Towards a Quality Care Climate Perspective: A Systematic Review of Associations Among Patient Experience, Patient Outcomes, and Organisational Climate Factors in Hospitals

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

I would like to sincerely thank you for the opportunity to review your manuscript entitled
“Towards a Quality Care Climate Perspective: A Review of Associations among Patient Experiences, Patient Outcomes and Organisational Climate in Hospitals.”

This is an ambitious, timely, and relevant study that synthesises an impressive body of evidence (220 studies) to examine links between organisational climate, patient experience, and outcomes, culminating in the conceptual proposal of a Quality Care Climate. The topic is of considerable importance to healthcare management, patient safety, and caring science.

The manuscript is clearly written, well-structured, and ethically sound. The research team has undertaken a large and complex review with care and rigor. I particularly commend the clarity of the background, the comprehensive search strategy, and the thoughtful attempt to integrate patient experience with organisational context.

Below I provide constructive comments aimed at helping you strengthen the scientific transparency and methodological robustness:

- Please expand the description of your synthesis methods. The process used to determine when an association was considered “positive” or “negative,” and how heterogeneity was handled, needs clarification. If meta-analysis was not feasible, explain why, and provide tabular summaries of directions and magnitudes of effects (where available).

-  Given the inclusion of varied study designs (cross-sectional, cohort, RCT, quasi-experimental), I suggest re-evaluating or at least justifying the use of a single adapted NIH tool. Consider supplementing it with design-specific tools (e.g., RoB 2 for RCTs, ROBINS-I for quasi-experimental studies). A table summarizing risk of bias by study type would be highly valuable.

- The decision to exclude qualitative studies is understandable but limits contextual insight. Please justify this decision more explicitly and consider adding a short complementary overview of key qualitative findings in the literature to illuminate mechanisms underlying associations.

- A concise table summarizing the main PREMs (e.g., HCAHPS, Picker, NORPEQ, national variants) and their psychometric status would enrich the paper and will also support your argument regarding the need for periodic validation of patient experience measures.

- Your proposed Quality Care Climate model is highly promising. However, to be theoretically useful, it needs further operational definition: identify its core dimensions and subcomponents; explain how it differs from existing constructs such as safety climate or service climate and outline how it could be empirically validated (e.g., scale development, factor structure, outcomes).

- Ensure that PROSPERO registration (CRD42021291787) is linked or cited with date of registration, and that any deviations from the protocol are transparently described. Note also that the PRISMA 2020 flow-diagram should be formatted and labelled in accordance with the official diagram format (https://www.prisma-statement.org/prisma-2020-flow-diagram) to ensure compliance with the statement’s standards.

- Your discussion is well grounded but could more explicitly, I suggest link findings to caring science principles and Donabedian’s framework. Explore implications for management and policy (e.g., leadership training, team climate interventions).

- Suggest priorities for future research, such as testing the proposed model quantitatively or incorporating patient and staff perspectives.

Author Response

Response to Reviewer 1 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
3. Point-by-point response to Comments and Suggestions for Authors
Comments 1: - Please expand the description of your synthesis methods. The process used to determine when an association was considered “positive” or “negative,” and how heterogeneity was handled, needs clarification. If meta-analysis was not feasible, explain why, and provide tabular summaries of directions and magnitudes of effects (where available)
Response 1: Under Data extraction and synthesis at the Method section, we have described how positive or negative associations were determined. We have also explained why meta-analysis was not feasible. Regarding, a table summary, Table 1 and the full version in the supplementary file provide information on the directions. We think assessing magnitude of effects is not necessary for the purpose and scope of this paper. Also, the interactive mapping in Figure III shows details of all included articles for further clarification. Heterogeneity was handled by synthesizing based on themes. For instance, the theme of forms of interventions focused mainly on intervention and RCTs.
Comments 2: Given the inclusion of varied study designs (cross-sectional, cohort, RCT, quasi-experimental), I suggest re-evaluating or at least justifying the use of a single adapted NIH tool. Consider supplementing it with design-specific tools (e.g., RoB 2 for RCTs, ROBINS-I for quasi-experimental studies). A table summarizing risk of bias by study type would be highly valuable.
Response 2: Although we somewhat agree, a huge majority of the studies were cross-sectional, cohort or observational and thus the NIH served very well. Secondly, we adapted questions from the tool which served all types of studies including RCTs. Thirdly, sensitivity was done among the authors with a high agreement. Unfortunately, a table of risk of bias is not probable and not feasible now considering the time frame.   Comment 3: The decision to exclude qualitative studies is understandable but limits contextual insight. Please justify this decision more explicitly and consider adding a short complementary overview of key qualitative findings in the literature to illuminate mechanisms underlying associations.   Response 3: While a complementary qualitative overview may be useful, we think that we touch on it in the theoretical proposition to explain why patients should be trusted. We have however provided more justification for excluding qualitative studies under Eligibility criteria at the Methods section.   Comment 4: A concise table summarizing the main PREMs (e.g., HCAHPS, Picker, NORPEQ, national variants) and their psychometric status would enrich the paper and will also support your argument regarding the need for periodic validation of patient experience measures.   Response 4: Thank you but I struggle to see how much this helps the entire focus of the paper. First, this is a consequent of the synthesis which we noted. Secondly, we cited a related paper which justifies the reexamination of a PREM. Current psychometric status is quite vague and that may mean actually testing them. Additionally, summarizing psychometric status for all these PREMs seems like a different review altogether with a different focus.   Comment 5: Your proposed Quality Care Climate model is highly promising. However, to be theoretically useful, it needs further operational definition: identify its core dimensions and subcomponents; explain how it differs from existing constructs such as safety climate or service climate and outline how it could be empirically validated (e.g., scale development, factor structure, outcomes).   Response 5: We have further defined the quality care climate framework and explained how it differs from other climate dimensions. Empirical validation would be based on further development as indicated in the recommendations for future studies.   Comment 6: Ensure that PROSPERO registration (CRD42021291787) is linked or cited with date of registration, and that any deviations from the protocol are transparently described. Note also that the PRISMA 2020 flow-diagram should be formatted and labelled in accordance with the official diagram format (https://www.prisma-statement.org/prisma-2020-flow-diagram) to ensure compliance with the statement’s standards.   Response 6: We have added date of registration to the citation under Method. We have also formatted the figure according to the prisma guidelines.   Comment 7: Your discussion is well grounded but could more explicitly, I suggest link findings to caring science principles and Donabedian’s framework. Explore implications for management and policy (e.g., leadership training, team climate interventions). Response 7: We have added more text to the end of the Discussion section in relation to this. Comment 8: Suggest priorities for future research, such as testing the proposed model quantitatively or incorporating patient and staff perspectives. Response 8: The study already has this under Recommendations section.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Title:

- Please clarify that the review is systematic and revise to a more concise form

Suggestion: “Quality Care Climate in Hospitals: A Systematic Review of Links Among Patient Experience, Outcomes, and Organizational Factors”

Abstract:

- Please start with a clear background to specify the rationale or gap motivating the inquiry and why these associations matter for healthcare outcomes or organizational policy

- The use of “these concepts” assumes prior knowledge. Please restate “patient experiences, outcomes, and organizational climate” for standalone clarity within the abstract

- Please specify the quality appraisal/risk of bias tool used

- Please state whether multiple reviewers conducted independent screening to reduce selection bias

- The phrase “more conclusive and generally positive” is too generic. Please detail which relationships (between patient experience and outcomes, or between climate and outcomes) were strongest or most supported

- Please define what constitutes “quality-oriented care climate theory” and how it builds upon existing organizational climate models

- Please elaborate how the mention of “subjective” versus “objective” outcomes could be operationalized or linked in future research

- The conclusion restates rather than synthesizes findings. Please strengthen the theoretical contribution by summarizing how the findings justify a “quality care climate” framework. Also add a sentence linking how the proposed framework could inform quality improvement initiatives or patient-centered strategies. Please specify examples such as communication quality, leadership climate, staff responsiveness

Introduction and rationale:

- Please integrate a brief statement clarifying how patient experience functions within the broader hospital climate framework

- Please reframe the sentence “Since the hospital is the framework” to emphasize the hospital environment as a mediating factor between experience and outcomes

- Please express more on the specific conceptual gap this review intends to fill

- Please clarify which dimensions are most relevant for linking with climate factors

- Please state that patient-based assessments complement, rather than replace, employee perspectives

- Please add a logical progression from the theoretical differentiation between organizational culture and climate to current empirical evidence on leadership and system-level drivers of organizational climate, before introducing the scope of the current systematic review  

Suggestion: “The current study however distinguishes between climate and culture, as done by MacDavitt et al. (2007), and focuses on the former, and its associations with patient-reported variables. Recent hospital-based evidence demonstrates that leadership style and Lean management capabilities can significantly enhance healthcare service quality, staff engagement, and patient satisfaction through structured process improvement frameworks https://doi.org/10.18549/PharmPract.2025.3.3263

Method:

- Please clarify whether this study protocol was registered in PROSPERO

- Please include the date of the last search and why overlap exists between PubMed and Medline

- Please add whether a third reviewer or consensus protocol was employed for unresolved disagreements

- Please consider including a summary table in the Results showing bias distribution across studies for readers’ assessment of evidence strength. Please specify if different instruments were applied depending on study type such as ROBINS-I for nonrandomized, Cochrane RoB for RCTs

- Please specify whether any data aggregation, thematic clustering, or meta-summary was used

Results:

- Country distribution is dominated by the USA (118/220 ≈ 54%); this creates contextual over-representation of HCAHPS-driven systems; Please analyze how health-system structure may bias associations and perform sensitivity analyses excluding USA studies

- Please report inter-rater reliability

- Please explore whether level-of-care, specialty mix, or occupancy moderates the size–experience association

Discussion:

- Please discuss how pay-for-performance and public reporting may inflate correlations (common-method/halo effects) and please conduct country-restricted sensitivity summaries (USA vs non-USA)

- Please add limitations paragraph after the Discussion before the conclusion. Also, several limitations should be acknowledged:

* Only English-language and peer-reviewed studies were included, potentially excluding relevant research published in other languages or grey literature

* The omission of qualitative data may have limited insight into contextual, experiential, and behavioral dimensions of organizational climate and patient experiences

* Limiting inclusion to inpatient populations, the review excludes valuable insights from outpatient, emergency, and primary care settings, which may reflect different organizational dynamics and patient experience patterns

* Variations in study designs, data collection instruments, and healthcare settings limited comparability and may have influenced synthesis accuracy

* Underrepresentation of low- and middle-income countries (LMICs)

Conclusion:

- Please revise the conclusion to emphasize conceptual contribution

- Please highlight implications for healthcare policy, leadership, and hospital quality improvement practices

- Please conclude with a forward-looking sentence that signals next research directions and potential for model validation

General:

- Please ensure English proofreading is completed to maintain grammatical consistency, avoid spelling mistakes, tense consistency, and ensure a uniform concise academic tone throughout the text.

- Use consistent terminology throughout the manuscript.

- Please ensure that the intext citation and reference list follows journal formatting guidelines

Author Response

Response to Reviewer 2 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
3. Point-by-point response to Comments and Suggestions for Authors
Comment 1: - Title: - Please clarify that the review is systematic and revise to a more concise form Suggestion: “Quality Care Climate in Hospitals: A Systematic Review of Links Among Patient Experience, Outcomes, and Organizational Factors”
Response 1: Thank you for the suggestion. We have added ‘systematic’ to the title.
Comment 2: Abstract: - Please start with a clear background to specify the rationale or gap motivating the inquiry and why these associations matter for healthcare outcomes or organizational policy - The use of “these concepts” assumes prior knowledge. Please restate “patient experiences, outcomes, and organizational climate” for standalone clarity within the abstract - Please specify the quality appraisal/risk of bias tool used - Please state whether multiple reviewers conducted independent screening to reduce selection bias - The phrase “more conclusive and generally positive” is too generic. Please detail which relationships (between patient experience and outcomes, or between climate and outcomes) were strongest or most supported - Please define what constitutes “quality-oriented care climate theory” and how it builds upon existing organizational climate models - Please elaborate how the mention of “subjective” versus “objective” outcomes could be operationalized or linked in future research - The conclusion restates rather than synthesizes findings. Please strengthen the theoretical contribution by summarizing how the findings justify a “quality care climate” framework. Also add a sentence linking how the proposed framework could inform quality improvement initiatives or patient-centered strategies. Please specify examples such as communication quality, leadership climate, staff responsiveness.
Response 2: These comments on the abstract are quite difficult to follow. The details of all these are in the paper. Considering the word limit and the nature of abstracts, incorporating these comments are nearly impossible and unnecessary. I have, however, made a few changes.   Comment 3: Introduction and rationale: - Please integrate a brief statement clarifying how patient experience functions within the broader hospital climate framework Response: The first two sentences indicate how patient experience functions: as an indicator and determinant of healthcare quality.   - Please reframe the sentence “Since the hospital is the framework” to emphasize the hospital environment as a mediating factor between experience and outcomes Response: It says the hospital is the framework within with healthcare is delivered and thus the environment counts for something. It is not necessarily a mediating factor (although I can understand the confusion based on the figure I, which is only a search framework). It would not be adequate to describe it as merely a mediator. It goes beyond that since patients interact and experience with hospital factors (as clearly indicated in the manuscript).   - Please express more on the specific conceptual gap this review intends to fill Response: Quite vague but we have specified this optimally.   - Please clarify which dimensions are most relevant for linking with climate factors Response: I do not understand this comment but we have clarified foundational climate factors and specific climate factors. - Please state that patient-based assessments complement, rather than replace, employee perspectives Response: Under the ‘Quality Care Climate’ we have already indicated the complementary nature. We did not indicate a replacement.   - Please add a logical progression from the theoretical differentiation between organizational culture and climate to current empirical evidence on leadership and system-level drivers of organizational climate, before introducing the scope of the current systematic review   Suggestion: “The current study however distinguishes between climate and culture, as done by MacDavitt et al. (2007), and focuses on the former, and its associations with patient-reported variables. Recent hospital-based evidence demonstrates that leadership style and Lean management capabilities can significantly enhance healthcare service quality, staff engagement, and patient satisfaction through structured process improvement frameworks https://doi.org/10.18549/PharmPract.2025.3.3263 Response: Thank you but I do not see the relevance of this comment and the suggested inclusion to the current study.   Comment: Method: - Please clarify whether this study protocol was registered in PROSPERO Response: Clarified.   - Please include the date of the last search and why overlap exists between PubMed and Medline Response: I Last date of search has been included under Search strategy and information sources. We do not know why overlaps exist between PubMed and Medline but it is quite common.   - Please add whether a third reviewer or consensus protocol was employed for unresolved disagreements Response: The review team was made up of 5 member and all disagreements were resolved.   - Please consider including a summary table in the Results showing bias distribution across studies for readers’ assessment of evidence strength. Please specify if different instruments were applied depending on study type such as ROBINS-I for nonrandomized, Cochrane RoB for RCTs Response: A huge majority of the studies were cross-sectional, cohort or observational and thus the NIH served very well. Secondly, we adapted questions from the tool which served all types of studies including RCTs. Thirdly, sensitivity was done among the authors with a high agreement. Unfortunately, a table of risk of bias is not probable and not feasible now considering the time frame.   - Please specify whether any data aggregation, thematic clustering, or meta-summary was used Response: Qualitative synthesis based on themes was used, as already specified in the study.     Comment: Results: - Country distribution is dominated by the USA (118/220 ≈ 54%); this creates contextual over-representation of HCAHPS-driven systems; Please analyze how health-system structure may bias associations and perform sensitivity analyses excluding USA studies Response: We have added a summary of this at the end of the Overview of Associations.   - Please report inter-rater reliability Response: We have reported this under Study quality and sensitivity analysis.   - Please explore whether level-of-care, specialty mix, or occupancy moderates the size–experience association Response: We indicated how number of beds (occupancy) defined size and showed how associations differed between small and big hospitals under Groups of comparisons. Level of care and specialty mix are not applicable considering the articles included.     Comment: Discussion: - Please discuss how pay-for-performance and public reporting may inflate correlations (common-method/halo effects) and please conduct country-restricted sensitivity summaries (USA vs non-USA) Response: We have added some text to the first paragraph of the Discussion to address this. - Please add limitations paragraph after the Discussion before the conclusion. Also, several limitations should be acknowledged: Response: We have repositioned the limitations and added these. * Only English-language and peer-reviewed studies were included, potentially excluding relevant research published in other languages or grey literature * The omission of qualitative data may have limited insight into contextual, experiential, and behavioral dimensions of organizational climate and patient experiences * Limiting inclusion to inpatient populations, the review excludes valuable insights from outpatient, emergency, and primary care settings, which may reflect different organizational dynamics and patient experience patterns * Variations in study designs, data collection instruments, and healthcare settings limited comparability and may have influenced synthesis accuracy * Underrepresentation of low- and middle-income countries (LMICs)   Comment: Conclusion: - Please revise the conclusion to emphasize conceptual contribution - Please highlight implications for healthcare policy, leadership, and hospital quality improvement practices - Please conclude with a forward-looking sentence that signals next research directions and potential for model validation Response: We have added some text to the conclusion to address these.   Comment: General: - Please ensure English proofreading is completed to maintain grammatical consistency, avoid spelling mistakes, tense consistency, and ensure a uniform concise academic tone throughout the text. - Use consistent terminology throughout the manuscript. - Please ensure that the intext citation and reference list follows journal formatting guidelines Response: We have addressed these.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for submitting the paper to the International Journal of Environmental Research and Public Health

 

Towards a quality care climate perspective: a review of associa- 2 tions among patient experiences, patient outcomes and organi- 3 sational climate in hospitals .

 

This paper is well-written, interesting, and addresses an important and timely topic. However, some comments need to be addressed.

 

• Title: is clear and informative. However, consider shortening it slightly for conciseness while retaining key elements. 

 

• Abstract: The abstract includes two research questions but does not clearly present the overall aim or purpose of the review in a single, explicit statement. While the questions outline what was examined, the reader should be able to identify the main aim or objective directly and succinctly. For example: start with this review aim… then… The authors said, “Quality assessments were done on the remaining 19 articles.” But how, using which checklist?

 

• Introduction: The introduction begins directly with “Patient experience is deemed as an essential and well-recognised indicator for assessing hospital performance.” While accurate, this opening could be strengthened by first providing a broader conceptual statement about what patient experience entails before emphasizing its importance. I suggested considering starting the introduction with a more general definition and recent refernce, such as: “Patient experience refers to the range of interactions patients have with the healthcare system, including healthcare providers, staff, and facilities[1].”
• Alsubahi, N., Pavlova, M., Alzahrani, A. A., Ahmad, A. E., & Groot, W. (2025). The Association Between Patient-Reported Experience Measures and Patient-Reported Outcome Measures Among Patients With Diabetes in the Kingdom of Saudi Arabia. Value in Health Regional Issues, 101149.

 

The sentence “The increasing attention on patient experience has also yielded research on its relationships with patient outcomes such as patient satisfaction (Oyvind Bjertnaes et al., 2012; Jenkinson et al., 2002; Rathert et al., 2011; Taylor et al., 2019)” relies mainly on older references, some of which are over a decade old.Consider updating this section with more recent studies (2022–2025) to reflect current research trends on patient experience and patient outcomes. For instance, recent studies and international studies—such as:

Alsubahi, N., Groot, W., Alzahrani, A. A., Ahmad, A. E., & Pavlova, M. (2025). Patient-centered care and satisfaction of patients with diabetes: insights from a survey among patients at primary healthcare centers in Saudi Arabia. BMC primary care, 26(1), 140.

Healthcare quality from the perspective of patients in Gulf Cooperation Council countries: A systematic literature review

Wong, E. L. Y., et al. (2022). Patient experience and satisfaction in healthcare systems: Recent evidence and policy implications. Health Policy.
Adding recent references would strengthen the scientific currency of the paper and better demonstrate how the field has evolved since 2022.

 

• In the Risk of bias and overall quality assessments, not clear which tool used, please add the tables in appendix.
• Figure II Flow diagram from literature identification to final inclusion( use the PRISMA 2020 diagram)

 

Disscuion

The discussion correctly highlights that most studies using secondary data were conducted in countries with well-established and publicly accessible health databases (e.g., the U.S. and Norway). However, it would be valuable to acknowledge that several countries in Asia, such as Saudi Arabia, China, and South Korea, have recently developed national patient experience measurement systems and hospital performance initiatives.

Please consider expanding this section by noting the growing body of work from Asian contexts—particularly studies from Saudi Arabia, which have explored patient experience and satisfaction using national and regional survey data. Including such studies would strengthen the global perspective of the review. For instance, you may wish to cite:

• Healthcare quality from the perspective of patients in Gulf Cooperation Council countries: A systematic literature review
• Patient-centered care and satisfaction of patients with diabetes: insights from a survey among patients at primary healthcare centers in Saudi Arabia
• The Association Between Patient-Reported Experience Measures and Patient-Reported Outcome Measures Among Patients With Diabetes in the Kingdom of Saudi Arabia

This recent references provides relevant evidence from the Gulf region and supports the discussion on expanding validated patient experience measures beyond Western contexts.

 

 

 

Overall: The review covers studies published between 2007 and 2022, which provides a strong historical overview. However, several new studies on patient experience, patient outcomes, and organisational climate have been published since 2022.

It would be valuable to update the literature search to include studies from 2023–2025, as recent years have seen increasing research on patient experience measurement, hospital quality climate, and patient-centered care, particularly in Asia and the Middle East. Updating the review period will enhance the relevance and comprehensiveness of the findings and ensure that the conclusions reflect the most current evidence.

Register the review in PROSPERO

Author Response

Response to Reviewer 3 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

 

 

3. Point-by-point response to Comments and Suggestions for Authors

Comment: - Title: is clear and informative. However, consider shortening it slightly for conciseness while retaining key elements.

Response: Thank you for the suggestion. We have considered it.

 

 

Comment: Abstract: The abstract includes two research questions but does not clearly present the overall aim or purpose of the review in a single, explicit statement. While the questions outline what was examined, the reader should be able to identify the main aim or objective directly and succinctly. For example: start with this review aim… then… The authors said, “Quality assessments were done on the remaining 19 articles.” But how, using which checklist?

 

Response: Thank you. We have added the aim of the study.

 

 

Comment: Introduction: The introduction begins directly with “Patient experience is deemed as an essential and well-recognised indicator for assessing hospital performance.” While accurate, this opening could be strengthened by first providing a broader conceptual statement about what patient experience entails before emphasizing its importance. I suggested considering starting the introduction with a more general definition and recent refernce, such as: “Patient experience refers to the range of interactions patients have with the healthcare system, including healthcare providers, staff, and facilities[1].”

Alsubahi, N., Pavlova, M., Alzahrani, A. A., Ahmad, A. E., & Groot, W. (2025). The Association Between Patient-Reported Experience Measures and Patient-Reported Outcome Measures Among Patients With Diabetes in the Kingdom of Saudi Arabia. Value in Health Regional Issues, 101149

 

Response: There is a subsection explaining what patient experience entails so we believe that is adequate.

 

 

Comment: The sentence “The increasing attention on patient experience has also yielded research on its relationships with patient outcomes such as patient satisfaction (Oyvind Bjertnaes et al., 2012; Jenkinson et al., 2002; Rathert et al., 2011; Taylor et al., 2019)” relies mainly on older references, some of which are over a decade old.Consider updating this section with more recent studies (2022–2025) to reflect current research trends on patient experience and patient outcomes. For instance, recent studies and international studies—such as:

Alsubahi, N., Groot, W., Alzahrani, A. A., Ahmad, A. E., & Pavlova, M. (2025). Patient-centered care and satisfaction of patients with diabetes: insights from a survey among patients at primary healthcare centers in Saudi Arabia. BMC primary care, 26(1), 140.

Healthcare quality from the perspective of patients in Gulf Cooperation Council countries: A systematic literature review

Wong, E. L. Y., et al. (2022). Patient experience and satisfaction in healthcare systems: Recent evidence and policy implications. Health Policy.
Adding recent references would strengthen the scientific currency of the paper and better demonstrate how the field has evolved since 2022.

Response: While this is a useful comment, we believe the current scope is appropriate and any major change to the scope would disrupt the flow of the study. Future research has been recommended which could tackle the issue from 2022 forward.

 

 

 

Comment: In the Risk of bias and overall quality assessments, not clear which tool used, please add the tables in appendix.

Response: We have indicated the tool used and also addressed the possibility of a table.

 

Comment: Figure II Flow diagram from literature identification to final inclusion (use the PRISMA 2020 diagram)

Response: We have formatted the figure.

 

 

 

Comment: Discussion

The discussion correctly highlights that most studies using secondary data were conducted in countries with well-established and publicly accessible health databases (e.g., the U.S. and Norway). However, it would be valuable to acknowledge that several countries in Asia, such as Saudi Arabia, China, and South Korea, have recently developed national patient experience measurement systems and hospital performance initiatives.

Please consider expanding this section by noting the growing body of work from Asian contexts—particularly studies from Saudi Arabia, which have explored patient experience and satisfaction using national and regional survey data. Including such studies would strengthen the global perspective of the review. For instance, you may wish to cite:

Healthcare quality from the perspective of patients in Gulf Cooperation Council countries: A systematic literature review

Patient-centered care and satisfaction of patients with diabetes: insights from a survey among patients at primary healthcare centers in Saudi Arabia

The Association Between Patient-Reported Experience Measures and Patient-Reported Outcome Measures Among Patients With Diabetes in the Kingdom of Saudi Arabia

This recent references provides relevant evidence from the Gulf region and supports the discussion on expanding validated patient experience measures beyond Western contexts.

Response: We do not think adding these would change the texture and direction of the discussion. It would only be a buttress to what has already been discussed. Also, the discussion mainly focused on the included studies so discussing studies outside the review would be pointless.

 

 

 

Comment: Overall: The review covers studies published between 2007 and 2022, which provides a strong historical overview. However, several new studies on patient experience, patient outcomes, and organisational climate have been published since 2022.

It would be valuable to update the literature search to include studies from 2023–2025, as recent years have seen increasing research on patient experience measurement, hospital quality climate, and patient-centered care, particularly in Asia and the Middle East. Updating the review period will enhance the relevance and comprehensiveness of the findings and ensure that the conclusions reflect the most current evidence.

Response: We think further studies could tackle the issue from 2022 forward.

 

Comment: Register the review in PROSPERO

Response: We have registered in PROSPERO.

 

 

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

I would like to thank the authors for carefully addressing all review comments and substantially strengthening the manuscript.

Regards,

Author Response

Thank you for your review.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for your revisions. However, after reviewing the updated manuscript and your responses, I must note that several key issues raised in the first round have not been adequately addressed. Many of the responses did not align with the required corrections, and essential revisions remain missing from the manuscript.

I kindly request that you carefully review all comments and ensure that each one is fully addressed within the manuscript, not only in the response document. Please incorporate the required updates accordingly and ensure compliance with standard systematic review guidelines (e.g., PRISMA, transparent reporting of quality assessment tools, PROSPERO details, updated recent literature, and proper contextualization in the discussion).For your convenience and clarity, I have provided detailed comments in the review, which specify the necessary actions. I expect these revisions to be implemented thoroughly before the manuscript can proceed further in the review process.

 

Comment 1: Abstract: The authors have revised the abstract to include an aim statement; however, they have not addressed the second part of my original comment. Specifically, the abstract still states that “Quality assessments were done on the remaining 19 articles” without specifying how these assessments were conducted or which tool/checklist was used. For transparency and scientific rigor, readers must be informed of the methodology applied. Therefore, the authors should explicitly state the checklist used for the quality assessment directly in the abstract (e.g., “using the … Critical Appraisal Checklists” or whichever tool was actually used). Also, you should add the quality tables to the appendix.

 

Comment 2: Introduction: The justification provided is not sufficient. While a subsection later in the introduction may explain what patient experience entails, my comment specifically referred to the opening sentence of the introduction. The introduction should begin by framing the concept before discussing its importance. Starting immediately with performance indicators omits the broader conceptual foundation, which is a key element of academic writing structure.

I strongly recommend restructuring the opening to include a general definition of patient experience supported by a recent reference. For example, the definition and reference previously suggested:

“Patient experience refers to the range of interactions patients have with the healthcare system, including healthcare providers, staff, and facilities.”

References

1-The Association Between Patient-Reported Experience Measures and Patient-Reported Outcome Measures Among Patients With Diabetes in the Kingdom of Saudi Arabia

2-Association of patient experience and the quality of hospital care

 

 

Comment 3: The sentence “The increasing attention on patient experience has also yielded research on its relationships with patient outcomes such as patient satisfaction (Oyvind Bjertnaes et al., 2012; Jenkinson et al., 2002; Rathert et al., 2011; Taylor et al., 2019)” relies mainly on older references, some of which are over a decade old.Consider updating this section with more recent studies (2022–2025). the authors’ justification is not acceptable.

My original comment did not request a change in the study scope. It requested updated citations to strengthen the scientific relevance of a specific sentence. Updating references does not alter the study design, research questions, or scope — it simply ensures the introduction reflects the current state of knowledge (2022–2025), which is a standard requirement for publication quality.

Relying primarily on older references from more than a decade ago weakens the paper, especially in a field that has advanced significantly in recent years. Adding at least a few recent, high-quality studies to support the claim would enhance the credibility of the manuscript without disrupting its structure or flow.

I therefore strongly request that the authors revise this section by incorporating relevant recent literature before the manuscript can be considered further.

 

3-Patient-centered care and satisfaction of patients with diabetes: insights from a survey among patients at primary healthcare centers in Saudi Arabia. BMC primary care, 26(1), 140.

4-Healthcare quality from the perspective of patients in Gulf Cooperation Council countries: A systematic literature review

5-Wong, E. L. Y., et al. (2022). Patient experience and satisfaction in healthcare systems: Recent evidence and policy implications. Health Policy.

6-Patient-reported experience, patient-reported outcome and overall satisfaction with care: What matters most to people with diabetes?
Adding recent references would strengthen the scientific currency of the paper and better demonstrate how the field has evolved since 2022.

 

Comment 4: In the Risk of bias and overall quality assessments, simply mentioning the tool used is not sufficient. For systematic reviews, reporting risk of bias and quality assessments must follow established standards, such as PRISMA. It is standard practice (and a requirement in published systematic reviews) to provide a detailed table of the quality assessment for each included study, typically in the appendix or supplementary materials. The authors’ response that they “addressed the possibility of a table” is not aligned with PRISMA guidelines. This is not optional; readers must be able to see the scoring and evaluation of each study.

 

Comment 5: Discussion

The purpose of the discussion section in a systematic review is not only to summarize the included studies, but also to contextualize the findings within the broader international evidence base. This is a fundamental expectation of high-quality systematic reviews.

The point previously raised is not to change the “texture and direction” of the discussion, but to ensure the review:

Countries such as Saudi Arabia, China, and South Korea have made significant progress in developing national patient experience initiatives, including published work directly relevant to the themes reported in this review. Ignoring recent developments in these regions limits the completeness and global applicability of the discussion.

It is entirely appropriate  and expected  to cite relevant external studies in the discussion to contextualize the implications of the findings. This does not alter the results or scope of the review; it simply ensures a balanced and internationally informed interpretation. Therefore, I strongly request that the authors revise the discussion to acknowledge recent progress in Asia( check references above or search also for recent only), supported by appropriate citations. This is essential for improving scientific rigor and relevance.

 

 

Comment 6: Updating the literature search to include studies published after 2022 is not a suggestion for “future studies” but a required component of ensuring the relevance and completeness of this systematic review. The field of patient experience and patient-centered care has evolved rapidly in recent years, particularly with significant developments in Asia and the Middle East. Restricting the search to 2007–2022 excludes a growing and important body of current evidence and weakens the validity of the review’s conclusions. Therefore, the authors must update the search to include studies from 2023–2025 and revise the results and discussion accordingly for the manuscript to be considered scientifically current.

 

Comment 7: Although the authors state that the review has been registered in PROSPERO, the registration number and date are not reported anywhere in the manuscript. This information must be transparently included in the Methods section (e.g., “This review was registered in PROSPERO under registration number: XXXX, registered on DD/MM/YYYY”) so that readers can verify the protocol and compliance with prospective registration standards. Registration details are mandatory for transparency and credibility, and should be added before the manuscript can proceed.

 

 

For all the issues above, a Major revision is required before the manuscript can be reconsidered for publication.

Author Response

Response to Reviewer 3 Comments
1. Summary
Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.
3. Point-by-point response to Comments and Suggestions for Authors
Comment 1: Abstract: The authors have revised the abstract to include an aim statement; however, they have not addressed the second part of my original comment. Specifically, the abstract still states that “Quality assessments were done on the remaining 19 articles” without specifying how these assessments were conducted or which tool/checklist was used. For transparency and scientific rigor, readers must be informed of the methodology applied. Therefore, the authors should explicitly state the checklist used for the quality assessment directly in the abstract (e.g., “using the … Critical Appraisal Checklists” or whichever tool was actually used). Also, you should add the quality tables to the appendix.
Response 1: I have added the tool to the abstract. Quality table has been added as a supplementary file.
Comment 2: Introduction: The justification provided is not sufficient. While a subsection later in the introduction may explain what patient experience entails, my comment specifically referred to the opening sentence of the introduction. The introduction should begin by framing the concept before discussing its importance. Starting immediately with performance indicators omits the broader conceptual foundation, which is a key element of academic writing structure. I strongly recommend restructuring the opening to include a general definition of patient experience supported by a recent reference. For example, the definition and reference previously suggested: “Patient experience refers to the range of interactions patients have with the healthcare system, including healthcare providers, staff, and facilities.” References 1-The Association Between Patient-Reported Experience Measures and Patient-Reported Outcome Measures Among Patients With Diabetes in the Kingdom of Saudi Arabia 2-Association of patient experience and the quality of hospital care
Response 2: I have added the definition at the beginning. Since the paper adopted a definition, I used that instead of the suggested definition.     Comment 3: The sentence “The increasing attention on patient experience has also yielded research on its relationships with patient outcomes such as patient satisfaction (Oyvind Bjertnaes et al., 2012; Jenkinson et al., 2002; Rathert et al., 2011; Taylor et al., 2019)” relies mainly on older references, some of which are over a decade old.Consider updating this section with more recent studies (2022–2025). the authors’ justification is not acceptable. My original comment did not request a change in the study scope. It requested updated citations to strengthen the scientific relevance of a specific sentence. Updating references does not alter the study design, research questions, or scope — it simply ensures the introduction reflects the current state of knowledge (2022–2025), which is a standard requirement for publication quality. Relying primarily on older references from more than a decade ago weakens the paper, especially in a field that has advanced significantly in recent years. Adding at least a few recent, high-quality studies to support the claim would enhance the credibility of the manuscript without disrupting its structure or flow. I therefore strongly request that the authors revise this section by incorporating relevant recent literature before the manuscript can be considered further.   3-Patient-centered care and satisfaction of patients with diabetes: insights from a survey among patients at primary healthcare centers in Saudi Arabia. BMC primary care, 26(1), 140. 4-Healthcare quality from the perspective of patients in Gulf Cooperation Council countries: A systematic literature review 5-Wong, E. L. Y., et al. (2022). Patient experience and satisfaction in healthcare systems: Recent evidence and policy implications. Health Policy. 6-Patient-reported experience, patient-reported outcome and overall satisfaction with care: What matters most to people with diabetes? Adding recent references would strengthen the scientific currency of the paper and better demonstrate how the field has evolved since 2022. Response: I have added one of the suggested references.   Comment 4: In the Risk of bias and overall quality assessments, simply mentioning the tool used is not sufficient. For systematic reviews, reporting risk of bias and quality assessments must follow established standards, such as PRISMA. It is standard practice (and a requirement in published systematic reviews) to provide a detailed table of the quality assessment for each included study, typically in the appendix or supplementary materials. The authors’ response that they “addressed the possibility of a table” is not aligned with PRISMA guidelines. This is not optional; readers must be able to see the scoring and evaluation of each study. Response: A table showing quality assessments and risk analysis has been added as a supplementary file.   Comment 5: Discussion The purpose of the discussion section in a systematic review is not only to summarize the included studies, but also to contextualize the findings within the broader international evidence base. This is a fundamental expectation of high-quality systematic reviews. The point previously raised is not to change the “texture and direction” of the discussion, but to ensure the review: Countries such as Saudi Arabia, China, and South Korea have made significant progress in developing national patient experience initiatives, including published work directly relevant to the themes reported in this review. Ignoring recent developments in these regions limits the completeness and global applicability of the discussion. It is entirely appropriate  and expected  to cite relevant external studies in the discussion to contextualize the implications of the findings. This does not alter the results or scope of the review; it simply ensures a balanced and internationally informed interpretation. Therefore, I strongly request that the authors revise the discussion to acknowledge recent progress in Asia( check references above or search also for recent only), supported by appropriate citations. This is essential for improving scientific rigor and relevance. Response: An addition has been made to include this.   Comment 6: Updating the literature search to include studies published after 2022 is not a suggestion for “future studies” but a required component of ensuring the relevance and completeness of this systematic review. The field of patient experience and patient-centered care has evolved rapidly in recent years, particularly with significant developments in Asia and the Middle East. Restricting the search to 2007–2022 excludes a growing and important body of current evidence and weakens the validity of the review’s conclusions. Therefore, the authors must update the search to include studies from 2023–2025 and revise the results and discussion accordingly for the manuscript to be considered scientifically current. Response: I disagree with this comment that it is a required component. Updating the search to revise the results and discussion means largely redoing the entire study which at this point is not reasonable and not feasible. The scope of the study has been clearly defined. Any search beyond this scope is more appropriate for another study. Considering the aim and conclusion, an update will only buttress the conclusion. The study sought to see the conclusiveness of the relationships between the variables. The main finding confirms this conclusiveness. So, again, I strongly believe future studies could tackle an update.   Comment 7: Although the authors state that the review has been registered in PROSPERO, the registration number and date are not reported anywhere in the manuscript. This information must be transparently included in the Methods section (e.g., “This review was registered in PROSPERO under registration number: XXXX, registered on DD/MM/YYYY”) so that readers can verify the protocol and compliance with prospective registration standards. Registration details are mandatory for transparency and credibility, and should be added before the manuscript can proceed. Response: We have included the date and ID under Method.