Patients satisfaction from hospital services in 2019

Introduction

Majority of hospital are attempting to get empanelled with various insurance companies and empanelment agencies, to increase quantum of patients getting treatment on cashless/reimbursement basis in their hospital but such empanelment requires NABH [national accreditation board for hospital] accreditation. As per NABH rules, point-63 of checklist of quality indicator for NABH accreditation, which includes record of patient’s satisfaction in hospital documents to be checked by inspectors of NABH. With inclusion of health care services under consumer protection act [1986], amended in 2019, in India, hospitals have started giving more importance to patient’s satisfaction in order to (i) avoid litigations (ii) to maintain and improve reputation of hospital.1

Patient satisfaction is defined as degree of congruency between expectations of patient about ideal care & her/his perception of actual care she/he received in hospital. It is a vital marker for the quality of health care delivery & is an internationally accepted factor, which needs to be studied thoroughly & repeatedly for smooth functioning of health care provided by hospitals.2 Patient's perspective about standard of health care services can be obtained by their feedbacks.3 Therefore obtaining & analysing feedbacks from patients is required regularly.

Review of Literature

Satisfaction of patients is important tool to measure success of health care services provided by hospitals.4 Expectations and demands of patients and their relatives have increased many fold due to (a) easier access to other options (b) their higher (i) paying capacity, (ii) levels of education &(iii) exposure and growth of media.5

Before arrival in Hospital, patient and their relatives have image about hospital because they enquire about (a) cost of treatment& (b) reputation of hospital from their social contacts. Their main aim to get cured at earliest but other factors may influence their satisfaction. If their social contacts rate hospital services as poor but they find it up to their satisfaction, then they may rate services of hospital as satisfactory. Conversely, if their social contacts rate hospital services as good and they find services below their expectation, then they may rate services as unsatisfactory. Very high and unrealistic expectations from hospital services may lead to unsatisfactory response, in spite of reasonably good care provided by hospital.5 Patient is consumer of hospital and is in distress and therefore expects comfort, care and cure at earliest.3

In past Government Hospital services were almost free and therefore expectations were minimal. Now Government hospitals have started charging money from patients. Charges of private hospital may be higher and therefore expectations of patients and their relatives have increased proportionately⁵. Patients (customer’s) perception about health care services provided by hospital is becoming increasingly important and its analysis contributes in forming strategy to evaluate and improve performance of Hospital.6, 7 Survey helps Administrative authorities of Hospital to find out ways of improving existing methods of patient’s care.4 Work culture of caring for patients and improvement in patient care can be initiated by analysis of inputs received from feedbacks from patients.3, 4, 5

Patient satisfaction survey is a set of questions used to get feedback from patients, to measure their satisfaction from quality & care of health care provided in hospital. Various authors reported study of questionnaire in studies to find out patient’s satisfaction & other issues about patient’s satisfaction from overall hospital services, quality of food , cleanliness of toilets & behaviour of doctors etc.1, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28

Patient’s opinion about health care provided by hospital, which is also expressed in feedback forms, is likely to be discussed by patients and their relatives socially amongst their social contacts. In this manner reputation of hospital spreads by mouth-to-mouth publicity. By analysing feedback forms, hospital authorities will be able to know about reputation which is likely to be spread by patients and their relatives. 10 Few authors have reported patient’s satisfaction exclusively from patients of outpatient department. [OPD]. 2, 9, 19

Data available on study of satisfaction of admitted patients is relatively less, as compared to large quantum of patients getting admitted in various Hospitals in India. 9 Therefore this study was planned to evaluate satisfaction levels of admitted patients in clinical departments of tertiary care teaching hospital.

Aims and Objectives

To study level of satisfaction of admitted patients or their relatives from hospital services during patient’s indoor stay in hospital in calendar year 2019, in tertiary care teaching hospital in Central India.

Materials and Methods

This study was cross sectional, and was conducted in various wards of clinical departments of tertiary Care, teaching hospital in Central India.

This study included all willing patients, admitted and discharged from this hospital between 1/1/2019 to 31/12/2019. Permission of ethical committee of Medical College was obtained prior to start of study vide IEC/NKPSIMS/1/2018 dated 27/12/2018.

Sample size was calculated keeping in consideration, 87.4% overall satisfaction reported in study at this hospital^9. The formula used for sample size calculation was –

N=Z_/2 *P*[100-P]/L² Where P=87.4%Z_/2 - standard normal variant at /2 level=0.05 β = 20%L – Absolute error = ±2Required sample size is 1101In present study, total respondents were 3004

Before inclusion in this study, informed and written consent of patients or their relatives was obtained. On the day of discharge, patients or their relatives were requested to write their answers to ten questions related to non-clinical services and ten questions related to clinical services.[Table 1]. These ten non-clinical and ten clinical questions [parameters] were pre-validated and were based on various parameters used& published in previous studies. 11, 14, 15 Twenty parameters used during this study were already in use in this hospital in 2019 and were translated in local Marathi, Hindi from English language, as per standard protocol. Questions were drafted about hospital functioning and various hospital services in such a manner, so that relatively less educated patients and their relatives can also understand all questions easily. The printed feedback forms in language of choice of respondents, were given to them by medico-social workers [MSW] of hospital, at time of face to face interview with authors at the time of discharge. These twenty questions were based on issue of patient’s concern. [Table 1] e.g. Grading of hospital services was divided in four, easy to reply, catchy scales namely (i) Excellent (A1), Good (A), (iii) Bad (C) (iv) Worst (D), & respondents were requested to give answers in appropriate column of Feed Back Forms and put their answer by ticking in appropriate column [A1 OR A, OR B1 OR C] & responses of A-1 & A were included in category of satisfactory results & responses in category of B & C were included in category of not satisfactory group. 11

The feedback forms, duly signed by respondents were collected by MSW of this hospital. It was ensured that patients were fully conscious and oriented and clinically fit for discharge, at time of giving their judgment on hospital services. Willing relatives of patients of psychiatry and paediatric wards were requested to give their grading about hospital services, in appropriate column of feedback forms. The data collected was analysed by t- Test [unpaired].

Results

In calendar year 2019, total 3004 respondents participated in study which was 7.3% of all admitted patients in hospital, except patients of Skin, ear, nose & throat department& Respiratory wards because feedbacks from these wards could not be collected. As per compliance of NABH accreditation rules, obtaining feed backs from Indoor patients is an ongoing procedure is this hospital.

The number of respondents who gave feedback from various wards was Ophthalmology - N-898, Psychiatry - N-309, Paediatric - N-544, Medicine - N-428, Surgery - N-418, Obstetrics & Gynaecology - N-233 and Orthopaedics -N-176.

Overall, in non-clinical ten parameters, 62.67% to 97.96%, out of 3004 respondents expressed satisfaction with services provided by non-clinical staff. In comparison, overall 95.2% to 98.26% respondents, out of total 3004 were satisfied with services provided by clinical staff of hospital including doctors, nurses, technicians [question-20 of Table 1]. 82% to 88.06% respondents were satisfied with (i) “May i help you counter” [question- 1] (ii) admission process [question- 2&3] and (C) general cleanliness of hospital (question- 4&7). 62.67% respondents were satisfied with toilets and wash room facilities. (question-5) 75.63% respondents expressed satisfaction with free food provided to indoor patients. (Question-6). 73.15% respondents were satisfied with billing services. (Question-8). 92% to 97.96% respondents were satisfied with security services and help given by MSW. (Question-9-10). Analysis of feedback forms revealed that 97.02% to 97.68% respondent were satisfied with care given by clinical staff [question-11 to 17]. These questions pertained to listening problems of patients, services provided in emergency, daily rounds of doctors and their standard and information provided to patients about their illness and decisions taken by doctors about treatment plan of patients. 95.2% respondents were satisfied with nursing services [question-18] and 98.57% respondents were satisfied with advises given to respondents at time of discharge [question-19].

Statistical analysis of results were done by t-test [unpaired]. Mean score in % of satisfaction in ten non clinical parameters was 82.49% with SD 10.07% and in ten clinical parameters was 97.45% with S.D. 0.90%. This difference was statistically significant [P value < 0.001].

Discussion

A study based on feedbacks given by patients & their relatives is considered valid only if responses are more than 200. If responses are less than 200, then margin of errors is unacceptable.14 In our present study 3004 respondents participated in study.

Available literature revealed that 50 to 3985 Responses had been analysed& reported. This tertiary care teaching hospital is NABH accredited and therefore obtaining and analysing feedback of patients is an ongoing process. Patient satisfaction levels were studied in 2008 in this hospital in 2008 [n-907] and reported in 2012. This study showed overall satisfaction level of 87.8%.10 In year 2016-17, similar study of satisfaction level of respondents [n-384] was conducted exclusively in medicine wards of this hospital and reported in year 2018, & overall satisfaction level was reported to be 95.44%.15

Patient satisfaction survey was conducted in 25 district hospital in Andhra Pradesh in year 1994. They reported 1179 responses, out of which 942 were patients and 239 were Attendants/ Relatives of patients. They reported overall 65% patients’ satisfaction from total of 1179 responses, [approximately 40-50 responses per hospital].14 Overall satisfaction in our study is 98.10% [Table 1 ]

Various other authors reported responses by 200, 619, 1485, 3985, 446, 270 respondents in year 2000,2004, 2006, 2009, & 2012 respectively.14 Various authors reported varying degree of satisfaction among patient regarding quality of food, cleanliness of toilets, behaviour of doctors ,& also satisfaction about overall hospital services & and all these parameters were included in our study.1, 4, 6 Three authors reported patient’s satisfaction amongst n-1625, n-100 & n-200, exclusively among OPD patients in year 2009, 2014, 2016 respectively. 2, 9, 18

One study [n-200] outside India in 2000, reported satisfaction levels of 86.43% about nursing care and 89.72% about medical care and 75.12% satisfaction about overall care,14 Syed S [2012] et al 17 reported study of patient satisfaction, in which 450 outdoor & indoor patients participated & they replied to questionnaire & overall 89.1% respondents were satisfied with health care services. In year 2012, a study of satisfaction among 50 admitted patients of a surgical unit of a teaching hospital was reported. They reported satisfactory response from admission process 82%, nursing services 80%, behaviour of nurses and doctors 92%, cleanliness of toilets 49% and quality of food 78%. The five major satisfiers were behaviour of doctors, explanation about disease and treatment, courtesy of staff at admission counter, behaviour and cooperation of nurses. The five major dissatisfies were cleanliness of toilets, quality of food, explanation about rules and regulation, behaviour of orderlies and sanitary attendants. All these parameters were included in our current study & results are described in Table 1.

In year 2013 a cross sectional study was conducted in two teaching hospitals in India and aim of the study was to establish dimensions/ design/ methodology/ approach of patient satisfaction. The result of this study revealed that patient’s satisfaction is multidimensional & dimensions reported were physician care, nursing care, internal facility etc. & all these parameters were included in our current study.23 In 2016 results of an Indian cross sectional study was reported, in which sample size was 100 patients. This study revealed overall satisfaction as 73.1% with mean value 3.655.24 In January to March 2019 a cross-sectional study was conducted in India & questionnaire were used to find out patient’s satisfaction among admitted patients. They reported that 77% patients were satisfied.27 In February-March, 2017, a cross sectional Indian study was conducted for patient satisfaction among 150 patients admitted in various emergency wards for more than 24 hours. The questionnaire included admission process, discharge information, cleanliness of toilets and explanation of disease by doctor and availability of doctors. They reported 55% satisfaction with overall care, 51% satisfaction with admission process, 61% satisfaction with explanation of disease and 49% were satisfied with availability of doctors. They also reported unsatisfactory response of 59% with general cleanliness and 58% cleanliness of toilets.25

In year 2016 a cross sectional study about patient satisfaction in north India was reported, in which questionnaires were used to find out level of satisfaction among 3278 outdoor &1614 admitted patients. They reported that most of admitted patients were satisfied with care by doctors, nurses & hospital environment. Unsatisfactory responses were reported from cleanliness of toilets in this study & all these parameters were included in our study. 28

In Saudi Arabia, during 2018, questionnaire were used, to find out patient satisfaction among 303 outdoor & admitted patients & 82.8% were satisfied with treatment given by nurses, 90.1% were satisfied with treatment given by doctors, & about 79.6% were satisfied with cleanliness & all these parameters were included in our study. 20 One study from Romania, reported one third of respondents were unsatisfied with hospital services in year 2020. 22

Our present study has sample size of 3004 and overall satisfaction from non -clinical services varied between 62.67% to 97.96% (question no 1-10 in Table 1) and overall satisfaction from clinical services varied between 95.2% to 98.57%.(question- 11-20 in table-1)& results are discussed in Table 1. Few possible reasons for higher satisfaction levels in clinical services given by respondents, in our present study are1 availability of post-graduate students with MBBS degree and nursing students in all wards on 24 hours basis & it is known fact that these category of health care workers are more educated & likely to behave in a better manner because education improves behaviour.2 This hospital is located in outskirts of city & other hospitals are located at a distance of 10-15 km.

Conclusions & Recommendations

Higher education standard and higher paying capacity of patients and their relatives have increased their expectations from hospital services. Majority of hospital are attempting to get empanelled with various insurance companies and empanelment agencies, which resulted in increase in quantum of patients getting treatment on cashless basis. Patients have multiple options to get themselves treated and they are likely to choose hospital with best feedback. Satisfaction standard of patients about services provided by hospital are discussed socially by patients in their social circle. Hence all hospitals should obtain feedbacks from majority of patients and their feedback should be analysed on monthly basis, so that remedial actions can be taken by hospital administration, wherever & whenever required.

Acknowledgements

We acknowledge contributions of all Medico Social Workers (MSW) of hospital for encouraging indoor patients or their relative to give their feedback in spite of patient’s hurry to go home. Especially we acknowledge contributions of Mrs Jaya Awale, Mr Rashid Diwan, Mrs Mangala Vinchurkar, Mrs Sandhya Pathade, Mrs Sangita Mule and Mrs Sunita Ramtekkar.

Limitations of study

Due to cross-sectional design of study, all responses were collected at a single point of time of discharge from hospital. Many discharged patients & their relatives are in hurry to go home & therefore expressed unwillingness to participate in study& their unwillingness is beyond control of authors. Unhappiness from hospital services could not be excluded as a reason for not participation in study.

Conflict of Interest

The authors declare that there are no conflicts of interest in this paper.

Source of Funding

None.