Luận án: Mức độ hài lòng của bệnh nhân nội trú tại bệnh viện quốc gia Belize

Taipei Medical University School of Health Care Administration Master’s Thesis Patient satisfaction with inpatient services at the national referral hospital of Belize Graduate Student: Tisa C. Grant Advisor: Che-Ming Yang, M. June, 2012 ACKNOWLEDGEMENTS I give thanks to God for the completion of this thesis requirement, for grace, mercy, and guidance throughout my time at Taipei Medical University, and for all the people and opportunities He has placed in my path on this academic journey. I have been blessed and the names are too numerous to mention.

I can only hope that each individual knows who he/she is, the profound difference each made and that my sincere gratitude has been sufficiently and appropriately expressed to each one. To my advisor, Dr. Che-Ming Yang, and my committee members, thank you for your guidance, your patience, and for being firm but kind. To the management and staff of Karl Heusner Memorial Hospital (KHMH) and the survey respondents, without your help this simply would not have been possible and I thank you! To my family and dear friends for their support of this aspiration, their reassurances, assistance, encouragement and patience to the very end of this milestone, I give my heartfelt thank you.

I ABSTRACT Title of thesis: Patient satisfaction with inpatient services at the national referral hospital of Belize Author: Tisa C. Grant Thesis advised by: Che-Ming Yang, M. Background - The Ministry of Health in Belize has implemented several policies and service level agreements to improve patient satisfaction country wide. Although these initiatives rely on results to appropriately measure patients’ satisfaction with the quality of care, the extent to which a patient’s experience explains his or her satisfaction with the health-care system remains unclear.

Objectives - Despite what may appear to be the general consensus on health care services provided nationally, some health care experiences may very well be more influential than others to the patient in forming their overall satisfaction level. The objective of this study is to ascertain the effects that specific variables have on patients’ overall evaluation of hospital care and their intention to recommend the hospital. Methods - The HCAHPS Survey was self-administered at the national referral hospital of Belize to inpatients. Simple and multiple step-wise linear regression models were used to identify the predictor factors of patient satisfaction using, separately, the two dependent variables: “Overall evaluation of hospital care” and the “Intention to recommend the hospital”, controlling for age, gender, ethnicity, education and perceived health.

Results - It was found that patient’s highest priority was communication with nurses and doctors encompassing courtesy and respect, taking the time to explain things, and listening to the patients carefully. Discussion - From the patient’s perspective, the quality of care must include not only the quality of medical care provided but also the quality of caring associated with it. Health-care managers and other decision makers may need to remind their nurses and staff members that patients are II experiencing an intensely critical and emotional moment, and thus, they need to provide patient- centered care Keywords: Patient satisfaction, inpatient, Belize, developing country III TABLE OF CONTENT ACKNOWLEDGEMENTS. II TABLE OF CONTENT.

IV LIST OF TABLES. VI LIST OF FIGURES. VII CHAPTER 1: INTRODUCTION .2 Belize: The Healthcare System and the People .3 Statement of the Problem .4 Significance of the Study. 10 CHAPTER II: LITERATURE REVIEW .1 Definition of Patient Satisfaction .2 Development of HCAHPS Survey Instrument .3 Determinants of Patient Satisfaction .4 Clinical Staff Influence on Patient Satisfaction .5 Patient Demographic and Patient Satisfaction.

17 CHAPTER III: METHODOLOGY .2 Operational Definitions of Variables .7 Data Source and Collection. 34 IV CHAPTER 4: RESULTS .2 Descriptions of the variables .1 Categorical variables description for ‘Overall evaluation of Hospital Care’ .3 Mean age difference between “Overall Evaluation of Hospital” and “Care Intention to recommend” .3 Univariate and multivariate analysis for predicting “Overall evaluation of hospital care” .4 Univariate and multivariate analysis for predicting “Intention to recommend” .1 Hospital care factors as predictors of patient satisfaction .2 Implications of patient demographics on patient satisfaction .3 Perceived health as a predictor of satisfaction.6 Implications for further research. 63 Appendix I – HCAHPS Survey Instrument. 63 Appendix II – Ethical Approval Request Letter.

70 Appendix III – Ethical Approval Letter. 71 Appendix IV – Patient Consent Form. 72 V LIST OF TABLES Table 1: Operational definitions of variables. 20 Table 2: Reliability test results.

30 Table 3: Recoding of variables. 31 Table 4: Description of categorical variables by frequency and percentage (N=176). 37 Table 5: Description of the categorical variables for “Overall evaluation of hospital care”. 38 Table 6: Description of the categorical variables for ‘Intention to recommend’.

39 Table 7: Mean age difference between rating group for overall evaluation of hospital care (N=169). 40 Table 8: Mean age difference between rating group of ‘Intention to recommend’ (N=168). 41 Table 9: Univariate analysis of independent variables to predict overall evaluation of hospital care. 43 Table 10: Multivariate analysis of all independent variables to predict overall evaluation of Hospital Care.

44 Table 11: Univariate analysis of independent variables to predict intention to recommend. 46 Table 12: Multivariate analysis of independent variables to predict intention to recommend. 47 VI LIST OF FIGURES Figure 1 - Conceptual Framework for Patient Satisfaction at the National Referral Hospital of Belize. 18 VII CHAPTER 1: INTRODUCTION 1.1 Background Patient satisfaction (or customer satisfaction) is a term that is widely used with reference to health care.

Identified as an integral factor in the evaluation of health care, the inclusion of ‘patient satisfaction’ measurements and interpretation can easily go unquestioned. In fact, quality of care reforms and health care delivery in developed countries such as the United States of America and Europe allow for an increasingly important role of patient satisfaction as an indicator (Bleich, Ö zaltin, & Murray, 2009). However, at the hospital level, many clinicians appear unconvinced of the usefulness of satisfaction measures. Since clinicians are often more concerned about treatment outcomes, their skepticism may be attributed to the belief that other indicators of healthcare quality such as how patients feel about the cost and/or accessibility of services, the food, interpersonal relationships and overall satisfaction levels are administrative issues (Hudak & Wright, 2000).

Over the years, health care managers have utilized various methods, from complaint boxes to satisfaction surveys, to gather information that can be used to improve patient satisfaction. There have been many patient satisfaction studies that utilized patient satisfaction surveys, even if the focus may have been different than it is today. Some studies attempted to learn who, for example, would be more satisfied (Otani, Herrmann, & Kurz, 2011). Despite the increased focus on satisfaction as an outcome measure and the growing body of research to support it, satisfaction has remained difficult to compartmentalize.

Although numerous satisfaction surveys have been developed, most with acceptable psychometric properties, it remains largely unknown the factors patients use to consider themselves satisfied (Jackson, Chamberlin, & Kroenke, 2001). Patients’ satisfaction with health care in comparison to their experience is increasing in its importance. Likewise, according to Bleich et al. (2009), the continued interest in comparing people’s satisfaction with the health system across different countries and time periods suggests the need to distinguish the relationship between them.

Otani et al. (2011) suggested that it is likely that a positive experience with important factors will result in a good satisfaction overall. Conversely, if the patient had a negative experience with important factors, the overall satisfaction will be bad. The extent to which a patient’s experience explains his or her satisfaction with the health-care 1 system remains unclear.

Some experiences may very well be more influential than others to the patient in forming their overall satisfaction level.2 Belize: The Healthcare System and the People Belize is a former British Colony and the only English-speaking country in Central America, divided into six districts. It is more similar to other English–speaking Caribbean countries in culture, politics, and economy. Due to location, however, Spanish is widely spoken (Ministry of Health, 2006a). The area of Belize (mainland and cayes) is 8,867 square miles, the greatest length being 280 kilometers and its greatest width is 109 kilometers.

Considered to be a “melting pot of many races” resulting from the influx of many people of Central America, Asia, Europe and the Caribbean (Ministry of Health, 2006a), the population is now at 312,698 based on the 2010 population census (The Statistical Institute of Belize, 2011). The population census also shows that the five main ethnic groups are Mestizo, Creole, Maya, Garifuna and Mennonite. Mestizo is the largest group (50%), Creole accounted for 21%, Maya and Garifuna made up 10% and 4. Other ethnic groups in Belize are East Indian, Chinese, Arabs and Africans, among others.

The ethnic groups, however, are heavily intermixed. Although, English is the official language of Belize, English Creole is widely spoken. It remains a distinctive part of everyday conversations for most Belizeans. However, Spanish is spoken as a first language for majority of the people in the northern districts, the north of the Belize District, and the Cayo District in the west.

In the southern Districts, there are people whose first language is Garifuna or Maya. The basic structure for health care delivery is provided by a network of seven district hospitals which are divided into four regions: Northern Region (Orange Walk and Corozal Districts), Central Region (Belize District), Western Region (Cayo District) and Southern Region (Stann Creek and Toledo Districts) with the Karl Huesner Memorial Hospital (KHMH), the Central Regional Hospital, being the national referral hospital (Ministry of Health, n. In terms of population, the Central Health Region is the biggest of the four health regions of the country and therefore, provides health care services to 30.5% of the entire population of the country. The Region has three administrative areas: Belize City, Belize Rural and the Cayes.

As the commercial capital, 2 Belize City is considered the ‘bustling metropolis’ of the country and attracts local and international visitors, thus increasing the servicing population by 6% (Ministry of Health, n. As a result, the Belize District has the greatest density of health care providers relative to its population (Pan American Health Organization, 2009a) with a total of 285 staff members (Ministry of Health, n. There were 2,283 workers employed in the health system in 2009, 1279 (56%) were health care providers while the remaining 1004 (44%) were administrative and other support staff. About 43% of health care providers were employed in the Belize District.

There are approximately 30 nationalities and ethnic groups represented in the Belize health care provider workforce, Mestizo and Creole totaling 61%. Of the 1279 health care providers (i. clinical workers and health professionals) about 80% are employed in the public sector. Between 2005 and 2009, the number of registered nurses remained relatively stable while the number of specialists fell from 159 to 60.

The combined ratio of registered nurses and physicians per 10,000 population dropped from 23. Among the five, major ethnic groups in Belize, Mestizo and Mayans are not well represented in the health care provider workforce (36% combined) although together they represent 63% of the total population. Women are 68% of the health care provider workforce, outnumbering men 2. This ratio is reflective of the results of the 2010 population census which reported that “women outnumber males by a ratio of two to one at the university level” and “in terms of highest level of education completed, females outnumber males from secondary to university level” (The Statistical Institute of Belize, 2011).

It should be noted, however, that to date, most physicians and physician-specialists have been trained abroad (in the Caribbean or neighboring Central American Countries). Local training for nurses and midwives is provided at the national university. Current social indicators for the country include Infant Mortality Rate (18.