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MEASUREMENT OF PATIENT SATISFACTION

AT THE ACADEMIC HOSPITAL

by

Sunita Ramlochan Tewarie

SURINAME
2008

ACKNOWLEDGEMENTS
The MBA study at the F.H.R Lim A Po Institute in Paramaribo was a very pleasant and interesting
learning journey to me, supplying me with lot of contemporary theories and practices on
management which I can recommend every one who is able to do it in Suriname. The
accommodations and staff members can be characterized as excellence because it is a very
pleasant place to be there with a very motivated staff.
Finalizing my study and at the end going through the research of patient satisfaction was not
possible without the moral support of my family and parents. They were of tremendous importance
to me during the study and especially my little princess Sherani had to miss me lots of evenings. But
I am very grateful to them that they bear a lot of hours without many complaints.
This research where patients of the Academic Hospital are the main subject was not possible if they
had not corporate to fill in the questionnaire. To those ex patients I want to express my gratitude and
maybe this study will bring some positive changes when entering the hospital next time. Also thanks
to some special persons from the nursery, who gave me ideas and were a very important feedback.
Also some experts on using SPSS-program were of great help to me.
I want also to thank all the persons that were helpful in the distribution of the survey forms.
Finally I want to thank Mr. Silvio De Bono, the supervisor of the thesis for the response on the
paragraphs during our conference calls on frequently basis. To all my friends from the MBA study
who supported me, it was very nice period to be with you and hopefully we will spent a lot of hours
together.

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EXECUTIVE SUMMARY
This paper is about measuring the patient satisfaction at the Academic Hospital, a topic that is
related to quality management, which is not yet adequately and effectively implemented at this
hospital. The results of this study can be used as input for an integral quality management for the
hospital, which is in a premature phase. The major aspects during the process of incoming till
dismissal are investigated on quality care. The main reason for this part of the process is because of
the many rumors from society about the service component at our largest hospital in Suriname. As
the role of nurses and the medical specialists are a major part of this process they are not part of this
research.
Theories about quality management are used to measure the quality of care in the hospital, the way
patients experience the hospital care and recommendations are made to improve these.
For research in Suriname, at the Academic Hospital, the choice is made for KQCAH Scale, the Key
Quality Characteristics Assessment for Hospitals Scale of 2001 because of the service component
and the organization processes it retains. It is a combination of qualitative and quantitative research
methodology and identifies the dimensions of hospital quality care, operationalizes the dimensions
and is an instrument to measure patient satisfaction.
The application of KQCAH instrument can add value for improvement within the services of the
hospital through the tested dimensions: respect and caring, effectiveness & continuity,
appropriateness, information, efficiency, effectiveness-meals, first impression and staff diversity.
The categories are: Category A represents patients from the private insurance companies, category B
from SZF, mainly consisting of civil servants, and category C (SOZA) from the low or no income
class.
The main research question is: Are patients at the Academic Hospital satisfied and what is the
difference in satisfaction between the three categories?
With two sub questions:
1.

Which dimensions in satisfaction contribute to more satisfaction among all three categories
A, B and C?

2.

Is there difference in satisfaction between the 1st, 2nd and the third class treatment?

Analysing these results have shown that patients at the Academic Hospital are on average satisfied.
Those results suggest that there is room for quality improvement. The most satisfied category is
category B in comparison to the 2 other categories taking 3 significant dimensions into account. Five
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dimensions are not significant at the 0.1 level, (at confidence interval of 90%) so the results of the
tests on the first sub research question are not confident. Respect and caring especially is significant
at the 0.05 level showing that this is a very important aspect to be taken into account for a judgement
about satisfactory. The least relevant dimension seems to be Information for all 3 different
categories.
For the survey, 73 questions were prepared, of which 67 were applicable and a total of 211 patients
out of 300 responded on these research purposes.
For answering the main question use of the statistical program SPSS version 15.0 (Statistical
Package for the Social Sciences) is made to quantify and analyze the information. The result of sub
question 1 about the differentiation of the 3 categories is derived from SPSS, e.g. the Kruskas-Wallis
method. For the second sub question, as it will be a comparison of different dimensions between the
2 categories of classes, the Independent t-test is used. Before applying the t-test, the Chi-square
method has been used to make clear the relationship between staying in classes and the insurance
involved, through the use of cross tables.

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TABLE OF CONTENTS
ACKNOWLEDGEMENTS
EXECUTIVE SUMMARY
TABLE OF CONTENTS
GLOSSARY

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CHAPTER I: INTRODUCTION
1.1
Motivation
1.1.1 The Academic Hospital in an changing environment
1.2
Problem statement
1.2.1 Research objectives
1.2.2 Research questions
1.3
Scope and limitations
1.4
Approach and research method
1.5
Relevance of the research
1.6
Structure of the paper

1
2
2
3
4
5
5
5
6

CHAPTER II: THEORETICAL BACKGROUND


2.1
Definition of quality
2.2
Development of quality systems
2.2.1 Quality systems in health care sector
2.2.2 Quality care systems in developing countries
2.3
Evolution of measurements for service quality in hospitals
2.4
KQCAH
2.5
Quality care in hospitals in Suriname
2.6
Summary

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10
12
14
17
22
23
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CHAPTER III: METHOLODOLOGY


3.1
Introduction
3.2
Target groups and pre test
3.3
Application of KQCAH
3.4
Application of SPSS
3.5
Design
3.6
Data Collection
3.7
Summary

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27
29
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CHAPTER IV: RESULTS OF THE EMPIRICAL ANALYSES


4.1
Introduction
4.2
Reliability test
4.3
Analyses and outcomes
4.4
Outcome sub question 1
4.5
Outcome sub question 2
4.6
Summary

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37
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CHAPTER V: CONCLUSIONS AND RECOMMENDATIONS


5.1
Introduction
5.2
Conclusions
5.3
Recommendations
5.4
Limitations of the research and suggestion for further research

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BIBLIOGRAPHY

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APPENDICES
APPENDIX A Questionnaires
APPENDIX B Reliability test
APPENDIX C Statistical outcome main question
APPENDIX D Statistical outcome sub question 1
APPENDIX E Statistical outcome sub question 2

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GLOSSARY

Definitions
Quality management: relates to the production process and tests the normal routine with regard to
processes and product specifications; quality management starts from
normative criteria and tries to exercise control on the basis of these criteria.

Abbreviations
KQCAH

Key Quality Characteristics Assessment for Hospitals Scale

AHP

Academic Hospital Paramaribo

SOZA

Ministry of Social Affairs

SZF

State health insurance company

JCAHO

Joint Commission on Accreditation or Healthcare Organizations

CAHPS

Consumers assessment of health care providers and systems

PDSA

Plan-Do-Study-Act

CQI

Continuous Quality Improvement

TQM

Total Quality Management

IOM

Institute of Medicines

HKZ

Harmonization of quality care

NIAZ

Netherlands institute for Accreditation

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CHAPTER 1

1.1

INTRODUCTION

Motivation

Working at a hospital is a very intricate and contra dictionary place to work in, as
managing a hospital is better off when people are sick. This is in contradiction with the
policy of the government, in this case the Ministry of Health, to improve the health care
sector through the reduction of sick people. The hospital has to cope with different
stakeholders, who have their own interest at the hospital and where management has to
deal with these, in order to improve the competitive advantage of the hospital. Hospitals
today can reach this advantage through improvement of their processes on patient flow
care, medical care, quality services and so on.
The concept of quality has several meanings depending on the stakeholder, from the point
of view of patient and family, from management perspective, from Ministry of Health,
Inspection, from professionals. This research will be about the quality perceptions of the
patient.
Statistical results suggest that hospital leadership has more influence on process quality
than on clinical quality, which is predominantly the doctors' domain. A general definition
of quality health care system is: "the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge". There are several ways to improve quality care within
hospitals. In general a health care system has three primary goals: the provision of highquality care, access to the system, and limited costs. However a more accessible system
of high-quality care will tend to lead to higher costs, while a low-cost system available to
everyone is likely to be achieved at the price of diminishing quality. Quality comprises
three elements:

Structure: refers to stable, material characteristics (infrastructure, tools,


technology) and the resources of the organizations that provide care and the
financing of care (levels of funding, staffing, payment schemes, incentives).

Process: is the interaction between caregivers and patients during which structural
inputs from the health care system are transformed into health outcomes.

Outcomes: can be measured in terms of health status, deaths, or disabilityadjusted life years, a measure that encompasses the morbidity and mortality of
patients or groups of patients. Outcomes also include patient satisfaction or
patient responsiveness to the health care system (WHO 2000).

This research will focus on the second part that is about the process within the Academic
Hospital in Suriname, especially that part of the process where the patient comes in and
stays during the care related to the treatment within the hospital. As the Academic
Hospital (AHP) is the largest hospital in Suriname with the most beds (440) and the most
specialists, it is important to have a good image; however rumours from society indicate
different because of the poor quality service patients receive. Patients from different
categories of insurance share the same view, no matter in which class of service they
stay. As the hospital is in a changing environment since 2003, slightly improvements
have already been realized, but hardly on the part of customer service, in this case patient
care.
There are different levels to stay in the hospital, depending on the insurance of the
patients and on the service of the insurance company or patient is willing to pay. In the
hospital the service level is related on the class within the hospital, e.g. the first class
patient will have better facilities in the hospital than a third class patient. But even the
first class patients are complaining about the service they receive at the hospital and they
are an important income generating source for the hospital. These patients are mainly
from the private sector while third class patients are normally from the low to middle
income group.

1.1.1

The Academic Hospital in a changing environment

The Central Hospital was founded in 1966. On September 25, 1969 the hospital was
renamed into Landsbedrijf Academisch Ziekenhuis (Academic Hospital).
Before the changing process the hospital had a mechanistic structure with a supervisory
board which was supervising the management on behalf of the government. In 2002, a
change process has been initiated which should lead to a more independent functioning of
the hospital, in particular to operate more efficiency and effectiveness. This change

process focuses on improving the internal structure, internal communications and


relations. In 2003 a seminar and a workshop were held with stakeholders to discuss this
change process and a new organizational structure was proposed. The new organizational
structure entails a broader management structure and a number of policlinics were
clustered as well as related support services. Six clusters were formed which are managed
by a cluster manager. The cluster manager is responsible for the operations of several
departments of the hospital. It is envisaged that these clusters will operate relatively
independent and will share a joint secretariat.
Late 2008, the organization structure is almost formalized and the main focus is on
improving quality care in the hospital.

1.2

Problem statement

Suriname has 7 hospitals, of which two are private and one in Nickerie. The private
hospitals have already focused on the improvement of the service part of the patients and
are therefore more popular for health treatment. However they are not able to provide all
medical treatment that is needed, so patients are obliged to have their treatment at AHP.
The AHP has therefore already a competitive advantage. But the hospital should not only
gain its important position through this channel but also through becoming more
customer oriented, as patients should become more willingly to enter the hospital.
Hence, the problem definition is: How satisfied are patients of the Academic Hospital
from entering till dismissal?
This research will focus on differences between satisfaction in health care between three
categories of patients and improvements to obtain better quality care through service
quality theories.

1.2.1

Research objectives

This research will make a contribution:


-

to awareness of different satisfaction levels among several categories of patients

to establish the importance of service quality

to gather input for a service quality policy in the hospital

to implement other aspects of quality in the hospital to gain competitive


advantage

for quality improvement

1.2.2

Research questions

As already stated, patients are divided in three main categories that represent almost 95%
of the total visitors of the hospital. These categories are:
Category A: private patients
Category B:

patients from the State Health Insurance (SZF); merely middle income
class; civil servants and private persons

Category C:

patients from low income class (SOZA)

In general, private patients (Category A) and the private component of SZF stay in the
first and second class of the hospital, while SZF (excluding private component) and
SOZA patients are staying in the third class because of their coverage at the insurance
company and Ministry of Social Affairs. Most of the patients at AHP (80%) are for a
third class treatment and therefore it is important to find out in what way they experience
the differences in satisfaction.
Patients in the first and second class (20%) seem also to have complaints about the
services of the hospital and are therefore included in the research.

MAIN RESEARCH QUESTION


Are patients at the Academic Hospital satisfied and what is the difference in satisfaction
between the three categories?

SUB QUESTIONS
1.

Which dimensions in satisfaction contribute to more satisfaction among all three


categories A, B and C?

2.

Is there difference in satisfaction between the 1st, 2nd and the 3rd class treatment?

1.3 Scope and limitations of research


The focus on this research is on the process of in- and outflow of patients in 2007 within
the hospital. Therefore patients visiting the policlinics are not subject of this research.
Annually some 35.000 patients enter the hospital and about 53.000 patients visit the
specialist for treatment at the policlinics. Service quality at the medical services of the
specialists is excluded. It will merely focus on services about entrance, food, transport,
attitude of the nurses, environment, and other attributes to make the staying relative
pleasant.

1.4 Approach and research method


This research is a practical oriented research that will have a diagnostic and design
character. One method has been used to measure objective results, which is a
combination of a quantitative and a qualitative method.
The KQCAH questionnaire was used for data collection to gather information about the
satisfaction of patients as it is a well known instrument to measure services at hospitals.
This method is a combination of a quantitative and a qualitative analysis.

1.5 Relevance of the research


Social relevance: The main reason to focus the research on this part of the process is
because of the many rumours about the poor service quality at the hospital. As the AHP
is the largest hospital in Suriname with the most beds and most specialists, the hospital
should have an integer image. As the hospital is an important integral part of the health
care sector, these rumours should be investigated. Patients from different categories of
insurance are taking part of this research in order to get a general view of the possible
causes for these rumours. As the hospital is in a changing environment since 2003,
slightly improvements have already been realized, but hardly on the part of customer
service, in this case patient care.
Economic relevance: To stress the importance of service quality in hospitals, because
competitive advantage cannot only be realised through more and specialized medical
services but also by improvements on other services for the patients
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Scientific relevance: as there is not yet much research in hospitals from developing
countries, this research can contribute to the awareness of becoming more quality
oriented in hospitals which will be in the advantage of the patient.

1.6 Structure of the paper


After the introduction (chapter 1), the theoretical background is presented in chapter 2.
In this chapter the distinction between quality and quality management system is made
clear and the relationship between service quality and satisfaction in general is pointed
out and adapted to hospital care. In this chapter, the development of contemporary
theories of health care satisfaction is reviewed. It also focuses on quality systems in
developing countries.
Chapter 3 reveals the methodology used to measure patient satisfaction at the Academic
Hospital. It also assesses the main category of patients at the AHP. In chapter 4 the
findings of the research is presented, while in chapter 5 the conclusions and
recommendations are formulated.

CHAPTER 2

2.1

THEORETICAL BACKGROUND

Definitions of quality

In order to make clear the several definitions used in theory about service quality the
main concepts will be clarified. According to the International Organization for
Standardization quality can be defined as a totality of characteristics of an entity that
bear on its ability to satisfy stated and implied needs. Edward Deming agreed that
quality is subjective and must have commercial value. What is quality? A product or
service possesses quality if it helps somebody and enjoys a good and sustainable market.
Trade depends on quality.
The American Society of Quality defines quality as a subjective term for which each
person has his or her own definition. In technical usage, quality can have two meanings:
1) the characteristics of a product or service that bear on its ability to satisfy stated or
implied needs and
2) a product or service free of deficiencies.
A variant of quality is service quality. In general services can be defined as social acts
which take place in direct contact between the customer and representatives of the service
company. It is more difficult to measure services objectively compared with products
because services characteristics include intangibility and inseparability of the production
and consumption of services. This makes the definition of service quality an abstract and
personal (subjective) concept. The relationship with service quality and health care is
described by Ross (1995). According to him, services in health care are intangible
because it is not possible to count, measure, inventory test or verify them in advance of
sale. Customer experience, either directly or vicariously from outside sources, is
frequently the only means of verifying whether health care services meets manifest
quality.
Caretakers provide services differently because of variations in factors, such as their
specialty training, experience and individual abilities and personalities. Patient needs
frequently vary from person to person and from visit to visit. Interactions among
physicians, nurses, administrators, patients and timing factors combine in an infinite
number of ways to affect the quality of the health care service rendered.
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Finally, in health care, production and consumption are inseparable. The services are
consumed when they are produced, which makes quality control difficult.
Grnroos(1984) divides the customer's perception of any particular service into two
dimensions:
1. Technical quality - What the consumer receives; the technical outcome of the
process and
2. Functional quality - How the consumer receives the technical outcome, what
Grnroos calls the "expressive performance of a service"
Grnroos suggested that, in the context of services, functional quality is generally
perceived to be more important than technical quality, assuming that the service is
provided at a technically satisfactory level. On the other hand he also points out that the
functional quality dimension can be perceived in a very subjective manner because each
person has its own experiences.
The distinction between the technical and functional aspects for quality is widely
accepted within the medical literature. In the healthcare field technical quality is referred
to as clinical quality which focuses on the technical accuracy diagnosis and treatments.
Functional quality refers in general to the manner or process by which health care is
delivered. However, hospital managers should take into account that clinical quality is at
least as important as process quality in predicting patient satisfaction.
According to De Nederlandse Normalisatie Instituut in Delft, Holland quality policy
has to do with the objectives of an organization with regard to quality and the ways and
means to achieve these objectives. Quality policy should be adapted by all employers
and specialists.
Quality policy should be implemented through well defined and applicable quality
management systems and must be quantified by certain measurements.
Therefore quality policy should be part of the total policy of the hospital and should be
implemented through the means of procedures and protocol.

Quality management system (QMS) is an instrument to implement quality policy and can
be defined as the organizational structure, procedures, processes, and resources needed
to implement quality management. In theory, a Total Quality Management (also called
Continuous Quality Improvement (TQM/CQI)) is a process of quality improvement and
quality control in the industrial and business world. It was first Edward Deming (1945)
and Joseph Juran (1954), among others, who developed TQM by applying statistical
techniques to the production process. The process can be defined as an ongoing effort to
provide services that meet or exceed customer expectations through a structured,
systematic process for creating organization-wide participation in planning and
implementing quality improvements.
Within the QMS, satisfaction of customers is an important part as they can contribute to a
well functioning quality system since customers are one of the stakeholders for
improvement of service quality. Service quality is part of a total quality system and can
be derived for instance by measuring the satisfaction of customers. But the dilemma with
measuring satisfaction is that it is subjective. Several researchers state that services are
not actions and behaviors in and of themselves, but the way customers perceive and
interpret those actions. Historically, the establishment of quality standards has been
delegated to the medical profession and has been defined by clinicians in terms of
technical delivery of care.
More recently, patients assessment of quality care has begun to play an important role,
especially in the advanced industrialized countries, and their satisfaction or
dissatisfaction with services has become an important area of research. Although
different, satisfaction and service quality are closely related. The literature indicates a
positive relationship between service quality and patient satisfaction with hospital care
and a willingness to return to the hospital. Three different opinions are mentioned as
relevant. According to Oswald and Taylor (1992), consumers must rely on attitudes
toward caregivers and the facility itself in order to evaluate their experience. They
maintain that there is a strong connection between health service quality perceptions and
customer satisfaction. Donabedian (1988) suggests that, patient satisfaction should be
considered to be one of the desired outcomes of care and information about patient

satisfaction should be as indispensable to assessments of quality as to the design and


management of health care systems.
This relationship has also been acknowledged in the dissertation of Chieh-Lu Li (2003),
title: A Multi-ethnic comparison of service quality and satisfaction of service quality and
satisfaction in national forest recreation. It appears that service quality and satisfaction of
customers are distinct concepts but interrelated constructs. He found that service quality
is more likely to the perspective of managers, because they control the services provided
for customers; whereas, customers are more likely to evaluate their satisfaction with
services
Another link is that satisfaction is concerned with the short-term and specific transaction;
while service quality is concerned with more general, long term, and global effects.
Therefore, satisfaction is an antecedent of service quality and consequently, satisfaction
is theoretically influenced by service quality.
Further he found that satisfaction was likely based on emotional evaluations and
subjective judgment. In contrast to satisfaction, service quality, however, tends to be
based on rational evaluations and objective judgments.
Finally, in literature, consumer expectations have usually been defined as forecasted or
anticipated levels of performance. These expectations are combined with actual
performance to create the concept of disconfirmed expectations. Disconfirmed
expectations, in turn, are used as predictors of consumer satisfaction. Researchers in the
service quality area, however, emphasized that expectations in service quality models
were not forecasts. This is an important distinction. If service expectations were defined
as forecasts, the service quality model (P-E) became undifferentiated from the
disconfirmed expectations component of the consumer satisfaction model (Teas, 1994).
Last but not least measurements of quality systems can be done by several methods
depending on the sector and the applicable dimensions relevant in these sectors.

2.2

Development of quality systems

Quality control striving towards perfect quality is since the Middle Ages (Baker 2002). In
the medieval masters and enslave designed strict rules concerning quality of raw
materials, the production process, the professional skills and the quality of the end
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product. The end products were checked by the master and after customers approval,
provided with a guarantee seal, as the product certificate. Quality seems therefore as
something that has been there always. This development continued in the period of the
Industrial Revolution. The customer and producer views about the production process
became different and instead of tailored made products standard products were made.
Thereby the manufacturer himself stipulated if the product was produced according to
specific measures. At the beginning of the 20 statistics were included and for the first
time inspections took place on the basis of samples. Quality control became a separate
appropriate mean and the quality inspector was appointed. As from 1945 up to the 1960s
a tremendous development evolved in the striving towards quality. It is worth
remembering that quality methods were first developed and put into widespread use in
Japan after the Second World War, a country with few resources and then re-imported
into the West. The Japanese realized rapidly that quality could be an important
competition mean. Some of the challenges in applying and adapting quality methods as
well as the potential for testing and developing more cost effective methods, were
developed by them. In the 50 the foundation service level for the industry has been set
up. Statistics are no longer only applied to do samples but are also used to make the
production process transparent, on basis of which decisions are taken. Process control
does its entrance. Afterwards it was considered that by measuring the process and the
results, a rule ring arise and the well-known Deming-circle became famous. Gradually,
the notion grows that quality control is not only concerned with the output of production
but also assembly other phases in the production process. In the period between 1980 till
1990, flexibility will play a role beside efficiency and quality. The three criteria should be
applied simultaneously and integral. This was a new quality golf. In this period also the
service will play a larger role beside the production. Quality control becomes a
component of the total management function because of the care of a good product
quality. Organizations are involved in writing quality policy where it is indicated how
required quality should be implemented. In 2005 quality control almost no more means a
competition advantage but a condition to survive on the market.

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Graph 1: Relationship between organization and labor development

Product

Process

System

Concatenate

Society

Organization

Developments in

development

Management

Strategic QualityManagement

Quality
Assurance

Quality
Control

Inspection
Developments in labor

Source:Kleemans WVCS (2007)

Since the 1990s, there is a general trend for stakeholders to put more pressure on
hospitals for accountability, transparency and equity of access to health. The
governments of various American and European countries have, therefore, stimulated the
use of Quality Management systems (QMS) and external evaluation in healthcare.
Former research has identified models and variants of external evaluation, e.g. medical
specialty-driven visitation, traditional accreditation against explicit standards, European
Quality Awards based on the model of the European Foundation of Quality Management
(EFQM), and certification using ISO standards (ISO 9000 series).

2.2.1

Quality systems in the health care sector

Although there are many quality instruments, not all systems are suitable for the health
care sector. Quality care through quality management systems are applicable because it is
about improving the process around the customer/patient and therefore enhance the
satisfaction of the customer /patient. Other motives for the necessities of quality
improvements are: patients become more demanding, the fact that competitiveness of
other hospitals will evolve not only by price but also through service and quality
12

management will lead to better outcome and finally it will conduct a more specialized
organization.
The difficulty in measuring hospital service quality is that there is no valid and reliable
instrument with respect to the functional aspect for quality as patients define quality
based on their subjective perception. Several researchers have tried to identify several
different dimensions to be applicable for hospital, but it is still very difficult because of
the focus on determining perceptions and attitudes. In the Netherlands the Customer
Quality Index has been developed which is based on two American measurements:
CAHPS (Consumer Assessment of Healthcare Providers and Services) and QUOTE
(Quality of care through the patients eyes). This instrument measures the experiences of
the consumers of health care. In their opinion, using information about the experiences of
patients is more effective for quality improvements than subjective information about
satisfaction.
In the health care sector quality policy became much more important due to the fact that
deregulation and market orientation became more important. In most countries the
government has to retrieve and health institutions are taken the responsibility to improve
the quality of care. The patient became therefore a crucial partner in developing standards
for quality. Transparency about the quality of care is one of the key factors and external
assessment should be made on regular base. In the table below the different stakeholders
in the health care sectors are identified for information about their specific process
improvement.

Table 1: Information need


Patients

Pressure group

Health care insurances

Procurement

Government

Monitor information

Health care Inspection

Supervision

Managers and professionals

Quality care information

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In general changes in quality care systems show a development on certain characteristics:

From static: image building towards dynamic: change management

From the inner to also outward oriented: client and market focus

Shifts from organizational items towards professional items: it is about care and
the effectiveness of care

From: Patient Client Consumer Visitor

Professionals are central

Efficiency and flexibility are important factors to take into account in the new
developed quality systems.

2.2.2

Quality care systems in developing countries

In developing countries the development and quality of health services is severely limited
by lack of resources and knowledge about quality methods. However developing
countries increasingly recognize the value of quality methods and the need to raise the
quality of their services.
Developing countries face severe limitations to health care. The average spending on
public health care per head of population is low (US$6-US$10 a year), the services are
not evenly distributed and there is a lack of many essential drugs (despite various
programs to solve this problem). Health personnel are not trained sufficiently,
unsupervised, and morale and incomes are low.
In most of these countries policy makers think that quality methods and concepts are not
relevant and applicable. They argue that some quality approaches are inappropriatefor
example, large amounts spent on accreditation systems to improve the quality of hospital
services could be put to better use. Accreditation is certainly easy to understand than
many other quality methods and it is often supported by donors, but it is often
unsustainable, ineffective and inappropriate in many of these countries. Therefore they
are reluctant to implement quality systems.
However, nowadays developing countries become aware of using quality methods
because it can have an important part to play in improving the performance of the health
care system if the right ones are chosen for the situation and adapted in a culturally
appropriate way.
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By introducing quality management systems in hospitals the organization can amend and
qualify on international standards in order to provide a better service and treatment, and
can expand.
In recent years, organizational change in the health care system can influence quality of
care and can focus on the continual design and redesign of systems. The emphasis is on
developing organizational and individual capabilities where they most profoundly affect
the process of care. Design and redesign interventions assume that simply adding a new
resource or a new process in isolation will not improve care because better care is the
product of many processes working together. Although change interventions have not
been widely used in the developing world because they require large investments to plan
and implement, four related models of organizational change have been successful in
changing provider practice in developing nations (World Bank Group, 2006):

Total Quality Management in health care

Advances in business management practices to continually design and redesign systems for
quality improvement is possible and have been adapted for health systems. Teams in Total
Quality Management, also known as Continuous Quality Improvement, use mutually
reinforcing techniques in a cycle of planning, implementing, evaluating, and revising to
improve the quality of clinical and administrative processes. These techniques include
process mapping, statistical quality control, and structured team activities. Two cases which
were TQM is implemented with success, are in Bihar, India and in Malaysia. In rural Bihar,
private practitioners were provided with standard case-management information, were
given feedback on their performance, and were tracked and monitored over time. This
strategy produced significant improvements in practitioners' case- management skills. In
Malaysia, anesthesia safety has been improved through the implementation of consensusbased protocols that emphasize (a) communication among the operating, recovery, and
ward team members; (b) individual feedback and (c) frequent monitoring to identify areas
for improvement.

15

Collaborative Improvement Model

The early success of Total Quality Management techniques has given rise to a related
model, the Collaborative Improvement Model. It has been applied to broad and complex
systemic processes within health care systems and has facilitated the scale-up of quality
improvements. This model, designed to continuously improve organizational and individual
performance, comprises four elements: definition of an aim, measurement, innovation, and
testing to see whether the innovation meets the original aim. This approach strikes a
balance between the need for action and the need to be scientifically grounded. It has been
used with success in Peru and the Russian Federation. The results have led to changes in
the process of care, but it is too early to determine whether they have been effective in
improving quality.

Plan-Do-Study-Act cycle

The Plan-Do-Study-Act (PDSA) cycle calls for action oriented learning in quality
improvement. Team members using the PDSA model design a quality improvement
intervention (plan), implement it on a small scale (do), evaluate the results (study), and
implement or alter the intervention accordingly (act). Multiple PDSA cycles are necessary
before the appropriate improvement method can be identified. All improvement techniques
that involve the design and redesign of systems use some form of the PDSA cycle.
Successful PDSA prototype is possible with careful leadership oversight. Although the
experience of researchers implementing interventions that are based on system redesign in
the developing world has been largely positive, it is not clear whether the resources and
leadership exist to bring these interventions through country or regional policies. Further
evidence is needed concerning the real-world feasibility and cost-effectiveness of system
redesign.

Internal enabling environment

Creating the right environment for change involves leadership and leadership training;
clinicians empowered to make quality improvement decisions, and resources for quality
improvement planning activities. The internal enabling environment in Costa Rica
promoted strong leadership that led to the adoption of structural adjustment loans in the
early stages of health sector reforms. The loans were used to maintain such public health
16

programs as mother and child nutrition, even though public spending dropped and prices
increased dramatically. An environment can also be created by teams of individuals, each
representing different stakeholder groups (physicians, nurses, staff members, patients, and
so forth) or simply by a strong leader with an interest in teamwork and the resources to
support a discrete quality improvement function for team members.

2.3

Evolution of measurements for service quality in hospitals

Measuring service quality was not well known and became popular after the 1990s. One
of the pre-eminent instruments for measuring service quality in general is SERVQUAL
also known as the Gap model, developed by Parasuraman through testing on 5
dimensions. It provides a structure for understanding service quality, measuring it,
diagnosing service quality problems and offering solutions to the problems (Zeithaml et
al., 1990). Furthermore it is mostly applied in service sectors which were financially well
established, for instance the banking sector. Through an exploratory study it was possible
to define service quality as the discrepancy between customers expectations and
perceptions and to suggest key factors that influence customers expectations, which are
word of mouth communication, personal needs, and past experience.
SERVQUAL enables the tracking of customers expectations and perceptions (on
individual service attributes and or the SERVQUAL dimensions) over time. It further
allows for comparison of a companys SERVQUAL score against those of competitors.
T. P van Dyke (2003) several weaknesses when using this tool.
In general, the difficulties with the Servqual measure can be grouped into 4 main
categories:
1. The use of the difference of gap score: subtracting one measure with the other is a
poor choice for measuring the psychological construct.
2. Reliability problems and poor validity with gap scores: Servqual instrument is not
proper to use Cronbachs alpha, the method to measure reliability because the
component scores are highly correlated.
Validity issues: The mentioned instrument concerns poor predictive and
convergent validities of the measure. Babakus and Boiler (1992) indicated that it
is difficult to demonstrate that the difference score is measuring something unique
17

from the perceptions component, and therefore a high correlation between the
difference and perception score.
3. The ambiguous definition of the expectations construct: multiple definitions of
expectations result in a concept that is loosely defined and open to multiple
interpretations and can result in measurement validity problems.
4. Unstable dimensionality: a theoretical construction combined with the use of gap
scores raise the questions about the true factor structure of the service quality
construct.
The Massachusetts Health Quality Partnership (1988) is a statewide patient survey project
named Results of Hospital Patient Care Survey designed to meet the dual goals of
supporting internal hospital quality improvements throughout Massachusetts while
advancing public accountability through public reporting of comparative information on
patient care experiences. Fifty-two institutions participated in this study, which accounts
for about eighty percent of the states medical/ surgical inpatient discharges and ninety
percent of all childbirth patients. The Picker Institute administered the surveys, which
focused on dimensions of care which patients themselves identified as important. The
Picker Institute is a nationally recognized organization, which assesses the healthcare
experiences of patients across the country.
Dimensions measured by the Massachusetts Health Quality Partnership included:
Respect for patient preferences, Physical comfort, Involvement of family and friends,
Continuity and transition, Coordination of care, Information and education and Emotional
support.
The survey went far beyond general satisfaction or evaluation, asking the patients to
report what happened during their hospital stay. Massachusetts hospitals scored above the
national average for surveyed hospitals. The findings were strongest relative to the rest of
the country in emotional support, and were weakest in continuity and transition.
The Joint Commission on Accreditation of Health care organizations (JCAHO, 1990)
related the dimensions of Coddington and Moore with the dimensions of SERVQUAL
and finally 9 dimensions were selected as the theoretical framework of hospital quality.
The Joint Commission on Accreditation or Healthcare Organizations (JCAHO) is an

18

independent, non-profit organization that evaluates and accredits more than 15,000 health
care organizations and programs in the United States.
Bowers (1994) added caring (personal, human involvement) and patient outcomes (relief
from pain, saving of life, or anger/disappointment with life after medical intervention).
Another dimension, collaboration, was discussed by all of Juns groups. Collaboration
encompasses the concepts of teamwork and the synergistic effect of various actors in
providing health care. It is the commingling of the roles of all members of the health
care team, including payers, physicians patients, family members and members of the
community that define health care quality from the patients viewpoint. Jun further
emphasizes that communication is essential for collaboration because it fills in the gaps
to prevent disjointed service.
Mittal and Baldasar (1996) measured the effect of certain quality factors in a physicians
practice, and found that physician competence, communication, respect, caring, taking
time to learn history, and follow up treatment were weighted more heavily if patients
were not satisfied. The condition of the office environment and waiting time, received
lower weighting scores.
Young (1996), et al surveyed 2000 discharged hospital patients, nursing staff and
managers to compare differences in the relative importance of four key nursing variables:
physical care, patient participation in care, patient teaching and pain control.
They found that patients ranked patient teaching of highest importance, and participation
in care lowest, but the variation in statistical results was narrow. They maintain that
knowing how much importance patients place on an aspect of care is valuable for
developing and achieving improvement in that aspect of care. Furthermore, they found
gaps in the scores of both nurses and managers when they rated the importance (to the
patient) of these variables. The usefulness lies in understanding how the lack of
understanding of patients values and expectations can impede service quality
improvement strategies within hospital units.
Chakrapanis (1998) uses a model that consists of 5 dimensions related to patient
satisfaction in Bangladesh, Pakistan. In his view patients voice must play a greater role
in the design of health care service delivery processes in the developing countries. This
study is patient centered and identifies the service quality factors that are important to
19

patients; it also examines their links to patient satisfaction in the context of Bangladesh.
Evaluations were obtained from patients on several dimensions of perceived service
quality including responsiveness, assurance, communication, discipline, and baksheesh.
In table 1 these dimensions are mentioned.
Alan M. Rees (1998) maintains that satisfaction with hospital care is too often assessed
on the basis of amenities that have little relationship to the clinical quality of care. He
feels that amenities do not indicate the quality of what happens to people while they are
in the hospital and what happens to them after discharge. He recommends the measures
of: respect for patient values, preferences and needs; coordination of care (scheduling
tests and procedures); information and education provided; physical comfort (waiting
time after call bell sounded); emotional support and alleviation of fear and anxiety;
opportunity for involvement of family and friends; provision for continuity and transition
to the home environment.
Seihoff (1998) documented continuity of care and caring behaviors in evaluating the use
of unlicensed assistive personnel vis--vis patient satisfaction. In a study of the British
Medical System, administrators, providers and patients, agreed about quality priorities for
elderly people.
All groups considered improving the quality of life (adding life to years) as important,
whereas reducing mortality rates (adding years to life) was unimportant. The key
difference between professionals and patients occurred in the importance attached to
reducing the burden on family caregivers (understanding the patient). Patients attached
higher importance to this factor.
Ford and Fottler (2000) suggest that service specific dimensions should be added to the 5
SERVQUAL dimensions to appeal the patients definition of health care in the health
care sector. Various environmental changes forces the hospitals to be more responsive to
customers wants, needs and expectations and have to focus on what the patients really
wants.
Coddington and Moore (2001) developed a list of 5 dimensions from a consumers
perspective. In their model they stress the importance of technology on quality of the
hospital. The general research hypothesis tested is that hospital technology directly drives
(affects) quality and hospital financial performance. The results indicate that the type of
20

hospital technology (clinical or information) drives different types of quality-related


performance (clinical or process), and directly and indirectly affects hospital financial
performance.
The dimensions of quality care and performance (table 2) provide the framework for
quality management activities in all healthcare settings from a balanced and wellintegrated quality, cost, and risk perspective.
Table 2: Several researchers on hospital quality
Dimensions
Massachusetts

Health

Quality Partnership (1988)

Respect for patient preferences, Physical comfort, Involvement of family and


friends, Continuity and transition, Coordination of care, Information and
education and Emotional support

JCAHO (1990)

Appropriateness, Efficiency, Timeliness, Respect and Caring, Safety,


Continuity, Availability

Bowers (1994)

Caring (personal, human involvement) and patient outcomes (relief from


pain, saving of life, or anger/disappointment with life after medical
intervention)

Young (1996)

Physical care, Patient participation in care, Patient teaching and pain control

Mittal and Balsadar (1996)

Competence, Communication, Respect, Caring, Taking time

Rees (1998)

Respect for patient values, Preferences and needs, Coordination of care


(scheduling tests and procedures), Information and education provided,
Physical comfort (waiting time after call bell sounded), Emotional support
and alleviation of fear and anxiety, Opportunity for involvement of family
and friends, Provision for continuity and transition to the home environment

Chakrapani (1998)

Service/product, Dependability, Support, Exceeding, Expectations

Jun (1998)

the roles of all members of the health care team, including payers, physicians
patients, family members and members of the community, Communication

Seihoff (1998)

Continuity, Understanding

Coddington (2001)

Warmth/Caring, Available, Specialization, Technology Equipment

Sower,Duffy et al

Respect and caring, Efficiency and continuity, Effectively, Staff diversity,


Appropriateness, Information, Meals, First impression

21

2.4

KQCAH

A recent developed measurement is the Key Quality Characteristics Assessment for


Hospitals Scale (KQCAH, 2001) which can be relevant because of the service component
and the organization processes it retains. Knowledge of these dimensions facilitates the
measurement of patient satisfaction by hospitals. Hospitals know that they are measuring
dimensions that are important to patients. The Institute of Medicine's (IOM 1999) identifies
nine domains of care that can provide useful guidelines for survey-item development. These
nine domains are: respect for patient's values; attention to patient's preferences and
expressed needs; coordination and integration of care; information, communication, and
education; physical comfort; emotional support; involvement of family and friends;
transition and continuity; and access to care. The CAHPS Hospital Survey domains (nurse
communication, nursing services, doctor communication, physical environment, pain
control, communication about medicines, and discharge information) were derived from the
IOM domains (Goldstein et al. 2005).Other conditions that are important for hospitals are
the pressure on hospitals for accountability, transparency and equity of access to health. In
European countries the use of Quality Management system (QMS) in healthcare has
extensively been used and has led to better health service. The Netherlands are
implementing the quality assurance standards of NIAZ (The Netherlands Institute for
Accreditation of Hospitals) and HKZ (Harmonization of quality care). These standards
contain requirements for the organization of a hospital. They describe what has to be
regulated in a hospital in order to warrant that the quality of care delivered is not depending
on individuals or left to chance.
This method, Key Quality Characteristics Assessment for Hospitals, is a combination of
qualitative and quantitative research methodology and identifies the dimensions of hospital
service quality, operationalizes the dimensions and is an instrument to measure patient
satisfaction. It is developed by Sower and Duffy et al (2001) and based upon the JCAHO
dimensions. Eight dimensions have been incorporated and were tested on Cronbachs
alpha. For hospitals it is even more difficult to measure satisfaction as patients have their
own definitions for quality and comparing these definitions is not possible because of the
lack of a valid and reliable instrument. This method takes into account the customers
perspective and makes it possible to effectively improve the performance of the hospital.
22

Research has indicated that the KQCAH have high levels of content, validity and
reliability. It is a tool which that provides the hospital to be responsiveness to their marketoriented environment. It also has the means to improve quality audits by periodically using
the questionnaire to monitor quality indicators. It is also a tool for identifying areas needed
to improve within a hospital.

2.5

Quality in hospital care in Suriname

Suriname has no quality systems yet implemented in hospitals and it is doubtful if


implementation will be useful mainly because of the lack of awareness of these systems and
the professionals for implementing quality standards.
In the Meerjaren Sectorplan Gezondheidszorg 2004-2008, the goals of health care are
formulated which have to be achieved by the Ministry of Health. One of the goals is:
improve the efficiency and quality of the hospital care.
Therefore a strategy is defined with 5 process indicators. These are:
-

rating of hospitals and departments by well defined and standardized process or


outcome indicators

technical standards of interventions

standardized/ comparable staying in days

maintenance of the infrastructure and medical apparatus

target of beds capacity of 80%

In order to reach these indicators 4 sub goals are formulated and the one regarding the
quality of hospital services has to do with Medical services should be qualitative and
cost effective for all hospitals. Although this sub goal is mainly applicable for medical
treatments, one could derive that this is also applicable for the services in the hospital. In
the same report however it is also mentioned that the policy of the ministry is not further
developed because of the many departmental discussions about the financing of hospital
care which become a burden for the government budget the last 10 years, and therefore
they were not able to focus on other important health care issues like developing a
general quality policy.
In the daily newspaper De Ware Tijd of December 6th 2007, page A4, under the head of:
Ministry of Health want to improve the relationship between health care providers
23

plans have to be developed in the next few years to create a unit to coordinate and
facilitate health care tasks through ordering and regulation. The main task will be to
create a platform for every Surinamese citizen to guarantee a certain level of information
and quality. Therefore plans will be made for implementing quality guarantee and quality
maintenances.
The Academic Hospital had installed a quality sub commission for the nursery in 1996,
because of complaints about the not adequate care to the patient, the lack of appropriate
facilities at the hospital and the poor maintenance. In 1999 the commission became the
Commission quality guarantee to control quality care. The commission had to do an
audit which consists of a checklist about the welfare, environment and comfort for
patients, sufficient information in reports, application of a nursery plan and the facilities
at the department. Depending on the results, the department is receiving a score related to
a defined benchmark. This audit includes also recommendations to overcome the
shortcomings at the department.
The last audit was held in 2003 and has not been continued for several reasons. The main
reason is that these audits took too much time for the nursery to do, besides their own
nurses tasks. Another major reason is that although the commission is making
recommendations for improvements, not all the departments are aware of the urge to
follow up the instructions. So there was no follow up and no sanctions.
As the Academic hospital is in a transition phase of change, one of the priority areas of its
policy is the development of quality care, in the broadest way. In the next few years
protocols and procedures have to be written in documents and should be standardized in
order to improve the quality of all services, including medical services. Another aspect
which will be developed is the installation of a quality mentor, who will give advises
about quality improvements and a commission of complaints. Nowadays patients can
complain through a letter to the general director, who tries to solve the problem in his
own convenient way.

24

2.6

Summary

It appears that a clear objective definition for quality is hardly possible because it
depends on a persons perception if there is quality. Service quality is much more
subjective because it is hardly tangible and measurable. Services in health care for
instance are not possible to count or verify and depended on patients experiences.
Quality control is difficult because production and consumption take place on the same
time. By developing several management systems to improve quality in recent years,
customers expectations will meet which can contribute to a more satisfied client. These
management systems are instruments to implement quality policies. However not all
management systems are suitable for the health care sector.
Quality service at the hospital can be divided in 2 dimensions in general: functional,
which has to do with the manner or process health care is delivered, while technical
quality focuses on clinical quality and thus focuses on technical accuracy diagnosis and
treatments.
Quality service and measuring satisfaction are distinct but interrelated concepts. A major
distinction is that service quality is concerned with more general, long term effect likely
to the perspective of managers while measuring satisfaction is basically an emotional
judgment from customers.
The problem when implementing quality system in the health care sector is that there is
no valid and reliable instrument with respect to the functional aspect for quality because
this is subjective as the focus is on determining perception and attitudes. However it is
still important to develop these systems because it is about improving the process around
the patients and enhance their satisfaction. The organization can become more
competitive and will conduct a more specialized organization.
Several researchers have tried to identify several dimensions applicable to hospitals but
there is still not a general model determined. It is obvious that these measurements are
more popular in developed countries mainly because they have the instruments, data and
the facilities to do so. Another reason is also the growing competitiveness especially in
the USA, as there are many hospitals there.
For research purposes in Suriname, at the Academic Hospital the choice have been made
for KQCAH Scale, the Key Quality Characteristics Assessment for Hospitals in 2001
25

because of the service component and the organization processes it retains. It is a


combination of qualitative and quantitative research methodology and identifies eight
dimensions of hospital quality care, operationalizes the dimensions and is an instrument
to measure patient satisfaction.

26

Chapter 3.
3.1

Methodology

Introduction

As stated in chapter 1 the main research question of this thesis is: Are patients at the
Academic Hospital satisfied and what is the difference in satisfaction between the three
categories? The main question is supported with 2 sub questions and all 3 questions
were subject of research according to the KQCAH Scale. This method took the
experiences of the 3 categories patients in consideration and therefore obtains a
measurement of the service quality at the Academic Hospital through theoretical and
practical issues. Questionnaires regarding the functional level of service quality through
the 8 dimensions were applicable and have been distributed to 300 ex patients of the 3
categories, of which 211 were filled in. They have been translated into Dutch in order to
make sure that it would be understood and again re-translated in English to verify the
correct interpretation. In appendix A, the English and Dutch versions of the questionnaire
are included.
In the next paragraph this method is discussed. Furthermore, it will elaborate on the
target groups, design, data collection and types of analyses.

3.2

Target groups and pre test

The target groups for research are divided in 3 main categories: Category A (private),
Category B (SZF) and Category C (SOZA). The respondents, in total 211, are of the age
of 18 and above. No difference has been made in sexes, income group and education.
Category A represents patients from private insurance companies and is the smallest
group of patients at AHP (table 3), because in general they prefer to stay at a private
hospital, mainly because of the notion of better services provided by those hospitals. At
the AHP, the rooms for patients of the 1st and 2nd class are on one floor, which implies
that there are not many rooms for this category. Category A represents 18.5% of the total
respondents and therefore is a good reflection of the patients share of this category at the
AHP, namely 17% on average between 2004 and 2006.
Category B (SZF) is the middle income group of patients which has more freedom to
choose for medical treatment. It is also a medical insurance for almost every civil citizen
27

and they can have medical treatment divided over all 3 classes depending on their
hierarchical function at work and the insurance possibilities. But most of the civil citizens
have a basic insurance and could stay for treatment at the 3rd class. They prefer to stay at
a private hospital in general, but because the many medical disciplines at AHP they have
often no choice than staying at this hospital. Another target group within category B is
that of private persons, but their share in the total is minor. Category B has a share of
32.7% in the total respondents, thus overrepresented when judged against the share of
this category in the total patients population of about 25% at the AHP. No differentiation
is made between civil servants and private persons.
Category C (SOZA) represents patients from the low or no income class that get a card
from the Ministry of Social Affairs if they can prove their inability to work. The validity
of a card varies from 2 weeks, when the request is still in charge, half a year and 1 year.
These patients have the right for treatment only at 3rd class and consist of about 60% of
the total patient population of the hospital. The reason for this is that they are obliged to
make use of the medical treatments from only public hospitals and there are only 2 of
them in the main city. In the test this category represents 48.8% of the total respondents
of 211. Judged against the share of this category patients of 58% between 2004 and 2006
in the total population of AHP (table 3), category C is underrepresented in the survey.

Table 3: Percentages of patients population at AHP


In %

2004

2005

2006

Private

17

16

19

SZF

24

27

24

SOZA

59

57

57

After identifying the targets group a pre test was done with 20 patients to find out if the
questionnaire was suitable and understandable. Most of the respondents had many
complains about the quantity of questions, and it appeared that 5 questions from the
original version were not applicable in Suriname. These questions were about after care
services, after dismissal from hospital which is in Suriname not yet developed as well and
the non personal relationship between nursery and patient.

28

3.3

Application of KQCAH

The application of KQCAH instrument can add value for improvement within the
services of the hospital and is suited particularly for determining the perceptions and
attitudes regarding 8 dimensions of service. These dimensions are: respect and caring,
effectiveness & continuity, appropriateness, information, efficiency, meals, first
impression and staff diversity. It is deducted from the dimensions of JCAHO and only the
dimension of efficacy is excluded as the reliability of this dimension was not acceptable.
Efficacy of care is generally determined by using such measures as mortality and
complications. From the original questionnaire of 75 questions, 5 were excluded because
they were not appropriate for Suriname.
In Suriname, however, there are several dimensions that influence the satisfaction of
patients. Some staff members of the nursery were interviewed in order to identify if the
dimensions according to the KQCAL scale were applicable at AHP and if there were
other specific dimensions possible to be added at the mentioned instrument to measure
patients satisfaction.
In their view the eight dimensions are appropriate, but they insist that there are certainly
other relevant factors that could be important for the patients. Factors like their privacy
when the medical specialist is consulting the patient, the cultural diversity and therefore
for instance differences in languages, the availability of linen for the beds, the visiting
hours play an important role in the Surinamese case.

3.4

Applications of SPSS

Using a survey to measure satisfaction among patients is a common instrument although


there are many hindrances to use it. Some of these are: the selected population is not
representative, partial non responses, the effects of an interviewer on the respondent, the
formulation and effect of the questions, the effect of questions filled in by people that all
questions are positive. However, a survey is the only reliable instrument to do so. The
objective of this survey is to give a description, comparison and explanation of
knowledge, attitude and behavior and is therefore applicable.
Indicators for satisfaction depend in general on factors as trust, sexes, profession, own
living standard and education. For research purposes these indicators are not all neglected
29

as a main approach to measure satisfaction at the hospital other factors are applicable
which can be divided in: 1. factors in output related services (medical services at the
hospital) and 2. factors in process oriented services. As already mentioned, this survey is
about the process oriented services with regarding to the relationship between nurses and
patients and the environment.
For answering the sub question 1: Which dimensions in satisfaction contribute to more
satisfaction among all three categories A, B and C? the Kruskas-Wallis method has been
used because of the 3 categories.
For answering the sub question 2: Is there difference in satisfaction between the 1st,
2nd and the 3rd class treatment? use is made of the t- test. As it will be a comparison of
different dimensions between the 2 classes, the survey gave answer of the question if
patients have different experiences when staying at the hospital.
The comparison is between the 1st and 2nd class, the 1st with the 3rd class and the 2nd with
the 3rd class.

3.5

Design

The questionnaire includes eight dimensions which will give a relative objective answer
that are measurable, on the main question when using the KQCAH instrument. Before
using the data, all variables were tested on reliability. The questions that scored a low
Crombach alpha were deleted. To measure the differences between the 3 categories, use
is made of the Kruskal-Wallis method. For the 70 ordinal level variables, ex-patients
were asked to indicate their degree of agreement or disagreement with a statement
regarding hospital care by marking a cross to indicate Strongly Disagree, Disagree,
Agree, Strongly Agree or Undecided.
Responses were then coded as follows: Strongly Disagree = 1, Disagree = 2,
Undecided = 3, Agree = 4and Strongly Agree = 5.
Three other questions were included to obtain general information.
The data obtained from the respondents was imported into the statistical program SPSS
version 15.0 (Statistical Package for the Social Sciences) to quantify and analyze the
information.

30

The result of the main question and the sub question 1 was derived from the usual method
of SPSS.
The result of sub question 2 had been analyzed using the t-test. Before applying the t-test,
the Chi-square method was used to make clear the relationship between staying in classes
and the medical insurance involved, through the use of cross tables.
The results of all the questions are discussed in chapter 4.

3.6

Data collection

To measure satisfaction between classes and the 3 categories the ideal situation should be
to include the same numbers of patients to analyze. The survey, however did not include
an equal distribution between the several targets groups but as the AHP has relatively
more SOZA patients as their customer, the fact that most of the respondents are of this
category, could be interpret as representative. For the survey, 73 (70 ordinal and 3
nominal) questions were prepared, and a total of 211 out of 300 patients were selected for
research purposes. On annual basis the AHP has about 35.000 patients in house, while
53.000 patients enter the clinics.

3.7

Summary

This paragraph is a reproduction of the subjects involved and the dimensions used. It also
elaborated on the target groups, design, data collection and types of analyses used.
The main research question is supported with 2 sub questions and all 3 questions were
subject of research according to the KQCAH Scale. This method took the experiences of
3 categories patients in consideration and therefore obtains a relatively objective
measurement of service quality at the Academic Hospital through theoretical and
practical issues. The application of KQCAH instrument can add value for improvement
within the services of the hospital through the tested dimensions: respect and caring,
effectiveness & continuity, appropriateness, information, efficiency, effectiveness-meals,
first impression and staff diversity.
Category A is the group of patients from the private insurance companies. This category
is the smallest group of patients. Category B (SZF) is the middle income group of
patients which has more freedom to choose for medical treatment in hospitals. It is also
31

an insurance for almost every civil citizen and they can have medical treatment divided
over all 3 classes depending on the hierarchical function and their assurance possibilities.
Category C (SOZA) are patients from the low or no income class and receive a card from
the Ministry of Social Affairs if they can prove not able to work and are obliged to stay in
the 3rd class for medical treatment at public hospitals. For the survey, 73 questions are
prepared, of which a total of 211 patients out of 300 (70.3%) responded on these research
purposes. To answer the questions, used is made of the Likert-type scale of 1 to 5. The
statistical program SPSS version 15.0 (Statistical Package for the Social Sciences) is used
to quantify and analyze the information. The result of sub question 1 about the
differentiation of the 3 categories is derived from a variant of SPSS, the Kruskas-Wallis
method. For the second sub question, as it will be a comparison of different dimensions
between the 2 categories of classes, the Independent t-test is used. Before applying the ttest, the Chi-square method has been used to make clear the relationship between staying
in classes and the insurance involved, through the use of cross tables.

32

Chapter 4.
4.1

Results of the empirical analysis

Introduction

The primary purpose of the study is to explore and determine the patient satisfaction
regarding the healthcare services delivered at AHP.
Individual overall satisfaction scores were computed for each of the 211 study subjects
by summing scores on each of the 8 items from the KQCAH Survey determined to be
indicators of the construct general satisfaction. The items regarded are: respect and
caring, effectively and continuity, appropriately, information, efficiency, food, first
impression and different workers. Three other questions were also formulated for data on
their insurance and class.
Findings and analysis of the patient satisfaction survey data are presented in paragraph
4.3. The results are arranged and presented according to the formulated research
questions.

4.2

Reliability of the questionnaire

Six out of 8 dimensions were tested on reliability and validity. Two dimensions First
impression and Staff diversity could not be tested because they exist of only 1
question, which represent the respectively dimensions without doubt. A special motive
for this test is that the questionnaire from KQCAH is from American origin and as
Suriname has different standards and perception for satisfaction in health care, it is
obviously to test it for local use. After the test it appears that three dimensions showed a
low scale on reliability and were therefore adapted. The reliability of Respect and
caring became 0.967 after excluding 3 questions. The dimension Efficiency was in
first instance not reliable with an alpha of 0.502. After excluding one question which
carried out the low scale, the alpha became 0.808. The score of the dimension
Information was in first instance 0.593 and when deleting the 2 low scoring questions
the scale did not change that much and became 0.635. The questions involved were also
deleted for research purposes. All other dimensions appear to be high and these
connected questions remain the same. In table 4 the Cronbach alpha is reflected, after

33

adapting the questionnaires. The analyses have been done with 67 questions (64 ordinal
and 3 nominal). The details are mentioned in appendix B.

Table 4: Cronbach alpha


Dimension

Cronbach alpha

Respect and caring

0.967

Effectiveness and continuity

0.869

Efficiency
Appropriateness
Information
Meals

4.3

0.808 (was 0.502)


0.722
0.635 (was 0.593)
0.873

Analyses and outcomes

Main question: Are patients at the Academic Hospital satisfied and what is the
difference in satisfaction between the three categories?
The main research question is quantitative in nature and is analyzed through summation
and calculation of means of the 8 items from the Key Quality Characteristics Assessment
for Hospitals (KQCAH). The relationship between satisfaction and the three different
categories of patients because of their health care insurance has also been quantified and
is part of this objective.

Table 5: Health Insurance type


Health insurance

Percentage

Private insurance companies (A)

39

18.5

State Health Insurance (B)

69

32.7

Ministry of Social Affairs (C)

103

48.8

Total

211

100

34

Table 6: Patients at different classes


Class

Percentage

1st

27

12.8

2nd

31

14.7

3rd

153

72.5

211

100

Total

Table 5 and 6 contain the relative distribution between the 3 categories/classes for the
survey. From the 211 respondents, 168 (79.6%) responded of the 3 categories and 100%
responded on the question about the classes.
The answer to answer the main question, are patients of AHP satisfied, can be derived
from graph 2. According to the normal curve of this graph and taken into account the
mean and median of respectively 201.70 and 205.0 (SD = 41.58), the outcome indicates
that 50% of the respondents are slightly more than average satisfied, which could be
interpreted as moderate satisfaction. However, the mode (mode=186) is lower than the
mean, implying that most of the respondents are less than on average satisfied. But taking
into account the standard deviation, the outcome is still that patients are on average
satisfied.
Patients are satisfied, although not very much, but they are also not very dissatisfied, as
the outcomes of the options Strongly disagree and Strongly agree are not prominent
marked in the survey.

35

Graph 2. Histogram of total satisfaction


Histogram

25

Frequency

20

15

10

5
Mean =201.70
Std. Dev. =40.578
N =168
0
50.00

100.00

150.00

200.00

250.00

300.00

350.00

sattot

The test shows the relationship between satisfaction and the 3 different categories. The
respondents from different health insurance companies are represented and it appears that
168 respondents (79.6%) are taken into account when measuring total satisfaction. The
difference in respondents can be ascribed to subjects that did not fill in the regarding
questions.
According to the Kruskal-Wallis-test there is a difference in satisfaction between the 3
categories. The mean of the respondents with a SZF card (category B, mean= 97.94,
n=49) is the highest of the 3 categories, which indicates that this category represents the
most satisfied patients, followed by the patients from the private insurance companies
(category A, mean= 88.64, n=33). The least satisfied patients are from the Ministry of
Social affairs (category C, mean =75.26, n=86). The differences are significant (KruskalWallis test, Chi-square= 7.086; df =2; p=0.029<0.05). In appendix C all the
corresponding statistics are included.

36

Table 7: Total satisfaction


Ranks
Insurance
Satisftot

Mean Rank

PART

33

88.64

SZF

49

97.94

SOZA

86

75.26

Total

168

As table 7 indicates, the difference between these means is minimal and as the test shows,
these differences are significant which indicates that these differences are not a
coincidence.

4.4

Sub question 1. Which dimensions in satisfaction contribute to more

satisfaction among all three categories A, B and C?


In the tables 8 till 15 the 8 several dimensions are measured for the different categories of
patients to explain which of these dimensions the respondents declare to be important of
contributing satisfactory. It appears that there is again a difference in the total
respondents when analyzing the dimensions and that the differences are not always
significant. This is measured by confidence intervals.
The dimension Respect and caring is most confident dimension with a p-value =0.05.
All other dimensions have a p-value > 0.05 which can be explained by either the limited
number of answering the relevant questions and/or the limited number of questions
related with that respective dimension. The dimensions Efficiency and Effectively
have a p-values of respectively 0.101 and 0.066, which imply that they are applicable
within a confidence interval of 90%. Two other dimensions Staff diversity and First
Impression show difference above the confidence interval of 90% , respectively p-value
=0.125 and p-value =0.134, which imply that they are not significant, even not at the 90%
level. This is also true for the dimensions Appropriateness, Information and Meals
which have a confidence interval of more than 90% and are therefore not significant (see
Appendix D).
According to the tests, SZF-patients (category B) scored the highest on each dimension,
implying that they are most satisfied category on each dimension of satisfaction.
37

However, those dimensions with p-value > 0.1 are not significant, meaning that no
conclusions can be derived. The patients of the private category also appreciate most of
the dimensions except for the dimension Effectively where patients of category 3
appreciate this dimension more.
Another method for comparing dimensions is through comparing the mean of total
satisfaction with the means of the distinguished 8 dimensions. Most of these means were
higher than the total mean of satisfaction. However it is difficult to make a premise out of
these outcomes as the number of respondents differs from each other and a higher mean
per dimension above the total mean of satisfaction does not explain that these dimensions
are more than average, contribute to total satisfaction.

Table 8: Respect and Caring total


Ranks
Insurance
Resptot

Mean Rank

PART

39

104.74

SZF

62

114.64

SOZA

96

86.57

Total

197

The dimension Respect and caring consisting of 23 questions is the most reliable
dimension (alpha=0.967) and significant (Kruskas -Wallis, Chi-square= 10.544, df=2, pvalue=0.05). Category B has the highest mean (table 8) and therefore this category is
satisfied with the way they are treated on respect and care. Almost 92.9 % of the total
respondents have filled in these questions. Category A differs slightly from the highest
mean, which can be interpreted that those patients are also satisfied although not that
much. Category C is least satisfied.

38

Table 9: Appropriateness total


Ranks
Insurance
approtot

Mean Rank

PART

36

99.71

SZF

66

110.26

SOZA

97

93.13

Total

199

According to the Kruskas-Wallis test (Chi-square=3.479, df=2, p-value=0.176) in table 9,


the outcome of the dimension Appropriateness is not significant at the .05 or 0.1 level.
The results demonstrate that satisfaction about this dimension regarding category B
(SZF) is relatively high in comparison with the 2 other categories.
This indicates that although category B has the highest mean, this could be a coincidence
and therefore not significant to be regarded as satisfied on appropriateness. For
measuring this dimension 15 questions has been formulated from whom 93.8% has filled
in the regarding questions.

Table 10: Information total


Ranks
Insurance

Mean Rank

infotot

PART

37

104.54

SZF

66

107.05

SOZA

99

96.67

Total

202

In table 10 is the result of the test (Kruskas -Wallis, Chi-square 1.376, df=2, pvalue=0.502) which can be interpreted as not significant, as the p-value is very high
(>0.1). Therefore the result that category B is most satisfied about the information they
get, is not even within the confident interval of 90%. Seven questions have been
answered and 95.3% of the respondents have filled in these questions.

39

Table 11: Effectiveness and continuity total


Ranks
Insurance

Mean Rank

infotot

PART

35

88.16

SZF

60

109.66

SOZA

96

90.32

Total

191

Effectiveness has been measured (Kruskas -Wallis, Chi-square 5.426, df=2, pvalue=0.066) through 10 questions in the survey of which 90.5% has been filled in. The
result of this measurement (table 11) is that category B tend to be the most satisfied
within a confidence interval of 90% for this aspect, regarding the way personnel were
able to handle on questions of the patients. Category A is least satisfied.

Table 12: Efficiency total


Ranks
Insurance
effictot

Mean Rank

PART

36

102.03

SZF

63

109.37

SOZA

97

90.13

Total

196

In table 12 the dimension Efficiency consists of 4 questions and 92.4% has responded
on these questions. Within a confidence interval of 90% (and significant), category B
tends to be the most satisfied category on this dimension (mean = 109.37, Kruskas Wallis, Chi-square 4.577, df=2, p-value=0.101), while category A is not so satisfied.
Category C is the least satisfied regarding this dimension.

40

Table 13: Meals total


Ranks
Insurance
foodtot

Mean Rank

PART

39

108.73

SZF

66

111.92

SOZA

100

94.88

Total

205

This dimension is not significant (Kruskas -Wallis, Chi-square 3.755, df=2, pvalue=0.153) and although the outcome is that category B is the most satisfied than all 2
other categories, this result is not applicable. Five questions have to been answered in this
regard and 96.7% have responded (table 13).
Table 14: First impression total
Ranks
Insurance
First impr

Mean Rank

PART

39

107.78

SZF

69

116.30

SOZA

103

98.43

Total

211

Table 15: Staff diversity total


Ranks
Insurance

Mean Rank

Different Staff PART

39

103.55

SZF

69

117.27

SOZA

103

99.38

Total

211

In Table 14 and 15, 2 dimensions were tested and consisted of only on 1 question per
dimension. The reason for this is that there was only 1 way to formulate a question to

41

know more about these dimensions. Looking at a confidence interval of 90%, one can
derive to the conclusion that those two dimensions are not significant.
The results of the tests are for First impression: Kruskas -Wallis, Chi-square 3.755, df=2,
p-value=0.125 and for Staff diversity: Kruskas -Wallis, Chi-square 4.020, df=2, pvalue=0.134.
Analysing these results, it is obvious that category B tends to be the most satisfied
category in comparison to the 2 other categories taking the 8 dimensions into account.
Although 3 dimensions are significant at the 0.1 level, (the confidence interval of 90%),
results of the tests on the second research question indicate that the dimensions involved
tends to be reflecting the satisfactory of patients although not in the same confident level.
Respect and caring especially is very significant at the 0.05 level, showing that this is a
very important aspect to be taken into account for a judgement about satisfactory. The
least relevant dimension seem to be Information for all 3 different categories which can
be explained by the fact that this dimension is the dimension with a low Cronbach alpha
(0.6) which indicate that the questions involved were not relevant or the reactions of the
subjects on getting information on time or not from specialists, nurses or other personnel
does not make feel the patients more or less comfortable when staying at the hospital.
4.5 Sub question 2. Is there difference in satisfaction between the 1st, 2nd and the
3rd class treatment?
For the purpose of the analysis, the Independent t-test is used to compare the means of
the several classes per dimension. Graph 3 shows a large part of class 3 patients in the
survey. Although this category represents the largest part of patients at AHP, it is
overrepresented in the survey. The second class is underrepresented in relationship with
the actual share of this class in the total population of AHP, while the first class is a good
representation of the population at AHP. (Source: AHP, internal audit)

42

Graph 3: Class distribution

PAT class

12.80%

class1
class2
class3

14.69%

Pies show counts

72.51%

Before testing the different classes on the several dimensions, a correlation test has been
done between classes and the 3 categories. In cross table 16 the different categories and
the classes are illustrated. According to the Pearson Chi-square test which is high at
84.869 it is significant within a confidence interval of more than 99.9% (df=4,
Asymp.Sig.=0.000). Therefore there is no correlation between the variables involved.
(See Appendix E)
Table 16: PAT class* INSURANCE Cross tabulation

Insurance

Total

PART

SZF

SOZA

CLASS

CLASS1

14

13

27

PAT

CLASS2

13

18

31

CLASS3

12

38

103

153

Total

39

69

103

211

Difference in satisfaction between the 1st and 2nd class


The mean of class 1 in table 17 is higher than that of class 2 meaning that the patients in
class 1 are more satisfied. However, the test results indicate that the difference is not
significant at 10% level, so this could be an coincidence (t=0.811, df=32.584, p>0.1).

43

Table 17: Group Statistics between the 1st and 2nd class
PAT CLASS

Mean

Std. Deviation

Std. Error
Mean

Satistot

CLASS1

19

231.5789

44.61105

10.23448

CLASS2

26

222.0385

34.36449

6.73943

Difference in satisfaction between the 1st and 3rd class


For the second case the results are also not significant; test results show that t=1.171, df
=24.756, p>0.1, although the mean of the first class is higher than the mean of the third
class.
Table 18: Group Statistics between the 1st and 3rd class
PAT CLASS

Mean

Std. Deviation

Std. Error
Mean

Satistot

CLASS1

19

231.5789

44.61105

10.23448

CLASS3

120

218.0917

46.96235

4.28706

Difference in satisfaction between the 2nd and 3rd class


Taking into account the mean of these 2 classes it appears that class 2 patients is slightly
more satisfied than the 3rd class patients. This difference is significant at a 95% level
(t=4.494, df =47.685, p<0.05).
Table 19: Group Statistics between the 2nd and 3rd class
PAT CLASS

Mean

Std. Deviation

Std. Error
Mean

Satistot

CLASS2

26

222.0385

34.36449

6.73943

CLASS3

120

218.0917

46.96235

4.28706

The results of the tests for satisfaction for 2 different combination of classes seems to be
not significant, except for the differences in satisfaction between the 2nd and 3rd classes,
which makes it difficult to answer the question if the classes differs in satisfaction.

44

4.6

Summary

According to the tests, patients at AHP are on average satisfied, meaning they are
moderate satisfied as the outcomes of the options Strongly disagree and Strongly
agree are not prominent marked in the survey.
Analysing these results, it is obvious that category B tends to be the most satisfied
category in comparison to the 2 other categories taking the 8 dimensions into account.
Although 5 dimensions are not significant at the 0.1 level, (the confidence interval of
90%) results of the tests on the first sub research question indicate that the other 3
dimensions tends to be reflecting the satisfactory of patients although not in the same
confident level. Respect and caring especially is significant at the 0.05 level showing that
this is an important aspect to be taken into account for a judgement about satisfactory.
The least relevant dimension seems to be Information for all 3 different categories.
This can be explained by the fact that this dimension has h a low Cronbach alpha (0.6)
which indicate that the questions involved were not relevant or the reaction of the
subjects for getting sufficient information and on time or not from specialists, nurses or
other personnel does not make feel the patients more or less comfortable when staying at
the hospital.
The results of the tests for satisfaction for the 2 comparing groups of different classes are
not significant, except the differences in satisfaction between the 2nd and 3rd classes,
which make it difficult to answer the question if the 3 classes differ in satisfaction.

45

CHAPTER 5 Conclusion & Recommendations


5.1

Introduction

According to literature effective managing of service quality is evident to gain


competitive advantage. To implement quality systems with success in the hospital, three
main stakeholders are important: the nursery, the patients and the medical specialists. At
the AHP, provisions will be taken to implement quality standards for the medical
specialists (e.g. this is a more technical procedure) and the nursery, although for the latter
group quality audits are already in place but not yet adequate in place. The role of
patients is not considered as an active part of implementing quality systems at the AHP
and this research can be a tool to take this into account. In general, the role of patients
with regard to customers focus can be measured through research on their experiences or
through measuring their satisfaction. This thesis is about the second method and the
relationship with service quality is made clear.
Appropriate service quality leads to satisfied patients who can become loyal customers as
is known in other service related sectors. These patients have positive experiences which
can create a spin off effect when utilizing other medical services from the hospital,
ending to enhance profitability. This survey identifies that the consumer, in addition to
providers, is a key player in the processes of defining and measuring quality and his/her
voice provides an important component to the process. The incorporation of those
dimensions related to how the consumer defines the experience of health care can be
important for a more comprehensive service quality.
The objectives of this research is to contribute the awareness of service quality in
hospitals in Suriname; to stimulate professional practices concerning quality systems as
management tools and to incorporate patients opinion in the hospital health care policy
because through satisfied patients, the added value of a hospital can be improved.

46

5.2

Conclusions

The following dimensions were measured at the AHP: respect and caring, effectiveness
& continuity, appropriateness, information, efficiency, effectiveness and continuity,
meals, first impression and staff diversity. These dimensions are derived from the
KQCAH Scale which is originally deducted from the dimensions of JCAHO and only
one dimension, the dimension of efficacy, was excluded in the KQCAH as the reliability
of this dimension was not acceptable. Efficacy of care is generally determined when
using measures as mortality and complications.
For testing the reliability of KQCAH for Suriname purpose, the test of reliability had
been carried out again according to the input from the respondents and certain questions
appeared not be relevant and were therefore deleted.
Dismissed patients above 18 years and not longer than half a year dismissed were
approached for filling in the questionnaire. The survey consisted of 300 questionnaires
that were distributed according to their insurance and 70.3% responded. SPSS 15.0 was
used to analyse the results, with 2 different variances of it.

Main research question: Are patients at the Academic Hospital satisfied and what
is the difference in satisfaction between the three categories?
Taking the results into account it seems that patients at the AHP are on average satisfied
and the results are significant. Analysing the outcome, category B (SZF) tends to be the
most satisfied category in comparison to the two other categories. The answer of this
question is quantitative in nature and is analyzed through summation and calculation of
means of the 8 items from the Key Quality Characteristics Assessment for Hospitals
(KQCAH) Scale. For the 70 ordinal level variables, ex-patients were asked to indicate
their degree of agreement or disagreement with a statement regarding hospital care by
using the Likert scale 1 to 5. Six questions were not found reliable and therefore not
taken into account in the analysis. Three nominal variables were used to determine the
classes and insurances of the ex-patients.

47

Sub question 1. Which dimensions in satisfaction contribute to more satisfaction


among all three categories A, B and C?
The research conducted under patients of the Academic hospital shows that, out of the
eight dimensions of service quality developed by KQCAH in general, the score on
Respect and caring is the highest. Effectively and continuity and Efficiency are two
other dimensions that contribute to satisfaction and are significant.
When classifying patients into 3 categories, the outcome of satisfaction is in general the
same for significant dimensions, resulting that category B is the most, category A less
and category C least satisfied. Only for Effectiveness and continuity, category C is
more satisfied than category A. From all 8 dimensions, 5 dimensions are not significant at
the 0.1 level, (the confidence interval of 90%). Table 20 provides an overview of the
outcomes. The least significant dimension seems to be Information for all 3 different
categories which technically means that the outcome is probably a coincidence.

Table 20: Dimensions of diminishing significance


Dimensions/category

Category A

Category B

Category C

=104.73

=114.63

=85.42

n=196; p= 0.05

=88.6

=109.66

=90.32

n=198; p= 0.066

=102.01

=109.37

=89.03

n=195; p= 0.101

Staff diversity

=203.42

=117.17

=98.40

n=210; p= 0.134

First impression

=107.73

=116.24

=97.38

n=210; p= 0.125

Meals

=108.62

=111.82

=93.88

n=204; p= 0.153

Appropriateness

=99.68

=110.26

=92.04

n=198; p= 0.176

Information

=104.54

=107.01

=95.62

n=201; p= 0.502

Respect and caring


Effectively
Efficiency and
continuity

48

Sub question 2. Is there difference in satisfaction between the 1st, 2nd and the 3rd
class treatment?
For answering sub question 2, use is made of the Independent t- test. As it will be a
comparison of different dimensions between 2 independent categories of classes each, the
survey investigates the question if patients have different experiences when staying at the
hospital. The comparison is between the 1st and 2nd class, with the 1st and 3rd class and
the 2nd with the 3rd class.
According to the test, there is only difference in satisfaction between the 2nd and 3rd class
and significant. The 2 other independent paired groups appeared not be significant.

5.3 Recommendations
The results of the study indicates that patients at the AHP are satisfied on average; still
there is room for quality improvements. As the AHP is in the environment for change,
also for quality improvements, recommendations will be made in order to convince
management to take these changes into account when implementing quality standards.
Outcomes of patients satisfaction surveys have a signaling function. Improvements can
be made when for instance patients are not satisfied after medical treatment. Another
reason for the signaling function is that most organizations in Suriname have traditional
authority structures, and introducing quality systems in these organizations means
introducing management processes which challenge the existing structures and culture
and therefore are quickly rejected. But to overcome these situations multidisciplinary
improvement team approaches have to be adapted for existing culture in these
organizations.
1. Improvements of dimensions
The dimensions that are not significant (p >0.1) in this study for measuring the
differences in satisfaction between the 3 categories (Meals, Appropriateness, Information,
Staff diversity and First impression), could be The dimensions that are not significant (p
>0.1) in this study for measuring the differences in satisfaction between the 3 categories
(Meals, Appropriateness, Information, Staff diversity and First impression), should be
approached in a manner that in a next study they can be made significant, from which
conclusions can be drawn for quality policy purposes at the Academic Hospital. Possible
49

reasons for the insignificance of several dimensions can be that the patient population
was too small or that more relevant questions on those dimensions should have been
included in the questionnaire. Researchers are being recommended to take those two
aspects into account in the future. Furthermore, the management of the hospital is being
recommended to investigate which other aspects are relevant to the patients regarding
earlier mentioned dimensions.
Management can for instance enhance the internal organization for these purposes by:
*Improve facilities
Making facilities more pleasant and accessible is an aspect of quality improvement
mentioned by all researchers who identify tangibles as part of the quality constellation.
Important is how to improve the performance of the health system and how to establish a
basic infrastructure which includes training and management capacity building.
*Awareness of health care information for consumers
Patients should be furnished with information about their illness as well as reasons for the
awaiting time they have to endure.
Informational needs of consumers as well as to the unique information needs of rural
consumers and persons with bad health conditions and disabilities should be adapted for
those groups by using relevant methods of reporting information to consumers.
*Meals
Recently, in December 2007 the kitchen and laundry facilities at AHP were improved
according to HACCP standards, meaning that meals will be served on international
standards. Some important improvements are: the supply of food products and
ingredients have to be of certain standards and the function of dieticians will be
emphasize. So the expectation is that the dimension Meals will improve at the next
research.
*Listening to the patient
Management should listen more to a valuable resource to improve health care quality: the
patient. The way patients are treated by hospital personnel during their staying should be
understanding and meeting the needs of the patients. As they come in sick, pain and fear
produce anxiety which make them vulnerable for bad circumstances. The American
Hospital Associations nation-wide survey of consumers for instance advises hospital
50

administrators to listen to staff, to members of the community and to patients to learn


more about what is important to them in the provisions of hospital. When patient enters
the hospital they can receive a questionnaire in which they can suggest and/or give their
opinion for improvement on certain aspects during their staying at the hospital. Or taking
surveys on regularly basis is also another method to hear the patients voice for
improvements.
2.

Reform the commission of quality care at the Academic Hospital

The commission of quality care is not able to incorporate the tasks involved with quality
care in their regular tasks and this should be separated from their nursery tasks. As the
hospital is planning to install a quality mentor, these tasks from the commission should
be carried over. Further more, stimulis for improvements like motivation should be
introduced to stimulate the departments that successfully implement the standards and
sanctions for those that ignore the standards.
3.

Teamwork

Within the institution, a fundamental shift in organizational strategy and culture is


required to move to a more team oriented and quality improvement approach.
Research has showed that improvement of patient care quality requires a breakdown of
the stratified hierarchy of quality improvement. Specific tasks have to be assigned and
feedback options are agreed upon. Through investment in skill development and managed
role responsibilities interaction and quality can be enhanced. The result for instance is
that waiting time in the clinic can be reduced by eliminating cumbersome steps in clinic
traffic/treatment flow process.
4.

Corporate qualitative studies of technical dimensions to measure


satisfaction

In order to define quality, it is not enough to look at structured or statistical methods for
doing so. The concept of quality has many dimensions, some of which are difficult to
quantify, but not less essential to its definition. Separated qualitative studies can
supplement the regular quantitative methods especially when measuring quality of certain
functional services.
Health care institutions have to evaluate the effectiveness of their technical initiatives to
determine satisfaction. The integration of measurable and quantifiable dimensionssuch
51

as clinical outcomes with functional dimensions such as patient satisfaction should be


advocated for better results.
An expansion of the physicians central role in delivering, assessing and improving the
quality of medical care requires that the medical professions expand its traditional role as
patients advocate. It is stated that satisfaction results from meeting the patients
informed expectations about the outcomes of care and respecting their dignity and values.
5.

Consider patient and physicians as customers

Physicians have been identified as valuing the technical aspects of quality to a greater
extent than the functional aspects. Training for physicians which incorporates the
functional aspects of quality has been discussed for a long time. However, in order to
implement this strategy, various researchers advocate reducing the bureaucratic burden
on physicians in order to make more time available to patients.
5.4 Limitations of the research and suggestion for further research
This research is only done in Paramaribo. Important social and demographic data for
instance, age, gender, annually net income, education and race are not taken into account.
Another important limitation is that medical services are not part of this research,
although to measure patient satisfaction this is an essential part.
The Ministry of Health is in fact also a major stakeholder for implementing quality
measurements, but till now there is no general policy for health care quality systems
formulated. As indicated by nurses of the AHP, the following factors can be taken into
consideration in a follow up study: patients privacy when being consulted by the medical
specialist, the cultural diversity e.q. differences in languages, the availability of linen for
the beds, the visiting hours of the hospital.

52

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Coddington and Moore, (2001), Ohio illustrate further the dimension of creativity and
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55

APPENDIX A: QUESTIONNAIRE
Questionnaire according to the KQCAH method with 8 dimensions (original)

Factor 1: Respect and caring


1. The staff responded to my requests in a friendly way.
2. Overall, the staff is pleasant to deal with.
3. The staff is cheerful and smiling.
4. The staff is courteous to me.
5. The staff treated me with respect.
6. The staff is very friendly.
7. The staff provided for my needs before I asked.
8. Overall, the hospital staff treated me with respect.
9. The staff paid attention to me.
10. The staff went out of their way to help me.
11. The staff appeared interested in me.
12. The staff is very patient in attending to my needs.
13. When I had a complaint, it was handled quickly.
14. The staff had a positive attitude.
15. The staff showed me where the things I needed would be.
16. Overall, the staff went out of their way to help me.
17. The staff was very reassuring.
18. Overall, the staff respected my rights as a person.
19. Overall, the staff responded to my needs.
20. The staff listened to me about my needs.
21. My needs were attended to quickly.
22. My personal privacy was protected.
23. I knew my caregivers names.
24. I did not have to wait for the things I needed.
25. Caregivers gave me information I needed.
26. I did not have to wait long to check in.

56

Factor 2 Effectiveness and Continuity


1. I was told about the necessary home care when I left.
2. When being discharged, they considered what I could do.
3. Overall, moving from the hospital to home went well.
4. Overall, the hospital staff did their jobs very well.
5. All preparations for discharge were handled well.
6. The necessary care was there when I returned home.
7. I was allowed to take part in decisions about my care.
8. I was not left without care when I moved home.
9. They told me all the things I needed to know.
10. Overall, the staff seemed to care about my condition.
11. Overall, the hospital staff was very professional.
12. When I was in pain, they tried to control it.
13. I was able to stay in contact with the hospital easily.
14. Overall, the staff was very competent.
15. They handled me gently.

Factor 3 Appropriateness
1. The facilities were very clean.
2. The facilities were comfortable.
3. Overall, the services I needed were available.
4. Overall, the facilities were very good.
5. The staff was appropriately dressed.
6. I did not have to fill out too many forms at check-in.
7. The facilities were very attractive.
8. The facilities allowed for personal privacy.
9. I was able to communicate with the staff.
10. It was quiet enough for me.
11. The hospital had everything I needed.
12. I felt they really wanted me to get well.
13. My personal items were take care of well.
57

14. The lights were at an appropriate level.


15. I felt that my needs were kept confidential.

Factor 4 Information
1. I was given information quickly by doctors.
2. The doctors gave me information I needed.
3. Doctors informed me about the outcomes of procedures.
4. The doctors were available to me when needed.
5. Overall, I was given the all information I needed.
6. They told my family what they needed to know.
7. Financial counselors gave me information I needed.

Factor 5 Efficiency
1. Overall, my hospital bill was handled well.
2. My bill was in line with the service provided to me.
3. I was able to understand my bill.
4. A staff member was available to explain my bill to me.
5. Any complaints I had about the bill were handled well.

Factor 6 Meals
1. Overall, the food service was very good.
2. Meals were served at the proper temperature.
3. Meals tasted good.
4. Meals were served on time.
5. Dirty dishes were removed promptly.
Factor 7 First impression

My first contact with the staff made me feel comfortable.

Factor 8 Staff diversity

There were many different types of people on the staff.

58

Vragenlijst patinten beddenhuis AZP


Deze vragenlijst is in het kader van een afstudeerproject en gaat over de verbetering van
de kwaliteitszorg in het ziekenhuis, waaronder ook de tevredenheid van de patinten valt.
U wordt beleefd verzocht uw medewerking te verlenen. Het onderzoek zal een beeld
verschaffen in hoeverre het ziekenhuis voldoet aan de verwachtingen van de patint met
name in het beddenhuis. De resultaten kunnen als input worden gebruikt om de
kwaliteitszorg op een hoger niveau te brengen.
De vragenlijst bestaat uit 3 algemene en 75 specifieke vragen. Bij de algemene vragen
dient u, middels het aankruisen van een vakje, aan te geven in welke klasse u ligt, wie uw
ziektekosten betaalt en wat uw etniciteit is. Bij de specifieke vragen heeft u de keuze
tussen een der volgende antwoordmogelijkheden:
++ :
+ :
+-:
- :
-- :

helemaal eens
eens
noch eens/ noch oneens
oneens
helemaal oneens

Kruist u per vraag slechts 1 vakje aan op pagina 2 tot en met 7.


Ook kunt u uw eventuele opmerkingen plaatsen aan de onderzijde of achterzijde van een
pagina, betreffende het onderwerp.
De antwoorden van de vragenlijsten zijn anoniem. Gelieve de vragen zo eerlijk mogelijk
te beantwoorden.
Bij voorbaat hartelijk dank voor uw medewerking.
Hoogachtend,
.......................
Drs. S. Ramlochan Tewarie

59

Vragenlijst
Algemene informatie
1. Ik ben een patint van de
1ste klasse

2de klasse

3de klasse

2. Wie betaalt uw ziektekosten


Ik zelf/
particulier

SZF

Sociale
Zaken

3. Etniciteit
Javaan

Creool

Hindoestaan

Chinees

Overig

Specifieke informatie
Factor 1. Respect en zorg
Nr.
1

Stelling
++
Het personeel handelt mijn verzoeken
vriendelijk af
In het algemeen is het personeel prettig
in de omgang
Het personeel is vrolijk en vriendelijk

Het personeel is beleefd tegen mij

Het personeel behandelt mij met


respect
Het personeel is zeer vriendelijk

6
7
8
9
10
11

+-

--

+-

--

Het personeel voorziet in mijn wensen


als ik wat vraag
In het algemeen behandelt het
personeel mij met respect
Het personeel schenkt aandacht aan mij
Het personeel behandelt mij op een
zeer behulpzame wijze
Het personeel toont interesse in mij
Stelling
++

61

12
13
14
15
16
17
18

Het personeel is zeer geduldig bij het


vervullen van mijn wensen
Als ik een klacht heb, wordt het snel
behandeld
Het personeel heeft een positieve
houding
Het personeel toont mij waar de dingen
staan die ik nodig heb
In het algemeen helpt het personeel mij
op hun manier
Het personeel is zeer geruststellend

20

Het personeel toont respect voor mijn


rechten als persoon
In het algemeen voldoet het personeel
aan mijn wensen
Het personeel luistert naar mijn wensen

21

Mijn wensen worden snel vervuld

22

Mijn persoonlijke privacy is beschermd

23

Ik ken de namen van mijn verzorgers

24

Ik moet niet wachten op de dingen die


ik vraag
Het verzorgend personeel geeft mij
informatie die ik nodig heb
Ik hoefde niet lang wachten voor
opname

19

25
26

Opmerkingen:

62

Factor 2. Efficiency en continuteit


Nr.
Stelling
++
27
Ik word op de hoogte gesteld van de
noodzakelijke thuiszorg na ontslag
28
In
het
algemeen
doet
het
ziekenhuispersoneel het werk zeer goed
29
Alle voorbereidingen voor ontslag
worden goed getroffen.
30
Ik mag ook helpen beslissen over mijn
nazorg
31
Aan mij wordt informatie verstrekt die
nodig is na ontslag
32
In het algemeen toont het personeel
belangstelling over mijn gesteldheid
33
In het algemeen handelt het
ziekenhuispersoneel zeer deskundig
34
Als ik in pijn heb, proberen zij dat te
verhelpen
35
In het algemeen is het personeel zeer
bekwaam.
36
Het personeel behandelt mij met zorg

+-

--

Opmerkingen:

63

Factor 3. Geschiktheid
Nr.
Stelling
37
De faciliteiten zijn erg schoon
38

De faciliteiten zijn comfortabel

39

In het algemeen zijn de diensten die ik


nodig heb ook aanwezig
In het algemeen zijn de faciliteiten zeer
goed
Het personeel is dienovereenkomstig
gekleed
Ik moest niet veel formulieren invullen
bij de opname
De faciliteiten zijn zeer aantrekkelijk

40
41
42
43
44
45
46
47
48
49
50
51

++

+-

--

De faciliteiten zijn zodanig dat


rekening is gehouden met persoonlijke
privacy
Ik kon goed met het personeel
communiceren
Het is rustig genoeg voor mij
Het ziekenhuis heeft alles dat ik nodig
heb
Ik vind dat zij hun best doen om mij
snel te laten herstellen
Er wordt goed gelet op mijn
persoonlijke spullen
Er is voldoende licht in het ziekenhuis
Ik heb het idee dat mijn wensen
vertrouwelijk worden behandeld.

Opmerkingen:

64

Factor 4. Informatie
Nr.
Stelling
++
52
Ik word snel van informatie voorzien
door de specialisten
53
De specialisten geven mij informatie
die ik nodig heb
54
Specialisten informeren mij over de
resultaten van de onderzoeken
55
De specialisten zijn beschikbaar
wanneer ik ze nodig heb
56
In het algemeen wordt aan mij alle
informatie verstrekt die ik nodig heb
57
De specialisten geven mijn familie de
informatie die zij nodig hebben
58
De afdeling financile administratie
geeft mij de juiste informatie

+-

--

Factor 5. Effectiviteit
59
In het algemeen wordt mijn
ziekenhuisrekening goed afgehandeld
60
Mijn ziekenhuisrekening is conform de
diensten waarvan ik gebruik maak of
heb gemaakt
61
Ik kan/kon mijn ziekenhuisrekening
begrijpen
62
Een personeelslid was beschikbaar om
mij de ziekenhuisrekening uit te leggen
63
Eventuele klachten die ik heb/had over
de ziekenhuisrekening worden/werden
goed afgehandeld

Opmerkingen:

65

Factor 6. Maaltijden
Nr.
Stelling
++
64
In het algemeen waren voeding en
drank heel goed
65
Maaltijden worden op de juiste
temperatuur opgediend
66
Maaltijden zijn lekker
67

Maaltijden worden op tijd opgediend

68

Vuile
borden/glazen
onmiddellijk verwijderd

+-

--

worden

Factor 7. Indruk
69
Het eerste contact met het personeel gaf
mij een goed gevoel
Factor 8. Verschillende personeelsleden
70
Er zijn verschillende personeelsleden
met wie ik te maken kreeg

Opmerkingen:

66

APPENDIX B: Reliability tests


RELIABILITY
/VARIABLES=EFF1 EFF2 EFF3 EFF4 EFF5 EFF6 EFF7 EFF8 EFF9 EFF10
/SCALE('ALL VARIABLES') ALL/MODEL=ALPHA
/STATISTICS=SCALE
/SUMMARY=TOTAL MEANS VARIANCE CORR .

Reliability
[DataSet1] E:\Thesis MBA hfd\data5.sav

Scale: ALL VARIABLES


Case Processing Summary
N
Cases

Valid
Excludeda
Total

%
85,2
14,8
100,0

196
34
230

a. Listwise deletion based on all


variables in the procedure.

Reliability Statistics

Cronbach's
Alpha
,869

Cronbach's
Alpha Based
on
Standardized
Items
,894

N of Items
10

RELIABILITY
/VARIABLES=MLT1 MLT2 MLT3 MLT4 MLT5
/SCALE('ALL VARIABLES') ALL/MODEL=ALPHA
/STATISTICS=CORR
/SUMMARY=MEANS VARIANCE CORR .

Reliability
[DataSet1] E:\Thesis MBA hfd\data5.sav

Scale: ALL VARIABLES

67

Case Processing Summary


N
Cases

Valid
Excludeda
Total

%
89,1
10,9
100,0

205
25
230

a. Listwise deletion based on all


variables in the procedure.

Reliability Statistics

Cronbach's
Alpha
,873

Cronbach's
Alpha Based
on
Standardized
Items
,872

N of Items
5

RELIABILITY
/VARIABLES=RESP1 RESP2 RESP3 RESP4 RESP5 RESP6 RESP7 RESP8 RESP9 RESP10
RESP11 RESP12 RESP13 RESP14 RESP15 RESP16 RESP17 RESP18 RESP19 RESP20
RESP21 RESP22 RESP23
/SCALE('ALL VARIABLES') ALL/MODEL=ALPHA
/STATISTICS=SCALE CORR
/SUMMARY=TOTAL MEANS VARIANCE CORR .

Reliability
[DataSet1] E:\Thesis MBA hfd\data5.sav

Scale: ALL VARIABLES


Case Processing Summary
N
Cases

Valid
Excludeda
Total

%
86,1
13,9
100,0

198
32
230

a. Listwise deletion based on all


variables in the procedure.

Reliability Statistics

Cronbach's
Alpha
,967

Cronbach's
Alpha Based
on
Standardized
Items
,968

N of Items
23

RELIABILITY
/VARIABLES=EFFE1 EFFE2 EFFE3 EFFE5

68

/SCALE('ALL VARIABLES') ALL/MODEL=ALPHA


/STATISTICS=SCALE CORR
/SUMMARY=TOTAL MEANS VARIANCE CORR .

Reliability
[DataSet1] E:\Thesis MBA hfd\data5.sav

Scale: ALL VARIABLES


Case Processing Summary
N
Cases

Valid
Excludeda
Total

%
83,5
16,5
100,0

192
38
230

a. Listwise deletion based on all


variables in the procedure.

Reliability Statistics

Cronbach's
Alpha
,808

Cronbach's
Alpha Based
on
Standardized
Items
,828

N of Items
4

RELIABILITY
/VARIABLES=GESCH1 GESCH2 GESCH3 GESCH4 GESCH5 GESCH6 GESCH7 GESCH8 GESCH9
GESCH10 GESCH11 GESCH12 GESCH13 GESCH14 GESCH15
/SCALE('ALL VARIABLES') ALL/MODEL=ALPHA
/STATISTICS=SCALE CORR
/SUMMARY=TOTAL MEANS VARIANCE CORR .

Reliability
[DataSet1] E:\Thesis MBA hfd\data5.sav

Scale: ALL VARIABLES


Case Processing Summary
N
Cases

Valid
Excludeda
Total

199
31
230

%
86,5
13,5
100,0

a. Listwise deletion based on all


variables in the procedure.

69

Reliability Statistics

Cronbach's
Alpha
,722

Cronbach's
Alpha Based
on
Standardized
Items
,874

N of Items
15

RELIABILITY
/VARIABLES=INFO1 INFO2 INFO3 INFO4 INFO5
/SCALE('ALL VARIABLES') ALL/MODEL=ALPHA
/STATISTICS=CORR COV
/SUMMARY=TOTAL MEANS VARIANCE COV CORR .

Reliability
[DataSet1] F:\Thesis MBA hfd\DATA2.sav

Scale: ALL VARIABLES


Case Processing Summary
N
Cases

Valid
Excludeda
Total

%
76.8
23.2
100.0

146
44
190

a. Listwise deletion based on all


variables in the procedure.

Reliability Statistics

Cronbach's
Alpha
.635

Cronbach's
Alpha Based
on
Standardized
Items
.842

N of Items
5

70

ATTACHMENT C: MAIN QUESTION


COMPUTE sattot = RESP1+RESP2+RESP3+RESP4+RESP5+RESP6+RESP7+RESP8+RESP9
+RESP10+RESP11+RESP12+RESP13+RESP14+RESP15+RESP16+RESP17+RESP18+RESP19
+RESP20+RESP21+RESP22+RESP23+EFF1+EFF2+EFF3+EFF4+EFF5+EFF6+EFF7+EFF8+EFF9
+EFF10+GESCH1+GESCH2+GESCH3+GESCH4+GESCH5+GESCH6+GESCH7+GESCH8+GESCH9
+GESCH10+GESCH11+GESCH12+GESCH13+GESCH14+GESCH15+INFO1+INFO2+INFO3+INFO4
+INFO5+EFFE1+EFFE2+EFFE3+EFFE5+MLT1+MLT2+MLT3+MLT4+MLT5+INDR1+VERSPZ1 .
EXECUTE .
FREQUENCIES
VARIABLES=sattot
/STATISTICS=STDDEV MEAN MEDIAN MODE
/HISTOGRAM NORMAL
/ORDER= ANALYSIS .
Frequencies
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Statistics
sattot
N

Valid
Missing

168
62
201.7024
205.0000
186.00a
40.57750

Mean
Median
Mode
Std. Deviation

a. Multiple modes exist. The smallest value is shown

sattot

Frequency
Valid

Percent

Valid Percent

Cumulative
Percent

88.00

.4

.6

.6

92.00

.4

.6

1.2

127.00

.4

.6

1.8

134.00

.9

1.2

3.0

136.00

.4

.6

3.6

141.00

1.3

1.8

5.4

142.00

.9

1.2

6.5

143.00

.9

1.2

7.7

146.00

.4

.6

8.3

147.00

.9

1.2

9.5

150.00

.4

.6

10.1

151.00

1.3

1.8

11.9

152.00

.4

.6

12.5

155.00

.4

.6

13.1

156.00

.4

.6

13.7

158.00

.4

.6

14.3

160.00

1.3

1.8

16.1

71

161.00

1.3

1.8

17.9

162.00

1.3

1.8

19.6

164.00

.4

.6

20.2

165.00

.9

1.2

21.4

166.00

.4

.6

22.0

167.00

.4

.6

22.6

168.00

1.3

1.8

24.4

169.00

.4

.6

25.0

171.00

1.3

1.8

26.8

172.00

1.3

1.8

28.6

173.00

.4

.6

29.2

174.00

.9

1.2

30.4

176.00

.9

1.2

31.5

178.00

.4

.6

32.1

179.00

1.3

1.8

33.9

180.00

.9

1.2

35.1

182.00

.4

.6

35.7

183.00

.4

.6

36.3

186.00

1.7

2.4

38.7

190.00

.4

.6

39.3

191.00

.4

.6

39.9

192.00

.4

.6

40.5

193.00

.4

.6

41.1

194.00

.9

1.2

42.3

195.00

.9

1.2

43.5

196.00

.4

.6

44.0

197.00

.4

.6

44.6

198.00

1.3

1.8

46.4

199.00

.4

.6

47.0

201.00

.4

.6

47.6

202.00

.4

.6

48.2

204.00

.9

1.2

49.4

205.00

1.3

1.8

51.2

206.00

.4

.6

51.8

207.00

.9

1.2

53.0

208.00

.4

.6

53.6

210.00

.4

.6

54.2

211.00

1.7

2.4

56.5

213.00

.9

1.2

57.7

214.00

.4

.6

58.3

215.00

.4

.6

58.9

216.00

.9

1.2

60.1

217.00

.4

.6

60.7

218.00

.9

1.2

61.9

219.00

.4

.6

62.5

220.00

.9

1.2

63.7

221.00

1.3

1.8

65.5

222.00

1.3

1.8

67.3

223.00

.9

1.2

68.5

224.00

.9

1.2

69.6

225.00

1.3

1.8

71.4

72

226.00

.4

.6

72.0

227.00

.9

1.2

73.2

229.00

.4

.6

73.8

230.00

1.3

1.8

75.6

231.00

.4

.6

76.2

232.00

1.7

2.4

78.6

234.00

1.3

1.8

80.4

235.00

.9

1.2

81.5

238.00

.9

1.2

82.7

240.00

.4

.6

83.3

242.00

1.3

1.8

85.1

244.00

1.7

2.4

87.5

245.00

.4

.6

88.1

247.00

.4

.6

88.7

249.00

.4

.6

89.3

250.00

.4

.6

89.9

251.00

.9

1.2

91.1

252.00

1.3

1.8

92.9

253.00

.4

.6

93.5

256.00

.4

.6

94.0

259.00

.4

.6

94.6

271.00

1.3

1.8

96.4

282.00

.4

.6

97.0

289.00

.4

.6

97.6

292.00

.4

.6

98.2

296.00

.4

.6

98.8

303.00

.4

.6

99.4

308.00

.4

.6

100.0

168

73.0

100.0

Total
Missing
Total

System

62

27.0

230

100.0

73

Histogram

25

Frequency

20

15

10

5
Mean =201.70
Std. Dev. =40.578
N =168
0
50.00

100.00

150.00

200.00

250.00

300.00

350.00

sattot

NPAR TESTS
/K-W=sattot
BY INSURANCE(1 3)
/MISSING ANALYSIS.
NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

sattot

INSURANCE
PRIV

SZF

33

Mean Rank
88.64

49

97.94

SOZA

86

75.26

Total

168

Test Statisticsa,b

Chi-Square
df

sattot
7.086
2

Asymp. Sig.

.029

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

74

ATTACHMENT D: SUB QUESTION 1

NPAR TESTS
/K-W=resptot
BY INSURANCE(1 3)
/MISSING ANALYSIS.
NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

resptot

INSURANCE
PRIV

SZF

39

Mean Rank
104.73

62

114.63

SOZA

95

85.42

Total

196

Test Statisticsa,b

Chi-Square

resptot
10.544

df

Asymp. Sig.

.005

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

NPAR TESTS
/K-W=approptot
BY INSURANCE(1 3)
/MISSING ANALYSIS.
NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

approptot

INSURANCE
PRIV
SZF

N
36

Mean Rank
99.71

66

110.26

SOZA

97

93.13

Total

199

75

Test Statisticsa,b

Chi-Square

approptot
3.479

df

Asymp. Sig.

.176

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

NPAR TESTS
/K-W=effictot
BY INSURANCE(1 3)
/MISSING ANALYSIS.

NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

effictot

INSURANCE
PRIV

N
36

Mean Rank
102.03

SZF

63

109.37

SOZA

97

90.13

Total

196

Test Statisticsa,b

Chi-Square
df

effictot
4.577
2

Asymp. Sig.

.101

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

NPAR TESTS
/K-W=effetot
BY INSURANCE(1 3)
/MISSING ANALYSIS.
NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav

76

Kruskal-Wallis Test
Ranks

effetot

INSURANCE
PRIV

N
35

Mean Rank
88.16

SZF

60

109.66

SOZA

96

90.32

Total

191

Test Statisticsa,b

Chi-Square

effetot
5.426

df

Asymp. Sig.

.066

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

NPAR TESTS
/K-W=infotot
BY INSURANCE(1 3)
/MISSING ANALYSIS.

NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

infotot

INSURANCE
PRIV

N
37

Mean Rank
104.54

SZF

66

107.05

SOZA

99

96.67

Total

202

Test Statisticsa,b

Chi-Square

infotot
1.376

df

Asymp. Sig.

.502

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

NPAR TESTS
/K-W=foodtot

BY INSURANCE(1 3)

77

/MISSING ANALYSIS.
NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

foodtot

INSURANCE
PRIV

SZF

39

Mean Rank
108.73

66

111.92

SOZA

100

94.88

Total

205

Test Statisticsa,b

Chi-Square

foodtot
3.755

df

Asymp. Sig.

.153

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

NPAR TESTS
/K-W=INDR1
BY INSURANCE(1 3)
/MISSING ANALYSIS.
NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

FIRST IMPR

INSURANCE
PRIV
SZF

N
39

Mean Rank
107.78

69

116.30

SOZA

103

98.43

Total

211

78

Test Statisticsa,b

Chi-Square

FIRST IMPR
4.020

df

Asymp. Sig.

.134

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

NPAR TESTS
/K-W=VERSPZ1
BY ZIEKTEKS(1 3)
/MISSING ANALYSIS.
NPar Tests
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Kruskal-Wallis Test
Ranks

STAFF DIV

INSURANCE
PRIV
SZF

N
39

Mean Rank
103.55

69

117.27

SOZA

103

99.38

Total

211

Test Statisticsa,b

Chi-Square
df

STAFF
DIV
4.163
2

Asymp. Sig.

.125

a. Kruskal Wallis Test


b. Grouping Variable: INSURANCE

79

ATTACHMENT E: SUB QUESTION 2


CROSSTABS
/TABLES=KLS BY INSURANCE
/FORMAT= AVALUE TABLES
/STATISTIC=CHISQ CORR
/CELLS= COUNT
/COUNT ROUND CELL .
Crosstabs
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Case Processing Summary
Cases
Valid

Missing

N
CLASS PAT *
INSURANCE

Percent
211

91.7%

Total

Percent
19

8.3%

Percent
230

100.0%

CLASS PAT * INSURANCECrosstabulation


Count
INSURANCE
CLASS
PAT

CLASS1

PRIV
14

CLASS2

13

18

31

CLASS3

12

38

103

153

39

69

103

211

Total

SZF

SOZA
13

Total
27

T-TEST
GROUPS = CLS(1 3)
/MISSING = ANALYSIS
/VARIABLES = satisftot
/CRITERIA = CI(.95) .
T-Test
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Group Statistics

satisftot

CLASS PAT
CLASS1
CLASS3

19

Mean
231.5789

Std. Deviation
44.61105

Std. Error
Mean
10.23448

120

218.0917

46.96235

4.28706

80

Independent Samples Test


Levene's Test for
Equality of Variances

F
satisftot

Equal variances
assumed
Equal variances
not assumed

t-test for Equality of Means

Sig.

.038

.846

df

Sig. (2-tailed)

Mean
Difference

Std. Error
Difference

95% Confidence
Interval of the
Difference
Lower
Upper

1.171

137

.244

13.48728

11.52090

-9.29451

36.26907

1.215

24.756

.236

13.48728

11.09610

-9.37701

36.35157

T-TEST
GROUPS = CLS(2 3)
/MISSING = ANALYSIS
/VARIABLES = satisftot
/CRITERIA = CI(.95) .
T-Test
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav
Group Statistics

satisftot

CLASS PAT
CLASS2

26

Mean
222.0385

Std. Deviation
34.36449

Std. Error
Mean
6.73943

120

218.0917

46.96235

4.28706

CLASS3

Independent Samples Test


Levene's Test for
Equality of Variances

F
satisftot Equal variances
assumed
Equal variances
not assumed

4.219

Sig.
.042

t-test for Equality of Means

df

Mean
Std. Error
Sig. (2-tailed) Difference Difference

95% Confidence
Interval of the
Difference
Lower
Upper

.405

144

.686

3.94679

9.74068 -15.30639 23.19998

.494

47.685

.623

3.94679

7.98741 -12.11572 20.00931

T-TEST
GROUPS = CLS(1 2)
/MISSING = ANALYSIS
/VARIABLES = satisftot
/CRITERIA = CI(.95) .
T-Test
[DataSet1] C:\Documents and Settings\stewarie\Desktop\data5.sav

81

Group Statistics

satisftot

CLASS PAT
CLASS1
CLASS2

19

Mean
231.5789

Std. Deviation
44.61105

Std. Error
Mean
10.23448

26

222.0385

34.36449

6.73943

Independent Samples Test


Levene's Test for
Equality of Variances

F
satisftot Equal variances
assumed
Equal variances
not assumed

2.381

Sig.
.130

t-test for Equality of Means

Mean
Sig. (2-tailed) Difference

df

Std. Error
Difference

95% Confidence
Interval of the
Difference
Lower
Upper

.811

43

.422

9.54049

11.76567 -14.18725 33.26822

.779

32.584

.442

9.54049

12.25416 -15.40290 34.48387

82