Assessment of Work System at Internal Medicine and General ... · Assessment of Work System at...

Aim of work

Assessment of Work System at Internal Medicine and General

Surgery Clinics in Fayoum University Hospital

Aim of work

Goal

Exploring the factors that may affect the quality of services provided at Internal Medicine and

General Surgery out-patient clinics in Fayoum University Hospital to upgrade the quality of

services.

Objectives 1. Study the patient satisfaction with services offered at Internal Medicine and General Surgery

outpatient clinics in Fayoum University Hospital.

2. Understand the health service providers' satisfaction with system of work at Internal Medicine

and General Surgery outpatient clinics in Fayoum University Hospital.

3. Know the service delivery at Internal Medicine and General Surgery out patient clinics.

4. Set a plan to improve services in Internal Medicine and General Surgery out-patient clinics

according to the results of the study.

Introduction

2

INTRODUCTION

Services are becoming an increasingly important element of national economies and it is

crucial to distinguish the qualities of services. Perception of service quality is an attitude. Service

quality can be divided into two sets, i.e. functional, which include measures such as ambiance;

provider attentiveness and technical such as outcome that describes how the service is delivered

(Carman, 2000).

Healthcare quality is defined as the extent to which health services provided to patient

populations improve desired health outcomes. The care should be based on the strongest clinical

evidence and provided in a technically and culturally competent manner with good

communication and shared decision making (Pelletier and Beaudin, 2008). Health service

quality has three dimensions: client, professional and management quality. Client quality is the

dimension that receives most attention based on how satisfied clients with their care (Carman,

2000).

In the past, the medical service providers ran their business by adopting selling orientation

rather than customer orientation approach. The supply is more than the demand in medical service

market and the patient’s perception is arising. Therefore, the medical service administrators adopt

customer orientation approach to run their business for creating values of patients and increasing

patient satisfaction (Lee Wan et al., 2010). Determining factors associated with patients’

satisfaction is thus critical for healthcare providers in order to understand what is valued by

patients, how the quality of care is perceived by the patients and to know where, when and how

service changes and improvements could be made (De Jager, 2010).

An accurate assessment of work climate can identify the obstacles to the health care

providers interfering with their best performance. It an indicative of how the organization is

realizing its full potential (Abdel-Aziz et al., 2005). The work of individual staff must be assessed

so that each person's strengths and weakness can be identified and appropriate support can be

provided (ESPA, 2004). Performance assessment is defined as the measurement of an individual's

ability to carry out specific task. The use of the term "performance" focuses attention on the total

Introduction

3

behavior of an individual in accomplishing a task including their organization, retention, and use

of specialized knowledge, as well as their attitudes and interaction with other people. (WHO &

UNICEF, 2003)

The terms “culture” and “climate” have been used interchangeably. Organizational climate

refers to the atmosphere of aggregate attitudes and perceptions of how individuals feel about their

places of work, which are associated with both individual and team motivation and satisfaction.

The climate within an organization represents a moveable set of perceptions related to conditions

within the workplace, which can be changed by the values, attributes, skills, actions, and priorities

of organization leaders and mangers (Clarke SP., 2006).

A safety climate is a type of organizational culture and is the result of effective interplay

of structure and processes factors and the attitude, perception, and behavior of staff related to

safety. A climate of safety is represented by employee perceptions of: the priority of safety within

the work environment on their unit and across the organization, and is influenced by management

decisions; safety norms and expectations; and safety policies, procedures, and practices within the

organization (Gadd S., Collins AM., 2007).

Customer satisfaction is a person’s feeling of pleasure or disappointment resulting for

comparing service’s perceived or outcome in relation to his or her expectations (Avis et al., 1995).

If the performance falls short of expectations, the Customer is dissatisfied. If the performance

matches the expectations, the customer is satisfied. If the performance exceeds expectations, the

customer is highly satisfied or delighted. (Sinay, 2002)

Patient's satisfaction is one of the main components of quality of care which includes respect

for the patient and understanding their need and providing services accordingly. It is a major

indicator of the quality of service, assessed by mapping out patient satisfaction with care

providers. A hospital may be well organized, ideally located and well equipped but it will fail its

responsibility to provide quality care if patient satisfaction is not of a high calibre. (Tarantino,

2004; March et al., 2006; Alzolibani, 2011).

Introduction

4

The patient is not just a customer in these processes. The patient is always a controlling,

active participant and is as much a processor and supplier to the process as a customer. The best

hospitals give their physicians, nurses, and other staff the tools and support they need to practice

high-quality medicine on a daily basis and to identify and investigate quality problems when they

do services (Meyer et al., 2002).

Out-patient clinic in any hospital is considered to be shop window of the hospital. There are

various problems faced by the patients in outpatient clinic like overcrowding, delay in

consultation, lack of proper guidance etc that leads to patient dissatisfaction (Srinivasan, 2000).

Medical service providers that focus on interaction with people, make patients satisfied are their

priority; so achieve their ultimate goal to sustainable development (Lee Wan et al., 2010).

Public healthcare organisations all over the world are increasingly concerned about their

insufficient financial resources and their ability to meet social obligations. Increasing financial aid

alone will not improve healthcare systems, but drastic restructuring with sound management

principles need to be implemented (De Jager et al,. 2000).

Quality must be associated with high technical capabilities providing effective care in an

efficient manner requires high technical skills of health care professionals, who must do the right

thing right the first time and do it better the next (WHO, 2004).

According to Cunningham (1991), the patient's definition of quality consists of nine

elements: good patient care, responsiveness, good doctors, good reputation, up-to-date equipment,

cleanliness, adequate food, limited noise, and prompt and accurate billing (Chilgren, 2008).

Factors influencing satisfaction with medical care include confidence in the system and a

positive outlook on life in general. Finally; satisfaction is the judgment of the patient on the care

that has been provided. The physician remains a key element in patient satisfaction. The

measurement of satisfaction is, therefore, an important tool for research, administration and

planning (Baker, 2006). The organizational structure of public healthcare providers must facilitate

the delivery of a responsive and flexible healthcare system that is people centered with the interest

of the clients guiding the decision making (De Jager et al., 2000). Employee satisfaction, loyalty,

and commitment had a sizable impact on product and service quality (Beatson et al., 2008).

Introduction

5

Rational of the study:

In Egypt, the health care infrastructure is reasonable in terms of facilities and personnel. The real

challenge is to improve staff performance and patient satisfaction in order to minimize rework

wastage, delay and costs. Today, we recognize that quality as perceived by the health care

recipient is vitally important. As a result of this new focus, measurement of customer satisfaction

has become important (Gadallah et al., 2003).

This study was done to Explore the factors that may affect the quality of services provided at

Internal Medicine and General Surgery out-patient clinics in Fayoum University Hospital to

upgrade the quality of services and raise the patient as well as the healthcare providers

satisfaction.

Introduction

6

Introduction about the hospital:

The University hospital was opened inside one of the University buildings; where it is treated

architecturally to fit with the function of the hospital.

The vision of the hospital is to supply the local communities, national, regional and international

with a qualified doctor able to recognize and solve the community health problems. Also conduct

researches to ensure health promotion and to be a tool to change and improve the health beliefs

and behaviors.

The mission of the hospital is training of all employees in the health sector including the

students of the Faculty of Medicine, house officers and residents and postgraduate students, in a

safe environment that preserve the rights of the trainee and the rights of the patient through an

integrated quality health care. Implementation of a research related to health problems in the

community to develop the best solutions to deal with it with a health education and behavioral

change of the community.

(Available at:http://www.fayoum.edu.eg/Medicine/AboutCollegePage1.aspx 2013)

The important goals of hospitals are to deliver high quality health services and to respond to

the needs of the patients. Patient satisfaction is one of the most sensitive indicators of the quality

of their services as it measures the gap between what is expected and ideal from one side and

what actually exists in reality (Aldebasi and Issa, 2011). The delivery of healthcare depends on

individual providers, coordination within teams, and the structure of the work setting (Kelly et

al., 2010).

http://www.fayoum.edu.eg/Medicine/AboutCollegePage1.aspx

Chapter(1) Review of literature

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Chapter (1) Health System in Egypt

The Egyptian health care system faces multiple challenges in improving and ensuring the

health and wellbeing of the Egyptian people. The system faces not only the burden of combating

illnesses associated with poverty and lack of education, but it also respond to emerging diseases

and illnesses associated with modern, urban lifestyle. A high birth rate combined with a longer

life expectancy is increasing the population pressure on the Egyptian health system (ESPA,

2002).

Egypt has a highly pluralistic health care system, with many different public and private

providers and financing agents. Health services in Egypt are currently managed, financed, and

provided by agencies in all three sectors of the economy (government, parastatal, and private).

The government sector represents activities of ministry that receive funding from the Ministry of

Finance (MOF). The government health services in Egypt are organized as an integrated delivery

system in which the financing and provider functions are included under the same organizational

structure. This means that government providers receiving budgetary support from the

government general revenues (MOF) are also subject to the administrative rules and regulations

that govern all civil service organizations. For example, staffs are subject to the Civil Service

Employment Law, and remuneration is based on the civil service salary scale determined by the

Central Agency for Organization and Administration (CAOA).Government providers are

permitted to generate their own income through various means, including charging user fees in

special units or departments known as economic departments. Income from these non budgetary

sources is classified as “self-funding" (WHO, 2006).

The parastatal sector is composed of quasi-governmental organizations in which

government ministry have a controlling share of decision-making, including the Health Insurance

Organization (HIO), the Curative Care Organization (CCO) and the Teaching Hospitals and

Institutes Organization (THO). Although the distinction between the government sector and the

parastatal or quasi-governmental sector is usually made when describing the Egyptian health

sector, both sectors are run by the state. From an operational and a financial perspective, the


8

parastatal sector is governed by its own set of rules and regulations, has separate budgets, and

exercises more autonomy in daily operations. However, from a political perspective, the Ministry

of Health and Population (MOHP) has a controlling share of decision-making parastatal

organizations " (WHO, 2006).

The private sector includes for-profit and nonprofit organizations and covers everything

from traditional midwives, private pharmacies, private doctors, and private hospitals of all sizes.

Also in this sector there are a large numbers of nongovernmental organizations (NGOs) providing

services, including religiously affiliated clinics and other charitable organizations, all of which are

registered with the Ministry of Social Affairs (MOSA). The private sector has 2,024 inpatient

facilities, with a total of about 22,647 beds. This accounts for approximately 16 percent of the

total inpatient bed capacity in (Handoussa H et al.,2010).

Organization of the Ministry of Health and Population The organizational structure of the MOHP consists of two functional structures: the

administrative structure and the service delivery structure.

• Administrative Structure

The administrative organization of the MOHP comprises the central headquarters and the

governorate level health directorates.

• Service Delivery Structure

The MOHP is currently the major provider of primary, preventive, and curative care in Egypt,

with around 5,000 health facilities and more than 80,000 beds spread nationwide. There are no

formal referral systems in the MOHP delivery system. The MOHP service delivery units are

organized along a number of different dimensions. These include geographic (rural and urban),

structural (health units, health centers, and hospitals), functional (maternal child health centers),

or programmatic (immunization, and diarrheal disease control) (Mahi Al Tehewy et al., 2009).

Integrated hospitals are small, 20- to 60-bed hospitals providing primary health care and

specialized medical services in the rural areas. Integrated hospitals contain well-equipped surgical

theatres, X-ray equipment, and laboratories and are responsible for serving a catchment

population of between 10,000and 25,000 people (ESPA, 2002).


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District hospitals are 100- to 200-bed hospitals that provide more specialized medical

services and are available in every district. District hospitals are responsible for serving a

catchment population of between 50,000 to 100,000 people in the urban district area. General

hospitals contain more then 200 beds and contain all medical specialties. General hospitals are

available in every capital of a governorate. Specialty hospitals are located in urban areas and

include specialties such as eye, psychiatric, chest (34), fever (88), heart ophthalmology (31),

tumors, and gynecology and obstetrics. Specialty hospitals are available in all governorates

(Saleh, 2006).

MOHP Public Health Programs The MOHP has attempted to target many health priorities in Egypt through vertical

programs that rely heavily on donor assistance. These programs include the following

• Reproductive Health, and Family Planning Program

• Control of Diarrheal Diseases and Acute Respiratory Infections Programs

• Expanded Program on Immunization

• Maternal Health

Health Reform Strategy The government of Egypt has articulated as its long-term goal of basic health services coverage of

all citizens. It has also stated the importance of targeting the most vulnerable population groups as

its priority. Major components of the strategy include expanding the social health insurance

coverage from 47 percent (in 2003) of the population to universal coverage based on the “family”

as the basic unit. An affordable and cost-effective package of basic health services based on the

priority health needs of the population will be provided (Sameh El-Saharty, 2004).

The health sector reform strategies are assisted through the Health Sector Reform Program

(HSRP), it includes: Provision of the basic package will be based on competition and choice

among the different public and private service providers, under a single Public and Health

Insurance Fund (PHIF) using incentive-based and other provider payment mechanisms.

Strengthening management systems and developing a regulatory framework and institutional

relationships to ensure quality of care and to support the reform of the health sector. Developing


10

the domestic pharmaceutical industry and reducing government involvement in the production of

pharmaceuticals while strengthening its role as a financier (Egypt National Human Development

Report, 2005).

Other Government and Public Sector Agencies Many other ministries operate their own health facilities that cater to their employees. The most

important is the Ministry of Interior, which operates health facilities for police and the prison

population; the Transport Ministry, which operates at least two hospitals for railway employees;

the Ministry of Agriculture; the Ministry of Religious Affairs; and the Defense Ministry, which is

responsible for health facilities run by the Armed Forces. Egypt has 14 medical schools (Faculties

of Medicine), affiliated with the major universities and 36university hospitals. University

hospitals are regarded as secondary and tertiary care facilities and tend to be much more advanced

in terms of technology and medical expertise in comparison with MOHP facilities. Cairo

University, with a new modern hospital, is considered the largest and most sophisticated hospital

in this group. These university hospitals are operated under the authority of Ministry of Higher

Education (ESPA, 2002).

Parastatal Sector

The parastatal organizations are governmental establishments operated through the MOHP or

other ministries. They include the Teaching Hospitals and Institutes Organization (THO), the

Health Insurance Organization (HIO), and the Curative Care Organization (CCO).

General Organization of Teaching Hospitals and Institutes THO includes nine institutes and nine hospitals distributed over Egypt. The nine THO hospitals

are distributed as follows: four hospitals in Cairo, two hospitals in Upper Egypt governorates, and

three hospitals in Lower Egypt governorates.

Health Insurance Organization There are four broad classes of HIO beneficiaries: all employees working in the government

sector, some public and private sector employees, pensioners, and widows. In February 1993, the

Student Health Insurance Program (SHIP) was introduced to cover 15million students and school


11

age children, thus increasing the total beneficiary population from 5 million in 1992 to 20 million

in 1995. The 1997 Ministerial Decree 380 extended coverage to newborns (under one) and, by

2002, had increased the eligible beneficiary population to more than 30 million (Eliya et al.,

1997).

The Curative Care Organizations The Curative Care Organization (CCO) is a nonprofit system established in 1964 under the

ultimate authority of the MOHP. CCOs operate 11 hospitals, which together account for about 1.5

percent of Egypt's total hospital beds. Each CCO is run independently on a nonprofit basis, with

surplus revenue being invested into service improvement. In general, the 11 hospitals are high-

quality institutions, providing a full range of quality curative care services and programs. In 2002,

the CCOs operated facilities with 2,127 beds

(Jafar et al., 2011).

Private and Nongovernmental Sector Private-sector provision of services includes everything from traditional healers, midwives,

private pharmacies, private doctors, and private hospitals of all sizes. Also in this sector are a

large number of NGOs providing services, including religiously affiliated clinics and other

charitable organizations, all of which are registered with the Ministry of Social Affairs (ESPA,

2002).

Private Practices

Physicians represent the most powerful professional group in the health sector. Doctors are

permitted to work simultaneously for the government and in the private sector. Those who are

employed by the government but run a private practice because of their low salaries account for a

large portion of private providers. Many other physicians, however, cannot afford to open their

own private clinics and work in more than one nongovernmental religious or private facility in

addition to their government jobs.

The Egyptian National Health Care Provider Survey (Nandakumar et al., 1999) showed

that 89% of the physicians with private clinics had multiple jobs. 73% of the physicians had two

jobs, 14% had three jobs, and 2% had four jobs. The MOHP employs 53% of physicians with


12

multiple jobs, followed by universities with 14%, and HIO with 11%. The remaining physicians

include well-established and qualified senior physicians who are usually faculty members in the

major medical schools or shareholders in modem private hospitals. These physicians have the

technology, the resources, and the visibility required to run very successful and profitable private

practices.

Nongovernmental Organizations

Nongovernmental organizations (NGOs) provide many developmental, social, and health care

services, including reproductive health and family planning service delivery. Reproductive health

and family planning services are delivered through the Egyptian Family Planning Association

(EFPA), the Clinical Services Improvement (CSI) project, and other NGOs that are able to

provide health services (e.g., mosque health units, church health units, and other NGO clinics).

According to the 2000 Egypt Demographic and Health Survey, the public sector is providing 49

% of family planning services in Egypt, and the private sector is providing 44 %. PVOs/NGOs

were found to be providing 7 % of family planning services. There is a system of supervision and

monitoring based on a regular follow-up for the NGO clinics. Supervision is conducted at two

levels: from local directors at clinics and from the central staff (EDHS, 2000).

Teaching hospitals A teaching hospital is a hospital that provides clinical education and training to future and current

doctors, nurses, and other health professionals, in addition to delivering medical care to patients.

They are generally affiliated with medical schools or universities (hence the alternative

term university hospital), and may be owned by a university or may form part of a wider regional

or national health system.( Wikipedia 2012)

When people need medical treatment they may be given it in a “teaching hospital.” This is a

place where student doctors and other trainee healthcare workers are receiving part of their

education. Teaching hospitals are usually large establishments and in most countries they are

regarded as being among the very best hospitals available, with leading physicians and surgeons

among the staff. It is usually assumed that patients who are being treated in a teaching hospital are

lucky, because they are getting such high-quality healthcare. However, it has sometimes been


13

suggested that, because some of the people involved in their care are still in training, the patients

may face higher risks than those who are in nonteaching hospitals.( Panagiotis N., et al. 2006)

Teaching hospitals foster a higher quality of care, including the treatment of rare diseases

and complex patients, the provision of specialized services and advanced technology, and the

conduct of biomedical research. Some services, such as specialized surgery are provided

predominantly at teaching hospitals (Vartak S., et al. 2012). Other distinctive missions of

teaching hospitals include medical education and training, innovations in clinical care, and

treatment of indigent patients, particularly at public teaching hospitals (Kupersmith J. 2005).

The Education Ministry through its budget supports twenty university hospitals, with

over 15,000 beds. These provide a higher quality of care than MOH facilities, and receive a

higher level of government subsidies per unit of service. The university hospitals are linked to

the universities, but they are open to all patients. They charge user fees from patients (Ravi

P. Rannan Eliya, et al. 1997).

Teaching hospitals in fact rely heavily on income from more routine services, such as the

care of heart disease, pneumonia, and stroke. They therefore may justify their comparatively

higher charges for these clinical services by claiming that they provide better care than other

hospitals do. It is possible, however, that for common conditions, teaching hospitals may offer a

lower quality of care than do nonteaching hospitals, particularly if the substantial involvement of

inexperienced trainees and the attenuated role of senior physicians in teaching hospitals results in

more fragmented and less appropriate care. Both purchasers and patients have an interest in

knowing whether teaching hospitals provide added value through a higher quality of care or

whether services of comparable quality could be obtained at a lower cost in nonteaching hospitals

(John Z. and Joel S. 2002).

Role of teaching hospitals § Teaching hospitals are valuable assets as they educate future generations of health care

professionals.

§ Conduct state of the art research to discover cures and advance surgical techniques


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§ Provide care to the nation’s underserved and uninsured populations.

§ Serve as referral centers for complex and severely ill or injured patients (Hayanga AJ., et

al.2010).

Advantages of teaching hospitals

§ Teaching hospitals work in larger teams than in a district general hospital.

§ Manage a greater variety of patients. These include patients with complex illness or rare

conditions.

§ There is also exposure to tertiary (highly specialist) practice.

§ The subspecialty environment of a teaching hospital can be good to extend knowledge in

an area of interest.

§ The regular ‘grand rounds’ and other teaching sessions give an insight into rarer

conditions which might otherwise pass trainees by.

§ Teaching hospitals also provide an excellent opportunity to ‘sample’ a specialty, which is

important in career choice." Another key attraction of teaching hospitals is the opportunity

to be involved in the many trials, audits, and research projects going on within the

departments (John Z. and Joel S. 2002).


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Chapter (2) Quality in health care

There are different definitions to the term "Quality of care". It is a kind of care which is expected

to maximize an inclusive measure of patient welfare, after one has taken account of the balance of

expected gains and losses that attend the process of care in all its parts (IOM, 1990). It is the

degree to which the treatment dispensed increases the patient’s chances of achieving the desired

results and diminishes the chances of undesirable results regard to the current state of knowledge

(WHO, 1998). It is the level of attainment of health systems’ intrinsic goals for health

improvement and responsiveness to legitimate expectations of the population (WHO, 2000). It is

the care that meets the expectations of patients and other customers of healthcare

services(Conway and Weingart, 2005).

Al-Assaf and Sheikh (2004) explained the different terms of Quality as: quality of care 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. Quality

assurance is the process of planning for quality, development of objectives and goals for quality,

setting standards, communicating standards to users, developing indicators, setting thresholds and

collecting data to monitor compliance with set standards. Quality improvement is reducing

variation of performance from standards in order to achieve a better outcome for the

organization's customers. Quality management is structural umbrella over all processes and

activities related to Quality assurance and Quality control. Quality Control is the ongoing effort to

maintain the integrity of a process to maintain the reliability of achieving an outcome.

Quality management has a specific meaning within many business sectors. This definition can

be considered to have four main components: quality planning, quality control, quality assurance and

quality improvement. Quality management is focused not only on product/service quality, but also the

means to achieve it. Quality management therefore uses quality assurance and control of processes as

well as products to achieve more consistent quality.


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Health expenditure in industrialized countries has doubled in the last 30 years; however, the

highest spending countries are not always those with the best results. One reason is the fragmentation

of their health care delivery systems. Taking a systems perspective, and orienting systems to the

delivery and improvement of quality, are fundamental to progress and to meeting the expectations of

both populations and health-care workers (Rose and Kenneth, 2005).

Achieving the Millennium Development Goals (MDGs) in low income countries require an

organized whole system perspective. However, many low income countries have substantial

difficulties in achieving the MDGs. The lack of sufficient financial investment, the fragmentation of

the delivery of health services, and poor quality are considered key obstacles to the successful

implementation of health programs. A reflection of this is shown in Pakistan, Sri Lanka, and the

United Republic of Tanzania studies as poor people bypass local services perceived as being low

quality, and instead going to the private sector in spite of geographically distant or even costs. This

practice may aggravate poverty (Leatherman and Sutherland, 2004).

Quality principles:

Principle 1: Customer focus

Since the organizations depend on their customers, therefore they should understand current and

future customer needs, meet their requirements and try to exceed customers' expectations. An

organization attains customer focus when all people in the organization know both the internal

and external customers' requirements try to be met with insurance of customers' satisfaction

(Rose and Kenneth, 2005).

Principle 2: Leadership

Leaders of an organization establish unity of purpose and direction of it. They should go for

creation and maintenance of such an internal environment, in which people can become fully

involved in achieving the organization's quality objectives.

Principle 3: Involvement of people: People at all levels of an organization are the essence of it.

Their complete involvement enables their abilities to be used for the benefit of the organization.


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Principle 4: Process approach the desired result can be achieved when activities and related

resources are managed in an organization as process.

Principle 5: System approach to management an organization's effectiveness and efficiency in

achieving its quality objectives are contributed by identifying, understanding and managing all

interrelated processes as a system.

Principle 6: Continual improvement one of the permanent quality objectives of an organization

should be the continual improvement of its overall performance.

Principle 7: Factual approaches to decision making effective decisions are always based on the

data analysis and information.

Principle 8: Mutually beneficial supplier relationships since an organization and its suppliers are

interdependent; therefore a mutually beneficial relationship between them increases the ability of

both to add value. These eight principles form the basis for the quality management system standard

ISO (9001:2008).

(Westcott and Russell, 2003)

Quality improvement There are many methods for quality improvement. These cover product improvement, process

improvement and people based improvement. Some of the common differentiators between success

and failure include commitment, knowledge and expertise to guide improvement, scope of change, and

adaptation to enterprise cultures. Enterprises therefore need to consider carefully which quality

improvement methods to adopt (WHO, 2000).

It is important not to underestimate the people factors, such as culture, in selecting a quality

improvement approach. Any improvement takes time to implement, gain acceptance and stabilize as

accepted practice. Improvement must allow pauses between implementing new changes so that the

change is stabilized and assessed as a real improvement, before the next improvement is made.

Improvements that change the culture take longer as they have to overcome greater resistance to


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change. It is easier and often more effective to work within the existing cultural boundaries and make

small improvements than to make major transformational changes. On the other hand,

transformational change works best when an enterprise faces a crisis and needs to make major changes

in order to survive. Well organized quality improvement programs take all these factors into account

when selecting the quality improvement methods (Thareja, 2008).

Dimensions of quality of care

• Effectiveness and Efficiency refers to which the intervention produces the intended effects

with minimum resources (WHO, 2000). The goal is to continually identify waste and

inefficiency in the provision of health care services and eliminate them (Starfield, 2002).

• Access and Appropriateness of health services: availability of health services and

treatment to the person needed and at the proper time. (Ann Bowling, 2002). Health care

needs to be organized to meet the needs of patients in a timely manner.

• Safety refers to the reduction of risk to the patient including problems in practice,

products, procedures, and systems. Patient safety has traditionally been considered as one

among many dimension of quality of care, but it is increasingly being seen as absolutely

key to quality overall (Kohn et al., 2000).

• Equity and Acceptability and Responsiveness to patients as fairness so that, in some

circumstances, individuals will receive more care than others according to their particular

needs.

• Patient-centered care (Satisfaction) recognizes that listening to the patient’s needs, values,

and preferences is essential to providing high-quality care. Health care services should be

personalized for each patient, care should be coordinated, family and friends on whom the

patient relies should be involved and care should provide physical comfort and emotional

support (Schoen et al., 2007).

• Efficacy and Assessment refers to the degree to which effective health care has been

implemented and achieved and results have been attained (Council of Europe, 2006). The

choice of dimensions to measure quality of care is critical as it will influence the health

care policies adopted. Thus, the key challenge for every country to recognize these diverse


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expectations and to reconcile them in a responsive and balanced health system (Shaw and

Kalo, 2002).

Levels of quality of care The quality is divided into four levels at which it can be assessed:

• The first level involved providers, patients and communities as well as the setting in which

health care takes place.

• The second level involves the amenities of care, focusing on the desirable attributes of the

settings in which care is provided.

• The third level refers to the actual implementation of care, responsibility for which is shared

between the provider and the patient.

• The final level refers to the care received by the community as a whole and considers issues of

social distribution of levels of quality. Thus, the definition of quality becomes either narrower or

more expansive, depending on how the concept of health and related responsibilities are being

defined. Good structure increases the likelihood of good process, and good process increases the

likelihood of good outcome” (Donabedian, 1988; Braithwaite and Dwan, 2005).

Quality assessment Service quality is viewed as the degree and direction of discrepancy between clients perceptions

and expectations”. Patients’ satisfaction is truly measured based on two factors, their expectations

of the service and their perceptions of the actual service they received (Tarantino, 2004). They

developed a model of service quality based on the magnitude and directions of five “gaps,” which

include client expectations-experiences discrepancies in addition to differences in service design,

communications, management, and delivery (Legido et al., 2008).

Evaluating the Quality of Health Care One of the challenges in understanding quality is how to measure, and how to improve it. The

influence of physical, socioeconomic, work environments, income, race, and gender affect health.

They found that differences in internal factors, such as collaborative relationships with physicians,


20

decentralized clinical decision-making, and positive administrative support, impact nurse and

patient outcomes and the quality and safety of care (Rosenstein et al., 2002).

Differences in external factors, such as insurance and geographic location, can influence

access to available health care professionals and resources, what type of care is afforded patients

and the impact of care on patients. The structure, process, and outcome dimensions of quality are

influenced by both internal and external factors (Clarke et al., 2002).

Evaluation of the process of care can be done by applying the six goals for health care

quality. Was the patient’s safety protected? Was care timely and not delayed or denied? Were the

diagnosis and treatments provided consistent with scientific evidence and best professional

practice? Was the care patient centered? Were services provided efficiently? Was the care

provided equitable? Answers to these questions can help us understand if the process of care

needs improvement and where quality improvement efforts should be directed (IOM, 2003).

Structure of Health Care The structure of health care broadly includes the facilities, personnel (e.g., number of nurses and

physicians) on-call resources, technology and support services (laboratory, pharmacy, radiology)

that create the capacity to provide health services. Also adequacy of the structural resources of

health care facilities is the foundation upon which quality health care services are provided. The

value of health care services lies in their capacity to improve health outcomes for individuals and

populations. Health outcomes are broadly conceptualized to include clinical measures of disease

progression, patient-reported health status or functional status, satisfaction with health status or

quality of life, satisfaction with services, and the costs of health services (Mark et al., 2003).

Benchmarks Definition: Benchmarking in health care is defined as the continual and collaborative discipline of measuring

and comparing the results of key work processes with those of the best performers in evaluating

organizational performance.


21

Types of Benchmarking: There are two types of benchmarking that can be used to evaluate patient safety and quality

performance:

• Internal benchmarking is used to identify best practices within an organization, to compare

best practices within the organization and to compare current practice over time. The

information and data can be plotted on a control chart with statistically derived upper and

lower control limits. However, using only internal benchmarking does not necessarily

represent the best practices elsewhere.

• Competitive or external benchmarking involves using comparative data between

organizations to judge performance and identify improvements that have proven to be

successful in other organizations. (National Healthcare Quality Report, 2006).

Efforts to improve quality need to be measured to demonstrate “whether improvement

efforts lead to change in the primary end point in the desired direction, contribute to

unintended results in different parts of the system and require additional efforts to bring a

process back into acceptable ranges (Varkey et al., 2007).

The rationale for measuring quality improvement is the belief that good performance

reflects good-quality practice and that comparing performance among providers and

organizations will encourage better performance (Schoen et al., 2006). Some providers have

been sensitive to comparative performance data (Marshall et al., 2000). And consumers have

had problems interpreting the data in reports and consequently not used the reports to the

extent hoped to make informed decisions for higher-quality care (Schneider and Lieberman,

2001).

The complexity of health care systems and delivery of services, the unpredictable nature

of health care and the occupational differentiation and interdependence among clinicians and

systems make measuring quality difficult (Ferlie et al., 2005). One of the challenges in using

measures in health care is the attribution variability associated with high-level cognitive

reasoning, discretionary decision-making, problem-solving and experiential knowledge

(Berwick, 2002). Another measurement challenge is whether a near miss could have resulted


22

in harm or whether an adverse event was a rare aberration or likely to recur. The Agency for

Healthcare Research and Quality (AHRQ), the National Quality Forum, the Joint Commission

and many other national organizations endorse the use of valid and reliable measures of

quality and patient safety to improve health care. Measures of quality and safety can track the

progress of quality improvement initiatives using external benchmarks (National Healthcare

Quality Report, 2006).

Quality Improvement Strategies A quality improvement strategy is defined as “any intervention aimed at reducing the quality gap

for a group of patients’ representative of those encountered in routine practice”. Quality

improvement is also defined “as systematic data-guided activities designed to bring about

immediate improvement in health care delivery in particular settings” (Shojania et al., 2004).

Quality improvement projects and strategies differ from research: while research attempts

to assess and address problems that will produce generalizable results, quality improvement

projects can include small samples, frequent changes in interventions, and adoption of new

strategies that appear to be effective (Varkey et al., 2007). There are criteria that distinguish the

two:

(1) Quality improvement applies research into practice, while research develops new

interventions; (2) risk to participants is not present in quality improvement, while research could

pose risk to participants; (3) the primary audience for quality improvement is the organization,

and the information from analyses may be applicable only to that organization, while research is

intended to be generalizable to all similar organizations; and (4) data from quality improvement is

organization-specific, while research data are derived from multiple organizations (Reinhardt and

Ray, 2003).

The TQM model is an organizational approach involving organizational management,

teamwork, defined processes, systems thinking, and change to create an environment for

improvement. This approach incorporated the view that the entire organization must be

committed to quality and improvement to achieve the best results. In health care, continuous

quality improvement (CQI) is used interchangeably with TQM. CQI has been used as a means to


23

develop clinical practice and is based on the principle that there is an opportunity for

improvement in every process and on every occasion. Hospital quality assurance (QA) programs

generally focus on issues identified by regulatory or accreditation organizations such as checking

documentation, reviewing the work of oversight committees and studying credentialing processes

(Wallin et al., 2003).

The lack of scientific health services literature has inhibited the acceptance of quality

improvement methods in health care. It has been asserted that a quality improvement project can

be considered more like research when it involves a change in practice affects patients and

assesses their outcomes, employs randomization or blinding and exposes patients to additional

risks or burdens, all in an effort towards generalizability (Lynn, 2004). Regardless of whether the

project is considered research, human subjects need to be protected by ensuring respect for

participants, securing informed consent, and ensuring scientific value (Harrington, 2007).

Methods of improvement:

1. Plan-Do-Study-Act (PDSA)

This is a method that has been widely used for rapid cycle improvement. One of the unique

features of this model is the cyclical nature of impacting and assessing change, most effectively

accomplished through small and frequent PDSAs rather than big and slow ones, before changes

are made system wide. The purpose of PDSA quality improvement efforts is to establish a

functional or causal relationship between changes in processes (specifically behaviors and

capabilities) and outcomes. The PDSA cycle starts with determining the nature and scope of the

problem, what changes can and should be made, a plan for a specific change, who should be

involved, what should be measured to understand the impact of change and where the strategy

will be targeted. Change is then implemented and data are collected. Results from implementation

study are assessed and interpreted by reviewing several key measurements that indicate success or

failure. Lastly, action is taken on the results by implementing the change or beginning the process

again (Berwick, 2003).


24

2. Six Sigma

Six Sigma, originally designed as a business strategy, involves improving, designing, and

monitoring process to minimize or eliminate waste while optimizing satisfaction and increasing

financial stability (Pande et al., 2000). The performance of a process is used to measure

improvement by comparing the baseline process capability with the process capability after

piloting potential solutions for quality improvement (Barry et al., 2003).

One component of Six Sigma uses a five-phased process that is structured, disciplined, and

rigorous, known as define, measure, analyze, improve, and control (DMAIC) approach. DMAIC

is pronounced "de-may-ick," is a tool for improving an existing process. The steps can be

summarized as follows:

• Define: State the problem, specify the customer set, identify the goals, and outline the

target process.

• Measure: Decide what parameters need to be quantified, work out the best way to

measure them, collect the necessary data, and carry out the measurements by experiment.

• Analyze: Identify gaps between actual and goal performance, determine causes of those

gaps, determine how process inputs affect outputs, and rank improvement opportunities.

• Improve: Devise potential solutions, identify solutions that are easiest to implement, test

hypothetical solutions, and implement actual improvements.

• Control: Generate a detailed solution monitoring plan, observe implemented

improvements for success, update plan records on a regular basis, and maintain a workable

employee training routine.

(Tushar and Shrivastava, 2008)

To begin, the project is identified, historical data are reviewed and the scope of

expectations is defined. Next, continuous total quality performance standards are selected,

performance objectives are defined and sources of variability are defined. As the new project is

implemented, data are collected to assess how well changes improved the process. To support this

analysis, validated measures are developed to determine the capability of the new process (Pande

and Newman, 2002).


25

3. Toyota Production System/Lean Production System

Application of the Toyota Production System used in the manufacturing process of Toyota cars

resulted in what has become known as the Lean Production System or Lean methodology

(Sahney, 2003). This methodology overlaps with the Six Sigma methodology, but differs in that

Lean is driven by the identification of customer needs and aims to improve processes by

removing activities that are non-value-added. This methodology depends on root-cause analysis to

investigate errors and then to improve quality and prevent similar errors (Endsley et al., 2006).

Printezis and Gopalakrishnan, (2007) reported that using Toyota Production System methods in

health care organizations improved patient safety and the quality of health care by systematically

defining the problem; using root-cause analysis; then setting goals, removing ambiguity and

workarounds and clarifying responsibilities. When it came to processes, team members in these

projects developed action plans that improved, simplified and redesigned work processes.

4. Root Cause Analysis

Root cause analysis (RCA) used extensively in engineering and similar to critical incident

technique is a formalized investigation and problem-solving approach focused on identifying and

understanding the underlying causes of an event as well as potential events that were intercepted

(Kemppainen, 2000). RCA is a technique used to identify trends and assess risk that can be used

whenever human error is suspected with the understanding that system, rather than individual

factors are likely the root cause of most problems (IOM, 2004).

The Joint Commission requires RCA to be performed in response to all sentinel events

and expects, based on the results of the RCA, the organization develop and implement an action

plan consisting of improvements designed to reduce future risk of events and to monitor the

effectiveness of those improvements. The final step of a traditional RCA is developing

recommendations for system and process improvement based on the findings of the investigation

(Joint Commisssion, 2003).

5. Failure Modes and Effects Analysis

Failure modes and effects analysis (FMEA) is an evaluation technique used to identify and

eliminate known and/or potential failures, problems and errors from a system, design, process

and/or service before they actually occur ( Spath and Hickey, 2003). FMEA used to proactively


26

identify steps in a process that could reduce or eliminate future failures. The goal of FMEA is to

prevent errors by attempting to identify all the ways a process could fail, estimate the probability

and consequences of each failure, and then take action to prevent the potential failures from

occurring. In health care, FMEA focuses on the system of care and uses a multidisciplinary team

to evaluate a process from a quality improvement perspective (Reiling et al., 2003).

6. Health Failure Mode and Effect Analysis (HFMEA)

The health failure modes and effects analysis (HFMEA) tool is used for risk assessment. There

are five steps in HFMEA:

(1) Define the topic.

(2) Assemble the team.

(3) Develop a process map for the topic, and consecutively number each step and sub step of that

process.

(4) Conduct a hazard analysis.

(5) Develop actions and desired outcomes. In conducting a hazard analysis, it is important to list

all possible and potential failure for each of the processes, to determine whether the failure modes

warrant further action and to list all causes for each failure mode when the decision is to proceed

further. Then it is important to consider the actions needed to be taken and outcome measures to

assess including describing what will be eliminated or controlled and who will have responsibility

for each new action (DeRosier et al., 2002).

7. 5 S

Is the name of a workplace organization method that uses a list of five Japanese words, they

all start with the letter "S“. These words are (Seiri, Seiton, Seiso, Seiketsu, Shitsuke).

The list describes how to organize a work space for efficiency and effectiveness by

identifying and storing the items used, maintaining the area and items, and sustaining the new

order. The decision-making process usually comes from a dialogue about standardization, which

builds understanding among employees of how they should do the work. 5 S is an organization-

wide participation program involving everyone in the place. It is recommended to start

implementing 5 S in a well-chosen pilot unit or pilot process, and spread to the others step by

step. It is within the reach of organizations of any size; small, medium, and large results are


27

visible to everyone; insiders and outsiders. Visible results will enhance the generation of more

and new ideas (Mike Bresko, 2013).

Factors for Successful 5 S

• Continued commitment and support by top management.

• 5 S starts with education and training of all workers.

• There are no observers in 5 S, everyone participates.

• Repeat the 5 S cycle in order to achieve a higher standard.

An organization that is implementing 5 S successfully is always: High in Productivity, consistent

in quality, cost-effective, accurate in delivery, safe for people to work in and High in Morale

(Mike Bresko, 2013).

The 5 S Principles

• Seiri : Organisation/Sort

• Seiton : Orderliness/Systemize

• Seiso : Cleaning/Shining

• Seiketsu: Standardize

• Shitsuke : Sustain/Discipline

(Paula and Pedene, 2012).


28

Chapter (3) Patient satisfaction Definitions: Patients' satisfaction with health care service is mainly dependent on the duration and efficiency

of care, degree of communication and empathetic with the health care providers. Also, informed

patients of the clinical procedures and the time it is expected to take are generally more satisfied

even if there is a longer waiting time (Pulia, 2011).

Satisfaction, like many other psychological concepts, is easy to understand but hard to

define. The concept of satisfaction overlaps with similar themes such as happiness, contentment,

and quality of life. A simple and practical definition of satisfaction would be the degree to which

desired goals have been achieved. Satisfaction comprises both cognitive and emotional facets and

relates to previous experiences, expectations and social networks (Keegan et al., 2003).

Customer satisfaction is an important measure of service quality in health care

organizations. From a management perspective. Gadallah et al.,( 2003) explained the importance

of patient satisfaction with health care in the following reasons:

1. Satisfied patients are more likely to maintain a consistent relationship with a specific provider.

2. An organization can address system weaknesses, thus improving its risk management by

identifying sources of patient dissatisfaction.

3. Satisfied patients are more likely to follow specific medical regimens and treatment plans.

Finally, patient satisfaction measurement adds important information on system performance,

thus contributing to the organization’s total quality management.

Factors influencing patient satisfaction

When including patient satisfaction mechanisms in health care systems; should take account of

the capacity of users to understand what is being asked of them and to communicate their

opinions and feelings effectively. Important factors influencing patients in this regard include

literacy levels, intellectual and physical/sensory disability levels and difficulties with language


29

proficiency or ethnic and cultural diversity. Social elements within our society must be considered

as they can often dictate whether the consumer will provide feedback and express their

satisfaction or otherwise, e.g., financial status, educational status, demographics, technology.

Satisfaction may be influenced by many factors that should be considered:

1. Patient expectation The meeting of patient expectations is assumed to play a role in the process by which an outcome

can be said to be satisfactory or unsatisfactory. Expectations are an important influence on the

patient’s overall measurement of satisfaction with a health care experience. Patient satisfaction is

influenced by the degree to which care fulfills expectation (Mahon, 1996). The link between

satisfaction and fulfillment of patient expectations is not necessarily the case, since it is possible

that the patient’s evaluation of a service may be largely independent of actual care received

(Williams, 1994).

Patients with inappropriately high expectations may be dissatisfied with optimal care, and

those with inappropriately low expectations may be satisfied with deficient care. Furthermore,

observed differences in satisfaction between people from different social classes, age, sex and

cultural group or between different services and types of care may be confounded by match or

mismatch between expectation and the service received (McKinley and Roberts, 2001).

2. Age Older respondents generally record higher satisfaction; possible explanations include lower

expectations of health care and reluctance to articulate their dissatisfaction (Pope and Mays,

1993; Williams and Calnan, 1991; Owens and Batchelor, 1996).

3. Illness Every patient who comes for consultation has expectations based on his or her understanding of

their illness. Patients with better self-reported health status have rated their satisfaction with

access to care better than those with poor health (De Boer et al., 2010).


30

Several studies have found that people with chronic conditions are less satisfied with the quality

and access to health services than the other population. As frequent users of health services,

patients with chronic conditions have more opportunities to experience difficulties in access, such

as long waiting times, costs of care, fragmentation of care, and lack of continuity and coordination

of care (Bentur et al., 2004).

4. Prior experience of satisfaction

Satisfaction was linked to prior satisfaction with health care and granting patients’ desires (Crow

et al., 2003).

5. Patient/professional relationship There is consistent evidence across settings that the most important health service factor affecting

satisfaction is the patient/practitioner relationship, including information and technical

competence, doctor understanding of patient expectations, feelings, and social context of his

illness. When doctor's perceptions and patient's preferences are not concordant, it results in

dissatisfaction of patients and poor outcomes of consultation. It was also found that people who

are satisfied with their doctor have more positive attitudes about the health reforms and evaluate

the health system better (Põlluste et al., 2004).

6. Gender, ethnicity, and socio-economic status The cost of care has also been found to be a reason for dissatisfaction with access to care (kinci

and Sinay, 2003).

The last few decades have witnessed fast economic growth and revolution in information

technology worldwide has led to increased demands and new expectations of patients. Now

increasingly knowledgeable patients armed with the information from the media confront

physicians with the expectation of quality care of highest standards. On the other hand

technological innovations in medicine have shifted doctor's attention away from the personal care

of the patients. The sense of the growing gap between what patients wants and what practitioners


31

perceive as important has resulted in increased dissatisfaction of patients with the health care

system (Meehanic, 2003).

Patient perspectives of quality Quality is the core of a healthcare organization's excellence. A focus on quality should be the

foundation of every interaction with every patient, and it is management's responsibility to ensure

that quality processes are followed throughout the organization. Excellence is determined by the

patients' perception that they received extraordinary service and quality. This is the factor that

makes the organization, in the mind of patients, unique and unparalleled among competing

facilities. Simply, this new definition of quality is based on how a patient experienced a service,

rather than whether the actual service was effective (Studer, 2003).

Patient evaluation of care is increasingly seen as a valuable outcome in itself besides

measures of clinical effectiveness. It may reveal quality problems and provide suggestions of not

only improving the quality of care but to improve clinical and functional outcomes (Peers, 2002).

The Difference between Quality and Patient Satisfaction The new definition of quality is really the existing meaning of "patient satisfaction",

Accreditation is tied to this definition. The Joint Commission and the National Committee for

Quality Assurance, require healthcare organizations to submit patient satisfaction data. This

requirement demonstrates that the overall satisfaction of customers has a role in determining the

value of providers. The primary focus of physicians and other providers, involves the clinical

quality, scientific measurement and comparison of specific healthcare data and outcomes.

Although it is an important aspect of the overall definition of quality, it is largely outside the

knowledge of patients because it uses language and methods that are too technical for regular

patients. As such, clinical quality is not viewed by patients as a critical contributor to their overall

experience of quality care. Patients care more about the overall experience of a healthcare visit

rather than any particular clinical element of the encounter (Hereford and LePore, 2001).

The patient's view of quality is influenced by everything that goes on in the hospital or

clinic at the time of the visit, including the interactions between patient and provider and the


32

surrounding sounds and sights; these all add to the patient's perception of quality care. As patient-

perceived overall quality, the healthcare providers can predict whether patients will return to the

organization, will recommend the facility to others, and perhaps even will sue regarding a legal

issue. If patients deem that they are being genuinely cared for and if they trust their healthcare

providers, they are more inclined to follow or comply with recommended treatment plans. Those

patients have a "greater tolerance for uncomfortable or frightening procedures (Press, 2006).

Specific preferences about healthcare and quality naturally differ for each patient and each

organization. However, information and data about patient satisfaction are well known to

healthcare managers. Patient's definition of quality consists of nine elements: good patient care,

responsiveness, good doctors, good reputation, up-to-date equipment, cleanliness, adequate food,

limited noise, and prompt and accurate billing. (Allison, 2008) explained the first four elements:

1. Good patient care includes proper nursing care, effective communication, clear and easy-to-

understand explanations, and a compassionate and caring nursing staff.

2. Responsiveness is the ability of nurses to respond "right away" when the call button is

activated.

3. Good doctor relates to the patient's opinion of his or her doctor. If the patient thinks the doctor

is excellent, he or she is likely to think highly of the hospital as well.

4. Good reputation is based on the word-of-mouth observations by friends and family.

Twelve of the top 15 drivers of patient satisfaction are not clinical factors. Instead, they

relate to courtesy and empathy of staff and providers, including compassion, caring, helpfulness,

kindness, and ability to comfort. These are the factors driving up their satisfaction with the

healthcare experience. Ultimately, this satisfaction feeds into improved clinical quality. If patients

get a smile and squeeze of the hand during a difficult procedure rather than brash treatment, they

are most likely to classify their experience as high quality. This is also the case if a nurse calls to

check in on the patient two days after a procedure. Of course, clinical excellence also contributes

to total patient satisfaction, but delivering the intangible factors well can make up for

complications in technical care that are sometimes unavoidable (Allison, 2008).


33

Chapter (4): Employee Satisfaction

Employees in service-based industries strongly influence customer satisfaction. As the

U.S. and other advanced economies continue to shift from manufacturing to information and

service based industries, employees take on an increasing role in driving organizational

performance. One of the most important ways that employees affect performance is in their

interactions with customers. Accordingly, it is vital that companies understand concepts such as

employee engagement and satisfaction and how the levels of engagement and satisfaction relate to

customer satisfaction and overall customer experiences (Newman et al., 2001).

The role of employees in quality care:

A healthcare manager's job is to ensure that patients receive an experience that makes

them want to return to the facility to continue treatment or to set up an appointment for another

service. Managers have a great level of control over this area and can deliver on the patient's

expectation of quality by focusing first on their employees. Without satisfied and confident

employees, quality practices have no hope of being successful as satisfied employees do a better

job. Employees want only three things: to believe that the organization has the right purpose, to

know that their job is worthwhile, and to make a difference in other's lives (Studer, 2003).

The irony is that the person who greets you in any company probably is going to be one

of the lowest-paid individuals on staff, yet what they do and how they say it can make all the

difference in the world to the success of any business. According to (Lauer, 2002) healthcare

customers are the same as any other business consumers, so they should be greeted with a "quality

customer service attitude." Simply, healthcare customers desire to be treated with dignity, respect,

and care. However, patients are often treated abruptly, which detracts from their overall

experience of care or their perceived experience of quality.

Every staff member feels personally and passionately responsible for recommending and

implementing quality improvement measures. Satisfied employees are an excellent representation


34

of the organization and provide stellar service to all customers, which add to the total experience

and are in turn perceived as high quality by patients (Selberg, 2007).

Employee Engagement Definitions:

A heightened emotional connection that an employee feels for his or her organization, that

influences him or her to exert greater discretionary effort to his or her work (Gibbons and

Woock, 2006). Another definition is a state of aroused, situation specific motivation that is

correlated with both attitudinal and behavioral outcomes (Thomas and Christopher,

2007). Dimensions of engagement: intellectual engagement: thinking hard about the job and

how to do it better, affective engagement: feeling positively about doing a good job and

Social engagement: actively taking opportunities to discuss work-related improvements

with others at work. (CIPD, 2008).

Effects of employee engagement on employee's satisfaction: A. Reduce the Job Stress & Turnover

There is a negative relationship between empowerment and job stress, suggesting that as

employees are more empowered; their job stress decreases (Joine et al., 2004). In addition to

stress, increased employee satisfaction helps reduce employee turnover, leaves of absence, and

lower work-related disability and violence claims (Harmon et al., 2003). There are several ways

in which the lack of engagement and high turnover rates impact health care organizations

(Morrison et al., 2007). Some of these factors include turnover costs, which range between 3.4%

and 5.8% of the operating budget (Waldman and Kelly, 2004). High turnover rates are also

thought to lead to higher discharge costs, so there are financial concerns to administrators beyond

just recruitment and retention costs (Jcaho, 2005).

When employees feel unsatisfied and unappreciated and leave the organization this puts

higher workloads and stress levels on those who remain and ultimately further drives down

satisfaction for both employees and patients. Feelings of support and sense of accomplishment at

work which may play an integral role in middle management retention and attracting nurses to


35

management positions. Conversely, this would suggest that organizations that do not foster

employee empowerment may experience problems retaining and attracting middle level managers

(Fukuyama, 1995; Patrick and Laschinger, 2006).

B. Active Role in Decision Making, Feelings of Support & Accomplishment

Organizations that promote employee empowerment can help nurses take a more active role in

daily care decisions, which is believed to enhance employee satisfaction (Berlowitz et al., 2003).

When employees are more active in decision making not only in nursing practice and unit

management but also patient care, they feel more engaged which leads to higher satisfaction and

lower turnover rates (Relf, 1995). Changes in the perception of employee empowerment appear to

have long-lasting positive effects on employee satisfaction. Changes in access to structural

empowerment impacted staff nurses’ feelings of psychological empowerment and satisfaction

with their jobs over a three-year time frame (Laschinger et al., 2004).

Nurses at magnet hospitals experience higher levels of empowerment and job satisfaction

due to greater access to work empowerment structures when compared with nurses from non-

magnet hospitals (Upenieks, 2003). Employees of nursing homes where Quality Improvement

(QI) practices were adopted exhibited significantly higher job satisfaction than others due to

empowerment to take a more active role in daily care decisions. In other words, by empowering

employees to make decisions, hospitals can increase employee engagement and in turn employee

satisfaction. The impact of empowering work conditions may play an even more important role at

the middle level of nurse management (Berlowitz et al., 2003).

C. Better Relationships with Management

The primary factor in employee’s satisfaction and loyalty to that employer is the employee’s

relationship with his or her immediate supervisor. This finding further demonstrates the need for

health care administrators to be concerned with employee satisfaction as hospitals face nursing

shortages (Wagner, 2006). It also is in line with findings that nurses indicated management that

is out of touch with the realities of patient care lead to lower nurse satisfaction and loyalty

(Curran, 2001).


36

The quality of relationships including communication between management and

employees not only impacts the employees themselves but also has an impact on organizational

effectiveness by affecting productivity and turnover rates. When management helps an employee

feel engaged and offers them the support and resources necessary to provide quality patient care,

employees are not only more satisfied with their employer but also remain more loyal (Brunetto

and Wharton, 2006).

While many studies show that engagement and empowerment in health care settings can

lead to greater job and organizational satisfaction, not everyone has found a connection between

the two (Suominen et al., 2006) determined that based on their study of a multidisciplinary team

at the Rheumatism Foundation Hospital in Finland, job satisfaction is not related to any of the

fields of empowerment. While this differs from previous studies, it does raise the question of

when and how does empowerment and engagement impact employee satisfaction.

The increased interest from health care administrators also stems from the belief that high

turnover rates and the lack of commitment negatively affect the provision of care and ultimately

the financial performance of organizations (Morrison et al., 2007). The important distinction

between job engagement and organizational engagement. (Saks, 2006) determined that perceived

organizational support predicts both job and organization engagement. Therefore, health care

organizations need to find ways to address these internal marketing issues at both the job and

organizational levels.

While employee engagement and recognition programs have always been important to

administrators, it is only recently that these practices have seen an increased level of interest in

health care because the employee’s role in patient care is more evident when considering the

scarce resources of hospitals and the overall shortage of nurses (Freed, 1999).

Management and organizational culture, along with empowering employees appear to be

three of the biggest factors in employee engagement levels. The span of control had some effect

on employee engagement and that adding management positions to reduce the span of control

helped increase employee engagement scores (Cathcart, 2004).


37

There are many factors that influence employee engagement as workplace culture, organizational

communication and managerial styles, trust and respect, leadership, and company reputation

(Lockwood, 2007). Specifically, high involvement work practices may enhance the financial

performance of health care organizations (Huselid, 1995; Harmon et al., 2003).

Elements that appear to account for differences in empowerment and job satisfaction

scores include: (1) greater accessibility of leaders, (2) better support of clinical autonomous

decision making by leaders, and (3) greater access to work empowerment structures such as

opportunity, information, and resources. These suggest that hospitals that have highly accessible

leaders, provide support for autonomous decision making, and provide access to empowerment

structures have a greater likelihood of increasing employee satisfaction (Upenieks, 2003).

Health care organizations that routinely achieve high employee satisfaction scores tend to

have the following in common (1) accessible leadership, (2) frequent communication, and (3)

employees are empowered to satisfy patients (Fassel, 2003).

Internal marketing efforts have been shown to develop better relationships between

employees and their organizations while increasing satisfaction and retention. It was determined

that structural bonds followed by social and financial bonds have the most impact on nurse

loyalty. (Peltier et al., 2003).

A study of nurses and midwives in London hospitals determined that the three main

factors influencing their job satisfaction were patients, the inherent characteristics of nursing, and

the nursing team. It was found that improving working conditions was more important than

increased pay. It was found that improving working conditions was more important than increased

pay. This seems to be in line with (Peltier et al., 2003) findings that structural and social bonds

were more important than financial bonds from an internal marketing perspective. While pay for

performance activities may lead to increased satisfaction and higher quality of care, these types of

reward systems tend to be short-lived in comparison to other recognition or engagement programs

(Newman et al., 2002).


38

By allowing employees to provide higher quality care to patients, the employees tend to

take greater pride in their job and feel good about the organization and its values. Also notes the

importance of sustaining engagement, something that will help have a long-lasting impact on

employee satisfaction and the delivery of high quality care (Freed, 1999).

The concept of internal marketing in the health care sector suggests that the best way to

satisfy patients is by viewing employees as internal customers and that by understanding and

meeting employees’ needs, wants, expectations, and concerns their level of satisfaction will

increase thereby leading to better quality of care and higher patient satisfaction (O’Neill, 2005). A

relationship marketing approach to HR practices is one way health care organizations can

overcome the global problem of nursing shortages. By focusing on improving the quality of care,

health care organizations can not only improve patient satisfaction, but also improve employee

satisfaction and loyalty to the organization. This in turn will further impact the quality of care

because of the interrelationship of this chain (Peltier et al., 2003; 2004; 2007).

Effects of Employee Satisfaction on Patient Care and Patient Satisfaction There's a clear interrelationship between employee satisfaction, the quality of care, and patient

satisfaction. Employee dissatisfaction negatively impacts the quality of care and ultimately has an

adverse effect on patient loyalty and in turn hospital profitability (Newman et al., 2001). Quality

improvement initiatives were shown to have a positive correlation with employee satisfaction as

well as client satisfaction (Kammerlind et al., 2004). Health care employee morale also

demonstrates a strong correlation with patient satisfaction scores, showing that the lack of

commitment and engagement have far-reaching impacts on more than just employee turnover

(Jcaho, 2005).

Employees’ satisfaction with their organization is a better predictor of client satisfaction

than employees’ job satisfaction. The volatile relationship between employee and client

satisfaction which can be in conflict. While employees are more satisfied when they have regular

work schedules this decreases client satisfaction as employees are deemed less available to

patients. This shows that employee and patient satisfaction are related, but sometimes at conflict

with each other (Ott and van Dijk, 2005).


39

Employee satisfaction also appears to have a strong relationship with the quality of care

delivered and related costs. When employees are more satisfied it helps reduce stress, turnover,

leaves of absence, and lower work-related disability and violence claims (Harmon et al., 2003;

Joiner and Bartram, 2004). All of these factors help increase the level of care given to patients.

Nurses who are satisfied with their jobs exhibit higher levels of patient safety and less medication

errors which help increase patient satisfaction (Rathert and May, 2007).

Satisfied employees also were found to lead to shortened lengths of stay for patients and

lower variable costs (Karasek, 1990; Harmon et al., 2003). The reductions in recruitment and

retention costs and fewer employees missing work combined with lower patient variable costs and

mistakes make improving employee satisfaction more appealing.

A relationship marketing approach to HR practices is one way health care organizations

can overcome the global problem of nursing shortages. By focusing on improving the quality of

care, health care organizations can not only improve patient satisfaction, but also improve

employee satisfaction and loyalty to the organization. This in turn will further impact the quality

of care because of the interrelationship of this chain (Peltier et al., 2003; 2004; 2007).

Quality leadership in health care organizations helps foster an environment that provides

quality care which is linked with patient satisfaction. Organizations who seek to improve patient

satisfaction and encourage return visits or customer loyalty should focus on improving the quality

of care. quality leadership that provides empowering work environments are more likely to result

in engaged employees and tend to be the most successful at increasing the quality of care

provided. This again gets at the point that management plays an integral role in the level of care

provided even when they are not directly involved(Al-Mailam, 2005).

Front-line staff--including nurses, laboratory technicians, and receptionists is extremely

important contributors to quality. Receptionists have the first and last "touch" in many healthcare

organizations, and as such they give the first and last impressions of the hospital or clinic, which

are critical for any visitor (Studer, 2003).


40

There's a chain of connectivity such that internal conditions and environment affect → the

service capability of staff which influences → nurse satisfaction which, in turn, affects →

retention of nurses. All of those factors can reduce → quality of patient care and ultimately → the

level of patient satisfaction. Organizations that desire to improve patient satisfaction must

therefore be concerned about internal issues related to employee satisfaction and view their

employees as customers too. A connection appears to exist between how engaged an employee is

with the employee’s role in the patient care process and the level of patient satisfaction. This

interrelationship affects not only satisfaction levels but also patient loyalty and financial

performance (Newman et al., 2001).


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Chapter (5): Communication in Health Care

A doctor's communication and interpersonal skills encompass the ability to gather

information in order to facilitate accurate diagnosis, counsel appropriately, give therapeutic

instructions, and establish caring relationships with patients. These are the core clinical skills in

the practice of medicine, with the ultimate goal of achieving the best outcome and patient

satisfaction, which are essential for the effective delivery of health care (Fong, 2010).

Doctors are often hurried and unable to adequately listen to all their patients concerns.

Nurses are a vital aspect in providing patient communication in the hospital. Patients heal better

and feel safer when they have a nurse that they feel is an advocate for them and their health. It is

the job of the nurse is to relay the vital information to the doctor. Among the many other duties a

nurse performs in the hospital, listening to what their patients have to say about how they are

feeling and what they need is one of the most important aspects of being a good nurse. Another

reason that patient communication is so vital is because health care providers are human and

accidents happen sometime (Puspoky et al., 2006).

As important to the hospital community as doctors are, nurses are the communication glue

that holds everything together and ensures the safe recovery of the patients (Mineko et al., 2006).

Categories of Communication: • Content skills: what health care provider says e.g., the substance of the questions he asks and

the answers he receives, the information he gives, the differential diagnosis list, the medical

knowledge base he works from.

• Process skills: how health care provider says it, e.g., how he asks questions, how well he

listens, how he sets up explanation and planning with the patient, how he structures his interaction

and make that structure visible to the patient through signposting or transitions, how he build

relationships with patients.


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• Perceptual skills: what health care provider is thinking and feeling, e.g., awareness of his own

decision making and other thought processes, awareness of and response to his own attitudes and

emotions during an interview, whether he likes or dislikes the patient, his biases and prejudices,

noise or discomfort that distracts him from attending to the patient Content and process skills are

more interpersonal in nature, while perceptual skills are more intra-personal.

The three types of skills are linked and each influences the other. Communication process

skills were given the least attention in medical education. Currently process skills tend to be the

primary focus of communication skills programs while content and perceptual skills receive

significant secondary emphasis (Kurtz, 2002).

Teamwork and communication failures are a leading cause of patient incidents. Though

many healthcare providers must work in teams, they are not well trained in teamwork and

communication skills; also they come from different backgrounds, making it difficult to establish

a shared mental model in a team setting. Moreover, healthcare workers may not be supported by

the organisational culture in which they work. Team collaboration is essential. When health care

professionals are not communicating effectively, patient safety is at risk for several reasons: lack

of critical information, misinterpretation of information, unclear orders over the telephone, and

overlooked changes in status (Joint Commission, 2005).

Lack of communication creates situations where medical errors have the potential to cause

severe injury or unexpected patient death. According to the Joint Commission on Accreditation of

Healthcare Organizations, (JCHAO), if medical errors appeared on the National Center for Health

Statistic’s list of the top 10 causes of death in the United States, they would rank number (5)

ahead of accidents, diabetes, and Alzheimer’s disease, as well as AIDS, breast cancer, and

gunshot wounds. More specifically, the Joint Commission cites communication failures as the

leading root cause for medication errors, delays in treatment, and wrong-site surgeries, as well as

the second most frequently cited root cause for operative and postoperative events and fatal falls

(Joint Commission, 2005).


43

Traditional medical education emphasizes the importance of error-free practice, utilizing

intense peer pressure to achieve perfection during both diagnosis and treatment. Errors are

therefore perceived normatively as an expression of failure. This atmosphere creates an

environment that precludes the fair, open discussion of mistakes required if organizational

learning is to take place (Flin et al., 2003).

Common Barriers to inter-professional Communication:

Personal values and expectations, Personality differences, Hierarchy, Disruptive behavior, Culture

and ethnicity, Generational differences, Gender, Historical inter professional and intra

professional rivalries, Differences in language and jargon, Differences in schedules and

professional routines, Varying levels of preparation, qualifications, Differences in requirements,

regulations, and norms of professional education, Fears of diluted professional identity,

Differences in accountability, payment, and rewards, Concerns regarding clinical responsibility,

Complexity of care and Emphasis on rapid decision making (Hughes and Rockville, 2008).

The barriers within disciplines, most notably between physicians and residents, surgeons

and anesthesiologists, and nurses and nurse managers (Gaba et al., 2001). However, most often

the barriers manifest between nurses and physicians. Even though doctors and nurses interact

numerous times a day, they often have different perceptions of their roles and responsibilities as

to patient needs, and thus different goals for patient care. One barrier compounding this issue is

that cultural differences can exacerbate communication problems. In cultures such as these, nurses

may communicate their concern in very indirect ways. Culture barriers can also hinder nonverbal

communication. For example, some cultures ascribe specific meaning to eye contact, certain

facial expressions, touch, tone of voice, and nods of the head (Joint Commission, 2005).

The common barrier to effective communication and collaboration is hierarchies.

Communication failures in the medical setting arise from vertical hierarchical differences,

concerns with upward influence, role conflict, and ambiguity and struggles with interpersonal

power and conflict. Communication is likely to be distorted or withheld in situations where there

are hierarchical differences between two communicators, particularly when one person is


44

concerned about appearing incompetent, does not want to offend the other, or perceives that the

other is not open to communication (Weick, 2002). Staff who witness poor performance in their

peers may be hesitant to speak up because of fear of retaliation or the impression that speaking up

will not do any good (Rosenstein et al., 2002).

Leaders in both medicine and nursing have issued ongoing initiatives for the development

of a cooperative rather than a competitive agenda to benefit patient care. A powerful incentive for

greater teamwork among professionals is created by directing attention to the areas where changes

are likely to result in measurable improvements for the patients they serve together, rather than

concentrating on what, on the surface, seem to be irreconcilable professional differences. The fact

that most health professionals have at least one characteristic in common, a personal desire to

learn, and that they have at least one shared value, to meet the needs of their patients or clients, is

a good place to start (Rosenstein and O’Daniel, 2005).

Hughes and Rockville, (2008) enumerate the components of successful teamwork as:

• Open communication

• Non punitive environment

• Clear direction and known roles and tasks for team members

• Respectful atmosphere

• Shared responsibility for team success

• Appropriate balance of member participation for the task at hand

• Acknowledgment and processing of conflict

• Clear specifications regarding authority and accountability

• Clear and known decision-making procedures

• Regular and routine communication and information sharing

• Enabling environment, including access to needed resources

• Mechanism to evaluate outcomes and adjust accordingly

Unfortunately, many health care workers are used to poor communication and teamwork,

as a result of a culture of low expectations that has developed in many health care settings. This

culture, in which health care workers have come to expect faulty and incomplete exchange of


45

information, leads to errors because even conscientious professionals tend to ignore potential red

flags and clinical discrepancies. They view these warning signals as indicators of routine

repetitions of poor communication rather than unusual, worrisome indicators (Chassin and

Becher, 2002).

Although poor communication can lead to tragic consequences, effective communication

can lead to the following positive outcomes: improved information flow, more effective

interventions, improved safety, enhanced employee morale, increased patient and family

satisfaction, and decreased lengths of stay (Joint Commission, 2005). Gittell et al., (2000)

showed that implementing systems to facilitate team communication can substantially improve

quality. Effective communication among staff encourages effective teamwork and promotes

continuity and clarity within the patient care team. Good communication encourages

collaboration, fosters teamwork, and helps prevent errors. (Cleary, 2003).

Team performance Teamwork can be conceptually nested within team performance as a “set of interrelated

cognitions, attitudes, and behaviours contributing to the dynamic processes of performance”.

Team effectiveness represents an evaluation of team performance outcomes relative to some

criteria set (Legido et al., 2008). Thus, the definitions of performance and effectiveness on the

team level encompass the activities engaged in while completing a task and an appraisal of the

outcomes of that activity (Rooney and Vanden, 2004).

The Salas conceptual framework identifies five core components for effective teamwork:

team leadership, collective orientation, mutual performance, backup behaviour and adaptability.

The interplay among the five components suggest that, 1) leadership directly affects collective

orientation, performance monitoring and backup behaviour; 2) collective orientation and back up

behaviour influence performance monitoring; 3) performance monitoring and backup behaviour

generate adaptability (Lynn, 2004). These relationships are promoted through three coordinating

mechanisms, shared mental models, closed loop communication and mutual trust (Benner et al.,

2002; Berwick, 2003; Harrington, 2007).


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Table (A): Mickan (2005) showed the Outcome measures of effective teamwork

Individual benefits Organizational benefits

Team benefits Patients Team members

Reduced hospitalisation time and costs Reduced unanticipated admissions Better accessibility for Patients

Improved coordination of care Efficient use of health care services Enhanced communication Professional diversity

Enhanced satisfaction Acceptance of treatment Improved health outcomes

Enhanced job satisfaction Greater role clarity Enhanced well-being

Structured communication techniques Communication between individuals is often “informal, disorganised and variable” However, in

situations where specific and complex information must be communicated and responded to in a

timely manner, combined with the dire consequences of omitting critical information, it is

essential to add structure to the exchange. Such structure can ensure that the right information is

shared at the right time with the right people. Some specific structured communication techniques

that patient care teams can use include: briefings, debriefings, SBAR, assertive language, critical

language, common language, closed communication loops, active listening and callouts (Makary

et al., 2005).

Briefings

Briefings are a critical element in team effectiveness and determine whether people work together

as a cohesive team or as a group of individuals in proximity to one another. Briefings set the tone

for team interaction, ensuring that care providers have a shared mental model of what is going to

happen during a process, identify any risk points and plan for contingencies. When done

effectively, briefings can establish predictability, reduce interruptions prevent delays and build

social relationships and capital for future interactions (Makary et al., 2005).


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Debriefings

Debriefings are concise exchanges that occur after events have been completed to identify what

happened, what was learned, and what can be done better next time. It allows the team to

determine how members are feeling about processes and recognises opportunities for

improvement and further education (Frankel and Leonard, 2008).

SBAR SBAR is an acronym for Situation, Background, Assessment, and Recommendation. The

communication process involving SBAR is as follows; the Situation is conveyed by the initiating

individual and establishes the topic of discussion; the Background involves any information

needed to make an informed decision for the patient; in Assessment, report the patient’s situation

and status; finally, the Recommendation (Guise and Lowe, 2006).

Assertive language Because medicine has an inherent hierarchal structure with power distances between individuals,

it is important that, health care providers politely assert themselves to support patient safety.

Effective assertion is pleasant, persistent, timely and clear in offering solutions to presenting

problems (Frankel and Leonard, 2008).

Critical language Sometimes, using assertive language may not be strong enough to signal a problem. Critical

language may include a phrase such as, “I need a little clarity” as a strategy to garner another’s

attention. Teams that respond to agreed upon critical language recognize the immediacy of a

concern and direct their attention to resolving the situation. (Adachi and Lodolce, 2005).

Common language

Using a common language, which is agreed upon by all providers in a particular setting to

describe critical issues or observations, may be helpful to ensure consistency and

comprehensiveness in communication (Frankel and Leonard, 2008).


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Chapter (6): Doctor-Patient Relationship

Quality of doctor–patient communication is a multidimensional concept which includes

both medical technical and psychosocial aspects but also involves facets of the interaction. The

quality of the doctor–patient interaction also determines patients' active participation and

encourages self-management skills that are necessary when dealing with chronic diseases (Cooper

et al., 2009). Moreover, fostering the doctor–patient relationship is considered an essential and

universal value within medical practice (Epstein and Street, 2007).

The doctor-patient relationship is central to the practice of healthcare and is essential for

the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor-

patient relationship forms one of the foundations of contemporary medical ethics. Most

universities teach students from the beginning, how to maintain a professional rapport with

patients, uphold patients’ dignity, and respect their privacy. The quality of the relationship is

important to both parties. The better the relationship in terms of mutual respect, knowledge, trust,

shared values and perspectives about disease and life, and time available, the better will be the

amount and quality of information about the patient's disease transferred in both directions,

enhancing accuracy of diagnosis and increasing the patient's knowledge about the disease (Pulia,

2011).

Factors affecting the doctor-patient relationship: The following issues negatively affect the doctor-patient relationship:

• Physician superiority:

The physician may be viewed as superior to the patient, because the physician has the knowledge

and credentials. The physician-patient relationship is complicated by the patient's suffering and

limited ability to relieve it on his/her own, resulting in a state of desperation and dependency on

the physician. A physician should be aware in order to optimize communication with the patient.

It may be beneficial for the doctor-patient relationship to have a form of shared care with patient

empowerment to take a major degree of responsibility for her or his care (Bensing and Verhaak,

2006).


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• Benefiting or pleasing

A dilemma may arise in situations creates a disagreement between the physician and the patient,

for any number of reasons. In such cases, the physician needs strategies for presenting

unfavorable treatment options or unwelcome information in such a way that minimizes strain on

the doctor-patient relationship while benefiting the patient's overall physical health and best

interests (Quilliam, 2011).

• Formal or casual

There may be differences in opinion between the doctor and the patient in how formal or casual

the doctor-patient relationship should be. Some familiarity with the doctor generally makes it

easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a

very high degree of familiarity may make the patient reluctant to reveal such intimate issues

(Quilliam, 2011).

• Transitional care

Transitions of patients between health care practitioners may decrease the quality of care in the

time it takes to reestablish proper doctor-patient relationships. Generally, the doctor-patient

relationship is facilitated by continuity of care in regard to attending personnel. (Gröne and

Barbero, 2002).

• Presence of other people

These may provide psychological support for the patient, but in some cases it may compromise

the doctor-patient confidentiality and inhibit the patient from disclosing uncomfortable or intimate

subjects (Kawabata et al. 2009).

• Bedside manner

A good bedside manner is typically one that reassures and comforts the patient while remaining

honest about a diagnosis. Vocal tones, body language, openness, presence, and concealment of

attitude may all affect bedside manner. Poor bedside manner leaves the patient feeling unsatisfied,

worried, frightened, or alone. Bedside manner becomes difficult when a healthcare professional


50

must explain an unfavorable diagnosis to the patient, while keeping the patient from being

alarmed (Pulia, 2011).

Nurse Patient Relationship Importance of nurse patient relationship:

Nurses spend more time with patients than doctors. Patients see nurses’ interactions with others

on the care team and draw conclusions about the hospital based on their observations. Nurses’

attitudes toward their work, their coworkers and the organization affect patient and family

judgments of all the things they don’t see behind the scenes . he work environment in which

nurses provide care to patients can determine the quality and safety of patient care. Nurses apply

their knowledge, skills, and experience to care for the various and changing needs of patients. A

large part of the demands of patient care is centered on the work of nurses (IOM, 2004).

A positive nurse patient relationship, make an environment that supports anxiety reduction

and healing. Patients and families count on nurses to keep them informed, to connect them to their

physicians, to listen to them, to ease their anxiety, and to protect and watch over them during their

healthcare experience. Service improvement strategies in health care have emphasized cosmetic

aspects of the service relationships. Nurses are keenly aware of working with people who are

emotionally drained and emotionally charged, and facing traumatic life circumstances. Making

them happy hardly seems like a relevant goal, and nurses perceive it as superficial and

discounting of the important work they do. Resistance to raised service standards is also

understandable when nurses perceive leaders as doing too little to remove obstacles to provide

excellent care and service (Kurki et al., 2001)


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Chapter (7): Patient rights &responsibilities

Patients' Rights The Royal College of Surgeons of England (2005) reported the patients' rights as follow:

The Right to

• Be Treated with Respect.

• Make a Treatment Choice.

• Refuse Treatment.

• Obtain Your Medical Records.

• Privacy of Your Medical Records.

• Informed Consent.

• Make Decisions About End-of-Life Care.

• Be treated with courtesy and with respect for his privacy and dignity.

• Receive treatment on the basis of his clinical need.

• Be able to choose to have a relative or friend with him during consultations and

• Staff to understand that he might be feeling anxious and vulnerable and that this may affect

the way he behaves.

• Be told approximately when an appointment is likely to be.

• Be encouraged to ask questions about his diagnosis and treatment and to receive clear

information in writing.

• Be given a telephone number and the name of someone he can ring.

• Know the names and professional status of all the staff involved in his care.

• Be operated on by an appropriately trained and experienced surgeon or one under the close

supervision of a suitably experienced surgeon.

• Be told what aftercare including rehabilitation and how long this Should last and the

anticipated outcome

• Receive an explanation and where appropriate an apology if things go wrong.


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The entitlement of patients' rights is accompanied by patients' responsibilities, too. In order to

get the best care and find our most successful medical outcomes, we must adhere to these

responsibilities.

Patients' Responsibilities The Royal College of Surgeons of England (2005) reported the Patients' Responsibilities as

follow:

Responsible for

• Maintaining healthy habits

• Being respectful and honest to providers

• Complying with treatment plans

• Preparing for Emergencies

• Making Decisions Responsibly

• Understanding prescription drugs and their possible effects

• Meeting financial obligations

• Reporting fraud and wrong doing

• Avoiding putting others at risk

• To inform the hospital at once of any change in contact address or telephone number.

• To attend appointments on time, or give reasonable notice of inability to attend.

• To understand that there are pressures and limitations of resources on the health service and

those working within it.

• To consider the consequences of refusing treatment or not following medical advice and

accept responsibility for his own actions.

• To let the staff know if he have any allergies or sensitivities to medications.

• To give staff full information about his condition including permanent disabilities along

with details of any medicines he is taking.

• To treat other patients with courtesy and respect.

• To attend follow up appointments as requested.

• Wise patients understand all three: their rights, their responsibilities. Understanding them

will make it easier to get the care and outcomes they seek.


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Patient empowerment Concepts and Definitions:

The patient empowerment concept, a recent outgrowth of the natural health movement, asserts

that to be truly healthy, people must bring changes in their social situations and in the

environment that influences their lives, not only in their personal behavior (Moynihan and Smith,

2002). Empowerment has been broadly defined as an enabling process through which individuals

or communities take control of their lives and their environment.

Patient empowerment in the health care context means to promote autonomous self-

regulation so that the individual's potential for health and wellness is maximized. Patient

empowerment begins with information and education seeking about illness or condition, and

actively participating in treatment decisions (Berger and Kavookjian, 2002).

Patient involvement is understood as the extent to which patients participate in decisions

related to their condition through informed consent, therapy plan or self-management and

contribute to organizational learning through their expert knowledge acquired during illness and

hospitalization (IOM, 2001). Empowerment is a process of helping people to assert control over

factors that affect their health. The concept of empowerment can be described as a “social process

of recognizing, promoting, and enhancing people’s abilities to meet their own needs, solve their

own problems, and mobilize necessary resources to take control of their own lives”. There is a

strong link between the concept of empowerment and that of development of the community

(Moynihan and Smith, 2002).

There is a difference between individual and community empowerment. Individual

empowerment refers primarily to the individual's ability to make decisions and have control over

his or her personal life. Community empowerment involves individuals acting collectively to

gain greater influence and control over the determinants of health and the quality of life in their

community (WHO, 1998).


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Real definitions of patient empowerment are hard to find. "The term “patient

empowerment” describes a situation that citizens are encouraged to take an active part in their

own health management. Patient empowerment is considered as a philosophy of health care that

proceeds from the perspective that optimal outcomes of health care interventions are achieved

when patients become active participants in the health care process (Monteagudo and Moreno,

2007).

Patient empowerment has a handful of definitions. Most focus on the concept of the

patient taking an active role in his disease management and supporting that participation by

learning all he can about his disease or condition and treatment options. Until the past few years,

the thought that a patient would participate so fully was unheard of. Today, many patients realize

that this level of participation is vital to maintaining health in the face of medical problems or

challenges (Trisha, 2009).

Tools of patient empowerment 1. Disclosure: the patient should be informed of the nature of his condition, the various options,

potential risks, the professional’s recommendation, and the nature of consent as an act of

authorization.

2. Understanding: information is provided at the patient's level of understanding, using

appropriate language.

3. Voluntaries: the patient must be in a position to practice self-determination free from any

coercion, manipulation, or constraint.

4. Competence: based on the patient’s past experience, maturity, responsibility, and capacity for

independent decision making.

5. Consent: a freely given authorization to the medical or nursing intervention.

To enable patients to express their informed preferences, patients must be given sufficient and

appropriate information, including detailed explanations about their conditions and the likely

outcomes with and without treatment (Trisha, 2009).


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Limits for patient empowerment The patients express difficulties in obtaining information relevant to their needs due to the

following reasons:

(A) Barriers to the informations:

• Health care professionals might have underestimated a patient’s desire for and ability to cope

with information.

• Consultation times are limited and thus there is often insufficient time to fully explain the

condition and the treatment choices.

• The extent of the information to be given to the patient is difficult to decide.

• Too much information may deter the patient from having necessary treatment.

• The ways in which information is delivered and the kind of materials given to the patient are

of particular importance to support a patient’s involvement in treatment decisions.

• Many information materials adopt a patronizing tone and few actively promote a shared

approach to decision making. Information should therefore be made simple in order to

maximize its comprehension and to minimize any potential imposition of the professional’s

view.

• An interval should elapse between the presentation of the advantages and possible

disadvantages of the proposed treatment and the patient's decision, so that there is an

opportunity for the patient to consider the decision, to ask further questions, and to discuss it

with family and significant others.

(American Medical Association, 2011)

(B) Systemic Barriers: The structure of the medicolegal system can also serve as a barrier.

Achieving the desired outcome of consumer-driven health care requires health care providers

who are skilled in communication and who are able and willing to discuss the relative benefits

of given treatment options in light of a specific patient’s condition and values.

1. Systems and structures

• Some providers may also fear participating with their patients in shared

decision making, believing that patients who experience an adverse outcome of


56

their decision may sue. Indeed, a patient sued successfully in just such a

scenario (Alex et al., 2007).

• Fear of malpractice suits is an additional incentive for providers to order

unnecessary care. Although it is difficult to identify exactly what percentage of

health care costs could be eliminated by tort reform, one study estimated

savings of 5 percent to 9 percent (Paul Ginsburg, 2008).

2. Attitudes and Skills of Medical Professionals Clinician attitudes and training can

affect patients’ ability to participate effectively in decisions about their health care

(Ellen Fox, 2011).

Elements of empowerment Are knowledge, behavioral skills and self-responsibility. To ensure the success of patient

empowerment, enhancement of the working partnership between patients and health care

professionals is important. Finding out what matters to patients, making use of information

technology to disseminate knowledge, establishing standards for disease management, and

promotion of clinical research are likely to increase the benefit of the health care provided. Trisha

(2009) has noted the elements as follow:

• Taking responsibility: Realizing that the one knows his body better than anyone else, he

will refer to all the resources at his disposal from people to the printed word and you will

use that knowledge to help make decisions about the treatment that are the decisions to

make.

• Setting goals: Understanding that the human body does not always react the way we

expect it to; therefore, it's best to set a treatment goal and work toward that goal. In some

cases a patient can have a goal to heal, another may simply want to manage a disease or

condition, or another may need to learn to cope with a new medical problem.

• Collaboration with others: Active participation in the healthcare team, including

providers, support personnel, payors and even other patients helps in the decision-making

aspects of the diagnosis and treatment processes.


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• Gathering evidence: Including resources that range from observation to recording

symptoms and family histories to participating in medical tests, to discussions with

providers and other patients, to using the Internet and libraries for researching relevant

diseases, conditions and treatments.

• Being a smart healthcare consumer: Sometimes the challenges a patient faces are

related more to customer service and costs of service than they are to the health aspects of

care. Understanding health insurance choices or learning when to walk away from a

doctor's practice when necessary, are examples of these kinds of choices.

• Staying safe in the healthcare environment: We often read about major medical errors,

but millions of "smaller" mistakes take place every day. Administration of the wrong

drugs, acquiring infections in hospitals even surgeries gone bad. These are all examples of

the safety problems an empowered patient should be aware of.

• Understanding and support: the tenets of patient advocacy. In the bigger picture, the

patient can take advantage of those who have learned about his medical problems before

him and you can help patients who come after to find better medical outcomes. Advocacy

runs the gamut from government and not-for profit organizations to individual navigators

that help patients transition through the steps of their diagnosis and care.

• Adherence to decisions: Since you will have collaborated with knowledgeable members

of your healthcare team to arrive at decisions, you will feel confident following along with

the decisions you've made together.

To achieve patient engagement, policymakers must reduce or eliminate barriers to patient

decision making, including patient ignorance of and insulation from the true costs of care, the lack

of information on medical prices and options, and medical malpractice and inadequate skills

among doctors and nurses and other medical professionals in dealing with an engaged patient.

Policymakers need to make the health care sector far more transparent. They can do this by

promoting a free market for health insurance coverage in which prices and the content of

insurance are clear and transparent; creating an information-driven system of choice to enable

patients to better understand the range of available benefits and services; enacting medical

malpractice reform in the states where it is sorely needed; and encouraging better education of


58

medical professionals to prepare them to communicate more effectively and clearly with all

patients, including those facing a long illness or the end of life itself (Karen McKeown, 2011).

Patient Education

Definition: Is the process by which health professionals and others impart information to patients that will

alter their health behaviors or improve their health status. Education providers may include:

physicians, pharmacists, registered dietitians, nurses, hospital discharge planners, medical social

workers, psychologists, disease or disability advocacy groups, special interest groups, and

pharmaceutical companies. Health education is also a tool used by managed care plans, and may

include both general preventive education or health promotion and disease or condition specific

education (Koongstvedt, 2001).

The value of patient education: • Improved understanding of medical condition, diagnosis, disease, or disability.

• Improved understanding of methods and means to manage multiple aspects of medical

condition.

• Improved self advocacy in deciding to act both independently from medical providers and in

interdependence with them.

• Increased Compliance: Effective communication and patient education increases patient

motivation to comply.

• Patient Outcomes: Patients more likely to respond well to their treatment plan fewer

complications.

• Informed Consent: Patients feel that they have provided with the information they need.

• Utilization: More effective use of medical services and fewer unnecessary phone calls and

visits.

• Satisfaction and referrals: Patients more likely to stay with the physician practice and refer

other patients.

• Risk Management: Lower risk of malpractice when patients have realistic expectations

(Rankin et al., 2005).


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Patient Responsiveness

According to (WHO, 2000) report, there's some systems are highly unresponsive. A common

complaint in many countries about public sector health workers focuses on their rudeness in

relation with patients.

Definitions:

Is a measure of how the system performs relative to non health aspects, meeting or not

populations’ expectations of how it should be treated by providers of prevention, curative services

(Sara and Christopher, 2009).

Elements of responsiveness: 1. Dignity

The right of a care seeker to be treated as a person in their own right rather than merely as a

patient who due to asymmetric information and physical incapacity has rescinded his/her right

to be treated with dignity. This includes:

• The safeguarding of human rights such as the liberty to free movement even

for individuals who have leprosy, tuberculosis or are HIV+

• Treatment with respect by health care staff;

• The right to ask questions and provide information during consultations and

treatment;

• Privacy during examination and treatment

• Being shown respect.

(Yongyuth and Wim Van, 2006).

2. Confidentiality of information Information relating to the patient and his illness should not be divulged

during the course of care, except in specific contexts, without the prior permission of

the patient. This is linked to the idea that the patient’s welfare is the supreme concern

of the health care provider. This would involve:

• Conducting consultations with the patients in a manner that protects their


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privacy

• Safeguarding the confidentiality of information provided by the patient,

and information relating to an individual’s illness, except in cases where

such information needs to be given to a health care provider, or where

explicit consent has been gained.

• Medical history kept confidential.

• Consulting with health providers in a manner that his discussions could not be overheard.

(Pongsupap and Van Lerberghe, 2006).

3. Autonomy

• Being involved in deciding on your case and treatment if he wants to.

• Having the providers ask his permission before starting treatments or tests.

• The right of an individual to information on his/her disease and alternative

• The right to be consulted about treatment

• Informed consent in the context of testing and treatment

• The right of patients of sound mind to refuse treatment


4. Prompt Attention • Patients should be entitled to rapid care in emergencies, and

• Patients should be entitled to care within reasonable time periods

even in the case of non-emergency health care problems or surgery

so waiting lists should not cover long periods.

• Patients seeking care at healthcare units should not face long

waiting times for consultations and treatment.


5. Communication

• Having the provider to listen to him carefully.

• Having the provider explain things so he can understand.


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• Having patients to ask questions.

6. Quality of Basic Amenities

• clean surroundings

• regular procedures for cleaning and maintenance of hospital buildings and premises

• adequate furniture

• sufficient ventilation

• clean water

• clean toilets

• clean linen

• healthy and edible food


7. Access to social support networks during care

• Regular visits by relatives and friends

• Provision of food and other consumables by relatives and friends, if not provided by the

hospital

• Religious practices that do not prove a hindrance to hospital activities or hurt the

sensibilities of other individuals


8. Choice of Care Provider

Differences between responsiveness and patient satisfaction Responsiveness is different from patient satisfaction and quality of care though there

are many overlapping aspects. Three main differences can be highlighted:

(1) Scope: patient satisfaction focuses on clinical interaction in specific health

care settings whereas responsiveness evaluates the health system as a whole;

(2) Range: patient satisfaction generally covers both medical and non-medical

aspects of care while responsiveness focuses only on the non-health enhancing


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aspects of the health system;

(3) Rationale: patient satisfaction represents a complex mixture of perceived

need, individually determined expectations and experience of care.

Responsiveness evaluates individual’s perceptions of the health system against

‘legitimate’ universal expectations.

(Sara and Christopher, 2009)

Medical records Medical records are the footprints we make through the medical system. From the moment we are

born, to the day we die, our medical records are a chronology of everything that has affected our

health or has created a medical problem. Until the past few years, those records were kept entirely

on paper, filed in folders in various doctors' offices and hospitals. Today, more and more of those

records are being recorded and stored electronically. One doctor on one side of the globe might be

able to instantly access the records being kept by a provider located in a different corner of the

world. More practically, primary care physicians refer us to specialists, and before we even arrive

at the specialist's office, our records are transferred electronically, and reviewed on her computer

monitor. Our footprints are no longer restricted to one folder in one doctor's office (Trisha, 2009).

This new use for technology may seem like a great advance for patients and providers alike and

for the most part it is. But the advancement of electronic medical record storage has also

highlighted and expanded three problems:

• Privacy / Security: Who can legally access a patient's records and how may they be shared?

What happens if medical records fall into the wrong hands?

• Errors / Mistakes in Patient Medical Records: If mistakes are recorded in a patient's file,

they may be replicated through the use of electronic recordkeeping. How do we make sure

that doesn't happen?

• Denials: Covered entities are required by law to provide patients with copies of their medical

records, but not all records are provided the way they should be.


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Chapter (8): Strategies to manage the long waiting time

An inadequate supply of providers is leading to a crisis in access. Pressures are being placed to

increase panel sizes. The impact of these pressures on clinical processes, patient satisfaction and

waiting times is largely unknown, although evidence from recent literature shows that longer

waiting time results in higher mortality rates and other adverse outcomes. Panel sizes are

correlated with clinical process indicators, patient satisfaction and waiting times, controlling for

practice, provider and patient characteristics. Larger panel sizes are related to statistically

significant increases in waiting time. However, larger panel sizes appear to have generally small

effects on patient process indicators and satisfaction. Panels with more support staff have lower

waiting times and small improved outcomes (Stefosetal, 2011).

Definition of Waiting Time: The total time from registration until consultation with a doctor. There were two waiting times,

the first is time taken to see a doctor and the second is time to obtain medicine (Jamaiah et al.,

2003).

Definition of Registration Time: Defined as waiting time from the moment patients submit a clinic appointment card or referral

letters at the counter until getting a call from the counter. During this time the payment process

and record classification are made. Registration time is part of patient’s waiting time (Lim and

Manaes, 2001).

Causes of long Waiting Time: Murray et al (2007) expressed the causes of long waiting time as follow: • Poorly organized services: inefficiencies, lack of coordination among all those involved in

delivering services, poor planning, slow down the system and create bottlenecks in providing

surgeries and other services.

• Shortages of health care workers: if patients can't get to see a doctor quickly (or at all) they

turn to emergency rooms (ERs), extending wait times in ERs.


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• Physicians don’t work in teams: most doctors' offices work alone, so all appointments and

procedures leading up to surgery are managed individually, leading to delays and

inefficiencies at every step.

• Cuts to hospital services: between (1988 – 2002) there were 64,000 hospital beds cut in

Canadian hospitals.

• The need for more long-term care and home care: under-funding of home care and

residential long-term care has increased inappropriate and preventable hospitalization and

adds pressure on emergency rooms.

• Better outcomes: when we improve services, more people can benefit from them. This mean

increase the number of external customers and increase utilization of services leading to

increase waiting time (e.g. many patients now have surgeries that would have been too

dangerous a few years ago. So many patients start to use health services would have been

dangerous or not available in the past.

The public health care solutions: • Fund the public solutions: the governments need to make system-wide improvements based on

the successful projects in public hospitals and clinics that are dramatically reducing wait times.

We need more than isolated pilot projects.

• Put patients before profits: it seems obvious, but when efficient and appropriate patient care is

made a priority, administrative and clinical practices improve and wait times are shortened.

• Common waiting lists: all patients waiting for certain surgeries go into a single list for the first

available surgeon. Patients could still choose their surgeon, but they might have to wait longer.

• Better coordination: by staggering start-time for surgery and standardizing surgical equipment

and procedures including-screening and tests. Where this has been tried, wait times dropped 75%

and the number of surgeries completed increased by 136%.

• Expand team work: establishing teams of health care providers including physicians, nurses,

nurse practitioners and other health professionals eliminates duplication, improves coordination

and makes better use of scarce resources.

• Modernizing electronic information systems: so everyone in the health care team has timely

access to accurate and up-to-date patient information and there is no unnecessary waiting for

patient records.


65

• Improve community care: by putting resources into long term care, home care and home

support, we can keep people healthier and out of hospital and relieve the pressure on hospital

beds.

• Improve access to family health care: when patients can get timely access to family health care

teams, through community clinics and urgent care centers, the wait time in ERs drops

dramatically (Postl, 2009).

The health care system is increasingly recognizing the importance of improving patient access to

care and is embracing the principles of advanced access, or “same-day scheduling.” Access

improvement depends on correctly matching patient demand with appointment supply without a

delay (Murray and Berwick, 2003) and without harming continuity of care (Christakis et al.,

2001). In other words, it means seeing patients when their needs arise, not bumping them to

another day or to another provider.

The relationship between patients and their primary care providers is so importance which it

defined as a “sustained partnership” (Smith and Dooley, 2004). For this sustained partnership to

become actualized, practices need to recognize that there are limits to the number of services each

provider can deliver and the number of patients each provider can be accountable for and these

limits must be defined (Hall, 2007).

Definition of panel size: Panel size is simply the number of individual patients under the care of a specific provider. Panel

size is easiest to determine in practices that can use enrollment data to link patients to individual

providers and capture that linkage in their information system. This is most feasible in “closed”

systems, such as some HMOs. In other environments, where panel size can shift rapidly or where

it is not determined by enrollment or not permanently codified in the information system, other

methods are required to link patients with providers and establish the panel size (Randolph

GD,2004).


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Definition of the practice panel: The panel for an entire practice can be defined as the unique patients who have seen any provider

(physician, NP or PA) in the last 18 months. Some practices may prefer to use data for the last 12

months; however, this method tends to underestimate the panel size, as many patients do not visit

the practice within a year (Murray M., 2007).

The importance of panel

Wright J.G and Menaker RJ (2011) referred to the importance of panel:

1. It makes patients happy: Patient surveys clearly demonstrate that patients want the

opportunity to choose a provider; they want access to that provider when they choose; and

they want a quality health care experience. Establishing a panel links each patient with a

provider with whom they have a health care relationship.

2. It defines the workload: Establishing a panel helps divide and define workload within a

practice and helps ensure that each provider is carrying his or her fair share.

3. It predicts patient demand: Panels are the source of demand not only for visits but also for

non-visit work (paperwork, e-mail, etc.), tests, procedures and hospitalizations. Understanding

the panel helps a practice anticipate that demand both.

4. It reveals provider performance issues: Understanding the panel allows groups to see the

effects of provider variability. For example, if two providers have the same panel size but one

provider has more demand than the other, then the practice can explore why this difference

exists (e.g., one physician uses shorter return-visit intervals) and whether it is justified.

5. It helps improve outcomes: Identifying individual panels enables providers to make a

commitment to continuity (that is, to taking care of their own patients for all their visits),

which results in improved clinical outcomes, reduced costs and enhanced revenue per visit

(O’Hare and Corlett, 2004).

Determining the individual provider panel: Each patient on the practice's panel should then be placed on the panel of only one provider.

Because patients may have seen multiple providers in a practice, this requires deciding which

patients “belong” to which provider.


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(Postl, 2009) explained the following “four-cut” method:

1. Patients who have seen only one provider for all visits are assigned to that provider.

2. Patients who have seen more than one provider are assigned to the provider they have seen most

often.

3. The remaining patients who have seen multiple providers the same number of times are assigned

to the provider who performed their most recent physical or health check.

4. The remaining patients who have seen multiple providers the same number of times but have not

had a sentinel exam are assigned to the provider they saw last.

This four-cut method may not be 100-percent accurate (some patients will be assigned to the

incorrect provider and some patients will ultimately choose a different provider than the one they

were initially assigned to); however, it's a good start. Panel assignments can be refined by asking

and confirming at every opportunity the patient's choice of provider (Postl, 2009).

Determining the “target” panel: The target panel is the practice panel (defined earlier)

divided by the number of full-time-equivalent (FTE) clinical providers. To determine the number

of FTE clinical providers, take the total FTE providers and subtract the portion of each provider's

time spent on no appointment or no clinical duties such as hospital rounds, operating room duties,

procedures, management duties and meeting time (Postl, 2009).These calculations relate to the

current panel size. But the current panel size is not always the right size.

Practices and individual providers should not take on more work than they can manage. If a

panel is too large, the excess demand results in a never-ending and ever-expanding delay in

services in addition to constant deflections to other providers, resulting in discontinuity. On the

other hand, if a panel is too small, demand may not be adequate to support the practice. The

demand for appointments must equal the supply of appointments if timely service is desired.

A simple equation can be used to express this: Panel size × visits per patient per year (demand) =

provider visits per day × provider days per year (supply).

(Murray et al., 2007))

This equation reveals each provider's ideal panel size based on his or her historical level of

productivity. Often a provider will want to increase the ideal panel size (e.g., to retain current


68

patients or to expand access to the community), which requires making adjustments to the

following variables:

• Visits per patient per year: practices should calculate this figure for themselves by

dividing the number of unique patients seen in the last 12 or 18 months into the number of

visits to the practice that these patients generated within the same period. To increase the

size of the panel that a provider can successfully care for, the number of visits per patient

per year can be decreased by improving continuity (when patients see their own provider

they require fewer visits), lowering the visit return rate (i.e., the percentage of visits for

which the provider requests a follow-up visit (Schectman et al., 2005) providing more

service at each visit, increasing teamwork (Grumbach and Bodenheimer, 2004) and using

alternatives to traditional visits such as e-mail, telephone care and group visits

(Bodenheimer, 2003).

• Provider visits per day: This variable is determined by looking at historical data

regarding the number of visits provided per day; it is not simply the number of

appointment slots available per day. This variable can be increased by optimizing care

delivery models, decreasing the no-show rate, offering more appropriate help so that

providers can reduce individual visit length, (Grumbach and Bodenheimer, 2004)

improving the workflow by reducing bottlenecks and providing more “just in time”

support, increasing the number of exam rooms, (Smith and Dooley, 2004) and removing

unnecessary work from the providers to allow them to maximize appointment supply (

Grumbach and Bodenheimer, 2004).

• Provider days per year: This variable is determined by looking at the number of days a

provider's schedule was booked for patient visits per year. It can be influenced by

changing expectations about the number of days that should be booked with appointments

and making critical decisions about how provider time is distributed (e.g., shifting

providers away from no clinical duties in favor of clinical duties). When doing this

exercise, practices are sometimes surprised by the relatively small amount of provider

time they have devoted to appointment work (Bodenheimer, 2003).


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The bottom line

There is a limit to the number of patients each provider can effectively care for. That limit

depends on the system in which the provider practices. Having an appropriate panel size is a

key for managing clinical workloads and optimizing patient access to care (Murray et al.,

2007).

Variables that affect panel size Panel size can be influenced by the number of patients seen per day, the number of days the

provider is available per year and the average number of visits per patient per year. For example,

a provider who sees 20 patients per day, 210 days per year, with an average of three visits per

patient per year, could manage a panel of 1,400 patients. By increasing capacity to 25 patients per

day, the provider could manage a panel of 1,750 patients.

Figure (A): panel size

( Murray et al., 2007)

What this demonstrates is that panel size is an outcome of the system in which providers operate.

The ideal panel can be determined, but its size will necessarily differ in different environments

depending on all the provider and system factors noted above.


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Limits to panel size There is a limit to practice and individual panel sizes. If a practice or individual provider keeps

saying “yes” to new patients and exceeds the limit, the overage can initially be absorbed into a

waiting time. However, patients' willingness to wait has a limit. At some point, patients quit.

Thus, despite saying “yes” to an endless stream of new patients with our words, we say “no” with

our actions because these patients won't have access to care. Those providers who insist, “I have

to say ‘yes’ to new work. I have no choice,” are simply deceiving themselves. This is an

irrefutable act of denial (Hudon E B and Roberge D,2004).

In addition, the increasing wait time for an appointment leads to escalating chaos within

the practice as evidenced by an increased number of phone calls to the practice; longer handling

time for those calls; more patient complaints; increasing no-show, cancel and reschedule rates;

greater numbers of “walk-ins” to the practice due to patients getting impatient; greater use of

triage resources to determine who has to wait and who cannot wait; and an increased level of

discontinuity, which worsens patient outcomes and satisfaction and increases the return visit rate

and visit length, which in turn lowers productivity ( Lewandowski et al., 2006). The main point is

that if the panel is too big, the provider creates “overwork” (can't get the work done), “overtime”

(needs consistent overtime support) and “over there” (sends the work away). If the panel is too

small, the provider will not generate enough revenue to cover expenses (O'Hare and Corlett,

2004).

Over-paneled provider Once a provider's individual panel has been identified and all strategies for adjusting the panel

have been dutifully applied, it might be found that the provider is indeed “over-paneled.”If a

provider is over-paneled, these strategies will reduce his or her panel:

1. Let attrition take its course. Every year in a typical practice, patients move away, die or change

insurance.

2. Close the over-paneled doctor to new patients, at least temporarily, and excuse him or her from

seeing the patients of absent providers.


71

3. Shift more resources to support that provider. This may take the form of additional nursing or

clerical staff, or possibly additional exam rooms.

4. Move patients away from that panel. In this situation, providers will need to inform their patients

directly, for example, by sending a letter to patients informing them that they are being moved to

another provider's panel.

(Haggerty JL et al. 2008)

Adjusting for practice style Some providers claim that their practice style warrants a smaller panel size. For example, a

provider with a highly personable style of practice may feel more effective conducting longer

office visits. In a practice where physicians' salaries are fixed, decreasing the panel size for one

provider can be controversial because it increases the size of others' panels. One possible solution

is to provide a salary adjustment that corresponds to the panel adjustment. For example, a

physician whose practice style involves lengthy office visits, resulting in a panel size that is 80

percent the size of the typical panel in the practice, might need to be paid 80 percent of what a

fully paneled provider receives. In productivity models, some degree of practice style adjustment

can be accommodated; however, if the smaller panel size pulls revenue down below daily

expenses, then accommodation makes no business sense (Carlson B, 2002).

Adjusting for age and gender Providers sometimes claim that their patients are older and sicker than those on the panels of other

providers, which justifies a smaller panel. Sometimes these arguments can become self-fulfilling

prophecies, as providers can “prove” that their patients have higher acuity by creating more return

visits (which increases demand) or longer visits (which limits supply). Still, it's true that panels

equal in number are not necessarily equal in acuity at any single point in time. In some practices,

panel acuity tends to balance out over time. In others, due to many factors such as patient mix and

provider interests, permanent acuity differences exist. Patients' age and gender can predict visit

utilization and reflect acuity. For example the average visit rate for all patients was approximately

3.19 visits per patient per year. The number of visits in each age and gender subset was divided by

the average visit rate to determine the likelihood of a visit within the subset. For example, a 0- to


72

11-month-old male is 5.02 times more likely to visit than a 55- to 59-year-old male, whereas a 35-

to 39-year-old female is half as likely to visit as a 75- to 79-year-old female (Murray et al., 2007).

Practices with sophisticated information systems could use this data to adjust provider

panels. However, the process is complicated and requires caution. If one panel is adjusted down

due to higher acuity, this needs to be a parallel adjustment up in panels with lower acuity. In

addition, practices should consider whether many of the acuity factors could be managed more

effectively by providing focused team support than by adjusting panels (Bundy DG et al., 2005).

Important points • The number of patients a physician can effectively care for is not unlimited. Having a panel of

manageable size promotes higher quality care by enabling physicians to see their patients in a

timely manner without inevitably off-loading them to other providers, which can reduce

satisfaction, increase costs, reduce revenues and adversely affect clinical care (Murray et al.,

2007)

• The number of visits a physician can provide in a day is variable and influenced by several

factors, particularly the visit length. Visit length can be optimized by having patients see their

own doctor. When patients see their own doctor, the physician doesn't have to spend time

establishing credibility, building rapport and gathering an entire history, since much of that

work has already been done. As a result, the visit tends to be shorter, and the physician can

increase the number of visits in a day (Murray M, 2005).

• Visit length can also be optimized by eliminating interruptions during patient visits.

Interruptions can be eliminated by making sure before the visit that all equipment and

information will be available when you need it. If all of the exam tools are accessible and in

the same place, and if test results and other clinical data are in the chart, the time spent

looking for these items is eliminated.

• Some physicians may need a refresher on how to focus on the visit. This can significantly

improve the effectiveness of the visit and shorten the visit length.

• Visits per day can also be increased through better and more focused teamwork supporting the

clinician before, during and after the visit. In addition, visits can be increased if no

appointment work (e.g., telephone calls, refill requests and staff management) can be reduced


73

for the clinician. This requires an extensive review of all the no appointment processes that

occur in the practice and a meticulous study of the tasks involved and who should be doing

them (Francis et al. 2009).

• Fixed-salary environment can be challenging. If each doctor has a fixed salary, then, to be

equitable and fair, the panel size has to be fixed as well. However, because of differences in

patient acuity, there may be various times of the year when one physician's panel will generate

more demand and the physician will feel that his or her salary is unfair (Blendon R.J. et al.

2002).

• Practice style also plays a huge role in salaried environments. Doctors may claim that their

personal style or their patients' style requires longer visits, which translate to fewer visits per

day, which translate to a smaller panel. The risk is that the physician's personal style will

begin to dictate the panel size, and then panel size becomes a subjective exercise based on

preference, not based on equitable workload. Some organizations that reimburse physicians

with a fixed salary may adjust panel expectations based on the number of exam rooms

available, the number of support staff and the acuity of the panel. In our experience, the best

environments do not rely on fixed salaries, and they allow physicians to choose their own

panel size. This choice, of course, comes with two requirements: Providers have to see their

own patients, and their patients cannot wait. Continuity and a no-wait culture are built into the

system and are immutable. So, physicians in these environments who choose a large panel

size and commit to seeing those patients as their needs arise can obtain higher reimbursement.

Escalating reimbursement thresholds can be set for patient satisfaction and for selected

clinical outcome measures to ensure they are not adversely affected. In such environments,

physicians whose style is conducive to a small panel size are free to practice in that way but

receive less reimbursement (Ferrante JM et al., 2010).

• For the new physician, there are three obstacles to growing the panel: 1) the physician needs

time to get used to the system; 2) all patients are new, so they require more time; 3) new

patients generate more return visits than established patients. Filling every other appointment

slot in the new physician's schedule for the first two to three weeks. The result is that each

new patient gets an appointment that is twice as long as the standard. Then, gradually release

the in-between slots so they can be booked with return patients (Blendon RJ et al., 2002).


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Service agreements between primary care physicians and other specialists can have a

huge effect on visits per patient per year in specialty care because they help ensure

appropriate, complete handoffs between physicians. Patients who do not show up for

scheduled appointments affect the supply side of the equation (specifically, the provider visits

per day). Since no-show visits are scheduled but do not materialize, they waste visit capacity.

As a consequence, some groups will measure the no-show rate and adjust expected provider

visits per day downward. The risk, of course, is that this method provides no incentive to

eliminate the no-shows. If no-shows are high, practices should take steps to reduce them or

schedule more visits than they have room for with the expectation that a certain percentage of

patients will not show up (Russell GM et al., 2009).

Every organization has to make a fundamental decision about the expected workload of

midlevel providers. Some practices treat midlevel providers the same as physicians and expect

them to carry the same panel size. Other practices expect fewer visits per day from midlevel,

so the panel size expectation is also lower. For example, a full-time midlevel might be

expected to carry half of a physician-sized panel. The best option will depend on your

individual practice's circumstances (Katz A et al., 2010).

The extensive time required for obstetrics care will reduce the ideal panel size, so we

recommend removing this work from the demand-supply equation. If the obstetrics work is

separate from the primary care work (for example, each physician devotes one day a week to

OB call), then you can simply subtract that time from the supply side of the equation and

subtract those patients from the demand side of the equation. If the obstetrics work interrupts

the office practice, then you'll need to estimate the time spent and subtract it from regular

office time. Because of constant turnover in practices, panel size should be determined

monthly. If a practice uses the four-cut method to determine panel size and tracks this

information via a monthly panel report, then it can determine net panel gain or loss per month

(Mayo-Smith MF, 2004).

New patients should be assigned to physicians whose panels are below the group's target

or below the ideal panel number determined by the equation. This makes the assignment more


75

objective. An easy way to do this is to create a “new patient” appointment type in your

scheduling system, with only eligible providers having that appointment type. Alternatively,

you can give your scheduler a list of eligible providers. In some practices, there are popular

and unpopular physicians. Should we allow patient choice, or should we assign patients to

panels so they will be relatively even? While patient choice is critical, it will result in some

panels exceeding the ideal panel size. Once the limit is exceeded, it would be unwise to allow

a patient to select an over paneled physician. In practices that have a high rate of patient

turnover, we measure panel size based on the unique patients seen in the last 12 months.

Using more than 12 months will overestimate the panel, and using less than 12 months will

underestimate the panel. The visits per patient per year may be lower than in practices with

normal turnover, which would make the ideal panel size higher (Carlson B, 2002).

On the other hand, practices with high patient turnover will also have to deal with more

new patient visits, which require more time and effort. This reduces the number of visits per

provider per day, which affects the demand side of the equation. To counter this, we would

suggest that you mitigate the physician work associated with new patient visits as much as

possible by delegating tasks to nurses or medical assistants. In certain academic environments,

panel size can be calculated for a team of linked providers. In this situation, the team's supply

is simply the sum of each individual supply (Bodenheimer T, 2003).

Subjects & Methods

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Subjects and Methods

Rational of the study

The current study focused on measuring the patient as well as the health care providers

satisfaction with all aspects of services offered at Internal Medicine and General Surgery out

patient clinics in Fayoum University Hospital supported by observing the performance of health

care providers (doctors and nurses) at out-patient clinics. So the study was planned to detect the

defect in the services provided at out-patient clinics in Fayoum university hospital.

Subjects& Methods A. Study design The study was an operational health service research (Time bound study)

The study design was an exploratory cross sectional one

The design depended on measuring the observations at the time of study, through the following:

1. The observations: assessment of patient and health care provider satisfaction of health

services at outpatient clinics of Internal Medicine and General Surgery using structured

English questionnaire for health care providers(doctors and nurses), structured Arabic

questionnaire for patient and observational checklist for the work area. In addition to

observational checklist to assess provider performance and service delivery at Internal

Medicine and General Surgery outpatient clinics also measuring the time consumed by

the patient, in the patient flow cycle to detect which part of the cycle let the patient

spending a long time.

2. The implementation: information derived from the collected data was analyzed and

used to formulate a policy brief to present the situation analysis at the clinics of Internal

Medicine and General Surgery. And set a plan as hardcopy (Arabic and English) to be

presented to the stakeholders to take action in order to change and correct the defects in

the offered service.

Subjects & Methods

77

B. Study settings: The study conducted at Fayoum University Hospital in the following areas:

1) The outpatient clinic of General Surgery.

2) The outpatient clinic of Internal Medicine.

Due to:

- The level of illiteracy in the society is high, most patients are unaware about the types of

specialties and subspecialties so both clinics (the outpatient clinic of general surgery and the

outpatient clinic of internal medicine) represent the first choice for patients before deciding

the specialty they will need.

- High patient flow clinics.

- Regular work cover the whole week.

C. Time Frame The study was conducted during a period of 31 months (January, 2011 till July, 2013).

D. Study population

The study populations were divided into 2 categories:

- First: Patients attending Internal Medicine and General Surgery outpatient clinics in Fayoum

University hospital.

- Second: Health care provider actually working in the clinics (physicians and nurses).

E. Study hypothesis: The study hypothesis is that: empowering the staff members and patients about the quality of

health services. They will become inspired to make changes to improve the quality of services

provided at outpatient clinics. This will improve the level of satisfaction of both internal

customers (providers) and external customers (patients).

F. Description of the study intervention

The intervention was conducted by the investigator is composed of three phases:

• Quantitative and Qualitative data collection

• Both data were analyzed to present system analysis (table 18, 19, 20 )

Subjects & Methods

78

• A plan had been presented as a solution to solve the root causes of the problem in form

of short term strategic plan and long term strategic plan

• A project was formulated to set up a communication and health education unit at the

hospital to empower the internal and external customers in order to improve quality of

service.. The plan was presented in Arabic and English to the stakeholders (Annex 7)

G. Operational variables :

i. Independent variables

1. Assessment of patients and providers satisfaction

2. Observing service delivery at the clinic

ii. Intermediate variables

1. System analysis through conducting patient and provider satisfaction survey and

observation the service delivery at the clinic

2. Developing a plan that depends on findings derived from the current study to improve

quality of service.

iii. Dependent variables

1. Decision making and action taken by the stakeholders guided by the items mentioned in

the policy.

2. Increase the level of patient satisfaction.

G. Sample size 1. A pilot study was done on (50 patients- 2 physicians – 2 nurses) for testing the

questionnaire prior to the actual implementation of work. The result of pilot study was

used to modify and correct the questionnaire. It was excluded from the final results of this

study. Finally the questions developed through in-depth discussion with the supervisors to

reach the final form.

2. Patients: The total number of interviewed patients was 495 (207 patients from clinic of

General Surgery and 288 patients from clinic of Internal Medicine) this was based on:

Subjects & Methods

79

• The period selected for data collection from (September, 2011 to March, 2012), 6

months.

• The number of the clients that accepted to be interviewed by the researcher.

The response rate was (92.9%).

3. Health care providers: The total number of interviewed health care providers was 39 (19

health care providers from clinic of general surgery and 19 health care providers from

clinic of internal medicine). The investigator selected all medical personnel that actually

attending the clinic (physicians and nurses):

• At the outpatient clinic of internal medicine it was (1 assistant professor, 1 lecturer, 2

lecturer assistants, 2 residents, 11 house officers and 2 nurses).

• At the outpatient clinic of general surgery it was (3 lecturers, 2 lecturer assistants, 2

residents, 10 house officers and 2 nurses).

This was done taking in consideration their different characteristics and work experience

that may have an impact on the quality of service delivery at out patient clinic of general

surgery and internal medicine.

• The response rate for health care providers at the outpatient clinic of internal

medicine was (68.96%).

• The response rate for health care providers at the outpatient clinic of general surgery

was (51.4%).

Subjects & Methods

80

Table (B): Number of staff of internal medicine and general surgery departments (2010)

General surgery

(N:27)

Internal medicine

(N:18)

Categories

2 1 Professors

3 2 Assistant professors

7 3 Lecturers

9 8 Assistant Lecturers

4 3 Residents

2 2 Nurses

27 18 Total

Ø Sampling Procedures:

♦ Patient exit Interviews:

ü The investigator attended the clinics for 22 weeks using the following schedule: In the odd

weeks (1st ,3rd ,5th ,7th ……. weeks) of the study; the first three days of the weeks were

allocated for internal medicine clinic and the 2nd three days were allocated for general

surgery clinic. The days were alternated in the even weeks (2nd, 4th, 6th, 8th,……) of the

study and so on till the end of the period of study (as in flow chart).

ü The whole day was covered (from start till end of the clinic) in different seasons to cover

the seasonal variation and to ensure diversity and representation of the sample.

ü The sample was self-selected and was distributed across the two clinics at the waiting area

as they had the same waiting area.

ü The interview was done with patients who approved to participate and had the following

inclusion criteria:

- Seeking medical care at outpatient clinics of general surgery and internal

medicine in Fayoum University Hospital.

- Exit patients after receiving the service and before going out.

Subjects & Methods

81

- Acceptance of the patient to be interviewed.

- Age above 20.

- Able to answer the questions.

- Both genders.

- The investigator interviewed the patients and completes the questionnaire by

himself to ensure enrollment of all categories of patients (educated and non

educated).

♦ Service providers interview

ü The interview started after finishing the allocated time for patients exit interviews.

ü The (21st, 22nd week) of the study were allocated for interviewing the medical health

care providers of Internal Medicine and observing their performance. The (23rd week)

was allocated for interviewing the medical health care providers of General Surgery

and observing their performance (as in flow chart).

ü The service providers of General Surgery were easier to reach them than the service

providers of Internal Medicine as they attend the clinic regularly according to their

timetable.

ü The investigator try to reach the physicians through the timetable of attendance at the

clinic.

ü The health care providers(physicians) interviews consisted of two parts:

1. 1st part is a structured English questionnaire

2. 2nd part is in-depth personal interview with guided discussions.

ü The nurses interview was done by self administered English questionnaire.

ü Some physicians refused the interview.

ü Some health care providers had completed the questionnaire form others the investigator

had forced to do the interview by himself .Each interview took about 10- 20 minutes

according to the acceptance of the health care provider to continue the interview.

ü The interviewer tried to obtain full responses.

Subjects & Methods

82

♦ Service delivery

ü Observation was done using observational checklist for both the health care providers and

the area of service delivery.

ü Observation was conducted at the out patient clinics of General Surgery and Internal

Medicine and the waiting area

ü Observation of health care providers was done on alternative days for two weeks and for

all providers actually attending the clinics at the time of the study (2 residents at out

patient clinic of Internal Medicine; 2 residents and 4 assistant lecturers at outpatient clinic

of General Surgery).

ü Observation of health care providers performance was done during examining 100 patients

(50 patients at out patient clinic of internal medicine and 50 patients at out patient clinic of

general surgery) on alternative days over 10 days in a rate of 10 patients\ day (5 at the

beginning of the clinic and 5 at the end of the clinic)

♦ Patient Flow cycle chart: It measured the time spent in each phase of the clinic visit.

Ten patients were selected (Annex 5).

Subjects & Methods

83

flow chart

1st day 2ndday 3rdday 4thday 5thday 6thday

1st day 2ndday 3rdday 4thday 5thday 6thday

3rd week

15th week

13th week

11th week

5th week

7th week

9th week

1st week

17th week

19th week

Patient exit Interviews

Internal medicine clinic N:288

General surgery clinic N:207

2nd week

4th week

6th week

8th week

10th week

12th week

14th week

16th week

18th week

20th week

24th week observing 2patients/day for 5

days

Observation of Patient cycle for 10 persons

Subjects & Methods

84

Health care Service providers

Internal medicine health care providers

N: 19

General surgery health care providers

N:19

nurses N:2

Service provider's observation for 100 patients (50 patients at each clinic) on alternative days over 10 days at a rate of 10 patients\ day (5 at the beginning of the clinic and 5 at the end

of the clinic in 2nd week and 23rd week

Service provider's

interviews

physicians N:17

physicians N:17

nurses N:2

21st week 22nd week 23rd week

1st day and 2nd day (one lecturer, one lecturer assistant, one resident and one nurse) in each

day

3rd day and 4th day (one lecturer and four house

officers) in each day

6th day of the 21st week one professor and one assistant professor

1st day and 2nd day of the 21st week (one lecturer, one lecturer assistant, one

resident and one nurse) in each day

3rd day and 4th day of the 21st week (one lecturer, one lecturer assistant, one

resident and one nurse) in each day

5th day and 6th day three house officers in each day

1st 5 days of the week

two house officers in each day

5th day one house officer

Subjects & Methods

85

H. Study phases The study was divided into the following phases:

a. Preparatory phase

Started from (January, 2011 to August, 2011) and included, preparing the following:

1. Study of hospital Records of a number of patients attending at outpatient clinics in

Fayoum University Hospital.

2. Structured Arabic questionnaire for exit patients.

3. Formulate a health service providers questionnaire.

4. Observational checklist.

b. Data collection phase

It was conducted from (September, 2011 to March, 2012) to cover the different seasons &

different days that will cover all working days of the week.

Types of data:

i.Quantitative data

o Hospital Records of the year (2010) for the number of patients attending at outpatient

clinics in Fayoum University Hospital.(Table:1)

o Structured Arabic questionnaire for exit patients.

o Structured English questionnaire for healthcare providers.

o Patient statistics of (April, August, September and October 2010) for the number of

patients attending the Internal Medicine and General Surgery out patient clinics.

ii.Qualitative data

o Interview with physicians (juniors and seniors) and house officers with guided

discussions.

o Interview with nurses with structured Arabic questionnaire and guided discussions

Subjects & Methods

86

Table (C): Total General internal medicine and General surgery out patient clinic

attendants according to hospital statistics in four selected months (2010)

Clinic April

(2010)

August

(2010)

September

(2010)

October

(2010)

Average

number\year

General internal

medicine

1318 1067 814 1223 13266

General surgery 1142 1015 901 1228 12858

Data collection Tools

To collect data on the following:

• General physical layout of the health facility

• Time taken by the patient in the patient flow cycle.

• The number of patients attending the clinics were obtained from the statistical

office at the hospital and compared with that at the clinic record.

The tools were :

1) Reviewing the medical records statistics of four months. (table B)

2) Structured interview with exit patients

• Arabic questionnaire form was used covering the various aspects of patient

satisfaction.

• Arabic questionnaire form was developed with reference to scientific articles

(Gadallah et al 2003; Saadoun F. Al-azmi etal 2006)

• The choice of questions for this research was based on the analysis of the results of

interviews that were conducted before the study with patients to explain their

experiences about their health care at Fayoum University hospital. An exit interview

questionnaire was administered to the patients in the selected hospital. The

questionnaire was given to patient attending the Internal Medicine and General

Surgery outpatient clinics in Fayoum University Hospital

Subjects & Methods

87

• The questionnaire consisted of 60 close-ended questions tapping 6 aspects of

satisfaction with care:

ü Access to care, continuity and choice of care had been covered by (15 questions; for

example: The physician assigns appointment to the patient for follow up visit ),

ü The communication and patient rights maintenance had been covered by (15

questions; for example: the physician ask you about your name before examination),

ü The technical quality and physician performance was covered by (8 questions; for

example : the physician can diagnose correctly),

ü The financial aspects were covered by (4 questions; for example :price of tickets),

the time management was covered by (4 questions; for example: examination time)

ü The outcome and over all satisfaction was covered by (11 questions ; for example

:Planning to come in the future).

• Responses were given 4 –point scale ranging from always agree, sometimes agree,

uncertain and not agree. (Annex1)

• The instrument contained both positively word and negatively word items.

3) Interview with the health care providers

• Physician and nurses were interviewed within the following items:

o Attending training courses

o Working hours at the clinic

o Monitoring of work by senior staff

o Work environment and infrastructure

o The main problems facing them.

o Their suggestions to solve the problem

• The health care providers (physicians) interviews consisted of two parts:

First part was a structured English questionnaire developed to assess the health

care providers' satisfaction of health services provided at General Surgery and

Internal Medicine outpatient clinics and was covered by 27 close-ended questions

(23 questions for doctor and 5 questions for nurse; for example : Attending training

programs) taping the following aspects of satisfaction:

- General physical layout of the clinic

Subjects & Methods

88

- The applied polices in the clinics

- The system and load of work at the clinic

- Load of work

(Annex 2 )

Second part was in-depth personal interview that was covered by 16 open-ended

questions (7 questions for doctor and 9 questions for nurses).

• Few of the health care providers completed the questionnaire form by them selves.

But with some of the health care providers, the researcher had to complete the

questionnaire by himself after getting the responses of the questions from them.

• Each interview took about 10 - 20 minutes according to the acceptance of the health

care provider to continue in the interview.

• Responses were given 3 – point scale ranging from yes always, yes sometimes, no.

(Annex 2)

4) Field observation & situation analysis

§ Observational check list for provider's performance

It was done at Internal Medicine and General Surgery out-patient clinics. The

performance was assessed by observing the health providers while dealing with the

patients at clinic. It was covered by (30 close-ended questions for observing the

physician and 5 close-ended questions for observing the nurse )taping the following

aspects:

ü Observing communication between the patients and healthcare providers.

ü Observing the patient rights maintenance.

ü Observing the technical quality of healthcare providers.

ü Observing the cooperation between the physician and the nurse at the clinic.

Responses were given 4 – point scale ranging from yes always, yes sometimes, no, not

applicable (Annex 3).

Subjects & Methods

89

§ Observational check list for work area at the clinic

It was done for 3 areas and was covered by 71 questions (61close-ended questions and 9

open-ended questions) as follow:

ü Observing clinics of Internal Medicine and General Surgery was covered by 30 close-

ended questions and 6 open-ended questions.

ü Observing the waiting area of both clinics was covered by 7 close-ended questions and 3

open-ended questions

ü Observing the reports & records of both clinics was covered by 5 close-ended questions.

ü And finally 9 close-ended questions were added in general.

Responses to the close-ended questions were given 4 – point scale ranging from yes always,

yes sometimes, no, not applicable (Annex 4).

and 9 open-ended items)

5) Patient flow cycle chart

It measures time consumed in registration and examination (Annex 5).

c. Data management and analysis phase

Started from (April, 2012 to July, 2013) and it included:

- Qualitative data management

Qualitative data was collected and analyzed day by day. A written report of each interview

was prepared.

- Quantitative data management

The collected interview questionnaires were revised for completeness and logical consistency.

Recoded data was entered on computer using Microsoft excel software program for windows

2003 after being translated to English to facilitate data manipulation. Data was then

transferred to the Statistical Package for Social Science (SPSS) version 20 to be statistically

analyzed by the following levels of analysis:.

• Simple frequency distribution analysis to help in writing the plan.

Subjects & Methods

90

• The questions of health care providers questionnaire were answered using three

points scale “yes always” "yes sometimes" " no".

• Three points scale "yes " " no" "non applicable" was used in answering the

questions of the observational checklist.

• The questions of patient satisfaction survey were answered using Likert scale (e.g.,

four points scale ranging from “always agree” to “disagree. The researcher used

the same scale on all questions to facilitate comparing the results.”

• Analysis using Chi square to identify the effect of sociodemographic

characteristics on the level of satisfaction.

• A scoring method was used to assess the patient satisfaction level as follow:

ü For positive responses (3=always agree, 2=sometimes agree, 1=disagree, 0=

not applicable or uncertain). (e.g.: The physician greet the patient).

ü For negative responses (0=always agree, 1=sometimes agree, 2=disagree, 3=

non applicable or uncertain). (e.g.: The physician may not come and the patient

leave without an examination).

• The responses were grouped and presented in three categories as follow:

ü High satisfaction including the patients who always agree to the quality of

service.

ü Moderate satisfaction including the patients who sometimes agree to the

quality of service.

ü Grouping the patients who disagree and uncertain/not applicable to the

quality of service together to represent the dissatisfaction.

The scale ratings converted into the following scores: (100, 50, 0).

(table C)

Subjects & Methods

91

Table (D): Scale and score distribution High satisfaction

=(always agree)

Moderate

satisfaction

=(sometimes agree)

Dissatisfaction

=(disagree, non

applicable/uncertain)

High satisfaction

=(always agree)

Scale

Positive responses

(e.g: The physician

greet the patient)

3 2 1

Negative responses

(e.g: The physician

may not come and the

patient leave without

an examination)

1 2 3

Score

Positive responses 100 50 0

Negative responses 0 50 100

The average of these scores were calculated. Each patient had a score for every question that was

answered. For each patient, a section score was calculated as the mean (average) of all the

question scores in that particular section

(Press Ganey,2012)

Subjects & Methods

92

Table (E): Sample data for five Patients for two aspects of satisfaction (Time

management and Financial aspect

Patient Time management (Section A)

Financial aspect (Section B)

Section A

Section B

Total

Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4

1 50 0 50 100 0 50 50 0 0 40 25 32.5 2 0 0 0 50 50 100 100 0 0 20 50 35 3 100 100 50 50 50 50 50 50 100 70 62.5 66.3 4 0 50 50 0 0 0 50 50 50 20 37.5 28.8 5 0 50 0 0 50 100 100 50 50 50 75 62.5 Mean: 40 50 45.02

Section A = ( Q1+ Q2+ Q3+ Q4+Q5) /5 = 40

Section B = (Q1+ Q2+ Q3+ Q4) / 4 = 25

Total = (Section A + Section B) / 2 = 32.5

the overall facility rating score displayed

The mean of all patients’ overall scores, rounded to one decimal place =

(32.5+ 35+66.3+28.8+62.5) / 5 = 45.02

Ethical considerations: • The study protocol was discussed by selected staff members of Public Health

Department, Faculty of Medicine, from both Cairo and Fayoum Universities and the

research ethical committee.

• The official approval was obtained from: Council of faculty departments and Council of

Faculty of medicine .

• Both the researcher and study individuals were acceptable to each other especially

culturally.

• A written consent was obtained from the director of the hospital and another one from

the director of the outpatient clinics before application of the study.

Subjects & Methods

93

• A written consent was obtained from the head of both Internal Medicine and General

Surgery departments.

• The study protocol was revised and approved by the supervisors.

• An approval was taken from Medical Ethical Committee.

• Verbal consent was taken from all the participants

• The procedures of the study were conducted after explaining the aim of the study to the

participants and the stalk holders (the director of the hospital, the director of the

outpatient clinics and the head of both Internal Medicine and General Surgery

departments).

• Confidentiality was expressed to the participants.

Study limitations:

• Preparing the tools took a lot of time, to be matched and suitable to our Egyptian

population.

• Difficulty in obtaining documented data on patient numbers at outpatients for the year

(2010-2011).

• Difficulty in reaching the staff members of Internal Medicine for doing the interview

due to absence of most of them from attending the clinic.

• Permissions were difficult to be obtained from Internal Medicine department.

• Poor cooperation of some included staff members.

• Some staff members didn’t accept the presence of the investigator at the clinic.

• Most of the medical health care providers were very conservative in speaking about the

work problems at the clinic.

• Most of the staff members of Internal Medicine were absent from the clinic during the

period allocated for observation of the clinic.

• The medical health care providers interviews were completed at the time of the clinic.

Other interviews of some medical health care providers were completed at different

places in the hospital where the investigator could reach them.

Results

94

Results

The results of the study will be displayed in the following sequence according to the findings

derived from the survey as follow:

I. Results of patient satisfaction survey

II. Time of patient flow cycle

III. Results from interviewing the health care providers at the clinic

IV. SWOC analysis of the system of work at the clinic

V. System analysis of outpatients clinic according the researcher observations

Part I

Results of patient satisfaction survey The current study considers the following parameters affecting the patient satisfaction from

services offered at internal medicine and general surgery outpatient clinics:

1. Socio-demographic background

2. Communication

3. Access and Continuity of care

4. Technical quality and Health care providers performance

5. Financial aspects

6. Time management

7. Overall satisfaction and outcome of care

Results

95

Table (1): Distribution of studied patients by background characteristics

(%) N (495) Variable Sex

48.3 239 Male 51.7 256 Female

Marital status 14.3 71 Single 80.2 397 Married 3.4 17 Divorced 2 10 Widow

Occupation 11.7 58 Full time work 47.1 233 Part time work 31.3 155 Not work 9.1 45 Student 0.8 4 Retired

Clinic 58.2 288 Internal Medicine 41.8 207 General Surgery

Income 42 208 <150 Egyptian pound 58 287 >150 Egyptian pound

Visit 24.6 122 1st 75.4 373 Follow up

Education 13.5 67 University 47.9 237 Secondary 16.8 83 Can read & write 21.8 108 Illiterate

Table (1): this table demonstrated the demographic characteristics of the studied group (495)

patients from the outpatient clinics of internal medicine (58.2%) and general surgery. Most of

them (75.4%) came for follow up visits.

Results

96

Table (2): Distribution of patients according to communication and their rights with the

healthcare providers (N=495)

Always agree Sometimes

agree Non

applicable\ Uncertain

Disagree Variable

N % N % N % N % The physician greet the patient 156 31.5 36 7.3 20 4.0 283 57.2 The physician asked the patient about his name

before examination 186 37.6 18 3.6 5 1.0 286 57.8

The physician apologized on coming late and

give a reason 68 13.7 57 11.5 139 28.1 231 46.7

The physician listen to patient explanation of

his complain 223 45.1 144 29.1 18 3.6 110 22.2

The physician explained condition to the patient 205 41.4 145 29.3 28 5.7 117 23.6 The physician examine more than one patient at

the clinic 340 68.7 26 5.3 8 1.6 121 24.4

The physician close the door of the examine

room during examination 341 68.9 47 9.5 21 4.2 86 17.4

The physician talk to the staff neglecting the

patient presence 104 21.0 193 39.0 22 4.4 176 35.6

The physician respect to the patient 301 60.8 151 30.5 26 5.3 17 3.4 The nurse deal with the patient in a good way 198 40.0 78 15.8 32 6.5 187 37.8 The nurse answered the patient questions 74 14.9 163 32.9 13 2.6 245 49.5 The security men deal with the patient in a good

way 163 32.9 80 16.2 25 5.1 227 45.9

The physician explain how to take the medicine 182 36.8 28 5.7 41 8.3 244 49.3 The physician gives choices in your treatment (clinical or surgical) 94 19.0 46 9.3 57 11.5 298 60.2 The physician gives choices in your medications (syrup or tablets or injection) 50 10.1 21 4.2 166 33.5 258 52.1

Table (2): regarding communication of patient with their physician (45.1%) of the patients were

satisfied by being listening for their complain by doctor and (41.4%) of them express their pleasant by

explaining the physician their condition. As regards the patient right of being examined in close

Results

97

examining room (68.9%) approved it and (60.8%) revealed that their physicians were respecting

them while dealing.

On the other side (57.2%) of the patients were unsatisfied from communicating with their health

care providers as not being greeted from the physician. Also (57.8%) were not asking about their

names before examination. Regarding maintaining the patient rights; (68.7%) of the patients was

unsatisfied from examining more than one patient at the clinic; nearly half of the patients (49.3%)

expressed dissatisfaction from not explaining how to take the medicine. As well as (49.5%) of the

patients expressed dissatisfaction from not answering their questions by the nurse and (45.9%)

said that the security men not dealing with them well.

Results

98

Table (3): Distribution of patients regarding access, continuity and choice of care(N=495)

Disagree Non applicable\ Uncertain

Sometimes agree

Always agree

% N % N % N % N

Variable

4.8 24 14.3 71 32.1 159 48.7 241 The physician gave the referred patient a

referral paper

6.7 33 10.3 51 30.7 152 52.3 259 The physician assigns appointment to the

patient for follow up visit

17.0 84 17.4 86 34.3 170 31.3 155 The physician is always present in follow up

visit

49.7 246 4.8 24 23.4 116 22.0 109 The security men take the patient to any

place at hospital

6.7 33 4.0 20 30.1 149 59.2 293 The place of the hospital is in a good

location

8.7 43 .8 4 30.1 149 60.4 299 Hospital is easy accessible.

33.9 168 2.4 12 6.9 34 56.8 281 The transports to the hospital are

comfortable

13.9 69 23.0 114 29.3 145 33.7 167 All imaging investigations are in the hospital

11.5 57 31.5 156 5.5 27 51.5 255 All laboratory investigations are in the

hospital

3.4 17 5.9 29 31.5 156 59.2 293 Taking tickets occurs in an organized

manner

33.3 165 3.4 17 6.7 33 56.6 280 Entry for examination is organized

3.2 16 15.2 75 27.9 138 53.7 266 Entry for imaging investigation occurs in an

organized manner

4 20 14.7 73 29.7 147 51.5 255 Entry for laboratory investigation occurs in

an organized manner

3.4 17 79.8 395 1.2 6 15.6 77 Taking medication occurs in an organized

manner

79.8 395 3.6 18 6.3 31 10.3 259 Choosing your physician

Results

99

Table (3): The above table showed that patients were satisfied for the following points as:

(59.2%) were satisfied from the hospital location; (59.2%) from organization in taking tickets;

and (53.7 %) (56.6%) of patients were satisfied from entry in an organized manner for imaging

investigation and examination respectively. Accessibility of transport to the hospital was agreed

by (60.4%) of patients. (48.7%) of the patients were satisfied from giving the referral paper and

(52.3%) assignment an appointment by the physician for follow up visit.

Other patients (79.8%) expressed dissatisfaction from not choosing physician and nearly half of

the patients (49.7%) expressed dissatisfaction from not directed by the security.

Results

100

Table (4): Perception of studied patients regarding technical quality and physician

performance(N=495)

Always agree Sometimes agree

Non applicable\ Uncertain

Disagree Variable

N % N % N % N % The physician examine all body 114 23.0 44 8.9 44 8.9 293 59.2

The physician gives many drugs 61 12.3 206 41.6 66 13.3 161 32.5

The physician ask for many laboratory tests

93 18.8 86 17.4 49 9.9 267 53.9

the physician can diagnose correctly

190 38.4 158 31.9 57 11.5 90 18.2

The physician may not come and the patient leave without an examination

71 14.3 172 34.7 50 10.1 202 40.8

If another physician comes, he knows well about the patient health condition

84 17.0 51 10.3 103 20.8 257 51.9

The physician informed the patient about how to change the unhealthy habits and the healthy lifestyle according their conditions.

38 7.7 4 0.8 55 11.1 398 80.4

Table (4): Regarding the technical quality the above table revealed that (59.2%) of patients

expressed dissatisfaction from not examining their whole body. More than half of the patients

(51.9%) said that if another physician comes, he doesn't know about their health condition;

(80.4%) of patient claimed that the physician didn’t inform them about how to change the

unhealthy habits and the healthy lifestyle

Results

101

Figure (1): Patients dissatisfaction related to financial aspects

Figure (1): remarks that (54.1%) expressed dissatisfaction from high price of the medications;

(51.7%) expressed dissatisfaction from high price of the imaging investigation; (82.8 %)

expressed dissatisfaction from high price of the laboratory investigations.

100%

17%

21%

7.3%

0%

12.8%

10.5%

3.6%

0%

54.1%

51.7%

82.8%

0% 20% 40% 60% 80% 100% 120%

The ticket's price is

affordable

The medication's price

is affordable*

The imaging

investigation's price is

affordable

The laboratory

investigation's price is

affordable

Disagree

Sometimes agree

Always agree

Results

102

Figure (2): Distribution of patients according to the time management

Figure (2): remarks that (55.8%) expressed dissatisfaction from long waiting time for taking a

ticket and (93.3%) claimed that the physician didn’t stay with them enough time

0%10%20%30%40%50%60%70%80%90%

100%

Wai

ting

alon

g tim

e fo

r tak

ing

a ...

Wai

ting

a lo

ng ti

me

for t

akin

g ...

Wai

ting

a lo

ng ti

me

for i

mag

ing.

..

The p

hysici

an s

tays

with

you

e...

The p

hysici

an c

ome

on ti

me

% o

f p

ati

en

ts

Always agree

Sometimes agree

Disagree

Results

103

10.9%15.2% 15.4%

58.6%

0%

10%

20%

30%

40%

50%

60%

70%

10 minutes 11-20 minutes 21-30 minutes >30 minutes

Time in minutes

% o

f pat

ient

s

Figure (3): Distribution of patients according to the time spent for registration

Figure (3): The time taken for registration is too long as (58.6%) of patients said that they took

more than 30 minutes for registration.

Results

104

Figure (4): Distribution of patients according to the time spent for examination

Figure (4): Patients were dissatisfied about time taken for examination as (38.8%) said that they

took less than 5 minutes for examination

29.10%

8.10%

38.8%

24%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

<5 minutes 6-10 minutes 11-15 minutes >15 minutes

Time in m inutes

% o

f pat

ient

s

Results

105

Figure (5): Distribution of patients regarding the time spent for laboratory investigations

Figure (5): The patients were distributed regarding the time taken for laboratory investigation as

(43.6%) said that they took three days for the results of the investigation to appear.

43.60%

36.20%

19%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

3days 4days -Week more

Time

% o

f pat

ient

s

Results

106

Table (5): Distribution of patients according to the overall satisfaction and outcome of

care(N=495)

Always agree

Sometimes agree

Non applicable\ Uncertain

Disagree Variable

N % N % N % N % Satisfaction with care 20 4.0 47 9.5 4 0.8 424 85.7

Expectation to find a better care in the hospital

408 82.4 1 0.2 1 0.2 85 17.2

The way that people dealing with you here is good

158 31.9 121 25 - - 203 43

Expectation to find a better dealing in the hospital

216 43.6 56 11.3 34 6.9 189 38.2

Planning to come in the future 245 49.5 165 33.3 50 10.1 35 7.1

Advise the relatives to come here in future

258 52.1 153 30.9 33 6.7 51 10.3

The hospital is clean 425 85.9 55 11.1 10 2.0 5 1.0

The number of waiting chairs are suitable

51 10.3 36 7.3 30 6.1 378 76.4

The light in the waiting area is good 320 64.6 61 12.3 27 5.5 87 17.6

All what patient needs are at hospital 100 20.2 39 7.9 66 13.3 290 58.6

Physicians performance 242 48.9 175 35.4 45 9.1 33 6.7

Table (5): Regarding the overall satisfaction and outcome of care at the hospital the above table

revealed that (85.7%); expressed dissatisfaction with care; (82.4%) of patients were expected to

find a better care in the hospital ;( 43.6%) of patients were expected to find a better dealing in the

hospital; ( 76.4%) said that the number of chairs at the waiting area are few; (58.6%) said that all

what patient needs are not at hospital ;( 48.9%) are satisfied with physician performance ;( 43%)

were not satisfied with the way that people dealing with them at the hospital.

Results

107

Table (6): Distribution of patients according to their communication satisfaction level score

by background characteristics (N=495)

* Statistical significant difference (P< 0.05)

Table (6): The above table showed that the patients were more satisfied in communication with health

care providers in internal medicine clinic than general surgery clinic and there was a significant

difference in level of satisfaction between patients regarding to communication in sex, marital status,

occupation, income, visit and education.

High level of satisfaction

Moderate level of satisfaction

Dissatisfaction P value

Variable

N % N % N % Sex

Male 92 18.59 134 27.07 13 2.63 Female 51 10.30 189 38.18 16 3.23 0.000*

Marital status Single 28 5.66 37 7.47 6 1.21 Married 100 20.20 274 55.35 23 4.65 Divorced 11 2.22 6 1.21 - - Widow 4 0.81 6 1.21 - -

0.003*

Occupation Full time work 35 7.07 21 4.24 2 0.40 Part time work 45 9.09 176 35.56 12 2.42 No work 41 8.28 104 21.01 10 2.02 Student 18 3.64 22 4.44 5 1.01 Retired 4 0.81 - - -

0.000*

Clinic Internal medicine 93 18.79 181 36.57 14 2.83 General surgery 50 10.10 142 28.69 15 3.03 0.103

Income

<150 Egyptian pound 83 16.77 107 21.62 18 3.64 >150 Egyptian pound 60 12.12 216 43.64 11 2.22

0.000*

Visit First visit 44 8.89 66 13.33 12 2.42 Follow up 99 20 257 51.92 17 3.43 0.006*

Education University 38 7.68 23 4.65 6 1.21 Secondary 32 6.46 191 38.59 14 2.83 Can read & write 40 8.08 43 8.69 - - Illiterate 33 6.67 66 13.33 9 1.82

0.000*

Results

108

Table (7): Distribution of patients according to their access satisfaction level score by

background characteristics(N=495)

Table (7): The above table showed that there was a significant difference in level of satisfaction

between patients regarding to access to service in sex, marital status, occupation, clinic, income,

visit and education.


Moderate level of satisfaction Dissatisfaction P

value Variable N % N % N %

Sex Male 101 20.40 137 27.68 1 0.20 Female 106 21.41 143 28.89 7 1.41 0.000*

Marital status Single 43 8.69 27 5.45 1 0.20 Married 140 28.28 250 50.51 7 1.41 Divorced 14 2.83 3 0.61 - - Widow 10 2.02 0.00 - -

0.003*

Occupation Full time work 34 6.87 24 4.85 - -

Part time work 69 13.94 162 32.73 2 0.40

No work 81 16.36 69 13.94 5 1.01 Student 22 4.44 22 4.44 1 0.20 Retired 1 0.20 3 0.61 - -

0.000*

Clinic

Internal medicine 138 27.88 147 29.70 3 0.61

General surgery 69 13.94 133 26.87 5 1.01 0.103

Income

<150 Egyptian pound 114 23.03 89 17.98 5 1.01

>150 Egyptian pound 93 18.79 191 38.59 3 0.61 0.000*

Visit First visit 64 12.93 53 10.71 5 1.01 Follow up 143 28.89 227 45.86 3 0.61 0.006*

Education University 35 7.07 31 6.26 1 0.20 Secondary 77 15.56 160 32.32 - - Can read & write 49 9.90 29 5.86 5 1.01 Illiterate 46 9.29 60 12.12 2 0.40

0.000*

Results

109

Table (8): Distribution of patients according to their technical quality satisfaction level score by

background characteristics(N=495)


between patients regarding to the technical quality in marital status, occupation, income and

education.




Variable

N % N % N % Sex

Male 182 36.77 31 6.26 25 5.05 Female 182 36.77 45 9.09 29 5.86 0.329

Marital status Single 49 9.90 12 2.42 10 2.02 Married 299 60.40 55 11.11 42 8.48 Divorced 7 1.41 8 1.62 2 0.40 Widow 9 1.82 1 0.20 - -

0.010*

Occupation Full time work 37 7.47 16 3.23 5 1.01 Part time work 188 37.98 20 4.04 24 4.85 No work 103 20.81 32 6.46 20 4.04 Student 35 7.07 5 1.01 5 1.01 Retired 1 0.20 3 0.61 - -

0.000*

Clinic Internal medicine 205 41.41 48 9.70 35 7.07 General surgery 159 32.12 28 5.66 19 3.84 0.322

Income <150 Egyptian pound 129 26.06 47 9.49 32 6.46 >150 Egyptian pound 235 47.47 29 5.86 22 4.44 0.000*

Visit First visit 82 16.57 27 5.45 13 2.63 Follow up 282 56.97 49 9.90 41 8.28 0.057

Education University 47 9.49 18 3.64 2 0.40 Secondary 192 38.79 22 4.44 22 4.44 Can read & write 54 10.91 13 2.63 16 3.23 Illiterate 71 14.34 23 4.65 14 2.83

0.000*

Results

110

Table (9): Distribution of patients according to financial aspects satisfaction level score by

background characteristic(N=495)


between patients regarding to the financial aspects satisfaction in Marital Status, Occupation, Clinic,

Income, Visit and Education satisfaction level there’s a significant difference.




Variable

N % N % N % Sex

Male 71 14.34 162 32.73 4 0.81 Female 77 15.56 169 34.14 6 1.21 0.85

Marital status Single 29 5.86 36 7.27 4 0.81 Married 111 22.42 276 55.76 6 1.21 Divorced 2 0.40 15 3.03 - - Widow 6 1.21 4 0.81 - -

0.004*

Occupation Full time work 16 3.23 42 8.48 - - Part time work 54 10.91 173 34.95 2 0.40 No work 62 12.53 89 17.98 4 0.81 Student 14 2.83 25 5.05 4 0.81 Retired 2 0.40 2 0.40 - -

0.000*

Clinic Internal medicine 98 19.80 179 36.16 6 1.21 General surgery 50 10.10 152 30.71 4 0.81 0.05*

Income <150 Egyptian pound 80 16.16 118 23.84 18 3.64 >150 Egyptian pound 68 13.74 213 43.03 11 2.22 0.000*

Visit First visit 47 9.49 63 12.73 10 2.02 Follow up 101 20.40 268 54.14 - - 0.000*

Education University 18 3.64 45 9.09 4 0.81 Secondary 46 9.29 187 37.78 - - Can read & write 40 8.08 39 7.88 2 0.40 Illiterate 44 8.89 60 12.12 4 0.81

0.000*

Results

111

Table (10): Distribution of patients according to their perception to the provided

Services (N=495)

Table (10): This table revealed that (65.3%) and (56.6%) of patients showed moderate degree of

satisfaction in communication aspects and in access and continuity of care respectively. While

(73.5%) and (87.9%) of patients were highly satisfied in technical quality and financial aspects

respectively. The over all satisfaction and outcome of care score (66.9%).

Satisfaction scores

High

Satisfaction

Moderate

Satisfaction

Unsatisfied

Variable score

N % N % N %

Communication score 143 28.9 323 65.3 29 5.9 Access and continuity of care score 207 41.8 280 56.6 8 1.6 Technical quality and Health care providers

performance score 364 73.5 76 15.4 54 10.9

Financial aspects score 435 87.9 55 11.1 3 .6 Time management score 42 8.5 80 16.2 371 74.9 Over all satisfaction and outcome of care score 148 29.9 331 66.9 10 2.0

Results

112

Table (11): Mean satisfaction score of patients according to their perception to the provided

Services(N=495)

Table (11): The mean satisfaction score is calculated for the studied patients to consider the

responses of each individual in the sample. This table revealed that the mean satisfaction score for

communication aspect was (50.5), the mean satisfaction score for Access and continuity of care

was (44.4), the mean satisfaction score for technical quality and health care providers

performance was (70.8), the mean satisfaction score for financial aspects was (39.7), the mean

satisfaction score for time management was (64.8), the mean satisfaction score for over all

satisfaction and outcome of care was (51.9), comparing to the mean of total satisfaction score that

was (54.5).

Variable score Mean SD

Communication score 50.5 14.9

Access and continuity of care score 44.4 14.5

Technical quality and Health care providers performance score 70.8 15.6

Financial aspects score 39.7 18.4

Time management score 64.8 15.9

Over all satisfaction and outcome of care score 51.9 16.3

Total satisfaction score 54.5 6.99

Results

113

Part II: Time of Patient Flow Cycle

Figure (6): Distribution of observed patients according to the booking time in minutes

(10 patients)

Figure (6): showed that two out of ten observed patients spent more than 45 minutes and five

out of ten observed patients spent about 25 minutes in registration and booking a ticket.

3028

25

2018

40

45

22 2320

0

5

10

15

20

25

30

35

40

45

50

1 2 3 4 5 6 7 8 9 10

Number of patients

wait

ing t

ime i

n m

inu

tes

Results

114

Figure (7): Distribution of observed patients regarding waiting time after registration and

before consultation in minutes (10 patients)

Figure (7): remarks six out of ten observed patients spent more than 3 hours waiting for

examination

139 144

300

350

243

180

220190

70

248

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10

Number of patients

Tim

e i

n m

inute

s

Results

115

Figure (8): Distribution of observed patients according to the time spent in consultation in

minutes (10 patients)

Figure (8): referred that seven out of ten observed patients spent less than 12 minutes in

examination.

1011

12

9

13

109

14

11 11

0

2

4

6

8

10

12

14

16

1 2 3 4 5 6 7 8 9 10

Number of patients

Tim

e i

n m

inute

s

Results

116

Part III:

Health care providers satisfaction survey findings:

In-depth interviews with staff members from both outpatient clinics of Internal medicine and

General surgery. It took about "10" to "20" minutes with each staff member to answer the

mentioned questions in (annex ). The participants explored the problems faced during work at

the clinic and suggestions for its improvement.

Table (12): Distribution of the health care providers participated in the study and their

categories

N. of Participants Years of work

Job Category Internal

medicine

General

surgery

Internal

medicine

General

surgery

Assistant professor 1 - 15 -

Lecturer 1 3 10 9

Lecturer assistant 2 2 5-4 5-6

Resident 3 2 1-2 1-2

House officer 11 10 8 months 8 months

Nurse 2 2 7-9 7

I.Interview with health care providers at outpatient clinic of general surgery. the physicians

had expressed the following:

• The majority of health care providers expressed dissatisfaction from the following:

1. Shortage in the number of staff members with high caseload up to 60 patients/day.

فى الیوم ا مریضستونوخصوصا ان كل الحمل علیھم ده ممكن یدخل حوالى فیھ نقص كبیر فى عدد النواب فى العیادة

2. Long exhausting working hours/day up to 6 hours then we continue working in the

department. وبعدھا بنكمل فى القسمحوالى ستة ساعات فى العیادة كتیرة ومرھقة الیومىساعات الشغل عدد

Lighting at the clinic is insufficient and it needs reparation. For example: we need a

searchlight for examination. محتاجة تتظبط یعنى مثال محتاجین كشاف للكشفغیر كافیة و االضاءة

3. The clinic has a narrow space. العیادة مساحتھا ضیقة

Results

117

a. Most of the house officers and some residents expressed dissatisfaction from

unorganized patient flow (case mix) the new mixed with the follow up cases with the

employees and the referral cases. الحاالت الجدیدة والمتابعة ھناك خلط بین. مفیش تنظیم فى دخول المرضى

والموظفین والحالت المحولة

• All Health care providers suggested the following:

1. Increase the number of physicians at the clinic ة نزود عدد النواب فى العیاد

2. Decrease the number of examined patients per day تقلیل عدد المرضى الیومى

3. Obligate the senior staff to attend the clinic اجبار األساتذة على حضور العیادة

• One of Heath care providers suggested the following:

Organize the patient flow by using numbers on the ticket

. التذاكرقام علىأ ر.عن طریق وضعتنظیم دخول المرضى

• One of Health care providers suggested the following:

- Supply the deficient in supply and equipment's االالت الناقصة واالجھزة فى العیادةتوفیر

- Putting the sterile dressing that is used for a single patient in a single package instead of putting more than one dressing for more than one patient in a single package

ما یوضع كلھ مع بعضھدلوضع الشاش الذى یستخدم للمریض الواحد فى عبوة منفصلة ب

II.Interview with health care providers at outpatient clinic of internal medicine. The physicians

had expressed the following:

• The majority of Health care providers expressed dissatisfaction from the following:

1. Shortage in sphygmomanometers and thermometers. كبیر فى أجھزة الضغط والترمومتر فیھ نقص

2. Shortage in the number of staff members.

. فیھ نقص كبیر فى عدد النواب فى العیادة

3. High number of patients affect the physician concentration leading to missing important

points in diagnosis.

. مركز فى الكشف وممكن ما یاخدش بالھ من حاجات مھمة فى التشخیص مش لى الدكتوربیخ عدد المرضى الكتیر

4. Long exhausting working hours/day up to 6 hours then we continue working in the

department وبعدھا بنكمل فى القسم حوالى ستة ساعاتساعات الشغل فى العیادة كتیرة ومرھقة عدد

5. Shortage in number of nurses and their dependence on patients' registration. They don't share

in preparing the patients for examination.

Results

118

نقص فى عدد التمریض واعتمادھم على مجرد تسجیل المرضى وعدم المشاركة فى اعداد المرضى للكشف

6. Difficulty for follow up cases to reach their physicians

مش كل حاالت المتابعة بتقدر توصل للدكتور الى كشف علیھا اول مرة

7. Most patients are of low socioeconomic class so they may not do all investigations as it paid

ر مدعممش كل التحالیل واالشعة والعالج الى بیكتب بیجیبوھا ألن السعر غالى والعالج غی

8. The ultrasonography not work at the clinic جھاز األشعة الى فى العیادة مش مفعل

9. Lack of a well recording system نحتاج الى ادخال نظام الملفات فى العیادة

• The majority of house officers expressed dissatisfaction from the following:

- Most of the residents in the clinic are juniors with few experiences. Many cases escape

from diagnosis and come after that with complications

معظم النواب لسة متخرجین جدید وخبرتھم قلیلة وفي حاالت كتیر بتعدى منھم فى التشخیص وبترجع بعد فترة فى مضاعفات

- Most of the doctors at the clinic prescribe high price medications. Although there are

cheaper medications make the same effect. The people are of low socioeconomic class.

النواب بیكتبوا عالج غالى مع ان فیة حاجة أرخص تؤدى الغرض وظروف الناس الى بتاجى تعبانة

- The work in the clinic was carried most of the week by the residents.

معظم األسبوع ھو النائب ومفیش حد تانى بییجى الى بیشیل العیادة -

- Cases recommended from private clinics of the teaching staff take the upper hand in care.

درسین بتعامل معاملة خاصةالحاالت الى جایة من عیادات األساتذة والم


1. Setting up an electronic file system inside the clinic عمل نظام الكترونى متكامل للملفات فى العیادة

2. Decrease the number of examined patients per day . ومیای المفحوصین تقلیل عدد المرضى

3. Organize the patient flow using numbers on the ticketsتنظیم دخول المرضى بأرقام على التذاكر

4. Supply the deficient in supply and equipment's توفیر االالت الناقصة واالجھزة فى العیادة

5. Respect the timetable. االلتزام بجدول الحضور

• One of the Health care providers suggested the following:

- The staff should be from Fayoum

الحال علشان یتغیر الزم تكون ھیئة التدریس من الفیوم ویكون قلبھم على الناس مش بس بییجوا یقضوا ساعة ویمشوا


Results

119

- Setting up a separate clinics for each speciality in internal medicine and identify certain

days in the week for each speciality.

عمل عیادات مستقلة لكل تخصص فى الباطنة وتحدید أیام معینة فى األسبوع لكل تخصص

Interview with nurses at outpatient clinic of general surgery and internal medicine.

• All nurses expressed dissatisfaction from the following:

1. Shortage in numbers of Staff Members comparing to the number of patients.

نقص عدد االطباء بالنسبة لعدد المرضى

2. High work pressure due to large number of patient.

كبیر ألن عدد المرضى كتیرضغط العمل

• All nurses suggested the following

Increase the number of physicians. نزود عدد الدكاترة

Results

120

Table (13): Perception of the nurses to the work system at the clinic

always sometimes No Not

applicable

Variables

N % N % N % N %

Supervision by head nurse 2 50 2 50 - - - -

Working hours/day to manage the load of the patients are sufficient

4 100 - - - - -

Attend training programs - - - - 4 100 - -

The number of doctors/day are sufficient - - - - 4 100 - -

Table (13): showed that all interviewed nurses were not attend any training courses.

Results

121

Table (14): Perception of the physician to the work system at the clinic

always sometimes No Variables N % N % N %

Supervision by senior staff 16 47.1 6 17.6 12 35.3 Lighting of the clinic is adequate 19 55.9 - - 15 44.1 Ventilation is good 19 55.9 - - 15 44.1 Space of the clinic is adequate 19 55.9 - - 15 44.1 Job description is present and applied 12 35.3 9 26.5 11 32.4 Working hours/day to manage the load of the patients are sufficient 19 55.9 3 8.8 12 35.3

Attend training programs 10 29.4 24 70.6 - -

Referral policies are present and used - - - - 34 100 The number of nurses are sufficient 29 85.3 3 8.8 2 5.9 Nurses are cooperative 32 94.1 2 5.9 - - Nurses are well trained - - 15 44.1 - -

The patient sheet contain complete data - - - - - -

There's feedback for referral cases between departments of the hospital 21 61.8 3 8.8 10 29.4

There's feedback for referral cases between other hospitals - - 3 8.8 31 91.2 There's continuous update for knowledge of diagnosis - - 4 11.8 30 88.2 There's continuous update for treatment methods - - 4 11.8 30 88.2 It is easy for follow up cases to reach to their physician? 2 5.9 6 17.6 26 76.5 The number of doctors working in the clinic are sufficient - - - - 34 100 All prescribed drugs at the hospital are available - - - - 34 100. All investigations needed for the patient at the hospital are available 5 14.7 - - 29 85.3

Table (14): The above table could provide an overview about perception of the physician to the

system of work at the clinic. They reported that the nurses were sufficient in numbers and they

were cooperative. All of them said that there's no referral policy, not all drugs were present at the

hospital and the number of doctors were not sufficient at the clinic. (88.2%) said no continuous

update for knowledge and treatment methods (76.5%) said that the cases cannot reach their

physician easily and (85.3%) said that not all investigations needed for the patient were available

at the hospital.

Results

122

Table (15): Total numbers of Internal Medicine and General Surgery outpatient clinics

attendants according to hospital statistics in four selected months (2010)

Table (15): this table demonstrated the workload for the resident at both clinics, with the total

outpatient of Internal Medicine in year (2010) was accounted for (1223) patients in October 2010

/ working day.

April

(2010)

August

(2010)

September

(2010)

October

(2010)

Average

number\year

Internal Medicine 1318 1067 814 1223 13266

General Surgery 1142 1015 901 1228 12858

Results

123

Table (16): Observation of physicians at outpatient clinic of General Surgery and Internal

Medicine regarding doctor / patient communication and patient rights

NA No Yes % No. % No. % No.

Variable

- - 84.6 126 15.4 23 The doctor greets the patient

- - 100 149 The doctor show respect to the patient

- - 61.1 91 38.9 58 The doctor gives the patient enough time to describe his/her

complain

- - 69.2 103 30.9 46 The doctor gives patient his/her full attention

- - 77.9 116 22.1 33 The doctor sometimes ignore what the patient tells him

- - 10.1 15 42.3 63 The doctor explains to the patient his\her medical problems

- - 85.2 127 14.8 22 The doctor prescribes medications

75.8 113 24.2 36 - - The doctor gives patient choices when deciding his/her

medical care

- - 100 149 - - The doctor gives the patient choices when deciding his/her

treatment

- - 79.9 119 20.1 30 The doctor explains to the patient the diet his/her should

follow

18.1 27 71.8 97 10.1 15 The doctor explains to the patient the investigations his/her

should do

22.8 34 71.8 107 5.4 8 The doctor explains the reasons for medical tests

69.8 104 10.1 15 30.2 45 The doctor explains the place of referral if needed

- - - - 85.2 127 The doctor hurries too much when treat patient (<15 minutes)

- - 100 149 - - The doctor pays attention to the patient's privacy

- - 65.1 97 34.9 52 The doctor do his/her best to keep the patient from worrying

- - 95.3 142 4.7 7 The doctor sometimes use medical terms to the patients

without explaining

- - 38.3 57 61.7 92 The doctor tells the patient the time of the next visit

- - 100 149 - - The doctor's office has everything needed to provide complete

medical care

Results

124

Table (16): this table revealed that (84.6%) of the patients not welcomed by the physician, and

(61.1%) of the physicians didn’t give enough time to of patients to describe their complain. The

physician didn’t explain the investigations his/her should do to (71.8%) of the patients, The physician

didn’t explain the diet his/her should follow to (79.9%) of the patients, The physician didn’t pay

attention to the patient's privacy for all patients, The physician sometimes use medical terms to the

patients without explaining with (95.3%)

Results

125

Table (17): Observation of physicians at outpatient clinic of General Surgery and Internal

Medicine regarding technical quality

Yes No Variable No. % No. %

The doctor asks/or the patient tells about present history 149 100 - - The doctor asks/or the patient tells about past history 85 57 64 52 The doctor asks/or the patient tells about family history - - 149 100 The doctor asks/or the patient tells about medical history 44 29.5 105 70.5 The doctor does a general examination 33 22.1 116 77.9 The doctor does a abdominal examination 115 77.2 34 22.9 The doctor does a chest examination 79 53.0 70 47 The doctor or the nurse measures the pulse 25 16.8 124 83.2 The doctor or the nurse measures the temperature - - 149 100 The doctor uses a stethoscope 100 67.1 49 32.9 The doctor uses a sphygmomanometer 79 53 70 47 Table (17): The above table showed that the physician didn’t ask the patient about family history

for all selected group, the physician didn’t ask the patient about medical history for (70.5%) the

physician didn’t do general examination for (77.9%) the physician didn’t measure the pulse for

(83.2%) the nurse didn’t measure the temperature for all selected group.

Results

126

Table (18): Observation of nurses at outpatient clinic of General Surgery and Internal

Medicine regarding technical quality

Yes No Variable

No. % No. %

The nurse greets the patient - - 149 100 The nurse shows respect the patient 149 100 - -

The nurse registers the patient 149 100 - -

The nurse Measures blood pressure - 149 100 The nurse helps the doctor during examination - - 149 100

Table (18): The above table showed that the nurse didn’t greet any one of the patients, the nurse

didn’t measure blood pressure and the nurse didn’t help the doctor during examination in the all

observed patients.

Results

127

Part IV:

Table (19): System Analysis of the input of Internal Medicine and Surgery clinics

Input Internal Medicine General Surgery

- Both the outpatient clinic of Internal Medicine and General Surgery serves about more

than 1000 patients per month according to the hospital record of outpatient clinics

(2010)

Man power

- The number of health care providers

was (2nurses/one physician) examined

more than 60 case per day

- About 5 house officers /clinic

- The number of health care providers

was (1nurse/3 physician) examined

more than 60 case per day

- 2 house officers /clinic

- Both the outpatient clinic of Internal Medicine and General Surgery have one table for

the nurse to register and 4 chairs

- One sphygmomanometer/one physician

and about 5 house officers /clinic

- No direct source of light

- No sphygmomanometer

- Both the outpatient clinic of Internal Medicine and General Surgery have one

Stethoscope and one thermoter

infastructures

- Three Examination beds is present

separated by partitions to examine

three patients at the same time

- Two Examination beds is present

separated by partitions to examine two

patients at the same time

Hand washing facilities

- No hand washing facilities (no

disinfection, no tools for hand drying,

sink at separate partition of the clinic)

- No hand washing facilities( no

disinfection, no tools for hand drying,

sink)

Educational material

- Posters and brochures at clinic for

information ,education, communication

are present in few number

- No Posters or brochures at clinic for

information, education,

communication

Results

128

Table (20): System Analysis of the process in Internal Medicine and Surgery clinics

Process Internal Medicine General Surgery

- Both the outpatient clinic of Internal Medicine and General Surgery were working all the

days of the week

- Both the outpatient clinic of Internal Medicine and General Surgery had weekly regular

staff round for updating the knowledge

- Both the outpatient clinic of Internal Medicine and General Surgery had unorganized

patient flow

- Both the outpatient clinic of Internal Medicine and General Surgery had a long waiting

time before consultation according to the results of the study

- Both the outpatient clinic of Internal Medicine and General Surgery had the medications

and investigations are not affordable for the patients.

- Both the outpatient clinic of Internal Medicine and General Surgery had the ticket price

is in an affordable price for the patients

- Both the outpatient clinic of Internal Medicine and General Surgery had no referral

polices

- Both the outpatient clinic of Internal Medicine and General Surgery had no organized

system for follow up cases

- Both the outpatient clinic of Internal Medicine and General Surgery had no separation

between the follow up cases and the new cases

- Both the outpatient clinic of Internal Medicine and General Surgery had no team work

coordination between the outpatient doctor and the other health care providers

- Both the outpatient clinic of Internal Medicine and General Surgery had no collaboration

between the nurse and the physician during patient examination (nurse registers the

patients only)

- No health education messages given to

targeted patients by the doctors in charge.

- There were some few brochures to raise

the awareness and provide simple

- No health education messages given

to targeted patients by the doctors in

charge.

Results

129

information

- Both the outpatient clinic of Internal Medicine and General Surgery had Poor healthcare

providers /patient communication

- Not all the health care providers attend

the clinic as present in the table of

attendance (the resident was attended

alone at the clinic most of the days) this

was observed for two weeks.

- Most of the health care providers

attend the clinic as present in the

table of attendance this was

observed for two weeks.

- Absence of supervision by the medical

staff

- Presence of supervision by the

medical staff

- Both the outpatient clinic of Internal Medicine and General Surgery their patients not

diagnosed by the resident wait till end of the clinic to be taken to the teaching staff

members

- Both the outpatient clinic of Internal Medicine and General Surgery had no free

medication

- Both the outpatient clinic of Internal Medicine and General Surgery had no plan for

patient education

Results

130

Table (21): System Analysis of the output of Internal Medicine and General Surgery clinics

output Internal medicine General surgery - Increase work load that affected on the

patient rights.

- Increase work load that affected on the

patient rights.

- The interviewed patients reported their

dissatisfaction from services offered

according to the displayed results

- The interviewed patients reported their

dissatisfaction from services offered

according to the displayed results

- The health care providers expressed

their dissatisfaction with the system at

the clinic

- The health care providers expressed

their dissatisfaction with the system at

the clinic

- Loss of patient time - Loss of patient time

- Loss of resources - Loss of resources

- Escaped cases from diagnosis - Escaped cases from diagnosis

Results

131

Part V

Table (22): SWOC Analysis of the work system at both clinics

Strengths:

• Serve wide base of

population

• There's statistical office at hospital

• Group of qualified staff • Equitable access to

healthcare for all • Written policies on

patients’ rights are

available, disseminated, or

made visible to patients

Weakness:

• Deficient policy for assessing reliability and validity of

work system at the clinic in each department and the

introduction of new assessment methods.

• Lack of standard practice guidelines.

• Deficient policy for coordination between departments.

• Expected staff resistance to attend the clinic

• Lack of experience for providers attending the clinic

• Shortage in physicians staff with high patients load

• Double burden on physicians ( inpatient and outpatient)

• Deficient equipment's

• Patient privacy not well maintained (no curtains on

windows, the clinic divided into three partitions in away

doesn't maintain the patient privacy in a complete way also

more than one patient at the same clinic

• No training courses for outpatient physicians and nurses)

• The only source for learning is the staff round

• The job of the nurse at the clinic is task-oriented

• Patient rights are not well maintained

• Referral policies are not applied

• Poor doctor/patient/nurse communication

• No organized team work at the clinic

• No periodic supervision on the clinic

• Job description not applied

• Deficiency in recording system

Results

132

• Storage of the medical record is not organized

• No continuous update of methods of treatment

investigations

• No financial support for medications and investigations

• Not all medications and investigations are available

• Long registration time >2hours

• Short examination time <10 minutes

• Lack of signs that refer to the direction of the clinics

• Lack of posters and brochures for information

• No hand washing facilities

• Infection control measures are not applied

• Waiting area is not suitable to the patient load

Opportunities

• Have a high political and

public profile.

Challenges

• No clear policy for outpatient management

• No actual support from higher authorities

• Laws allow physicians and nurses to combine working in

both the public and private sector.

Discussion

133

Discussion

The present study aimed to assess the work system at outpatient clinics of General Surgery

and Internal Medicine at Fayoum University Hospital and addressed the important issues related

to the health care which form the corner stone for achieving the goal of health program. The study

is concerned with continuous quality improvement through patient-provider satisfaction surveys

(PPSS); direct the attention of policy makers for action taking and adapting alternative strategies

to improve efficiency and effectiveness of hospital care and satisfaction of internal and external

customers. This was done through assessment the work climate and the work discipline.

The study intervention depends on the collaboration between the Public Health &

Community Medicine department and the other clinical departments in setting up a health

education and communication unit aim to empower the patient, improve communication

skills and raise the satisfaction of both the internal and external customers as a step of

quality improvement.

The current study focused on the importance of patient and provider satisfaction survey and

based on utilizing the findings of PPSS. The study emphasized an important issues related to the

work system at outpatient clinics at Fayoum University Hospital. This was done through four

domains: patient satisfaction, health care providers’ satisfaction, observation of health care

providers’ performance, observation of the work area and measuring the time taken by the patient

to receive the service.

To measure user satisfaction in the health care service is not a simple task. Contrary to what

happens in the area of service provision, which takes public opinion into high account,

satisfaction expressed by users in the health sector is generally seen with disinterest or even

suspicion. Sullivan (2003) insisted on evaluation of quality must be based on both objective and

subjective criteria, the latter being those related to the users.

Discussion

134

(I )Analysis of the work system

Pitaloka and Rizal, (2006) reported that it is important to evaluate the health care system.

There are many reasons for evaluation of care, as to improve accountability, to raise standard and

quality of care, to improve responsiveness to patients, to monitor health care seeking behaviour,

to improve patients' compliance with care, and to improve outcomes of care.

(A)System input

In the current study analysis of the system of Internal Medicine and Surgery clinics

inputs revealed that there was deficient in clinics infrastructures (table 19).

A study was done by (Prahlad Rai Sodani,etal., 2010) revealed that (83%) of the patients

chose the public health facilities due to good infrastructure.

The current study showed that both the two departments have no mission, no clear

policies regulate the coordination between different hospital departments and deficient

policy for assessing reliability and validity of work system at the clinic in each department.

This result was in contrary with Carney (2009) that emphasized the importance of mission

statement as a tool to improve organizational performance; also keeps staff focused on

professional care delivery.

The two departments also were lack of standard practice guidelines and lack of

experience for health care providers attending the clinics.

Moret et al. (2008) explained that one of the raised issues related to technical performance

is lack of standard practice guidelines. Physicians are exposed to experiences of the professional

staff members that could have different views, and influence strategies for patient management.

The current study declared that Job description was not applied and there was no

organized periodic supervision by the staff on the clinic.

Discussion

135

Susan, (2010) and Conley, (2010) referred to the importance of job description as

communication tools that are significant in organization's success. Poorly written job descriptions,

lead to workplace confusion and make people feel as if they don't know what is expected from

them. Also Rhode, (2006) reported that supervision improves services by focusing on meeting

staff needs for management support, logistics, and training and continuing education.


inputs, showed that there were few posters and brochures for information, education, and

communication which is very important in initiating patient education (table 19).

This was declared by Conrad, (2010) that using educational posters to educate a group of

workers or inform visitors can be a big help.

(A)System process

In the current study analysis of the system of Internal Medicine and General Surgery

clinics process showed that there was unorganized patient flow (table 19).

Cote M. (2000) said that understanding patient flow is one of the keys for any health care

facility to deliver its services efficiently. It was pointed out by Cote (2000) that one of the major

elements in improving efficiency in the delivery of health care services is patient flow.

(Potisek et al (2007) referred to unorganized patient flow processes increase waiting times

and decrease patient satisfaction. Decrease in patient satisfaction can affect patient return rates,

which is a necessary component of treating patients with chronic conditions. Quality

improvement efforts can help to overcome the barriers to effective patient flow by decreasing

patient waiting time, thus improving the efficiency of care.

In the current study analysis of the system of Internal Medicine and General Surgery

clinics process showed that there were no separation between the follow up cases and the

new cases, no team work coordination between the outpatient doctor and the other health

Discussion

136

care providers, no collaboration between the nurse and the physician during patient

examination (nurse registers the patients only) (table 20).

Canadian Health Services Foundation Research (2006) stressed on a healthcare system

that supports effective teamwork can improve the quality of patient care, enhance patient safety,

and reduce workload issues that cause burnout among healthcare professionals. Teams work most

effectively when they have a clear purpose; good communication; co-ordination; protocols and

procedures; and effective mechanisms to resolve conflict when it arises. The active participation

of all members is another key feature. Successful teams recognize the professional and personal

contributions of all members; promote individual development and team interdependence;

recognize the benefits of working together; and see accountability as a collective responsibility.


process showed that, no referral polices (table 20).

Cervantes K. et al., (2003) said that an effective referral system ensures a close

relationship between all levels of the health system and helps to ensure people receive the best

possible care closest to home. It also assists in making cost-effective use of hospitals and enhance

access to better quality care. Clients receive optimal care at the appropriate level and not

unnecessarily costly, Hospital facilities are used optimally and cost-effectively and Clients who

most need specialist services can accessing them in a timely way.


process showed that not all the health care providers attend the clinic as present in the table

of attendance and there was absence of supervision by the medical staff (table 19).

Bush RW.(2010) referred that supervision is important in allowing residents to receive

guidance for giving and coordinating care, even as they progress toward independent practice.

residents who were more closely supervised through direct observation acquired primary-care

skills more rapidly than those who were supervised after the fact.

Discussion

137

A classic study was done by (Boor K. et al., 2008) showed that when faculty physicians

personally examined patients cared for by residents, they reached different conclusions about the

severity of patients’ illness, diagnosis, treatment and required follow-up and were more critical of

the residents’ assessment and care plan than when they provided remote supervision.

(II) Patient satisfaction survey (PSS):

The tool used in patient survey is a structured questionnaire form, where data were collected

through interviews. The researcher had designated the questionnaire form with consideration to:

1- accessibility of the healthcare, 2- quality of care, 3- patient rights. So the questionnaire covered

four areas (Is the patient satisfied with the medical care?), (Is the patient satisfied with

accessibility of medical service?), (Is the patient satisfied with the interpersonal issues?), (Is the

patient satisfied with the financial aspect of care?).

The current study included measurement of patient satisfaction from communication

with health care providers and reported that more than half of the patients expressed

dissatisfaction from not being greeted from physician; and not being asked about their

names before examination (table 2). Regarding the communication score (65.3%) of patients

showed moderate degree of satisfaction (table 10).And the the mean satisfaction score for

communication aspect was (50.5) (table 11).The researcher observed that (84.6%) of the

patients were not welcomed by the doctor, the doctor didn’t give enough time to (61.1%) of

patients to describe their complains and the doctor sometimes ignore what the patient told

in (77.9%) of patients (table 15).

A study was done by (Yousef Hamoud Aldebasi and Mohamed Issa Ahmed, 2011) in

Qassim resulted in (7%) of the patients believed that sometimes the doctors ignored the patients

and (36%) of the patients felt that doctors were not providing enough time to the patients to

satisfy their queries and the majority of the patients (40%) said that the physicians were working

seriously and impartially for the patients.

Discussion

138

Rainer SB et al. (2002) declared that The character of doctor- patient interactions

influences a variety of patient outcomes, including short-term outcomes such as satisfaction and

recall, intermediate outcomes such as adherence, and long-term outcomes such as symptom

resolution and quality of life.

A health care provider’s ability to form a therapeutic relationship with patients’ and

subsequently influence health outcomes could be strengthened through improving the provision of

whole person care. Langen et al. (2006) compare patient’s satisfaction with expectations of the

medical staff. The patients generally showed a high degree of satisfaction with communication

and support by the health care providers. Patient – centered communication is found to be crucial

factor influencing patient satisfaction and likewise compliance. Patients attending each hospital

are responsible for spreading the good image of the hospital and therefore satisfaction of patients

attending the hospital is equally important for hospital management.

In the current study, The investigator observed that the doctor didn’t prescribe the

medications for (85.2%) of patients, The doctor didn’t give choices when deciding the

treatment for any of the patients, The doctor didn’t explain the investigations that his/her

should do to (71.8%) of the patients, The doctor didn’t explain the diet his/her should follow

to (79.9%) of the patients (Table 15).

A study was done by (Saadoun F. Al-azmi,et al. 2006) In Kuwait, Primary Heath Care

Centers showed that The majority of interviewees (97%) were satisfied from examination and

accuracy of diagnosis and the advices that were given by the physician to follow to avoid illness

and the lowest items of satisfaction were those related to explanation of medical procedures and

tests (46.5%).

Lehman et al. (2009) insisted on that good doctor-patient communication has a positive

impact on patient satisfaction, adherence to treatment, health outcomes and well-being, and it has

been linked to reduced anxiety, increased recall and improved understanding. During the

diagnostic phase and the course of the illness, patients exhibit a range of mood changes. These

include sadness and worry, frustration and anger, uncertainty, fear of disease recurrence,

Discussion

139

difficulties in inter-personal relationships, changing roles, and concerns about body image.

Medical consultations can be influenced by different expectations concerning the doctor-

patient interaction, by individual roles and beliefs and by a different understanding of health and

well-being, influenced by cultural and other factors not necessarily associated with the medical

situation.

Fornazari et al. (2006) directed attention to the fact that most of the physicians do not

introduce themselves to the patients during the visit or ask about their names. Maybe concerned

with the medical task about to be performed, resident physicians, who most of the time establishes

the first medical contact with the patient, overlook creating that link. In addition, at each return

visit, service may be provided by a different professional, according to a scheduling. In public

health services, doctor patient relationships tend to be impersonal, a link being formed with the

service itself, but not between people. The link established in a doctor-patient relationship is one

of the essential elements for the creation of a quality practice, allowing for the increase in

efficiency of health actions.

In the current study the investigator observed that the doctor didn’t pay attention to

the patient's privacy for all patients (table 15) and more than half of the patients (68.7%)

were unsatisfied from examining more than one patient at the clinic (table 2).

This disagree with a study was done by (Gadallah M. et al.,2003) to measure patient

satisfaction in upper and lower Egypt showed that level of privacy in the consultation room was

described as unsatisfactory by (33%) of the patients.

This also disagree with a study was done by (Jawahar SK. 2007) on Out Patient

Satisfaction at a Super Specialty Hospital in India showed that With regard to the privacy in

consultation (97.5%) of the patients were satisfied.

A study was done by (Zewdie Birhanu,Tsion Assefa, et al. 2010) in central Ethiopia

declared that (22.9%) of the respondents claimed that their privacy was not respected during

Discussion

140

consultation and (19.9%) of the respondents felt that the consultation rooms did not provide

adequate privacy.

This can be explained that there was a shortage in the physicians with increase number of

patients per physician and the physician wants to finish in the allocated time for the clinic. This

will lead to poor patient doctor communication, the patient becomes uncomfortable and this lead

to he will not tell the doctors points that may be important in diagnosis. The patient will not

respond to the treatment and this lead to increase the unnecessary return visits and increase

number of patients attending the clinic that lead to increase case load and so on.

The current study included measurement of patient satisfaction from the degree to

which the patient rights is maintained and reported that nearly half of the patients (49.3%)

expressed dissatisfaction from not explaining how to take the medicine. More than half of

the patients (60.2%) expressed dissatisfaction from not giving them choices in treatment

(clinical or surgical) and more than half of the patients (52.1%) expressed dissatisfaction

from not giving them choices in medications (syrup or tablets or injection) (Table 2). The

investigator observed that that seven out of ten observed patients spent less than 12 minutes

in examination (figure 8).

This agree with a study was done by (Md. Ziaul Islam and Md. Abdul Jabba,2008) to

measure the patient satisfaction at Dhaka outpatient revealed that half of the patients (47.9%)

were dissatisfied because the treatment was not explained and/or enough information was not

given.

This disagree with a study was done by (Yousef Hamoud Aldebasi and Mohamed Issa

Ahmed, 2011) revealed that only (27%) of the patients believed that sometimes the doctors

ignored the patients complain and (36%) of the patients felt that doctors were not providing

enough time to the patients to satisfy their queries. A study was done by (Saadoun F. Al-azmi, et

al.,2006) In Kuwait, Primary Heath Care Centers showed that the lowest items of satisfaction

were those related to explanation of medical procedures and tests (46.5%).

Discussion

141

Lis et al. (2009) declared that patients are usually not in a position to reliably judge the

accuracy of a diagnosis or treatment plan, but they can judge whether they have been provided

with sufficient information, and they can judge the demeanor and attitudes of their physicians.

Reassuringly, these latter factors are under the direct control of medical staff, which makes it

possible for patient satisfaction to be improved with appropriate efforts. Informing the patients

about different aspects of their health care is an important aspect of management. Also, treating

patients as co-participants in the process of decision-making have been repeatedly emphasized as

an important patient’s right.

Stewart (1995) said that when patients are well-informed and participate in treatment

decisions, their anxiety decreases and their therapeutic adherence improves, thus increasing the

chances of getting better health outcomes. Improving the physician's interpersonal skills can

increase patient satisfaction, which is likely to have a positive effect on treatment adherence and

health outcomes.

This study revealed that (80.4%) of patient claimed that the physician didn’t inform

them about how to change the unhealthy habits and the healthy lifestyle and the investigator

observe that The doctor didn’t explain the diet his/her should follow to (79.9%) of the

patients and that doctor sometimes use medical terms to the patients without explaining

with (95.3%) of the patients (table 4).

This agree with a study was done by (Zewdie Birhanu et al. 2010) showed that only

(33.3%) of the respondents were given advices on how to prevent the reoccurrence of their current

illness and other similar conditions in the future. Only (45.2%) of the patients were told to return

if their symptoms get worse.

This disagree with a study was done by (Saadoun F. Al-azmi et al.,2006) In Kuwait,

Primary Heath Care Centers showed that The majority of interviewees (96%) were satisfied the

advices that were given by the physician to follow to avoid illness.

Discussion

142

Fornazari (2006) referred to that post-visit quality is one of the factors that may affect

service satisfaction and efficiency. The continuity established by post-visit informative and

educative actions is part of service quality. Lack of this information by the health team about the

treatment to be given may cause unnecessary returns. Would an efficient health education

program exist, with participation of physicians and health care professionals, many patients would

be able to adjust their social needs to their health conditions, thus resulting in the decrease of

unnecessary visits that burden the institution and society.

Explanations given by doctors are frequently forgotten or not understood and as a result of

this poor communication, recommendations are frequently not followed. In spite of stating that

he/she understood the explanation, the patients may have felt ashamed to declare having

difficulties in understanding the medical jargon. All service providers in the current study find

striving to fulfill his item due to high caseload. Also there’s difficulty to communicate with non-

educated patients. The current study intervention focused on how to disseminate this concept.

This study revealed that nearly half of the patients expressed dissatisfaction from not

answering their questions by the nurse and said that the security men not dealing with them

well (table 2).

This disagree also with a study was done by (Gadallah M. et al.,2003) to measure patient

satisfaction in upper and lower Egypt showed that (99.6%) of respondents were satisfied with the

performance of nurses.It also inconsistent with the result of a study was done by (Omar Awwab,

et al. 2012) showed that patients’ satisfaction with nursing care is high (96.8%).

The study conducted by Matiti and Trorey (2008) emphasized on importance of nursing

care in maintaining patient’s dignity. There are six themes related to the maintenance of dignity

are: privacy, confidentiality, choice and involvement in care, communication, respect and the

need for information. Spetz (2008) said that many health care leaders prefer to conceptualize

workload as a nurse-to-patient ratio, such as “one nurse for every five patients.

Discussion

143

The study conducted by Olgu et al., (1999) on patient satisfaction in Turkey had shown that satisfaction from physician’s performance achieved the highest score, followed by nurses .Such finding observed in both the public and private hospitals.

Delman and Beineke, (2005) affirmed that the major reason of patient satisfaction was

the believing that the health providers treating them with respect and dignity and that they felt better as a result of the service.

This study revealed that (54.1%) expressed dissatisfaction from high price of the

medications; (51.7%) expressed dissatisfaction from high price of the imaging investigation;

(82.8 %) expressed dissatisfaction from high price of the laboratory investigations (figure 1).

This agree with a study was done by (Gadallah M. et al.,2003) to measure patient

satisfaction in upper and lower Egypt declared that most of the respondents expressed

dissatisfaction from un availability of most of medications and laboratory tests at the units with

high price of medications and tests.

A study was done by Jayasinghe et al., (2008) revealed that worsened functioning has

been found to be associated with dissatisfaction with the ease and costs of care because patients

with a poor health status have higher expectations. Another study was done by Schmittdiel et al.,

(2008) illustrated that patients with higher quality of life evaluate chronic care management better

while patients with lower physical and mental health status scores were significantly less satisfied

with the availability of care.

A Study was done by Dyah and Rizal, (2006) examining the cost of care have found that the

higher the cost, the lower the level of patient satisfaction.

Regarding patient satisfaction from access to care, continuity and choice of care

revealed that (49.7%) expressed dissatisfaction from not directed by the security (table 3).

This also disagree with a study was done by (Jawahar SK. 2007) on Out Patient

Satisfaction at a Super Specialty Hospital in India showed that The guidance was provided to 59%

Discussion

144

of the patients by the Medico Social Workers and 40% of patients by the security staff and nurses

were perceived as friendly by 61%.

The study revealed that nearly half of the patients were satisfied from giving the

referred patient a referral paper and assignment an appointment by the physician to the

patient for follow up visit (table 3).

Salisbury et al., (2007) said that satisfaction with access could be determined by

organizational aspects, such as obtaining referrals, ease of arranging appointments, and the

opportunity to be seen on the patient's day of choice.

Regarding patient satisfaction from access to care, continuity and choice of care

revealed that (79.8%) expressed dissatisfaction from not choosing physician (table 3).

This study agree with a study was done by (S. Bu-Alayyan, A. Mostafa,et al.2008) in

Kuwait which have shown that continuity and being seen by a particular doctor improve

concordance and satisfaction.

A study was done by (Saadoun F. Al-azmi,et al.,2006) In Kuwait, Primary Heath Care

Centers showed that the lowest items of satisfaction were ease of seeing physician of choice

(61.0%).This finding disagree with a study was done by declared that Patients often request to

see particular doctors, but this was not shown to influence their satisfaction.

A study was done by (Zewdie Birhanu,Tsion Assefa, et al. 2010 in central Ethiopia

revealed that (64.6%) of the respondents didn’t previously know the health care provider who

treated them.

The relation between patient satisfaction and accessibility to care had been studied by De

Boer et al., (2010). The study illustrated that patients with better self-reported health status have

rated their satisfaction with access to care better than those with poor health.

Discussion

145

A study was done by Jayasinghe et al., (2008) showed that Patients' satisfaction with

accessibility has been found to be associated with a number of patient characteristics such as age,

self-reported health status, and quality of life. In general, patients with better self-reported health

status have rated their satisfaction with access to care better than those with poor health. Another

study was done by Schmittdiel et al., (2008) has been reported that patients with higher quality

of life evaluate chronic care management better while patients with lower physical and mental

health status scores were significantly less satisfied with the availability of care.

In this study more than half of the patients (51.9%) said that if another physician comes,

he doesn't know about their health condition (table 4).

A study was done by (Saadoun F. Al-azmi,et al.,2006) In Kuwait, Primary Heath Care

Centers resulted in that (72.4%) of patients were unsatisfied due to inability to see the same

physician in every visit.

A study was done by (S. Bu-Alayyan, A. Mostafa,et al.2008) in Kuwait which have shown

that only (30 %) admitted their ability to see their regular physician always and (33. %)

sometimes.

Post-visit quality is one of the factors that may affect service satisfaction and efficiency. The

continuity established by post-visit informative and educative actions is part of service quality.

Lack of this information by the health team about the treatment to be given may cause

unnecessary returns. Existence of an efficient health education program, with participation of

physicians and health care professionals, many patients would be able to adjust their social needs

to their health conditions, thus resulting in the decrease of unnecessary visits that burden the

institution and society.

In this study the researcher found that there are some factors affecting patient

satisfaction with accessibility of services as there was significant difference in level of

satisfaction between patients regarding to access to service in marital status, occupation,

clinic, income, visit and education (table 7).

Discussion

146

This disagree also with a study was done by (Gadallah M. et al.,2003) to measure patient

satisfaction in upper and lower Egypt showed that There was no association between overall

patient satisfaction and age, gender, education level or type of service received.

In this study the researcher found that the satisfaction score of access to services was

(41.8%) highly satisfied and(56.6%) moderately satisfied (table 10).And the mean

satisfaction score for Access and continuity of care was (44.4) (table 11).

This disagree with a study by (Kaja Põlluste,et al.,2012) in Estonian revealed that half of

the respondents were either satisfied (14%) or somewhat satisfied (36 %) with their access to

health services.

Regarding the technical quality, more than half of the patients (59.2%) expressed

dissatisfaction from not examining their whole body. This occurred due to shortage in

physician numbers and absence staff from attending the clinic most of the days in addition

to high patient flow that affect the quality of care (table 4).

Kleeberg et al. (2008)stressed on that it has become increasingly important for health care

professionals to systematically measure patients’ satisfaction with their care. Measuring patient

satisfaction involves evaluating patient’s perceptions and determining whether they felt that their

needs were adequately met.

Tabolli et al. (2003) clarified that Identification of patient requests, needs and judgment on

health care received is the starting point of a patient centered approach. Therefore patient

satisfaction is considered as an important measure to evaluate the quality of health services and

can predict both compliance and utilization that is associated with the continuity of care, the

doctor's communication skills and confidence in the medical system. Patients can participate in

evaluation of quality of heath care in three ways: by defining what is desirable or undesirable (i.e.

setting standards of care), by providing information that permits others to evaluate the quality of

care; and by expressing satisfaction or dissatisfaction with care.

Discussion

147

The study recommendation were directed to involvement of the house- officers in health care

through hand on training, following standards of case taking- and patient centered care was

necessary. This intervention helps capacity building of the house-officers and organizing them to

work as team with other service providers and staff members.

Regarding the financial aspects of care the study revealed that all interviewed patients

were satisfied with the price of the ticket; (54.1%) expressed dissatisfaction from high price

of the medications (figure 1).

This agree with a study was done by (Gadallah M. et al.,2003) to measure patient

satisfaction in upper and lower Egypt referred that (95%) of patients satisfied from the price of the

tichets (1 Egyptian pounds).

These findings are inconsistent with the results of a study was done by (Iliyasu Z.et

al.,2010) in Nigeria revealed that (27%) of the patients were dissatisfied with cost of treatment. It

also inconsistent with the result of a study was done by (Omar Awwab, et al. 2012) showed that

The lowest rating was for the cost of medicine at pharmacy 28.2% patients considered medication

costly and expensive.

About (51.7%) of the patients expressed dissatisfaction from high price of the

imaging investigation; (82.8 %) expressed dissatisfaction from high price of the laboratory

investigations (figure 1).

This disagree with a study done by (Omar Awwab et al. 2012) showed that (96.1%) were

satisfied with the laboratory services at hospital and (95.3%) rated ultrasound and radiological

services as satisfactory.

Bentur et al. (2004) revealed that the cost of care has also been found to be a reason for

dissatisfaction with access to care and they found that the higher the cost, the lower the level of

patient satisfaction.

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148

Regarding the time management the study revealed that (55.8%) expressed

dissatisfaction from long waiting time for taking a ticket (93.3%) claimed that the physician

didn’t stay with them enough time (figure 2). the investigator observed that six out of ten

observed patients spent more than 3 hours after registration and before examination (figure

7).

This agree with a study was done by (Abdullateef A. Alzolibani 2011) revealed that (48%)

felt that the consultation time was inadequate and (36.7%) felt that they were not allowed to

express their symptoms in details. He suggested that Informing patients about different aspects of

their health care is an important aspect of management. Also, treating patients as co-participants

in the process of decision-making have been repeatedly emphasized as an important patient’s

right.

Nicholas (2007) Said that the Patient Flow Analysis (PFA) process outlines the care

process, and measures time spent in each phase of the clinic visit, a potentially effective and

efficient technique to collect data and evaluate the effect of interventions to improve patient visit

efficiency by decreasing wait time in clinic. Once PFA is performed in clinic, potential targets for

improvement can be identified to reduce bottleneck effects in the patient visit, and provide

objective data to improve utilization of existing resources. If measures are not easily obtainable,

data collection can be an impediment to successful change. Easily replicated in clinic settings,

PFA allows staff to evaluate their services, identify problems, and attempt to develop workable

solutions fostering a sense of ownership of both problems and solutions among clinic staff. In an

early evaluation of its use in two busy family planning clinics in Kenya, feedback on waiting

times at different stages of an office visit were used to re-engineer work flow, resulting in 33 to

50% reductions in total visit length.

In this study about (58.6%) of the patients said that they took >30h for registration ;(

38.8%) said that they took<5 minutes for examination and (43.6%) said that they took three

days for labs (figure 3, 4, 5).

Abdullateef A. Alzolibani, (2011) stressed on that the examination time could be variable

corresponding to the nature of the disease, that is, it can be as short as 10 min or as long as half an

Discussion

149

hour and also spending longer time with the patient may pose a problem to treating physicians in

busy clinics.These findings are supported by the findings of a study was done by (Bamidele AR

.2011) in South Africa revealed that (63.9%) were unsatisfied with the time spent in the facility.

This agree also with a study was done by (Jawahar SK. 2007) on Out Patient Satisfaction

at a Super Specialty Hospital in India showed that 57% said that they need to wait occasionally

for long hours and the waiting time for consultation seems to be delayed; in some cases it extends

to more than three hours. With regard to the time spent by the doctors during consultation 96.5%

of the patients were satisfied.

As the waiting time is variable (Fabian Camacho et al. 2006) considered in his study that

patients waiting more than 75 minutes was considered too unreliable.

Salisbury et al. (2007) said that the opportunity to choose an appointment time was found

to be an essential determinant of satisfaction with access. In order to be satisfied with their access

to health services, the ease of arranging appointments and the question of whether the patient

could make an appointment on the day of their choice play an important role.

Akinci and Sinay (2003) related the impact that the opportunity to choose the

appointment time has on their satisfaction with access might be related to the opportunity costs

for the patient. This is primarily important for employed people who may lose some wages

because they have to take time to see the doctor during their working hours.

A previous study by Greene et al. (1994) reported that there was positive correlation and

significant relationship between level of satisfaction and waiting time whereas patients who wait

shorter time were more satisfied compare with patients who wait long time.

This disagrees with result from Thompson et al., (1996) showed that there was no

significant relationship between level of satisfaction and waiting time.

It is similar with the result of Dyah and Rizal, (2006) showed that there was no

significant relationship between level of satisfaction and waiting time. One of the explanations of

Discussion

150

the non-significant finding is that the respondents realized that they received treatment at teaching

hospital which also a government hospital. Therefore, they were expected to wait longer time

because of too many patients.

Many studies have highlighted the patients’ concern and perception about too little time

spent by the physicians during consultations. In fact, the examination time could be variable

corresponding to the nature of the disease, that is, it can be as short as 10 min or as long as half an

hour and also spending longer time with the patient may pose a problem to treating physicians in

busy clinics Nevertheless, some studies have stressed that ‘more effective and frequent use of

written information is clearly indicated as having the potential to address some of the patients’

information needs’ (Waghorn and McKee, 2000; Souter et al. 1998). Improvements may be

made by providing patients with more explanation and written information particularly in relation

to the causes, investigation, treatment and preventive aspects of the disease.

Regarding the over all satisfaction and outcome of care at the hospital the study

revealed that (85.7%); expressed dissatisfaction with care; (82.4%) of patients were

expected to find a better care in the hospital ;( 43.6%) of patients were expected to find a

better dealing in the hospital; ( 76.4%) said that the number of chairs at the waiting area

are few; (58.6%) said that all what patient needs are not at hospital ( 43%) were not

satisfied with the way that people dealing with them at the hospital (table 5).And the mean

satisfaction score for overall satisfaction and outcome of care was (51.9) (table 11).

Madan P.D Kumar and Fathima Zahra (2008) explained that The patients often are

dissatisfied when their felt needs are not fulfilled. felt need is what the patient feels, wants and

thinks need to be done and expectations of patients are based on their experiences, environment,

social background and personality.

(Wolosin RJ, 2005) considers that patient satisfaction as an indicator of the quality of care and

integrates in its definition the patients’ experiences as a key-element of unsatisfaction. He argues

that experiences that exceed expectations lead to satisfied patients, while those that fail to meet

Discussion

151

expectations cause dissatisfaction. Patient's satisfaction is the voice of patient that counts since it

reflects the response to experienced interactions with the care givers.

Arries and Newman (2008) advocate that quality within healthcare service delivery refers

to services that meet set standards, implying excellence, and satisfy the needs of both consumers

and healthcare practitioners in a way that adds significant meaning to both parties’ healthcare

experiences. (Sohail, 2003; Zineldin, 2006; Akter, Hani and Upal, 2008) advocate that quality

healthcare should be regarded as the right of all patients and ought to be the responsibility of all

the staff within healthcare organizations. Internationally, healthcare quality is still a concern for

various healthcare stakeholders (e.g. decision makers and patients). In recent years patients have

increasingly been considered as consumers or customers by the health care system (Kleeberg et

al., 2008).

Regarding the over all satisfaction and outcome of care at the hospital the study

revealed that ( 48.9%) are satisfied with physician performance (table 5).

This study agree with a study was done by (S. Bu-Alayyan, A. Mostafa,et al.2008) in

Kuwait which have shown (47% ) of respondents rated physicians consultation skills excellent.

This study evaluated the patient satisfaction score concerning the interpersonal

skills of the physicians and technical competence and it was addressed that (73.5%) of

patients were highly satisfied in technical quality (Table 10). The mean satisfaction score for

technical quality and health care providers performance was (70.8) (Table 11).

This disagree with a study was done by (Zewdie Birhanu,Tsion Assefa, et al. 2010)

revealed that (35%) the respondents strongly disagreed about the technical competency of the

providers.

A study was done by (Yousef Hamoud Aldebasi and Mohamed Issa Ahmed, 2011) in

Qassim showed that the satisfaction score was (45.66%) regarding the technical competency of

the providers.

Discussion

152

These satisfaction scores are comparable to those of similar studies which were conducted

in Kuwait city for the physician services, which scored (44.2%) were un satisfied (Al-Doghaither

et al., 2001) and other studies which were conducted in Riyadh and Jeddah cities Saudi Arabia,

which ranged from (61% to 97%) were unsatisfied. Sodani et al. (2010) have shown that the

physicians’ communication skills and the length of the time that they spend talking, explaining

and responding to their patients’ queries and offering reassurance and support, involving the

patients in decision-making, and discussing test results and findings from physical examinations

were strong and important correlates of the patients’ satisfaction. This is not the same in this

study, as the above factors didn’t play any effect on patient satisfaction as the satisfaction was

high regarding the technical aspects although (57.2%)were unsatisfied from communicating with

the their health care providers regarding not be greeted from The physician; More than half of the

patients (57.8%) were unsatisfied from the physician not ask about their names before

examination and nearly half of the patients (49.3%) expressed dissatisfaction from not explaining

how to take the medicine.

The current study showed that there is significant difference in satisfaction between

the patients with higher education and others with increasing satisfaction with decrease the

level of education regarding financial aspects of care, technical quality, access to care and

communication aspect (table 6,7,8,9). In this study, based on level of education, Chi-square

test showed that there was no relationship between level of satisfaction and level of

education. The explanation of this finding may be because this study was conducted at non

private hospital, so people in whatever level of education may have similar expectation with

the care that they will get (table 6, 7, 8, 9).

The findings were similar with study which conducted by Dyah and Rizal (2006). The

result of their study showed that there was no relationship between satisfaction and education

level.

Discussion

153

The current study showed that there was significant difference between male and

female regarding the satisfaction from communication and access to care with more

satisfaction associated with female gender (table 6).

This agree with a study was done by (Md. Ziaul Islam and Md. Abdul Jabba,2008) to

measure the patient satisfaction at Dhaka outpatient revealed that females being significantly

more satisfied than males (p<0.05).

This also agree with a study was done by Alzolibani, (2011) at Outpatient Clinics at

Qassim University in Saudi Arabia, have shown that a significantly high level of satisfaction was

associated with female gender. These findings are inconsistent with the results of other studies.

(Al-Sakkak and Al- Nowaiser, 2008) and (Al-Eisa and Al-Mutar, 2005) found that males were

significantly more satisfied than females.

This disagree with a study was done by (S. Bu-Alayyan, A. Mostafa,et al. 2008) in

Kuwait which have shown that (60.7%) Females were more satisfied than males.

The current study showed that there was significant difference regarding education

level with more satisfaction associated with low educated regarding communication, access

to care and financial aspects but become lower with satisfaction in technical aspects (table 6,

7, 8, 9).

This agree with a study was done by Alzolibani, (2011) at outpatient clinics at Qassim

University in Saudi Arabia. And disagree with (Al-Sakkak and Al-Nowaiser, 2008) and (Al-

Eisa and Al-Mutar, 2005).

This disagree with a study was done by (Muhammad Afzal, Ahmad Khan et al., 2011)

showed that the rate of satisfaction increased as the educational level increased.

Al Emadi et al. (2009) said that educational level has a positive and sometimes negative

effect on satisfaction. In general, less educated people tend to be more satisfied, as they are less

Discussion

154

demanding (Banaszak et al., 2001), while highly educated people may be more critical. These

contradictory results provided by different studies indicate that patient satisfaction is a complex

phenomenon.

The current study showed that there was significant difference in marital status

regarding the different aspects service with more satisfaction was seen in married category

(table 6, 7, 8, 9).

This agree with a study was done by (Asma Ibrahim,2008) showed that the married group

had high satisfaction compared to other groups, this can be explained that satisfaction can be

affected by frequent exposure to services. As married persons utilize more medical services than

the single due to their families from both sides.

This disagree with a study was done by (Muhammad Afzal, Ahmad Khan et al., 2011)

declared that The highest satisfaction with respect to marital status was seen in widowed category

and minimum satisfaction in single patients.

Margolis et al. (2003) concluded that patient satisfaction is a complex phenomenon. The

overall satisfaction was not statistically significantly related to any of the measured demographic

characteristics. He ported that socio-demographic characteristics were at best a minor predictor of

patient satisfaction. Jenkinson et al., (2002) suggested that the most important determinants of

patient satisfaction appear to be physical comfort, emotional support, and respect for patient

preferences. Tabolli et al., (2003) emphasized that irrespective of demographic status, health care

systems should attempt to achieve a balance in services that offer not only clinically effective

care, but are also perceived by the patients as acceptable and beneficial.

Piper, (2010) claimed that patient satisfaction survey scores will become the new mirror

and engine in guiding health services. Survey scores will become a major factor in the selection of

health care providers. However, depending on patient satisfaction alone to reflect quality is

biased. He considered that patients` predisposition about the hospital will influence their attitude

about the care. This attitude will in turn influence a patient’s perception of the healthcare

Discussion

155

experience and thus the response on a satisfaction survey. In the cognitive domain, one’s attitude

will guide how one thinks, perceives, and responds to his/her perception. If one’s thoughts are

irrational, then his/her perception will be irrational. Therefore, studies on patient survey should

not be once and it should consider all activities; it should be integral part of the hospital activities.

Although most patients are on return visits, already familiar with the service routine, or who

were already aware of the procedures, in the current study there was no significant difference

in opinion regarding service quality except regarding the financial aspect of service.

A sample of 495 patients is relatively not large enough to detect any significant association

between demographic characteristics and patients’ overall satisfaction. Therefore, in quantitative

studies of patient satisfaction a large sample size is required and this fact should be taken into

consideration for future studies on the topic.

Many satisfaction studies have tried to relate patients’ demographic characteristics to the

level of satisfaction. Most of satisfaction studies showed variable determinants of satisfaction,

which revealed that satisfaction is multi-factorial and no one factor could be claimed to be the

only contributor to satisfaction or dissatisfaction (Al-Sakkak and Al-Nowaiser, 2008;

Zastowny, 1989; Baker, 1993).

III. The Interviews with health care providers at outpatient clinics

In the current study, the majority of Health care providers expressed dissatisfaction from

shortage in numbers of staff members with long working hours. And they have suggested

increasing the number of physicians at the clinic.

This agree with a study done by (Rosta and Gerber, 2007) in a study based on a national

sample of hospital physicians in Germany found that the majority of Health care providers were

unsatisfied from long working hours\clinic up to 6 hours then continue the rest of the day at the

inpatient. Extended hours and night shifts have also long been customary in other Western

countries, as is documented by working weeks of 60 hours in England or 85 hours in the US.

Discussion

156

Even the laws of the European Union are consistent with physicians' apparently higher tolerance

of working time overload and allow working hours of up to 58 hours a week over a seven-day

period, as opposed to the 48 hours per seven-day week that applies to the rest of the working

population.

Nylen et al., (2001) in a study based on data from the Swedish twin registry said that the

regulation of working hours is required for health and safety reasons. A study was made by

Canadian Medical Association, (2003) revealed that the more hours worked per week,

excluding on-call, the more likely a physician is to be in advanced stages of burnout. Of

importance, over half (53%) of those working 80 and more hours/ week considered themselves to

be in advanced stages of burnout.

A study was made by Bogue et al., (2006) revealed that physicians who worked a greater

number of hours per week reported higher levels of stress. In addition, highly stressed physicians

were less satisfied with the quality of their personal time, workload, personal growth and family

issues.

Another study was made by Pattani et al., (2006) revealed that Physician stress can lead

to career dissatisfaction, disruptive behavior, burnout and career exit, substance abuse, health

concerns, personal and family problems and in the worst cases, suicide.

This agrees with another study done by Caruso et al., (2005) showed that Feelings of

irritability, uneasiness and brooding were significantly associated with physicians working

excessively long hours. In addition to long-term effects of working time overload such as

cardiovascular and gastrointestinal disorders.

A study done in Germany by Rosta and Gerber, (2007) examine the impact of

excessively long working hours on health, among a representative sample of hospital physicians

in Germany. The most significant finding is that a positive correlation exists between excessively

long working hours and general health, as well as health complaints including: mental and

physical fatigue, gastrointestinal and heart disorders.

Discussion

157

Most of the house officers and some residents expressed dissatisfaction from

unorganized patient flow (case mix) the new mixed with the follow up cases with the

employees and the referral cases and high caseload and they have suggested to decrease the

number of examined patients per day organize the patient flow using numbers on the

tickets.

Balasubramanian et al. (2010) said that patient categorization according to Age, gender

and a chronic condition are the simplest patient classification in absence of other data, yet is

generally effective for clinics because they enhance a practice's understanding of its population

and disease trends, and allow it to design its care models effectively. There is interrelationship

between panel size, case-mix and the individual capacities of physicians. This is done by

measuring the overflow frequency of the physicians in relation to each other. The overflow

frequency is the probability that the demand from a physician panel will exceed the physician's

capacity.

Murray et al. (2007) focused on the importance of appointment scheduling in healthcare

to deal with high caseload. Clinical necessities (follow ups for chronic conditions) and patient

preferences require practices to allow the future booking of appointments, while at the same time

enable same-day access for acute needs. Yet, whatever appointment system or blend a practice

may follow, effective access is possible only if the panel sizes of the physicians and their case-

mixes are in balance with the available capacity.

Medical Council Ireland (2005) during the first national conference of the health of the

doctors said that the stability of the entire health care system stands or falls with the health of its

physicians since, for example, healthy physicians have a favorable impact on the quality of health

care and the relationship among colleagues.

The majority of Health care providers expressed dissatisfaction that high patient

flow lead to lack of time to communicate well with the patient or to do general examination

leading to missing important points in diagnosis and they suggested to Decrease the number

of examined patients per day.

Discussion

158

These agree with observations of the researcher. the researcher observed that the doctor

didn’t give enough time to (61.1%) of patients to describe their complain, The doctor sometimes

ignore what the patient told in (77.9%) of patients, The doctor didn’t prescribe medications for

(85.2%) of patients, The doctor didn’t give choices when deciding the treatment for any of the

patients, The doctor didn’t explain the investigations his/her should do to (71.8%) of the patients,

The doctor didn’t explain the diet his/her should follow to (79.9%) of the patients, The doctor

didn’t pay attention to the patient's privacy for all patients, The doctor sometimes use medical

terms to the patients without explaining with (95.3%) (table 15).

Platt and Keating (2007) said that Good doctor-patient communication has the potential to

help to regulate patients’ emotions, facilitate comprehension of medical information, and allow

for better identification of patients’ needs, perceptions, and expectations.

Shiu et al. (2007) said that Patients reporting good communication with their doctor are

more likely to be satisfied with their care, and especially to share pertinent information for

accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment.

Patients’ agreement with the doctor about the nature of the treatment and need for follow-up is

strongly associated with their recovery. And this will lead to decrease in follow up visits →

decrease in patient flow → decrease the load on physician → better communication → accurate

diagnosis → patient follow advice and adhere to the prescribed treatment → decrease in follow up

visits.

Fong et al. (2010) said that there are reported observations of doctors avoiding discussion

of the emotional and social impact of patients’ problems because it distressed them when they

could not handle these issues or they did not have the time to do so adequately. This situation

negatively affected doctors emotionally and tended to increase patients’ distress. This avoidance

behavioural result in patients being unwilling to disclose problems, which could delay and

adversely impact their recovery.

The majority of Health care providers expressed dissatisfaction from shortage of

nurses that lead to their absence from patient-centered care.

Discussion

159

A study was done by (Emam et al., 2005) showed that the nurses in medical and surgical

units had lack of performance management, absence of feeling of responsibility and supportive

relationships, quality of communication, morale, organizational clarity and feeling of identity and

belongings to the hospital. Nurses are lacking work climate conducive to conflict resolution,

participation in decision making, opportunity for training and development, fair rewards and

recognition, calculated risks, sufficient resources, effective leadership and team-work.

A study was made by (Richard et al., 2006) revealed that the areas that contributed most

to doctors’ happiness with their lives as physicians seem to focus on the people they work with,

the people they live with, and most of all, the people for whom they provide medical intelligence

and care. The higher the satisfaction rating, the more satisfied physicians were with that factor.

Carney (2009) identified the scope, synergy and distinctive competencies. Scope is

determined by the identification of the number and the type of several products and services that

is offered by the organization. Synergy refers to the state that is deemed to exist when the

organization parts interact in harmony so as to produce an effect that is greater than the sum of its

parts acting alone. Distinctive competence is the position that the organization achieves through

its scope and synergistic interactions with reference to its competitors in health care.

Ancarani et al. (2009) defined organizational climate as the individual`s perceptions of

organizational policies, practices and procedures.Organizational climate is rooted in the

organizational`s culture.

The majority of Health care providers expressed dissatisfaction from Difficulty for

follow up cases to reach their physicians.

Ouwens et al. (2005) said that having appointments with the same doctor promotes better

continuity of care, which is an essential factor in order for people with chronic conditions to be

satisfied with access.

Discussion

160

Some health care providers expressed dissatisfaction that most patients are of low

socioeconomic class so they may not do all investigations or take all prescribed medications

as it is paid.

Soumerai et al. (2006) has shown that high financial barriers increase medication

nonadherence, including among elderly with chronic conditions. The extent to which low levels

of trust in the physician contribute to these lower compliance rates is unknown.

Monheit (2003) has shown that some medically related financial problems are temporary

and therefore may not have serious or long-term consequences for patient care. However, some

persons experience persistently high medical costs and out-of-pocket expenses, usually because of

chronic conditions that require ongoing treatment.

The majority of house officers expressed dissatisfaction that many cases escape from

diagnosis and come after that with complications.

Clack et al. (2004) said that doctors with better communication and interpersonal skills

are able to detect problems earlier, can prevent medical crises and expensive intervention, and

provide better support to their patients. This may lead to higher-quality outcomes and better

satisfaction, lower costs of care, greater patient understanding of health issues, and better

adherence to the treatment process.

A study done in Europe by (Moonesinghe et al., 2011) to examine the association

between reducing working hours and objective measures of outcomes in patients shows that there

is no clear signal to indicate either benefit or harm. While it might seem intuitive that doctors

working fewer hours (duty hours in accordance with European legislation are below 56 or 48

hours a week) will be less tired, make fewer errors, and that therefore patients’ outcomes should

improve.

Moonesinghe et al. (2011) said that The patient outcomes affected by the number and

quality of clinical handovers, the level of supervision of doctors in training, the continuity of care

Discussion

161

provided by the entire multidisciplinary team, the standard of nursing care, and many other

differences within and between institutions in delivery of healthcare.

Staff remuneration is important because heavy workload and low salary will demotivate

and decrease staff productivity and satisfaction towards work. Work related to training should be

done regularly and supervision from Superiors will also improve staff capability and increase

morale among workers. A better working shift schedule should be made to balance workload

among staff. There should be at least one staff assign to provide information to patients while

others handle new cases. A doctor’s ability to properly handle problems would improve patient

care and reduce treatment time. Amore reasonable salary and a well planned schedule would

improve the doctors’ performance and effectiveness. Bates (2010) delineated that low salaries is

de-motivating to service providers.

Lack of experience of residents that present most of the days alone at the clinic due

to irregular attendance of the teaching staff at the clinic. And (88.2%) said no continuous

update for knowledge and treatment methods. They suggested to insist on regular

attendance of teaching staff at the clinic according to the attendance table.

Incompetent' junior doctors who have not had enough hands-on training because of a

clampdown on their working hours putting patients at risk. Temple (2010) said that changes in

postgraduate medical education and provision of healthcare might influence the quality of

training. Concurrently, and consequently, there has been a change in the role of the junior doctor

in healthcare service delivery. Use of ancillary staff to provide services previously provided by

junior doctors, such as phlebotomy, cannulation, and basic administrative duties, allows more

time for useful training activity in a working week limited by duty hour regulations. It is possible

that cohorts of doctors whose training outcomes did not change with a reduction in working hours

have also seen an alteration in their clinical and administrative responsibilities. The requirement

for this sort of change was a key recommendation of the recent inquiry into the implications of the

European Working Time Directive on medical training in England: “make every moment count.

Discussion

162

A study done by Niteesh et al. (2005) for evaluating the relationship between clinical

experience and performance suggested that physicians who have been in practice for more years

and older physicians possess less factual knowledge, are less likely to adhere to appropriate

standards of care, and may also have poorer patient outcomes. These effects seem to persist in

those studies that adjusted for other known predictors of quality, such as patient co morbidity and

physician volume or specialization. The results are somewhat paradoxical since it is generally

assumed that clinical experience enhances knowledge and skill and, therefore, leads to better

patient care. The study explained this finding that physicians' “toolkits” are created during

training and may not be updated regularly. Older physicians seem less likely to adopt newly

proven therapies and may be less receptive to new standards of care.

Some health care providers referred to cases recommended from private clinics of

the teaching staff take the upper hand in care

In Egypt. the national health policy that allow physicians and nurses to combine working in both

the public and private sector could lead to draining of governmental resources to serve private

able to pay patients, through private- public referral services. This made the physicians abuse the

governmental hospitals to serve their benefits and giving the priorities to the patients who come

from their private clinic to receive the hospital services before and better than the patients who

came directly to the hospitals` clinic.

In the current study all Health care providers said that there’s no referral policy

Hensher et al. (2006) said that an ideal referral system would ensure that patients can receive

appropriate, high-quality care for their condition in the lowest-cost and closest facility possible,

given the resources available to the health system, with seamless transfer of information and

responsibility as that patient is required to move up or down the referral chain. Although few

referral systems anywhere in the world live up to this ideal fully, it does provide a target in

relation to improving the current situation. Improving the effective functioning of referral systems

broadly requires progress in three areas: referral system design, facilitation of the smooth transfer

of patients and information between levels.

Discussion

163

Some of Health care providers expressed dissatisfaction from lack of a well recording

system and suggested to set up of an electronic file system inside the clinic

The registration system should be improved. For example, unifying assignments based on

importance and avoiding work that could lengthen registration time will improve the registration

process. Improving the record searching process, displaying information of facilities and

improving working environment will also smoothen the registration process. The consultation

time should also be stated in the appointment card and the usage of computers will optimize the

number of patients per hour.

One of the Health care providers suggested that the staff should be from Fayoum to

attend regularly at the clinic and work for the benefit of the people

A study from Canada by (Comeau, 2001) showed that the vast majority of physicians (86%) were

satisfied with their relationship with patients and at least three-quarters were satisfied with their

relationship with other physician and non-physician providers. Work climate is indicative of how well

the organization is realizing its Full potential. An accurate assessment of work climate can identify

the unnecessary obstacles to the health care providers interfering with their best performance.

The majority of health care providers express dissatisfaction from not attending

regular training courses.

Susan (2002) expressed that increased productivity is often said to be the most important

reason for training. But it is only one of the benefits. Training is essential not only to increase

productivity but also to motivate and inspire workers by letting them know how important their

jobs are and giving them all the information they need to perform those jobs lists the following as

general benefits from employee training: increased job satisfaction and morale ,increased

motivation, increased efficiencies in processes, resulting in financial gain ,increased capacity to

adopt new technologies and methods, increased innovation in strategies and products and reduced

employee turnover. If students and faculty were involved only in district-based services, they

would miss many important advances in biomedical science and the care of complex problems

Moreover; doctors need to know enough about what the various tertiary specialties do to be able

to refer patients appropriately and to make personal career choices.

Discussion

164

The current study delineated that nurses are not the source of information to the

patients. The doctor has the major responsibility to communicate information about the

disease condition and management strategy with the patient. The nurse didn’t help the

doctor during examination in the all observed patients. The patient privacy not well

maintained.

A study conducted by (Laurant et al., 2008) showed that patients preferred the doctor for

medical aspects of care, whereas for educational and routine aspects of care. Half of the patients

preferred the nurse or had no preference for either the nurse or doctor.

Genomics and World Health Report (2002) declared that in North America and Europe

there are at least four models which depict this relationship: the paternalistic model, the

informative model, the interpretive model, and the deliberative model. Each of

these suggests different professional obligations of the physician toward the patient. For instance,

in the paternalistic model, the best interests of the patient as judged by the clinical expert are

valued above the provision of comprehensive medical information and decision-making power to

the patient. The informative model, by contrast, sees the patient as a consumer who is in the best

position to judge what is in her own interest, and thus views the doctor as chiefly a provider of

information. There continues to be enormous debate about how best to conceive of this

relationship, but there is also growing international consensus that all patients have a fundamental

right to privacy, to the confidentiality of their medical information, to consent to or to refuse

treatment, and to be informed about relevant risk to them of medical procedures.

Despite variations in local legislation and administration of patients' rights, it is important

in the case of genomics, as with any other medical intervention that patients receive treatment

consistent with the dignity and respect they are owed as human beings. This means providing, at

minimum, equitable access to quality medical care, ensuring patients’ privacy and the

confidentiality of their medical information, informing patients and obtaining their consent before

employing a medical intervention, and providing a safe clinical environment (New England

Journal of Medicine, 2003).

Discussion

165

Assuring that the rights of patients are protected requires more than educating policy makers

and health providers; it requires educating citizens about what they should expect from their

governments and their health care providers—about the kind of treatment and respect they are

owed.

Conclusion & Recommendations

166

Conclusion and Recommendations

Conclusion: The model that was presented in the current study is to help the policy makers in improving the

quality of services at the hospital according to accreditation standards. Patient and provider’s

satisfaction surveys as well as observation of work system is crucial for continues quality

improvement.

The following are the key findings from which recommendations had been derived:

Observation checklist provided important information that assesses performance of the

healthcare providers at the outpatient’s clinics.

Provider satisfaction survey revealed information about the current clinical practices and

suggestions for service improvement.

SWOT analysis that was presented as “policy Brief” to develop clear guidelines for

priority setting, and action taking for service improvement, and providing the deficiency in

the infrastructures.

Service provider-patient communication/interaction is pivotal and integral part of all

hospital care services that significantly influence patient satisfaction so the study

presented a plan to set up a health education unit.

The patients were satisfied with the price of the tickets but not with price of laboratory and

imaging services.

The study attract attention to the importance of giving appointment to the patient to reduce

the time spent at the hospital by the patients.

The study highlighted the role of medical students in improving health care services and

facing the high case load.

The national health policy and by laws that allow physicians and nurses to combine

working in both the public and private sector could lead to draining of governmental

resources to serve private able-to-pay patients, through private public referral services, and

absence of most providers from attending the clinics.

Residents do not have documents that illustrate the standard of practice.


167

The physicians ignore the importance of health education messages for the patients.

The study stressed on the importance of empowering the patients and involving them in

the treatment plan.

The study referred to the importance of collaboration in a systematized way between the

different hospital departments and community departments to empower the patients and to

improve the communication between them and the health care providers.

The study focused on the importance of regular training courses for all health care

providers for continuous updating of knowledge.

Some issues identified during the study are difficult to be improved because they are

related to the general governmental polices as for example the needs to increase the

number of health care providers.


168

Recommendations Short term plan: v Political and programmatic support to the outpatient services through development

of an updated documents including ;policies, strategies and procedures for outpatient

services as follow:

- Develop goal, mission, and objectives for each clinic.

- The supervision system and on-the job training.

- Policies and regulations related to manpower management including clear job description

in all health services.

- Develop the referral policies. A referral sheet containing patient’s clinical

information is completed and sent with the Patient when referred to another facility

(Annex 10 )

1. A copy is retained in the patient’s record

2. The referral sheet contains at least the following:

a) Reason for referral/transfer

b) Significant findings, including investigations

c) Procedures, medications, and/or other treatments

d) Patient’s condition at time of referral or transfer

e) Name of the facility the patient is being transferred.

- Develop of monitoring and evaluation indicators.

- The timeframes for emergent and routine test results should be identified on the

request paper.

- A time table for staff attendance at the clinic with their signature.

- Follow up patients should be given a number on the follow up form and is

registered in the record of the outpatient clinic.

v Improve infrastructure management as follow:

- Capitalize on house officers to provide patient centered care through:

1. Survey to identify the impact of involvement of house officers in patient

centered care on patient satisfaction.


169

2. Training the house officers will optimize the benefits of the man power

resources and expand the scope of work of house officers through shifting

from job oriented tasks to comprehensive services under supervision of

professors.

- Capitalize on nurses through shifting from job oriented tasks to comprehensive

services.

- Establishment of WITS: Work improvement teams responsible for strict

supervision of outpatient clinics and being transparent.

- Supply the clinic with the needed equipment.

- Increase the man power at the out patient clinics.

- Take the results of patient satisfaction survey into consideration in decision

making.

- Study deeply the root causes that affect the equity among patients and eliminate it.

- Study deeply the root causes that affect the job satisfaction and eliminate it.

- More attention should be done to the infection control measures at the clinics.

- Patients rights should be included in the medical and nursing curricula.

- Provide strong leadership and support for hand hygiene and other infection

prevention and control activities.

v Organize the patient flow at the outpatient clinics by :

Giving numbers at the tickets for each patient.

Fix the number of patient \day.

Each house officer will be responsible for a number of patient completing their

sheet.

Separate the new cases from follow up cases.

Choose the most loaded days with patients at the clinic and fix these day for

general internal medicine and general surgery and the other days for other sub

specialties.

Develop the strategies of panel size and use the panel sheet. (Annex 8 )


170

Long term plan: Patient flow long term plan: Review of the model of patient care to include specific care plans for all patients. Care plans

should then be explicitly communicated to all members of the care team as well as the patient and

their families. The care plan may include, but may not be limited to items such as:

o Expected wait times for various services,

o Expected discharge dates and times,

o General expected outcomes of treatment course,

o Options available with regards to each possible outcome,

o The role of each member of the care team

• Collection of patient feedback regarding the care provided which will help guide prioritization

of initiatives within the hospitals.

• Revision of team member roles and responsibilities and empowering members of the care team

at all levels (Patient care coordinator, physicians, social workers etc.) to expedite patient

movement through the system by providing:

o Adequate communication regarding the importance of patient flow

o Training to help address areas of concern as identified by staff (e.g. technology, standardization

of work practices),

o Ability and authority to resolve day-to-day situations that impede patient flow (e.g.

organizational effectiveness training, team building for all staff, driving ownership of problems,

ensuring rewards tied to identifying and resolving flow related challenges).

• Encouraging management presence on clinical units in order to facilitate dialogue regarding

day-to-day challenges that may need addressing.

• Ensuring all staff are working to their full capacity and ensure that training and support is

provided to encourage this change.

• Ensuring buy-in of all relevant stakeholders prior to roll-out of newer patient management

initiatives. For example, involving physicians in the planning of the bed management strategy will

ensure its successful uptake in the long run.

• All committees require a greater emphasis on action-oriented planning, based on gaining input

and buy-in from all stakeholders rather than policy-making. Upper management should be


171

involved to remove any road-blocks financial or otherwise. Policies may be subsequently derived

from pilot studies that do well.

• Establishing a culture that is grounded in metrics based and data driven decision-making at all

levels within the organization by:

o Automating data collection of key metrics such as wait times, number of patients waiting for

certain services etc.,

o Encouraging staff participation in developing solutions to improve metrics,

o Making patient care delivery and operational decisions based on data, and,

o Developing a communications strategy to share the organizations’ successes in process

improvement.

• The Electronic Patient Record (EPR) should be developed in partnership with I.T. and should

include efficient online documentation, Computerized Physician Order Entry (CPOE), electronic

Medication Administration Record (eMAR) along with bar-coding and point-of-care medication

check solutions.

Other aspects of long term plan: • Improve the salary system for the service providers to increase motivation and job

performance

• Design of pay-for-performance (P4P) programs. In many P4P programs, financial incentives

are used to reward individual providers, typically physicians, for achieving quality-related

performance targets.

• Increase expenditure in health services at out patient clinic.

• Develop a strategy to cover the cost of medications and investigations for low socioeconomic

patients through collaboration with pharmaceutical companies.

• Establish a medical record system at the outpatient clinics contains data about the diagnosis

and treatment and any follow-up steps done for the patient. Each medical record contains

sufficient information to perform the following:

- Identify the patient, including name, address, and date of birth

- Promote continuity of care

- Support the diagnosis

- Justify the treatment


172

- Document the patient’s course and results of treatment

• Participation of other NGOs in SWOT analysis for building strategies and decisions to

improve the service delivery at outpatient clinic.

• Partnership between the community medicine department and other hospital departments is

highly recommended for work system surveys and teamwork building inside the outpatient

clinics.

• Conduct the same study in other departments.

• Introduction of patient satisfaction survey system in the department through simple patient

satisfaction questionnaire.

• Introduction of health care providers survey system in the department through providers

satisfaction survey.

• Apply and training of all employees on 5 S principles.

• Establishment of a health education Unit that will be responsible for performing the

following: (Annex 7 )

- Inspire the staff to participate in improving the work area.

- Encourage involvement of medical students in services directed to the patients.

- Empower the patient to know his rights and responsibilities by different methods.

- Information about patient s rights and responsibilities should be disseminated by

different methods.

- Setting up a team responsible for continuous monitoring of satisfaction of internal and

external customer of hospital services.

- Setting up an information system to help in developing the outpatient clinics and

develop indicators to measure the work load on health care providers to rearrange the

work schedule (panel sheet).

- Training the hospital service providers on principles of communication, decision

making, strategies to manage the work stress and leadership.

- Periodic SWOT analysis for the work area to help in building up policies and strategies.

- Develop a strategy for the internal and external marketing.

- Educate the health care providers on the infection control standards.

- House officers management and empowerment through training courses to provide

patient centered.


173

- Sustainable patient satisfaction survey.

- Sustainable healthcare providers satisfaction survey.

Summary

174

Summary

This current study focus on study of patient as well as health care provider's satisfaction with

services offered at Internal Medicine and General Surgery out patient clinics in Fayoum

University Hospital. It explores the factors that may affect the quality of services provided by

observing the performance of health care providers (doctors and nurses) at out-patient clinics.

The aim of this study was exploring the factors that may affect the quality of services

provided at Internal Medicine and General Surgery out-patient clinics in Fayoum University

Hospital to upgrade the quality of the services. The specific objectives included studying the

patient satisfaction with services offered at the previous out-patient clinics, understanding the

health service providers' satisfaction with system of work at those out-patient clinics, knowing the

service delivery then presenting the findings of the study to both departments staff as a policy

brief for decision making to improve quality of care and setting up a Health education and

communication unit by collaboration between the community medicine department and the other

hospital departments to improve the doctor-patient relationship, health care providers

communication and empowering the patients and to improve services in Internal Medicine and

General Surgery out-patient clinic according to the results of the study.

The study is an operational health service research (Time bound study). The data was

both quantitative data (including the hospital Records of number of patients attending the

Internal Medicine and General Surgery out-patient clinic in Fayoum University Hospital,

structured Arabic questionnaire for exit patients, structured English questionnaire for healthcare

providers and Patient statistics of April, August, September and October 2010). Qualitative data

(including interview with physicians (juniors and seniors) and house officers with guided

discussions and interview with nurses using structured Arabic questionnaire and guided

discussions.

The sample size was 495 patients and 35 physicians and 4 nurses. The study was

conducted during a period of 31 months (January, 2011 till July, 2013) in three phases:

preparatory phase from (January, 2011 to August, 2011) and this included literature revision,

Summary

175

hospital records of the numbers of patients attending outpatient clinics, developing the two

questionnaires Arabic and English for both patients and health care providers respectively and

testing it by doing a pilot study on (50 patients- 2 physicians – 2 nurses) prior to the actual

implementation of the work. Data collection phase was 7 months from (September, 2011 to

March, 2012) 3 times per week to cover the different seasons & all working days of the week.

Data analysis phase from (April, 2012 to July, 2013). Analysis was done using simple frequency

distribution, scoring and Chi square.

The current study revealed the following key findings:

• Results of the study according to the situation analysis of the outpatient clinics of internal

medicine and general surgery indicated that there is loss of patient time, loss of resources,

lack of equipments, deficient in heath care providers, lack of hand washing facilities, job

description not applied, no clear polices, no plan for supervision of the clinic by staff,

training of health care providers, patient health education, follow up of cases, referral of

patients and feedback.

• Results of patient satisfaction survey indicated that more than half of the patients

(57.2%) were unsatisfied from communicating with their health care providers regarding

not be greeted from the physician; More than half of the patients (57.8%) were unsatisfied

from the physician not asking about their names by the physician before examination; The

mean satisfaction score for communication aspect was (50.5); Regarding maintaining the

patient rights; More than half of the patients (68.7%)were unsatisfied from examining

more than one patient at the clinic. A health care provider’s ability to form a therapeutic

relationship with patients’ and subsequently influence health outcomes could be

strengthened through improving the provision of whole person care. So good doctor-

patient communication has a positive impact on patient satisfaction, adherence to

treatment, health outcomes.

• Nearly half of the patients (49.3%) expressed dissatisfaction from not explaining how to

take the medicine ; More than half of the patients (60.2%) expressed dissatisfaction from

Summary

176

not giving them choices in treatment(clinical or surgical)we can say that Patients are

usually not in a position to reliably judge the accuracy of a diagnosis or treatment plan, but

they can judge whether they have been provided with sufficient information, and they can

judge the demeanor and attitudes of their physicians. Reassuringly, these latter factors are

under the direct control of medical staff, which makes it possible for patient satisfaction to

be improved with appropriate efforts.

• About (59.2%) were satisfied from the hospital location;(82.4%) of patients were expected

to find a better care in the hospital ;( 43.6%) of patients were expected to find a better

dealing in the hospital. the mean satisfaction score for over all satisfaction and outcome of

care was (51.9).

• Results of interview with health care providers at outpatient clinic of general surgery

showed that the majority of health care providers expressed dissatisfaction from shortage

in numbers of staff members with high caseload up to 60 patients/day, long working

hours/day up to 6 hours at the clinic. Most of the house officers and some residents

expressed dissatisfaction from unorganized patient flow (case mix) the new mixed with

the follow up cases with the employees and the referral cases. All Health care providers

suggested some suggestions included: increase the number of physicians at the clinic, to

decrease the number of examined patients per day, to obligate the senior staff to attend the

clinic, to supply the deficient in supply and equipment's, putting the sterile dressing that is

used for a single patient in a single package instead of putting more than one dressing for

more than one patient in a single package and to organize the patient flow using numbers

on the tickets.

• Results of interview with health care providers at outpatient clinic of internal

medicine showed that the majority of Health care providers expressed dissatisfaction from

shortage in supply and equipment's,shortage in numbers of staff members with high

caseload up to 70 patient\day, lack of time to communicate well with the patient or to do

general examination leading to missing important points in diagnosis,long working

hour/day up to 6 hours at the clinic,shortage of nurses lead to their absence from patient-

Summary

177

centered care,difficulty for follow up cases to reach their physicians,most patients are of

low socioeconomic class so they may not do all investigations as they are paid, lack of a

well recording system. The majority of house officers expressed dissatisfaction from many

cases escape from diagnosis and come after that with complications, most of the doctors at

the clinic prescribe high price medications, lack of experience of residents that present

most of the days alone at the clinic due to irregular attendance of the teaching staff at the

clinic, cases recommended from private clinics of the teaching staff take the upper hand in

care. One of Health care providers suggested setting up of an electronic file system inside

the clinic, decreasing the number of examined patients per day, organizing the patient flow

using numbers on the tickets, importance of regular attendance of teaching staff at the

clinic according to the time table and Setting up a specialized clinics in the Internal

Medicine.

• Results of observation showed that (84.6%) of the patients not welcomed by the

physician, and (61.1%) of the physicians didn’t give enough time to their patients to

describe their complain. The physician didn’t explain the investigations his/her should do

to (71.8%) of the patients, The physician didn’t pay attention to the patient's privacy for all

patients, The physician sometimes use medical terms to the patients without explaining

with (95.3%). About (65.3%) and (56.6%) of patients showed moderate degree of

satisfaction in communication aspects and in access and continuity of care respectively.

And about (73.5%) and (87.9%) of patients were highly satisfied in technical quality and

financial aspects respectively. The mean of total satisfaction score that was (54.5).

• Results of system Analysis of Internal Medicine and Surgery clinics showed deficient in

(man power, infastructures, hand washing facilities, educational material).Both the

outpatient clinic of Internal Medicine and General Surgery had unorganized patient flow,

the medications and investigations are not affordable for the patients, had no referral

polices, no organized system for follow up cases, no separation between the follow up

cases and the new cases, no team work coordination between the outpatient doctor and the

other health care providers and had no collaboration between the nurse and the physician

during patient examination.

Summary

178

• Results of SWOC Analysis of the work system at both clinics regarding the weakness

points: were deficient policy for assessing reliability and validity of work system at the

clinic in each department and the introduction of new assessment methods, lack of

standard practice guidelines. It also revealed that there was deficient policy for

coordination between departments, lack of experience for healthcare providers attending

the clinic, shortage in physicians staff with high patients load, double burden on

physicians ( inpatient and outpatient) and deficient equipments.It was observed that

patient privacy not well maintained (no curtains on windows, the clinic divided into three

partitions in away doesn't maintain the patient privacy in a complete way. The physician

examined more than one patient at the same time , no training courses for outpatient clinic

physicians and nurses),the only source for learning is the staff round, the job of the nurse

at the clinic is task-oriented. The challenges' points revealed that there were no clear

policy for outpatient management, no actual support from higher authorities, laws allow

physicians and nurses to combine working in both the governmental and private sector.

It has been concluded that: the observation checklist has provided important information

that assesses the performance of the healthcare providers at the outpatient’s clinics, the

provider satisfaction survey revealed information about the current clinical practices and

suggestions for service improvement, SWOT analysis was presented as “policy Brief” to

develop clear guidelines for priority setting, and action taking for service improvement, and

providing the deficiency in the infrastructures. Service provider-patient

communication/interaction is pivotal and integral part of all hospital care services that

significantly influence patient satisfaction so the study presented a plan to set up a health

education and communication unit, the importance of giving appointment to the patient to

reduce the time spent at the hospital by the patients, the role of medical students in improving

the health care services and facing the high case load, the national health policy and by laws

that allow physicians and nurses to combine working in both the governmental and private

sector could lead to draining of governmental resources to serve private able-to-pay patients,

through private - public referral services, the importance of empowering the patients and

involving them in the treatment plan, the importance of collaboration in a systematized way

between the different hospital departments and community departments to empower the

Summary

179

patients and to improve the communication between them and the health care providers, the

importance of regular training courses for all health care providers for continuous updating of

knowledge.

Recommendations:

Political and programmatic support to the outpatient services through development of an updated

documents including ;policies, strategies and procedures for outpatient services, improving the

infrastructure management, organize the patient flow at the outpatient clinics, establishment of a

health education and communication unit, setting a patient flow long term plan, improve the

salary system for the service providers to increase motivation and job performance, increase

expenditure in health services at out patient clinic. Partnership between the community medicine

department and other hospital departments is highly recommended for work system surveys and

teamwork building inside the outpatient clinics, apply and training of all employees on 5S

principles and establish a medical record system at the outpatient clinics contains data about the

diagnosis and treatment and any follow-up steps done for the patient.

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180

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