Chất lượng dịch vụ y tế công tại Bệnh viên Đa Khoa Trung Ưng Thái Nguyên (1)

EXECUTIVE SUMMARY Title: Public health service quality at Thai Nguyen National General Hospital From October, 2016 the hospital has been renamed to Thai Nguyen National Hospital by Min

AT THAI NGUYEN NATIONAL GENERAL HOSPITAL

EXECUTIVE SUMMARY

CENTRAL PHILIPPINE UNIVERSITY

DOCTOR IN PUBLIC ADMINISTRATION

NGUYEN THI LAN ANH

DECEMBER 2016

EXECUTIVE SUMMARY

Title: Public health service quality at Thai Nguyen National General Hospital

(From October, 2016 the hospital has been renamed to Thai Nguyen National

Hospital by Ministry of Health of Vietnam)

Total number of page: 138

Researcher: Nguyen This Lan Anh

Degree Program: Doctor of Public Administration

Institution: Central Philippine University

Jaro, Iloilo City Region VI

Rational/Introduction of Study

Health quality can be defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine, 2001)

Major health care quality concerns (such as patient safety and effectiveness of care) are basically the same across different types of countries In a low – income country like Vietnam, quality related problems are much more prevalent Major factors that cause health care quality problems in Vietnam are: Lack of sufficient management (clinical and administrative); Inadequate medical staffs and training; Weak performance monitoring systems; Non-empowered patients and families Once we can assess the relative appropriateness and effectiveness of health services, we can provide optimal care to patients and maximize our use of scarce resources

Because of increasing competition, service providers and more demanding patients, service quality has become a watchword for healthcare service providers but as yet has proven difficult to measure Service quality has been directly linked to repeat sales, positive word-of-mouth and recommendation Consumer satisfaction is directly linked to service quality thus perceived quality, patient satisfaction and behavioural intentions are concepts of foremost importance to healthcare marketers (Ross et al., 1987, John Joby, 1992, Paul, 2003)

There exists number of shortcomings in medical policies and medical services mechanisms in Vietnam Large investment resources but effective use of resources to supply medical services doesn‟t meet practical requirements posed Currently, people assess the quality of health services are implemented only sensible levels, mainly

through external audio visual facilities and the behaviour, reception and care of medical staffs As for the quality of technical, medical science, in fact, underestimate people The provision of health services is now revealing many negative issues such as drug abuse, chemical, laboratory to the attitude, spirit of service, ethics It was real severe economic and popular in many establishments providing health services, both public and private sector (Tran Tuan - Director of the Centre for Research and Training Community Development, Vietnam Union of Science and Technology Associations)

Vietnam‟s health sector hasn‟t met the criteria of both quantity and quality of health services for the people The accessibility of people to health services is very difficult, especially for the poor, near poor and remote populations Inequality in the supply and beneficiaries of health services tends to increase Mechanisms and policies

in managing operating health sector are inadequate Management information system for health care is not comprehensive and overlaps Quality management system of health services as well as quality inspection of health services in both the public sector and private sector remains weak The management of drug prices in hospitals is inadequate push higher drug costs put pressure on hospital charges for patients (Truong Bao Thanh, 2013)

Vietnamese health sector is facing with an imbalance in the demand for health care among central hospitals and local people in the provinces and cities nationwide Demand for health care is increasing, whereas, only a few hospitals in the big city have capabilities to deal with Especially over the last 10 years, the phenomenon of hospital overcrowding has worsened and appeared at all levels The situation of combining 2-3 patients a bed; 1 clinic doctor must examine 60-100 patients per day is common in Central National, provincial hospitals and becomes a priority health issue, an urgent concern of the health sector as well as the entire society needs to be addressed The utilization rate of over 100 % regular beds and ranged from 120 % to 150 %, even up to 200% in some large hospitals (Le Quang Cuong et al., 2011)

According to Vietnam health statistics, there are about 40,000 Vietnamese people go overseas for treatment every year They spent more than 5 billion USD for their treatment in developed countries such as Singapore, South Korea, the US, France, and Thailand This figure is estimated to rise to 50,000 people by 2016 Doctors in Vietnam are considered as not inferior to the advanced countries mentioned above It is caused by overworked staff, poor service quality, and complex

administrative procedures; cumbersome A survey of over 700 patients taken by VN Express in Vietnam showed that 57 % Vietnamese people do not want to use the services of hospitals in the country by the attitude and ethics of the medical staffs It is raising a question of “Does the medicine of our country have won the confidence of the patient?”

Medical service is a very special service In essence, health service includes activities performed by medical staff as health examination and treatment for patients and families (Journal of Marketing, 2009)

Institute of Medicine (2001) defines quality of health care is the degree to which the health services are provided to individuals and the population to increases the desire of health outcomes and match current professional knowledge Quality of health services determined the existence of hospital and can be measured through the patients‟ satisfaction

Previously, it is thought that the evaluation and quality assurance is limited in developed countries (Thomason & Edwards, 1991), in the developing countries; the problem of improving medical quality received little interest until recently (Reerinks and Sauerborn, 1996) For public services, the quality assessment has also received little attention (Narang and Ritu, 2011) The quality of medical services is assessed from two points of view: technical and functional (Institute of Medicine, 2001) Technical quality refers to aspects related to the diagnosis and procedures while functional quality refers to aspects related to the way services are provided to the patients (Narang and Ritu, 2010) To be successful in long term a health care organization must effectively monitor and manage both technical and functional quality (Babakus and Mangold, 1992) Functional quality is often considered as the main key to determine the quality by customer perception because it is difficult to precisely assess the technical quality due to lack of professional experience (Donabedian, 1980)

Thai Nguyen is a large mountainous province in northern area of Vietnam with 1.2 billion inhabitants It is nationally known as a No 3 center for training human resources after Hanoi and Ho Chi Minh City with 6 universities, 11 colleges, 9 vocational center, training nearly 100,000 workers each year This unique demographic situation has led to a marked diversity of public health agencies in Thai Nguyen province There are one national general hospital, 08 provincial hospitals and more than fifteen medical centres at district level For this reason, public health

agencies in Thai Nguyen were classified differently from other cities of Vietnam According to General Statistic Office of Vietnam, in 2013 the province had 520 health establishments with 23 hospitals and 4719 patient beds; The number of medical staffs was 4219 persons, doctors per thousand populations was 7.6, number of beds per thousand populations was 31.6 beds, and the percentage of children under age 1 fully injected vaccine was 98% Specifically, the State own unit account for 42% but served 98% of patient bed The national health program was implemented and performed relatively well, the state of food safety and hygiene has been improved However, the quality of services in some health facilities was not high due to lack of technical facilities and doctors (Thainguyen Statistic Office)

Public health services are more favorable with reasonable price for most people

in Thainguyen city Community pharmacy is recognized as an easily accessible source

of advice in primary health care and pharmacists as competent and well-trained health professionals An essential factor to consider when analyzing the quality of health care

in facilities is the perspective of the clients For clients and communities, quality care

is something that meets their perceived needs Since a client's needs often differ from one and other, his/her personal satisfaction ultimately depends on the individual perception, attitude and expectations Patient satisfaction is a strong influencing factor

in determining whether a person seeks medical advice, complies with treatments and maintains a relationship with the provider/health facility Ultimately, the dimensions

of quality that relate to client satisfaction affect the health and well-being of the community The results of the literature review suggest that the most important dimensions of quality for the client are technical competence, interpersonal relations, accessibility and amenities

Thai Nguyen National Hospital (TNH) is located at Phan Dinh Phung ward, right center of Thainguyen City The hospital was established in 1951, this is a state own hospital – one of the largest hospital in Thai Nguyen province and in North mountainous region TNH is maintained the first class hospital with bed size of 1200 units, the highest level of treatment is responsible for direct health care for more than 1.2 million people in Thainguyen province, and the ultimate treatment venue in North moutainous provinces The hospital has 40 wards, department and centers with high quality medical staffs In order to reach the mission of deploying advanced techniques

of thoracic surgeries, tumors, resuscitation, heart disease; the satellite clinics of leading Central hospital in Northern mountainous area of Vietnam, the completion of

human resources and enhancing quality of hospital‟s health services is necessary Especially, in the coming competitiveness and higher demand as well as quality for health services boost all hospital to a number of opportunities and threats

Today for the healthcare service market in Thainguyen, there is a need for a healthcare service quality model that takes into consideration a complete coverage of the dimensions that consumers use in evaluating healthcare service quality Hence, the evaluations of health services through the patients‟ satisfaction as well as health provider‟s perspective of awareness and managing quality is needed Provision of health service quality is the top priority in hospital management, especially in public

sector That is why the topic “Public health service quality at Thai Nguyen National

Hospital” was chosen as the dissertation title The research is conducted with focusing

on service quality, patient satisfaction and intentions to return, as well as the patient role in the medical service encounter

Objectives of the Study

General objective

This study concentrates on quality assessment of the public health services at Thai Nguyen National General Hospital Thus, improving health service quality as well as the competition ability of hospital and contributing to meet the strategic objectives of Vietnam in terms of public health services quality up to 2020

Specific objectives

Specifically, this study seeks to:

1 Describe the current status of health services quality at Thai Nguyen National Hospital – a public hospital in Thai Nguyen city;

2 Determine factors affecting functional quality of health service at Thai Nguyen National Hospital

3 Examine the overall perceived quality of patients toward the quality of health services at Thai Nguyen National Hospital;

4 Determine relationships between overall patient satisfaction and factors affecting their satisfaction level including tangibility, reliability, responsiveness, assurance, and empathy;

5 Determine relationships between patient demographics characteristics and their overall level of satisfaction;

6 Propose recommendations for a better healthcare quality improvement at Thai Nguyen National Hospital

Research Hypothesis

- Hypothesis 1 (H1): There are no significant effects of SERVQUAL dimensions as Tangibles, Reliability, Assurance, Responsiveness, and Empathy on patient‟s overall perceived of health service quality

+ H1.1 There is no significant effect of “Tangibility” on patient’s overall perceived of health service quality

+ H1.2 There is no significant effect of “reliability” on patient’s overall perceived of health service quality

+ H1.3 There is no significant effect of “Assurance” on patient’s overall perceived of health service quality

+ H1.4 There is no significant effect of “Responsiveness” on patient’s overall perceived of health service quality

+ H1.5 There is no significant effect of “Empathy” on patient’s overall perceived of health service quality

- Hypothesis 2 (H2): There are no significant different in overall perceived hospital service quality of patient according to their personal characteristics as age, gender, occupation, income and educational level

+ H2.1 There is no significant different in overall perceived hospital service quality of patient according to their age

+ H2.2 There is no significant different in overall perceived hospital service quality of patient according to their gender

+ H2.3 There is no significant different in overall perceived hospital service quality of patient according to their occupation

+ H2.4 There is no significant different in overall perceived hospital service quality of patient according to their income

+ H2.5 There is no significant different in overall perceived hospital service quality of patient according to their educational level

- Hypothesis 3 (H3): The higher patients‟ perceive of overall quality of health service is, the better their satisfaction would be

- Hypothesis 4 (H4): There is no significant correlation between overall patient satisfaction and the patients' intention to return and to recommend other for coming

to hospital

Conceptual Framework

Research Design and Procedure

The study used both qualitative and quantitative methods to analyze the health care service quality A list of quality assessment indices was formed based on Donabedian theory and SERVQUAL model The author divided research process into two phases:

The first phase: Conduct a qualitative exploration of the characteristics of the healthcare service in Thainguyen upon which consumer build their perceptions about the quality of the healthcare service This was performed through conducting a series

of in-depth interviews from patients as well as business and healthcare experts frequenting the publichealthcare sector in Thainguyen city Then the author conducted

a pilot study to test the questionnaire and the reliability of data Final modification on the questionnaire format was done, prior to the quantitative data collection procedure

In the second phase, themes and information from previous phase was developed into a valid and reliable instrument for measurement of healthcare service quality A modified conceptual model of service quality is constructed that was based

on the work of previous authors in the field as well as data gathered from the

Overall Perceived Service Quality

Retention to return or recommend

SERVQUAL

Expected Service Quality

Perceived Service Quality

5 SERQUAL FACTORS Tangibility Reliability Responsiveness Assurance Empathy

qualitative section of the study Then a quantitative survey for a sample of patients frequenting the public healthcare sector in Thai nguyen National Hospital was performed to test the overall perceived service quality, satisfaction and retention to return of patients

The researcher also use descriptive-rational as it describes certain characteristics of the respondent and its relation with other variables in the study To obtain the data needed, a survey design was used by using an interview schedule to get the right information from the respondents

Determine

problems

Setting research objectives

Determine research problem

Test the questionnaire (n = 20)

Research model

Group discussion (n

= 10) Preliminary studies

Official questionaire

Adjust

Delivery questionaire (n =367)

Data analysis

Data processing

Desk study

Not meet the Expectation Meet Expectation

Study population and Sampling technique

 Population: Individuals have been used Thai Nguyen National General Hospital

service from June to August, 2016

 Sampling Methods: Random stratified sampling technique Heterogeneous

samples are obtained that reflect, as much as possible, all patients who would receive health care in the hospital Evaluating the representativeness of such samples is problematic According to the latest statistics from GSO of Vietnam, every month there is more than 3500 in patients come to stay in Thai Nguyen National General hospital with different demographical characteristics The variability in demographics ensured varied opinions and responses of individuals covering all the sampling criteria to be used in the present research

 Sampling Criteria: Patients who use public health service in the hospital in

2016, have had at least one overnight stay in the hospital

 Sample Size: Based on research by Hair, Anderson, Tatham and Black (1998) to

refer to the expected sample size Accordingly, the minimum sample size was 5 times the total number of observed variables Applying in this study, the number of observed variables are 25, so we can get n = 125 But the author decided to choose

n equal to 367 patients in order to make the sample be more reliable It covers almost one third of the hospital scale of patient bed

 The process of choosing 367 patients will be as follow:

In order to ensure the randomly, representatively, the process of choosing sample will be followed this procedure:

1 Ask the patients at 6 departments including 3 types of bed rate from high, medium and low level and Outpatient Department

2 In each department, choose patient according to the list of them in the record book Choose name of the patient according to the first letter of their name

3 Choose 3 letters in one day, and continue that process until reach the number of respondents of 30 - 70 patients in each department

In the list of patient associated with department, choose only one who has been stayed at the hospital at least 4 days or more

Planning the time and department as well as the letter will choose when conducting survey as follow:

Order Department

Level of bed occupation rate

respondents

7 Outpatient department Special August, 2016 90

In the Pilot study, the number of experts will take part in will be approximately

10 persons, including: Board of director of hospital, Head of department in hospital, leader of health department in Thainguyen province The discussion focuses on the quality of health services in hospital, from the awareness of director, the direction of manager‟s board to the indicator for health service quality The author also ask experts view point of 5 dimensions in the Parasuraman service model that using in assessing the quality of health service in hospital And ask them to weight the importance of each dimension with the assumption that total quality dimension equal to 100 percent

Data collection and instrumentation

The five dimensions of SERVQUAL as proposed by Parasuraman et al (1988), Othman & Owen (2001, 2002) and Jabnoun and Al-Tamimi (2003) will be adapted and modified in this study The instrument poses aset of 25 structured and paired questions designed to assess patients„expectations of service provision and the

patients „perceptions of what was actually delivered A five-point Likert-type scale is used in this study, anchored by - strongly disagree to―strongly agree Content validity (wording and meaning) was checked carefully by experts A pre-test was then conducted with a group of patients, and minor changes to the scales were made accordingly to ensure that the questions were not repetitive The researchers will use the structured and paired questions to measure Expectation (E) and Perception (P) for service quality of Hospitals

Likert Scale

Using the Likert 5 point scale, with choices ranging from 1 to 5 as follows

Cronbach's Alpha

Assess the reliability of variables through Cronbach's alpha coefficient In statistics, Cronbach's is a coefficient of internal consistency It is commonly used as an estimate of the reliability of a psychometric test for a sample of study

Exploratory Factor Analysis

Exploratory factor analysis is a statistical technique that is used to reduce data

to a smaller set of summary variables and to explore the underlining theoretical structure of the phenomena It is used to identify the structure of the relationship between the variable and the respondent In this research, the author uses Q-type factor analysis because factors are calculated from the individual respondent Driving factor is determined by Principle component factor analysis method in order to drive the minimum number of factors and explain the maximum portion of variance in the original variable The author also intent to use varimax rotation method to simplify the column of the factor matrix so that the factor extracts are clearly associated and there should be some separation among the variables

Factor loading can be classified based on their magnitude: