Chapter One

CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Various health centres, for example Koforidua regional hospital, St Joseph hospital,

Adweso clinic ect, have made considerable efforts to improve access to health services.

However, public health resources have been so stretched that the quality of services has

sturdily declined over the last decade. As a result of this, the public is becoming attracted

to private providers than to public hospitals and clinics. Many reasons, such as lack of

infrastructure, hygienic nature of the facilities ect, has led to further declines in the

quality and efficiency of public sector health services. It remains a challenge to find

proper approaches that improve the quality of health service delivery. National Quality

Assurance Programmes are one way to improve standards, but strategies to implement

Quality Assurance at district and sub-district level are sometimes ill conceived or may

not exist at all. This is surprising in view of the fact that health sector reform policies

usually include quality as an explicit priority. Whilst greater decentralisation of

responsibility and resources might allow enthusiastic districts to remedy this situation,

staffs need models of good practice to boost morale and, indeed, improve their quality of

care. Over the last ten years, there has been a dramatic increase in the references to and

interest in quality assurance as it applies to health care. A World Health working group.

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Quality Assurance discerned four sets of reasons: economic, social, political, and

professional (WHO, 1985).Demand for health care is increasing. Not only are people

living longer and requiring care over a long period and an extended old age but also

expectations are rising through education and general interest. There is therefore an

increasing emphasis on value for money and cost efficient solution. As resources become

more over used, there is a commensurate need to ensure that standard that is quality; are

upheld. So Quality Assurance is advanced as a way of ensuring that standards are

maintained and that resources are used as effectively as possible. The demand for health-

for cure or alleviation of undesirable conditions and for longer life is a social variable and

reflects the values preoccupations of the western world in the late twentieth century.

Another social pressure is the customer movement. Patients expect to be told what is

being provided foe them and to have redress if the service falls below standards. In the

US particularly, one reason for Quality Assurance is the need for medical practitioners to

ensure quality to avoid litigation. In order to achieve patient orientation and to improve

cost effectiveness, approaches are imported from business and commerce. It is suggested

that whiles Health Care may not be a business; it should be run in a business-like way. It

is important that this dive for efficiency should not be seen as just cost-cutting.

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1.1 STATEMENT OF THE PROBLEM

Improvement of the quality of service provided in the health institutions has been the

main theme of Ministry of Health trust since 1989. At the regional level in Ghana, the

Regional Director of Health service and Deputy Director of nursing services at various

meetings thought critically and produce different views of what quality of service should

be. In the late1990 and early 1991, key aspects of various services were incorporated into

a “Quality of Health Checklist”.

In the “checklist” quality of care is evaluated by variables including:

- the sanitary state of Health facility

- the state of repair of infrastructure

- availability of essential drugs and a smooth flow of patients at Out –Patients

Department.

Since 1989, a lot has gone on such as the completion of the essential drug list, supply of

input examples gloves, linen, cotton ect, in the improvement of drug supply by the “cash

and carry system” and the creation of incentives such as best nurse award. Service

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providers (supervision) feel that due to the number of measures in place in Health

Institutions, a change for the better has occurred, but patients are not satisfied with the

effort being made by the providers. Based on comments from the media, individuals and

analysis of Hospitals returns patient satisfaction is still observed to be low. It is possible

that there are differences of perception of quality of service between the service providers

and patients. The latter needs to be considered if Ministry of Health wants to improve its

services. Hence the need to find patients perception of quality of care to supplement the

checklist and improve service delivery.

1.2 OBJECTIVES OF THE STUDY

General Objectives

To determine factors contributing to patient’s dissatisfaction with service in Government

Health Facilities on the Koforidua Central Hospital as a basis for taking measures to

improve these services.

Specific Objectives

To identify service provider factors that influence patient’s satisfaction.

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To identify structural and environmental factors that influence patient’s

satisfaction.

To develop a comprehensive checklist for monitoring level of quality of care to meet

patients expectation.

1.4 SIGNIFICANCE OF THE STUDY

The study is carried out for the following reasons:

Firstly, the study is the major work aimed at knowing patients views about treatment

received at Government Health Institutions in the New Juabeng Municipality and how

they feel in general concerning the whole environment of these institutions. The outcome

of the survey is going to help the medical officer together with their team to identify were

there are lapses and make sure that attention is paid to those areas.

Secondly, the survey is going to enlighten patients on what is expected of a good health

institution so they would know which health institution to visit in the district in order to

receive quality care.

Finally, all staffs of health institutions in the districts are going to perform their duties

promptly and with care because they are now aware patients would be interviewed

regularly regarding treatments they receive.

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1.5 SCOPE OF THE STUDY

This project or research work will cover young men and women together with the elderly

ones who fall within the ages 15 years and above in the New Juabeng Municipality of

Koforidua in the eastern region of Ghana.

1.6 LIMITATION OF THE STUDY

There are some limitations and problems which must be kept in mind in interpreting the

results. These range from technical limitations to socio-cultural problems. Some

limitations of this study of user satisfaction was time constraint, financial constraint, and

also the problem of illiteracy on the part of young men and women who find it difficult to

provide the necessary information.

1.8 ORGANIZATION OF THE STUDY

The research report has been divided into five chapters and these are as follows:

Chapter One: - This presents the background of the study, statement of the problem,

objectives of the study, significance of the study, and the scope of the study.

Chapter Two: - This discusses related literature on Quality Assurance in general.

Chapter Three: - This discusses the research design, the population and sample base on

which analysis was made. It also discusses the research instrument that was used in the

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data collection, the procedure used in the data collection process and method used for

analysing the data.

Chapter Four: - This comprises of hypothesis, limitations, findings and analysis of data

obtained.

Chapter Five: - This covers conclusion and underlying recommendations for the project.

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CHAPTER TWO

2.0.0 LITERATURE REVIEW

2.1.0 INTRODUCTION

Studies of practitioner-patient relationships have demonstrated the importance of

understanding the patient’s point of view. Emphasis should therefore be put on

customer’s opinion in the assessment to extend that they are into account in policy

formulation. This is an indirect form of customer participation, a much desired ingredient

in the primary health care strategy. It has been realised that satisfaction with care is an

important influence determining whether a person seeks medical advice, compiles with

treatment and maintains a continuing relationship with the practitioner.

A study conducted by Castowny T. R et al reveal that:

A causal relationship between patient satisfaction and the use of health service

exit.

It is bi-directional and reciprocal in nature.

It is highly related to the provider from which patients seek care.

In some providers, achievement of satisfaction has been positive whiles others have been

negative. Currently, there is little information available to indicate the extent to which

patients are satisfied with the quality of care they receive. Available information indicates

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that patient satisfaction is influenced by provider- patient interaction, service

characteristics and patient characteristics. Provider- patient interaction is the key

determinant of patient satisfaction. In a summary of the major studies, Inus and Cater

concluded that patient satisfaction is maximized when the physician with the patient

expectation and concerns, communicates with warmth and interest and when the

physician provide information to the patient. Background characteristics of patients

including health status, age, gender, social class

are related to user satisfaction in different ways DiMatteo M. et al male inpatients and

older patients were satisfied with the care received.

Consumer satisfaction studies can be used for three related but distinct purposes:

As evaluation of quality of care

As indicators of which aspects of service need to be changed to improve patient

response.

Finally, satisfaction studies can function to give providers of health care some idea of

how they would have to satisfy their client’s. In order to be used in this way, studies

should be based on consumers’ actual experiences with these and be sufficiently detailed

to provide clear guides as to which areas require modifications in service delivery to

people.

Definition of Quality: The Oxford Advanced Learner’s Dictionary defines “quality” as

“how good or bad a thing is”. Thus we can refer to a good quality thing or poor quality

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thing. This thing may be a product or service. Another definition in the same says quality

is the extent to which customers or clients fill that product or service perceives their

needs or expectations or it is basically a simple ideal standard set for a product or service;

production is organised so that these standards are met consistently. Patients would be

assured that they would receive quality care when everything is managed to ensure set

down standards are met. Standards must then be checked regularly to make sure that they

are indeed being met. If they are not, then steps must be taken to put things right and try

to that shortfalls do not occur in the future.

Avedis Donabedian defined quality as, the extent to which the care provided is expected

to achieve the most favourable balance of risks and benefits.

(Avedis Donabedian, M.D., 19802)

2.2.0 DIMENSIONS OF QUALITY

These dimensions of quality are a useful framework that helps health teams to define and

analyze their problems and to measure the extent to which they are meeting program

standards. The eight dimensions discussed in detail in this section have been developed

from the technical literature on quality, and synthesize ideas from various Quality

Assurance experts. We feel that these dimensions are relevant to LDC settings; however,

not all eight deserve equal weight in every program. Each should be considered in the

light of specific programs and should be defined according to the local context.

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These dimensions of quality are as appropriate for clinical care as for management

services that support service delivery.

Technical Competence

Technical competence refers to the skills, capability, and actual performance of health

providers, managers, and support staff. For example, to provide technically competent

services, a Rural/Urban health worker must have the skills and knowledge (capability) to

carry out specific tasks and to do so consistently and accurately (actual performance).

Technical competence relates to how well providers execute practice guidelines and

standards in terms of dependability, accuracy, reliability, and consistency. This

dimension is relevant for both clinical and no clinical services. For health providers, it

includes clinical skills related to preventive care, diagnosis, treatment, and health

counselling. Competence in health management requires skills in supervision, training,

and problem solving. The requisite skills of support staff depend on individual job

descriptions. For instance, a technically competent receptionist must be able to respond to

information requests, while a pharmacist might be expected to possess competence in

logistics and inventory management. Technical competence can also refer to material

resources: for example, an X-ray machine must produce radiation that consistently meets

accepted standards. A lack of technical competence can range from minor deviations

from standard procedures to major errors that decrease effectiveness or jeopardize patient

safety.

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Access to Services

Access means that health care services are unrestricted by geographic, economic, social,

cultural, organizational, or linguistic barriers. Geographic access may be measured by

modes of transportation, distance, travel time, and any other physical barriers that could

keep the client from receiving care. Economic access refers to the affordability of

products and services for clients. Social or cultural access relates to service acceptability

within the context of the clients cultural values, beliefs, and attitudes. For example,

family planning services may not be accepted if they are offered in a way that is

inconsistent with the local culture. Organizational access refers to the extent to which

services are conveniently organized for prospective clients, and encompasses issues such

as clinic hours and appointment systems, waiting time, and the mode of service delivery.

For example, the lack of evening clinics may reduce organizational access for day

labourers. Where travel is difficult, lack of home visits or Village-based services may

create an access problem. Linguistic access means that the services are available in the

local language or a dialect in which the client is fluent.

Effectiveness

The quality of health services depends on the effectiveness of service delivery norms and

clinical guidelines. Assessing the dimension of effectiveness answers the questions, does

the procedure or treatment, when correctly applied, lead to the desired results?

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And is the recommended treatment the most technologically appropriate for the setting in

which it is norms and specifications are defined. Effectiveness issues should also be

considered at the local level, where managers decide how to carry out norms and how to

adapt them to local conditions. When selecting standards, relative risks should be

considered. For example, more frequent use of caesarean section might be warranted in a

population with many high risk pregnancies, despite the associated risks. To determine

this strategy,

effectiveness, the procedures potential harm must be compared with its potential net

benefits.

Interpersonal Relations

The dimension of interpersonal relations refers to the interaction between providers and

clients, managers and health care providers, and the health team and the community.

Good interpersonal relations establish trust and credibility through demonstrations of

respect, confidentiality, courtesy, responsiveness, and empathy. Effective listening and

communication are also important. Sound interpersonal relations contribute to effective

health counselling and to a positive rapport with patients. Inadequate interpersonal

relations can reduce the effectiveness of a technically competent health service. Patients

who are poorly treated may be less likely to heed the health care provider,

recommendations, or may avoid seeking care.

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Efficiency

The efficiency of health services is an important dimension of quality because it affects

product and service affordability and because health care resources are usually limited.

Efficient services provide optimal rather than maximum care to the patient and

community; they provide the greatest benefit within the resources available. Efficiency

demands that necessary or appropriate care is provided. Poor care resulting from

ineffective norms or incorrect delivery should be minimized or eliminated. In this way,

quality can be improved while reducing costs. Harmful care, besides causing unnecessary

risk and patient discomfort, is often expensive and time-consuming to correct. It would

be misleading, however, to imply that quality improvements never require additional

resources. But by analyzing efficiency, health program managers may select the most

cost-effective intervention.

Continuity

Continuity means that the client receives the complete range of health services that they

need, without interruption, cessation, or unnecessary repetition of diagnosis or treatment.

Services must be offered on an ongoing basis. The client must have access to routine and

preventive care provided by a health worker who knows his or her medical history. A

client must also have access to timely referral for specialized services and to complete

follow-up care.

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Continuity is sometimes achieved by ensuring that the client always sees the same

primary care provider; in other situations, it is achieved by keeping

accurate medical records so that a new provider knows the patients history and can build

upon and complement the diagnosis and treatment of previous providers. The absence of

continuity can compromise effectiveness, decrease efficiency, and reduce the quality of

interpersonal relations.

Safety

As a dimension of quality, safety means minimizing the risks of injury, infection, harmful

side effects, or other dangers related to service delivery. Safety involves the provider as

well as the patient. For example, safety is an important dimension of quality for blood

transfusions, especially since the advent of AIDS. Patients must be protected from

infection, and health workers who handle blood and needles must be protected by safety

procedures. Additional safety issues related to blood transfusions include maintaining

aseptic conditions and using proper techniques for transfusing blood. While safety may

seem most important when complex clinical services are provided, there are safety

concerns in the provision of basic health services as well. For example, health centre

waiting rooms can put clients at risk of infection from other patients if risk-reducing

measures are not taken. If a health worker does not provide proper instruction on the

preparation of oral rehydration solution (ORS), a mother may administer to her child

ORS containing a dangerously high concentration of salt.

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Amenities

Amenities refer to the features of health services that do not directly relate to clinical

effectiveness but may enhance the client’s satisfaction and willingness to return to the

facility for subsequent health care needs. Amenities are also important because they may

affect the client’s expectations about and confidence in other aspects of the service or

product. Where cost recovery is a consideration, amenities may enhance the client’s

willingness to pay for services. Amenities relate to the physical appearance of facilities,

personnel, and materials; as well as to comfort, cleanliness, and privacy. Other amenities

may include features that make the wait more pleasant such as music, educational or

recreational videos, and reading materials. While some amenities -- clean, accessible

restrooms; and privacy curtains in examination rooms -- are considered luxuries in most

LDC health care settings, they are nevertheless important for attracting and retaining

clients and for ensuring continuity and coverage.

2.3.0 PERSPECTIVES ON THE MEANING OF QUALITY

The definitions and dimensions outlined above constitute a broad conceptual framework

that includes almost every aspect of the health system performance. All these dimensions

come into play as clients, health providers, and health care managers try to define quality

of care from their unique perspectives.

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What does quality of health care mean for the Communities and clients that depend on it,

the clinicians who provide it and the managers and administrators who oversee it?

The Client

For the clients and communities served by health care facilities, quality care meets their

perceived needs, and is delivered courteously and on time. In sum, the client wants

services that effectively relieve symptoms and prevent illness. The client’s perspective is

very important because satisfied clients often are more likely to comply with treatment

and to continue to use primary health services. Thus, the dimensions of quality that relate

to client satisfaction affect the health and well-being of the community. Patients and

communities often focus on effectiveness, accessibility, interpersonal relations,

continuity, and amenities as the most important dimensions of quality. However, it is

important to note that communities do not always fully understand their

health service needs--especially for preventive services--and cannot adequately assess

technical competence. Health providers must learn about their community’s health status

and health service needs, educate the community about basic health services, and involve

it in defining how care is to be most effectively delivered. Which decisions should be

made by health professionals and which should be made by the community? Where does

the technical domain begin and end? This is a subjective and value-laden area that

requires an ongoing dialogue between health workers and the community. Answering

these questions requires a relationship of trust and two way communication between the

parties.

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The Health Service Provider

From the provider’s perspective, quality care implies that he or she has the skills,

resources, and conditions necessary to improve the health status of the patient and the

community, according to current technical standards and available resources. The

provider’s commitment and motivation depend on the ability to carry out his or her duties

in an ideal or optimal way. Providers tend to focus on technical competence,

effectiveness, and safety. Key questions for providers may be: How many patients are

providers expected to see per hour? What laboratory services are available to them, and

how accurate, efficient, and reliable are they? What referral systems are in place when

specialty services or higher technologies are needed? Are the physical working

conditions adequate and sanitary, ensuring the privacy of patients and a professional

environment? Does the pharmacy have a reliable supply of all the needed medicines? Are

there opportunities for continuing medical education? Just as the health care system must

respond to the patient’s perspectives and demands, it must also respond to the needs and

requirements of the health care provider. In this sense, health care providers can be

thought of as the health care systems, internal clients. They need and

expect effective and efficient technical, administrative, and support services in providing

high-quality care.

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The Health Care Manager

Quality care requires that managers are rarely involved in delivering patient care,

although the quality of patient care is central to everything they do. The varied demands

of supervision and financial and logistic management present many unexpected

challenges and crises. This can leave a manager without a clear sense of priorities or

purpose. Focusing on the

various dimensions of quality can help to set administrative priorities. Health care

managers must provide for the needs and demands of both providers and patients. Also,

they must be responsible stewards of the resources entrusted to them by the government,

private entities, and the community. Health care managers must consider the needs of

multiple clients in addressing questions about resource allocation, fee schedules, staffing

patterns, and management practices. The multidimensional concept of quality presented

here is particularly helpful to managers who tend to feel that access, effectiveness,

technical competence, and efficiency are the most important dimensions of quality.

2.4.0 THE HEALTH SECTER REFORM RESEARCH WORK PROGRAMM

2.4.1 Why is Quality Assurance important?

However, public health resources have been so stretched that the quality of services has

declined markedly over the last decade. Policy makers have realised that health services

of inferior quality do not promote equity or maximise health gain.

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As a result of this, the public is becoming attracted more to private providers than to

public hospitals and clinics. For many reasons, such as low staff morale and reduced

income, this has led to further declines in the quality and efficiency of public sector

health services. It remains a challenge to find innovative approaches that improve the

quality of health service delivery. National Quality Assurance Programmes are one way

to improve standards, but strategies to implement Quality Assurance at district and sub-

district level are sometimes ill conceived or may not exist at all. This is surprising in view

of the fact that health sector reform policies usually include quality as an explicit priority.

Whilst greater decentralisation of responsibility and resources might allow enthusiastic

districts to remedy this situation, staffs need models of good practice to bolster morale

and, indeed, improve their quality of care. This briefing paper proposes Quality

Assurance (QA) as an approach that governments and health managers should consider in

their attempts to systematically monitor and improves service delivery. We ask:

1. What is Quality Assurance in health care?

2. What kind of QA policy is needed to ensure good quality of care?

3. Can governments introduce an "off the shelf" QA package?

4. How can a QA policy be put into practice?

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The answers we provide are based on experiences and results from Quality Assurance

programmes in India, Ghana, Honduras, Costa Rica and Panama. No answers apply

equally to all situations; we welcome dialogue and ask readers to share their experiences

in implementing quality assurance programmes. In exchange we offer to assist those

involved in the lengthy and difficult process of improving quality in the health sector.

Broad Definition: Quality Assurance (QA) is a planned and systematic approach to

monitoring, assessing and improving the quality of health services on a continuous basis

within the existing resources. As the Quality Assurance field has evolved and developed,

various definitions of quality assurance have emerged. Dr. Donabedian broadly defines it

as .all the arrangements and activities that are meant to safeguard, maintain, and promote

the quality of care. Drs. Ruelas and Frenk, who have conducted extensive Quality

Assurance work in Mexico, define it as .a systematic process for closing the gap between

actual performance and the desirable outcomes. According to Dr. Heather Palmer, a

Quality Assurance expert in U.S. ambulatory care, it is a .process of measuring quality,

analyzing the deficiencies discovered, and taking action to improve performance

followed by measuring quality again to determine whether improvement has been

achieved. It is a systematic, cyclic activity using standards of measurement. Dr. Donald

Berwick, a U.S.-based clinician, is working to apply principles of continuous quality

improvement (CQI) to health services.

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This approach to Quality Assurance is an integrated organizational approach for meeting

client needs and expectations involving both management and staff while improving

processes and services using quantitative techniques and analytical tools. According to

Berwick, it is a systematic managerial transformation designed to address the needs and

opportunities of all organizations as they try to cope with increasing change, complexity

and tension within their environments. All these definitions of Quality Assurance share

several characteristics. Each, for example, refers to a systematic, ongoing process that is

oriented toward improving performance and using data in the process, either implicitly or

explicitly. In essence, quality assurance is that set of activities that are carried out to set

standards and to monitor and improve performance so that the care provided is as

effective and as safe as possible. Quality assurance is not a new .magic bullet, but has

been a part of health care for the past100 years. It was introduced into modern medicine

by a British nurse, Florence Nightingale, who assessed the quality of care in military

hospitals during the Crimean War. She introduced the first standards in nursing care;

these resulted in dramatic reductions of mortality rates in hospitals. Until recently, quality

assurance was primarily used by hospitals in developed countries and relied heavily on

standards of care developed by accrediting agencies. In the 1980s, quality assurance

expanded to primary health care in the United States and Europe. Simultaneously,

internationally accepted standards of care were introduced by diarrhoea and acute

respiratory infection (ARI) case management algorithms developed by ‘WHO’.

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After 1985, WHO and several projects such as PRICOR and CCCD began using systems

analysis and facility assessments to assess the quality of care. There has recently been a

revolution in quality assurance approaches and an explosion of interest in developing

national Quality Assurance programs for several reasons Democratization movements

have led politicians to consider more carefully the demands of citizens for better quality

cares Economic problems in all countries have limited their ability to improve quality by

Spending more. Countries have realized that improvements in quality must come by

improving the efficiency and effectiveness of current resources Managers see the need for

more cost recovery, but realize that it will be difficult to charge for services unless the

quality is improved The success of quality management approaches employed by

industry in Japan, and recently in the United States and Europe, has inspired health care

organizations to apply these same methods to their quality assurance programs. After

only five years, there are dramatic examples of the improvements in quality and

efficiency that can be achieved. Recent experience in applying quality management to

health care systems suggests that four tenets should be adhered to in an ideal quality

assurance program:

2.4.2 What kind of QA policy ensures good Quality of care?

It has become fashionable for the government health policy around the world to include

statements on the quality of their services. Such Quality Assurance statements usually

reflected a responsive to public needs. Examples of National Policy Statements;

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Objective: To provide universal access to primary health services and to improve the

quality of services.

Strategy: Institute a process for quality assurance and develop a framework for

monitoring and regulation of services – this will about through the establishment of

standards of practice, intensive training and supervision, the use of sanctions and rewards

and strengthening of supervisory and regulatory mechanisms.

(Medium Term Health Strategy, Ghana, 1995)

The new agenda commits to delivering the highest quality health care; therefore

improving quality of health services in the search for efficiency and equity constitutes a

fundamental health policy for the next four years.

(The New Health Agenda, Honduras, 1998).

These statements seek to promote quality of care in general terms, and this recognition at

a Central level is important. But such statements are fairly nebulous, and if they merely

reflect government lip service to an ideal, they are meaningless. Quality statements that

apply to particular aspects of health service delivery are much more manageable, and

specific quality objectives are far more useful. Here are two examples:

Targets for waiting time for acute hospital services.

“80% of in-patient admissions to be within 6 months of diagnosis”

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Targets for compliance for TB control programmes.

“90% of patient receiving TB treatment completes the full treatment”

In addition to setting specific objectives for policy statements, outline strategies for

implementation should be made clear at Central level. Detailed implementation plans

are best left to service providers at the local level.

2.4.3 Is there a ‘Universal Quality Assurance package’?

Is there a model Quality Assurance programme that will secure quality improvements in

all countries and settings? Agencies involved in the development of Quality of Care

models offer a variety of blueprints which governments of developing countries might

find attractive in providing a ‘quick fix’ solution to improve health service quality.

However, experience shows that changes in health service culture are a prerequisite for

achieving quality improvements. Ownership of the Quality Assurance programme by the

health personnel themselves is part and parcel of this culture change. This would argue

against the notion of a universal Quality Assurance package. Adopting an off-the-shelf

package might be evidence of a government’s response to public demand for better

services.

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But improving quality of services demands a response from the service providers

themselves. This is unlikely to happen with the top-down imposition of a bolt-on system

for quality improvement. In Ghana the Quality Assurance process began with an initial

focus on patients’ perceptions of outpatient department services. The main tool used for

monitoring quality was a locally developed exit interview. Quality Assurance teams used

the information from these patient perceptions to develop low-cost interventions for

improving service quality. The next step was to extend this monitoring and improvement

of quality to primary health-care facilities. Now that Quality Assurance has become more

institutionalised in Ghana the emphasis is moving towards clinical and management

quality issues. If there is no genuine commitment from the top, Quality Assurance

initiatives can develop in a piecemeal way. Different geographical areas may develop at a

different rate, and they may use different approaches. This can fragment the drive for

quality. A more systematic approach to Quality Assurance development has been taken in

a project in Central America. Development of a Regional Quality Assurance system in

Costa Rica, Panama and Honduras involved four different stages.

2.4.4 How can a Quality Assurance Policy be put into Practice?

Implementing Quality Assurance systems is as much a 'people' issue as a 'technical' one.

Providers implementing Quality Assurance should guard against over-ambition. They

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may wish to start by focusing on a single issue, then, as a quality culture develops in the

health service, add additional elements to the Quality Assurance programme. Districts

should be encouraged to develop their own Quality Assurance initiatives that should be

part of the annual work plan with their own budgets. Care should be taken to ensure that

these initiatives are guided by national policies with nationally agreed standards and

indicators of quality of care. Menus of practical options for Quality Assurance strategies

should be collected centrally and actively promoted to support weaker districts where

Quality Assurance development is not taking place. However, ownership by local service

providers remains the secret to success in turning policy on quality of care into practice.

Interdisciplinary Quality Assurance teams represent the best mechanism for driving the

Quality Assurance process and at least some of the team members should have

managerial responsibility to take decisions that can directly influence service quality.

However, for long-term sustainability Quality Assurance must be integrated into the

existing roles and responsibilities of all staff. Quality Assurance must be driven from

both the bottom and top of the health system if it is become an integral part of the health

delivery system. Resource people are required at national, regional and district level to

support the Quality Assurance process. External technical assistance can act as a catalyst

for getting things started, especially if there is limited country expertise.

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The role of National level is to advocate the importance of quality improvements

strategies, and facilitate them locally by:

providing resources,

co-ordinating training

co-ordinating standards of care.

A national Quality Assurance committee would be an appropriate body to have this

responsibility. The committee could also support district development by requiring

quality of care to be included in the training curriculum of all health service workers, so

that a culture of quality is fostered in the health service community, both public and

private.

At Regional level a quality strategy group should monitor quality and provide supportive

supervision to districts. A regional training programme should reflect the national

strategy with quality indicators and standards based on regional priorities.

At District level a quality steering team should support facility-level quality

improvements. To support consistent goals for quality across the district, this quality

steering team should facilitate effective communications between primary and secondary

level facilities.

At Facility level an interdisciplinary Quality Assurance team should be responsible for

continuously monitoring, assessing and improving quality. Each facility should have

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targets for its services in line with regional standards. Teams should be able to re-allocate

resources according to priorities and planned interventions

2.5.0 The Four Tenets of Quality Assurance

Quality Assurance is oriented toward meeting the needs and expectations of the

patient and the community.

Quality assurance focuses on systems and processes.

Quality assurance uses data to analyze service delivery processes.

Quality assurance encourages a team approach to problem solving and quality

improvement.

Quality assurance is oriented toward meeting the needs and expectations of the patient

and the community. Quality assurance requires a commitment to finding out what

patients and the community need, want, and expect from the health services. The health

team must work with communities to meet service demand and to promote acceptance of

needed preventive services. Subsequent program planning and quality improvement

efforts should be evaluated according to these needs and expectations.

29

Quality assurance also requires that health workers, Professional needs and expectations

be met.

Quality assurance focuses on systems and processes. By focusing on the analysis of

service delivery processes, activities, and tasks as well as outcomes, quality assurance

approaches allow health care providers and managers to develop an in-depth

understanding of a problem and to address its root causes.

Rather than merely treating the symptoms of a quality-related problem, quality assurance

seeks to find a cure. In the advanced stages of a Quality Assurance program, the health

centre team can go even further by analyzing processes to prevent problems before they

occur.

Quality assurance uses data to analyze service delivery processes. Simple quantitative

approaches to problem analysis and monitoring are another important aspect of quality

improvement. Data-oriented methods allow the Quality Assurance team to test its

theories about root causes; effective problem solving should be based on facts, not

assumptions.

Quality assurance encourages a team approach to problem solving and quality

improvement. Participatory approaches offer two advantages. First, the technical product

is likely to be of higher quality because each team member brings unique perspective and

insight to the quality improvement effort. Collaboration facilitates a thorough problem

analysis and makes development of a feasible solution more likely. Second, staff

members are more likely to accept and support changes that they helped to develop.

30

Thus, participation in quality improvement builds consensus and reduces resistance to

change. It is important to note that the definition of Quality Assurance can be extremely

broad and can include all program management activities. Quality Assurance can include

everything from applied research to comprehensive management assessments and

interventions. In practice, the scope of a Quality Assurance effort depends on the needs

and capacities of the health service organization.

Usually, the Quality Assurance effort will be developed as a limited activity that is

integrated into the existing management system. However if an organization desires a

comprehensive approach, a Quality Assurance initiative can be developed as a

component of a general management improvement effort or a total quality management

system. Quality Assurance comes in many guises, and may be known as Total Quality

Management, Continuous Quality Improvement, Clinical Audit or Quality Circles.

Quality of care has different meanings to different stakeholders, for example, doctors and

patients. All Quality Assurance systems should encompass three perspectives on quality:

Clinical standard

Performance management

Client satisfaction

Hence there are usually several elements within the Quality Assurance system, such as

clinical audit, quality control of laboratory services, standards setting and client

satisfaction surveys. These components do not have to be introduced simultaneously, but

can be introduced as distinct packages.

31

CHAPTER THREE

METHODOLOGY

3.0 INTRODUCTION

This chapter describes methods employed in carrying out the study. It involves

description of the study area, population of the study, source of data, research instrument

and data collection method, sampling technique and sample size, and methods of data

analysis.

3.1 DESCRIPTION OF THE RESEARCH OR STUDY AREA

The research project was made to cover the people of the New Juabeng Municipality.

The New Juabeng Municipality covers a geographical area of approximately 110km2 and

consists of 57% of the total area of the Eastern Region.

New Juabeng Municipality is made up of 46 communities which we would like to

mention a few of them and they are Adweso, Efiduase, Asokore, Okorase, Akwadum,

Jumapo, Koforidua, Oyoko, ect.

According to the1984 population Census, the total population of the New Juabeng

Municipality, then district was 124,482 and that of 2000 was 136,768 which constitute

48.5% males and 51.5% females and the population growth rate is 2%.

The reason for selecting Koforidua central hospital as the targeted area was that, almost

75%of the inhibiters in new Juaben attend the Koforidua regional hospital.

32

3.2 POPULATION OF THE STUDY

The study population was defined as:

Adult users of and adults who accompanied children to the government health institutions

in the New Juabeng Municipality(Koforidua Regional Hospital). However, from the

study

we defined adults as being between the ages 15 to 60 years and above.

3.3 RESEARCH INSTRUMENT AND DATA COLLECTION METHOD DATA

Data was collected using semi-structured questionnaires to interview the respondents.

It was under two sections:

Out-patients satisfaction

Inpatient satisfaction

The questionnaires consist of a series of structured questions and were administered in

the form of interview by the researchers and one assistant to collect the information since

the majority of the respondents were illiterate. In view of this, questions which are

simple, clear, opened ended, and closed ended were used. These questions could

translate research objectives into specific questions to be answered by the respondent.

33

3.4 SAMPLING TECHNIQUE AND SAMPLE SIZE

Data was collected using convenience sampling method, whereby exit interviews were

performed, using the most readily available people willing to participate as respondents

in the study. In all, (100) hundred sample size was used for the various satisfaction-level

categories namely Out- patient, and Inpatient

3.5 METHOD OF DATA ANALYSIS

This chapter is more technical due to the nature of the research work, as it explains the

exact nature of the statistical test that the researcher intends to conduct. It was designed to

tabulate and make qualitative and quantitative analysis from the survey data. All

information collected were from primary source and we sorted out, edited, and collated

with the aid of simple tables to enable the overall data to be determined quickly and

easily as well as drawing conclusions. Graphs and Charts were also used.

34

CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND INTERPRETATION

4.0 INTRODUCTION

This chapter deals with presentation, analysis and interpretation of the data obtained in

the course of the research, questionnaires which were administered to obtain the views of

patients towards quality assurance they receive in government health facilities in the New

Juabeng Municipality in the Eastern Region of Ghana. The case study was the Eastern

regional hospital. Interviews were conducted where applicable, and a summary of the

questionnaires and the findings have been summarised below.

Table 4.1 Questionnaires administered and responds obtained

Number of questionnaire administered

Number returned

percentage(%)

Total 100 100 100

As indicated in table 4.1 above, out of hundred (100) questionnaires which were

administered, the number that returned were 100, representing 100% of the total number

of questionnaires administered.

35

4.2 DEMOGRAPHIC DISTRIBUTION OF RESPONDENTS

The questionnaires covered background of respondents with variables such as Gender

distribution, Age distribution, Educational level and the Occupational level.

Table 4.1.2 Gender distribution of respondents

Gender Frequency Percentage (%)

Male 62.0 62.0

Female 38.0 38.0

Total 100.0 100.0

From table 4.1.2, the analysis of data revealed that out of hundred (100) respondents

interviewed, sixty two (62) represents 62.0% were male, while thirty eight (38) represents

38.0% were female.

Table 4.1.3 Age distribution of respondents

Age Frequency Percentage (%)

18-27 37.0 37.0

28-37 38.0 38.0

38-47 15.0 15.0

48 and above 10.0 10.0

Total 100.0 100.0

Table 4.1.3 shows the Age distribution of respondents, out of the 100 questionnaires

36

administered, the largest age group who responded were 28-37 representing 38.0%,

followed by 18-27 representing 37.0%, followed by 38-47 representing 15.0% and the

least group interviewed were 48 and above with 10 respondents representing 10%.

Table 4.1.4 Educational distribution of respondents

Educational Level Frequency Percentage (%)

Basic school 17.0 17.0

Secondary school 23.0 23.0

post secondary school 27.0 27.0

Tertiary school 27.0 27.0

Others 4.0 4.0

No education 2.0 2.0

Total 100.0 100.0

Table 4.1.4 shows the educational distribution of respondents, out the 100 questionnaires

administered; groups of interviewers who responded largely were people from post-

secondary and tertiary school, which is they all responded to 27 questionnaires

representing 27.0%, followed by 23 from secondary school representing 23.0%, followed

by 17 people who had their basic formal education representing 17.0%, followed by 4

people who had education in other educational level representing 4.0% and for the No

education we had 2 people who responded representing 2.0%

37

Table 4.2.0 Occupational distribution of respondents

Occupation Frequency Percentage (%)Teachers 12.0 12.0

Students 42.0 42.0

Traders 14.0 14.0

Farmers 13.0 13.0

Business men 8.0 8.0

Dressmakers 5.0 5.0

Others 6.0 6.0

Total 100.0 100.0

From table 4.2.0, analysis of the data revealed that out of the 100 questionnaires

administered, 42 representing 42.0% were students who responded, 14 were traders who

responded representing 14.0%, followed by farmers 13 representing 13.0%, followed by

teachers 12 representing 12.0% and the least number of people who responded to the

questionnaire were dressmakers, they were 2 representing 2.0%.

38

Table 4.2.1 Category of user (respondents)

Category Frequency Percentage (%)

out patient 56.0 56.0

inpatient 44.0 44.0

Total 100.0 100.0

Table 4.2.1 shows the category of users which consist of out-patient and inpatient, out of

the 100 questionnaires administered, 56.0% who responded were out-patient and the

remaining 44.0% were inpatient.

Table 4.2.2 Satisfaction level of respondents

Satisfaction

Frequency

Percentage (%)

very satisfied 22.0 22.0

satisfied 58.0 58.0

dissatisfied 19.0 19.0

very dissatisfied 1.0 1.0

Total 100.0 100.0

Table 4.2.2 shows the satisfaction level of respondent, out of the 100 questionnaires that

were administered 58 respondents said they were satisfied with the service they received

39

representing 58.0%, 22 said they were very satisfied representing 22.0%, followed by 19

respondents who said they were dissatisfied representing 19.0% and 1 person was very

dissatisfied.

Table 4.2.3 Behaviour of staffs towards clients

Behaviour Frequency Percentage (%)

very good 16.0 16.0

good 48.0 48.0

poor 32.0 32.0

very poor 4.0 4.0

Total 100.0 100.0

Table 4.2.3 shows the behaviour of staffs towards clients, out of the 100 questionnaires

administered, 48 responded that the staffs were good to them representing 48.0%, 32

responded that the performance of the staffs was poor representing 32.0%, followed by

16 who said the staffs were very good to them representing 16.0% and 4 said their

behaviour towards them was very poor representing 4.0%.

40

Table 4.2.4 Hours spent at each service points

Hours spent at each service points

Frequency Percentage (%)

Within 30

minutes

Up to 1 hour

2 hours and

aboveRecords 9 7 3 19 19.0

waiting to

see doctor

31 13 5 49 49.0

dispensary 7 5 1 13 13.0

lab/x-ray 2 1 0 3 3.0

revenue 5 2 0 7 7.0

NHIS 3 5 1 9 9.0

Total 57 33 10 100 100.0

Table 4.2.4 shows the hours spent at each service point, out of 100 questionnaires that

were administered, 49% responded that they spent much hours waiting to see the doctor,

from which 31 said they waited within 30 min,13 said up to 1 hour and 5 said 2 hours and

above, 19% indicated that they spend much time at the records from which 9 waited

within 30 min, 7 up to 1 hour, and 3 said 2 and above, 13% at dispensary from which 7

said they spent within 30 min, 5 up to 1 hour and 1, 2hrs and above, 9% NHIS, out of

which 3 said within 30 min, 5 up to 1hr and 1, 2hrs and above, 7% revenue, out of which

5 said within 30 min and 2 up to 1hr, and 3% from lab/X-ray, out of which 2 waited

within 30 min and 1 up to 1hr.

41

Figure 1.0 The graph below shows the service points were patients spend most of

their time.

Table 4.2.5 Cleanliness of the whole Hospital Premises/Clinic (Surroundings)

Cleanliness Frequency Percentage (%)

very clean 24.0 24.0

clean 61.0 61.0

dirty 15.0 15.0

Total100.0 100.0

Table 4.2.5 shows the cleanliness of the environment together with the health facilities,

42

out of the 100 questionnaires administered, 61 of the respondents expressed their

sentiments that it was clean which represent 64.0%, whereas 24 said it was very clean

which represent 24.0% and 15 responded that it was dirty representing 15.0%. Most of

the patients interviewed indicated that the clients of the hospital were those who made the

surrounding unclean.

Table 4.2.5 Cost of services to clients

Cos

t Frequency Percentage (%)

very expensive 6.0 6.0

expensive26.0 26.0

normal 33.0 33.0

Not expensive because of

NHIS35.0 35.0

Total 100.0 100.0

Table 4.2.5 shows the cost of service to clients, out of 100 questionnaires

administered, 35 of the respondents expressed their sentiment that it was not expensive

because of NHIS which is introduced into the system representing 35.0%, whereas 33said

it was normal which represent 33.0%, 26 said it was expensive representing 26.0% and 6

said it was very expensive representing 6.0%.

43

Table 4.2.6 Reception at the wards

Reception Frequency Percentage (%)

very good 28.0 28.0

good 60.0 60.0

poor 11.0 11.0

very poor 1.0 1.0

Total100.0 100.0

Table 4.2.6 shows reception given to clients at the various wards, out of the 100

questionnaires that were administered, 60 respondents said reception accorded them was

good representing, 28 said it was very good representing 28.0%, 11 said reception

accorded them was poor representing 11.0%, 1 said it was very poor which represent

1.0%.

44

Table 4.2.7 Cleanliness of the various facilities

Facilities cleanliness Frequency Percentage (%)

Very clean

clean dirty

Bathroom 4 15 1 20 20.0

Toilet 4 9 5 18 18.0

Floor 8 15 5 28 28.0

Wards in general

22 8 4 34 34.0

Total 38 47 15 100 100.0

Table 4.2.7 shows the cleanliness of the wards. About 4 expressed their sentiments that

bathrooms were very clean whereas said it was clean and 1 think it was dirty representing

20%. Also 4 of the respondents who have used the toilet facility said very clean, 9 said it

was clean and 5 said it was dirty representing 18%. 8 said the floor was very clean, 15

said it was clean, 5 said it was dirty representing 28%. Also, majority of the respondents

attested to the fact that wards in general was clean representing 34%, out of which 22

said it was very clean, 8 said it was clean and 4 said it was dirty. Most of the patients

interviewed indicated that clients of the hospital were those who made the place unclean.

45

Figure 2.0 Cleanliness of the various facilities

46

Table 4.2.7 Dispensing of drugs

Drugs Frequency Percentage (%)

All 61.0 61.0

Most 37.0 37.0

Non 2.0 2.0

Total100.0 100.0

Table 4.2.7 shows that out of the 100 questionnaires that were administered, 61%

responded that they received all drugs that were prescribed to them, 37% said not all

drugs were prescribed to them, 2% said they received non.

47

Table 4.2.8 SPSS Output of Test Statistics (Chi – Square)

Satisfaction level of

respondents

Behaviour of staffs towards clients

Time spent at

each service point

Cost of services

Reception at the

various wards

Drugs received

from dispensary

Computed value of

Chi-Square

68.400 44.000 68.720 21.040 77.840 52.820

Degree of Freedom

(df) 3 3 5 3 3 2

Asymp. Sig. 0.000 0.000 0.000 0.000 0.000 0.000

Level of significant 0.05 0.05 0.05 0.05 0.05 0.05

Critical value of

Chi - Square

7.815 7.815 11.071 7.815 7.815 5.99

4.3 HYPOTHESIS OF THE STUDY

State the Null and Alternate Hypothesis

Select the level of significance

Select the test statistics

Formulate the decision rule

Make a decision

48

4.3.1 THE RELATIONSHIP BETWEEN PATIENT PERCEPTION OF QUALITY

ASSURANCE AND THE SATISFACTION LEVEL IN GOVERNMENT HEALTH

FACILITIES.

Step 1: Hypothesis

Null Hypothesis (Ho)

There is no relationship between patient perception of Quality Assurance and the

satisfaction level in Government Health facilities.

Alternative Hypothesis (H1)

There is relationship between patient perception of Quality Assurance and the

satisfaction level in Government Health facilities.

Step 2: Level of significant is α=0.05

Step 3: The Test statistic chosen is 68.400

Step 4: The decision rule is that do not reject the null hypothesis if, Computed value of

Chi-Square less than Critical value of Chi – Square.

Critical value of Chi – Square (0.05, 3) =7.815

Step 5: From the ANOVA table above, Computed value of Chi-Square =68.400

The purpose for using 0.05 significance is to test the strong evidence that (Ho) is

not true, Since Computed value of Chi-Square is greater than the Critical value of

Chi–Square (68.400>7.815), we fail to accept the Null Hypothesis (Ho) per the

decision rule.

49

We therefore conclude that the relationship between patient perception of Quality

Assurance in Government Health facilities and the satisfaction level is significant.

4.3.2 RELATIONSHIP BETWEEN PATIENT PERCEPTION OF QUALITY

ASSURANCE AND BEHAVIOR OF STAFFS TOWARDS CLIENTS IN

GOVERNMENT HEALTH FACILITIES.


There is no relationship between patient perception of Quality Assurance and

Behaviour of staffs towards clients in Government Health facilities.


There is relationship between patient perception of Quality Assurance and the

Behaviour of staffs towards clients in Government Health facilities.





Step 5: From the ANOVA table above, Computed value of Chi-Square =44.000

Since Computed value of Chi-Square is greater than the Critical value of Chi –

Square (44.000>7.815), we fail to accept the Null Hypothesis per the decision

rule.

50

We therefore conclude that the relationship between patient perceptions of Quality

Assurance in Government Health facilities and the Behaviour of staffs towards clients is

significant.


ASSURANCE AND THE TIME SPENT AT EACH SERVICE POINT IN

GOVERNMENT HEALTH FACILITIES.


There is no relationship between patient perception of Quality Assurance in

Government Health facilities and the Time spent at each service point.


There is relationship between patient perception of Quality Assurance in

Government Health facilities and the Time spent at each service point



Chi-Square is less than Critical value of Chi – Square.


Step 5: From the ANOVA table above, Computed value of Chi-Square=68.720



rule.

51


Assurance in Government Health facilities and the Time spent at each service point is

significant.


ASSURANCE IN GOVERNMENT HEALTH FACILITIES AND COST OF

SERVICES.



Government Health facilities and Cost of services.



Government Health facilities and Cost of services.








rule.

52


Assurance in Government Health facilities and the Cost of services is significant.


ASSURANCE IN GOVERNMENT HEALTH FACILITIES AND DRUGS

RECEIVED FROM DISPENSARY.



Government Health facilities and Drugs received from dispensary.



Government Health facilities and Drugs received from dispensary.



Chi-Square less than critical value of Chi – Square.

Critical value of Chi – Square (0.05, 2.00) =5.99



Square (52.82>5.99), we fail to accept the Null Hypothesis per the decision rule.

53


Assurance in Government Health facilities and Drugs received from dispensary is

significant.

In conclusion, all the results of the test that was conducted using Chi-square is showing

that the tests are significant.

54

CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATION

5.0 SUMMARY

The main objective of this study was to find out the perceptions of patients towards the

service rendered in the Government health facilities. The services rendered include

- Dispensing of drugs to patients.

- Interaction between Doctors and Patient in the consulting room.

- Reception in the ward or level of tolerance of ward attendants to Patients

- Time spent in the hospital.

The research also looked in to consideration the cleanliness of the various infrastructural

facilities such as –bathroom and toilet

The research was conducted by using sampling procedure

5.1 FINDINGS AND CONCLUSION

From the research findings it found out that 80% of the respondents said they were

satisfied with the service that they received and 20% said that they were dissatisfied with

the service.

With the behaviour of staff towards clients, the research revealed that 64% of the

respondents said staffs were good to them and 36% responded that staffs behaviour

towards them were poor. The findings revealed that 46% spend much time waiting to see

55

the doctor than in all the service points.

With the cleanliness of the environment, 85% expressed their views that it was clean,

whereas the remaining 15% said it was unclean. Most of the patients interviewed

indicated that the clients of the hospital were those who made the surroundings unclean.

Further more, the findings revealed that 35% responded that cost of service to them, was

not expensive because of the NHIS, 33% said it was normal, whereas 32% said it was

expensive. Also for the reception at the wards, 88% expressed their views that it was

good, whereas 12% said it was poor.

5.2 RECOMMENDATION

The aim of the study was to fined out how patients satisfaction are met through the

quality of service that they receive in the health care centre. Based on the findings and

conclusions, the following were recommended.

Long waiting time: caused by inadequate staff strength, increasing number of

clients due to NHIS, delay in starting time of service. Staff should be increase in

their various professions.

Poor staff attitude at the history table and at the NHIS desk: caused by pressure

from workload, lack of patience for clients by the staff. We would like to suggest

that, clients should be admonished to exercise restrain when they visit the

56

hospital, customer care should be organized for the staffs, staffs are encouraged to

treat clients with respect and dignity, and also NHIS staffs should be made to

understand that, they are rendering services to the hospital and are bound by its

ethics and code of conduct.

Admissions without telling the reasons to Patients: caused by staff attrition and

lack of encouragement or reminder. Staff should be reminded of the importance

of informing patients why they are admitted and also educate or orientate new

staff.

Patients not maintaining cleanliness at the various wards: caused by lack of

education and we suggest that health care advert, like posters, magazines should

be provided and also provision of bins on every corridor will help curb this

insanitary situation in the wards.

.

57

APPENDIX: GLOSSARY OF COMMON TERMS

Access: The extent to which user can reach and obtain services

Accreditation: A voluntary process by which a recognized governmental or non-

governmental body assesses and determines whether or not a health facility meets already

agreed standards.

Checklist: A list of items and conditions expected to be present.

Client: User of a product or service, clients may be internal, that is, among the providers

themselves, or external, that is, outside the providers.

Confidentiality: Protection of information from persons who are not expected to have

access to it.

Continuity of services: Ability of the client to receive the complete package of services

that he needs from service provision system over time, without interruption or cessation.

Customer: Used interchangeably with client.

Effectiveness: The ability of a process to produce the anticipated desirable effect(s).

Efficiency: Carrying out an activity or process with the least waste of time, effort and

resources.

Equity: Fairness in the distribution of services.

Evaluation: Assessment of the outcome of a set of processes in relation to set objectives.

Expectation: What is seen as being satisfactory?

Guideline: Direction on how an activity may be carried out.

Indicator: A yardstick used to measure the level of quality.

Input: The set of people and things needed to carry out an activity.

Interpersonal relations: Relationship between users and providers and among providers.

Model of Quality: The different angles from which one can define, monitor, measure

and improve quality.

Monitoring: Continuing assessment of the progress made in the implementation of a

plan or activity, with recommendations for modification of methods as appropriate.

Perception: Expression of what is experienced.

Perspective: Approach or point of view.

Privacy: The state of not being seen or head by a person not expected to do so.

Quality: The degree to which a product or service meets the expectations of an

individual or group.

Quality Assurance: A planned systematic approach for continuously monitoring,

measuring and improving quality of health services, with available resources, to meet the

expectations of both users and providers.

REFERENCES

1. Roemer, M.I., and Montoya-Aguilar, C., .Quality Assessment and Assurance in

Primary Health Care, WHO Offset Publication No., 105, World Health

Organization, Geneva, Switzerland, 1988.

2. Adogboba, Kwame; Offei, Aaron; Tweneboa, Nicholas; Acquah, Seth; Arvorke,

Getrud; Ankrah, Victor; March 2000: Towards a unified QA Strategy for Ghana:

Quality Assurance Review 98. Ministry of Health Ghana in Collaboration with

Liverpool School of Tropical Medicine

3. Donabedian, pp. 5-6.

4. Ruelas, Enrique and Frenk, Julio, .Framework for the Analysis of Quality in

Transition: The Case of Mexico,. Australian Clinical Review, 9, 1989, pp. 9-16.

5. Palmer, Heather, Ambulatory Health Care Evaluation Principles and Practice,

Chicago: American Hospital Association, 1983, p. 139.

6. Berwick, Donald, Improving Health Care Quality, Boston: Institute for Healthcare

Improvement, 1991, p. II-3.

7. De Geyndt, Willy, 1995: Managing the Quality of Health Care in Developing

Countries. World Bank Technical Paper.

8. Donabedian , Avedis, 1996: Evaluating the Quality of Medical care. Milbank

Memorial Fund Quarterly 44:166-203.

9. Nicholas, David D., Heiby, James R., and Hatzell, Theresa A., .The Quality

Assurance Project: Introducing Quality Improvement to Primary Health Care in

Less Developed Countries, Quality Assurance in Health Care, 3:3, Great Britain,

1991, pp. 147-165.

10. Doyle, Vicki; 2000 Quality Assurance Training handouts.otes

11. Field, Marilyn J., and Lohr, Kathleen N. (editors), Clinical Practice Guidelines –

Directions for a New Program, Institute of Medicine, National Academy Press,

Washington, D.C., 1990, p. 8.

12. Copies can be obtained by writing to Centre for Human Services, 7200 Wisconsin

Avenue, Suite 600, Bethesda, MD 20814, U.S.A.

13. The comparative analyses summarize the work of PRICOR II:

Burns Jaeger, Janice, Franco, Lynne Miller, and Newman, Jeanne S., .Oral

Rehydration Therapy in Diarrheal Disease Control: A Review of Experience in

Eight Countries,. September 1990.

14. Donabedian, Avedis, Explorations in Quality Assessment and Monitoring, Ann

Arbor, MI: Health Administration Press, 1980, pp. 5-6.

15. Acquah, S.D., 2002: Quality Assurance Training Handouts.

16. Amstrong, M.; 1997: Human Resources Management. Strategy and Action. Kogan

Page

17. Baah-Odoom, Dinah, 2002: Quality Assurance Training handouts

18. Brown, Lori Di Prete: Franco, Lynne M.; Rafeh, Nadwa; Hatzell, Theresa: Quality

Assurance of Health Care in Developing Countries. Bethesda, USA (USAID).

QUESTIONNAIRE ON PATIENTS PERCEPTON OF QUALITY ASSURANCE

IN GOVERNMENT HEALTH FACILITIES

A CASE STUDY IN THE KOFORIDUA REGIONAL HOSPITAL

INTRODUCTION

Please there are observed, opened ended and subjective questions. Tick [√] where

boxes are provided and give reasons where there are necessary.

QUESTIONNAIRE FOR BOTH OUT-PATIENT AND INPATIENT

1.0 BACKGROUND VARIABLES

1. Gender ……….. a) Male [ ] b) Female [ ]

2. Age …………... a) 15-24 [ ] b) 25-34 [ ] c) 35-44 [ ] 45 and above [ ]

3. Educational level:

a) Basic school [ ] b) Secondary school [ ] c) Post Secondary school [ ]

d) Tertiary education [ ] e) Others [ ] f) No education [ ]

4. Occupation ………………………………………………………………………........

5. When was the last time you used the government health facility?

a) 0-2 years [ ] b) 2-4 years [ ] c) 4-6 years [ ] d) 6 years and above [ ]

6. Category of user:

a) Out- patient [ ] b) Inpatient [ ]

7. Type of respondent:

a) Self user [ ] b) Accompanied ward [ ] c) Both [ ]

8. Which type of facility? a) Hospital [ ] b) Health centre/post [ ]

c) Maternal and child health care centre [ ]

9. Were you satisfied with the services you received?

a) Very satisfied [ ] b) Satisfied [ ] c) Dissatisfied [ ]

d) Very dissatisfied [ ]

10. Do you have any difficulty in finding your way around the facility?

a) Yes [ ] b) No [ ]

11. How was the behaviour of the staffs towards you when you last reported sick?

a) Very good [ ] b) Good [ ] c) Poor [ ] d) Very poor [ ]

d) Shorter than expected

12. Can you give details?

………………………………………………………………………………………………

………………………………………………………………………………………………

13. Do you feel comfortable discussing your complaints (sickness) with the nurse/doctor

or at the O.P.D in the presence of the other staffs? a) Yes [ ] b) No [ ]

14. Did you receive all the drugs that were prescribed to you? a) Yes [ ] b) No [ ]

15. Where was the place you spent much time? a) Records [ ]

b) Waiting to see the doctor [ ] c) Dispensary [ ] d) Laboratory/X- rays [ ]

e) Revenue [ ] f) NHIS [ ]

16. Why do you think you spent much time?

……………………………………………………………………………………………

……………………………………………………………………………………………

17. Do you have any suggestion to reduce the time spent?

………………………………………………………………………………………………

………………………………………………………………………………………………

18. What do you think of the cost the service you received?

a) Very expensive [ ] b) Expensive [ ] c) Normal

d) Cheap because of NHIS [ ]

19. How clean is the environment (surrounding)?

a) Very clean [ ] b) Clean [ ] c) Dirty [ ]

FOR INPATIENT ONLY

20. Were you told why you were to be admitted? a) Yes [ ] b) No [ ]

21. How would you describe your reception at the ward? a) Very good [ ]

b) Good [ ] c) Poor [ ] d) Very poor [ ]

22. Were you attended to prompt when you needed help? a) Yes [ ] b) No [ ]

23. What was/is the attitude of the health staffs? a) Very friendly [ ]

b) Friendly [ ] c) Rude [ ]

24. Who maintained your physical hygiene? a) Parent [ ] b) Health staff [ ]

c) Brother [ ] d) Sister [ ]

25. How would you describe the cleanliness of the following areas?

a) Very clean b) Clean c) Dirty

Bathroom

Toilet

Floor

Ward in general

26. How would you describe the following services?

a) Very satisfied b) Satisfied c) Not satisfied

Nursing care

Medicine

Laboratory service

Doctors

Health aids

Laundry service

Any comment:……………………………………………………………………………..

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Chapter One

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Transcript of Chapter One