In recent years, healthcare has undergone a paradigm shift toward patient-centered care, positioning the patient not as a passive recipient of care but as an active partner in shared clinical decision-making. This approach fosters patient empowerment and supports collaboration between patients and healthcare professionals in the planning, delivery, and follow-up of care.1–6

Patient-centered care (PCC) is acknowledged as a core pillar of healthcare by reference organizations such as the National Academy of Medicine and the World Health Organization.1–3,5,7 This model not only addresses therapeutic aspects but also social, cultural, and financial factors with an impact on health.3 The available evidence consistently demonstrates the beneficial effects of PCC, including improved patient satisfaction, clinical outcomes, therapeutic adherence, and trust on healthcare professionals, with a positive impact on the quality of life of patients.1–4,8–10 International recognition was consolidated in 2001 with the Institute of Medicine's Crossing the Quality Chasm report, which called for this paradigm shift to be guided by six aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.5

Quality management systems (QMSs) based on the ISO 9001:2015 standard have become a core strategy within hospital management for standardizing procedures and improving operational efficiency. Nevertheless, current scientific literature cautions that the regulatory framework may be insufficient if not grounded in the realities of clinical practice. Recent research, such as that by Kyriakeli et al.11, suggests that ISO certification alone may have a limited impact on staff perception of safety culture. Accordingly, integrating dynamic tools that capture patient experience is essential to turning technical requirements into an active-listening model that drives genuine, patient-centered improvements in care.

In this setting, where patients take an active role as reviewers of the healthcare system, evaluating patient experience—expressed through PREMs—has become established as one of the three core pillars of healthcare quality, together with clinical safety and effectiveness.5,9 Systematic assessment of patient experience through surveys and other tools moves beyond simple evaluation, becoming a consistent and reliable means of identifying opportunities for improvement.1,7 The implementation of this approach supports clinical safety, communication, and cross-level coordination.1,3,7,9 Additionally, the new model contributes to bridging the widely documented gap between the perspectives of professionals and those of patients. Whereas professionals identify technical skills and clinical knowledge as core elements of healthcare, patients consider empathy, emotional support, and the patient-clinician relationship more relevant. Overlooking this discrepancy is a critical error, as patient voice should not be dismissed in favor of professionals' perceptions.5 Therefore, it is necessary that patient experience is assessed through structured interviews that guide future improvements in healthcare practice.

Providing clear information, empathic communication, and consideration of patient preferences fosters patient autonomy, shared decision-making, and treatment adherence. Incorporating patient voice using structured methods is essential to fostering culture transformation across healthcare organizations.1,4,5,9

In this context, hospital pharmacy (HP)—more specifically outpatient hospital pharmacy (OHP)—has progressively gained relevance. OHP care has become an organizational priority given the steady rise in healthcare demand and the associated cost increase.12 Previous surveys conducted to assess patient satisfaction with OHP care demonstrated high levels of satisfaction, especially regarding professional skills, communication quality, and care provided by hospital pharmacists.10,12 Nevertheless, patients consistently identify areas for improvement, including waiting times, facilities and signage.12 Additionally, the progressive digitalization of healthcare services requires healthcare professionals to acquire digital skills to optimize workflows and support professional-patient interaction via technology-based tools.13

This study aimed to evaluate a continuous improvement model for outpatient pharmaceutical care, whereby the results of annual patient experience and satisfaction surveys are translated into organizational and structural measures within the ISO 9001:2015 framework. Secondary objectives were to: (i) describe satisfaction with face-to-face versus telepharmacy modalities and identify the distinct features of each modality; (ii) identify items with low satisfaction scores to prioritize improvements in structural, organizational, and pharmaceutical counseling domains; and (iii) describe the integration of patient voice as an input for defining the QMS's annual strategic goals.

This was an observational, descriptive, retrospective study based on repeated annual cross-sectional surveys conducted between 2023 and 2025 among outpatients attending the outpatient hospital pharmacy clinic of a tertiary care hospital serving a population of approximately 500,000 inhabitants. The study included all questionnaires completed by outpatients or their caregivers during the study period, excluding incomplete questionnaires or those containing inconsistent information.

Variables included age, sex, scores for the different items, and overall satisfaction.

Analysis included two pharmaceutical care modalities:

• a)

  Face-to-face pharmaceutical care, whereby the pharmacist provides pharmacotherapeutic monitoring, follow-up, and counseling, and dispenses medication or nutritional support at the outpatient HPS.

• b)

  Telepharmacy, whereby the pharmacist remotely provides pharmacotherapeutic monitoring, follow-up, and counseling, while medication or nutritional support is dispensed outside the outpatient HPS, either through the patient's primary care center or via designated medication and nutritional support collection points.

The study methodology is based on the PDCA cycle (Plan–Do–Check–Act).

The structured integration of patient experience into a HPS QMS helps translate subjective perceptions into a dynamic continuous improvement model. This process was structured according to the PDCA cycle, consolidating PCC as a key approach. According to the latest scientific literature, the systematic review by Kendir et al. (2026)14 highlights that the routine use of PROM and PREM is crucial in the evaluation of healthcare system performance and advances toward a truly person-centered healthcare model. The annual survey model used in this study aligns with this global tendency, using PREM not only as performance indicators but also as drivers of quality improvement actions.

The starting point of this cycle was the identification of patient needs through the 2022 SATISFAR project15, aimed at evaluating telehealth during and after the pandemic. The results of this project contributed to defining patient needs and establishing quality goals for the 2023–2025 period. By aligning patient need with the ISO 9001:2015 standard, the organization transitioned from reactive listening to strategic planning. Items with traditionally low ratings, such as appointment scheduling, became an institutional priority.

With regard to planning, interventions were designed to improve accessibility and information quality. Of special note is the FarmaLink platform for asynchronous scheduling of appointments and consultations. This initiative met the identified need to improve communication outside the clinic. According to Amat-Fernandez et al.16, the success of these measurement tools relies on their ability to identify barriers and facilitators from the perspective of both patients and professionals. In this line, the integration of these findings into our ISO 9001:2015-certified QMS enabled patient participation to implement “co-design” or “participative consultation” as defined by Bombard et al.17 This approach is critical to avoiding symbolic participation and achieving shared decision-making, and generating a genuine shift in organizational culture.

In relation to humanization, the development of electronic and paper-based patient onboarding guides addressed patients’ claims for clear information. This finding is consistent with that reported by Wilcock et al.18, who reported that 42% of patients preferred oral and written information to improve management of their home medication.

The “check” stage, supported by 3175 questionnaires, revealed a high level of satisfaction with patients’ expectations, with an overall satisfaction (4.32) exceeding that of the hospital. These results are notably more satisfactory than those reported by Surur et al.19 in Ethiopia, where mean satisfaction was 2.48, with critical gaps identified in relation to adverse effects (1.27) and medication storage. A response rate of 21.1% was achieved within a one-week survey period, supporting the feasibility of this electronic approach. These aspects support its usefulness as a robust tool for identifying opportunities for improvement and the applicability of the method to other pharmacy services.

The response rate is lower than that reported in previous studies reporting questionnaire distribution, though with different goals.20

Despite overall satisfaction, the “check” stage identified deviations in the remote modality, particularly in the ease of rescheduling appointments (2.86 in 2025) and telephone consultation operation (2.07). Consistent with Wilcock et al.18, who reported that 20% of patients’ perceived waiting time to be too long, the qualitative results of this study confirmed that overload and delay remain primary barriers to excellence. Zhang et al.21 found that healthcare managers should improve patient experience by reducing waiting times and improving patient experience through the provision of timely information in an appropriate waiting space. The measures implemented at the HPS, including the establishment of a new clinic, extension of opening hours, and signage improvements, are aimed at acting in the two dimensions, namely: reducing effective times and improving subjective perception.

Results show that the most relevant satisfaction factors include professionalism, the time devoted, and courtesy of the pharmacist. These findings are in agreement with the ones reported by Chandra et al.22, who identified communication skills and trust in the professional as key predictors of patient satisfaction, even over waiting time.22,23 These results are closely related to the ones reported by Makowski et al.24 for a tertiary hospital. Their study showed that programs centered on systematic patient-pharmacy communication strategies have significant positive effects on information clarity (35.2% increase) and in response quality (29.5%). These findings support the idea that the direct involvement of the clinical pharmacist is a key predictor of patient satisfaction and medication safety.

The dispensing mode also influenced satisfaction. Previous studies demonstrate that satisfaction increases with collaborative hospital-community models, as compared to exclusive hospital-based models, particularly in terms of accessibility and waiting times.25 Although this study focused on secondary care, study findings suggest that decentralization or hybrid models should be considered in any hospital or healthcare district. This way, digital initiatives such as FarmaLink can be implemented as the first step toward a more flexible, patient-centered, pharmaceutical care model.

The “Act” stage involved reporting these findings to the hospital management and Quality Committee to ensure resource allocation. The establishment of a new pharmacy clinic in 2025 and consolidation of regular meetings with patient associations are corrective actions aimed at mitigating the identified healthcare overload. This model illustrates how the integration of patient voice can contribute to organizational transformation within a quality management framework. The contribution of this study lies in the development of a reproducible, scalable model for integrating patient voice in planning processes to improve pharmaceutical care quality, beyond quantifying the immediate impact of each intervention.26 This approach aligns with the international quality of care framework, which acknowledges patient experience as one of the core pillars, along with medication safety and effectiveness.

Finally, although this study analyzed tendencies over time, the progressive digitalization of the HPS through tools such as FarmLink paves the way to the integration of advanced technologies in pharmaceutical care. Current research, such as that by Alanezi et al.27, explores the potential of artificial intelligence and machine learning to predict PROM, which would be the next level of QMS evolution, as it incorporates personalized preventive interventions based on massive data.

This study, however, has some limitations. Firstly, a comparator group was not used; therefore, findings only reflect temporal associations between improvements such as FarmaLink and patient perception. Secondly, although participants’ age was collected, an age-based analysis was not performed. Accordingly, the influence of age on patient satisfaction could not be determined, which has been explored in previous studies.28 Additionally, waiting times were analyzed, but a distinction was not performed between objective and perceived duration, factors that were identified by other authors as determinants of patient experience.21 Questionnaires were distributed through the SERGAS platform “Lembra”, which did not reach the whole population, since some patients cannot use it or do not have it installed on their mobile phones. Therefore, patients with poor digital skills could have been excluded. Finally, the voluntary, self-administered nature of the questionnaire may have involved selection (more committed or satisfied patients could have participated) and response (tendency to positive responses) biases. The impact of the interventions implemented in 2025, such as FarmaLink, will be evaluated in the next data collection period.

The systematic integration of patient experience as a follow-up and performance requirement within the framework of an ISO 9001:2015 QMS provided a structured approach to incorporating PCC into hospital pharmacy practice. Translating patient voice into measurable strategic goals enabled the continuous improvement cycle to drive specific corrective and humanizing actions, including the digital tool FarmaLink, the creation of a new pharmacy clinic, and the development of patient onboarding guides. High overall satisfaction was observed in 2025 (4.32), exceeding overall satisfaction with the hospital.

This model identified and addressed recurrent non-conformity outputs in critical areas such as telephone communication and appointment scheduling, and increased patient participation toward an HPS co-design model. The active involvement of hospital management in this process, through management review, was key to the appropriate allocation of structural, technological, and workforce resources. This approach shed light on the strategic role of the hospital pharmacy in outpatient hospital pharmacy care. This work provides a reproducible and scalable model for other pharmacy services. Nevertheless, further studies are needed to determine whether improvements in perceived experience have an impact on clinical outcomes such as therapeutic adherence, clinical safety and quality of life.

This study provides evidence on the structured integration of patient experience into a quality management system as an organizational improvement tool in hospital pharmacy practice. Unlike previous works focused on measuring patient satisfaction, this study demonstrates that the structured assessment of patient experience can be integrated into a continuous improvement model, since it identifies areas for improvement and helps implement specific interventions in healthcare practice. The repeated annual cross-sectional design allowed the assessment of temporal trends and the persistence of specific areas for improvement, by providing a practical model that can be reproduced in other hospital pharmacy services.

The authors declare that no generative Artificial Intelligence model was used for in this study.

Vázquez-Gómez Silvia: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Castro-Luaces Susana: Writing – review & editing, Validation, Investigation, Formal analysis. Herrero-Poch Leticia: Writing – review & editing, Visualization, Data curation. Gayoso-Rey Mónica: Writing – review & editing, Validation. Rodríguez-Lorenzo David: Writing – review & editing, Validation, Investigation. Freire-González Mercedes: Writing – original draft, Data curation. Martínez-López de Castro Noemí: Writing – review & editing, Validation, Supervision, Methodology, Formal analysis, Conceptualization.

This study was conducted in accordance with Organic Law 3/2018 governing personal data protection. This study was conducted in accordance with the tenets of the Declaration of Helsinki and applicable laws and regulations on human rights and biomedical research. This study did not involve research on human beings or animals. Traceable personal data were not used in this study.

This study did not receive any financial support from public, private or non-profit organizations.