Purpose To extend existing knowledge about health care quality and patient satisfaction by exploring Japanese context having a different health care system and a different culture from the USA and Europe. Design/methodology/approach A structural equation model is used to explore links between quality perception and patient satisfaction as well as between patient satisfaction and intentional behavior relying on 159 Japanese outpatient replies. Findings Japanese healthcare service quality is evaluated using its process characteristics (patient-provider interaction) and physical attributes (settings and appearance). Process quality attributes were found to be patient satisfaction antecedents. Satisfaction in turn predicts patient intentional behavior (to return and to recommend). Japanese society cultural specificity seems to be an interesting background to understand Japanese evaluation when patients assess health service quality. Research limitations/implications The sample investigated is relatively small. The study relied on a linear approach to assess patient satisfaction and intentional behavior. However, the non-linear model should yield a better reality fit. Practical implications To improve Japanese patient satisfaction, cultural values such as courtesy, empathy and harmony should be emphasized when delivering medical services. Satisfied consumers are an important asset for the healthcare provider as they intend to reuse the service and to recommend it to their families and friends. Both foreign and Japanese providers should adopt a consumer perspective to enhance the service quality and then to maintain long-term relationships with their customers. Originality/value The study used structural equation analysis to assess patient satisfaction in a scarcely investigated context. Moreover, the study relies on Japanese society's cultural characteristics to explain and understand results.