MEASUREMENT OF PATIENT SATISFACTION
AT THE ACADEMIC HOSPITAL
by
Sunita Ramlochan Tewarie
SURINAME 2008
ACKNOWLEDGEMENTS
The MBA study at the F.H.R Lim A Po Institute in Paramaribo was a very pleasant and interesting learning journey to me, supplying me with lot of contemporary theories and practices on management which I can recommend every one who is able to do it in Suriname. The accommodations and staff members can be characterized as “excellence” because it is a very pleasant place to be there with a very motivated staff.
Finalizing my study and at the end going through the research of patient satisfaction was not possible without the moral support of my family and parents. They were of tremendous importance to me during the study and especially my little princess Sherani had to miss me lots of evenings. But I am very grateful to them that they bear a lot of hours without many complaints.
This research where patients of the Academic Hospital are the main subject was not possible if they had not corporate to fill in the questionnaire. To those ex patients I want to express my gratitude and maybe this study will bring some positive changes when entering the hospital next time. Also thanks to some special persons from the nursery, who gave me ideas and were a very important feedback.
Also some experts on using SPSS-program were of great help to me.
I want also to thank all the persons that were helpful in the distribution of the survey forms.
Finally I want to thank Mr. Silvio De Bono, the supervisor of the thesis for the response on the paragraphs during our conference calls on frequently basis. To all my friends from the MBA study who supported me, it was very nice period to be with you and hopefully we will spent a lot of hours together.
EXECUTIVE SUMMARY
This paper is about measuring the patient satisfaction at the Academic Hospital, a topic that is related to quality management, which is not yet adequately and effectively implemented at this hospital. The results of this study can be used as input for an integral quality management for the hospital, which is in a premature phase. The major aspects during the process of incoming till dismissal are investigated on quality care. The main reason for this part of the process is because of the many rumors from society about the service component at our largest hospital in Suriname. As the role of nurses and the medical specialists are a major part of this process they are not part of this research.
Theories about quality management are used to measure the quality of care in the hospital, the way patients experience the hospital care and recommendations are made to improve these.
For research in Suriname, at the Academic Hospital, the choice is made for KQCAH Scale, the Key Quality Characteristics Assessment for Hospitals Scale of 2001 because of the service component and the organization processes it retains. It is a combination of qualitative and quantitative research methodology and identifies the dimensions of hospital quality care, operationalizes the dimensions and is an instrument to measure patient satisfaction.
The application of KQCAH instrument can add value for improvement within the services of the hospital through the tested dimensions: respect and caring, effectiveness & continuity,
appropriateness, information, efficiency, effectiveness-meals, first impression and staff diversity.
The categories are: Category A represents patients from the private insurance companies, category B from SZF, mainly consisting of civil servants, and category C (SOZA) from the low or no income class.
The main research question is: Are patients at the Academic Hospital satisfied and what is the difference in satisfaction between the three categories?
With two sub questions:
1. Which dimensions in satisfaction contribute to more satisfaction among all three categories A, B and C?
2. Is there difference in satisfaction between the 1st, 2nd and the third class treatment?
Analysing these results have shown that patients at the Academic Hospital are on average satisfied.
Those results suggest that there is room for quality improvement. The most satisfied category is category B in comparison to the 2 other categories taking 3 significant dimensions into account. Five
dimensions are not significant at the 0.1 level, (at confidence interval of 90%) so the results of the tests on the first sub research question are not confident. Respect and caring especially is significant at the 0.05 level showing that this is a very important aspect to be taken into account for a judgement about satisfactory. The least relevant dimension seems to be “Information” for all 3 different categories.
For the survey, 73 questions were prepared, of which 67 were applicable and a total of 211 patients out of 300 responded on these research purposes.
For answering the main question use of the statistical program SPSS version 15.0 (Statistical Package for the Social Sciences) is made to quantify and analyze the information. The result of sub question 1 about the differentiation of the 3 categories is derived from SPSS, e.g. the Kruskas-Wallis method. For the second sub question, as it will be a comparison of different dimensions between the 2 categories of classes, the Independent t-test is used. Before applying the t-test, the Chi-square method has been used to make clear the relationship between staying in classes and the insurance involved, through the use of cross tables.
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ii
EXECUTIVE SUMMARY iii
TABLE OF CONTENTS v
GLOSSARY vii
CHAPTER I: INTRODUCTION
1.1 Motivation 1
1.1.1 The Academic Hospital in an changing environment 2
1.2 Problem statement 2
1.2.1 Research objectives 3
1.2.2 Research questions 4
1.3 Scope and limitations 5
1.4 Approach and research method 5
1.5 Relevance of the research 5
1.6 Structure of the paper 6
CHAPTER II: THEORETICAL BACKGROUND
2.1 Definition of quality 7
2.2 Development of quality systems 10
2.2.1 Quality systems in health care sector 12
2.2.2 Quality care systems in developing countries 14 2.3 Evolution of measurements for service quality in hospitals 17
2.4 KQCAH 22
2.5 Quality care in hospitals in Suriname 23
2.6 Summary 25
CHAPTER III: METHOLODOLOGY
3.1 Introduction 27
3.2 Target groups and pre test 27
3.3 Application of KQCAH 29
3.4 Application of SPSS 29
3.5 Design 30
3.6 Data Collection 31
3.7 Summary
CHAPTER IV: RESULTS OF THE EMPIRICAL ANALYSES
4.1 Introduction 33
4.2 Reliability test 33
4.3 Analyses and outcomes 34
4.4 Outcome sub question 1 37
4.5 Outcome sub question 2 42
4.6 Summary 45
CHAPTER V: CONCLUSIONS AND RECOMMENDATIONS
5.1 Introduction 46
5.2 Conclusions 47
5.3 Recommendations 49
5.4 Limitations of the research and suggestion for further research 52
BIBLIOGRAPHY 53 APPENDICES
APPENDIX A Questionnaires 55
APPENDIX B Reliability test 67
APPENDIX C Statistical outcome main question 71
APPENDIX D Statistical outcome sub question 1 75
APPENDIX E Statistical outcome sub question 2 80
GLOSSARY
Definitions
Quality management: relates to the production process and tests the normal routine with regard to processes and product specifications; quality management starts from normative criteria and tries to exercise control on the basis of these criteria.
Abbreviations
KQCAH Key Quality Characteristics Assessment for Hospitals Scale AHP Academic Hospital Paramaribo
SOZA Ministry of Social Affairs SZF State health insurance company
JCAHO Joint Commission on Accreditation or Healthcare Organizations CAHPS Consumers assessment of health care providers and systems PDSA Plan-Do-Study-Act
CQI Continuous Quality Improvement TQM Total Quality Management
IOM Institute of Medicine’s
HKZ Harmonization of quality care
NIAZ Netherlands institute for Accreditation
CHAPTER 1 INTRODUCTION
1.1 Motivation
Working at a hospital is a very intricate and contra dictionary place to work in, as managing a hospital is better off when people are sick. This is in contradiction with the policy of the government, in this case the Ministry of Health, to improve the health care sector through the reduction of sick people. The hospital has to cope with different stakeholders, who have their own interest at the hospital and where management has to deal with these, in order to improve the competitive advantage of the hospital. Hospitals today can reach this advantage through improvement of their processes on patient flow care, medical care, quality services and so on.
The concept of quality has several meanings depending on the stakeholder, from the point of view of patient and family, from management perspective, from Ministry of Health, Inspection, from professionals. This research will be about the quality perceptions of the patient.
Statistical results suggest that hospital leadership has more influence on process quality than on clinical quality, which is predominantly the doctors' domain. A general definition of quality health care system is: "the degreeto which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge". There are several ways to improve quality care within hospitals. In general a health care system has three primary goals: the provision of high- quality care, access to the system, and limited costs. However a more accessible system of high-quality care will tend to lead to higher costs, while a low-cost system available to everyone is likely to be achieved at the price of diminishing quality.Quality comprises three elements:
• Structure: refers to stable, material characteristics (infrastructure, tools, technology) and the resources of the organizations that provide care and the financing of care (levels of funding, staffing, payment schemes, incentives).
• Process: is the interaction between caregivers and patients during which structural inputs from the health care system are transformed into health outcomes.
• Outcomes: can be measured in terms of health status, deaths, or disability- adjusted life years, a measure that encompasses the morbidity and mortality of patients or groups of patients. Outcomes also include patient satisfaction or patient responsiveness to the health care system (WHO 2000).
This research will focus on the second part that is about the process within the Academic Hospital in Suriname, especially that part of the process where the patient comes in and stays during the care related to the treatment within the hospital. As the Academic Hospital (AHP) is the largest hospital in Suriname with the most beds (440) and the most specialists, it is important to have a good image; however rumours from society indicate different because of the poor quality service patients receive. Patients from different categories of insurance share the same view, no matter in which class of service they stay. As the hospital is in a changing environment since 2003, slightly improvements have already been realized, but hardly on the part of customer service, in this case patient care.
There are different levels to stay in the hospital, depending on the insurance of the patients and on the service of the insurance company or patient is willing to pay. In the hospital the service level is related on the class within the hospital, e.g. the first class patient will have better facilities in the hospital than a third class patient. But even the first class patients are complaining about the service they receive at the hospital and they are an important income generating source for the hospital. These patients are mainly from the private sector while third class patients are normally from the low to middle income group.
1.1.1 The Academic Hospital in a changing environment
The Central Hospital was founded in 1966. On September 25, 1969 the hospital was renamed into “Landsbedrijf Academisch Ziekenhuis” (Academic Hospital).
Before the changing process the hospital had a mechanistic structure with a supervisory board which was supervising the management on behalf of the government. In 2002, a change process has been initiated which should lead to a more independent functioning of the hospital, in particular to operate more efficiency and effectiveness. This change
process focuses on improving the internal structure, internal communications and relations. In 2003 a seminar and a workshop were held with stakeholders to discuss this change process and a new organizational structure was proposed. The new organizational structure entails a broader management structure and a number of policlinics were clustered as well as related support services. Six clusters were formed which are managed by a cluster manager. The cluster manager is responsible for the operations of several departments of the hospital. It is envisaged that these clusters will operate relatively independent and will share a joint secretariat.
Late 2008, the organization structure is almost formalized and the main focus is on improving quality care in the hospital.
1.2 Problem statement
Suriname has 7 hospitals, of which two are private and one in Nickerie. The private hospitals have already focused on the improvement of the service part of the patients and are therefore more popular for health treatment. However they are not able to provide all medical treatment that is needed, so patients are obliged to have their treatment at AHP.
The AHP has therefore already a competitive advantage. But the hospital should not only gain its important position through this channel but also through becoming more customer oriented, as patients should become more willingly to enter the hospital.
Hence, the problem definition is: “How satisfied are patients of the Academic Hospital from entering till dismissal?”
This research will focus on differences between satisfaction in health care between three categories of patients and improvements to obtain better quality care through service quality theories.
1.2.1 Research objectives
This research will make a contribution:
- to awareness of different satisfaction levels among several categories of patients - to establish the importance of service quality
- to gather input for a service quality policy in the hospital
- to implement other aspects of quality in the hospital to gain competitive advantage
- for quality improvement
1.2.2 Research questions
As already stated, patients are divided in three main categories that represent almost 95%
of the total visitors of the hospital. These categories are:
Category A: private patients
Category B: patients from the State Health Insurance (SZF); merely middle income class; civil servants and private persons
Category C: patients from low income class (SOZA)
In general, private patients (Category A) and the private component of SZF stay in the first and second class of the hospital, while SZF (excluding private component) and SOZA patients are staying in the third class because of their coverage at the insurance company and Ministry of Social Affairs. Most of the patients at AHP (80%) are for a third class treatment and therefore it is important to find out in what way they experience the differences in satisfaction.
Patients in the first and second class (20%) seem also to have complaints about the services of the hospital and are therefore included in the research.
MAIN RESEARCH QUESTION
Are patients at the Academic Hospital satisfied and what is the difference in satisfaction between the three categories?
SUB QUESTIONS
1. Which dimensions in satisfaction contribute to more satisfaction among all three categories A, B and C?
2. Is there difference in satisfaction between the 1st, 2nd and the 3rd class treatment?
1.3 Scope and limitations of research
The focus on this research is on the process of in- and outflow of patients in 2007 within the hospital. Therefore patients visiting the policlinics are not subject of this research.
Annually some 35.000 patients enter the hospital and about 53.000 patients visit the specialist for treatment at the policlinics. Service quality at the medical services of the specialists is excluded. It will merely focus on services about entrance, food, transport, attitude of the nurses, environment, and other attributes to make the staying relative pleasant.
1.4 Approach and research method
This research is a practical oriented research that will have a diagnostic and design character. One method has been used to measure objective results, which is a combination of a quantitative and a qualitative method.
The KQCAH –questionnaire was used for data collection to gather information about the satisfaction of patients as it is a well known instrument to measure services at hospitals.
This method is a combination of a quantitative and a qualitative analysis.
1.5 Relevance of the research
Social relevance: The main reason to focus the research on this part of the process is because of the many rumours about the poor service quality at the hospital. As the AHP is the largest hospital in Suriname with the most beds and most specialists, the hospital should have an integer image. As the hospital is an important integral part of the health care sector, these rumours should be investigated. Patients from different categories of insurance are taking part of this research in order to get a general view of the possible causes for these rumours. As the hospital is in a changing environment since 2003, slightly improvements have already been realized, but hardly on the part of customer service, in this case patient care.
Economic relevance: To stress the importance of service quality in hospitals, because competitive advantage cannot only be realised through more and specialized medical services but also by improvements on other services for the patients
Scientific relevance: as there is not yet much research in hospitals from developing countries, this research can contribute to the awareness of becoming more quality oriented in hospitals which will be in the advantage of the patient.
1.6 Structure of the paper
After the introduction (chapter 1), the theoretical background is presented in chapter 2.
In this chapter the distinction between quality and quality management system is made clear and the relationship between service quality and satisfaction in general is pointed out and adapted to hospital care. In this chapter, the development of contemporary theories of health care satisfaction is reviewed. It also focuses on quality systems in developing countries.
Chapter 3 reveals the methodology used to measure patient satisfaction at the Academic Hospital. It also assesses the main category of patients at the AHP. In chapter 4 the findings of the research is presented, while in chapter 5 the conclusions and recommendations are formulated.
CHAPTER 2 THEORETICAL BACKGROUND
2.1 Definitions of quality
In order to make clear the several definitions used in theory about service quality the main concepts will be clarified. According to the International Organization for Standardization “quality” can be defined as“a totality of characteristics of an entity that bear on its ability to satisfy stated and implied needs”. Edward Deming agreed that quality is subjective and must have commercial value. “What is quality? A product or service possesses quality if it helps somebody and enjoys a good and sustainable market.
Trade depends on quality.”
The American Society of Quality defines quality as “a subjective term for which each person has his or her own definition. In technical usage, quality can have two meanings:
1) the characteristics of a product or service that bear on its ability to satisfy stated or implied needs and
2) a product or service free of deficiencies.
A variant of quality is service quality. In general services can be defined as social acts which take place in direct contact between the customer and representatives of the service company. It is more difficult to measure services objectively compared with products because services characteristics include intangibility and inseparability of the production and consumption of services. This makes the definition of service quality an abstract and personal (subjective) concept. The relationship with service quality and health care is described by Ross (1995). According to him, services in health care are intangible because it is not possible to count, measure, inventory test or verify them in advance of sale. Customer experience, either directly or vicariously from outside sources, is frequently the only means of verifying whether health care services meets manifest quality.
Caretakers provide services differently because of variations in factors, such as their specialty training, experience and individual abilities and personalities. Patient needs frequently vary from person to person and from visit to visit. Interactions among physicians, nurses, administrators, patients and timing factors combine in an infinite number of ways to affect the quality of the health care service rendered.
Finally, in health care, production and consumption are inseparable. The services are consumed when they are produced, which makes quality control difficult.
Grönroos(1984) divides the customer's perception of any particular service into two dimensions:
1. Technical quality - What the consumer receives; the technical outcome of the process and
2. Functional quality - How the consumer receives the technical outcome, what Grönroos calls the "expressive performance of a service"
Grönroos suggested that, in the context of services, functional quality is generally perceived to be more important than technical quality, assuming that the service is provided at a technically satisfactory level. On the other hand he also points out that the functional quality dimension can be perceived in a very subjective manner because each person has its own experiences.
The distinction between the technical and functional aspects for quality is widely accepted within the medical literature. In the healthcare field technical quality is referred to as clinical quality which focuses on the technical accuracy diagnosis and treatments.
Functional quality refers in general to the manner or process by which health care is delivered. However, hospital managers should take into account that clinical quality is at least as important as process quality in predicting patient satisfaction.
According to “De Nederlandse Normalisatie Instituut” in Delft, Holland quality policy has to do with ‘the objectives of an organization with regard to quality and the ways and means to achieve these objectives’. Quality policy should be adapted by all employers and specialists.
Quality policy should be implemented through well defined and applicable quality management systems and must be quantified by certain measurements.
Therefore quality policy should be part of the total policy of the hospital and should be implemented through the means of procedures and protocol.
Quality management system (QMS) is an instrument to implement quality policy and can be defined as the ‘organizational structure, procedures, processes, and resources needed to implement quality management’. In theory, a Total Quality Management (also called Continuous Quality Improvement (TQM/CQI)) is a process of quality improvement and quality control in the industrial and business world. It was first Edward Deming (1945) and Joseph Juran (1954), among others, who developed TQM by applying statistical techniques to the production process. The process can be defined as “an ongoing effort to provide services that meet or exceed customer expectations through a structured, systematic process for creating organization-wide participation in planning and implementing quality improvements”.
Within the QMS, satisfaction of customers is an important part as they can contribute to a well functioning quality system since customers are one of the stakeholders for improvement of service quality. Service quality is part of a total quality system and can be derived for instance by measuring the satisfaction of customers. But the dilemma with measuring satisfaction is that it is subjective. Several researchersstate that services are not actions and behaviors in and of themselves, but the way customers perceive and interpret those actions. Historically, the establishment of quality standards has been delegated to the medical profession and has been defined by clinicians in terms of technical delivery of care.
More recently, patients’ assessment of quality care has begun to play an important role, especially in the advanced industrialized countries, and their satisfaction or dissatisfaction with services has become an important area of research. Although different, satisfaction and service quality are closely related. The literature indicates a positive relationship between service quality and patient satisfaction with hospital care and a willingness to return to the hospital. Three different opinions are mentioned as relevant. According to Oswald and Taylor (1992), consumers must rely on attitudes toward caregivers and the facility itself in order to evaluate their experience. They maintain that there is a strong connection between health service quality perceptions and customer satisfaction. Donabedian (1988) suggests that, patient satisfaction should be considered to be one of the desired outcomes of care and information about patient
satisfaction should be as indispensable to assessments of quality as to the design and management of health care systems.
This relationship has also been acknowledged in the dissertation of Chieh-Lu Li (2003), title: A Multi-ethnic comparison of service quality and satisfaction of service quality and satisfaction in national forest recreation. It appears that service quality and satisfaction of customers are distinct concepts but interrelated constructs. He found that service quality is more likely to the perspective of managers, because they control the services provided for customers; whereas, customers are more likely to evaluate their satisfaction with services
Another link is that satisfaction is concerned with the short-term and specific transaction;
while service quality is concerned with more general, long term, and global effects.
Therefore, satisfaction is an antecedent of service quality and consequently, satisfaction is theoretically influenced by service quality.
Further he found that satisfaction was likely based on emotional evaluations and subjective judgment. In contrast to satisfaction, service quality, however, tends to be based on rational evaluations and objective judgments.
Finally, in literature, consumer expectations have usually been defined as forecasted or anticipated levels of performance. These expectations are combined with actual performance to create the concept of disconfirmed expectations. Disconfirmed expectations, in turn, are used as predictors of consumer satisfaction. Researchers in the service quality area, however, emphasized that expectations in service quality models were not forecasts. This is an important distinction. If service expectations were defined as forecasts, the service quality model (P-E) became undifferentiated from the disconfirmed expectations component of the consumer satisfaction model (Teas, 1994).
Last but not least measurements of quality systems can be done by several methods depending on the sector and the applicable dimensions relevant in these sectors.
2.2 Development of quality systems
Quality control striving towards perfect quality is since the Middle Ages (Baker 2002). In the medieval masters and enslave designed strict rules concerning quality of raw materials, the production process, the professional skills and the quality of the end
product. The end products were checked by the master and after customer’s approval, provided with a guarantee seal, as the product certificate. Quality seems therefore as something that has been there always. This development continued in the period of the Industrial Revolution. The customer and producer views about the production process became different and instead of tailored made products standard products were made.
Thereby the manufacturer himself stipulated if the product was produced according to specific measures. At the beginning of the ‘20 statistics were included and for the first time inspections took place on the basis of samples. Quality control became a separate appropriate mean and the quality inspector was appointed. As from 1945 up to the 1960’s a tremendous development evolved in the striving towards quality. It is worth remembering that quality methods were first developed and put into widespread use in Japan after the Second WorldWar, a country with few resources and then re-imported into the West. The Japanese realized rapidly that quality could be an important competition mean. Some of the challengesin applying and adapting quality methodsas well as the potential for testing and developing more cost effective methods, were developed by them. In the ‘50 the foundation service level for the industry has been set up. Statistics are no longer only applied to do samples but are also used to make the production process transparent, on basis of which decisions are taken. Process control does its entrance. Afterwards it was considered that by measuring the process and the results, a rule ring arise and the well-known Deming-circle became famous. Gradually, the notion grows that quality control is not only concerned with the output of production but also assembly other phases in the production process. In the period between 1980 till 1990, flexibility will play a role beside efficiency and quality. The three criteria should be applied simultaneously and integral. This was a new quality golf. In this period also the service will play a larger role beside the production. Quality control becomes a component of the total management function because of the care of a good product quality. Organizations are involved in writing quality policy where it is indicated how required quality should be implemented. In 2005 quality control almost no more means a competition advantage but a condition to survive on the market.
Graph 1: Relationship between organization and labor development
Source:Kleemans WVCS (2007)
Since the 1990s, there is a general trend for stakeholders to put more pressure on hospitals for accountability, transparency and equity of access to health. The governments of various American and European countries have, therefore, stimulated the use of Quality Management systems (QMS) and external evaluation in healthcare.
Former research has identified models and variants of external evaluation, e.g. medical specialty-driven visitation, traditional accreditation against explicit standards, European Quality Awards based on the model of the European Foundation of Quality Management (EFQM), and certification using ISO standards (ISO 9000 series).
2.2.1 Quality systems in the health care sector
Although there are many quality instruments, not all systems are suitable for the health care sector. Quality care through quality management systems are applicable because it is about improving the process around the customer/patient and therefore enhance the satisfaction of the customer /patient. Other motives for the necessities of quality improvements are: patients become more demanding, the fact that competitiveness of other hospitals will evolve not only by price but also through service and quality
Product Process System Concatenate Society
Organization development
Developments in labor Inspection
Quality Control
Quality Assurance
Strategic Quality- Management
Developments in Management
management will lead to better outcome and finally it will conduct a more specialized organization.
The difficulty in measuring hospital service quality is that there is no valid and reliable instrument with respect to the functional aspect for quality as patients define quality based on their subjective perception. Several researchers have tried to identify several different dimensions to be applicable for hospital, but it is still very difficult because of the focus on determining perceptions and attitudes. In the Netherlands the Customer Quality Index has been developed which is based on two American measurements:
CAHPS (Consumer Assessment of Healthcare Providers and Services) and QUOTE (Quality of care through the patient’s eyes). This instrument measures the experiences of the consumers of health care. In their opinion, using information about the experiences of patients is more effective for quality improvements than subjective information about satisfaction.
In the health care sector quality policy became much more important due to the fact that deregulation and market orientation became more important. In most countries the government has to retrieve and health institutions are taken the responsibility to improve the quality of care. The patient became therefore a crucial partner in developing standards for quality. Transparency about the quality of care is one of the key factors and external assessment should be made on regular base. In the table below the different stakeholders in the health care sectors are identified for information about their specific process improvement.
Table 1: Information need
Patients Pressure group
Health care insurances Procurement
Government Monitor information
Health care Inspection Supervision
Managers and professionals Quality care information
In general changes in quality care systems show a development on certain characteristics:
• From static: image building towards dynamic: change management
• From the inner to also outward oriented: client and market focus
• Shifts from organizational items towards professional items: it is about care and the effectiveness of care
• From: Patient →Client→ Consumer→ Visitor
• Professionals are central
• Efficiency and flexibility are important factors to take into account in the new developed quality systems.
2.2.2 Quality care systems in developing countries
In developing countries the developmentand quality of health services is severely limited by lack of resources and knowledge about quality methods. However developing countries increasinglyrecognize the value of quality methods and the need to raisethe quality of their services.
Developing countries face severe limitations to health care. The average spending on public health care per head of population is low (US$6-US$10 a year), the services are not evenly distributed and there is a lack of many essential drugs (despite various programs to solve this problem). Health personnel are not trained sufficiently, unsupervised, and morale and incomesare low.
In most of these countries policy makers think that quality methods and conceptsare not relevant and applicable. They argue that somequality approaches are inappropriate—for example, largeamounts spent on accreditation systems to improve the qualityof hospital services could be put to better use. Accreditation is certainly easy to understand than many other quality methods and it is often supported by donors, but it is often unsustainable, ineffective and inappropriate in many of these countries. Therefore they are reluctant to implement quality systems.
However, nowadays developing countries become aware of using quality methods because it can have an importantpart to play in improving the performance of the health care system if the right ones are chosen for the situation and adapted in a culturally appropriate way.
By introducing quality management systems in hospitals the organization can amend and qualify on international standards in order to provide a better service and treatment, and can expand.
In recent years, organizational change in the health care system can influence quality of care and can focus on the continual design and redesign of systems. The emphasis is on developing organizational and individual capabilities where they most profoundly affect the process of care. Design and redesign interventions assume that simply adding a new resource or a new process in isolation will not improve care because better care is the product of many processes working together. Although change interventions have not been widely used in the developing world because they require large investments to plan and implement, four related models of organizational change have been successful in changing provider practice in developing nations (World Bank Group, 2006):
• Total Quality Management in health care
Advances in business management practices to continually design and redesign systems for quality improvement is possible and have been adapted for health systems. Teams in Total Quality Management, also known as Continuous Quality Improvement, use mutually reinforcing techniques in a cycle of planning, implementing, evaluating, and revising to improve the quality of clinical and administrative processes. These techniques include process mapping, statistical quality control, and structured team activities. Two cases which were TQM is implemented with success, are in Bihar, India and in Malaysia. In rural Bihar, private practitioners were provided with standard case-management information, were given feedback on their performance, and were tracked and monitored over time. This strategy produced significant improvements in practitioners' case- management skills. In Malaysia, anesthesia safety has been improved through the implementation of consensus- based protocols that emphasize (a) communication among the operating, recovery, and ward team members; (b) individual feedback and (c) frequent monitoring to identify areas for improvement.
• Collaborative Improvement Model
The early success of Total Quality Management techniques has given rise to a related model, the Collaborative Improvement Model. It has been applied to broad and complex systemic processes within health care systems and has facilitated the scale-up of quality improvements. This model, designed to continuously improve organizational and individual performance, comprises four elements: definition of an aim, measurement, innovation, and testing to see whether the innovation meets the original aim. This approach strikes a balance between the need for action and the need to be scientifically grounded. It has been used with success in Peru and the Russian Federation. The results have led to changes in the process of care, but it is too early to determine whether they have been effective in improving quality.
• Plan-Do-Study-Act cycle
The Plan-Do-Study-Act (PDSA) cycle calls for action oriented learning in quality improvement. Team members using the PDSA model design a quality improvement intervention (plan), implement it on a small scale (do), evaluate the results (study), and implement or alter the intervention accordingly (act). Multiple PDSA cycles are necessary before the appropriate improvement method can be identified. All improvement techniques that involve the design and redesign of systems use some form of the PDSA cycle.
Successful PDSA prototype is possible with careful leadership oversight. Although the experience of researchers implementing interventions that are based on system redesign in the developing world has been largely positive, it is not clear whether the resources and leadership exist to bring these interventions through country or regional policies. Further evidence is needed concerning the real-world feasibility and cost-effectiveness of system redesign.
• Internal enabling environment
Creating the right environment for change involves leadership and leadership training;
clinicians empowered to make quality improvement decisions, and resources for quality improvement planning activities. The internal enabling environment in Costa Rica promoted strong leadership that led to the adoption of structural adjustment loans in the early stages of health sector reforms. The loans were used to maintain such public health
programs as mother and child nutrition, even though public spending dropped and prices increased dramatically. An environment can also be created by teams of individuals, each representing different stakeholder groups (physicians, nurses, staff members, patients, and so forth) or simply by a strong leader with an interest in teamwork and the resources to support a discrete quality improvement function for team members.
2.3 Evolution of measurements for service quality in hospitals
Measuring service quality was not well known and became popular after the 1990’s. One of the pre-eminent instruments for measuring service quality in general is SERVQUAL also known as the Gap model, developed by Parasuraman through testing on 5 dimensions. It provides a structure for understanding service quality, measuring it, diagnosing service quality problems and offering solutions to the problems (Zeithaml et al., 1990). Furthermore it is mostly applied in service sectors which were financially well established, for instance the banking sector. Through an exploratory study it was possible to define service quality as the discrepancy between customer’s expectations and perceptions and to suggest key factors that influence customers’ expectations, which are word of mouth communication, personal needs, and past experience.
SERVQUAL enables the tracking of customers’ expectations and perceptions (on individual service attributes and or the SERVQUAL dimensions) over time. It further allows for comparison of a company’s SERVQUAL score against those of competitors.
T. P van Dyke (2003) several weaknesses when using this tool.
In general, the difficulties with the Servqual measure can be grouped into 4 main categories:
1. The use of the difference of gap score: subtracting one measure with the other is a poor choice for measuring the psychological construct.
2. Reliability problems and poor validity with gap scores: Servqual instrument is not proper to use Cronbach’s alpha, the method to measure reliability because the component scores are highly correlated.
Validity issues: The mentioned instrument concerns poor predictive and convergent validities of the measure. Babakus and Boiler (1992) indicated that it is difficult to demonstrate that the difference score is measuring something unique
from the perceptions component, and therefore a high correlation between the difference and perception score.
3. The ambiguous definition of the “expectations” construct: multiple definitions of
“expectations” result in a concept that is loosely defined and open to multiple interpretations and can result in measurement validity problems.
4. Unstable dimensionality: a theoretical construction combined with the use of gap scores raise the questions about the true factor structure of the service quality construct.
The Massachusetts Health Quality Partnership (1988)is a statewide patient survey project named “Results of Hospital Patient Care Survey” designed to meet the dual goals of supporting internal hospital quality improvements throughout Massachusetts while advancing public accountability through public reporting of comparative information on patient care experiences. Fifty-two institutions participated in this study, which accounts for about eighty percent of the state’s medical/ surgical inpatient discharges and ninety percent of all childbirth patients. The Picker Institute administered the surveys, which focused on dimensions of care which patients themselves identified as important. The Picker Institute is a nationally recognized organization, which assesses the healthcare experiences of patients across the country.
Dimensions measured by the Massachusetts Health Quality Partnership included:
Respect for patient preferences, Physical comfort, Involvement of family and friends, Continuity and transition, Coordination of care, Information and education and Emotional support.
The survey went far beyond general satisfaction or evaluation, asking the patients to report what happened during their hospital stay. Massachusetts hospitals scored above the national average for surveyed hospitals. The findings were strongest relative to the rest of the country in emotional support, and were weakest in continuity and transition.
The Joint Commission on Accreditation of Health care organizations (JCAHO, 1990) related the dimensions of Coddington and Moore with the dimensions of SERVQUAL and finally 9 dimensions were selected as the theoretical framework of hospital quality.
The Joint Commission on Accreditation or Healthcare Organizations (JCAHO) is an
independent, non-profit organization that evaluates and accredits more than 15,000 health care organizations and programs in the United States.
Bowers (1994) added caring (personal, human involvement) and patient outcomes (relief from pain, saving of life, or anger/disappointment with life after medical intervention).
Another dimension, collaboration, was discussed by all of Jun’s groups. Collaboration encompasses the concepts of teamwork and the synergistic effect of various actors in providing health care. It is the “commingling” of the roles of all members of the health care team, including payers, physicians patients, family members and members of the community that define health care quality from the patient’s viewpoint. Jun further emphasizes that communication is essential for collaboration because it “fills in the gaps to prevent disjointed service.”
Mittal and Baldasar (1996) measured the effect of certain quality factors in a physician’s practice, and found that physician competence, communication, respect, caring, taking time to learn history, and follow up treatment were weighted more heavily if patients were not satisfied. The condition of the office environment and waiting time, received lower weighting scores.
Young (1996), et al surveyed 2000 discharged hospital patients, nursing staff and managers to compare differences in the relative importance of four key nursing variables:
physical care, patient participation in care, patient teaching and pain control.
They found that patients ranked patient teaching of highest importance, and participation in care lowest, but the variation in statistical results was narrow. They maintain that knowing how much importance patients place on an aspect of care is valuable for developing and achieving improvement in that aspect of care. Furthermore, they found gaps in the scores of both nurses and managers when they rated the importance (to the patient) of these variables. The usefulness lies in understanding how the lack of understanding of patients’ values and expectations can impede service quality improvement strategies within hospital units.
Chakrapani’s (1998) uses a model that consists of 5 dimensions related to patient satisfaction in Bangladesh, Pakistan. In his view patients’ voice must play a greater role in the design of health care service delivery processes in the developing countries. This study is patient centered and identifies the service quality factors that are important to
patients; it also examines their links to patient satisfaction in the context of Bangladesh.
Evaluations were obtained from patients on several dimensions of perceived service quality including responsiveness, assurance, communication, discipline, and baksheesh.
In table 1 these dimensions are mentioned.
Alan M. Rees(1998) maintains that satisfaction with hospital care is too often assessed on the basis of amenities that have little relationship to the clinical quality of care. He feels that amenities do not indicate the quality of what happens to people while they are in the hospital and what happens to them after discharge. He recommends the measures of: respect for patient values, preferences and needs; coordination of care (scheduling tests and procedures); information and education provided; physical comfort (waiting time after call bell sounded); emotional support and alleviation of fear and anxiety;
opportunity for involvement of family and friends; provision for continuity and transition to the home environment.
Seihoff (1998) documented continuity of care and caring behaviors in evaluating the use of unlicensed assistive personnel vis-à-vis patient satisfaction.In a study of the British Medical System, administrators, providers and patients, agreed about quality priorities for elderly people.
All groups considered improving the quality of life (adding life to years) as important, whereas reducing mortality rates (adding years to life) was unimportant. The key difference between professionals and patients occurred in the importance attached to reducing the burden on family caregivers (understanding the patient). Patients attached higher importance to this factor.
Ford and Fottler (2000) suggest that service specific dimensions should be added to the 5 SERVQUAL dimensions to appeal the patient’s definition of health care in the health care sector. Various environmental changes forces the hospitals to be more responsive to customers wants, needs and expectations and have to focus on what the patients really wants.
Coddington and Moore (2001) developed a list of 5 dimensions from a consumer’s perspective. In their model they stress the importance of technology on quality of the hospital. The general research hypothesis tested is that hospital technology directly drives (affects) quality and hospital financial performance. The results indicate that the type of
hospital technology (clinical or information) drives different types of quality-related performance (clinical or process), and directly and indirectly affects hospital financial performance.
The dimensions of quality care and performance (table 2) provide the framework for quality management activities in all healthcare settings from a balanced and well- integrated quality, cost, and risk perspective.
Table 2: Several researchers on hospital quality
Dimensions Massachusetts Health
Quality Partnership (1988)
Respect for patient preferences, Physical comfort, Involvement of family and friends, Continuity and transition, Coordination of care, Information and education and Emotional support
JCAHO (1990) Appropriateness, Efficiency, Timeliness, Respect and Caring, Safety, Continuity, Availability
Bowers (1994) Caring (personal, human involvement) and patient outcomes (relief from pain, saving of life, or anger/disappointment with life after medical intervention)
Young (1996) Physical care, Patient participation in care, Patient teaching and pain control
Mittal and Balsadar (1996) Competence, Communication, Respect, Caring, Taking time
Rees (1998) Respect for patient values, Preferences and needs, Coordination of care (scheduling tests and procedures), Information and education provided, Physical comfort (waiting time after call bell sounded), Emotional support and alleviation of fear and anxiety, Opportunity for involvement of family and friends, Provision for continuity and transition to the home environment
Chakrapani (1998) Service/product, Dependability, Support, Exceeding, Expectations
Jun (1998) the roles of all members of the health care team, including payers, physicians patients, family members and members of the community, Communication Seihoff (1998) Continuity, Understanding
Coddington (2001) Warmth/Caring, Available, Specialization, Technology Equipment
Sower,Duffy et al Respect and caring, Efficiency and continuity, Effectively, Staff diversity, Appropriateness, Information, Meals, First impression
2.4 KQCAH
A recent developed measurement is the Key Quality Characteristics Assessment for Hospitals Scale (KQCAH, 2001) which can be relevant because of the service component and the organization processes it retains. Knowledge of these dimensions facilitates the measurement of patient satisfaction by hospitals. Hospitals know that they are measuring dimensions that are important to patients. The Institute of Medicine's (IOM 1999) identifies nine domains of care that can provide useful guidelines for survey-item development. These nine domains are: respect for patient's values; attention to patient's preferences and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support; involvement of family and friends;
transition and continuity; and access to care. The CAHPS Hospital Survey domains (nurse communication, nursing services, doctor communication, physical environment, pain control, communication about medicines, and discharge information) were derived from the IOM domains (Goldstein et al. 2005).Other conditions that are important for hospitals are the pressure on hospitals for accountability, transparency and equity of access to health. In European countries the use of Quality Management system (QMS) in healthcare has extensively been used and has led to better health service. The Netherlands are implementing the quality assurance standards of NIAZ (The Netherlands Institute for Accreditation of Hospitals) and HKZ (Harmonization of quality care). These standards contain requirements for the organization of a hospital. They describe what has to be regulated in a hospital in order to warrant that the quality of care delivered is not depending on individuals or left to chance.
This method, Key Quality Characteristics Assessment for Hospitals, is a combination of qualitative and quantitative research methodology and identifies the dimensions of hospital service quality, operationalizes the dimensions and is an instrument to measure patient satisfaction. It is developed by Sower and Duffy et al (2001) and based upon the JCAHO dimensions. Eight dimensions have been incorporated and were tested on Cronbach’s alpha. For hospitals it is even more difficult to measure satisfaction as patients have their own definitions for quality and comparing these definitions is not possible because of the lack of a valid and reliable instrument. This method takes into account the customer’s perspective and makes it possible to effectively improve the performance of the hospital.
Research has indicated that the KQCAH have high levels of content, validity and reliability. It is a tool which that provides the hospital to be responsiveness to their market- oriented environment. It also has the means to improve quality audits by periodically using the questionnaire to monitor quality indicators. It is also a tool for identifying areas needed to improve within a hospital.
2.5 Quality in hospital care in Suriname
Suriname has no quality systems yet implemented in hospitals and it is doubtful if implementation will be useful mainly because of the lack of awareness of these systems and the professionals for implementing quality standards.
In the “Meerjaren Sectorplan Gezondheidszorg 2004-2008”, the goals of health care are formulated which have to be achieved by the Ministry of Health. One of the goals is:
improve the efficiency and quality of the hospital care.
Therefore a strategy is defined with 5 process indicators. These are:
- rating of hospitals and departments by well defined and standardized process or outcome indicators
- technical standards of interventions - standardized/ comparable staying in days
- maintenance of the infrastructure and medical apparatus - target of beds capacity of 80%
In order to reach these indicators 4 sub goals are formulated and the one regarding the quality of hospital services has to do with “Medical services should be qualitative and cost effective for all hospitals”. Although this sub goal is mainly applicable for medical treatments, one could derive that this is also applicable for the services in the hospital. In the same report however it is also mentioned that the policy of the ministry is not further developed because of the many departmental discussions about the financing of hospital care which become a burden for the government budget the last 10 years, and therefore they were not able to focus on other important health care issues like developing a general quality policy.
In the daily newspaper “De Ware Tijd of December 6th 2007, page A4, under the head of:
“Ministry of Health want to improve the relationship between health care providers”
plans have to be developed in the next few years to create a unit to coordinate and facilitate health care tasks through ordering and regulation. The main task will be to create a platform for every Surinamese citizen to guarantee a certain level of information and quality. Therefore plans will be made for implementing quality guarantee and quality maintenances.
The Academic Hospital had installed a quality sub commission for the nursery in 1996, because of complaints about the not adequate care to the patient, the lack of appropriate facilities at the hospital and the poor maintenance. In 1999 the commission became the
“Commission quality guarantee” to control quality care. The commission had to do an audit which consists of a checklist about the welfare, environment and comfort for patients, sufficient information in reports, application of a nursery plan and the facilities at the department. Depending on the results, the department is receiving a score related to a defined benchmark. This audit includes also recommendations to overcome the shortcomings at the department.
The last audit was held in 2003 and has not been continued for several reasons. The main reason is that these audits took too much time for the nursery to do, besides their own nurse’s tasks. Another major reason is that although the commission is making recommendations for improvements, not all the departments are aware of the urge to follow up the instructions. So there was no follow up and no sanctions.
As the Academic hospital is in a transition phase of change, one of the priority areas of its policy is the development of quality care, in the broadest way. In the next few years protocols and procedures have to be written in documents and should be standardized in order to improve the quality of all services, including medical services. Another aspect which will be developed is the installation of a quality mentor, who will give advises about quality improvements and a commission of complaints. Nowadays patients can complain through a letter to the general director, who tries to solve the problem in his own convenient way.
2.6 Summary
It appears that a clear objective definition for “quality” is hardly possible because it depends on a person’s perception if there is quality. Service quality is much more subjective because it is hardly tangible and measurable. Services in health care for instance are not possible to count or verify and depended on patient’s experiences.
Quality control is difficult because production and consumption take place on the same time. By developing several management systems to improve quality in recent years, customer’s expectations will meet which can contribute to a more satisfied client. These management systems are instruments to implement quality policies. However not all management systems are suitable for the health care sector.
Quality service at the hospital can be divided in 2 dimensions in general: functional, which has to do with the manner or process health care is delivered, while technical quality focuses on clinical quality and thus focuses on technical accuracy diagnosis and treatments.
Quality service and measuring satisfaction are distinct but interrelated concepts. A major distinction is that service quality is concerned with more general, long term effect likely to the perspective of managers while measuring satisfaction is basically an emotional judgment from customers.
The problem when implementing quality system in the health care sector is that there is no valid and reliable instrument with respect to the functional aspect for quality because this is subjective as the focus is on determining perception and attitudes. However it is still important to develop these systems because it is about improving the process around the patients and enhance their satisfaction. The organization can become more competitive and will conduct a more specialized organization.
Several researchers have tried to identify several dimensions applicable to hospitals but there is still not a general model determined. It is obvious that these measurements are more popular in developed countries mainly because they have the instruments, data and the facilities to do so. Another reason is also the growing competitiveness especially in the USA, as there are many hospitals there.
For research purposes in Suriname, at the Academic Hospital the choice have been made for KQCAH Scale, the Key Quality Characteristics Assessment for Hospitals in 2001
because of the service component and the organization processes it retains. It is a combination of qualitative and quantitative research methodology and identifies eight dimensions of hospital quality care, operationalizes the dimensions and is an instrument to measure patient satisfaction.
Chapter 3. Methodology
3.1 Introduction
As stated in chapter 1 the main research question of this thesis is: “Are patients at the Academic Hospital satisfied and what is the difference in satisfaction between the three categories?” The main question is supported with 2 sub questions and all 3 questions were subject of research according to the KQCAH Scale. This method took the experiences of the 3 categories patients in consideration and therefore obtains a measurement of the service quality at the Academic Hospital through theoretical and practical issues. Questionnaires regarding the functional level of service quality through the 8 dimensions were applicable and have been distributed to 300 ex patients of the 3 categories, of which 211 were filled in. They have been translated into Dutch in order to make sure that it would be understood and again re-translated in English to verify the correct interpretation. In appendix A, the English and Dutch versions of the questionnaire are included.
In the next paragraph this method is discussed. Furthermore, it will elaborate on the target groups, design, data collection and types of analyses.
3.2 Target groups and pre test
The target groups for research are divided in 3 main categories: Category A (private), Category B (SZF) and Category C (SOZA). The respondents, in total 211, are of the age of 18 and above. No difference has been made in sexes, income group and education.
Category A represents patients from private insurance companies and is the smallest group of patients at AHP (table 3), because in general they prefer to stay at a private hospital, mainly because of the notion of better services provided by those hospitals. At the AHP, the rooms for patients of the 1st and 2nd class are on one floor, which implies that there are not many rooms for this category. Category A represents 18.5% of the total respondents and therefore is a good reflection of the patients’ share of this category at the AHP, namely 17% on average between 2004 and 2006.
Category B (SZF) is the middle income group of patients which has more freedom to choose for medical treatment. It is also a medical insurance for almost every civil citizen
and they can have medical treatment divided over all 3 classes depending on their hierarchical function at work and the insurance possibilities. But most of the civil citizens have a basic insurance and could stay for treatment at the 3rd class. They prefer to stay at a private hospital in general, but because the many medical disciplines at AHP they have often no choice than staying at this hospital. Another target group within category B is that of private persons, but their share in the total is minor. Category B has a share of 32.7% in the total respondents, thus overrepresented when judged against the share of this category in the total patients’ population of about 25% at the AHP. No differentiation is made between civil servants and private persons.
Category C (SOZA) represents patients from the low or no income class that get a card from the Ministry of Social Affairs if they can prove their inability to work. The validity of a card varies from 2 weeks, when the request is still in charge, half a year and 1 year.
These patients have the right for treatment only at 3rd class and consist of about 60% of the total patient population of the hospital. The reason for this is that they are obliged to make use of the medical treatments from only public hospitals and there are only 2 of them in the main city. In the test this category represents 48.8% of the total respondents of 211. Judged against the share of this category patients of 58% between 2004 and 2006 in the total population of AHP (table 3), category C is underrepresented in the survey.
Table 3: Percentages of patient’s population at AHP
In % 2004 2005 2006
Private 17 16 19
SZF 24 27 24
SOZA 59 57 57
After identifying the targets group a pre test was done with 20 patients to find out if the questionnaire was suitable and understandable. Most of the respondents had many complains about the quantity of questions, and it appeared that 5 questions from the original version were not applicable in Suriname. These questions were about after care services, after dismissal from hospital which is in Suriname not yet developed as well and the non personal relationship between nursery and patient.
3.3 Application of KQCAH
The application of KQCAH instrument can add value for improvement within the services of the hospital and is suited particularly for determining the perceptions and attitudes regarding 8 dimensions of service. These dimensions are: respect and caring, effectiveness & continuity, appropriateness, information, efficiency, meals, first impression and staff diversity. It is deducted from the dimensions of JCAHO and only the dimension of efficacy is excluded as the reliability of this dimension was not acceptable.
Efficacy of care is generally determined by using such measures as mortality and complications. From the original questionnaire of 75 questions, 5 were excluded because they were not appropriate for Suriname.
In Suriname, however, there are several dimensions that influence the satisfaction of patients. Some staff members of the nursery were interviewed in order to identify if the dimensions according to the KQCAL scale were applicable at AHP and if there were other specific dimensions possible to be added at the mentioned instrument to measure patient’s satisfaction.
In their view the eight dimensions are appropriate, but they insist that there are certainly other relevant factors that could be important for the patients. Factors like their privacy when the medical specialist is consulting the patient, the cultural diversity and therefore for instance differences in languages, the availability of linen for the beds, the visiting hours play an important role in the Surinamese case.
3.4 Applications of SPSS
Using a survey to measure satisfaction among patients is a common instrument although there are many hindrances to use it. Some of these are: the selected population is not representative, partial non responses, the effects of an interviewer on the respondent, the formulation and effect of the questions, the effect of questions filled in by people that all questions are positive. However, a survey is the only reliable instrument to do so. The objective of this survey is to give a description, comparison and explanation of knowledge, attitude and behavior and is therefore applicable.
Indicators for satisfaction depend in general on factors as trust, sexes, profession, own living standard and education. For research purposes these indicators are not all neglected
