PaAbstract
In this research we address a very important subject for the medical field and to improve the medical service, which is patient satisfaction. It is known very well about the medical field that it is greatly influenced by the exchange of words among the community, which is known as the word of mouth. This indicator will vary according to the patient's satisfaction with the service provided to the friends and relatives. In this study, all the variables affecting the patient's satisfaction will be studied by reviewing the studies that have been carried out and published in advance to reach the most important factors affecting the patient's satisfaction and how to develop them to reach a distinguished medical service that satisfies the patient
Introduction
Because of the importance of the concept of word of mouth in medical business. That affects both of, reputation and income of any medical organization. There is an important tool that; must be considered either to improve the quality of service. Or to be used as an indicator to assess the degree of success of any hospital. That is, Patient satisfaction. In Donabedian's quality measurement model, patient satisfaction is defined as patient-reported outcome measure while the structures and processes of care can be measured by patient-reported experiences. Jenkinson C et al. (2002) and Ahmed et al. (2011) pointed out that patient satisfaction mostly appears to represent attitudes towards care or aspects of care.8,9 While Mohan et al. (2011) referred to patient satisfaction as patients’ emotions, feelings and their perception of delivered healthcare services.10
On the other hand, other authors defined patient satisfaction as a degree of congruency between patient expectations of ideal care and their perceptions of real care received.9
The Importance of patient satisfaction is represented in the following (1)It creates a positive word of mouth toward the hospital (2)Improves reputation of the hospital (3)Increase recommendations to use the facilities of the good hospital (4)It decreases rumors about this hospital(5) Finally has a financial impact by increasing customers and building up reputation
This review will focus on the impact of improving patient satisfaction. Through literature review, that concerns implementation of good management system in the hospital by reviewing the following aspects
a- Inpatient follow up and internal quality of service
b- Continuity of care even after discharge
c- Social relation
The aim of the research is to reach a better understanding and identifying of critical factors, which are affecting patient satisfaction. This study can help to show the patient satisfaction in-patient (in wards) department. Information obtained from the results can be used, as guidelines to implement better policies than the current ones. This study focuses on patient satisfaction on the healthcare services provided by hospitals. This study also helps to the HealthCare organizational future growth.
Methodology
In this study that based on literature review will be categorized according to the research objectives into three categories. The first one is the effect of quality of service on patient satisfaction and it contains 10 researches. The second one is related to the continuity of care and it contains 12 researches. The last category is related to the effect of social relation that affects the loyalty towards hospitals. All of these studies are analyzed regarding methodology, results and conclusions to obtain the final conclusion of the research to help medical organization in developing its policies, services and patient relation to reach the optimum
This study will discuss the three main axis that affect patient’s satisfaction
Service quality
Regarding service quality there are 13 articles that are reviewed between qualitative and quantitative method. All of these articles touched upon the patient's satisfaction, but according to his interests and perspective.
There is a study of the doctor (Dr.R.Kavitha.2012) which examined the change in patient satisfaction due to change in the type of medical institution (private and public one) he has conducted a survey of opinion among 400 patients in the two surveys on satisfaction with the performance and he use the survey questions SERVQUAL model and also Donabedian's framework that was used to measure the patients' satisfaction. The change in satisfaction with two hospitals reveals that the satisfaction varies between the private hospital and the public one. It is recorded that in public hospital, and by using the simple correlation co-efficient. There is no significant change in satisfaction by the perceived service with regard to all dimensions. But in private hospital, there is significant correlation between the perceived service and satisfaction as regards to all dimensions except Tangibles dimension and hence the perceptions of service quality are higher than the expected service. Therefore, the result shows that the private hospital is performing better in providing service quality according to needs of the
Another quantitative study was conducted in Serbia (Vladimir Senic1 and Veljko Marinkovic 2012) to determine the satisfaction level from the medical service that is provided in outpatient polyclinics in an university. The research considered three main factors which can affect the level of satisfaction. The three factors are, (1) personal relationship between patients and service providers (2) tangibility (3) promptness.
The conducted research used 152 students from different campuses from different faculties of the same university in different cities. The study depended on questionnaire that was according to SERVOQUAL. Study used the American Customer Satisfaction Index model (Fornell et al., 1996) by considering three main statements (1) satisfaction relative to expectations (2) satisfaction compared with ideal service in the healthcare sector (3) overall satisfaction. Study paid its interest to students those visited clinics at least one time in the previous 12 months. Statistical analysis was done by SPSS and found that there are four categories of students according to experience by visits from one visit to more than three visits. The acceptable reliability was measured by Cronbach’s alpha coefficient For all three factors (personal relation- ships – alpha = 0.93; promptness – alpha = 0.81; tangibility – alpha = 0.80), the values are greater than 0.7 the results showed that three factors have a significant effect on students satisfaction with the great effect of the relationship factors and study recommended to service providers to pay more of their time to the patient and to make a strong bond with them.
Some limitations are mentioned here as the study did measure the awareness of student of healthy life and how should it be. It also miss measuring of willingness of students to recommend this polyclinics to another and finally they recommended to add non student patient in any future survey.
Another number of papers discussed factors that affect the satisfaction of patient from the provided service and in the following reviews many discussed factors are highlighted to be critical issues that must be improved by service providers in any hospital to reach the optimum satisfaction and then gain many customers by recommending their organization from experienced patients those have got a good service.
This article that was conducted by (Ahmed Rizwan Raheem et all 2014) has the following criteria that will lead us to find the type of the study that it is quantitative (1) Presence of the hypothesis which is the relation between service that is provided and patient satisfaction which is the dependent variable (2) Using a valid instrument. That was the questionnaire that was (3) Results were analyzed statistically
However there is a qualitative aspect in this research which is found in the following
Using nonrandom sample and Using interview in some cases and spend more time with participants. This study is not an experimental study. Because there is no treatment that supposed to be introduced to make change. the patient are asked by questionnaire to evaluate the current service without any intended additional changes in services
The researcher examining causal effect by using causal comparative method by determining the cause or consequences of differences that already exist between or among groups of individuals. (Satisfaction regarding various services such as ward service, reception service, food service among various kinds of patients)
Instrument: this was questionnaire. The content of the questionnaire was not discussed enough. But in the results analysis we can find the area of interest in this questionnaire that was the degree of satisfaction regarding services in various department The type of questions have to be described in the introduction of research to give us enough data about the area of interest in research and to give a weights for each category of questions. The sample was not a random sample. It was a questionnaire that done by interview and patient were informed about the importance of the study and also they informed that it is unpaid.
Regarding response rate it was described as a percentage of valid number of patients that responded to the questionnaire that was 92.5%
Researcher described in a broad sentence that the demographics affecting both dependent and independent variables of satisfaction. But we need to know how and to what extend the demographics affects satisfaction and
Statistically study found a difference between R- square and the adjusted R-square not significant. When it recorded 2.1 which is less than 5. And so, there is no sample error. At the other hand the variation of the model was 15.8% which is significant as F-statistics of ANOVA is greater than 4
The researcher did not describe any limitation of the research because of the following:
a-The availability of participants every day in hospitals
b-The easiness in getting valid feedback as the participants have enough waiting time either in ward or in outpatient department
The results of this study showed that the major number of the patients are satisfied with the following services (1) in-patient department of private hospitals in Karachi (2) food services (3) reception staff services (4) welfare services. On the other side some cases showed no significant impact on patients’ satisfaction with the following services (1) physical appearance (2) pharmacy services (3) laboratory services (4) blood bank and x-rays, ultrasound services (5) billing services (6) outpatient and emergency
By Joshua J. Fenton and others from California university in 2012 one paper built its study to present an econometric model which tried to find the relation between factors of patient satisfaction (perceived quality of healthcare services, their price, personal factors, regarding the patient, and contextual factors) with two behavioral aspects (patients • loyalty towards the healthcare provider and their compliance to treatment) ( cost of satisfaction; modelling patient satisfaction in healthcare 2014). This is a new method in which model is created by combining elements of existing models, based on literature and on the managerial discussion with the managing staff of many medical institutions. The study used data analysis technique of structural equation modelling (SEM).with the soft-ware WarpPLS 4.0.
The questionnaire contained 23 questions, of which 22 closed questions (dichotomous and multichotomous) and 1 open question. Concerning research variables, it were measured using nominal, ordinal and interval scales. Data collection (between 29 May and 03 August 2014) resulted in a total of 589 questionnaires
Study found that, The perceived healthcare quality has the greatest influence on patient satisfaction (0.37; P<.Ol), also patient satisfaction is influenced by the waiting time and the equity with which services are provided Similar to quality
The personal factors had its influence on patients' satisfaction which was measured by the following variables: (1) patient's knowledge, (2) previous experience, and (3) emotions. Along these lines, data analyses confirmed the direct, positive influence of the latent variable personal factors on patients' satisfaction. it was concluded that, the previous experiences have the greatest influence on patients' satisfaction(0.18; P<.01),
The contextual factors measured by the following variables: (1) urgency (2) family members’ opinions (3) opinions of other patients. Study concluded that, the variable urgency has the greatest influence on patients’ satisfaction (= 0.16; P<.01),
Most questioned patients (62.6%) affirmed they are satisfied with their healthcare provider (fact confirmed by the overall score of 3.98).
Regarding the other aspect of the study which is satisfaction responses
Patients' loyalty measured by the variables: (1) repurchase intention, (2) provider recommendation and (3) positive word of mouth. The hypothesis regarding this variable have been also confirmed (= 0.82; P<.01). So, patients' satisfaction has a direct, positive influence on their loyalty towards the service provider,
Another satisfaction response is patients’ compliance with treatment .the results of the research confirming the direct, positive influence of patients' satisfaction on this variable (= 0.41; P<.01).
By calculating the path coefficients p and the R-squared coefficients of determination) the result is determinants of patient satisfaction and its responses, in healthcare, being identified. Hence, also, because the model fit and quality indices have very good values, the proposed model is validated.
By another point of view (Gagan Saini and S. K. Chadha) from Panjab University, India assessed Factor of Services that affect a Patient’s attitude towards Private multidisciplinary Hospitals in North and South India. This paper studied both of tangible and intangible factors of service quality that can affect patient’s attitude and by using a binary regression model and assuming the most important factors by putting a long list of factors and a survey was conducted by an interview of 500 respondents. The target population was patients of private multidisciplinary hospitals of North and South India those completed their treatment at those hospitals. By using ROC graph to obtain the accuracy of the test. It found the area under the curve is 97%, at 95% confidence interval as (.95 – .994) which are close enough for accuracy.
The result then concluded that there were some factors that have strong effect on patient attitude toward hospital and these factors are (1) Professional attitude by hospital staff (2) Doctors should examine patients thoroughly before prescribing treatment plan(3) Complete health information to be conveyed (4) Doctors should be readily available during emergency (5) Cost of hospital services are reasonable. The study found that, functional factors of services are the most effective factors which are related to rational human thought. Patients seek understanding and partnership from both of doctors and hospital staff. Cost is effective also and has a strong significant impact on positive word of mouth only. Study assumed that the effect of cost may related to the nature of Indian people like any people in many developing countries those respect the value of money.
For the same objective that concern the difference between public and private hospitals an empirical study was conducted by (Ismail Bakan and others 2014 ) from Kahramanmaras Sutcu Imam University in turkey but the difference in this study that they considered factors that may affect satisfaction in both kind of hospitals. The hypotheses are taken from a literature review of service quality and quality in the healthcare industry. The instrument was questionnaires and the results were statistically analyzed by descriptive statistics, Pearson product moment correlation and linear regression (imail Bakan et al). This study put some hypotheses to measure relationship between service quality and some variants such as (1) Hospital process(2) Medical care and treatment (3) Staff and administrative staff (4) Hospital expenses (5) Hospital environment (6) social responsibility. By using survey instrument, study used a convenience sampling method a convenience sampling method The research questionnaire was adapted as the following. It was in Turkish language, the first part of questionnaire respected demographic aspect and second part concerned with patient attitude. This part of questionnaire took the model of five points scale and the sample was 200 patients those were 100 patients per each hospital. The statistical analysis used was SPSS and regression analysis was done and result revealed that, that the dimensions of TQS significantly affect patients’ satisfaction as the following, Social responsibility has the highest predictor and core dimension of patients’ satisfaction, followed by Administrative procedures and overall experience of medical care received.
In 2012 there is a study that was conducted by (Dr. Wathek S Ramez College of Business and Finance Ahlia University, Bahrain)
In this study the researcher preferred to investigate patient satisfaction and its motivators in Arabic countries because of the limitation of such studies in this area. The objectives were (1) Patient expectations and perceptions toward the service quality of Bahraini hospitals. (2) The relative importance of service quality dimensions. (3) The relationship between overall service quality and overall patients' satisfaction and their willingness to recommend the services of healthcare providers to others. A literature review was done using studies that are done in other Arabic countries such as ( mostafa 2005) and (Alasas and Ahmed 2003).null hypotheses was done regarding the following
H1: there are no significant differences in patient perceptions of service quality dimensions, (tangibles, reliability, responsiveness, assurance and empathy) of Bahraini hospitals.
H2: there is no significant relationship between overall service quality and overall patient satisfaction of Bahraini hospitals.
H3: there is no significant relationship between overall patient satisfaction of Bahraini hospitals and propensity of patients to recommend the health services to others. ((Dr. Wathek S Ramez 2012).
A sample was 235 patients of hospitals and medical centers by questionnaire survey in which two techniques were used. The first was, SERQUAL scale which is a multi-dimensional research instrument, designed to capture consumer expectations and perceptions of a service along the five dimensions that are believed to represent service quality. And it explained 62.75% of the cumulative variance in the overall service quality, and the other one was SERVPERF scale which explained 69.716%. Regarding statistical analysis, regression and correlation statistical techniques were used. The first was, SERQUAL scale and it explained 62.75% of the cumulative variance in the overall service quality, and the other one was SERVPERF scale which explained 69.716%. Regarding statistical analysis, regression and correlation statistical techniques were used and this analysis resulted in rejection of all of three null hypothesis and then it confirmed the strong relation between patient satisfaction and the positive word of mouth.
Continuity of care
Another aspect of this research will focus in the importance of continuity of care that occurs when healthcare is provided by the same professional over time. The continuity of care and reassurance prevent both of patient’s health and cost by preventing readmission that may be done by ignorance and discontinuity of care. This is important for outpatient care more than inpatient one.
Some studies are reviewed, one of them was published in 2014 and conducted by Jonathan Turner, et al in Chicago, Illinois and based on collecting data from a medical system about patients those were admitted to nonteaching hospital between the periods from 2008 to 2011. The study used two indicators to measure progress notes that were written by one physician that will indicate the positive continuity. One of them was NPI which is the total number of unique authors of progress notes for a patient. The UPC is the largest number of notes which are written by a single physician divided by the total number of notes written for a patient. By these indicators study could detect the level of continuity as the following; the continuity is increased when NPI is increased and UPC is decreased. Then study linked that with the percentage of readmission within 30 days and then the extra cost. Collecting data was by the help of ICD9 system of diagnosis and analytical system was SAS windows. By these tools, study observed that lower percentage of unique progress notes followed by discontinuity and the readmission and extra cost.
Another observation was the load of extra and not indicated tests that may be requested by some physician make a load on patient by its extra cost.
A qualitative study that done by Shivan J. Mehta, MD, MBA and published in 2015 discussed a critical aspect of continuity of care which is patient experience that was defined by agency for healthcare research and quality by the range of interactions that patients have with the health care system, including their care from health plans, and from doctors, nurses, and staff in hospitals, physician practices, and other health care facilities. This study recommended a tool for measuring patient experience which is widely used. It is Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) which is a survey that consists of 32 questions used for a random sample of hospital patients. Study also showed the benefit of measuring patient experience for both of hospitals and patients. Study showed that a high level patient experience makes hospitals to focus more in its technical level by adding more clinical experience and increasing patient relations for sustainable positive reputation and continuity. And for the patient also, it showed that continuous measuring will improve quality of care by respecting patient experience and then will increase positive word of mouth that will increase number of customer which will make the hospital to look for improving quality not prices because the revenue is sustained and even increases by the increase of number of customers by good reputation.
Patient- doctor relationship as an important tool of continuity of care was discussed in a study that was conducted by Van Den Assem (2012) and published in 2015. this study developed a model of Mayer et al. (1995, p. 715), that was based on three major constructs(1) trust(2) relationship (3) outcomes. The adjusted model measured patient trust in doctors, by measuring doctor practice orientation, performance and outcomes, specifically patient satisfaction with their doctors. Closed ended questionnaire was adjusted and the sample was a representative sample of 372 patients from 7 institutions. Statistical analysis was done by using SPSS. Results showed that the contributions of variables was as the following (1)demographic variables contributed 12.7 per cent (2) care continuity 19.7 per cent(3) trust 38.6 per cent(4) doctors’ practice orientation 0.3 per cent (5) doctor performance 3.2 per cent, totally, 74.5 per cent of the patient satisfaction variance. Finally results showed that the relationship between trust and doctor performance was strong. Doctors’ interpersonal abilities and skills were also regarded by patients to be important considerations in determining doctor performance. Regarding the scale of continuity of care That included four (1) consultation frequency (2) visiting the surgery(3) consultation length(4) how well the patient knew the doctor. The results showed that patient trust, doctor performance, doctors’ practice orientation and continuity of patient care are important to patient satisfaction.
The limitation of this study was described as the study did not respect physicians as they are the decision makers and further researches must include physicians and other surveys about home care service quality, phone consultations and outpatient clinic service
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