

While the one visitor-per-patient rule remains in effect at South Miami Hospital, if that visitor leaves the hospital, they are now permitted to return. 

Similar strict policies were common in other hospitals, especially during the height of the pandemic, when COVID-19’s impact on babies was relatively unknown. According to the Centers for Disease Control and Prevention (CDC), while most newborns who contract the virus have either mild or no symptoms, there have been reports of newborns who develop severe cases of COVID-19.

“We had to be creative to continue offering family-centered care," Perez says. The Kidz Medical team at his hospital communicated daily with the parents of patients in the NICU. In addition, they provided 24/7 viewing cameras so parents and extended family members could view infants in real-time and follow their progress. 

“It’s known that women have better birth outcomes when stress levels are reduced and when they’re surrounded by support and advocacy," Talitha Phillips , a labor and postpartum doula in Los Angeles and CEO of Claris Health, tells Verywell. "This is especially critical for women of color who already face health disparities when it comes to labor and delivery.”

Phillips is no stranger to the emotional difficulties pregnant women face when forced to choose only one support person to accompany them in the hospital. She and her clients were devastated to learn about the restrictive visitation rules that went into effect this March. 

“I will never forget sitting in an Uber, crying after I had to leave a mom and her husband at the entrance of a hospital," she says. "We’d labored together for 12 hours and in her most intense moments, I had to ‘abandon’ her.”

She explains that although the ability to provide her labor and postpartum doula services in-hospital is still limited, “in the last two weeks, two hospitals in LA have started allowing women to bring a partner and one support person with them.”

For ICU Patients

ICU visitation rules vary greatly by hospital and state. For example, the University of California San Francisco Health System now allows up to two visitors at a time in the ICU. Visitors may visit at any time and one visitor may stay overnight.

Studies show that visitation is highly important to patients in intensive care units, especially those who aren’t able to speak up for themselves. Researchers found that family presence at the bedside can help reduce delirium as well as help families make better decisions regarding their loved one’s care.

Schmitz and her family wish they could've been at her father's side during his hospitalization. Strict COVID-19 visitation rules made it difficult for her and her siblings to stand up for him, and keep track of the care he needed.

“The message I want to get across most urgently is the importance of having an advocate for your family member, speaking up, and taking it to the top if you have to," Schmitz says.

Valley T, Schutz A, Nagle M, et al. Changes to visitation policies and communication practices in michigan ICUs during the COVID-19 pandemic .  Am J Respir Crit Care Med . 2020;202(6):883-885. doi:10.1164/rccm.202005-1706le

Centers for Disease Control and Prevention. Ten Ways Healthcare Systems Can Operate Effectively during the COVID-19 Pandemic .

MedStar Health. Temporary Visitor Restrictions and Guidance During COVID-19 .

Centers for Disease Control and Prevention (CDC). COVID-19 and Pregnancy .

UCSF Health. Visitor Restrictions at UCSF Due to the Coronavirus (COVID-19) .

By Kara-Marie Hall, RN, BSN, CCRN ​

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Preventing infections when visiting someone in the hospital

Infections are illnesses that are caused by germs such as bacteria, fungi, parasites, and viruses. Patients in the hospital are already ill. Exposing them to these germs may make it harder for them to recover and go home.

If you are visiting a friend or loved one in the hospital, you need to take steps to prevent spreading germs.

The best way to stop the spread of germs is to:

• Wash your hands often
• Stay home if you are sick
• Use a face mask when directed or when infections may be transmitted through the air
• Keep your vaccines up to date

Hand Washing and Alcohol-based Hand Cleaners

Clean your hands:

• When you enter and leave a patient's room
• After using the bathroom
• After touching a patient
• Before and after using gloves

Remind family, friends, and health care providers to wash their hands when they enter a patient's room.

To wash your hands:

• Wet your hands and wrists, then apply soap.
• Rub your hands together for at least 20 seconds so the soap gets bubbly.
• Remove rings or scrub under them.
• If your fingernails are dirty, use a scrub brush.
• Rinse your hands clean with running water.
• Dry your hands with a clean paper towel.
• Do not touch the sink and faucets after you wash your hands. Use the paper towel to turn off the faucet and open the door.

You may also use alcohol-based hand cleaners (sanitizers) if your hands are not visibly soiled.

• Dispensers can be found in a patient's room and throughout a hospital or other health care facility.
• Apply a dime-sized amount of sanitizer in the palm of one hand.
• Rub your hands together, making sure all surfaces on both sides of your hands and between your fingers are covered.
• Rub until your hands are dry.

Stay Home If You are Sick

Staff and visitors should stay home if they feel sick or have a fever. This helps protect everyone in the hospital.

If you think you were exposed to COVID-19 , chickenpox, the flu, or any other infections, stay home.

Remember, what may seem like just a little cold to you can be a big problem for someone who is sick and in the hospital. If you are not sure if it is safe to visit, call your provider and ask them about your symptoms before you visit the hospital.

Anybody who visits a hospital patient who has an isolation sign outside their door should stop at the nurses' station before entering the patient's room.

Isolation precautions create barriers that help prevent the spread of germs in the hospital. They are needed to protect you and the patient you are visiting. The precautions are also needed to protect other patients in the hospital.

When a patient is in isolation, visitors may:

• Need to wear gloves, a gown, a mask, or some other covering
• Need to avoid touching the patient
• Not be allowed into a patient's room at all

Other Things You Can Do to Prevent Infections

Hospital patients who are very old, very young, or very ill are at the greatest risk for harm from infections such as colds and the flu. To prevent getting the flu and passing it to others, get a flu vaccine each year. To prevent getting COVID-19 and passing it to others, get COVID-19 vaccines according to current recommendations from the Centers for Disease Control. Ask your provider what other vaccines you need.

When you visit a patient in the hospital, keep your hands away from your face. Cough or sneeze into a tissue or into the crease of your elbow, not into the air.

Calfee DP. Prevention and control of health care-associated infections. In: Goldman L, Cooney KA, eds. Goldman-Cecil Medicine . 27th ed. Philadelphia, PA: Elsevier; 2024:chap 261.

Centers for Disease Control and Prevention website. Infection control. www.cdc.gov/infectioncontrol/index.html . Updated November 18, 2022. Accessed October 20, 2023.

Review Date 10/13/2023

Updated by: Linda J. Vorvick, MD, Clinical Professor, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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• Health Facilities
• Infection Control

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Hospital visitation rights: family members and partners

By HealthSherpa

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When you’re hospitalized, a few important questions come up. What are my hospital visitation rights? Who is allowed to visit me in the hospital? Who can make medical decisions for me when I’m unable to? Over the years, laws have changed and been updated so we want to highlight what you can expect during a hospitalization.

What are my hospital visitation rights?

Since 2011, federal regulations requires any hospital accepting Medicare and Medicaid to allow patients to say who they want as visitors. And this includes the majority of hospitals. The patient’s wishes must be respected regardless of gender, sexual orientation, or relationship. General hospital rules regarding visiting hours will be enforced. However, the enforcement will not discriminate according to relationship.

In addition, if you’re a hospital patient, you may choose someone to act as your advocate. This person can ask questions, speak to doctors on your behalf, and generally become part of your care team.

When do hospital visitation rights get blurry?

Confusion can still come up if you are hospitalized and unable to communicate. And you do not have any signed documents on file with your physician or primary care provider. This can be especially problematic if you don’t have a trusted family member who will show up and make medical decisions on your behalf. Without you being able to make this decision, state rules vary about who can make medical decisions for you. This role may be limited to people related to you by legal marriage or blood, depending on your state’s policies.

Furthermore, under the HIPAA Privacy Rule , if you are unable to give consent, providers can use their judgment regarding who they share your information with. And they do not have to share it with any specific person.

As a patient, what legal documents do I need to protect my rights?

You will need to draw up a Medical Power of Attorney or Health Care Proxy. This allows you to designate an advocate (or two) to make medical decisions on your behalf when you’re unable to. You can also revoke this document at any time, and it only applies in instances where you are incapacitated. It’s also helpful to create an Advance Directive. This includes your personal health care wishes that you want that person to base their decisions on. Rules for these documents differ between states, and you can look up your state’s forms here .

The rules surrounding medical care are complex and shifting but many of today’s laws work on behalf of supporting the patient’s wishes. Our Consumer Advocates are always available to help you understand your rights regarding healthcare coverage as well as general health policies.

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My significant other’s wishes were adhered to in the hospice as long as she was alert and conscious. When she became un-alert and semi-conscious her family banned me from visiting her. She died in the hospice a week later and I was told I would be arrested if I attended her funeral. The family was angry that she started dating (me) after her husband died and did not want to provide child care for her family’s grandchildren, as she and her husband had done for several years. This occurred in a large Catholic hospital with chaplains and social workers on hospice staff. Before she entered the hospice I and visiting nurses cared for her at home. Beware of vindictive and malicious family members. Hospital staffs do whatever they request, you are just a nuisance as the long time friend.

My son-in-law, who is still vindictive and malicious had hospitals ban me from visiting my daughter even when she could talk and communicate herself. He threatened her that he would stop seeing and caring for her if she said I could visit. The hospital carried out all of his wishes. If it had not been for my insistence on visiting anyway, she would have died alone.

I am having similar issues. My sister suffered an Aneurysm and her memory has been foggy since, going to be a long recovery and her husband is being a complete a**. He is, “the husband”, far from the sharpest tool in the shed. He’s always been a little to insecure and involved in all aspects of her life, she can’t even have a conversation on the phone without him inserting himself. He’s not liked by most that meet him, one neighbor told me, “he thinks he’s the king of the block.” Even his own family has had issues, son went as far as changing last name to disassociate himself from him but here we are with him making all her decisions. I truly think my sister has stayed because she feels sorry for him, she definitely can and did do better in the past. But this fool is also trying to control everything and me and my mom are jumping through hoops to prevent from getting banned. I pray my sister recovers 100% because all his actions might be the straw that broke her back. 🤞🏽 He’s gone as far as preventing us from maintaining my sister’s bills because he can handle it, then turns around and creates a go fund me page 😡 using my sisters name and image. Praying that he doesn’t ever gain the power to have us banned, I worry about her care under his authority.

Thanks for another fantastic post. Where else may anyone get that kind of information in such an ideal way of writing?

I’ve a presentation subsequent week, and I am on the look for such info.

Dose anyone no a lawyer cuz lawyer I call at malpractice n need something bad to happen. Frist like an injery they not letting me or my mom visit do to his condition now he told them they can talk to me n my mom about what’s rong he’s is a drug addict but he’s there for amonna we were seeing him for 4 days now no one aloud to come they thretin to have me arested for trust passing but u still can walk into his room so I do so there not keeping him safe the drug dealer still going to walk in it’s just my mom wwho respect there rules when I go up they not giving him his meds for he’s sugger a few times already we came n he has not eat because they didn’t bring it or never gave him his inclin so he won’t eat I need help finding a lawyer in new York City for visit in hospital not family Court

my fried has a son , who is in the hospital (NJ) he is 28 has no children of his own and NO spouse… he isher only child .. no they wont let his mother come visit because she not his spouse … discrimination?????

That’s crazy.

My wife is in the hospital and its gonna be a few days before she gets out .she has pancreatitis and is in need of plasma .as her husband they say I cant be with her..she is terrified to be alone throught this due to the covid there is a no visitor rule…is this legal?

Sorry to hear about your wife! There are extenuating circumstances right now, so many hospitals have temporarily removed visitation rights. It is legal.

why couldnt they wheel th patient down to th lobby in a wheel chair? my wife had a touchup surgery from a bk amputation, shes fine, sitting up arguing w th nurses lol, nothing stopping her from moving around, theyr waiting for test results of infections. told us maybe 1 overnight, turns out definitely, thn 2, now 3 more. no answers being answered directly, neither surgeon or infection specialists know wtf to do. shes scared sh*tless n panicking. theyr worried her bp is going up higher n higher- they clueless n thinking of more meds… i mentioned bring her to me in th lobby for 5minutes n see th instant changes… we are a cpl days away from green phase, they wont budge! im ready to drive my truck through th building!

That sounds really tough! It sounds like these restrictions will be cleared soon in your state.

No, it is not legal. Those are policies. There are laws that protect patients and loved ones from those cruel, unfair policies.

you need to sue them for that. NO Doctor has a right to bar you from your wife, NO DOCTOR AT ALL! If that were my wife i’d be dragging them to federal court. It doesn’t matter WHAT your wife is giong through, You have EVERY RIGHT To see her in the medical system. REGARDLESS!

Wondering if the hospital is allowed to deny my mother being with me in the hospital during the delivery of my first child since she is blood. This shouldn’t be a concern however lately it has been! And what can I do to ensure my patient rights are respected?

A lot of hospitals are not allowing visitors because of the risks of COVID-19. You’ll have to talk to the hospital about this.

Trust and believe me I will and if they don’t my family will be forcing our way in you can not refuse me service or I’ll sue their whole organization for slander and for grievance pay

In general covid put aside can a spouse decide who can visit the other spouse at the hospital?

It’s up to the patient to determine who can visit them at the hospital. But a patient may choose someone to act as their advocate. This person can ask questions, speak to doctors on your behalf, and generally become part of your care team.

So my husbands father was murdered when he was 14 the only parent he has left is his mother she only has a week to live drive from Canada to California and the tell him they already made the exception for his half sister so he can’t go in and say his good bye know tell me if this is some bull…. I his wife am a nurse I understand the COVID stuff but this is immediate family same blood and you can’t let one and not the other unless you want siblings fighting when they should be their for each other tell me if this isn’t WRONG

The hospital rules right now are really tough for a lot of people. Many hospitals are only allowing one visitor total. I’m sorry for your situation, and I recommend you speak to the hospital about this.

My partner of 25 years suffered a stroke. He at his best REVOKED his mother of all powers of ATTORNEY had it notarized and sent by mail to the hospital banks and one to her. This was well documented to every party involed. I as his partner began making all the best medical decisions for him. The doctors were gonna let him die but I signed the papers and he had surgery is still alive today. His mother is a genuine NARCISSISTIC behavior. My partner would have lucid phases. At times wasn’t sure reality from floating tables. Anyhow his mother closed his bank accounts took possession of the home we shared. Convinced one nurse she was his agent showing a 5 year old power of attorney. And will not tell no family or friends where she put him. She will not discuss it. I fear for him. She was revoked. What can I do. It’s been 6 months and I’ve tried everything to find him. She’s the only one. And she’s 92. Help!!! I love him

My boyfriend of 8 years was admitted into hospital 23 days ago, and has some confusion and disorientation at times. I would visit him at lunch and dinner to bring him food and feed him if he was hungry and give him some company. They can’t find his glasses and can’t watch TV because his bed obstructs his view, who wouldn’t be disorientated. Yesterday the Dr came in and told me that I wasn’t allowed to visit him or receive updates anymore because I am not married to him and his brother is the next of kin and removed me from the visiting list. I was verbally attacked in the hospital parking lot by his brother confronted with lies about me. How I was responsible for his condition and then verbally and physically attacked by his mother with a cane, one hit to my side. My partner knows I am there and definately would want me to visit. What are my rights? Is he able to say that he wants me to visit? And if he does can I?

If your partner can communicate, he can let them now he wants you to visit. Since 2011, federal regulations requires any hospital accepting Medicare and Medicaid to allow patients to say who they want as visitors. And this includes the majority of hospitals. Confusion can still come up if you are hospitalized and unable to communicate. And you do not have any signed documents on file with your physician or primary care provider. This can be especially problematic if you don’t have a trusted family member who will show up and make medical decisions on your behalf. Without you being able to make this decision, state rules vary about who can make medical decisions for you. This role may be limited to people related to you by legal marriage or blood, depending on your state’s policies.

So if my partner brings me to the ER do I have the right to share only certain medical issues with her from the Doctors?

Yes, you are under no legal obligation to share your medical issues with her and your doctors are not obligated to share any medical information about you with her either.

Hello can anyone tell me if it is illegal to not allow the family of a possibly dying persons (24 hours to live) not be able to visit? Said it was my wishes and that I told my co- Ordinator I didn’t want to see anyone. Lie !!!!! thank Goodness everything turned out well, I am so mad and wondering if a violation of the law was committed. Transplant went very well but I spent most of the time by myself 🙂 made as hell. TT

So a month ago my dad passed away in the hospital from covid/pneumonia. During his whole stay no one at all was allowed to see him, even when he was in ICU contained in a room with glass. The day that he died my family was allowed to see him through the glass after he had passed. This makes no sense to me at all. Should I take legal action???

Due to COVID-19, there are legal rules like this in place to reduce spread within hospitals to those who are sick or immunocompromised. Sorry for your loss.

It is happening to us right now. At a Pittsburgh VA hospital.

My son in law is dying with ards. HVH wont allow family to come and go one at a time to visit. he could die tonight. Charge Nurses should kind and gentle. I know I was a nurse for m40 years.

I’m very sorry to hear that.

My 89 year old Father was recently taken to the ER by ambulance. We instructed them not to admit him until we got there and discussed it. They were supposed to meet up with another ambulance to do an EKG and discuss the results with us. My Mother has MPA over my Father. He suffers extreme PTSD, Anxiety, and Clastrophobia. He also has coherency issues. To further complicate things he is unable to sleep in a bed for the past 12 years and has been confined to a medical recliner and power chair.

When we arrived at the hospital we told them that Mom had an MPA and that he had PTSD, Anxiety, etc….. They said doe to Covid she couldn’t go back. We mentioned again that we needed to speak with charge nurse so that we could relay everything. After waiting 45 minutes a Dr. called to ask questions and probably new less than a 1st year nurse. The questions were ridiculous. We again relayed the PTSD etc. and specifically the MPA. We also told him he was overdue to for his anxiety meds. To no avail in speaking with someone. In the interim we find out later they were forcing him down on a bed holding him down and somewhere along the lines infected him with something to calm him down apparently. He was highly agitated and finally 10 hours later after he had been transferred to an “Observation Room” a floor nurse called to say he was super riled up and if Mom could come down. This is our first conversation with someone at the hospital since the Doctor. 9 hours prior. He at this point is over 13 hours past his needed anxiety and pain meds for his back. Once we got there he looked like he had been beat up. We convince them to let him go after a the blood work finally came back and a Dr. Cleared him. By 12:30 am he was released. Set him back multiple years on control of the PTSD barely sleeps and is agitated most of the time. Also, he never agreed to be admitted and asked several times

My question is relatively simple. At what point does the hospital have to acknowledge the MPA and ask the family for supporting information that could help in the treatment and explain excessive agitation, yelps of pain, etc.. If they had only talked to us even by phone we could have relayed this additional information on his back etc. Again, we did tell the Dr. but I think he was too busy to pay attention and listen.

We spoke tot the Patient Advocate (Hospital employee ) and they of course said their investigation said they followed all guidelines. We asked why they didn’t even come out or call to get background information and we got “Crickets” then is there anything else.

Thanks for any helpful information on what our possible courses of actions are.

Hello, My father was admitted to a local hospital on Saturday night after experiencing a week-long manic episode that escalated to him not sleeping or eating. He was transferred yesterday to an inpatient psychiatric facility in a neighboring city. He does not have his cell phone. My sister, uncle and I have tried calling the hospital to talk to him, but keep being told we have to have a pin (no one in our family has this pin, despite all three of us being given clearance to receive his medical information at the previous hospital). I was told tonight that my dad has to call someone and give them the pin. However, when I asked what happens if he isn’t cognitively healthy enough to call someone, she started repeating “I can’t confirm or deny if he’s here.” I asked if he will be prompted each day to call someone and she again said “I can’t confirm or…” My question for you is what we are supposed to do if he is unable to make the decision to call someone. I was also told there are no visiting hours. So, we have no idea what is happening to him, what state he is in (mentally or physically), how long he will be there, if he’s being treated, etc. Is there anything we can do? Thank you.

I am in the same boat as all who posted. I didn’t ask to get sick, my taxes help support these hospitals etc, but to be scared,lying in a bed knocking at heavens door and to be told sorry sir you are denied any contact with the people who actually love you. You think they could double designate a hospital to COVID patients and give a designated family member the same protection as the medical stafff have. It’s quite obvious this COVID pandemic isn’t as bad as they say it is as I know from personal experience That these icu nurses are allowed to go home with no restrictions and go about mingling with the general public etc. mean while a 1 family number is a risk but not the 1,000’s of medical staff in and out. So why not put patients and staff with COVID in 1 hospital or 2 and have dyeing/ sick people the last few days etc with their loved one designated etc. may god forgive the people who neglect to see that patients are imprisoned from their life as their only crime was getting sick and these medical decision makers play god with no regard to a human need of love from their family

My father is in a care facility after an aneurysm. His wife has banned all FaceTime and visiting from my sister and myself. She allows FT and visiting my other siblings. She also said before Christmas she would take him Off life support. She did not she uses my father to control. The care facility said we can only do FT with a password. However she calls the facility to know who has called. We always had a good and caring relationship with my father. I live in another country and FT was the only way to visit him— also with Covid situation. Is there any transparent Legal Help for helpless situations? Apparently we need to see a judge.

My boyfriend is in the process of getting a divorced unfortunately he is in CCU on a ventilator, and she made a restriction list for visitors and won’t let me see him. Is there a way that I can fight this?

My brother has a wife of 30 years and a girlfriend of 30 years. He’s hospitalized and conscious and very aware of what’s going on. He doesn’t want his wife to stop his girlfriend from visiting him in the event the wife gets angry and tries to keep the girlfriend out. The wife has definitely threatened to tell the hospital about the situation. She even said she going to tell them to ban the girlfriend. We’re from Georgia. Can the wife ban the girlfriend?

hi i need some advice my boyfriend of 4 years is in roseville point and wellness center and i am the only one he has and e had a brain stem bleed so the place where he is at is doing things to him when he dont want it to be done so i speek up for him and they did not like that so they put a no trustpassing order on me and i have not seen my boyfrend for almost 2 months they wont even let me call him i am the only one he has please if anyone can give me some advice on what to do to be able to see my boyfriend again i would really apprate it

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• Jun 8, 2020

15 Rules You Need To Know Before Visiting Someone In Hospital

Visiting a patient in a hospital isn’t as simple as stopping by someone’s home for a coffee and a chat. You are going to see a person who isn’t feeling or looking their best. They’re in a place where no one likes to be. It can be difficult to find the right thing to say to help them feel better, and there can be awkward pauses in conversation.

A ‘good’ visit can really cheer a patient up, and feeling positive will aid their recovery, but when it doesn’t go well it can make your friend or family member feel worse, which is the last thing anyone would want.

So based on our many years of visiting patients in hospital, we’ve compiled 15 top tips for successful hospital visits. Follow these and you can be confident that your visit did not detract from the patient’s care and hopefully in some way aided their recovery. And check out the bonus tip at the end of this blog for the patient or their close family.

Hospital Visit Etiquette

Planning the actual visit to someone in hospital needs a little thought and empathy. And there are a few ‘rules’ that anyone visiting a hospital patient should be sensitive to:

1. Not The Right Time For Questions

People tend to combine wishing a patient well with a short interrogation.

“Oh my gosh - I was so shocked when I heard! How are you doing? What on earth happened? What can I do?”

The intention is well-meaning, but the execution may need a little work! This is not about your need for information, but what the patient’s needs. They can feel vulnerable and they are in an unfamiliar place facing a health crisis and for various reasons they may not want to share details about their diagnosis/prognosis or the treatments and tests they are facing.

So before launching into questions, you need to ascertain their frame of mind. Be guided by their responses and the information they freely offer.

2. Plan When you’re Going to Visit:

First, you should notify the patient or a family member when you plan to come. Make sure it’s a good time for the patient.

3. Know The Rules:

You need to be cognizant of the hospital visiting guidelines. Most hospitals have their visitation times and rules posted near the main entrance, as well as on their website. Before you visit your friend or family member, make sure you check that your planned time is ok with the hospital as well as the patient!

4. When To Stay Away:

At all times, but even more so in this era of Covid-19, don't visit if you are sick . Stay well away if you have a fever, cough, or any other sign of sickness. The last thing that is needed in a place where people's immune systems are weak, are your germs.

5. Hand Sanitizer isn’t Just For Covid-19!

Continuing from item 4 above, it is important to be diligent about washing (or sanitizing) your hands before and after you visit your friend or family member. You don't want to take germs into or out of the hospital.

6. Set limits for your stay:

There is no need to stay for hours and hours (unless you are the spouse, parent, or child of the patient.). Most of the time, 15 or 20 minutes is an adequate amount of time for a meaningful visit. Staying too long may interfere with the patient’s need for rest and they may be too polite to say anything, so you need to be sensitive.

7. Respecting Privacy:

A patient has to give up privacy to the medical staff, but that does not extend to others. Before entering the room, knock and enter only after you are invited.

8. Don’t offer Medical Advice:

Avoid the urge to “diagnose” unless you are a doctor. Uncle Max may have had similar symptoms, but this is not the time or place to share them or to detail his sad demise.

9. Show a Little Sensitivity:

Never tell a person how bad he or she looks. It may be true but it is hardly helpful for them to be reminded of that and try to ignore any tubes or beeping machines. You may understandably be a little shocked by all this but don't show it. Bursting into tears when you see your friend is also probably not going to help them to feel better. And if you are squeamish, consider whether a phone call might be better for all concerned.

Try to keep the noise down. A hospital isn’t a library but it still is not a good place for loud voices, laughter or YouTube videos played from your phone at full volume. And the person you are visiting may be on an open ward or in a semi-private room, so have some consideration for the other patients.

11: Patients Have Ears:

The patient may appear to be asleep or perhaps be non-responsive but that does not necessarily mean they cannot hear you, so don’t say anything in front of them that you would not say if they were awake.

12: Ease up on The Chanel No.5:

It is a really good idea when visiting a hospital not to wear perfume or cologne.

13. Consider Where to Sit:

Don’t sit on the patient’s bed. There is usually a chair near each bed or not far away and if not, simply stand.

14. Try to Leave The Kids at Home:

Unless the purpose of the visit is for the child to see the patient (perhaps a parent) it is best to leave them at home, especially younger children. They can get rowdy, put things in their mouths (not a great idea in a place like a hospital), touch things they should not, etc.

15: Know When to Step Out:

If a Doctor or nurse comes in while you are there, always leave the room unless the patient invites you to stay. Obviously, If the patient is your child or you are the patient’s advocate, you will be allowed to stay when the doctor is present.

Bonus Tip For the Patient, or Immediate Family

Designate one spokesperson for friends and visitors to contact for updates.

This will save nurses having to repeatedly fill in visitors (and deal with the confidentiality issues involved in this) and it can stop the patient being bombarded with texts and WhatsApp messages all asking the same thing.

What other hospital visit tips would you add to our list? Please comment below. You’ll be helping other people to have successful visits!

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Hozzászólások

Visiting someone in hospital

The information in this section is a general guide to visiting someone in hospital.

Details will vary depending on which hospital you're visiting, including if you need to wear a face covering over your nose and mouth.

Check on the hospital's website for more information.

Find the contact details of a hospital

Visiting hours

Most hospitals have times at which you can visit your friend or relative.

Check with the relevant hospital for information about when you can visit, and bear in mind that different wards often have different visiting times.

If you're unable to attend during visiting hours, talk to the member of staff in charge of the ward to arrange an alternative time to visit.

Hospitals encourage relatives and friends to visit patients. But patients can get tired very quickly.

For this reason, the number of visitors each patient is allowed is usually restricted, typically to no more than 2 people at any one time.

It might be necessary to stagger the visitors so they come at different times.

There can be restrictions on children visiting a patient.

Check the arrangements with the ward you're going to before your visit.

Hand hygiene

When visiting someone in hospital, always clean your hands using soap and water or alcohol hand rubs. Do this when you enter or leave a patient's room or other areas of the hospital.

If you're concerned about the hand hygiene of doctors, nurses or anyone else you come into contact with in hospital, you're encouraged to ask them whether they have cleaned their hands.

You must not visit someone in hospital if you have a cough, cold, diarrhoea, vomiting or any other infectious condition.

Presents for patients

Patients like to receive gifts while in hospital. Most hospitals encourage visitors to bring gifts like fruit or books and magazines, but it's important not to clutter the patient's bed area.

You may not be allowed to bring some foods into hospital – check with the ward before you visit.

Many hospitals do not allow flowers on the wards or other clinical areas. Check with the ward staff before bringing or sending someone flowers.

Many hospitals do not allow smoking, including e-cigarettes, in any part of their buildings or grounds.

If smoking is allowed at the hospital you're visiting, only smoke in the designated outdoor areas.

Parking at hospitals is limited and can be expensive. Where possible, use public transport when visiting someone in hospital.

Violence and aggression towards staff

Violence and aggression towards staff, patients or members of the public are not tolerated in any hospital.

Assault is a crime, and hospitals may seek legal penalties for anyone behaving in this way.

What not to do when visiting someone in hospital

• It's best not to sit on the patient's bed, as this can spread germs. Use the chairs provided.
• Do not put your feet on the patient's bed.
• Do not touch the patient's wounds or any medical equipment they're attached to, such as drips or catheters. This can cause infections.
• Do not use the patients' toilets. Use the hospital's public toilets.
• Do not share a patient's toiletries, tissues or hospital equipment with other patients or leave them in communal areas.

Page last reviewed: 14 April 2023 Next review due: 14 April 2026

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Hospitals are still limiting visitors due to covid. Here’s what you need to know.

If nurse Joseph Falise could impart one tip to those with a loved one in the hospital nowadays, it would be to call ahead and confirm the visitation policy. Most hospitals still have tighter pandemic-related rules throughout their facilities, not just on covid wards. At University of Miami Hospital and Clinics, where Falise works, for example, only one visitor is permitted per day . When other family members or friends show up, he said, “It’s like a surprise attack when we say, ‘I’m really sorry, but you can’t come in.’”

Nearly two years into the pandemic, keeping up with visitor restrictions is one more stressor for already anxious friends and family of hospital patients. In addition to limiting visitors, some hospitals have shortened visiting hours, restricted visitors to one for a patient’s entire stay, and closed lobbies and other public places. (Some loosen certain restrictions if a patient is in hospice care.) Some hospitals also require all visitors to be vaccinated.

The University of Miami hospital’s policy has changed numerous times throughout the coronavirus pandemic, said Falise, the nurse manager in the cardiovascular and neuroscience ICUs. And “there’s a hospital across the street that's doing it differently than we are.”

There is no standardized visitation policy for hospitals in the United States. Restrictions on visitors are typically determined by the hospital’s administrators and patient family advisory council, said Robyn Begley , senior vice president of the American Hospital Association and CEO of the American Organization for Nursing Leadership. “The safety of the patient, safety for visitors and family members, and safety to the staff are always factors” that influence policies, she said.

“On top of that,” she added, “there’s local government mandates right now. So, there are safeguards that every hospital examines in the determination of what their visitation policy is, and it gets revisited depending on what’s happening regionally.”

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Throughout the pandemic, some experts and patients have pushed for less restrictive visitation policies. A study published in April in the Patient Experience Journal found that quality of care suffers when hospital visits are limited. The researchers hypothesize that a lack of advocates might lead patients to feel less acknowledged in their care, and the lack of third-party observers could lead to less safe care.

“Families of patients serve two roles: emotional and as an advocate,” said Anthony C. Stanowski, a study co-author and president and CEO of the Commission on Accreditation of Healthcare Management Education. Visiting family members “are the best source of patient information and patient comfort, and have a vested interest in the well-being of the patient,” he said.

Falise said he has supported open visitation in the past, “because having your family members bedside has been proven to decrease mortality and increased patient satisfaction.” But, he added, “Hospitals are really good-intentioned on this. The reality is, we have to adjust to the times.”

Here are some tips for visitors dealing with covid-era hospitals rules and advice for being the best advocate possible — especially if that responsibility falls entirely on one person.

If it’s a planned admission, have a serious conversation ahead of time. Find out the hospital’s visitation policy by calling or checking its website, Falise said. You can then have a discussion about who will be the primary visitor and set expectations by letting other family members know. This is also a good time to find out “exactly who among the family the patient would want to have information shared with,” said Nancy Foster, AHA’s vice president of quality and patient safety policy, and whether they have an advanced directive that stipulates what type of medical measures they would want.

Expect to wait. All visitors need to be checked in, and it can take some time. If you come at the beginning of visiting hours you might find yourself in a long line outside the hospital.

Prepare in advance for talks with the doctor. Have questions written down, so you’re not caught off guard when a doctor comes in, said Kati Kleber , a nurse educator based in Urbana, Ill. and author of “ Admit One: What You Must Know When Going to the Hospital, But No One Actually Tells You .” Keep a running log of questions as they pop up; you could even store them in a Google doc accessible to family members who are unable to visit. If you want another person to also hear the doctor’s updates, “you can always call and put them on speakerphone,” Kleber said. “However, I recommend giving family members a heads-up to be near their phone and ready to answer if you call,” because provider schedules are unpredictable, and you won’t be able to plan a specific time.

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Some hospitals, such as University of Miami, have teams of nonclinical workers who act as a liaison between patients and their families, passing questions to the doctors and information to loved ones at home.

Ask about proxy access to the patient’s medical records. At Cleveland Clinic, a patient’s loved ones can be granted proxy access “so they can see what’s going on with test results,” said Stephanie Bayer, the hospital’s senior director of patient experience. “It’s the same point of view you would see if you were looking at your own record, and it helps keep people informed.” Ask a nurse to walk you through the options, and note that the patient will need to approve this access.

Get in touch with the hospital social worker. Advocating for a loved one in the hospital will almost definitely be confusing and overwhelming, said Ivelyse Andino , founder and CEO of Radical Health, which helps people with issues such as understanding health care rights. She suggests seeking out a social worker or patient navigator, who are professionals “provided by the hospital to help connect you with resources and support.” These folks can help you make sense of treatment options and prepare an at-home discharge plan, plus ensure you don’t burn out while caring for your loved one.

If you can’t visit, find other ways to show a patient you’re thinking about them. “There’s text, there’s FaceTime, there’s Zooming,” said George F. Blackall , a pediatric psychologist at Penn State Health Children’s Hospital in Hershey, Pa. “Offering to connect in that way is really helpful, particularly with adolescents.” Prioritize silly or lighthearted messages that might spark a patient’s first laugh of the day.

Gifts are almost always welcome, so long as there’s enough space in the room — just check first with whoever is spending time there. One idea: You could present the patient with a digital photo frame; “people just need the email address, and they can send photos that rotate on the display,” Kleber said. That can help brighten a patient’s days and remind them of those they’ll hopefully see soon.

If you’re visiting a senior, it’s especially important to advocate. You’re an essential part of your family member’s care team, said K. Andrew Crighton , an advisory board member at Family First , which offers caregiving benefit plans for employees. Let the doctors know if a patient has a hearing, visual or cognitive impairment, he said, in which case “your role becomes more critical.” (Sometimes visitation exceptions are made in those situations.)

Follow the rules. Whether it’s wearing a mask, practicing social distancing, leaving at a certain time, or not roaming the halls or loitering in the lobby, do what the hospital asks, Bayer said. Flouting the rules is not helpful to anyone. And don’t take out your frustration on the staffers who must implement a policy they did not draw up.

Be kind. Hospitals across the nation are dealing with staffing shortages. “This is a very challenging time for all our clinicians,” Begley said, calling for “a little extra patience.” Speaking of which: Say thank you. There’s no need to send the health-care team a gift, but “taking a minute to say, ‘I see you and appreciate the work you’re doing’” goes a long way, Bayer said. “It helps when people notice that we’re working hard.”

If you’re not able to visit, help out in other ways. During the pandemic, it’s likely that only one or two people are doing most of the visiting. You can help by doing grocery shopping, bringing them meals, offering to drive them to and from the hospital, and taking care of what needs to be done at the ill person’s house. “Things like walking their dogs, cleaning their house, doing laundry and paying for their parking can go a long way,” Kleber said.

Consider setting up a website to keep others informed. There are lots of “really great communication tools,” like CaringBridge , that allow friends and family to document a loved one’s health journey, Bayer said. These sites are typically so easy to use that they don’t add much stress to a patient advocate’s life, she notes — plus, someone other than the primary visitor could be designated to post updates.

Take care of yourself. Spending long days advocating for — and worrying about — your loved one will inevitably take a toll. “One of the things people forget to do is take care of themselves,” Bayer said. “So that means make sure you’re sleeping, make sure you’re eating. We need to keep ourselves resilient.” Many hospitals offer some form of spiritual care, she adds; seek it out if that would be helpful to you. And know that what you’re doing is important. “We recognize that family members are vital components of the patient’s healing,” Bayer said. “The love and support that patients get from their family and their visitors does help them and motivate them and keep them on the track of progress.”

Angela Haupt is a freelance writer and editor. Follow her on Twitter: @angelahaupt .

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INTRODUCTION

Researchers in the field of Transitions of Care evaluate the effectiveness of various approaches to improve the discharge process. One classification scheme to categorize these interventions is to consider them as: pre-discharge interventions (patient education, discharge planning, medication reconciliation, scheduling a follow-up appointment); post-discharge interventions (follow-up phone call, communication with ambulatory provider, home visits); and bridging interventions (transition coaches, patient-centered discharge instructions, clinician continuity between inpatient and outpatient settings) [ 4 ].

This topic presents an overview of the discharge process, determination of the appropriate next site of care, and review of interventions to reduce the likelihood of unplanned readmissions and adverse events after discharge. Much of the discussion relates to structures of care available in the United States; there is significant variability in the availability of services and types of facilities across geographic areas.

APPROPRIATENESS FOR DISCHARGE

However, patients often appropriately remain in the hospital even when these criteria are met, due to the lack of a suitable alternative setting to provide necessary care or other social factors.

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Open Access

Peer-reviewed

Research Article

Medical service quality, patient satisfaction and intent to revisit: Case study of public hub hospitals in the Republic of Korea

Roles Conceptualization, Data curation, Formal analysis, Methodology, Resources, Writing – original draft

Affiliation Department of Health Policy & Management, BK21 FOUR R&E Center for Learning Health Systems, College of Health Science, Korea University, Anam-ro, Seongbuk-gu, Seoul, South Korea

Roles Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

• Selin Woo, 
• Mankyu Choi

• Published: June 28, 2021
• https://doi.org/10.1371/journal.pone.0252241
• Peer Review
• Reader Comments

This study aimed to construct and test structural equation modeling of the causal relationship between quality of healthcare, patient satisfaction, and intent to revisit perceived by patients using regional hub public hospitals. In this study, data of 2,951 outpatients and 3,135 inpatients were collected using the “2018 Regional Hub Public Hospital Operational Evaluation.” A structural equation model was used to understand the relationship between patient satisfaction and intent to revisit, and bootstrap analysis was performed. In the direct effect, outpatients were presented in the order of the physician’s practice service, the hospital’s environment, and patient satisfaction. Inpatients were in the order of the physician’s practice service and, medical staff’s kindness and consideration,; patient satisfaction was shown in this order. In the indirect effect, the outpatients were presented in the order of physician’s practice service, medical staff’s kindness and consideration, and hospital’s physical environment. Inpatients were introduced in the order of medical staff’s kindness and consideration, nurse’s practice service, physician’s practice service, and patient satisfaction. Regional hub public hospitals need high-quality medical services and efforts from all departments to treat patients with sincerity to improve patient satisfaction and increase intent to revisit.

Citation: Woo S, Choi M (2021) Medical service quality, patient satisfaction and intent to revisit: Case study of public hub hospitals in the Republic of Korea. PLoS ONE 16(6): e0252241. https://doi.org/10.1371/journal.pone.0252241

Editor: M. Mahmud Khan, University of Georgia, UNITED STATES

Received: January 12, 2021; Accepted: May 11, 2021; Published: June 28, 2021

Copyright: © 2021 Woo, Choi. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because data are owned by a third party. According to Korea National Medical Center Institutional data are protected and cannot be shared publicly. We received permission to access the data by submitting research proposals to the Korea National Medical Center Institutional. Data can be made available upon request. Individual researchers must submit research proposals and obtain approval when using them. For any data request researchers may contact: Korea National medical center Institutional, Center for public healthcare policy, 251, Eulji-ro, Jung-gu, Seoul; [email protected] , +82 02-6362-3724.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: AVE, average variance extraction; CR, construct reliability

Introduction

With improved living standards, convenience in access to various information, and rapid societal aging, quantitative and qualitative demands and medical services expectations increase. Additionally, the sharp increase in the number of medical professionals and institutions has made competition between medical institutions inevitable. The increasing level of consciousness and expectations of citizens and the number of medical services consumers mean that only medical institutions meeting these expectations can be managed sustainably. In response to such social trends, the healthcare market is shifting from being supplier-oriented to customer-oriented [ 1 ]. Customer-oriented marketing is a standard business administration concept aiming to identify and satisfy customers’ needs [ 2 ]. The medical industry was previously dominated by a supplier-oriented market where patients visited hospitals without receiving patient-oriented medical services. However, the customer-oriented market is currently widespread because hospitals survive when they understand medical consumers’ diverse needs and provide high-quality medical services desired by customers [ 3 ]. The essence of customer-oriented marketing in healthcare organizations is to provide quality services to medical consumers. Medical institutions in Korea continue to increase in number. Thus, for the maintenance and survival of healthcare institutions by achieving a competitive advantage, a customer-oriented marketing strategy that satisfies customers’ needs by providing quality medical services, leading to revisit, is required.

Healthcare institutions are obligated to provide safe and quality medical services to patients before considering their management and operation. Donabedian [ 4 ] divided healthcare quality into “professional skills of the healthcare provider” and “the patient’s perception of the served medical service.” Bopp [ 5 ] also categorized healthcare quality into the medical provider’s technical quality and the functional quality perceived by the patient, the medical consumer, and argued that the latter is more important than the former in evaluating healthcare quality. The medical provider-centered quality concerns the level of capacity to provide professional medical skills such as proficiency in medical skills and accurate diagnosis. Contrastingly, the quality perceived by the patients means, in addition to medical skills, the functional quality that indicates the extent to which the patient’s demands such as those for facilities, equipment, physical environment, and communication are satisfied [ 1 ]. Woolley et al. [ 6 ] found that patients may report a “perception of satisfaction” despite a poor medical treatment outcome. In another study by Zifko-Baliga and Krampf [ 7 ], if the patient did not recognize that the medical provider provided an accurate diagnosis and treatment, healthcare quality is not high. The quality of healthcare services, in particular, significantly depends on the criteria used in the evaluation by the patients themselves. As patients’ needs are diverse and advanced, subjective evaluation based on the patient’s position is considered more important in evaluating healthcare quality [ 8 ]. Hwang and Shim [ 9 ] showed that the quality of healthcare perceived by patients affects their satisfaction and medical services in the future. This means that patient satisfaction, in addition to the quality of healthcare, is significant in terms of hospital profitability. Patient satisfaction with a hospital leads to an intent to revisit the hospitalpublic and private hospitals.

The dramatic increase and development of private hospitals have led to a rapid decrease public hospitals’ proportion and role. Recently, the functions and roles of public hospitals have decreased as a result of the avoidance phenomenon due to several reasons: low quality of healthcare failing to meet the expectations of medical consumers, the image that they are old-fashioned, difficulty in obtaining capable medical staff, and the perception that they treat only the vulnerable. They also experience problems in management due to deteriorating financial conditions [ 10 ]. Public hospitals are expected to perform functions such as maintaining the medical and social safety net, implementing central and local government policies, and conducting activities for the local community’s public interest. Specifically, they provide healthcare services for vulnerable and disabled people, services in maternal-child health (which is in short supply due to low profitability), mental illness, infectious diseases, and emergency care. Public hospitals’ maintenance is essential because they are responsible for areas considered challenging to service by private hospitals. However, the de-publicization occurring in the healthcare field, like in other fields, and the decrease in the government’s investment in public health led to public hospitals’ financial deterioration [ 11 ]. Jinju Medical Center is an excellent example of this outcome. The center was established in 1910 and played the role of a public hospital caring for residents’ health. However, it closed due to the accumulation of deficits resulting from severe financial deterioration. The decline in the local populations, a phenomenon in which patients are concentrated in large hospitals due to the expansion of medical insurance coverage in South Korea, and intensification of competition among hospitals are additional factors complicating local medical centers’ management [ 12 ]. Therefore, the profitability should not be overlooked if the regional hub public hospitals aim to improve residents’ health, provide quality medical treatment, and perform the function of a medical safety net that is difficult for private hospitals. Accordingly, the Korean government attempted to establish a system to develop regional hub public hospitals while promoting the public healthcare system’s reform. The government’s policies to build regional hub public hospitals include the “Comprehensive Plan for the Expansion of Public Health and Medical Care” in 2005, “Plan for Development of Regional Hub Public Hospital” in 2010, “Plan for Improvement of Public Health Care by Development of Regional Medical Center” in 2013, “Master Plan for Public Health Care” in 2016, and “Comprehensive Plan for Development of Public Health Care” in 2018. These policies aimed to re-establish the functions and roles of regional hub public hospitals in the provision of high-quality medical care, medical safety net, and medical care for the vulnerable. If regional hub public hospitals pursue the medical safety net function, which private hospitals do not provid, and profitability, they need to develop measures to increase the revisit rate by improving the quality of medical care and patient satisfaction by reflecting social trends.

Korea’s public medical institutions include public health centers, medical institutions for special needs, national university hospitals, and public hub hospitals. Among them, the most crucial role is played by public hub hospitals [ 13 ]. Many studies have investigated the effect of quality of medical care service on patient satisfaction and intent to revisit. However, the studies on the use of regional hub public hospitals were scant due to limited available data. There have been no studies, in particular, examining all the regional hub public hospitals across the country as well as both outpatients and inpatients.

This study aimed to investigate the influence of the quality of healthcare perceived by patients who use regional hub public hospitals on their satisfaction and intent to revisit. Based on the results, this study intends to help generate appropriate profits, and perform a medical safety net’s function and provide treatment to the vulnerable, which are regional hub public hospitals’ goals, by increasing patient satisfaction and intent to revisit. The specific research hypotheses are as follows:

1. In the outpatient case, the physician’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment will directly or indirectly affect the intent to revisit.

2. In the inpatient case, the physician’s practice service, nurse’s practice service, the medical staff’s kindness and consideration, and the hospital’s physical environment will directly or indirectly affect the intent to revisit.

Materials and method

Research model.

This study measured the direct effect of the quality of healthcare perceived by patients on patient satisfaction and intent to revisit in inpatients and outpatients who used regional hub public hospitals and the indirect impact of healthcare quality on the intent to revisit through the parameter of patient satisfaction. The research model was developed under the assumption established from the literature review that the patient’s healthcare quality has a structural causal relationship with patient satisfaction and intent to revisit. In this model, patient satisfaction was a mediating variable reinforcing the relationship between the quality of medical service as an independent variable and the intent to revisit as a dependent variable. The quality of healthcare was composed of physician’s practice service, nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment. The gender, age, education, and health status of patients were controlled in the analysis.

Data and participants

This study utilized the patient satisfaction survey results from data collected through the “2018 Evaluation for Operation of Regional Hub Public Hospital” conducted by the Ministry of Health and Welfare and the National Medical Center. Patient satisfaction was divided into outpatient and inpatient satisfaction, and the survey was commissioned to a specialized survey institution. The survey participants were patients over the age of 18 years who used regional hub public hospitals from May 2017 to April 2018. After excluding 1,152 patients who provided no response or incomplete responses 6,086 patients were included in the analysis (response rate: 84.0%), with 2,951 outpatients and 3,135 inpatients. The survey was conducted by investigators of a specialized research survey institution through telephone using a structured self-reported questionnaire.

Instruments

In this study, healthcare quality, patient satisfaction, and intent to revisit perceived by patients using regional hub public hospitals were measured using a structured questionnaire developed by academic experts, public officials, and public hospital practitioners. The “survey of patient satisfaction” was adapted from the “2018 Evaluation for Operation of Regional Hub Public Hospital” hosted by the Ministry of Health and Welfare and the National Medical Center. The measurement method for each variable is as follows.

Healthcare service quality.

The measurement instrument was developed through review and opinion collection by a team of related academics, researchers, and practitioners. The “quality of healthcare service” for the outpatient group was composed of three items: physician’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment. The “physician’s practice service” included questions on appropriate hours of care, medical history check, intelligible explanation, doctor’s listening, polite attitude, and professional health care delivery. Further, “medical staff’s kindness and consideration” included questions on the attitude of the examination and administration staff, consideration of the medical staff, and description of the reminder. The “hospital’s physical environment” included questions on bathroom and, hospital cleanliness and convenience of waiting and auxiliary facilities. For inpaients, “Nurse’s practice service” was included, and “quality of medical service” was composed of four items. The nurse’s practice service” included questions on polite attitude, nurse’s listening, intelligible explanation, quick response to inconveniences, periodic patient check, professional health care delivery, and nurse’s satisfaction. The items were answered using a four-point Likert scale (1 = not at all, 2 = sometimes, 3 = mostly, 4 = always) and an 11-point Likert scale. The degree of consistency among items was measured using Cronbach’s α [ 14 ], which were .901 for “physician’s practice service,” .821 for “medical staff’s kindness and consideration,” and .796 for “hospital’s physical environment” in the outpatient group. Further, in the inpatient group, the values were .886 for “physician’s practice service,” .887 for “nurse’s practice service,” .842 for “medical staff’s kindness and consideration,” and .824 for “hospital’s physical environment.”

Patient satisfaction and intent to revisit.

The data for patient satisfaction and intent to revisit were extracted from the “Survey of Patient Satisfaction” from the “2018 Evaluation for Operation of Regional Hub Public Hospital.” These variables were measured using one item, which was rated on a scale from 0 to 10. Higher scores indicated higher patient satisfaction and intent to revisit.

First, to verify data normality and identify the participants’ demographic characteristics, descriptive statistics and frequency analysis were performed. Second, reliability, correlation, and multicollinearity analyses of the variables were conducted. Third, confirmatory factor analysis was conducted to confirm the model’s goodness-of-fit and validity for the structural equation model analysis. Fourth, the structural equation model was used to identify the goodness-of-fit of the final model and the effect of patients’ healthcare quality on the relationship between patient satisfaction and intent to revisit. The bootstrap analysis was conducted to test the mediating effect of patient satisfaction. Statistical analyses were performed using SPSS 23.0 and AMOS 24.0 programs.

Ethical consideration

As this study only uses anonymized secondary data, according to national guidelines, receiving the exemption from Institutional Review Board. This study was conducted after receiving the KUIRB-2020-0124-01 exemption from the Korea University Institutional Review Board.

Demographic characteristics of participants

The participants were 6,086 patients including 2,951 outpatients and 3,135 inpatients over the age of 18 who used regional hub public hospitals (regional medical center: n = 34; Red Cross Hospital: n = 5) across the country. Table 1 shows the participants’ demographic characteristics. For the outpatients, there were more male patients (n = 1,705; 57.8%) than female patients (n = 1,246; 42.2%). The most common age group was those in the 60s (n = 812; 27.5%), followed by those aged over 70 years (n = 761; 25.8%). The most common education level was high school graduation (n = 1,094; 37.1%), followed by under middle school graduation (n = 968; 32.8%) and over college graduation (n = 889; 30.1%). The most common health status perceived by patients was “moderate” (n = 1,091; 37%), followed by “relatively good” (n = 1,024; 34.7%).

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https://doi.org/10.1371/journal.pone.0252241.t001

For the inpatients, there were more male patients (n = 1,686; 53.8%) than female patients (n = 1,449; 46.2%). The most common age group was those aged over 70 years (n = 1,130; 36.1%), followed by those in their 60s (n = 822; 26.2%). The most common education level was under middle school graduation (n = 1,469; 46.9%), followed by high school graduation (n = 1,005; 32.1%) and over college graduation (n = 661; 21.0%). The most common health status perceived by patients was “moderate” (n = 950; 30.3%), followed by “very bad” (n = 265; 8.5%).

Goodness-of-fit test of research model

The association analysis among significant variables showed that the association among all latent variables was significant with P<0.01. The multicollinearity problem was not found because the Variance Inflation Factor was under 10. It was under four for all the outpatient group’s measured variables and under six for all the inpatient group’s measured variables.

The convergence and discriminant validities were tested to determine whether the target concept or attribute was measured. The average variance extraction (AVE) and the concept of construct reliability (CR) were used to test validities [ 15 ]. The validities were supported because AVE values were 0.5 or higher and CR values were 0.7 or higher in both the outpatient and inpatient groups [ 16 ].

The results of testing the overall structural model used in this study were as follows. For the outpatient group, χ2 = 1303.176, TLI = 0.948, CFI = 0.961, and RMSEA = 0.053 ( Table 2 ). For the inpatient group, χ2 = 3581.292, TLI = 0.939, CFI = 0.949, and RMSEA = 0.055 ( Table 3 ). These results indicate that the indices were within the recommended level, suggesting that the model is suitable.

https://doi.org/10.1371/journal.pone.0252241.t002

https://doi.org/10.1371/journal.pone.0252241.t003

Structural model analysis

Fig 1 illustrates the structural model analysis results for the outpatient group. It was found that physician’s practice service had a positive (+) significant effect on patient satisfaction (β = 0.377, p < .001) and intent to revisit (β = 0.243, p < .001). Medical staff’s kindness and consideration had a positive (+) significant effect on patient satisfaction (β = 0.303, p < .001) but not on intent to revisit (β = 0.036, p = .286). The hospitals’ physical environment had a positive (+) significant effect on patient satisfaction (β = 0.186, p < .001) and intent to revisit (β = 0.049, p = .046). Patient satisfaction had a positive (+) significant effect on the intent to revisit (β = 0.652, p < .001).

https://doi.org/10.1371/journal.pone.0252241.g001

The better the physician’s and nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment, the more likely they are to increase patient satisfaction. It was also found that the better the physician’s practice service and hospitals’ physical environment, the more these were likely to increase patient satisfaction and intent to revisit.

Fig 2 displays the structural model analysis results for the inpatient group. It was found that physician’s practice service had a positive (+) significant effect on patient satisfaction (β = 0.223, p < .001) and intent to revisit (β = 0.191, p < .001). Nurses’ practice service had a positive (+) significant effect on patient satisfaction (β = 0.236, p < .001) but not on intent to revisit (β = 0.04, p = .089). Medical staff’s kindness and consideration had a positive (+) significant effect on patient satisfaction (β = 0.29, p < .001) and intent to revisit (β = 0.096, p = .014). The hospital’ physical environment had a positive (+) significant effect on patient satisfaction (β = 0.182, p < .001) but not on intent to revisit (β = -0.013, p = .51). Patient satisfaction had a positive (+) significant effect on the intent to revisit (β = 0.498, p < .001).

https://doi.org/10.1371/journal.pone.0252241.g002

Thus, the better the physician’s and nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment, the more likely these are to increase patient satisfaction. It was also found that the better the physician’s practice service and the medical staff’s kindness and consideration, the more these were likely to increase patient satisfaction and intent to revisit.

Analysis of the mediating effect

This study used covariance structural analysis to confirm the overall influence among factors as a causal effect. The total, direct, and indirect effects were measured to determine the effect of the independent variable “quality of healthcare” on the dependent variable “intent to revisit,” which revealed the importance of the mediating variable “patient satisfaction.” The total effect was expressed as the sum of all direct and indirect effects of the independent variable on the dependent variable. The direct effect reflected the direct relationship between the independent and dependent variables; the indirect effect represented the independent variable’s effect on the dependent variable through a mediating variable by regression analysis.

Table 4 shows the total, direct, and indirect effects in the outpatient group. The values of the standardized direct effect on “patient satisfaction” were 0.377 for “physician’s practice service,” 0.303 for “medical staff’s kindness and consideration,” and 0.186 for “hospital’s physical environment,” which were statistically significant. The values of the standardized direct effect on “intent to revisit” were 0.243 for “physician’s practice service,” 0.036 for “medical staff’s kindness and consideration,” 0.049 for “hospital’s physical environment,” and 0.522 for “patient satisfaction.” Here, the values for “physician’s practice service,” “hospital’s physical environment,” and “patient satisfaction” were statistically significant. The values of the standardized indirect effect of the independent variable on the dependent variable through the mediating variable “patient satisfaction” were 0.197 for “physician’s practice service,” 0.158 for “medical staff’s kindness and consideration,” and 0.097 for “hospital’s physical environment,” which were statistically significant. “Patient satisfaction” was found to mediate the relationship between the quality of healthcare perceived by the patient (“physician’s practice service,” “medical staff’s kindness and consideration,” and “hospital’s physical environment”) and intent to revisit.

https://doi.org/10.1371/journal.pone.0252241.t004

The direct effect on “intent to revisit” was highest for “patient satisfaction,” followed by “physician’s practice service,” “hospital’s physical environment,” and “medical staff’s kindness and consideration.” The indirect effect on “patient satisfaction” through “intent to revisit” was highest for “physician’s practice service,” followed by “medical staff’s kindness and consideration” and “hospital’s physical environment.” The total effect was highest for “physician’s practice service,” followed by “medical staff’s kindness and consideration,” and “hospital’s physical environment.” These results indicated that “physician’s practice service” is the most significant factor influencing “patient satisfaction” and “intent to revisit.”

Table 5 shows the analysis results of total, direct, and indirect effects in the inpatient group. The values of the standardized direct effect on “patient satisfaction” were 0.223 for “physician’s practice service,” 0.236 for “nurse’s practice service,” 0.290 for “medical staff’s kindness and consideration,” and 0.182 for “hospital’s physical environment,” which were statistically significant. The values of the standardized direct effect on “intent to revisit” were 0.191 for “physician’s practice service,” 0.040 for “nurse’s practice service,” 0.096 for “medical staff’s kindness and consideration,” -0.013 for “hospital’s physical environment,” and 0.498 for “patient satisfaction” where the values for “physician’s practice service,” “medical staff’s kindness and consideration,” and “patient satisfaction” were statistically significant. The values of the standardized indirect effect of the independent variable on the dependent variable through the mediating variable “patient satisfaction” were 0.111 for “physician’s practice service,” 0.117 for “nurse’s practice service,” 0.145 for “medical staff’s kindness and consideration,” and 0.090 for “hospital’s physical environment,” which were statistically significant. “Patient satisfaction” was found to mediate the relationship between the quality of healthcare perceived by the patient (“physician’s practice service,” “medical staff’s kindness and consideration,” and “hospital physical environment”) and intent to revisit.

https://doi.org/10.1371/journal.pone.0252241.t005

The direct effect on “intent to revisit” was highest for “patient satisfaction,” followed by “physician’s practice service,” “medical staff’s kindness and consideration,” “nurse’s practice service,” and “hospital’s physical environment.” The indirect effect on “patient satisfaction” through “intent to revisit” was highest for “medical staff’s kindness and consideration,” followed by “nurse’s practice service,” “physician’s practice service,” and “hospital’s physical environment.” The total effect was highest for “physician’s practice service,” followed by “medical staff’s kindness and consideration,” “nurse’s practice service,” and “hospital’s physical environment.”

This study examined the effect of healthcare quality perceived by patients using regional hub public hospitals on their patient satisfaction and intent to revisit the hospital. A research model was established through a theoretical literature review. To test the model, 6,086 patients, including 2,951 outpatients and 3,135 inpatients over 18 years of age who had experience using regional hub public hospitals were analyzed using the results of the “2018 Evaluation for Operation of Regional Hub Public Hospital.” The analysis used in this study is structural equation modeling. There is also a similar path analysis. Path analysis is a concept first used by Professor Sewall Green Wright [ 17 ]. It has the advantage of being able to verify the causal relationship between multiple independent and dependent variables. However, path analysis makes a statistical assumption that there is no measurement error [ 18 ]. Such an assumption does not matter if it is measured as a single item. Nevertheless, a problem arises when it is converted into a single item form, such as the average or total score measured by several observation variables [ 18 ]. What can solve this problem is structural equation modeling [ 19 ]. Structural equation modeling originates from the “JKW model,” in which path analysis and confirmatory factor analysis are integrated [ 20 ]. Structural equation modeling differs from path analysis and uses the concept of latent variables. Latent variables are not directly observed or measured, but indirectly measured by the observed variable [ 21 ]. In other words, this study used structural equation modeling that can use latent variables.

The summarized results are as follows.

First, the variables that directly affected intent to revisit were, for the outpatient group, physician’s practice service, hospital’s physical environment, and patient satisfaction, and for the inpatient group, physician’s practice service, medical staff’s kindness and consideration, and patient satisfaction. This is consistent with the results of Kang [ 22 ] regarding inpatients in public medical institutions. Kang [ 22 ] reported that medical professionalism, the staff’s kindness, interest in and service for patients, the convenience of the process of being served in the hospital, and hospital facilities and environment had a positive (+) correlation with intent to revisit. These are consistent with the claims by Yoon [ 23 ] and Han [ 24 ], respectively, that a higher satisfaction with physician’s practice service and hospital environment are likely to increase intent to revisit and that the medical staff’s medical service and hospital facility influenced intent to revisit. These results indicate the significance of the physician’s treatment skills, which are the essence of medical institutions. Cooperation with private medical institutions is also an excellent way to develop the knowledge and skills of medical personnel working for regional hub public hospitals.

Second, all the variables for the inpatient and outpatient groups had a significant effect on patient satisfaction. The mediating effect on intent to revisit through patient satisfaction was also significant in all variables. This is consistent with the results of Park [ 25 ], who investigated the effect of healthcare service quality on intent to revisit and the mediating effect of patient satisfaction in patients who use small and medium hospitals. Park [ 25 ] reported that patient satisfaction mediated the relationship between healthcare service quality and intent to revisit. Amarantou et al. [ 26 ] investigated the effect of quality of healthcare service on the intent to revisit through the mediating effect of patient satisfaction in emergency room patients in Greece. They reported that patient satisfaction had a positive (+) significant mediating effect. These results suggest that it is necessary to develop various strategies to enhance the quality of medical care services and continuously increase patient satisfaction to improve patients’ intent to revisit.

The effect analysis results indicated that the indirect effect is highest, in the outpatient group, for physician’s practice service, followed by medical staff’s kindness and consideration, and the hospital’s physical environment. Further, in the inpatient group, the indirect effect is highest for medical staff’s kindness and consideration, followed by nurse’s practice service, physician’s practice service, and the hospital’s physical environment. The results showed that, among healthcare quality factors, medical staff’s kindness and consideration had the most substantial effect in outpatient and inpatient groups. Park [ 25 ] had investigated the effect of quality of healthcare on intent to revisit through patient satisfaction and had results consistent with those of this study, reporting that the indirect effect was highest in the empathy factor, which indicates a consideration for customers, among the quality of medical services factors. Aliman and Mohamad [ 27 ] showed that, among the quality of medical service factors, the staff’s ability and the confidence representing goodwill, respectful attitude, and sincere interest in patients had the most potent effect on patient satisfaction and intent to revisit. The difference in the most critical factor between outpatient and inpatient groups of this study is due to the practice process. Outpatients are likely to leave the hospital just after seeing the physician; therefore, the physician’s practice is most important. However, unlike outpatients, inpatients are present in the hospital for medical services. This allows them many opportunities to communicate with hospital employees. For the customer’s maintenance, the medical service provider should ensure that quality healthcare service, which is the essence of healthcare, is provided. The medical staff show kindness, sincerity, care, and respect for patients to be encouraged to revisit. For example, Hospital A ranked 1st in the patient experience evaluation conducted by the Health Insurance Review and Assessment Service. The most frequently mentioned factor was the staff’s kindness toward patients. Hospital B, which ranked 2nd in the evaluation, implemented the “Activity as Patient for Experience,” in which employees experienced the patient’s treatment process to find a space for improvement to create a patient-oriented medical culture in their hospital. These examples demonstrate that the provision of a service that considers the patient’s position influences patient satisfaction. If regional hub public hospitals seek to provide quality healthcare to the public while maintaining and surviving in the current strong competition, developing programs to educate medical staff and all staff dealing with patients to treat patients sincerely is needed. Regular management of patients through active training and monitoring by the quality assurance team is also necessary.

This study has several limitations. First, there is an insufficient understanding of the causal relationship between variables. This is a cross-sectional study using data from the “2018 Evaluation for Operation of Regional Hub Public Hospital.” Thus, future studies using longitudinal data are recommended to clarify how healthcare quality affects patient satisfaction and intent to revisit. Second, this study did not include factors that may affect patient satisfaction and intent to revisit due to data restrictions on personal information protection and confidentiality, consultation of doctors, nurses, or designees, especially in inpatients with major diseases. In the future, research will need to proceed with the study, including other factors that may affect patient satisfaction and intent to revisit.

Nevertheless, this study contributed to this field in that it investigated the management strategy to generate appropriate profits for regional hub public hospitals by analyzing the relationship among quality of healthcare, patient satisfaction, and intent to revisit. Previous studies have been conducted mainly targeting private hospitals, in outpatients and inpatients using regional hub public hospitals after controlling for gender, age, health status, and education level.

This study used a structural equation model to examine whether there is a relationship among patient’s healthcare service quality, patient satisfaction, and intent to revisit in outpatients and inpatients visiting regional hub public hospitals. The study aimed to provide fundamental data to improve patient satisfaction and service in regional medical centers and Red Cross hospitals.

The results indicated that, in the outpatient group, the better the physician’s practice service, hospital’s physical environment, and patient satisfaction, the more likely these were to increase the patients’ intent to revisit. The indirect effect on intent to revisit through patient satisfaction was highest for physician’s practice service, followed by medical staff’s kindness and consideration, and the hospital’s physical environment. Moreover, in the inpatient group, the better the physician’s practice service, medical staff’s kindness and consideration, and patient satisfaction, the more these were likely to increase the patients’ intent to revisit. The indirect effect on intent to revisit through patient satisfaction was highest for medical staff’s kindness and consideration, followed by nurse’s practice service, physician’s practice service, and patient satisfaction.

Based on the results, we present the following suggestions. First, public hospitals’ environment should be improved to satisfy medical consumers to strengthen publicity through fiscal consolidation. Second, providing active healthcare service through cultivating professional knowledge and technical expertise in healthcare professionals should be attempted. Finally, the medical service provider should ensure the provision of quality healthcare service and that medical staff show kindness, sincerity, care, and respect for patients so that they are encouraged to revisit.

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Medical service quality, patient satisfaction and intent to revisit: Case study of public hub hospitals in the Republic of Korea

Department of Health Policy & Management, BK21 FOUR R&E Center for Learning Health Systems, College of Health Science, Korea University, Anam-ro, Seongbuk-gu, Seoul, South Korea

Mankyu Choi

Associated data.

Data cannot be shared publicly because data are owned by a third party. According to Korea National Medical Center Institutional data are protected and cannot be shared publicly. We received permission to access the data by submitting research proposals to the Korea National Medical Center Institutional. Data can be made available upon request. Individual researchers must submit research proposals and obtain approval when using them. For any data request researchers may contact: Korea National medical center Institutional, Center for public healthcare policy, 251, Eulji-ro, Jung-gu, Seoul; rk.ro.cmn@sms , +82 02-6362-3724.

This study aimed to construct and test structural equation modeling of the causal relationship between quality of healthcare, patient satisfaction, and intent to revisit perceived by patients using regional hub public hospitals. In this study, data of 2,951 outpatients and 3,135 inpatients were collected using the “2018 Regional Hub Public Hospital Operational Evaluation.” A structural equation model was used to understand the relationship between patient satisfaction and intent to revisit, and bootstrap analysis was performed. In the direct effect, outpatients were presented in the order of the physician’s practice service, the hospital’s environment, and patient satisfaction. Inpatients were in the order of the physician’s practice service and, medical staff’s kindness and consideration,; patient satisfaction was shown in this order. In the indirect effect, the outpatients were presented in the order of physician’s practice service, medical staff’s kindness and consideration, and hospital’s physical environment. Inpatients were introduced in the order of medical staff’s kindness and consideration, nurse’s practice service, physician’s practice service, and patient satisfaction. Regional hub public hospitals need high-quality medical services and efforts from all departments to treat patients with sincerity to improve patient satisfaction and increase intent to revisit.

Introduction

With improved living standards, convenience in access to various information, and rapid societal aging, quantitative and qualitative demands and medical services expectations increase. Additionally, the sharp increase in the number of medical professionals and institutions has made competition between medical institutions inevitable. The increasing level of consciousness and expectations of citizens and the number of medical services consumers mean that only medical institutions meeting these expectations can be managed sustainably. In response to such social trends, the healthcare market is shifting from being supplier-oriented to customer-oriented [ 1 ]. Customer-oriented marketing is a standard business administration concept aiming to identify and satisfy customers’ needs [ 2 ]. The medical industry was previously dominated by a supplier-oriented market where patients visited hospitals without receiving patient-oriented medical services. However, the customer-oriented market is currently widespread because hospitals survive when they understand medical consumers’ diverse needs and provide high-quality medical services desired by customers [ 3 ]. The essence of customer-oriented marketing in healthcare organizations is to provide quality services to medical consumers. Medical institutions in Korea continue to increase in number. Thus, for the maintenance and survival of healthcare institutions by achieving a competitive advantage, a customer-oriented marketing strategy that satisfies customers’ needs by providing quality medical services, leading to revisit, is required.

Healthcare institutions are obligated to provide safe and quality medical services to patients before considering their management and operation. Donabedian [ 4 ] divided healthcare quality into “professional skills of the healthcare provider” and “the patient’s perception of the served medical service.” Bopp [ 5 ] also categorized healthcare quality into the medical provider’s technical quality and the functional quality perceived by the patient, the medical consumer, and argued that the latter is more important than the former in evaluating healthcare quality. The medical provider-centered quality concerns the level of capacity to provide professional medical skills such as proficiency in medical skills and accurate diagnosis. Contrastingly, the quality perceived by the patients means, in addition to medical skills, the functional quality that indicates the extent to which the patient’s demands such as those for facilities, equipment, physical environment, and communication are satisfied [ 1 ]. Woolley et al. [ 6 ] found that patients may report a “perception of satisfaction” despite a poor medical treatment outcome. In another study by Zifko-Baliga and Krampf [ 7 ], if the patient did not recognize that the medical provider provided an accurate diagnosis and treatment, healthcare quality is not high. The quality of healthcare services, in particular, significantly depends on the criteria used in the evaluation by the patients themselves. As patients’ needs are diverse and advanced, subjective evaluation based on the patient’s position is considered more important in evaluating healthcare quality [ 8 ]. Hwang and Shim [ 9 ] showed that the quality of healthcare perceived by patients affects their satisfaction and medical services in the future. This means that patient satisfaction, in addition to the quality of healthcare, is significant in terms of hospital profitability. Patient satisfaction with a hospital leads to an intent to revisit the hospitalpublic and private hospitals.

The dramatic increase and development of private hospitals have led to a rapid decrease public hospitals’ proportion and role. Recently, the functions and roles of public hospitals have decreased as a result of the avoidance phenomenon due to several reasons: low quality of healthcare failing to meet the expectations of medical consumers, the image that they are old-fashioned, difficulty in obtaining capable medical staff, and the perception that they treat only the vulnerable. They also experience problems in management due to deteriorating financial conditions [ 10 ]. Public hospitals are expected to perform functions such as maintaining the medical and social safety net, implementing central and local government policies, and conducting activities for the local community’s public interest. Specifically, they provide healthcare services for vulnerable and disabled people, services in maternal-child health (which is in short supply due to low profitability), mental illness, infectious diseases, and emergency care. Public hospitals’ maintenance is essential because they are responsible for areas considered challenging to service by private hospitals. However, the de-publicization occurring in the healthcare field, like in other fields, and the decrease in the government’s investment in public health led to public hospitals’ financial deterioration [ 11 ]. Jinju Medical Center is an excellent example of this outcome. The center was established in 1910 and played the role of a public hospital caring for residents’ health. However, it closed due to the accumulation of deficits resulting from severe financial deterioration. The decline in the local populations, a phenomenon in which patients are concentrated in large hospitals due to the expansion of medical insurance coverage in South Korea, and intensification of competition among hospitals are additional factors complicating local medical centers’ management [ 12 ]. Therefore, the profitability should not be overlooked if the regional hub public hospitals aim to improve residents’ health, provide quality medical treatment, and perform the function of a medical safety net that is difficult for private hospitals. Accordingly, the Korean government attempted to establish a system to develop regional hub public hospitals while promoting the public healthcare system’s reform. The government’s policies to build regional hub public hospitals include the “Comprehensive Plan for the Expansion of Public Health and Medical Care” in 2005, “Plan for Development of Regional Hub Public Hospital” in 2010, “Plan for Improvement of Public Health Care by Development of Regional Medical Center” in 2013, “Master Plan for Public Health Care” in 2016, and “Comprehensive Plan for Development of Public Health Care” in 2018. These policies aimed to re-establish the functions and roles of regional hub public hospitals in the provision of high-quality medical care, medical safety net, and medical care for the vulnerable. If regional hub public hospitals pursue the medical safety net function, which private hospitals do not provid, and profitability, they need to develop measures to increase the revisit rate by improving the quality of medical care and patient satisfaction by reflecting social trends.

Korea’s public medical institutions include public health centers, medical institutions for special needs, national university hospitals, and public hub hospitals. Among them, the most crucial role is played by public hub hospitals [ 13 ]. Many studies have investigated the effect of quality of medical care service on patient satisfaction and intent to revisit. However, the studies on the use of regional hub public hospitals were scant due to limited available data. There have been no studies, in particular, examining all the regional hub public hospitals across the country as well as both outpatients and inpatients.

This study aimed to investigate the influence of the quality of healthcare perceived by patients who use regional hub public hospitals on their satisfaction and intent to revisit. Based on the results, this study intends to help generate appropriate profits, and perform a medical safety net’s function and provide treatment to the vulnerable, which are regional hub public hospitals’ goals, by increasing patient satisfaction and intent to revisit. The specific research hypotheses are as follows:

1. In the outpatient case, the physician’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment will directly or indirectly affect the intent to revisit.

2. In the inpatient case, the physician’s practice service, nurse’s practice service, the medical staff’s kindness and consideration, and the hospital’s physical environment will directly or indirectly affect the intent to revisit.

Materials and method

Research model.

This study measured the direct effect of the quality of healthcare perceived by patients on patient satisfaction and intent to revisit in inpatients and outpatients who used regional hub public hospitals and the indirect impact of healthcare quality on the intent to revisit through the parameter of patient satisfaction. The research model was developed under the assumption established from the literature review that the patient’s healthcare quality has a structural causal relationship with patient satisfaction and intent to revisit. In this model, patient satisfaction was a mediating variable reinforcing the relationship between the quality of medical service as an independent variable and the intent to revisit as a dependent variable. The quality of healthcare was composed of physician’s practice service, nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment. The gender, age, education, and health status of patients were controlled in the analysis.

Data and participants

This study utilized the patient satisfaction survey results from data collected through the “2018 Evaluation for Operation of Regional Hub Public Hospital” conducted by the Ministry of Health and Welfare and the National Medical Center. Patient satisfaction was divided into outpatient and inpatient satisfaction, and the survey was commissioned to a specialized survey institution. The survey participants were patients over the age of 18 years who used regional hub public hospitals from May 2017 to April 2018. After excluding 1,152 patients who provided no response or incomplete responses 6,086 patients were included in the analysis (response rate: 84.0%), with 2,951 outpatients and 3,135 inpatients. The survey was conducted by investigators of a specialized research survey institution through telephone using a structured self-reported questionnaire.

Instruments

In this study, healthcare quality, patient satisfaction, and intent to revisit perceived by patients using regional hub public hospitals were measured using a structured questionnaire developed by academic experts, public officials, and public hospital practitioners. The “survey of patient satisfaction” was adapted from the “2018 Evaluation for Operation of Regional Hub Public Hospital” hosted by the Ministry of Health and Welfare and the National Medical Center. The measurement method for each variable is as follows.

Healthcare service quality

The measurement instrument was developed through review and opinion collection by a team of related academics, researchers, and practitioners. The “quality of healthcare service” for the outpatient group was composed of three items: physician’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment. The “physician’s practice service” included questions on appropriate hours of care, medical history check, intelligible explanation, doctor’s listening, polite attitude, and professional health care delivery. Further, “medical staff’s kindness and consideration” included questions on the attitude of the examination and administration staff, consideration of the medical staff, and description of the reminder. The “hospital’s physical environment” included questions on bathroom and, hospital cleanliness and convenience of waiting and auxiliary facilities. For inpaients, “Nurse’s practice service” was included, and “quality of medical service” was composed of four items. The nurse’s practice service” included questions on polite attitude, nurse’s listening, intelligible explanation, quick response to inconveniences, periodic patient check, professional health care delivery, and nurse’s satisfaction. The items were answered using a four-point Likert scale (1 = not at all, 2 = sometimes, 3 = mostly, 4 = always) and an 11-point Likert scale. The degree of consistency among items was measured using Cronbach’s α [ 14 ], which were .901 for “physician’s practice service,” .821 for “medical staff’s kindness and consideration,” and .796 for “hospital’s physical environment” in the outpatient group. Further, in the inpatient group, the values were .886 for “physician’s practice service,” .887 for “nurse’s practice service,” .842 for “medical staff’s kindness and consideration,” and .824 for “hospital’s physical environment.”

Patient satisfaction and intent to revisit

The data for patient satisfaction and intent to revisit were extracted from the “Survey of Patient Satisfaction” from the “2018 Evaluation for Operation of Regional Hub Public Hospital.” These variables were measured using one item, which was rated on a scale from 0 to 10. Higher scores indicated higher patient satisfaction and intent to revisit.

First, to verify data normality and identify the participants’ demographic characteristics, descriptive statistics and frequency analysis were performed. Second, reliability, correlation, and multicollinearity analyses of the variables were conducted. Third, confirmatory factor analysis was conducted to confirm the model’s goodness-of-fit and validity for the structural equation model analysis. Fourth, the structural equation model was used to identify the goodness-of-fit of the final model and the effect of patients’ healthcare quality on the relationship between patient satisfaction and intent to revisit. The bootstrap analysis was conducted to test the mediating effect of patient satisfaction. Statistical analyses were performed using SPSS 23.0 and AMOS 24.0 programs.

Ethical consideration

As this study only uses anonymized secondary data, according to national guidelines, receiving the exemption from Institutional Review Board. This study was conducted after receiving the KUIRB-2020-0124-01 exemption from the Korea University Institutional Review Board.

Demographic characteristics of participants

The participants were 6,086 patients including 2,951 outpatients and 3,135 inpatients over the age of 18 who used regional hub public hospitals (regional medical center: n = 34; Red Cross Hospital: n = 5) across the country. Table 1 shows the participants’ demographic characteristics. For the outpatients, there were more male patients (n = 1,705; 57.8%) than female patients (n = 1,246; 42.2%). The most common age group was those in the 60s (n = 812; 27.5%), followed by those aged over 70 years (n = 761; 25.8%). The most common education level was high school graduation (n = 1,094; 37.1%), followed by under middle school graduation (n = 968; 32.8%) and over college graduation (n = 889; 30.1%). The most common health status perceived by patients was “moderate” (n = 1,091; 37%), followed by “relatively good” (n = 1,024; 34.7%).

For the inpatients, there were more male patients (n = 1,686; 53.8%) than female patients (n = 1,449; 46.2%). The most common age group was those aged over 70 years (n = 1,130; 36.1%), followed by those in their 60s (n = 822; 26.2%). The most common education level was under middle school graduation (n = 1,469; 46.9%), followed by high school graduation (n = 1,005; 32.1%) and over college graduation (n = 661; 21.0%). The most common health status perceived by patients was “moderate” (n = 950; 30.3%), followed by “very bad” (n = 265; 8.5%).

Goodness-of-fit test of research model

The association analysis among significant variables showed that the association among all latent variables was significant with P<0.01. The multicollinearity problem was not found because the Variance Inflation Factor was under 10. It was under four for all the outpatient group’s measured variables and under six for all the inpatient group’s measured variables.

The convergence and discriminant validities were tested to determine whether the target concept or attribute was measured. The average variance extraction (AVE) and the concept of construct reliability (CR) were used to test validities [ 15 ]. The validities were supported because AVE values were 0.5 or higher and CR values were 0.7 or higher in both the outpatient and inpatient groups [ 16 ].

The results of testing the overall structural model used in this study were as follows. For the outpatient group, χ2 = 1303.176, TLI = 0.948, CFI = 0.961, and RMSEA = 0.053 ( Table 2 ). For the inpatient group, χ2 = 3581.292, TLI = 0.939, CFI = 0.949, and RMSEA = 0.055 ( Table 3 ). These results indicate that the indices were within the recommended level, suggesting that the model is suitable.

All coefficient of correlations are significant at the 0.001 level.

Structural model analysis

Fig 1 illustrates the structural model analysis results for the outpatient group. It was found that physician’s practice service had a positive (+) significant effect on patient satisfaction (β = 0.377, p < .001) and intent to revisit (β = 0.243, p < .001). Medical staff’s kindness and consideration had a positive (+) significant effect on patient satisfaction (β = 0.303, p < .001) but not on intent to revisit (β = 0.036, p = .286). The hospitals’ physical environment had a positive (+) significant effect on patient satisfaction (β = 0.186, p < .001) and intent to revisit (β = 0.049, p = .046). Patient satisfaction had a positive (+) significant effect on the intent to revisit (β = 0.652, p < .001).

The better the physician’s and nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment, the more likely they are to increase patient satisfaction. It was also found that the better the physician’s practice service and hospitals’ physical environment, the more these were likely to increase patient satisfaction and intent to revisit.

Fig 2 displays the structural model analysis results for the inpatient group. It was found that physician’s practice service had a positive (+) significant effect on patient satisfaction (β = 0.223, p < .001) and intent to revisit (β = 0.191, p < .001). Nurses’ practice service had a positive (+) significant effect on patient satisfaction (β = 0.236, p < .001) but not on intent to revisit (β = 0.04, p = .089). Medical staff’s kindness and consideration had a positive (+) significant effect on patient satisfaction (β = 0.29, p < .001) and intent to revisit (β = 0.096, p = .014). The hospital’ physical environment had a positive (+) significant effect on patient satisfaction (β = 0.182, p < .001) but not on intent to revisit (β = -0.013, p = .51). Patient satisfaction had a positive (+) significant effect on the intent to revisit (β = 0.498, p < .001).

Thus, the better the physician’s and nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment, the more likely these are to increase patient satisfaction. It was also found that the better the physician’s practice service and the medical staff’s kindness and consideration, the more these were likely to increase patient satisfaction and intent to revisit.

Analysis of the mediating effect

This study used covariance structural analysis to confirm the overall influence among factors as a causal effect. The total, direct, and indirect effects were measured to determine the effect of the independent variable “quality of healthcare” on the dependent variable “intent to revisit,” which revealed the importance of the mediating variable “patient satisfaction.” The total effect was expressed as the sum of all direct and indirect effects of the independent variable on the dependent variable. The direct effect reflected the direct relationship between the independent and dependent variables; the indirect effect represented the independent variable’s effect on the dependent variable through a mediating variable by regression analysis.

Table 4 shows the total, direct, and indirect effects in the outpatient group. The values of the standardized direct effect on “patient satisfaction” were 0.377 for “physician’s practice service,” 0.303 for “medical staff’s kindness and consideration,” and 0.186 for “hospital’s physical environment,” which were statistically significant. The values of the standardized direct effect on “intent to revisit” were 0.243 for “physician’s practice service,” 0.036 for “medical staff’s kindness and consideration,” 0.049 for “hospital’s physical environment,” and 0.522 for “patient satisfaction.” Here, the values for “physician’s practice service,” “hospital’s physical environment,” and “patient satisfaction” were statistically significant. The values of the standardized indirect effect of the independent variable on the dependent variable through the mediating variable “patient satisfaction” were 0.197 for “physician’s practice service,” 0.158 for “medical staff’s kindness and consideration,” and 0.097 for “hospital’s physical environment,” which were statistically significant. “Patient satisfaction” was found to mediate the relationship between the quality of healthcare perceived by the patient (“physician’s practice service,” “medical staff’s kindness and consideration,” and “hospital’s physical environment”) and intent to revisit.

Bootstrap standardized direct, indirect, total effect.

*p < .05

**p < .01

***p < .001.

The direct effect on “intent to revisit” was highest for “patient satisfaction,” followed by “physician’s practice service,” “hospital’s physical environment,” and “medical staff’s kindness and consideration.” The indirect effect on “patient satisfaction” through “intent to revisit” was highest for “physician’s practice service,” followed by “medical staff’s kindness and consideration” and “hospital’s physical environment.” The total effect was highest for “physician’s practice service,” followed by “medical staff’s kindness and consideration,” and “hospital’s physical environment.” These results indicated that “physician’s practice service” is the most significant factor influencing “patient satisfaction” and “intent to revisit.”

Table 5 shows the analysis results of total, direct, and indirect effects in the inpatient group. The values of the standardized direct effect on “patient satisfaction” were 0.223 for “physician’s practice service,” 0.236 for “nurse’s practice service,” 0.290 for “medical staff’s kindness and consideration,” and 0.182 for “hospital’s physical environment,” which were statistically significant. The values of the standardized direct effect on “intent to revisit” were 0.191 for “physician’s practice service,” 0.040 for “nurse’s practice service,” 0.096 for “medical staff’s kindness and consideration,” -0.013 for “hospital’s physical environment,” and 0.498 for “patient satisfaction” where the values for “physician’s practice service,” “medical staff’s kindness and consideration,” and “patient satisfaction” were statistically significant. The values of the standardized indirect effect of the independent variable on the dependent variable through the mediating variable “patient satisfaction” were 0.111 for “physician’s practice service,” 0.117 for “nurse’s practice service,” 0.145 for “medical staff’s kindness and consideration,” and 0.090 for “hospital’s physical environment,” which were statistically significant. “Patient satisfaction” was found to mediate the relationship between the quality of healthcare perceived by the patient (“physician’s practice service,” “medical staff’s kindness and consideration,” and “hospital physical environment”) and intent to revisit.

The direct effect on “intent to revisit” was highest for “patient satisfaction,” followed by “physician’s practice service,” “medical staff’s kindness and consideration,” “nurse’s practice service,” and “hospital’s physical environment.” The indirect effect on “patient satisfaction” through “intent to revisit” was highest for “medical staff’s kindness and consideration,” followed by “nurse’s practice service,” “physician’s practice service,” and “hospital’s physical environment.” The total effect was highest for “physician’s practice service,” followed by “medical staff’s kindness and consideration,” “nurse’s practice service,” and “hospital’s physical environment.”

This study examined the effect of healthcare quality perceived by patients using regional hub public hospitals on their patient satisfaction and intent to revisit the hospital. A research model was established through a theoretical literature review. To test the model, 6,086 patients, including 2,951 outpatients and 3,135 inpatients over 18 years of age who had experience using regional hub public hospitals were analyzed using the results of the “2018 Evaluation for Operation of Regional Hub Public Hospital.” The analysis used in this study is structural equation modeling. There is also a similar path analysis. Path analysis is a concept first used by Professor Sewall Green Wright [ 17 ]. It has the advantage of being able to verify the causal relationship between multiple independent and dependent variables. However, path analysis makes a statistical assumption that there is no measurement error [ 18 ]. Such an assumption does not matter if it is measured as a single item. Nevertheless, a problem arises when it is converted into a single item form, such as the average or total score measured by several observation variables [ 18 ]. What can solve this problem is structural equation modeling [ 19 ]. Structural equation modeling originates from the “JKW model,” in which path analysis and confirmatory factor analysis are integrated [ 20 ]. Structural equation modeling differs from path analysis and uses the concept of latent variables. Latent variables are not directly observed or measured, but indirectly measured by the observed variable [ 21 ]. In other words, this study used structural equation modeling that can use latent variables.

The summarized results are as follows.

First, the variables that directly affected intent to revisit were, for the outpatient group, physician’s practice service, hospital’s physical environment, and patient satisfaction, and for the inpatient group, physician’s practice service, medical staff’s kindness and consideration, and patient satisfaction. This is consistent with the results of Kang [ 22 ] regarding inpatients in public medical institutions. Kang [ 22 ] reported that medical professionalism, the staff’s kindness, interest in and service for patients, the convenience of the process of being served in the hospital, and hospital facilities and environment had a positive (+) correlation with intent to revisit. These are consistent with the claims by Yoon [ 23 ] and Han [ 24 ], respectively, that a higher satisfaction with physician’s practice service and hospital environment are likely to increase intent to revisit and that the medical staff’s medical service and hospital facility influenced intent to revisit. These results indicate the significance of the physician’s treatment skills, which are the essence of medical institutions. Cooperation with private medical institutions is also an excellent way to develop the knowledge and skills of medical personnel working for regional hub public hospitals.

Second, all the variables for the inpatient and outpatient groups had a significant effect on patient satisfaction. The mediating effect on intent to revisit through patient satisfaction was also significant in all variables. This is consistent with the results of Park [ 25 ], who investigated the effect of healthcare service quality on intent to revisit and the mediating effect of patient satisfaction in patients who use small and medium hospitals. Park [ 25 ] reported that patient satisfaction mediated the relationship between healthcare service quality and intent to revisit. Amarantou et al. [ 26 ] investigated the effect of quality of healthcare service on the intent to revisit through the mediating effect of patient satisfaction in emergency room patients in Greece. They reported that patient satisfaction had a positive (+) significant mediating effect. These results suggest that it is necessary to develop various strategies to enhance the quality of medical care services and continuously increase patient satisfaction to improve patients’ intent to revisit.

The effect analysis results indicated that the indirect effect is highest, in the outpatient group, for physician’s practice service, followed by medical staff’s kindness and consideration, and the hospital’s physical environment. Further, in the inpatient group, the indirect effect is highest for medical staff’s kindness and consideration, followed by nurse’s practice service, physician’s practice service, and the hospital’s physical environment. The results showed that, among healthcare quality factors, medical staff’s kindness and consideration had the most substantial effect in outpatient and inpatient groups. Park [ 25 ] had investigated the effect of quality of healthcare on intent to revisit through patient satisfaction and had results consistent with those of this study, reporting that the indirect effect was highest in the empathy factor, which indicates a consideration for customers, among the quality of medical services factors. Aliman and Mohamad [ 27 ] showed that, among the quality of medical service factors, the staff’s ability and the confidence representing goodwill, respectful attitude, and sincere interest in patients had the most potent effect on patient satisfaction and intent to revisit. The difference in the most critical factor between outpatient and inpatient groups of this study is due to the practice process. Outpatients are likely to leave the hospital just after seeing the physician; therefore, the physician’s practice is most important. However, unlike outpatients, inpatients are present in the hospital for medical services. This allows them many opportunities to communicate with hospital employees. For the customer’s maintenance, the medical service provider should ensure that quality healthcare service, which is the essence of healthcare, is provided. The medical staff show kindness, sincerity, care, and respect for patients to be encouraged to revisit. For example, Hospital A ranked 1st in the patient experience evaluation conducted by the Health Insurance Review and Assessment Service. The most frequently mentioned factor was the staff’s kindness toward patients. Hospital B, which ranked 2nd in the evaluation, implemented the “Activity as Patient for Experience,” in which employees experienced the patient’s treatment process to find a space for improvement to create a patient-oriented medical culture in their hospital. These examples demonstrate that the provision of a service that considers the patient’s position influences patient satisfaction. If regional hub public hospitals seek to provide quality healthcare to the public while maintaining and surviving in the current strong competition, developing programs to educate medical staff and all staff dealing with patients to treat patients sincerely is needed. Regular management of patients through active training and monitoring by the quality assurance team is also necessary.

This study has several limitations. First, there is an insufficient understanding of the causal relationship between variables. This is a cross-sectional study using data from the “2018 Evaluation for Operation of Regional Hub Public Hospital.” Thus, future studies using longitudinal data are recommended to clarify how healthcare quality affects patient satisfaction and intent to revisit. Second, this study did not include factors that may affect patient satisfaction and intent to revisit due to data restrictions on personal information protection and confidentiality, consultation of doctors, nurses, or designees, especially in inpatients with major diseases. In the future, research will need to proceed with the study, including other factors that may affect patient satisfaction and intent to revisit.

Nevertheless, this study contributed to this field in that it investigated the management strategy to generate appropriate profits for regional hub public hospitals by analyzing the relationship among quality of healthcare, patient satisfaction, and intent to revisit. Previous studies have been conducted mainly targeting private hospitals, in outpatients and inpatients using regional hub public hospitals after controlling for gender, age, health status, and education level.

This study used a structural equation model to examine whether there is a relationship among patient’s healthcare service quality, patient satisfaction, and intent to revisit in outpatients and inpatients visiting regional hub public hospitals. The study aimed to provide fundamental data to improve patient satisfaction and service in regional medical centers and Red Cross hospitals.

The results indicated that, in the outpatient group, the better the physician’s practice service, hospital’s physical environment, and patient satisfaction, the more likely these were to increase the patients’ intent to revisit. The indirect effect on intent to revisit through patient satisfaction was highest for physician’s practice service, followed by medical staff’s kindness and consideration, and the hospital’s physical environment. Moreover, in the inpatient group, the better the physician’s practice service, medical staff’s kindness and consideration, and patient satisfaction, the more these were likely to increase the patients’ intent to revisit. The indirect effect on intent to revisit through patient satisfaction was highest for medical staff’s kindness and consideration, followed by nurse’s practice service, physician’s practice service, and patient satisfaction.

Based on the results, we present the following suggestions. First, public hospitals’ environment should be improved to satisfy medical consumers to strengthen publicity through fiscal consolidation. Second, providing active healthcare service through cultivating professional knowledge and technical expertise in healthcare professionals should be attempted. Finally, the medical service provider should ensure the provision of quality healthcare service and that medical staff show kindness, sincerity, care, and respect for patients so that they are encouraged to revisit.

Abbreviations

Funding statement.

The author(s) received no specific funding for this work.

Data Availability

• PLoS One. 2021; 16(6): e0252241.

Decision Letter 0

18 Mar 2021

PONE-D-21-00964

The effect of quality of medical service on patient satisfaction and intent to revisit: for public hub hospitals in Republic of Korea

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Reviewer #1: 1. Research purpose should be listed as hypotheses, such as hypothesis 1, 2, etc.

2. Professional translation is recommended. Many sentences and paragraphs have grammatical errors and are not clear.

3. Clear definition on variables are suggested. What is 'practice service'? What are the difference between 'physician's practice service' and 'nurce's practice service'? Staff's consideration?

4. Also define 'regional public hub hospital in Korea'. Based on function, work scope, and size of the hospitals, user group could be vary. Could you generalize the results of this study to all public hospitals in Korea?

5. Recommend to use a table to describe results of the Goodness-of-fit test (page 9).

6. (Page 10) This is 'Path analysis', not 'Structural Equation Modeling'.

7. (Page 16) Authors described, 'This study has several limitations', but list one limitation. Is there any other limitation in this study?

Reviewer #2: The paper is successful in its attempt and addressed its objectives well. However, it may also shed lights on some other issues related to patient’s satisfaction. This may not be necessarily related to the quality of healthcare as perceived by the patients, such as some local issues related to the local culture and tradition, practices, etc. Issues of privacy and confidentiality, counselling by doctors, nurses or designated, especially for the inpatients suffering from some major ailments, etc. are also major factors which affect the satisfaction of the patients and their intension to revisit the public health facilities. The problem of overcrowding and shortfalls of medical and paramedical staff especially in the developing country is also a major challenge faced by the public health facilities.

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Reviewer #2:  Yes:  Rajeev K Kumar

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Submitted filename: Reviewers comments- RKK 02.03.21.docx

Author response to Decision Letter 0

13 Apr 2021

Reviewer 1:

Comment 1. Research purpose should be listed as hypotheses, such as hypothesis 1, 2, etc

Response 1: Thank you for your comment. In reflection of the reviewer’s opinion we added the following to the to the research purpose (page 5).

“The specific research hypotheses are as follows:

2. In the inpatient case, the physician’s practice service, nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment will have a direct or indirect effect on the intent to revisit.”

Comment 2. Professional translation is recommended. Many sentences and paragraphs have grammatical errors and are not clear.

Response 2: Thank you for your comment. In reflection of the reviewer’s opinion, we revised the manuscript for the English language.

Comment 3. Clear definition on variables are suggested. What is 'practice service'? What are the difference between 'physician's practice service' and nurse's practice service'? Staff's consideration?

Response 3: Thank you for your comment. Based on the reviewer’s opinion, the following sentence has been added to the Healthcare Service Quality section in Materials and Methods (page 7):

The “physician’s practice service” included questions on appropriate hours of care, medical history check, intelligible explanation, doctor’s listening, polite attitude, and professional health care delivery. Further, “medical staff’s kindness and consideration” included questions on the attitude of the examination and administration staff, consideration of the medical staff, and description of the reminder. The “hospital’s physical environment” included questions on bathroom and hospital cleanliness and convenience of waiting and auxiliary facilities. For inpatients, “nurse’s practice service” was included, and “quality of medical service” was composed of four items. The “nurse’s practice service” included questions on polite attitude, nurse’s listening, intelligible explanation, quick response to inconveniences, periodic patient check, professional health care delivery, and nurse’s satisfaction.

Figures 1 and 2 refer to the following questions about the physician’s practice service, nurse’s practice service, medical staff’s kindness and consideration, and the hospital’s physical environment. You can see that the physician’s practice service is focused on clinical medical services, and the nurse’s practice service includes social services. Medical staff’s kindness and consideration include a question about whether the medical staff had sufficient consideration so that the patient’s body was not exposed during the treatment or examination, such as exposure to the patient’s body; therefore, the variable name was set as “medical staff’s kindness and consideration.”

The questions for each item were regarding the following:

- physician’s practice service: appropriate hours of care, medical history check, intelligible explanation, doctor’s listening, polite attitude, professional health care delivery

- nurse’s practice service: polite attitude, nurse’s listening, intelligible explanation, quick response to inconveniences, periodic patient check, professional health care delivery, nurse’s satisfaction

- medical staff’s kindness and consideration: attitude of the examination and administration staff, consideration of the medical staff, description of the reminder

- hospital’s physical environment: bathroom and hospital cleanliness, convenience of waiting and auxiliary facilities

Comment 4. Also define 'regional public hub hospital in Korea'. Based on function, work scope, and size of the hospitals, user group could be vary. Could you generalize the results of this study to all public hospitals in Korea?

Response 4: Thank you for the comments. Based on the reviewer’s opinion, the following sentence has been added to the Introduction section (page. 4):

Korea’s public medical institutions include public health centers, medical institutions for special needs, national university hospitals, and public hub hospitals. Among them, the most crucial role is played by public hub hospitals [13].

13. PUBLIC HEALTH AND MEDICAL SERVICES ACT https://law.go.kr/engLsSc.do?menuId=1&subMenuId=21&tabMenuId=117&query=%EA%B3%B5%EA%B3%B5%EB%B3%B4%EA%B1%B4#

Public health institutions in Korea include public health centers, public hub hospitals (public hub hospitals, Red Cross hospitals), national university hospitals, and medical institutions for special needs (police, industrial accidents, veterans, military hospitals, etc.). Among them, public hospitals with regional bases are the core of Korean public health. They are established to provide public health care to residents, for whom private health care cannot be performed, and private health care cannot be performed in vulnerable areas. The data used in this study were targeted at all 39 public hub hospitals (34 local medical centers, 5 Red Cross hospitals). The results of this study cannot be generalized to all public hospitals. However, as samples were extracted from all 39 public hub hospitals, which are hospitals in regional units distributed across the country, generalization is possible for public hub hospitals.

Comment 5. Recommend to use a table to describe results of the Goodness-of-fit test (page 9).

Response 5: Thank you for your comment. In response to the reviewer's opinion, the following table has been added to the fitness test on pages 10-11.

Comment 6. (Page 10) This is 'Path analysis', not 'Structural Equation Modeling'.

Response 6: Thank you for your comment. Based on the reviewer’s comment, Figures 1 and 2 are modified and presented in the text (page 12). Further, the following sentence has been added to the discussion section (page 16).

“The analysis used in this study is structural equation modeling. There is also a similar path analysis. Path analysis is a concept first used by Professor Sewall Green Wright [17]. It has the advantage of being able to verify the causal relationship between multiple independent and dependent variables. However, path analysis makes a statistical assumption that there is no measurement error [18]. Such an assumption does not matter if it is measured as a single item. Nevertheless, a problem arises when it is converted into a single item form, such as the average or total score measured by several observation variables [18]. What can solve this problem is structural equation modeling [19]. Structural equation modeling originates from the “JKW model,” in which path analysis and confirmatory factor analysis are integrated [20]. Structural equation modeling differs from path analysis and uses the concept of latent variables. Latent variables are not directly observed or measured but indirectly measured by the observed variable [21]. In other words, this study used structural equation modeling that can use latent variables.”

17. WRIGHT, Sewall. The method of path coefficients. The annals of mathematical statistics, 1934, 5.3: 161-215.

18. James B. Schreiber, Amaury Nora, Frances K. Stage, Elizabeth A. Barlow & Jamie King (2006) Reporting Structural Equation Modeling and Confirmatory Factor Analysis Results: A Review, The Journal of Educational Research, 99:6, 323-338, DOI: 10.3200/JOER.99.6.323-338

19. CHEUNG, Gordon W.; LAU, Rebecca S. Testing mediation and suppression effects of latent variables: Bootstrapping with structural equation models. Organizational research methods, 2008, 11.2: 296-325.

20. Bentler, P. M. Multivariate analysis with latent variables: Causal modeling. Annual review of psychology. 1980;31(1), 419-456.

21. BOLLEN, Kenneth A. Latent variables in psychology and the social sciences. Annual review of psychology, 2002, 53.1: 605-634.

Comment 7. (Page 16) Authors described, 'This study has several limitations', but list one limitation. Is there any other limitation in this study?

Response 7: Thank you for your comment. One more limit has been added to reflect reviewer 2’s opinion in the Discussion section (page 18).

“Second, this study did not include factors that may affect patient satisfaction and intent to revisit due to data restrictions on personal information protection and confidentiality, consultation of doctors, nurses, or designees, especially in inpatients with major diseases. In the future, research will need to proceed with the study, including other factors that may affect patient satisfaction and intent to revisit.”

Reviewer 2:

Comment 1. The paper is successful in its attempt and addressed its objectives well. However, it may also shed lights on some other issues related to patient’s satisfaction. This may not be necessarily related to the quality of healthcare as perceived by the patients, such as some local issues related to the local culture and tradition, practices, etc. Issues of privacy and confidentiality, counselling by doctors, nurses or designated, especially for the inpatients suffering from some major ailments, etc. are also major factors which affect the satisfaction of the patients and their intension to revisit the public health facilities. The problem of overcrowding and shortfalls of medical and paramedical staff especially in the developing country is also a major challenge faced by the public health facilities.

Response 1: Thank you for your comment. Based on the reviewer's opinion, the following sentence has been added to the Discussion section (page 18):

Submitted filename: Response to reviewers.docx

Decision Letter 1

12 May 2021

Medical service quality effect on patient satisfaction and intent to revisit: For public hub hospitals in the Republic of Korea

PONE-D-21-00964R1

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Additional Editor Comments (optional):

There are still some awkward sentences in the manuscript and needs editing. In my opinion, the title needs changes as well. I suggest that the title of the paper be changed to reflect the content of the paper. A possible title could be, "Medical service quality, patient satisfaction and intent to revisit: Case study of public hub hospitals in the Republic of Korea". 

Acceptance letter

17 May 2021

Medical service quality, patient satisfaction and intent to revisit: Case study of public hub hospitals in the Republic of Korea

Dear Dr. Choi:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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Verifying Your Japanese National Health Insurance Card

Patients who checked-in at the first visit/ revisit (without appointment) counter.

Your Japanese National Health Insurance card will be verified at the time of registration

Patients who register at the “Return Visit Reception Machine”

Patients who register at the “Return Visit Reception Machine” must have their Japanese National Health Insurance card verified at the “Insurance Card Verification Desk” (1st floor of the Main Building) before your consultation at the first visit of each month.

Note: If you do not have time before your consultation, you can show your insurance card at the time of your payment.

Note: We kindly ask you to have your insurance card verified before your consultation so that you do not have to wait long at the time of payment.　

Consulting Your Department

When it is your turn, you will be called by the “number” printed on your “Confirmation Sheet”.　

Billing and Payment

Patients with payment.

Please show your “Confirmation Sheet” at the Billing counter. (If you are a patient only with a blood test, please show your hospital ID card.) If it is your first visit of the month and you have not had your Japanese National Health Insurance card verified, please show your “insurance card” as well.

Note: If you have an “out-of-hospital prescription”, we need to stamp the prescription as a means of authenticating the document. Please show your “out-of-hospital prescription” at the Billing counter. Payment is to be made at the automated payment machine. After billing is done, your number will show up on the digital display board. When your number shows up, please make your payment at the automated payment machine. Your receipt and appointment slip for your next visit will be issued from the machine (Patients with an “in-hospital prescription” will be given a “Medicine Voucher” which is needed to receive your prescribed medications from the pharmacy inside the hospital).

Patients without payment

Please show your “Confirmation Sheet” at the Billing counter after your consultation. If it is your first visit of the month and you have not had your Japanese National Health Insurance card verified, please show your insurance card as well.

Note: If you have an “out-of-hospital prescription”, we need to stamp the prescription as a means of authenticating the document. Please show your “out-of-hospital prescription” at the Billing counter.

Note: Patients with an “in-hospital prescription” will be given a “Medicine Voucher” which is needed to receive your prescribed medications from the pharmacy inside the hospital.

Changing your Appointment

We can make changes or cancel your appointment at the Outpatient Appointment Desk. You can also reach us by phone at the number below.

However, in case you need to make changes to a test or examination, you will need to discuss with your doctor.

Outpatient Appointment Desk on the 3rd floor (next to the Department of Urology)

Open Hours: 8:30 – 17:00 (Monday-Friday)

Appointment Call Center

Telephone numbers to change your appointment: Tel: +81-3-3202-7494 / +81-3-3202-7495 (available only in Japanese) Tel: +81-3-6228-0749　(direct number, available in English, Chinese, and Vietnamese)

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Superhero window washers visit Dauphin County hospital

• Updated: Apr. 26, 2024, 7:09 p.m. |
• Published: Apr. 26, 2024, 7:01 p.m.

• Dan Gleiter | [email protected]

A trio of superhero window washers suited up Friday as Spiderman, Superman and Captain America to rappel down the side of UPMC Children’s Hospital in Harrisburg.

A UPMC Pinnacle Foundation staff member stayed inside the building, dressed as Wonder Woman, mingling with pediatric patients and staff. A pair of therapy dogs, each wearing a superhero outfit, were also on hand.

Children and staff in the pediatrics inpatient unit were treated to views of the superheroes waving and posing for photos through the windows of the hospital.

“Today is superhero day and, we, the UPMC Pinnacle Foundation, does it in partnership with UPMC Children’s, to honor what we say is our true superheroes, the patients and the families that are here in and out of the hospital system every day,” said UPMC Pinnacle Foundation President Jessica Ritchie.

“We also do it to honor our staff-who are amazing and provide the care that’s needed for the children that are here.”

The event is also a fundraiser with t-shirts and capes being sold for the event, and the funds going toward the UPMC Pinnacle Foundation Brooks/Schiffman Pediatric Fund.

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FTC Announces Rule Banning Noncompetes

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Today, the Federal Trade Commission issued a final rule to promote competition by banning noncompetes nationwide, protecting the fundamental freedom of workers to change jobs, increasing innovation, and fostering new business formation.

“Noncompete clauses keep wages low, suppress new ideas, and rob the American economy of dynamism, including from the more than 8,500 new startups that would be created a year once noncompetes are banned,” said FTC Chair Lina M. Khan. “The FTC’s final rule to ban noncompetes will ensure Americans have the freedom to pursue a new job, start a new business, or bring a new idea to market.”

The FTC estimates that the final rule banning noncompetes will lead to new business formation growing by 2.7% per year, resulting in more than 8,500 additional new businesses created each year. The final rule is expected to result in higher earnings for workers, with estimated earnings increasing for the average worker by an additional $524 per year, and it is expected to lower health care costs by up to $194 billion over the next decade. In addition, the final rule is expected to help drive innovation, leading to an estimated average increase of 17,000 to 29,000 more patents each year for the next 10 years under the final rule.

Noncompetes are a widespread and often exploitative practice imposing contractual conditions that prevent workers from taking a new job or starting a new business. Noncompetes often force workers to either stay in a job they want to leave or bear other significant harms and costs, such as being forced to switch to a lower-paying field, being forced to relocate, being forced to leave the workforce altogether, or being forced to defend against expensive litigation. An estimated 30 million workers—nearly one in five Americans—are subject to a noncompete.

Under the FTC’s new rule, existing noncompetes for the vast majority of workers will no longer be enforceable after the rule’s effective date. Existing noncompetes for senior executives - who represent less than 0.75% of workers - can remain in force under the FTC’s final rule, but employers are banned from entering into or attempting to enforce any new noncompetes, even if they involve senior executives. Employers will be required to provide notice to workers other than senior executives who are bound by an existing noncompete that they will not be enforcing any noncompetes against them.

In January 2023, the FTC issued a  proposed rule which was subject to a 90-day public comment period. The FTC received more than 26,000 comments on the proposed rule, with over 25,000 comments in support of the FTC’s proposed ban on noncompetes. The comments informed the FTC’s final rulemaking process, with the FTC carefully reviewing each comment and making changes to the proposed rule in response to the public’s feedback.

In the final rule, the Commission has determined that it is an unfair method of competition, and therefore a violation of Section 5 of the FTC Act, for employers to enter into noncompetes with workers and to enforce certain noncompetes.

The Commission found that noncompetes tend to negatively affect competitive conditions in labor markets by inhibiting efficient matching between workers and employers. The Commission also found that noncompetes tend to negatively affect competitive conditions in product and service markets, inhibiting new business formation and innovation. There is also evidence that noncompetes lead to increased market concentration and higher prices for consumers.

Alternatives to Noncompetes

The Commission found that employers have several alternatives to noncompetes that still enable firms to protect their investments without having to enforce a noncompete.

Trade secret laws and non-disclosure agreements (NDAs) both provide employers with well-established means to protect proprietary and other sensitive information. Researchers estimate that over 95% of workers with a noncompete already have an NDA.

The Commission also finds that instead of using noncompetes to lock in workers, employers that wish to retain employees can compete on the merits for the worker’s labor services by improving wages and working conditions.

Changes from the NPRM

Under the final rule, existing noncompetes for senior executives can remain in force. Employers, however, are prohibited from entering into or enforcing new noncompetes with senior executives. The final rule defines senior executives as workers earning more than $151,164 annually and who are in policy-making positions.

Additionally, the Commission has eliminated a provision in the proposed rule that would have required employers to legally modify existing noncompetes by formally rescinding them. That change will help to streamline compliance.

Instead, under the final rule, employers will simply have to provide notice to workers bound to an existing noncompete that the noncompete agreement will not be enforced against them in the future. To aid employers’ compliance with this requirement, the Commission has included model language in the final rule that employers can use to communicate to workers. 

The Commission vote to approve the issuance of the final rule was 3-2 with Commissioners Melissa Holyoak and Andrew N. Ferguson voting no. Commissioners Rebecca Kelly Slaughter , Alvaro Bedoya , Melissa Holyoak and Andrew N. Ferguson each issued separate statements. Chair Lina M. Khan will issue a separate statement.

The final rule will become effective 120 days after publication in the Federal Register.

Once the rule is effective, market participants can report information about a suspected violation of the rule to the Bureau of Competition by emailing  [email protected] . 

The Federal Trade Commission develops policy initiatives on issues that affect competition, consumers, and the U.S. economy. The FTC will never demand money, make threats, tell you to transfer money, or promise you a prize. Follow the  FTC on social media , read  consumer alerts  and the  business blog , and  sign up to get the latest FTC news and alerts .

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Think Out Loud

Rural hospitals ‘in crisis mode,’ with situation worsening, says new report.

Broadcast: Tuesday, April 23

Samaritan North Lincoln Hospital in Lincoln City is one of two critical care hospitals in the county, comprising a large portion of the rural health care safety net.

Courtesy Samaritan North Lincoln Hospital

“Unrelenting pressure” on the nation’s rural healthcare safety net means more hospital closures and many operating on the brink. That’s according to a new report by the Chartis Center for Rural Health. The center says hospitals have been in crisis mode for the last 15 years, but even in just the last 12 months, the situation has worsened further, with the percentage of America’s rural hospitals operating in the red jumping from 43% to 50% in that time.

Some of the report’s other key findings include:

• Access to inpatient care continues to deteriorate, as 167 rural hospitals since 2010 have either closed or converted to a model that excludes inpatient care.
• Between 2011 and 2021, 267 rural hospitals dropped OB services. This represents nearly 25% of America’s rural OB units.
• Between 2014 and 2022, 382 rural hospitals have stopped providing chemotherapy services.

We get more details about what’s driving these trends from Michael Topchik , director of the Chartis Center for Rural Health. We’re also joined by Dr. Lesley Ogden , the CEO of two Lincoln County hospitals: Samaritan North Lincoln Hospital in Lincoln City and Samaritan Pacific Communities Hospital in Newport.

Contact “Think Out Loud®”

If you’d like to comment on any of the topics in this show or suggest a topic of your own, please get in touch with us on Facebook , send an email to [email protected] , or you can leave a voicemail for us at 503-293-1983. The call-in phone number during the noon hour is 888-665-5865.

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King Charles Announces His Return to Public Duties

Today, Buckingham Palace announced that King Charles will return to public-facing duties next week, after four months out of the spotlight undergoing “treatment and recuperation” in the aftermath of his cancer diagnosis in February. To mark this milestone, the king and Queen Camilla are set to visit a cancer treatment center on Tuesday, where they will meet with both medical specialists and patients. “This visit will be the first in a number of external engagements His Majesty will undertake in the weeks ahead,” the Palace said, also sharing that the royals will host the Emperor and Empress of Japan for a state visit in June.

In January, the British monarch shared the news that he was undergoing a “corrective procedure” for an enlarged prostate, the day after the Princess of Wales announced that she had undergone abdominal surgery. On February 7, the Palace shared another statement confirming that the king had been diagnosed with cancer, which had been discovered during his previous hospital treatment. They also noted that the king would be stepping back from public-facing duties for a period, but would be continuing with his constitutional role as head of state, which includes paperwork and private meetings.

The news comes after growing speculation over the past weeks around the status of the king’s health, with some international outlets, including The Daily Beast, reporting that the monarch’s funeral plans were being “regularly updated.” (It’s worth noting that this doesn’t necessarily augur the worst, given the plans surrounding the Queen’s death—known as Operation London Bridge—were also refreshed periodically throughout her reign.)

It has been a turbulent year for the British royal family: in particular, due to the rampant social media speculation surrounding the health of the Princess of Wales, which led her to release a public statement confirming her own cancer diagnosis on March 22. Yet Buckingham Palace ended their briefing on a positive note—by looking ahead to May 6, when King Charles and Queen Camilla will be celebrating one year on the throne. “As the first anniversary of The Coronation approaches, Their Majesties remain deeply grateful for the many kindnesses and good wishes they have received from around the world throughout the joys and challenges of the past year,” the statement concluded.

By Rachel Besser

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By Alexandra Macon

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Heat-Related E.R. Visits Rose in 2023, C.D.C. Study Finds

By Noah Weiland

Reporting from Washington

The rate of emergency room visits caused by heat illness increased significantly last year in large swaths of the country compared with the previous five years, according to a study published on Thursday by the Centers for Disease Control and Prevention.

The research, which analyzed visits during the warmer months of the year, offers new insight into the medical consequences of the record-breaking heat recorded across the country in 2023 as sweltering temperatures stretched late into the year.

What the Numbers Say: People in the South were especially affected by serious heat illness.

The researchers used data on emergency room visits from an electronic surveillance program used by states and the federal government to detect the spread of diseases. They compiled the number of heat-related emergency room visits in different regions of the country and compared them to data from the previous five years.

Nearly 120,000 heat-related emergency room visits were recorded in the surveillance program last year, with more than 90 percent of them occurring between May and September, the researchers found.

The highest rate of visits occurred in a region encompassing Arkansas, Louisiana, New Mexico, Oklahoma and Texas. Overall, the study also found that men and people between the ages of 18 and 64 had higher rates of visits.

How It Happens: Heat can be a silent killer, experts and health providers say.

Last year was the warmest on Earth in a century and a half, with the hottest summer on record . Climate scientists have attributed the trend in part to greenhouse gas emissions and their effects on global warming, and they have warned that the timing of a shift in tropical weather patterns last year could foreshadow an even hotter 2024.

Heat illness often occurs gradually over the course of hours, and it can cause major damage to the body’s organs . Early symptoms of heat illness can include fatigue, dehydration, nausea, headache, increased heart rate and muscle spasms.

People do not typically think of themselves as at high risk of succumbing to heat or at greater risk than they once were, causing them to underestimate how a heat wave could lead them to the emergency room, said Kristie L. Ebi, a professor at the University of Washington who is an expert on the health risks of extreme heat.

“The heat you were asked to manage 10 years ago is not the heat you’re being asked to manage today,” she said. One of the first symptoms of heat illness can be confusion, she added, making it harder for someone to respond without help from others.

What Happens Next: States and hospitals are gearing up for another summer of extreme heat.

Dr. Srikanth Paladugu, an epidemiologist at the New Mexico Department of Health, said the state had nearly 450 heat-related emergency room visits in July last year alone and over 900 between April and September, more than double the number recorded during that stretch in 2019.

In preparation for this year’s warmer months, state officials are working to coordinate cooling shelters and areas where people can be splashed by water, Dr. Paladugu said.

Dr. Aneesh Narang, an emergency medicine physician at Banner-University Medical Center in Phoenix, said he often saw roughly half a dozen heat stroke cases a day last summer, including patients with body temperatures of 106 or 107 degrees. Heat illness patients require enormous resources, he added, including ice packs, fans, misters and cooling blankets.

“There’s so much that has to happen in the first few minutes to give that patient a chance for survival,” he said.

Dr. Narang said hospital employees had already begun evaluating protocols and working to ensure that there are enough supplies to contend with the expected number of heat illness patients this year.

“Every year now we’re doing this earlier and earlier,” he said. “We know that the chances are it’s going to be the same or worse.”

Noah Weiland writes about health care for The Times. More about Noah Weiland

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