An exercise in the prioritization of patient experience dimensions: What is important and for whom? A resource allocation simulation

Abstract

Introduction

Patient experience (PX) is now recognized as the third pillar of healthcare quality, with evidences linking PX dimensions to improved clinical outcomes. As health systems shift toward value-based care, understanding which aspects of care citizens value most is essential for aligning services with their expectations and improving health outcomes.

Methodology

This study explores how citizens (n = 78; 29 men, 49 women) prioritize PX dimensions, through a simulation conducted during an open day at a University Hospital. Participants at the PX team’s outreach stand received information on seven PX dimensions—Information, Therapeutic education, Physical environment, Participation in service governance, Shared decision-making, Professional accessibility, and Respectful treatment—identified through literature and over 70 focus groups. Each was asked to allocate a simulated 500€ budget across these dimensions using play money. Color-coded envelopes were distributed based on gender identity.

Results

Participants prioritized Professional accessibility (22%), followed by Therapeutic education (17%) and Respectful treatment (17%). Shared decision-making (12%), Information (11%), Participation (11%), and Physical environment (10%) followed. Gender differences were observed: while both men and women placed highest value on Professional accessibility (21%), men favoured Therapeutic education (19% vs 16%), while women prioritized Respectful treatment (18% vs 14%).

Conclusions

These findings highlight the potential of participatory approaches to reveal citizens’ true priorities, informing more targeted, equitable, and people-centred strategies. By aligning PX improvements with dimensions citizens value most, particularly accessibility, education, and respectful care, healthcare systems can enhance both responsiveness and overall quality.

Keywords

patient experience Citizen’s priorities quality care improvement value-based health care health system responsiveness

Introduction

Over the last decade, patient experience (PX) has emerged as a key independent dimension of healthcare quality.^1,2 Along with security and effectiveness, PX has become the third pillar of healthcare quality³ and is increasingly seen as central to healthcare leadership and context-based organizational strategy. PX encompasses all aspects of patient interactions, with and within the healthcare system, that may occur in relation to a range of factors, including information transparency, quality of the hospital visit, access to professionals, effective communication with providers, and the physical environment of care facilities, among others.⁴ PX goes beyond patient satisfaction, capturing a broader range of elements, each contributing to a more responsive healthcare system that anticipates and adapts to users’ needs.^5–9 PX is best understood as process indicator to reflect what actually happens during the process of receiving treatment, in contrast with patient satisfaction, which is an outcome measure of healthcare delivery and mainly reflects patients’ subjective expectation.¹⁰

In parallel with these developments, the value-based health care (VBHC) movement has gained significant momentum over the last two decades. The core principle of this paradigm is that value in healthcare is a function of the outcomes that matter to patients for the cost over the full cycle of care.^11,12 While these authors did not position PX as a standalone component in the original VBHC framework, the evolution of VBHC implementation has increasingly come to recognize PX as an essential dimension of value. The integration of PX into VBHC has been reinforced through frameworks such as the “3Cs” - capability, comfort, and calm - which emphasize that healthcare should support patients’ ability to live their lives (capability), reduce suffering (comfort), and minimize the burden of care (calm).¹³ These dimensions link patient experience with value by focusing not only on outcomes, but also on how care is delivered and perceived. From this perspective, process measures such as PX are not alternatives to outcomes, but essential complements, capturing how well healthcare systems understand and adapt to patients’ evolving needs. Organizations focused on capturing outcomes such as the International Consortium for Health Outcomes Measurement (ICHOM) has recently incorporated patient-reported experience measures (PREMs) alongside patient-reported outcome measures (PROMs) in several standard sets for use, for example, in pregnancy and childbirth care, and integrated care for older people. This integration reflects the growing recognition that PX is a natural progression in VBHC rather than a separate consideration.

Based on available evidence, PX measures on the whole present a significant positive association with clinical outcomes,^3,14–17 although several inconsistencies in these findings continue to warrant further research.¹⁸ Thus, while our study does not claim a causal relationship between PX and clinical outcomes, it affirms that understanding which experience dimensions people prioritize is central to assessing what they value in care. In this regard, people’s involvement is a foundational element of PX and can occur at different levels of decision-making, from individual treatment choices to collective health system design.¹⁹ Efforts to improve patient experience must be grounded in genuine partnership with patients, recognizing that PX cannot be done for patients without being conceived together with them.²⁰ Involvement is not merely procedural, but it is also substantive with the capacity to shorten hospital stays and promote patient safety.²¹ To effectively integrate PX into VBHC, it is critical that we identify which dimensions of this experience patients prioritize. Without a systematic understanding of these priorities, healthcare organizations risk misallocating resources on aspects of care that do not align with what people value most.

Yet, despite the importance attached to these concepts, initiatives to assess and improve PX are frequently being designed and implemented with inadequate involvement, resulting in a mismatch between what people actually feel and need, and what healthcare providers offer as solutions to improve PX.^22,23 Accordingly, the failure to promote comprehensive involvement in the growing movement to VBHC, which precisely emphasizes the importance of understanding and addressing the specific needs, preferences, and values of patients, appears to be impairing the ability of the healthcare system’s stakeholders to craft innovations that effectively cover the needs that matter most to people.²⁴ For instance, it has been shown that quality-improvement programs work better when tailored to the factors deemed most important to specific groups, given that the priorities might differ across different segment of users.^6,25,26

Previous studies suggested that PX may be influenced by various socio-demographic variables such as age and gender^27,28 which is why further research is needed to explore how these associations manifest in different contexts. With this study, we contribute to advancing the understanding of how citizens allocate value to different PX dimensions, through a simulated budget exercise, and how gender might influence the prioritization patterns.

Methods

We designed a simulation-based prioritization exercise with two main objectives: first, to promote a culture of PX by showcasing the activities of the Patient Experience Observatory of Hospital Clinic Barcelona (HCB) to patients, caregivers, and citizens attending the hospital’s open day, and second, to identify patient PX priorities, while seeking to determine any differences in this prioritization by gender, with the aim of providing guidelines for the future efforts of the PX Observatory. The sample was composed of 78 participants (49 women and 29 men).

This study was also embedded in a participatory approach, as it sought to meaningfully engage citizens visiting our stand, both to raise awareness of our hospital’s commitment to inclusive research and patient experience, and to involve them in articulating their preferences and shaping PX-related priorities through the prioritization exercise. In this sense, what defines participatory research is not only the method itself, but the context of its application, and its focus on producing knowledge for action.²⁹

Researchers from the PX Observatory invited the participants of the outreach event held at the HCB to take on the role of decision-makers and allocate a hypothetical budget across seven key dimensions of PX namely: Information, Therapeutic education, the Physical environment, Participation in service governance, Shared decision-making, Professional accessibility, and Respectful treatment. These dimensions were selected based on their consistent appearance both in the literature, particularly the review by Escarrabill et al.,⁹ and in over 70 patient focus groups conducted by the PX Observatory at HCB over the past 10 years. The overlap between these two sources was used as a key criterion to ensure the dimensions reflected both theoretical grounding and patient-identified priorities. Additionally, by analysing the way in which the budget was allocated by male and female participants, the study sought to reveal potential gender bias in the importance attached to the different dimensions of PX.

The participatory approach taken in the study adhered to the following design. Visitors to the PX stand were greeted by a team member who explained the purpose of the study to them, that is, to help the HCB understand the most relevant dimensions of PX from their perspective. The researcher clearly explained to each participant what is understood by PX, provided a brief description of each dimension, and was available to clarify any doubts the participants might have about the written definitions provided (see Table 1).

Table 1.

Given definitions of the dimensions of PX.

Dimension	Given definition
Therapeutic education	The process of providing structured, ongoing support to help patients acquire the knowledge and skills necessary to manage their health conditions.
Physical environment (Environment)	The quality and comfort of the hospital itself, including its facilities and amenities.
Participation in service governance (Participation)	The involvement of patients and citizens in decision-making processes related to hospital policies and service improvements.
Shared decision- making (Shared decisions)	The collaborative decision-making process between patients and healthcare professionals to discuss treatment plans and healthcare choices.
Professional accessibility	The ease with which patients can access healthcare professionals for consultations and advice, and to raise treatment-related questions and doubts.
Information	The provision of clear and timely communication regarding diagnoses, treatments, and procedures.
Respectful treatment	The degree to which patients are treated with dignity, kindness, and respect by healthcare providers.

To simulate the budget allocation process, each participant received an envelope containing play money, specifically, for a total budget of 500€: two 100€, four 50€, and five 20€ bills. This amount was selected for its simplicity and relatability, offering participants a concrete and manageable framework for decision-making under a constraint budget scenario. The distribution of the bill denominations was made to avoid an equal distribution across the dimensions and, hence, to oblige participants to prioritize. In total, the simulation exercise involved 161 bills of 100€, 308 bills of 50€, and 375 bills of 20€, amounting to a cumulative hypothetical budget of 39,000€. Participants were asked to allocate their budget according to their personal priorities among the seven dimensions. To facilitate the gender-based analysis of PX priorities, both the envelopes (white envelopes were given to male participants and purple to female participants) and bills were colour coded. For participants that did not identify with either gender, envelopes and bills of a different colour were prepared.

To allocate their hypothetical budget, participants entered a tent in which different non-transparent boxes were placed under a sign corresponding to each dimension. Participants were not accompanied by researchers during this exercise and did not interact with them, unless they specifically required clarifications.

The data collected after the budget allocation exercise were analysed using descriptive statistics to quantify the relative importance assigned to each of the seven PX dimensions. This analysis was conducted by, first, compiling all individual allocations into a comprehensive dataset, recording the amounts allocated to each dimension by each participant. The dataset was then organized by the total allocations made to each dimension and disaggregated by gender. The primary analysis focused on identifying the dimensions that received the highest and lowest average allocations, understood as being indicative of their relative prioritizations among the participants. All statistical analyses were conducted using R studio, with results expressed in terms of mean allocations, standard deviations, and interquartile ranges. To assess the independence of the distribution of bills across the PX dimensions, we performed a set of Pearson’s chi-square tests with Monte Carlo simulation. Monte Carlo simulation was used to obtain exact p-values given the contingency table structure and low frequency cells, using 2000 random replications with a significance level of α = 0.05. We first perform an aggregate test and then for each dimension, a 2 × 3 contingency table was constructed with gender (men vs women) as rows and financial scenarios (€20, €50, €100 bills) as columns. Standardized residuals were calculated to identify specific cells contributing to significant associations, with values >2 or <-2 indicating cells with notably higher or lower frequencies than expected under independence.

Results

This study explored how citizens allocate monetary resources to prioritize different dimensions of PX. Table 2 provides insights into the perceived importance of various aspects of healthcare delivery, as reflected in the distribution of funds by the 78 individuals that participated in this exercise. Professional accessibility emerged as the most highly prioritized dimension, receiving 22% of the total budget, suggesting that citizens place great emphasis on timely access to healthcare professionals. Similarly, Therapeutic education and Respectful treatment both garnered significant portions of the budget, each accounting for 17%. This allocation underscores the importance of patients being well-informed and of receiving therapeutic education about their conditions and treatment, as well as the necessity of respectful, empathetic interactions within the healthcare setting.

Table 2.

Budget allocation across dimensions.

Dimensions	100 € bills	50 € bills	20 € bills	Total allocated budget (€)	Allocated budget (%)
Therapeutic education	32	52	49	6.780,00 €	17%
Environment	13	31	54	3.930,00 €	10%
Participation	11	42	54	4.280,00 €	11%
Shared decisions	15	43	50	4.650,00 €	12%
Professional accessibility	49	48	57	8.440,00 €	22%
Information	15	35	54	4.330,00 €	11%
Respectful treatment	26	57	57	6.590,00 €	17%
Total	161	308	375	39.000,00 €	100%

However, Shared decision-making and Participation – concerned with patient involvement in their own care and at the organizational level, respectively – received more modest allocations (12% and 11%, respectively).

Conversely, Environment was allocated the smallest portion of the budget (10%), indicating that while the physical setting of care remains relevant, participants consider it less critical compared to dimensions directly related to patient-provider interactions and accessibility.

Although these descriptive differences appear relevant in their own right, we proceeded to perform a chi-square test with Monte Carlo simulations to assess the independence of the distribution of bills across the dimensions. The chi-square test result was 36.031 with an associated p-value (<0.001), indicating statistically significant differences in the distribution of bill types (20, 50, and 100€) across the seven dimensions. This suggests that certain dimensions received notably different investment patterns, likely influenced by participant priorities or perceived importance of the dimension. For instance, the high allocation of 100€ bills to Professional accessibility might imply a preference for, or a higher valuation of, this dimension. Conversely, the preferred allocation of smaller denomination bills to Environment might indicate that this dimension is considered a lower priority or reflect more cautious investment behaviour.

Figure 1 helps to identify which dimensions are over or under represented for each bill type based on the standardized residuals. Significant deviations (either purple or blue) indicate that a particular dimension received a higher or a lower allocation, respectively, of a certain bill type compared to what would be expected if the distributions were independent. This helps provide insights into preferences or priorities, such as specific dimensions that tend to receive higher value bills (e.g., 100€) more frequently than others. The figure reveals both the distribution pattern across dimensions and significant differences in the allocation of resources. Professional accessibility is prioritized with higher monetary allocations, while other dimensions are associated with more evenly distributed monetary allocations or even with lower denominations.

Figure 1.

Standardized residuals heatmap from chi-square test (Monte Carlo simulations). Note: Purple indicates higher than expected frequencies, blue indicates lower than expected frequencies. Values >2 or <-2 suggest significant deviations from independence.

Furthermore, we examined the heterogeneity in the distribution of bills across the dimensions of PX prioritization by gender (29 identifying as men and 49 as women). Figure 2 reports the gender differences in the prioritization of the different PX dimensions. Although both gender coincided in allocating the highest percentage of their budget to Professional accessibility (21% in the case of men and 22% in that of women) and maintained Shared decisions, Environment, Information and Participation in an equivalent tier for budget distribution (with all four dimensions receiving between 10 and 12% of the overall budget), significant differences emerged in the statistical analyses conducted by gender for the Treatment and Respect and Therapeutic education dimensions. Men allocate a higher share of resources than women to Therapeutic Education (19% vs 16%), while women allocate a higher share of resources than men to Treatment and Respect (18% vs 14%).

Figure 2.

Percentage of budget distribution for the proposed PX dimensions by gender.

Figure 3 highlights the dimensions in which specific bill allocation preferences differ by gender when distributing a fixed budget across health PX priorities, providing insights into how men and women prioritize different aspects in budget distribution. Men presented a preference for allocating 100€ bills to the Environment dimension, which may indicate their prioritization of this area with a need for higher value investments (χ² = 6.542, df = 2, p = 0.038). Additionally, men tended to allocate 20€ bills to Information, suggesting this dimension is considered less of a priority. Conversely, women exhibited a different pattern, predominantly allocating 100€ bills to the Respectful treatment dimension (χ² = 4.684, df = 2, p = 0.096). Furthermore, women – in contrast here with men – showed a tendency to allocate 20€ bills to the Environment dimension.

Figure 3.

Standardized residuals heatmap from chi-square test by gender (Monte Carlo simulations). Note: Purple indicated higher than expected frequencies, blue indicates lower than expected frequencies. Values >2 or <-2 suggest significant deviations from independence. Each panel shows one gender.

Discussion

Our results show that having access to healthcare professionals is the most important priority for the participants, allocating the greatest share of the budget to this dimension (22%). This was followed by Therapeutic education (17%) and Respectful treatment (17%), with Shared decision-making (12%), Patient participation, Information, and the Physical environment (10%) occupying a third tier in their priorities.

Our results report a hierarchical logic in the prioritization of PX dimensions, suggesting that patients first value foundational aspects, access to professionals (22%) and the acquisition of information and therapeutic education (17%), before progressing to more active participation in decision-making. This sequence aligns with established models of patient activation, in which information acquisition precedes active involvement.³⁰

The emphasis on Therapeutic education (17%) underscores its critical role in the patient journey. Effective therapeutic education has been shown to improve PX, knowledge and skills acquisition, as well as health outcomes, increase adherence and enhanced quality of life,^31,32 while lack of comprehensive therapeutic education may lead to confusion, poor health management, and worse outcomes.³³

The shared prioritization of professional accessibility (22%) and therapeutic education (17%) by each gender suggests a clear demand for more timely, continuous, and patient-centred interaction with healthcare professionals. In this regard, digital health tools, such as telemedicine platforms and remote monitoring systems, able to capture real-time ePROMS and ePREMS, also offer promising strategies to enhance access and quality of care and extend therapeutic education beyond in-person visits.^34–36

Disaggregated results by gender reveal that men allocated more budget to Therapeutic education (19% vs 16% for women), while women prioritized Respectful treatment (18% vs 14% for men). Women also assigned a greater share of high-denomination bills (particularly 100€ notes) to Respectful Treatment, suggesting that they place a relatively higher value on interpersonal and compassionate care. This aligns with the denomination effect from behavioural economics, where higher-value bills are spent more deliberately.³⁷ This finding is consistent with the literature indicating that women often experience less favourable hospital interactions, particularly in communication, discharge, and cleanliness.^38,39 Women, in particular those with a higher education and aged between 45 and 64, tend to rate hospital care lower than men.⁴⁰ Similar trends have been observed in US Veterans Affairs hospitals, where women reported more negative experiences in areas like communication and access.⁴¹

The importance citizens, especially women, place on respectful patient-provider relationships and dignified treatment reveals that compassionate care represents a core expectation in healthcare service delivery. Respect has been linked to greater satisfaction, adherence, and even patient’s self-assessed ability to return to work.^42,43 Gender bias in pain management, for example, still contribute to delayed diagnosis and inadequate treatment, most strikingly in conditions like endometriosis, where pain is trivialized as routine menstrual discomfort, leading to an average diagnostic delay of 7 to 10 years.⁴⁴ These disparities reflect deep-rooted structural biases in medicine, reinforced through both formal training and implicit messaging in medical education.^45,46 These gendered differences underscore the need for gender-sensitive and intersectional approach in PX research and service design. Failing to account for these sociodemographic diversity risks rendering improvement strategies ineffective or inequitable.

Interestingly, the Environment dimension was among the least prioritized. Research show that the physical environment of hospitals can significantly influence both patient outcomes and the performance of healthcare professionals.⁴⁷ Elements such as cleanliness, noise levels and lighting tend to influence PX through less visible pathways, by improving staff satisfaction and efficiency, reducing clinical errors, and facilitating better communication.⁴⁸ But these effects are often indirect and less perceptible. Participants may have also considered infrastructure changes less feasible in our old building, a hospital founded in the 19th century.

In line with the principles of VBHC and the growing emphasis on PX, it is apparent that the active involvement of citizens, at both individual and collective levels, ensures that healthcare is more responsive and better aligned with the actual priorities of those it serves. By involving citizens directly in a budget allocation simulation, we gain invaluable insights into which specific factors are deemed most essential by citizens living in the area of influence of our tertiary-level university hospital, insights that fail to emerge from traditional, top-down quality improvement initiatives.²²

The PX Observatory at Hospital Clínic Barcelona provides an institutional model for this participatory approach, situated within Catalonia’s Value-Based Healthcare transformation.⁴⁹ It actively involves citizens in healthcare and health research,^9,50 facilitating shared ownership and the translation of user insights into feasible and sustainable changes.

The recent approval of a new health campus, including the HCB, the faculty of medicine and life sciences, and two research centres, offers a timely opportunity to expand this work. Our team is developing a cross-cutting participation strategy at Campus level with patients considered as partners. As part of this, we plan to digitalize and scale the current study into a citizen science initiative, to validate the pilot findings and build a community of patients engaged in shaping PX priorities and institutional transformation.

The study presents several limitations. It focused on a subset of patient experience dimensions derived from a locally validated framework, which, while grounded in extensive participatory work, may not capture the full range of PX elements identified in broader international literature. Although the sample was diverse, it remained limited in size and based on voluntary participation by citizens attending the open doors event at the HCB. Participants were self-selected and may have been more health-literate or engaged than the general population. As such, the findings cannot be deemed generalizable beyond this particular context.

Future research could further build on this work by conducting longitudinal studies to assess how PX evolves over time and across different contexts. In addition, expanding demographic data collection would allow for more intersectional analyses, considering how factors such as age, socioeconomic status and education shape healthcare priorities. Exploring the perspectives of healthcare professionals and testing alternative participatory formats could also help align stakeholder views. Finally, future research could examine how digital health interventions can be co-designed with patients to enhance accessibility to professionals, rather than replace interpersonal care, and improve PX, particularly in resource-constrained or high-demand environments.

Conclusion

This research underscores a critical gap in the way in which healthcare institutions approach PX: too often, teams design and implement PX initiatives without sufficient participation or without involving patients at all, essentially creating “patient experience for the patient, without the patient”. By directly engaging citizens, as was done here, healthcare organizations can better align their strategies with actual needs and preferences rather than having to rely on care providers’ assumptions. The overall goal for all healthcare institutions should be to develop PX improvements that are not only designed for their users but co-created with them as active partners in these efforts. Such a collaborative approach represents a fundamental shift from viewing citizens as passive recipients of care to recognizing them as essential contributors to healthcare design and delivery, thereby reinforcing a culture of health democracy.

Improving PX also requires acknowledging the realities faced by healthcare professionals. Barriers such as time constraints, uneven engagement, resistance to change, and lack of training must be addressed for PX efforts to succeed.⁵¹ The human experience framework emphasizes that compassionate care depends on a supportive work environment for staff.⁴ True transformation requires a symbiotic approach where the needs of both patients and professionals are addressed in parallel.⁵²

These insights can also support policy-makers, particularly in the context of VBHC reforms, by informing more equitable and targeted funding strategies. As bundled payment models become increasingly central to VBHC, aligning payment incentives with citizens’ prioritized experience dimensions may help ensure that financial mechanisms reward care practices that users truly value.

At a broader level, our findings also resonate with the WHO framework on health system responsiveness, which emphasizes on non-medical expectations such as dignity, autonomy, and prompt attention.⁵³ By surfacing locally defined priorities through a bottom-up approach, this study offers actionable insights that can support system-level improvements for a more responsive and people-centred care models.

Finally, while technology can address many aspects of PX, it is far from being the sole panacea. Creating a truly compassionate, respectful healthcare environment requires a concerted effort in leadership and organizational culture. Healthcare institutions must foster a culture of empathy, respect, and patient-centred care, driven by leaders who prioritize these values. Our study underscores the need to focus on improvement strategies in these dimensions and to do so with attention to gender-based differences. Ensuring that all patients, especially women, receive respectful and compassionate care should be the cornerstone of healthcare.

Footnotes

Acknowledgments

I would like to express my sincere gratitude to the entire Patient Experience Team for their dedicated support and collaboration. A special thanks goes to Dr Joan Escarrabill, a pioneer in introducing the concept of patient experience and value-based healthcare in our local context, whose vision and leadership on advancing patient-centred care have been truly inspirational. I also wish to acknowledge the exceptional support of our executive board, in particular Dr Josep Maria Campistol, the General Director of Hospital Clinic Barcelona, whose commitment to improving care from the patient’s perspective made possible the creation of our Patient Experience Unit—the first of its kind in a university hospital in our region. Finally, I extend heartfelt thanks to all the patients who have participated in our studies. Their generosity, time, and sincere desire to contribute to better care for those who will come after them are at the heart of everything we do. We acknowledge support from the grant CEX2023-0001290-S funded by MCIN/AEI/10.13039/501100011033, and support from the Generalitat de Catalunya through the CERCA Program. Rosario Scandurra is a Ramón y Cajal fellow (RYC2022-038527-I) funded by MICIU/AEI/10.13039/501100011033 and FSE+.

ORCID iDs

Anne-Sophie Gresle

Brittany Taylor

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Appendix

Annex A1.

Budget distribution across genders. Overall participants (n = 78).

	100 €	50 €	20 €	Total (€)	Mean (€)	%
Men (n = 29)
Therapeutic education	15	19	21	2.870	99	20
Environment	7	13	12	1.590	55	11
Participation	5	15	21	1.670	58	12
Shared decisions	5	17	18	1.710	59	12
Professional accessibility	18	16	21	3.020	104	21
Care information	5	11	27	1.590	55	11
Respectful treatment	5	21	25	2.050	71	14
Women (n = 49)
Therapeutic education	17	33	28	3.910	80	16
Environment	6	18	42	2.340	48	10
Participation	6	27	33	2.610	53	11
Shared decisions	10	26	32	2.940	60	12
Professional accessibility	31	32	36	5.420	111	22
Care information	10	24	27	2.740	56	11
Respectful treatment	21	36	32	4.540	93	19

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