Patients in Bangladesh in general express displeasure and frustration at the services they receive from many healthcare facilities, particularly those from public sector providers and lesser-known, smaller private facilities. Services are also perceived to be poorer in quality and inadequate in rural, remote, and poor areas. This has been cited by most experts as the primary reason why well-to-do citizens seek care overseas when they have a health issue or if they do seek care inside the country, they attend the upper-end very costly private facilities which are customarily situated in certain areas of Dhaka city and there are a few in other large cities. Is patient satisfaction a missing element here?
Without a good understanding of or in absence of its definition or operationalisation, patient satisfaction will remain to be an elusive target to meet. The definitions of and expectations of patient satisfaction seem to differ by stakeholders. What is patient satisfaction to care recipients may be different from what health professionals understand about it; what is patient satisfaction to the government policymakers and regulators may be different from what care recipients expect to receive or what health professionals are willing to provide. In other countries, extensive efforts and attempts are undergoing by accreditation agencies, corporate buyers, or large payers like the government or the powerful health insurance companies to ensure services to satisfy the patients and these are regularly measured through surveys, audits, or observations.
Operationalisation of satisfaction about a service received is not easy in general compared to satisfaction about a product as the latter comes with distinct specifications and features. Products have a batch number, production documents, and production and expiry dates for monitoring, surveillance, and quality assurance purposes. Service on the other hand depends on perception. It becomes more complicated in healthcare settings where patients have different and a wide range of expectations and they themselves may not be always sure what they are expecting. They may be dissatisfied with the wait-time, cost, and cleanliness but in the end, are satisfied if the healthcare provider's attention to and behaviour with them is good enough. But, some may receive good healthcare but in the end, may be dissatisfied in general if the food they are served at the canteen is poor or the washrooms dirty.
It is believed that in many government hospitals, it is more the environmental, structural, or management factors such as very long wait-time, overcrowding, unclean patient rooms, filthy washrooms, poor quality food, and interference of the "dalals" that deter patients from coming than the exact healthcare service they receive from the doctors. They would rather see the same doctor in a clean and tidy, professionally managed upscale private clinic or hospital paying much higher fees.
Satisfaction occurs when expectations are met during a healthcare access encounter and it does not occur when expectations are not met. Two patients who receive the exact same care, but who come with dissimilar expectations about how that care should have been provided, will provide dissimilar satisfaction scores. Current research views patient satisfaction as multidimensional as patients differ in their views about specific aspects of their healthcare. The most important factor is often the behaviour of the doctor as this influences the rating of all the other aspects of healthcare.
Is there any way to standardize the service quality so that care providers know what makes good quality care and how to deliver it? Can facilities be given a target set of process and outcome measures so that they make their care delivery process good enough?
Customer satisfaction is the degree of positive feeling that one experiences after using a service. Another way of saying it is that this is the gap between the quality of service expectation and the actual experience of the service received. The narrower is this gap, the greater the satisfaction. It has become a fundamental constituent of the quality of healthcare services these days and has become a popular and accepted healthcare quality indicator. It is proven that satisfaction influences compliance with medical advice and seeking regular or more medical attention.
Bangladeshi hospitals should take this seriously as patients' evaluation of care is a conclusive tool to 1) provide opportunities for improvement, 2) improve organisational care-related decision making, 3) decrease cost, 4) meet patients' expectations, 5) formulate effective strategies for clinical management, 6) assure payment by health insurance plans or large corporate buyers, and 7) provide benchmarking for own performance monitoring and for other healthcare institutions.
Several publicly available and standardised measurement instruments are available for evaluating patient satisfaction. Standardised questionnaires have been the most common assessment tool. Such instruments have good reliability and validity. However, there is a great variation in patient satisfaction measuring instruments or questionnaires. The use of more exhaustive methods which require patients to describe their experiences of healthcare from their own perspective, typically provides a more critical view.
Medicare-- the United States government national health insurance programme identifies the following elements of patient satisfaction 1) communication with nurses, 2) communications with doctors, 3) communication about medicine, 4) responsiveness of hospital staff, 5) pain management, 6) cleanliness and quietness of the hospital environment, 7) discharge instructions, and 8) overall hospital rating.
Patient satisfaction survey instruments do not need to be very complicated as a rehabilitation provider only asks four simple questions: 1. would you come back to us for future treatment? 2. would you pay for our services on your own if you do not have an insurance company or employer paying for it? 3. would you send your child here for treatment? 4. Would you recommend us to others?
It is time to become serious about patient care quality and patient satisfaction in Bangladesh. Hospitals in Bangladesh can develop their own instruments by importing questions from existing standardised instruments and then supplementing those with culture or context-specific questions.
Hasnat M Alamgir is a Professor of Public Health