Development and psychometric testing of the quality of care for trauma patients scale using exploratory and confirmatory factor analysis
-
Ehsan Sarbazi
,
Homayoun Sadeghi-Bazargani
,
Mostafa farahbakhsh
,
Alireza Ala
,
Amirhesam Pouraghaei
,
Hassan Soleimanpour
Abstract
Objective: Identifying trauma care quality from the trauma victims' viewpoints is key to patient-centered care, identifying service gaps, developing effective protocols, and building trust in medicine. The current study aims to establish a new quality of trauma care questionnaire and to assess its psychometric characteristics within the hospital context in Iran. Methods: First, items were developed through a combination of literature review and interviews. Then, the validity of the items, including content, face, and internal consistency, was evaluated. Construct validity was assessed using exploratory factor analysis (EFA) on a sample of 220 patients, followed by confirmatory factor analysis (CFA) with a separate group of 253 patients from August to October 2022. Results: Content validity, as measured using modified Kappa, was 0.95. Cronbach's alpha for internal consistency was 0.91, and test-retest reliability over two weeks was 0.94. The EFA revealed four factors: interpersonal quality, technical quality, outcome quality, and non-medical quality, which collectively accounted for 67% of the total variance in measuring the quality of care in trauma victims. Using CFA, researchers validated the final version of the trauma quality scale from patients' perspective (TQS-PP), which includes 22 items across four dimensions. The CFA model of the TQS-PP demonstrated an acceptable fit, with χ2/df = 2.064, RMSEA=0.058, CFI=0.912, and NNFI=0.920. Conclusion: Psychometric evaluations demonstrated sufficient validity and reliability for TQS-PP application in quality research involving trauma victims in Iran. The developed and evaluated TQS-PP serves as a reliable measure of health care quality from the perspective of trauma victims. The new tool could assist public health researchers in assessing the quality of care in emergency departments (EDs) and similar contexts.
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3. Naghavi M, Shahraz S, Bhalla K, Jafari N, Pourmalek F, Bartels D, et al. Adverse health outcomes of road traffic injuries in Iran after rapid motorization. 2009.
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12. Fecso AB, Szasz P, Kerezov G, Grantcharov TP. The effect of technical performance on patient outcomes in surgery: a systematic review. Ann Surg. 2017;265(3):492-501.
13. Endeshaw B. Healthcare service quality-measurement models: a review. Journal of Health Research. 2021;35(2):106-17.
14. Li Min LM, Lowrie D, Huang ChengYu HC, Lu XiangChan LX, Zhu YingChu ZY, Wu XingHua WX, et al. Evaluating patients' perception of service quality at hospitals in nine Chinese cities by use of the ServQual scale. Asian Pac J Trop Biomed. 2015:1-8.
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16. Zarei E. Service quality of hospital outpatient departments: patients’ perspective.Int J Health Care Qual Assur. 2015;28(8):778-90.
17. Manulik S, Rosińczuk J, Karniej P. Evaluation of health care service quality in Poland with the use of SERVQUAL method at the specialist ambulatory health care center. Patient Prefer Adherence. 2016:1435-42.
18. Singh A, Prasher A. Measuring healthcare service quality from patients’ perspective: using Fuzzy AHP application. Total Quality Management & Business Excellence. 2019;30(3-4):284-300.
19. Upadhyai R, Upadhyai N, Jain AK, Chopra G, Roy H, Pant V. Development and validation of a scale for measuring hospital service quality: a dyadic approach. Journal of Health Research. 2022;36(3):473-83.
20. Abbasi-Moghaddam MA, Zarei E, Bagherzadeh R, Dargahi H, Farrokhi P. Evaluation of service quality from patients’ viewpoint. BMC Health Serv Res. 2019;19:1-7.
21. Jamshidi Z, Norouzi Tabrizi K, Khankeh H, Zeraati Nasrabadi M, Sadeghi H, Eghbali M. Design and psychometric properties of the acute care quality in trauma emergency units scale. Eur J Trauma Emerg Surg. 2024;50(2):447-53.
22. Muntlin Å, Gunningberg L, Carlsson M. Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement. J Clin Nurs. 2006;15(8):1045-56.
23. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007;30(4):459-67.
24. Munro BH. Statistical methods for health care research: lippincott williams & wilkins; 2005.
25. Sarbazi E, Sadeghi-Bazargani H, Sheikhalipour Z, Farahbakhsh M, Ala A, Soleimanpour H. Trust in Medicine: a scoping review of the instruments designed to measure trust in medical care studies. J Caring Sci. 2024;13(2):2.
26. Sadeghi-Bazargani H, Razzaghi A, Atabak A, Bazargani-Hejazi S, Basirat SB, Doshmangir L, et al. Setting research priorities to achieve long-term national road safety goals in Iran. J Glob Health. 2022;12:09002.
27. Liu Y, Aungsuroch Y, Gunawan J, Sha L, Shi T. Development and psychometric evaluation of a quality nursing care scale from nurses’ perspective. Nurs Open. 2021;8(4):1741-54.
28. Soleimanpour H, Gholipouri C, Salarilak S, Raoufi P, Vahidi RG, Rouhi AJ, et al. Emergency department patient satisfaction survey in Imam Reza hospital, Tabriz, Iran. Int J Emerg Med. 2011;4:1-7.
29. Larsson G, Wilde‐Larsson B. Quality of care and patient satisfaction: a new theoretical and methodological approach. Int J Health Care Qual Assur . 2010;23(2):228-47.
30. Bobrovitz N, Santana MJ, Kline T, Kortbeek J, Widder S, Martin K, et al. Multicenter validation of the quality of trauma care patient-reported experience measure (QTAC-PREM). J Trauma Acute Care Surg. 2016;80(1):111-8.
31. Grøndahl VA, Karlsson I, Hall‐Lord ML, Appelgren J, Wilde‐Larsson B. Quality of care from patients’ perspective: impact of the combination of person‐related and external objective care conditions. J Clin Nurs. 2011;20(17‐18):2540-51.
32. Tawil S, Iskandar K, Salameh P. Pain management in hospitals: patients’ satisfaction and related barriers. Pharm Prac (Granada). 2018;16(3).
33. Otani K, Chumbler NR, Herrmann PA, Kurz RS. Impact of pain on patient satisfaction integration process: how patients with pain combine their health care attribute reactions. Health Serv Res Manag Epidemiol. 2015;2:2333392815615103.
34. La Vonne AD, Zun LS. Pain management in the emergency department and its relationship to patient satisfaction. J Emerg Trauma Shock . 2010;3(4):326-30.
35. Mosadeghrad AM. A conceptual framework for quality of care. Materia socio-medica. 2012;24(4):251.
36. Sarbazi E, Sadeghi-Bazargani H, Farahbakhsh M, Ala A, Soleimanpour H. Psychometric properties of trust in trauma care in an emergency department tool. Eur J Trauma Emerg Surg. 2023;49(6):2615-22.
37. Mallett-Smith S, Jadalla A, Hardan-Khalil K, Sarff L, Brady M. Implementation of an assault prevention quality improvement initiative in an urban emergency department.J Nurs Care Qual. 2023;38(4):341-7.
38. Sarbazi E, Razzaghi A, Moghaddam AA, Sharifi H, Habibzadeh S, Heydari ST, et al. WHO survey tool for behavioral insights on COVID-19: A psychometric study for translation, adaptation and content validity in Persian.J Res Clin Med. 2025;13:34519.
2. Organization WH. Injuries and violence: the facts 2014. 2014.
3. Naghavi M, Shahraz S, Bhalla K, Jafari N, Pourmalek F, Bartels D, et al. Adverse health outcomes of road traffic injuries in Iran after rapid motorization. 2009.
4. Butchart A, Mikton C, Dahlberg LL, Krug EG. Global status report on violence prevention 2014. BMJ Publishing Group Ltd; 2015.
5. Aagja JP, Garg R. Measuring perceived service quality for public hospitals (PubHosQual) in the Indian context. International Journal of Pharmaceutical and Healthcare Marketing. 2010;4(1):60-83.
6. Gaffarifam S, Sarbazi E, Ghorbani Z, Azizi H, Soleimanpour H, Khami B, et al. An epidemiological analysis of injuries among cyclists and clinical characteristics of them: a single-center experience from Northwest of Iran. Archives of Trauma Research. 2022;11(1):26-31.
7. Alberdi F, García I, Atutxa L, Zabarte M. Epidemiology of severe trauma. Medicina Intensiva (English Edition). 2014;38(9):580-8.
8. Azami-Aghdash S, Sadeghi-Bazargani H, Shabaninejad H, Gorji HA. Injury epidemiology in Iran: a systematic review. Journal of injury and violence research. 2017;9(1):27.
9. Gould JC. The Institute of Medicine and the Pursuit of Quality. Quality in Obesity Treatment. 2019:23-7.
10. Lashoher A, Schneider EB, Juillard C, Stevens K, Colantuoni E, Berry WR, et al. Implementation of the world health organization trauma care checklist program in 11 centers across multiple economic strata: effect on care process measures. WorldJ Surg. 2017;41(4):954-62.
11. Reynolds TA, Stewart B, Drewett I, Salerno S, Sawe HR, Toroyan T, et al. The impact of trauma care systems in low-and middle-income countries. Annual review of public health. 2017;38(1):507-32.
12. Fecso AB, Szasz P, Kerezov G, Grantcharov TP. The effect of technical performance on patient outcomes in surgery: a systematic review. Ann Surg. 2017;265(3):492-501.
13. Endeshaw B. Healthcare service quality-measurement models: a review. Journal of Health Research. 2021;35(2):106-17.
14. Li Min LM, Lowrie D, Huang ChengYu HC, Lu XiangChan LX, Zhu YingChu ZY, Wu XingHua WX, et al. Evaluating patients' perception of service quality at hospitals in nine Chinese cities by use of the ServQual scale. Asian Pac J Trop Biomed. 2015:1-8.
15. Haghshenas E, Arab M, Foroshani AR, Movahed E. Assessing the quality of services provided at outpatient clinics among hospitals affiliated to Tehran University of Medical Sciences based on SERVQUAL Model in 2015. jhosp 2017, 16(2): 9-17.
16. Zarei E. Service quality of hospital outpatient departments: patients’ perspective.Int J Health Care Qual Assur. 2015;28(8):778-90.
17. Manulik S, Rosińczuk J, Karniej P. Evaluation of health care service quality in Poland with the use of SERVQUAL method at the specialist ambulatory health care center. Patient Prefer Adherence. 2016:1435-42.
18. Singh A, Prasher A. Measuring healthcare service quality from patients’ perspective: using Fuzzy AHP application. Total Quality Management & Business Excellence. 2019;30(3-4):284-300.
19. Upadhyai R, Upadhyai N, Jain AK, Chopra G, Roy H, Pant V. Development and validation of a scale for measuring hospital service quality: a dyadic approach. Journal of Health Research. 2022;36(3):473-83.
20. Abbasi-Moghaddam MA, Zarei E, Bagherzadeh R, Dargahi H, Farrokhi P. Evaluation of service quality from patients’ viewpoint. BMC Health Serv Res. 2019;19:1-7.
21. Jamshidi Z, Norouzi Tabrizi K, Khankeh H, Zeraati Nasrabadi M, Sadeghi H, Eghbali M. Design and psychometric properties of the acute care quality in trauma emergency units scale. Eur J Trauma Emerg Surg. 2024;50(2):447-53.
22. Muntlin Å, Gunningberg L, Carlsson M. Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement. J Clin Nurs. 2006;15(8):1045-56.
23. Polit DF, Beck CT, Owen SV. Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Res Nurs Health. 2007;30(4):459-67.
24. Munro BH. Statistical methods for health care research: lippincott williams & wilkins; 2005.
25. Sarbazi E, Sadeghi-Bazargani H, Sheikhalipour Z, Farahbakhsh M, Ala A, Soleimanpour H. Trust in Medicine: a scoping review of the instruments designed to measure trust in medical care studies. J Caring Sci. 2024;13(2):2.
26. Sadeghi-Bazargani H, Razzaghi A, Atabak A, Bazargani-Hejazi S, Basirat SB, Doshmangir L, et al. Setting research priorities to achieve long-term national road safety goals in Iran. J Glob Health. 2022;12:09002.
27. Liu Y, Aungsuroch Y, Gunawan J, Sha L, Shi T. Development and psychometric evaluation of a quality nursing care scale from nurses’ perspective. Nurs Open. 2021;8(4):1741-54.
28. Soleimanpour H, Gholipouri C, Salarilak S, Raoufi P, Vahidi RG, Rouhi AJ, et al. Emergency department patient satisfaction survey in Imam Reza hospital, Tabriz, Iran. Int J Emerg Med. 2011;4:1-7.
29. Larsson G, Wilde‐Larsson B. Quality of care and patient satisfaction: a new theoretical and methodological approach. Int J Health Care Qual Assur . 2010;23(2):228-47.
30. Bobrovitz N, Santana MJ, Kline T, Kortbeek J, Widder S, Martin K, et al. Multicenter validation of the quality of trauma care patient-reported experience measure (QTAC-PREM). J Trauma Acute Care Surg. 2016;80(1):111-8.
31. Grøndahl VA, Karlsson I, Hall‐Lord ML, Appelgren J, Wilde‐Larsson B. Quality of care from patients’ perspective: impact of the combination of person‐related and external objective care conditions. J Clin Nurs. 2011;20(17‐18):2540-51.
32. Tawil S, Iskandar K, Salameh P. Pain management in hospitals: patients’ satisfaction and related barriers. Pharm Prac (Granada). 2018;16(3).
33. Otani K, Chumbler NR, Herrmann PA, Kurz RS. Impact of pain on patient satisfaction integration process: how patients with pain combine their health care attribute reactions. Health Serv Res Manag Epidemiol. 2015;2:2333392815615103.
34. La Vonne AD, Zun LS. Pain management in the emergency department and its relationship to patient satisfaction. J Emerg Trauma Shock . 2010;3(4):326-30.
35. Mosadeghrad AM. A conceptual framework for quality of care. Materia socio-medica. 2012;24(4):251.
36. Sarbazi E, Sadeghi-Bazargani H, Farahbakhsh M, Ala A, Soleimanpour H. Psychometric properties of trust in trauma care in an emergency department tool. Eur J Trauma Emerg Surg. 2023;49(6):2615-22.
37. Mallett-Smith S, Jadalla A, Hardan-Khalil K, Sarff L, Brady M. Implementation of an assault prevention quality improvement initiative in an urban emergency department.J Nurs Care Qual. 2023;38(4):341-7.
38. Sarbazi E, Razzaghi A, Moghaddam AA, Sharifi H, Habibzadeh S, Heydari ST, et al. WHO survey tool for behavioral insights on COVID-19: A psychometric study for translation, adaptation and content validity in Persian.J Res Clin Med. 2025;13:34519.
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How to Cite
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Sarbazi E, Sadeghi-Bazargani H, farahbakhsh M, Ala A, Pouraghaei A, Soleimanpour H. Development and psychometric testing of the quality of care for trauma patients scale using exploratory and confirmatory factor analysis. Front Emerg Med. 2026;:e30.
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