This chapter discusses the related topics, the literature and studies reviewed as well; it also showed the theoretical, conceptual and analytical frameworks. Literature cited was bridged in the present study. Likewise, literatures cited were synthesized. Terms used in the study were defined for easy reference.
Review of Related Literature and Studies
Health Care Delivery in the Philippines
The Philippine Health Care Delivery. Health care system is an organized plan of health services. The rendering of health care services to the people is called health care delivery system. Thus, health care delivery system is the network of health facilities and personnel which carries out the task of rendering health care to the people. In the Philippines health care system is complex set of organizations interacting to provide an array of health services.
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In the Philippines the components of the health care delivery system as mandate of the Department of Health (DOH) is to be responsible for the following: formulation and development of national health policies, guidelines, standards and manual of operations for health services and programs; issuance of rules and regulations, licenses and accreditations; promulgation of national health standards, goals, priorities and indicators; development of special health programs and projects and advocacy for legislation on health policies and programs. The primary function of the Department of Health is the promotion, protection, preservation or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services (E.O. No. 119, Sec. 3).
The DOH vision is "Health as a right. Health for All Filipinos by the year 2000 and Health in the Hands of the People by the year 2020." While its mission is "DOH, in partnership with the people to ensure equity, quality and access to health care by: making services available; arousing community awareness; mobilizing resources; and promoting the means to better health.
In the Philippine healthcare setting health care facilities are level as Level I, Level II, and Level III. Level I (Primary Level of Health Care Facility) are the rural health units, their sub-centers, chest clinics, malaria eradication units, and schistosomiasis control units are directly operated by the DOH; puericulture centers operated by League of Puericulture Centers; tuberculosis clinics and hospitals of the Philippine Tuberculosis Society; private clinics, clinics operated by the Philippine Medical Association; clinics operated by large industrial firms for their employees; community hospitals and health centers operated by the Philippine Medicare Care Commission and other health facilities operated by voluntary religious and civic groups.
The Level II (Secondary Level of Health Care Facilities) is the smaller, non-departmentalized hospitals including emergency and regional hospitals. The services offered to patients with symptomatic stages of disease, which require moderately specialized knowledge and technical resources for adequate treatment. While the Level III (Tertiary Level of Health Care Facilities) are the highly technological and sophisticated services offered by medical centers and large hospitals. These are the specialized national hospitals. The services rendered at this level are for clients afflicted with diseases which seriously threaten their health and which require highly technical and specialized knowledge, facilities and personnel to treat effectively.
Health care workers are also classified. There are three levels of health workers in the Philippine. These are: the village or grassroots health workers; the intermediate level of health workers; and the first line hospital personnel. The village or grassroots health workers are the first contacts of the community and initial links of health care. They provide simple curative and preventive health care measures promoting healthy environment and participate in activities geared towards the improvement of the socio-economic level of the community like food production program. These are the barangay health worker, volunteers or traditional birth attendants or hilot.
The intermediate level of health workers represents the first source of professional health care. They attend to health problems beyond the competence of village workers and provide support to front-line health workers in terms of supervision, training, supplies, and services. These are the medical practitioners, nurses and midwives. While the first line hospital personnel provide backup health services for cases that require hospitalization and establish close contact with intermediate level health workers or village health workers. These are the physicians with specialty, nurses, dentist, pharmacists, and other health professionals.
Parts of the healthcare setting are patients. A patient is any recipient of healthcare services. According to Wikipedia, the patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider. The word patient originally meant "one who suffers". This English noun comes from the Latin word patiens, the present participle of the deponent verb, patior, meaning 'I am suffering,' and akin to theGreek verb Ï€Î¬ÏƒÏ‡ÎµÎ¹Î½ (= paskhein, to suffer) and its cognate noun Ï€Î¬Î¸Î¿Ï‚ (= pathos) (en.wikipedia.org/wiki/Patient).
Patients' satisfaction with an encounter with health care service is mainly dependent on the duration and efficiency of care, and how empathetic and communicable the health care providers are. It is favored by a good doctor-patient relationship. Also, patients that are well informed of the necessary procedures in a clinical encounter, and the time it is expected to take, are generally more satisfied even if there is a longer waiting time. (Pulia, 2011)
Patient satisfaction represents a complex mixture of perceived need, expectations and experience of care. "Quality healthcare" can cover a wide spectrum. It may be structural quality which relates to dimensions such as continuity of care, costs, accommodation and accessibility; while process quality involves the dimensions of courtesy, information, autonomy and competence. The terms "service quality" refer to a set of issues including communication, sign posting, information provision and staff interaction with patients. Interpersonal aspects of quality and amenities of care together with the technical aspects of quality to be the three components of health care quality. The interpersonal component of quality is defined as the quality of interaction between the patient and provider or the responsiveness, friendliness, and attentiveness of the healthcare provider.
Patient satisfaction focuses on clinical interaction in specific healthcare settings whereas responsiveness evaluates the health system as a whole. Patient satisfaction generally covers both medical and non-medical aspects of care while responsiveness focuses only on the non-health enhancing aspects of the health system. Patient satisfaction represents a complex mixture of perceived need, individually determined expectations and experience of care.
Satisfaction is a relative judgment. It is a comparison between perceived performance and aspiration. The basic point to asses' satisfaction is to measure the extent to which aspirations are met given the self perceived performance level. Both the level of aspiration and of perceived performance has to be measured. This is necessary because aspirations may be unrealistic given the level of available resources while evaluation of performance levels by individuals may differ widely from the actual or objective levels of achievement.
Patient-related factors. A citied in the study of Thiedke (2007) patients' demographic and social factors are a minor factor in patient satisfaction, while others concluded that majority of the demographics represent the variance in rates of satisfaction. On the other hand, the literature does shed some light on how particular demographic factors affect patient satisfaction. The most consistent result was the finding of Haviland, et. al., (2006), which was older patients tend to be more satisfied with their health care. Studies that have looked at ethnicity have generally held that being a member of a minority group is associated with lower rates of satisfaction. Most studies have found that individuals of lower socio economic status and less education tend to be less satisfied with their health care. However, the study of Kersnik, et, al, (2001) found that frequent visitors to a family practice had lower educational status, lower perceived quality of life, and higher anxiety and depression scores and were more satisfied with their family physician. Other studies have shown that poorer satisfaction with care is associated with experiencing worry, depression, fear or hopelessness (Frostholm, 2005), and having a psychiatric diagnosis such as schizophrenia, post-traumatic stress disorder or drug abuse (Desai 2005).
Physician-related factors. According to literature physicians can promote higher rates of satisfaction by improving the way they interact with their patients. Possibly the most important characteristics of a physicians is to take the time and effort to elicit patients' expectations. A study of Rao, et. al., (2005) shows that when physicians recognize and address patient expectations, satisfaction is higher not only for the patient but also for the physician; it may help to remember that patients often show up at a visit desiring information more than they desire a specific action. In addition, Bell, et. al. (2001) found out that approximately few patients had one or more unvoiced desires in a visit with their physician. The desire for a referral or for physical therapy was the most common. Young and undereducated patients were more likely to experience unmet needs at their visit, and they demonstrated less symptom improvement and evaluated their visit less positively.
Communication. Shaw, and his colleague (2005) presented that doctor-patient communication can also affect rates of satisfaction. When patients who presented to their family physician for work-related, low-back pain felt that communication with the physician was positive (i.e., the physician took the problem seriously, explained the condition clearly, tried to understand the patient's job and gave advice to prevent re-injury), their rates of satisfaction were higher than could be explained by symptom relief. As cited by Thiedke, (2007) in his study physicians can also improve patient satisfaction by relinquishing some control over the encounter. Studies have found that when physicians exhibited less dominance by encouraging patients to express their ideas, concerns and expectations, patients were more satisfied with their visits and more likely to adhere to physicians' advice. Thus, Patient satisfaction can also be influenced by physicians' medical decision making. Patients expressed a preference for physicians who recognized the importance of their social and mental functioning as much as their physical functioning.
The Webster's Dictionary defines communication as "the imparting or interchange of thoughts, opinions, or information by speech, writing, or signs." Whereas the spoken words contain the crucial content, their meaning can be influenced by the style of delivery, which includes the way speakers stand, speak, and look at a person (Joint Commission Resources; 2005). The collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for patient care.
Collaboration between physicians, nurses, and other health care professionals increases team members' awareness of each others' type of knowledge and skills, leading to continued improvement in decision making. Effective teams are characterized by trust, respect, and collaboration, one of the greatest proponents of teamwork. Teamwork, is believes, to be endemic to a system in which all employees are working for the good of a goal, who have a common aim, and who work together to achieve that aim. When considering a teamwork model in health care, an interdisciplinary approach should be applied. Unlike a multidisciplinary approach, in which each team member is responsible only for the activities related to his or her own discipline and formulates separate goals for the patient, an interdisciplinary approach combine a joint effort on behalf of the patient with a common goal from all disciplines involved in the care plan.
The pooling of specialized services leads to integrated interventions. The plan of care takes into accounts the multiple assessments and treatment regimens, and it packages these services to create an individualized care program that best addresses the needs of the patient. The patient finds that communication is easier with the cohesive team, rather than with numerous professionals who do not know what others are doing to manage the patient.
It is important to point out that fostering a team collaboration environment may have hurdles to overcome: additional time; perceived loss of autonomy; lack of confidence or trust in decisions of others; clashing perceptions; territorialism; and lack of awareness of one provider of the education, knowledge, and skills held by colleagues from other disciplines and professions. However, most of these hurdles can be overcome with an open attitude and feelings of mutual respect and trust. A study determined that improved teamwork and communication are described by health care workers as among the most important factors in improving clinical effectiveness and job satisfaction. (Flin, et. al., 2003)
Extensive review of the literature shows that communication, collaboration, and teamwork do not always occur in clinical settings. For example, a study by Sutcliff, Lewton, and Rosenthal (2004) reveals that social, relational, and organizational structures contribute to communication failures that have been implicated as a large contributor to adverse clinical events and outcomes. Another study shows that the priorities of patient care differed between members of the health care team, and that verbal communication between team members was inconsistent (Flin, 2003). Other evidence shows that more than one-fifth of patients hospitalized in the United States reported hospital system problems, including staff providing conflicting information and staff not knowing which physician is in charge of their care (Cleary, et. al., 2003).
Over the past several years, we have been conducting original research on the impact of physician and nurse disruptive behaviors (defined as any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment) and its effect on staff relationships, staff satisfaction and turnover, and patient outcomes of care, including adverse events, medical errors, compromises in patient safety, poor quality care, and links to preventable patient mortality. Many of these unwanted effects can be traced back to poor communication and collaboration, and ineffective teamwork (Rosenstein, et. al., 2005).
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Unhappily, many health care workers are used to poor communication and teamwork, as a result of a culture of low expectations that has developed in many health care settings. This culture, in which health care workers have come to expect faulty and incomplete exchange of information, leads to errors because even conscientious professionals tend to ignore potential red flags and clinical discrepancies. They view these warning signals as indicators of routine repetitions of poor communication rather than unusual, worrisome indicators. (Chassin, 2002)
Although poor communication can lead to tragic consequences, a review of the literature also shows that effective communication can lead to the following positive outcomes: improved information flow, more effective interventions, improved safety, enhanced employee morale, increased patient and family satisfaction, and decreased lengths of stay. (Joint Commission Resources, 2005). Gittell and others (2000) show that implementing systems to facilitate team communication can substantially improve quality. Effective communication among staff encourages effective teamwork and promotes continuity and clarity within the patient care team. At its best, good communication encourages collaboration, fosters teamwork, and helps prevent errors.
In health care environments characterized by a hierarchical culture, physicians are at the top of that hierarchy. Consequently, they may feel that the environment is collaborative and that communication is open while nurses and other direct care staff perceive communication problems. Hierarchy differences can come into play and diminish the collaborative interactions necessary to ensure that the proper treatments are delivered appropriately. When hierarchy differences exist, people on the lower end of the hierarchy tend to be uncomfortable speaking up about problems or concerns. Intimidating behavior by individuals at the top of a hierarchy can hinder communication and give the impression that the individual is unapproachable (Joint Commission Resources, 2005; Weick, 2002 ) .
Staff who witness poor performance in their peers may be hesitant to speak up because of fear of retaliation or the impression that speaking up will not do any good. Relationships between the individuals providing patient care can have a powerful influence on how and even if important information is communicated. Research has shown that delays in patient care and recurring problems from unresolved disputes are often the by-product of physician-nurse disagreement. Several results of research has identified a common trend in which nurses are either reluctant or refuse to call physicians, even in the face of a deteriorating status in patient care. Reasons for this include intimidation, fear of getting into a confrontational or antagonistic discussion, lack of confidentiality, fear of retaliation, and the fact that nothing ever seems to change. Many of these issues have to deal more with personality and communication style (Rosenstein. 2002). The major concern about disruptive behaviors is how frequently they occur and the potential negative impact they can have on patient care. Our research has shown that 17 percent of respondents to our survey research in 2004-2006 knew of a specific adverse event that occurred as a result of disruptive behavior. A quote from one of the respondents illustrates this point: "Poor communication" postop because of disruptive reputation of physician resulted in delayed treatment, aspiration, and eventual demise." (Rosenstein, 2005)
Time spent. Time spent during a visit plays a role in patient satisfaction, with satisfaction rates improving as visit length increases. Time spent chatting during the visit was also related to higher rates of satisfaction. Physicians with high-volume practices were more efficient with their time but had lower rates of patient satisfaction, offered fewer preventive services and were viewed as less sensitive in the doctor-patient relationship (as cited by Thiedke, 2007). Interestingly, one study showed that while physicians felt rushed 10 percent of the time, patients felt that way only 3 percent of the time. Patient satisfaction was identical whether the physician did or did not feel rushed. This suggests that physicians may be more sensitive to feelings of being rushed and their feelings may not reflect the actual time spent during the visit. (Lin, et. al., 2001)
Technical skills/quality. In the healthcare delivery, healthcare quality has two distinct facets: technical quality (also called quality in fact) and functional quality. Technical quality refers to the accuracy of medical diagnoses and procedures, and is generally comprehensible to the professional community, but not to patients. Study conducted by Jaipul (2003) patient perceives functional quality as the manner in which the service is delivered. Functional quality perceptions may influence future decisions to return to a facility for service. Some empirical evidence suggests that patients' quality judgment may be positively associated with technical quality, as reflected in outcomes such as risk-adjusted mortality among hospitalized patients for medical conditions (Lin, et. al., 2002).
Technical quality cannot be attained without the technical skills of the health care personnel. The study conducted by Chang, et. al. (2006) has looked at patients' assessment of their physicians' technical skills and the effect on satisfaction, but the findings are contradictory. However, Fung, et. al., (2005) study found that when forced to make a trade-off, participants expressed a strong preference for physicians who have high technical skills. Otani, et. al., (2005) findings revealed that patients also indicated that a physician's ability to make the correct diagnosis and craft an effective treatment plan were more important than his or her "bedside manner."
System-related factors. Patient satisfaction is not simply a product of the patient's demographics and the physician's skills. It is also affected by the system in which care is provided. Otani's (2005) findings disclosed that although it is clear that patients' first concern is their doctor, but they also value the team with which the doctor works with. One study (Wolosin, et, al., 2005) found that while physician care was most influential to patients' satisfaction, the compassion, willingness to help and promptness of the physician's staff were next in importance. In another large database of surveys, nurses were the next most important source of satisfaction, ahead of access-to-care issue. Patients who had remained in a practice for more than 15 years attributed their loyalty to their physician first and to the "team concept" second as cited by Thiedke (2007). Effective referrals play a role in patient satisfaction (Roseanne et. al., 2006) . One study looked at referrals from the standpoint of the family physician, the referral physician and the patient, and found that satisfaction with the referral's outcome was higher when the family physician initiated the referral (Bekkelund , et. al., 2005). Similarly, a study of patients treated for recurring headaches revealed that those who self-referred to a neurologist were less satisfied than those whose primary doctor had referred them. A survey of cancer patients found that they valued their family physician highly and wanted to maintain contact with him or her, even when they were receiving cancer care elsewhere (cited by Thiedke 2007).
Donahue, et. al. (2005) states that continuity of care, one of the pillars of family medicine, is felt to have suffered under managed care Norman, et. al., (2001). While it is unclear to what degree patients in general value continuity of care, it is clear that patients who have been followed by their physician for more than two years are more satisfied with their care - particularly when they are able to see their own physician (Gary, et. al, (2005). Beach et. al.. (2005) exposed that patients who reported being treated with dignity and who were involved in decisions were more satisfied and more adherent to their doctor's recommendations. Stelfox, et. al, (2005) exposed that patient satisfaction surveys of inpatient physician performance showed an inverse relationship between satisfaction and risk management episodes. In addition, physicians can find practical take-away lessons in the literature, such as the following: treat patients with dignity and include them in decision making; work with a team; elicit patients' concerns; and dress in semiformal attire and always smiling. Lastly, while it may not be as easy as the above lessons, find pleasure in what you do. Physicians who report high professional satisfaction have patients who are more satisfied with their care. (Haas, et. al., 2000).
Synthesis of the Arts
Studies of Thiedke (2007), Haviland, et. al., (2006), Haviland, et. al., (2006), Frostholm (2005), and Desai (2005) studied if there is significant relationship between demographic profile and patient's satisfaction. Studies of Rao, et. al., (2005), and Bell, et. al. (2001) focused on the physician-related factors of patient satisfaction. This patient satisfaction was attributed in recognizing and addressing patient expectations while Bell, et. al. (2001) looked into the desire for a referral or for physical therapy as the reason for patient satisfaction.
Shaw, and his colleague (2005), Thiedke (2007), Flin, et. al., 2003, Sutcliff, Lewton and Rosenthal (2004), Chassin (2002), and Rosenstein, et. al., 2005 presented that doctor-patient communication can also affect rates of satisfaction. Extensive review of the literature shows that communication, collaboration, and teamwork do not always occur in clinical settings. An example was the study by Sutcliff, Lewton, and Rosenthal (2004) reveals that social, relational, and organizational structures contribute to communication failures that have been implicated as a large contributor to adverse clinical events and outcomes.
Jaipul (2003) and Lin, et. al., (2002) studied on the technical quality (also called quality in fact) and functional quality. While the study conducted by Chang, et. al. (2006), and Fung, et. al., (2005), and Otani (2005) has looked at technical skills of the health workers. The study of Otani (2005) also center on system related factor such as teamwork of other health professional, Wolosin, et. al., (2005) stress that compassion and willingness to help of the health care professions, Bekkelund, et. al., (2005) and Roseanne et. al., 2006 disclosed referrals as factors that persuade patient satisfaction. Donahue, et. al. (2005), Norman, et. al. (2001) states that continuity of care are factors that offer patient satisfaction. (Gary, et. al, (2005), Beach et. al.. (2005), Stelfox, et. al., (2005), and (Haas, et. al., 2000), exposed that patients who reported being treated with dignity, as factors that influence patient's satisfaction.
Gaps Bridged by the Study
While most of the literature cited which had been reviewed concerned whether there is relationship between demographic profile and patient's satisfaction, physician-related factors addressing patient expectations the desire for a referral or for physical therapy was the reason for patient satisfaction. Extensive review of the literature shows that communication, collaboration, and teamwork do not always occur in clinical settings. Technical quality, technical skills of the health workers, communication and teamwork of other health professional, compassion and willingness to help, patients who reported being treated with dignity as factors that influence patient's satisfaction were also studied. However, there is no research yet conducted on the same topic and on the recommendations to have quality management program of the healthcare services at Dr. Fernando B. Duran Sr. Memorial Hospital (DFDMH).
This study will be anchor to Expectation Fulfillment Theory by Linder-Pelz (1982). Expectations, which are central to the consumer model, play in determining satisfaction with healthcare. The work of Linder-Peltz on the interaction between patient expectations and perceptions is seen to be particularly influential in this respect. Linder-Peltz's viewed expectations have an effect on satisfaction independent of other variables (i.e., irrespective of their fulfillment) leading to conclude that this is not to say that expressions of satisfaction have little to do with the qualities of the service provided or the care offered and clearly "engendering positive expectations' must not be confused with raising false hopes which deliberately mislead patients. Even so, the assumption that satisfaction is entirely the product of an evaluation by itself but it may not apply in all situations.
In this regard Zeithaml, et. al., (1990) have noted that while consumers ultimately judge the quality of services on their perceptions of the technical outcome provided and how that outcome was delivered (process quality), many professional services are highly complex and a clear outcome is not always evident. This is certainly true of many healthcare scenarios where the technical quality of the service- the actual competence of the provider or effectiveness of the outcome - is not easy to judge. The patient may never know for sure whether the service was performed correctly or even if it was needed in the first place. Williams (1994) has observed that the greater the perceived unexplained or technical nature of treatment the more likely it is that many service users will not believe in the legitimacy of holding their own expectations, or of their evaluations (Zelthaml, et. al., 1990).
In addition, if a service user is coming into contact with the system for the first time then expectations, which for many have been formed through past experience, might be waiting formation. In both cases a patient might wish for the health professional to adopt a paternalistic role in the relationship ('doctor knows best') while they themselves remain a passive partner. Donabedian (1980) sees quality of healthcare as a trilogy comprising 'structure, process and outcome'( Zeithaml, et. al., 1990). However, Shaw (1984) argue that service users who cannot judge the technical quality of the outcome effectively will base their quality judgments on structure and process dimensions such as physical settings, the ability to solve problems, to empathies, time-keeping, courtesy and so on.
This study is also anchored on Lydia Hall's Care, Core and Cure theory. The CARE focuses on hands-on bodily care and the belief that a caring touch and thorough assessment is therapeutic. This nurturing component which is also referred to as "mothering" the patient, is done with the goal of comforting the patient and helping them meet their needs. The "motherly" care provided by nurses and the medical staff may include, but is not limited to provision of comfort measures, provision of patient teaching activities and helping the patient meet their needs where help is needed. The members of the staff help the patient or the family in accepting and adapting to the emotional and other stresses the condition may bring. It also opens channels of communication to allow expression of feelings and help the patient/family work out through it. Thus, it is utilized when patient is provided with care and teachings at each phase of the nursing process, providing him/her with comfort both physiologically and psychosocially.
According to the theory, the CORE is the person or patient to whom nursing care is directed and needed. The core (patient) has goals set by him/herself and not by any other person, and that these goals need to be achieved. The "core", in addition, behaved according to his feelings, and value system. In Hall's theory, "core" refers to using therapeutic communication to help the patient understand not only his condition, but also his life. The goal is to help patients learn their roles in the healing process. Thus, it is realized when the patient is able to express his/her feelings about the procedure and participates in exploring these feelings, helping him/her towards a faster recovery.
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