Measurement of Patient Satisfaction at the Academic Hospital by Sunita Ramlochan - Tewarie MBA3

8/17/2019 Measurement of Patient Satisfaction at the Academic Hospital by Sunita Ramlochan - Tewarie MBA3

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MEASUREMENT OF PATIENT SATISFACTION

AT THE ACADEMIC HOSPITAL

by

Sunita Ramlochan Tewarie

SURINAME

2008


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ACKNOWLEDGEMENTS

The MBA study at the F.H.R Lim A Po Institute in Paramaribo was a very pleasant and interesting

learning journey to me, supplying me with lot of contemporary theories and practices on

management which I can recommend every one who is able to do it in Suriname. The

accommodations and staff members can be characterized as “excellence” because it is a very

pleasant place to be there with a very motivated staff.

Finalizing my study and at the end going through the research of patient satisfaction was not

possible without the moral support of my family and parents. They were of tremendous importance

to me during the study and especially my little princess Sherani had to miss me lots of evenings. ButI am very grateful to them that they bear a lot of hours without many complaints.

This research where patients of the Academic Hospital are the main subject was not possible if they

had not corporate to fill in the questionnaire. To those ex patients I want to express my gratitude and

maybe this study will bring some positive changes when entering the hospital next time. Also thanks

to some special persons from the nursery, who gave me ideas and were a very important feedback.

Also some experts on using SPSS-program were of great help to me.

I want also to thank all the persons that were helpful in the distribution of the survey forms.

Finally I want to thank Mr. Silvio De Bono, the supervisor of the thesis for the response on the

paragraphs during our conference calls on frequently basis. To all my friends from the MBA study

who supported me, it was very nice period to be with you and hopefully we will spent a lot of hours

together.


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EXECUTIVE SUMMARY

This paper is about measuring the patient satisfaction at the Academic Hospital, a topic that is

related to quality management, which is not yet adequately and effectively implemented at this

hospital. The results of this study can be used as input for an integral quality management for the

hospital, which is in a premature phase. The major aspects during the process of incoming till

dismissal are investigated on quality care. The main reason for this part of the process is because of

the many rumors from society about the service component at our largest hospital in Suriname. As

the role of nurses and the medical specialists are a major part of this process they are not part of this

research.

Theories about quality management are used to measure the quality of care in the hospital, the way

patients experience the hospital care and recommendations are made to improve these.For research in Suriname, at the Academic Hospital, the choice is made for KQCAH Scale, the Key

Quality Characteristics Assessment for Hospitals Scale of 2001 because of the service component

and the organization processes it retains. It is a combination of qualitative and quantitative research

methodology and identifies the dimensions of hospital quality care, operationalizes the dimensions

and is an instrument to measure patient satisfaction.

The application of KQCAH instrument can add value for improvement within the services of the

hospital through the tested dimensions: respect and caring, effectiveness & continuity,

appropriateness, information, efficiency, effectiveness-meals, first impression and staff diversity.

The categories are: Category A represents patients from the private insurance companies, category B

from SZF, mainly consisting of civil servants, and category C (SOZA) from the low or no income

class.

The main research question is: Are patients at the Academic Hospital satisfied and what is the

difference in satisfaction between the three categories?

With two sub questions:

1. Which dimensions in satisfaction contribute to more satisfaction among all three categories

A, B and C?

2. Is there difference in satisfaction between the 1st, 2nd and the third class treatment?

Analysing these results have shown that patients at the Academic Hospital are on average satisfied.

Those results suggest that there is room for quality improvement. The most satisfied category is

category B in comparison to the 2 other categories taking 3 significant dimensions into account. Five


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dimensions are not significant at the 0.1 level, (at confidence interval of 90%) so the results of the

tests on the first sub research question are not confident. Respect and caring especially is significant

at the 0.05 level showing that this is a very important aspect to be taken into account for a judgement

about satisfactory. The least relevant dimension seems to be “Information” for all 3 different

categories.

For the survey, 73 questions were prepared, of which 67 were applicable and a total of 211 patients

out of 300 responded on these research purposes.

For answering the main question use of the statistical program SPSS version 15.0 (Statistical

Package for the Social Sciences) is made to quantify and analyze the information. The result of sub

question 1 about the differentiation of the 3 categories is derived from SPSS, e.g. the Kruskas-Wallis

method. For the second sub question, as it will be a comparison of different dimensions between the

2 categories of classes, the Independent t-test is used. Before applying the t-test, the Chi-square

method has been used to make clear the relationship between staying in classes and the insurance

involved, through the use of cross tables.


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BIBLIOGRAPHY 53

APPENDICESAPPENDIX A Questionnaires 55

APPENDIX B Reliability test 67APPENDIX C Statistical outcome main question 71APPENDIX D Statistical outcome sub question 1 75APPENDIX E Statistical outcome sub question 2 80


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GLOSSARY

Definitions

Quality management: relates to the production process and tests the normal routine with regard to

processes and product specifications; quality management starts from

normative criteria and tries to exercise control on the basis of these criteria.

Abbreviations

KQCAH Key Quality Characteristics Assessment for Hospitals Scale

AHP Academic Hospital Paramaribo

SOZA Ministry of Social Affairs

SZF State health insurance company

JCAHO Joint Commission on Accreditation or Healthcare Organizations

CAHPS Consumers assessment of health care providers and systems

PDSA Plan-Do-Study-Act

CQI Continuous Quality Improvement

TQM Total Quality Management

IOM Institute of Medicine’s

HKZ Harmonization of quality care

NIAZ Netherlands institute for Accreditation


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CHAPTER 1 INTRODUCTION

1.1 Motivation

Working at a hospital is a very intricate and contra dictionary place to work in, as

managing a hospital is better off when people are sick. This is in contradiction with the

policy of the government, in this case the Ministry of Health, to improve the health care

sector through the reduction of sick people. The hospital has to cope with different

stakeholders, who have their own interest at the hospital and where management has to

deal with these, in order to improve the competitive advantage of the hospital. Hospitals

today can reach this advantage through improvement of their processes on patient flow

care, medical care, quality services and so on.

The concept of quality has several meanings depending on the stakeholder, from the point

of view of patient and family, from management perspective, from Ministry of Health,

Inspection, from professionals. This research will be about the quality perceptions of the

patient.

Statistical results suggest that hospital leadership has more influence on process quality

than on clinical quality, which is predominantly the doctors' domain. A general definition

of quality health care system is: "the degree to which health services for individuals and

populations increase the likelihood of desired health outcomes and are consistent with

current professional knowledge". There are several ways to improve quality care within

hospitals. In general a health care system has three primary goals: the provision of high-

quality care, access to the system, and limited costs. However a more accessible system

of high-quality care will tend to lead to higher costs, while a low-cost system available to

everyone is likely to be achieved at the price of diminishing quality. Quality comprises

three elements:

• Structure: refers to stable, material characteristics (infrastructure, tools,

technology) and the resources of the organizations that provide care and the

financing of care (levels of funding, staffing, payment schemes, incentives).

• Process: is the interaction between caregivers and patients during which structural

inputs from the health care system are transformed into health outcomes.


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• Outcomes: can be measured in terms of health status, deaths, or disability-

adjusted life years, a measure that encompasses the morbidity and mortality of

patients or groups of patients. Outcomes also include patient satisfaction or

patient responsiveness to the health care system (WHO 2000).

This research will focus on the second part that is about the process within the Academic

Hospital in Suriname, especially that part of the process where the patient comes in and

stays during the care related to the treatment within the hospital. As the Academic

Hospital (AHP) is the largest hospital in Suriname with the most beds (440) and the most

specialists, it is important to have a good image; however rumours from society indicate

different because of the poor quality service patients receive. Patients from different

categories of insurance share the same view, no matter in which class of service theystay. As the hospital is in a changing environment since 2003, slightly improvements

have already been realized, but hardly on the part of customer service, in this case patient

care.

There are different levels to stay in the hospital, depending on the insurance of the

patients and on the service of the insurance company or patient is willing to pay. In the

hospital the service level is related on the class within the hospital, e.g. the first class

patient will have better facilities in the hospital than a third class patient. But even the

first class patients are complaining about the service they receive at the hospital and they

are an important income generating source for the hospital. These patients are mainly

from the private sector while third class patients are normally from the low to middle

income group.

1.1.1 The Academic Hospital in a changing environment

The Central Hospital was founded in 1966. On September 25, 1969 the hospital was

renamed into “Landsbedrijf Academisch Ziekenhuis” (Academic Hospital).

Before the changing process the hospital had a mechanistic structure with a supervisory

board which was supervising the management on behalf of the government. In 2002, a

change process has been initiated which should lead to a more independent functioning of

the hospital, in particular to operate more efficiency and effectiveness. This change


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process focuses on improving the internal structure, internal communications and

relations. In 2003 a seminar and a workshop were held with stakeholders to discuss this

change process and a new organizational structure was proposed. The new organizational

structure entails a broader management structure and a number of policlinics were

clustered as well as related support services. Six clusters were formed which are managed

by a cluster manager. The cluster manager is responsible for the operations of several

departments of the hospital. It is envisaged that these clusters will operate relatively

independent and will share a joint secretariat.

Late 2008, the organization structure is almost formalized and the main focus is on

improving quality care in the hospital.

1.2 Problem statement

Suriname has 7 hospitals, of which two are private and one in Nickerie. The private

hospitals have already focused on the improvement of the service part of the patients and

are therefore more popular for health treatment. However they are not able to provide all

medical treatment that is needed, so patients are obliged to have their treatment at AHP.

The AHP has therefore already a competitive advantage. But the hospital should not only

gain its important position through this channel but also through becoming more

customer oriented, as patients should become more willingly to enter the hospital.

Hence, the problem definition is: “How satisfied are patients of the Academic Hospital

from entering till dismissal?”

This research will focus on differences between satisfaction in health care between three

categories of patients and improvements to obtain better quality care through service

quality theories.

1.2.1 Research objectives

This research will make a contribution:

- to awareness of different satisfaction levels among several categories of patients

- to establish the importance of service quality

- to gather input for a service quality policy in the hospital


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- to implement other aspects of quality in the hospital to gain competitive

advantage

- for quality improvement

1.2.2 Research questions

As already stated, patients are divided in three main categories that represent almost 95%

of the total visitors of the hospital. These categories are:

Category A: private patients

Category B: patients from the State Health Insurance (SZF); merely middle income

class; civil servants and private persons

Category C: patients from low income class (SOZA)

In general, private patients (Category A) and the private component of SZF stay in the

first and second class of the hospital, while SZF (excluding private component) and

SOZA patients are staying in the third class because of their coverage at the insurance

company and Ministry of Social Affairs. Most of the patients at AHP (80%) are for a

third class treatment and therefore it is important to find out in what way they experience

the differences in satisfaction.

Patients in the first and second class (20%) seem also to have complaints about the

services of the hospital and are therefore included in the research.

MAIN RESEARCH QUESTION

Are patients at the Academic Hospital satisfied and what is the difference in satisfaction

between the three categories?

SUB QUESTIONS

1. Which dimensions in satisfaction contribute to more satisfaction among all three

categories A, B and C?

2. Is there difference in satisfaction between the 1st, 2

nd and the 3

rd class treatment?


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1.3 Scope and limitations of research

The focus on this research is on the process of in- and outflow of patients in 2007 within

the hospital. Therefore patients visiting the policlinics are not subject of this research.

Annually some 35.000 patients enter the hospital and about 53.000 patients visit the

specialist for treatment at the policlinics. Service quality at the medical services of the

specialists is excluded. It will merely focus on services about entrance, food, transport,

attitude of the nurses, environment, and other attributes to make the staying relative

pleasant.

1.4 Approach and research method

This research is a practical oriented research that will have a diagnostic and design

character. One method has been used to measure objective results, which is a

combination of a quantitative and a qualitative method.

The KQCAH –questionnaire was used for data collection to gather information about the

satisfaction of patients as it is a well known instrument to measure services at hospitals.

This method is a combination of a quantitative and a qualitative analysis.

1.5 Relevance of the research

Social relevance: The main reason to focus the research on this part of the process is

because of the many rumours about the poor service quality at the hospital. As the AHP

is the largest hospital in Suriname with the most beds and most specialists, the hospital

should have an integer image. As the hospital is an important integral part of the health

care sector, these rumours should be investigated. Patients from different categories of

insurance are taking part of this research in order to get a general view of the possible

causes for these rumours. As the hospital is in a changing environment since 2003,

slightly improvements have already been realized, but hardly on the part of customer

service, in this case patient care.

Economic relevance: To stress the importance of service quality in hospitals, because

competitive advantage cannot only be realised through more and specialized medical

services but also by improvements on other services for the patients


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Scientific relevance: as there is not yet much research in hospitals from developing

countries, this research can contribute to the awareness of becoming more quality

oriented in hospitals which will be in the advantage of the patient.

1.6 Structure of the paper

After the introduction (chapter 1), the theoretical background is presented in chapter 2.

In this chapter the distinction between quality and quality management system is made

clear and the relationship between service quality and satisfaction in general is pointed

out and adapted to hospital care. In this chapter, the development of contemporary

theories of health care satisfaction is reviewed. It also focuses on quality systems in

developing countries.

Chapter 3 reveals the methodology used to measure patient satisfaction at the Academic

Hospital. It also assesses the main category of patients at the AHP. In chapter 4 the

findings of the research is presented, while in chapter 5 the conclusions and

recommendations are formulated.


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CHAPTER 2 THEORETICAL BACKGROUND

2.1 Definitions of quality

In order to make clear the several definitions used in theory about service quality the

main concepts will be clarified. According to the International Organization for

Standardization “quality” can be defined as “a totality of characteristics of an entity that

bear on its ability to satisfy stated and implied needs”. Edward Deming agreed that

quality is subjective and must have commercial value. “What is quality? A product or

service possesses quality if it helps somebody and enjoys a good and sustainable market.

Trade depends on quality.”

The American Society of Quality defines quality as “a subjective term for which each

person has his or her own definition. In technical usage, quality can have two meanings:

1) the characteristics of a product or service that bear on its ability to satisfy stated or

implied needs and

2) a product or service free of deficiencies.

A variant of quality is service quality. In general services can be defined as social acts

which take place in direct contact between the customer and representatives of the service

company. It is more difficult to measure services objectively compared with products

because services characteristics include intangibility and inseparability of the production

and consumption of services. This makes the definition of service quality an abstract and

personal (subjective) concept. The relationship with service quality and health care is

described by Ross (1995). According to him, services in health care are intangible

because it is not possible to count, measure, inventory test or verify them in advance of

sale. Customer experience, either directly or vicariously from outside sources, is

frequently the only means of verifying whether health care services meets manifest

quality.

Caretakers provide services differently because of variations in factors, such as their

specialty training, experience and individual abilities and personalities. Patient needs

frequently vary from person to person and from visit to visit. Interactions among

physicians, nurses, administrators, patients and timing factors combine in an infinite

number of ways to affect the quality of the health care service rendered.


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Finally, in health care, production and consumption are inseparable. The services are

consumed when they are produced, which makes quality control difficult.

Grönroos(1984) divides the customer's perception of any particular service into two

dimensions:

1. Technical quality - What the consumer receives; the technical outcome of the

process and

2. Functional quality - How the consumer receives the technical outcome, what

Grönroos calls the "expressive performance of a service"

Grönroos suggested that, in the context of services, functional quality is generally

perceived to be more important than technical quality, assuming that the service is

provided at a technically satisfactory level. On the other hand he also points out that the

functional quality dimension can be perceived in a very subjective manner because each

person has its own experiences.

The distinction between the technical and functional aspects for quality is widely

accepted within the medical literature. In the healthcare field technical quality is referred

to as clinical quality which focuses on the technical accuracy diagnosis and treatments.

Functional quality refers in general to the manner or process by which health care is

delivered. However, hospital managers should take into account that clinical quality is at

least as important as process quality in predicting patient satisfaction.

According to “De Nederlandse Normalisatie Instituut” in Delft, Holland quality policy

has to do with ‘the objectives of an organization with regard to quality and the ways and

means to achieve these objectives’. Quality policy should be adapted by all employers

and specialists.

Quality policy should be implemented through well defined and applicable quality

management systems and must be quantified by certain measurements.

Therefore quality policy should be part of the total policy of the hospital and should be

implemented through the means of procedures and protocol.


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Quality management system (QMS) is an instrument to implement quality policy and can

be defined as the ‘organizational structure, procedures, processes, and resources needed

to implement quality management’. In theory, a Total Quality Management (also called

Continuous Quality Improvement (TQM/CQI)) is a process of quality improvement and

quality control in the industrial and business world. It was first Edward Deming (1945)

and Joseph Juran (1954), among others, who developed TQM by applying statistical

techniques to the production process. The process can be defined as “an ongoing effort to

provide services that meet or exceed customer expectations through a structured,

systematic process for creating organization-wide participation in planning and

implementing quality improvements”.

Within the QMS, satisfaction of customers is an important part as they can contribute to a

well functioning quality system since customers are one of the stakeholders for

improvement of service quality. Service quality is part of a total quality system and can

be derived for instance by measuring the satisfaction of customers. But the dilemma with

measuring satisfaction is that it is subjective. Several researchers state that services are

not actions and behaviors in and of themselves, but the way customers perceive and

interpret those actions. Historically, the establishment of quality standards has been

delegated to the medical profession and has been defined by clinicians in terms of

technical delivery of care.

More recently, patients’ assessment of quality care has begun to play an important role,

especially in the advanced industrialized countries, and their satisfaction or

dissatisfaction with services has become an important area of research. Although

different, satisfaction and service quality are closely related. The literature indicates a

positive relationship between service quality and patient satisfaction with hospital care

and a willingness to return to the hospital. Three different opinions are mentioned as

relevant. According to Oswald and Taylor (1992), consumers must rely on attitudes

toward caregivers and the facility itself in order to evaluate their experience. They

maintain that there is a strong connection between health service quality perceptions and

customer satisfaction. Donabedian (1988) suggests that, patient satisfaction should be

considered to be one of the desired outcomes of care and information about patient


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satisfaction should be as indispensable to assessments of quality as to the design and

management of health care systems.

This relationship has also been acknowledged in the dissertation of Chieh-Lu Li (2003),

title: A Multi-ethnic comparison of service quality and satisfaction of service quality and

satisfaction in national forest recreation. It appears that service quality and satisfaction of

customers are distinct concepts but interrelated constructs. He found that service quality

is more likely to the perspective of managers, because they control the services provided

for customers; whereas, customers are more likely to evaluate their satisfaction with

services

Another link is that satisfaction is concerned with the short-term and specific transaction;

while service quality is concerned with more general, long term, and global effects.

Therefore, satisfaction is an antecedent of service quality and consequently, satisfaction

is theoretically influenced by service quality.

Further he found that satisfaction was likely based on emotional evaluations and

subjective judgment. In contrast to satisfaction, service quality, however, tends to be

based on rational evaluations and objective judgments.

Finally, in literature, consumer expectations have usually been defined as forecasted or

anticipated levels of performance. These expectations are combined with actual

performance to create the concept of disconfirmed expectations. Disconfirmed

expectations, in turn, are used as predictors of consumer satisfaction. Researchers in the

service quality area, however, emphasized that expectations in service quality models

were not forecasts. This is an important distinction. If service expectations were defined

as forecasts, the service quality model (P-E) became undifferentiated from the

disconfirmed expectations component of the consumer satisfaction model (Teas, 1994).

Last but not least measurements of quality systems can be done by several methods

depending on the sector and the applicable dimensions relevant in these sectors.

2.2 Development of quality systems

Quality control striving towards perfect quality is since the Middle Ages (Baker 2002). In

the medieval masters and enslave designed strict rules concerning quality of raw

materials, the production process, the professional skills and the quality of the end


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product. The end products were checked by the master and after customer’s approval,

provided with a guarantee seal, as the product certificate. Quality seems therefore as

something that has been there always. This development continued in the period of the

Industrial Revolution. The customer and producer views about the production process

became different and instead of tailored made products standard products were made.

Thereby the manufacturer himself stipulated if the product was produced according to

specific measures. At the beginning of the ‘20 statistics were included and for the first

time inspections took place on the basis of samples. Quality control became a separate

appropriate mean and the quality inspector was appointed. As from 1945 up to the 1960’s

a tremendous development evolved in the striving towards quality. It is worth

remembering that quality methods were first developed and put into widespread use in

Japan after the Second World War, a country with few resources and then re-imported

into the West. The Japanese realized rapidly that quality could be an important

competition mean. Some of the challenges in applying and adapting quality methods as

well as the potential for testing and developing more cost effective methods, were

developed by them. In the ‘50 the foundation service level for the industry has been set

up. Statistics are no longer only applied to do samples but are also used to make the

production process transparent, on basis of which decisions are taken. Process control

does its entrance. Afterwards it was considered that by measuring the process and the

results, a rule ring arise and the well-known Deming-circle became famous. Gradually,

the notion grows that quality control is not only concerned with the output of production

but also assembly other phases in the production process. In the period between 1980 till

1990, flexibility will play a role beside efficiency and quality. The three criteria should be

applied simultaneously and integral. This was a new quality golf. In this period also the

service will play a larger role beside the production. Quality control becomes a

component of the total management function because of the care of a good product

quality. Organizations are involved in writing quality policy where it is indicated how

required quality should be implemented. In 2005 quality control almost no more means a

competition advantage but a condition to survive on the market.


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Graph 1: Relationship between organization and labor development

Source:Kleemans WVCS (2007)

Since the 1990s, there is a general trend for stakeholders to put more pressure on

hospitals for accountability, transparency and equity of access to health. The

governments of various American and European countries have, therefore, stimulated the

use of Quality Management systems (QMS) and external evaluation in healthcare.

Former research has identified models and variants of external evaluation, e.g. medical

specialty-driven visitation, traditional accreditation against explicit standards, European

Quality Awards based on the model of the European Foundation of Quality Management

(EFQM), and certification using ISO standards (ISO 9000 series).

2.2.1 Quality systems in the health care sector

Although there are many quality instruments, not all systems are suitable for the healthcare sector. Quality care through quality management systems are applicable because it is

about improving the process around the customer/patient and therefore enhance the

satisfaction of the customer /patient. Other motives for the necessities of quality

improvements are: patients become more demanding, the fact that competitiveness of

other hospitals will evolve not only by price but also through service and quality

Product Process System Concatenate Society

Organization

development

Developments in labor

Inspection

Quality

Control

Quality

Assurance

Strategic Quality-

Management

Developments in

Management


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management will lead to better outcome and finally it will conduct a more specialized

organization.

The difficulty in measuring hospital service quality is that there is no valid and reliable

instrument with respect to the functional aspect for quality as patients define quality

based on their subjective perception. Several researchers have tried to identify several

different dimensions to be applicable for hospital, but it is still very difficult because of

the focus on determining perceptions and attitudes. In the Netherlands the Customer

Quality Index has been developed which is based on two American measurements:

CAHPS (Consumer Assessment of Healthcare Providers and Services) and QUOTE

(Quality of care through the patient’s eyes). This instrument measures the experiences of

the consumers of health care. In their opinion, using information about the experiences of

patients is more effective for quality improvements than subjective information about

satisfaction.

In the health care sector quality policy became much more important due to the fact that

deregulation and market orientation became more important. In most countries the

government has to retrieve and health institutions are taken the responsibility to improve

the quality of care. The patient became therefore a crucial partner in developing standards

for quality. Transparency about the quality of care is one of the key factors and external

assessment should be made on regular base. In the table below the different stakeholders

in the health care sectors are identified for information about their specific process

improvement.

Table 1: Information need

Patients Pressure group

Health care insurances Procurement

Government Monitor information

Health care Inspection Supervision

Managers and professionals Quality care information


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In general changes in quality care systems show a development on certain characteristics:

• From static: image building towards dynamic: change management

• From the inner to also outward oriented: client and market focus

• Shifts from organizational items towards professional items: it is about care and

the effectiveness of care

• From: Patient→Client→ Consumer → Visitor

• Professionals are central

• Efficiency and flexibility are important factors to take into account in the new

developed quality systems.

2.2.2 Quality care systems in developing countries

In developing countries the development and quality of health services is severely limited

by lack of resources and knowledge about quality methods.

However developing

countries increasingly recognize the value of quality methods and the need to raise the

quality of their services.

Developing countries face severe limitations to health care. The average spending on

public health care per head of population is low (US$6-US$10 a year), the services are

not evenly distributed and there is a lack of many essential drugs (despite various

programs to solve this problem). Health personnel are not trained sufficiently,

unsupervised, and morale and incomes are low.

In most of these countries policy makers think that quality methods and concepts are not

relevant and applicable. They argue that some quality approaches are inappropriate—for

example, large amounts spent on accreditation systems to improve the quality of hospital

services could be put to better use. Accreditation is certainly easy to understand than

many other quality

methods and it is often supported by donors, but it is often

unsustainable, ineffective and inappropriate in many of these countries. Therefore they

are reluctant to implement quality systems.

However, nowadays developing countries become aware of using quality methods

because it can have an important part to play in improving the performance of the health

care system if the right ones are chosen for the situation and adapted in a culturally

appropriate way.


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By introducing quality management systems in hospitals the organization can amend and

qualify on international standards in order to provide a better service and treatment, and

can expand.

In recent years, organizational change in the health care system can influence quality of

care and can focus on the continual design and redesign of systems. The emphasis is on

developing organizational and individual capabilities where they most profoundly affect

the process of care. Design and redesign interventions assume that simply adding a new

resource or a new process in isolation will not improve care because better care is the

product of many processes working together. Although change interventions have not

been widely used in the developing world because they require large investments to plan

and implement, four related models of organizational change have been successful in

changing provider practice in developing nations (World Bank Group, 2006):

• Total Quality Management in health care

Advances in business management practices to continually design and redesign systems for

quality improvement is possible and have been adapted for health systems. Teams in Total

Quality Management, also known as Continuous Quality Improvement, use mutually

reinforcing techniques in a cycle of planning, implementing, evaluating, and revising to

improve the quality of clinical and administrative processes. These techniques include

process mapping, statistical quality control, and structured team activities. Two cases which

were TQM is implemented with success, are in Bihar, India and in Malaysia. In rural Bihar,

private practitioners were provided with standard case-management information, were

given feedback on their performance, and were tracked and monitored over time. This

strategy produced significant improvements in practitioners' case- management skills. In

Malaysia, anesthesia safety has been improved through the implementation of consensus-

based protocols that emphasize (a) communication among the operating, recovery, and

ward team members; (b) individual feedback and (c) frequent monitoring to identify areas

for improvement.


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• Collaborative Improvement Model

The early success of Total Quality Management techniques has given rise to a related

model, the Collaborative Improvement Model. It has been applied to broad and complex

systemic processes within health care systems and has facilitated the scale-up of quality

improvements. This model, designed to continuously improve organizational and individual

performance, comprises four elements: definition of an aim, measurement, innovation, and

testing to see whether the innovation meets the original aim. This approach strikes a

balance between the need for action and the need to be scientifically grounded. It has been

used with success in Peru and the Russian Federation. The results have led to changes in

the process of care, but it is too early to determine whether they have been effective in

improving quality.

• Plan-Do-Study-Act cycle

The Plan-Do-Study-Act (PDSA) cycle calls for action oriented learning in quality

improvement. Team members using the PDSA model design a quality improvement

intervention (plan), implement it on a small scale (do), evaluate the results (study), and

implement or alter the intervention accordingly (act). Multiple PDSA cycles are necessary

before the appropriate improvement method can be identified. All improvement techniques

that involve the design and redesign of systems use some form of the PDSA cycle.

Successful PDSA prototype is possible with careful leadership oversight. Although the

experience of researchers implementing interventions that are based on system redesign in

the developing world has been largely positive, it is not clear whether the resources and

leadership exist to bring these interventions through country or regional policies. Further

evidence is needed concerning the real-world feasibility and cost-effectiveness of system

redesign.

• Internal enabling environment

Creating the right environment for change involves leadership and leadership training;

clinicians empowered to make quality improvement decisions, and resources for quality

improvement planning activities. The internal enabling environment in Costa Rica

promoted strong leadership that led to the adoption of structural adjustment loans in the

early stages of health sector reforms. The loans were used to maintain such public health


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programs as mother and child nutrition, even though public spending dropped and prices

increased dramatically. An environment can also be created by teams of individuals, each

representing different stakeholder groups (physicians, nurses, staff members, patients, and

so forth) or simply by a strong leader with an interest in teamwork and the resources to

support a discrete quality improvement function for team members.

2.3 Evolution of measurements for service quality in hospitals

Measuring service quality was not well known and became popular after the 1990’s. One

of the pre-eminent instruments for measuring service quality in general is SERVQUAL

also known as the Gap model, developed by Parasuraman through testing on 5

dimensions. It provides a structure for understanding service quality, measuring it,

diagnosing service quality problems and offering solutions to the problems (Zeithaml et

al., 1990). Furthermore it is mostly applied in service sectors which were financially well

established, for instance the banking sector. Through an exploratory study it was possible

to define service quality as the discrepancy between customer’s expectations and

perceptions and to suggest key factors that influence customers’ expectations, which are

word of mouth communication, personal needs, and past experience.

SERVQUAL enables the tracking of customers’ expectations and perceptions (on

individual service attributes and or the SERVQUAL dimensions) over time. It further

allows for comparison of a company’s SERVQUAL score against those of competitors.

T. P van Dyke (2003) several weaknesses when using this tool.

In general, the difficulties with the Servqual measure can be grouped into 4 main

categories:

1. The use of the difference of gap score: subtracting one measure with the other is a

poor choice for measuring the psychological construct.

2. Reliability problems and poor validity with gap scores: Servqual instrument is not

proper to use Cronbach’s alpha, the method to measure reliability because the

component scores are highly correlated.

Validity issues: The mentioned instrument concerns poor predictive and

convergent validities of the measure. Babakus and Boiler (1992) indicated that it

is difficult to demonstrate that the difference score is measuring something unique


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from the perceptions component, and therefore a high correlation between the

difference and perception score.

3. The ambiguous definition of the “expectations” construct: multiple definitions of

“expectations” result in a concept that is loosely defined and open to multiple

interpretations and can result in measurement validity problems.

4. Unstable dimensionality: a theoretical construction combined with the use of gap

scores raise the questions about the true factor structure of the service quality

construct.

The Massachusetts Health Quality Partnership (1988) is a statewide patient survey project

named “Results of Hospital Patient Care Survey” designed to meet the dual goals of

supporting internal hospital quality improvements throughout Massachusetts while

advancing public accountability through public reporting of comparative information on

patient care experiences. Fifty-two institutions participated in this study, which accounts

for about eighty percent of the state’s medical/ surgical inpatient discharges and ninety

percent of all childbirth patients. The Picker Institute administered the surveys, which

focused on dimensions of care which patients themselves identified as important. The

Picker Institute is a nationally recognized organization, which assesses the healthcare

experiences of patients across the country.

Dimensions measured by the Massachusetts Health Quality Partnership included:

Respect for patient preferences, Physical comfort, Involvement of family and friends,

Continuity and transition, Coordination of care, Information and education and Emotional

support.

The survey went far beyond general satisfaction or evaluation, asking the patients to

report what happened during their hospital stay. Massachusetts hospitals scored above the

national average for surveyed hospitals. The findings were strongest relative to the rest of

the country in emotional support, and were weakest in continuity and transition.

The Joint Commission on Accreditation of Health care organizations (JCAHO, 1990)

related the dimensions of Coddington and Moore with the dimensions of SERVQUAL

and finally 9 dimensions were selected as the theoretical framework of hospital quality.

The Joint Commission on Accreditation or Healthcare Organizations (JCAHO) is an


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independent, non-profit organization that evaluates and accredits more than 15,000 health

care organizations and programs in the United States.

Bowers (1994) added caring (personal, human involvement) and patient outcomes (relief

from pain, saving of life, or anger/disappointment with life after medical intervention).

Another dimension, collaboration, was discussed by all of Jun’s groups. Collaboration

encompasses the concepts of teamwork and the synergistic effect of various actors in

providing health care. It is the “commingling” of the roles of all members of the health

care team, including payers, physicians patients, family members and members of the

community that define health care quality from the patient’s viewpoint. Jun further

emphasizes that communication is essential for collaboration because it “fills in the gaps

to prevent disjointed service.”

Mittal and Baldasar (1996) measured the effect of certain quality factors in a physician’s

practice, and found that physician competence, communication, respect, caring, taking

time to learn history, and follow up treatment were weighted more heavily if patients

were not satisfied. The condition of the office environment and waiting time, received

lower weighting scores.

Young (1996), et al surveyed 2000 discharged hospital patients, nursing staff and

managers to compare differences in the relative importance of four key nursing variables:

physical care, patient participation in care, patient teaching and pain control.

They found that patients ranked patient teaching of highest importance, and participation

in care lowest, but the variation in statistical results was narrow. They maintain that

knowing how much importance patients place on an aspect of care is valuable for

developing and achieving improvement in that aspect of care. Furthermore, they found

gaps in the scores of both nurses and managers when they rated the importance (to the

patient) of these variables. The usefulness lies in understanding how the lack of

understanding of patients’ values and expectations can impede service quality

improvement strategies within hospital units.

Chakrapani’s (1998) uses a model that consists of 5 dimensions related to patient

satisfaction in Bangladesh, Pakistan. In his view patients’ voice must play a greater role

in the design of health care service delivery processes in the developing countries. This

study is patient centered and identifies the service quality factors that are important to


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patients; it also examines their links to patient satisfaction in the context of Bangladesh.

Evaluations were obtained from patients on several dimensions of perceived service

quality including responsiveness, assurance, communication, discipline, and baksheesh.

In table 1 these dimensions are mentioned.

Alan M. Rees (1998) maintains that satisfaction with hospital care is too often assessed

on the basis of amenities that have little relationship to the clinical quality of care. He

feels that amenities do not indicate the quality of what happens to people while they are

in the hospital and what happens to them after discharge. He recommends the measures

of: respect for patient values, preferences and needs; coordination of care (scheduling

tests and procedures); information and education provided; physical comfort (waiting

time after call bell sounded); emotional support and alleviation of fear and anxiety;

opportunity for involvement of family and friends; provision for continuity and transition

to the home environment.

Seihoff (1998) documented continuity of care and caring behaviors in evaluating the use

of unlicensed assistive personnel vis-à-vis patient satisfaction. In a study of the British

Medical System, administrators, providers and patients, agreed about quality priorities for

elderly people.

All groups considered improving the quality of life (adding life to years) as important,

whereas reducing mortality rates (adding years to life) was unimportant. The key

difference between professionals and patients occurred in the importance attached to

reducing the burden on family caregivers (understanding the patient). Patients attached

higher importance to this factor .

Ford and Fottler (2000) suggest that service specific dimensions should be added to the 5

SERVQUAL dimensions to appeal the patient’s definition of health care in the health

care sector. Various environmental changes forces the hospitals to be more responsive to

customers wants, needs and expectations and have to focus on what the patients really

wants.

Coddington and Moore (2001) developed a list of 5 dimensions from a consumer’s

perspective. In their model they stress the importance of technology on quality of the

hospital. The general research hypothesis tested is that hospital technology directly drives

(affects) quality and hospital financial performance. The results indicate that the type of


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hospital technology (clinical or information) drives different types of quality-related

performance (clinical or process), and directly and indirectly affects hospital financial

performance.

The dimensions of quality care and performance (table 2) provide the framework for

quality management activities in all healthcare settings from a balanced and well-

integrated quality, cost, and risk perspective.

Table 2: Several researchers on hospital quality

Dimensions

Massachusetts Health

Quality Partnership (1988)

Respect for patient preferences, Physical comfort, Involvement of family and

friends, Continuity and transition, Coordination of care, Information and

education and Emotional support

JCAHO (1990) Appropriateness, Efficiency, Timeliness, Respect and Caring, Safety,

Continuity, Availability

Bowers (1994) Caring (personal, human involvement) and patient outcomes (relief from

pain, saving of life, or anger/disappointment with life after medical

intervention)

Young (1996) Physical care, Patient participation in care, Patient teaching and pain control

Mittal and Balsadar (1996) Competence, Communication, Respect, Caring, Taking time

Rees (1998) Respect for patient values, Preferences and needs, Coordination of care

(scheduling tests and procedures), Information and education provided,

Physical comfort (waiting time after call bell sounded), Emotional support

and alleviation of fear and anxiety, Opportunity for involvement of family

and friends, Provision for continuity and transition to the home environment

Chakrapani (1998) Service/product, Dependability, Support, Exceeding, Expectations

Jun (1998) the roles of all members of the health care team, including payers, physicians patients, family members and members of the community, Communication

Seihoff (1998) Continuity, Understanding

Coddington (2001) Warmth/Caring, Available, Specialization, Technology Equipment

Sower,Duffy et al Respect and caring, Efficiency and continuity, Effectively, Staff diversity,

Appropriateness, Information, Meals, First impression


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2.4 KQCAH

A recent developed measurement is the Key Quality Characteristics Assessment for

Hospitals Scale (KQCAH, 2001) which can be relevant because of the service component

and the organization processes it retains. Knowledge of these dimensions facilitates the

measurement of patient satisfaction by hospitals. Hospitals know that they are measuring

dimensions that are important to patients. The Institute of Medicine's (IOM 1999) identifies

nine domains of care that can provide useful guidelines for survey-item development. These

nine domains are: respect for patient's values; attention to patient's preferences and

expressed needs; coordination and integration of care; information, communication, and

education; physical comfort; emotional support; involvement of family and friends;

transition and continuity; and access to care. The CAHPS Hospital Survey domains (nurse

communication, nursing services, doctor communication, physical environment, pain

control, communication about medicines, and discharge information) were derived from the

IOM domains (Goldstein et al. 2005).Other conditions that are important for hospitals are

the pressure on hospitals for accountability, transparency and equity of access to health. In

European countries the use of Quality Management system (QMS) in healthcare has

extensively been used and has led to better health service. The Netherlands are

implementing the quality assurance standards of NIAZ (The Netherlands Institute for

Accreditation of Hospitals) and HKZ (Harmonization of quality care). These standards

contain requirements for the organization of a hospital. They describe what has to be

regulated in a hospital in order to warrant that the quality of care delivered is not depending

on individuals or left to chance.

This method, Key Quality Characteristics Assessment for Hospitals, is a combination of

qualitative and quantitative research methodology and identifies the dimensions of hospital

service quality, operationalizes the dimensions and is an instrument to measure patient

satisfaction. It is developed by Sower and Duffy et al (2001) and based upon the JCAHO

dimensions. Eight dimensions have been incorporated and were tested on Cronbach’s

alpha. For hospitals it is even more difficult to measure satisfaction as patients have their

own definitions for quality and comparing these definitions is not possible because of the

lack of a valid and reliable instrument. This method takes into account the customer’s

perspective and makes it possible to effectively improve the performance of the hospital.


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Research has indicated that the KQCAH have high levels of content, validity and

reliability. It is a tool which that provides the hospital to be responsiveness to their market-

oriented environment. It also has the means to improve quality audits by periodically using

the questionnaire to monitor quality indicators. It is also a tool for identifying areas needed

to improve within a hospital.

2.5 Quality in hospital care in Suriname

Suriname has no quality systems yet implemented in hospitals and it is doubtful if

implementation will be useful mainly because of the lack of awareness of these systems and

the professionals for implementing quality standards.

In the “Meerjaren Sectorplan Gezondheidszorg 2004-2008”, the goals of health care are

formulated which have to be achieved by the Ministry of Health. One of the goals is:

improve the efficiency and quality of the hospital care.

Therefore a strategy is defined with 5 process indicators. These are:

- rating of hospitals and departments by well defined and standardized process or

outcome indicators

- technical standards of interventions

- standardized/ comparable staying in days

- maintenance of the infrastructure and medical apparatus

- target of beds capacity of 80%

In order to reach these indicators 4 sub goals are formulated and the one regarding the

quality of hospital services has to do with “Medical services should be qualitative and

cost effective for all hospitals”. Although this sub goal is mainly applicable for medical

treatments, one could derive that this is also applicable for the services in the hospital. In

the same report however it is also mentioned that the policy of the ministry is not further

developed because of the many departmental discussions about the financing of hospital

care which become a burden for the government budget the last 10 years, and therefore

they were not able to focus on other important health care issues like developing a

general quality policy.

In the daily newspaper “De Ware Tijd of December 6th 2007, page A4, under the head of:

“Ministry of Health want to improve the relationship between health care providers”


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plans have to be developed in the next few years to create a unit to coordinate and

facilitate health care tasks through ordering and regulation. The main task will be to

create a platform for every Surinamese citizen to guarantee a certain level of information

and quality. Therefore plans will be made for implementing quality guarantee and quality

maintenances.

The Academic Hospital had installed a quality sub commission for the nursery in 1996,

because of complaints about the not adequate care to the patient, the lack of appropriate

facilities at the hospital and the poor maintenance. In 1999 the commission became the

“Commission quality guarantee” to control quality care. The commission had to do an

audit which consists of a checklist about the welfare, environment and comfort for

patients, sufficient information in reports, application of a nursery plan and the facilities

at the department. Depending on the results, the department is receiving a score related to

a defined benchmark. This audit includes also recommendations to overcome the

shortcomings at the department.

The last audit was held in 2003 and has not been continued for several reasons. The main

reason is that these audits took too much time for the nursery to do, besides their own

nurse’s tasks. Another major reason is that although the commission is making

recommendations for improvements, not all the departments are aware of the urge to

follow up the instructions. So there was no follow up and no sanctions.

As the Academic hospital is in a transition phase of change, one of the priority areas of its

policy is the development of quality care, in the broadest way. In the next few years

protocols and procedures have to be written in documents and should be standardized in

order to improve the quality of all services, including medical services. Another aspect

which will be developed is the installation of a quality mentor, who will give advises

about quality improvements and a commission of complaints. Nowadays patients can

complain through a letter to the general director, who tries to solve the problem in his

own convenient way.


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2.6 Summary

It appears that a clear objective definition for “quality” is hardly possible because it

depends on a person’s perception if there is quality. Service quality is much more

subjective because it is hardly tangible and measurable. Services in health care for

instance are not possible to count or verify and depended on patient’s experiences.

Quality control is difficult because production and consumption take place on the same

time. By developing several management systems to improve quality in recent years,

customer’s expectations will meet which can contribute to a more satisfied client. These

management systems are instruments to implement quality policies. However not all

management systems are suitable for the health care sector.

Quality service at the hospital can be divided in 2 dimensions in general: functional,

which has to do with the manner or process health care is delivered, while technical

quality focuses on clinical quality and thus focuses on technical accuracy diagnosis and

treatments.

Quality service and measuring satisfaction are distinct but interrelated concepts. A major

distinction is that service quality is concerned with more general, long term effect likely

to the perspective of managers while measuring satisfaction is basically an emotional

judgment from customers.

The problem when implementing quality system in the health care sector is that there is

no valid and reliable instrument with respect to the functional aspect for quality because

this is subjective as the focus is on determining perception and attitudes. However it is

still important to develop these systems because it is about improving the process around

the patients and enhance their satisfaction. The organization can become more

competitive and will conduct a more specialized organization.

Several researchers have tried to identify several dimensions applicable to hospitals but

there is still not a general model determined. It is obvious that these measurements are

more popular in developed countries mainly because they have the instruments, data and

the facilities to do so. Another reason is also the growing competitiveness especially in

the USA, as there are many hospitals there.

For research purposes in Suriname, at the Academic Hospital the choice have been made

for KQCAH Scale, the Key Quality Characteristics Assessment for Hospitals in 2001


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because of the service component and the organization processes it retains. It is a

combination of qualitative and quantitative research methodology and identifies eight

dimensions of hospital quality care, operationalizes the dimensions and is an instrument

to measure patient satisfaction.


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Chapter 3. Methodology

3.1 Introduction

As stated in chapter 1 the main research question of this thesis is: “Are patients at the

Academic Hospital satisfied and what is the difference in satisfaction between the three

categories?” The main question is supported with 2 sub questions and all 3 questions

were subject of research according to the KQCAH Scale. This method took the

experiences of the 3 categories patients in consideration and therefore obtains a

measurement of the service quality at the Academic Hospital through theoretical and

practical issues. Questionnaires regarding the functional level of service quality through

the 8 dimensions were applicable and have been distributed to 300 ex patients of the 3

categories, of which 211 were filled in. They have been translated into Dutch in order to

make sure that it would be understood and again re-translated in English to verify the

correct interpretation. In appendix A, the English and Dutch versions of the questionnaire

are included.

In the next paragraph this method is discussed. Furthermore, it will elaborate on the

target groups, design, data collection and types of analyses.

3.2 Target groups and pre testThe target groups for research are divided in 3 main categories: Category A (private),

Category B (SZF) and Category C (SOZA). The respondents, in total 211, are of the age

of 18 and above. No difference has been made in sexes, income group and education.

Category A represents patients from private insurance companies and is the smallest

group of patients at AHP (table 3), because in general they prefer to stay at a private

hospital, mainly because of the notion of better services provided by those hospitals. At

the AHP, the rooms for patients of the 1st and 2nd class are on one floor, which implies

that there are not many rooms for this category. Category A represents 18.5% of the total

respondents and therefore is a good reflection of the patients’ share of this category at the

AHP, namely 17% on average between 2004 and 2006.

Category B (SZF) is the middle income group of patients which has more freedom to

choose for medical treatment. It is also a medical insurance for almost every civil citizen


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and they can have medical treatment divided over all 3 classes depending on their

hierarchical function at work and the insurance possibilities. But most of the civil citizens

have a basic insurance and could stay for treatment at the 3rd class. They prefer to stay at

a private hospital in general, but because the many medical disciplines at AHP they have

often no choice than staying at this hospital. Another target group within category B is

that of private persons, but their share in the total is minor. Category B has a share of

32.7% in the total respondents, thus overrepresented when judged against the share of

this category in the total patients’ population of about 25% at the AHP. No differentiation

is made between civil servants and private persons.

Category C (SOZA) represents patients from the low or no income class that get a card

from the Ministry of Social Affairs if they can prove their inability to work. The validity

of a card varies from 2 weeks, when the request is still in charge, half a year and 1 year.

These patients have the right for treatment only at 3rd

class and consist of about 60% of

the total patient population of the hospital. The reason for this is that they are obliged to

make use of the medical treatments from only public hospitals and there are only 2 of

them in the main city. In the test this category represents 48.8% of the total respondents

of 211. Judged against the share of this category patients of 58% between 2004 and 2006

in the total population of AHP (table 3), category C is underrepresented in the survey.

Table 3: Percentages of patient’s population at AHP

In % 2004 2005 2006

Private 17 16 19

SZF 24 27 24

SOZA 59 57 57

After identifying the targets group a pre test was done with 20 patients to find out if the

questionnaire was suitable and understandable. Most of the respondents had manycomplains about the quantity of questions, and it appeared that 5 questions from the

original version were not applicable in Suriname. These questions were about after care

services, after dismissal from hospital which is in Suriname not yet developed as well and

the non personal relationship between nursery and patient.


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3.3 Application of KQCAH

The application of KQCAH instrument can add value for improvement within the

services of the hospital and is suited particularly for determining the perceptions and

attitudes regarding 8 dimensions of service. These dimensions are: respect and caring,

effectiveness & continuity, appropriateness, information, efficiency, meals, first

impression and staff diversity. It is deducted from the dimensions of JCAHO and only the

dimension of efficacy is excluded as the reliability of this dimension was not acceptable.

Efficacy of care is generally determined by using such measures as mortality and

complications. From the original questionnaire of 75 questions, 5 were excluded because

they were not appropriate for Suriname.

In Suriname, however, there are several dimensions that influence the satisfaction of

patients. Some staff members of the nursery were interviewed in order to identify if the

dimensions according to the KQCAL scale were applicable at AHP and if there were

other specific dimensions possible to be added at the mentioned instrument to measure

patient’s satisfaction.

In their view the eight dimensions are appropriate, but they insist that there are certainly

other relevant factors that could be important for the patients. Factors like their privacy

when the medical specialist is consulting the patient, the cultural diversity and therefore

for instance differences in languages, the availability of linen for the beds, the visiting

hours play an important role in the Surinamese case.

3.4 Applications of SPSS

Using a survey to measure satisfaction among patients is a common instrument although

there are many hindrances to use it. Some of these are: the selected population is not

representative, partial non responses, the effects of an interviewer on the respondent, the

formulation and effect of the questions, the effect of questions filled in by people that all

questions are positive. However, a survey is the only reliable instrument to do so. The

objective of this survey is to give a description, comparison and explanation of

knowledge, attitude and behavior and is therefore applicable.

Indicators for satisfaction depend in general on factors as trust, sexes, profession, own

living standard and education. For research purposes these indicators are not all neglected


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as a main approach to measure satisfaction at the hospital other factors are applicable

which can be divided in: 1. factors in output related services (medical services at the

hospital) and 2. factors in process oriented services. As already mentioned, this survey is

about the process oriented services with regarding to the relationship between nurses and

patients and the environment.

For answering the sub question 1: Which dimensions in satisfaction contribute to more

satisfaction among all three categories A, B and C? the Kruskas-Wallis method has been

used because of the 3 categories.

For answering the sub question 2: Is there difference in satisfaction between the 1st,

2nd

and the 3rd

class treatment? use is made of the t- test. As it will be a comparison of

different dimensions between the 2 classes, the survey gave answer of the question if

patients have different experiences when staying at the hospital.

The comparison is between the 1st and 2

nd class, the 1

st with the 3

rdclass and the 2

nd with

the 3rd class.

3.5 Design

The questionnaire includes eight dimensions which will give a relative objective answer

that are measurable, on the main question when using the KQCAH instrument. Before

using the data, all variables were tested on reliability. The questions that scored a low

Crombach alpha were deleted. To measure the differences between the 3 categories, use

is made of the Kruskal-Wallis method. For the 70 ordinal level variables, ex-patients

were asked to indicate their degree of agreement or disagreement with a statement

regarding hospital care by marking a cross to indicate “Strongly Disagree,” “Disagree,”

“Agree,” “Strongly Agree” or “Undecided.”

Responses were then coded as follows: “Strongly Disagree = 1,” “Disagree = 2,”

“Undecided = 3,” “Agree = 4”and “Strongly Agree = 5.”

Three other questions were included to obtain general information.

The data obtained from the respondents was imported into the statistical program SPSS

version 15.0 (Statistical Package for the Social Sciences) to quantify and analyze the

information.


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The result of the main question and the sub question 1 was derived from the usual method

of SPSS.

The result of sub question 2 had been analyzed using the t-test. Before applying the t-test,

the Chi-square method was used to make clear the relationship between staying in classes

and the medical insurance involved, through the use of cross tables.

The results of all the questions are discussed in chapter 4.

3.6 Data collection

To measure satisfaction between classes and the 3 categories the ideal situation should be

to include the same numbers of patients to analyze. The survey, however did not include

an equal distribution between the several targets groups but as the AHP has relatively

more SOZA patients as their customer, the fact that most of the respondents are of this

category, could be interpret as representative. For the survey, 73 (70 ordinal and 3

nominal) questions were prepared, and a total of 211 out of 300 patients were selected for

research purposes. On annual basis the AHP has about 35.000 patients in house, while

53.000 patients enter the clinics.

3.7 Summary

This paragraph is a reproduction of the subjects involved and the dimensions used. It also

elaborated on the target groups, design, data collection and types of analyses used.

The main research question is supported with 2 sub questions and all 3 questions were

subject of research according to the KQCAH Scale. This method took the experiences of

3 categories patients in consideration and therefore obtains a relatively objective

measurement of service quality at the Academic Hospital through theoretical and

practical issues. The application of KQCAH instrument can add value for improvement

within the services of the hospital through the tested dimensions: respect and caring,

effectiveness & continuity, appropriateness, information, efficiency, effectiveness-meals,

first impression and staff diversity.

Category A is the group of patients from the private insurance companies. This category

is the smallest group of patients. Category B (SZF) is the middle income group of

patients which has more freedom to choose for medical treatment in hospitals. It is also


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an insurance for almost every civil citizen and they can have medical treatment divided

over all 3 classes depending on the hierarchical function and their assurance possibilities.

Category C (SOZA) are patients from the low or no income class and receive a card from

the Ministry of Social Affairs if they can prove not able to work and are obliged to stay in

the 3rd class for medical treatment at public hospitals. For the survey, 73 questions are

prepared, of which a total of 211 patients out of 300 (70.3%) responded on these research

purposes. To answer the questions, used is made of the Likert-type scale of 1 to 5. The

statistical program SPSS version 15.0 (Statistical Package for the Social Sciences) is used

to quantify and analyze the information. The result of sub question 1 about the

differentiation of the 3 categories is derived from a variant of SPSS, the Kruskas-Wallis

method. For the second sub question, as it will be a comparison of different dimensions

between the 2 categories of classes, the Independent t-test is used. Before applying the t-

test, the Chi-square method has been used to make clear the relationship between staying

in classes and the insurance involved, through the use of cross tables.


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Chapter 4. Results of the empirical analysis

4.1 Introduction

The primary purpose of the study is to explore and determine the patient satisfaction

regarding the healthcare services delivered at AHP.

Individual overall satisfaction scores were computed for each of the 211 study subjects

by summing scores on each of the 8 items from the KQCAH Survey determined to be

indicators of the construct “general satisfaction”. The items regarded are: respect and

caring, effectively and continuity, appropriately, information, efficiency, food, first

impression and different workers. Three other questions were also formulated for data on

their insurance and class.

Findings and analysis of the patient satisfaction survey data are presented in paragraph

4.3. The results are arranged and presented according to the formulated research

questions.

4.2 Reliability of the questionnaire

Six out of 8 dimensions were tested on reliability and validity. Two dimensions “First

impression” and “Staff diversity” could not be tested because they exist of only 1

question, which represent the respectively dimensions without doubt. A special motivefor this test is that the questionnaire from KQCAH is from American origin and as

Suriname has different standards and perception for satisfaction in health care, it is

obviously to test it for local use. After the test it appears that three dimensions showed a

low scale on reliability and were therefore adapted. The reliability of “Respect and

caring” became 0.967 after excluding 3 questions. The dimension “Efficiency” was in

first instance not reliable with an alpha of 0.502. After excluding one question which

carried out the low scale, the alpha became 0.808. The score of the dimension

“Information” was in first instance 0.593 and when deleting the 2 low scoring questions

the scale did not change that much and became 0.635. The questions involved were also

deleted for research purposes. All other dimensions appear to be high and these

connected questions remain the same. In table 4 the Cronbach alpha is reflected, after


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adapting the questionnaires. The analyses have been done with 67 questions (64 ordinal

and 3 nominal). The details are mentioned in appendix B.

Table 4: Cronbach alpha

Dimension Cronbach alpha

Respect and caring 0.967

Effectiveness and continuity 0.869

Efficiency 0.808 (was 0.502)

Appropriateness 0.722

Information 0.635 (was 0.593)

Meals 0.873

4.3 Analyses and outcomes

Main question: Are patients at the Academic Hospital satisfied and what is the

difference in satisfaction between the three categories?

The main research question is quantitative in nature and is analyzed through summation

and calculation of means of the 8 items from the Key Quality Characteristics Assessment

for Hospitals (KQCAH). The relationship between satisfaction and the three different

categories of patients because of their health care insurance has also been quantified and

is part of this objective.

Table 5: Health Insurance type

Health insurance n Percentage

Private insurance companies (A) 39 18.5

State Health Insurance (B) 69 32.7

Ministry of Social Affairs (C) 103 48.8

Total 211 100


43/89

35

Table 6: Patients at different classes

Class n Percentage

1st 27 12.8

2nd 31 14.7

3rd 153 72.5

Total 211 100

Table 5 and 6 contain the relative distribution between the 3 categories/classes for the

survey. From the 211 respondents, 168 (79.6%) responded of the 3 categories and 100%

responded on the question about the classes.

The answer to answer the main question, are patients of AHP satisfied, can be derived

from graph 2. According to the normal curve of this graph and taken into account the

mean and median of respectively 201.70 and 205.0 (SD = 41.58), the outcome indicates

that 50% of the respondents are slightly more than average satisfied, which could be

interpreted as moderate satisfaction. However, the mode (mode=186) is lower than the

mean, implying that most of the respondents are less than on average satisfied. But taking

into account the standard deviation, the outcome is still that patients are on average

satisfied.

Patients are satisfied, although not very much, but they are also not very dissatisfied, as

the outcomes of the options “Strongly disagree” and “Strongly agree” are not prominent

marked in the survey.

Date post:	06-Jul-2018
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Measurement of Patient Satisfaction at the Academic Hospital by Sunita Ramlochan - Tewarie MBA3

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