Identification of patient's requirements in quality management system in health care institutions

Abstract

Aim

To present the solutions implemented in health care institution in the context of identification of patient's requirements, and evaluation of the level of patients’ satisfaction in accordance with the requirements of ISO norm 9001:2008 based on the experience of GPCC.

Background

The fundamental mechanisms behind the free market, such as competition, start applying also to the public health sector. Health service providers are gradually realising that patients are actual clients of health care institutions, with physicians, nurses, supporting personnel, registration officers and other staff responding to patients demand for medical and auxiliary services (e.g. exam registration, provision of information).

Material and methods

PN-EN ISO 9001:2009 “Quality Management Systems. Requirements”, relevant literature and documentation of quality management system from the GPCC.

The review of relevant literature and legal requirements; interpretation of provisions in relation to the functioning of health care institutions.

Results

Model of identification of patient's requirements and satisfaction in accordance with the requirements of ISO 9001:2008 has been elaborated and implemented in the GPCC.

Conclusion

The identification of patient's requirements is much more complicated than evaluating the same parameters in manufacturing companies. In the context of medical services one should be aware of the subjectivity of patient's feelings, the psycho-social status and the general state of health during his or her treatment. Therefore, the identification of patient's requirements and satisfaction must be carefully thought out, implemented and regularly improved.

“Everybody knows their client and if they do not know

who their client is and what his/her expectations are …

then they do not understand their work.”

Edward Deming

1. Background

The modern concept of quality does not only refer to a product or service offered by a company, but also to all the processes occurring in that company to contribute to the final quality of that product or service. Therefore, implementation of a quality management system based on the ISO 9001:2008 standard, aimed at ensuring quality at each stage of production/provision of a product or service, implies a variety of changes ranging from company's policy, through infrastructure, techniques and technology to staff awareness. A quality-oriented approach is the basis and key to a consistent rise in the quality of services provided and products offered. The ability to actively and continuously identify client's needs and expectations is a critical and inherent factor in the process of improving the quality management system.

Identification, monitoring and supplying client's expectations are some of the key conditions to ensure success and development of a free-market entity. After all, a satisfied client is the best advertisement for a company, whose gains are not only translated into economic terms, but also into company's reputation for being able to adequately identify and meet its clients’ expectations by promptly and effectively responding to changing market needs.¹

First, however, in order to implement and maintain efficient client requirement monitoring mechanisms within a functioning quality management system, we need to identify what kind of clients we actually deal with. The term “client” tends to be associated primarily with a purchase of a product or service, an obvious connotation considering that a market entity without a client has no raison d’être. But one should not forget either about the other group of clients, referred to as ‘internal clients’, i.e. employees of the company. While these are not direct recipients of a product or service, they do affect the external clients’ level of satisfaction.² Therefore, it is so crucial for the senior management to implement, maintain and improve quality standards as well as promote a quality-oriented policy among the staff, while raising their awareness of the influence they have on assuring quality and success of the enterprise.

The fundamental mechanisms behind the free market, such as competition, start applying also to the public health sector. Health service providers are gradually realising that patients are actual clients of health care institutions, with physicians, nurses, supporting personnel, registration officers and other patient contact staff responding to those clients’ demand for medical and auxiliary services (e.g. exam registration, provision of information). In view of that, all patient-related processes have to be placed in the focus of interest for health care institutions using an ISO 9001:2008 compliant quality management system.

In recent years, the Polish health care sector has shown a clear tendency to increase the proportion of privately owned centres providing patients with high-class and reasonably priced health services, although the concept of ‘reasonable price’ is certainly relative. It is worth noting, though, that many of those centres are also contracted by the National Health Fund, their services thus being available for all people, regardless of their material status. Consequently, new patients can be attracted without having to charge them with costs of medical services. In these circumstances, state-owned health care units are facing real and constructive competition. To remain competitive for private firms, they have to develop a particular ability to identify the needs and expectations of their existing and potential patients-clients. The reason being that, apart from institution's technical resources and the amount of specialist medical equipment it has at its disposal, it is the acknowledgment and fulfilment of patient's psycho-physical needs that determine whether a hospital is perceived as patient-friendly or not.

The most significant areas of patient expectations are commonly agreed to include:

• •availability of medical services;
• •waiting time for a medical service;
• •information on health status, good communication with medical staff;
• •respect for Patient Rights with particular emphasis on patient's right to decide on the manner and method of treatment;
• •broadly understood psychological well being during the treatment process and its components;
• •flexibility of health care in terms of its being adjusted to individual needs.³

On-line surveys conducted on 107 respondents between 1 January 2010 and 31 May 2010 by the Greater Poland Cancer Centre show that, apart from the above-listed factors, patients also point out to the importance of the following:

• •Setting of medical services (infrastructure, colours, rooms, temperature, sanitary conditions)—100%.
• •Psycho-social factors (respect for personal dignity, empathy, personnel's politeness, friendliness and honesty)²;
• •Ethical and cultural factors (freedom of culture and religion, consent to be treated)—OK; 80% of respondents⁴;
• •Availability within the health care institution of: ATM—43% respondents, cafe/bar—60% respondents; and
• •Access to information brochures and leaflets (on registration process, hospital admission procedure), access road maps and graphic hospital layout—57% respondents.

2. How to identify patients’ requirements and measure their level of satisfaction?

The Greater Poland Cancer Centre initiated the process of professional identification of patient satisfaction levels (the difference between what a patient received and what he/she had imagined or expected) upon implementation of the Quality Management System based on ISO 9001 that expressly indicates the obligation to monitor patient satisfaction levels in the following clauses:

• •7.2.1. Product requirement identification
• •7.2.2. Review of customers’ product requirements
• •7.2.3. Customer communication⁵

Given the specific nature of the health care sector, it is much more difficult to identify patient requirements than to measure the same parameters for manufacturing companies, where client satisfaction levels and requirements are monitored based on characteristics of a final product in accordance with established standards.⁶ Whereas perception of a medical service is very much affected by patients’ subjective impressions, their psycho-social status in the course of treatment, and their general health condition while at hospital. The approach of a patient subjected to preventive examination is very likely to be more favourable than that undergoing a physically and psychologically traumatic experience of an oncology therapy. It is typical for cancer patients to be engulfed by very strong emotions: hope for recovery or loss of hope, fear of mutilation or bodily damage, fear of disease incurability or death, stress. The emotional aspects related to the experience of disease and numerous side effects of the therapy have significant impact on how an institution is perceived by its patient. In many cases these factors matter more than substantive aspects of medical aid, determining the final level of patient's satisfaction after hospitalisation. It is true that most patients do not have sufficient medical knowledge to assess whether the service they receive is of the best quality possible, delivered by qualified personnel using the most advanced equipment. Yet medically ignorant as they are, patients are able to judge from their own experience if the hospital staff is competent, friendly, responsive to their needs and problems and respectful of their rights, if the staff works in harmony or contrary: in chaos adding to patients’ emotional tension.^7,8,13 For those reasons, the process of identifying patient's requirements and satisfaction has to be carefully devised and, considering the subjective nature of each patient's perception, involve joint effort of an interdisciplinary team composed of:

• –physician (head of department, head of clinic or a unit where patient's expectations are identified);
• –ward nurse;
• –quality officer;
• –psychologist;
• –health care institution management (as a decision-making body for requirements that can be met).

The process of identifying patient's requirements may differ across health care institutions. Alongside with the primary duty of each health care institution to implement provisions of the Act of 6 November 2008 on Patient Rights and on the Commissioner for Patient Rights (Journal of Laws from 31 March 2009) and the obligation to examine complaints and grievances referred to the Representative for Patient Rights, the institutions holding a certificate of quality management system are required to take some additional initiatives. Listed below are tools that have been implemented in the Greater Poland Cancer Centre:

• 1.Electronic questionnaire survey to be published on a health care institution's website
  With the access to ICT becoming more and more common, the publication of an electronic questionnaire seems to be an effective tool to gather information on general level of patient satisfaction. This tool forms also the basis for a more detailed analyses of lowly rated areas. The following rules should be followed while implementing the questionnaire:

  • –
    a link to the questionnaire should be clearly highlighted in the graphic structure of the website to ensure that patients can easily find it;
  • –
    choice of questions—questions should be relevant for the purpose of identifying patients’ requirements and measuring their level of satisfaction;
  • –
    form of questions—questions should be simple and straightforward, well adjusted to recipients: open and closed. Closed questions facilitate statistical analyses and reduce the risk of misinterpretations. Closed questions may be divided into the following categories:

    • •
      Ranking questions—arranging items in order of importance from 1 to 10 or 1 to 5;
    • •
      Scale of rating—arranging items from “poor” to “excellent”;
    • •
      Scale of intent—testing respondents’ intent (I would definitely come, I would definitely use);
    • •
      Scale of relevance—arranging items from “irrelevant” to “highly relevant”;
    • •
      Likert's scale—determining the degree of approval for a statement (does the registration service meet your expectations to a higher degree than that of the other hospital?) Responses: to a similar degree, I have no opinion, to a higher degree, no difference, etc.;
    • •
      Multiple choice questions;
    • •
      Dichotomic questions—with two possible answers: YES/NO
  • –
    vocabulary—simple words, clearly stated questions, not suggesting any answers;
  • –
    sequence of questions—the lead question should be placed at the beginning so as to make respondents interested, hard/personal questions should follow in the further part of the survey.^9,10 For a sample electronic questionnaire, please see Appendix 1.
  It is worth stressing that the survey is addressed to a selected group of respondents, namely those with access to the Internet and minimum level of computer literacy. The experiences of the Greater Poland Cancer Centre prove that:

  • •
    This evaluation tool is used mostly by the 18–39 age group, 80% of whom have secondary or higher education.
  • •
    Electronic questionnaires surveys are more often completed by women, accounting for 75% of all respondents.b

  This taken into account, for statistics to be complete and objective, other methods need to be applied (direct interview at the department/clinic) to collect information on satisfaction levels of other patients.

• 2.Electronic form “Comments and Complaints”

  The electronic form of comments and complaints is in a way complementary to the information received through the questionnaire (Appendix 2). Owing to its open form, it is also a good alternative for patients who wish to express their (positive or negative) opinion on a specific subject. In most part, patients comments relate to their visits to a particular clinic or hospital department. Each comment is examined by and responded to by the Representative for Patient Rights. Favourable opinions are published in the Intranet as a motivating feedback for the staff. Critical comments are analysed by the managing team of the unit concerned, the Representative for Quality System, Representative for Patient Rights or other relevant persons. A respondent who has put his/her contact details in the form will be given a feedback to his/her comment/complaint by e-mail, phone or mail.

• 3.Patient satisfaction and requirement survey in units providing medical services

  The questionnaire is used for this purpose. The Representative for Patient Rights appoints units to be covered by the patient satisfaction survey in a given year and provides written notice of his/her decision to managers of the units concerned. A patient satisfaction survey may also be conducted on request from a head of unit. This stage of patient requirement and satisfaction identification calls for close cooperation within the interdisciplinary team both in the development of the questionnaire survey and subsequent interpretation of its results. The process of measuring patient satisfaction with services provided by the Greater Poland Cancer Centre is presented below in the form of a block diagram (Appendix 3) and is applicable in any health care institution regardless of its principal line of activity. Results of patient satisfaction and requirement surveys should be communicated to all staff members, as the awareness of being assessed by service recipients is likely to bring about an improvement in the institution's image as a caring medical centre, concerned about its patients’ interest and well-being.

  Concluding, the process of determining patient's requirements and satisfaction levels should be carefully designed so that results provide grounds for an appropriate upgrade in the quality of medical services and, by the same token, a good response to patient's demand.

Patient satisfaction surveys should be a matter of interest for all heads of units directly involved in the treatment process. It is where they acquire the knowledge on patient's general level of satisfaction with services delivered by the unit, the level of satisfaction with particular components of those services (doctors’ and nurses’ performance, food, sanitary and epidemiological conditions, etc.) and the importance of those components for patient satisfaction. With data thus collected, the process of segmentation begins, whereby objectives are assigned to those aspects of the process which are of highest relevance for the satisfaction level and have so far been lowly rated.^11,12

A well prepared and well implemented evaluation of patient requirements and satisfaction levels allows the institution to see its strengths and identify areas requiring changes and further monitoring. Effective as they are, the above presented mechanisms will not work unless patients’ needs and requirements are actively recognised on every day basis by staff members having direct contact with patients.

Conflict of Interest

None declared.

Appendix 1.

Appendix 2.

Appendix 3.