Factors Influencing Customer Satisfaction in Healthcare Services

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Factors influencingCustomer

satisfaction in healthcare

services.

Umar Asif

Department of Commerce, Islamia University Bahawalpur, Pakistan

Abstract

Purpose To measure the quality of health care services patient

satisfaction is used as one of the most important indicators. The studyaims to identify factors affecting patients satisfaction at primary healthcare clinics.

Design/methodology/approach The data was collected duringJune 1 and June 3 through a randomly-distributed questionnaire. Thequestionnaires were distributed in primary healthcare clinics in Pakistan.A total of 100 completed questionnaires, out of 125, were returnedresulting in a response rate of 80 percent.

FindingsThe majority (87 percent) of the patients responded that theindependent variables are the factors influencing customer satisfaction.

Research limitations/implications Its based on sample andliterature review.

Originality/value The authors hope that this study identifies areasof dissatisfaction that can be quickly remedied and ensures enhancementin the areas of satisfaction with ongoing attention and emphasis.

Keywords: Patient care, Health services, Customer satisfaction, Pakistan,PaktanGovt Hospitals, patient satisfaction.

Paper type:Research paper


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1. IntroductionPatient satisfaction can be defined as judgment made by a recipient of

care as to whether their expectations for care have been met or not(Palmer et al., 1991). Themodern view of quality of care looks to thedegree to which health services meetpatients needs and expectationsboth as to technical and interpersonal care (Campbellet al., 2000; Eschetal., 2008). Investigation of patient satisfaction has been used tomeetthree main objectives in health care delivery industry (Ware et al.,1978; Patrick et al.,1983; Al-Doghaither and Saeed, 2000). First, todetermine how and to what extentsatisfaction influences patients seekingcare in terms of complying with treatment andcontinuing to use the care.

Second, to use satisfaction as an indicator of the quality ofcare; and thirdto help physicians and the health care organizations betterunderstandthe patients point of view, and to use this feedback toincrease accountability and toimprove the services provided.

Patient satisfaction with medical care is a multidimensional concept,withdimension that corresponds to the major characteristics of providersand services(Ware et al., 1983; Moretet al., 2008; Donahue et al.,2008). Patient satisfaction withhealth care services is considered to be of

paramount importance with respect toQuality improvement programsfrom the patients perspective, total qualitymanagement, and theexpected outcome of care (Vouri, 1991; Donabedian, 1992;Aggarwaland Zairi, 1998; Brown and Bell, 2005). Within the health careindustry,patient satisfaction has emerged as an important component andmeasure of thequality of care (Aharony and Strasser, 1993; Grogan etal., 2000; Salisbury et al., 2005).Patient satisfaction plays an importantrole in continuity of service utilization(Thomas, 1984). Satisfied patientsare more likely to adhere to doctorsrecommendations and medicalregimens (Ross et al., 1981). Besides, dissatisfiedpatients do not utilizeprimary health care services optimally and over-utilize theemergencyrooms in the general hospitals (Shah et al., 1996; Al-Hay et al., 1997).

The quality of the communication relationship between physician andpatientshowed positive influence on patient satisfaction measure (Moretet


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al., 2008; Merceret al., 2008; Lin et al., 2009).Several studies havebeen performed regarding patient satisfaction and its correlates invarious countries (Rahmqvist, 2001; Margolis et al., 2003;Bronfman-Pertzovskyet al., 2003). Only two studies have been conducted to

dateregarding the concept of patient satisfaction in Kuwait (Bo Hamraand Al-Zaid, 1999;Al-Doghaitheret al., 2000). They found significantrelationship of age, gender,nationality, marital status; education,occupation, and income with patient satisfaction.

Although many studies have been done on patient satisfactioninternationally butlimited studies were done on patient satisfaction in theGulf region and in particular inKuwait. Identification of predictors ofpatient satisfaction (what aspects of care matterthe most to patients)

enables policy makers at the Ministry of Health in Kuwait to focuson theseaspects and improve them. The correlates of socio-demographiccharacteristics of patients with satisfaction allow the healthcare providers to caterto the different needs of patients based on theirsocio-demographic characteristics.This study aims at identifying predictorsof patient satisfaction in the primary careclinics of the Ministry of Health,Kuwait (factors leading to patient satisfaction ordissatisfaction) and itssocio-demographic correlates.1.1 Background

A Introduction about Pakistan Healthcare Services:

Health plays the key role in determining the human capital. Betterhealthimproves the efficiency and the productivity of the labour force,ultimatelycontributes the economic growth and leads to human welfare.To attain better,more skilful, efficient and productive human capital

resources, governmentssubsidise the health care facilities for its people. Inthis regard, the public sectorpays whole or some part of the cost ofutilising health care services. The sizeand distribution of these in-kindtransfers to health sector differs from country tocountry but thefundamental question is how much these expenditures areproductive andeffective? It very much depends on the volume and thedistribution of


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these expenditures among the people of different areas of thecountry.Besides the nature of the existing circumstances of the humanresource,any marginal change in public sector spending on health servicesmay havepositive impact on the human capital and economic growth.

According to the Economic Survey of Pakistan (2005-06), thegovernmentspent 0.75 percent of GDP on health sector in order to makeitspopulation more healthy and sturdy. In this regard, a number ofvertical andhorizontal programmes regarding health facilities areoperative in Pakistan. Thefederally funded vertical programmes include:Lady Health Worker Programme;Malaria Control Programme;Tuberculosis and HIV/AIDS Control Programme;National Maternal andChild Health Programme; the Expanded Programme onImmunisation;

Cancer Treatment Programme; Food and Nutrition Programme,and; the Prime Minister Programme for Preventive and Control ofHepatitis A &B.

To effectively address the health problems facing Pakistan, a numberofpolicies emphasise better health care services. These include: HealthrelatedMillennium Development Goals; Medium Term DevelopmentFramework;Poverty Reduction Strategy Papers; National Health Policy,and; Vision 2030. Inspite of these policies, to overcome the healthrelated problems in Pakistanseems suspicious and distrustful. Thecommunicable diseases are still achallenge and the statistics reveal thatthe nutrition and reproductive healthproblem in communicable diseasesare still liable for the 58 percent of the BODin Pakistan. Non-communicable diseases (NCD), caused by sedentarylifestyles, environmental pollution, unhealthy dietary habits, smoking etc.accountfor almost 10 percent of the BOD in Pakistan.

Social Policy Development Centre (SPDC), 2004, demonstrates that outofevery 1,000 children who survive infancy, 123 die before reaching theage offive. A large proportion of those who surviving suffers frommalnutrition,leading to impaired immunity and higher vulnerability toinfections.


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Malnutrition is big problem in Pakistan. Human Conditions Report(2003)clearly points out that about 40 percent children under 5 year ofage aremalnutrited. About 50 percent of deaths of children under 5years old childrenare due to malnutrition.

Following the introduction to the research theme, Section 2 putforwardsthe Literature Review. Health is an integral part of the socialsector and hence anumber of policies emphasising better health servicedelivery in this area.Section 3 highlights Policy Emphasising Health CareServices followed byPublic Health Care Service Delivery in Pakistan.Research methodology anddata sources are discussed under ResearchFocus in Section 5, followed byResults and Discussion, and Conclusion andPolicy Recommendations inSections 6 and 7 respectively.

Pakistan Health care takes care of 161 million lives of the Pakistani

nationals. Viewing the health in Pakistan, the Pakistan Health Ministry

has formulated certain policies to improve it. The Pakistan hospitals not

only serve the ailing with the basic health facilities but also provide

primary and secondary education on health care. There are 947

hospitals in Pakistan giving a good portion of budget on Healthcare

services.

Literature Review:

Patient safety, which has been defined as freedom from accidental injuryduringmedical care or from medical errors has become a critical topic inmedicine (Kohn et al.,1999). The desire to avoid harm has existed as aconcern in medicine since the fourthcentury BC when Hippocrates theFather of Medicine admonished medicalprofessionals to do no harm(Hippocrates, 2004). The healthcare industry is fraughtwith dangers for

both patients and employees (Yassi and Hancock, 2005). Thesedangersare linked directly to the environment and culture that surroundsmedicalprofessionals and patients with their distinctive norms, values andshared beliefs(Stone et al., 2004). Although medical professionals havefor years sought to improvequality by standardizing good processes, it isnot enough to just design better ways tocontrol errors. The organizational


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climate must also encourage information sharingand support safety(Hofmann and Mark, 2006).

Creating a proper patient safety climate includes changing

managementbehaviours, safety systems and employee safetyperceptions that directly influencehealthcare professionals to chooseproper behaviors that enhance patient safety (Collaet al., 2005;Fleming, 2005). However, many studies and safety interventions havenotaddressed actual safety climate, but have focused on activities such asdata collection,reporting, reducing blame, involving leaders, or focusingon processes (Singer et al.,2003). Climate consists of shared employeeperceptions relating to the practices,procedures and behaviours that getrewarded and supported in an organization(Schneider et al., 1998). An

organizational climate is gained by the experiencesemployees have andhow they perceive their environment. The climate influenceshoworganizational members behave by how they think and feel abouttheir workenvironment. Employees work environment perceptions causethem to interpretevents and develop attitudes, which dictate how theywork (Bowen and Ostroff, 2004).Although organizational climateperceptions are significant safety indicators, therehave been feworganizational safety climate studies in hospitals and even less withaninternational scope (Collaet al., 2005; Navehet al., 2005; Stone et al.,2004).

Many countries and international organizations created regulations andrules fortheir medical sectors to improve patient safety. These effortssought to create a patientsafety climate to improve healthcare processesand outcomes through regulatoryprocesses.

At present, the U.S. healthcare system is of vital interest to the nations

economy and government policy (spending). The U.S. healthcare system ischaracterized as the worlds most expensive yet least effective as

compared to other nations. Growing healthcare costs have made millions

of citizens vulnerable. Major drivers of the healthcare costs are

institutionalized medical practices and reimbursement policies, technology

induced costs and consumer behavior(Examining Quality and Efficiency of


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the U.S. Healthcare System By Sameer Kumar1, Neha S. Ghildayal2 and

Ronak N. Shah3 ).

Management support, a proper reporting system and adequate

resources were found to influence the hospital patient safetyclimate(Factors affecting the climate ofhospital patient safety By Stephen

L. Walston).

The majority (87 percent) of the patients responded that the time for

communication between physician and patient was not enough. Seventy-

nine-percent of the surveyed patients said they would go to the

emergency room of the hospital in future if needed instead of going to

the primary care clinic. Regarding the quality of the communicationrelationship between physician and patients most of the patients

responded negatively. Exploratory factor analysis identified six factors

and reliability of overall scale was found to be 0.61(Factors influencing

patient satisfaction in primary healthcareclinics in Kuwait Abdul

MajeedAlhashem, HabibAlquraini andRafiqul I. Chowdhury).

Methodology:

2.1 Sample

The study population consisted of the patients who came for services tothe primaryhealth care centers covering all health regions in Pakistan.Patients were randomly selected a size of 125. Out of 125Questionnaires 100 were returned with a respondents of 80 percent. Inkeeping with thestandard research protocol, necessary permission wasobtained from the concernedauthorities of the Ministry of Health for datacollection.

2.2 Instrument

This descriptive cross-sectional study used a questionnaire that consistedof 22closed-ended questions and specific questions on background(gender, age, nationality,marital status, occupation, education, and


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income) characteristics. The questionnairebased on Ware et al. (1978)model, is divided into six dimensions of care. Eachdimension of care(interpersonal, technical, accessibility, convenience, availability,andoverall) has a number of statements that measure patients satisfaction

(dependent variable) which is an ultimate outcome in evaluating qualityof medical care.Interpersonal dimension measured the satisfaction to theamount of caring showntowards the patients and communicationsbetween them. Technical dimension alsopertains to provider conduct,focuses on the competence of providers and theiradherence to highstandards of diagnosis and treatment. Accessibility andconveniencedimension measures satisfaction related to time and effortrequired to get anappointment, distance and proximity to site of care,convenience of location time toreach, hours during which care can be

obtained etc. Availability dimension focuseswhether there are enoughphysicians, nurses, and other providers, and such facilities asclinics andhospitals in the area. Other similar studies have used different namesforthe dimension and called them attributes (Otaniet al., 2005). Eachdimension used inthis study and its specific attributes were found to havesome correlations with patientsatisfaction in previous studies (Harrison,1996; Al-Fariset al., 1996; Makhdoomet al.,1997; Gross et al., 1998;Shelton, 2000; Saeedet al., 2001). To measure patientPatientsatisfaction 251 satisfaction, interviews or open ended questions producemuch detailed informationand allow for clarification of respondentsviews but are considered difficult to analyze(Fitzpatrick, 1991a). Morestructured approaches such as multiple item questionnaireswith Likertscale response categories produce data that are easier to handle butrequireparticular attention to validity and reliability to use in a differentcultural settings(Fitzpatrick, 1991b; Rees, 1994). In different cultural settings beforeapplying anyexisting scale it need re-evaluation (Kinnersleyet al., 1996;

Grogan et al., 2000).

The instrument used a modified five-point Likert scale as choices ofanswer,ranging from very dissatisfied (0) to very satisfied (5). Anadditional choice, notapplicable, was added to allow respondents tochoose in case of service not provided orwhere a given item was notapplicable. The majority of statements used in thequestionnaire, 17 out of


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22, are positively phrased to avoid any confusion that mightresult fromusing a mix of positive and negative phrasing. In addition, there weretwoquestions relating to the patients number of visits to the primary careservice duringthe past year and the patients perception of his/her own

overall health status. Thequestionnaire was translated into Arabic andtranslated back into English by anindependent professional to check thevalidity. Prior to the actual administration, thequestionnaire was pilotedin a small group of patients to validate the language, contentand flow ofinformation aimed at appropriate rapport to make necessary changes.Bysumming 11 positive questions on different aspect of satisfactions wecomputed an overall satisfaction score. The overall satisfaction scoreranges from 0 to 44. The lowestpossible score of 22 was considered asthe lowest level of satisfaction. Cronbachs alpha(reliability coefficient)

was used to determine the internal consistency of theinstrument. The valueof the alpha of the overall scale was 0.61. The construct validitywasassessed by factor analysis using factor loadings; these ranged from0.41 to 0.76.

2.3 Statistical analysisDescriptive statistics (frequency distribution, mean, and standarddeviation) were usedto describe the data. Exploratory factor analysiswas used to identify theunderlying factors and Cronbachs alpha wasused to measure the internal consistencyof the scale and subscales.

Purpose To measure the quality of health care services patientsatisfaction is used as one of the most important indicators. The studyaims to identify factors affecting patients satisfaction at primary healthcare clinics.


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3. Theoretical Frame Work:

Dependent

Variable

Satisfied

Customers

Independent

Variable

Quality Control

Availability of

Medicines & other

suport staff

Patient Safety

Caring Staff

Dependent

variable

Caring Staff

Quality

controlPatient Safety

Avalability of

Medicines &

other suportstaff

H3

H1H2

H4

Governmental

Restrictions

H5


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Quality Control:

Patient determined quality literature inconclusively predicts the directionofsatisfaction and quality from the patients perspective (Tucker and

Adams, 2001).Quality is positively correlated with satisfaction; however,the direction and strength ofthe predictive relationship between qualityand satisfaction remains unclear. Someauthors believe that complexhealthcare services and the patients lack of technicalknowledge to assessthem should incorporate broader healthcare quality measures,including financial performance, logistics, professional and technicalcompetence (Eirizand Figueiredo, 2005). Quality is a judgmental concept(Turner and Pol, 1995) andoperational quality definitions, as we haveseen, are based on values, perceptions andattitudes (Taylor and Cronin,

1994). The implication thus is to develop qualitymeasures based onexpert judgement, specifically insightful customers andrespectedpractitioners (Turner and Pol, 1995).

Quality Control is one of the most important factor consider by patients

to there satisfaction level in health care. The Results observed from

questionnaires suggested that quality control will play a vital role in

Customer satisfaction for health care services in Pakistan. Thus we can

Hypothes it as H1.

H1: Significant relation ship between independent Variable Quality Control and Dependent

variable.

Patient Safety:

A key positive patient safety climate dimension is managerial support

and its ability todirect staff to formulate proper strategic plans andpriorities. Organizational climate islinked to managerial behaviours(Schneider et al., 1998). Managerial and physiciansupport playsignificant roles in the success of any patient safety activity, as eachdirecta portion of the organization and care provision (Cooper, 2000).Involvingmanagers and physicians is especially critical because they are


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ultimately responsiblefor hospital policy and decisions that affect thewhole organization (Nieva and Sorra,2003).

H2: Significant relation ship between independent variable patient safety and dependent

variable Customer Satisfaction.

Caring Staff:

Staff plays a vital role in Satisfaction of customers by giving positive

attitude and responses. If Staff cares about its patients then its allneeded for a customer to be satisfied. Thus a Hypothesis can be

developed.

H3: Significant relation ship between independent variable Caring Staff and dependent

variable Customer Satisfaction.

Availability of Medicines and other support staff:

If a Health care service station like hospital has proper equipment and

required medicines which is needed for the treatment of special cases

like cancer is available then it will be playing most important role in

patient satisfaction. Thus a Hypothesis can be developed.

H4: Significant relation ship between independent variable availability of medicines,

other support staff and dependent variable Customer Satisfaction.

Governmental Restrictions:

Government Restrictions in quality control, Patient Safety, Availability of

Medicines and other support stuff, and Staff Responsibilities defined by


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government is the Moderating variable thus a hypothesis can be

developed.

H5: Significant relation ship lays between independent variable and dependent variable

the Moderating variable.

Findings

Statistics

Do Pakistan

health care

industry needs a

research?

Which Hospital

you Preffer?

Will Discounts

influence

customer

satisfaction?

N Valid 100 100 100

Missing 1 1 1

Do Pakistan health care industry needs a research?

Frequency Percent Valid Percent

Cumulative

Percent

Valid Yes 96 95.0 96.0 96.0

No 4 4.0 4.0 100.0

Total 100 99.0 100.0

Missing System 1 1.0

Total 101 100.0


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Ho: Its Tested that Research on Healthcare industry is Needed

Which Hospital you Prefer?


Cumulative

Percent

Valid Private 61 60.4 61.0 61.0

Government 39 38.6 39.0 100.0

Total 100 99.0 100.0


Total 101 100.0

95%

95%


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H1: Large number of people trend to go to Private hospitals rather then

governmental free of cost.

Will Discounts influence customer satisfaction?


Cumulative

Percent

Valid Yes 75 74.3 75.0 75.0

No 25 24.8 25.0 100.0

Total 100 99.0 100.0


Total 101 100.0

60%

37%


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H4: Discounts offered in medicines trend towards customer satisfaction

Statistics

What is your

Income level?

Will Quality control

influence customer

satisfaction?

Will patient

safety influence

customer

satisfaction?

Will Caring staff

influence

customer

satisfaction?

Will Medicines

&suport stuff

customer

satisfaction?

How much

Doctor's Fee

you can

afford?

Valid 100 100 100 100 100 100

Missing 1 1 1 1 1 1

What is your Income level?


Cumulative

Percent

74%

25%


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Valid Less then 10,000 30 29.7 30.0 30.0

10,000 to 20,000 26 25.7 26.0 56.0

20,000 to 30,000 20 19.8 20.0 76.0

30,000 and above 24 23.8 24.0 100.0

Total 100 99.0 100.0


Total 101 100.0

Will Quality control influence customer satisfaction?


Cumulative

Percent

Valid Strongly Disagree 21 20.8 21.0 21.0

Disagree 18 17.8 18.0 39.0

Nither agree nor Disagree 15 14.9 15.0 54.0

Agree 30 29.7 30.0 84.0

Strongly Agree 16 15.8 16.0 100.0

Total 100 99.0 100.0


Total 101 100.0

24%

20%

26%

30%


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H1: Quality control is one of the tested variable of customer satisfaction.

Will patient safety influence customer satisfaction?


Cumulative

Percent

Valid Strongly DIsagree 11 10.9 11.0 11.0

Disagree 24 23.8 24.0 35.0

Nither agree nor disagree 17 16.8 17.0 52.0

Agree 34 33.7 34.0 86.0

Strongly Agree 14 13.9 14.0 100.0

Total 100 99.0 100.0


Total 101 100.0

30%

16%

18%

21%

15%


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H2: Patient safety is a tested independent variable to wards customer satisfaction.

Will Caring staff influence customer satisfaction?


Cumulative

Percent

Valid Strongly DIsagree 15 14.9 15.0 15.0

Disagree 30 29.7 30.0 45.0

Nither agree nor disagree 13 12.9 13.0 58.0

Agree 28 27.7 28.0 86.0

Strongly Agree 14 13.9 14.0 100.0

Total 100 99.0 100.0


Total 101 100.0

17%

34%

24%

14% 11%


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H3: Majority of test samples suggest Caring staff is a key towards customer

satisfaction.

Will Medicines &suport stuff customer satisfaction?


Cumulative

Percent

Valid Strongly Disagree 12 11.9 12.0 12.0

Disagree 29 28.7 29.0 41.0

Nether agree nor disagree 12 11.9 12.0 53.0

Agree 37 36.6 37.0 90.0

Strongly Agree 10 9.9 10.0 100.0

Total 100 99.0 100.0


Total 101 100.0

14%

28%

95

13%

30%

15%


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H4: Its tested majority of people agree medicines and support stuff leads towards

customer satisfaction.

How much Doctor's Fee you can afford?


Cumulative

Percent

Valid Rs. 200 47 46.5 47.0 47.0

Rs. 400 26 25.7 26.0 73.0

Rs. 600 20 19.8 20.0 93.0

Rs. 800 7 6.9 7.0 100.0

Total 100 99.0 100.0


Total 101 100.0

29%

10%

37%

12%

12%


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Majority of customers in health care services are willing to pay less in health care services.

Crosstabs:

Case Processing Summary

Cases

Valid Missing Total

N Percent N Percent N Percent

What is your Income level? *

Which Hospital you Preffer?100 99.0% 1 1.0% 101 100.0%


Will Quality control influence

customer satisfaction?

100 99.0% 1 1.0% 101 100.0%


Will patient safety influence


100 99.0% 1 1.0% 101 100.0%

26%

20%

47%

7%


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Will Caring staff influence


100 99.0% 1 1.0% 101 100.0%


Will Medicines &suport stuff


100 99.0% 1 1.0% 101 100.0%

Will Discounts influence

customer satisfaction? *

Which Hospital you Preffer?

100 99.0% 1 1.0% 101 100.0%


customer satisfaction? * Will

Quality control influence


100 99.0% 1 1.0% 101 100.0%



patient safety influence


100 99.0% 1 1.0% 101 100.0%



Caring staff influence


100 99.0% 1 1.0% 101 100.0%


customer satisfaction? * WillMedicines &suport stuff


100 99.0% 1 1.0% 101 100.0%

How much Doctor's Fee you

can afford? * Which Hospital

you Preffer?

100 99.0% 1 1.0% 101 100.0%


can afford? * Will Quality

control influence customer

satisfaction?

100 99.0% 1 1.0% 101 100.0%


can afford? * Will patient

safety influence customer

satisfaction?

100 99.0% 1 1.0% 101 100.0%


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can afford? * Will Caring staff

influence customer

satisfaction?

100 99.0% 1 1.0% 101 100.0%


can afford? * Will Medicines

&suport stuff customer

satisfaction?

100 99.0% 1 1.0% 101 100.0%

Crosstabsbeen taken of all the questions which were used in questioners. They were matched

by the dependent variable and independent variables. Below is the Detailed report of all the

crosstabs.

What is your Income level? * Which Hospital you Preffer? Crosstabulation

Count


TotalPrivate Goverment

What is your Income level? Less then 10,000 17 13 30

10,000 to 20,000 16 10 26

20,000 to 30,000 10 10 20

30,000 and above 18 6 24

Total 61 39 100

Crosstabs : Income level Vs Hospital preffred:


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In this crosstabs you can see majorty of people look towards private hospitals rather then

governmental hospitals. But people with high income trend more towards Private hospitals

What is your Income level? * Will Quality control influence customer satisfaction? Crosstabulation

Count

Will Quality control influence customer satisfaction?

Total

Strongly

Disagree Disagree

Nither agree

nor Disagree Agree

Strongly

Agree

What is your Income

level?

Less then 10,000 6 6 1 10 7 30

10,000 to 20,000 7 5 2 6 6 26

20,000 to 30,000 3 3 4 8 2 20

30,000 and above 5 4 8 6 1 24

Total 21 18 15 30 16 100

Crosstabs : Income level VsQuality Control:

In this cross tabs majority of people agreed that quality control is a

key towards customer satisfaction.

What is your Income level? * Will patient safety influence customer satisfaction? Crosstabulation

Count

Will patient safety influence customer satisfaction?

Total

Strongly

DIsagree Disagree

Nither agree

nor disagree Agree

Strongly

Agree

What is your Income

level?

Less then 10,000 5 7 0 13 5 30

10,000 to 20,000 1 6 6 7 6 26

20,000 to 30,000 1 3 7 6 3 20

30,000 and above 4 8 4 8 0 24

Total 11 24 17 34 14 100


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Crosstabs : Income level Vspatient Satisfaction:

In this cross tabsmajority of people agreed Patient safety is the key

towards customer satisfaction and they are from all income levels.

Crosstabs : Income level VsMedical & other support stuff:In this cross tabs majority of people agreed Medical & other

support stuffis the key towards customer satisfaction and they are from

all income levels.

Crosstabs : Income level VsCaring stuff:

In this cross tabs majority of people disagreed Caring staffis the

key towards customer satisfaction and they are from all income levels.


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Will Discounts influence customer satisfaction? * Which Hospital you

Preffer? Crosstabulation

Count


TotalPrivate Goverment



Yes 50 25 75

No 11 14 25

Total 61 39 100

Crosstabs : Income level VsCaring stuff:

In this cross tabs majority of people agreed Discountsis the key

towards customer satisfaction and they are from all income levels.


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Crosstabs : DiscountsVsQuality control:

In this crosstabs majority of people agreed Quality controlis the key

towards customer satisfaction.

Crosstabs : DiscountsVspatient Safety:

In this cross tabs majority of people agreed patient safetyis the key

towards customer satisfaction.

Crosstabs : DiscountsVsCaring stuff:

In this cross tabs majority of people disagreed caring staffis the

key towards customer satisfaction.

Crosstabs : DiscountsVsmedicines & other support stuff:

In this cross tabs majority of people agreed Medicines and othersupport stuffis the key towards customer satisfaction

How much Doctor's Fee you can afford? * Which Hospital you Preffer?

Crosstabulation

Count

Which Hospital you Prefer?

TotalPrivate Government

How much Doctor's Fee you Rs. 200 26 21 47


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can afford? Rs. 400 15 11 26

Rs. 600 14 6 20

Rs. 800 6 1 7

Total 61 39 100

Crosstabs : Doctors FeeVsPrivate of Govt hospital:

In this cross tabs majority of people willing to pay more has more

trend to go to govt hospital rather then lowest fee level like 200 which

has some what equal percent chance.

Crosstabs : Doctors FeeVsQuality control:

In this cross tabs majority of people willing to pay low Fee200 has

more trend to agree on Quality Control rather then highest fee level like

800 which has some what equal percent chance.

Crosstabs : Doctors FeeVsQuality control:

In this cross tabs majority of people willing to pay low Fee 200 has

more trend to agree on Quality Control rather then highest fee level like

800 which has some what equal percent chance.


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Crosstabs : Doctors FeeVspatient Safety:


more trend to agree on patient Safety rather then highest fee level like800 .

Crosstabs : Doctors FeeVscaring Staff:


more trend to agree on caring Staffrather then highest fee level like 800

which has some what equal percent chance.

Crosstabs : Doctors FeeVsMedicines & Other Suport Stuff:


more trend to agree on Medicines and other support Stuff rather then

highest fee level like 800.


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Conclusion:

This study has demonstrated the relationship between satisfaction and specific Independent variables.

The subject is important enough to recommend that theMinistry of Health conduct patient satisfaction

studies on a regular basis. This practicewill identify areas of dissatisfaction that can quickly beremedied and ensureenhancement in satisfaction. More studies should be conducted in the primary

caresetting to reexamine those variables examined in the current study which have notproven to be

significant and to validate the significant relationship found in this study.Before using patients

satisfaction questionnaire which was developed for differentcultural settings one should validate it in

local context to measure the patientsatisfaction.

Result of This Research:

This Research showed me Some Factors which were backed by the samples results showing they will

influence them towards customer satisfaction. Hence this report is accepted. Independent Variables are

the factors which will influence customer satisfaction.

eferences

1. Health care service quality perception in Japan by Miss amiraeleuchepkoubaa Vol. 24Iss: 6 2011.

2.Does patient satisfaction affect patient loyalty by Daniel P. Kessler, Deirdre Mylod Vol.24 Iss: 4, 2011,?

3.A case study of collaborative communications within healthcare logistics by Jerry D.VanVactor, (2011) Vol. 24 Iss: 1.

4.Relational impact of service providers' interaction behavior in healthcare by SanjayaSingh Gaur, YingziXu, Ali Quazi, Swathi Nandi, (2011) Vol. 21 Iss: 1.

5.Factors influencing patient satisfaction in primary healthcare clinics in Kuwait by AbdulMajeedAlhashem, HabibAlquraini, Rafiqul I. Chowdhury, (2011) Vol. 24 Iss: 3.

6.Predictors of satisfaction with child birth services in public hospitals in Ghana byGertrude SikaAvortri, Andy Beke, Gordon Abekah-Nkrumah, (2011) Vol. 24 Iss: 3.

7.Patient safety analyses using Lombardy administrative archives by Pietro GiorgioLovaglio, (2011) Vol. 24 Iss: 2.


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Proposal

To:

From: Imrana Shamas, Misbah

Research Topic : Factors influencing customer satisfaction in healthcare services.


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Purpose:

To read the impact of brand judgment from different alternative.

Aim to develop a model that includes self congrueces, attitude satisfaction explain their role on

behavior.

How people are satisfied?

Literature Review:

Patient satisfaction can be defined as judgment made by a recipient of care as to whether their

expectations for care have been met or not (Palmer et al., 1991). Themodern view of quality of care

looks to the degree to which health services meetpatients needs and expectations both as to technical

and interpersonal care (Campbellet al., 2000; Eschet al., 2008). Investigation of patient satisfaction has

been used to meetthree main objectives in health care delivery industry (Ware et al., 1978; Patrick et

al.,1983; Al-Doghaither and Saeed, 2000). First, to determine how and to what extentsatisfaction

influences patients seeking care in terms of complying with treatment andcontinuing to use the care.

Second, to use satisfaction as an indicator of the quality ofcare; and third to help physicians and the

health care organizations better understandthe patients point of view, and to use this feedback to

increase accountability and toimprove the services provided.

Patient satisfaction with medical care is a multidimensional concept, withdimension that corresponds

to the major characteristics of providers and services(Ware et al., 1983; Moretet al., 2008; Donahue et

al., 2008). Patient satisfaction withhealth care services is considered to be of paramount importance

with respect toQuality improvement programs from the patients perspective, total q ualitymanagement,

and the expected outcome of care (Vouri, 1991; Donabedian, 1992;Aggarwal and Zairi, 1998; Brown and

Bell, 2005). Within the health care industry,patient satisfaction has emerged as an important

component and measure of thequality of care (Aharony and Strasser, 1993; Grogan et al., 2000;

Salisbury et al., 2005).Patient satisfaction plays an important role in continuity of service

utilization(Thomas, 1984). Satisfied patients are more likely to adhere to doctorsrecommendations and

medical regimens (Ross et al., 1981). Besides, dissatisfiedpatients do not utilize primary health careservices optimally and over-utilize theemergency rooms in the general hospitals (Shah et al., 1996; Al-

Hay et al., 1997).

The quality of the communication relationship between physician and patientshowed positive influence

on patient satisfaction measure (Moretet al., 2008; Merceret al., 2008; Lin et al., 2009).Several studies


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have been performed regarding patient satisfaction and its correlates in various countries (Rahmqvist,

2001; Margolis et al., 2003;Bronfman-Pertzovskyet al., 2003). Only two studies have been conducted to

dateregarding the concept of patient satisfaction in Kuwait (Bo Hamra and Al-Zaid, 1999;Al-Doghaitheret

al., 2000). They found significant relationship of age, gender,nationality, marital status; education,

occupation, and income with patient satisfaction.

Theoretical Framework:

Dependent

Variable

Satisfied

Customers

Independent

Variable

Quality Control

Availability of

Medicines &

other suport staff

Patient Safety

Caring Staff

Dependent

variable

Caring Staff

Qualitycontrol Patient Safety

Avalability of

Medicines &

other suport

staff


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Hypothesis Development:

H1: Independent variable like Advertisement has relation to dependent variable like sales.

H2: Moderating variable like Income of people is between Dependent variable and independent

variable.

Limitations: Time constraints of the semester require less time than may be ideal for an ethnographic

study. By being in the organisation for only four hours a week for five weeks, there are bound to be

aspects of leadership practice, organisational culture and team communication that will not be revealed

during my observations. Being an outsider may also limit what is revealed to me. The team members

may be guarded in their conversations around me, especially in my initial observations.

Time period:

The time period required round about 2 week.

Factors affecting the climate ofhospital patient safetyA study of hospitals in Saudi ArabiaStephen L. WalstonHealth Administration and Policy, University of Oklahoma City,Oklahoma City, Oklahoma, USA

Badran A. Al-OmarKing Saud University, Riyadh, Saudi Arabia, and

Faisal A. Al-MutariSaudi Ministry of Health, Riyadh, Saudi ArabiaAbstractPurposeThe purpose of this paper is to describe three organizational dimensions that influencehospital patient safety climate, also showing and discussing differences between organizational types.Design/methodology/approachSurveys were conducted in four types of Saudi Arabian

hospitals. Resultant information was analyzed using factor analysis and multiple-regression.FindingsManagement support, a proper reporting system and adequate resources were found toinfluence the hospital patient safety climate.Research limitations/implicationsThe cross-sectional hospital survey took place in a countrythat is radically redesigning its healthcare system. Major changes including hospital privatisation andhealthcare insurance systems may have significant effects on hospital organizational climates.Originality/valueImproving a hospitals patient safety climate is critical for decreasing errors andproviding optimal services. Although much patient safety research has been published, theorganizational climate in non-Western countries has not been studied. The paper provides a unique


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Saudi Arabian hospital perspective and suggests that three dimensions influence the patient safetyclimate. Hospital managers are encouraged to improve these critical dimensions to positively developtheir patient safety climate.Keywords Safety, Saudi Arabia, HospitalsPaper type Research paper

Introduction

Hospitals continue to be a major source of risk to people. Instead of solely benefitingpatients, hospitals and medical interventions often harm them (Baker, 2004). However,efforts are made across the globe to improve patient care and diminish harm. Theseefforts include many changes, including clinical and organizational improvements toprovide proper, quality care and treatment. Patient safety and service quality havejoined evidence-based medicine to better meet patient needs and preferences (Kohnet al., 1999; Parasuramanet al., 1985). To accomplish this, health care providers mustincorporate safety and quality into their organization to assure appropriate clinical andadministrative activities. Although organizational patient safety factors are critical,they have been much less studied in healthcare research (Navehet al., 2005).The current issue and full text archive of this journal is available atwww.emeraldinsight.com/0952-6862.htm

A study ofhospitals inSaudi Arabia35Received 9 April 2008Revised 29 May 2008Accepted 7 July 2008International Journal of Health CareQuality AssuranceVol. 23 No. 1, 2010pp. 35-50q Emerald Group Publishing Limited0952-6862DOI 10.1108/09526861011010668

Organizational climate has emerged as a major factor that can influence patientsafety. The absence of a proper safety climate can lead to greater risk to patients andsafety deterioration. Limited research has examined the effect of patient safety culturefactors on organizational outcomes in the USA and Europe (Hofmann and Mark, 2006;Navehet al., 2005; Carr et al., 2003; Parker et al., 2003). However, no research hasexamined the relevance of a safety climate in hospitals located in the Middle East. Ourpurpose was to study the factors that create a patient safety climate in Saudi Arabianhospitals, how they differ by ownership and their effect on the perceived overallclimate of patient safety.BackgroundPatient safety, which has been defined as freedom from accidental injury duringmedical care or from medical errors has become a critical topic in medicine (Kohn et al.,1999). The desire to avoid harm has existed as a concern in medicine since the fourthcentury BC when Hippocrates the Father of Medicine admonished medicalprofessionals to do no harm (Hippocrates, 2004). The healthcare industry is fraughtwith dangers for both patients and employees (Yassi and Hancock, 2005). Thesedangers are linked directly to the environment and culture that surrounds medicalprofessionals and patients with their distinctive norms, values and shared beliefs(Stone et al., 2004). Although medical professionals have for years sought to improvequality by standardizing good processes, it is not enough to just design better ways to


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control errors. The organizational climate must also encourage information sharingand support safety (Hofmann and Mark, 2006).Creating a proper patient safety climate includes changing managementbehaviours, safety systems and employee safety perceptions that directly influencehealthcare professionals to choose proper behaviours that enhance patient safety (Collaet al., 2005; Fleming, 2005). However, many studies and safety interventions have notaddressed actual safety climate, but have focused on activities such as data collection,reporting, reducing blame, involving leaders, or focusing on processes (Singer et al.,2003). Climate consists of shared employee perceptions relating to the practices,procedures and behaviours that get rewarded and supported in an organization(Schneider et al., 1998). An organizational climate is gained by the experiencesemployees have and how they perceive their environment. The climate influences howorganizational members behave by how they think and feel about their workenvironment. Employees work environment perceptions cause them to interpretevents and develop attitudes, which dictate how they work (Bowen and Ostroff, 2004).Although organizational climate perceptions are significant safety indicators, therehave been few organizational safety climate studies in hospitals and even less with an

international scope (Collaet al., 2005; Navehet al., 2005; Stone et al., 2004).Many countries and international organizations created regulations and rules fortheir medical sectors to improve patient safety. These efforts sought to create a patientsafety climate to improve healthcare processes and outcomes through regulatoryprocesses. Typically, regulatory efforts involve three safety dimensions:(1) Safety policies and procedures (Caldwell, 1995; Sloan and Torpey, 1995).(2) Disseminating safety information to employees (Reber and Wallin, 1984).(3) Prioritising safety among leaders (Zohar, 2000; Roberts, 1990; Zbaracki, 1998).

IJHCQA23,136

Saudi Arabian healthcare safety effortsThe Kingdom of Saudi Arabia like many other countries is investing significant efforts toimprove healthcare quality. Their Ministry of Health created a directorate in the early2000s to take responsibility for educating, training and improving patient care throughoutthe Kingdom. Specific patient safety and quality training programs educate healthcarepersonnel. A set of hospital national standards has been developed and hospitals will inthe near future be required to be accredited by the national accreditation body. Hospitalsin the Kingdom are also pursuing external accreditation, including the Canadian Councilon Health Services Accreditation and the Joint Commission International.The Saudi Arabian healthcare system is unique regarding professionals providingcare. The country has both public and private providers. About 75 percent ofhealthcare is provided from governmental providers. However, public sector

healthcare is subdivided into the Ministry of Health, university hospitals, specializedhospitals (such as the King Faisal Specialist Hospital) and military hospitals (e.g.national guard and military systems) with unique funding, authority and management.The Ministry of Health now provides about 62 percent of the Kingdoms inpatient care.Also, a significant difference from other Western national healthcare systems is thatless than 20 percent of physicians and nurses working for the Ministry of Health areSaudi citizens. The remainder come from all over the world. These expatriates whoprovide care have a high turnover with an average tenure of less than two and a half


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years. Also, a higher percentage of Saudis make up the governmental healthcareworkforce; for example, about 20 percent of Ministry of Health physicians are Saudiscompared to only five percent in the private sector (Walstonet al., 2008).Creating a positive patient safety climateCreating a positive patient safety climate inside an organization can only beaccomplished through managerial commitment, strong communication, dedicatedorganizational resources and mutual trust shared by organizational members(Fleming, 2005; Singer et al., 2003). A proper patient safety culture is built throughcommitment from an organizational leadership that does not punish when errors areshared. It promotes collaborative efforts and experiences across hierarchies andinvolves both patients and families (Battles, 2004; Fleming, 2005; Nieva and Sorra,2003). A positive safety climate involves manager and physician commitment andeffort, as both are dependent on each other for creating positive patient outcomes andeach share dual roles in supervising care provision.The positive patient safety climate organizational dimensions have beencategorized into management engagement, reporting systems with proper policiesand procedures and organizational resources (Singer et al., 2003; Navehet al., 2005).

These organizational factors suggest a strong positive relationship with anorganizational climate that promotes patient safety and safe care. Studies suggestthat positive safety climates result when leaders are committed to safety activities andbehaviours, and when policies encourage proper behaviours (DeJoy, 1985; Zohar, 1980).North American research shows the importance of organizational factors and hospitalclimate, which include management perceptions, stress levels, job satisfaction andworking conditions (Pronovostet al., 2003; Huang et al., 2007). Figure 1 illustrates threedimensions that influence patient safety, its relationship to an organizational climateand resultant patient safety.

A study ofhospitals in

Saudi Arabia37Patient safety climate dimensionsManagement supportA key positive patient safety climate dimension is managerial support and its ability todirect staff to formulate proper strategic plans and priorities. Organizational climate islinked to managerial behaviours (Schneider et al., 1998). Managerial and physiciansupport play significant roles in the success of any patient safety activity, as eachdirect a portion of the organization and care provision (Cooper, 2000). Involvingmanagers and physicians is especially critical because they are ultimately responsiblefor hospital policy and decisions that affect the whole organization (Nieva and Sorra,2003).

Managers have overall responsibility for organizing hospital medical services toassure basic safety patient outcomes. Patient safety is derived from combineddirectives, behaviours and actions formulated by managers and often interpreted andimplemented by physicians, to improve service and erase obstacles that may impedesuccess and improvement. Manager and physician efforts, therefore, affect patientsafety climate (Nieva and Sorra, 2003; Fleming, 2005). Managers define employeepriorities by their actions, goals and focus. This motivates employees work pace,establishes workloads, rewards, punishments and the resultant pressures for


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production and safety. Leaders prioritise safety by emphasizing specific safetybehaviours and de-emphasizing others. Employees view safety often through theleaders lens (Flinet al., 2000; Zohar, 2002). Employees working in organizations whosesupervisors are committed to safety reflect manager commitment and perceive safetyto be important (Hofmann and Stetzer, 1998). However, if managers allowsafety-related activities to be perceived as mere rhetoric or pretence then there willbe a poor safety climate (Navehet al., 2005).Continuous motivation and clarification are important to achieve a positive safetyclimate. Supervisor and manager information sharing and feedback behaviourcritically affects the safety environment (Bisognanoet al., 2005) with the supervisorscommunication actions and efforts more important than senior executives (Pronovostet al., 2003). A patient safety climate necessitates a continuous feedback flow andaccess to safety information from various modes, including communication andtraining. To effectively motivate and maintain the climate, feedback should beFigure 1.Patient safety climatedimensions

IJHCQA23,138sufficiently clear and unambiguous. Organizations vary according to the feedback theyprovide and the amount of safety information disseminated, depending on frequencyand routines (Hofmann and Stetzer, 1998). Safety information dissemination oftendemonstrates staffs planned efforts to improve safety performance by augmentingtheir knowledge (Ford et al., 1994). Clear feedback should decrease errors and causeemployees to be aware what it takes to assure safety (Erez, 1977). This awarenessincreases the likelihood that employees will use information (Reber and Wallin, 1984).Managers can direct employees attention toward safety when they distribute safetyinformation and provide training. This facilitates disseminating knowledge amongorganizational members and reinforces shared perceptions regarding safety thatdevelops an appropriate safety climate (Navehet al., 2005).Communication between workers in the medical field is critical for safety. Goodcommunication supports planning, decision-making, problem solving and goal setting,and promotes shared responsibility for patient care. Cooperation and collaborationthrough proper communication determines positive patient outcomes. Climate caninfluence communication regarding patient safety. It is important to ensure that allcommunication channels are used properly to create a patient safety climate for staffand patients. A positive safety climate is founded on mutual trust through goodcommunication) Nieva and Sorra, 2003). Errors occur when communication problemsarise (Singer et al., 2003). Feedback from managers and physicians is a critical

dimension that promotes a patient safety climate. Many studies show its importancefor improving and developing safety. The organization with a strong patient safetyclimate seeks to develop its services through robust feedback and learn from its errors(Nieva and Sorra, 2003). Good feedback increases staff involvement and commitment(Fleming, 2005). We propose:H1. Management support has a positive effect on the organizational climate ofpatient safety.Reporting systemProper reporting systems are a patient safety climate key facet. Improving patient


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safety requires encouraging error reporting and improving systems to reduceincidence (Tamuz and Thomas, 2006). Reporting systems should enhance patientsafety by allowing learning from past errors and determining risk patterns, which maygo unnoticed without a reporting system (McFadden et al., 2006). A patient safetyclimate is facilitated by clear and direct rules, policies and procedures for all workers tofollow. Organizations often spend great time and effort developing and implementingsafety rules and procedures (Gaba, 2000). Procedures that instruct employees how toimplement new technologies have been suggested to create a positive implementationclimate (Klein et al., 2001). A work environment that does not contain clear work rulesmay lead to an unsafe environment. Formal safety policies are written organizationalrules and routines that define how organizational requirements for safety will be met.They exist to assure safety by reducing risk, managing uncertainty and risk present inhealthcare services (Navehet al., 2005; Brunsson and Jacobsson, 2000). Most hospitalsin industrialized countries have adopted written systems for patient safety tostandardize patient care practices (Al-Omar and Al-Fawzan, 2008). It is important toestablish and adhere to policies and procedures including patient and medical staffrights and responsibilities, service scope, clinical privilege definitions and protocols

A study ofhospitals inSaudi Arabia39and treatment plans. Safety procedures establish expectations and standards toimprove service quality. Organization staff increase their safety demands by creatingpolicies and procedures (Navehet al., 2005). We propose, therefore:H2. Good reporting systems positively affect organizational climate for patientsafety.Resource adequacyPatient safety climates are also created by appropriate resources, including relevant

information technology and staff. Information technology is needed to adequatelycommunicate in todays complex healthcare organizations. Technologies such asautomated drug order, entry and reminder systems increase accurate communicationand decrease common medical errors (Menachemiet al., 2007). Medical informationtechnologies decrease human errors and help medical service providers to offer higherquality services Workload can also affect an organizations climate. Overworkedemployees tend to minimize communication flows and feedback, resulting inresentment and cynicism. Inappropriate workloads diminish critical informationtransmission leading to errors that negatively affects the organizations safety climate(Firth-Cozens, 2001; Blegenet al., 2004). Thus:H3. Adequate resources positively affect organizational climate for patient safety.This descriptive and analytical study was derived primarily from a survey

conducted among Kingdom of Saudi Arabia hospital staff. The target populationincluded clinical staff, such as physicians, pharmacists, nurses, specialists andtechnicians located in different hospitals in the Ministry of Health, the militarysystem, teaching hospitals and private hospitals in Riyadh, Saudi Arabia. Astructured questionnaire with a five-point Likert scale (strongly agree to stronglydisagree) was used to measure respondents patient safety perceptions and toascertain the respondents personal characteristics. The questionnaire was developedafter reviewing pertinent patient safety and climate literature. The questionnaire


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contained 60 items: seven for personal information; 44 core questions on keydimensions influencing patient safety climate and nine for developing a patientsafety climate index. The questions were then reviewed by healthcare professionalsand altered to reflect their suggestions. Finally, a pilot study among 35professionals gathered their suggestions. The questionnaires were then distributedto 800 healthcare professionals in four hospitals categories: Ministry of Health,private, military and teaching facilities. The questionnaire was produced in Englishand Arabic and administrated according to language preference. Of thosedistributed, 496 or 62 percent were returned completed. Table I showsrespondents characteristics. A little over 60 percent were women, 30 percentwere Saudis and the overall average age was 35 years. Also, they had 10.6 years ofwork experience, 57 percent had a bachelor degree, 30 percent were physicians and27 percent nurses. Most respondents worked either for the Ministry of Health (36percent) or for private hospitals (43 percent).AnalysisUnivariate and covariate properties were explored by compiling basic descriptivestatistics and comparing them among the organizational groups. Differences between

IJHCQA23,140respondent characteristics and the overall score were examined using chi-square tests.Significant differences between gender, holding a degree, being a registered nurse anda Ministry of Health and private hospital employee were found. The only variable notsignificant was being a physician. Multiple regression analyses were then used toestimate managerial behaviour effects, reporting system and adequate resources on thepatient safety climate index. In addition to compiling a correlation matrix, a varianceinflation factor (VIF) was included in the regressions to ascertain the absence of multico-linearity. No VIF exceeded 1.7, which is well under the accepted guidelines of less

than ten (Kennedy, 1992). All analyses and statistical modelling were conducted usingSAS v.9.Independent variablesSurvey responses were subjected to a principal component analysis using priorcommunality estimates. This method is designed to identify conceptual domains in thesurvey and provides an accepted means for identifying underlying constructs(Hatcher, 1994). The principal axis method was applied to extract the components,followed by a Varimax (orthogonal) rotation. Only the first three components displayedEigenvalues greater than one while scree tests suggested that only these threecomponents were meaningful. Therefore, only the first three components were retainedfor rotation. Combined components one, two and three accounted for 54 percent of thetotal variance. Questionnaire items and corresponding factor loadings are presented in

(%)GenderMale 38.40Female 61.60NationalitySaudi 30.1Arab (non-Saudi) 28.9Other 39.0Age 35.3Years experience 10.6


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EducationPostgraduate 20.3Bachelor 56.9Diploma or high school 22.8OccupationPhysician 30.0Pharmacist 9.3Nurse 26.6Technician/other 34.0WorkMinistry of Health 35.8Private 43.2Military 16.6Teaching 4.4Table I.Respondentcharacteristics


Saudi Arabia41Table II. On the rotated factor pattern an item loads on a given component if the factorloading is 0.40 or greater for that component and less than 0.40 for the other. Usingthese criteria, nine questions were found to load on the first component, which wassubsequently labelled the managerial support component. Eight questions loaded onthe second component, which was labelled reporting system. The third factorresource adequacy loaded four questions. We achieved reasonable coefficient alphareliability estimates: 0.86 for the first two factors and 0.69 for the third factor (Hatcher,1994). Loading strengths are represented by the communalities h2 - the variance in anobserved variable that is accounted for by the common factors. These numbers seem

strong for the all three factors (Hatcher, 1994). After closely examining the questions,we feel that they fairly represent the designated constructs.Main variable means and correlations, including the three factors/dimensionsgenerated, are presented in Table III. No high inter-variable correlations wereobserved. All three factors have the expected zero correlation with one another, sincean orthogonal rotation in principal component analysis creates this relationship(Hatcher, 1994).Control variablesControl variables, anticipated to have systematic effects on organizational climate wereentered into the model. The tendency toward a patient safety climate may bedifferentially affected by characteristics such as profession, education andorganizational type. These factors may reflect differential resources, expertise and

other pressures. Control variables were drawn from the survey.StatementsManagementsupportReportingsystem Resource adequacy0.57 Proper means to ask about patient safety0.56 Top managers create suitable work environment0.66 Medical staff discusses ways to prevent errors


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0.48 Supervisor welcomes suggestions0.7 Patient safety instructions are clear for medical staff0.8 Medical staff take responsibility for patient safety0.74 Medical staff follow guidelines that enhance patient safety0.57 Medical staff trained about patient safety0.45 Reporting not structured to punish0.66 Reporting errors leads to positive change0.73 Medical believe in the importance of reporting errors0.78 Physicians believe in the importance of reporting near-misses0.63 Information from reported errors is used to improve safety0.68 Physicians are encouraged to report problems0.59 Reporting system procedures are clear0.45 There are enough staff for workload0.68 Electronic reporting system0.8 Computerized physician order system0.8 Patient electronic medical record0.69 0.86 0.86 Alpha2.45 4.28 4.59 Variance explained by each factorTable II.Loadings and statements

making up patient safetyclimate factors

IJHCQA23,14210.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 Mean n1 0 378 Managementsupport1 0 0 378 Reporting system1 0 0 0 378 Resourceadequacy1 20.088 20.171 * * * 20.072 0.369 578 Male

1 0.218 * * * 20.095 20.248 * * * 20.253 * * * 0.301 578 Saudi1 0.132 * * 0.160 * * * 0.031 20.048 0.05 0.941 578 Graduate degree1 0.063 20.008 0.366 * * * 20.034 20.039 20.007 0.223 578 Physician1 20.413 * * * 0.116 * * 20.302 * * * 20.365 * * * 0.007 0.197 * * * 0.113 * 0.372 578 Nurse1 20.104 * 0.002 0.141 * * * 0.256 * * * 0.085 * 20.129 * 20.256 * * * 20.145 * * 0.324 578 Ministry ofHealthhospital1 20.556 * * * 0.121 * * 20.014 0.126 * * 20.281 * * * 20.049 0.150 * * 0.159 * * 0.251 * * * 0.393 578Private hospitalNotes: *p , 0:5; * *p , 0:01; * * *p , 0:0Table III.Means and correlations

A study of

hospitals inSaudi Arabia43Dependent variableA patient safety culture index was constructed from nine statements reflecting overallsafety climate dimensions. These were established from an extensive literature review.Various patient safety indexes have been published, including one of nine items (Zohar,


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1980; Mueller et al., 1999), 13 items (Rybowiaket al., 1999), and three items (Hofmannand Mark, 2006). The survey statements we used are shown in Table IV. Questions,again, were on a five-point Likert scale from 1 strongly agree to 5 stronglydisagree. An overall patient safety climate index was created by averaging responsesfrom nine statements:(1) Medical staff members receive continuous education about patient safety.(2) My supervisors behaviour reflects that patient safety is a top priority.(3) The quality department in this hospital cooperates with staff regarding patientsafety.(4) This hospital has a reward system for reporting errors.(5) Information obtained from reported errors is used to improve patient safety.(6) Patient electronic medical records are used to improve patient safety.(7) Senior manager behaviour demonstrates that patient safety is a top priority.(8) Medical staff takes care to achieve high standards of patient safety in theirwork.(9) The workload is appropriate for the available staff.The three factors relationship to patient safety climate was evaluated using multiple

regression analysis (Table IV). Controls were added in the model and having a degreeultimately deleted as it added little to the analysis (only 0.003 was added to theadjusted R-square).The differences among organizational types for each question were then reviewedusing a Tukey HSD test, which compares group means and indicates significantpair-wise differences. We categorized significant differences by hospital type (Table V).Patient safety climate index,0.0001 30.5 F-value /Pr. F0.441 0.456 R sq/adjR sqPr. t S. error Coefficient,0.0001 0.082 3.108 Intercept0.687 0.067 20.027 Male0.031 0.074 0.161 Saudi

0.639 0.079 20.037 Physician0.973 0.072 20.002 RN0.702 0.078 20.030 Ministry of Health0.850 0.070 20.013 Private,0.0001 0.029 0.319 Factor 1: management support,0.0001 0.030 0.276 Factor 2: reporting system,0.0001 0.028 0.197 Factor 3: resource adequacyTable IV.Regression analysis

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FindingsA patient safety climate represents a composite of employees organizationalconditions, operations and demands (Navehet al., 2005). Safety culture reflects manyprofessionals including physicians, nurses and technicians (Kohn et al., 1999). Ourstudy indicates that the Saudi Arabian Ministry of Health may have a better patientsafety climate than the others. Overall, our analyses suggest that Ministry of Healthhospitals score consistently better on their patient safety climate questions than otherorganizations. As shown in Table VI, MOH hospitals were better than other facilities in


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28 from 44 questions. In 11 questions there was no difference and in no question wasany other organizational type better than the Ministry of Health. Relatively, therefore,the MOH appears to have a better patient safety environment. However, if responseabsolute values are examined then the Ministry of Health can improve hospitals thatmay have potential patient safety problems. For example, scores on the statement thatThe quality department in this hospital cooperates withstaff regarding patientsafety, shown in Table VI, are statistically significant between the Ministry of Healthand private hospitals. Private hospitals have a mean negative score of 4.09(5 strongly disagree). The Ministry of Health average is less negative, but with onlya mean of 3.34, which can at best be seen as neutral. As we saw in the other statements,four of which are shown in Table VI, this pattern is repeated.Our multiple regression analysis demonstrates that the patient safety climate ispositively and significantly influenced by all three factors, supporting all threehypotheses. H1: that management support influences a climate of patient safety isaccepted with a positive and significant coefficient of 0.319. Likewise, H2: theorganizations reporting system has an effect on the patient safety climate is alsosupported with a positive, significant coefficient of 0.276. Last, H3: adequate resources

positively affect the climate for patient safety is also accepted with a positivecoefficient of 0.197.DiscussionAn improved patient safety climate can lead to better outcomes. Research suggeststhat an improved safety climate encourages error and problem discussions; on theother hand, a poor safety climate causes problems to be covered-up and not freelydiscussed (Hofmann and Stetzer, 1998; Frese and van Dyck, 1996; Edmondson, 1996).Number significantly different Survey question5 MOH better than private8 MOH better than private and University1 MOH better than military6 MOH better than University6 MOH better than all

2 MOH and military better than private and University1 Private better than military1 Military better than University2 University better than all1 University better than military11 No difference44 Total questionsTable V.Significant differences byorganizational type


Saudi Arabia45Negative safety climates deter individuals from acting appropriately and ensuringsafety (Dobbins and Russell, 1986; Hofmann and Stetzer, 1998). Interestingly, in ourstudy, Saudi Arabian public services appear to perform better than private hospitals.The Ministry of Health invested substantial money and effort in the past few years toincrease service quality and safety. They sponsored symposiums and training in allhospitals and initiated licensure. These efforts seem to improve patient safety


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perceptions. However, although they are relatively better than the other hospital types,some absolute scores are at best neutral. This demonstrates that continuedimprovements are required. Our findings that private hospitals have negativeratings and score worse on their patient safety climate may have implications for theproposed Saudi Arabian hospital privatization (Ghafour, 2007). If the patient safetyclimate is currently worse in the private sector, then assurances are needed that:. patient safety will be improved; and. existing Ministry of Health hospital patient safety climate should not decline.There may be organizational reasons for private hospitals lower patient safety climatescores. Saudi Arabian private hospitals have a reputation for providing reasonablequality but are primarily staffed by expatriates who often have financial incentives toinvestigate patients unnecessarily. Saudi Arabian private hospitals primaryadvantage is their accessibility. Instead of waiting months for tests and surgery,investigations in private hospitals may be done quickly if financial arrangements areQuestion 6: The quality department in this hospital cooperates with staff regarding patient safetyDifferent MeanMOH vs private 3.34 MOHF 20.0, p , 0.000 4.09 Private

3.49 Military3.79 UniversityQuestion 13: Top managers create a suitable work environment to encourage patient safetyDifferent MeanMOH vs private 3.40 MOHF 16:75 4.02 Private3.77 Military3.74 University5 Strongly disagree 1 Strongly agreeQuestion 20: My supervisor welcomes our suggestions about patient safetyDifferent MeanMOH vs private, and MOH vs University 3.34 MOHF 10.75, p 0.000 3.86 Private

Different 3.73 Military4.00 University5 Strongly disagree 1 Strongly agreeQuestion 27: Department rules are effective in preventing errors occurringDifferent MeanMOH vs private, MOH vs University, 3.42 MOHMilitary vs private, and Military vs University 4.03 PrivateF 16.47, p 0.000 3.63 Military4.29 UniversityTable VI.Organizationaldifferences

IJHCQA

23,146met. However, our findings suggest that private hospitals have much further to go toimprove their patient safety focus.Practice implicationsOur findings provide practice implications and suggest that three dimensions needhighlighting:(1) Management support.


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(2) Reporting systems.(3) Resource adequacy significantly affect patient safety climates.Patient safety is a critical component in the quality of patient care. Yet, manyorganizations ignore the underlying factors that contribute to improved patient safety.Healthcare organizations, especially hospitals, need to allocate the time and resourcesto assure that these conditions exist in their facilities that create not only monitors tomeasure quality but processes, encouragement, and resources that produce a climateand eventually a culture that becomes self-regulating and promotes patient safety.This transformation has occurred in other industries, but only after interventions andsustained efforts to change their work environments and climate (Gaba, 2000).Communication and executive support are needed. Executives must understand whattheir clinical providers believe. Other research shows that top managers are oftenoblivious to staffs true perceptions within their organization and frequently are muchmore positive than their clinical staff (Walston and Chou, 2006). Hospital leadersshould take time to evaluate staff perceptions using interviews, discussions andsurveys to better comprehend employee perceptions and feelings. Such interventionsallow appropriate changes to policies and resource allocation that may improve

managers support for patient safety.Study limitations and implications for further researchThere are limitations in our study and further research is needed to understand patientsafety climates. Our study was conducted in a developing country that is extensivelymodifying its healthcare system. The statistical systems in the country are limited orunavailable. Our research also represents a cross-sectional survey of hospitalemployees patient safety perceptions and involved only patient care providers. Also,as with all survey research, this study is possibly subject to sampling and responsebias, although efforts were made to control potentialities. Further research is needed tovalidate and provide greater information on patient safety climate. Longitudinal datawould strengthen this research. Also, including patient feedback would add to ourresearch. Patient safety research generally lacks the patients perspective. Additional

research including patients hospital climate perceptions could be enlightening.Likewise, performing the survey in multiple countries would provide an interestingcross-country perspective to evaluate the potency of these factors and how they affectpatient safety climate and its interaction with local/country culture.ConclusionPatient safety continues to be a critical healthcare factor in all countries. There is aneed to provide better and safer care. Our research provides an internationalperspective on how staff can differ in their patient safety focus and demonstrates how

A study ofhospitals inSaudi Arabia

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