Patients and Clinicians Satisfaction with Clinical Laboratory Services at a Tertiary Care Hospital: A Cross-sectional Study

1. Associate Professor, Department of Biochemistry, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Madurantakam, Chengalpattu, Tamil Nadu, India. 2. Professor and Head, Department of Biochemistry, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Madurantakam, Chengalpattu, Tamil Nadu, India. 3. Undergraduate Student, Department of Biochemistry, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Madurantakam, Chengalpattu, Tamil Nadu, India. 4. Assistant Professor, Department of Biochemistry, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Madurantakam, Chengalpattu, Tamil Nadu, India.

Abstract

Introduction: Clinical laboratories are an essential part of the healthcare system providing vital information required for patient’s care. As the importance of monitoring the satisfaction status is becoming necessary and no data regarding the same is available in this region, so present study was designed to implement it in the institution.

Aim: To estimate the clinicians and patients satisfaction status with the services provided by the Central Clinical Laboratory, Karpaga Vinayaga Institute of Medical Sciences and Research Centre (CCL-KIMS and RC) in Kanchipuram District, Tamil Nadu, India.

Materials and Methods: A cross-sectional study was conducted in the Central Clinical laboratory, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, a tertiary care Medical college hospital in Kanchipuram district, Tamil Nadu, India between April 2019 to December 2019 in three phases including a total of 150 clinicians and 150 patients. The patient’s satisfaction status was assessed using questionnaires by the investigator. Self-administered structured questionnaire was used for determining the clinician’s satisfaction status. Likert scale was used and the mean score of satisfaction for each, patients and clinician was calculated. Data entry and analysis was done using Statistical Package for the Social Sciences (SPSS) 25.0 V software. Chi-square test was used to find out the association between satisfaction status and the different attributes. Spearman’s correlation was performed to assess the relationship between the satisfaction status and the different phases of the study.

Results: In present study, the mean age of patients was 38.0±11.6 years and clinicians 42.9±8.7 years, respectively. Majority of participants among patients were females 82 (54.7%), and clinicians were males 105 (70%). Among patients 95% were married 63.3%, 135% came from the middle category of socio-economic status (90), while 122% resided in the semi-urban area 81.3%. 101 of the clinicians (67.3) had an experience of more than three years at KIMS and RC. Overall 131 (87.3) of the patients and 106 (70.7) of the clinicians were satisfied with the services provided by the central clinical laboratory at KIMS and RC. An improvement in the satisfaction status of the patients and clinicians from phase I to III was observed. Around n=19 (12.7%) and n=44 (29.3%) of the patients and clinicians were dissatisfied with the laboratory services.

Conclusion: In the present study, the overall level of patients and clinicians satisfaction status was high and satisfactory. An improvement in the observed satisfaction status from phase I to III was attributed to the trainings given to the laboratory staff on the international standards of laboratory management. Domains like the turn around time, interface of laboratory and hospital information system and waiting time for specimen collection required improvement.

Attitude of health personnel, Clinical laboratory standards, Patient care, Quality assurance, Quality improvement tool

Clinical laboratories are an essential part of the healthcare system providing important information required for patient’s care (1),(2),(3). Customer satisfaction with the services provided in a medical laboratory is one among the 12 quality essentials of Total Quality Management System (TQMS). It is emphasised by all the standards for quality assurance including ISO 17025, ISO 15189 and ISO 9001 (4). Customers’ satisfaction is an expression of the gap between the expected and perceived characteristics of a service. Customers reviewing a healthcare facility are patients, their relatives, physicians, paramedical staff, health officials, communities and interested parties (4).

In developing countries services from the healthcare sectors have an overwhelming work load, due to which the focus on the concept of quality in the care provided is neglected, although it is the right of the beneficiary (5). Needs of patients should be taken into account, as the assumption, of them to be uneducated with few options for healthcare services is invalid. They are well educated and aware of the healthcare choices. Recently, accreditation bodies for a hospital or a clinical laboratory emphasise on the beneficiaries’ role in the improvement of the services provided (6),(7). It is in contrast to the traditional assessment of healthcare which emphasised on technical improvements only (8),(9).

The customer is the king in medical laboratory services and their satisfaction is core in quality of healthcare delivered. Services provided are meaningless when it does not satisfy its users. Periodically analysing patients and clinicians satisfaction with the healthcare services provided has a vital role in prioritising the funds and implementing the essentials required for the laboratory in a timely manner (4).

Patients are referred as the main value of the clinical environment. They are the reason for all works and therefore work cannot be done without them. Patient’s satisfaction has a positive effect on their recovery from illness, patient’s willingness to follow-up in the same institution, appropriate clinical care by physicians and job satisfaction for all healthcare personnel (8),(10). Customer satisfaction gives an opportunity to identify the deficiencies between the expected versus received care. Comforting and reassuring the apprehensive patients prior to sample collection by a well trained phlebotomist who is the first person a patient meets in the laboratory was found to be an effective factor in ascertaining patient satisfaction (7).

The best way of measuring and improving the quality of laboratory service is to take into account the valuable suggestions by the test requesting clinician who is the prime user of the laboratory (11). The 70% of all medical decisions are based on laboratory results (1). The reports generated from the laboratory gives an added value to the clinical expertise for prompt decision making by the clinician and to minimise guess work.

Quality and improvement in healthcare without considering the medical laboratory service is incomplete. The quality improvement in healthcare is mainly proven by the high quality of medical laboratory results (9),(12). It also aids in providing better service, remain in competition with other hospitals, participating confidently in recognition and accreditation programs (5),(13). Poor infrastructure, shortage of supplies, lack of trained technical staff, ineffective equipment maintenance and material-man power mismanagement are some of the problems faced by the laboratories in rural locality (1). Satisfied services needs team work among all healthcare workers (14),(15),(16).

Patient and clinician satisfaction assists in the evaluation of healthcare services from the beneficiaries’ point of view. As the importance of monitoring the satisfaction status is becoming necessary and no data regarding the same is available in this region, hence, present study was designed to estimate the patients and clinicians satisfaction status with the services provided by CCL-KIMS and RC.

Material and Methods

A cross-sectional study was conducted in the Central Clinical laboratory, at Karpaga Vinayaga Institute of Medical Sciences and Research Centre (CCL-KIMS and RC), a tertiary care Medical college Hospital in Kanchipuram district, Tamil Nadu, India between April 2019 to December 2019. The study was conducted with prior approval from the Institutional Ethics committee (IEC Ref No. KIMS/SUG/2019/05). The laboratory caters to the people from the surrounding 20 villages around it in the disciplines of clinical chemistry, pathology and microbiology. The laboratory functions 24*7 and on all days.

Inclusion criteria: All available clinicians in KIMS and RC who regularly required laboratory investigations to be performed for their patients and agreed to participate in the study were included. All patients above the age of 18 years who were willing to participate in the study were included randomly and interviewed after completing their laboratory examinations upon leaving the hospital. Patients availing laboratory services between 08.00 AM-05.00 PM were only included in the study.

Exclusion criteria: Patients and clinicians not willing to participate in the study were excluded.

Sample size calculation: The required sample size for the participants was determined by using a single population formula considering the following assumptions: proportion of 87.6% level of significance=0.05, margin of error (d)=5% and a non respondent rate of 10%. The calculated sample size for the study was 150 patients and 150 clinicians (1).

Study Procedure

A written consent for participation in the study was obtained after the study objectives were explained to each participant. The study period of nine months was divided into three phases, phase I (April- June), phase II (July-September) and phase III (October-December) respectively to ensure guiding and addressing the issues requiring improvements then and there throughout the study. Data collection and methodology employed was uniform during all the three phases of the study. ISO 15189:2012 is a standard available for quality and competence testing in a medical laboratory. ISO 15189: 2012 and feedbacks from the participants were used as a guide to identify the existing gaps and to implement the improvements during the study period. Training and implementation on all the different clauses was done based on ISO 15189: 2012 (17).

The (Table/Fig 1) depicts the number of participants enrolled during the three phases of the study. Modified patient and clinician satisfaction questionnaires were used for data collection. These questionnaires were developed after referring to a validated published survey tool from the CAP Q-Probes program (18). Adaptation to the questionnaire was done by the senior consultants from the department of biochemistry, KIMS and RC. The patient’s satisfaction questionnaire contained 15-items. Socio-demographic details of the patients (marital status, education, occupation, income, socio-economic status by Standard of Living Index (SLI) scale (19), residence, language, number of times patient has visited and availed the hospital services) were collected through face-to-face interviews by the investigator and the satisfaction survey was carried out using paper based questionnaires. A 12-items paper based clinician’s satisfaction questionnaire was distributed to the participating clinicians and was collected the same day (18). The questionnaire was standardised and validated by piloting on 10 patients and 10 clinicians. Details like number of years working in KIMS and RC and department to which the clinician belonged were collected as profile from the clinicians.

A 5-point and 3-point Likert scale was used for clinician’s and patient’s satisfaction questionnaires respectively. 1-Very satisfied, 2-Satisfied, 3-Neutral, 4-Dissatisfied, 5-Very dissatisfied was employed for clinicians and 1-satisfied, 2-neutral and 3-dissatisfied was employed for patients. The mean score of satisfaction for each patient and clinician was calculated as the average of all satisfaction domains. A mean score of less than 2 was taken as patient’s perceived satisfaction and a score of more than or equal to 2 was taken as patient’s perceived dissatisfaction. A mean score of less than 3 was taken as clinician’s perceived satisfaction and a score of more than or equal to 3 was taken as clinician’s perceived dissatisfaction.

Participants were informed to attend all the questions and tick the appropriate option mentioned in the questionnaire. Suggestions/ recommendation for improvement from the current laboratory practice from the participants were documented in the comments section of both the questionnaires.

Statistical Analysis

Data entry and analysis was done using SPSS software version 25.0. Socio-demographic variables were analysed as percentages. Association of the variables with the satisfaction status was checked with Chi-square test. The p-value <0.05 was considered to be statistically significant. Spearman’s correlation was performed to assess to relationship between the satisfaction status with the different phases of the study participation.

Results

In this study, the mean age of patients was 38.0±11.6 years (range: 19-66). Majority of participants among patients were females n=82 (54.7%) and n=68 (45.3%) of the patients were males.

In (Table/Fig 2) among patients 95 (63.3%) were married and 53 (35.3%) were graduated, 17 (11.3%) of the patients were unemployed whereas 54 (36%) were professionals and 135 (90%) came from the middle category of socio-economic status while 122 (81.3%) resided in the semi-urban area. It was observed that 116 (77.3%) of patients spoke Tamil. The 13 (8.7%) of patients said that they had visited the hospital services more than thrice. Around two thirds of the patients 93 (62%) had visited the hospital services more than once.

According to (Table/Fig 3) the clinician’s profile have mean age of clinicians was 42.9±8.7 years (range: 28-67). The clinicians were males with 105 (70%) while 45 (30%) were females.

The (Table/Fig 4) describes the association between the socio-demographic variables and satisfaction status of the patients and clinicians. Among the socio-demographic variables considered, marital status of patients (p-value=0.04) and gender of clinicians (p-value=0.002) was found to be significantly associated with the satisfaction status. This implied that married patients and male clinicians were more satisfied with the services provided. Patient variables such as age, gender, language, education, occupation, residence, socio-economic status and number of patient visits to the hospital services were not statistically significant.

(Table/Fig 5) depicts that overall 131 (87.3%) of the patients and 106 (70.7%) of the clinicians were satisfied with the services provided by the central clinical laboratory at KIMS and RC. The patients and clinicians dissatisfied with the laboratory services were 19 (12.7%) and 44 (28.7%) respectively. Among the 150 patients and clinicians in each group, who participated in the study, 36 (24%), 60 (40%), 54 (46%) of the patients and 30 (20%), 70 (46%), 50 (34%) of the clinicians were enrolled during the phase I, II and III respectively. Progressive and a statistically significant improvement in the satisfaction status of the patients and clinicians from phase I to III is depicted in (Table/Fig 5). Conversely there is a reduction in dissatisfaction status from both the groups. As and when the study progressed, as an outcome of the training, the compliance of the employees of the laboratory improved which showed an improvement in the satisfaction levels of both the patients and the clinicians.

Spearman’s correlation was performed to assess to relationship between the satisfaction status and the different phases of the study. A statistically significant correlation indicating an improvement in the satisfaction status of the participants is observed in the present study. No significant response was observed for adequacy of test menu on the test request form and turn around time from the clinicians (Table/Fig 6).

Discussion

The study was intended to find out patients and clinicians satisfaction status at central clinical laboratory- KIMS and RC. The participants of the study were young, married women predominated as patients. Similar study done by Alelign A and Belay YA also reported the same (10). Another study by Teklemariam Z et al., concluded that 50% of the population were females (1). Only 6.7% of our patients were illiterate and 11.3% were unemployed. 90% of our patients were from the middle category of socio-economic status and 81.3% resided in the semi-urban area. The study also concluded that 38% of patients were using the laboratory services for the first time. Among the clinicians 54% were above the age of 40 years and of the total clinicians 30% were females. The average experience of the clinicians at KIMS and RC was more than three years. However this relationship had no impact on the satisfaction status of the laboratory services.

There was an improvement in the patient and clinician’s satisfaction score as the study progressed from phase I to III. The study concluded that clinician’s satisfaction score was 70.7% which improved from 60% in phase I to 88.2% in phase III (p-value=0.01). This difference may be attributed to the study design with participation involving three phases and also to the sample size in different phases.

The initial clinician’s satisfaction score was similar to that observed from Pusan National University hospital in South Korea (58.1%), Millennium medical college (60%) and Nekemte referral hospital (65%) Ethiopia (20),(21),(22). The final satisfaction score from the clinicians was similar to the studies from hospitals in north eastern parts of Ethiopia (80%) and college of American Pathologist Q-probes study of 81 institutions (85.7%) (1),(23). Hailu L et al., (24) observed that 50% of the clinicians were satisfied with the general laboratory services, gender was not associated with satisfaction status, while specialisation was significantly correlated. In the present study gender of the clinicians was associated with satisfaction status while the departments to which they belonged was not associated with the satisfaction status.

Among the different domains assessed in our study, a significant improvement was observed from phase I to phase III by the clinicians for despatch services (Chi-square=64.28, p=0.0001), notification of the critical value (Chi-square=39.39, p=0.0001) and introduction of a new test (Chi-square=35.99, p=0.0001). They were also satisfied with the availability of lab staff during the working hours (Chi-square=33.92, p=0.0001), quality/reliability of laboratory test results (Chi-square=29.26, p-0.0001), departmentalisation of hospital laboratory (Chi-square=29.23, p=0.0001), provision for emergency/urgent test (Chi-square=28.54, p=0.001). In this study dissatisfaction was observed for Turn Around Time (TAT) and Laboratory Information System- Hospital Interface System (LIS- HIS) interface. Similar studies done by Almatrafi D et al., and Hailu HA et al., also concluded dissatisfaction for TAT from the clinicians (9),(25).

The overall patient’s satisfaction status was 87.3% and it had improved from 72.2% in phase I to 96.3% during phase III (p-value=0.03). In this study the satisfaction was high among women, especially married women as they were the predominant population using the laboratory services.

Across the three phases a statistically significant improvement was observed predominantly in most of the domains from the patients. Doubts from patients were encouraged and addressed by lab staff (Chi-square=50.34, p=0.0001), crowd regulation in counters (Chi-square=46.49, p=0.0001), lab personnel availability during working hours (Chi-square=33.8, p=0.0001), seating availability in waiting area (Chi-square=32.84, p=0.0001), location of the laboratory (Chi-square=27.3, p=0.0001) were among the most satisfied domains over the three phases. Explanation of procedure by lab personnel before sample collection (Chi-square=23.3, p=0.0001) had improved over the three phases due to the effective trainings conducted to the lab technicians.

Patients in this study were satisfied with the available toilet facility for sample collection. However Qadri SS et al., has reported dissatisfaction for the toilet facility in his study (2). Fondoh VN et al., observed a statistically significant reduction in the dissatisfaction scores for waiting time (34.9% to 19.3%), issuing of results (22% to 8.1%), specimen collection (21.5% to 13.8%) and duty consciousness (21% to 4.7%) after addressing the feedbacks received from the customers (26). Similar to this study, they assessed the satisfaction scores for waiting area and explaining sample collection procedure before the sample collection. However, low satisfaction scores were reported from their study. Gupta A et al., reported that 70% of participants were satisfied with the phlebotomy services. However, sitting arrangements in waiting area and knowledge of universal precaution were poor (6). Dawar R observed that comforting and reassuring the apprehensive patients prior to sample collection by a well trained phlebotomist who is the first person a patient meets in the laboratory was found to be an effective factor in ascertaining patient satisfaction (7). Factors like poor communication, long waiting periods and repeated pricks were considered as negative experience by the patients thereby decreasing their satisfaction (7). Service quality, short waiting period to receive test reports, availabilty of advised lab tests and clean and accesible washrooms and staff behaviour influences patients satisfaction for laboratory services, (11).

However at CCL-KIMS and RC, 12.7% of patients and 29.3% of clinicians were dissatisfied with the laboratory services. The main dissatisfaction was observed for HIS-LIS interface and turn around time from the clinicians and waiting time for specimen collection from the patients.

Limitation(s)

Participants were limited to patients availing services between 08.00 AM-5.00 PM only. Patients coming during the evenings and night could not be included as the services are 24×7.

Conclusion

The overall degree of patients and clinicians satisfaction status was 87.3% and 70.7%, although domains like the turn around time, interface of laboratory and hospital information system and waiting time for specimen collection required improvement. It is also concluded that there was an improvement with the satisfaction levels from phase I to III which was attributed to the trainings given to the laboratory staff on the international standards of laboratory management. There were also 12.7% of patients and 28.7% of clinicians who were dissatisfied. Root cause analysis was discussed with all the stakeholders of the laboratory. Corrective and preventive actions were planned for implementation to improve the overall percentage of satisfaction. Regular studies like this will improve good laboratory practices thereby ensuring quality healthcare system.

Acknowledgement

The authors acknowledge all the participants of the study. They also acknowledge the efforts from Mrs. Gladius Jennifer and Ms. Manjula Devi, statisticians at SRM Medical College Hospital and Research Centre and Karpaga Vinayaga Institute of Medical Sciences and Research for their aid in statistical analysis.

DOI and Others

DOI: 10.7860/JCDR/2022/56436.16416

Date of Submission: Mar 17, 2022
Date of Peer Review: Apr 04, 2022
Date of Acceptance: May 05, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
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ETYMOLOGY: Author Origin