Patient Satisfaction inPatient Satisfaction in

Primary Health CarePrimary Health Care

Dr Andrew AgiusMD MSc (Family Medicine) MMCFD

Are our patients satisfied?Are our patients satisfied?

““Yesterday I needed treatment because I couldnYesterday I needed treatment because I couldn’’t t

swallow with a bad sore throat and my GP wasnswallow with a bad sore throat and my GP wasn’’t t

available and I was disgusted. I told the doctor I available and I was disgusted. I told the doctor I

had bad sore throat, he got a normal torch and saw had bad sore throat, he got a normal torch and saw

my throat, wrote antibiotics and I was out without my throat, wrote antibiotics and I was out without

any checkups in 20 seconds after 2 hours waitany checkups in 20 seconds after 2 hours wait””

Are our patients satisfied?Are our patients satisfied?

““Sometimes I really am disgusted by the Sometimes I really am disgusted by the

behaviour of medics and paramedics towards behaviour of medics and paramedics towards

patients in waiting rooms, as if they are patients in waiting rooms, as if they are

invisible. The behaviour of some staff in some invisible. The behaviour of some staff in some

health centres should be questionedhealth centres should be questioned””

Are our patients satisfied?Are our patients satisfied?

““When it comes to health centres much has to be done. When it comes to health centres much has to be done.

I went to a clinic suffering abdominal pains one I went to a clinic suffering abdominal pains one

night. I waited 15 minutes for the so called doctor to night. I waited 15 minutes for the so called doctor to

wake up. He came down and sat on a chair in the wake up. He came down and sat on a chair in the

corridor and I stood up!!!! He made a wrong corridor and I stood up!!!! He made a wrong

diagnosis verbally because he never palpated me or diagnosis verbally because he never palpated me or

did a check up and sent me to Mater Dei Hospital. did a check up and sent me to Mater Dei Hospital.

Very, very unprofessionalVery, very unprofessional””

Patient SatisfactionPatient Satisfaction

�� Increasingly important in evaluating quality of Increasingly important in evaluating quality of health carehealth care (Williams and (Williams and CalnanCalnan, 1991), 1991)

�� Depends mainly on the quality of the doctorDepends mainly on the quality of the doctor--patient relationship and good communication patient relationship and good communication skillsskills

�� Higher in the private sector in MaltaHigher in the private sector in Malta ((AsciakAsciak et al., et al.,

2003)2003)

Research QuestionsResearch Questions

�� Which factors are associated with patient Which factors are associated with patient

satisfaction in primary health care?satisfaction in primary health care?

�� Is there a difference in patient satisfaction Is there a difference in patient satisfaction

between public and private sectors of primary between public and private sectors of primary

health care?health care?

�� Is the level of patient satisfaction achieved from Is the level of patient satisfaction achieved from

a consultation perceived differently by patients a consultation perceived differently by patients

and doctors?and doctors?

AimsAims

�� To identify the characteristics of a family To identify the characteristics of a family doctor most likely to lead to patient doctor most likely to lead to patient satisfactionsatisfaction

�� To compare and contrast characteristics of To compare and contrast characteristics of family doctors in public and private sectors of family doctors in public and private sectors of primary health careprimary health care

�� To compare patient satisfaction between To compare patient satisfaction between public and private sectors of primary health public and private sectors of primary health carecare

ObjectivesObjectivesTo identify:To identify:

�� the perceptions of patients in the the perceptions of patients in the government government health centreshealth centres of their doctorsof their doctors’’ personality traits, personality traits, professional values, duties and responsibilities, professional values, duties and responsibilities, communication skills, and clinical carecommunication skills, and clinical care

�� the perceptions of patients in the the perceptions of patients in the private primary private primary health care sectorhealth care sector of their family doctorsof their family doctors’’personality traits, professional values, duties and personality traits, professional values, duties and responsibilities, communication skills, and clinical responsibilities, communication skills, and clinical carecare

�� the perceptions of patients in the perceptions of patients in both public and both public and private sectorsprivate sectors of primary health care on the most of primary health care on the most important characteristics of a family doctor that lead important characteristics of a family doctor that lead to patient satisfactionto patient satisfaction

ObjectivesObjectives

�� To To comparecompare patient satisfaction between public patient satisfaction between public

and private sectors of primary health careand private sectors of primary health care

�� To To identifyidentify the perceptions of family doctors as the perceptions of family doctors as

regards critical factors in their practice regards critical factors in their practice

associated with patient satisfactionassociated with patient satisfaction

�� To To provide feedbackprovide feedback on the results of the on the results of the

study to doctors in various sectors of primary study to doctors in various sectors of primary

health carehealth care

Research SettingResearch Setting

�� Malta is a small island with an estimated Malta is a small island with an estimated

population of 410,290 population of 410,290 ((National Statistics OfficeNational Statistics Office, 2008), 2008)

�� TwoTwo--thirds of primary care provided by private thirds of primary care provided by private

sectorsector

�� Public sector consists of 9 regional health Public sector consists of 9 regional health

centres and 47 district clinics centres and 47 district clinics

�� 2424--hour comprehensive health care services free hour comprehensive health care services free

at point of deliveryat point of delivery

Primary Health CarePrimary Health Care

�� PatientsPatients’’ first contact with health care systemfirst contact with health care system

�� Hub from which patients are guided through the Hub from which patients are guided through the health system health system ((The World Health Report, 2008)The World Health Report, 2008)

�� Place where relationships between doctors and Place where relationships between doctors and patients developpatients develop

�� Health promotion and disease preventionHealth promotion and disease prevention

�� Basis consists of good doctorBasis consists of good doctor--patient patient relationships and continuity of care relationships and continuity of care ((AzzopardiAzzopardi & &

Dixon, 1999)Dixon, 1999)

Factors Affecting Patient SatisfactionFactors Affecting Patient Satisfaction

�� Good doctorGood doctor--patient relationshippatient relationship

�� Being empathic; giving the patient time and Being empathic; giving the patient time and

attentionattention

�� Honesty, trustworthiness, able to keep Honesty, trustworthiness, able to keep

confidentiality confidentiality

�� Meeting the patientsMeeting the patients’’ desires and expectations; desires and expectations;

congruence between doctorcongruence between doctor’’s and patients and patient’’s s

perceptions of the consultationperceptions of the consultation

Factors Affecting Patient SatisfactionFactors Affecting Patient Satisfaction

�� Easy accessibilityEasy accessibility

�� Good communication Good communication

�� Good clinical care; giving an explanation of Good clinical care; giving an explanation of

the symptomsthe symptoms

�� Continuity of careContinuity of care

�� Quality of medical facilitiesQuality of medical facilities

Primary Health Care in MaltaPrimary Health Care in Malta

�� 1996 1996 –– public sector public sector -- 60% claim it was 60% claim it was ‘‘very very goodgood’’ and 34.5% claim that it was and 34.5% claim that it was ‘‘goodgood’’((AzzopardiAzzopardi & Dixon, 1999)& Dixon, 1999)

�� 2002 2002 -- higher in the private sector (96.1%) than higher in the private sector (96.1%) than in the public sector (83.1%) in the public sector (83.1%) ((AsciakAsciak et al. , 2003)et al. , 2003)

�� Trend shows deterioration in quality of care in Trend shows deterioration in quality of care in public sector public sector -- why?why?

MethodologyMethodology

�� 4 health centres in representative areas of the 4 health centres in representative areas of the

islandisland

�� 4 private clinics in the same areas as the health 4 private clinics in the same areas as the health

centrescentres

�� 30 patients in each clinic, aged 3030 patients in each clinic, aged 30--70years 70years –– 240 240

patients in totalpatients in total

�� Patient questionnaires distributed in each clinicPatient questionnaires distributed in each clinic

�� Interviews with doctors from each clinicInterviews with doctors from each clinic

Data Collection ToolData Collection Tool

�� Adapted from questionnaire by Murray Adapted from questionnaire by Murray LoughLough (2006)(2006)

�� Measures what factors are important for patient Measures what factors are important for patient

satisfactionsatisfaction

�� 7 sections, 32 questions, 7 sections, 32 questions, LikertLikert scale 1scale 1--5, English and 5, English and

Maltese versionsMaltese versions

�� Asks about doctorAsks about doctor’’s personality traits, professional s personality traits, professional

values, duties and responsibilities, communication skills, values, duties and responsibilities, communication skills,

clinical careclinical care

�� Final section asks about patient satisfactionFinal section asks about patient satisfaction

SemiSemi--structured Interviewsstructured Interviews

�� Carried out on one doctor from each clinicCarried out on one doctor from each clinic

�� Ask about doctorsAsk about doctors’’ perceptions of patient perceptions of patient

satisfaction and doctor satisfaction satisfaction and doctor satisfaction

�� Discuss same subjects as those Discuss same subjects as those

in the questionnairein the questionnaire

LimitationsLimitations

�� Convenience sampling Convenience sampling

vsvs random samplingrandom sampling

�� Different methods of data collection in public Different methods of data collection in public and private sectorsand private sectors

�� Doctors interviewed at health centres assumed Doctors interviewed at health centres assumed to represent other doctorsto represent other doctors

ResultsResults

�� 94% response rate94% response rate (226 out(226 out

of 240 questionnaires returned)of 240 questionnaires returned)

�� 100 male, 126 female respondents100 male, 126 female respondents

�� Higher response rate in public sectorHigher response rate in public sector

�� No significant age or gender difference between No significant age or gender difference between public and private sectorspublic and private sectors

�� 85% of public sector respondents have a private 85% of public sector respondents have a private family doctorfamily doctor

ResultsResults

�� How many times have you seen your doctor in How many times have you seen your doctor in

the last year?the last year?

0

10

20

30

40

50

60

70

Never 1-5 6-10 11-15 16-20 M orethan 20

PublicSectorPrivateSector

ResultsResults

�� How many times have you seen another doctor How many times have you seen another doctor

in the last year? in the last year?

0

10

20

30

40

50

60

Never 1-5 6-10 11-15 16-20 M orethan 20

PublicSectorPrivateSector

Factors most likely toFactors most likely to

lead to patient satisfactionlead to patient satisfaction

�� Being ready to explain what is wrong before Being ready to explain what is wrong before

giving treatmentgiving treatment

�� Being up to date with recent developments in Being up to date with recent developments in

the profession the profession

�� The ability to make the right diagnosisThe ability to make the right diagnosis

�� Being enthusiasticBeing enthusiastic

�� Having a nice attitude with patientsHaving a nice attitude with patients

�� Being honesty and trustworthyBeing honesty and trustworthy

Scale means most likely to Scale means most likely to

lead to patient satisfactionlead to patient satisfaction

�� Communication skillsCommunication skills

�� Clinical careClinical care

Comparison of patient satisfaction Comparison of patient satisfaction

between public and private sectors between public and private sectors

�� 75.7% in public sector are satisfied with the service that 75.7% in public sector are satisfied with the service that

the doctor providesthe doctor provides

�� 98.2% of private sector respondents are satisfied 98.2% of private sector respondents are satisfied

�� 78.2% of patients believe that the doctor at the health 78.2% of patients believe that the doctor at the health

centre is a good family doctor centre is a good family doctor

�� 99.1% of patients believe that their private family 99.1% of patients believe that their private family

doctor is a good family doctor doctor is a good family doctor

�� Difference in patient satisfaction between public and Difference in patient satisfaction between public and

private sectors is highly significant (p<0.001)private sectors is highly significant (p<0.001)

Comparison of public Comparison of public

and private sectors and private sectors

Factors most likely to lead to patient satisfaction Factors most likely to lead to patient satisfaction

0

20

40

60

80

100

120

140

160

Has a nice attitude w

ith the

patients

Is enthusiastic about his/her job

Honest and trustw

orthy

Up to date w

ith recent

developments

Capable of m

aking the right

diagnosis

Ready to explain w

hat is

wrong before giving treatm

ent

PublicSector

PrivateSector

Comparison of public Comparison of public

and private sectors and private sectors

Patient satisfaction in different areas of Malta Patient satisfaction in different areas of Malta

0

20

40

60

80

100

Paola Gzira/SanGwann

Qormi/Zebbug Mosta

PublicSectorPrivateSector

Comparison of scale means between Comparison of scale means between

public and private sectorspublic and private sectors

�� Difference between public and private sectors is Difference between public and private sectors is

statistically significant (p<0.001) for all the five statistically significant (p<0.001) for all the five

dimensionsdimensions

�� Largest difference between the means in public Largest difference between the means in public

and private sectors is for communication skills and private sectors is for communication skills

DoctorsDoctors’’ perceptions perceptions

of patient satisfactionof patient satisfaction

�� SemiSemi--structured interviews carried out on structured interviews carried out on

doctors working in the clinicsdoctors working in the clinics

�� In the public sector, doctors spend much less In the public sector, doctors spend much less

time with the patient than in the private sectortime with the patient than in the private sector

�� Limited time explains difference in Limited time explains difference in

communication skills between sectorscommunication skills between sectors

�� Poor perception of patient satisfaction in the Poor perception of patient satisfaction in the

public sectorpublic sector

Doctor SatisfactionDoctor Satisfaction

�� Depends on good doctorDepends on good doctor--patient relationships patient relationships

and continuity of careand continuity of care

�� Very low in public sector, high in private sectorVery low in public sector, high in private sector

�� Affects level of Affects level of

patient satisfaction patient satisfaction

achievedachieved

Relationship between staff & patient satisfaction

2.7

2.8

2.9

3

3.1

3.2

3.3

3.4

Low High

Staff Satisfaction

Pat

ient S

atis

fact

ion

BorrillBorrill et al. (2001)et al. (2001)

DiscussionDiscussion

�� Communication skills and clinical care most Communication skills and clinical care most

important to achieve patient satisfactionimportant to achieve patient satisfaction

�� Good doctorGood doctor--patient relationships and patient relationships and

continuity of care are necessary for doctor and continuity of care are necessary for doctor and

patient satisfaction patient satisfaction

�� There is a statistically significant difference There is a statistically significant difference

(p<0.001) in patient satisfaction between public (p<0.001) in patient satisfaction between public

and private sectors of primary health careand private sectors of primary health care

DiscussionDiscussion

�� The difference in patient satisfaction between The difference in patient satisfaction between

public and private sectors is mainly due to poor public and private sectors is mainly due to poor

communication skills in the public sectorcommunication skills in the public sector

�� This is the result of an increasing shortage of This is the result of an increasing shortage of

doctors, high workload and limited time for the doctors, high workload and limited time for the

patient in the public sectorpatient in the public sector

�� Doctors in the public sector are dissatisfied with Doctors in the public sector are dissatisfied with

their positions and have poor perceptions of their positions and have poor perceptions of

patient satisfactionpatient satisfaction

Barriers to improvement Barriers to improvement

of the public sectorof the public sector

�� Adequacy of resourcesAdequacy of resources

�� Shortage of doctorsShortage of doctors

�� PublicPublic--private splitprivate split

�� Lack of staff motivationLack of staff motivation

�� Abuse of the primary Abuse of the primary

health care systemhealth care system

RecommendationsRecommendations

�� Patient registrationPatient registration

�� Better working conditions for doctorsBetter working conditions for doctors

�� Control over abuse of resourcesControl over abuse of resources

�� Increasing access to investigations from the Increasing access to investigations from the

private sectorprivate sector

�� Computerization of patient recordsComputerization of patient records

�� Increase motivation for doctorsIncrease motivation for doctors

�� Monitoring of patient satisfactionMonitoring of patient satisfaction

agius.andrew@gmail.com