TY - JOUR
AU - Bar-Dayan,, Yaron
AB - ABSTRACT Patient satisfaction is gaining recognition as an important determinant of the quality of medical care. We conducted an analysis to evaluate the effect of a computerized online system that comparatively displays grades of patient satisfaction among primary care military infirmaries. Fifteen Israel Air Force primary care infirmaries served as the intervention group, and 130 Israel Defense Force infirmaries were the control group. Baseline patient satisfaction was surveyed in all infirmaries. In the intervention group only, infirmaries were resurveyed at 3-month intervals during a 1-year period. Satisfaction scores were continuously displayed on an intranet site in a comparative graphical manner by using the computerized system, available only to the intervention group. At the end-point, patient satisfaction improved in both groups. However, the magnitude of improvement in the intervention group was significantly greater, in comparison with the control group. The most pronounced improvement was noted in availability of service (intervention group, 57.9% at baseline vs. 66.0% at endpoint, p < 0.001; control group, 67.5% vs. 69.6%, p < 0.025). We conclude that the use of this computerized system in conjunction with promotional efforts resulted in significant improvements in patient satisfaction. Introduction Patient satisfaction with various elements of medical service has become a central component in the assessment of medical care quality in recent years. The importance of patient satisfaction stems not only from marketing or economic points of view but most importantly from its positive effects on patient adherence to medical follow-up treatment and compliance with therapeutic regimens, parameters that are related to patient outcomes.1,–5 Moreover, it has been shown that low patient satisfaction correlates with frequent changes of medical care providers and medical malpractice suits.6,7 Various determinants of patient satisfaction are recognized, and numerous methods to improve satisfaction have been reported and tested scientifically, including foundation enhancements, organizational and procedural improvements, service provision training for medical staff members, and privatization of services.8,–12 A study recently performed in the Israel Air Force (IAF) by Shachar et al. (personal communication) demonstrated the efficacy, in increasing compliance with occupational medicine protocols, of a computerized system that monitored the status of performance of occupational medicine examinations among IAF personnel. The software reflected the status of performance of examinations among different squadrons and units within IAF bases comparatively and was available to executives at different levels, including base commanders. The authors showed that the effect of the software was long-lasting. The objective of the current study was to evaluate the effect of a computerized online system, which comparatively displays grades of patient satisfaction with medical services among IAF base infirmaries, on patient satisfaction. Methods Population Subjects were enlisted IAF and Israel Defense Force (IDF) personnel, 18 to 45 years of age, who filled out patient satisfaction questionnaires after a visit to an IAF or IDF primary care infirmary. The populations of the IAF and IDF groups were similar demographically. Study Design The study was a prospective controlled analysis of patient satisfaction. The intervention group consisted of IAF personnel who visited one of 15 participating IAF primary care infirmaries. IDF personnel who visited one of 130 IDF primary care infirmaries served as the control group. Intervention (IAF) and Control (IDF) Infirmaries The participating infirmaries from both the intervention (IAF) and control (IDF) groups are primary care facilities located within military bases and serving military personnel only. They are headed by infirmary commanders who are physicians by profession. Each infirmary is staffed by one to five primary care physicians, a variable number of medics, and additional administrative and logistics personnel. All infirmaries share a similar organizational structure and are run according to mandatory procedures and guidelines established by the IDF Medical Corps Headquarters. They are similarly equipped and have similar infrastructures. Study Proceedings Baseline patient satisfaction was surveyed in all participating infirmaries from both groups (IAF and IDF) by using a standard IDF Medical Corps patient satisfaction questionnaire (see details below). Altogether, 1,209 questionnaires from IAF infirmaries and 5,797 questionnaires from IDF infirmaries were included in the baseline survey. The questionnaires were filled out by consecutive patients who stated that this was not their first visit to the infirmary. First-time patients were excluded to correct for a possible “first-impression” bias. In the IAF (intervention) group only, baseline results were entered into the computerized grading system (see details below) and the system was subsequently brought online. Participating IAF infirmaries were resurveyed every 3 months by using an identical patient satisfaction questionnaire. Each of these surveys consisted of 450 questionnaires altogether. The results of every survey from each IAF infirmary were entered into the computerized system immediately upon receipt at the IAF Surgeon General Headquarters. The computerized system was unavailable at IDF infirmaries (control group). At the conclusion of a 1-year period, an end-point survey was performed in all infirmaries from both groups. This survey consisted of 1,222 questionnaires from IAF infirmaries and 7,460 questionnaires from IDF infirmaries. The results of the endpoint survey were compared with baseline results. Computerized Online Grading System The computerized system that was put to use in the intervention group (IAF infirmaries) included a relational database that stored information regarding the infirmary, dates of surveys, and numerical grades in each of the survey topics (Microsoft Access; Microsoft, Redmond, Washington). Additionally, the system included a series of World Wide Web pages that presented the data from the database by using color charts (Microsoft Web Components; Microsoft). Every chart depicted the most recent grade for each of the 15 participating infirmaries on a certain topic in a comparative way. The infirmaries were sorted on every chart according to their grade (Fig. 1). The World Wide Web pages were incorporated into the IAF Surgeon General intranet site and were available for viewing online, by using the IAF intranet in all IAF bases and headquarters, by officers and commanders at all levels. Fig. 1 Open in new tabDownload slide Screen shot from the computerized grading system. The chart illustrates the most recent scores of patient satisfaction from the 15 participating IAF infirmaries. The infirmaries appear on the chart according to their scores, in descending order. Therefore, infirmaries with relatively high scores are readily distinguished from those with lower grades. This chart depicts scores in the topic of general impression. Similar charts were automatically generated by the computerized system for all other counterparts as well. The charts were available for viewing on the IAF Surgeon General intranet site. The actual charts depicted infirmary names on the x (category) axis; these are not shown here to avoid identification. Fig. 1 Open in new tabDownload slide Screen shot from the computerized grading system. The chart illustrates the most recent scores of patient satisfaction from the 15 participating IAF infirmaries. The infirmaries appear on the chart according to their scores, in descending order. Therefore, infirmaries with relatively high scores are readily distinguished from those with lower grades. This chart depicts scores in the topic of general impression. Similar charts were automatically generated by the computerized system for all other counterparts as well. The charts were available for viewing on the IAF Surgeon General intranet site. The actual charts depicted infirmary names on the x (category) axis; these are not shown here to avoid identification. Patient Satisfaction Questionnaire We used a standard IDF Medical Corps patient satisfaction questionnaire. The questionnaire consisted of 29 questions on five topics, that is, interpersonal attitude, availability of service, work environment, quality of care, and general impression. The questionnaire used a Likert scale grading system of five choices; responses 4 and 5 represented positive reactions, response 3 was an intermediate reaction, and responses 2 and 1 were negative reactions. The quantitative grade of each survey was calculated as the percentage of responses 4 and 5 in each sample. This value can be regarded as the percentage of satisfied patients. A separate grade was calculated for every one of the five topics. This questionnaire was previously validated.8 Additional Interventions during the Study Period The use of the computerized system for viewing patient satisfaction status was promoted by the IAF Surgeon General Headquarters during the study period in a series of meetings with squadron and base commanders. During the course of these meetings, the commanders received a “hands-on” demonstration of the system's capabilities. Promotional efforts also included detailed explanations regarding the use of the computerized system during a gathering of infirmary commanders that took place at the beginning of the study period at the IAF Surgeon General Headquarters. Infirmary commander gatherings were headed by the IAF Chief of the Medical Services Branch and were held every 6 weeks at the Headquarters throughout the study period. At every gathering, patient satisfaction status was presented to the participants directly from the World Wide Web site, using the computerized system. A discussion was then held among the officers. Infirmary commanders were instructed to hold similar gatherings within their own clinics, during which the status of patient satisfaction relative to other participating infirmaries was displayed to the infirmary's staff. These promotional and educational efforts were unique to the intervention group and were not used in the control group. Statistical Analyses The general intervention group (IAF) and control group (IDF) patient satisfaction scores were calculated from the raw questionnaires from all participating infirmaries at the beginning and end of the study period by using a method identical to the method in which the individual infirmary grades were determined. Separate grades were calculated for every survey topic. Differences in grades at the baseline and endpoint of the study were evaluated for statistical significance in both study groups by using the χ2 statistic; 95% confidence intervals for the differences in the percentages of satisfied patients between baseline and endpoint in both study groups were calculated by using the z statistic. Results In the fields of general impression, availability of service, and quality of care, statistically significant improvements in patient satisfaction, expressed as the percentage of satisfied patients, were noted in both study groups. However, the magnitudes of changes in these fields were greater in the intervention (IAF) group. In the field of interpersonal attitude, a statistically significant improvement was noted in the intervention group only; in the field of work environment, a statistically significant improvement was noted in the control group and not the intervention group. The most pronounced improvement in the intervention group was noted in availability of service. For this topic, the percentage of satisfied patients improved from 57.9% at baseline to 66.03% at endpoint (p < 0.001), compared with 67.5% and 69.6% (p < 0.001), respectively, in the control group. Table I summarizes changes in patient satisfaction parameters in the intervention group. Table II shows the same parameters from the control group. TABLE I INTERVENTION GROUP (IAF) RESULTS Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 75.9 83.5 7.6 <0.001 Interpersonal attitude 76.7 83.7 7 <0.001 Availability of service 57.9 66.0 8.1 <0.001 Quality of care 73.3 80.1 6.8 <0.001 Work environment 79.9 82.4 2.5 Not significant Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 75.9 83.5 7.6 <0.001 Interpersonal attitude 76.7 83.7 7 <0.001 Availability of service 57.9 66.0 8.1 <0.001 Quality of care 73.3 80.1 6.8 <0.001 Work environment 79.9 82.4 2.5 Not significant Satisfied patients were those answering 5 or 4 on satisfaction questionnaires. Open in new tab TABLE I INTERVENTION GROUP (IAF) RESULTS Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 75.9 83.5 7.6 <0.001 Interpersonal attitude 76.7 83.7 7 <0.001 Availability of service 57.9 66.0 8.1 <0.001 Quality of care 73.3 80.1 6.8 <0.001 Work environment 79.9 82.4 2.5 Not significant Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 75.9 83.5 7.6 <0.001 Interpersonal attitude 76.7 83.7 7 <0.001 Availability of service 57.9 66.0 8.1 <0.001 Quality of care 73.3 80.1 6.8 <0.001 Work environment 79.9 82.4 2.5 Not significant Satisfied patients were those answering 5 or 4 on satisfaction questionnaires. Open in new tab TABLE II CONTROL GROUP (IDF) RESULTS Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 84.1 86.3 2.2 <0.001 Interpersonal attitude 81.0 82.0 1 Not significant Availability of service 67.5 69.6 2.1 <0.025 Quality of care 78.3 80.3 2 <0.01 Work environment 83.5 86.7 3.2 <0.001 Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 84.1 86.3 2.2 <0.001 Interpersonal attitude 81.0 82.0 1 Not significant Availability of service 67.5 69.6 2.1 <0.025 Quality of care 78.3 80.3 2 <0.01 Work environment 83.5 86.7 3.2 <0.001 Satisfied patients were those answering 5 or 4 on satisfaction questionnaires. Open in new tab TABLE II CONTROL GROUP (IDF) RESULTS Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 84.1 86.3 2.2 <0.001 Interpersonal attitude 81.0 82.0 1 Not significant Availability of service 67.5 69.6 2.1 <0.025 Quality of care 78.3 80.3 2 <0.01 Work environment 83.5 86.7 3.2 <0.001 Satisfied Patients (%) Parameter Baseline Value Endpoint Value Difference p General impression 84.1 86.3 2.2 <0.001 Interpersonal attitude 81.0 82.0 1 Not significant Availability of service 67.5 69.6 2.1 <0.025 Quality of care 78.3 80.3 2 <0.01 Work environment 83.5 86.7 3.2 <0.001 Satisfied patients were those answering 5 or 4 on satisfaction questionnaires. Open in new tab To assess variations in the magnitudes of changes in patient satisfaction among the two study groups, 95% confidence intervals were calculated for the percentages of satisfied patients for all five study topics. These are depicted in Fig. 2. For the topics of general impression, availability of service, interpersonal attitude, and quality of care, the minimum values for the change in patient satisfaction in the intervention group were higher than the maximum respective values for the control group. In the topic of work environment, the confidence intervals for the values for the two groups were overlapping. Fig. 2 Open in new tabDownload slide Differences in percentages of satisfied patients between baseline and endpoint results for the two study groups. The 95% confidence intervals for the differences are shown. For all parameters except work environment, the minimum value of the difference for the IAF group falls above the maximum value of the difference for the control group, indicating a significantly greater magnitude of change in the IAF group. Fig. 2 Open in new tabDownload slide Differences in percentages of satisfied patients between baseline and endpoint results for the two study groups. The 95% confidence intervals for the differences are shown. For all parameters except work environment, the minimum value of the difference for the IAF group falls above the maximum value of the difference for the control group, indicating a significantly greater magnitude of change in the IAF group. Discussion In recent years, the issue of patient satisfaction is increasingly recognized as a major determinant of the quality of medical care. This is apparent from the increasing volume of scientific research that deals with patient expectations and the importance of understanding and meeting them.13,–17 Patient satisfaction is linked to compliance, which is a significant determinant of treatment outcome. These concerns were addressed by IAF health system managers and served as a trigger for the establishment of the computerized online grading system, the effects of which are described in the current study. Our data show that the use of this relatively simple and low-cost computerized system can produce substantial improvements in patient satisfaction and its various counterparts. We think that the computerized system is merely a tool that exploits the “built-in” competitiveness that characterizes officers who strive to achieve better results, compared with their fellows. This is true at all levels, including the physician, infirmary commander, squadron commander, and base com- mander. The virtue of the system lies in its ability to mirror results as soon as they are available and to present them in a comparative, graphical, colorful manner. Patient satisfaction grades in the intervention group improved in all five counterparts, with statistically significant improvements registered in four topics, that is, general impression, availability of service, quality of care, and interpersonal attitude. Improvements in these counterparts were also noted in the control group (three of them with statistical significance). However, the magnitudes of changes, as evident from the confidence interval analysis, were significantly greater in the intervention group. The results for the work environment counterpart were incongruent with respect to the other four counterparts and are therefore of special interest. This was the only topic for which no significant improvement was noted in the intervention group. Moreover, a small but statistically significant improvement in this topic was noted in the control group. The explanation for these observations might be that the work environment counterpart represents a more material subject influenced by budgetary investments, which were grossly similar for the two groups and were unaffected during the study period. The other four counterparts are probably more readily influenced by changes in human behavior and infirmary bureaucracy. The actual mechanisms that brought on the improvements in patient satisfaction in the participating infirmaries are complex and are not necessarily the same for each clinic. It is clear that the use of the computerized system merely served to bring the subject into awareness and to fuel competitiveness, rather than having a direct effect on patient satisfaction. The key issues that were discussed repeatedly by the commanders during infirmary commander gatherings as having a major positive influence included educating infirmary staff members on the importance of patient satisfaction and on the presence on an ongoing “competition” among IAF clinics, reorganizing infirmary operation schedules in a way that increased availability of services, simplifying procedures while decreasing unnecessary infirmary bureaucracy, improving and personalizing communications between the infirmary and its patients, decreasing the waiting time for physician appointments within the clinic, and dealing with infirmary-specific weaknesses as reflected by open-text remarks made by patients on the questionnaire forms. We think that the effects of the computerized system cannot be separated from those of the additional interventional measures that were taken, including promotional efforts during business meetings with commanders and infirmary commander gatherings. The knowledge that senior health system officers are concerned with the issue of patient satisfaction may be enough to fuel improvement efforts by subordinate officers. However, these effects, known as “Hawthorne effects,”18 were not unique to the intervention group. We think that the added improvement in patient satisfaction parameters that was demonstrated in this work in the intervention group, compared with the control group, is the result of the combination of interventional measures described that were unique to the IAF group. These interventions prompted specific actions within the infirmaries. We trust that the formulation of a readily accessible, up-to-date, computerized online comparison between the participating infirmaries was a major contributor to the effects shown. Other researchers may want to consider pursuing a follow-up study while trying to control for the variables mentioned above. 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TI - Effect of a Computerized Online Grading System on Patient Satisfaction in a Military Primary Health Care Setting
JF - Military Medicine
DO - 10.7205/MILMED.172.4.431
DA - 2007-04-01
UR - https://www.deepdyve.com/lp/oxford-university-press/effect-of-a-computerized-online-grading-system-on-patient-satisfaction-MpUZDfJ04R
SP - 431
VL - 172
IS - 4
DP - DeepDyve
ER -