Assessment of Level of Patient Satisfaction with Day-Care Surgery: An Observational Study

Abstract

To assess the level of patient satisfaction with day-care surgery at a tertiary care centre and to find out the different determinants that influence the patient satisfaction. Observational study; Tertiary care hospital in Western India; Patients undergoing Day-care surgery at Dept of ENT from Feb 2018 to Aug 2018; All patients who underwent day-care surgery were given a questionnaire to determine level of satisfaction. On analysis of data according to questions the average score was in the range of 3.5 to 4.22 out of a maximum score of 5. On analysis of data according to domains of patient care the scores ranged from 3.61 to 4.19. Although patients were generally satisfied with the level of care being provided to them there is still scope of improvement.

Introduction

Day-care surgery is being practised worldwide. It gives quicker return to a familiar home environment without compromising the safety of the patient. This is an efficient way of reducing the costs and waiting time, maximizing the use of resources, and avoiding unnecessary stay in the hospital [1, 2]. Probably the greatest benefit of day care surgery is reduction in cost of treatment by reducing hospital stay [3]. Various different types of safe anaesthesia techniques are also available which have made day care surgery safe [4]. At present day-care surgery ranges from 40 to 50% of all surgeries being performed in Ear Nose throat (ENT) department of any hospital [5, 6]. This is possible due to the advanced medical technology and a better understanding of what can be performed safely in a day. Effective preoperative assessment and preparation plus protocol driven discharge of patients are fundamental for safe day-care surgery.

On reviewing relevant literature, two groups of determinants of satisfaction of patients have been identified: those relating to the characteristics of patient and those relating to health service delivery features. The patient’s expectation is an important determinant among individual factors. Care process is an important determinant regarding health delivery system. Other determinants specific to day-care surgery are postoperative complications, postoperative pain, waiting time before surgery, readmission, and the clinical outcome.

The patient satisfaction surveys using validated instrument should be able to measure the structure, process, and outcome of a health-care system. The patient satisfaction score is indispensable to the assessment of quality and it helps in improving the health care services.

The aim of this study was to assess the level of patient satisfaction with day-care surgery at a tertiary care centre and to find out the different determinants that influence the patient satisfaction.

Material and Methods

This was a descriptive study which was conducted in ENT department of a tertiary care hospital. Ethical clearance was taken from institutional review board. The study period was from Feb 2018 to Aug 2018 among ENT day-care surgery patients. To determine the level of patient satisfaction with day-care surgery and to find out the different determinants that influence the patient satisfaction, a survey questionnaire was used whose responses were analysed. From the responses to the questionnaire, the determinants that influence the patient satisfaction were found.

Sample size: On an average the ENT department performs about 20 day care surgeries per month. Based on this the estimated convenience sample size was 120. All patients undergoing day care surgery during the study period were included.

For participants to be included in the study they were required to have been accepted in American society of Anaesthesiologist physical status class (ASA) I or II for anaesthesia and needed a surgery which would last not more than ninety minutes [7]. They could reach hospital within two hours in case of emergency. Patients or parents of patient were physically and mentally able to understand, comply and cope with post-procedural instructions after receiving adequate information. All patients selected for day surgery were required to have a physically and mentally capable escort, who was responsible for patient’s care and could accompany patient home as well as supervise their recovery at home for a minimum of 24 h. Suitable transport was confirmed available to transport patient home post surgery and also to come back to the hospital in the event of emergency. Surgeries selected had minimal risk of complications like haemorrhage or airway compromise, had minimal postoperative pain that could be controlled by simple analgesia and no special postoperative nursing care was required post surgery. Also rapid return of normal food and fluid intake was possible after the procedure. Patients who were older than 75 years or younger than 06 months and patients who required emergency surgery were excluded from the study.

The surgeries performed as day care cases included myringoplasty, cortical mastoidectomy, septoplasty, reduction of nasal bone fracture, removal of foreign bodies from nose/throat, laser excision of leukoplakia of buccal mucosa, endoscopic dacryo-cysto-rhinostomy, earlobe repairs, drainage of septal haematoma, cervical lymphnode/lipoma excisions.

All patients underwent a pre-operative assessment before the planned surgery and were explained about day-care procedure, expected problems and anaesthesia by the doctor. Clearly printed pre-op instructions were given to patients after pre-op clinic in ENT department. The Day care cases were mentioned clearly in the operation theatre (OT) list. Patients reported to OT directly on day of surgery with one attendant where they were assessed again by the surgeon and the anaesthetist. A reception checklist was made and all points were checked before taking up the patient for surgery.

After surgery patients were observed for a few hours in day care observation room (post-op room). A set of formalised discharge criteria were created and were strictly adhered to. Discharge form incorporating Modified Post Anaesthesia Discharge Scoring System (PADSS) was filled and signed by treating surgeon. A score of less than 8 on the modified PADSS was considered as an indication of admission to the hospital for overnight observation (Fig. 1) [8, 9]. A post-op follow up form was also filled by the doctor and record maintained. Common and surgery specific discharge instructions were handed over to patients and patients went back with an attendant after establishing fitness to go home.

Fig. 1.

Modified PADSS [9]

Study Tool

The “core questionnaire for the assessment of patient satisfaction for general day care” (COPS-D) was chosen as it is a validated questionnaire designed for day care including day-care surgery [11] (Fig. 2). It assesses seven dimensions/domains: as preadmission visit (4 items), admission at the day-care center (3 items), operation room (3 items), nursing care (2 items), medical care (2 items), information (4 items), autonomy (3 items), and discharge and after care (3 items). The response for each item was assessed on 1–5 Likert scale (1 = unsatisfied, 2 = somewhat satisfied, 3 = rather satisfied, 4 = quite satisfied and 5 = very satisfied). Average of the item score constituted the domain score. The scores of all these categories gave the complete picture of the patient satisfaction [10, 11].

Fig. 2.

COPS-D Questionnaire [11]

The questionnaire was also translated into Hindi language and it was verified with back translation for patients who could not understand English. The questionnaire was given to the patient when they came for their second postoperative visit, which was usually a week after surgery by the outpatient department staff. They were asked to fill up the forms and drop it in the drop box kept in the reception area of the department. Informed consent was obtained from the respondents. Questionnaire response was kept anonymous. Incomplete questionnaires were excluded from the study.

Results

A total of 108 patients underwent day care surgery during the study period, however 8 of these patients had to be admitted due to inability to meet the pre decided discharge criteria. Of the remaining 100 patients 25 refused to fill the questionnaire required and were hence excluded from the study. The remaining 75 patients filled the requisite questionnaire. The data thus collected from the filled questionnaires was analysed. Demographic data was not available as the study used anonymous questionnaire. Results obtained were analysed according to average score per question and average score per domain of the COPS-D questionnaire.

On question-wise analysis of data it was found that the highest score was achieved by question number (Q No) 11 “How satisfied were you with technical expertise of doctors?” which achieved an average score of 4.22 and the lowest score was achieved by Q No 8 “How satisfied were you with personal attention of nurses?” which achieved an average score of 3.5 (Table 1) (Fig. 3).

Table 1.

Average scores achieved by questions

Domain	Q. no	Question	Average score
Pre admission visit	1	The reception	3.96875
	2	The personal attention of the nurse	4
	3	The expertise of the nurse	4.09375
	4	The information and instruction	4.09375
Operation room	5	The reception at the Operation Room	4.03125
	6	The personal attention of the operation staff	4.09375
	7	The expertise of the operation staff	4.0625
Nursing care	8	The personal attention of the nurses	3.5 (Lowest score)
	9	The expertise of the nursing staff	3.71875
Medical care	10	The personal attention of the doctors	4.15625
	11	The expertise of the doctors	4.21875 (Highest score)
Information	12	The clarity of information given by nurses	3.875
	13	The clarity of information given by doctors	4.03125
	14	The way information was transferred from one person to another	3.8125
	15	The rapidity of learning research results	3.9375
Autonomy	16	The degree of encouragement to be self-sufficient	3.8125
	17	The degree to which you could participate in treatment decisions	3.96875
	18	The privacy you were given such as in conversations with doctors during physical examinations and during visiting times?	3.78125
Discharge and after care	19	The information provided about further treatment	4.03125
	20	The transfer of information to external professionals, such as your G.P	3.9375
	21	The discharge procedure	4.03125

Fig. 3.

Question-wise score

On analysing the data according to the domains it was found that ratings received for all domains were in the range of 3.61 to 4.19. These results showed that the scores were lowest for “nursing care” and highest for “medical care” (Table 2) (Fig. 4).

Table 2.

Analysis of data according to domains

S. no	Domain	No of questions	Average score
1	Pre admission visit	4	4.039
2	Operation room	3	4.073
3	Nursing care	2	3.61 (Lowest score)
4	Medical care	2	4.19 (Highest score)
5	Information	4	3.9
6	Autonomy	3	3.81
7	Discharge and after care	3	3.97

Fig. 4.

Average scores according to domain

Discussion

The values obtained from the questionnaire were analysed both according to question and according the domain involved. This was done in order to identify any particular question or domain which received persistently low scores, so that problem areas in patient care could be identified and appropriate course correction could be done to improve patient satisfaction.

In our study it was discovered that based on questions, the scores varied from 3.5 to 4.22 and when based on domains the scores varied from 3.61 to 4.19. No particular question or domain received exceptionally low scores. A lowest average score of 3.5 out of a maximum of 5 meant that the patients were generally satisfied with the care being provided to them in surgeries being performed as day care cases. However the scores revealed that there was still a lot of scope for improvement in patient satisfaction with day care surgery. Our efforts should be directed towards achievement of higher average scores in all domains of patient care and also in all individual questions.

It is important to understand that patient satisfaction is a subjective score and as such there can be no ‘Gold-standard’ for patient satisfaction score [12]. However, the use of patient satisfaction questionnaires can help to identify areas which require improvement and when these surveys are combined with other objective criteria like post operative results and surgical audits we can get a comprehensive assessment of quality of healthcare [13].

It should also be noted that technical expertise of the doctor is just one of the factors affecting patient satisfaction and a holistic approach where all aspects of patient care are looked after has to be implemented to ensure high clientele satisfaction [14]. Most of the surveys done to assess patient satisfaction have concluded that “post operative pain” is the most important factor causing patient dissatisfaction and hence lower scores. It is therefore essential to give adequate pain relief to patients post operatively and to strictly adhere to the PADSS before discharging the patient [15].

Conclusion

Establishment of a day care surgery centre is a team effort which requires active involvement of the surgeon, the anaesthetist, the para-medical staff and the administrators. As surgical and anaesthesia techniques get further refined day care surgery will become more and more prevalent. It is important to reiterate that patient safety is paramount and day care surgery should not be performed if it jeopardizes patient safety in any form.

To further improve our clientele satisfaction these kind of quality improvement studies should be performed which can help us in identifying problem areas and they can be subsequently addressed.

Author Contributions

All authors have contributed in scientific content of the study.

Funding

No funding was received for the study.

Data Availability

Data and material used were available to the authors.

Compliance with Ethical Standards

Conflict of interest

Authors have no conflict of interest to declare.