CHAPTER 1INTRODUCTION1.1 Rationale and justificationFor every hospital, patients are the main users. The primary function of the hospital is patient care. It is one of the yardsticks to measure the success of services that it produces. Effectiveness of the hospital relates to provision of good patient care as intended. According to Swamy (1975) patient satisfaction is the real testimony to the efficiency of hospital administration. As the hospital serves all the members of the society, the expectations of the users differ from one individual to another individual because everyone carries a particular set of thoughts, feelings and needs. Hence determination of patient’s real feelings is very difficult. It is the responsibility of the administrator team. "Put yourself in your patient''''''''s shoes," was a proverb that explains how to proceed with a patient (1).Consumer satisfaction is generally defined as the consumer’s view of services received and the results of the treatment. It has been used by program evaluators to enhance health care providers’ ability to render services that meet consumers need (2). Society now acknowledges the importance of the views of users in developing services, and the healthcare sector has used a range of methods to identify the views of patients and the public (3). Dansky and Miles (1997) state that from a management perspective, client satisfaction with health care is important for various reasons. First, satisfied patients are more likely to maintain a consistent relationship with a specific provider. Second, by identifying sources of patient satisfaction, an organization can address system weakness, thus improving its risk management. Third, satisfied patients are more likely to follow specific medical regimens and treatment plans. Finally, patient satisfaction measurement adds important information on system performance, thus contributing to the organization’s total quality management (4). Research on patient satisfaction with medical care can be traced back to the late 1960s. Over 40 years, an overwhelming number of publications on the topic have appeared. At first, research focused on patient satisfaction as a condition to be satisfied in order to reach desirable clinical outcomes, such as appointment keeping or compliance with recommended treatment. Gradually, interest shifted to patient satisfaction as a dependent variable. Nowadays, hardly any hospital will fail to incorporate in-patient satisfaction rating into their evaluation of care (5).According to the South African Black Population study 76% rely on public hospitals and the facilities are overcrowded, understaffed and under resourced, contributing to waiting time of more than 1 hour to see a health provider (6). Thomas et al investigated patient satisfaction in a oncology outpatient clinic in Middlesex University in Enfield UK and reported that out of 252 patients 92% were "always" or "usually" reassured as a consequence of their visit. This study also confirmed the fact that clinical staffs are one of the most important sources of satisfaction. Similar Italian and British studies also reported strong and weak points of their services that were brought out by patient satisfaction surveys and took measures to rectify the problem areas. The health care system is basically a service based industry and customer satisfaction is of utmost importance just as in other service-oriented sectors (7).Maldives is a developing country and most efforts in health services seek to provide basic health care needs to all citizens adequately and equally. There was a paucity of reliable and valid satisfaction measures. In addition, no studies have investigated the relationship between the component of patient satisfaction and health status. The Indira Gandhi Memorial Hospital serves as the major tertiary referral hospital. It also serves as the focal point for entry to health service for the people of the whole country. This hospital is situated in Male, the capital of Maldives. The hospital, with its wide ranging departments and modern diagnostic facilities, are manned by qualified and experienced medical personnel. The IGMH policy is to deliver an affordable and wide-ranging health care service to Maldivians. To achieve this IGMH has been conducting several methods to enhance their services; however they need to go through a long path to reach the goal. The customer image of the
PATIENT SATISFACTION WITH HEALTH SERVICES AT THE OUTPATIENT DEPARTMENT OF INDIRA GANDHI MEMORIAL HOSPITAL, MALE’ MALDIVES ASMA IBRAHIM A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF PRIMARY HEALTH CARE MANAGEMENT FACULTY OF GRADUATE STUDIES MAHIDOL UNIVERSITY 2008 COPYRIGHT OF MAHIDOL UNIVERSITY ACKNOWLEDGEMENTS This thesis would not have been possible without the help and support of many people I express my deep sincere of gratitude to Associated Professor Jiraporn Chompikul, my major advisor, who offers me her endless support and remarkable kindness from the beginning until the completion of my thesis I also would like to express my sincere thanks to my co-advisor, Associated Professor Sirikul Isaranurug, for her constructive comments and suggestions I would like to acknowledge and pay my special thanks to Ministry of Health Maldives for offering me this scholarship My special thanks go to my sponsor, World Health Organization (WHO) for giving me this great opportunity to achieve my goals from this MPHM course and gain precious experience from here I would never forget endless support given by MPHM staffs working in this institute, especially Ms Sirilak Leyeskul and her elegant staffs I eager to say “Thank you very much” to my all classmates who always inspire me, especially Dr In Sokhanya and Dr Kazi Asadur Rahman Without your help I might not be successful to achieve this I would also like to express my thanks to three Senior Staff Nurses who participated in the process of data collection and give their valuable time to complete the process with limited time I thank to all my friends in Indira Gandhi Memorial Hospital (IGMH) for encouraging me during data collection Lastly of all, I would like to thanks to my devoted husband and beloved mother, brothers and sisters for their encouragement and support to make this successful Asma Ibrahim Fac of Grad Studies, Mahidol Univ Thesis / iv PATIENT SATISFACTION WITH HEALTH SERVICES AT THE OUTPATIENT DEPARTMENT OF INDIRA GANDHI MEMEORIAL HOSPITAL, MALE’ MALDIVES ASMA IBRAHIM 5037998 ADPM/M M.P.H.M (PRIMARY HEALTH CARE MANGEMENT) THESIS ADVISORS: JIRAPORN CHOMPIKUL, Ph.D., SIRIKUL ISARANURUG, M.D., Dip Thai Board of Pediatrics ABSTRACT A cross-sectional study was conducted on patient satisfaction with health services at the outpatient department of Indira Gandhi Memorial Hospital, Male’ Maldives, with the aim determining the relationship between satisfaction and explanatory factors Suggestions and comments from the patients were also revealed in this study Using a structured questionnaire, data were derived from 251 patients using the OPD services Descriptive statistics were used to describe satisfaction level and independent variables while the relationships between these factors were determined by Chi-square test The average score of patient satisfaction was 3.5 and 10.4% of the patients were highly satisfied with health services Patients were highly satisfied with courtesy (45.8%), quality of care (44.2%), physical environment (41.8%), convenience (24.7%), and out of pocket cost (23.5%) Regarding predisposing factors, attitude were significantly associated with level of satisfaction (p=0.002) The majority of the patients was concerned about waiting time to seek a doctor’s service and counter services are being delayed due to not enough staff being available Strategies emphasizing improving the image of the hospital should be continuously implemented while the attitude of the patients could change with good reputation of hospital Patient satisfaction surveys can be conducted in each unit to get the real picture for further strategies KEY WORDS: PATIENT SATISFACTION / OUTPATINET DEPARTEMNT / HEALTH SERVICES 76 pp CONTENTS Page ACKNOWLEDGEMENTS iii ABSTRACT iv LIST OF TABLES vii LIST OF FIGURES viii LIST OF ABBREVIATIONS ix CHAPTER INTRODUCTION 1.1 Rationale and Justification 1.2 Research Questions 1.3 Research Objectives………………………………………… 1.4 Conceptual framework 1.5 Operational definition of study variables 1.6 Limitation of the study 10 LITERATURE REVIEW 2.1 Patient satisfaction ………………………………………… 11 2.2 Theoretical model 14 2.3 Factors related to satisfaction 2.4 Health services in the Maldives 17 18 RESEARCH METHODOLOGY 3.1 Research design 22 3.2 Study site 22 3.3 Study population 22 3.4 Sample size determination 23 3.5 Sampling technique 24 3.6 Data collection tools 25 3.7 Pre-test 29 vi CONTENTS (cont.) Page 3.8 Data collection procedure 3.9 Data analysis 30 3.10 Ethical consideration 30 31 RESULTS 4.1 Socio-demographic characteristics of the patients 4.2 Expectation towards health services at OPD 36 4.3 Patient attitude towards health services at the OPD 36 4.4 Patient satisfaction towards health services at OPD 37 4.5 Association between independent and dependent variables 39 4.6 Patient’s comments and suggestion 32 43 DISCUSSION 5.1 Methodological concern 45 5.2 Patient satisfaction towards health services of IGMH hospital………………………………………………… 46 5.3 Socio-demographical factors…………………………… 48 5.4 Patient attitude towards health services of IGM hospital 50 5.5 Patient expectation towards health services of IGMH hospital ……………………………………………… … 5.6 Comments and suggestions from the patients…………… 51 51 CONCLUSION AND RECOMMENDATION 6.1 Conclusion 54 6.2 Recommendations 56 REFERENCES 59 APPENDIX 63 BIOGRAPHY 76 LIST OF TABLES Table Page Total number of patients per day in each unit…………………………………… 24 Measurement and classification of variables …………………………………… 28 Socio-demographic characteristic of the patients ……………………………… 34 Overall expectation of patient towards health services at the OPD of IGM hospital ………………………………………………………………… 36 Overall attitudes of the patients towards health services at the IGM hospital… 37 Number and percentage of patients by overall satisfaction for each component 38 Overall satisfactions towards health services at OPD………………………… 39 Association between attitude and satisfaction ………………………………… 40 Association between expectation and satisfaction …………………………… 40 10 Association between satisfaction and socio-demographic factors …………… 42 11 Patient’s comments and suggestion for improving the quality of health services at the OPD of IGM hospital 44 12 Frequency and percentage of patient’s attitude towards health services at OPD of IGM hospital by item of question…………………………………………….… 70 13 Frequency and percentage of the patients expectation towards health services at OPD of IGM hospital ……………………………………………………… … 71 14 Frequency and percentage of the patients satisfaction towards health services at OPD of IGM hospital ………………………………………………………… 72 15 Frequency and percentage of overall patient’s satisfaction with 75 cut-off point 75 LIST OF FIGURES Figure Page Conceptual framework Andersen’s behavioral model 16 Service system of OPD 21 LIST OF ABBREVIATIONS ANC : Antenatal Care CI : Class interval ENT : Ear Nose and Throat ICCU : Intensive Coronary Care Unit IGMH : Indira Gandhi Memorial Hospital NTC : National Thalassemia Center OPD : Out Patient Department PNC : Postnatal Care STO : State Trading Organization TBA : Traditional Birth Attendance Asma Ibrahim References / 62 35 Roy PP Client satisfaction on outpatient medical care services in Sampran Community Hospital, Thailand [M.P.H.M Thesis in Primary Health Care Management] Nakhon Pathom: Faculty of Graduate Studies, Mahidol University; 2007 36 Aldana JM, Piechulek H, Al-Sabir A Client Satisfaction and Quality of Health Care in Rural Bangladesh Bulletin of World Health Organization 2001.79: 512-517 Available from: http://www.who.int/bulletin/archives/79(6)512 [Accessed 2008 Jan 15] 37 Renzi C, Abeni D, Picardi A, el al Factors associated with patient satisfaction with care among dermatological out patients Br J Dermatol 2001 Oct; 145(4): 617-23 38 Sitza J, Wood N Patient satisfaction: A review of issues and concepts Social science 1997; 45(12): 1829-43 39 O’Neill C Benchmarking Client Satisfaction with General Practitioner Services: results and lessons from a population based survey Reader in Health Economic Policy Available from; http://www.priory.com/fam/bench.htm [Accessed 2008 Mar 9] 40 Offei AK, Bannerman C, Keyeremeh K Healthcare Quality Assurances manual: from sub-sub districts July 2004 [Online] [cited 2008 Feb 25] Available from: http://www.ghanaqhp.org/fileadmin/user_upload/QHP/Healthcare_Quality_su bdistrict.pdf Fac of Grad Studies, Mhidol Univ M.P.H.M (PHC Management) / 63 APPENDIX Asma Ibrahim Appendix / 64 APPENDIX A QUESTIONNAIRE ID no - Patient satisfaction towards Outpatient department services This questionnaire is constructed for assessing your satisfaction towards services provided by Indira Gandhi Memorial Hospital Information obtained will be used for the hospital service improvement and will be kept confidential Your honesty in responding is most helpful Thank you in advanced for your response Hospital number: ……………………………… Date of data collection: ……………………… Name of interviewer: ………………………… Part- I Socio-demographic Factors Please tick mark ( ) the appropriate answer in the box or fill in the blanks as required What is your sex? Male Female What is your Age (in years)? What is your marital status? Single Married Divorce/ Separated Widowed What is your highest level of education attainment? No education literate Primary school Fac of Grad Studies, Mhidol Univ M.P.H.M (PHC Management) / 65 Secondary school Higher secondary school Higher education Others (please specify) ………………………………… What is your occupation? Civil Servants Private sector Self-employed Unemployed Student Other (please specify) …………………………………… Average family income per month? ……………………………Ruffiya (Immediate family) Total number of visits to this hospital (during last six months) ……………………………………………… (including this visit) What is the current problem that you came to hospital today? ……………………………………………………………………………… How you are going to pay for this visit? Private scheme Government scheme (skip Q10) Insurance scheme (skip Q10) Others (specify)………………………………………… Asma Ibrahim Part- II Appendix / 66 Patient expectation towards health services at OPD of Indira Gandhi Memorial Hospital Before utilizing the services, what is your expectation towards the services of IGM Hospital? (Please select the choice that is closest to the level of your expectation) 10.What is your expectation to the total cost paid out of your pocket for health services (e.g Payment for registration, laboratory and medication)? I expected the total cost out of pocket might not be affordable I expected that total cost out of pocket might be affordable I expected that total cost out of pocket might be enough to cover this visit I don’t have any expectation 11 What is your expectation towards the quality of care (e.g quality of equipment, service providers and medication)? I expected that the quality of care will not be good I expected that the quality of care will be acceptable I expected that the quality of care will be excellent I don’t have any expectation 12 What is your expectation towards waiting time? I expected that the waiting time will be long I expected that the waiting time will be acceptable I expected that the waiting time will be short I don’t have any expectation 13 What is the expectation towards the surrounding of the hospital (e.g cleanliness, ventilation, health messages)? I expected that the condition of the OPD surrounding might not be good I expected that the condition of the OPD surrounding might be acceptable I expected that the condition of the OPD surrounding might be excellent Fac of Grad Studies, Mhidol Univ M.P.H.M (PHC Management) / 67 I don’t have any expectation 14 What is your expectation about the information that you would acquire from the doctor concerning your illness? I expected that any useful information might not obtained I expected that some of useful information might be obtained I expected that a lot of useful information might be obtained I don’t have any expectation Part III Patient attitude towards health services at the OPD of IGMH How you feel about the medical services you have received from OPD? Please read each one carefully and circle one number How strongly you “Agree” or “Disagree” with each of the following statements Strongly Agree = Agree = uncertain =3 Disagree =2 Patient Attitude 15 The hospital has a good reputation 16 Queuing system in IGMH are trouble free 17 The doctors here are competent 18 Doctors are not acting businesslike and impersonal 19 Medical staff treat in a friendly and courteous manner 20 Overall health care services get from this OPD is very good Strongly Disagree =1 Asma Ibrahim Appendix / 68 Part IV: Satisfaction towards health services at OPD Please tick ( ) the appropriate answer in the box Scale: = very satisfied, = satisfied, = neutral, = dissatisfied, = very dissatisfied Convenience 21 Simplicity and trouble free of service system 22 Availability of instruments like BP apparatus, thermometer, weighing scale and other instruments 23 The arrangements for cooling in waiting area for patients 24 Availability of Nurse/clinical assistance for consultation 25 Availability of doctors for consultation courtesy 26 Friendliness and courteous manner of medical staff 27 The attentiveness of doctors/nurses while answering your questions 28 Provide appropriate time for medical examination 29 Maintain privacy appropriately before doing any procedure Quality of care 30 Competency of doctor for treating the patient 31 The qualities of instrument used for medical care 32 Doctors examine patient carefully 33 Pharmacists are skillful and dispensed drug Out of pocket cost 34 Costs of medical services are affordable Fac of Grad Studies, Mhidol Univ Convenience 35 M.P.H.M (PHC Management) / 69 Protected financially against medical problem Physical Environment 36 The atmosphere of this OPD is clean and tidy 37 Sitting chairs are available at the waiting area 38 Availability of drinking water and clean toilets 39 Clear signs and directions to indicate where to go in the service area and easy to follow 40 The inside of the hospital has good ventilation Part V: Patient’s suggestion and comments to improve the quality of health services at the OPD of IGM Hospital 41 Do you have any comments or suggestion to improve the quality of health services at the OPD? ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………… ….Thank you very much for your kind cooperation 11(4.38) 13(5.18) Doctors here are competent The doctors are not acting businesslike and hospital is very good Overall health care services get from this manner Medical staff treats in a friendly and courteous 18(7.17) 12(4.78) 9(3.59) Queuing system in IGMH are trouble free impersonal 11(4.38) 162(64.54) 175(69.72) 114(45.42) 154(61.35) 154(61.35) 149(56.36) 35(13.94) 34(13.55) 26(10.36) 33(13.15) 8(3.19) 26(10.36) (3) 27(10.76) 21(8.37) 64(25.50) 31(12.35) 42(16.73) 32(12.75 (2) Strongly 9(3.59) 9(3.59) 37(14.74) 22(8.76) 38(15.14) 33(13.15) (1) (4) Disagree (5) Uncertain disagree Agree Frequency & Percent (%) agree Strongly The hospital has a good reputation Questions by item of question Table 12 Frequency and percentage of patient’s attitude towards health services at OPD of IGM hospital APPENDIX B Asma Ibrahim Appendix / 70 Poor doctor concerning your illness What is your expectation about the information that you would acquire from the 12(4.9) ventilation, health messages) What is the expectation towards the surrounding of the hospital (e.g cleanliness, 12(4.9) pharmacy services What is your expectation towards waiting time (e.g registration, consultation and 162(64.5) providers and medication) What is your expectation to the quality of care (e.g quality of equipment, service 10(4.1) (e.g payment for registration, laboratory and medication) What is your expectation to the total cost paid out of your pocket for health services 13(8.6) Questions by item of questions 56(23.0) 52(21.3) 50(19.9) 62(25.6) 20(13.2) Fair Frequency 176(72.1) 180(73.8) 39(15.5) 170(70.2) 118(78.1) Good Percent (%) Table 13 Frequency and percentage of patient’s expectation towards health services at OPD of IGM hospital Fac of Grad Studies, Mhidol Univ M.P.H.M (PHC Management) / 71 5(1.99) 5(1.99) 6(2.39) 11(4.38) Friendliness and courteous manner of medical staff 8(3.19) Availability of doctors for consultation consultation Availability of nurses/clinical assistance for patients The arrangement for cooling in waiting area for scale etc.) 8(3.19) Availability of (BP, Thermometer and weighing 178(70.92) 139(55.38) 171(68.13) 191(76.10) 173(68.92) 143(56.97) 28(11.16) 16(6.37) 23(9.16) 10(3.98) 48(19.12) 15(5.98) (3) 30(11.95) 67(26.69) 44(17.53) 28(11.16) 18(7.17) 48(19.12) (2) Very 7(2.79) 24(9.56) 7(2.79) 11(4.38) 4(1.59) 40(15.94) (1) (4) Dissatisfied (5) Neutral Percent (%) Dissatisfied Satisfied Frequency Satisfied Very Simplicity and trouble free of service system Convenience Questions hospital by item of questions Table 14 Frequency and percentage of patient’s satisfaction towards health services at OPD of IGM Asma Ibrahim Appendix / 72 appropriate time for medical 16(6.37) 8(3.19) Doctors examine patient carefully examination 14(5.58) The quality of instruments used for medical 10(3.98) Competency of doctor for treating the patients Quality of care any procedure Maintain privacy appropriately before doing 8(3.19) examination Provide answering your questions (2) Very 181(72.11) 164(65.34) 177(70.52) 164(65.34) 158(62.95) 172(68.53) 28(11.16) 43(17.13) 24(9.56) 47(18.73) 29(11.55) 25(9.96) 21(8.37) 22(8.76) 30(11.95) 25(9.96) 38(15.14) 42(16.73) 7(2.79) 12(4.78) 12(4.78) 7(2.79) 10(3.98) 7(2.79) (1) (3) Dissatisfied (5) (4) Neutral Dissatisfied Satisfied Frequency & Percent (%) Satisfied Very The attentiveness of doctors/nurses while 5(1.99) Questions by item of questions (cont.) Table 14 Frequency and percentage of patient’s satisfaction towards health services at OPD of IGM hospital Fac of Grad Studies, Mhidol Univ M.P.H.M (PHC Management) / 73 21(8.37) The inside of the hospital has good ventilation 38(15.14) 170(67.73) Clear signs and directions to indicate where to 18(7.17) go in the service area and easy to follow 125(49.80) 12(4.78) Availability of drinking water and clean toilets 189(75.30) 168(66.93) 21(8.37) Sitting chairs are available at the waiting area 72(28.69) 20(7.97) 110(43.82) The atmosphere of this OPD is clean and tidy Physical Environment 11(4.38) Protected financially against medical problem 158(62.95) 7(2.79) 16(6.37) 36(14.34) 11(4.38) 38(15.14) 23(9.16) 12(4.78) (3) 9(3.59) 28(11.16) 42(16.73) 41(16.33) 63(25.10) 67(26.69) 39(15.54) (2) Very 8(3.19) 19(7.57) 36(14.34) 10(3.98) 58(23.11) 40(15.94) 21(8.37) (1) (4) Dissatisfied (5) Neutral Dissatisfied Satisfied Frequency & Percent (%) Satisfied Very Costs of medical services are affordable Out of pocket cost Questions by item of questions (cont.) Table 14 Frequency and percentage of patient’s satisfaction towards health services at OPD of IGM hospital Asma Ibrahim Appendix / 74 74 178 Low satisfaction Frequency High satisfaction Levels of satisfaction 70.6 29.4 Percent (%) Table 15 Frequency and percentage of overall patient’s satisfaction with 75% cut-off point Fac of Grad Studies, Mhidol Univ M.P.H.M (PHC Management) / 75 Asma Ibrahim Biography / 76 BIOGRAPHY NAME Asma Ibrahim DATE OF BIRTH 5th July 1976 PLACE OF BIRTH LH/ Kurendhoo, Nirolhuge Maldives INSTITUTION ATTENDED Faculty of Health Sciences Male’ Maldives 1995-1998 / 2001-2002/2008 Diploma in Nursing and Midwifery Monash University, Malaysia Bachelor’s Degree in Nursing Mahidol University, Thailand Master of Primary Health Care Management ASEAN Institute for Health Development FELLOWSHIP / Ministry of Health, Maldives/ WHO RESEARCH GARNT RECENT POSITION Senior Staff Nurse Indira Gandhi Memorial Hospital Male’ Maldives ... from patients were analyzed thoroughly 1.2 Research questions What is the level of patient satisfaction towards health services at the outpatient department of IGMH? What are the factors related... satisfaction with health services at the outpatient department of Indira Gandhi Memorial Hospital, Male’ Maldives, with the aim determining the relationship between satisfaction and explanatory factors... (15) .Patient satisfaction is generally defined as the consumer''s view of services received and the results of the treatment The importance of patient satisfaction has had a long history of debate,