title: Analyzing the ambiguous relationship between efficiency, quality and patient satisfaction in healthcare services: the case of public hospitals in Turkey.
abstract: OBJECTIVE
  This paper empirically analyzes the effects of efficiency and structural quality on patient satisfaction in Turkish public hospitals. It also investigates the controversial relationship between hospital efficiency and structural quality for small, medium and large size hospitals in a comparative perspective.
  
  
  METHODS
  Data envelopment analysis (DEA) is used to analyze the efficiencies of hospitals. Data concerning 523 public hospitals is obtained from Turkish Ministry of Health. Due to the missing data of some hospitals, the sample of this study is composed of the remaining 348 observations. Multiple regression analysis is used to evaluate the relationship between patient satisfaction as a dependent variable and structural quality, hospital efficiency and institutional factors as independent variables. Furthermore, stepwise process multiple regression analysis is used to analyze the moderator effects of hospital efficiency on the form of the relationship between quality and satisfaction.
  
  
  RESULTS
  The findings indicate that hospital efficiency changes the form of the relationship between structural quality and patient satisfaction as a moderator variable. The trade-off between quality and efficiency is found to vary depending on the hospital size. Negative correlation is found between quality and efficiency for small-size hospitals. However, positive correlation between efficiency and quality is found significant as indicated by Total Quality Management (TQM) approach for large-size hospitals. This study also provides the empirical evidence on the negative relationship between patient satisfaction and hospital size.
  
  
  CONCLUSIONS
  The effect of hospital efficiency on patient satisfaction might be improved for inefficient small and medium size hospitals by taking successful large hospitals as role models.
authors.affiliation: Gebze Institute of Technology, Faculty of Business Administration, Gebze, Kocaeli, Turkey. msahingok@gmail.com
authors.forename: Mehmet Sahin
authors.initials: MS
authors.lastname: Gok
authors.forename: Bulent
authors.initials: B
authors.lastname: Sezen
mesh_terms: D017598:Efficiency, Organizational; D019538:Health Care Surveys; D006779:Hospitals, Public / Q000592:standards*; D006801:Humans; D017060:Patient Satisfaction; D036301:Qualitative Research; D011787:Quality of Health Care; D012044:Regression Analysis; D014421:Turkey
keywords: Data envelopment analysis; Hospital efficiency; Patient satisfaction; Structural quality