Luận Án TS y học: Factors influencing patient satisfaction in a free health care system in the national referral hospital (NRH), Thimphu, Bhutan

1. Background CHAPTER I INTRODUCTION Bhutan, a small land locked country in the Himalayas pursues a lofty philosophy of Gross National Happiness (GNH) as the overarching developmental philosophy (Vision 2020, 2000). This is contrary to the conventional Gross National Product (GNP) or Gross Domestic Product (GDP) that most countries follow for development and achieving economic goals. This philosophy emphasizes the wholesome development of Bhutanese society taking into considerations economic, social, psychological and even spiritual dimensions of development. The strategies engaged towards fulfillment of this utopian goal of GNH are economic development, environmental preservation, cultural promotion and good governance (Gross National Happiness, 1999, The Center for Bhutan Studies). This is again not to undermine economic gains, which are equally important for Bhutan whose GDP stands at about US $500 per person. Through this concept, the Royal Government of Bhutan (RGOB) strives to provide basic essential services in the social sectors like health and education freely to all Bhutanese citizens. Health care services in Bhutan are still in a fledgling stage. An independent Ministry of Health (MOH) was constituted on 26 th June 2003. Before that it was the Ministry of Health and Education. Primary Health Care (PHC) is the strategy for health care

HOSPITAL (NRH), THIMPHU, BHUTAN

Tapas Gurung

A Thesis Submitted in Partial Fulfillment of the Requirements

for the Degree of Master of Public Health in Health Systems Development

College of Public Health Chulalongkorn University Academic Year 2003 ISBN-974-9599-38-1 Copyright of Chulalongkorn University

By : Tapas Gurung

Program : Health Systems Development

Thesis Advisor : Robert Sedgwick Chapman, M.D., M.P.H

Accepted by the College of Public Health, Chulalongkorn University, Bangkok Thailand in Partial Fulfillment of the Requirements for the Master's Degree

……… Acting Dean of the College of Public Health (Associate Professor Prida Tasanapradit, M.D.)

……… ……… Member (Professor Edgar J Love, M.D., Ph.D.)

PH: 032393 : MAJOR HEALTH SYSTEMS DEVELOPMENT

KEY WORDS : INPATIENT SATISFACTION / DOMAINS OF CARE / ALL

WARDS / THE NRH TAPAS GURUNG: FACTORS INFLUENCING PATIENT SATISFACTION

IN A FREE HEALTH CARE SYSTEM IN THE NATIONAL REFERRAL HOSPITAL, THIMPHU, BHUTAN THESIS ADVISOR: ROBERT SEDGWICK CHAPMAN, M.D., M.P.H., 130 pp ISBN 974-9599-38-1

Apparent rise in patient dissatisfaction at The National Referral Hospital at Thimphu, Bhutan, warranted a study to find out levels and factors for dissatisfaction A cross sectional hospital-based study was conducted involving 180 inpatients from all wards and cabins in January-February 2004 An interviewer administered questionnaire survey on patients, 5 key informants were interviewed and a short questionnaire survey

of physicians were conducted Mostly young, both genders represented equally, 61.1%

of study population was illiterate 66.1% was poor with a monthly income below Ngultrum 5000 (about US$110), 35% were farmers and though a referral hospital, 56% patients were self-admitted patients mainly for acute conditions (58.3%) Overall, there were 91.7% satisfied and 8.3% dissatisfied patients Among wards, the cabin had the highest overall satisfaction at 66.7%, followed by EENT, surgical and maternity at 64.7%, 62.1% and 60.0% respectively Wardwise differences were statistically significant (p=0.029) Age, ethnicity and duration of hospital stay had statistically significant association with accessibility (p=0.003, 0.041 and 0.014 respectively); referral status and admission history with comfort in ward (p=0.026 and 0.021 respectively) Gender, referral status and admission history had significant associations with waiting time (p=0.047, 0.009 and 0.007 respectively) Nurses’ competence and ethnicity had significant associations with disease status and doctor patient relationship (p=0.046 and 0.045 respectively) Provider-related domains were more important for patient satisfaction than were hospital milieu-related domains (p <0.001) Free health care, kind and helpful staff, their competencies, good nursing and medical care, reputation of this apex hospital were some of the main factors for satisfaction Visitor restrictions, long waiting time, inadequate communication between physicians and patients were some of the factors highlighted for dissatisfaction Lack of adequate staff was identified as one of the main bottlenecks for the NRH in not being able to meet patients’ expectations Lack of staff also impeded physicians from practicing “Service with a Humane Face” Encouraging a good doctor-patient relationship, reviewing visitor restriction rules and hospital diet, and provision of a decent resting place for patient attendants/companions at night were some of the main recommendations worth considering

Field of study Health Systems Development Student’s signature

ACKNOWLEDGEMENTS

This academic work would not have been accomplished without the support and guidance of a number of persons I hereby extend my sincere and most humble acknowledgements and thanks to all concerned with special mention of the following

I would like to thank Ajarn Ong-arj Viputsiri, chairman of my thesis committee, Dr Robert S Chapman, my thesis advisor, Ajarn Buddhagarn Rutchatorn, my external examiner, Ajarn Sathirakorn Pongpanich and Professor Edgar J Love, committee members for consenting to be my mentors and guides in this maiden venture of mine in research

I would also like to extend my heartfelt thanks to the Royal Government of Bhutan for giving me this opportunity to pursue a masters course in the prestigious College of Public Health, Chulalongkorn University, Bangkok I will always persevere to serve my country and the Bhutanese people to the best of my abilities and with most sincere efforts for the rest of my career

I will fail in my duty as a student here if I do not mention and thank all those faculty members who taught me with diligence and love I hope that what I do in the domain of public health in future, in my own small ways will be significant (with p<0.05) and I will definitely attribute those to all of you too The assistances of the ever cheerful and helpful administrative and other support staff here will always be remembered I will cherish my days here and try and live up to the lofty goals and visions of this institute

My sincere thanks go also to all those who facilitated me in this research work including the staff and inpatients and patient attendants of the National Referral Hospital, Thimphu I hope this small research of mine will be of some use to you in some ways

To all my friends of this MPH cohort, my thanks for sharing many things beyond the academic confines of CPH I will always try to remember and reminisce our days together and I wish you the best in all your ventures in life

I would also like to make a special mention and acknowledge the support from all my Bhutanese friends at Rangnam apartment and elsewhere studying at various institutions here at Bangkok Our days together will always be remembered down memory lane And lastly, I would like to thank my wife, three children and other near and dear ones for their moral and other valuable support I will make sincere efforts to make up for the twelve months we all missed one another

8 Operational Definitions of Variables 12

2 Literature Related to Patient Satisfaction 14

3 Some Models and Theories of Patient Satisfaction 15

4 Literature Review Related to Doctor–Patient Relationship 21

5 Literature Review of Factors in Relation to Patient Satisfaction 26

3 Time Line for Data Collection 33

4 A Brief Description of the National Referral Hospital

10 Validity Testing of Questionnaires 36

11 Reliability Testing of Questionnaires 36

12 Training of Data Collectors/Survey Interviewers 37

13 Ethical and Administrative Clearances 37

14 Data Collections and Analysis 38

CHAPTER IV RESEARCH FINDINGS 41

2 Salient Features of Study Findings 41

4 Levels of Satisfied and Dissatisfied Patients 58

5 Factors for Satisfaction as Responded by Satisfied Patients 62

6 Recommendations from the Satisfied Group of Patients

for Improving Services and Patient Satisfaction 64

7 Factors for Dissatisfaction for Dissatisfied Group of Patients 65

8 Tests of Associations Between Socio-Demographic Factors

and Specific Domains of Satisfaction 66

9 Associations Between Patient Factors and Service

10 Associations Between Patient Factors and Overall

11 Overall Satisfaction with Age and Duration of Hospital Stay 73

11 Test of Differences in Terms of Satisfaction Between

Factors Under Hospital Milieu and Provider Aspects 74

13 Interviews with Key Informants 75

14 Findings of the Self-Administered Questionnaire Survey

CHAPTER V DISCUSSIONS, CONCLUSIONS,

2 Salient Socio-Demographic Characteristics of Sample Population 83

3 Summary of Satisfaction Levels of Different Services

in the Wards of NRH as Rated by Study Population 86

4 Salient Features of Dissatisfied Patients in the NRH 91

6 Factors for Satisfaction as Responded by Satisfied Patients 99

7 Scores for Various Services Among Dissatisfied Group of Patients 99

8 Factors for Dissatisfaction Among the Dissatisfied Patients 100

9 Recommendations for Improvement as Suggested

10 Interviews of Key Informants 101

11 Questionnaire Survey of Physicians on their Perceptions

of Patient Satisfaction at the NRH 102

12 Discussions on Some Factors/Variables Under Certain Domains 103

2 Satisfaction Levels in the NRH 106

3 Satisfaction Levels for Different Service Domains at Different Wards 107

5 Factors for Dissatisfaction as Responded by Dissatisfied Patients 108

6 Recommendations for Improvement of Inpatient Services

7 Summary of the Interviews with Key Informants 109

8 Questionnaire Survey of Physicians at the NRH 109

9 Some Limitations of the Study 110

ANNEX I Questionnaires for Structured Interview Survey

of Inpatients of Thimphu General Hospital (TGH) 119

ANNEX III Questionnaires for physicians’ survey at the

National Referral Hospital (NRH), Thimphu 124 ANNEX IV Outline of topics for interviews with key informants of the

Department and National Referral Hospital at Thimphu, Bhutan 127

LIST OF TABLES

Page Table 1: Operational definition of variables 12 Table 2: Age distribution of study population 42 Table 3: Duration of hospital stay (in days) during time of survey 42 Table 4: Socio-demographic characteristics of sample population 43 Table 5: Satisfaction levels for whole sample population 46 Table 6: Satisfaction levels in the Eye, Ear, Nose and Throat ward 47 Table 7: Satisfaction levels in medical ward 48 Table 8: Satisfaction levels in the orthopedic ward 49 Table 9: Satisfaction levels in the maternity ward 50 Table 10: Satisfaction levels in the surgical ward 52 Table 11: Satisfaction levels in pediatric ward 53 Table 12: Satisfaction levels in the cabin 54 Table 13: Ward wise satisfaction matrix for hospital milieu,

provider factors and overall combined 56 Table 14: Table showing ward-wise distribution of satisfied

Table 15: Characteristics of dissatisfied patients 60 Table 16: Scores for service domains for dissatisfied patients 61 Table 17: Tests for differences in means of satisfaction scores between

satisfied and dissatisfied patients in hospital

and provider domains and overall satisfaction 62 Table 18: Factors for satisfaction as responded by satisfied patients 63

Table 19: Recommendations from the satisfied group 64 Table 20: Factors for dissatisfaction for dissatisfied patients 65 Table 21: Associations between age, ethnicity and duration

Table 22: Association between gender, referral status

and admission history with waiting time 68 Table 23: Association between Referral status and Admission

history with Comfort in the ward 69 Table 24: Disease status with nurses’ competency 71 Table 25: Ethnicity with Doctor-patient relationship 71 Table 26: Association between age and overall satisfaction

with domains under provider aspect 72 Table 27: Association between Age and Overall combined satisfaction 73 Table 28: Association between duration of admission

and overall combined satisfaction 74 Table 29: Test of differences between means of scores

under hospital milieu and provider aspects 75 Table 30: Distribution of physicians specialty/ward wise for

LIST OF FIGURES

Page Figure 1: Graph patient referrals and expenditure 1992-2002 in NRH1 3 Figure 2: Conceptual frame work of research 9

Figure 4: Cognition-Affect Model of Satisfaction 18 Figure 5: Zone of Tolerance by Nelson E and Larson C 19 Figure 6: The Making of Patient Satisfaction Happen 20 Figure 7: Patient flow in the National Referral Hospital (NRH) 34

ABBREVIATIONS

BHUs : Basic Health Units

EENT : Eye, Ear, Nose and Throat

GNH : Gross National Happiness

GNP : Gross National Product

GDP : Gross Domestic Product

JDWNRH : Jigmi Dorji Wangchuck National Referral Hospital

(NRH in short) Khengpas : The Central Bhutanese people

Lhotshampas : The Southern Bhutanese people

MOH : Ministry of Health

Ngalongs : The Western Bhutanese people

Nu : Ngultrum, the Bhutanese currency (US $ 1= Nu 46)

ORCs : Out Reach Clinics

PHC : Primary Health Care

RGOB : Royal Government of Bhutan

Sharchops : The Eastern Bhutanese people

Health care services in Bhutan are still in a fledgling stage An independent Ministry of Health (MOH) was constituted on 26th June 2003 Before that it was the Ministry of Health and Education Primary Health Care (PHC) is the strategy for health care

delivery based on the Alma Ata declaration in 1978 with particular emphasis on decentralization and integration of activities up to community level These are implemented through an equitably distributed network of 29 hospitals, 166 Basic Health Units (BHUs), one traditional (indigenous) hospital and 19 dispensaries, and about 455 outreach clinics As of now, primary health coverage stands at about 90% and an army of about 1450 health workers across Bhutan is striving to achieve the remaining 10%

No private practices exist in the country and the only alternative medicine; the indigenous system is integrated with general medical care services Medical care, at all levels is free for the Bhutanese except for some advanced technology-based interventions like crown and bridge procedures in dentistry and laproscopic surgeries in Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), The National Referral Hospital in short With a minimal 2% deduction as health contribution from monthly salary of government servants, government even pays for cost of treatment outside in India and Thailand The referral cost incurred mainly for tertiary care has spiraled from

US $ 2.9millions in 1992-93 to US $11.3 millions by 2001-002

Patients referral and expenditure 1992 - 2002

445 384

690 593 541 545

418

11.3 10.4 9.4 8.2 3.9 4.8

5.9

2.6

3.4 2.9

1993- 1995

1994- 1996

1995- 1997

1996- 1998

1997- 1999

1998- 2000

1999- 2001

2000- 2002

2001-No of cases Expenditure in million $

Source: The National Referral Hospital, 2003

Figure 1: Graph patient referrals and expenditure 1992-2002 in NRH1

By and large, most Bhutanese health care seekers are simple and law-abiding people reposing full trust on care providers who are educated and also employed by the state The overall motto of service delivery to our people is consonant with the principles of

“Professionalism” and “Service With Humane Face” However, there are indications that certain sections of people in the capital city, Thimphu are no longer satisfied and happy with whatever free health care the government is providing to them

These expressions are appearing in the media and as anecdotal evidences from people

we know and interact within Thimphu, which is a small town For example in May and August 2003, two topics as “Wrong Diagnosis” and “Doctors Hate Patients”

April-respectively made national headlines in the electronic media engaging a wide spectrum

of Bhutanese elites in the debate Both these complaints originated from The National Referral Hospital in Thimphu These incidences disturb and frustrate the ministry, department of health including the rank and file of health personnel who are doing their best to render services despite limitations and constraints

2 Problem Identification

The apparent rising trend of patient dissatisfaction in a free health system as in The NRH in Thimphu is a concern for policy makers and administrators in the ministry and departments of health The royal government is spending a substantial amount of money for health care at all levels of services including tertiary care for referred treatment even outside the country As a developing country, resources are limited and there are competing priorities at national level The amount of budgetary resources allocated to social sectors to the tune of about 10-12% yearly bears testimony to the fact that health is high on the development agenda of Bhutan Most countries in the South East Asia region have an allocation of 2-8% of gross domestic product for health sector (Than Sien, 2001) The best use of resources and to cater services to the satisfaction of general public is one of the overriding development objectives of health sector

Geopolitically, Bhutan, a small nation with an area of 47,000 square kilometers and a population of about 700,000, lies sandwiched between two Asian giants; India in the south and China in the north It is a paramount national goal for the government to keep her people satisfied and happy conforming to the philosophy of Gross National

Happiness National solidarity, in essence, is a goal for Bhutan’s very survival and as a strategy towards this; satisfaction and happiness of the public are dear objectives of all social sectors of the Bhutanese government

Bobadella et al (1992) said that no country in the world can provide health care services

to meet all the needs of the population However, the kingdom of Bhutan aspires to take the challenges of providing these and that too freely to her citizens

The problem of patient dissatisfaction may not be substantial and there have been no surveys or studies carried out to ascertain this Also it has been difficult to pinpoint as

to which categories of patients are complaining regarding the services Few instances of grievances had focused both inpatient and outpatient services The few complaints represent only the tip of the iceberg as only 4% of those dissatisfied patients complain (Roderick M McNealy, 1994) There may be, therefore, quite a number of dissatisfied patients in town and elsewhere harboring bad experiences regarding health services at the NRH And what happens at Thimphu spreads fast and wide to the districts with even possible backlash on patient referral to this pioneer hospital The fact this has started warrants us to initiate and find out the factors and service areas related to patient dissatisfaction for initiating timely and necessary administrative and policy changes The attempt to study the issues and factors related to patient satisfaction is also a testimony that we care for their needs and expectations

3 The Research Questions

The following are some of the research questions related to the issues of patient dissatisfaction:

3.1 What are the socio-demographic characteristics of patients at the NRH? 3.2 Are there marked differences in quality of services and satisfaction levels among inpatients of different wards of NRH?

3.3 What is the level of dissatisfaction among inpatients of NRH?

3.4 What are the main factors that determine patient satisfaction in the Bhutanese context?

3.5 What are the perceptions of physicians, policy makers and administrators about issues of patient dissatisfaction?

4 Rationale of the Research

The following are the rationale for the research:

4.1 Patient satisfaction is a measure of quality of health services (Donabedien, 1966) Quality assessment and satisfaction are often used interchangeably though, as per Bitner M and Hubbert A (1994) satisfaction is generally considered in a broader term

4.2 Patient satisfaction is an indicator of patient and health provider relationship In our system too as elsewhere, a congenial health provider and patient relationship is crucial for the satisfaction of the latter Ware and Davis (1993) said that satisfaction is a cementing process that binds a patient and the health care provider This bond can be used as one of the

predictors whether patients are likely to continue or change their health care providers

4.3 Patient satisfaction increases likelihood of compliance to treatment and better follow up of patient care (Wilson P., McNamara, 1982)

4.4 Patient satisfaction may also lead to provider satisfaction and motivation

to work better Tzeng Huey-Ming (2002) found a positive relationship between these two parameters in a study among nurses in a Taiwan teaching hospital In an altruistic sense, this is important in our system as there are no private practices and patient satisfaction may be an important factor for job satisfaction for our physicians and health care workers 4.5 Roderick M Mc Nealy in his book Making Customer Satisfaction Happen says that only 4% of dissatisfied patients complain The other 96 % walk away quietly Hence, the few instances of complaints represent only the tip of iceberg of dissatisfied population among the clientele base of this hospital

5 Purpose of the Research

The main purpose of the study was to assess level of dissatisfaction among inpatients of NRH and to ascertain the main factors for satisfaction/dissatisfaction in a free health care system in the Bhutanese context And ultimately, this would be used to improve patient care, patient satisfaction and utilization of inpatient services at NRH

6 Objectives of the Research

6.2.2 To characterize patient satisfaction levels in respect to different

service domains in all wards of NRH

6.2.3 To find out the level of dissatisfaction among inpatients of NRH 6.2.4 To ascertain the main factors that influence patient satisfaction

among inpatients in NRH

6.2.5 To find out perceptions of physicians, hospital administrators and

department policy makers in terms of patient satisfaction or dissatisfaction, quality and sustainability of health care services in NRH

6.2.6 To seek recommendations for specific factors or service areas for

improvement from inpatients and physicians of NRH

7 Conceptual Framework

Increased Health Services Utilization

Attitude of Support Staff

Accessibility, Waiting Time

Free Health Care

Figure 2: Conceptual frame work of research

7.1 Variables in the Conceptual Framework

These were divided into Dependent and Independent variables as follows:

7.1.1 Dependent Variable

The Dependent Variable was Patient Satisfaction

These were divided under two broad domains as follows:

7.1.1.1 Factors under Hospital Milieu domain

These were as follows:

• Accessibility- pertained to services, location, and access for admission

• Cleanliness – pertained to wards, toilets, bathrooms

• Waiting Time- pertained to length and quality

• Attitude of Support Staff – Ward boys, cooks and sweepers

• Comfort in the Ward- light, ventilation, noise control etc

• Hospital Diet- quality, quantity, timing

• Social Support- pertained to visitors/attendants and visiting times

7.1.1.2 Factors under Provider domain

• Competence of Health Providers – pertained to doctors and nurses

• Type of disease- acute or chronic

• Duration of hospital stay

• Admission history - first time or repeat admission

The Policy and Infrastructure domains, which consisted of the driving and enabling forces or factors in our health system among independent variables, were not included for the study

8 Operational Definitions of Variables

Table 1: Operational definition of variables

Patient/Consumer Factors

Demographic and socio-economic features of inpatients that have relationship with satisfaction

Patient Satisfaction

Proportion/levels of inpatients’ expectations fulfilled in regards to health care services in NRH in respect to the following

1 Hospital Milieu

Inpatient environment that facilitates smooth service delivery leading to inpatient satisfaction

Independent

Dependent

2.Provider Factors Qualities or values in doctors and nurses that

affect satisfaction levels of inpatients

LITERATURE REVIEW

1 Introduction

In the last two decades alone, about 15, 000 studies were carried out related to patient satisfaction and its factors (Peterson R., 1992) Sociologists, psychologists, marketing and health managers gave much focus since the 1960s when satisfaction studies were first conducted (Cordosa R., 1965) During early days of studies, service users were either known as consumers, customers, clients or patients

There are a number of important models of health seeking behavior explaining various attributes that influence patient satisfaction Some important and relevant ones were reviewed and included as background material in the development of this thesis

In the Bhutanese context and as per our own experiences as physicians, doctor-patient relationship is vital for patient satisfaction This aspect was reviewed too Literature review, therefore, mainly dealt around defining satisfaction, inclusion of some conventional health seeking models and theories related to patient satisfaction and doctor-patient relationship Mentions are also made of some important findings on factors that influence patient satisfaction

2 Literature Related to Patient Satisfaction

The oxford dictionary defines satisfaction as “gratification of desire, contentment in possession and enjoyment, repose of mind resulting from compliance with its desires or demands”

As per Ross et al (1987), patient satisfaction is defined as “A patient’s affective (or emotional) response to his or her cognitive (or knowledge-based) evaluation of health care provider’s performance (or perceived quality) during a health care consumption experience”

Patient satisfaction is, thus, a multidimensional concept and a subjective phenomenon that is linked to perceived needs, expectations and experience of care (Smith C., 1992)

As per Donabedien (1966), satisfaction is an outcome that reflects quality of health care and Vuori H (1987) elaborated further by saying that patients are satisfied only if care

is of high quality signifying yet again that satisfaction is closely related to quality of health care However, Bitner M., Hubbert A (1994) perceived quality as only one of a number of antecedent factors for patient satisfaction

More recent definitions emphasize satisfaction as a complex evaluative process As per Hunt H (1977), satisfaction is an outcome of what was expected and what the patient received in the process of seeking health care

Zeithaml and Bitner (1996) strongly emphasized a close relationship between satisfaction and expectation They explained that there are three types of expectations These are the “desired” or “wished for” services which patients hope to receive Patients feel that this level of performance can be and should be available to them However, they are also cognizant of the fact that these may not be feasible and hence are mentally prepared to accept a lower performance or service level These are

“adequate” services that are the “minimal tolerated” services that they are willing to accept Lastly, the “predicted” services pertain to services patients are “likely to receive” and imply some objective calculation Any changes in these expectations will determine satisfaction or dissatisfaction Pascoe (1983) who evaluated many models of patient satisfaction put the role of expectation as a central component Ruggeri (1994) too supports this by saying that expressions of satisfaction are derived from prior expectations Westbrook (1980) had agreed that expectations have direct relationship with services and satisfaction

However, some argue that this expectation theory contributes to only about 8% variance in patient satisfaction

3 Some Models and Theories of Patient Satisfaction

Various theories and models related to patient satisfaction were reviewed and some important and relevant ones are included here Some of them are as follows:

• Aday and Anderson Model (1974)

• Cognition-Affect Model of Satisfaction by Oliver R.(1993)

• Theory of Zone of Tolerance by Nelson E and Larson C.(1993)

• Making Customer Satisfaction Happen Model of Roderick M.McNealy

(1994)

3.1 A day and Anderson Model (1974)

Consumer Satisfaction

Provider Characteristics Convenience, Quality Availability Information Financing.

Predisposing Enabling Need

Source: Aday and Anderson 1974

Figure 3: Aday and Anderson Model

As per this model, national health policies and national health systems are the driving forces for optimal utilization of health services These two factors with patient satisfaction are considered as inputs Health service utilization is considered as the

outcome Consumer or patient satisfaction and health service utilization are portrayed

as having direct and complementary relationship

3.2 Cognition -Affect model of Satisfaction by Oliver R (1993)

This model explains the complex relationship between beliefs, perceptions and satisfaction Here the main antecedents to health seeking behavior are considered as beliefs and perceptions of patients Other important factors included in the model are attribution, equity/inequity of services, positive or negative attitudes of health care providers Expectations of patients and performances of health care providers have direct effects on satisfaction Effects may be mediated through a phenomenon of

“disconfirmation” This is the difference between patients’ expectations of care before treatment and level of services received in the process of seeking health care

This model conceptualizes a variety of emotional responses including such affects as joy, excitement, pride, anger, sadness guilt etc for an outcome of satisfaction As per this model satisfaction can be viewed as a positive or negative affective response

Attribution

DisconfirmationExpectation

Source: Oliver R 1993

Figure 4: Cognition-Affect Model of Satisfaction

This theory also emphasizes that quality assessment comprises patient perceptions of a number of attributes related to care providers and service centers as follows:

• Reliability- ability to perform promised services dependably and accurately

• Responsiveness- willingness to help customer and provide prompt services

• Assurance- knowledge, courtesy and ability to inspire trust and confidence

• Empathy- caring and individualized attention

• Tangibles- quality of physical facilities, equipment, personnel and written materials

3.3 Zone of tolerance for different dimensions by Nelson E., Larson C (1993)

Level of Expectation

More Important Factors e.g Service Outcome

Less Important Factors e.g Service Process

Desired Services Desired Services

Narrow zone of

Tolerance

Tolerance Adequate Services

Source: Nelson E., Larson C., 1993

Figure 5: Zone of Tolerance by Nelson E and Larson C

Here Nelson E., Larson C (1993) emphasizes importance of the so-called zone of tolerance This theory explains that expected service could either equate with adequate

or desired service but most likely may fall between the two i.e within the zone of tolerance The zone of tolerance is also considered like a range in which patients do not pay particular attention to service performance and do not normally complain When performance falls above or below this range, patients express satisfaction or dissatisfaction respectively Again if interest of patient is service outcome, an important factor, the zone of tolerance is narrow In such cases the patients and/or party are sensitive and prone to express dissatisfaction If interest is service processes, which are

considered less important factors, the zone of tolerance is wider and patients and/or party are less prone to complain or be dissatisfied

The zone of tolerance also explains the effects of “good” and “bad” surprises and their culmination into expressions of satisfaction or dissatisfaction Good surprises are when care received is above the desired level and bad surprises, conversely, pertain to care received being below adequate service level The “no surprise” effect pertains to services falling within the zone of tolerance Good and no surprises lead to patient satisfaction and bad surprises lead to dissatisfaction

3.4 The Making Customer Satisfaction Happen Model by Roderick M McNealy (1994)

Source: Making Customer Satisfaction Happen, Roderick M Mc Nealy (1994)

Figure 6: The Making of Patient Satisfaction Happen

The author, Roderick M McNealy, in his book Making Customer Satisfaction Happen emphasizes the importance of “perception gap” or the gap between patients’ perceptions of care providers’ performances and their needs and expectations Determination of this gap is crucial and has strategic implications as a function of efforts towards patient satisfaction If this gap is non-existent and performance level is already at satisfaction or at the “delight” levels, patients will be happy and satisfied

The author also highlights that only 4% of dissatisfied patients complain 96% move away to greener pastures but each of them at least tells 10-15 persons about their bad experiences A radical group of 13% out of them, known as, the “lunatic fringe” tells about 23 persons each about their bad experiences About 5% from both the informed groups get influenced This theory also explains that out of the 4% who complain, 60% will maintain loyalty if issues related to their complaints are resolved and 95% will remain with the services if issues are resolved fast Every delighted patient tells about their experiences to at least 5 other persons

In our situation, however, patients keep on frequenting same hospitals or health centers despite their dissatisfaction as there are no other alternatives for care or private

practices

4 Literature Review Related to Doctor–Patient Relationship

Hypocrites, the great Greek philosopher said, “Treat the patient, not the disease” and the oath with the very name that all health personnel undertake has clear roles for both physicians and patients But as time passed by, these sacred roles prescribed and followed for centuries have sadly deteriorated The process of seeking professional help

and the doctor-patient relationship has changed over the years with significant transition occurring in the second half of the last century

According to J Hughes (1994), Talcot Parson was the first social scientist who theorized the doctor-patient relationship He assumed that illness was a physical dysfunction that required medical attention Illness could also be feigned and hence a legitimized sick role was advocated to maintain social order He put forward four norms to define sick role mainly fitting the western society These are described as follows:

• That individual is not responsible for an illness

• That sick may be exempted from normal duties till they are all right

• That illness is not a desired outcome

• That sick should seek professional help

Parson (1964) said that the initial western model of doctor- patient relationship was a harmonious one in which patients accepted physicians’ superior status and medical skills without any questions and doubts He also pointed out that the shift between doctors and patients over the years occurred as a result of emotional barrier between them All these are relevant to the oriental as well as the Bhutanese context

Even as late as the sixties, physical illness and their recoveries were considered as having close psychological relationship A physician was considered like a drug Vijay P.Sharma (1996) quotes a popular saying “Half the problem goes away when you see a doctor and the remaining half goes away when you take the medicine”

According to Scott T Learner (1986) there were three factors responsible for the changes in the doctor-patient relationship These were patients’ loss of trust in their doctors, changes in financing systems of health care and lastly the changes in organization of health care as an offshoot of consumerism and commercialization of health care services According to Dranove and White (1987) and Buchnan (1988) patients are interested in maximizing utility of health services and physicians are more inclined towards maximizing profits This has been one of the features of consumerism coming in the way of doctor-patient relationship This aspect is still an unknown phenomenon in Bhutan

Barbara Seaman (1986) in Charting Doctor-Patient Relationship symbolizes this relationship as a tug of war in which physicians and patients are on opposite ends of a rope To the doctor, illness is a disease process measurable by laboratory and clinical tests To a patient, it is a disrupted life pattern Updating advances in medical practices pre-occupies doctors while patients need to be heard and understood for which they are not given enough attention This is further substantiated by a Journal of American Medical Association study (1999) which found out that 72% of doctors interrupted their patients’ opening statements after an average of about 23 seconds Patients who were allowed to continue further were interrupted in about another 6 seconds

Information sharing seems to be an important aspect of relationship and for positive outcome of diseases Crock R.D et al (1999) explained that doctors feel frustrated when patients withhold relevant information regarding their health However, patients are said to withhold information, as they are afraid of being ridiculed or reprimanded by

physicians Patients feel devalued if doctors behave like mechanics who find and fix diseases in them like in a workshop

Doctor- patient relationship also varies depending on the type and severity of diseases

that they present with Szasz, T.S and Hollender, M.H (1956) proposed that in case of

acute illness the usual scenario is a passive patient and an assertive physician; in less acute condition it is a guiding physician and a cooperating patient In the case of a chronic condition physicians participate in treatment plans and patients have the major responsibility of helping themselves with treatment

The whole concept of disease process seems to have changed over the years in the perception of physicians and other health care providers This has reached to such an extent that physicians and even public some times perceive certain diseases like lung cancer, obesity and AIDS as the responsibilities of the ill Kelly (1987) emphasized this point further by saying that physicians and other care providers even react less favorably to such kind of disorders According to Hafferty (1988) it is said that physicians often react negatively to dying patients, patients they do not like and those who complain too much

Reeder (1973) and Haug and Lavin (1983) have demonstrated in their studies that an increasing proportion of educated population has begun to challenge the traditional sacred relationship between patients and doctors The relationship now has changed more towards a provider-consumer relationship from the traditional one of respect and trust between them

There are also researches pointing out that educated patients often take more assertive roles in the relationship downsizing the conventional role of passivity They are more in favor of participating in self-diagnosis and negotiated management of their health conditions Davis Roberts C and Kutumbuwa Ogonjuwa (1981) reported on similar line and highlighted that patients in Africa are entitled to argue with doctors over diagnosis and management of their diseases This scenario apparently seems to be on the rise even in Bhutan and does not include only educated but also the rich

The concept of disease itself has taken a different form due to changing doctor-patient relationship Anspack (1998) described that physicians separate diseases from the patients as biological processes, treat medical technology as agents and consider patients’ accounts of their illnesses as subjective Physicians have used their medical knowledge as an advantage to gain an upper hand over patients in all these processes and negotiations

As per Hayes-Bautista (1976) cited in Approaches to Doctor-patient relationship by J Hughes (1994), there are varying tactics that are being used by both patients and physicians in mutually managing the formers’ health Patients usually start by being submissive and try to convince for changes in their treatment Patients argue saying that treatment is inadequate, too weak or too powerful in more assertive ways if the initial move fails Physicians defend the treatment they prescribe using their medical knowledge as tools and threatening of consequences about non-compliance and ignoring advices Ultimately, if this fails they change their tone and even plead the patients In the process of this bargain, end results are compromise and continuation of

relationship, patient termination of relationship, physician termination or a mutual termination

Kaplan et al (1989) concludes that physician-patient relationship is a prerequisite for a social support, which will influence patients’ health status

Kasteler et al (1976) pointed out that patients tend to change doctors or “doctor shop”

as per the services they deliver Suchman (1964-66), in similar line, explains that a social environment of health conscious and scientific colleagues, neighbors and friends have a role in molding health-seeking behavior and a word-of–mouth referral to doctors who deliver well usually by acquaintances is a pre-requisite to a lasting doctor-patient relationship

In summary the attributes that hold stead for a good doctor-patient relationship are sympathy and kindness, good communication between patients and doctors, patience and shared responsibility in managing the latters’illness Listening to patients’ version

of illnesses is equally important and finally the human bond between them is crucial

5 Literature Review of Factors in Relation to Patient Satisfaction

There are innumerable factors that influence patient satisfaction with perhaps regional, ethnic, economic, social and cultural variations These factors are classified as distal and proximal ones Distal ones are mainly those related to national health system, health sector and economic policies that countries pursue Insurance system, health care financing, patient referral, communication and transport system etc are other important

factors Only proximal and relevant factors that influence inpatient satisfaction are dealt with as reflected in the conceptual framework

5.1 Socio-demographic factors

As per A.G Zwier and D Clark (2001) who carried out a survey in New Zealand, age, gender, ethnicity, occupation, education and socio-economic status are some of the important variables that predict patient satisfaction Older patients were found to be more satisfied than younger ones Di Matteo and Hayes (1980) reported similar finding

As far as gender is concerned, satisfaction depends on what aspect of care is in question Female patients are more prone to be dissatisfied with nursing care More Asian patients expressed dissatisfaction as compared to others showing ethnicity as being a predictor too Patients who were socio-economically well off rated satisfaction about 5% higher than those with lower socio-economic status Sitzia and Wood (1997) have reported similar findings Patients hailing from rural background expressed satisfaction at about 20% higher than those coming from urban background

In the research proposal patient education, occupation, referral status, type of disease, duration of treatment and admission history will be other relevant variables in the Bhutanese context

5.2 Hospital milieu

Jun Gao et al (2002) says that accessibility to services and the availability of required services at affordable prices are important determinants for patient satisfaction and service utilization in a health care center