Chất lượng dịch vụ y tế công tại Bệnh viên Đa Khoa Trung Ưng Thái Nguyên (1)

PUBLIC HEALTH SERVICE QUALITY AT THAI NGUYEN NATIONAL GENERAL HOSPITAL EXECUTIVE SUMMARY CENTRAL PHILIPPINE UNIVERSITY DOCTOR IN PUBLIC ADMINISTRATION NGUYEN THI LAN ANH DECEMBER 2016 EXECUTIVE SUMMARY Title: Public health service quality at Thai Nguyen National General Hospital (From October, 2016 the hospital has been renamed to Thai Nguyen National Hospital by Ministry of Health of Vietnam) Total number of page: 138 Researcher: Nguyen This Lan Anh Degree Program: Doctor of Public Administration Institution: Central Philippine University Jaro, Iloilo City Region VI Rational/Introduction of Study Health quality can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 2001) Major health care quality concerns (such as patient safety and effectiveness of care) are basically the same across different types of countries In a low – income country like Vietnam, quality related problems are much more prevalent Major factors that cause health care quality problems in Vietnam are: Lack of sufficient management (clinical and administrative); Inadequate medical staffs and training; Weak performance monitoring systems; Non-empowered patients and families Once we can assess the relative appropriateness and effectiveness of health services, we can provide optimal care to patients and maximize our use of scarce resources Because of increasing competition, service providers and more demanding patients, service quality has become a watchword for healthcare service providers but as yet has proven difficult to measure Service quality has been directly linked to repeat sales, positive word-of-mouth and recommendation Consumer satisfaction is directly linked to service quality thus perceived quality, patient satisfaction and behavioural intentions are concepts of foremost importance to healthcare marketers (Ross et al., 1987, John Joby, 1992, Paul, 2003) There exists number of shortcomings in medical policies and medical services mechanisms in Vietnam Large investment resources but effective use of resources to supply medical services doesn‟t meet practical requirements posed Currently, people assess the quality of health services are implemented only sensible levels, mainly through external audio visual facilities and the behaviour, reception and care of medical staffs As for the quality of technical, medical science, in fact, underestimate people The provision of health services is now revealing many negative issues such as drug abuse, chemical, laboratory to the attitude, spirit of service, ethics It was real severe economic and popular in many establishments providing health services, both public and private sector (Tran Tuan - Director of the Centre for Research and Training Community Development, Vietnam Union of Science and Technology Associations) Vietnam‟s health sector hasn‟t met the criteria of both quantity and quality of health services for the people The accessibility of people to health services is very difficult, especially for the poor, near poor and remote populations Inequality in the supply and beneficiaries of health services tends to increase Mechanisms and policies in managing operating health sector are inadequate Management information system for health care is not comprehensive and overlaps Quality management system of health services as well as quality inspection of health services in both the public sector and private sector remains weak The management of drug prices in hospitals is inadequate push higher drug costs put pressure on hospital charges for patients (Truong Bao Thanh, 2013) Vietnamese health sector is facing with an imbalance in the demand for health care among central hospitals and local people in the provinces and cities nationwide Demand for health care is increasing, whereas, only a few hospitals in the big city have capabilities to deal with Especially over the last 10 years, the phenomenon of hospital overcrowding has worsened and appeared at all levels The situation of combining 2-3 patients a bed; clinic doctor must examine 60-100 patients per day is common in Central National, provincial hospitals and becomes a priority health issue, an urgent concern of the health sector as well as the entire society needs to be addressed The utilization rate of over 100 % regular beds and ranged from 120 % to 150 %, even up to 200% in some large hospitals (Le Quang Cuong et al., 2011) According to Vietnam health statistics, there are about 40,000 Vietnamese people go overseas for treatment every year They spent more than billion USD for their treatment in developed countries such as Singapore, South Korea, the US, France, and Thailand This figure is estimated to rise to 50,000 people by 2016 Doctors in Vietnam are considered as not inferior to the advanced countries mentioned above It is caused by overworked staff, poor service quality, and complex administrative procedures; cumbersome A survey of over 700 patients taken by VN Express in Vietnam showed that 57 % Vietnamese people not want to use the services of hospitals in the country by the attitude and ethics of the medical staffs It is raising a question of “Does the medicine of our country have won the confidence of the patient?” Medical service is a very special service In essence, health service includes activities performed by medical staff as health examination and treatment for patients and families (Journal of Marketing, 2009) Institute of Medicine (2001) defines quality of health care is the degree to which the health services are provided to individuals and the population to increases the desire of health outcomes and match current professional knowledge Quality of health services determined the existence of hospital and can be measured through the patients‟ satisfaction Previously, it is thought that the evaluation and quality assurance is limited in developed countries (Thomason & Edwards, 1991), in the developing countries; the problem of improving medical quality received little interest until recently (Reerinks and Sauerborn, 1996) For public services, the quality assessment has also received little attention (Narang and Ritu, 2011) The quality of medical services is assessed from two points of view: technical and functional (Institute of Medicine, 2001) Technical quality refers to aspects related to the diagnosis and procedures while functional quality refers to aspects related to the way services are provided to the patients (Narang and Ritu, 2010) To be successful in long term a health care organization must effectively monitor and manage both technical and functional quality (Babakus and Mangold, 1992) Functional quality is often considered as the main key to determine the quality by customer perception because it is difficult to precisely assess the technical quality due to lack of professional experience (Donabedian, 1980) Thai Nguyen is a large mountainous province in northern area of Vietnam with 1.2 billion inhabitants It is nationally known as a No center for training human resources after Hanoi and Ho Chi Minh City with universities, 11 colleges, vocational center, training nearly 100,000 workers each year This unique demographic situation has led to a marked diversity of public health agencies in Thai Nguyen province There are one national general hospital, 08 provincial hospitals and more than fifteen medical centres at district level For this reason, public health agencies in Thai Nguyen were classified differently from other cities of Vietnam According to General Statistic Office of Vietnam, in 2013 the province had 520 health establishments with 23 hospitals and 4719 patient beds; The number of medical staffs was 4219 persons, doctors per thousand populations was 7.6, number of beds per thousand populations was 31.6 beds, and the percentage of children under age fully injected vaccine was 98% Specifically, the State own unit account for 42% but served 98% of patient bed The national health program was implemented and performed relatively well, the state of food safety and hygiene has been improved However, the quality of services in some health facilities was not high due to lack of technical facilities and doctors (Thainguyen Statistic Office) Public health services are more favorable with reasonable price for most people in Thainguyen city Community pharmacy is recognized as an easily accessible source of advice in primary health care and pharmacists as competent and well-trained health professionals An essential factor to consider when analyzing the quality of health care in facilities is the perspective of the clients For clients and communities, quality care is something that meets their perceived needs Since a client's needs often differ from one and other, his/her personal satisfaction ultimately depends on the individual perception, attitude and expectations Patient satisfaction is a strong influencing factor in determining whether a person seeks medical advice, complies with treatments and maintains a relationship with the provider/health facility Ultimately, the dimensions of quality that relate to client satisfaction affect the health and well-being of the community The results of the literature review suggest that the most important dimensions of quality for the client are technical competence, interpersonal relations, accessibility and amenities Thai Nguyen National Hospital (TNH) is located at Phan Dinh Phung ward, right center of Thainguyen City The hospital was established in 1951, this is a state own hospital – one of the largest hospital in Thai Nguyen province and in North mountainous region TNH is maintained the first class hospital with bed size of 1200 units, the highest level of treatment is responsible for direct health care for more than 1.2 million people in Thainguyen province, and the ultimate treatment venue in North moutainous provinces The hospital has 40 wards, department and centers with high quality medical staffs In order to reach the mission of deploying advanced techniques of thoracic surgeries, tumors, resuscitation, heart disease; the satellite clinics of leading Central hospital in Northern mountainous area of Vietnam, the completion of human resources and enhancing quality of hospital‟s health services is necessary Especially, in the coming competitiveness and higher demand as well as quality for health services boost all hospital to a number of opportunities and threats Today for the healthcare service market in Thainguyen, there is a need for a healthcare service quality model that takes into consideration a complete coverage of the dimensions that consumers use in evaluating healthcare service quality Hence, the evaluations of health services through the patients‟ satisfaction as well as health provider‟s perspective of awareness and managing quality is needed Provision of health service quality is the top priority in hospital management, especially in public sector That is why the topic “Public health service quality at Thai Nguyen National Hospital” was chosen as the dissertation title The research is conducted with focusing on service quality, patient satisfaction and intentions to return, as well as the patient role in the medical service encounter Objectives of the Study General objective This study concentrates on quality assessment of the public health services at Thai Nguyen National General Hospital Thus, improving health service quality as well as the competition ability of hospital and contributing to meet the strategic objectives of Vietnam in terms of public health services quality up to 2020 Specific objectives Specifically, this study seeks to: Describe the current status of health services quality at Thai Nguyen National Hospital – a public hospital in Thai Nguyen city; Determine factors affecting functional quality of health service at Thai Nguyen National Hospital Examine the overall perceived quality of patients toward the quality of health services at Thai Nguyen National Hospital; Determine relationships between overall patient satisfaction and factors affecting their satisfaction level including tangibility, reliability, responsiveness, assurance, and empathy; Determine relationships between patient demographics characteristics and their overall level of satisfaction; Propose recommendations for a better healthcare quality improvement at Thai Nguyen National Hospital 6 Research Hypothesis - Hypothesis (H1): There are no significant effects of SERVQUAL dimensions as Tangibles, Reliability, Assurance, Responsiveness, and Empathy on patient‟s overall perceived of health service quality + H1.1 There is no significant effect of “Tangibility” on patient’s overall perceived of health service quality + H1.2 There is no significant effect of “reliability” on patient’s overall perceived of health service quality + H1.3 There is no significant effect of “Assurance” on patient’s overall perceived of health service quality + H1.4 There is no significant effect of “Responsiveness” on patient’s overall perceived of health service quality + H1.5 There is no significant effect of “Empathy” on patient’s overall perceived of health service quality - Hypothesis (H2): There are no significant different in overall perceived hospital service quality of patient according to their personal characteristics as age, gender, occupation, income and educational level + H2.1 There is no significant different in overall perceived hospital service quality of patient according to their age + H2.2 There is no significant different in overall perceived hospital service quality of patient according to their gender + H2.3 There is no significant different in overall perceived hospital service quality of patient according to their occupation + H2.4 There is no significant different in overall perceived hospital service quality of patient according to their income + H2.5 There is no significant different in overall perceived hospital service quality of patient according to their educational level - Hypothesis (H3): The higher patients‟ perceive of overall quality of health service is, the better their satisfaction would be - Hypothesis (H4): There is no significant correlation between overall patient satisfaction and the patients' intention to return and to recommend other for coming to hospital 7 Conceptual Framework ANTECENDENT VARIABLE INDEPENDENT VARIABLE DEPENDENT VARIABLE SERVQUAL Expected Service Quality DEMOGRAPHICS  Age  Gender  Ethnic   Occupation Income  Education  Using HIC Overall Perceived Service Quality Perceived Service Quality Patient Satisfaction SERQUAL FACTORS Tangibility Reliability Responsiveness Assurance Empathy Retention to return or recommend Research Design and Procedure The study used both qualitative and quantitative methods to analyze the health care service quality A list of quality assessment indices was formed based on Donabedian theory and SERVQUAL model The author divided research process into two phases: The first phase: Conduct a qualitative exploration of the characteristics of the healthcare service in Thainguyen upon which consumer build their perceptions about the quality of the healthcare service This was performed through conducting a series of in-depth interviews from patients as well as business and healthcare experts frequenting the publichealthcare sector in Thainguyen city Then the author conducted a pilot study to test the questionnaire and the reliability of data Final modification on the questionnaire format was done, prior to the quantitative data collection procedure In the second phase, themes and information from previous phase was developed into a valid and reliable instrument for measurement of healthcare service quality A modified conceptual model of service quality is constructed that was based on the work of previous authors in the field as well as data gathered from the qualitative section of the study Then a quantitative survey for a sample of patients frequenting the public healthcare sector in Thai nguyen National Hospital was performed to test the overall perceived service quality, satisfaction and retention to return of patients The researcher also use descriptive-rational as it describes certain characteristics of the respondent and its relation with other variables in the study To obtain the data needed, a survey design was used by using an interview schedule to get the right information from the respondents Determine problems Setting research objectives Determine research problem Research model Desk study Preliminary studies Group discussion (n = 10) Test the questionnaire (n = 20) Adjust Not meet the Expectation Meet Expectation Official questionaire Delivery questionaire (n =367) Data processing Data analysis Study population and Sampling technique  Population: Individuals have been used Thai Nguyen National General Hospital service from June to August, 2016  Sampling Methods: Random stratified sampling technique Heterogeneous samples are obtained that reflect, as much as possible, all patients who would receive health care in the hospital Evaluating the representativeness of such samples is problematic According to the latest statistics from GSO of Vietnam, every month there is more than 3500 in patients come to stay in Thai Nguyen National General hospital with different demographical characteristics The variability in demographics ensured varied opinions and responses of individuals covering all the sampling criteria to be used in the present research  Sampling Criteria: Patients who use public health service in the hospital in 2016, have had at least one overnight stay in the hospital  Sample Size: Based on research by Hair, Anderson, Tatham and Black (1998) to refer to the expected sample size Accordingly, the minimum sample size was times the total number of observed variables Applying in this study, the number of observed variables are 25, so we can get n = 125 But the author decided to choose n equal to 367 patients in order to make the sample be more reliable It covers almost one third of the hospital scale of patient bed  The process of choosing 367 patients will be as follow: In order to ensure the randomly, representatively, the process of choosing sample will be followed this procedure: Ask the patients at departments including types of bed rate from high, medium and low level and Outpatient Department In each department, choose patient according to the list of them in the record book Choose name of the patient according to the first letter of their name Choose letters in one day, and continue that process until reach the number of respondents of 30 - 70 patients in each department In the list of patient associated with department, choose only one who has been stayed at the hospital at least days or more Planning the time and department as well as the letter will choose when conducting survey as follow: 10 Level of bed Order Department occupation Time rate Number of respondents Labor ward High July, 2016 67 Gastroenterology High July, 2016 60 Traumatology Medium August, 2016 50 Cardiology Medium August, 2016 40 Odontology Low August, 2016 30 ICU and poison control Low August, 2016 30 Outpatient department Special August, 2016 90 Total 367 In the Pilot study, the number of experts will take part in will be approximately 10 persons, including: Board of director of hospital, Head of department in hospital, leader of health department in Thainguyen province The discussion focuses on the quality of health services in hospital, from the awareness of director, the direction of manager‟s board to the indicator for health service quality The author also ask experts view point of dimensions in the Parasuraman service model that using in assessing the quality of health service in hospital And ask them to weight the importance of each dimension with the assumption that total quality dimension equal to 100 percent Data collection and instrumentation Delphi study Using the table of the survey questionnaire, interviews Patients who have been used hospital‟ services will receive a table of survey question and a detail instruction to get correctly answers Objective of survey questionnaire is evaluatingexpectations and perceptions satisfaction of them with hospital‟s services Use SERVQUAL model to evaluate patients‟ satisfaction with hospital health services follow factors determinants and 25 items.The patients‟ satisfaction is measured by the gap between the perception and expectations (Perception - Expectation), and use Liker scale with SERQUAL model to evaluate customer satisfaction The five dimensions of SERVQUAL as proposed by Parasuraman et al (1988), Othman & Owen (2001, 2002) and Jabnoun and Al-Tamimi (2003) will be adapted and modified in this study The instrument poses aset of 25 structured and paired questions designed to assess patients„expectations of service provision and the 11 patients „perceptions of what was actually delivered A five-point Likert-type scale is used in this study, anchored by - strongly disagree to―strongly agree Content validity (wording and meaning) was checked carefully by experts A pre-test was then conducted with a group of patients, and minor changes to the scales were made accordingly to ensure that the questions were not repetitive The researchers will use the structured and paired questions to measure Expectation (E) and Perception (P) for service quality of Hospitals Likert Scale Using the Likert point scale, with choices ranging from to as follows Scale Range Evaluating level 4.21 - 5.0 Highly satisfied 3.41 - 4.2 Satisfied 2.61 - 3.4 Neutral 1.81 - 2.6 Dissatisfied 1.0 - 1.8 Highly dissatisfied Use primary data of customer survey by questionnaire to analysis Data collected from 367 patients‟ questionnaire to evaluate patients‟ satisfaction and overall perceived in service quality with health services at Thai Nguyen National Hospital Cronbach's Alpha Assess the reliability of variables through Cronbach's alpha coefficient In statistics, Cronbach's is a coefficient of internal consistency It is commonly used as an estimate of the reliability of a psychometric test for a sample of study Exploratory Factor Analysis Exploratory factor analysis is a statistical technique that is used to reduce data to a smaller set of summary variables and to explore the underlining theoretical structure of the phenomena It is used to identify the structure of the relationship between the variable and the respondent In this research, the author uses Q-type factor analysis because factors are calculated from the individual respondent Driving factor is determined by Principle component factor analysis method in order to drive the minimum number of factors and explain the maximum portion of variance in the original variable The author also intent to use varimax rotation method to simplify the column of the factor matrix so that the factor extracts are clearly associated and there should be some separation among the variables Factor loading can be classified based on their magnitude: 12 Greater than + 0.30 - minimum consideration level + 0.40 - more important + 0.50 - practically significant Factor analysis will be used to combine data for regression model Regression models Y  0  1TAN  2 REL  3 RES  4 ASS  5 EMP  ei Y: is the overall perceived about service quality of patients TAN : Tangibility (physical facilities, equipment, and appearance of personnel) REL : Reliability (ability to perform the promised service dependably and accurately) RES : Responsiveness (willingness to help customers and provide prompt service) ASS : Assurance (knowledge and courtesy of employees and their ability to inspire trust and Confidence) EMP : Empathy (caring individualized); ei is the stardard error Test of validity Correlation matrix is used to measure correlation coefficient of variables, if the significant level of variable is higher than 0.5, the correlation is strong and vice versa Testing of multi-collinearity Multi-collinearity is the phenolmena that independent variable have almost linear relationship Skipping the mulitcollinearity often makes the standard errors higher, the statistical value lower and may not be meaningful To examine this phenomenon, we can use Pearson correlation matrix If the correlation coefficient between independent variables less than 0.5, there is the multicollinearity In addition, using Variance Inflation Factor (VIF) to test the phenomenon of correlation between the independent variables (VIF smaller than 2) Exploratory Factor Analysis (EFA) including steps: Step 1: Accreditation conditions for implementing EFA Including number of observations, number of variables in each dimensions Reliability test (Cronbach alpha); KMO and Bartlett's Test Step 2: Factors extracting Step 3: Analyse of factor extracting results Step 4: Naming and interpretation of factors Step 5: Check the reliability of the scales has edited Step 6: Analyze each observed variables affect in the same direction or viceverce 13 Analysis of variance This is a multi - applied method This is a classification problem, where two or more groups or clusters or populations are known a priori and one or more new observations are classified into one of the known populations based on the measured characteristics In this study, the author intent to use disciminant analysis to test whether there are any different in patients‟ perception interms of diferent age, gender, occupation and level of educational attainment Data processing and analysis Collect documents and related information of health care service from Thai Nguyen National General Hospital‟spatients who has been used hospital‟s services Send mail for getting a permission of using data to hospital‟s director If approved, the work continues to prepare data collection Preparing and using tools for data collection: usb, voice recorder, camera … Research conducted on the data collected * Primary and secondary data Primary data: Data was collected by the research questions and techniques of interviewing the patients who have usedthe health careservices of the hospital Secondary data: information, data reporting of health careservices are stored in the quality management department of the hospital * Tools of table of survey questions for patients including parts: - Part I is general information, the profile of the respondents who use / receive the health careservice of hospital - Part II is the expectation, the desire of patient with elements: Reliability, Responsiveness, Assurance, Empathy, Tangibles of health careservices - Part III is the perception of the customer‟s comments with health care services by factors: Reliability, Responsiveness, Assurance, Empathy, Tangibles by the measure of 5-level Likert scale - Part IV reviews the patient‟s satisfaction with the health care services of the hospital The results of the data collected were processed by using software on our computer (Excel and SPSS 20.0) Aftercoding and cleaning, the following analyzes were done: descriptive statistics, reliability assessment of scales, factor analysis, discriminant analysis and regression analysis To meet the aim at being able to evaluate patients‟ satisfaction with health care service of Thai Nguyen National Hospital, we used the measurement of expectations 14 and perceptions on quality of health services and patients‟ satisfaction with health service quality Patients‟ satisfaction is measured by the gap between the perception and expectations (Perception - Expectation) If the gap score proved positive then patients satisfied and patients‟ satisfaction as the perception over expectations If the gap score is negative, indicating the patients' perception of service quality is lower and did not meet their expectations for the service Findings The following are major findings of the study: SWOT Analysis of Thainguyen National Hospital Strength This is a state own hospital and served as a regional hospital Good facilities and modern equipment High quality of human resources Good scientific research with support from Thai Nguyen University of Medicine Good examination, emergency treatment for patients in normal disease Receiving the direct attention by the Department of Health, Provincial Committee - People's Council and Committee, Provincial Health Office The hospital has a team of young civil servants qualified, enthusiastic and energetic in their work Weakness - Finance is not flexible - Facilities and equipment is not really efficiency used - Reward and penalty regime is not really encouraged doctor and nurse - Information system and promotion are weak The budget for health care is not efficient - The facilities are inefficient, although the Government has been invested to renovate, expand and upgrade but still does not meet the requirements because patients increase overload - Lack of captial to invest in high tech health machinary - There is a shortage of human resources, especially lack of doctors Opportunity Threat - Capital resources are funded by - Competition also occurs in health government and get a lot of attention and services with private sectors investment from NGOs - The increase of market price and - The development of medical and higher living standard health care services in Vietnam and all - The higher demand of health care over the world services of people - Living standard of people in Thai - The payment policies are not really 15 nguyen province increase with higher flexible for patients average potential income per person - The - Invested in upgrading equipment and expanding Hospital expectation of patients in Thainguyen and mountainous areas is increasing sharply Status of public health service quality at Thainguyen National Hospital The board of manager of hospital early awarded about quality improvement In 2012, hospital built advanced planning stages for hospital quality in the period 20122017 The department of Hospital Quality Council was established also in 2012 In the period from 2012 to 2013, the hospital has implemented quality improvement activities according to the plan: Outpatient department and reception area on Examination and upgrading computer software, connect the tests on the software, fix repair, building infrastructure such as constructing 7-storey building, home repairs for scientific department of Neurology, Psychiatry The hospital has provided training and guidance for staffs on the work of the department to ensure the quality and form buliding logos; slogans ensure scientific quality of each unit In the interest of the Party Steering Committee and board of director of the hospital's effort dragon collective contract staff across units and is facilitated by the Department of Health, the Institute, the central hospitals and the close collaboration of the unit under the Department of Health, the unit was gradually improve the quality of professional activities, as well as other conditions required for the purposes of the examination unit 16 We can see that the quality score was increased significantly after year (from 2014 to 2015) The board of director had paid attention to qualtiy improvement, building plan of long –term (5 years) and short-term (every year) Main survey results and findings The survey results showed that most patients were examined using health insurance cards (representing 86.4%), including various types of insurance, such as pension insurance, voluntary insurance, health insurance for the poor, for family policies the remaining 20% of patients are subject to premium, health insurance cards when not in use examined and treated at the hospital There have 91% of patients interviewed residents in Thainguyen, of which 52% is urban population, 48% came from rural areas Only 9% of the patients come from other provinces such as Bac Kan, Tuyen Quang, Cao Bang So, we can see the number of patients coming from other provinces were modest Hospital inpatients in Thainguyen, most of them come from the rural areas, the rest of them from urban area There was 36.3% of patients who choose to care and treatment at the hospital because the hospital has a good reputation; followed by the level of trust in doctors (23.6%); then the right choice online (almost 20%); 13.2% selected hospitals is due to better facilities Medical expenses by a majority of respondents are in accordance with the general provisions of the State and of health insurance; spirit of service attitude is the last option for only approximately 5.3% rate The survey showed that, of 367 patients were treated in the hospital at the time of the survey, 186 male patients and 181 female patients Percentage of men - and women are quite similar at 50.7 and 49.3% respectively The average age of study subjects was most patients aged 18 to 30 (representing 35.7%); followed by ages 30-60 (31%), concentrated mainly in the Orthopaedic department, other gastrointestinal and hepatobiliary obstetrics; 24% of patients over 60 years of age, mostly retired officers, are treated in cardiovascular internal medicine and digestive About their career, the team with 19.6% are farmers, workers and 26.43% are selfemployed, 12% were retired, 16:07% are State civil servants, students, the rest are students (approximately 25%) Most patients in the study group had to diagnosis and treatment for the first time (65%); 35% of patients who have used the services of the hospital from the 2nd or higher Average monthly income of the respondents mainly from 2-5 million, (45.5%), equivalent to the average income of residents in urban area Some patients 17 have a high proportion of income is very low, only about 4.6%; income patients fairly (5-10 million) account for nearly 30%, the rest is poor (earning less than million / month) accounted 19.3% Educational level of the majority of patients are asking is a new high school graduation or finished level 2; Some patients have a university degree and postgraduate very low (only 8.63% occupied) Thus it is possible that people who have higher levels of education and income are less good option to use medical services at the hospital The gap between expectations and perceived by patients to quality medical services at hospitals is relatively uniform in all levels (point gap ranged from -0.71 to 0.88) in which is the distance of the highest quality facilities This suggests that hospitals need further investment to improve facilities, tangible means of serving patients, especially improving the garage and the equipment serving healthcare The gap between the expected second-largest and the patient's perception of empathy factor of health workers The medical staff should have an interest in each patient, listen and understand them to better serve the health care needs and create trust for their patient greater confidence in the quality of patient rim The level of confidence and meet patients to better evaluate other factors but there is still a certain gap between expectations or expectations and realistic feel when using the health service of the hospital Some conclusions from results of EFA Firstly, out of 25 variables included in the model, only 19 variables can be analyzed (statistically significant) The cause may be due to restrictions by the number of observations (sample is 367 samples) Secondly, in all 19 variables can be analyzed in the EFA model, results showed that all of them have a positive effect for each group of factors Therefore, the TNH can devise policies to develop and enhance patient satisfaction for each group of factors in order of priority as follows: Facilities factor TAN = 0.317 * A_1 + 0.326 * A_3 + 0.295 * A_4 + 0.374 * A_5 (1) The equipment of the hospital; (3) Apparel of medical staff, doctor; (4) Health care services where patients dealing with convenient; (5) Parking at the hospital Reliability factor REL = 0.290 * B_7 +0.289 * B_8 +0.210 * B_9 + 0.181 * B_10 + 0.277 * B_11 18 (1) Hospital staff respect the decision of the patient, understand the needs of the patient; (2) Medical staff with higher qualifications; (3) The appointment and regular treatment done on time; (4) The hospital stays of patient information a systematic manner and keeps such information confidential; (5) Patients should be informed of the risks that may occur during the implementation of health care services are proposed relating to the health of patients Assurance factor ASS = 0.475 * C_12 + 0.461 * C_14 + 0.326 * C_16 (1) Patients were provided full information about their condition and be notified when the service will be implemented; (2) The patient comfort when in contact with staff at the hospital; (3) The patient was carefully instructed before hospital discharge Responsiveness factor RES = 0.414 * D_17 + 0.356 * D_18 + 0.394 * D_19 (1) The hospital staff must have good knowledge and answer the patient's questions correctly and quickly; (2) The hospital staff must be polite attitude and patient-friendly; (3) Amount applicable fees must be reasonable, correct regulations Empathy Factor EMP = 0.280 * E_22 + 0.271 * E_23 + 0.271 * E_24 + 0.263 *E_25 (1) The hospital staff understands the needs and desires of the patient; (2) Medical procedures simple and convenient for the patient; (3) Hospital staff listens and address patients' questions quickly and logically; (4) The hospital staff irrespective of insured patients and patient self-closing fees Resutl of regression of standardized model is: SAT = -0.224 + 0.153*TAN + 0.298*REL + 0.126*ASS + 0.242*RES + 0.236*EMP Conclusions about the regression model: Firstly, value VIF (Variance Inflation Factor, variance magnification)