Luận án TS Y học: Patient satisfaction with inpatient services at the national referral

1.1 Background Patient satisfaction (or customer satisfaction) is a term that is widely used with reference to health care. Identified as an integral factor in the evaluation of health care, the inclusion of ‘patient satisfaction’ measurements and interpretation can easily go unquestioned. In fact, quality of care reforms and health care delivery in developed countries such as the United States of America and Europe allow for an increasingly important role of patient satisfaction as an indicator (Bleich, Ö zaltin, & Murray, 2009). However, at the hospital level, many clinicians appear unconvinced of the usefulness of satisfaction measures. Since clinicians are often more concerned about treatment outcomes, their skepticism may be attributed to the belief that other indicators of healthcare quality such as how patients feel about the cost and/or accessibility of services, the food, interpersonal relationships and overall satisfaction levels are administrative issues (Hudak & Wright, 2000). Over the years, health care managers have utilized various methods, from complaint boxes to satisfaction surveys, to gather information that can be used to improve patient satisfaction. There have been many patient satisfaction studies that utilized patient satisfaction surveys, even if the focus may have been different than it is today. Some studies attempted to learn who, for example, would be more satisfied (Otani, Herrmann, & Kurz, 2011). Despite the increased focus on satisfaction as an outcome measure and the growing body of research to support it, satisfaction has remained difficult to compartmentalize. Although numerous satisfaction surveys have been developed, most with acceptable psychometric properties, it remains largely unknown the factors patients use to consider themselves satisfied (Jackson, Chamberlin, & Kroenke, 2001). Patients’ satisfaction with health care in comparison to their experience is increasing in its importance. Likewise, according to Bleich et al. (2009), the continued interest in comparing people’s satisfaction with the health system across different countries and time periods suggests the need to distinguish the relationship between them. Otani et al. (2011) suggested that it is likely that a positive experience with important factors will result in a good satisfaction overall. Conversely, if the patient had a negative experience with important factors, the overall satisfaction will be bad. The extent to which a patient’s experience explains his or her satisfaction with the health-care system remains unclear. Some experiences may very well be more influential than others to the patient in forming their overall satisfaction level.

Taipei Medical University School of Health Care Administration

Master’s Thesis

Patient satisfaction with inpatient services at the national referral

hospital of Belize

Graduate Student: Tisa C Grant

Advisor: Che-Ming Yang, M.D., J.D., Ph.D

To my advisor, Dr Che-Ming Yang, and my committee members, thank you for your guidance, your patience, and for being firm but kind To the management and staff of Karl Heusner Memorial Hospital (KHMH) and the survey respondents, without your help this simply would not have been possible and I thank you!

To my family and dear friends for their support of this aspiration, their reassurances, assistance, encouragement and patience to the very end of this milestone, I give my heartfelt thank you

ABSTRACT

Title of thesis: Patient satisfaction with inpatient services at the national referral hospital

of Belize Author: Tisa C Grant

Thesis advised by: Che-Ming Yang, M.D., J.D., Ph.D

Background - The Ministry of Health in Belize has implemented several policies and service level

agreements to improve patient satisfaction country wide Although these initiatives rely on results to appropriately measure patients’ satisfaction with the quality of care, the extent to which a patient’s

experience explains his or her satisfaction with the health-care system remains unclear

Objectives - Despite what may appear to be the general consensus on health care services provided

nationally, some health care experiences may very well be more influential than others to the patient

in forming their overall satisfaction level The objective of this study is to ascertain the effects that specific variables have on patients’ overall evaluation of hospital care and their intention to recommend the hospital

Methods - The HCAHPS Survey was self-administered at the national referral hospital of Belize to

inpatients Simple and multiple step-wise linear regression models were used to identify the predictor factors of patient satisfaction using, separately, the two dependent variables: “Overall evaluation of hospital care” and the “Intention to recommend the hospital”, controlling for age, gender, ethnicity, education and perceived health

Results - It was found that patient’s highest priority was communication with nurses and doctors

experiencing an intensely critical and emotional moment, and thus, they need to provide

patient-centered care

Keywords: Patient satisfaction, inpatient, Belize, developing country

TABLE OF CONTENT

ACKNOWLEDGEMENTS I ABSTRACT II TABLE OF CONTENT IV LIST OF TABLES VI LIST OF FIGURES VII

CHAPTER 1: INTRODUCTION 1

1.1 Background 1

1.2 Belize: The Healthcare System and the People 2

1.3 Statement of the Problem 5

1.4 Significance of the Study 8

1.5 Research Objectives 10

CHAPTER II: LITERATURE REVIEW 11

2.1 Definition of Patient Satisfaction 11

2.2 Development of HCAHPS Survey Instrument 12

2.3 Determinants of Patient Satisfaction 14

2.4 Clinical Staff Influence on Patient Satisfaction 15

2.5 Patient Demographic and Patient Satisfaction 16

2.6 Summary 17

CHAPTER III: METHODOLOGY 18

3.1 Conceptual Framework 18

3.2 Operational Definitions of Variables 19

3.3 Hypotheses 23

3.4 Survey Instrument 25

CHAPTER 4: RESULTS 35

4.1 Samples’ characteristics 35

4.2 Descriptions of the variables 35

4.2.1 Categorical variables description for ‘Overall evaluation of Hospital Care’ 35

4.2.3 Mean age difference between “Overall Evaluation of Hospital” and “Care Intention to recommend” 36

4.3 Univariate and multivariate analysis for predicting “Overall evaluation of hospital care” 42

4.4 Univariate and multivariate analysis for predicting “Intention to recommend” 45

CHAPTER 5: DISCUSSION 48

5.1 Hospital care factors as predictors of patient satisfaction 48

5.2 Implications of patient demographics on patient satisfaction 50

5.3 Perceived health as a predictor of satisfaction 52

5.5 Recommendations 54

5.6 Implications for further research 55

5.7 Conclusion 57

APPENDIXES 63

Appendix I – HCAHPS Survey Instrument 63

Appendix II – Ethical Approval Request Letter 70

Appendix III – Ethical Approval Letter 71

Appendix IV – Patient Consent Form 72

LIST OF TABLES

Table 1: Operational definitions of variables 20

Table 2: Reliability test results 30

Table 3: Recoding of variables 31

Table 4: Description of categorical variables by frequency and percentage (N=176) 37

Table 5: Description of the categorical variables for “Overall evaluation of hospital care” 38

Table 6: Description of the categorical variables for ‘Intention to recommend’ 39

Table 7: Mean age difference between rating group for overall evaluation of hospital care (N=169) 40

Table 8: Mean age difference between rating group of ‘Intention to recommend’ (N=168) 41

Table 9: Univariate analysis of independent variables to predict overall evaluation of hospital care 43

Table 10: Multivariate analysis of all independent variables to predict overall evaluation of Hospital Care 44

Table 11: Univariate analysis of independent variables to predict intention to recommend 46

Table 12: Multivariate analysis of independent variables to predict intention to recommend 47

LIST OF FIGURES

Figure 1 - Conceptual Framework for Patient Satisfaction at the National Referral Hospital of Belize 18

CHAPTER 1: INTRODUCTION

1.1 Background

Patient satisfaction (or customer satisfaction) is a term that is widely used with reference to health care Identified as an integral factor in the evaluation of health care, the inclusion of ‘patient satisfaction’ measurements and interpretation can easily go unquestioned In fact, quality of care reforms and health care delivery in developed countries such as the United States of America and Europe allow for an increasingly important role of patient satisfaction as an indicator (Bleich,

Ö zaltin, & Murray, 2009) However, at the hospital level, many clinicians appear unconvinced of the usefulness of satisfaction measures Since clinicians are often more concerned about treatment outcomes, their skepticism may be attributed to the belief that other indicators of healthcare quality such as how patients feel about the cost and/or accessibility of services, the food, interpersonal relationships and overall satisfaction levels are administrative issues (Hudak & Wright, 2000)

Over the years, health care managers have utilized various methods, from complaint boxes

to satisfaction surveys, to gather information that can be used to improve patient satisfaction There have been many patient satisfaction studies that utilized patient satisfaction surveys, even if the focus may have been different than it is today Some studies attempted to learn who, for example, would be more satisfied (Otani, Herrmann, & Kurz, 2011) Despite the increased focus on satisfaction as an outcome measure and the growing body of research to support it, satisfaction has remained difficult to compartmentalize Although numerous satisfaction surveys have been developed, most with acceptable psychometric properties, it remains largely unknown the factors patients use to consider themselves satisfied (Jackson, Chamberlin, & Kroenke, 2001) Patients’ satisfaction with health care in comparison to their experience is increasing in its importance Likewise, according to Bleich et al (2009), the continued interest in comparing people’s

system remains unclear Some experiences may very well be more influential than others to the patient in forming their overall satisfaction level

1.2 Belize: The Healthcare System and the People

Belize is a former British Colony and the only English-speaking country in Central America, divided into six districts It is more similar to other English–speaking Caribbean countries in culture, politics, and economy Due to location, however, Spanish is widely spoken (Ministry of Health, 2006a) The area of Belize (mainland and cayes) is 8,867 square miles, the greatest length being 280 kilometers and its greatest width is 109 kilometers Considered to be a “melting pot of many races” resulting from the influx of many people of Central America, Asia, Europe and the Caribbean (Ministry of Health, 2006a), the population is now at 312,698 based on the 2010 population census (The Statistical Institute of Belize, 2011)

The population census also shows that the five main ethnic groups are Mestizo, Creole, Maya, Garifuna and Mennonite Mestizo is the largest group (50%), Creole accounted for 21%, Maya and Garifuna made up 10% and 4.6%, respectively Other ethnic groups in Belize are East Indian, Chinese, Arabs and Africans, among others The ethnic groups, however, are heavily intermixed Although, English is the official language of Belize, English Creole is widely spoken It remains a distinctive part of everyday conversations for most Belizeans However, Spanish is spoken as a first language for majority of the people in the northern districts, the north of the Belize District, and the Cayo District in the west In the southern Districts, there are people whose first language is Garifuna or Maya

The basic structure for health care delivery is provided by a network of seven district hospitals which are divided into four regions: Northern Region (Orange Walk and Corozal Districts), Central Region (Belize District), Western Region (Cayo District) and Southern Region (Stann Creek and Toledo Districts) with the Karl Huesner Memorial Hospital (KHMH), the Central Regional Hospital, being the national referral hospital (Ministry of Health, n.d.) In terms of population, the Central Health Region is the biggest of the four health regions of the country and therefore, provides health care services to 30.5% of the entire population of the country The Region has three administrative areas: Belize City, Belize Rural and the Cayes As the commercial capital,

Belize City is considered the ‘bustling metropolis’ of the country and attracts local and international visitors, thus increasing the servicing population by 6% (Ministry of Health, n.d.) As a result, the Belize District has the greatest density of health care providers relative to its population (Pan American Health Organization, 2009a) with a total of 285 staff members (Ministry of Health, n.d.)

There were 2,283 workers employed in the health system in 2009, 1279 (56%) were health care providers while the remaining 1004 (44%) were administrative and other support staff About 43% of health care providers were employed in the Belize District There are approximately 30 nationalities and ethnic groups represented in the Belize health care provider workforce, Mestizo and Creole totaling 61% Of the 1279 health care providers (i.e clinical workers and health professionals) about 80% are employed in the public sector Between 2005 and 2009, the number of registered nurses remained relatively stable while the number of specialists fell from 159 to 60 The combined ratio of registered nurses and physicians per 10,000 population dropped from 23.3 in

2005 to 17.7 in 2009 Among the five, major ethnic groups in Belize, Mestizo and Mayans are not well represented in the health care provider workforce (36% combined) although together they represent 63% of the total population Women are 68% of the health care provider workforce, outnumbering men 2.2 to 1 (Pan American Health Organization, 2009a) This ratio is reflective of the results of the 2010 population census which reported that “women outnumber males by a ratio

of two to one at the university level” and “in terms of highest level of education completed, females outnumber males from secondary to university level” (The Statistical Institute of Belize, 2011) It should be noted, however, that to date, most physicians and physician-specialists have been trained abroad (in the Caribbean or neighboring Central American Countries) Local training for nurses and midwives is provided at the national university

Current social indicators for the country include Infant Mortality Rate (18.4 for 1,000 live births in 2005), Maternal Mortality Rate (5 deaths per 1,000 live births in 2005), Life Expectancy at Birth Life expectancy at birth (72.2 years in 2005), Crude Birth Rate (25.6 births per thousand in 2005) Crude Mortality Rate (4.7 deaths per 1,000 population in 2005) (Government of Belize, n.d.),

benefits However, more than a decade ago, a National Health Insurance (NHI) scheme was established under the Social Security Amendment Act of August 2001 to provide comprehensive healthcare services NHI is a strategy developed by the Government, as part of its Health Sector Reform program, to provide health care services to all residents of Belize The strategy is derived from the need to provide an improved, equitable and sustainable system of health care to the people

of Belize An initial pilot project was launched on the south side of Belize in August 2001 and still continues today to facilitate decision making in the nationwide implementation of NHI and its financing mechanism (Social Security Board, 2009)

1.3 Statement of the Problem

Patient satisfaction is an important quality outcome indicator of health care in the hospital setting and is considered in the total quality of care more widely in developed nations than in developing nations (Singh, Mustapha, & Haqq, 1996; Syed Saad, 2001) While strides are being made to develop technical efficiency or improve facility, patients’ perception of and satisfaction with the quality of care beyond the treatment outcome often lags behind Health care that is perceived as less than quality can potentially discourage patients from using the available services According to Syed (2001), patients will underutilize, bypass, and use as a measure of last resort a system that fails to guarantee a certain level of quality In Belize, Many individuals cross the border from Belize to take advantage of services and supplies in the neighboring countries of Guatemala and Mexico (Pan American Health Organization, 2009b) Others, such as urban users with financial ability, choose among various providers for specific types of service in the private sector This trend has increased in the last five years Rural users, on the other hand, do not have this privilege, since the private sector has developed primarily in the urban areas (Pan American Health Organization, 2002)

In developing countries, such as Belize, the issue of public medical facilities has become a topic of current concern Some members of the population vocally condemn the quality of service at these facilities, particularly the national referral hospital, KHMH Such expressions have been given prominence in the media from the time Because actual surveys have not been conducted regarding patients’ satisfaction, much is left to speculation and it cannot be justly determined that the quality

of service at KHMH is in fact poor or over-sensationalized by the media Despite the pioneering efforts of the Government of Belize (GOB) and the Ministry of Health (MOH) - Belize is the first Caribbean nation to implement a National Health Information System and National Health Insurance - and the many other structural changes being made (physically and administratively), the negative public opinion remains

In 1994, the Government of Belize signed a technical co-operation document with the

programs were often managed by medical doctors without management training, inadequate supply

of well trained health professionals, especially medical specialists and managers Others demonstrated minimal commitment to patient care, poor accountability, discipline, attendance and

“customer service” (Ministry of Health, 2006a)

The Pan-American Health Organization/World Health Organization (PAHO/WHO), through the Public Health in the Americas Initiative, defined 11 Essential Public Health Functions (EPHF) necessary to strengthen public health practice EPHF 9, which covers quality assurance of personal and population based health services, is carried out by the Regulatory Unit and National Health Insurance (NHI) This EPHF 9 was one of three to receive the lowest scores after an assessment of the health system by MOH and PAHO In response, clinical protocols were developed and implemented for 40 medical conditions A Complaints Policy and Reporting and Resolution Mechanism have been developed (Pan American Health Organization, 2002)

Since then, the Ministry of Health has initiated several projects to introduce systems that would assist in improving the publics' confidence in the public health care system One such scheme was the patient feedback system, developed through their current Complaints Mechanism to improve customer satisfaction All health care providers are trained to understand and respect patients' beliefs and values and to protect patient’s dignity through the provision of respectful care These added interpersonal skills are intended to support the complaint mechanism and to assure patients satisfaction Ensuring that patients are informed of, understand, and act when they believe their rights have been violated; as well as, ensuring that patients understand that they too have a responsibility for their health care, are among the responsibilities of the health care provider One study found that the ratings of clinician listening or interest were indeed associated with greater patient satisfaction and this can be done through the implementation of communication-based interventions or training programs that aim to improve clinicians’ warmth and listening (Henry, Fuhrel-Forbis, Rogers, & Eggly, 2012) The health system of Belize is not specifically designed to accommodate this function, but under the National Health Insurance Scheme, (NHIS) more emphasis is being placed on patient satisfaction as an indicator of the health system’s response to the needs of communities (Pan American Health Organization, 2009b)

Health service level agreements (SLA) were initiated during 2001 to 2004 in all four health regions for provision of primary, secondary, and tertiary health The principal goal of these SLAs is

to “strengthen the optimal provision of health care services for all populations within the framework

of access, equity, quality of care, efficiency, patient satisfaction, and harmonizing the health care

service delivery in Belize” (The Cameron Health Strategies Group Limited, 2009) The SLAs define the relationship between the provider function and regulator function of the regional health services and MOH, respectively These agreements rely on the evaluation of results as a means to measure institutional and management performance relative to the goals and targets defined within the agreements (Ministry of Health, 2006a) The availability of reliable and timely information to support the decision making process, however, is a problem in Belize This is being addressed so that administrative decision making can be information based (Pan American Health Organization, 2002)

1.4 Significance of the Study

In most Western health care systems, particularly the developed nations, patients are generally allowed to choose their own physicians In the absence of assigning patients to different facilities, it is sometimes very difficult to tell whether continual use of a service eventually lead to satisfaction, or if satisfaction, in fact, leads to continuity and is likely to be bidirectional (Saultz & Albedaiwi, 2004) Likewise in Belize, to increase efficiency in the health system internally and holistically, under the Belize Social Security Board – National Health Insurance (BSSB-NHI) scheme, it is the patient’s right to select their physician (Pan American Health Organization, 2002)

The Vision for Belize’s Health Workforce, as documented in the Belize’s Health Workforce Strategic Plan 2010 – 2014, is for Belize to have a sustainable health workforce that is knowledgeable, skilled and adaptable The plan is for the health workforce, suitably trained and competent, to be distributed as such to achieve equitable health outcomes Once the workforce are valued and working within a supportive environment and culture, they will be better able to provide safe, quality, preventative, curative and supportive care, that is “population and health consumer focused and capable of meeting the health needs of the Belizean” (Ministry of Health, 2010)

The ‘Licensing and Accreditation Standards for Hospitals and In-patient Health Facilities’ manual, divided into six major sections, approved in July 2009, is intended to focus on the entire hospital The first set of standards, Patient-Centered Standards, focuses on the patient and those functions involved in diagnosing, treating and educating patients The second set of standards, Health Care Organization Management Standards, focuses on functions involved in the overall effective and efficient management of the health care facility (Ministry of Health, 2009) which is as much a part of patient satisfaction

Under the ‘Quality Management Standards”, level one of subsection 2.2.1 – Quality Leadership - the inpatient facility should carry out activities intended to evaluate the quality of care The quality of professional performance, within the establishment, can be demonstrated and guaranteed by the use of patient satisfaction surveys, department specific surveys, and others Administering surveys actually formed part of the Operational Plan for 2010 (Ministry of Health, 2010) but the mode of delivery and whether those were administered is unclear at this time Conducting this survey at KHMH, which is considered the ultimate level for in-patient and specialized care in Belize (Ministry of Health, 2006b), will set in motion all the regulations and policies implemented thus far to ultimately improve the health care services received by patients,

and by extension, their satisfaction All quality improvement efforts without an evaluation process

to measure success are futile and who better can confirm their satisfaction but the patients themselves This survey will set the stage for future inpatient satisfaction surveys and studies at the National referral hospital and influence management decision making in quality of care improvement initiatives such as staff training, etc In the long run, it is hoped that a survey instrument that captures Belize’s unique demographic, culture and health system in its measurement

of patient satisfaction, can be developed and applied nationally as a part of a national reporting system Such a system will inform the public of the performance of the health facility they choose (private and public, inpatient and outpatient) as well as play an integral part in informing the decisions made by MOH in the accrediting and licensing procedures and the overall improvement

of the health system in aggregate

1.5 Research Objectives

with doctors, responsiveness of hospital staff, staff care, and the hospital environment)

on patients’ overall evaluation of hospital care and their intention to recommend the national referral hospital of Belize

2 Evaluate the effect of patient’s perceived health on their overall evaluation of hospital

care and their intention to recommend the national referral hospital of Belize

3 Evaluate the effect of socio-demographic factors (age, gender, education, and ethnicity)

on patient’s overall evaluation of hospital care and their intention to recommend the national referral hospital of Belize

CHAPTER II: LITERATURE REVIEW

2.1 Definition of Patient Satisfaction

The ultimate validation of quality care is patient satisfaction (Donabedian, 1997) In today’s health care realm, patient satisfaction is an important quality outcome indicator of health care, particularly in the hospital setting The interesting situation, however, is that the attention to patient satisfaction has gone far beyond a clear definition of its meaning and measurement (Yellen, Davis,

& Ricard, 2002) Because of the way in which meaning influences the design and interpretation of measures, Hudak & Wright (2000) exacts that ambiguity about the meaning of satisfaction itself is

in fact the dominant weakness in this field of inquiry

Subjective factors are important sources of bias when using patient satisfaction in quality measurement For example, the fulfillment of a patient’s expectations as a quality indicator would mean if a patient had low expectations of a hospital prior to their visit, then any poorly performing hospital could potentially be ranked highly (Bjertnaes, Sjetne, & Iversen, 2012) Although it is believed that expectations are an important predictor in conceptual models of patient satisfaction, the effect of expectations is rarely assessed empirically, despite the observed effects of the instrument on expectations (Peck et al., 2001) For the purpose of this research, we will utilize a simple definition of patient satisfaction which is a patient-reported outcome measure (Bjertnaes et al., 2012)

2.2 Development of HCAHPS Survey Instrument

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), also known as CAHPS Hospital Survey, is a core set of questions that can be combined with a customized set of hospital-specific items Whether used alone or in conjunction with other outcome measures such as clinical process outcomes, the scope and metrics of health care quality is expanded (Giordano, Elliott, Goldstein, Lehrman, & Spencer, 2010)

HCAHPS is a joint developmental effort by the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS), implemented in the United States in October 2006 (Goldstein, Farquhar, Crofton, Darby, & Garfinkel, 2005) HCAHPS was implemented on a voluntary basis by participating hospitals (approximately 50% of the 2600 eligible) and quickly gained support For the 2008 fiscal year, certain hospitals reimbursed through Inpatient Prospective Payment Systems (IPPS) were required to report results of the survey in order

to receive their Annual Payment Update (APU)

The Quality Assurance Guidelines V6.0 provided three broad goals which shaped the HCAHPS survey

 First, the survey is designed to produce comparable data on the patient perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers

 Second, public reporting of the survey results is designed to create incentives for hospitals to improve their quality of care

 Third, public reporting will serve to enhance public accountability in health care by increasing the transparency of the quality of hospital care provided in return for the public investment (Centers for Medicare & Medicaid Services, 2012)

The initial research and testing phase of HCAHPS included a 2000 call for measures, survey and item development in 2002-2003, and a subsequent pilot test in the same year A longer version

of the survey was administered to 49,812 inpatients in 132 hospitals in Arizona, Maryland, and New York (Goldstein et al., 2005) Standardized survey administration protocols were developed and implemented to balance the principles of comparability and flexibility (Giordano et al., 2010)

The HCAHPS survey consists of 27 items (1 to 22 include 18 substantive items used in publicly reported measures and 4 screener items used to determine eligibility of patients for a subset

of the 18 substantive items Items 23 to 27 are demographic in nature and are used in patient-mix adjustment) The 18 substantive items include 14 report items used to construct 6 composite measures (communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, communication about medicines, and discharge information) The 2 individual items are cleanliness of hospital environment and quietness of hospital environment; and

2 global ratings (overall rating of hospital and willingness to recommend this hospital (Giordano et al., 2010)

2.3 Determinants of Patient Satisfaction

Determinants of patient satisfaction has been extensively reported (Cheng, Yang, & Chiang, 2003) A consensus is still lacking on a mechanism which produces expressions of “satisfaction” In fact, the concept of satisfaction is said to be at the root of the problem itself Because the concept remains undefined, the development of tools to measure same sometimes create difficulty (Danielsen et al., 2010)

Satisfaction with the fulfillment of positive expectations are believed to be more valid, the high levels of satisfaction which are reported from just about every field of health care suggest that the large majority of patients are either very happy with almost everything, or that patients' expectations are generally low Sitzia & Wood (1997) suggested the necessity to examine detailed characteristics of patients and sociological and psychological issues to further examine the lack of variability in responses Expectations are deemed dependent on the circumstance of the clinical encounter with the clinicians, the clinician’s knowledge of the patient, and the patient’s experience which is likely to change over time (Sitzia & Wood, 1997; Williams, Coyle, & Healy, 1998) Bottom line, expectations make more complex the concept of satisfaction as an evaluative tool (Sitzia & Wood, 1997)

Some dimensions of concern to many patients include communication with doctors and nurses, being treated with consideration and respect, waiting times, food, and cleanliness (Cohen, 1996; Syed Saad, 2001) For others, the concern was the association between socio-demographic variables and user satisfaction/experiences as well as between user-reported experiences and global satisfaction (Danielsen et al., 2010) On the contrary, Bleich et al (2009) study of the relationship between satisfaction with the health-care system and patient experience revealed that the latter explains about 10% of the variation of patient satisfaction However, it is believed that most of the variation is explained by factors unrelated to patient experience such as patient expectations and self-reported health status, and personality

2.4 Clinical Staff Influence on Patient Satisfaction

Clinician negativity is believed to be associated with lower patient satisfaction, however, (Henry et al., 2012) found this result was more consistent for patient–nurse interactions than patient–physician interactions Yellen et al (2002) suggests that nursing influence in patient satisfaction is a particularly important measurement of patients’ satisfaction nursing service is often

a primary determinant of overall satisfaction during a hospital stay Psychometric testing done in this study signified three components which contribute to patient satisfaction with nursing care:

“professionally competent nursing care, interpersonal relationship with the nurse involving availability, and interpersonal relationship with the nurse involving humaneness

On the other hand, some studies have focused on physician communication skills and have found a relationship with satisfaction such as communication barriers These can include lack of warmth and friendliness on the part of the doctor and/or failure to consider the patient's concerns and expectations (Jackson et al., 2001) The most important conclusion of one study in Estonia found that there is an association between personal choice and patient satisfaction with respect to physician care (Kalda, Põlluste, & Lember, 2003) Patients’ opinion about organizational and interpersonal aspects of care was more favorable when doctors were chosen from a smaller organization rather than a larger facility such as a big polyclinic

Satisfaction, however, is a complex concept influenced by many factors For example, one study conducted in Norway suggested that other factors include expectations, the nature of the problem, and the physician’s ability to solve the problem In fact, beyond interpersonal skills, a physician’s interpersonal skills should include affective sensitivity (Gulbrandsen et al., 2011) It was found that when the frequency of visits increases, patients would way ‘physician’s care’ as the most important determinant of their satisfaction (Kuttichira & Rejani, 2011)

2.5 Patient Demographic and Patient Satisfaction

Patient characteristics, such as age and education, are factors not controlled by a hospital but are related to the patient’s experiences and survey responses (Elliott et al., 2009) Age is considered one of the strongest correlates of patient satisfaction Cohen (1996) reported very large effects for age in his study For example, “there was a sevenfold increase in the odds of feeling that doctors have no time to listen between the over 65 and the 16-44 age groups” One study conducted in Turkey showed that unmarried men under the age of forty were likely to be unsatisfied and it was speculated that there was a barrier in communicating with predominantly female nurses (Oflaz & Vural, 2010) On the other hand, patients with severe pain are likely to be older and hence less dissatisfied on that account, therefore bodily pain and dissatisfaction can only be obtained after controlling for age Jackson et al (2001) agreed that older patients were more likely to be fully satisfied, but suggested that other demographic characteristics had no effect at any time point In fact, the likelihood of being satisfied can be independently predicted if a person has no unmet expectations, receives an explanation of symptom cause and duration, having better functional status, and being older than 65 years of age

Most patient satisfaction make some attempt to relate satisfaction to demographic and other background variables, but studies that relate satisfaction to a patient’s perceived health status are very rare (Cohen, 1996) However, understanding the individual's experiences of health services, and how they articulate their problems and desires is not an easy task It requires a detailed understand of the social circumstances and perceived health beliefs of the patient (Williams et al., 1998) Although the factors related to clinician communication and treatment had the highest scores, Danielsen et al (2010) healthier respondents, as well as older ones generally have higher satisfaction and evidence related to socio-economic status, gender and ethnicity was equivocal

Kuttichira & Rejani(2011) found that there were gender difference in patient satisfaction Women were clearly less satisfied However, in Indonesia (a developing country), the largest and only statistically significant gender difference were concerns of the facility’s cleanliness (Bernhart, Wiadnyana, Wihardjo, & Pohan, 1999) Despite concerns that persons with different cultural background would rate factors differently, that was not the case

2.6 Summary

Patient satisfaction surveys are geared at informing decision makers about patient’s perspectives on the health care services received Despite the popularity of patient satisfaction, the concept is relatively new and lacking in a standardized definition and measurements that accurately captures patient preferences and what influences them

Some studies utilize patients’ demographic variables such as age and gender but these variables are not for a manager who wants to improve on their service quality and patient satisfaction Other studies focus on health attributes and the overall patient satisfaction Others yet, found that certain attributes, such as nursing care, physician care and staff care have more influence than others on overall satisfaction With patients’ now being considered as consumers, hospital management also wants to know what influences overall satisfaction and a patient’s intention to return to or recommend their hospital As Saultz & Albedaiwi (2004) eloquently put it, it appears that many aspects of the traditional interpersonal model of care are once again very essential elements of the future rather than outdated characteristics of the past

CHAPTER III: METHODOLOGY

Communication with Nurses

Communication with Doctors

3.2 Operational Definitions of Variables

The two dependent variables include a one-item question for each:

(1) Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best

hospital possible, what number would you use to rate this hospital during your stay?

(2) Would you recommend this hospital to your friends and family? (1: definitely no, 2:

probably no, 3: probably yes and 4: definitely yes)

The independent variables related to each of the attributes are communication with nurses, communication with doctors, responsiveness of hospital staff, staff care, and the hospital environment Each of the attributes includes multiple questionnaire items in the survey which measure the attribute, except for responsiveness of hospital staff

The control variables include age, gender, perceived, health, education level and ethnicity (Table 1)

Table 1: Operational definitions of variables

Definitely No = 1 Probably No = 2 Probably Yes = 3 Definitely Yes = 4

Categorical

Categorical

Independent Variables

experience with nurses (courtesy and respect, ability to listen, and ability to explain things)

Never = 1 Sometimes = 2 Usually = 3 Always = 4

Categorical

experience with doctors (courtesy and respect, ability to listen, and ability to explain things)

Never = 1 Sometimes = 2 Usually = 3 Always = 4

Categorical

assistance promptly upon request

Never = 1 Sometimes = 2 Usually = 3 Always = 4

Categorical

Table 1: (Cont’d)

Independent Variables Cont’d

Staff Care

(Pain Management and

communication about Medicines)

How well hospital staff were able to control pain and communication with patient about the use and side effects

of new drugs

Never = 1 Sometimes = 2 Usually = 3 Always = 4

Categorical

environment

Never = 1 Sometimes = 2 Usually = 3 Always = 4

Categorical

Control Variables

Some high school, but did

not graduate = 2, High school graduate = 3,

Some college or 2-year

Categorical

Table 1: (Cont’d)

Control Variable Cont’d

of the patient

Mestizo = 1 Creole = 2 Maya = 3 Garifuna = 4 Mennonite = 5 Other = 6

Categorical

health status

Excellent = 1 Very good = 2 Good = 3 Fair = 4 Poor = 5

Categorical

3.3 Hypotheses

This study comprises of seven hypotheses per each of the two dependent variables

Hypothesis 4 Staff care affects patients’ overall evaluation of hospital care

Hypothesis 5 The hospital environment affects patients’ overall evaluation of hospital

care

Hypothesis 7 Self-perceived health affects patients’ overall evaluation of hospital care

Hypothesis 13 Demographics affect patients’ intention to recommend

3.4 Survey Instrument

The Agency for Healthcare Research and Quality (AHRQ) in the Department of Health and Human Services of the United States developed HCAHPS The AHRQ had RAND Corporation, Harvard Medical School and American Institutes for Research carry out a rigorous, scientific process

to develop and test the HCAHPS instrument for psychometric properties including validity and reliability (Goldstein et al., 2005), credibility, usefulness, etc (see http://www.hcahpsonline.org for the

full text of the survey instrument)

This study adapted the use of the HCAHPS Survey Instrument (Appendix I) and adjusted for

the demographic structure of Belize Question 25 (Are you of Spanish, Hispanic, or Latino origin or

descent? 1 No, not Spanish/Hispanic/Latino; 2 Yes, Puerto Rican; 3 Yes, Mexican, Mexican American, Chicano; 4 Yes, Cuban; 5 Yes, other Spanish/Hispanic/Latino) was deleted for irrelevance

and questions 26 and 27 reflect the major ethnic groups and major languages spoken in Belize

KHMH has a capacity of 134 beds and the country’s largest surgical center with three surgical suites and two labor and delivery suites The operating theaters function on a 24 hour basis to cover elective and emergency cases There are weekend pharmacy services, a 24/7 stat lab, and over 25 specialists; additionally, private services are offered at the Private Ward, allowing KHMH patients more options even within the parameter of being a public institution Other wards include the Medical, Surgical, Pediatric, Labor & Delivery, Adult Intensive Care Unit, and a Neonatal Intensive Care Unit (NICU)

The hospital is presently staffed by 583 employees comprised of nurses, technicians, specialists, general practitioners, technologists, administrators, clerical and social workers, and ancillary staff The diverse employee backgrounds that make up the KHMH population mirror the country’s own multiculturalism, contributing to the hospital’s national character and regional linkages

3.6 Study Sample

Consecutive sampling method was utilized for patient recruitment according to inclusion criteria All patients who were 18 years of age (minimum legal age for legal or medical counseling without parental consent in Belize) or older on admission and have:

 A non-psychiatric primary discharge diagnosis for medical, surgical, or maternity care;

 Have an overnight stay (or longer) as an inpatient;

 Not admitted under observation status;

 And, patients who are alive at discharge

Some additional exclusions have been added following the dry runs conducted by AHRQ in

2006 and 2007 (e.g., patients discharged to a hospice setting, prisoners, patients with a foreign home address, and no-publicity patients are now excluded) All eligible discharged inpatients were provided the opportunity to participate in the survey upon discharge provided that the inclusion and exclusion criteria are met, or during subsequent follow-up visits

The HCAHPS guidelines recommend that at least 300 completed surveys over a rolling quarter/12-month reporting period has been established, which is designed to achieve a reliability of 0.8 or higher for all reported measures Hospitals and survey vendors are required to sample continuously throughout each month of the year (Giordano et al., 2010) even if the target of 300 completed surveys is reached prior to the end of the quarter Although KHMH is not required to maintain such stipulations as a foreign hospital conducting this survey and that this survey will be carried out at KHMH for one period in time, the aim is to maintain the target of 300 completed surveys

measures is 0.8 or higher Based on this target, hospitals must obtain at least 300 completed HCAHPS surveys over each 12-month reporting period The reliability target for the HCAHPS global items and most composites is 0.8 or higher

3.7 Data Source and Collection

Data for this cross-sectional survey study was collected from April 2012 to May 2012 from the Karl Heusner Memorial Hospital (KHMH) which is the national referral hospital in Belize KHMH has been piloting the principles of autonomy and has been established as an authority under the KHMHA Act and serves a major percentage of nation’s people in primary, secondary and tertiary care Institutional strengthening measures have been taken there, particularly in the areas of financial and human resource management, information systems and clinical quality assurance (Ministry of Health, 2006b), therefore it is the appropriate facility to pilot a patient satisfaction survey

The approved modes of collection under the HCAHPS survey guidelines were developed to ensure that survey results can be compared fairly across participating hospitals and as a result it is sometimes necessary to adjust for factors that affect the scores patients report on the survey that are not directly related to hospital performance such as mode of data collection, patient mix (case mix), and non-response biases (Elliott et al., 2009) However, and, like many other developing nations, some citizens do not have telephone access or valid mailing addresses Once patients are allowed to leave the facility, the chance of capturing vital satisfaction data may be lost Hudak and Wright (2000) suggested that satisfaction questionnaires should be given (rather than mailed) to patients known to be leaving the facility Kuttichira & Rejani (2011) interviewed soon after discharge outside the ward on the hospital premises but without the presence of any of the treating staff In consideration of the factors named earlier, and the fact that only one hospital was surveyed (i.e there was no comparison between hospital) and since individuals may assist the patient with reading the survey, writing responses, or translation of the survey (Centers for Medicare & Medicaid Services, 2012), face-to-face interviews were conducted for this survey, where needed, by the staff members of the public relations department From a total of

378 eligible patients 176 participated (46.6% response rate)