Irrational use of medicines remains one of the pressing issues in many healthcare systems across the world (1). This results in widespread wastage of scarce resources and health hazards (1, 2). In 2017, the World Health Organization (WHO) highlighted that the global cost related to medication errors was estimated at US$42 billion annually (3). Moreover, at least 1 in 20 patients were affected by preventable medication-related harm globally (4). These issues were particularly acute in contexts where traditional pharmacy administration was limited. In China, the primary responsibility of hospital pharmacy departments was largely restricted to medication distribution, which hindered interdisciplinary collaboration with hospital administration (5, 6). Furthermore, pharmacy leaders were tasked mainly with ensuring drug supply but lacked the institutional authority to implement clinical pharmaceutical management (7–9). Based on this, the Chief Pharmacist System (CPS) was proposed by the Chinese government in 2016 to improve the quality of pharmaceutical administration and services.

In the context of CPS, the pharmacy department has been transformed into an administrative and technical department, focusing on high-quality pharmacy services (10). The chief pharmacist is defined as the organizer and leader of the pharmacy administration at the hospital, who is responsible for building collaborative relationships among different departments, controlling medication procurement budget, promoting pharmacists’ development, and advancing the pharmacy discipline (11). Furthermore, CPS mainly includes three key strategies. Firstly, an indicator system for the rational use of medicines is established, whereby clinical departments meeting these indicators are allocated financial incentives. Secondly, pharmacy departments are entailed to transition pharmacy operations from a “drug-centered” model to a “patient-centered” one, where pharmacists are actively engaged in clinical pharmaceutical services. Thirdly, an interdisciplinary team is established to monitor and review key medicines, such as ancillary medicines, high-priced medicines, off-label use medicines, and those with abnormal usage surges.

Previous studies showed that medicine revenues and expenditures changed after the implementation of CPS. A study found that CPS could achieve substantial reductions in medicine expenditures and significant promotion of rational medicine use (5). Another indicated that the proportion of outpatient herbal medicine revenues in healthcare settings increased by 11.9% (12). As the CPS remains in the exploratory phase, it inevitably faces numerous challenges, including an unclear delineation of authority between the chief pharmacist and the pharmacy department director, as well as a lack of clinical capabilities among pharmacists (10). However, these studies had mainly focused on the perspectives of both pharmacy managers and pharmacists (5, 10, 12), leaving the patient perspective underexplored. As a direct manifestation of service recipients’ perceptions, patient satisfaction is a fundamental component in the assessment of policy efficacy (13, 14). It reflects the extent to which the services delivered by the policy meet patients’ needs, expectations, and preferences (15). Therefore, analyzing patient satisfaction within the CPS context to identify strengths and weaknesses in service performance offers critical evidence for improving healthcare management and public health policy (16, 17). To the best of our knowledge, there remains a limitation in empirical analysis regarding the association between the CPS and patient satisfaction with pharmaceutical services.

A cross-sectional survey was designed to investigate the current state of patient satisfaction with pharmaceutical services in public hospitals that had piloted CPS and those that had not. The study aims to explore the association between CPS and patient satisfaction by comparing pilot and non-pilot public hospitals. The study hypothesized that patients in CPS pilot hospitals would report significantly higher satisfaction than those in non-pilot hospitals. This study will provide a reference for governments to advance CPS implementation, as well as for guiding hospitals to adopt pharmacist incentives for better patient satisfaction with pharmaceutical services. In addition, this study will contribute to readers’ understanding of CPS in China.

As the reform of public hospitals progresses, CPS plays an increasingly active role in promoting rational medicine use and pharmaceutical service quality. To the best of our knowledge, this is the first study to compare patient satisfaction with pharmaceutical services between the pilot and non-pilot public hospitals and to explore the association between implementation of CPS and patient satisfaction. The study had three important findings.

Firstly, overall patient satisfaction with pharmaceutical services was high, and it was significantly higher in pilot hospitals than in non-pilot hospitals. Specifically, the mean satisfaction score in the pilot group (89.13 ± 10.99) was higher than that of the non-pilot group (85.67 ± 13.87). While this absolute difference may appear modest, it should be interpreted in the context of the well-documented ceiling effect typical of patient satisfaction metrics in healthcare settings, where responses tend to cluster at the top of the scale (31). This phenomenon arises from the inherently positive perceptions of essential care services (32). Within such a compressed high-scoring distribution, even marginal improvements can indicate meaningful enhancements in the patient experience and service quality. In the context of CPS, higher patient satisfaction likely serves as a clear mandate for management to redirect resources into patient-centered initiatives, thereby reducing irrational drug expenditure and improving both patient well-being. In addition, the mean satisfaction score in the pilot group was higher than that reported in a Chinese study by Huang et al. (33), which showed a score of 86.19 ± 16.13 in primary care settings. Our score was also higher than those reported in studies from Ethiopia (30.6) (34) and Iran (57) (35). Compared to the systems in Ethiopia, where the director of pharmacy is primarily responsible for managing drug dispensaries (36), the CPS establishes an integrated organizational framework that promotes collaboration among medical staff in China (5). While comparable to roles like the “director of pharmacy” in terms of managerial duties, the Chinese Chief Pharmacist not only retains their foundational identity as a medication expert, but also assumes an executive leadership position in the hospital’s pharmaceutical administration (11, 37). This hybrid role facilitates the implementation of pharmaceutical services, which may contribute to higher patient satisfaction. These comparisons must be interpreted cautiously, as patient satisfaction with pharmaceutical services was measured with different tools and types of hospital services. Nevertheless, the practices and experiences of CPS could provide guidance for hospitals in China and other developing countries wishing to develop pharmaceutical services.

Secondly, although the percentage of satisfied patients with medication education time was lowest, the pilot group still performed better than the non-pilot group. This is likely attributed to the understaffing of pharmacists in Chinese public hospitals. The survey of tertiary hospitals in China (6) found that the average number of pharmacists per 100 beds was 5.6, approximately half that of the United States (24). The shortage of pharmacists, combined with high patient volumes, limits the time pharmacists can devote to individual consultations (38, 39). Consequently, patients often struggle to identify prescribed medications (40, 41), and pharmacists have insufficient opportunity to provide clear verbal or written explanations (42). In the future, innovative approaches such as Telepharmacy could offer a promising direction for expanding the reach and efficiency of pharmacist-led patient education in resource-constrained settings (43, 44). In addition, no significant differences were observed between the groups for items such as “medication name clarity” and “medication appearance and quality.” This is an expected finding, as the characteristics of the medication are predominantly governed by pharmaceutical manufacturers and national drug regulatory standards. Therefore, CPS has a limited impact on improving drug packaging and physical quality.

Thirdly, there was a positive association between the implementation of CPS and patient satisfaction with pharmaceutical services. This association may be explained by the following three hypothesized mechanisms. The first potential mechanism is that establishing an indicator system for rational medication use could improve service efficiency, which might correlate with higher patient satisfaction. Our finding indicated that the pilot hospitals had a higher satisfaction rate regarding the promptness of medication receipt compared to the non-pilot hospitals, which aligns with Yang et al. (10). Furthermore, the satisfaction rate for clear medication label instructions in the pilot hospitals was 13.65 percentage points higher than that in the non-pilot hospitals. This is consistent with Alburikan et al. (45), who suggested that independent access to and understanding of medication information fosters patient confidence, thereby potentially increasing satisfaction. The second proposed mechanism involves the transition of pharmacy departments from a “drug-centered” to a “patient-centered” service model, which is hypothesized to enhance the quality and accessibility of pharmacist-patient interactions. We speculate that this improved interaction quality would be associated with higher patient satisfaction. In the context of CPS, this shift may be supported by professional training and optimization of pharmacy environments. Professional training equips pharmacists with expanded pharmacotherapy knowledge, which may improve their effectiveness in patient counseling (5, 46). As Aziz et al. (47) indicated, such improvements in service quality directly fulfill patients’ needs for competent and attentive care, thereby boosting satisfaction. Our findings also offer partial support for this hypothesis. Pilot hospitals had a higher patient satisfaction rate than non-pilot hospitals across several dimensions, including pharmacists’ attitude toward resolving medication issues, understanding medical cases, and providing clear explanations of medication rationale, side effects, and storage requirements. Furthermore, the cleanliness and acceptability of pharmacy areas, suitable pharmacy working hours, and private teaching spaces were associated with higher satisfaction. These findings are common with previous studies. Suleiman et al. (48) and Altarifi et al. (49) suggested that pharmacy location, cleanliness, and service hours were key factors contributing to improved patient satisfaction with pharmaceutical services. Notably, availability of private counseling areas serves as an essential component of pharmaceutical service quality and plays a key role in improving patient satisfaction (15). The third hypothesized mechanism is that establishing an interdisciplinary team to monitor and review key medicines might improve prescribing rationality and medication safety. It is plausible that these improvements are likely associated with greater patient satisfaction. Ma et al. (5) noted that with the implementation of CPS, pharmacists could actively participate in multidisciplinary teams to optimize antibacterial drug selection and adjust drug dosages, which could reduce irrational prescribing. Based on the above findings, this study suggests that the government should make efforts to expand the implementation of the CPS to non-pilot hospitals to enhance pharmaceutical services. The pilot hospitals should prioritize resolving the time constraints on individualized patient counseling and medication education. These supplementary measures could be adopted, such as optimizing pharmacy physical spaces and advancing targeted pharmacist training.

Fourthly, our findings indicated that satisfaction among rural patients was significantly lower than that of their urban counterparts, a result consistent with previous studies (50, 51). Disparities in socioeconomic conditions and healthcare resources between rural and urban areas may result in different patient perceptions during pharmaceutical services utilization (52). Additionally, rural patients may encounter greater barriers related to convenience and access to pharmaceutical information, which may further constrain their satisfaction with such services (53). It is suggested that there is a need to improve rural healthcare infrastructure and staffing to enhance the quality and accessibility of rural pharmaceutical services.

This study has several limitations. Firstly, as a cross-sectional survey, this study is limited to identifying associations and cannot establish causality between implementation of CPS and patient satisfaction. It is unable to capture any long-term dynamics. Therefore, longitudinal or experimental studies are required to investigate potential causal relationships, analyze the evolution of satisfaction, and identify the determinants that drive its improvement over time. Secondly, several measurement biases may be present. Although patients were surveyed immediately after leaving the pharmacy, the potential for recall bias remains. The self-reported satisfaction is subject to ceiling effects that may compress variance and reduce the discernibility of group differences. Furthermore, social desirability bias may have been introduced as participants were surveyed on-site and might have provided more favorable responses than they actually held. Sampling based on inpatient dispensing records may introduce selection bias by omitting patients who were dissatisfied and disengaged. Thirdly, although hospital grade was considered, other hospital-level confounders such as staffing ratios and institutional resources were not controlled. Fourthly, multiple chi-square tests were conducted without correction for multiple comparisons, which may increase the risk of type I error. Although these comparisons were performed primarily among control variables, future studies should apply appropriate statistical adjustments to enhance the robustness of the findings. Finally, the study sample was drawn exclusively from Shaanxi Province, China, which may be affected by local healthcare systems, culture, and socio-economic factors. This regional concentration may limit the generalizability of the conclusions.

Patient satisfaction with pharmaceutical services was higher in pilot hospitals than in non-pilot hospitals. The implementation of CPS was positively associated with this satisfaction. Although satisfaction regarding medication education time remained the lowest among all items, the pilot group still outperformed the non-pilot group in this aspect. These findings suggest that expanding CPS could be a beneficial strategy for enhancing patient satisfaction. Pilot hospitals should consider prioritize addressing time constraints in individualized patient counseling. As potential supportive measures, optimizing pharmacy physical spaces and advancing targeted pharmacist training may also be considered.