ASSESSMENT OF PATIENT SATISFACTION

WITH SERVICES PROVIDED BY F. H. C IN

ELMONEEB-GIZA-EGYPT

By

Ahmed Bayoumy Mohamed Elgabry

(M.B., B.Ch.)

Submitted to The Egyptian Board of Family Medicine in

Partial Fulfillment for The Degree of Fellowship in Family
Medicine

Supervised By

Prof. Dr. Gabr Metwally Sayed

Professor of Community Medicine and Public Health,
Faculty of Medicine, Al-Azhar University

Egyptian Fellowship of
Family Medicine
2009
 ‫بسم اهلل الرحمن الرحيم‬

‫{فبما رحمة من ال له لنت لهم و لو كنت‬

‫فظ ا غليظ الق لب لنفضوا من حولك‪،‬‬
‫ف اعف عنهم واستغفر لهم وشاورهم فى‬
‫األمر‪ ،‬ف إذا عزمت فتوكل على ال له إن‬
‫ال له يحب المتوكلين }‬
‫آل عمران‬
‫اآلية التاسعة و الخمسون بعد المائة‬

‫‪ii‬‬
 DEDICATION

To my parents and older brothers who lighted the first candles

in my mind, to my family who were the victims of my interest in
medicine and to every doctor who has the will and the intention to
help his patients the way he respects and the way they expect.

iii
 ACKNOWLEDGEMENTS

To the special people whose support has encouraged me to

fulfill this study in particular Prof. Dr. Gabr Metwally Sayed for
your guidance and patience throughout the entire process. You are
always available for your students.
I have also to acknowledge all the staff working in Elmoneeb
Family Health Center for their help and facilitation specially the
manager, Dr. Iman Lotfy Elsayed. Thanks are to be expressed to my
trainer Dr. Hanaa Abdel Elah for her great support. I’d like also to
express my deepest thanks and sincere gratitude to every participant
in this study, those simple people who were patient while I was
asking a long list of questions trying to probe the truth from their
hearts and minds through their simple language.

iv
 IDIOMS AND DIALECTS

 A review of the literature reveals practical ways to improve patient

satisfaction and compelling reasons to do so.
[Thiedke C (2007)]

 A patient is a person and not a statistic. It is our job to satisfy him.

[Credo W (1921)]

 One reason our customers are so satisfied is that we aren’t.

[Honda Automotive Co. Slogan (1998)]

 We’ll never be 100% satisfied until you are, too.

[Cigna Advertisers Co. (2002)]

 In the past man has been first. In the future the System will be first.
[Taylor WF (1995)]

 Excellence is not a gift from the gods. It is a human trait that is acquired
only by relentless training and ruthless self-assessment…. We are what
we repeatedly do. Excellence is not a glamorous or singular
achievement. It’s a habit.
[Gardner J (1993)]

v
 TABLE OF CONTENTS

Subject Page
Cover Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Entree from the Holy Quran . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii
DEDICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
ACKNOWLEDGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
IDIOMS AND DIALECTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2. LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
CUSTOMERS OF HEALTH CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
DEFINITION OF PATIENT SATISFACTION . . . . . . . . . . . . . . . . . . 14
MODELS OF PATIENT SATISFACTION AND COMPLIANCE . . . 15
A. Satisfaction Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
B. Compliance Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
COMPONENTS OF PATIENT SATISFACTION . . . . . . . . . . . . . . . . 23
DETERMINANTS OF PATIENT SATISFACTION . . . . . . . . . . . . . . 23
1. Patient characteristics and psychosocial determinants . . . . . . . . 23
2. Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
a. Definition of expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
b. Classification of expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

vi
 c. Importance of expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
d. Prioritization of patient expectations . . . . . . . . . . . . . . . . . . . . . . 25
e. Influence of patient expectations on patient satisfaction . . . . . . . 25
PATIENT-CENTEREDNESS STRATEGY . . . . . . . . . . . . . . . . . . . . . 26
Applicable patient centeredness methods and techniques . . . . . . . . . . . 29
1. Health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2. Public reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
3. Needs assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4. Shared decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5. Patient-held records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
GOALS OF PATIENT SATISFACTION STRATEGY. . . . . . . . . . . . 32
A. Elimination of the patient turnoffs . . . . . . . . . . . . . . . . . . . . . . . 32
1. Value turnoffs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2. System turnoffs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3. People turnoffs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
B. Exceeding customer expectations . . . . . . . . . . . . . . . . . . . . . . . . 33
Ways (opportunities) for achieving E-plus . . . . . . . . . . . . . . . . . . . . . . 34
PATIENT SATISFACTION AS A DYNAMIC PROCESS . . . . . . . . . 36
IMPORTANCE OF PATIENT SATISFACTION . . . . . . . . . . . . . . . . 37
IMPACT OF PATIENT SATISFACTION ON COMPLIANCE . . . . . 39
Influence of patient satisfaction on patient adherence and compliance 44
PATIENT SATISFACTION, A TOOL FOR BEHAVIOR CHANGE 49
Understanding Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
PATIENT SATISFACTION AS A QUALITY DETERMINANT 52
Quality from different perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Patient Satisfaction as a Dimension of Quality . . . . . . . . . . . . . . . . . . . 56

vii
Application of Patient Satisfaction concept in QM Principals . . . . . . . 56
Patient Satisfaction in the Quality Management Process . . . . . . . . . . . 59
History of quality and patient satisfaction . . . . . . . . . . . . . . . . . . . . . . . 62
Patient Satisfaction as a basis of total quality management (TQM) . . . 65
CORRELATIONS OF PATIENT SATISFACTION . . . . . . . . . . . . . . 66
A. Socio-demographic Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
B. Physician’s behaviors and patient health status . . . . . . . . . . . . . . 72
C. Other correlates of patient satisfaction . . . . . . . . . . . . . . . . . . . . 83
PATIENT MANAGEMENT CONCEPT . . . . . . . . . . . . . . . . . . . . . . . 86
FAMILY MEDICINE MODEL OF PRACTICE . . . . . . . . . . . . . . . . . 89
ACCESSIBILITY AS A PREREQUISITE. . . . . . . . . . . . . . . . . . . . . . 92
MEDICAL CONSULTATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
PATIENT SATISFACTION, A COMMUNICATION OUTCOME 94
PATIENT RESPECT, THE KEY FOR PATIENT SATISFACTION 97
ELICITING THE PATIENT'S AGENDA . . . . . . . . . . . . . . . . . . . . . . 98
PATIENT SATISFACTION RELATION TO THE TIME FACTOR 99
1. Effect of consultation time on patient satisfaction . . . . . . . . . . . 99
2. Out-of-hours care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
NURSES AS SATISFACTION PROMOTERS . . . . . . . . . . . . . . . . . 103
THE MARKETING MIX, A PATIENT SATISFACTORY TOOL . . . 103
PATIENT SATISFACTION IN PRACTICE . . . . . . . . . . . . . . . . . . . 105
ASSESSMENT OF PATIENT SATISFACTION . . . . . . . . . . . . . . . . 106
Methods used for assessment of patients’ wants and needs . . . . . . . . . 106
Measurement Scales of Patient Satisfaction . . . . . . . . . . . . . . . . . . . . . 108
General characteristics of satisfaction instruments . . . . . . . . . . . . . . . . 114
Patient Satisfaction Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

viii
Types of surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Surveys Challenges and negative assumptions . . . . . . . . . . . . . . . . . . . 117
Importance of surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Factors affecting assessed patient satisfaction . . . . . . . . . . . . . . . . . . . . 118
1. Patient-related factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
2. Physician-related factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
3. System-related factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
4. Survey related factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
PATIENT SATISFACTION IN SPECIAL SITUATION . . . . . . . . . . . 127
1- Emergency medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
2- Complaining patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
3- Difficult patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
4- Elderly patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
5- Uncertainty in diagnosis and management . . . . . . . . . . . . . . . . . . 144
6- Breaking bad news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7- Referring procedure as a satisfaction challenge . . . . . . . . . . . . . . 150
PEARLS OF EXPERIENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
I. Increasing satisfaction by noting patient interests . . . . . . . . . . . . 154
II. The three secrets strategy for patient satisfaction . . . . . . . . . . . . . 154
III. The three secrets methodology for patient satisfaction . . . . . . . . 156
IV. The ten keys to a positive first impression . . . . . . . . . . . . . . . . . . 155
V. Skills for ending the medical visit with greater satisfaction . . . . . 160
3. THE AIM OF THE STUDY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
4. SUBJECTS AND METHODS . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 167

ix
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
The setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Research Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Authorization Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Selection of Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Inclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Process and procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Data collection (administrative procedures) . . . . . . . . . . . . . . . . . . . . . 175
Statistical analysis and representation . . . . . . . . . . . . . . . . . . . . . . . . . 175
Ethical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Limitations and obstacles of the study . . . . . . . . . . . . . . . . . . . . . . . . . 176
5. RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Description of Sample (Demographics) . . . . . . . . . . . . . . . . . . . . . . . . 180
Characteristics of the non utilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Utilization Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Awareness Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Accessibility Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Perception of the services prices (fees) . . . . . . . . . . . . . . . . . . . . . . . 195
Availability of resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Waiting area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Manners of the staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Competence of the staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Social approach of the doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

x
Topics of patient centered model of practice . . . . . . . . . . . . . . . . . . . . . 198
Health education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
General patients’ satisfaction score . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Feedbacks of the open questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
6. REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
7. APPENDICES . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . 235
1. Checklist for the content of patient information materials . . . . . . 236
2. The ten most common customer service mistakes . . . . . . . . . . . . 237
3. Patients’ expectations whenever they make a complaint . . . . . . 238
4. Key principles of patient management . . . . . . . . . . . . . . . . . . . 239
5. Overall rank order of patients' priorities . . . . . . . . . . . . . . . . . . . . 240
6. Reasons for referral from primary care physicians to specialists 241
7. The questionnaire used in the study . . . . . . . . . . . . . . . . . . . . . . . 242
8. The answer sheet used in the study . . . . . . . . . . . . . . . . . . . . . . . . 249
9. The ABCDE Mnemonic for Breaking Bad News . . . . . . . . . . . 250
10.The Approved request for authorized permission . . . . . . . . . . . . . 252
11.Map of the catchment area of Elmoneeb FHC . . . . . . . . . . . . . . . 253
12.Performance Indicators of Elmoneeb FHC in April 2009 . . . . . . 254

13.The mission of Elmoneeb FHC . . . . . . . . . . . . . . . . . . . . . . . . . . 255

14.Services presented by Elmoneeb FHC . . . . . . . . . . . . . . . . . . . . . 256
15.Results of similar study conducted simultaneously by
independent entity on a larger scale . . . . . . . . . . . . . . . . . . . . . 257

xi
 ABBREVIATIONS

ACT Affective Communication Test

AN Appointment Noncompliance
CD Compact Disk
(dis) satisfaction satisfaction or dissatisfaction
(dis) satisfied satisfied or dissatisfied
DO’s things to do
DONOT’s things not to do
CTA Classification Tree Analysis
ED Emergency Department
E-Plus the process of exceeding customer expectations
ER Emergency Room
FFS Fee For Service Plan
FHC Family Health Center
FHID Factored Homogeneous Item Dimension
FHR Family Health Record
GP General Practitioner
HBM Health Beliefs Model
HES Hogan Empathy Scale
HLOC Health Locus of Control
HRQL Health-Related Quality Of Life
IPS Interpersonal Skills
JCAHO Joint Commission for Accreditation of Health Care
Organizations
MISS Medical Interview Satisfaction Scale
MOH Ministry Of Health

1
MOHO Model of Human Occupation
MOHP Ministry Of Health and Population
MUPS Medically Unexplained Physical Symptoms
NAHQ National Association of Healthcare Quality
PCC Primary Care Center
PCPQ Physician’s Clinical Perspective Questionnaire
PDM physician Participatory Decision-Making style (the physician-
patient interaction)
PI Performance Improvement
PONS the Profile of Nonverbal Sensitivity
PPI Patients’ Perceptive Interview
PPG Prepaid Group Practice plan.
PRFSS the Patient Request For Services Schedule
PSQ Patient Satisfaction Questionnaire
QM Quality Management
RIAS Roter Interaction Analysis System
SCAs Sustainable Competitive Advantage
SCQ Standardized Compliance Questionnaire
SMS Snyder Self-Monitoring Scale
SPC Statistical Process Control
TQM Total Quality Management
USCB United States Census Bureau
USA United States of America
VSQ Visit-Specific Satisfaction Questionnaire
WHO World Health Organization
WWII World War II

2
 LIST OF TABLES

PAGE Table number and title

90 Table (1) Stages and steps of a management plan [Jones R et al.

(2004)]
126 Table (2) Most important factors affecting patient satisfaction. [Mertz
MG (1999)]
133 Table (3) Client complaint procedures [Griffiths A (2006)]
134 Table (4) Characteristics associated with difficult patients [Jones R et
al. (2004)]
143 Table (5) Content and design for an information sheet as a take
homemessage
161 Table (6) The bathe technique, a structured, time-sensitive method for
addressing psychosocial issues. [Stuart MR, Lieberman JA (1993)]
180 Table (7) Percentages of males, females, married and unmarried
participants in the sample
181 Table (8) Percentages of participants in different levels of education
182 Table (9) Percentages of participants among different age groups
183 Table (10) Percentages of participants attending various departments
in the health care facility
183 Table (11) Percentage of the participants working in each job category
187 Table (12) Percentages of participants reporting different reasons for
accessing the health facility
188 Table (13) Percentages of participants reporting different reasons for
non utilization

3
PAGE Table number and title

190 Table (14) Suggestions of the non utilizers for improving the quality of
the service
191 Table (15) Health education fulfillment rate among the non utilizers
193 Table (16) Percentages of participants in various utilization indicators
203 Table (17) The general satisfaction rates given by the participants

4
 LIST OF FIGURES
PAGE Figure number and title
19 Figure (1) The Health Belief Model as a predictor of preventive health
behavior [Becker M and Maiman L (1975)]
21 Figure (2) The Model of Human Occupation [Chen et al. (1999)]
60 Figure (3) The process of quality control
64 Figure (4) The process of quality improvement
65 Figure (5) The quality improvement in TQM model [Egyptian MOHP
Health Reform program (2007)]
88 Figure (6) Psychosocial factors may cause changes in disease
susceptibility. [Cohen S and Herbert TB (1996)]
169 Figure (7) The distribution of population under 15 years on different
age groups in Elmoneeb district.
180 Figure (8) Percentages of males, females, married and unmarried
participants in the sample
181 Figure (9) Percentages of participants in different levels of education
182 Figure (10) Percentages of participants among different age groups
184 Figure (11) Percentage of participants attending various departments in the health
care facility
185 Figure (12) The percentage of the participants working in each job category
187 Figure (13) Percentages of participants reporting different reasons for
accessing the health facility
188 Figure (14) Percentages of non utilization reasons reported by the non-
utilizers
201 Figure (15) The percentages of participants ranking best
202 Figure (16) The percentages of participants ranking worst services or
aspects of services

5
 ABSTRACT

Objectives: To measure the level of satisfaction with primary health care

services in Elmoneeb FHC, Giza, Egypt.
Methodology:
Design and setting: A community based cross sectional study that involved
a descriptive survey design by means of interviewing attendants in Elmoneeb
FHC using a self developed survey instrument tailored for measuring patient
satisfaction with primary health care services presented in the mentioned
health facility.
Study participants: Total of one hundred consecutive patients were
approached out of which 85% were females, 86% were married, 72% were in
the age group 20 to 39 years old, the education level of 55% was high school
education while 24% were not educated at all, 67% were not working, 30%
were working in various work profiles and 3% were students.
Main outcome measure: Percentages of participants’ evaluation feedbacks
for specific parameters and indicators regarding the services they receive in
the facility mentioned.
Results: General satisfaction score represented by the mean value was
67.9%, 20% access the facility as it was easily accessible and 17% as the
services are good. The distance to the facility from the participants’ homes
took less than 15 minutes in the majority (71%).More than half of the
participants (53%) were utilizing four to six services out of ten health care
services presented by the health care facility. 25% were aware of only one up
to three services. 63% reported that the facility was fairly equipped. 48%
considered the nurses’ dealing and communications manners accepted, 79%
reported that the doctor’s communication style was welcoming and friendly

6
and 26% of the participants complained of the bad manners of the personnel
in the charge at the ticket office. 43% of the participants reported that the
nurse was fairly competent while 50% of the participants reported that the
doctor was competent and 57% considered the medical examination was
through and excellent. 44% of the participants ignored that they were told the
name and nature of the diseases affecting them. The highest ranked service
was the pregnant mother follow up and the highest ranked aspects of services
were easy accessibility and affordable prices while the lowest ranked service
was the tickets office and the lowest ranked aspects of services were the
waiting area and loss of discipline.
Conclusions: General patient satisfaction score in Elmoneeb, Giza was
67.9%. It was affected by paramedical staff and non medical aspects of
services. The staff manners and communication skills had an impact on
patient satisfaction just as their competence.
Keywords: Patient Satisfaction, Primary Health Care, Quality Improvement,
Patient Survey, Health Care Marketing, Patient/Doctor Communications.

7
 CHAPTER 1

INTRODUCTION

8
 CHAPTER 1
INTRODUCTION

Theories and models derived from job satisfaction and consumer

literature have been applied to the medical environment. [Sitzia J and Wood
N (1997)] and [DiPalo M (1997)]
Patient satisfaction has been identified as an attitudes or affective
response that depends on expectations (beliefs that something will happen)
and whether they are met or not. [Linder-Pelz S (1982)]
Since the introduction of managed care, interest in patient satisfaction
has increased, and it has been considered one of the core outcome measures
of health care because of its impact on effectiveness and efficiency of a
health care program. [Sitzia J and Wood N (1997)] and [DiPalo M (1997)]
Many health care plans have incorporated family physicians who have
not only treated the patient, but also played a key role in granting (or
denying) access to other medical providers. In other common plans, patients
may not have had a personal physician; rather they were required to see
whoever was available on the day of their clinic visit. Thus, patients have
been greatly concerned with the kind of care received under the financial
restraints of modern health service delivery. [Sitzia J and Wood N (1997)]
and [DiPalo M (1997)]
Since managed health care has been on the rise in Egypt along with the
health reform that incorporates the application of family medicine model, it is
important that patients trust their physicians and are satisfied with the care
they have received.
Patients who are more satisfied with their medical care, have shown
greater compliance, healed quicker, complained less, have had more trust in

9
the care provider, and have been less likely to engage in litigation. [Merkel
W (1984)] and [DiPalo M (1997)]
There has been an intuitive appeal to believe that patient satisfaction
would be easy to assess and would largely mirror health provider (i.e.,
physician) perceptions. Yet, studies have routinely reported that physicians’
assessment of patient satisfaction may vary greatly from patients’ actual
satisfaction with an office visit. [Suchman A et al. (1993)] and [Wolf M et
al. (1978)]
Because patient satisfaction is a complex construct, researchers have
moved from uni-dimensional to multidimensional conceptualizations of
patient satisfaction. [Merkel W (1984)], [Wolf M et al. (1978)] and [DiPalo
M (1997)]
For example, patient satisfaction may include assessment of cognitive
elements (e.g., how well the patient understood their diagnosis and treatment
regimen), affective components (e.g., did the patient feel cared for as a
person rather than as a medical problem) and behaviors that care providers
may have exhibited during an examination. Similarly, the object of patient
satisfaction ratings has varied from direct care providers (e.g., physicians,
nurses, and auxiliary staff) to the ease of navigating the multitude of
administrative requirements and the perceived cleanliness of the facility.
[Sitzia J and Wood N (1997)], [Wolf M et al. (1978)], [Batchelor C et al.
(1994)],[ Buhrlen-Armstrong B et al. (1998)], [DiPalo M (1997)], [Hall JA
and Dornan M (1988)], [Kohlmann, T and Raspe H (1998)] and [Keith R
(1998)]
However, patients’ ratings of their physicians during an office visit
have become the focus of patient satisfaction literature. The Medical
Interview Satisfaction Scale (MISS) was developed specifically to assess

10
patients’ perception of the physician-patient interaction that occurred during
an office visit. [Wolf M et al. (1978)] and [Willson P and McNamara J
(1982)]
It has been used to assess patients’ thoughts, feelings, and reactions to
physician behavior.

11
 CHAPTER 2

LITERATURE REVIEW

12
 CHAPTER 2
LITERATURE REVIEW

CUSTOMERS OF HEALTH CARE

“Meeting customer’s needs and expectations” is a client perspective
definition for quality. Well-designed services create customer satisfaction
because they provide the features or characteristics that customers need.
Customers’ satisfaction is a high priority for any organization.
The better an organization meets its customers’ needs by providing the
right combination of desirable features the higher its revenue is likely to be.
Before exploring patient satisfaction as a concept it is needed to identify the
customers of health care.
Customers are all those affected by the work of health care providers.
They could be classified as external and internal customers.

External Customers
External customers are not a part of the organization that provides the
service. Patients are the most obvious external customers in healthcare.
However, there are other customers as well such as third-party payers,
insurance companies, employers or government agencies (who pay the bills
for most patients) and the referring doctors who refer their patients to the
organization to receive a specific service as immunization for example.
Internal Customers
Internal customers are those within the organization who are affected
in some way by the work. Satisfaction of the external customers will not
achieved without satisfying the needs of the internal customers. For example,

13
when prescribing medication to an inpatient, the attending nurses are internal
customers of the hospital’s pharmacy. Nurses need to have the medicine
delivered at the right time, in the correct form, and the correct dosage. The
patient’s needs cannot be met unless the related needs of the nurses are
satisfied.

DEFINITION OF PATIENT SATISFACTION

Satisfaction is the feeling that one gets what he needs to get, what he
has to get and what he deserves to get.
There is a lack of clarity as to what patient satisfaction is conceptually
and a general lack of grounding in any theory. Generally, satisfaction is
assumed to result from the fulfillment of expectations; however, there is little
actual empirical evidence of this. [Williams B, Coyle J, and Healy D
(1998)]
Patient (customer) satisfaction happens when the consumer believes
that the service is superior to what is known of competitors, likes that service
more than others and intends to buy the focal service as opposed to
alternatives when buying decisions are taken. [Cambridge (2008)]
Other authors define patient satisfaction as an attitudes or affective
response that depends on expectations (beliefs that something will happen)
and whether they are met or not. There are three theoretical formulations that
could be used in understanding patient satisfaction:
 The first is discrepancy theory, which posts that satisfaction is the
perceived or relative discrepancy between what an individual desires
and what they receive.

14
  The second theory, fulfillment theory, is similar however it is not the
relative but the absolute difference between what is desired and
received that is important.
 Finally, equity theory holds that satisfaction is perceived equity, “or
perceived balance of inputs and outputs.” An important component of
this last theory is the comparison process that the individual uses to
determine satisfaction. [Linder-Pelz S (1982)]
Some suggest that Satisfaction is not a single concept made up of
multiple determinants, but that there exist three independent models of
satisfaction, each associated with one determinant. Thus, there is the “need
for the familiar”, the “goals of help-seeking” and the “importance of
emotional needs”. Furthermore, there is evidence that there are two states of
satisfaction, stable ones related to health care generally and dynamic ones
related to specific health care interactions. [Sitzia J and Wood N (1997)]

MODELS OF PATIENT SATISFACTION AND COMPLIANCE

A. Satisfaction Models
Research typically has been conducted to test theories to explain the
phenomenon of particular constructs. Patient satisfaction and compliance
have not been unique to this process.
In 1982, Linder-Pelz proposed the value-expectancy model that was
based on job satisfaction to explain patient satisfaction. Essentially, patient
satisfaction (attitude) is the sum product of belief strength (e.g., how strongly
one believes) and attribute evaluations (e.g., access, efficacy, cost,
convenience, etc.) of health care. For example, the patient would rate each
attribute using two measures. First, the patient decided to what degree they

15
believed in the attribute. Second, the patient positively or negatively rated
that attribute. Finally, the two scores were multiplied together and the
product summed, providing a patient satisfaction score (attitude). [Linder-
Pelz S (1982)], [DiPalo M (1997)] and [Pascoe G (1983)]
Linder-Pelz conducted a study using 125 patients visiting a primary
care clinic for the first time. Data incorporated health care values,
expectations, and sense of entitlement to care. Unfortunately, no support was
found for the value expectancy model. [Pascoe G (1983)] and [Williams B
(1994)]
Researchers have attributed the lack of support to both methodological
(e.g., mixing items and scale references) and fundamental (e.g.,
multiplication of determinants that may be independent to one another)
problems. [Pascoe G (1983)]
Alternative models constructed to explain patient satisfaction adapted
from the expectancy model are: the discrepancy theory, fulfillment theory,
and equity theory. [Pascoe G (1983)] and [Williams B (1994)]

The discrepancy theory suggested that satisfaction was the result of

what the individual desired compared to what the individual actually
experienced. Essentially the calculation required the individual to rate the
percentage of an outcome received based on the amount of what the
individual expected. [Pascoe G (1983)] and [Williams B (1994)]
For example, the ratio between the patient’s desires and the patient’s
experiences indicated the greatest patient satisfaction when these desires
were equal.
Conversely, the less the desires met in proportion to the desires
expected, would indicate that patients were least satisfied. For example, if an

16
individual had an insurmountable number of expectations and only a few
were met, then this would indicate that the patient was not satisfied. Whereas,
if an individual had a reasonable number of expectations and the same
expectations as mentioned above were met, then this would indicate that the
patient was satisfied. The problem with this measure is that the quality of the
expectations was not considered in the calculation. For instance, if patients
had very low expectations and did not receive a high quality of care, yet all
expectations were met, then this would indicate that the patient was very
satisfied. The fundamental flaw with this theory was that the desires met may
be of greater importance than the desires expected, yet this was not
considered for the patient satisfaction calculation.
The fulfillment theory defined satisfaction as the difference between
rewards desired and rewards received. For example, patients who greater
desires have met than expected would have positive patient satisfaction
scores, whereas patients who had less desires met than expected would have
negative patient satisfaction scores.
The fundamental problem with this theory was that if individuals had
equal expectations and experiences, then the patient satisfaction score was
zero indicating no satisfaction at all.
Furthermore, feedbacks from individuals who had many experiences
and expectations indicated that the person is not satisfied, when in fact the
person is just expecting more. [Pascoe G (1983)]
The equity theory defined satisfaction as a social comparison process
of perceived equity. Basically, did the perceived balance of inputs and
outputs of one patient equal the perceived balance of inputs and outputs of
another patient? Based on the literature, it is uncertain exactly how this
comparison was measured. [Williams B (1994)]

17
 Basically, the models that have been identified describing patient
satisfaction have empirical support, but they only accounted for a small
degree of variance in patient satisfaction.
Therefore, no specific patient satisfaction theory or model is superior
to another. However, the findings clearly suggested that expectations and
perceptions may play a role in determining patient satisfaction and these
experiences may be somewhat independent of actual ones received.

B. Compliance Models
As researchers investigated the physician-patient relationship and the
influence of the relationship on the patient’s health behavior (compliance),
models of compliance emerged.
One of the first models designed to describe and predict patient
behavior was termed the Health Beliefs Model (HBM). The HBM has been
described as a value expectancy model. [Becker M and Maiman L (1975)]
The HBM contains three major elements:
(1) Individual perceptions (e.g., perceived susceptibility to disease,
perceived severity of the disease).
(2) Modifying factors consisting of internal or external stimulus that
triggers the appropriate health behaviors (e.g., demographic
variables, social variables, psychological variables, media messages
that influence perceived threat of the disease, cues of action).
(3) Likelihood of action based on the person’s evaluation of the
recommended health behavior (e.g., perceived benefits perceived
barriers, likelihood of taking recommended preventative health
action). Figure (1)

18
INDIVIDUAL PERCEPTIONS MODIFYING VARIABLES LIKELIHOOD OF ACTION

Perceived benefits
Demographic variables (age, sex, of preventive
race, ethnicity, etc.) action

Socio-psychological variables minus

(social class, peer and reference Perceived barriers

group pressure, etc.) to preventive
action

Likelihood of
Perceived Taking
Susceptibility to
Perceived
Disease .X. Recommended
Threat of
Perceived Preventive Health
Seriousness Disease X. Action
(Severity) of

Disease .X.

Cues of Action

Mass media campaigns

Advice from others

Reminder postcard from

physician or dentist

Illness of family member or

friend

Newspaper or magazine
article

Figure (1) The Health Belief Model as a predictor of preventive

health behavior [Becker M and Maiman L (1975)]

19
 Technically, the perceptions of the person’s susceptibility and
seriousness of a disease influenced the perceived threat, which in turn
influenced the likelihood of taking recommended preventative health action
(perceived benefit). [Becker M and Maiman L (1975)]
Simply, the HBM considered the social and psychological factors that
affected compliance. Numerous studies evaluated a variety of preventive
health behaviors and sick role behaviors that have substantially supported the
HBM through empirical research. [Wilson B (1995)]
Specifically, the perceived barriers element was the most consistent
and favorable theoretical dimension supported for both the preventive health
behaviors and the sick role behavior studies. [Becker M and Maiman L
(1975)] and [Wilson B (1995)]
That is, the greater the perceived barriers the less likely a person
engaged in health care behavior. Perceived susceptibility contributed the
most to preventive health behaviors. For example, perceived susceptibility to
disease was positively correlated with the level of compliance with physician
recommendations (e.g., obtain screenings for cancer and heart disease) and
the engagement in preventive health actions (e.g., immunizations) reported.
[Becker M and Maiman L (1975)]
Perceived benefits contributed most to the sick role behavior. For
example, positive correlations were found with the level of compliance and
the belief that the screening was accurate and could lead to a better prognosis
of cancer. [Becker M and Maiman L (1975)]

The model has been cited with three specific downfalls. First, the focus
on avoiding illness does not address other issues that may have motivated one

20
to exercise other than for health reasons (e.g., enjoyment). Second, the focus
was on one specific reason that affected one behavior rather than multiple
behaviors that occurred regularly over time. Third, the HBM best predicted
whether a person would engage in detection-type health behavior (i.e.,
complete a medical screening) rather than ongoing health-promotion type
behaviors. Derived from his Social Learning Theory, the Health Locus of
Control (HLOC) model was first introduced by Rotter. [Ley P (2001)]

The Open System

Volition Subsystem
Input Output
Personal
Causation Habituation
HLOC
Subsystem

HBM Compliance
M
Occupational
Values
HBM Performanc
Interests e
Subsystem

Interests

Feedback (changes in symptoms,

over all improvement and other
benefits)

Figure (2) The Model of Human Occupation [Chen et al. (1999)]

21
 The HLOC referred to the concept that health is controlled by the
patient, chance, or powerful others, which may influence compliance
behaviors. [Chen C et al. (1999)]
An individual who believes the outcomes are based on the behaviors
one has employed (e.g., taking an active role in treatment) has an internal
locus of control. On the other hand, an individual who believes the outcomes
are based on luck, chance, or powerful others (e.g., the physician didn’t tell
me when to start rehabilitation) has an external locus of control. Typically,
individuals had a combination of these beliefs; however, most individuals
have fallen closer to one end of the scale. In a cross-sectional design study,
individuals who had a stronger belief in the internal locus of control initially
had fewer problems with treatment; however over time they became more
frustrated and noncompliant when the individual could not control their
disease. [Wilson B (1995)]
The Model of Human Occupation (MOHO) included similar HBM and
the HLOC concepts, but was considered more comprehensive because it
accounted for the interests of the individual, the patient’s roles, and reported
physical capacity housed within three specific subsystems. [Chen C et al.
(1999)] (Figure 2)
The patient’s values and interests (volition subsystem) were believed
to correspond to the perceived benefits in the HBM and the personal
causation element in the MOHO correlated to the HLOC.
Additionally, the patient’s roles (habituation subsystem) and the
reported physical capacity (performance subsystem) were expected to
influence the patient’s behavior. The variables selected were specific to three
models believed to be relevant to compliance:

22
 (1) The Model of Human Occupation (MOHO).
(2) The Health Beliefs Model (HBM).
(3) Health Locus of Control (HLOC).
A 19-item health beliefs survey was used to measure the components of the
HBM (e.g., perceived severity, benefits, barriers and self-efficacy). [Chen C
et al. (1999)]

Limited support has been found for the MOHO, and what support has been
found encompasses the characteristics of the HLOC and the HBM models.

COMPONENTS OF PATIENT SATISFACTION

Components of satisfaction consist of three aspects of care:
1. The structural aspects that include: access, physical setting, costs,
convenience, and treatment by non-clinical staff/insurers.
2. The technical aspects that include knowledge, competence/quality of care,
interventions, and outcomes.
3. The interpersonal aspects that include: communication, empathy, and
education.

DETERMINANTS OF PATIENT SATISFACTION

Determinants of satisfaction are patient characteristics and
psychosocial determinants along with patient expectations.
1. Patient characteristics and psychosocial determinants: There is a
relationship between patient satisfaction and patient characteristics, the
former is found to be associated with age and education and nearly
significantly associated with social and marital status. More satisfied
patients tended to be older, white, male, of higher social class, and
married. The associations may be due to response patterns on the part of

23
 the groups identified or they may be mediated by events and processes
that occur during the medical care encounter. [Hall J and Dornan M
(1990)]
2. Expectations:
a. Definition of expectations: Normative expectations are defined as
patients' opinions about what should happen, either because it is
desirable in itself or because it is related to specific values or objectives.
This should not be confused with descriptive expectations which are
ideas about what will actually happen, regardless of whether this is
desired or not (background expectations). Priorities are normative
expectations that are most important within a larger set of expectations.

b. Classification of expectations: according to weather they are related

to the patient or the doctor, expectations are divided into two main
groups: patients' expectations that refer to the interaction with the care
provider; these are called interaction expectations and patients'
expectations that refer to the actions performed by the care provider;
these are called action expectations. [Stimson G and Webb B (1975)]

c. Importance of expectations: Knowing patients' expectations is

important for a number of reasons. Firstly, it is an ethical imperative
that health care meets patients' needs and preferences as much as
possible, which implies that: patients' expectations should be taken into
account in the design and delivery of services. Secondly, effective
treatment is based on adequate insight into patients' expectations of
health care. For instance, a patient with low back pain who wants to
know whether she has serious damage in her back is not effectively

24
 helped by advice to keep active. Thirdly, specific expectations can
influence patients' health behaviour and effective use of treatment. For
instance, patients may have hearing problems, but if they do not expect
benefits from a hearing aid they will probably decide not to seek health
care or use a hearing aid. So patients' expectations can directly
influence functional health status and other outcomes of health care.
Fourthly, in a competitive market patients' expectations are important
because they influence the choice between different care providers.
Fifthly, learning about patients' expectations can be educational for care
providers, because it helps them to clarify their own expectations and to
set priorities for learning and improvement. [Jones R et al. (2004)]

d. Prioritization of patient expectations: As the patients have many

expectations in the health care system and facilities serving them,
prioritization is important to gain more patient satisfaction through
fulfilling their needs. A systematic review of the literature covering the
period 1966 until 1995 provided 57 studies on patients' overall
expectations of primary medical care. A ranked order is helpful in
exploring the patients’ priorities and expectations. [Wensing M et al.
(1998)], Appendix No.5

e. Influence of patient expectations on patient satisfaction: Patient

expectations are critical as they form the basis for the subjective
assessment of care that is the rating of satisfaction. There can be
different expectations for different aspects of care and patients with
lower expectations tend to be more satisfied. Satisfaction cannot be

25
 interpreted as a measure of quality of care and must be interpreted in
the context. [Sitzia J and Wood N (1997)]
Although measures of health-related quality of life (HRQL) are widely
used, it is unclear whether individual patients conceptualize their health in
the theoretical models used for HRQL. In particular, the source of items in
the measures may reflect expert opinions rather than patients' own
expectations. Patient expectations have been linked with satisfaction, but
there is little empirical evidence for the theoretical models. Expectations
may be tentative in nature and partly emerge from the consultation
process itself. The concept of patients' expectations differs from HRQL
and from patient satisfaction with care. [Jones Roger et al (2004)]

PATIENT-CENTEREDNESS AS A PATIENT SATISFACTORY

STRATEGY
Primary medical care has a long tradition of patient-centeredness.
[McWhinney IR (1998)]
There is a range of specific methods for integrating patients' views in
primary medical care and its improvement. Examples are needs assessment
questionnaires completed by patients before the consultation, procedures to
involve patients in the development of clinical guidelines, and surveys among
patients to provide feedback to care providers. Such methods can point out
aspects of care that would otherwise remain unnoticed by the care providers,
managers, and policy makers.
Many countries have laws and professional regulations that prescribe
that patients' voices are included in clinical decision-making, quality
improvement, and health care planning. In some countries, efforts are made
to create health care services around the preferences of the patient. The value

26
of the methods for patient involvement should be assessed in terms of their
effectiveness and feasibility. [Jones R et al. (2004)]
Involving patients in primary medical care and its improvement has
different aims. Firstly, it is an ethical and legal rule that individuals and
patients should be involved in the decisions concerning health care. Many
patients wish to be involved, at least to some extent, and it is important to
fulfill this need. Secondly, involvement may result in a better process and
outcome of care.
It helps care providers to reflect on patients' needs and preferences; it
may contribute to implementation of evidence-based practice; and it can
result in better self-management, health status, and satisfaction with care.
Patients can be seen as co-producers of their health care, as their decisions
and behaviour influence process and outcome of health care. Patient
involvement may have the political objective of legitimizing the national
view on what constitutes quality of care. In health care systems that promote
competition between providers, patient involvement may offer providers
competitive advantage.
Patient-centered communication is based on a moral philosophy that
calls for physicians to expand upon the biomedical approach to care by:
(1) Helping patients feel understood through inquiry into patients’ needs,
perspectives, and expectations.
(2) Attending to the psychosocial context.
(3) Expanding patients’ involvement in understanding their illnesses and in
decisions that affect their health. [Mead N and Bower P (2000)],
[Stewart M et al. (1995)] and [McWhinney R (1995)]
Patient-centered communication is a complex construct, aspects of which
have differential associations with such outcomes as patient satisfaction and

27
control of chronic disease. Most physicians tend to use a biomedical rather
than a patient centered communication style, whereas most patients prefer a
patient-centered approach. [Swenson SL et al. (2004)] and [Krupat E et al.
(2001)]
In primary care, the physician-patient consultation is the fundamental
platform for service delivery. Making consultations more congruent with
patients’ preferences is achievable through a number of mechanisms such as
competitions among health care professionals and continuous assessment of
patients’ satisfaction.
Achieving congruence is complicated, however, because of the many
attributes of primary care consultations that are important to patients. For
example, patients want rapid access to professionals and high-quality
technical and interpersonal care. [Wensing M et al. (1998)], [Campbell M,
Roland O and Buetow A (2000)] and [Coulter A (2001)]
Among different physician styles, greater patient-centeredness
(manifested as engaging in a more participatory style, obtaining agreement
on treatment, or supporting patient autonomy) has been associated with
greater improvements in back pain, headache resolution, diabetes control,
health status, compliance, and satisfaction.
Unmeasured patient factors that might alter the reporting of physician
style could confound interpretation of these studies, however. For example,
certain patient personality characteristics have been associated with better
perceived outcomes. [Dua K (1993)], [Duberstein R et al. (2003)] and [Dua
K (1994)]
Although the evidence linking patient-centered care to improved
patient outcomes is somewhat ambiguous, considerable scientific, ethical and
professional momentum supports the adoption of a patient-centered care

28
model. [Little P et al. (2001)], [Mead N and Bower P (2002)], [Stewart M
(1995)] and [Stewart M et al. (1995)]

Applicable patient centeredness methods and techniques

The strategy of patient centeredness is applicable through a range of
specific methods for integrating patients' views in primary medical care and
its improvement. Examples of these methods are:
1. Health education: Health education may enhance the
appropriateness of the decision to seek health care and stimulate self-
management of the health problem. For instance, written information on
common diseases, such as sore throat and sinusitis, distributed among
parents of young children could lead to better use of health care. A campaign
in the mass media on when to seek emergency care for different health
problems could influence individuals' use of emergency care. The role of
individuals is often limited to being the receiver of the information, but in an
increasing number of cases an attempt is made to tailor the information
according to their needs and preferences. In general, information on health
problems and their treatment is highly valued by individuals. It is of course
crucial that the information is valid, based on evidence, and understandable
to lay persons. Specific instruments are available to assess the quality of the
information. [Charnock D et al. (1997)], Appendix 1
2. Public reports: The choice of a care provider is an opportunity
of the individual to express his or her wishes and preferences regarding
primary medical care. Providing information on the range of services,
quality, costs, and health outcomes may help the individual in making
choices between different care providers. Report cards describe the

29
performance of different care providers on several indicators, such as types
of services offered and names of doctors attending the practice. Assessment
of the quality of care by patients, such as patient satisfaction figures, may be
included in the public reports. These cards have been used in the United
States, where individuals and their employers can chose between competing
managed care organizations. [Jones R et al. (2004)]
3. Needs assessment: The patient-centered approach to
consultations emphasizes that the meaning of illness for the patient should
be explored. Specific tools can be used to achieve this aim. The patient can
write down health problems, symptoms, and needs for care before the
consultation and introduce the list in the consultation. In its simplest form,
this is a sort of a questions list which is presented to the practitioner. Some
forms are made for unselected patient populations, for instance to assess
depressive symptoms or functional limitations in older patients. Other forms
are for specific patient groups, for instance to assess the needs for advice on
lifestyle changes in diabetes patients. A similar method used a separate
session with an assistant, shortly before the consultation with the primary
care provider, to help identify needs for care and motivate the patient to take
an active role.
4. Shared decision-making: Shared decision-making is a
communication strategy between clinicians and patients that implies explicit
recognition of patients' needs for health care, provision of information on
treatment options and explanation of their benefits and risks, discussion
about patients' preferences and choice between the options. [Elwyn, G,
Edwards A, and Kinnersley P (2000)]

30
 It has been proposed for complex clinical decisions, such as treatment
choices for lower urinary tract symptoms in men, hormone replacement
therapy in women, and atrial fibrillation.
Decision aids can support shared decision-making; these are information
tools that support an informed choice in the situation where more than one
treatment alternative is available. [Molenaar S et al. (2000)]
These decision aids differ from patient education programmes which
aim to provide information, advice, and support with regard to already
prescribed treatments. Implementation of shared decision-making and
decision aids in primary medical care is a challenge, because few doctors
have the skills required for their application and many patients do not want
to be involved in clinical decision-making. [Elwyn G, Edwards A, and
Kinnersley P (2000)]
The feasibility and acceptability of many decision aids was good
according to patients who actually used them. [Molenaar S, et al. (2000)]
5. Patient-held records: Information and counseling can be used
to motivate and enable the patient to take responsibility for treatment and
monitoring of the health problem during an episode of care. For instance, the
care provider can discuss barriers for adherence to treatment and strategies
to overcome those barriers.
Furthermore, special cards or books can be used to help the patient
register clinical symptoms during an episode of care. Examples are patient-
held personal health summaries with information on health promotion
activities and sharing medical records with the patient.
Patient-held mini-records can indeed improve preventive screening and
vaccination. They allocate control of preventive procedures to patients. A

31
review with seven studies showed that it improves patients' adherence to
management plans. [Dickey L (1993)]
Yet in spite of the general effectiveness of patient-centeredness, it is
reasonable to ask whether a one-size-fits-all approach to patient care is the
best one. Some patients, such as the elderly, or patients of certain ethnic
backgrounds, for example may desire a physician whose style is more
structured and who provides more guidance. [Doescher P (2000)] and
[Adelman D, Greene G, Charon R (1991)]
Patients who are sick or have serious health concerns may also want
their physicians to provide more direction. [Willson A et al. (1996)] and
[Bertakis D et al. (1993)]
Therefore, while accepting the overall value of patient-centeredness,
some physicians and researchers have advocated that the degree of “fit”
between patients and physicians, (the extent to which the physician holds
attitudes and beliefs that are congruent with those of the patient) should
have an independent effect upon patients’ reactions to their health care
providers. [Krupat E (2001)]

GOALS OF PATIENT SATISFACTION STRATEGY

A. Elimination of the patient turnoffs: Customer (patient) Turnoffs fall
into three categories:
1- Value turnoffs: It is the quality relative to price paid. If the patient
makes a major purchase, and it quits working or fails to meet his/her
needs, he/she will have a value turnoff. Generally, it is the top
leadership of the organization that is responsible for providing
appropriate value.

32
 2- System turnoffs: System is to describe the process, procedure, and
policy used to deliver the service to the patient. It is the way we get the
value to the patient. Systems will include things as: health facility
location, layout, parking facilities, employee training, consultation
time, waiting time, record keeping, marketing policies and customer
follow up programs.
Managers are responsible for reducing system turnoffs and employees
should be involved in suggesting system changing. Effective systems
have to create comfort not only for patients, but for both employees
and patients as well.
3- People turnoffs: People turnoffs are always communication problems.
Some examples of people turnoffs are failure to greet or even smile at
a patient, inaccurate information given or lack of knowledge, talking to
another employee or allowing phone interruption while conducting a
consultaion, rude or uncaring attitude (verbal or body language), high
pressure tactics and inappropriate, dirty or poor appearance.
People turnoffs are any communicated massage that causes the
customer to feel uncomfortable. Employees at all levels can create
people turnoffs.
B. Exceeding customer expectations: we have all grown accustomed
over many years to receiving health care services. So when a health care
provider does show an outstanding level of customer service, it’s
impossible not to notice. In U.S., where businesses spend more than $12
billion on advertising, 63 % said they would buy a product based on the
recommendation of a friend. Word-of-mouth is best spread by loyal
customers. An organization achieves customer satisfaction, retention and
loyalty by exceeding customer expectations in positive ways.

33
 Customer expects attention to detail, competitive pricing, honor
the promises, shared sense of urgency, prompt response and kept
informed, clearly defined customer service policy, reliable superior
services.
E-Plus is the process of exceeding customer expectations in
positive ways. It is the best way to reach a win–win situation. By E-
plus strategy, the organization is unbalancing the relationship, but
customers are more likely to restore the balance. Because of all
possible customers’ reaction, the challenge is to create positive
imbalances by exceeding customer expectations (E-plus). [Cambridge
(2008)]

Ways (opportunities) for achieving E-plus

There are six areas where a health care facility can exceed patients’
expectations:
1- Value: Health care systems can exceed patients’ expectations
regarding the value of the service presented. The value meant is not
the real quality of the service, but the perceived quality that may be
presented in the specifications or aspects of the services provided
such as the high quality of the prescription papers or patient files,
the air conditioned facility, presentable receptions, well equipped
clinic or luxurious furniture. Sometimes customers simply need to
be reminded of the value they are receiving.
2- Information: Health care systems can exceed customer
expectations by providing more, better or clearer information that
the patient can use. There are many opportunities in this aspect
concerning health care services such as the signs inside the health

34
 facility that direct clients to various departments, directing
customers phone calls to the right employee form the 1 st time, a
simple follow up phone call or visit, giving reasons for diseases
affecting the patients, prognosis probabilities, alternative
management plans, drug information, health educations and tips for
healthy life styles, diet recommendations, DO’s and DONOT’s
statements, investigation interpretations, procedure explanation
and counseling sessions.
These information may be given verbally or better in printed
versions either case oriented readymade or patient customized
computer liberated.
A learning CD, cassette or Videotape along with the service
such as long term management plans, counseling issues, an
electronic version of the investigations reports or the patient/family
health record are new heights of E-plus.
3- Speed: Health care systems can exceed customers’ expectations
with the speed of service delivery. Customers dislike having to wait
too long for receiving the services they need especially if they are
annoyed, anxious or suffering. In our culture, people rarely arrive
on time, so arrive earlier than promised is a great E-Plus.
Some organizations make it a policy to tell customers a precise
time then show earlier.
4- Personality: Health care systems can exceed customers’
expectations with the personality of the employees. Every
organization conveys a personality to its customers. Behaviors of
employees; friendliness, efficiency, professionalism, and work
quality may create organization’s personality.

35
 Some behaviors that display the organization’s personality are
how to greet customers, how to break the ice, how to communicate
effectively with customers verbally and non-verbally, how to follow
up with Customers, how to manage a win-win relation with the
customers, how to master key account management and deep
relations and how to manage post purchase problems.
5- Add-ons: Health care systems can exceed customer expectations by
giving the patients something else that will be needed or
appreciated, the best kinds of free add-ons are those with high
perceived value and low cost to the business. As a free drug sample,
a thermometer, a candy for a child patient, wall topped height scale
or a diabetes dairy.
6- Convenience: Health care systems can exceed customers’
expectations by making the service more convenient. Convenience
could be enhanced in two areas:
 Recovery for unhappy customers as by sending the results of the
investigations to home instead of waiting a lot.
 Attracting new customers as by exerting more care to older
patient as by giving him the priority in receiving the service in
spite of being the last comer.

PATIENT SATISFACTION STRATEGY AS A DYNAMIC PROCESS

Patient satisfaction is a necessary but not sufficient goal. Patient
satisfaction only weakly predicts customer retention in highly competitive
markets. Businesses regularly lose some percentage of their satisfied
customers.

36
 Businesses need to focus on customer retention, but even retention can
be misleading, as when it is based on habit or an absence of alternative
suppliers.
A Business needs to aim for a high level of customer loyalty or
commitment. The business should therefore aim to delight customers, not
simply satisfy them. Top companies aim to exceed customer expectations
and leave a smile on customers’ faces. But if they succeed, this becomes the
norm and the customer expectations rise to this level so the business has to
continue to exceed expectations after these expectations become very high.
How many more surprises and delights can a business create?
Interesting question as it is a challenge that increases with the success as a
computer game. [Kotler P (2003)]

IMPORTANCE OF PATIENT SATISFACTION

Most businesses pay more attention to their market share than to their
customers’ satisfaction. This is a mistake. Market share is a backward-
looking metric; customer satisfaction is a forward-looking metric. If customer
satisfaction starts slipping, then market share erosion will soon
follow.Organizations need to monitor and improve the level of customer
satisfaction. The higher the customer satisfaction, the higher the customer
retention. [Kotler P (2003)]

Reichheld F presented four facts highlighting the importance of

customer satisfaction; those are:
1. Acquiring new customers can cost 5 to 10 times more than the costs
involved in satisfying and retaining current customers.

37
2. The average company loses between 10 and 30 percent of its
customers each year.
3. A 5 percent reduction in the customer defection rate can increase
profits by 25 to 85 percent, depending on the business sector.
4. The customer profit rate tends to increase over the life of the retained
customer. [Reichheld F (1996)]

There are five general facts exploring the reason why health care
organizations monitor and improve the level of customer satisfaction;
those are:
2. It is a measure of social acceptability and has been demonstrated to be
related to health outcomes.
3. It is tied to a movement that attempts to democratize health services by
incorporating the consumer’s perspective.
4. It captures the fundamental principle that health care should serve the
needs and desires of the patient. [Calnan M (1988)]
5. Assessment of consumer opinions is an important marketing technique
used in the management of health care facilities. [Fitzpatrick R
(1991)]
6. Sustained patient satisfaction will lead to Customer loyalty which is a
deeply held commitment to rebuy a preferred product or service
consistently in the future. Despite situational influences and marketing
efforts having the potential to cause switching behavior, a loyal
customer is the one who is generally satisfied, committed to being a
repeat buyer, and willing to recommend the service to other people.
[Cambridge (2008)]

38
 Inventories of the medical staff have been administered for decades to
measure quality of care.Of special interest has been the satisfaction of
patients while receiving care from a medical professional. For nearly 5
decades patient satisfaction has been measured in the field of Nursing and
has recently become identified as a valid and important index of care
quality as well as a prerequisite for hospital license. [DiPalo M (1997)]
and [Merkouris A et al. (1999)]
Patient satisfaction with the services provided has been earmarked by
the Joint Commission for Accreditation of Health Care Organizations as
an important and valid measure of quality of care. [Merkouris A et al.
(1999)]
Patient satisfaction is considered a way to measure the perceptions or
feelings that the patients may have while being medically attended to for
their injuries or illnesses. [Sitzia J and Wood N (1997)] and [DiPalo M
(1997)]

IMPACT OF PATIENT SATISFACTION ON COMPLIANCE

Patient Attendance/Patient Adherence/Patient Compliance
Non-compliance with medical treatment has been documented as a
major problem in as many as 30-75% of patients receiving therapy.
[Comstock L et al. (1982)], [Imanaka Y et al. (1993)] and [Klein T
(1980)]
Furthermore, it has been suggested that those who are more satisfied
with their care are more likely to comply with management plans and
regimens (Merkouris A et al. (1999)] and [Sanazaro P (1985)] and in turn,
recover more progressively. [Treacy S et al. 1997)].

39
 Often patient adherence has been used synonymously with compliance.
Likewise, patient attendance and adherence have been used synonymously.
The mixing of terminology has made the interpretation of adherence and
compliance difficult.
However, physiotherapy practice being one of the practices that need
the patient to follow specific treatment regimen and thus need high degree of
adherence; physiotherapy literature has technically defined the measurement
of a frequency goal (i.e., attending all sessions) as adherence [Brewer B et
al. (1995)], whereas, compliance (i.e., meeting levels of intensity, duration,
and listening to advice) is the measurement of the quality of effort. [Brewer
B et al. (1998)] and [Brewer B et al. (1999)]
Therefore, it is possible that one may adhere to treatment without being
compliant. Through literature review, Cameron (1996) highlighted the social
and psychological factors to influence patient compliance that have been
measured in previous research. Unfortunately, as noted by Cameron (1996),
the literature related to compliance has used a variety of measures with
unreported supporting psychometric data. [Cameron C (1996)]
The use of a variety of measures is due in large part to the specific
compliance measured and the definition of compliance used. For example,
compliance has included the number of treatments scheduled and kept, taking
medications, following regimens for specific diseases, adhering to treatment
programs and protocol. [Brewer B (1998)], [Brewer B (1999)], [Cameron
C (1996)], [Chen C (1999)], [Imanaka Y et al. (1993)] and [Klein C
(1980)]
The most consistent adherence and compliance studies in the medical
field have evaluated medication-taking behaviors among chronically ill
patients. For example, Nagy and Wolfe (1984) evaluated cognitive variables

40
associated with compliance using chronic disease patients (N = 128). Patients
were interviewed two times. The first interview included demographic
information, value of health to the patient, satisfaction with the treatment,
social support, health locus of control beliefs, and perceived severity and
long-term outlook. The second interview consisted of self-reported
compliance to the medication and self-management procedures 6 months
later. The predictor variables included socioeconomic status, three HLOC
measures, perception of the medical problem, patient satisfaction, and social
support. Compliance was the outcome variable- measured by self-report,
provider-report, on-time refills, and research response measures. Stepwise
multiple regression analyses revealed that patient satisfaction was
significantly correlated with medication compliance and reported symptoms
were significantly negatively correlated with self-management procedures.
[Nagy V and Wolfe G (1984)]
Sanazaro (1985) surveyed by telephone patients who were receiving
care for chronic conditions, he evaluated the patients’ knowledge and
understanding of their condition, the satisfaction with their care, and their
compliance to treatment. Men (n = 91) and women (n = 110) were
interviewed over the telephone to answer five content areas: (1) availability
of physician, (2) patient’s knowledge of prescribed drugs, (3) patient’s
knowledge of own condition, (4) patient satisfaction, and (5) compliance.
The specific number of questions asked to represent each content area
was not reported. Normative data indicated that patients felt their physician
was readily available and patients knew the name and purposes of the
medications, but they did not know the side effects. Surprisingly, only a little
over half (57.7%) of the patients understood their condition. A large number
of patients were satisfied with the explanation the physician gave for the

41
condition (89.6%) and were satisfied with the physician answering questions
(88.6%). Moreover, a high percentage of patients felt the physician took
enough time (78.1%) and treated the patient as a person (79.6%). Finally, a
large portion of patients (91%) reported compliance with the drug regimen.
However, the compliance with a lows alt diet (39.2 %) and urine testing for
sugar (55.2%) was quite low. Sanazaro (1985) suggested that patients were
relatively satisfied with the physician, but were not compliant with their
medical care, however correlations or regression were not conducted on these
data. The low compliance rate may be due to the minimal number of patients
understanding their condition. [Sanazaro P (1985)]
In a prospective study design Wartman, Morlock, Malitz and Palm
(1983) evaluated the effects of patient understanding and satisfaction on
compliance with drug regimen. Patients (N = 515) completed three
instruments (a visit questionnaire, a provider form, an encounter form) at the
time of the visit. One week after their visits, by a telephone interview,
patients rated 4 satisfaction questions pertaining to the visit on a 4- point
Likert scale and indicated the result of the visit (whether the injury/illness
that they saw the physician one week earlier was better), and indicated
whether medications were prescribed. Multiple discriminate analyses
indicated that compliance was significantly negatively correlated with
patients’ satisfaction with questions answered (r = -0.18, p < .001), interest
shown (r = -0.16, p < .02), and explanations given (r = -0.13, p < .05).
[Wartman S et al. (1983)]
Furthermore, in canonical correlation analysis, self-reported
compliance with drug regimen was correlated with age (r = 0.70), presence of
musculoskeletal problems (r = 0.46), patients’ satisfaction with providers’
answers to their questions (r = -0.45), and prescription of psychotropic drug

42
(r = 0.35). These results suggested that patients who were more compliant
with their drug regimen are less satisfied with the patient-physician
relationship. These results are contrary to other findings. However, the
determination for compliance and noncompliance was not specified.
Therefore, one should use caution when interpreting these results. [Wartman
S et al. (1983)]
Also specific to compliance with medication regimens, Imanaka et al.
(1993) evaluated the effects of patients’ beliefs and satisfaction. Subjects
selected for the study included 318 men and 332 women outpatients in seven
general hospitals in Japan and ranged in age from birth to 93 years. Prior to
leaving the hospital, subjects completed a questionnaire that pertained to their
beliefs about their health condition and medication regimen (4 questions).
The attending physician rated the severity of illness for each participant. One
month later, the same patients completed a questionnaire pertaining to
medication compliance (3 questions) and patient satisfaction (12 questions).
High compliance was defined as a score above 80% compliant and was
used as the dependent variable in a multiple logistic regression analysis.
Specifically, patients who reported higher satisfaction scores were older and
were more likely to comply with medication. Additionally, greater self-
efficacy ratings, lower perception of barriers, greater perceived threat ratings,
greater severity of illness rated by the physician, and male gender were
significantly related to the rate of high compliance to medication use.
[Imanaka Y et al. (1993)]

Making and keeping an appointment has also been used as a measure

for compliance. For example, Goldman et al. (1982) used multivariate
analysis to examine a wide range of factors that are believed to influence

43
patient compliance. Specifically, 376 patients who had routine return and
scheduled visits with physicians in a Boston hospital participated in the
study. [Goldman L et al. (1982)]
Patient satisfaction was measured, prior to the visit, using a general
statement of quality of satisfaction with the physician and primary care center
(PCC), 15 hypothetical statements, and whether the patient would
recommend the PCC to a neighbor. Following the visit, patients rated general
satisfaction, the physician, and the clinic. Physician-patient gender
concordance was measured through pre and post questions by the patient and
after the visit with the physician. Compliance was based on making and
keeping an appointment during a six month follow up period. Eighty-two
percent of the appointments were kept and 18% were identified as no-shows.
Age (i.e., younger), race (i.e., non-white), physician-Patient identified
psychosocial problems, and history of late or missed prior appointments in
the previous 12 months were the four factors identified by logistic regression
to be associated with non-compliance. [Goldman L et al. (1982)]
Furthermore, patient satisfaction was associated with future
appointment keeping. For example, patients who were not satisfied with the
index visit resulted in no-shows 6 out of 9 future appointments. Although
compliance measures refer to attendance in this study, it should be noted that
this should be considered as an adherence measure. [Goldman L et al.
(1982)]

Influence of patient satisfaction on patient adherence and compliance

The literature has reported that the physician-patient interaction is
related to patient satisfaction. [Bartlett E et al. (1984)], [Hall J and Dornan

44
M (1988)], [Hall J et al. (1993)], [Hall J et al. (1998)], [Hall J et al. (1996)]
and [Stiles W et al. (1979)]

Furthermore, it has been alleged that patient satisfaction is related to patient

compliance. DiMatteo et al. (1986) investigated the paths linking these
concepts. Family practice residents (N = 57) completed self-report measures
of personality: (1) Hogan Empathy Scale (HES); (2) Snyder Self-Monitoring
Scale (SMS); and (3) Affective Communication Test (ACT). The short form
of the Profile of Nonverbal Sensitivity (PONS) was used to measure the non-
verbal decoding skill of the physicians. Ambulatory patients (N = 329) were
asked to complete a patient satisfaction questionnaire. Patient satisfaction
was measured with a 25-item survey specific to the visit. Each item was rated
on a 5-point Likert scale.
Patient Appointment Noncompliance (AN) was measured according to
the number of cancelled appointments divided by the number of patients a
physician was scheduled to see that month. Finally, the average number of
patients the physician saw per clinic day measured the physician’s
workload/schedule density.
The only variable that showed any significant correlation to
appointment noncompliance was audio-nonverbal decoding (r = -0.47, p <
.05). Specifically, the less the physician’s nonverbal communication the
greater the noncompliance. [DiMatteo M et al. (1986)]
The link between patient satisfaction and patient adherence and
compliance has been demonstrated in the medical literature. For example, in
a retrospective design, Bartlett et al. (1984) evaluated patient satisfaction and
adherence of 56 patients who received care from an educational hospital.
This visit was a follow up visit for an illness that had been previously

45
diagnosed and treated. Patients were interviewed over the phone 1-2 weeks
following their visit. Residents (N = 5) and their patients were videotaped
during the evaluation session. The resident’s communication skills and the
amount of patient teaching were also evaluated as part of the influence on
patient satisfaction, recall, and adherence. [Bartlett E et al. (1984)]
Interpersonal skills (IPS) were measured with 14 items that were
measured on a 5-point Likert scale. Using a Pearson’s product-moment
correlation, intra-observer reliability was recorded as 0.77 and the inter-
observer reliability was recorded as 0.52. Teaching was measured by the
summation of statements (sentences) made by the physician that contained
any instructional information relating to the patient’s visit. Using a Pearson’s
product-moment correlation, intra-observer reliability was recorded as 0.94
and the inter-observer reliability was recorded as 0.71. Patient satisfaction
was measured by an 8-item questionnaire.
The items asked the patients to rate on a 5-point Likert scale the degree
of satisfaction they had with information giving, quality of care, and the
physician’s interpersonal skills. The alpha reliability for the satisfaction items
was 0.88. Patient’s recall was measured on a percentage of correct responses
to three questions. One correct response out of the three questions would be
calculated as 33% correct. Medicine taking adherence was measured by
asking what medications that patient took the day prior to the phone
interview. The calculations were based on the percentage of completeness.
For example, if the patient was asked to take 4 pills, but only took 3, then the
adherence score is 75%.
Significant, but weak to moderate correlations were found between the
following: (1) race and interpersonal skills (r = -0.24, p = 0.04), (2) education
level of patients and patient satisfaction (r = -0.40, p =0.03), (3) complexity

46
of treatment regimen and interpersonal skills (r = -0.22, p = 0.05), (4)
complexity of treatment regimen and teaching statements (r = 0.38, p = 0.01),
(5) perceived post-visit health status and patient satisfaction (r = 0.37, p =
0.01), and (6) perceived post-visit health status and adherence (r = 0.37, p =
0.01). These results may suggest that poorer interpersonal skills were
demonstrated with black patients and with those who had more complex
treatment regimens. Patients with a more complex treatment regimen were
provided more teaching statements. Additionally, more educated patients
were less satisfied. Patients were more satisfied if they felt better after the
visit and those who felt better after their visit were more likely to adhere to
the regimen. [Bartlett E et al. (1984)]
Of particular interest, Bartlett et al. (1984) reported that the
observations between patient satisfaction and teaching statements
demonstrated a hyperbolic form, which indicates that there is a curvilinear
relationship. That is, satisfaction may go up with increasing teaching
statements but level off as the number of statements may overwhelm the
patient. [Bartlett E et al. (1984)]
Bartlett et al. (1984) also found that patient satisfaction and/or recall
mediated all the effects of the interpersonal skills and teaching statements on
patient adherence. However, physician’s communications did not have any
direct effect on adherence. These results suggest that adherence of medicine
taking was influenced by patient satisfaction and recall of regimen, which in
turn were determined by the quality of the physician’s interpersonal skills
and the summation of the teaching statements used by the physician.
[Bartlett E et al. (1984)]
Evaluating patient satisfaction and patient compliance with adult
patients (N = 7204) in the Commonwealth of Massachusetts, Safran et al.

47
(1998) concluded that trust was the most strongly associated variable with
patients’ satisfaction with: (1) their physician and (2) adherence. A single
item measured patient satisfaction, and adherence was measured by a ratio of
the seven behavioral risks discussed by the physician and the patient’s
behavior as a result of the advice. This was a cross-sectional study that
prevents one from interpreting that trust in the physician can influence patient
satisfaction or adherence during consecutive appointments. [Safran D et al.
(1998)]
Specific to cardiac patients and rehabilitation, Holm, Fink, Christman,
Reitz, and Ashley (1985) examined six factors that were thought to be
associated with patient compliance. During phase II of rehabilitation, 41
patients completed a questionnaire that consisted of socio-demographics,
health beliefs (Compliance Questionnaire), locus of control (HLOC), patient
satisfaction (developed by Counte), social support (Social Support Index),
and self-motivation (Self-Motivation Inventory). Psychometric properties for
these instruments had acceptable values. The Standardized Compliance
Questionnaire (SCQ) measured compliance. Psychometric properties for the
SCQ were not reported.
Administration of the questionnaires was also not reported. Men (n =
39) and female (n = 2) patients ranged in age from 34 to 75 and represented
the white (n = 29), black (n = 7) and Hispanic (n = 5) races. Correlations
were completed for all six constructs of health beliefs (general health
motivation, severity, resusceptibility, efficacy, barriers, and cues) and
compliance (HLOC, patient satisfaction with the program and the staff, social
support, and self-motivation).
Although weak, significant positive correlations were reported between
perceptions of severity of illness and general health motivation (r = 0.31, p <

48
0.05); between HLOC and general health motivation (r = 0.40, p < 0.01);
between cues to taking health-related action and satisfaction with program
staff (r = 0.37, p < 0.05); between program and staff satisfaction (r = 0.62, p
< 0.001); and between perceptions of severity and resusceptibility (r = 0.37, p
< 0.02). Inverse correlations between perceptions of resusceptibility and
social support (r = -0.25, p < 0.05) and between perceptions of
resusceptibility and self-motivation (r = -0.27, p < 0.05) were also reported.
[Holm K et al. (1985)]
In summary, the medical literature has evaluated compliance primarily
as a means of keeping an appointment, taking medications, and following
drug regimens.

PATIENT SATISFACTION AS A TOOL FOR BEHAVIOR CHANGE

Healthy behaviors can make a difference in patients' lives. In fact, it's
been estimated that half of all deaths in the United States could be prevented
by individual changes in diet, exercise, substance use and other health habits.
A small but growing body of evidence suggests that physicians can
play an important role in encouraging patients to practice healthy behaviors.
For example, almost 30 percent of Americans who have stopped smoking
report being urged to do so by their physicians. [U.S. Preventive Services
Task Force (1996)]
Helping patients change behavior is an important role for family
physicians. Change interventions are especially useful in addressing lifestyle
modification for disease prevention, long-term disease management and
addictions. The concepts of "patient noncompliance" and motivation often
focus on patient failure. [Zimmerman G, Olsen C and Bosworth M (2000)]

49
 Patient failure is a strait expression of the patient compliance which is
largely dependent on the patient satisfaction with the physician in the charge,
the importance and ultimate need to pass through the barriers (change
behavior) and the management plan stated by his physician.
Health habit advice is increasingly recognized as an important and
effective tool in maintaining patients' health. Such advice does not appear to
lower patients' satisfaction with the family practice visit. In fact, in some
cases, it leads to greater satisfaction. [Robin S et al. (2002)]
Understanding patient readiness to make change, appreciating barriers
to change and helping patients anticipate relapse can improve patient
satisfaction and lower physician frustration during the change process.
[Zimmerman G, Olsen C and Bosworth M (2000)]
One role of family physicians is to assist patients in understanding
their health and to help them make the changes necessary for health
improvement. Exercise programs, stress management techniques and dietary
restrictions represent some common interventions that require patient
motivation that is directly related to patient satisfaction. A change in patient
lifestyle is necessary for successful management of long-term illness and
relapse can often be attributed to lapses in healthy behavior by the patient.
Patients easily understand lifestyle modifications (i.e., "I need to reduce the
fat in my diet in order to control my weight.") but consistent, life-long
behavior changes are difficult. This difficulty may be dissolved by strong
physician-patient relationship, close follow up and practical problem solving
capabilities; the umbrella that covers all these issues is patient satisfaction
that has a dynamic interaction with all of them; each of these strategies
maximizes the patient satisfaction which itself empowers these strategies and
facilitates the barriers that appear during implementation.

50
 Relapse during any treatment program is sometimes viewed as a failure
by the patient and the physician. A feeling of failure, especially when
repeated, may cause patients to give up and avoid contact with their
physician or avoid treatment altogether. After physicians invest time and
energy in promoting change, patients who fail are often labeled
"noncompliant" or "unmotivated." Labeling a patient in this way places
responsibility for failure on the patient's character and ignores the complexity
of the behavior change process. [Zimmerman G, Olsen C and Bosworth M
(2000)]
Current views depict patients as being in a process of change; when
physicians choose a mode of intervention, "one size doesn't fit all." [Miller
R (1993)] and [Miller R and Rollnick S (1991]
Two important developments include the Stages of Change model and
motivational interviewing strategies. [Prochaska O, DiClemente C and
Norcross C (1992)] and [Miller R, Rollnick S (1991]
The developers of the Stages of Change model has validated and
applied it to a variety of behaviors that include smoking cessation, exercise
behavior, contraceptive use and dietary behavior. [Hellman EA (1997)] and
[Glanz K et al. (1994)]
Simple and effective "stage-based" approaches derived from the Stages
of Change model demonstrate widespread utility in many clinical situations
that have special difficulties being patient dependent where the patient
compliance is directly proportional to patient satisfaction. [Glanz K et al.
(1994)] and [Calfas J et al. (1997)]

51
Understanding Change
Physicians should remember that behavior change is rarely a discrete,
single event. Physicians sometimes see patients who, after experiencing a
medical crisis and being advised to change the contributing behavior, readily
comply. More often, physicians encounter patients who seem unable or
unwilling to change this is where patient satisfaction plays a major role in the
outcomes of the intervention. During the past decade, behavior change has
come to be understood as a process of identifiable stages through which
patients pass. Physicians can enhance those stages by taking specific action.
Understanding this process provides physicians with additional tools to assist
patients, who are often as discouraged as their physicians with their lack of
change. [Zimmerman G, Olsen C and Bosworth M (2000)]
Maintenance and relapse prevention involve incorporating the new
behavior "over the long haul." Discouragement over occasional "slips" may
halt the change process and result in the patient giving up. However, most
patients find themselves "recycling" through the stages of change several
times before the change becomes truly established. These “go and fro”
hesitations minimizes with the maximization of patient satisfaction rendering
the process of change more rapid with little slips. [Zimmerman G, Olsen C
and Bosworth M (2000)]

PATIENT SATISFACTION AS A QUALITY DETERMINANT

Patient satisfaction with the services provided by health care system
has been earmarked by the Joint Commission for Accreditation of Health
Care Organizations as an important and valid measure of quality of care.
[Merkouris A et al. (1999)]

52
 There are many definitions and perception of quality in healthcare; one
of them is “quality is what the patient prescribes”, actually this definition
arises with the emergence of the patient need assessment and patient
satisfaction concepts in the theme of health care and the definition was
interested in raising the value and importance of the patients along with their
perceptions and their point of view.
WHO (1988) has defined quality as the proper performance (according
to standards) of interventions that are known to be safe, affordable to the
society, and have the ability to produce an impact on morbidity, mortality
disability and malnutrition.
The Institute of Medicine, (1990) collected and analyzed over 100
definitions of quality of care and came to a consensus definition; Quality of
care 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. [Ley P (1976)]
Juran in 1989 added an important dimension of quality to its definition,
which is customer satisfaction. According to Juran Institute quality is defined
as both freedom from deficiencies and product features (fitness for use).
Freedom from deficiencies means absence of any avoidable error or
unnecessary step in the intervention required to achieve an equivalent
outcomes (e.g., nosocomial infection, postoperative wound infection,
excessive waiting time and lost lab results). Deficiencies are costly to health
organization. They waste time and scarce resources and must be identified
and corrected. Unlike deficiencies, product features in healthcare means
services that attract and satisfy patients and distinguish one practitioner or
organization from others (e.g., pleasant waiting area, computerized health
record and care management/care coordination). [Juran JM (1989)]

53
 However, providing more features can increase the costs of delivery
care. Careful planning is needed to identify which features when provide will
help your organization thrive.
The simplest and perhaps the most comprehensive definition is that
used by advocates of total quality management (TQM); doing the right things
right the first time and every time. [Brwon JA (2001)]
Two key dimensions of the quality of primary care are technical care
(i.e., the quality of clinical care) and interpersonal care (i.e., the quality of
communication between professional and patient). [Campbell SM, Roland
MO and Buetow SA (2000)]
Health care professionals’ communication skills are often described
under the broad label of patient-centered care, which encompasses a number
of communication issues, including:
(1)Giving attention to biological, psychological, and social aspects
of health (biopsychosocial perspective)
(2) Exploring the personal meaning of illness (patient as person)
(3)Increasing the involvement of patients in their care (sharing
power and responsibility)
(4) Giving greater priority to the personal relationship between
physician and patient (attending to the therapeutic alliance).
[Mead N and BowerP (2000)]

Another way to look at quality is to recognize that it is judged in three

ways;
1. Measurable quality can be defined objectively as compliance with, or
adherence to standards.

54
 2. Appreciative quality is the comprehension and appraisal of excellence
beyond minimal standards and criteria, requiring judgment of skilled
and experienced practitioners.
3. Perceptive quality is that degree of excellence that perceived by the
recipient or the observer of care rather than by the provider of care.
[Egyptian MOHP Health Reform program (2007)]

Quality from different perspectives

 Quality from the community point of view means:
1. A service that is available all the time
2. Easily accessible.
3. Feeling of comfort.
4. Politeness of health providers.
5. Relieves symptoms and prevents illness.

 Quality is perceived by the health care providers as:

1. Technical skills.
2. Availability of resources.
3. Suitable work conditions and environment.
4. Achieving the target outcome.

 For the health care manager (MOH), quality means:

1. Best service.
2. With least possible cost, and
3. Achieving best outcome.
[Egyptian MOHP Health Reform program (2007)]

55
Patient Satisfaction as a Dimension of Quality
Experts recognize several distinct dimensions of quality that vary in
importance depending on the context in which quality effort takes place, yet
the U.S. Joint Commission on Accreditation of Healthcare Organizations
(JCAHO, 1991) published key dimensions of quality care according to which
quality in any health care setting can be judged upon all of these dimensions
are related in a way or another to patient(or client) satisfaction, but about one
third of these dimensions(3 out of 10) is very dependent on client
satisfaction; these are:
1-Respect and Caring: The degree to which patients are involved in the
decision and the provider’s reaction in the meantime to the patient needs and
expectations.
2- Timeliness: The degree to which needed care and services are provided to
the patient at the most beneficial or necessary time from their point of view.
3-Appropriateness: The degree to which the care/intervention is relevant to
the patient’s clinical needs, given the current state of knowledge. It is
concerned with doing the right things in accordance with the purpose.
Evaluation of patient satisfaction has also become an important
measure for a quality assurance program. In fact, it is believed that without a
way for patients to report the care received by a nurse that a quality assurance
program is considered inadequate. [Merkouris A et al. (1999)]

Application of patient satisfaction concept in QM Principals

Quality management principles provide understanding of and guidance
on the application of quality and become important to leadership and
management of all organization. Recent experiences in applying quality

56
management in healthcare systems suggest that eight tenets should be
adherent to produce benefits for the customers, owners, people, suppliers and
society at large, patient satisfaction is not only one of these principles, but
represents a part of each of them.
Principle 1- Customer Focused Organization
Quality management is oriented toward meeting the needs and
expectations of the patient and community (external customers). Quality
management also requires that healthcare worker’s professional needs and
expectations be met (internal Customers). Health organization, therefore,
should understand current and future needs and strive to exceed customer
expectation.
Principle 2- Leadership
Leaders establish unity of purpose and direction of organization. They
should create and maintain the internal environment in which people (internal
and external customers) can become fully involved in achieving the
organization’s objectives.
Principle 3- Involvement of people
People at all levels are the essence of an organization and their full
involvement enables their abilities to be used for the organization’s benefit.
Those who know the most about process details must be empowered to
improve it. Focus on team approach for problem solving and quality
improvement is essential.
Principle 4- Process Approach
All work, including clinical practice, is accomplished through
processes and processes are sequentially related steps intended to produce
specific outcomes. A desired result is achieved more efficiently when related
resources and activities are managed as process. Focusing on the analysis of

57
service delivery process, activities and tasks will allow health care providers
to develop in-depth understanding of the problem and its root causes, the
patient is not an external to the process, but he is a genuine part of it.
Principle 5- System Approach
Health organizations are systems! In-order to understand any system; it
is necessary to find out its components. The system is composed of a group
of functions and each function is composed of series of processes.
Identifying, understanding and managing a system of interrelated processes
for a given objective improve the organization’s effectiveness and efficiency.
The patient who is said to be part of the process has another role in the
system as he exerts most of the feedback of the system namely, the health
outcomes, change in behavior and practices, usage rates, and opinion
feedbacks.
Principle 6- Continual improvement
Continual improvement should be a permanent objective of the
organization and this cannot take place without the fully participation of the
patient (client) to determine their satisfaction rate and to address the dynamic
changes in their perception, needs and expectations.
Principle 7- Factual Approach to Decision Making
Effective decision and actions are based on analysis of data and
information of which a reasonable part comes from users and target groups
(patients and clients)
Principle 8- Mutually Beneficial Supplier Relationship
An organization and its suppliers are independent, and a mutually
beneficial relationship enhances the ability to create value. In primary health
services the suppliers are not only the MOHP, but the community itself and
all stalk holders. [Egyptian MOHP Health Reform program (2007)]

58
Patient Satisfaction in the Quality Management Process:
Quality management (QM) and performance improvement (PI) are two
terms that are used interchangeably in quality review since the performance
improvement is the corner stone of the total quality management.
The aim of quality management is not to meet performance standards,
nor is it to deal with quality problems. It is to help every person in the service
to take responsibility for controlling quality and to enable them to use quality
methods to improve the process for delivering the service. To have the
maximum effect, these methods should be used as part of quality
management cycle. There are several models for quality management
process; however, Juran trilogy is one of the most famous models in quality
management which may be used as an example for other models to be
explored in the light of the client satisfaction philosophy to highlight the
importance of Patient Satisfaction in Quality Management.
According to Juran, the quality management cycle consisted of three
interrelated managerial processes of planning, control and improvement.
1. Quality Planning: It is a structured process designed to create services
that meet the customer’s needs. It involves six logical steps. These six
steps of quality planning can be explained through a series of logical
questions that planners need to answer:
Step 1: Establish the project (service)
Question: What do we want/need to build?
Answer: Project (service) mission/goals
Patient Satisfaction role: It is one of the health care service goals.
Step 2: Identify the customers
Question: Whom will we be building this for?

59
 Answer: Vital few internal and external customers
Patient Satisfaction role: Patients represent external customers.
Step 3: Discover client needs and expectations
Question: What benefit do they want from it?
Answer: Precise client needs
Patient Satisfaction role: a genuine need of patients is to get satisfied.
Step 4: Develop service
Question: What will create that benefit?
Answer: Detailed service features and service feature goals
Patient Satisfaction role: patient centered service.
Step 5: Develop process
Question: How do we deliver that service best?
Answer: Detailed process features and process feature goals.
Patient Satisfaction role: Patient involvement.
Step 6: Develop process control/ transfer to operation
Question: How do we ensure it works as designed?
Answer: Means to meet service and process quality goals.
Patient Satisfaction role: Patient Satisfaction surveys.
`

Measuring actual performance

Quality

Control
Compare the results with established standard
Steps

Act on the difference

Figure (3) The process of quality control

60
2. Quality Control/Measurement: Quality control process helps health
teams to understand and control their every day work processes, and
establish a basis for improvement of these processes. It helps assure that
routine activities and responsibilities are performed correctly and
consistently.
It involves the steps shown in Figure 3 in the first step actual
performance is to be measured by surveys. In the second step the
results of the surveys are to be analyzed and compared with the
standard guidelines. In the last step the perceived defects are acted
upon to complete the shortages.
Quality Improvement: This process is the means of raising
quality performance to unprecedented levels (breakthrough). It
involves the steps shown in Figure (4)
In the first step the improvement project is to change the practice
style towards a new one with a potential client satisfaction impacts, in the
second step the staff members who will be responsible for these actions that
maximize patient satisfaction are identified each is to be announced for his
tasks and responsibilities, in the third step the causes for practice deviations
from standards are traced and in step four suggested solutions are studied , in
step five the gains and advances are maintained by adding this methodology
to the protocols and in step sex refining the whole process takes place.
The three components of Juran trilogy work together to provide
quality management process that function like a loop. There is no starting
point or end point but all components work together in a continuous way.

61
History of quality and patient satisfaction and their impact on health
care standards
A review of the medical literature relating to the term "patient
satisfaction" shows little research on the topic in the 1960s and 1970s.
However, things began to pick up dramatically in the early 1980s. Between
1980 and 1996, there was a five-fold increase in the number of articles
devoted to this topic.
Why this burgeoning interest? Perhaps it was a natural outgrowth of
the consumer movement begun in the 1960s and 1970s. Or maybe it reflected
the maturation of the family medicine research agenda. Equally plausible
might be the emerging competitiveness of managed care, which led HMOs to
begin using patient satisfaction surveys to distinguish between providers.
[Thiedke C (2007)]
All of these are possible factors that coalesce to form the concept of
client satisfaction; tracing the history of quality and the emergence of the
client satisfaction as a determinant and basic principle of quality will help in
realizing the cause of the issue and the effects as well:
1920s: The American Walter A. Stewart raised the issue of finding and
fixing problems in the whole work process instead of finding and fixing
problems in the products at the end-point inspection. He developed a system
of measuring variance in production system known as statistical process
control (SPC). SPC is a major tool that TQM uses to monitor consistency, as
well as to diagnose problems in work process. [Maas KF (2000)]
1940s: His student Edwards Deming, a mathematical physicist, was hired to
teach SPC and quality control to U.S. defense industry. These methods were
considered so important to the war that they were classified as military
secrets.

62
1950s: After the World War II most U.S. companies stopped using SPC and
quality control procedures. At the meantime, Deming was invited after WWII
to lecture throughout Japan on SPC. The Japanese were quick to adapt and
modify Deming’s techniques. However, even today the highest award in
Japan for quality is named after Edward Deming.
1960s: This is the real beginning of the client satisfaction concept when
Joseph M. Juran stressed to the Japanese the importance of involving all
departments in the pursuit of quality and importance of client satisfaction,
rather than simple adherence to technical specification. Juran introduced a
new concept known as fitness for use (freedom from deficiencies and product
feature). Ishikawa enlarged the ideas of Juran to include as clients, internal
customers, those in an organization who depend upon the work output of
others. Ishikawa also developed the concept of quality circles based, in part,
on the work of the behavior scientists Herbert Maslow (Hierarchy of needs)
and Douglas McGregor (Theory Y).
1980s: The issue of applicability of TQM processes in healthcare was raised.
Two pioneer physicians, Dr. Berwick and Batalden, studied the industrial
methods and played a key role, in collaboration with industrial quality
consultants, in creating a National Demonstration Project on Quality
Improvement in Healthcare in U.S.A. This project has conclusively
demonstrated the applicability of TQM process in healthcare. [Berwick DM
(1990)]
While the initial focus of the project was on administrative aspects of
healthcare delivery, Brent James was a pioneer in applying these processes
directly to patients’ care and clinical outcomes. [James BC (1990)]

63
 1-Identify the Improvement Project (Specific needs for
improvement)
M
E 2-Establish the Project
A
(Project team & clear responsibility)
S 3-Diagnose the Cause
U
R 4-Remedy the Cause
E 5-Hold the Gains

6-Replicate results& Nominate New Projects

Figure (4) The process of quality improvement

1990s: Quality improvement methodologies became commonplace in

healthcare facilities. They focused on the continuous learning about all
aspects of processes and using this knowledge to change the processes to
reduce variation and improve performance. [NAHQ, (1998)]
By 1994, the Joint Commission introduced the new standards on improving
health organizations performance. The interest was shifted from performance
of individuals to performance of health organization’s system and processes,
although individual performance still maintained. There is no longer any
department-specific review. The new standards also require a shift from
improving only clinical quality to improving non-clinical care, value, and
patient satisfaction.

64
 The process model is the basis for the standard
Continual Improvement Of The
Quality Management System
Customer Requirements

Patient Satisfaction
Management
Responsibility

Measurement
Resource Analysis,
Management Improvement

Product
Realization Product

Value Added Activities

Information Flow

Figure (5) The quality improvement in TQM model [Egyptian MOHP

Health Reform program (2007)]

Patient Satisfaction as a basis of total quality management (TQM)

There are major differences between TQM and Traditional Management, as
TQM has been characterized by emphasizing the three C’s: Clients, Culture
and Counting. [Maas KF (2000)]

65
TQM is client not specialist driven: In TQM, client needs and expectations,
not agency, established standards and define quality. Users of products or
service define what they want rather than have their needs defined by others,
even if they are specialist. Figure (5)
One of the major cultural differences between TQM and traditional
management is in their respective views of individual versus organizational
performance. [Egyptian MOHP Health Reform program (2007)]

CORRELATIONS OF PATIENT SATISFACTION

A number of variables believed to be associated with patient
satisfaction have been measured in the medical population.
The most common characteristics found to correlate with greater satisfaction
ratings have included socio-demographic variables such as age, gender, race,
and education. [Chung K et al. (1999)]; [Cooper-Patrick L et al. (1999)];
[Hall J and Dornan M (1990)]; [Hall J et al. (1998)]; [Hall J et al. (1996)]
and [Like R and Zyzanski S (1987)]
Other variables correlated with patient satisfaction include retention of
medical information by the patient, communication, empathy, personable
behavior of the physician, and the inability of the patients. expectations being
carried out. [Ley P (1982)]
A. Socio-demographic Variables
Cooper-Patrick et al. (1999) used a telephone survey to ask adult
patients to complete a brief questionnaire. A self-defined race/ethnicity
question, a 3-item physician participatory decision-making (PDM) style (the
physician-patient interaction), and 6 patient factors (age, gender, self-rated
perceived health, education, marital status, and length of patient-physician
relationship) were the questions asked on the survey.

66
 Patient satisfaction was measured with four items. Patients (N =1816)
had to be 18 years or older, insured by the managed care organization, and
had to have visited their primary care physician within the previous 2 weeks
for depression. Patients evaluated male (n = 40) and female (n = 24)
physicians of Anglo, African American, Asian, and Latino decent. Results
from this collection indicated that individuals who were between the ages of
50-65, attended graduate school, had excellent self-report health status, knew
the physician for more than 3 years, and were white were more favorable of
the PDM style.
Furthermore, patient satisfaction was highly associated with PDM style
scores within all race/ethnicity groups. Although, race and gender
concordance between the patient and the physician were significant and
positively associated with patient satisfaction, the gender of the patient was
not related to patient satisfaction. Asian and Latino, but not African
American, patients were significantly less satisfied than whites with the
physician’s PDM style. [Cooper-Patrick L et al. (1999)]
Based on the fulfillment model, Like and Zyzanski (1987) evaluated
the social psychological factors believed to be associated with patient
satisfaction with the clinical encounter. Adult patients (N = 144) completed
two questionnaires (The Patients. Perceptive Interview (PPI) and the Patient
Request For Services Schedule (PRFSS)) prior to a visit with a physician and
one (Patient Services received Schedule (PSRS)) directly after the visit with
the physician. The physician completed the Physician’s Clinical Perspective
Questionnaire (PCPQ) directly after the visit.
The PPI is a 23-item survey that inquires about the patient’s reason for
the visit, expectations about the visit and various socio-demographic
variables. The PRFSS is a 27-item survey, which asked what services were

67
needed from the physician, and the importance of each service needed. The
PCPQ is a 23-item survey which included demographic information about the
physician, the patient’s chief complaints, methods used to treat the patient,
the feelings toward the patient, and the physician’s satisfaction with the
encounter.
After the visit with the physician, patients were asked to rank the
degree of satisfaction received with the encounter by placing an X on a
calibrated satisfaction line which ranged from 0- 100% for 5 questions. No
psychometric data is available for any of these instruments, and the authors
simply report that they were newly constructed. Through statistical analysis
(the specific method is not reported) items from 5 primary areas (patient
socio-demographic, patient illness behavior, patient encounter, physician
encounter, and health care system characteristics) were selected.
In general, patients were highly satisfied with their visit to the
physician’s office. Statistical associations were measured by Pearson and
point bi-serial correlations between various independent variables and patient
satisfaction scores with the encounter.
Patient satisfaction scores were significantly correlated with the
physician’s satisfaction with the encounter (r = 0.29, p < .001), physician’s
feelings about the patient (r = 0.27, p < .001), knowledge about the
presenting problem derived from the media (information reviewed by the
patient about their illness provided by the media) (r = 0.19, p < .05), and the
number of days since first visit (r = 0.18, p < .05). Women were more
satisfied than men (p < .05). Patient satisfaction was inversely correlated with
the amount of time desired with the physician (r = -0.19, p < .05) and with
the number of patient requests (r = -0.18, p < .05).

68
 Six independent variables (gender, number of days between first and
present visit and existing patient knowledge about the presenting problem
derived from the media, physician’s feelings toward the patient, and desires
met or not met) were entered into a hierarchical regression analysis. The
results indicated that all 6 variables combined, accounted for 34% of the
variance. [Like R and Zyzanski S (1987)]
Thus, there appears to be multiple predictors of patient satisfaction.
After construction of a patient satisfaction instrument, Hulka et al. (1975)
completed a retrospective study that surveyed 1713 adults living in a
Midwestern city.
Demographic data included the following: (1) 21% were 60 years of
age or older, (2) 90% were white and (3) 62% were females. These data was
relatively similar to the representation of the community.
The instrument included 42 items with 14 items in each of the content
areas (e.g., the professional and technical competence of the physician,
personal qualities of the physician, and accessibility and convenience of care
including cost). Scores obtained from the questionnaire revealed that ratings
tended to be lower for cost and convenience of care, whereas professional
competence and personal qualities were more highly rated. Using a
distribution of satisfaction scores, individual scores that fell above the 75th
percentile were considered as high satisfaction scores.

Cross tabulations against satisfactions scores grouped in quartiles were

used for the remaining analyses. Across all components of satisfaction,
women (19.6-30%) were more satisfied than males (12.5-22.8%) and African
American (12.5-19.6%) were less satisfied than Caucasians. Those who were

69
60 years of age or more had the highest percent (31.2) of high satisfaction
scores for the personal qualities component only.
Individuals who were from the upper middle class, based on
occupation and education, were more satisfied than either the low social class
or the high social class across all three components of patient satisfaction.
Other results indicated that individuals, who are members of a large family
(21.1%), live alone (20.7%), and do not have a regular physician (6.2%)
tended to be least satisfied with their health care. [Hulka B et al. (1975)]
Meta-analysis of 110 studies evaluated the socio-demographic
variables associated with patient satisfaction with medical care. [Hall J and
Dornan M 1990)]
The variables included in the analysis had to appear in at least 10
studies and included the following socio-demographic variables: (1) patient’s
age, (2) ethnicity, (3) sex, (4) social status, (5) income, (6) education, (7)
marital status, and (8) family size. [Hall J and Dornan M 1990)]

Patient satisfaction on 11 aspects of medical care and global

satisfaction were used as a measure. Correlation analyses indicated that age
(p < .01) and education (p < .05) were significantly related to greater
satisfaction.
Further analyses consisting of a priori weights to reveal a prediction of
the grouping variable (age, ethnicity, and percentage of male patients in the
sample) to the actual correlations obtained. Results across the eight socio-
demographic variables indicated the following for the adult sample:
(1) Older and less educated patients tended to be more satisfied.
(2) Higher class patients tended to be more satisfied for white than
black/Hispanic samples.

70
 (3) Black/Hispanic men tended to be more satisfied than whites.
(4) Less educated patients tended to be more satisfied among the white
than black/Hispanic samples.
(5) Patients with small family size tended to be more satisfied.
Finally, results across the eight socio-demographic variables for the
pediatric sample indicated higher income patients tended to be more satisfied.
[Hall J and Dornan M 1990)]

In summary, data analyses revealed no gender differences, but the

patient’s age and education did have a significant bearing on the patient
satisfaction relation. In general, people who were older, less educated, had
higher social status (occupational status), and were married tended to be more
satisfied with their medical care. [Hall J and Dornan M 1990)]

In an outpatient plastic surgery clinic, patients (N = 345) were asked to

complete a 9-item Visit Specific Patient Satisfaction Questionnaire (VSQ) at
the end of their physician visit. [Chung K et al. (1999)]
The instrument was used to evaluate the encounters between physician
and the patient. It is noteworthy that three of the nine items were specific to
the physician. The other 6 items were related to the facility. In a uni-variate
analysis, age was positively associated with overall satisfaction.
Finally, age, gender, education, ethnic background or type of clinic
were not found to be significantly associated with overall patient satisfaction
(Chung et al., 1999). Although some literature found significant patient
satisfaction relationships with gender and age, Chung et al., (1999) was not
able to support these findings. [Chung K et al. (1999)]

71
 B. Physician’s behaviors and patient health status
Other variables that have shown to be correlated with patient satisfaction
were characteristic of the physician’s interaction with patients and the
patient’s health status. [Comstock L et al. (1982)]; [Hall J et al. (1996)];
[Hsieh M and Kagle J (1991)]; [Willson P and McNamara J (1982)] and
[Yarnold P (1998)]
In Mexico, Comstock et al. (1982) evaluated the caring skills of
physicians (N = 15) and correlated them with patient satisfaction scores of
150 patients. Patient satisfaction was measured using an 8-item
questionnaire. A technician trained to observe physician behaviors through a
one-way mirror, evaluated physicians’ verbal and nonverbal behavior. Verbal
skills such as courtesy (r = 0.36, p < .001), information giving (r = 0.34, p <
.001), listening(r = 0.27, p < .001), and empathy(r = 0.19, p < .05) were
significantly correlated with patient satisfaction scores; whereas, non-verbal
skills (eye contact, bodily positioning, physical appearance) were not
significantly correlated with patient satisfaction. However, age of the patient
was positively associated with global satisfaction ratings. Patient satisfaction
ratings were unrelated to gender, and gender was unrelated to physician
behaviors. [Comstock L et al. (1982)]
In an experimental design, Willson and McNamara (1982) surveyed
undergraduate psychology students (N = 127) and randomly assigned them to
12 experimental sessions. The focus of the study was to have the subjects
differentiate between the levels of courtesy, but not confidence.
The study was designed to determine whether the subjects would base
their satisfaction ratings on the courtesy, rather than competence, of the
physician, and if physician competency or courtesy would then influence
subjects’ compliance behavior. More women than men participated in the

72
study, but no other demographic data were collected. Subjects completed an
18-item courtesy/competent identification scale, the 26-item Medical
Interview Satisfaction Scale (MISS), and three general questions related to
health care advice (overall satisfaction of the medical visit, intention to
comply with the medical recommendations, and would the subject follow the
doctor’s orders) measured on a 5-point Likert scale. The surveys were
completed after viewing one of four video vignettes over three consecutive
occasions.
The video vignette contained actors that represented a male college-
age patient presenting typical sore throat symptoms, a male middle-aged
physician, and a female nurse. Pilot testing of the video vignette showed 80%
accuracy discrimination between courtesy and competence. The video
vignette was randomized for each experimental group. Uni-variate ANOVAs
indicated that students were accurate with ratings of the specific categories.
The primary results indicated that courtesy had a significant effect on patient
satisfaction (MISS), but no effect on compliance.
However, manipulated competency produced significant effects on
patient satisfaction (MISS) and on compliance items. Finally, the MISS was
significantly correlated with the global satisfaction item (r = 0.77, p <
0.0001). Intercorrelations were reported between: (1) perceived courtesy and
competence (0.48), (2) satisfaction and perceived courtesy (0.86), (3)
satisfaction and perceived competence (0.60), and (4) satisfaction and
perceived compliance (0.47). [Willson P and McNamara J (1982)]
The results clearly showed that there was a relationship between the
physician’s behaviors and patient satisfaction ratings. However the sample
did not reflect a personal physician-patient relationship as the subjects were
not being examined (hypothetically answered the compliance and satisfaction

73
questions), nor were the medical personnel real (actors). Further, the article
did not indicate whether the subjects were aware that the medical personnel
and patient were actors.
In a retrospective study, medical personnel (physicians and nurses)
competency was measured in the emergency room department. Competency
of the medical personnel was considered an adequate measure of patient
satisfaction. Two emergency room (ER) departments in an academic hospital
and in a community hospital located in the Midwest of the United States of
America were used as sample sites. [Yarnold P et al. (1998)]
Patients (N = 1101), who had utilized the ER department at the
academic hospital but had not been admitted, were mailed a two-page survey
one week after their ER visit.
The survey was a 16-item questionnaire that asked for the patient to
rate the nurses (six items), doctors (seven items) and general areas (three
items) using a 5-point Likert scale. Patients (N = 1631) who utilized the
community hospital were asked to complete a telephone interview if they had
been to the ER during the previous 2-4 weeks. The interview consisted of
nine items with equal distribution throughout the nurse, physician, and
general area ratings. Patients were asked to rate each question on a 4-point
Likert type scale. Adult patients were interviewed directly, the adult
accompanying the pediatric patient was interviewed, and the caregiver who
accompanied the patient was interviewed. [Yarnold P et al. (1998)]

Data from each hospital was separated and a classification tree analysis
(CTA) was employed to predict overall patient (dis) satisfaction. This method
of statistical analysis was used to show a flowchart of results based on
specific decisions. The results showed a non-linear tree model for both

74
hospitals that suggested overall patient (dis) satisfaction with care received in
the ER was greatly predictable on the basis of patient-rated qualities of the
staff, particularly of the nurses and physicians. [Yarnold P et al. (1998)]

Specifically, fair or worse ratings of the staff treating the patient as a

person, very poor ratings of waiting time in the treatment area, and good or
worse ratings of the physician’s concern for the patient’s comfort during
treatment were indicative of (dis) satisfied ratings. These results supported
other findings indicating that a physician’s, as well as a nurse’s, behavior can
impact the satisfaction rating of a service provided.
In a longitudinal study, Hall et al. (1993) examined causal paths that
have not previously been investigated to understand how patient health status
and patient satisfaction are related. Two specific causal paths of the health-
satisfaction relationship that were of interest included: (1) whether the
patient’s perceived health at time one affects the patient’s satisfaction at time
two, or (2) whether the patient’s satisfaction at time one determines the status
of the health of the patient at time two. [Hall et al. (1993)]
HMO-based elderly patients (N = 560) qualified for the study if they
were: (1) over 74 years of age, or (2) between 70 and 74 years of age and had
been identified by the physician as being “very likely” or “probably likely”
to deteriorate or having “fair” or “worse” current overall health. Interviews
were taken at baseline and 12 months later.
One third of the subjects were assigned to one of the experimental
groups to receive one of the following interventions: (1) consultation from a
geriatrician specifically trained nurse and social worker, (2) special
consultation from “second opinion” internist, or (3) received standard HMO
services (control).

75
 The Sickness Impact Profile was used to measure functional ability.
Four parts of the 51-item multidimensional instrument were used, and the
four scales were highly correlated. The internal consistency for each scale
exceeded 0.80. Self-perceived health was measured using six items from a
previous self-perceived health survey developed for the Rand Health
Insurance Study. Internal consistency was reported as 0.86 for these items.
Satisfaction with providers was measured using 12 items, which were pilot-
tested on 50 patients. Items were adapted from other scales found in the
literature. The internal consistency was calculated at 0.89. The total
satisfaction score was used as the dependent measure. Multiple regression
analysis was used to establish a model to identify any path that was
significantly associated with satisfaction over time.
Both functional ability and self-perceived health were associated
significantly over time with satisfaction. Correlations between the health
status and satisfaction at both time points and over time were significant (r <
.25, p < .01). Specifically, the perception of one’s health at time one was
related to satisfaction at time one (r = 0.24, p < .01) and time two (r = 0.10, p
< .05), and the functional ability at time one was related to satisfaction at
time one (r = 0.11, p < .05) and time two (r = 0.08, p < .05). Tests for causal
models showed a significant path over time from overall perceived good
health status at time one to positive patient satisfaction at time two.
However, there was not a significant path from patient satisfaction at
time one to overall perceived health status at time two. What was not clear
was whether there was a mediating affect through the physician’s behavior
[Hall J et al. (1993)]
After reviewing several studies that tried to identify a link between
patient satisfaction and health care, Hsieh and Kagle (1991) summarized the

76
findings and posited that a patient’s expectations and the fulfillment of their
positive expectations would be more favorable to patient satisfaction. Hsieh
and Kagle (1991) then employed a cross-sectional design study to explore the
relationships between patient’s expectations, personal characteristics, health
status, service delivery type, and patient satisfaction with health care. [Hsieh
M and Kagle J (1991)]
Approximately 10% of the faculty and staff employed at a large
Midwestern university were randomly selected to participate in the study.
Subjects who lived within a 50-mile radius and who had not retired qualified
for the study. The sample was equally represented by gender, but ethnic
minorities were underrepresented. A large majority of the subjects (94.3%)
were full-time employees of the university. One third of the subjects were
between 26-36 years of age (30.8%), and the majority were nonacademic
staff (54.8%). A 63.5% return rate from 2 independent mailings was obtained
(N = 401).
Patient satisfaction was measured using a six-dimensional satisfaction
scale that was rephrased from the Patient Satisfaction Scale. Internal
consistency for the amended scale was very good (r = 0.91). Patient
expectation was measured with a similar six-dimensional anticipation scale
that was also rephrased from the Patient Satisfaction Scale. Internal
consistency was also very good (r = 0.87). Using factor analysis with an
orthogonal rotation, four factors for each scale (satisfaction and anticipation)
emerged and accounted for 61 % and 51.7% of the variance, respectively.
Results indicated that women were more satisfied than men, and
nonwhite subjects tended to be more dissatisfied with the health resources
available than white subjects. Age showed a significant curvilinear
association with satisfaction. Specifically, extreme age groups were more

77
satisfied with the physician’s conduct and general satisfaction than middle
age groups. Subjects who were considered to be in relatively poor health
were less satisfied with accessibility and reported lower scores in general
satisfaction than did other respondents. Further, subjects who were enrolled
in the fee for service (FFS) plan reported higher levels of satisfaction with the
physician’s conduct than those who were enrolled in the prepaid group
practice (PPG) plan.
In summary, white women who were either very old or very young,
and were considered to be in good health appeared to be generally more
satisfied. [Hsieh M and Kagle J (1991)]
These results were similar to the findings of Hall and Dornan (1990)
and Hulka et al. (1975). [Chung K et al. (1999)]
Previous studies (Hall et al., 1993; Hall, Roter, & Katz, 1988) have
supported the importance of the physician-patient relationship and its
influence on patient satisfaction among elderly Americans. [Hall J, Roter D
and Katz N (1988)] and [Hall J and Dornan M (1988)]
However, whether the patient’s health status has an effect on the
physician’s behavior has not been clearly supported. Therefore, Hall et al.
(1996) conducted 4 independent studies to investigate the physician-patient
relationship, specifically physician behavior, while delivering medical care to
patients receiving physical and mental health care.
Study one consisted of predominantly white men and women (N =
100) waiting for an appointment. The average age of the patient was 62 years
and they reported receiving treatment for a number of medical conditions.
Internists (N = 50) represented the medical staff being evaluated.
Study two consisted of predominantly white, female (58%) patients (N
= 547) waiting for an appointment. The average age of the patient was 60

78
years and the medical condition was heterogeneous. Physicians (N = 127)
represented the medical staff being evaluated.
Study three consisted of predominantly white, female (76%) patients
(N = 132) who had first visits to 22 rheumatologists for the symptoms of
arthritis.
Study four consisted of predominantly white, female (65%) patients (N
= 649) waiting for an appointment. The average age of the patient was 48
years and the medical condition was not homogenous.
All visits with the medical staff were audio taped. Each study was
conducted in varying parts of the Eastern United States of America and in
Canada. Following each visit the patients were asked to complete mental
health ratings and physical health ratings.
In studies two, three and four physicians rated the physical health of
the patients and in studies two and four physicians also rated the patient’s
mental health.
Physicians rated their own satisfaction with the visit in studies two and
four. Communication of both the physician and the patient was measured
using the Roter Interaction Analysis System (RIAS) to obtain a verbal
measures score. The RIAS is an instrument used to categorize verbal
utterances into content (e.g., laugh, social conversation, statements of
empathy or concern). The RIAS coding categories were clustered into nine
categories. After controlling for the physician and patient background
characteristics of all subjects in the four studies combined, significant
correlations were reported.
However, it is worth mentioning that the correlations were very low
(0.02-0.18). In comparison to more healthy patients, less healthy patients
(physical and mental) had more negative behaviors (negative statements), and

79
physicians tended to have mixed interactions with the less healthy patients.
For example, a positive association between positive statements made by the
physician and sicker patients occurred, while, the physician’s social
conversation decreased with the sicker patients. Also, physicians disagreed
more and used a more negative tone with less healthy individuals.
Furthermore, physicians were less satisfied with the visits by less healthy
individuals. [Hall J et al. (1996)]
Consequently, health status influenced physician-patient
communication. The results of these combined studies suggested that a
patient’s health status could influence patient satisfaction, especially if a
patient’s health status influenced physician-patient communication, which in
turn influenced patient satisfaction.
Later, Hall et al. (1998) investigated a direct model and a mediation
model to explain patient satisfaction. Hall et al. (1998) used social
conversation as a mediator of patient satisfaction in two independent studies.
Simply stated, Hall et al. (1998) investigated whether a physician’s
communication (verbal and non-verbal cues) will influence the relationship
between patient health status and patient satisfaction scores.
If there was a significant influence, then a mediation affect has
occurred. On the other hand, if there was no significance then no mediation
affect occurred. Therefore, only a direct relationship between the patient’s
health status and patient’s satisfaction is present, which would support
previous findings. [Hall J et al. (1996)]
In study one, first time visits by men and women (N = 114) patients
who were diagnosed with rheumatologic diseases and 20 rheumatologists
qualified for the study. The sample consisted predominantly (76%) of female

80
patients. The Sickness Impact Profile was used to measure the physical and
psychosocial health status of each subject.
The Medical Interview Satisfaction Scale (MISS) was used to measure
information giving behaviors and humanness. All physician-patient
interactions were audio taped thereby allowing the mediator variable
(communication) to be analyzed by the Roter Interaction Analysis System
(RIAS). A significant direct positive association between psychosocial health
and patient satisfaction was identified. A marginally significant direct
positive association between physical health and patient satisfaction was also
recognized. Thus, patients who were in better health reported greater
satisfaction.
However, no significant associations between the patient’s health and
physician behavior path or between the physician behavior and patient
satisfaction path were found. These findings suggested the style of
communication did not mediate the relationship between patients’ health
status and their patient satisfaction ratings. [Hall J et al. (1998)]
The second study completed by Hall et al. (1998) evaluated 649 males
and females with a wide range of medical problems and internists as well as
family physicians (N = 69) employed in private and HMO practices.
The general health status was self-reported by the patients and
included the following: (1) their general physical health, and (2) how much
their overall health interfered with their daily living activities. Physicians also
rated the patient’s current physical condition. Emotional health was measured
by three instruments: patients’ self-reports ratings of the patient’s health
made by the physicians, and by the patients’ scores on the General Health
Questionnaire.

81
 A 20-item questionnaire, which asked patients to evaluate their
physician’s technical competence, respect, and provision of information, was
used to measure satisfaction. Internal consistency was 0.87. Communication
was used as a mediator between the patient’s health status and the patient
satisfaction ratings for the analysis. RIAS and facilitative talk (addressing the
patient’s psychosocial concerns) were used to measure communication.
Internal consistency was 0.93. Results from study 1 and 2 showed a
significant direct path from psychosocial health status to patient satisfaction.
Additionally, significant support was found for mediating affects of
conversation for the psychosocial health status and the physical health status,
but in study 2 only. Essentially, the patient’s health status influenced the
physician’s communication (social conversation), which influenced the
patient’s rating of the physician’s communication, which in turn influenced
the patient satisfaction ratings. [Hall J et al. (1998)].
Differences between study 1 and study 2 results may have been due to
the sample selection (chronic disease vs. routine continuing care with HMO)
and instruments used to measure satisfaction (MISS vs. 20-item
questionnaire).
Additionally, the physician saw the patients in study 1 for the first
time, whereas the patients in study 2 were seen by their physicians for routine
care. The length of time the patient has known the physician may explain
why the physician’s communication (social conversation) was found to have
mediating affects on patient satisfaction in study two, only.
Furthermore, the physician’s communication was the only variable
tested to measure a physician’s behavior as a mediator. Therefore, one should
use caution when making reference to either one of these studies.

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 C. Other correlates of patient satisfaction
Patient satisfaction is considered a way to measure the perceptions
or feelings that the patients may have while being medically
attended to for their injuries or illnesses. [DiPalo M (1997)] and
[Sitzia J and Wood N (1997)]
Several studies have investigated the physician-patient relationship
using communication as a measure of patient satisfaction. [Hall J, Milburn
M and Epstein A (1993)]; [Hall J et al. (1998)] and [Hall J et al. (1998)]
Similarly, Stiles, Putnam, Wolf, and James (1979) evaluated the
physician-patient interaction, specifically verbal communication. Through
cross-sectional design, Stiles et al. (1979) evaluated 50 patients ranging in
age from 16-75 years and 19 physicians, primarily white males (90%).
Interviews were tape-recorded and physical evaluations were
completed. Following the interview, patients completed a 33-item patient
satisfaction questionnaire. Each item was rated on a 5-point Likert type scale.
The questionnaire was based on the MISS. [Wolf M et al. (1978)]
Communication/Interaction coding was based on taxonomy of
classification consisting of 8 basic modes that can also be mixed. Three
independent and trained coders coded the physician-patient interactions.
Factor analysis was performed on the mode frequencies and extracted 2
factors accounting for 73.8% of the variance. Affective and cognitive
domains were the two constructs of the questionnaire that were measured.
Average scores were computed for each component. The affective
domain evaluated the physician’s warmth and patients’ feeling of trust. The
cognitive domain evaluated the information giving style of physicians and the
patients’ understanding of the information. Although, the correlations were
relatively weak, patients who gave longer medical histories and provided

83
information in their own words had greater affective satisfaction scores (r =
0.30, p < .05). The provision of feedback by physicians was significantly
correlated with cognitive satisfactions scores (r = 0.31, p < .05).
These data suggest that the patient-physician interaction is important
when measuring patient satisfaction. [Stiles Wet al. (1979)]
Based on previous reports indicating that less healthy patients are less
satisfied with their health care [Hall J et al. (1993)] and [Hall J et al.
(1988)], Greenley, Young, and Schoenherr evaluated psychologically
distressed patients and their reports of (dis) satisfaction of health care.
[Greenley J, Young T and Schoenherr R (1982)]
In a retrospective study, Greenley et al. (1982) distributed a 10-item
questionnaire to acutely injured patients (N = 204) from 10 health,
rehabilitation, and related social service agencies six weeks following their
appointment with the physician.
Three specific satisfaction measures (humanness - five items,
competence - four items, and general quality of service - one item) were
used. Psychological distress (moderate depression and anxiety) was measured
using the Crandall and Dohrenwend 10- item psychological symptoms cluster
of the Langner 22-item psychiatric screening. [Greenley J, Young T and
Schoenherr R (1982)]

Sex, age, income, education and adult household role, were

significantly related to psychological distress and satisfaction. Therefore
these five variables were used as control variables throughout the multiple
regression analyses. Overall, psychological distress was significantly
correlated with humanness (r = -0.10, p < .05), competence (r = - 0.22, p <
.05), and general quality of service (r = -0.22, p < .05).

84
 Although the correlations were significant, they were weak and
accounted for only 5% of the variance. Individuals across all 10-service
organizations who are psychologically distressed and deny having emotional
or personal problems are less satisfied with health care and related services.
[Greenley J, Young T and Schoenherr R (1982)]

Specific to an emergency room setting, Bruce, Bowman, and Brown

(1998) evaluated the factors that influence patient satisfaction ratings.
Specifically, nursing care, emergency department environment, auxiliary
staff, and information received were measured using the Emergency
Department Patient Satisfaction Survey. A 30-item questionnaire rated by a
3-point Likert-type scale was distributed to 128 individuals who utilized the
emergency room and were asked to evaluate the care received and to return
the survey in the prepaid envelope provided. Non-urgent emergency room
patients (N = 28) returned the surveys. Specific to nursing skill, high
satisfaction scores were indicated for: (1) overall caring and compassion
(75%), (2) skill with medications and treatment (74%), and (3) explanation
given about care (71%). Specific to information given, the highest
satisfaction scores included: (1) information related to medications (46%), (2)
diagnosis (43%), and (3) self care (43%). Under the auxiliary service sector,
the patients were primarily dissatisfied with the receptionist (7.7%). In
general, patients were satisfied with the environment such as the comfort of
the waiting room, cleanliness, quietness, and staff working together. Chi-
square analysis revealed no statistical significant difference in satisfaction
between male and female patients. [Bruce T, Bowman J, and Brown S
(1998)]

85
 In summary, variables correlated with patient satisfaction in the
general patient satisfaction literature have included race and gender
concordance of physician and patient [Cooper-Patrick L et al. (1999)],
gender of the patient [Hulka B et al. (1975)]; [Like R and Zyzanski S
(1987)], socioeconomic status [Hall J and Dornan M, (1990)] and [Hulka B
et al. (1975)], and time spent with the physician [Chung K et al. (1999)] and
[ Like R and Zyzanski S (1987)]
The population samples have included elderly patients [Hall J et al.
(1993)] and [Hall J et al. (1998)], Mexicans [Comstock L et al. (1982)],
students in psychology and military personnel and families [Mangelsdorff D,
(1979)]
Other variables related to satisfaction ratings include physician-patient
interaction, physician communication [Hall J et al. (1993)]; [Hall J et al.
(1998)] and [Hall J et al. (1996)], and patient.s health status [Greenley J et
al. (1982)]; [Hall J et al., (1993)]; [Hall J et al. 1998)] and [Hall J et al.
(1996)]

PATIENT MANAGEMENT AS A PATIENT SATISFACTION

CONCEPT
An ever more popular movement towards strengthening the patient's
role (the consumer approach) and the increasing economic pressure on
primary care doctors has stimulated more rational planning of the
management of individuals in general practice. [Rivo L and Johnson R
(2002)]
The idea of patient management in primary care, however, is not new
and has always been about addressing the patient in his/her biomedical as
well as social and psychological context.

86
 Patient management aims to shift the focus from the disease to the sick
person or as Maimonides, the medieval Jewish physician and thinker, put it
800 years earlier the physician should not treat the disease but the patient
who is suffering from it. [Sweeney G, MacAuley D, and Gray P (1998)]
Such a patient-centered approach is based on a good (therapeutic)
doctor-patient relationship. The quality of the interaction between physician
and patient and their expectations may sometimes influence patient
outcomes more than specific treatment, for example, with a drug. Moreover,
patient-centered practice is associated with increased efficiency of care,
involving fewer diagnostic tests and referrals. [Stewart M et al. (2000)] and
[Di Blasi Z et al. (2001)]
Engel's theoretical assumptions are supported by recent evidence from
psycho-neuro-immunology. The term psycho-neuro-immunology expresses
the important links between the central nervous and the immune systems.
There is a strong bi-directional relationship between the brain and immune
systems. Several studies have confirmed the relationship between stressful
life events, immunological changes, and adverse health outcomes such as
heart disease, cancer, asthma, or infectious disease. [Cohen S and Herbert
TB (1996)] Figure (6)
Supportive relationships are an important mediator and often improve
the immunological condition, whereas bereavement, for example, can result
in a temporary down-regulation of the immune response. Also, other factors
such as chronic stress modulate a variety of immunological activities.
Engel was one of the first to develop a systematic approach towards
the biopsychosocial model. [Engel GL (1980)]

87
 Changes in
Psycho- Central Nervous
System

Immuno- Changes in
Social Changes in
Endocrine Disease
System Susceptibility
Changes in -logical
Changes in
factors
Behaviour
Processes
Figure (6) Psychosocial factors may cause changes in disease
susceptibility. [Cohen S and Herbert TB (1996)]

Drawing on systems theory, this model offers a framework of the

patient as a whole person with specific emphasis on subjective experience,
thoughts, and emotions related to objective data (e.g. medical findings).
It is essential, especially in patients with chronic conditions, not only
to structure each consultation but also to develop a structured long-term plan
for clinical management that should include the key principles of patient
management. Appendix No.4
Since immunological processes are embedded within a larger
biological, psychological, and social context, it is as Engel predicted
impossible to practice disease management without taking the patient's
concerns and background into consideration. [Engel GL (1980)]
Management programs may improve with active patient participation
and shared decision-making. There is evidence that most patients want a
patient-centered approach, and are less satisfied, less enabled, and may be

88
more burdened by symptoms if they do not get it. [Little P et al. (2001)] and
[Elwyn G, Edwards A and Kinnersley P (1999)]
Patient management is also an attempt to overcome clinical inertia: a
failure of health care providers to initiate or intensify therapy when indicated.
[Phillips S et al. (2001)]
Doctors may thus identify patients and situations in which more
intensive management of chronic conditions such as hypertension is
appropriate. Moreover, real-world primary care physicians can deliver
effective treatment if they are supported by organized systems for patient
education, proactive consultation for non-responders, physician education,
and patient monitoring, as Katzelnick demonstrated for the management of
depression. [Katzelnick J et al. (2000)]
A management plan should be based on evidence-based guidelines (if
available) for different conditions seen in general practice. The chronological
steps may help to structure a single consultation as well as the long-term
doctor-patient relationship. [Jones R et al. (2004)], (Table 1)

FAMILY MEDICINE AS A PATIENT SATISFACTORY MODEL OF

PRACTICE
As a discipline, family medicine has failed to formulate and deliver a
compelling message. An essential strategy to ensure the future success of the
proposed New Model of family medicine will be a comprehensive plan of
communication by developing communication strategies and messages
targeted to the attitudes and expectations of various constituencies to ensure
that the messages are clearly understandable to key audiences.

Table 1 Stages and steps of a management plan [Jones R et al. (2004)]

89
Consultation style Steps Stages at first or follow-up
@ binding, consultation
$ optional

@Defining roles, gaining trust,

Patient-centred Establishing a relationship
reassurance
Active listening @Formal arrangement; setting
Refrain from interruptions
@Screening of complaints and
Patient-centred Eliciting the patients
medical condition
agenda
@Hypothesis concerning the patient's
Active listening
reason for encounter
Structured procedure
@Evidence-based examinations,
Patient-centred Diagnostic procedures
laboratory tests
@Collecting information about
Active listening previous diseases (including genetic History/examinations
aspects)
@Regarding multiple causes and
Structured procedure Context
effects of illness
@The patient's background as well as
Informing the patient occupational, social, and personal
situation

Educational dialogue @Patient's health beliefs

Information

@Assessing resources (e.g. social

support and the patient's locus of
control)

@Discussing the diagnosis with the

patient (name, origin, and
consequences of the disease)
Aims of treatment
Considering patient
@Defining starting point and priorities
preferences

Educational dialogue $ Body/mind area

90
 Shared decision-making $ Pain (control or reduction)
$ Functioning, quality of life
$ Understanding, knowledge
$ Prevention

Motivating @Evidence-based treatment

Planning, choice, and
Considering patient $ Supporting the patient in active
progressive realization of
preferences and/or emotional coping
treatment
$ Modification of health behaviour,
Concordance/compliance
self-monitoring
$ Individualized written action plan
Educational dialogue,
(e.g. for use and adjustment of
instruction
medication)

Considering patient @Intensification of treatment if

Stepped care
preferences needed

Informing the patient $ Speciality consultation

$ Referral

Structured interview *Affective: patient satisfaction

Evaluation (immediate,
*Behavioural: patient adherence,
Standardized questionnaire intermediate, and long-
compliance
term outcome)
Test *Cognitive: patient recall
@Health outcome: symptom scores,
functional status, pain, quality of life
$ Economic: direct and indirect costs
(e.g. hospital admission, days off
work)

To be at the patient's
$ Optimization of outcome End of treatment, follow-up
disposal

Regular medical review $ Preventive activities

Translating some of the informative material into commonly

understood language suitable for a diverse set of audiences is a primary goal
as the messages proposed seek to address diverse audiences in terms they
understand and care about and in compelling terms that portray how family

91
physicians will deliver health care value, in which patient satisfaction is a
basic need and target, into the future.

The changing role of family physicians and the communication of this role
must be considered in the context of the following sweeping changes that are
taking place in the health care environment. [Magee M (2002)]
• The patient-physician relationship is changing and will continue to
evolve in the future.
• Egyptians are living longer, and the elderly comprise a larger and more
dominant segment of the Egyptians population.
• New technologies offer a wide range of communications options that
were not available a decade or two ago.
• Evidence-based medicine is emerging as perhaps the best opportunity to
balance scientific care with humanistic care.
• Predictive medicine and preventive medicine are making inroads with
health care providers and consumers alike.

ACCESSIBILITY AS A PREREQUISITE FOR PATIENT

SATISFACTION
Although some health care systems address the issue of provider
availability (e.g. defining this in terms of weeks and hours in the year
during which a health professional is available to patients), an important
distinction has been recognized by a number of authors in differentiating
between availability and accessibility of care. [Penchansky R and
Thomas JW (1981)], [Joseph AE and Phillips DR (1984)] and [Aday
LA and Andersen R (1974)]

92
 The supply of a service (availability) has been identified as a
prerequisite for accessibility, which, in these terms, is then of secondary
importance. The availability of primary medical care is subject to
professional and political constraints and will, at least in part, be
determined by the policies of governments and health care planners.
The accessibility of a service is probably of more direct relevance to
the consumer. Thus, a child-screening service may be made available
through the general practitioner, but if that service is located in
geographically distant areas from the target potential users, or provided at
times during which the users are unlikely to avail themselves of the
service, then accessibility becomes a real problem.
Penchansky and Thomas identified five dimensions of access; which
are:
1- Availability: volume and type of services

2- Accessibility: location considerations, include the geographical

elements of distance, travel time, and transport

3- Accommodation: organizational resources, include the design of

premises and the siting of facilities relative to the population

4- Affordability: financial constraints

5- Acceptability: attitudinal factors.

[Penchansky R and Thomas JW (1981)]

Researchers have often concentrated on service utilization and patient

satisfaction as proxy measures of accessibility. Distance from a service
may relate to the rate of utilization of that service the so-called distance
decay effect. [Shannon W and Dever A (1974)] and [Acton JP (1973)]

93
MEDICAL CONSULTATION, THE BASE OF PATIENT
SATISFACTION
The relationship between patient and family doctor can also be seen as an
indicator of the current values of a society, and of its evolution over time.
The expectations brought to the relationship are moderated not simply
by experience of previous consultations, but by a wide range of social and
cultural influences within which the consultation takes place. These
influences play on doctor and patient alike, although to different effect.
The consultation has been elegantly described by Dr James Spence as:
The essential unit of medical practice, the occasion when, in the intimacy of
the consulting room or sick room, a person who is ill, or believes himself to
be ill, seeks the advice of a doctor whom he trusts. The consultation is thus
seen as the main manifestation of the patient-doctor relationship, and the
primary situation in which it is built or destroyed. [Spence JC (1960)]
The consultation is at the centre of primary care. Serial consultations
establish long-term relationships with patients and knowledge about them,
and form the basis for follow-up.

PATIENT SATISFACTION AS A COMMUNICATION OUTCOME

It goes without saying that both the doctor and his patient have the
same objectives concerning cure and good prognosis. Both of them are
dependent on each other; the doctor has to seek another job if he has no
patient and the patient has to keep suffering if he has no doctor.
But the problem is that their visions are different, for example the
doctor needs to reach the target of complete cure and the patient needs to
reach the target of complete relief. Cure and relief although looks similar are
not that identical in practice; a good example is the famous singer who was

94
seeking relief from sudden loss of weight and change in her voice and her
doctor who was not concerning these “miniature” objectives as he was facing
thyroid carcinoma, the only exit from the dilemma is good communication.
Another issue is the patient perception of the messages sent by the
doctor that maybe not identical and totally different from the original
message sent, this perception is called decoding of the message that may alter
its meaning. A good example is the patient with a sore throat who demands
an antibiotic to be prescribed by his doctor, the doctors refusal will be
decoded as denial of his needs or as if the doctor considers this a waste of
resources not because the patient doesn’t need, but because he doesn’t
deserve! These two stories are just examples of the importance of
communication in the medical practice as it is the pathway for doctor patient
relationship, the trigger for patient satisfaction and a major determinant of
patient outcome.
Observational studies examining relationships between patients’
perceptions of their physicians and patient-reported adherence, health status
changes, and symptom resolution suggest that physicians’ interpersonal styles
may influence patient outcomes. [Bass MJ, Buck C and Turner L (1986)]
Several studies have investigated the physician-patient relationship
using communication as a measure of patient satisfaction. [Hall J, Milburn,
M, and Epstein A (1993)] and [Hall J et al. (1998)]
Similarly, Stiles, Putnam, Wolf, and James (1979) evaluated the
physician-patient interaction, specifically verbal communication. Through
cross-sectional design, Stiles et al. (1979) evaluated 50 patients ranging in
age from 16-75 years and 19 physicians, primarily white males (90%).
Interviews were tape-recorded and physical evaluations were completed.

95
Following the interview, patients completed a 33-item patient satisfaction
questionnaire.
Each item was rated on a 5-point Likert type scale. The questionnaire
was based on the MISS (Wolf et al., 1978). Communication /Interaction
coding was based on taxonomy of classification consisting of 8 basic modes
that can also be mixed. Three independent and trained coders coded the
physician-patient interactions. Factor analysis was performed on the mode
frequencies and extracted 2 factors accounting for 73.8% of the variance.
Affective and cognitive domains were the two constructs of the
questionnaire that were measured. Average scores were computed for each
component. The affective domain evaluated the physician’s warmth and
patient’s feeling of trust. The cognitive domain evaluated the information
giving style of physicians and the patient’s understanding of the information.
Although, the correlations were relatively weak, patients who gave longer
medical histories and provided information in their own words had greater
affective satisfaction scores (r = 0.30, p <.05). The provision of feedback by
physicians was significantly correlated with cognitive satisfactions scores (r
= 0.31, p < .05). These data suggest that the patient-physician interaction is
important when measuring patient satisfaction. [Wolf M et al. (1978)]
In an outpatient plastic surgery clinic, patients (N = 345) were asked to
complete a 9-item Visit Specific Patient Satisfaction Questionnaire (VSQ) at
the end of their physician visit. [Chung K et al. (1999)]
The instrument was used to evaluate the encounters between physician
and the patient. It is noteworthy that three of the nine items were specific to
the physician. The other 6 items were related to the facility. In a uni-variate
analysis, age was positively associated with overall satisfaction.

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 After adjusting for age and type of clinic, a multiple linear regression
analysis found that the following four questions contributed most to patient
satisfaction:
(1) Personal manner of the physician.
(2) Time spent with the physician
(3) Length of time to get an appointment.
(4) Explanation of what was done.
Specifically, the quality of the patient-physician interaction and
efficient clinic processes were the most significant predictor of patient
satisfaction. [Chung K et al. (1999)]
Actually, the patient satisfaction as a concept is a direct reflection of
quality as it is perceived by the patient; it’s about how do doctors
communicate their work through sending verbal and non verbal messages and
how do patients decode these messages; it is all about communication.

PATIENT RESPECT, THE KEY FOR PATIENT SATISFACTION

Patients should always be treated with the utmost respect.
Unfortunately, poor customer service generally stems from a real lack
of respect for patients. The patient, even if ignorant or of low socio-economic
class is not stupid. In fact, it’s highly unlikely that there are a lot of stupid
patients out there, yet many businesses still treat customers as if they were
idiots!
Treating patients with the respect that they deserve will benefit the
business enormously. The doctor has not to get caught in the trap of looking
at patients simply as numbers on a spreadsheet.
This is an area where many larger organizations have started to
flounder. The unique needs of every patient are being lost sight of as

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businesses focus on their balance sheets and profit and loss statements.
Customers know this and they have had enough. A flashy
advertisement and a few false promises just don’t cut it anymore.
Respect is a powerful word. Respect the patients’ intelligence, their time and
their decision to utilize the service or not when they could have utilized the
same item from another competitor up the road. [Griffiths A (2006)]

ELICITING THE PATIENT'S AGENDA AS A TOOL FOR PATIENT

SATISFACTION
In the first consultation with a new patient or at the beginning of a new
illness episode, it is a central task to elicit the patient's agenda. Even in well-
established patients, their problems should be reassessed from time to time.
One of the most prominent reasons for encounter is the patient's need for
explanation and not (only) for treatment. [McCormick JS (1991)]
At this stage, the doctor tries to enter the patient's world, get a holistic
picture of his or her problems, and obtain the full spectrum of concerns.
[Larivaara P, Kiuttu J and Taanilia A (2001)]
In addition, information from all levels of the biopsychosocial model
(cell-organ, psychological-individual, and family-community) is collected.
Information on the patient's symptoms, his or her ideas on the cause of
the problem, perception of symptoms, and potential influences on personal
and social life are all important.
A patient-centered style with open-ended questions as well as the feeling that
the doctor listens and understands the problem encourages patients to raise
their own concerns and agendas and appears to be most congruent with
patient reported quality of primary care. [McCormick JS (1991)]

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PATIENT SATISFACTION RELATION TO THE TIME FACTOR
1- Effect of consultation time on patient satisfaction
Patient satisfaction is certainly pertinent to the issue of time and the
consultation. [Morrell DC et al. (1986)]
In the twenty-first century time is a precious commodity. In many health
care systems in the industrialized world time dictates the quality of care
provided to patients. In the last 30 years, as family medicine has become a
distinct discipline, considerations on time and the consultation, in particular
of the question how much time is enough, have been of interest to primary
care physician scholars and researchers. As such, most research about the
impact of time on the patient-physician consultation has been conducted in
the primary care setting.
The length of the consultation varies around the world ranging from 5
minutes or less to over 10 minutes in the United Kingdom and Hong Kong to
as long as 21 minutes in Sweden. Consultations in Australia are on average
12 minutes long. In South Africa, Henbest and Fehrsen have documented the
mean length of a family practice visit as 11 minutes. Little et al. documented
patients' preferences for a patient-centered encounter. Stewart et al.'s research
in Canada determined that 9.4 min was a sufficient time frame to achieve a
patient-centered consultation. [Wiggers JH and Sanson-Fisher R (1997)]
and [Howie JG et al. (1991)]
The organization of the health care system, cultural influences and patient
expectations may all serve as influential factors. We can conclude that while
longer consultations do on the whole lead to better patient outcomes, some
physicians are able to achieve these outcomes without spending more time.
[Jones R et al. (2004)]

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 An association between length of visit, patient volume, and patient
satisfaction was found by Zyzanski et al. [Zyzanski SJ et al. (1998)]
Lower patient satisfaction was more common among high-volume
physicians whose visits were 30 per cent shorter than those of low-volume
physicians. Patients reported less follow-up on their problems, less attention
to their responses, and less than adequate explanations for their concerns. In
addition, high-volume physicians had significantly fewer patients who were
up to date on the recommended guidelines for screening, counseling, and
immunization.
Gross et al. identified two specific patient provider exchanges that
would improve patient satisfaction. First, providers need to allow a brief
period of time to chat about topics of a non-medical nature. This, they
suggest, may help the patient to connect with the provider. Secondly,
sufficient time must be taken when providing patients with feedback on
clinical findings. [Gross DA et al. (1998)]
As early as 1979, Mawardi in the United States reported that family
physicians were dissatisfied with the time pressures they experienced in
practice. Grol et al. in the Netherlands documented similar findings 4 years
later. In fact, their study indicated that physicians who experienced negative
feelings such as being frustrated, tense, and short of time prescribed more and
gave less explanation to patients. [Rivo ML and Johnson GR (2002)] and
[Sweeney KG, MacAuley D and Gray DP (1998)]
Certain patients, such as those with chronic illnesses, require more
time and hence should be reimbursed accordingly. Similarly, patient visits
dealing with complex problems, for example patients with substance abuse
problems, or individuals in psychological distress, are more time consuming,

100
yet no compensation is provided for caring for these patients. [Carr-Hill R et
al. (1998)] and [Sweeney KG, MacAuley D, and Gray DP (1998)]
There is an inextricable link between the needs, expectations, and
desires of both patients and doctors in relation to time and the consultation.
As Andersson et al. stated; Time is a concept of importance in the
search for quality consultation. But time itself is not the quality. The quality
is what takes place in a period of time. [Andersson SO, Ferry S, and
Mattsson B (1993)]
Thus, what takes place is often a complex, dynamic, and sometimes
intimate exchange, between patients and their physicians.
Yet, beyond this, time is strongly related to the subjective experience
of patients and physicians as described in their narrative accounts. The richer
the narrative the more time is needed.
The magnificent advantage of general practice as a mode of clinical
care is its longitudinal dimension and the opportunities this gives both doctor
and patients to develop and respond to complex narratives in relatively short
installments but over a sustained period of time.

2- Out-of-hours care
Primary care is required 24 h a day, 365 days a year and lifelong. In some
countries, as Egypt, the primary care facilities working hours are limited just
as the outpatient clinics and care out-of-office hours, especially in urban
settings, is provided by a combination of ambulances and hospitals
emergency departments.
Many people choose to attend accident departments rather than call their
family doctor, even when a full primary care based out-of-hours service is
available.

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Junior doctors in hospital emergency departments are often inexperienced in
primary care and they adopt the secondary care model.
Rather than accepting uncertainty, dealing with risks on the basis of
likelihood, and using time as a diagnostic tool, they tend to over-investigate,
over-refer, and over-treat. In some countries, such as Italy, the health service
funds a separate service that takes over from general practitioners at night or
weekends.
However, in many countries the responsibility for organizing and
providing 24-h cover is placed on the primary care service, often as a direct
contractual responsibility of general practitioners themselves. A range of
models for delivering this care has evolved.
The historical model is for the family physician to be on call for his or
her patients except when on holiday or away. Indeed, general practitioners
who rely on a fee for service direct from patients often still adopt this very
personal commitment. It is only viable when the demand for out-of-hours
care is low and the doctor is prepared to make the remarkable commitment to
the patient population, or is reimbursed sufficiently to make it attractive.
The model that usually took over from personal total cover was the
out-of-hours rota, by which groups of family physicians, usually those
collaborating in a group or partnership; share the out-of-hours work between
them. In urban areas, deputizing services have often been a popular option,
usually run commercially.

NURSES AS SATISFACTION PROMOTERS AND FACILITATORS

Inventories of the medical staff have been administered for decades to
measure quality of care. [DiPalo M (1997)] and [Merkouris A et al. (1999)]

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 Of special interest has been the satisfaction of patients while receiving
care from a medical professional. [Merkouris A et al. (1999)]

For nearly 5 decades patient satisfaction has been measured in the

field of Nursing and has recently become identified as a valid and important
index of care quality as well as a prerequisite for hospital license[DiPalo M
(1997)] and [Merkouris A et al. (1999)]
Nurse practitioner primary care at first point of contact improves
patient satisfaction and quality of care compared with physician care, with no
difference in health outcomes. [Horrocks S, Anderson E and Salisbury C
(2002)]
Similar to the physician population, it appears that patients are
concerned about the information given and the overall care and compassion
demonstrated by nurses, but psychometric properties of the instruments used
were not reported. Additionally, it is difficult to say what was considered as
high satisfaction scores.
Nursing care evaluations have also become an important measure for a
quality assurance program. In fact, it is believed that without a way for
patients to report the care received by a nurse that a quality assurance
program is considered inadequate. [Merkouris A et al. (1999)]

THE MARKETING MIX AS A PATIENT SATISFACTORY TOOL

The four aspects of marketing (The four P’s) are a very useful tool in
managing a patient satisfactory practice that maybe used as a guide that
highlights the guidelines for addressing patient needs, perspectives and
expectations to be met, fulfilled and satisfied.

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1- Place: It involves both the actual place where the customer may obtain
the service and the place of referral. Channel service outputs are the
parameters that identify the quality of the service place, these are:
facility size and capacity, waiting/delivery time, spatial convenience,
service variety and service backup.
2- People: They are the employees involved in delivering the service.
Any person coming into contact with customers can have an impact on
overall satisfaction. Whether as part of a supporting service to a
product or involved in a total service, people are particularly important
because, in the customer's eyes, they are generally inseparable from the
total service. As a result of this, they must be appropriately trained,
well motivated and the right type of person. Also their attitude and
appearance (uniform) are important.
3- Process: The process of giving a service and the behavior of people
who deliver are crucial for customer satisfaction. Issues such as
waiting time, information provided, and helpfulness of staff are vital to
keep the customer happy. Customers are not interested in the details of
how the business runs. What matters is that the system works.
4- Physical evidence: Unlike a product, a service cannot be experienced
before it is delivered, which makes it intangible. This, therefore, means
that potential customers could perceive greater risk when deciding
whether to use a service. To reduce the feeling of risk, thus improving
the chance for success, it is often vital to offer potential customers the
chance to see what a service would be like.
This is done by providing physical evidence, such as case
studies, testimonials or demonstrations. Also appearance of staff,
premises, and vehicles should be appropriated.

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PATIENT SATISFACTION IN PRACTICE
Patient satisfaction has become an important part of policy formulation
and medical, in as much as it affects compliance and participation in care.
[Locker D and Dunt D (1978)]
In today’s competitive health care environment, patients want and
expect better health care services than they did in the past. [Elbakry M
(2006)]
Health care professionals are encouraged to deliver patient-centered services.
In health policy terms, this refers to services “closely congruent with, and
responsive to patients’ wants, needs and preferences.” [Laine C and
Davidoff F (1996)]
Patient satisfaction is an important outcome of health care services and can
affect compliance with medical advice, service utilization, and the clinician-
patient relationship. [Kahan B and Goodstadt M (1999)] and [Hjortdahl P
and Laerum E (1992)]
Patients’ choice of site for care for perceived health problems is likely to
involve a multitude of factors and may, in turn, influence health care system
organization and continuity of care.
Given the increasing push toward health care provider accountability
and quality improvement initiatives, there is no doubt that the attention and
weight given to patient satisfaction is going to increase dramatically in the
coming years. [Elbakry M (2006)]

If service delivery is to be acceptable to patients, policy makers need to

understand patients’ priorities. The published literature does not clearly

105
define the relative importance patients place on attributes such as technical
and interpersonal care. [Sohi SC et al. (2008)]
Organizations must achieve Sustainable Competitive Advantage
(SCAs) to differentiate themselves in the market. If this (SCA) is achieved
only through marketing mix (product, price, place, and promotion) it is
easily to be imitated, but if organization achieves (SCA) through proper
design for relationship with customers, it lasts for long term and it is very
hard to be imitated. [Cambridge (2008)]

ASSESSMENT OF PATIENT SATISFACTION

A. Sitzia and Wood suggest that patient satisfaction could be assessed
by measuring:
a) The degrees to which patients believe that care possesses certain
attributes.
b) The patient’s evaluation of those attributes.
Organizations have an ongoing need to assess the ways their customers are
being treated. [Sitzia J and Wood N (1997)]

B. Methods used for assessment of patients’ wants and needs

1- Active listening: Doctors have to have the will and the intention not
only to listen actively and carefully to their patients suggestions and
demands nor to ask their patients about these issues but also to catch
the cues regarding their patients’ impressions as these cues are
usually hidden and may pass undiscovered or explored.
2- Complaint procedures: Every health system should have adequate
procedures for handling complaints expressed by patients. Complaints
are negative evaluations of health care provision, which can signal

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aspects of care that need to be improved. Most patient complaints
remain unnoticed, but some are expressed and handled by formal or
informal complaint procedures. Formal procedures include the use of
legislation and the courts. Many health care institutions have created
informal opportunities to express complaints. This may be a special
person or department who handles the complaints. Another method is
the collection of complaints and comments that are expressed in open
questions in patient satisfaction surveys, letters, or conversations with
patients. [Jones R et al. (2004)]
3- Focus groups (Patient participation groups): Patient participation
groups are groups of patients or former patients, linked to a specific
general practice or regional service, which can develop standards for
good practice, provide feedback on health care delivered and influence
local quality improvement programs. This method differs from the
survey methods, because patients discuss their experiences and views
with each other so that they can get a more comprehensive picture than
individuals. So the method is somewhat similar to qualitative group
interviews. Some would argue that care providers should be part of the
group; it has been suggested that patients should not be in clinical
relationships with them Particularly, groups at regional and national
level may also include patient advocates, which are people with a
general knowledge of the views and interests of patients and patient
groups but who are not necessarily patients or former patients
themselves. [Williamson C (1998)]
4- Feedback cards (surveys).
In this method, patients can complete pre-structured diaries during
episodes of care. The survey and the feedback to care providers may

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 focus on a broad range of aspects of care or on a specific domain of
clinical practice, such as preventive care or the waiting room. The
feedback can provide summaries of answers to open-ended questions or
figures based on the questions with answering scales. For comparison,
figures from previous surveys in the same setting or from surveys
among patients from other primary care providers can be added.

Discussions in the literature make it clear that quality of care is not

what is being measured in patient surveys. In fact, many surveys intentionally
avoid asking patients how they feel about the quality of their care,
presumably because patients are not in a position to judge their physician's
technical skill. It appears that what's being measured is typically a
combination of the patient's expectation before the visit, the patient's
experience at the visit and the extent to which the patient experienced a
resolution of the symptoms that led him or her to make the visit. [Thiedke C
(2007)]

C. Measurement Scales of Patient Satisfaction

There are a number of scales used to measure patient satisfaction with
treatment programs, recovery, medical professionals, or facilities. [Hulka B
et al. (1975)]; [Mangelsdorff D (1979)]; [Taylor A and May S (1995)];
[Ware J and Snyder M, (1975)] and [Wolf M et al. (1978)]
Construction of the first valid and reliable patient satisfaction
questionnaires in the medical population can be attributed to Ware and
Snyder (1975) and Hulka et al. (1975). [Ware J and Snyder M (1975)] and
[Hulka B et al. (1975)]

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 Hulka et al. (1975) attempted to develop an instrument to measure the
patient’s attitude toward physicians and medical services. The instrument was
designed to measure three distinct components of care:
(1) The professional and technical competence of the physician.
(2) Personal qualities of the physician.
(3) Accessibility and convenience of care, including cost.
Acceptable split-half correlations were reported for professional and
technical competence (0.75), and for personal qualities (0.86), but the internal
consistency was low for the accessibility and convenience of care (0.68)
scales. Hulka et al. (1975) reported adequate reliability measures using a
pretest sample, however, the specific development and analysis of results
were not indicated. The final instrument included 42 items with 14 items in
each content area. [Wolf M et al. (1978)]
Taking into consideration previous methods used to develop a valid
and reliable questionnaire, Ware and Snyder (1975) used factor analysis to
develop a standardized patient satisfaction rating instrument. During the early
construction of the various attitudinal indices, a Factored Homogeneous Item
Dimension (FHID) was used to include a priori logical criteria and an
empirical test. The FHID is a method used with personality research to
analyze a group of scale items having common content that was developed
from logic and statistical criteria. Items are validated through this process and
can be used as a single score when used in subsequent statistical analyses.
The FHID process is especially helpful when using multivariate
analyses because it allows the single score to be used without losing
explained variance. [Ware J and Snyder M (1975)]
After careful review of previous satisfaction questionnaires, Ware and
Snyder (1975) devised a standardized rating instrument to measure patient

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satisfaction across 22 dimensions. Each item was measured on a 5-point
Likert type scale (strongly agree to strongly disagree). In their reliability and
validity study Ware and Snyder (1995) asked adults (N = 433) to complete
the self-administered questionnaire during a 1-hour health-related interview.
The average time to complete the questionnaire was 15 minutes. The sample
was comprised of predominantly white (88%) men (n = 105) and women (n
= 328), between 16-83 years of age living in the Midwest.
The sample was a representative of the area surveyed; yet it was
different from the national norm. Through FHID validation, 56 of the 70
items were retained for further study. For example, item groupings relative
to the availability of resources (3), continuity of care (3), financial aspects of
medical care (2), and comprehensiveness of care (2) met the FHID
validation criteria. Two additional item groupings that were retained for
higher-order factor analysis included the humanness and quality of care.
Ultimately, four factors were extracted and accounted for nearly 75% of the
variance. The factors were physician conduct, physician availability,
continuity/convenience of care, and access mechanisms (e.g., cost,
insurance, payment, and access to the emergency room).
It is important to note that some overlap between the factors existed.
[Ware J and Snyder M (1975)]
The Patient Satisfaction Questionnaire (PSQ) was constructed by
factor analysis statistics from the responses of military personnel. First,
nineteen items were developed by a group of physicians, hospital
administrators, nurses and behavioral scientists.
The preliminary 19-item questionnaire was then administered to
military sponsors and spouses (N = 3287) who attended a general medical
clinic for an outpatient visit. Using this sample, a principal components

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factor analysis revealed 3 factors: (1) interest and courtesy, (2) convenience
and physical facilities, and (3) auxiliary services, and waiting time. (223)
A second questionnaire with 16 items was administered to 3272
military sponsors and spouses who attended a general medical clinic for an
outpatient visit. Differentiation between the 16 and 19-item questionnaire
was not described in the article. A principal components factor analysis was
calculated for the 16 items and resulted in 3 factors with Eigen values
greater than 1: (1) interest, courtesy, quality, and continuity, (2) nurse
interactions, auxiliary services, adequacy and convenience, and (3) nurse
services. [Mangelsdorff D (1979)]
A final version of the questionnaire (19-item) was administered to
1610 military sponsors to assess attitudes toward: physicians, nurses, medical
auxiliaries, professional interest, courtesy, quality of care, adequacy of
information, and convenience of the clinic. The subjects answered all
demographic questions prior to the visit with the physician and the PSQ was
administered directly following the physician visit. Each item was rated on a
5-point Likert scale. Factor analysis of the responses for the 1610 subjects
identified three components with Eigen values greater than 1.0 and accounted
for 67.7% of the total variance: (1) physician interactions, (2) non-physician
interactions, and (3) auxiliary services. After varimax rotation the three
variables accounted for 86.0, 7.7, and 6.3% of the variance, respectively.
Internal consistency correlation coefficients were 0.94, 0.93, 0.87 for each
component, respectively, and 0.972 for the overall scale. Validity was
assessed using correlations with specific criterion items and ranged from
0.592 to 0.876. [Mangelsdorff D (1979)]
Like earlier versions of patient satisfaction, the PSQ considered services
outside of the physician-patient interaction. Additionally, the samples were

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comprised of a specific group (military personnel) that may not be
representative of the general population. [Mangelsdorff D (1979)]
Using information from Hulka et al. (1975) and Ware and Snyder (1975),
Wolf et al. (1978) developed the Medical Interview Satisfaction Scale
(MISS). Unlike other satisfaction measurements, the MISS is a specific
questionnaire for patients to evaluate an individual interview with the
physician with whom they had an encounter. After careful review of the
literature Wolfe and colleagues (1978) concluded that patients expect a
positive interaction with the physician (e.g., comfort, providing information,
and appears competent). If this expectation was not met, then the patient was
less satisfied and was less likely to comply (Wolf et al., 1978). Therefore,
Wolf et al. (1978) felt it important to devise a reliable and valid instrument to
specifically measure the physician-patient interaction.
Wolf et al. (1978) based their item development on previous studies,
interviews with patients, and observation of consultations (Hulka et al., 1975;
Ware & Snyder, 1975). Sixty-three items were generated and categorized into
three specific constructs:
(1) Cognitive (information and explanations given by the physician and the
understanding of the patient’s illness).
(2) Affective (patient’s perceptions of the treatment relationship).
(3) Behavioral (the professional behaviors, examination, competency and
treatment the physicians use).
For example, after talking with the doctor, “I know just how serious
my illness is” (this is a cognitive item), “I really felt understood by my
Doctor” (this is an affective item) and “the doctor was too rough when he
examined me: (this is a behavioral item). [Wolf M et al. (1978)]

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 First, 50 patients in a screening clinic were asked to provide critical
feedback on the appropriateness and clarity of the items. This procedure was
used to validate the content of the questionnaire.
Next, 135 patients receiving care in the screening clinic or health
center completed the questionnaire. To discriminate between high and low
scored items, a contrasting group method was performed for each construct
and the total scale.
Pearson product moment correlation calculations for each item and the
total scale were used to calculate a correlation coefficient of each item and an
average score of the remaining items in its domain and total scale (item-
remainder correlations) to establish reliability. [Wolf M et al. (1978)]
For the final construction, 50 patients in the screening clinic who had
first time visits were surveyed. Item-remainder correlations were calculated
and 26-items were grouped into a cognitive subscale with 9 items, an
affective subscale with 9 items, and a behavioral subscale with 8 items.
Cronbach’s alpha was calculated to be 0.87 for the cognitive subscale,
0.86 for the affective subscale, and 0.87 for the behavior subscale, and 0.93
for the total scale. Interscale correlations ranged from 0.62 to 0.76. [Wolf M
et al. (1978)]
Statistical analysis revealed that occupation (coded by the
Hollingshead Index) was the only socio-demographic variable significantly
negatively correlated with satisfaction (r = -0.33, p < 0.05), specifically,
affective satisfaction. However, data were only available for a small group (n
= 35) of subjects (Wolf et al., 1978). It is unclear from the article how to
interpret the negative correlation. [Wolf M et al. (1978)]

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 D. General characteristics of satisfaction instruments
1- Directness of the question relates to how directly a patient was asked
about their satisfaction (how satisfied were you vs. describe the care
you received).
2- Specificity refers to how general of an encounter is being measured,
ranging from measures of a health system in general to measures of a
specific visit. Type of care refers to the type of service being accessed
(e.g. ambulatory care).
3- Dimensionality refers to the aspects of the care being measured. [Hall
J and Dornan M (1988)]

E. Patient Satisfaction Surveys

A patient satisfaction survey is probably the most well-known method
to collect patients' evaluations and report them to care providers and others.
Patient satisfaction surveys use structured or semi-structured questionnaires,
which are filled in by patients in the practice or at home, or which is
answered in a oral or telephone interview. [Wensing M, Grol R, and Smits
A (1994)]
Meeting expectations concerning a range of attributes may be difficult
within the constraints of limited budgets, however. For example, relational
continuity (i.e., the ability “to provide 1 or more named professionals with
whom the patient can develop a therapeutic and interpersonal relationship”
may be jeopardized if services prioritize rapid access. [Freeman K, Olesen F
and Hjortdahl P (2003)] and [Bower P et al. (2003)]

The range of attributes that are important to patients is relatively well

known; however, designing services that are sensitive to patients’ preferences

114
in the context of limited resources may require patients to choose between
attributes. [Wensing M et al. (1998)] and [Fung H et al. (2005)]
This reality has led to interest in methods of assessing priorities. [Ryan M et
al. (2001)]

Types of surveys
1-According to place of administration:
a) Inside the house surveys: These surveys are done inside the health
facility that presents the health service to the audience under the survey.
b) outside the house surveys: These surveys are done away from the
health facility under the survey, these include the surveys where the
surveyor is inside and the surveyed are outside as by phone, post or e-
mail.
2- According to surveyor:
a) Internally administered survey (internal audit): where the surveyor is
one of the workforces in the health facility under the survey either
directly related to the health service or not.
b) Externally administered survey (external audit): where the surveyor is
an outsider of the health facility under the survey.
3- According to surveyed number:
a) Sample survey.
b) Census survey.
4- According to questionnaire type:
a) Self administered questionnaire: distributed to the audience in hands,
by post or by e-mail then retained back.
b) Interviewing questionnaire: either face to face or by phone

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5- According to method of communication:
a) Verbal questionnaire.
b) Written questionnaire.
6- According to comprehensiveness:
a) Incomprehensive: This type of surveys is interested in measuring the
patients’ opinions in the most important attributes according to the
surveyor, the literature or shortages and defects in the system (e.g. the
nine-item Visit-Specific Satisfaction Questionnaire (VSQ)).
b) Comprehensive: This type of surveys is interested in collecting patient
demographic information and health status, prior health care
(continuity), and ancillary services utilized by the patient.
7- According to survey subject:
a) Per visit surveys: This type of surveys is interested in measuring the
patients’ opinions in the health care service received last time he visited
the facility (per visit evaluation).
b) Collective surveys: This type of surveys is interested in measuring the
patients’ opinions in the health care services received from the facility
in the charge (global, collective or cumulative evaluation).
8- According to questionnaire built up:
a) Structured: formed from a list of standardized list of questions, that
may be:
• Closed ended questions survey: It is more standardized as it gives
limited choices for the person to answer. It is easy on data analysis.
• Dichotomous: It gives only two choices either yes or no, so it is not
ideal for the in depth issues.
• Discrete choice experiment: It is based on the assumption that services
(such as consultations) can be described by their attributes and the value

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 of a service depends on the nature and level of these attributes.
Individuals are presented with alternative hypothetical services
consisting of a number of attributes with different levels, and are asked
to choose between them. It can ascertain individuals’ priorities by
estimating the relative importance of different attributes to them. [Ryan
M et al. (2001)]
b) Unstructured: formed for specific objective where the questions used
are open ended questions. It is used mainly on qualitative type of
research, when feedbacks are very multiple and heterogenous, where
the interviewees own words are needed or when the feedbacks may be
affected by the suggested answers.
9- According to the data source:
a) Patient (client) survey: where the client is the source of data.
b) Observational chick list: It is filled by the investigator. It is interested
in gathering information related to behavior or skills (e.g. washing hands
in infection control program) or observation of policy (e.g. antismoking
policy in hospital i.e. presence of documented instructions, presence of
signs and presence of ashtray in hospital).

Surveys Challenges and negative assumptions

1. One of the main Challenges of patient satisfaction surveys is that the
results are not always reliable; causes maybe due to:
a. Sample size: We tried to survey the largest group possible to get
reliable results yet, positive feedback may be much less than expected
b. Response rates: The more responses gathered the more accurate and
reliable the results were likely to be.
c. They will uncover widespread and general dissatisfaction.

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 d. Answers are uninformed or whimsical.
e. Invalidity due to reporting bias or the halo effect.
2. Analyzing the data: The need to have someone in-house with strong
analytical and database-management skills. This is the culminating step
that provides the interpretation and value in the process.

Importance of surveys
1- Survey data is a crucial element that is used by the TQM office in
monitoring and setting improvements plans.
2- Survey data helps in deducing the key drivers of satisfaction in our
hospital, which can help in creative marketing.
3- Designing patient education materials on the basis of questions
patients repeatedly asked in survey responses.
4- Survey data allowed us to compare our satisfaction scores to peer
groups. [Elbakry M (2006)]
5- It is useful in assessing consultations and communications patterns.
6- It enables choice between alternatives in the organizational protocols
and systems and provision of health care. [Fitzpatrick R (1991)]

F. Factors affecting assessed patient satisfaction

Patient Satisfaction as any variable (actually it is the sum of interaction
between multiple variables) is affected and exerts effects on many other
variables that must be put in consideration when assessing patient
satisfaction, these factors may be grouped as follows:
1. Patient-related factors
The literature appears mixed on the importance of patients'
demographic and social factors in determining satisfaction. Some studies

118
stated that patient demographics are a minor factor in patient satisfaction.
[Hall JA, Dornan MC. (1990)]
Others concluded that demographics represent 90 percent to 95 percent
of the variance in rates of satisfaction. [Sixma HJ, Spreeuwenberg PM, van
der Pasch MA. (1998)]
Nevertheless, the literature does shed some light on how particular
demographic factors affect patient satisfaction. [Thiedke C. (2007)]
1- Age: The most consistent finding has been related to age, older patients
tend to be more satisfied with their health care.
2- Ethnicity: Studies that have looked at ethnicity have generally held that
being a member of a minority group is associated with lower rates of
satisfaction. In a ranking of degrees of satisfaction, non-Hispanic whites
had the highest satisfaction, followed by African Americans,
Asian/Pacific Islanders and Hispanics. The lowest degree of satisfaction
was found in Indians/Alaskan natives. [Haviland MG et al. (2005)]
3- Gender: Studies on the effect of gender are contradictory, with some
studies showing that women tend to be less satisfied and other studies
showing the opposite.
4- Socioeconomic status: Most studies have found that individuals of
lower socioeconomic status and less education tend to be less satisfied
with their health care. However, one study 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. [Desai RA, Stefanovics EA and
Rosenheck RA (2005)]
5- Psychological Status: Other studies have shown that poorer
satisfaction with care is associated with experiencing worry, depression,

119
 fear or hopelessness as is having a psychiatric diagnosis such as
schizophrenia, post-traumatic stress disorder or drug abuse. [Redekop
WK et al. (2002)] and [Walling AD et al. (2005)]
6- Health status: Looking at patients with chronic disease has shown
some consistent patterns. Patients with poorly controlled diabetes were
less satisfied with their care, [Walling AD et al. (2005)] as were
migraine sufferers who reported more migraine-related disability..
[Parchman ML, Noel PH and Lee S. (2005)]
Dissatisfied migraine sufferers were less likely to use triptans
currently, were more than two times more likely to have stopped them
and were less likely to have their medications paid for by their
insurance. Patients with two or more chronic illnesses reported more
hassles with the health care system than those with a single chronic
illness. [Rao JK, Weinberger M and Kroenke K (2000)]
7- When communication and coordination of care increased, the patients'
perception of hassle decreased and satisfaction improved. [Thiedke C
(2007)]

2. Physician-related factors
Physicians can promote higher rates of satisfaction by improving the way
they interact with their patients, according to the literature. [Thiedke C
(2007)]

1- Addressing, realizing and meeting patients’ expectations: Perhaps the

most important lesson for physicians is to take the time and effort to elicit
patients' expectations. When physicians recognize and address patient
expectations, satisfaction is higher not only for the patient but also for the

120
 physician; it may help to remember that patients often show up at a visit
desiring information more than they desire a specific action. [Rao JK,
Weinberger M and Kroenke K (2000)]
In addition, approximately 10 percent of patients in one study had one or
more unvoiced desires in a visit with their physician. [Bell RA et al.
(2001)]
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.
2- Communication skills: 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. [Bell RA et al. (2001)]
3- Control: 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. [Shaw WS et al. (2005)]
4- Decision-making: 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. [Cecil DW and Killeen
I (1997)]

121
5- Time spent: Time spent during a visit plays a role in patient satisfaction,
with satisfaction rates improving as visit length increases. [Gross DA et al.
(1998)]
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. [Zyzanski SJ et al. (1998)]
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.
[Lin CT et al. (2001)]
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.
6- Technical skills: Several studies have looked at patients' assessment of
their physicians' technical skills and the effect on satisfaction, but the
findings are contradictory. In a survey of 236 "vulnerable" older patients,
better communication skills were linked to higher patient satisfaction but
technical expertise was not. [Chang JT et al. (2006)]
However, another study found that when forced to make a trade-off,
participants expressed a strong preference for physicians who have high
technical skills. [Fung CH et al. (2005)]
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." [Otani K, Kurz RS and Harris LE (2005)]

122
7- Appearance: Patients also appear to respond to a physician's appearance.
In one study from New Zealand, patients indicated that they preferred
"semiformal" attire and a smile. Next, in order of preference, were
"semiformal" dress without a smile, a white coat, a formal suit, jeans and
casual dress. [Lill MM, Wilkinson TJ (2005)]
They were less comfortable with facial piercings, short tops, or earrings
on men. In addition, most patients wanted to be called by their first name,
be introduced to the doctor by his full name and title, and see a name
badge.

3. 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.
1- The clinical team: Although it's clear that patients' first concern is their
doctor, they also value the team with which the doctor works. One study
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. [Otani K, Kurz RS and Harris
LE (2005)]
In another large database of surveys, nurses were the next most important
source of satisfaction, ahead of access-to-care issues. [Wolosin RJ (2005)]
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.
[Brown JB et al. (1997)]
2- Referrals: Effective referrals play a role in patient satisfaction. One study
looked at referrals from the standpoint of the family physician, the referral

123
 physician and the patient, and found that satisfaction with the referral's
outcome was higher when the family physician initiated the referral.
[Rosemann T (2006)]
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. [Bekkelund SI and Salvesen R
(2001)]
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. [Norman A et al. (2001)]
3- Continuity of care: Continuity of care, one of the pillars of family
medicine, is felt to have suffered under managed care. 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. [Donahue KE, Ashkin E and Pathman DE
(2005)]

4. Survey related factors

Other factors that are related to the process of measuring data
(surveying) may also affect the results and must be considered:
It is worth noting that most patient-satisfaction studies are based on
patients' experiences at one-time encounters rather than their experiences
over time. [Health Services Research Group (1992)]
1- Communication tool: personal one to one, group interview, telephone or
mail (either post or e-mail). Claims and complains are released easily and
readily in telephone and mail surveys while the effect or impression taken

124
 by the patient may fade out in these methods of surveys due to time lag
between the experience and the survey time.
2- The surveyor: Obviously affects the results either by leading the patient to
a specific reaction or indirectly being one of the work forces (the halo
effect).
3- The setting: the feedback differs between surveys done inside the health
facility and those done out of the house either in the patients’ homes or
elsewhere
4- Time: weather the survey is done just after or a long time after or even
before the health care episode is an important parameter that may affect the
feedback.

Table (2) Most important factors affecting patient satisfaction. [Mertz

MG (1999)]

Marc G. Mertz (1999): The top four factors influencing patient

satisfaction*
1. Front-office staff
2. The ambiance of the practice facility
3. Clinical support staff
4. Physicians

*Ranked in order of importance to patients.

Source: The Horizon Group Ltd., 1997 Survey of Family Practice.

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The surprising fact is that among the top four factors affecting and
influencing patient satisfaction, the physicians are the least influencing
factor. That is to say that the paramedical professional and the physical
facility state play an important role (actually the major role) in influencing
patient satisfaction. (Table 2)

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 PATIENT SATISFACTION IN SPECIAL SITUATIONS

1- Emergency medicine:
Patients reporting an urgent health problem who visited their family
physician or an after-hours clinic with which their physician was affiliated
were most satisfied, and patients who visited their family physician were
significantly more satisfied than patients who obtained care at the emergency
department or a walk-in clinic, or who used a telephone health advisory
service. [Howard M et al. (2000)]
Specific to an emergency room setting, (Bruce, Bowman, and Brown,
1998) evaluated the factors that influence patient satisfaction ratings.
Specifically, nursing care, emergency department environment, auxiliary
staff, and information received were measured using the Emergency
Department Patient Satisfaction Survey.
A 30-item questionnaire rated by a 3-point Likert-type scale was
distributed to 128 individuals who utilized the emergency room and were
asked to evaluate the care received and to return the survey in the prepaid
envelope provided. Non-urgent emergency room patients (N = 28) returned
the surveys. Specific to nursing skill, high satisfaction scores were indicated
for: (1) overall caring and compassion (75%), (2) skill with medications and
treatment (74%), and (3) explanation given about care (71%). Specific to
information given, the highest satisfaction scores included: (1) information
related to medications (46%), (2) diagnosis (43%), and (3) self care (43%).
Under the auxiliary service sector, the patients were primarily dissatisfied
with the receptionist (7.7%). In general, patients were satisfied with the
environment such as the comfort of the waiting room, cleanliness, quietness,
and staff working together.

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 Chi-square analysis revealed no statistical significant difference in
satisfaction between male and female patients. [Bruce T, Bowman J and
Brown S (1998)]
Many Family Health Centers in Egypt provide care only during regular
business hours. As a result, patients in these practices must use other
services, such as walk-in clinics or the emergency department in nearby
hospitals, if they require care after-hours for an urgent problem.

2- Complaining patient:
To be honest, every health care system has to face the occasional patient
complaint. Everybody makes mistakes from time to time; these mistakes can
lead to a patient making a complaint. When it comes to the practice of
medicine, complaining or even anger client may not be associated with a
mistaken management. Most probably complains are results of
misunderstanding, miscommunication or misinterpretation.
By knowing what patients expect, we may develop a greater
understanding of the complaint process and of ways to resolve complaints
quickly and fairly. Patients’ expectations whenever they make a complaint
vary and include many actions and reactions that are to be taken by the
encounter. Appendix No.3
It’s easy to be defensive when a patient makes a complaint. However,
we should all be grateful, because it gives us the opportunity to do something
about it. Unfortunately, most complaints are never voiced; unhappy patients
simply go elsewhere and tell their friends to avoid our health care facility.
We have to look at every complaint as an opportunity.

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 Many authors have developed methodologies and action plans to deal
with complaining client. The aim of having a structured complaint resolution
procedure is to ensure that any complaints that arise are handled in a
professional and fair manner for all parties involved.
One of the most widely accepted is the strategy developed by Griffiths
2002; “client complaint procedures. Table (3)
If the person in the charge is unable to resolve the situation, he/she may have
to consider legal action. This is not an ideal situation, but it does remove the
emotional aspect of the dispute. It is important that all staff be made aware of
how client complaints are to be handled.
Complaining client in its maximum presentation is the angered client,
when confronted with an angry person, one first has to accept that anger is a
legitimate emotion—one that many of us find difficult to express
appropriately. Therefore, when a person does express anger, the doctor must
assume that there is a valid reason for it.
The doctor also should recognize that some people are more volatile than
others, some have less self-control, and some respond more to “gut reaction”
than to logic. [Ukens L (2007)]
Here are some guidelines for managing an angry client:
• Respond with a firm approach and a direct facial expression. Maintain a
calm and composed stance throughout the encounter.
• Attract the client’s attention by saying his or her name, if possible. Keeping
eye contact, follow through immediately with a short statement, showing you
recognize and acknowledge the anger: “You are obviously very annoyed;
what exactly went wrong?”

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• Empathize, acknowledging the client’s point of view. It is important that
you don’t imply that the company is a mess or that the staff is incompetent.
Professionalism and loyalty to the organization must be paramount.
• Establish the facts of the situation while keeping a calm, even tone and level
of voice.
• If appropriate, apologize once and sincerely for the inconvenience caused
by any error or misunderstanding, then set about putting things right.
• Repeat your statement of intent until the client calms down. It may be
possible to offer an alternative: “Would you like to speak to the manager?”
• Ask if anything further can be done to improve things and, if the person has
any suggestions, use active listening to check facts. Affirm that you have
heard and understood.
• If the situation gets out of control, call for a manager or offer to have
someone call the client back. Remember that you have the right to be treated
with respect and not to be threatened.

 Things to Do
• Stay calm.
• Maintain a neutral posture, facial expression, and tone of voice. Keep
steady eye contact.
• Allow the other person some time to “let off steam.”
• Acknowledge the person’s anger and empathize, as appropriate.
• Listen well and let the other person know that you heard and understood
what was said.
• Don’t cut off the other person’s speech too abruptly; treat the situation with
care and sensitivity.

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 • Don’t overdo your apology or place blame on other employees and the
organization.
• Try to establish the cause of the anger and do what you can to establish a
solution, a workable relationship, a compromise, or some other positive
outcome.
• Help the other person behave assertively, rather than aggressively, by your
example. [Ukens L (2007)]

 Things to Avoid
• Don’t show impatience or annoyance.
• Don’t let the client dominate the conversation; gently intervene by restating
what was said and then move the conversation along.
• Don’t get sidetracked by other issues. [Ukens L (2007)]

3- Difficult patient:
Specifically, it is argued that doctors find a sizeable minority of
patients difficult and that they negatively label such patients.
The capacity for patients to exasperate, defeat, and overwhelm their doctors
has been widely reported. [O'Dowd TC (1988)]
Patients expect more of their doctors who should be above stereotyping
and venality. Many new concepts appear on the surface of the medical
practice: consumerism, patient advocacy, willingness to resort to litigation,
health service management which values patient satisfaction, health
promotion strategies which encourage people to take greater responsibility
for their own health, and the growth in alternative and complementary
medicine.

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 Patients now have access to much more medical knowledge. With
increasing prevalence of long-term chronic illnesses under medical
management and an ageing population, doctors have to deal with more expert
patients and relatives.
All of this renders the relationship between doctors and their patients
intrinsically more difficult than it was once thought to have been. The terms
difficult and heartsink patients are widely used. [O'Dowd TC (1988)];
[Gerrard TJ and Riddell JD (1988)]; [Mathers NJ, Jones N and Hannay
D (1995)]; [Hahn, SR et al. (1996)]; [John C et al. (1987)]; [Schwenk, TL
et al. (1989)]; [Sharpe M (1994)]; [Mathers NJ and Gask, L (1995)];
[Smith S (1995)] and [Butler C and Evans M (1999)]

Coupled with patients who cause trouble for their doctors, these concepts
serve as a primary focus of investigation in identifying how and why doctors
may perceive patients in different ways. It has been estimated that British
general practitioners have an average of six heartsink patients per
practitioner. [Mathers NJ, Jones N and Hannay D (1995)]
These figures appear conservative compared to the United States where
primary care physicians have defined almost one of every six patients seen as
difficult. [Hahn SR et al. (1996)]
Work on (good) and (bad) patients, and patients negatively stereotyped by
doctors and nurses, also contributes to an understanding of why some
therapeutic encounters may be problematic. Several characteristics have been
associated with difficult, heartsink and troublesome patients. [Kelly MP and
May D (1982)] and [Najman JM, Klein D and Munro C (1982)]

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 Table (3) Client complaint procedures [Griffiths A (2006)]
Situation Reaction
When a client notifies  Remain calm.
The doctor of a  Listen to the client.
complaint  Write down their name.
 Be patient and understanding.
 Ask the client how they would like to see the
problem resolved.
 Decide on a course of action and advise
superiors if necessary.
 Explain to the client what you will be doing
to assist with their complaint.
 If possible resolve the complaint
immediately.
If it cannot be  Let the client know exactly what you will be
resolved on the spot doing and when you will be doing it.
 Make certain that the right people are
advised of the complaint.
 Stay in touch with the client as promised.
 If other staff are brought into the dispute
make sure they are kept up-to-date.
 Work towards a fair resolution for both
parties.
 Keep records of all discussions and
telephone calls.
If it still cannot be  Look at getting a third party to mediate on
resolved the complaint.
 Stay in touch with the client.
 Look for ways to resolve the problem.

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Table (4) Characteristics associated with difficult patients [Jones R et al.
(2004)]

Reference Characteristic(s) of difficult patients

Groves JE Hateful. Dependent clingers. Entitled demanders. Manipulative help-
(1978) rejecters. Self-destructive deniers. Masochistic. Reap secondary gains.
Display self-murderous behaviour

Najman Vulgar. Garrulous. Know-it-alls. Alcohol/drug abusers. Those who lack

JM et al. hygiene, are unemployed/on welfare/are deviant. Those with sexually
transmitted diseases or seeking vaccinations or blood pressure checks
(1982)

O'Dowd Attend frequently. Demanding. Have endless complaints. Dissatisfied.

TC (1988) Exasperate, defeat, overwhelm doctors. Cause distress, puzzlement,
frustration, disappointment, and clinical insecurity
Schwenk Female. Have vague, difficult to describe, undifferentiated medical
TL et al. problems. Have an abrasive behavioural style. Unable to contribute to
definition of problem. Cause frustration, unmet expectations, and
(1989)
dissatisfaction
Sharpe M Attend frequently. Distressed. Lower satisfaction. Psychological and
(1994) psycho-social factors. Medically unexplained symptoms, coexisting social
problems and severe untreatable illness. Are more adversely affected by
their illness. Are more likely to misunderstand or disagree with the
explanation and treatment offered
Smith S Display abnormal illness behaviour, somatize, or suffer from a personality
(1995) disorder
Stimson Female. Demanding. Hypochondriac. Time-consuming. Uncooperative.
GV (1975) Neurotic. Ungrateful. Malingerers. Workshy. Lonely. Unsettled.
Inadequate. Insecure. Pseudo-sophisticated. Nouveau riche. Geriatric. Lack
common sense. Have inadequate personalities and low intelligence. Reside
in unhygienic conditions. Have trivial/vague complaints, psychiatric
illness, psychological symptoms. Unable to judge when to consult. Do not
follow advice. Critical of doctors. Not trusting of doctors. Unable to cope

However, the evidence is equivocal. In some cases this is a

methodological artifact; that is, different concepts, measures, and
epistemologies generate contradictory results.

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 In some studies, however, inconsistency arises from a failure to
acknowledge the dynamics produced by the situation and interaction that may
arise between doctors and their patients. Some of the key studies of patient
labeling as a difficult patient appear in Table (4) along with a range of labels
that have been used to characterize difficult patients. [Jones R et al. (2004)]
On the other hand, patients who caused least trouble for general
practitioners were those who could judge when to consult, were undemanding,
did not take time, described problems clearly, were healthy, presented with
specific symptoms of an organic/physical nature, were easy to diagnose and
manage, could be treated, had medical rather than social problems, wanted to
get better and got well, acknowledged the limits of the doctor's skill, accepted
the judgment of the doctor, had confidence in the doctor, followed advice,
were grateful, cooperative, intelligent, had common sense, could cope, were
happy, settled, adequate, working, and had good homes. Patients who deviated
from these criteria were more likely to be perceived as troublesome. [Jones R
et al. (2004)]Many authors have offered solutions and remedies for
problematic doctor-patient relationships. These remedies tend to reflect
current fashion in education and psychotherapy.
A good example of this genre is Blalock and Devellis who present four
strategies to decrease stereotyping and/or its effects: being attentive to cultural
factors; increasing active involvement of the patient; encouraging patient self-
disclosure of factors that may dispel stereotypes, and being attentive to
information provided by patients. [Blalock SJ and Devellis BM (1986)]

Other remedies include:

 Having a greater understanding of patients. [O'Dowd TC (1988)] and
[Gerrard TJ and Riddell JD (1988)]

135
 Recognizing difficult to help patients and reviewing them. [Sharpe M
(1994)]
 Recognizing doctors' own responses to patients and seeing these as targets
of intervention. [Smith S (1995)]
 Adopting a reflexive response that considers the roles of both the doctor
and the patient, the framework of the relationship and the relationship
between biological and social knowledge. [Butler C and Evans M (1999)]
 Improving communication skills and developing better interviewing,
patient rapport, and medical solving skills. [Schwenk TL et al. (1989)]
 Increasing counseling/communication training and stress management
techniques and making more use of specialist support services. [Mathers
NJ, Jones N, and Hannay D (1995)] and [Sharpe M (1994)]
 On a management level, models, including coping strategies, have been
suggested. [Mathers NJ and Gask, L (1995)]
 Organizational recommendations include a reduction in workload and
strategies to increase job satisfaction. [Mathers, NJ, Jones N and Hannay
D (1995)]

Another strategy that is widely accepted is the rule of three or the three
rules for managing difficult patients; these three rules are:
1. The awareness rule; the doctor needs to be aware that they are playing
a part in a broader set of social relationships and that patients bring with
them a constellation of broader social factors. Ideal types of encounters
that reflect moral and cultural norms sit uneasily with the realities of
practical clinical experience.

136
2. The avoidance rule; the doctor needs to avoid reinforcing
disadvantages that the patient may already experience. The doctor
should reflect on their powerful position and pause to consider whether
their behaviour or actions might exacerbate any disadvantage or
inequality.
3. The assumptive rule; the doctor needs to realize that problematic and
difficult patients may be a product of doctors and not patients. Doctors
should not assume that the dynamics that give rise to problematic and
difficult patients are uni-dimensional. Doctors should acknowledge that
what they bring to the interaction is as important in determining how
patients come to be perceived, as is what both patients and doctors do or
say. [Cochrane AL (1972)]

General Guidelines for Approaching the Challenging Patient

Encounter
1. Difficult patient relationships are a minority of physician-patient
interactions.
2. There is no such entity as a difficult patient, only difficult
relationships.
3. Difficult physician-patient relationships lead to significant physician
and patient frustration and anger, and are expensive, both financially
and legally.
4. Underlying causes of the difficult physician-patient relationship
include communication barriers, sensitive topics, patient and physician
behaviors, health care system factors, specific patient personality
styles, and undiagnosed psychiatric diseases.

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5. Specific communication, behavioral, diagnostic, and therapeutic
approaches can lead to improved clinical and/or psychosocial
outcomes.

4- Elderly patient
As the mean of patients’ ages increases, the face of the Egyptian
population will change dramatically. This is a worldwide phenomenon; in
USA, by the year 2030, a projected 71 million Americans will be age 65
or older, an increase of more than 200 percent from the year 2000,
according to the U.S. Census Bureau. [U.S. Census Bureau (2004)]
Aging health care consumers will increase the demand for physicians'
services. In the United States, people over the age of 65 visit their doctor
an average of eight times per year, compared to the general population's
average of five visits per year. [Thompson TL, Robinson JD and
Beisecker AE (2004)]
Physicians should prepare for an increasing number of older patients by
developing a greater understanding of this population and how to
enhance their satisfaction with the health care services presented to them.
The satisfaction process in general is complex and can be further
complicated by age. One of the biggest problems physicians face when
dealing with older patients is that they are actually more heterogeneous
than younger people. Their wide range of life experiences and cultural
backgrounds often influence their "perception of illness, willingness to
adhere to medical regimens and ability to communicate effectively with
health care providers.” [Halter JB (1999)]
Communication with the elderly can be hindered by the normal aging
process, which may involve sensory loss, decline in memory, slower

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 processing of information, lessening of power and influence over their
own lives, retirement from work, and separation from family and friends.
[Ostuni E, Mohl GR (1994)]
At a time when older patients have the greatest need to communicate
with their physicians, life and physiologic changes make it the most
difficult. Because "unclear communication can cause the whole medical
encounter to fall apart,"[physicians should pay careful attention to this
aspect of their practice. [Wiebe C (1997)]

Here are some suggestions to help physicians gain and maintain

their elderly patients’ satisfaction with their health care services. Many of
the suggestions can be applied to patients of all age groups; however,
they are particularly important with older adults, for whom less-than-
optimal communication may have more negative consequences.
1. Allow extra time for older patients. Studies have shown that older
patients receive less information from physicians than younger patients
do, when, in fact, they desire more information from their physicians.
[Beisecker AE (1988)] and [Haug MR and Ory MG (1987)]
Because of their increased need for information and their likelihood to
communicate poorly, to be nervous and to lack focus, older patients are
going to require additional time. If the doctor appears rushed or
uninterested, patients will sense it and shut down, making effective
communication nearly impossible and satisfaction a lost pearl.
2. Avoid distractions. Patients want to feel that their doctor has spent
quality time with them and that they are important. Researchers
recommend that if doctors give their patients undivided attention in the

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 first 60 seconds, they can "create the impression that a meaningful
amount of time was spent with them.” [Dreher BB (1987)]
Of course, the doctor should aim to give patients his full attention
during the entire visit. When possible, reduce the amount of visual and
auditory distractions, such as other people and background noise.
[Osborne H (2003)] and [Breisch SL (2001)]
3. Sit face to face. Some older patients have vision and hearing loss, and
reading your lips may be crucial for them to receive the information
correctly. [Nussbaum JF et al. (2000)]
4. Sitting in front of them may also reduce distractions. This simple act
sends the message that what the doctor have to say to his patients, and
what they have to say to him, is important. Researchers have found that
patient satisfaction and compliance with treatment recommendations is
greater following encounters in which the physician is face to face with
the patient when offering information about the illness. [Meryn S
(1998)]
5. Maintain eye contact. Eye contact is one of the most direct and powerful
forms of nonverbal communication. It tells patients that the doctor is
interested in them and they can trust him. Maintaining eye contact creates
a more positive, comfortable atmosphere that may result in patients
opening up and providing additional information. [Osborne H (2003)]
6. Listen. The most common complaint patients have about their doctors is
that they don't listen. [Schopick JE (2004)]
Patient satisfaction depends on good communication which in turn
depends on good listening, so the doctor has to be conscious of whether
he is really listening to every bit of speech that the older patients are
telling him. Many of the problems associated with noncompliance can be

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 reduced or eliminated simply by taking time to listen to what the patient
has to say. [Osborne H (2003)]
Researchers have reported that doctors listen for an average of 18
seconds before they interrupt, causing them to miss important
information patients are trying to tell them. [Schopick JE (2004)]
7. Speak slowly, clearly and loudly. The rate at which an older person
learns is often much slower than that of a younger person. Therefore, the
rate at which the doctor provides information can greatly affect how
much an older patients can take in, learn and commit to memory.
[Dreher BB (1987)] and [Breisch SL (2001)]
The doctor hasn’t to rush through his instructions to these patients
and has to peak clearly and loudly enough for them to hear you, but do
not shout.
8. Use short, simple words and sentences. Simplifying information and
speaking in a manner that can be easily understood is one of the best
ways to ensure that the elderly patients will follow the instructions. The
doctor hasn’t to use medical jargon or technical terms that are difficult
for the layperson to understand. [Dreher BB (1987)]
9. In addition, the doctor hasn’t to assume that patients will understand even
basic medical terminology. Instead, he has to make sure that he uses
words that are "familiar and comfortable" to your patients. [Baker SK
(2004)]
10. Simplify and write down the instructions. When giving patients
instructions, the doctor has to avoid making them overly complicated or
confusing. Instead, he has to write down his instructions in a basic, easy-
to-follow format. Writing is a more permanent form of communication

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 than speaking and provides the opportunity for the patient to later review
what his doctor said in a less stressful environment. [Ley P (1976)]
One way to accomplish this is to provide an information sheet that
summarizes the most important points of the visit and explains what the
patient needs to do after he or she leaves your office. Table (5) shows an
example of such a sheet.
With such a list, the patient can mentally check off each item as it is
completed each day. Posting the information on the refrigerator or a
bulletin board can help keep instructions fresh in the patient's mind.
[Dreher BB (1987)]
11. Schedule older patients earlier in the day. Older patients often get tired
later in the day, and medical offices tend to get busier as the day goes on.
Scheduling older patients earlier in the day will bring them in when the
office is quieter and will allow your staff to spend more time with them.
[Breisch SL (1999)]
12. Seat them in a quiet, comfortable area. Because reception areas can be
noisy and confusing, staff members should help seat older patients away
from noise and disruptions. In addition, your waiting area seating should
be firm and of standard height, with arm supports to make it easier for
older patients to get around independently.
Once the patient has checked in, bring them any forms that need to be
filled out. Be prepared to provide any assistance the patient may need in
reading or filling out forms. This will lower the amount of stress the
patient may feel during the initial visit. [Meryn S (1998)]
13. Make things easy to read. Lighting in the waiting and exam areas should
be bright and spread evenly throughout the room. Reduce all glares and
avoid sitting older patients in shadows. Good lighting will help the

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patient's ability to read printed material, see facial expressions and read
lips. In addition, use large, easy-to-read print on all of the business cards,
appointment cards, brochures and educational materials. Easy-to-read
signs posted throughout the practice can also help to provide important
information, since older individuals may be reluctant to ask seemingly
obvious questions of the medical staff. [Meryn S (1998)]

Table (5) Information sheet that used as a take home message

Name of the practice: Elmoneeb FHC Date of consultation: 26/5/09

Patient’s Name: Mr. Sayed Ali Follow up date: In two weeks

Key points discussed today:

 your blood pressure is 190/95

 your goal is less than 130/85

 diet and exercise are key to control your

hypertension
New medications:

Lotensil 10mg one tablet in the morning

Instructions:

 Get your new pill when you first get up in the

morning

 Have a walk around for half an hour every

morning and afternoon.

 Cut back on salt and smoking

Call our facility if symptoms worsen or you have any question

Physician Ahmed B. Elgabry

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14.Be ready to physically escort patients. Assisting the elderly patient from
room to room may be necessary, especially if there are steps or risers in
the office. Make sure the patient is comfortable and that any immediate
needs are filled. [Woods D (2004)]
15. Check on them from time to time. If older patients will be in the
examination or consultation room unattended for an extended period,
check on them so they know you have not left them or forgotten them. If
the doctor is delayed with another patient, let patients know that and keep
them updated on how long the wait might be.
16. Keep the patient relaxed and focused. This is a key standered to
obtaining reliable information from the patient. Lightly touching the
patient's shoulder, arm or hand will help them relax and increase their
level of trust. Also, call the patient by name (e.g., Mr. Thomas or Mrs.
Johnson) so the visit seems personal and important. [Meryn S (1998)]
17. Say goodbye. You want patients to have a good feeling about their visit
and your practice. You want them to leave knowing how much you care
about them and their health. One way to accomplish this is to walk the
patient to the checkout desk, thank them for their visit and tell them
goodbye. [Woods D (2004)]

5- Uncertainty in diagnosis and management:

Most patients prefer a doctor who is kind, patient, omniscient, and
confident of his or her diagnoses and the information he or she provides.
However, such doctors are rare. Being kind and patient can be learned, but
knowing everything and always being certain about the right diagnosis and
best treatment is practically impossible. The reason is that there is simply too

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much knowledge and scientific evidence to remember, and that such
knowledge and evidence change too fast, while at the same time the available
evidence, in particular, regarding diagnosis and management in daily general
practice, may be lacking or not applicable. [Royal College of General
Practitioners (1992)]
Uncertainty has different subtypes each of which requires a specific
management; these are:
a) Vague complains: These are complains that do not allow a diagnostic
conclusion. In the patient's view, however, complaints are rarely vague.
His or her pain or fatigue is real, despite difficulties in expressing their
nature or explaining the exact location in the body, or the disabilities they
cause in everyday life. It is the doctor's problem that he or she cannot
produce an explanation that fits into existing and widely used diagnostic
or therapeutic models or categories.
b) Unexplained complains: Doctors may feel uncomfortable with patients
presenting with unexplained complaints. One reason is the risk that
unexplained complaints can be the first symptoms of serious or even life-
threatening diseases, including malignancies, severe infections, or
cardiovascular events, and that, in the doctor's view, early diagnosis
might prevent unnecessary, prolonged suffering, or a fatal outcome.
Physical symptoms for which no relevant organic pathology can be found
after medical evaluation are common in general practice as well as in the
general population. [Barsky AJ and Borus JF (1995)]; [Fink P,
Rosendal M and Olesen F (2005)]; [Katon WJ and Walker EA
(1998)] and [Kirmayer LJ et al. (2004)]
Such medically unexplained physical symptoms (MUPS) are a burden for
the patient because they are associated with increased functional

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 impairments, impaired quality of life, and psychopathology, such as
anxiety and depression. [Kroenke K (2003)] and [Richardson RD,
Engel CC (2004)]
MUPS also burden health care providers through increased health care
utilization, and society at large with high costs due to sickness absence
and service use. [Reid S, et al (2002)]; [Smith GR, Monson RA, and
Ray DC (1986)]; [Barsky AJ, et al. (2001)] and [Kroenke K, et al.
(1997)]
Thus, effective management of medically unexplained symptoms is an
important public health issue.
Medically unexplained physical symptoms become especially
problematic when they become recurrent or chronic. A recent study on
persistent MUPS in general practice demonstrated that 2.5% of patients
who visited their general practitioner (GP) were regarded as having
persistent MUPS, defined as at least four consultations in one year with
MUPS. That study focused on socio-demographic characteristics of these
patients and their health care utilization, showing that patients with
persistent MUPS were older, more often female, from a lower socio-
economic status and of non-Western origin and they consulted the GP
more frequently than patients without persistent MUPS or patients who
visited the GP with a medical diagnosis.

c) Ill-defined complains or diseases: ill-defined complaints are common in

daily general practice, but their exact frequency is not well established
(estimates vary from 10 to 20 per cent across all reasons for encounter). It
is unclear what kind of complaints other than fatigue, dizziness, and pain
are most often seen as unexplained.

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 One cause of this frequent occurrence is that it is particularly the
general practitioner who sees the early, less-developed stages of diseases.
Furthermore, out of a wide variety of complaints presented, only a small
proportion predicts the presence of a particular disease, while other
complaints have a familial or social background. [Dirkzwager A and
Verhaak P (2007)]
d) Uncertain diagnosis: Diagnostic tests may be a miss not only in the
selection of tests, but also the interpretation of test results that may
represent a challenge for every general practitioner. Reference values for
laboratory tests, for instance, are usually derived from setting borders
around the 95 per cent of a non-diseased population in whom the test has
been performed.
This means that the probability of finding an abnormal test result
without clinical significance is implicitly 5 percent or 2.5 percent if a test
can only cross the reference values in one direction.
e) Uncertain treatment or management: Ultimately, it is the doctor who
plays the key role in managing uncertainty. Not surprisingly, the number
of years in practice is related to the general practitioner's frequency of
feeling uneasy or uncertain. Having seen more rare cases helps to detect
the next case sooner, and, more importantly, to rule out the presence of a
potentially harmful disease.
The doctor's fears, however, do not always match the patient's
feelings. [Breisch SL (2001)]
The patient may very well be able to live with the doctor's
conclusion that he or she does not (yet) know the diagnosis, or that the
complaint presented does not even allow a diagnosis. Furthermore,
treating the patient as a partner by taking sufficient time for a proper

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 history-taking, including an exploration of the patient's fears and worries,
and a good explanation of the doctor's conclusions, will help the patient
to understand the doctor's uncertainty. In addition, general practitioners
might use a more problem-solving approach, given that they have had
some preliminary training in handling psychological therapy. [Nussbaum
JF et al. (2000)]
Time and the opportunity for continuing care are very powerful
diagnostic instruments in the hands of the general practitioner. Two
studies have found that, of the patients consulting their general
practitioners with non-acute abdominal pain, 68% had recovered a year
later, while headaches were found to disappear within 4 weeks after
presentation. [Meryn S (1998)] and [Schopick JE (2004)]

6- Breaking bad news

Breaking bad news to patients is one of the most difficult responsibilities
in the practice of medicine.
Bad news is defined as: “any news that drastically and negatively alters
the patient's view of her or his future." [Buckman R (1984)]
There are many reasons why physicians have difficulty breaking
bad news. A common concern is how the news will affect the patient, a
famous example is the words said by the professional bicyclist Lance
Armstrong when he was diagnosed with metastatic testicular cancer
exemplifying the impact of this bad news on his self-image: "I left my
house on October 2, 1996, as one person and came back another."
[Armstrong L (2000)]

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 Physicians also have their own issues about breaking bad news. It
is an unpleasant task. Physicians do not wish to take hope away from the
patient. They may be fearful of the patient's or family's reaction to the
news, or uncertain how to deal with an intense emotional response.
Physicians may feel unprepared for the intensity of breaking bad news, or
they may unjustifiably feel that they have failed the patient. The
cumulative effect of these factors is physician uncertainty and
discomfort, and a resultant tendency to disengage from situations in
which they are called on to break bad news. [Rabow MW and McPhee
SJ (1999)]
Family physicians encounter many situations that involve imparting
bad news; for example, a pregnant woman's ultrasound that verifies an IUFD,
a middle-aged woman's magnetic resonance imaging scan that confirms the
clinical suspicion of multiple sclerosis, or an adolescent's polydipsia and
weight loss that prove to be the onset of diabetes.
How a patient responds to bad news can be influenced by the patient's
psychosocial context. It might simply be a diagnosis that comes at an
inopportune time, such as unstable angina requiring angioplasty during the
week of a daughter's wedding, or it may be a diagnosis that is incompatible
with one's employment, such as a coarse tremor developing in a
cardiovascular surgeon. When the physician cares for multiple members of a
family, the lines between the patient's needs and the family's needs may
become blurred. Most family physicians have faced a conference room full of
family members awaiting news about the patient, or have been pulled aside
for a hallway discussion with the request to withhold the conversation from
the patient or other family members. [Vandekieft Gk (2001)]

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 The common concern that bad news will negatively affect the patient is
often used to justify withholding bad news. Hippocrates advised "concealing
most things from the patient while you are attending to him. Give necessary
orders with cheerfulness and serenity...revealing nothing of the patient's
future or present condition. For many patients...have taken a turn for the
worse...by forecast of what is to come." [Jones WH (1923)]
A review of studies on patient preferences regarding disclosure of a
terminal diagnosis found that 50 to 90 percent of patients desired full
disclosure. [Kutner JS et al. (1999)]
The physician has to individualize the manner of breaking bad news
and the content delivered, according to the patient's desires or needs. Bad
news often must be delivered in settings that are not conducive to such
intimate conversations. The hectic pace of clinical practice may force a
physician to deliver bad news with little forewarning or when other
responsibilities are competing for the physician's attention. [Vandekieft Gk
(2001)]
Bad news is to be compassionately and effectively delivered using the
simple mnemonic ABCDE practical and comprehensive, model developed by
Rabow and McPhee. Although specific situations may preclude carrying out
many of these suggestions, the recommendations are intended to serve as a
general guide and should not be viewed as overly prescriptive. [Girgis A and
Sanson-Fisher RW (1998)]

7- Referring procedure as a satisfaction challenge

In a typical (or ideal) primary health care the majority of patients who
consult a primary care practitioner are dealt with entirely within primary care.
Consultations resulted in a specialist referral range between 2.6 per cent

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(France) and 8.1 per cent (Norway), with most European countries referrals
averaging between 4 and 6 per cent of consultations. [Royal College of
General Practitioners (1992)]
Wherever the boundary between primary and specialist care is set in an
individual country, care will be most efficient if all those patients who need
to be referred are referred, and no patients are referred unless they have a
need for specialist care. This, of course is never the case, and some patients
will be referred who have nothing to gain from the referral and others will be
cared for by their primary care physician where they would benefit from
consulting a specialist. These patients represent inefficiency in the health care
system, and considerable attention has been paid in some countries to
inappropriate referrals, especially by those with responsibility for funding
specialist services.
In some countries, like Egypt, there is two overlapping health care
systems one is presented by the primary health care that are related to
preventive medicine and presented through low caliber doctors who are either
fail to complete their postgraduate study or just graduated and serving the
obligatory service period in which they have to work in suburban areas and
another system of specialists working in outpatient polyclinics. Patients
could access any of the two systems directly.
This may not be the frank truth, but it is the perceived fact in the minds
of the health professionals and the population as well. The term “primary” is
decoded as primitive and immature, thus related to shortage in available
services, equipments and consumables where low quality services are
presented by low competency doctors. In this theme the referral is a sign of
professional illiteracy and failure in the point of view of the referred patient
and sometimes, the referring doctor as well.

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 This situation presents a barrier for the generalist to refer until he/she
“tries” to solve the problem by his own. Referral is considered a defect in the
system by the patient especially with the cultural concepts that may release
comments as “Sorry, but aren’t you a doctor, too?” or “You know what, my
doctor recommended me to visit a doctor!”
The clarifications presented to the patient by the referring doctors as “I
have nothing here to help you” may increase the problem.
Sooner or later, things will be put in the right arrangement by training
the primary care doctors, well equipping the facilities and conducting
awareness campaigns demonstrating and explaining the team work in health
care system and the role of the family doctors. This will take time during
which the primary care provider doctor weather a generalist or a family
physician has to pass through the conflict safely. The key factors for
perfection in such a situation are:
1- Communication skills: the generalist has to inform the patient why
he is referring him and what for.
2- Counseling: the generalist has to counsel the patient and explore the
patient’s ideas, concerns and expectations that may form referral
barriers, some of these barriers are:
“The hospital is far away and very crowded. I couldn’t catch any of
the staff anyway as they finish their work by now” and
“They don’t care about their patients in hospital; they just ask one
question and write down the prescription”
3- Strong inter-professional relations: the generalist hasn’t to rely on
the system alone in achieving good feedbacks, especially if it is a
loose system, but he has to build up strong personal relations with

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 specialists in the referring hospital that is to make up his supporting
crew.
4- Referring must be relevant, for clear reason and the patient must be
accompanied with a referral letter that includes full data, yet the
patient must know very well the content of the letter he is carrying.
5- Follow up: Actually this is one of the secrets of success in
medicine; it gives the patient the feeling that his doctor is caring
and gives the doctor the pearls of practice experience.
The ten causes for referral are listed in Appendix No.6

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 TIPS, TRICKS AND PEARLS OF EXPERIENCES THAT HELP
ACHIEVING PATIENT SATISFACTION

I. Increasing satisfaction by noting patient interests: Before beginning an

exam, the doctor may spend a little time talking with the patient about a
topic that interests him or her. Usually, these subjects are to be revealed
during the course of the patient's first or second visit, and to be put down on
the inside jacket of the patient's chart. Something as obvious as a team
sweatshirt the patient is wearing may suggest a topic of conversation.
Other times a doctor may ask about patients' vacations or hobbies.
Asking an avid gardener a question like, "How are your orchids doing?" and
listening to the answer increases satisfaction because the patient feels his
doctor has spent more time connecting with him or her. This increases the
doctor’s satisfaction as well. [Elder K (2008)]
II. The three secrets strategy for patient satisfaction:(Read, Meet and
Exceed)
1. Finding out what patients expect from the practice.
2. Meeting these expectations.
3. Trying to exceed these expectations.
This is the simplest strategy in achieving patient satisfaction. It is changeable
as the expectations differs from one to another and from time to time, but
commitment and insisting always leads to success.

III. The three secrets methodology for patient satisfaction: (Meet, Greet and
Treat): The meet and greet (first impressions last): The meet and greet is one
of the most important parts of the customer service experience in business.
Health care staff will be assessed by clients within the first few seconds and,

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rightly or wrongly, they will have formed an opinion about the system and
the encounters of the business within that time. Of course, this opinion may
change throughout the interaction, but the doctor will be miles in front if he
does a good job with the meet and greet methodology.
The health care staff who are working in a facility or a practice see the
same place day in and day out but for many of the attending patients it’s all
new. It is annoying to go into a health care facility that is ambiguous about
what a patient should do next. Should he go to the counter to ask where to go
or what to do? Is there any counter or receptionist at all in the health facility?
Should a patient stand around feeling awkward until someone comes and
serves him? Or should a patient start walking around the health facility until
he finds someone to help him?
When one of the staff is asked by a client about the place of a service,
does he answer “This is not of my business” or even “I don’t know, sorry”? It
can be very confusing if the health care facility management doesn’t make
this clear and unfortunately this is the case in most of the health care facilities
in the governmental sector and this altitude has to be changed if we are
looking for patient satisfaction.
When a client enters a health care facility where lots of staff people
walk around, generally trying not to make eye contact with him, it would take
any of them only a few seconds to stop, greet the client and ask any help
could be offered.
Have the staff the intention and the routine for introducing themselves?
It depends on the traditions and norms weather it is appropriate for the doctor
to actually shake hands, to introduce himself or is it as simple as welcoming
the patients, telling them his name and asking how he can help them.
However it works for the place where a doctor practices, he has to be certain

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 that the meet and greet methodology is fast, friendly and confidence-
inspiring. [Griffiths A (2006)]
Lastly “treat” refers to curing the patient; beside all of these
communication tips, the core need of the patient is to get relieved and this
need must be fulfilled. The word treat is a coin that has two faces; one is the
cure which represents the perspectives of the doctor and the other is the relief
which represents the perspectives of the patient that need to be explored and
fulfilled.

IV. The ten keys to a positive first impression

The time of transition between expectations and findings is the time
when first impression is taken. In this moment the patient decides if this is
the needed and accepted service or not and it will be a hard job to change his
mind. Here are some suggestions that help the doctor to guide patients
building positive first impression.
1. Hiring the kindest, most sincere person as a receptionist: The
receptionist's attitude has a lot to do with how a patient experiences a
medical visit.
A good example is Williamsport Hospital and Medical Center in
Williamsport, USA where administrators found that although the patient's
encounter with the Emergency Department physician and nurse was
important, it was the encounter with the receptionist that was most
important to satisfaction. Improving that experience improved satisfaction
ratings with the ED dramatically.
Granted, an ED is not a family practice office, but the effect is the
same. So, a health care management has to hire the smile and teach the
skills for this position. Also the health care management has not to overload

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 this individual as assigning too many duties to a receptionist can interfere
with making patients feel welcome and comfortable.
2. Respecting patient confidentiality. Patients should not have to state the
reason for their visit when other people are present. Health care system has to
avoid sign-in sheets, especially the kind that asks for the patient's chief
complaint. An alternative is to have numbered pads printed. The patient signs
the top sheet, tears it off and gives it to the receptionist. The receptionist can
then use this information in whatever way the sign-in sheets were used (e.g.,
to keep track of how many patients are seen, order of arrival, etc.).
3. Making sure the reception area is spotless. Cleanliness in the reception
area is extremely important. People seek to confirm their first impressions. If
the reception area furnishings are stained, patients will be checking to see if
the examination room equipment is dirty, too.
4. Monitoring the reception area materials. Airlines don't run movies that
involve plane crashes, and you should think twice about displaying
magazines with headlines such as "How I Made Millions Suing Doctors for
Malpractice." Also, the doctor has to keep in mind that the tremendous
amount of medical information in consumer magazines creates expectations
for patients. For example, the October 1996 issue of Good Housekeeping
contained an article titled "Breast Exam: Is Your Doctor Doing It Right?" A
patient who read that article while waiting for her doctor to do a breast exam
might have wondered about his competence if he didn't do the exam exactly
as described in the article. (Being familiar with such articles can also alert the
doctor to increased concerns about certain procedures or medications.)
5. Considering the impressions that signs in the clinic create. Do the
majority of the signs pertain to insurance and billing rather than helping the
patient feel comfortable? An example of a helpful sign would be one that

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says, "Please see our receptionist when you arrive." A sign that reads,
"Patients are seen in order of appointment, not arrival," can ease tensions in a
crowded reception area. Staff are to be discouraged from posting flip or
inappropriate sayings in prominent places. A sign that says, "The worst day
at the beach is better than the best day at work," may relieve staff tensions but
should be kept out of the patient’s view.
6. Being the first to say hello. Everyone in the practice should take the
initiative in greeting patients. The doctor hasn't to wait for the patient to
speak, because some patients will interpret the doctor’s reticence as
indifference. Using the patient's name whenever possible is a great
advantage. Staff are to be asked to review the schedule at the beginning of
the day so as to make it easier for everyone to remember names. It is to be
kept in mind that, while having staff members wear name tags encourages
patients to ask the appropriate person for information and assistance, tags are
not a substitute for a personal introduction.
7. Being prepared for the patient. The doctor has to review the patient's
chart before entering the exam room. The doctor’s ability to know and
remember information will impress patients. Social information, such as a
spouse's first name, can help the doctor make the personal connections that
are important to many patients.
One physician has discovered an effective way to start every visit. He
makes a note of the last thing the patient says as he or she is leaving a visit.
Glancing at the chart just before the next visit, he can recall that topic of
conversation and introduce it at the start of the visit. "Did your daughter's
team win the state championship?" This strategy makes each patient feel
important. If a patient has been referred to the doctor by another physician,

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saying something like "Dr. Verri and I spoke about you and she told me that
..." reassures the patient that his or her care is being coordinated.
8. Putting the patient at ease. Being alert to factors that might hinder
physician-patient communication is very important in gaining patient
satisfaction. One patient decided to look for another physician because his
physician had a habit of talking with his back turned. Another patient opted
not to return to a physician who greeted and examined her wearing a surgical
mask. The physician never explained why he was wearing the mask, and the
patient never asked.
9. Focusing first on the patient's needs. Every member in the practice
should use this strategy. When the receptionist asks about insurance first,
before asking how the patient is feeling, an impression is created that the
system/facility cares more about the patient's insurance than his or her well-
being.
Early in the visit, the doctor has to find out what issue is on the
patient's mind. It may not be the most significant problem clinically, but
when the doctor addresses this concern first, the patient can relax and
concentrate on what the doctor has to say.
10. Creating a favorable impression in 60 seconds. The amount of time a
physician spends with a patient contributes significantly to the patient's
satisfaction with an office visit. In a busy practice, it's not always possible to
dedicate as much time to a visit as a patient may want or expect.
If, however, the doctor gives a patient his undivided attention for the
first 60 seconds of the encounter, this will leave the patient feeling that he or
she had a meaningful interaction with his doctor -- and not feeling that the
visit was too short. [Baker S (1998)]

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V. Seven skills for ending the medical visit with greater satisfaction
1. Starting with an agenda. The doctor can prepare for a good end to a
patient visit by starting right. Agenda setting orients patients to the
structure and time frame of the visit, and it helps circumvent last-minute
concerns. Agenda setting includes "exhausting" the agenda. In other
words, after the initial query into the reason for the visit, the doctor may
ask, "Is there anything else?" until the patient answers, "That's it." After
adding his own items to the list, the doctor is advised to negotiate the
agenda with the patient. Through collaboration, the doctor has to decide
which concerns will be addressed at the current visit and which, if any,
will require a future visit.
2. Using verbal cues. Once the agenda is set, continuing to highlight the
structure of the medical visit as it progresses is recommended. For example,
transitional statements such as "Let me wash my hands, and then I'll take a
look…" and "As we wrap up today, let's make sure we are on the same
page…" drawing attention to the organization of the visit and contributing
to the natural flow toward closure are very helpful. Foreshadowing can also
be useful. For example, the doctor might say, "I am going to get those
samples for you. When I come back, we'll talk about how to take the
medication, and then we'll be through for today." Transitional statements
and foreshadowing help both the doctor and his patient stay organized.
3. Addressing the patient's emotions up front. Emotions, if not dealt with
strategically can sabotage the agenda, prolong the medical visit and lead to
an untidy closure. Eliciting patients' emotional or psychosocial issues early
in the visit can help provide a sense of control over what is often considered
a Pandora's Box

160
 .

Table (6) The bathe technique, a structured, time-sensitive method for

addressing psychosocial issues. [Stuart MR, Lieberman JA (1993)]

This five-step technique is designed to help physicians uncover patients' emotional

issues quickly during an encounter. The first four letters of the BATHE acronym
prompt physicians to ask questions that elicit the context for the visit. The final step is
to show empathy.
 Background: "What's going on in your life?"
 Affect: "How do you feel about it?" or "What has that been like for you?"
 Troubles: "What troubles (concerns, worries) you most about it?"
 Handling: "How are you handling (dealing with, coping with) it?"
 Empathy: "That must be difficult for you."
Source: Stuart MR, Lieberman JA. The Fifteen Minute Hour: Applied Psychotherapy for the Primary
Care Physician. 2nd ed. Westport, Conn: Praeger Publishers; 1993.

The BATHE technique (TABLE 5) provides a structured, time-

sensitive method for addressing psychosocial issues and can be employed at
any point in a medical encounter. If the doctor or his patient believes an
issue warrants more time than the agreed-upon agenda allows, simply
renegotiate the agenda or schedule a follow-up appointment.
4. Addressing the doctor’s own emotions. Physician emotions, especially
the feelings of guilt and inadequacy that often plague young physicians, can
play a major role in prolonging visits. These feelings may surface when the
doctor do not address all of a patient's complaints, ask a patient to return for

161
 follow-up care, keep the patient waiting too long, or fail to "fix" the
patient's problem. Compensating for these feelings by extending the current
visit is counterproductive and often leaves the doctor and the patient feeling
frustrated.
Instead, the doctor need to deal with what cognitive-behavioral therapists call
cognitive distortions, that is, overly negative and largely inaccurate thoughts
that typically underlie uncomfortable emotional states. Addressing these
errors in thinking is an adaptive method of handling the situation. For
example, if the doctor feels overwhelmed at the thought of having to address
all four of a patient's complaints at the current visit, he may replace that
thought with this: "I will overwhelm my patient and myself if I tackle too
much during this visit. I would serve my patient better if we focused on two
or three issues and reached some common ground on how to proceed." When
feeling confident, calm and optimistic, the doctor is more likely to close the
encounter successfully.
5. Having a seat. Physicians often need to leave the room near the end of a
visit to get medication samples, allow patients to get dressed or await lab
results. Although it is counterintuitive, the doctor should sit down when he
re-enter the room even if he do not expect a lengthy wrap-up. Research has
shown that most communication is nonverbal, and sitting down creates
positive perceptions. Additionally, sitting down gives the doctor the
opportunity to stand up at a later point. Standing up is a clear nonverbal cue
that the meeting is coming to a close.
6. Being prepared for "oh by the way." Last-minute patient complaints,
known as the "oh by the way" or "hand on the door" phenomenon, can
surface even when the doctor exhaust and negotiate the patient's agenda at
the beginning of the visit. It's important to evaluate these last-minute

162
 concerns and classify them as emergent or nonemergent. A patient's
overwhelming fear of a serious illness may preclude him or her from
mentioning chest pain at the beginning of a visit. Emotions can create
similar barriers to divulging serious mental health or psychosocial issues,
such as interpersonal violence or suicidal thoughts. These emergent issues
need to be addressed immediately.
Most last-minute issues are not emergencies. Patients' fears about bringing up
"sensitive" but nonemergent issues should not be reinforced. For instance, to
evaluate and treat sexual dysfunction, the doctor will need more than a
hurried prescription. An appropriate response is to say, "I know this can be
uncomfortable to discuss, and I am glad you brought it to my attention. In
order to deal with it adequately, I am going to need more time to talk to you.
I'd like to schedule an appointment so that we can give it the attention it
deserves. How does that sound?" The doctor acknowledges the patient's
possible discomfort in bringing up the topic, validate the concern and
maintain the structure of the visit. The same approach can be taken with less
sensitive issues, such as concerns about sleep. Over time, patients will learn
to prioritize their concerns even before the doctor asks them to do so.
7. Being more specific. One final behavior that can be problematic is when
the physician asks at the end of the visit for additional questions or concerns.
To the patient, this may appear as a genuine request for additional dialogue.
To the physician, this is often a rhetorical question intended as the
penultimate step to closing the visit. Patients will understand the signal for
closure better if the doctor replaces the broad query "Do you have any more
questions or concerns?" with a more specific question, such as "Do you have
any questions about what we discussed today?" [Lutton ME (2004)]

163
CHAPTER THREE

AIM OF THE STUDY

164
 OBJECTIVES

Aims of the study

The present study was conducted aiming at:
1- Determining the actual state of patient satisfaction among users of
family health services presented by Elmoneeb Family Health Center
located in Giza, Egypt and the degree to which demographic factors
(age, gender, job, educational level and marital state) were associated
with patient satisfaction.
2- Addressing the topics of shortage in the family health services
presented by the mentioned health facility from its users’ perspectives.
3- Developing comprehensive user friendly instrument for measuring
patient satisfaction suitable for family medicine in the patient centered
model of practice and compatible with the language and culture of
clients in the suburban areas.
4- Cultivating an environment that embraces quality improvements,
increase staff awareness of patient satisfaction and highlights the
importance of the patient expectations, perspectives, concerns and
ideas.

165
Research Questions

1- To what degree are clients satisfied with family health services

presented in the mentioned health facility? And how do patients rank
the services presented in the mentioned facility?
2- Which affects patient satisfaction more, human resources (health care
team) or physical resources (place and appliances), the competent
team/doctor or their manners?
3- What is the degree of satisfaction of the patient with various aspects of
the services and members of the team?
4- What are the major defects and shortages in the services presented
from the service receivers’ point of view?
5- How could the patient satisfaction improved among the population
under the study?

166
 CHAPTER FOUR

SUBJECTS AND METHODS

167
 SUBJECTS AND METHODS

Introduction
The four purposes of this study were to: (1) determine the actual state
of patient satisfaction with family health services presented by Elmoneeb
Family Health Center located in Giza, Egypt and the degree to which
demographic factors (age, gender, job, educational level and marital state)
were associated with patient satisfaction; (2) address the topics of shortage in
the family health services presented by the mentioned health facility from the
perspective of the target population; (3) develop comprehensive user friendly
instrument for measuring patient satisfaction suitable for family medicine in
the patient centered model of practice and compatible with the language and
culture of clients in the suburban areas in Egypt and (4) Cultivating an
environment that embraces quality improvements, increase staff awareness of
patient satisfaction and highlights the importance of the patient expectations,
perspectives, concerns and ideas.

The setting
The study was conducted in Elmoneeb FHC which lies in a suburban
district called Elmoneeb in Giza governorate at the beginning of Upper Egypt
road. The facility is the main health facility in the area that is consisted of
three floors each contains twelve rooms.
The catchment area of the facility is represented in the map present in
Appendix No.11. The target population is estimated to be 48099 inhabitants
out of which more than five thousands access the facility monthly.
19131(39.8%) of the total Population are under 15 years old. Figure (7)

168
 14000

12000

10000

8000

6000

4000

2000

0
< 15 years < 5 years < 1 years
Population Number 12506 5002 1623

Figure (7) The distribution of population under 15 years on

different age groups in Elmoneeb district.

The facility presents integrated curative and preventive health care

services (Appendix No. 14) through its team that is consisted of two family
physicians, fourteen dentists, an ophthalmologist, three pharmacists, nine
physiotherapists, twenty general practitioners (with no post graduate studies),
thirty-four supportive employees (management, administration, secretary,
social workers and drivers), sixteen workers and thirty-one nurses.
The facility is supported by the referral hospital; Ommel Masryeen
hospital which is a full services hospital lies seven kilometers (15 minutes)
away from the facility under the study. The performance indicators of
Elmoneeb FHC for April 2009 are listed in Appendix No. 12. The mission of

169
Elmoneeb FHC concentrates on satisfaction for the clients, the family, the
staff and the community as well, Appendix No. 13.

Research Design
A community based cross sectional study that involved a descriptive
survey design with concurrent assessments. The study was conducted in
Elmoneeb Family Health Center -Giza-Egypt. The independent variables
were (1) gender, (2) age, (3) educational level and (4) type of health care
services received in the health care episode just prior to the study.
The dependent variables were patient satisfaction scores, both general
ranking and specific correlates.

Authorization Procedures
Permission authorization was obtained from the management authority
as a formal written request was presented to the manager of Elmoneeb FHC
facility to permit the researcher to conduct the study interviews with the
attendants inside the facility.
The manager has approved the request by signing and stamping it with
the official facility stamp. Appendix No. 10

Selection of Subjects
The population sample of this study consisted of 19 men and 81
women (N = 100). The participants attended Elmoneeb Family Health Center
located in Giza, Egypt seeking health care services in health care episodes in
the period from 2-5-2009 to 24-5-2009 during the work hours 09:00 a.m. to
02:00 p.m. All participants, who volunteered for the study, were provided an
explanation of the study exploring the purpose of the study and contained

170
relevant information pertaining to the study, a statement regarding the
patient’s rights to participate in the study and a verbal consent (Appendices
No. 7 and No. 8).
Assigned code numbers were used, the names were demanded for the
purpose of the communication process and the interviewees were told that
they may not supply names to protect the anonymity of them.
Response to questionnaire, consent and demographic data sheets were filled
and filed in a locked file by the researcher.
In the days in which the interviews with the participants took place
orientation sessions with the present patients were held in the ticket office in
the beginnings of the working days, patients and their accompanying parties
were informed about the patient satisfaction study and were asked to
participate on demand, it was explained that this will help improving the
services presented to meet their needs.
As the facility under the study was in a structural maintenance and
upgrading operations along with the political theme and context of the
procedures taken for approving the law of the new insurance system in the
Perlman, the issue of the study was highly accepted by the public and on
approaching each of the attendants to ask for participation no one apologized
or refused except for three who were sorry that they couldn’t participate and
all the approached parties welcomed to participate in spite of the relatively
long questionnaire (more than sixty questions).

Inclusion Criteria
1- Age not less than 18 years old, the children whom were accompanied
by one of their parents were included if their parents met the inclusion
criteria and have none of the exclusion criteria. In these cases, the

171
 interviewee was the parent and the patient satisfaction asked upon was
his/her satisfaction not the child’s satisfaction.
2- Attending Elmoneeb FHC in the work hours(09:00 a.m. to 02:00 p.m.)
in any of the days when the study interviews were conducted; these
days were: 2-5-2009, 3-5-2009, 4-5-2009, 5-5-2009, 9-5-2009, 12-5-
2009, 14-5-2009, 21-5-2009, 23-5-2009 and 24-5-2009.
3- Being present in the mentioned health facility seeking health care
service(s) in a current personal health care episode (or an episode
affecting his/her own child).
4- Residency within the catchments area so as to be targeted by the
services presented by the mentioned health facility, this catchments
area is will distinct in a map present on the wall in the mentioned
health facility. Appendix 11
5- Accessing the health facility for the needed service (either received it
or not) by the time of the interview and on the same day.
6- Accepting for the participation in the study by approving a verbal
consent provided along with explanation exploring the purpose of the
study and contained relevant information pertaining to it.

Exclusion Criteria
1- Having a health care need that needed urgent interference inside the
facility or referral to the district hospital as an emergency.
2- Having a health problem that was inconsistent with being interviewed
for the time needed to complete the questionnaire as acute disease that
made the patient need rest and not at ease being interviewed.
3- Any disease or condition that affects the mental health state, memory
or conscious level.

172
4- Having any conflict of interest as being working in the mentioned facility or
a relative to one of the staff working in it.

Process and procedures

Attendants were approached randomly by the researcher while they were
just exiting the room where they received the needed health care service. The
randomization was made by tracking the attendants whose ticket number is
three or its multiplicities after making announcement in the ticket office to
the employee in the charge to take a note with the patient’s name and the
health care service needed by the marked attendant to address his/her target
department so as make it easy to find the attendant later after he/she just
finished receiving the service and the employee was instructed to send this
notes to the researcher every half an hour.
Sometimes the marked attendant when contacted while exiting from
the consultation room was not finished receiving the service as he/she was
targeting another department as the lab or the pharmacy, in this condition and
on his/her acceptance to share in the survey, the interview with him/her was
postponed after completing receiving the service.
In the first few cases, the marked attendant was trapped at the targeted
department by the researcher till it was found that the attendants were that
committed and intending to share so they were just told to come back after
they finished.
After the marked attendant was contacted by the researcher, he verified
who met the inclusion criteria and hadn’t any of the exclusion criteria then
the attendant was asked to approve an informed verbal consent subsequently
the interview was conducted by the researcher.

173
 All but three of the contacted attendants who met the criteria agreed to
participate in the study. The interviews were held in a privacy sitting where
the participants, the attending nurse and the researcher are inside alone with
the door closed. The researcher was asking the participant the questions in
the survey form verbally and writing down the feedbacks in the answer sheet.

Instrumentation
A tailored survey questionnaire was developed so as to serve the needed
objectives and be compatible with the cultures and language of the target
population.
A pilot version was developed and used in conducting ten survey
interviews to check its versatility. Many of the questions were vague, the
interviewees gave unlisted feedbacks and weren’t able to understand some
other questions, all these questions were changed and the entire questionnaire
is rephrased in a convenient form using simple Arabic language that are used
in the normal daily life of the population in the district area were the study
was conducted, Appendix 7.
The questionnaire consisted of sixty three questions; all were multiple
choice questions except six questions at the beginning inquiring about the
demographic and personal profiles (name, age, marital state, education level,
and job) along with the cause for attending the health facility the day of the
interview and three other questions at the end of the questionnaire that were
open ended questions to give the interviewees the chance to express their
opinions in the general three topics (the best thing in the facility, the worst
thing in the facility and suggestions for improving the services).

174
 Data collection (administrative procedures)
Feedbacks are documented under the supervision of the researcher by
four assistants whom were nurses trained by the researcher on data
documentation in specially made answer sheets; Appendix 8. Then, these
forms are filed and entered by the researcher to his personal lap top using
Microsoft Excel 2007 software.
This was done step wise during the study days. After completing the
targeted interviews and gathering the whole data, answer sheets were
handed to a professional data entry personnel to re-enter the data on his own
PC using the same mentioned software, then the two excel sheets were
compared and every difference found was revised to the original answer
sheets and corrected according to them.

Statistical analysis and representation

Data were analyzed using the functions of Microsoft Excel 2007
software then exported to Microsoft word 2007 software to represent the data
in graphic charts and tables.

Ethical considerations
1- The software used by the researcher and the data entry personnel
(Microsoft Excel 2007 software and Microsoft Excel 2007 software),
were original versions licensed from Microsoft Inc.
2- Verbal consents were taken from the participants whom were provided
with an explanation of the study exploring the purpose of the study and
contained relevant information pertaining to it and a statement
regarding their rights to participate or not to participate.

175
 3- The interviewees were told that they may not supply names to protect
the anonymity of them if they wish so, although 98% prefer to till and
document their names.
4- The interviews were held in a privacy environment with no
interruptions or interventions.
5- The interviews weren’t related to or depending on the health care
services received by the participants.
6- The acutely ill patients and those whose illnesses recommending rest or
who weren’t at ease are excluded from the study.

Limitations and obstacles of the study

1- As the interview was conducted just after the participants were received
a specific health care service presented by specific department and a
specific health team, the feedbacks of the participants were directly
related to their satisfaction with the health care service they were just
received and tot a general cumulative feedback about the health care
services they were receiving from the facility in the year prior to the
study.
2- The facility as mentioned earlier was under reconstruction at the time of
the study. This necessitated changes in the places of various
departments which made it a hard job for the attendants to reach their
targets inside the facility. The waiting area was crowded with workers
without enough places to sit on.
3- The majority of the participants were females and not working as the
work hour (9:00 am to 2:00 p.m.) was inconvenient to the working
males and the services presented subsequently were emergency services
only.

176
4- The researcher being a doctor and a temporal staff in the facility was a
barrier limiting the freedom of the participants to express their
dissatisfaction; not to be “bad-mannered”. In spite of the researcher’s
trials to dissolve this barrier, it was present in almost all the interviews
conducted in the study to some extent.

177
CHAPTER FIVE

RESULTS

178
 RESULTS

The purpose of the study is to determine the actual state of patient

satisfaction among utilizers of family health services presented by Elmoneeb
Family Health Center located in Giza, Egypt and to identify the topics of
shortage in the family health services presented by the mentioned health
facility from its utilizers’ perspectives.
The study involved interviewing participants using a questionnaire
consisting of sixty seven questions offered in Arabic. The participants were
residents of Elmoneeb district and were at least eighteen years old.

Data Collection
The survey included questions about demographics, access to health
care, reasons for accessing health care, awareness of presented health care
services, general satisfaction rating and specific satisfaction correlates that
include: physical resources, human resources and the health care process with
special focusing on the topics of patient centered model of practice.
The researcher trained and supervised 4 assistants, whom were familiar
to the patients being nurses working in the health facility under the study, for
data documentation during the interview to maintain positive concentration
with the interviewees.
The researcher approached potential participants for volunteer
participation. The participants were approached at Elmoneeb Family Health
Center after receiving the demanded service.

179
Description of Sample
The sample (n=100) obtained has the characters presented in Tables (7), (8),
(9) and (11). As the total number of the participants is 100, the percentage of
every piece of data equals the frequency.

Table (7) Percentages of males, females, married and unmarried

participants in the sample

marital Number of Number of Not

Married married Total
Gender state Participants Participants
Number of Male
9 6 15
Participants
Number of Female
77 8 85
Participants
Total 86 14 100

90
80
70
60
50 Unmarried Participants
40 Married Participants
30
20
10
0
Male Participants Female Participants

Figure (8) Percentages of males, females, married and unmarried

participants in the sample

180
Table (8) Percentages of participants in different levels of
education.
Level of education percentages of
participants
Not educated 24

Less than primary 8

Primary 2
Secondary 6

High school 55
University 6

Total 100

Levels of Education.
University
6%
Not educated
24%

Less than primary

High school 8%
54% Primary
2%
Secondary
6%

Figure (9) Percentages of participants in different levels of

education.

181
Table (9) Percentages of participants among different age groups
Age Groups Percentages of
participants
Less than 20 years old 6

20 years TO  30 years old 36

30 years TO  40 years old 36

40 years TO  50 years old 15

50 years TO  60 years old 5

60 years old or more 2

Age Groups
%5 %2 %6
%15

%36

%36

Less than 20 years old (6%) 20 years TO < 30 years old (36%)
30 years TO < 40 years old (36%) 40 years TO < 50 years old (15%)
50 years TO < 60 years old (5%) 60 years old or more (2%)

Figure (10) Percentages of participants among different age groups

182
 The health care services that were represented to the participants are a
variety of services, as shown in Table (10) and Figure (11). Although many
participants received more than one service, only one appears in the data that
is the place where the participant begins his healthcare service in.

Table (10) Percentages of participants attending various departments in the

health care facility

Gynaecological Consult.

Dermatologic Consult.
Ophthalmic Consult.
Orthopedic Consult.

Pediatric Consult.
Surgical Consult.
Medical Consult.

Family Planning
Pregnancy Care
Dental Consult.

Physiotherapy

Vaccination

Total
24 3 2 8 24 4 8 6 1 10 8 2 100

Table (11) Percentage of the participants working in each job category

Not working Employee Private work student Total

67 15 15 3 100

183
 Percentage of Participants

Dermatol. Consult.

Dental Consult.

Gynaecol. Consult.

Family Planning

Ophthalm. Consult.

Medical Consult.

Paediat. Consult.

Orthopaed. Consult.

Pregnancy care

Physiotherapy

Vaccination

Surgical Consult.

0
5
10
15
20
25

Percentage of Participants

Figure (11) Percentage of participants attending various departments in

the health care facility

184
 Job Categories
Not working (67%) Employee (15%)
Private work (15%) Student (3%)

%3
%15

%15

%67

Figure (12) The percentage of the participants working in each job category

Among the 100 participants, Elmoneeb FHC was the place attended in
health care episodes for 93 of them. Reasons for accessing the health care
facility are represented in Table (12) and Figure (13). For the remaining
seven participants, Elmoneeb FHC wasn’t the place of choice for satisfying
health care needs. The reasons for this non utilization are represented in Table
(13) and Figure (14)

185
Characteristics of the non utilizers
All of the seven participants who reported that Elmoneeb FHC isn’t the
place of choice for satisfying health care needs were married, one of them was
male and the rest were females.
All of them were educated; one of them stopped education after the
primary school, two had a university degree (out of six highly educated
participants) and the remaining four had high school degree.
Their ages ranged between 27 and 41 years old. Out of these seven
participants, five were with attendance duration less than a year and two with
attendance duration one to three years.
Five participants of the non-utilizers had attendance rate 1 to 3 times
during the12 months prior to the study and the remaining two participants had
attendance rate of three to six times.
Except one, all of them knew the availability of less than three services
out of the 10 services available at the health care facility. Four reported that
the services were under priced, two knew nothing about the prices and one
answered the prices are fair.
All of them refused the offer of raising the prices versus improving the
services, because (in their opinions) the services will not improve in spite of
raising the prices. Two reported that getting a consultation ticket was accepted
(neither an easy nor a hard job), whereas five reported that this was hard
because of crowdness and loss of discipline (1), absence of the employee in
the charge (1) or both (3).
The waiting time was reported to be more than an hour by four
participants and between half an hour and an hour by the remaining three. All
of them reported that it wasn’t easy to reach their target inside the facility; two
addressed the helpfulness of the facility staff that facilitated that hard job.

186
 Table (12) Percentages of participants reporting different reasons for
accessing the health facility
Percentage of
Reasons for accessing
participants

Good Services 17
Cheap Services 3
Easy Accessibility 20
Good Services+ Cheap Services 10
Good Services+ Easy Accessibility 16
Good Services+ Cheap Services+ Easy Accessibility 27
Total 93

Reasons for accessing the Facility

%18
Good Services (17%) %29

Cheap Services (3%) %3

Easy Accessibility (20%)

Good Services+ Cheap Services (10%)

Good Services+ Easy Accessibility (16%)

%22
%17
Good Services+ Cheap Services+ Easy %11
Accessibility (27%)

Figure (13) Percentages of participants reporting different reasons for accessing the
health facility

187
Table (13) Percentages of participants reporting different reasons for non
utilization
Reasons for Non Usability Percentage of Participants

Bad service 4

Limitations of work hours 1

Availability of better alternative 2

Total 7

Reasons for Non Utilization

Bad service (57%) Limitations of work hours (14%) Aailability of better alternative (29%)

%29
%57

%14

Figure (14) Percentages of non utilization reasons reported by the non-

utilizers

188
 Dealing manners of the nurses was reported as “bad” by four
participants and as “accepted” by three of them, while dealing manners of the
doctor was reported as “normal” which means “not good, not bad” by all of
them except one who reported that the doctor’s manners was excellent.
Doctor’s style was reported as “bad” by three of them, “practical and
formal” by another three and “friendly and welcoming” by the seventh.
Doctor’s competence was reported as “bad” by three of them and as
”accepted” by the remaining four while the nurse’s competence was reported
as “bad” by five participants and as “accepted” by the remaining two.
The examination techniques and through exam was ranked “medium”
by all of the seven except one who ranked it as “bad”. All of them had no
family files registered in the facility except one who had a family health
record (FHR) in the facility ,but it wasn’t available to the doctor in the
consultation.
The doctor greeted one of them, three weren’t greeted and three
couldn’t remember. The doctor called one of them by his name, three weren’t
called by name and three couldn’t remember.
The doctor introduced himself to none but one of them and took a
consent for medical examination from only three of them. The doctor didn’t
ask four of them about the impact of the health problem on their life (one was
asked and two couldn’t remember), didn’t ask four of them about problems at
home (one was asked and two couldn’t remember) and didn’t ask any of them
but one about problems at work.
The doctor told all of them when asked about treatment alternatives
except one participant. The doctor told two participants about date of follow
up, didn’t tell one participant and told the rest when asked.

189
 The doctor described to all of them how to use the medicines. The
fulfillment of the patient education topics is represented in Table (15)
All of them didn’t receive medicines from the facility pharmacy; three
participants demanded from the doctor to prescribe “external” medications (as
these are more effective from their point of view), three had told by the doctor
that the available medications at the facility pharmacy are weak and less
effective and one participant reported the cause was that the medication
needed wasn’t available.
All but one of them reported that the facility hadn’t the needed
medications, all but two of them reported that the facility hadn’t the needed
consumables and all but two of them reported that the facility had the needed
equipments

Table (14) Suggestions of the non utilizers for improving the quality of
the service

Inputs Structure Process

 Replacement of the tickets  Upgrading the  Care with patients

clerk equipments  Discipline
 Replacement of the health  Training staff for good
care staff manners.
 Availability of  Increase work hours
competent doctors
 Medications availability

190
 The mean for their rankings of the services presented by the facility was
31%.
When asked about the best thing in the facility, three found nothing to
address, two addressed the low prices, one addressed the near place and the
remaining one addressed the vaccination, pregnancy care and the lab.

Table (15) Health education fulfillment rate among the non utilizers
Percentage of Percentage of Percentage of
participants participants not participants
Education Topic educated educated about educated when
about the the topic they asked about
topic the topic

The Problem/The Disease 1 1 5

The Cause of The Problem 1 1 5

The Possible Complications 1 2 4

The Prophylaxis - 1 6

The Signs of Immediate

1 3 3
Return

Total 4 8 23

When asked about the worst thing in the facility, two mentioned the
crowdness, two addressed the medication shortage and the following topics

191
were mentioned by only one of them; carelessness, nurses, health care team,
bad manners, examination technique and the absence of the tickets clerk.
What to do to improve the quality of the services was the last inquiry in
the questionnaire; their answers are represented in Table (14)

Utilization Rates
Duration of accessing the facility was more than 5 years in 33%, one to
five years in 31% and less than one year in 36% of the participants.
43% of the participants in the study accessed the facility one to three
times to receive health care services in the 12 months prior to the study. This
access rate was 4 to 6 times in 31% of the participants and more than six times
in 26% of the participants.
More than half of the participants (53%) were using 4 to six services
out of ten health care services presented by the health care facility, 26% were
using more than six services while 21% were using one to three services only.
About a quarter of the participants (23%) had a FHR and 5% didn’t know
whether they had a FHR or not and the whole majority (72%) hadn’t.
28% of the participants obtained their medications from the facility
pharmacy, whereas 72% didn’t receive medicines from the facility pharmacy;
25% demanded from the doctor to prescribe “external” medications (as these
are more effective from their point of view), 12% had told by the doctor that
the available medications at the facility pharmacy are weak and less effective
and 35% reported the cause was that the medication needed wasn’t available.
86% of the participants had undergone one or more procedure including lab
analysis in the current health care episode.

192
Table (16) Percentages of participants in various utilization indicators.
Utilization Rates
1- Utilization Duration: (time lapsed from the first time the participant
accessedthe facility)
Less than one year One to three years More than three years
36% 31% 33%
2- Accessibility Rate: (number of times the participants accessed the facility
during the last 12 months)
One to three times Four to six times More than six times
43% 31% 26%
3- Services Accessed: (number of services currently or previously utilized by
the participant)
One to three Four to six services More than six services
services
21% 53% 26%
4- Pharmacy Utilization: (pharmacy utilizers are those who obtained their
medications from the facility pharmacy)
Pharmacy utilizers Pharmacy non utilizers
28% 72%
5- Registration in FHR: (the registered participants are those who had family
health record prior to the study )
Registered Not registered
23% 72%

193
Awareness Rates
40% of the participants were aware of four to six services presented by
the facility (out of more than ten), 35% were aware of more than six services
and 25% were aware of only one up to three services.
44% of the participants knew about the services presented by the health
facility from the facility staff, 3% from the facility staff and T.V. ads, 9%
from the facility staff, friends and neighbours and 5% from all these
mentioned sources.

26% of the participants knew about the services from their friends
and neighbours and 1% knew from T.V. ads beside their friends and
neighbours.
Only 7% knew about services from outdoors and street ads and 5% didn’t
know at all about the services.
32% of the participants weren’t aware of the work hour of the
health facility, 9% thought that they were aware of it, but when asked about
they couldn’t tell the right answers and 59% were aware of it.
Only 3% of the participants weren’t aware of the prices of the services
presented by the facility.

Accessibility Rates
The distance to the facility from the participants’ homes took less
than 15 minutes in the majority (71%), less than 30 minutes in 24% of the
participants and more than half an hour in as little as 5% of them.
8% of the participants reported that it was easy to get a consultation
ticket, 41% reported that this was reasonable and more than half of them

194
reported that it was a hard job to get a consultation ticket. The causes for this
difficulty were the crowding and loss of discipline (36%), unavailability of
tickets (5%), absence of the person in the charge (6%) and both the later
causes (4%).

Prices of the services

56% of the participants reported that the current prices of the
presented services were fair, while 41% reported that they were cheap. Out of
those who considered the prices cheap, only 7.84% (14% of the total sample)
accepted increase in the fees versus improving the quality. The fees of the
consultation (which was 1L.E.) at the time of the study was taken as a
measure of the suggested increase value of the services; 8 participants (8% of
the total sample, 1% of those who considered the prices cheap and about 14%
of those who accepted increase in the fees ) suggested two pounds increase in
the consultation fees, 5 participants suggested four pounds increase, one
participant suggested one pound increase and the remaining one suggested
three pounds increase in the fees.
Availability of resources
34% of the participants didn’t receive their medications from the
facility pharmacy as it wasn’t available, 35% reported that the facility hadn’t
the needed medications.
15% weren’t sure whether the facility had the needed equipments
or not, as few as 6% reported that the facility had the needed equipments, 63%
reported that the facility was fairly equipped and 16% reported that the facility
was well equipped.
25% weren’t sure whether the facility had the needed consumables
or not, 19% reported that the facility had not the needed consumables, 25%

195
reported that the facility had the needed consumables and 31% reported that
the facility had the needed consumables to a certain extent.
45% of the participants reported that the consultation room was
well equipped and designed in a way suitable for its purpose
Waiting area
9% of the participants reported that the waiting area wasn’t clean,
60% considered it fairly clean and 31% of the participants reported that the
waiting area was clean.
24% of the participants reported that the waiting area wasn’t
equipped with enough chairs, 64% considered the chairs available were fairly
enough and 32% reported that the chairs available were enough for the
number of clients in the waiting area the time they were there.
45% of the participants reported that they were in need to use the
toilet (W.C.), but they found it locked. 28% reported that the toilets were
available, but not enough and 27% considered the toilets available and
enough. 79% of the participants reported that the toilets weren’t clean to the
level they expect and accept.

Manners of the staff

49% of the participants reported that they were greeted by the
doctors when they entered the consultation room, 42% reported that they were
not and 9% failed to remember this issue.
58% of the participants reported that the presenting doctor used
their names while talking to them, 29% of the participants reported that they
were not called by their names and 13% failed to remember this issue.
26% of the participants complained of the bad manners of the
personnel in the charge at the ticket office, 23% reported that she dealt with

196
them in a good way and 51% considered her dealing and communications
manners accepted as “not good, not bad”.
17% of the participants reported that the nurses’ manners was bad,
35% considered it good and 48% considered the nurses’ dealing and
communications manners accepted as “not good, not bad”.
The doctor introduced himself to 44% of the participants,43%
reported that the doctor didn’t introduce himself to them and13% failed to
remember this issue.
9% of the participants reported that the doctor’s manners was bad, 3%
reported that the doctor communication style was practical and formal yet, it
was welcoming and friendly as well, 79% reported that the doctor’s
communication style was welcoming and friendly and 8% reported that the
doctor’s communication style was practical and formal.
Competence of the staff
40% of the participants reported that the nurse was competent,
43% of the participants reported that the nurse was fairly competent and 17%
of the participants reported that the nurse was not competent.
50% of the participants reported that the doctor was competent,
44% of the participants reported that the doctor was fairly competent and 6%
of the participants reported that the doctor was not competent.
57% considered the medical examination was through and
excellent, 3%reported that it was bad and 40% considered the medical
examination accepted as “not good, not bad”.

Social approach of the doctor

43% of the participants reported that they were asked by the
presenting doctor about the impact of their disease on their lives, 50% of the

197
participants reported that they were not asked about this topic and 7% failed
to remember this issue.
22% of the participants reported that they were asked by the
presenting doctor about problems they were facing at their homes, 34% of the
participants reported that they were not asked about this topic and 33% failed
to remember this issue.
9% of the participants reported that they were asked by the
presenting doctor about problems they were facing in work, 63% of the
participants reported that they were not asked about this topic and 28% failed
to remember this issue.

Topics of patient centered model of practice

49% reported that the doctor took their consent to conduct the
medical examination prior to the examination, 50% reported that they were
ordered to climb the examination bed to undergo the examination and only
1% failed to remember this issue.
27% of the participants reported that the doctor told them about
treatment alternatives to choose the suitable one, 70% report that they were
just told about the recommended treatment without having the chance to
choose between alternatives and 3% failed to remember this issue.
Out of 86% of the participants who undergone one or more
procedures in the facility in the health care episode they faced the day they
have been interviewed, 33% reported that the doctor didn’t explain to them
the nature of the procedure, the reason he was conducting nor how the
procedure would be done, 47% reported that they had been told these
information prior to the procedure and 6% failed to remember this issue.

198
Health education
44% of the participants ignored that they were told the name and
nature of the diseases affecting them, 53% reported that they have told about
the diseases they had and 3% failed to remember this issue.
13% of the participants ignored that they were told about the cause
of the diseases affecting them, 66% reported that they have told about the
cause of the diseases they had and 21% reported that they have told about the
cause of the diseases only when they had asked about.
39% of the participants ignored that they were told about the
complications of the diseases affecting them, 33% reported that they have told
about the cause of the diseases they had and 28% reported that they have told
about the cause of the diseases only when they had asked about.
33% of the participants ignored that they were told about the
prophylactic measures of the diseases affecting them, 36% reported that they
have told avoid the diseases they had and 31% reported that they have told
about this issue only when they had asked about.
28% of the participants reported that they were told by the pharmacist
how to use the medications prescribed to them, 65% of the participants
reported that they were told so by the doctor, 1% reported that they have told
by both the doctor and the pharmacist and 6% of the participants ignored that
they were told how to use the medications prescribed to them.
22% of the participants reported that they were told about the danger
signs that necessitate their urgent contact with the doctors, 63% reported that
they weren’t told about this issue and 15% reported that they were told so
when they had asked about.

199
General patients’ satisfaction score
When asked to give a score to the health services they receive from
the health facility, the participants gave the feedbacks represented in the
Table (14); the degree of general satisfaction represented as the mean of the
values was 67.9%.
Feedbacks of the open questions
1- High ranked services or aspects of services
An open ended question was asking about the best thing in the health care
facility from the point of view of the interviewees, the feedbacks for this
question were as follows:
 16 participants answered:” pregnant mother follow up”.
 12 participants answered:” dealing manners of the doctors and the
nurses”.
 12 participants answered:” the lab”.
 10 participants answered:” vaccination”.
 9 participants answered: “the dental department”.
 16 participants answered:”easy accessibility”.
 22 participants answered:” prices”.
 3 participants answered: “good recourses”.
These data are represented in Figure (15)

2- Low ranked services or aspects of services

Another open ended question was asking about the worst thing in the health
care facility from the point of view of the interviewees, the feedbacks for this
question were as follows:

200
 30 participants answered:” the tickets office”.
 16 participants answered:” the waiting area”.
 6 participants answered:” the nurses”.
 15 participants answered:” incompetent doctors”.
 14 participants answered:” bad dealing manners”.
 19 participants answered:” loss of discipline”.
These data are represented in Figure (16)

High ranked services or aspects of services

25

20

15

10

High ranked services or aspects of

services

Figure (15) The percentages of participants ranking best

201
 Table (17) The general satisfaction rates given by the participants

Degree of general satisfaction of the participants Number of the participants

1/10 1

2/10 2

3/10 7

4/10 2

5/10 17

6/10 10

7/10 22

8/10 18

9/10 17

10/10 4

202
 Low ranked services or aspects of services

30

25

20

15

10

Low ranked services or aspects of

services

Figure (16) The percentages of participants ranking worst services or

aspects of services

203
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234
APPENDICES

235
 APPENDICES

Appendix No.1
Checklist for the content of patient information materials. [Coulter A
(2001)]
1. Use patients' questions as the starting point.
2. Ensure that common concerns and misconceptions are addressed.
3. Refer to all relevant treatment or management options.
4. Include honest information about benefits and risks.
5. Include quantitative information where possible.
6. Include checklists and questions to ask the doctor.
7. Include sources of further information.
8. Use non-alarmist, non-patronizing language in active rather than passive
voice.
9. Design should be structured and concise with good illustrations.
10.Be explicit about authorship and sponsorship.
11.Include reference to sources and strength of evidence.
12.Include the publication date.

236
Appendix No.2
The ten most common customer service mistakes. [Griffiths A (2006)]
1. A lack of respect for the client’s time—always late, rushing, etc.
2. Making promises and not delivering.
3. Becoming too familiar (crossing boundaries).
4. Poor communication skills (lack of ability to talk to clients).
5. Airing company grievances to the client.
6. Inconsistent service (good one day and bad the next).
7. Changing staff frequently, client loses desire to form relationship.
8. Poor complaint resolution skills.
9. Client is taken for granted.
10.Not following up how is it going?

237
Appendix No.3
Patients’ expectations whenever they make a complaint. [Kotler P
(2003)]
1. To be treated with respect
2. To be addressed by name in a courteous and sincere manner.
3. To deal with someone in authority who can resolve the complaint
4. To have the complaint taken seriously.
5. To receive an explanation of how a particular problem occurred.
6. To be called back when promised.
7. To be given progress reports if a problem can’t be resolved on the spot.
8. To be given options to resolve a problem.
9. To receive a sincere apology when an error is made.
10.To be assured that the problem won’t happen again.

238
Appendix No.4
Key principles of patient management. [Jones, R et al. (2004)]
1. Collaborative definition of problems,
2. Action planning (targeting, goal setting),
3. Information,
4. Patient education and motivational training,
5. Scheduled follow-up,
6. Outcome monitoring,
7. Adherence monitoring,
8. Stepped therapy,
9. Specialty consultation and referral.

239
Appendix No.5
Overall rank order of patients' priorities (based on 19 studies;
percentage of studies with item in highest quartile). [Wensing M et al.
(1998)]
1. Respect and personal interest for the patient as an individual (humanity)
(86%).
2. Availability and adequate use of clinical knowledge and skills
(competence) (64%).
3. Adequate involvement in decisions about treatment (63%).
4. Time for patient care (60%).
5. Other aspects of availability/accessibility, e.g. emergency care (60%).
6. Adequate provision of all relevant information (58%).
7. Exploring patients' needs and wishes with regard to treatment (57%).
8. Other aspects of relation/communication (57%).
9. Availability of special services, e.g. preventive screening and vaccination
(57%).
10.Attention for the negative consequences of treatment for patients (50%).
11.Continuity over time (50%).
12.Effectiveness of treatment: improvement of patients' health status (33%).
13.Other aspects of medical care (33%).
14.Stimulating patients' self-management (33%).
15.Attention for patients' coping and psycho-social problems (counselling)
(29%).
16.Short waiting time before a care provider can be consulted (25%).
17.Other aspects of information/support (20%).

240
Appendix No.6
Reasons for referral from primary care practitioners to specialists.
[Wensing M et al. (1998)]
1. Referral for diagnosis.
2. Referral for specific investigation.
3. Referral for advice on management.
4. Referral for specific treatment.
5. Referral for follow up.
6. Sharing the load of a difficult or demanding patient.
7. Poor relationship with patient leading to need for second opinion.
8. Avoidance of malpractice complaint/litigation.
9. Response to requests from the patient or his/her caregiver.
10.Reassurance for the doctor or the patient.

241
‫‪Appendix No.7‬‬
‫‪The questionnaire used in the study‬‬
‫نموذج استبيان لقياس مدى رضا المنتفعين عن الخدمة المقدمة فى مركز طب األسرة بالمنيب‬
‫‪ ‬رقم مسلسل‪:‬‬
‫‪ ‬السالم عليكم‪.‬‬
‫‪................... o‬‬
‫‪ ‬أنا دكتور أحمد الجابرى من فريق العمل فى الوحدة‪ ،‬حضرتك جاى تكشف النهاردة؟‬
‫‪.................... o‬‬
‫‪ ‬إحنا بنعمل استطالع رأى علشان نعرف رأى الناس المترددين على الوحدة واللى‬
‫ساكنين فى المنيب فى مستوى الخدمة‪ ،‬حضرتك ساكن فين بالظبط؟‬
‫‪...................... o‬‬
‫‪ ‬ممكن تشترك معانا و أسألك شوية أسئلة‪.‬‬
‫‪.................... o‬‬
‫‪ ‬كل سؤال حاسأله حاديك له اختيارات تختار منها اللى يعبر عن رأيك وممكن تختار‬
‫أكتر من اختيار‬
‫‪ ‬لما تكون مش متأكد من معنى السؤال اطلب منى أوضح السؤال‪.‬‬
‫‪ ‬ممكن ما تجاوبش على السؤال اللى مش عايز تجاوب عليه‪.‬‬
‫‪ ‬التاريخ‪:‬‬
‫‪ ‬االسم(لو مش حابب تقول اسمك مافيش مشكلة)‪:‬‬
‫‪ ‬السن‪:‬‬
‫‪ ‬الحالة اإلجتماعية‪:‬‬
‫‪ ‬درجة التعليم‪:‬‬
‫‪ ‬الوظيفة‪:‬‬
‫‪ ‬انت جاى للوحدة ليه النهاردة؟‬
‫‪ ‬ليه؟‬ ‫‪ ‬انت حصلت على الخدمة اللى انت جاى علشانها؟‬

‫‪242‬‬
 ‫‪ -1‬هل الوحدة الصحية بالمنيب هى المكان اللى بتروح له لما بتحتاج خدمة طبية؟‬
‫‪-1‬الخدمة كويسة‬ ‫(‪)1‬أيوة ليه؟‬
‫‪ -2‬الخدمة رخيصة‬
‫‪-3‬سهل الوصول ليها‬
‫‪-4‬سبب تانى‪......................‬‬
‫‪-1‬الخدمة سيئة‬ ‫(‪)2‬أل ليه؟‬
‫‪-2‬الوحدةبتكون قافلة (مش شغالة)‬
‫‪ -‬إيه هوه؟‪..............‬‬ ‫‪-3‬بتروح مكان تانى‬
‫‪-4‬سبب تانى ‪......................‬‬
‫‪ -2‬انت بتيجى الوحدة بقالك قد إيه؟‬
‫(‪ )3‬أقل من سنة‬ ‫(‪ 5-1)2‬سنين‬ ‫(‪ )1‬أكتر من ‪ 5‬سنين‬
‫‪ -3‬كام مرة جيت الوحدة فى السنة اللى فاتت؟‬
‫(‪ 6-3)3‬مرات‬ ‫(‪)1‬أكتر من ‪ 6‬مرات (‪ 3-1)2‬مرات‬
‫‪ -4‬بتعرف إزاى الخدمات اللى بتقدمها الوحدة ؟‬
‫(‪)1‬من العاملين بالوحدة (‪)2‬من اعالنات الشوارع (‪)3‬من التليفزيون‬
‫(‪)5‬ما بتعرفش‬ ‫(‪)4‬من األصدقاء أو الجيران‬
‫‪ -5‬ممكن تقول لى الخدمات اللى بتقدمها الوحدة‪ ،‬إيه هية؟‬
‫(‪)1‬أكتر من ‪ 6‬خدمات (‪)2‬عارف ‪ 6-4‬خدمات (‪)3‬عارف ‪ 3-1‬خدمات‬
‫‪ -6‬إيه الخدمات اللى بتيجى علشانها للوحدة؟‬
‫(الكشف الطبى‪-‬التطعيمات‪-‬األشعة تلفزيونية‪-‬متابعة الحمل‪-‬تنظيم األسرة‪-‬معمل التحاليل‪-‬العالج‬
‫الطبيعى‪-‬عيادةاألسنان‪-‬نادى األسرة‪ -‬مكتب الصحة)‬
‫(‪)1‬أكتر من ‪ 6‬خدمات(‪ 6-4 )2‬خدمات (‪ 3-1 )3‬خدمات‬
‫‪ -7‬الوصول للوحدة من بيتك ياخد قد إيه وقت؟‬
‫(‪ )2‬أقل من نص ساعة (‪)3‬أكتر من نص ساعة‬ ‫(‪)1‬أقل من ربع ساعة‬
‫‪ -8‬إنت عارف الوحدة شغالة من الساعة كام للساعة كام؟‬
‫(‪ )2‬مش عارف (‪ )2‬عارف غلط‬ ‫(‪)1‬عارف صح‬

‫‪243‬‬
 ‫‪ -9‬أيه رأيك فى وقت العمل بالوحدة؟‬
‫(‪)3‬غير كافى‬ ‫(‪)2‬معقول‬ ‫(‪)1‬ممتاز‬
‫‪ -11‬فى رأيك وقت العمل المفروض يكون من الساعة كام للساعة كام؟‬
‫(‪ 24)3‬ساعة‬ ‫(‪ )2‬حتى الساعة ‪ 6‬مساء‬ ‫(‪)1‬حتى الساعة ‪ 3‬مساء‬
‫إيه رأيك فى أسعار الخدمات فى الوحدة؟‬ ‫‪-11‬‬
‫(‪)4‬مش عارف‬ ‫(‪)3‬غالية‬ ‫(‪)2‬معقولة‬ ‫(‪)1‬رخيصة‬
‫‪ -12‬إيه رأيك فى زيادة أسعار الخدمات علشان نقدم خدمة أحسن ؟‬
‫(‪)1‬أوافق ‪،‬ممكن زيادة سعر الكشف إلى‪.......‬جنيه‬
‫‪ -1‬حتبقى غالية عليه‬ ‫(‪)2‬مش موافق ليه؟‬
‫‪ -2‬الخدمة ال حتتحسن وال حاجة‬
‫‪ -3‬سبب آخر‬
‫‪ -13‬إيه رأيك فى سهولة الحصول على تذكرة الكشف؟‬
‫ليه‪-1:‬زحمة و مافيش نظام‬ ‫(‪)3‬صعب‬ ‫(‪)2‬معقول‬ ‫(‪)1‬سهل‬
‫‪-2‬ما فيش تذاكر‬
‫‪-3‬الموظفة مش موجودة‬
‫‪ -4‬سبب آخر‬
‫‪ -14‬إيه رأيك فى أسلوب موظفة شباك قطع التذاكر؟‬
‫(‪)3‬سيئ‬ ‫(‪)2‬عادى‪.‬‬ ‫(‪)1‬كويس‬

‫‪ -15‬استنيت قد إيه لغاية ما حصلت على الخدمة؟‬

‫(‪)2‬أقل من ساعة (‪)3‬أكتر من ساعة‬ ‫(‪)1‬أقل من نص ساعة‬
‫‪ -16‬انت كنت عارف المكان اللى انت عايزه جوة الوحدة(مكان تقديم الخدمة)‬
‫(‪)2‬أل‪ ،‬وصلت بسهولة وال بصعوبة؟‬ ‫(‪ )1‬أيوة‬
‫‪ -1‬بسهولة بسبب وجود لوحات و عالمات إرشادية‪.‬‬
‫‪ -2‬بسهولة بسبب تعاون العاملين بالوحدة‪.‬‬
‫‪ -3‬بصعوبة وأخذت وقت كتير‪.‬‬

‫‪244‬‬
 ‫‪ -‬إيه رأيك فى‪:‬‬
‫‪ -3‬سيئة‬ ‫‪ -2‬معقولة‬ ‫‪ -1‬كويسة‬ ‫‪ -17‬نضافة مكان االنتظار‬
‫‪ -3‬قليل‬ ‫‪ -2‬مقبول‬ ‫كافية‬ ‫‪-1‬‬ ‫‪ -18‬عدد أماكن االنتظار‬
‫‪-2‬مش موجودة أو‬ ‫‪ -1‬موجودة بس‬ ‫‪ -1‬موجودة و كافية‬ ‫‪ -19‬دورات المياه‬
‫مقفولة‬ ‫مش كفاية‬
‫‪ -3‬سيئة‬ ‫‪ -2‬مقبولة‬ ‫‪ -1‬ممتازة‬ ‫‪ -21‬نضافة دورات المياه‬
‫‪ -3‬سيئة‬ ‫‪ -2‬عادية‬ ‫‪-1‬ممتازة‬ ‫‪ -21‬معاملة الممرضة‬
‫‪ -3‬سيئة‬ ‫‪ -2‬عادية‬ ‫‪-1‬ممتازة‬ ‫‪ -22‬شطارة الممرضة‬
‫‪ -3‬سيئة‬ ‫‪ -2‬عادية‬ ‫‪-1‬ممتازة‬ ‫‪ -23‬معاملة الدكتور‬
‫‪ -3‬سيئ‬ ‫‪ -2‬ودود و مرحب‬ ‫‪-1‬عملى ورسمى‬ ‫‪ -24‬أسلوب الدكتور‬
‫‪ -3‬سيئة‬ ‫‪ -2‬عادية‬ ‫‪-1‬ممتازة‬ ‫‪ -25‬شطارة الدكتور‬
‫‪ -3‬سيء‬ ‫‪ -2‬عادية‬ ‫‪-1‬ممتازة‬ ‫‪ -26‬طريقة الكشف‬

‫‪ -27‬انت ليك ملف فى الوحدة؟‬

‫(‪ )2‬أل (‪ )3‬مش عارف‬ ‫(‪ )1‬أيوة‬
‫‪ -28‬الملف بتاعك دخل للدكتور قبلك؟‬
‫(‪ )3‬مش عارف‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -29‬الدكتور سلم عليك أو رحب بيك لما دخلتله؟ (قالك أهال وسهال مثال)‬
‫(‪ )3‬مش فاكر‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -31‬الدكتور نادى عليك بإسمك؟‬
‫(‪ )3‬مش فاكر‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫(قالك أنا الدكتور فالن)‬ ‫‪ -31‬الدكتور عرفك بنفسه؟‬
‫(‪ )3‬مش فاكر‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -32‬الدكتور استأذنك قبل الكشف؟‬
‫(‪ )1‬أيوة (قالك ممكن اكشف عليك) (‪ )2‬أل(قالك اطلع على السرير)‬

‫‪245‬‬
 ‫‪ -33‬الدكتور سألك عن المشاكل اللى المرض بتاعك مسببها ليك؟‬
‫(‪ )3‬مش فاكر‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -34‬الدكتور سألك إذا كان عندك مشاكل فى البيت؟‬
‫(‪ )3‬مش فاكر‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -35‬الدكتور سألك إذا كان عندك مشاكل فى الشغل؟‬
‫(‪ )3‬مش فاكر‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪-36‬الدكتور قالك على طرق العالج عشان تختار اللى يناسبك منها؟‬
‫(مثال حقن أو برشام)‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -37‬الدكتور قالك إيه المشكلة اللى عندك بالظبط؟‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -38‬الدكتور قالك إيه سبب المرض؟‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -39‬الدكتور قالك إيه مضاعفات المرض؟ (يعنى الحاجات اللى ممكن المرض يسببها)‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -41‬الدكتور قالك إزاى الوقاية من المرض ده؟ (إزاى المرض ده ما يجيلكش تانى)‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -41‬انت صرفت العالج من الوحدة؟‬
‫‪-1‬العالج مش موجود‬ ‫(‪ )2‬أل‪....‬ليه؟‬ ‫(‪ )1‬أيوة‬
‫‪-2‬الدكتور قاللى العالج اللى فى الوحدة ضعيف و مش حيجيب‬
‫نتيجة‬
‫‪-3‬أنا طلبت عالج خارجى عشان أحسن‬
‫‪ -42‬الدكتور شرحلك إزاى تستخدم العالج؟‬
‫(‪ )3‬الصيدلى شرحلى‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪-43‬الدكتور قالك إمتى اإلستشارة بتاعتك؟‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬

‫‪246‬‬
 ‫‪ -44‬الدكتور قالك إيه الحاجات اللى لو حصلت تيجيله على طول؟‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -45‬انت عملت أى إجراء طبى فى الوحدة؟‬
‫(تحليل‪ -‬أشعة‪ -‬جراحة‪ -‬غسيل أذن‪ -‬قياس نظر‪-‬خلع سن‪-‬تركيب لولب)‬
‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -46‬الدكتور شرحلك إيه اإلجراء الطبى و حيعمله إزاى بالظبط؟‬
‫(‪ )3‬قاللى لما سألته‬ ‫(‪ )2‬أل‬ ‫(‪ )1‬أيوة‬
‫‪ -47‬فى رأيك هل الوحدة فيها االجهزة الطبية الالزمة لتقديم خدمة جيدة؟‬
‫(‪ )4‬ما تعرفش‪.‬‬ ‫(‪ )2‬إلى حد ما‪ )3( .‬ال‪.‬‬ ‫(‪)1‬أيوة‪.‬‬
‫‪ - -48‬فى رأيك هل الوحدة فيها المستلزمات الالزمة للخدمة الطبية؟(السرنجات و الخيوط الجراحية‬
‫مثال)‬
‫(‪ )4‬ما تعرفش‪.‬‬ ‫(‪ )2‬إلى حد ما‪ )3( .‬ال‪.‬‬ ‫(‪ )1‬أيوة‬
‫‪ -49‬فى رأيك هل الوحدة فيها األدوية الالزمة؟‬
‫(‪ )4‬ما تعرفش‪.‬‬ ‫(‪ )2‬إلى حد ما‪ )3( .‬أل‪.‬‬ ‫(‪ )1‬أيوة‬
‫هل غرفة الكشف‪:‬‬
‫‪ -51‬مجهزة بطريقة مناسبة ؟‬
‫(‪ )4‬ما تعرفش‪.‬‬ ‫(‪ )2‬إلى حد ما‪ )3( .‬أل ‪.‬‬ ‫(‪ )1‬أيوة‬
‫‪ -51‬تشعرك بالخصوصية (حاسس ان ماحدش سامعك غير الدكتور و انت بتحكى وحاسس انك‬
‫مستور وانت بتكشف)‬
‫(‪ )4‬ال أعرف‬ ‫(‪ )2‬إلى حد ما‪ )3( .‬أل‪.‬‬ ‫(‪ )1‬أيوة‬
‫‪ -52‬إنت راضى عن الخدمة اللى بتقدمهالك الوحدة بنسبة كام من عشرة؟‬
‫‪ ........... o‬من عشرة‪.‬‬
‫‪ -53‬إيه الحاجة الكويسة الموجودة فى الوحدة؟‬
‫‪........................................ o‬‬
‫‪ -54‬إية أوحش حاجة فى الوحدة؟‬
‫‪........................................................................................ o‬‬

‫‪247‬‬
 ‫‪ -55‬إيه الحاجة اللى ممكن نعملها علشان نحسن مستوى الخدمة فى الوحدة؟‬
‫‪......................................................................................................... o‬‬
‫‪.........................................................................................................‬‬
‫‪.........................................................................................................‬‬
‫‪ ‬شكرا على وقتك ‪.‬‬
‫‪.......................... o‬‬

‫‪248‬‬
‫‪Appendix No.8‬‬
‫‪The answer sheet used in the study‬‬
‫التاريخ‪:‬‬ ‫ممكن تشترك معانا و أسألك شوية أسئلة؟‬ ‫رقم مسلسل‪:‬‬
‫درجة التعليم‪:‬‬ ‫الحالة اإلجتماعية‪:‬‬ ‫السن‪:‬‬ ‫االسم‪:‬‬
‫سبب الحضور للمركز اليوم‪:‬‬ ‫الوظيفة‪:‬‬
‫ليه؟‬ ‫هل تم الحصول على الخدمة؟‬
‫مكان تانى ‪:‬‬ ‫ليه ؟‬ ‫‪1.‬‬
‫‪5.‬‬ ‫‪4.‬‬ ‫‪3.‬‬ ‫‪2.‬‬
‫‪9.‬‬ ‫‪8.‬‬ ‫‪7.‬‬ ‫‪6.‬‬
‫‪12.‬‬ ‫‪11.‬‬ ‫‪10.‬‬
‫‪15.‬‬ ‫‪14.‬‬ ‫‪13.‬‬
‫‪18.‬‬ ‫‪17.‬‬ ‫‪16.‬‬
‫‪22.‬‬ ‫‪21.‬‬ ‫‪20.‬‬ ‫‪19.‬‬
‫‪26.‬‬ ‫‪25.‬‬ ‫‪24.‬‬ ‫‪23.‬‬
‫‪30.‬‬ ‫‪29.‬‬ ‫‪28.‬‬ ‫‪27.‬‬
‫‪34.‬‬ ‫‪33.‬‬ ‫‪32.‬‬ ‫‪31.‬‬
‫‪38.‬‬ ‫‪37.‬‬ ‫‪36.‬‬ ‫‪35.‬‬
‫‪41.‬‬ ‫‪40.‬‬ ‫‪39.‬‬
‫‪45.‬‬ ‫‪44.‬‬ ‫‪43.‬‬ ‫‪42.‬‬
‫‪49.‬‬ ‫‪48.‬‬ ‫‪47.‬‬ ‫‪46.‬‬
‫‪52.‬‬ ‫‪51.‬‬ ‫‪50.‬‬
‫‪54.‬‬ ‫‪53.‬‬
‫‪55.‬‬

‫‪249‬‬
 Appendix No.9
The ABCDE Mnemonic for Breaking Bad News. [Girgis A (1998)]
I. Advance preparation
1. Arrange for adequate time, privacy and no interruptions (turn pager off or
to silent mode).
2. Review relevant clinical information.
3. Mentally rehearse, identify words or phrases to use and avoid.
4. Prepare yourself emotionally.
II. Build a therapeutic environment/relationship
1. Determine what and how much the patient wants to know.
2. Have family or support persons present.
3. Introduce yourself to everyone.
4. Warn the patient that bad news is coming.
5. Use touch when appropriate.
6. Schedule follow-up appointments.
III. Communicate well
1. Ask what the patient or family already knows.
2. Be frank but compassionate; avoid euphemisms and medical jargon.
3. Allow for silence and tears; proceed at the patient's pace.
4. Have the patient describe his or her understanding of the
news; repeat this information at subsequent visits.
5. Allow time to answer questions; write things down and provide written
information.
IV. Deal with patient and family reactions
1. Assess and respond to the patient and the family's emotional
reaction; repeat at each visit.
2. Be empathetic.

250
 3. Do not argue with or criticize colleagues.
V. Encourage and validate emotions
1. Explore what the news means to the patient.
2. Offer realistic hope according to the patient's goals.
3. Use interdisciplinary resources.
Take care of your own needs; be attuned to the needs of
involved house staff and office or hospital personnel.

251
Appendix No.10
The Approved request for authorized permission

252
Appendix No.11
Map of the catchment area of Elmoneeb FHC

253
Appendix No.12
Performance Indicators of Elmoneeb FHC in April 2009

254
Appendix No.13
The mission of Elmoneeb FHC

255
Appendix No.14
Services presented by Elmoneeb FHC

256
Appendix No.15
Results of similar study conducted simultaneously by independent entity
on a larger scale [Alahram Newspaper Friday, 5 June 2009]

257