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Patient satisfaction as quality indicator in a Nuclear Medicine Department
original articles
Patient satisfaction as quality indicator in a Nuclear Medicine Department A.M. GARCÍA VICENTE, A. SORIANO CASTREJÓN, C. MARTÍNEZ DELGADO, V.M. POBLETE GARCÍA, S. RUIZ SOLÍS, M. CORTÉS ROMERA, S. RODADO MARINA, M.P. TALAVERA RUBIO AND M.A. PALOMAR MUÑOZ Nuclear Medicine Department. Research Unit. Hospital General de Ciudad Real. Ciudad Real. Spain.
Abstract.—Objective. To assess patient satisfaction and dissatisfaction with a Nuclear Medicine Department. Material and methods. A questionnaire was designed with 9 closed questions, 1 with a numerical scale (1-10) and 1 with an open question for suggestions. The questions included different quality dimensions of the department related with waiting time for the scan, information, facilities, attention manner with department staff and global satisfaction (numerical scale,1-10). Dissatisfaction was determined by analyzing the written complaints for the last 6 years. Results. A total of 671 questionnaires were obtained, 58 % of those surveyed being women. The mean age of patients was 56.5 (± 16.26). The information provided was correct in 81.7 % of cases. Equipment and facilities were correct for 74.5 % of patients. Waiting list and waiting time were correct for 70 % and 66.4 % respectively. The attention manner of the department staff was the most satisfactory dimension (98.7 %). Global satisfaction was positive (ⱖ 7 out of 10) in 82.8 % of the patients. Twenty-nine complaints were received. Most of them were based on waiting list (12) and disagreement with assistance (9). Conclusions. Global satisfaction was high in most of patients. Waiting time was the dimension with the lowest level of satisfaction and subsidiary of improvement plans. The primary spontaneous complain by our patients was due to the waiting list.
guntas consideraron diferentes dimensiones de calidad del servicio relacionadas con el tiempo de espera en la realización de la exploración, información, instalaciones, trato recibido por el personal del servicio y satisfacción global (escala numérica 1-10). El grado de insatisfacción se estableció mediante el análisis de quejas escritas recibidas en los últimos 6 años. Resultados. Se obtuvieron 671 cuestionarios. El 58 % de los encuestados fueron mujeres. La edad media fue de 56,5 años (DE: 16,26). La información suministrada fue correcta para el 81,7 % de los encuestados. El equipamiento y las instalaciones fueron correctos para el 74,5 % de los pacientes. La lista de espera y el tiempo de espera fueron correctos para el 70 % y el 66,4 % respectivamente. El trato correcto fue el parámetro más favorablemente valorado (98,7 %). La satisfacción global fue positiva (ⱖ 7 sobre 10) para el 82,8 % de los pacientes. Se recibieron un total de 29 quejas. La mayoría se basó en aspectos relacionados con la lista de espera (12) y disconformidad con la asistencia (9). Conclusiones. El grado de satisfacción fue alto en la mayoría de los pacientes. El tiempo de espera constituyó el parámetro con menor satisfacción y, por lo tanto, subsidiario de mejora. La principal queja espontánea referida por nuestros pacientes fue la lista de espera. PALABRAS CLAVE: satisfacción, paciente, evaluación, salud, calidad, Medicina Nuclear.
KEY WORDS: satisfaction, patient, evaluation, health, quality, Nuclear Medicine. LA SATISFACCIÓN DEL USUARIO COMO INDICADOR DE CALIDAD EN UN SERVICIO DE MEDICINA NUCLEAR
INTRODUCTION
Resumen.—Objetivo. Valorar el grado de satisfacción e insatisfacción del paciente con el servicio de Medicina Nuclear. Material y métodos. Se diseñó un cuestionario compuesto por 9 preguntas cerradas, una de escala numérica y otra pregunta abierta que recogió comentarios y sugerencias. Las pre-
The evaluation of satisfaction is a key tool in ascertaining and analyzing how healthcare services are provided. Since patient satisfaction faithfully reflects healthcare quality, healthcare professionals must understand, know and be aware of the patient’s point of view in order to optimize and improve both parameters in the medical care they provide.1 Donabedian2 described quality of care in three dimensions: technique, interpersonal interaction and comfort. The first one refers to the application of science and technology to solve the patient’s health problems. The second is the interaction between the
Correspondence: C. MARTÍNEZ DELGADO. Servicio de Medicina Nuclear. Unidad de Investigación. Hospital General de Ciudad Real. Tomelloso s/n. 13005 Ciudad Real. Spain. Received: 11-09-06 Accepted: 19-10-06
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García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
healthcare professional and patient when care is provided. Finally, comfort refers to all the elements of the physical setting related to the care process. All these dimensions are inseparable and occur simultaneously whenever a person comes into contact with the healthcare services. When the quality of health services is evaluated, health care professionals, particularly doctors, tend to attach greatest importance to the characteristics pertaining to structure and the technical dimension. However, repeat studies have shown that process-related problems, i.e. how we carry out our work, are more relevant than structural problems in determining the level of quality of healthcare outcomes and patient satisfaction.3 Surveys are an important tool that may help us to obtain more exact knowledge of patients’ perception and assessment of the healthcare system.4 This information is important, as it may become part of internal management, identifying problems and weak points in the system that can be solved by appropriate measures. However, it must be said that the value of satisfaction is underestimated in our everyday work. Few published studies have evaluated the degree of satisfaction of patients who come to the Nuclear Medicine Department for a diagnostic or therapeutic technique.5-7 This study aimed to determine the degree of satisfaction of our patients through the analysis of a questionnaire. Our secondary endpoint was to analyze the written complaints received over the last six years in the Patient Attention Service.
vations was included, where additional comments by patients are noted. The survey was administered randomly between January and October, 2005, among the patients who came to the Nuclear Medicine Department for a scintigraphic study. The questionnaire was distributed to patients (aged over 16 years and mentally competent) after the scintigraphy technique had been completed, and it was collected before they left the Department. Initially, the information obtained from the different variables was analyzed descriptively. Perceived overall satisfaction was expressed using the visual analogue scale, considering a score of 7 or more as positive. The nonparametric statistical method was used because the results did not have a normal distribution. The results of this scale were related to patient gender using the Mann-Whitney U test, to education levels using the Kruskal-Wallis test and to patient age using Spearman’s Rho correlation. As regards the analysis of complaints, all written complaints received from patients who had come to our Department between January 2000 and December 2005 were evaluated. The complaints were classified according to whether they expressed problems of structure, procedure or healthcare outcome. Furthermore, information was requested from the Patient Attention Department on the number of written complaints from patients who visited other hospital Departments and their proportion in terms of the total number of patients seen (hospitalization and consultations) in the same time period.
MATERIAL AND METHODS
RESULTS
A self-applied questionnaire for patients was designed. It had 9 closed and pre-coded questions, one with a numerical scale (from 1 to 10) and one open-ended question that included comments and suggestions. Patient sociodemographic information in terms of age, education and gender was also obtained. This questionnaire is provided in Table 1. The survey addressed aspects related to ease of access to the Department, information about the tests provided to patients before and after they visited the Department, quality of staff attention to the patient, the setting and facilities, as well as the appropriate time of care (whether the medical service was given on patient arrival). Furthermore, a section on obser-
A total of 671 valid questionnaires were collected, excluding those that were not completed (17) and those that were not valid due to partial completion (10). Patient satisfaction
Fifty-eight percent of the questionnaires corresponded to women and 42 % to men. Mean age was 56.5 years (SD: 16.26). A total of 74.7 % of the respondents stated they had been informed about the purpose of the test. In addition, 81.7 % of the respondents stated that the information provided in our Department was correct.
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García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
Table 1 PATIENT SATISFACTION SURVEY FORM 1. Were you informed of the purpose of the tests before you came to the department? Yes Average No No answer 2. Did you find it difficult to locate our department? Yes Average No No answer
7. When you came to the department, you were told about the approximate duration of your test. Do you think that the delay between the actual test and your initial expectations was excessive? Yes Average No No answer
3. Did the secretarial staff that gave you the appointment take into account, as far as possible, your personal situation when making your appointment? Yes Average No No answer
If you answered yes, did they tell you what caused the delay? Yes Average No No answer
4. Do you consider the waiting time between your requesting the appointment and the actual examination requested by your doctor as correct? Yes Average No No answer
8. Do you believe you were correctly handled by the department staff? Yes Average No No answer 9. What score would you give your global stay in the department? (from 1 to 10, where 1 is very bad and 10 is very good) 1—2—3—4—5—6—7—8—9—10
5. What is your opinion on the facilities and equipment of the department? (cleanliness, appearance, comfort) Good Average Bad No answer
10. Comments and suggestions____________________________
Regarding ease of access, 91.8 % stated they had no problems with the location of the Department and 66.5 % considered the attention received by the administrative staff to be correct. Seventy percent considered that the time lapse between the request for the examination and the actual date was correct. Both equipment and facilities were positively evaluated by 74.5 % of the patients and 66.4 % of the respondents considered that there had been no significant delay between the scheduled and actual time of the examination. A total of 38.9 % were informed of the reason for this delay. Correct patient management was the most favorably evaluated parameter (98.7 %). Finally, 82.8 % of the respondents positively evaluated the overall stay in the Department (ⱖ 7 out of 10). No association was found between degree of satisfaction and patient gender (Mann-Whitney’s U test = 45,597; p = 0.129) or education level (KruskalWallis = 2.47; p = 0.480). No correlation was found between degree of satisfaction and age (Spearman’s Rho = 0.042; p = 0.296) (Figs. 1-3). 148
6. The administrative and healthcare staff gave you oral and/or written information on the test that was to be done and the possible preparation needed. Was this information useful to you? Yes Average No No answer
Only 97 patients made comments and suggestions. This constitutes a response rate of 14 % out of all the questionnaires collected (Table 2). A total of 61 % (59/97) suggestions were negative. The most frequent ones pertained to comfort (31). Of the positive comments (33/97), 18 made a positive overall evaluation and 15 of patient handling. There was no evaluation in 5 cases. Patient dissatisfaction
During the period analyzed, 29 complaints were made to the Patient Attention Service, 58 % of them by women. The type of complaints focused fundamentally on waiting list aspects (12), disagreement with healthcare (9), and cancellation of the scheduled appointment (5). Complaints related to material resources (2) and mistaken identity (1) were the least prevalent. Complaints were answered by the solution of the problem in two cases and a letter of explanation or apology in the rest.
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10.00
10.00
8.00
8.00 Overall satisfaction
Overall satisfaction
García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
6.00
4.00
192
2.00
0.00
6.00
4.00
2.00
542
645
516
540
Man
0.00 0
Woman
20
40
Gender
60
80
100
Age
FIG. 1.—Representation of the distribution of the degree of overall satisfaction by gender of respondents. Overall satisfaction value (1-10) is shown on the vertical axis. The majority of the patients (95 %) have values of 7 to 10 on the satisfaction scale, and there are no differences between both genders (p = 0.129).
FIG. 3.—Representation of the distribution of the degree of overall satisfaction by age of respondents. Overall satisfaction value (1-10) is represented on the vertical axis and patient age in groups of 20 years on the horizontal axis. The majority of the patients (95 %) have values of 7 to 10 on the satisfaction scale. No significant differences were demonstrated between the patients with different study levels (p = 0.296).
Table 2 ANALYSIS OF SUGGESTIONS MADE BY PATIENTS IN THE SURVEY QUESTIONNAIRE
10.00
n
8.00 Overall satisfaction
Positive 6.00
Attention offered by the staff
15
Overall satisfactory evaluation
18
Negative
4.00
Comfort 2.00
192
65
3
Eating facilities Facilities
211 212 0.00 No education
Primary Secondary education education
University studies
Education level
FIG. 2.—Representation of the distribution of the degree of overall satisfaction by level of education of the respondents. Overall satisfaction value (1-10) is represented on the vertical axis. The majority of the patients (95 %) have values of 7 to 10 on the satisfaction scale. No significant differences were shown between the patients with different education levels (p = 0.480).
31 3 14
Cleanliness
5
Overcrowding
3
Accessibility
6
Information
9
Appointment delay
1
Test delay
16
Equipment
4
Results
3
Organization
1
Staff
6
Appointment
1
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Of all the hospital complaints received in this same time period, the complaint rate for the Nuclear Medicine Department was 1/289. If we consider that approximately 54,200 patients have been seen in our Department over the last 6 years, this would mean that 1 out of every 1,869 patients made a written complaint about the attention received. This rate was lower than that of other group hospitals for the same timeframe (1/497).
DISCUSSION
Satisfaction with health care is understood to be the result of the two-dimensional interaction between professional and organizational effort and patient expectations, which are comprised of personal experiences, attitudes and beliefs.8 The interest in ascertaining patient satisfaction stems from the idea that the service receiver is the quality mediator.9 Furthermore, different studies have found a strong association between the perception of the overall quality of the Department and patient satisfaction.5,10,11 Evaluating the quality of these Departments using patient satisfaction as a parameter expressed in the questionnaire is a complex task. What this procedure gives us is an opinion limited by the possible response options. However, in our case, securing the information just after the patient had received the service allowed us to capture the patient’s immediate perception, thus avoiding what some authors have termed bias due to perception contamination with the passing of time.12 Departments that perform tests or provide diagnostic support have scarcely been evaluated, and they have generally obtained a better score in satisfaction than the other specialties evaluated.13 In the national setting, we have only found one study that analyzes the degree of quality as perceived by the patients of a Nuclear Medicine Department.7 Our study found that waiting time is the parameter with the lowest degree of satisfaction. De Man et al.5 evaluated the impact of the perception of waiting time in a Nuclear Medicine Department, finding that the patients underestimated total waiting time and the time before the injection, overestimating the waiting time before the scintigraphy. Mean waiting time before injection was 25 minutes. Hui and De Man6,14 found that patients underestimated waiting time when 150
they did not receive information on it. Other authors have found contrary results.15 Our study did not evaluate waiting times. However, we did evaluate the patient’s impression of delay, as defined and explained to them on arrival and as perceived by them at the end of their stay, finding that 66.4 % of the respondents did not find a significant delay with regard to the scheduled examination time. Information is an essential parameter in evaluating patient satisfaction. In general, the patients reported a high degree of satisfaction.7 A total of 81.7 % of patients surveyed reported that they had been correctly informed. Similarly, 82.8 % gave a high score (≥ 7 on a scale of 10) when asked to make an overall evaluation of their stay in the Department. This seems to agree with the previous premise. In sociodemographic characteristics, we found no differences in the degree of satisfaction between men and women, similar to results reported by Hall and Dornan.16,17 On the contrary, other studies have found that women evince greater dissatisfaction than men.18-20 The parameters of patient age or academic level did not have an influence on overall satisfaction in the evaluation. However, other authors have found that elderly patients with lower levels of education were more conformist, and that patients with a higher level of education have greater requirements and demands in health services.3 Moreover, the survey evaluated delay times in access to the Department (waiting list), requesting an opinion on the suitability or unsuitability of the time waited. Although 70 % of the respondents agreed with this time, we think that this parameter shows room for improvement, since it was the most-mentioned one in the analysis of the written complaints and, according to our experience, is also the most usual oral complaint received. Furthermore, some authors have found that patient perceptions about the quality of the Department do not match those of the healthcare staff. They have found that patients perceive a better overall global quality than the staff polled.4,7 When the results of the different patient satisfaction surveys are considered, between 70 % and 80 % of the respondents are satisfied with the healthcare received in the National Health System. This coincides with our results.18
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García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
On the other hand, the most frequent complaints made to Social Security institutions pertained to structural problems and the attention process. In our study, women make more complaints than men. This tallies with the data collected by other authors, although our casuistry is too low to draw reliable conclusions, and the overall results of the bibliography reviewed also show inconsistent findings.21 While we realize that the analysis of written complaints accounts for a small percentage of all existing complaints, we consider that their analysis has helped to identify the most deficient aspects of our care, which fully met to our expectations. By analyzing the suggestions made in writing by some patients, we found that the most poorly evaluated parameter was comfort, while the most frequent complaint was about the waiting list. As for the latter, it is significant that the complaints came from patients who had still not been seen in the Department. The delay in getting an appointment for a scintigraphic study depends on two variables, namely supply (distribution and number of appointments) and demand (requests). In Castilla La Mancha there are only two public Nuclear Medicine Departments, which have to cover the whole population. Thus, supply is limited in comparison with other Autonomous Communities. The extensive population distribution has led to a proliferation of regional hospitals, where scintigraphic studies may also be requested, thus increasing demand considerably. Improvement plans introduced to correct this delay have included the purchase of new equipment, with the consequent increase in the number of appointments available. With regard to the delay in performing the examination, and barring unpredictable situations (such as equipment breakdown, the inclusion of unscheduled emergency studies), we think that most of the delays experienced by the patient from the time they arrived at the Department are manageable, i.e., they can be avoided with good organization and information. This is where our efforts must focus. Although expectations in the evaluation of a sporadic healthcare resource (such as the performance of a scintigraphic study) are not the same as those used more often, as a Central Service we should be more sensitive to the demands of quality, participation, transparency and speed demanded by our patients, be they outpatients or inpatients (requesting clinicians).
CONCLUSIONS
The degree of satisfaction was high in most of the patients surveyed. Delay in the performance of the examination was the parameter that gave rise to lowest satisfaction and can thus be improved. The main unprompted complaint made by our patients was the waiting list. Department quality can be improved through teamwork and the pooling of ideas and efforts to modify work so as to offer more satisfactory healthcare to patients.
ACKNOWLEDGMENTS
To the Patient Attention Service and the rest of the Nuclear Medicine Department for their collaboration and help.
REFERENCES 1. Lamata F, Conde J, Martínez B, Horno M. Marketing sanitario. Madrid: Díaz de Santos; 1994. 2. Donabedian A. La calidad de la atención médica. Definición y métodos de evaluación. México, DF.: Ediciones científicas La prensa Médica Mexicana; 1984. 3. Hall JA, Stein TS, Roter D, Rieser LN. Inaccuracies in physicians’ perceptions of their patients. Soc Sci Med. 1999;37:1164-8. 4. Ibern P. La mesura de la satisfacció en els serveis sanitaris. Gac Sanit. 1992;6:176-85. 5. De Man S, Gemmel P, Vlerick P, Van Rijk P, Dierckx R. Patients’ and personnel’s perceptions of service quality and patient satisfaction in nuclear medicine. Eur J Nucl Med. 2002;29: 1109-17. 6. De Man S, Vlerick P, Gemmel P, De Bondt P, Matthys D, Dierckx RA, et al. Impact of waiting on the perception of service quality in nuclear medicine. Nucl Med Commun. 2005;26:541-7. 7. Lledo R, Herver P, García A, Guell J, Setoain J, Asenjo MA, et al. Information as a fundamental attribute among outpatients attending the nuclear medicine service of a university hospital. Nucl Med Commun. 1995;16:76-83. 8. Mira JJ. Satisfecho, sí gracias... pero ahora qué… Rev Calidad Asistencial. 2003;18:567-9. 9. Donabedian A. Continuidad y cambio en la búsqueda de la calidad. Salud Pública Mex. 1993;35: 238-47. 10. Woodside AG, Frey LL, Daly RT. Linking service quality, customer satisfaction and behavioural intention. J Health Care Mark. 1989;9:5-17. 11. Vandamme R, Leunis J. Development of a multiple-item scale for measuring hospital service quality. Int J Service Industry Management. 1993;3:30-49. 12. Lahuerta J, Hernáez JM, Ruiz Ferrán J. Evaluación de la satisfacción asistencial en dos centros de Sanitas. Rev Calidad Asistencial. 1996;11:4. 13. Nelida Redondo. Encuesta de satisfacción a los usuarios del INSSJP: Alcances e inferencias. Serie II. Estado y Sociedad. Do-
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14.
15.
16.
17.
152
cumento n.º 36. Dirección Nacional de estudios y documentación. Dirección de estudios e investigación. Hui MK, Tse DK. What to tell consumers in waits of different lengths: an integrative model of service evaluation. J Marketing. 1996;60:81-90. Maister D. The psychology of waiting lines. En: Czepiel J, Solomon M, Suprenant C, editors. The service encounter. Lexintong, MA: D.C. Health and Co.; 1985. p. 113-23. Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30:811-8. Hall JA, Dornan MC. Meta-analysis of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Soc Sci Med. 1988;27:637-44.
18. Monteagudo O, Navarro C, Alonso P, Casas R, Rodríguez L, Gracia J, et al. Aplicación hospitalaria del SERVQHOS: factores asociados a la satisfacción e insatisfacción. Rev Calidad Asistencial. 2003;18:263-71. 19. Santiñá M, Prat A, González M, Trilla A, Asenjo MA. Calidad percibida y sexo de los pacientes atendidos en un hospital universitario. Rev Calidad Asistencial. 2002;17:218-23. 20. Caminal J, Sánchez E, Schiaffino A. El análisis por segmentos de población insatisfecha: una propuesta para optimizar la información de las encuestas de satisfacción global. Rev Calidad Asistencial. 2002;17:4-10. 21. Rees-Lewis J. Patient views on quality care in general practice: Literature review. Soc Sci Med. 1994;39:655-70.
Rev Esp Med Nucl. 2007;26(3):146-52
Patient satisfaction as quality indicator in a Nuclear Medicine Department A.M. GARCÍA VICENTE, A. SORIANO CASTREJÓN, C. MARTÍNEZ DELGADO, V.M. POBLETE GARCÍA, S. RUIZ SOLÍS, M. CORTÉS ROMERA, S. RODADO MARINA, M.P. TALAVERA RUBIO AND M.A. PALOMAR MUÑOZ Nuclear Medicine Department. Research Unit. Hospital General de Ciudad Real. Ciudad Real. Spain.
Abstract.—Objective. To assess patient satisfaction and dissatisfaction with a Nuclear Medicine Department. Material and methods. A questionnaire was designed with 9 closed questions, 1 with a numerical scale (1-10) and 1 with an open question for suggestions. The questions included different quality dimensions of the department related with waiting time for the scan, information, facilities, attention manner with department staff and global satisfaction (numerical scale,1-10). Dissatisfaction was determined by analyzing the written complaints for the last 6 years. Results. A total of 671 questionnaires were obtained, 58 % of those surveyed being women. The mean age of patients was 56.5 (± 16.26). The information provided was correct in 81.7 % of cases. Equipment and facilities were correct for 74.5 % of patients. Waiting list and waiting time were correct for 70 % and 66.4 % respectively. The attention manner of the department staff was the most satisfactory dimension (98.7 %). Global satisfaction was positive (ⱖ 7 out of 10) in 82.8 % of the patients. Twenty-nine complaints were received. Most of them were based on waiting list (12) and disagreement with assistance (9). Conclusions. Global satisfaction was high in most of patients. Waiting time was the dimension with the lowest level of satisfaction and subsidiary of improvement plans. The primary spontaneous complain by our patients was due to the waiting list.
guntas consideraron diferentes dimensiones de calidad del servicio relacionadas con el tiempo de espera en la realización de la exploración, información, instalaciones, trato recibido por el personal del servicio y satisfacción global (escala numérica 1-10). El grado de insatisfacción se estableció mediante el análisis de quejas escritas recibidas en los últimos 6 años. Resultados. Se obtuvieron 671 cuestionarios. El 58 % de los encuestados fueron mujeres. La edad media fue de 56,5 años (DE: 16,26). La información suministrada fue correcta para el 81,7 % de los encuestados. El equipamiento y las instalaciones fueron correctos para el 74,5 % de los pacientes. La lista de espera y el tiempo de espera fueron correctos para el 70 % y el 66,4 % respectivamente. El trato correcto fue el parámetro más favorablemente valorado (98,7 %). La satisfacción global fue positiva (ⱖ 7 sobre 10) para el 82,8 % de los pacientes. Se recibieron un total de 29 quejas. La mayoría se basó en aspectos relacionados con la lista de espera (12) y disconformidad con la asistencia (9). Conclusiones. El grado de satisfacción fue alto en la mayoría de los pacientes. El tiempo de espera constituyó el parámetro con menor satisfacción y, por lo tanto, subsidiario de mejora. La principal queja espontánea referida por nuestros pacientes fue la lista de espera. PALABRAS CLAVE: satisfacción, paciente, evaluación, salud, calidad, Medicina Nuclear.
KEY WORDS: satisfaction, patient, evaluation, health, quality, Nuclear Medicine. LA SATISFACCIÓN DEL USUARIO COMO INDICADOR DE CALIDAD EN UN SERVICIO DE MEDICINA NUCLEAR
INTRODUCTION
Resumen.—Objetivo. Valorar el grado de satisfacción e insatisfacción del paciente con el servicio de Medicina Nuclear. Material y métodos. Se diseñó un cuestionario compuesto por 9 preguntas cerradas, una de escala numérica y otra pregunta abierta que recogió comentarios y sugerencias. Las pre-
The evaluation of satisfaction is a key tool in ascertaining and analyzing how healthcare services are provided. Since patient satisfaction faithfully reflects healthcare quality, healthcare professionals must understand, know and be aware of the patient’s point of view in order to optimize and improve both parameters in the medical care they provide.1 Donabedian2 described quality of care in three dimensions: technique, interpersonal interaction and comfort. The first one refers to the application of science and technology to solve the patient’s health problems. The second is the interaction between the
Correspondence: C. MARTÍNEZ DELGADO. Servicio de Medicina Nuclear. Unidad de Investigación. Hospital General de Ciudad Real. Tomelloso s/n. 13005 Ciudad Real. Spain. Received: 11-09-06 Accepted: 19-10-06
146
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García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
healthcare professional and patient when care is provided. Finally, comfort refers to all the elements of the physical setting related to the care process. All these dimensions are inseparable and occur simultaneously whenever a person comes into contact with the healthcare services. When the quality of health services is evaluated, health care professionals, particularly doctors, tend to attach greatest importance to the characteristics pertaining to structure and the technical dimension. However, repeat studies have shown that process-related problems, i.e. how we carry out our work, are more relevant than structural problems in determining the level of quality of healthcare outcomes and patient satisfaction.3 Surveys are an important tool that may help us to obtain more exact knowledge of patients’ perception and assessment of the healthcare system.4 This information is important, as it may become part of internal management, identifying problems and weak points in the system that can be solved by appropriate measures. However, it must be said that the value of satisfaction is underestimated in our everyday work. Few published studies have evaluated the degree of satisfaction of patients who come to the Nuclear Medicine Department for a diagnostic or therapeutic technique.5-7 This study aimed to determine the degree of satisfaction of our patients through the analysis of a questionnaire. Our secondary endpoint was to analyze the written complaints received over the last six years in the Patient Attention Service.
vations was included, where additional comments by patients are noted. The survey was administered randomly between January and October, 2005, among the patients who came to the Nuclear Medicine Department for a scintigraphic study. The questionnaire was distributed to patients (aged over 16 years and mentally competent) after the scintigraphy technique had been completed, and it was collected before they left the Department. Initially, the information obtained from the different variables was analyzed descriptively. Perceived overall satisfaction was expressed using the visual analogue scale, considering a score of 7 or more as positive. The nonparametric statistical method was used because the results did not have a normal distribution. The results of this scale were related to patient gender using the Mann-Whitney U test, to education levels using the Kruskal-Wallis test and to patient age using Spearman’s Rho correlation. As regards the analysis of complaints, all written complaints received from patients who had come to our Department between January 2000 and December 2005 were evaluated. The complaints were classified according to whether they expressed problems of structure, procedure or healthcare outcome. Furthermore, information was requested from the Patient Attention Department on the number of written complaints from patients who visited other hospital Departments and their proportion in terms of the total number of patients seen (hospitalization and consultations) in the same time period.
MATERIAL AND METHODS
RESULTS
A self-applied questionnaire for patients was designed. It had 9 closed and pre-coded questions, one with a numerical scale (from 1 to 10) and one open-ended question that included comments and suggestions. Patient sociodemographic information in terms of age, education and gender was also obtained. This questionnaire is provided in Table 1. The survey addressed aspects related to ease of access to the Department, information about the tests provided to patients before and after they visited the Department, quality of staff attention to the patient, the setting and facilities, as well as the appropriate time of care (whether the medical service was given on patient arrival). Furthermore, a section on obser-
A total of 671 valid questionnaires were collected, excluding those that were not completed (17) and those that were not valid due to partial completion (10). Patient satisfaction
Fifty-eight percent of the questionnaires corresponded to women and 42 % to men. Mean age was 56.5 years (SD: 16.26). A total of 74.7 % of the respondents stated they had been informed about the purpose of the test. In addition, 81.7 % of the respondents stated that the information provided in our Department was correct.
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García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
Table 1 PATIENT SATISFACTION SURVEY FORM 1. Were you informed of the purpose of the tests before you came to the department? Yes Average No No answer 2. Did you find it difficult to locate our department? Yes Average No No answer
7. When you came to the department, you were told about the approximate duration of your test. Do you think that the delay between the actual test and your initial expectations was excessive? Yes Average No No answer
3. Did the secretarial staff that gave you the appointment take into account, as far as possible, your personal situation when making your appointment? Yes Average No No answer
If you answered yes, did they tell you what caused the delay? Yes Average No No answer
4. Do you consider the waiting time between your requesting the appointment and the actual examination requested by your doctor as correct? Yes Average No No answer
8. Do you believe you were correctly handled by the department staff? Yes Average No No answer 9. What score would you give your global stay in the department? (from 1 to 10, where 1 is very bad and 10 is very good) 1—2—3—4—5—6—7—8—9—10
5. What is your opinion on the facilities and equipment of the department? (cleanliness, appearance, comfort) Good Average Bad No answer
10. Comments and suggestions____________________________
Regarding ease of access, 91.8 % stated they had no problems with the location of the Department and 66.5 % considered the attention received by the administrative staff to be correct. Seventy percent considered that the time lapse between the request for the examination and the actual date was correct. Both equipment and facilities were positively evaluated by 74.5 % of the patients and 66.4 % of the respondents considered that there had been no significant delay between the scheduled and actual time of the examination. A total of 38.9 % were informed of the reason for this delay. Correct patient management was the most favorably evaluated parameter (98.7 %). Finally, 82.8 % of the respondents positively evaluated the overall stay in the Department (ⱖ 7 out of 10). No association was found between degree of satisfaction and patient gender (Mann-Whitney’s U test = 45,597; p = 0.129) or education level (KruskalWallis = 2.47; p = 0.480). No correlation was found between degree of satisfaction and age (Spearman’s Rho = 0.042; p = 0.296) (Figs. 1-3). 148
6. The administrative and healthcare staff gave you oral and/or written information on the test that was to be done and the possible preparation needed. Was this information useful to you? Yes Average No No answer
Only 97 patients made comments and suggestions. This constitutes a response rate of 14 % out of all the questionnaires collected (Table 2). A total of 61 % (59/97) suggestions were negative. The most frequent ones pertained to comfort (31). Of the positive comments (33/97), 18 made a positive overall evaluation and 15 of patient handling. There was no evaluation in 5 cases. Patient dissatisfaction
During the period analyzed, 29 complaints were made to the Patient Attention Service, 58 % of them by women. The type of complaints focused fundamentally on waiting list aspects (12), disagreement with healthcare (9), and cancellation of the scheduled appointment (5). Complaints related to material resources (2) and mistaken identity (1) were the least prevalent. Complaints were answered by the solution of the problem in two cases and a letter of explanation or apology in the rest.
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10.00
10.00
8.00
8.00 Overall satisfaction
Overall satisfaction
García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
6.00
4.00
192
2.00
0.00
6.00
4.00
2.00
542
645
516
540
Man
0.00 0
Woman
20
40
Gender
60
80
100
Age
FIG. 1.—Representation of the distribution of the degree of overall satisfaction by gender of respondents. Overall satisfaction value (1-10) is shown on the vertical axis. The majority of the patients (95 %) have values of 7 to 10 on the satisfaction scale, and there are no differences between both genders (p = 0.129).
FIG. 3.—Representation of the distribution of the degree of overall satisfaction by age of respondents. Overall satisfaction value (1-10) is represented on the vertical axis and patient age in groups of 20 years on the horizontal axis. The majority of the patients (95 %) have values of 7 to 10 on the satisfaction scale. No significant differences were demonstrated between the patients with different study levels (p = 0.296).
Table 2 ANALYSIS OF SUGGESTIONS MADE BY PATIENTS IN THE SURVEY QUESTIONNAIRE
10.00
n
8.00 Overall satisfaction
Positive 6.00
Attention offered by the staff
15
Overall satisfactory evaluation
18
Negative
4.00
Comfort 2.00
192
65
3
Eating facilities Facilities
211 212 0.00 No education
Primary Secondary education education
University studies
Education level
FIG. 2.—Representation of the distribution of the degree of overall satisfaction by level of education of the respondents. Overall satisfaction value (1-10) is represented on the vertical axis. The majority of the patients (95 %) have values of 7 to 10 on the satisfaction scale. No significant differences were shown between the patients with different education levels (p = 0.480).
31 3 14
Cleanliness
5
Overcrowding
3
Accessibility
6
Information
9
Appointment delay
1
Test delay
16
Equipment
4
Results
3
Organization
1
Staff
6
Appointment
1
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García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
Of all the hospital complaints received in this same time period, the complaint rate for the Nuclear Medicine Department was 1/289. If we consider that approximately 54,200 patients have been seen in our Department over the last 6 years, this would mean that 1 out of every 1,869 patients made a written complaint about the attention received. This rate was lower than that of other group hospitals for the same timeframe (1/497).
DISCUSSION
Satisfaction with health care is understood to be the result of the two-dimensional interaction between professional and organizational effort and patient expectations, which are comprised of personal experiences, attitudes and beliefs.8 The interest in ascertaining patient satisfaction stems from the idea that the service receiver is the quality mediator.9 Furthermore, different studies have found a strong association between the perception of the overall quality of the Department and patient satisfaction.5,10,11 Evaluating the quality of these Departments using patient satisfaction as a parameter expressed in the questionnaire is a complex task. What this procedure gives us is an opinion limited by the possible response options. However, in our case, securing the information just after the patient had received the service allowed us to capture the patient’s immediate perception, thus avoiding what some authors have termed bias due to perception contamination with the passing of time.12 Departments that perform tests or provide diagnostic support have scarcely been evaluated, and they have generally obtained a better score in satisfaction than the other specialties evaluated.13 In the national setting, we have only found one study that analyzes the degree of quality as perceived by the patients of a Nuclear Medicine Department.7 Our study found that waiting time is the parameter with the lowest degree of satisfaction. De Man et al.5 evaluated the impact of the perception of waiting time in a Nuclear Medicine Department, finding that the patients underestimated total waiting time and the time before the injection, overestimating the waiting time before the scintigraphy. Mean waiting time before injection was 25 minutes. Hui and De Man6,14 found that patients underestimated waiting time when 150
they did not receive information on it. Other authors have found contrary results.15 Our study did not evaluate waiting times. However, we did evaluate the patient’s impression of delay, as defined and explained to them on arrival and as perceived by them at the end of their stay, finding that 66.4 % of the respondents did not find a significant delay with regard to the scheduled examination time. Information is an essential parameter in evaluating patient satisfaction. In general, the patients reported a high degree of satisfaction.7 A total of 81.7 % of patients surveyed reported that they had been correctly informed. Similarly, 82.8 % gave a high score (≥ 7 on a scale of 10) when asked to make an overall evaluation of their stay in the Department. This seems to agree with the previous premise. In sociodemographic characteristics, we found no differences in the degree of satisfaction between men and women, similar to results reported by Hall and Dornan.16,17 On the contrary, other studies have found that women evince greater dissatisfaction than men.18-20 The parameters of patient age or academic level did not have an influence on overall satisfaction in the evaluation. However, other authors have found that elderly patients with lower levels of education were more conformist, and that patients with a higher level of education have greater requirements and demands in health services.3 Moreover, the survey evaluated delay times in access to the Department (waiting list), requesting an opinion on the suitability or unsuitability of the time waited. Although 70 % of the respondents agreed with this time, we think that this parameter shows room for improvement, since it was the most-mentioned one in the analysis of the written complaints and, according to our experience, is also the most usual oral complaint received. Furthermore, some authors have found that patient perceptions about the quality of the Department do not match those of the healthcare staff. They have found that patients perceive a better overall global quality than the staff polled.4,7 When the results of the different patient satisfaction surveys are considered, between 70 % and 80 % of the respondents are satisfied with the healthcare received in the National Health System. This coincides with our results.18
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García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
On the other hand, the most frequent complaints made to Social Security institutions pertained to structural problems and the attention process. In our study, women make more complaints than men. This tallies with the data collected by other authors, although our casuistry is too low to draw reliable conclusions, and the overall results of the bibliography reviewed also show inconsistent findings.21 While we realize that the analysis of written complaints accounts for a small percentage of all existing complaints, we consider that their analysis has helped to identify the most deficient aspects of our care, which fully met to our expectations. By analyzing the suggestions made in writing by some patients, we found that the most poorly evaluated parameter was comfort, while the most frequent complaint was about the waiting list. As for the latter, it is significant that the complaints came from patients who had still not been seen in the Department. The delay in getting an appointment for a scintigraphic study depends on two variables, namely supply (distribution and number of appointments) and demand (requests). In Castilla La Mancha there are only two public Nuclear Medicine Departments, which have to cover the whole population. Thus, supply is limited in comparison with other Autonomous Communities. The extensive population distribution has led to a proliferation of regional hospitals, where scintigraphic studies may also be requested, thus increasing demand considerably. Improvement plans introduced to correct this delay have included the purchase of new equipment, with the consequent increase in the number of appointments available. With regard to the delay in performing the examination, and barring unpredictable situations (such as equipment breakdown, the inclusion of unscheduled emergency studies), we think that most of the delays experienced by the patient from the time they arrived at the Department are manageable, i.e., they can be avoided with good organization and information. This is where our efforts must focus. Although expectations in the evaluation of a sporadic healthcare resource (such as the performance of a scintigraphic study) are not the same as those used more often, as a Central Service we should be more sensitive to the demands of quality, participation, transparency and speed demanded by our patients, be they outpatients or inpatients (requesting clinicians).
CONCLUSIONS
The degree of satisfaction was high in most of the patients surveyed. Delay in the performance of the examination was the parameter that gave rise to lowest satisfaction and can thus be improved. The main unprompted complaint made by our patients was the waiting list. Department quality can be improved through teamwork and the pooling of ideas and efforts to modify work so as to offer more satisfactory healthcare to patients.
ACKNOWLEDGMENTS
To the Patient Attention Service and the rest of the Nuclear Medicine Department for their collaboration and help.
REFERENCES 1. Lamata F, Conde J, Martínez B, Horno M. Marketing sanitario. Madrid: Díaz de Santos; 1994. 2. Donabedian A. La calidad de la atención médica. Definición y métodos de evaluación. México, DF.: Ediciones científicas La prensa Médica Mexicana; 1984. 3. Hall JA, Stein TS, Roter D, Rieser LN. Inaccuracies in physicians’ perceptions of their patients. Soc Sci Med. 1999;37:1164-8. 4. Ibern P. La mesura de la satisfacció en els serveis sanitaris. Gac Sanit. 1992;6:176-85. 5. De Man S, Gemmel P, Vlerick P, Van Rijk P, Dierckx R. Patients’ and personnel’s perceptions of service quality and patient satisfaction in nuclear medicine. Eur J Nucl Med. 2002;29: 1109-17. 6. De Man S, Vlerick P, Gemmel P, De Bondt P, Matthys D, Dierckx RA, et al. Impact of waiting on the perception of service quality in nuclear medicine. Nucl Med Commun. 2005;26:541-7. 7. Lledo R, Herver P, García A, Guell J, Setoain J, Asenjo MA, et al. Information as a fundamental attribute among outpatients attending the nuclear medicine service of a university hospital. Nucl Med Commun. 1995;16:76-83. 8. Mira JJ. Satisfecho, sí gracias... pero ahora qué… Rev Calidad Asistencial. 2003;18:567-9. 9. Donabedian A. Continuidad y cambio en la búsqueda de la calidad. Salud Pública Mex. 1993;35: 238-47. 10. Woodside AG, Frey LL, Daly RT. Linking service quality, customer satisfaction and behavioural intention. J Health Care Mark. 1989;9:5-17. 11. Vandamme R, Leunis J. Development of a multiple-item scale for measuring hospital service quality. Int J Service Industry Management. 1993;3:30-49. 12. Lahuerta J, Hernáez JM, Ruiz Ferrán J. Evaluación de la satisfacción asistencial en dos centros de Sanitas. Rev Calidad Asistencial. 1996;11:4. 13. Nelida Redondo. Encuesta de satisfacción a los usuarios del INSSJP: Alcances e inferencias. Serie II. Estado y Sociedad. Do-
Rev Esp Med Nucl. 2007;26(3):146-52
151
García Vicente AM et al. Patient satisfaction as quality indicator in a Nuclear Medicine Department
14.
15.
16.
17.
152
cumento n.º 36. Dirección Nacional de estudios y documentación. Dirección de estudios e investigación. Hui MK, Tse DK. What to tell consumers in waits of different lengths: an integrative model of service evaluation. J Marketing. 1996;60:81-90. Maister D. The psychology of waiting lines. En: Czepiel J, Solomon M, Suprenant C, editors. The service encounter. Lexintong, MA: D.C. Health and Co.; 1985. p. 113-23. Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Soc Sci Med. 1990;30:811-8. Hall JA, Dornan MC. Meta-analysis of satisfaction with medical care: description of research domain and analysis of overall satisfaction levels. Soc Sci Med. 1988;27:637-44.
18. Monteagudo O, Navarro C, Alonso P, Casas R, Rodríguez L, Gracia J, et al. Aplicación hospitalaria del SERVQHOS: factores asociados a la satisfacción e insatisfacción. Rev Calidad Asistencial. 2003;18:263-71. 19. Santiñá M, Prat A, González M, Trilla A, Asenjo MA. Calidad percibida y sexo de los pacientes atendidos en un hospital universitario. Rev Calidad Asistencial. 2002;17:218-23. 20. Caminal J, Sánchez E, Schiaffino A. El análisis por segmentos de población insatisfecha: una propuesta para optimizar la información de las encuestas de satisfacción global. Rev Calidad Asistencial. 2002;17:4-10. 21. Rees-Lewis J. Patient views on quality care in general practice: Literature review. Soc Sci Med. 1994;39:655-70.
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