statistical measures of customer satisfaction for health care quality assurance, a case study

Statistical measures of customer satisfaction for health care quality assurance:a case studyM.A.A.HasinBangladesh University of Engineering and Technology (BUET),Dhaka,BangladeshRoongrat SeeluangsawatLecturer,Kasetsart University,Bangkok,Thailand M.A.ShareefManaging Director,Trade Development Consulting,Dhaka,BangladeshIntroductionTo satisfy the customer is the best business strategy of all.In many countries,health careservice is not considered as a business,but a ``welfare''service offered by the public sector.Even though not a business,this sector needs extreme concentration on improvement in customer needs.On the contrary,in many countries,the health service has been opened to the private sector.Therefore,the service has become highly competitive in many countries of the world,including Thailand.Thus,a large number of hospitals are vying for ISO9000Quality Management System (QMS),national health care regulatory systems,and many tools and techniques of total quality management (TQM).Application of statistical tools and techniques of TQM in hospitals and other health care organizations have been reported (Coates and Willans,1993;McGinnis and Leeming,1993;Oza,1995;Thomson et al.,1993).The case under study also opted for implementing ISO9000QMS and practicing selected TQM tools and techniques toimprove the customer satisfaction level.This study focuses on the later part,i.e.measurement of customer satisfaction and segregating elements of dissatisfaction for attention.MethodologyIn this study,the customers are divided into two categories:in-patient and out-patient,relating them to operational quality in the in-patient department (IPD)and the out-patient department (OPD),respectively,of the hospital.It may be stated that the MPT hospital has 50beds available for internal patients and approximately 100for out-patients.For data collection,the interviewing was done according to the method of Eccles (Eccles et al.,1993),which suggests developing the instrument to measure outcomes of ``care''.The study starts with interviewing the patients about the quality of health care and its status,collecting data about the frequency of occurrence of dissatisfactory events,timings of service activities,frequency of visiting the hospital,etc.The study then performs scoring(Bowden,1993;Haran et al .,1993;McGinnis and Leeming,1993),according to the scale,for factors,such as dysfunction,well-being,and others,which are reflected in the outcome analysis.In this connection,it may be mentioned that Haran (Haran et al.,1993)suggests that the main factors,which affect the customer satisfaction in health care,are:doctor,drug,diagnosis,duration,distance,affordability,prompt service,etc.According to him,these are the factors that comprise the health care quality system,and the higher the efficiency of the quality system,the more will be the satisfaction of customers.The study aimed at finding out the following information,step-by-step:1Identification of the patients'characteristics.2Identification of the critical factors that affect the intention of the patients of coming to the hospital again in future needs.3Analysis of the patients'satisfaction about service and fee.4Classification of patients,usinghypothesis test,to find out satisfied and dissatisfied patient groups.5Analysis of the level of expected service quality,and identification of operational weaknesses.6Identification of the reasons for problems and suggestion to the hospital.The research register for this journal is available at The current issue and full text archive of this journal is available at International Journal of Health Care Quality Assurance 14/1[2001]6±13#MCB University Press [ISSN 0952-6862]KeywordsTotal quality management,Customer satisfaction,Health care,SurveysAbstract While applications of TQM toolsand techniques in health careservice industry are widelyadvocated,determination ofcustomer satisfaction and factors of dissatisfaction in the hospitals has become enormously importantas the main ingredient of TQM.This paper aims at determining the elements of customer satisfaction,by collecting information through survey,usingboth written questionnaire andinterview,and then statisticallydetermining correlation between factors and elements of dissatisfaction.The study isperformed at the Muang PetchThonburi Private Hospital,located in Petchaburi province of Thailand.The aim of the management is to gather information on customersatisfaction levels and factors ofdissatisfaction that need to beaddressed and subsequentlyeliminated in the near future.The survey identified the quality factors by interviewing the patients attending the OPD and IPD,through a pre-tested structured questionnaire(Coates and Willans,1993). Each customer listed many factors,based on which the following may be concluded:.Cleanliness..Service of doctor(quick response to request for service,intention andattention of doctors in listening to apatient,diagnosing method,treatmentexplanation,courtesy)..Service of nurses(quick response to request for nursing service,help andattention of nurses,courtesy)..Service of officers,i.e.staff(quick response to request for financial service, quick response to request for otherservices,courtesy of finance staff,courtesy of pharmacy staff,courtesy ofreceptionist,courtesy of patient handling officers,availability and reception ofinformation)..Other services(service rate,food and test).Sampling methodThe sample size was statistically derived (Montgomery,1997),as follows:Z=The standard normal deviation,derived from level of confidence.p=An estimate of proportion of attribute being studied,such as customersatisfaction.The p value was derivedfrom the response of40customers inOPD,and30in IPD,for analysis,considering normal distribution forhospital service satisfaction.q=1±p.h=accuracy intervaln Z2pqh2X 1From equation(1),the results were found as: n OPD=246n IPD=138This is the minimum for meeting the target of95percent confidence level,and0.05 sample error.Questionnaire developmentA survey was conducted,distributing a total of300sets of questionnaires to out-patient and160to in-patient department.In order to collect related data,the study designed the questionnaire in four sections as:1General service information±this section started with a simple and interesting 2Importance level±a patient has to select one of five importance levels for18quality factors in the list above.3Service level±a patient has to select one of five service levels for18quality factors in the list and state the reason fordissatisfaction.4Personal data±age,sex,salary,and responsibility for expenditures.Data collectionIn OPD:The questionnaires were distributed to the patient,after paying to the cashier and before waiting to receive medicine from the pharmacy.The patient who got the questionnaire was selected by symmetric random sampling.These patients returned the questionnaires before they went back home.In IPD:The questionnaires were distributed to the patients,admitted in each day.Data analysisPatient characteristicsIn order to resolve the first issue(first step), as stated in the methodology section,by analyzing section1and section4of the questionnaire,the characteristics of the patients,attending the OPD and IPD,were found,which are given in Table I.By and large,the two departments are well matched on factors,such as age,sex,``a previous patient'',and return intentions.A noticeable difference in the factor,``responsibility for expenditures'',is that while for the OPD customers,it is personal payment,for the IPD patients,it is health insurance company.A logical explanation can be:in case of OPD, the charges are relatively and considerably lower than those in the IPD.Factors affecting``return intention''For the second step of the methodology,in order to identify the critical factor(s)that affect the return intention,the cross-tabular computation facility of statistical package SPSS9.01was used.The cross-tabular computation is a useful tool to determine the significance of the relationship between two variables (factors).This method has been used for finding the relationship between``return intention''and``previous patient'',``service expense''and``responsibility for expenditures(payment)''.After that,chi-square test(Montgomery,1997)was applied to find the degree of correlation.It was found that``service expense'',``a previousRoongrat Seeluangsawat and M.A.ShareefStatistical measures of customer satisfaction for health care quality assurance: a case studyCare Quality Assurance14/1[2001]6±13do not have strong relation with ``return intention''of OPD patients.About IPD patients,the ``responsibility for payment''has considerable impact on ``return intentions''.Thus,it was recommended that the hospital might be more active inmanaging health insurance facilities for the IPD patients.Patent satisfaction opinion level (PSL)and patient important level (PIL)As customers'satisfaction is the main target of this hospital,attempt was made tomeasure satisfaction against each quality factor,identified earlier.Thus,the results are able to identify weak points for the hospital as well.Finally,the overallsatisfaction level was computed.For each question,a five-choice response was allowed (the most satisfied,highly satisfied,satisfied,less satisfied,not satisfied:scores 1-5).The ``Patient's Satisfaction Level''(PSL)was calculated from equation (2),as below:PSL 5S 5 4S 4 3S 3 2S 2 S 1 Â1100 2Where:subscript is the level of satisfaction(5=the most satisfied,F F F 1=not satisfied);S is the score in terms of percentage.The results are given in Table V (column A,column B).Classification of patient groupsFor the fourth step,as identified in the methodology section,above,the statistical measures,given below,were followed.Overall Service Satisfaction (OS):After the pretest questionnaire,18quality factors were identified,which are mentioned earlier.In the succeeding step,the overall service satisfaction for each patient was computed using equation (3):OSn i 1W i O i ni 1W iX 3 Where i is number of each factor;W is weight of each factor;O is service opinion for each factor;OSis overall service satisfaction.Hypothesis testingThe hypothesis testing (Montgomery,1997)was done for all 18factors,organizing the customers into groups,such as ``personal payment''customer group,``company's contract payment''group,and ``healthinsurance company payment''group.This study tested the mean satisfaction level in each payment group.Next,the overall service satisfaction,and the factors of dissatisfaction and corresponding groups were identified.Overall service is theprincipal factor that can measure the overall satisfaction of patient's attitudes to OPD and IPD services.The hypothesis testing is done in terms of mean value comparison to each payment group,as:H0:u 1=u 2=u 3.H1:Not all of u i are equal.Where:u 1is the overall service satisfaction mean of personal payment group;u 2is the overall service satisfaction mean of health insurance group;u 3is the overall service satisfaction mean of company's contract group.The null hypothesis is rejected when F calc >F crit ,or in turn, calc < crit .The one-way analysis of variance (ANOVA)method based on each of the groups considers independent sample groups from normal distribution.For this analysis,SPSS 9.01for WINDOWS was used.If the null hypothesis is rejected,then the study considers multi compare mean to identify characteristic of each group about the overall service mean.The results of one-way ANOVA forcomparison of mean are shown in Tables II and III.The outcome of OPD shows that the Patient characteristics Patient characteristic OPD (%)IPD (%)AgeBelow 2050.2520-404948.7540-603434.3Above 60 2.65No reply 9 5.6SexMale 3836.8Female 5654.3No reply 68.7PaymentPersonal49.340.6Company contract 41 6.8Health insurance 950.6No reply 0.6 1.8A previous patientYes 5955.6No37.742.5No reply 3.3 1.9Return intentionYes,I would 67.356.9No2.33.8Not sure 27.336.9No reply32.5Roongrat Seeluangsawat and M.A.ShareefStatistical measures of customer satisfaction forhealth care quality assurance:a case studyCare Quality Assurance14/1[2001]6±13critical value (0.05).Thus,it can be concluded that the means of overall satisfaction for each group are indifferent.At IPD,thesignificance level is less than the critical value.Thus,the study rejects the null hypothesis.Next,the study uses multi-compare mean to identify the characteristic of each group,as in Table IV.The studyfound that u 1Æu 2,u 1=u 3,u 2=u 3.Thus,it can be concluded that the mean of ``personal payment''group is different from (in fact,lower than)the ``health insurance''group,whereas the others are indifferent.This leads to a suggestion that the needs of ``personal payment''group be addressed first,in order to improve overall satisfaction.Operational weakness and expected service qualityTo achieve the fifth step,as outlined inmethodology section,the method below was followed.Quality characteristic weight:The patients were asked for their ratings of importance and their opinions about overall medical service.The average score for each service is the service point (score).The nurse team brainstormed to evaluate the present status and target status in future for each factor.The outcomes are given in Table V,as per computations given below,which is amodified method from that of Radharamanan and Godoy (1996),where:A =Patient Importance levelB =Patient Satisfaction levelC =PlanD =Ratio of Improvement (C/B)(an improvement ratio is computed by dividing the future goal/target rating (``us future'')by the current rating (``us today'').F =Absolute weight (A*D),The score/point is computed for each individual customer-need bymultiplying customer importance and improvement ratio.The products of these two numbers provide a hierarchy of customer needs based on the team's assessment of two variables.G =Demand weight (F/Total)*100.Table V identifies the factors affecting over-all hospital service,and their weightage.Quality chart :The study uses quality characteristic chart to identify the quality factors that are weak,and thus,require more attention.The nurses'brainstorming session identified the following points to resolve the weak operations:.Frequency of cleaning and time schedule should be adjusted..Number of canisters need to be increased..Number of specialist doctors should be increased..Service explanation and information should be provided in simple words..Suitable diagnosing time should be managed..Regular and timely visiting schedule for doctors in the ward should be arranged..Doctors and nurses should be fair spoken,smiling..Job environment should be addressed to increase enthusiasm in work..The doctors and nurses should pay more attention to understand patients'minds,should be interested in patients.They (doctors and nurses)should ask the patients about their symptoms,because some patients shy away..Training ±job and process training for doctors and nurses need attention..Patients should not be left alone for a long time,which needs more nurses appointed in the hospital..Attendance of officers is not satisfactory,and thus,need to be improved..Officers need to be more careful to reduce mistakes,utilize time and other resources..Follow up for complicated service is required.For the patients who need several special tests in severalTable IIAt OPD,one-way ANOVASum of squaresdf Mean square F Sig.Between groups 2.41130.804 2.4020.068Within groups 84.3072520.335Total86.718255At IPD,one-way ANOVASum of squaresdf Mean square F Sig.Between groups 4.6173 1.539 5.3040.002Within groups 39.1671350.290Total43.784138Table IVAt IPD,comparison of mean Responsibility for payment Mean Sample size (N )No reply3.75653Personal payment3.773554Company health insurance4.127572Roongrat Seeluangsawat and M.A.ShareefStatistical measures of customer satisfaction forhealth care quality assurance:a case studyCare Quality Assurance14/1[2001]6±13x-ray,etc.,a nurse should follow all the steps with test results.Finally,the nurse should combine all and prepare thedocument when the patient is discharged..Training ±job and process training are necessary for officers and technicians..Jobs need to be prioritized..Promptness of officers needs to beincreased keeping the manpower at the current level..The hospital should provide correct patient information when patients are discharged from IPD..Augment communication efficiency ±the officer should check and ensure that they understand in the same way..Power and efficiency of database systems need to be increased.The capability of data management of concerned officers should be increased..Several kinds of food should be arranged..If possible,service charges should be reduced.For computing scores for satisfaction,or importance,the study used three level rating:strong ±nine points,moderate ±three points,poor ±one point,multiplied by demand weight.The highest operating score would mean a critical operation in the system.The quality chart provides guidance to MPT hospital for process improvement.As can be noticed in Tables V and VI,thecustomers want some factors to improve at OPD and IPD.The four most important scores are:AT OPD:Service rate,Doctor's diagnosing,Quick response of doctor,Help of nurse.AT IPD:Service rate,Doctor's diagnosing,Courtesy of cashiers,Attention of doctor in listening to patient's symptom.It must be stated that in a hospital,customers do not pay much attention to cashier's activities,though apparently surprisingly the customers paid much attention to cashier's behavior,in this particular case.This only says that thecashier's behavior is noticeably bad,which needs immediate attention.It has been found that there are many weak operations in the system that should be addressed properly.Table VII identifies the most critical weak operations,which need necessary attention in the hospital process.It indicates the same critical point in OPD and IPD.The inefficient operations that have direct impact on the customer are:.Doctoral and Nursing service should pay more attention and take care of patients.Currently,the patients are left alone for a long time,which the patients do not like..The majority of the patients are critical about staff behavior.They need to be more munication efficiency should be improved..The patients like to consult with more specialist doctors (note:It must be noted that some specialist doctors have left the hospital recently,but the hospital did not recruit new ones).Table VAt OPD,quality characteristic weight Quality factorsAvg.importancelevel (A)Satisfaction point (B)As planned(C)Ratio of improvement (D)Absolute weight (F)Demand weight (G)Rank 1.Cleanliness4.394.154.5 1.084337 4.760245.53484122.Quick response (doctor's service) 4.633333 4.143333 4.5 1.08608 5.0539 5.8762833.Quick response (nurse's service 4.5566667 4.17 4.5 1.07913669 4.91727 5.7174174.Quick response (handling service) 4.09 3.85 4.5 1.16883117 4.78052 5.55841115.Quick response (cashier's service)3.96 3.714.5 1.212938 4.803235.58483106.Help of nurses4.52 4.08 4.5 1.1029412 4.985295.7965147.Intention of doctors in listening to patients4.6266667 4.18 4.5 1.076555 4.980865.7913658.Doctoral diagnosis 4.6866667 4.17 4.5 1.07913669 5.05755 5.8805329.Treatment explanation4.6133333 4.174.5 1.07913669 4.978425.78851610.Receive info from receptionist 3.9866667 3.913333 4.5 1.1499149 4.58433 5.33031511.Food3.6466667 3.4533334 1.15830124.22394 4.911271712.Courtesy (doctor) 4.4233333 4.233333 4.5 1.0629922 4.701975.467081413.Courtesy (nurse) 4.46 4.153333 4.5 1.083467 4.83226 5.61858914.Courtesy (cashier)4.16 3.83 4.5 1.1749347 4.887735.68307815.Courtesy (pharmacy center) 4.13 3.894 1.0282776 4.24679 4.937831616.Courtesy (receptionist) 4.163.9333334.5 1.1382799 4.735245.505771317.Courtesy (handling service) 3.9633333 3.794 1.055409 4.18294 4.863591818.Service rate 4.142.346666731.2784095.292616.153841Total86.0051100Roongrat Seeluangsawat and M.A.ShareefStatistical measures of customer satisfaction forhealth care quality assurance:a case studyCare Quality Assurance 14/1[2001]6±13Identification of reason to problemsTo achieve the sixth step,as outlined in methodology section,the method below was followed:Pareto chart and cause effect diagram:These two tools were used together to find critical problem (through Pareto analysis)and causes (reasons)to that problem (using Cause-effect diagram),as has been noticed in other hospitals (Radharamanan and Godoy,1996).The Pareto analysis is a techniqueemployed for prioritizing problems.From the data in section 3of the questionnaire,the study focused on the important defects(problems)that occur more frequently than many others.The data,when plotted in Pareto chart,show that the most critical problems in OPD are the service rate and inefficiency of officers'service.The chart in IPD indicates that the service rate,and long waiting time to complete the formalities after discharge order are the most commonly encountered defects (problems).Thus the cause of these defects (problems)should be identified and attended to first.Cause and effect analysis is a formal tool frequently used in identifying layeredpotential causes.The nurse team identified the causes and sub-causes of this problem by brainstorming.There are four main causes in OPD:work system,computer system,officer's service,and hospital policy.There are five main causes in IPD:work system,computer system,nurse aid,cashier (officer)and hospital policy.These causes also have many sub-causes as follows:.Information (inadequate information,specifically on price and service,is provided to the patients.Also enough information is not provided about insurance's right,and papers for claiming process)..Carelessness (some officers do not take care of the patients well.For example,when a relative comes to visit the patient,the officers do not urgently guide them,but rather leave them waiting)..Shortage of officers..Carelessness of nurses and sometimes,doctors..Inconsistent charging,because of inconsistent information (because ofinconsistent and inadequate information,presented to the customer,they tend to believe that customers have to pay differential charges.A thoroughbreakdown of charges may remove this wrong idea)ck of cooperation between insurance company and the hospital (patients find it difficult to process the insurance claim,based on the papers provided by thehospital.This also causes delay,when the poorer customers find it difficult to pay the hospital charges.Good relations and cooperation between insurancecompanies and hospital may inspire the patients to come to the hospital)ck of schemes for staff development (training).Table VIAt IPD,quality characteristic weight Quality factorsAvg.importancelevel (A)Satisfaction point (B)As planned (C)Ratio ofimprovement (D)Absolute weight (F)Demand weight (G)Rank 1.Cleanliness4.45625 4.15625 4.5 1.08270677 4.824815.47529132.Quick response (doctor's service) 4.73125 4.1625 4.5 1.08108108 5.11487 5.8044553.Quick response (nurse's service 4.60625 4.375 4.5 1.02857143 4.73786 5.37662144.Quick response (handling service) 4.11875 4.0125 4.5 1.12149533 4.61916 5.24191155.Quick response (cashier's service)4.09375 3.74.5 1.21621622 4.978895.6501486.Help of nurses4.6 4.13125 4.5 1.089258705.01059 5.6861277.Intention of doctors in listening to patients4.51875 3.95625 4.5 1.137440765.13981 5.8327648.Doctoral diagnosis 4.61875 3.9875 4.5 1.12852665 5.21238 5.9151229.Treatment explanation4.5125 4.04375 4.5 1.112828445.02164 5.69866610.Receive info from receptionist 4.05625 3.73125 4.5 1.20603015 4.89196 5.551491111.Food3.975 3.6254 1.103448284.38621 4.977561712.Courtesy (doctor) 4.54375 4.11875 4.5 1.09256449 4.964345.63363913.Courtesy (nurse) 4.61875 4.275 4.5 1.05263158 4.86184 5.517321214.Courtesy (cashier)4.26875 3.69375 4.5 1.218274115.20051 5.90164315.Courtesy (pharmacy center) 4.2625 3.718754 1.07563025 4.58487 5.203011616.Courtesy (receptionist) 4.30625 3.9125 4.5 1.15015974 4.95288 5.620621017.Courtesy (handling service) 4.14375 3.83754 1.04234528 4.31922 4.901541818.Service rate 4.152.3531.276595755.297876.012131Total88.1197100Roongrat Seeluangsawat and M.A.ShareefStatistical measures of customer satisfaction forhealth care quality assurance:a case studyCare Quality Assurance14/1[2001]6±13.No internal audit..Insufficient computer peripherals (specifically,printers).In fact,the longqueue at the cashier's desk is attributedmainly to inadequate printing facility..Inefficient computer program and system design.Control chart analysisThe control chart is a very useful tool for process monitoring(Montgomery,1997)in a hospital too(Tsacle and Aly,1996; Zimmerman,1996),when unusual sources of variability are present.This study used30 days in September,1999for collecting data by observing a patient in each day.The study used p-chart to study the unsatisfactory service that is caused by inefficiency of officers'service in OPD,and long waiting time after discharge in IPD,originating from cashier's service.In case of patients having insurance payment,a number of complexities arise that lead a patient to wait on an average for two hours after discharge. In case of a patient having personal payment, this waiting time period is15minutes, though this can be reduced further.In Figures1and2,it can be noticed that in a few cases,the points are plotted at a very high level(thus,may be considered out of control cause in OPD is lack of information,whereas in IPD,the causes are as follows:.In case of personal payment,the printing facility causes delay..In case of insurance payment,lack of papers required for claim and non-cooperation between insurance company and hospital cause the delay.Throughbenchmarking,it has been found thatmany hospitals arrange fax claim forinsurance,which needs cooperation. ConclusionFrom analysis,it has been found that though the hospital has a good level of overall service, there are many areas that need attention to further improve the service.Continuous improvement of TQM is thus very helpful to increase competitiveness in hospitals and many other health care organizations.The following are some factors which are found necessary at this specific hospital,though the study believes that they are necessary in any other health care organization:.Change attitude of employees about the nonconforming service,it does not mean deficiency in the department,rather itmeans that things should improve to meetThe total score of weak operations in the systemDegree of services in the hospital Operations and weaknesses At OPD At IPDDegree of cleanliness Cleaning frequencyNumber of canisters 49.7716.5949.3216.44Degree of doctoral and nursing service Specialist doctorsInformationDiagnosis time105.852.1117.37105.457.317.49 Ward arrangement70.0868.34 Fair spoken99.81100.3 Enthusiasm33.2733.45 Understanding patient69.5169.54 Training of doctors/nurses22.3322.19Degree of officers'service Take care of patient157.2156.9Attention49.4149.35Carefulness71.7671.5Follow-up50.2250.25Training of staff131.2133.9Understanding patient17.0417.7Job prioritization50.2250.85Promptness32.7316.95Suitable materials/resources50.0447.25Communication efficiency116.2114.7Capability of database50.2250.85Enthusiasm62.9764.86Fair spoken145.1150.4Other services Kind and taste of foodService charge 14.7318.4514.9418.03Roongrat Seeluangsawat and M.A.ShareefStatistical measures of customer satisfaction for health care quality assurance: a case studyCare Quality Assurance14/1[2001]6±13。