Quality Health Care

Introduction

Community participation forms one of the fundamental tenets of the Declaration of Alma-Ata, the rst global attempt of governments to reform the health sector in order to respond to stark health inequities, especially experienced by the poor and vulnerable across countries. Good governance (i.e. strengthening the health sector, addressing social determinants of health) and restoring community voice (ensuring an empowered citizenship) are essential to lasting changes (Chan, 2008). Governments, as the primary duty bearer of this right to health, has to ensure that quality health care servicesappropriate and scientically sound, accessible

and available, aordable and gender-fair and culturally-appropriateare provided to all.

Quality of health care has been traditionally gauged through data routinely collected by existing health information systems that are focused on coverage, morbidity and mortality. ere is, however, an increasing body of knowledge that these fail to suciently capture, among others,

what the instituted reforms are achieving across the range of social values and the associated outcomes that are central to PHC (primary health care): equity, people-centredness, protection of the health of communities and participation.(WHO, 2008:123)

e repercussions of poor quality care cannot be over-emphasized. In the extreme, Brown, Franco, Rafeh, and Hatzell (n.d.) noted that if providers do not oer quality services, they will fail to earn the populations trust, and clients will turn to the health system only when in dire need of curative care.

e Philippines Sentrong Sigla Movement was one of the early local attempts

a Medical Ocer, San Pablo Health Center, Pasay City Health Oceb Medical Ocer, Malibay Health Center, Pasay City Health Oce

Quality Health Care: What Do Patients SayA Five-Year Experience of

Patient Satisfaction Surveys in a

Government Primary Care Health Center

Carl Abelardo T. Antonio MD MPH-cand, Armando C. Leeb

MD MS, Portia Fernandez-Marcelo MD MPH

10

The Sentrong Sigla

movement was one of

the early local attempts

at quality assurance

and continuous quality

improvement in the

Philippines.

172 Part 3: Local Health Systems Development

at quality assurance (QA) and continuous quality improvement (CQI) in the Philippines. Initially intended for health facilities in the context of a devolved health care system, it began in the late 1990s and provided certication and public recognition for health facilities that meet quality standards set by the Department of Health (DOH). is was subsequently merged with accreditation standards of the Philippine Health Insurance Corporation (PhilHealth). One component indicator in both standards is the existence of systematic means of eliciting feedback from patients and their families regarding relevant aspects of care received from a particular facility.

Pasay City, a highly urbanized city in Metro Manila, caters to more than 400,000 individuals in 14 public primary care facilities, 13 of which are Sentrong Sigla-certied. While previously, methods of eliciting client satisfaction has been limited to passive collection of data through provision of client comments box in each health facility, the emergence of CQI standards in Sentrong Sigla, and later PhilHealth, prompted the discussion and implementation of patient satisfaction surveys for the health facilities.

is paper documents ve years experience in conducting patient satisfaction surveys in Malibay Health Center, one of primary care health facilities in Pasay City run by the local government unit. e Center provides major priority health programs of the government including but not limited to maternal and child health care, tuberculosis management, etc. Daily consults at the health center range from 80 to 150 patients, mostly for health promotivedisease preventive maternal and child health care services as well as care for acute respiratory infections. Malibay serves a population of 45,516 in 21 barangays where a big bulk of the Citys urban poor reside. ere is only one physician, two nurses, three midwives, one dentist, one medical technologist, one laboratory aide and an institutional worker; 20 BHWs augment the workforce especially for community health drives.

is paper elucidates the purpose of the patient satisfaction surveys embarked on by the Malibay Health Center sta, processes on how the survey tool was developed and how feedback was elicited from patients, outcomes of the surveys and the response of the Malibay health center sta to survey ndings, culled from available documents and interviews of key informants. Available reports of the UP Urban Health Team were studied. e Malibay health center experience is compared with other similar health facilities through a review of literature. Implications for local policy and options for scaling up and expansion are discussed in latter sections.

Results

Intentions of the PSSt

e PSS was implemented to comply with the requirements of the Sentrong

173Quality Care: What Do Patients Say

Figure 10.1. Comparison of mean scores for patient satisfaction survey 2008-2009, Malibay Health Center, Pasay City

Figure 10.2. Comparison of mean scores for patient satisfaction survey 2008-2009, Malibay Health Center, Pasay City


Figure 10.3: Comparison of mean scores for patient satisfaction survey 2009-2010,Malibay Health Center, Pasay City

Figure 10.4: Comparison of mean scores for patient satisfaction survey 2009-2010,Malibay Health Center, Pasay City


Sigla Level II Certication process, which included, among others, documenting and acting on patient feedback on services provided by the health center. Guidelines of Sentrong Sigla did not dictate any specic format or parameters; the health facilities were given free hand to develop their own feedback mechanism, other than the traditional suggestion box.

Process of development of the PSS tool and administration of tthe survey, collation and presentation of results of the PSS

In 2006, a short written survey developed by the Bureau of Primary Health Care (Health Resources and Services Administration, United States Department of Health and Human Services) was adapted and translated to Filipino by Dr. Rosario Bernardo, a senior resident physician of the Department of Family and Community Medicine (DFCM) of the UP, rotating in Malibay Health Center for the urban Community Medicine urban program.32 In order to allow patients to freely give feedback, the Malibay medical ocer thought a third party, not the health center sta themselves, would be best to administer, organize and present results of the survey. Due to the exigency of the situation (the Sentrong Sigla accreditation team was due anytime), validation of the Filipino survey instrument before it was formally introduced in Malibay Health Center was no longer attempted.

e questionnaire was administered by the resident physican-rotators in 2006, 2007 and 2009; fourth year medical students of the UP, who likewise had their Community Medicine rotation, administered this in 2008 and 2010. Survey forms were given at various times during the second half of each year between the periods 2006 to 2010 to a convenience sample of 100 individuals seeking care in Malibay Health Center. ere was neither standard script nor specic set of instructions to the patients when the forms were administered. e medical trainees devised their own strategies to get the patients to answer the forms while they wait for their turns to be seen by the physician or nurse.

e questionnaire consists of two parts. For Part I, respondents were asked to rate, on a scale of 1 to 5 (1 being the lowest, 5 being the highest), the level of service received, and four aspects of service (e.g. ease of getting care, waiting, sta-provider, nurse/medical assistants, and facilities), which are each measured by at least two parameters (or a total of 15 parameters, excluding general assessment of service). Part II requested respondents to describe what they liked most, and liked

32 e Urban Community Medicine rotation for the DFCM resident physicians from January 2002 to April 2010 had three components, one of which was health center-based. Aside from personal health care and patient education, it provided service-learning opportunities for the medical trainees to concretely con-tribute to health systems and in this case clinic systems improvement based on needs articulated by the patients and health center sta. In mid-2006, the Malibay Health Center was undergoing Sentrong Sigla Level II accreditation; thus, Dr. Bernardo responded to the expressed need.


least, in the health center, and were requested to provide comments or suggestions to improve provision of service in the health center. Scores for each component question were tabulated, and an over-all rating was computed by obtaining the arithmetic mean of the mean parameter scores.

UP medical trainees would then collate and present preliminary ndings of the survey to Malibays medical ocer, who is also charged with the responsibility of health facility management. e ndings would thus guide the choice of topic for the Malibay Health Center sta development activity of the resident-rotator. Summary of results of the survey conducted for the year would then be presented to the rest of the health center sta by the medical trainee/s, feedback and reactions are elicited, action points are decided on for improvement of services. e sta development activity, another service-learning requirement in the rotation, is supposed to be designed to provide additional cognitive handles for the health center sta to respond to one aspect that needs improvement raised in the survey. e summary of survey results would be provided to the Malibay medical ocer. is would also be included in their end-of-rotation nal reports submitted to the UP faculty.

ese end-of-rotation reports had varied formats, however, and raw data no longer available (except for 2010), precluding better analysis across ve years by these authors.

What do patients say? Results of the 2006 to 2010 Surveyst

A total of 500 respondents participated in the survey between 2006 and 2010. Mean scores for each item in Part I of the survey are summarized in Table 1. For this paper, ve-year averages for each parameter and for the over-all score were computed. For the second part of the survey, answers were categorized, and frequencies of responses noted.

Based on the survey results, some observations can be made about the quality of services in Malibay Health Center.

In general, services in Malibay Health Center were rated 4.27 out of a highest possible score of 5.00 [range 3.80-4.47]. Highest scores were given by respondents for the aspect Facility [mean score 4.27], followed by Ease of getting care and Nurse/medical assistants [4.18], Sta-provider [4.16], while the lowest score was given to Waiting [3.85]. Survey respondents felt that inside the center madaling hanapin kung saan pupunta [4.43], and they reported that ang Center ay bukas sa serbisyo ng pumunta kayo [4.42]. However, waiting time (particularly time spent in the reception room, and between the consultation and treatment rooms) was perceived to be long [3.70 and 3.85, respectively].

e surveys show that patients of Malibay Health Center are generally satised with services available in their health facility, since all parameters were given scores greater than 3 (adjectival rating Ok). In fact, 10 of the 15 parameters were

177Q

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lity C

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: Wh

at D

o P

atie

nts

Sa

y

Mga aspeto ng serbisyoYear Five-year

Average

Component

Average2006 2007 2008 2009 2010

Kadalian na makakuha ng pangagalaga 4.18

a. Nakapasok agad sa Center para makita 4.14 4.16 3.45 3.60 4.16 3.90

b. Ang Center ay bukas sa serbisyo ng pumunta kayo 4.50 4.96 4.24 3.90 4.48 4.42

c. Ang lokasyon ng center ay madaling puntahan 4.40 4.73 3.77 3.60 4.56 4.21

Paghihintay 3.85

a. Oras sa reception o waiting room 3.76 4.14 3.38 3.30 3.93 3.70

b. Oras sa consultation o treatment room 3.94 4.28 3.34 3.70 4.06 3.86

c. Paghihintay na may magawang examinasyon 3.86 4.15 3.71 4.10 3.94 3.95

d. Paghihintay makakuha ng resulta 3.82 4.14 3.72 3.80 4.00 3.90

Staff /Tagapagbigay alaga (physician, dentist, physician

assistant, nurse practitioner)4.16

a. Nakikinig sa inyo 4.24 4.56 4.21 3.50 4.24 4.15

b. May sapat na oras para kausapin kayo 4.20 4.59 4.00 3.70 4.26 4.15

c. Naipaliwanag ang gusto ninyo malaman 4.10 4.59 4.11 3.60 4.48 4.18

d. Nagbibigay ng payo sa paggamot 3.88 4.64 4.19 3.70 4.39 4.16

Nurses at Medical Assistants 4.18

a. Mabait, madaling lapitan at matulungin 4.20 4.62 3.54 3.90 4.39 4.13

b. Sumasagot sa inyong katanungan 4.22 4.57 3.95 4.00 4.41 4.23

Pasilidad 4.27

a. Malinis at masinop and center 4.34 4.63 3.78 3.60 4.20 4.11

b. Madaling hanapin kung saan pupunta 4.60 4.71 4.32 4.00 4.52 4.43

AVERAGE SCORE (FOR YEAR) 4.47 4.67 4.05 3.80 4.36 4.27

Table 10.1: Mean scores for patient satisfaction suvey, Malibay Health Center, Pasay City, 2006-2010 (n = 500)


given scores greater than 4 (adjectival rating Good).Across the study period, there was a noticeable decrease in patient scores for

nine of 15 parameters in 2009 [mean decrease of 6.17% compared to 2008 levels] (Table 2). Highest decrement was noted for the aspect Sta-provider [12.12%], followed by Facility [6.08%] and Ease of getting care [2.73%]. With respect to particular parameters, decrease of patient satisfaction scores was most notable (e.g. more than 10%) for three of four Sta-provider parameters: nakikinig sa inyo [16.86%], naipaliwanag ang gusto ninyong malaman [12.41%], and nagbibigay ng payo sa paggamot [11.69%].

Scores in 2010, however, increased by 14.74%, relevant to 2009 levels (Table 10.3). Score increase was highest for the aspects Sta-provider [19.84%] and Ease of getting care [19.03%]. Parameters with signicant (i.e. greater than mean score) score increases were ang center ay madaling puntahan [26.67%], naipaliwanag ang gusto ninyo malaman [24.44%], nakikinig sa inyo [21.14%], oras sa reception o waiting room [19.09%], nagbibigay ng payo sa paggamot

Mga aspeto ng serbisyoScores 2008-2009

Change

Component

Average2008 2009

Kadalian na makakuha ng pangagalaga -2.73%

a. Nakapasok agad sa Center para makita 3.45 3.60 4.35%

b. Ang Center ay bukas sa serbisyo ng pumunta kayo 4.24 3.90 -8.02%

c. Ang lokasyon ng center ay madaling puntahan 3.77 3.60 -4.51%

Paghihintay 5.27%

a. Oras sa reception o waiting room 3.38 3.30 -2.37%

b. Oras sa consultation o treatment room 3.34 3.70 10.78%

c. Paghihintay na may magawang examinasyon 3.71 4.10 10.51%

d. Paghihintay makakuha ng resulta 3.72 3.80 2.15%

Staff /Tagapagbigay alaga (physician, dentist, physician assistant, nurse practitioner) -12.12%

a. Nakikinig sa inyo 4.21 3.50 -16.86%

b. May sapat na oras para kausapin kayo 4.00 3.70 -7.50%

c. Naipaliwanag ang gusto ninyo malaman 4.11 3.60 -12.41%

d. Nagbibigay ng payo sa paggamot 4.19 3.70 -11.69%

Nurses at Medical Assistants 5.72%

a. Mabait, madaling lapitan at matulungin 3.54 3.90 10.17%

b. Sumasagot sa inyong katanungan 3.95 4.00 1.27%

Pasilidad -6.08%

a. Malinis at masinop and center 3.78 3.60 -4.76%

b. Madaling hanapin kung saan pupunta 4.32 4.00 -7.41%

AVERAGE SCORE (FOR YEAR) 4.05 3.80 -6.17%

Table 10.2: Comparison of 2008 and 2009 mean scores for patient satisfaction suvey, Malibay Health Center, Pasay City


Mga aspeto ng serbisyoScores 2008-2009

Change

Component

Average2008 2009

Kadalian na makakuha ng pangagalaga -2.73%

a. Nakapasok agad sa Center para makita 3.60 4.16 15.56%

b. Ang Center ay bukas sa serbisyo ng pumunta kayo 3.90 4.48 14.87%

c. Ang lokasyon ng center ay madaling puntahan 3.60 4.56 26.67%

Paghihintay 7.55%

a. Oras sa reception o waiting room 3.30 3.93 19.09%

b. Oras sa consultation o treatment room 3.70 4.06 9.73%

c. Paghihintay na may magawang examinasyon 4.10 3.94 -3.90%

d. Paghihintay makakuha ng resulta 3.80 4.00 5.26%

Staff /Tagapagbigay alaga (physician, dentist, physician assistant, nurse practitioner) 19.84%

a. Nakikinig sa inyo 3.50 4.24 21.14%

b. May sapat na oras para kausapin kayo 3.70 4.26 15.14%

c. Naipaliwanag ang gusto ninyo malaman 3.60 4.48 24.44%

d. Nagbibigay ng payo sa paggamot 3.70 4.39 18.65%

Nurses at Medical Assistants 11.41%

a. Mabait, madaling lapitan at matulungin 3.90 4.39 12.56%

b. Sumasagot sa inyong katanungan 4.00 4.41 10.25%

Pasilidad 14.83%

a. Malinis at masinop and center 3.60 4.20 16.67%

b. Madaling hanapin kung saan pupunta 4.00 4.52 13.00%

AVERAGE SCORE (FOR YEAR) 3.80 4.36 14.74%

Table 10.3: Comparison of 2009 and 2010 mean scores for patient satisfaction suvey, Malibay Health Center, Pasay City

[18.65%], malinis at masinop ang center [16.67%], nakakapasok agad sa center para makita [15.56%].

When asked what they liked most about the health center, respondents gave as top answers the courteous manner of sta towards patients (mabait, maasikaso, maayos makitungo), and the physical set-up (clean, air-conditioned center). On

NOTES:Respondents were asked to assign scores from 1 to 5 (1 being the lowest, 5 the 1.

highest) for 15 survey parameters

Scores indicated in each cell represent the average score given by 100 respondents for 2.

that particular year

Average Score (for year) represents the mean of the mean scores for all 15 3.

parameters for that particular year

Component Average refers to mean score of parameters for that particular aspect 4.

of service (i.e. average score for parameters malinis at masinop ang center and

madaling hanapin kung saan pupunta would correspond to component average for

Pasilidad)

Highlighted values in column 2008-2009 change indicate scores which are equal to or 5.

lower than over-all score change


the other hand, long waiting time (either on admission, or in transit from the consultation and treatment rooms) was what patients least liked about the health center, in addition to inadequate toilet facilities, and the feeling that the health center was too crowded. Interestingly, at least 20 respondents for each survey cycle reported that they did not dislike anything about the health center.

Suggestions to improve health center service include increasing number of sta, facilitating entry-to-exit time of patients in the facility, and expanding the facility so that it wouldnt be too crowded during consultation hours.

Response of the Malibay Health Center Staff t

Feedback on the survey was provided by data collectors to sta of Malibay Health Center once all data has been collated and analyzed. is was held during a specially convened meeting on a designated a!ernoon a!er the clinic sta has attended to the centers bulk of patients While some patient feedback has been critical of the health center and/or health center sta in certain parameters (i.e. cleanliness, perceived ineciency among sta), the sta nonetheless displayed eagerness to rectify these perceptions or address these patient concerns.

For instance, in 2006, the rst year of the survey, a major comment received from patients was the sta s attitude towards those seeking care in their health facility, with patients lamenting that some sta appeared cold or suplada. While

the sta came naturally on the defensive a!er rst hearing these comments, there was later on a consensus that this perception needs to be addressed.

Hence, subsequent sta development activities were tailored to this particular topic.

Cleanliness of the health center was a recurrent patient concern over the study period, and several mechanisms at ensuring cleanliness of work areas were introduced therea!er. An initial strategy was dubbed Tapat Mo, Linis Mo which emphasized that sta are responsible for ensuring cleanliness of their particular work areas (somewhat similar to the clean-as-you-go mantra in some private oces). is was later on improved to the 10 oclock habit where clean-up activities were performed at this particular hour everyday; clinics were temporarily suspended (for about ve to 10 minutes) while the 10 oclock habit was being performed. Finally, sta were provided a lecture on the 5S strategy to renew behavior on orderliness, cleanliness, standards, and discipline in the workplace, once it was noted that their practice of previous clean-up drives were "agging.

Discussion

Patient satisfaction surveys are acknowledged measures of health sector

Patients as expert

witnesses of care


accountability (specically performance accountability) and community empowerment8,9. Patient satisfaction harnesses the unique vantage point oered by patients as expert witnesses of care in the same way that private sector (i.e. hotels, banks, etc) and even politicians are seeking client feedback to collate information about their services10,11. By using a structured instrument, health managers may be able to screen aspects of care that warrant improvement, and solicit inputs from patients themselves on how to address these problems12. A World Health Organization report (2006) noted that engagement of patients and populations

is critical to quality improvement, because individuals and communities play so many roles within health systems. Either directly or indirectly, they will be nancing care, they will be working in partnership with health workers to manage their own care, and they will sometimes be the nal arbiter of what is acceptable and what is not across all the dimensions of quality.

e challenge to health systems is to ensure that engagement with patients and the population is at the heart of all policies and strategies for quality improvement, and that this commitment is translated into meaningful action. Strategies to this end include those which target improving health literacy, self-care, and patients experience with the health system. Communities and service users will want to be involved in the governance arrangements of the health system; they will want their views and preferences to be heard and taken into account in decision-making; and they will want to share the responsibility for their own health.13

What do patients say?

e surveys show that patients of Malibay Health Center are generally satised with services available in their health facility. On a scale of 1 to 5, with 5 being the highest, all parameters were given scores greater than 3 (equivalent to OK).

In fact, 10 of the 15 parameters were given scores greater than 4 (equivalent to a rating of Good). ese annual surveys have armed work of the health sta although they know more is still expected of them.

While the patient satisfaction survey documented in this paper was the rst systematic attempt at capturing patients perceptions with regards the quality of

care they are receiving as far as Pasay City is concerned, the extent to which generalizations can be made from available data are, however, precluded by several methodological limitations.

The surveys show that

patients of Malibay

Health Center are

generally satis!ed with

services available in their

health facility.


Improvements needed

First, while the survey instrument used in the conduct of the surveys was adapted from an existing, validated, and patient- and health care professional-developed tool in use since 19997, it is best that its translation into a Filipino checklist should still have been validated.

While the parameters of quality care used in the survey generally hold true and are applicable for all health systems, evidence from literature and local context need to be taken into account in the formulation of criteria or components for the survey. For instance, accessibility, waiting time, time spent with care provider, and providers technical and interpersonal skills were deemed important indicators of quality care14,15,16. Westaway, Rheeder, Van, and Seager (2003) suggested that patient satisfaction was strongly determined by interpersonal relations (e.g. Age, gender, socioeconomic, and ethnic dierences in patients assessments of primary health care) and organizational characteristics (e.g. Age, gender, socioeconomic, and ethnic dierences in patients assessments of primary health care); hence eorts at constructing patient satisfaction surveys must integrate and highlight these two domains17. Patient input, however, need to be viewed with respect to their expectations of the health team, current health status, and other sociodemographic factors (e.g. age, educational attainment, gender)18,19. It cannot be overemphasized that the construction of the survey instrument must be guided by input from patients themselves, since the very essence of a patient satisfaction survey is to capture what individuals value, and what they are looking for when they seek care in a health facility.

Second, sample size determination using acceptable statistical methodologies was not formally conducted for the survey. e sample size of 100 was an arbitrary gure, deemed appropriate and suciently large enough to account for biases or errors in sampling.

Lack of randomization, and limitation of survey respondents to those who are seeking care at the time data collectors are conveniently present in Malibay Health Center, may have disenfranchised some segments of the patient population who might be able to provide more insightful comments regarding the quality of services in the health facility. e feeling of a congested health center atmosphere, with more patients waiting behind them, might have also in"uenced survey respondents to quickly complete the survey without much thought on the quality, and accuracy, of answer being provided.

Since there is a constant shi! of resident- and medical student-rotators, methods of patient selection, respondent orientation, and data collection varied through the ve-year study period. e manner in which enumerators introduced the tool to respondents may have a bearing on the respondents understanding of the value and use of the survey questionnaire.


Institutionalizing a student requirement into a systemic and systematic process for CQI

The presence of academic partners and student af!liates of the Pasay

city Health Of!ce should be maximized, especially since the education

sector equally values research towards continuous quality improvement.

As partners of the City Health Of!ce, the faculty can be engaged as

stakeholder to standardize this system for student involvement in this

regular QA activity.

Essential respondent demographic information was noticeably absent in the reported survey summaries made available to the authors, and no data was available for Part II of the survey for the years 2006 and 2007.

Finally, while what was provided the authors were computed mean parameter scores, and some trends can be deduced from these, analysis of patterns and ranges of scores given for each parameter would have provided more insightful and relevant information for stakeholders.

Despite all these limitations, however, it must be emphasized that the activity documented in this paper is the rst attempt at institutionalizing patient satisfaction survey in the context of the Pasay City health system. Hence, while "aws may be present in the methodology of the survey, the pioneering nature of this endeavor means that it can be used as the basis for the development of a more systematic and scientically-sound survey in Pasay City in the future.

It must be noted that for years prior to 2006, the only mechanism available in Pasay City health centers for patients to be heard were through comments/suggestions boxes placed inside health centers, or through personal reports or letters addressed to health facility sta or supervisors. Utilization of either channel has been low, with the latter being used as a last resort for perceived grave oenses or serious cases of sta demeanor.

Actively soliciting feedback, on the other hand yields a robust throve of information, as documented in this paper, which can be, and is actually, used for instituting critical reforms, particularly on aspects of service patients feel need improvement, but which sta may not perceive as a problem. Patient feedback in Malibay Health Center, for instance, prompted the institution of a ve-minute break in health center operations to maintain cleanliness and order in the health center.

Conduct of survey by third-party individuals or groups appear to be essential to obtaining patient feedback. e residents and medical students who conducted the survey may have been perceived by patients as bearing no direct interest in obtaining only positive comments. Alternatively, respondents may have felt that


providing negative or critical feedback to residents and medical students will not threaten or aect future sta attitudes towards these patients since (a) personal information of respondents will be kept condential, and (b) data collectors are only assigned in the health facility for a limited period, compared to sta who are permanently assigned (or at least given long-term posts) in the health center.

A post script on Patient Satisfaction Surveys

While a patient satisfaction survey is able to capture essential feedback on services from individuals seeking care in a health facility, it must be noted that the PSS, by its very nature, limits itself only to those individuals seeking care in a health

facility, naturally excluding the voice of patients who are not seeking carea contravention of the fundamental idea of community participation and health for all. Using the ree Delays Model developed for analyzing maternal mortality, it must be emphasized that the decision to seek care is a composite of various factors, the most important

of which is the quality of care being provided in a facility (which in turn may be attributed to sta competence and behavior, availability of essential drugs and supplies, facility management)20.

Hence, it is imperative that any attempt at conducting PSS in a health facility be complemented with community-based surveys especially intended for those who are not seeking care in that health center. With these, a more comprehensive and complete picture of the quality of care may begin to emerge, facilitating the health workers appreciation of patients perception of services they are providing, and ultimately, guiding policy development and institution of needed change in all levels of the health system to truly embody the call made 30 years ago in Alma-ata of ensuring health for all peoples.

Prospectus

Pasay Citys vision of being home to self-reliant, healthy and morally upright people will be operationalized in the next ve years through the City-wide Investment Plan for Health 2011-201521. A key intervention in the said Plan is the institutionalization of patient satisfaction surveys in the Pasay City health system over the medium-term. is is part of the nationwide continuing reforms of the health system towards the promised universal health care.

With the experience of conducting patient satisfaction surveys in Malibay Health Center, we recommend the following:

A patient satisfaction survey

is able to capture essential

feedback on services but

is limited only to those individuals seeking care in a health facility


development of a more appropriate survey questionnaire by both health professionals and patient groups. While the focus on patient satisfaction and the short, easily administered nature of the current questionnaire should undoubtedly be retained, it is imperative that parameters, based on inputs by stakeholders, be tailored to the local context. e input by patients on what they liked most and liked least culled from the ve year studies should be further complemented by focused group discussions. Likewise, input of the health sta, health administrators, government administrators including politicians should be factored in. Furthermore, validation of the tool must be undertaken prior to its wide-scale use.determination of statistically acceptable and logistically feasible survey methodology (e.g. sample size, sampling design, frequency of data collection, means of data analysis and interpretation)continuation of the conduct of survey by student aliates / medical trainees trained in data collection using the patient satisfaction survey questionnaire. Standard scripts will have to be developed (1) for use of the Health Center physician or nurse to orient the faculty and students on the purpose of the QA activity, and processes associated with it (2) for use of the students as they administer the surveys to patients, explaining purpose and process to ll out the forms. Furthermore, a standard way of data collation, reporting and storage must be set in place. designation of a quality assurance program coordinator who will be in- charge of managing processes related to conduct of regular - either annual or biannual - patient satisfaction surveys. Budgets must be alloted, and /or external resources tapped to ensure that CQI activities such as this is regularly held as a standard management activity of the City Health Oce.

In summary, we have presented Malibay Health Centers experience in conducting patient satisfaction surveys, highlighting strengths and limitations of the current system, which may be used as springboards for discussion and development of a better patient satisfaction survey that will be implemented on a city-wide scale.


Acknowledgement

e authors would like to acknowledge the contribution of residents of the Department of Family and Community Medicine, Philippine General Hospital, as well as medical clerks of the University of the Philippines College of Medicine, in providing collated results of surveys they conducted over the ve-year study period. ey likewise provided a review of literature on the topic. Special mention is accorded to Dr. Ma. Rosario C. Bernardo who initiated in 2006 what would become the basis for subsequent patient satisfaction surveys conducted in Malibay Health Center, and to the faculty of the Section of Community Medicine who encouraged and supervised continual conduct of surveys through the years.

Salamat din!

Dr. Hector SM Dionisio, Dr. Louie R. Ocampo,

Clinical Clerks Serrano, Sese, Simbulan, Sobrio, Suarez, Suguitan, Sumalapaoi, Sy, Sy, Taladua, Tan, Tanayan, Tanchuling, Tiu, Totanes, Abello, Abuel, Adala, Agustin, Aman, Amurao, Arada, Bacena, Baclay, Bismark, Bragais


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