]OURNAL

OF HEALTH
MANAGEMENT
VOLUME: 10 NO. 2/ 20L2
Aovrson
Dr Rosl i nah Al i
MD ( UKM), M. Sc (NUS), Ph. D (Kent )
Dr Nor Fi l zatun Borhan
MD ( USM) , MPH ( UM)
Dati n Dr Nori ah Bi di n
MBBS (DOW) MPH (UM)
Datin Dr Ang Kim Teng
MBBS ( UKM) MPH ( UM)
Si ti Zubai dah Ahmad
En Mohd l dri s Omar
Si ti
Qurai syah
Abu Bakar
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Table of Content
Knowl edge of HI V Transmi ssi on Among Mal aysi ans :
A Popul at i on Based St udy
Jasvi ndar K
I mprovi ng t he Rat e of Aci d Fast Baci l i Sput um Screeni ng:
Si t i awan Heal t h Cl i ni c Experi ence
Muzaf f ar Z, Li ng HM, Suj i nder S, Nor i ah B, Zai nuddi n MA,
Nor Zaki ah AR, Mohd Shaf f ari M, Yeoh SF, Zai nal Abi di n M,
Er yda Li ana AR, Ai sah M, Nabi l ah H, Noor hai da U
20
Patient Expectation on Effective Treatment :
Have They Been Met ?
Rosl an J, Ang Kl , Rosl i nah A, Mohd I dri s O, Si t i Zubai dah A,
Farah Muni rah RJ
Measuri ng Hospi t al Perf ormance : Revi ew of Gl obal 39
Measures
Ang Kl, Roslan J
Pat i ent Saf et y : Do Pat i ent s Part i ci pat e?
Rosl i nah A, Sararaks S, Ret neswari M, Farrah OA, Noor I zni MS,
Look CH, Ruhai ni I , Pat i mah A, Nar i mah
I
Hasnah B, Kal som M
52
The Appropri at e Wai t i ng Ti me t o Get Treat ment at t he 59
Mi ni st ry of Heal t h Hospi t al s as Percei ved by Pat i ent s
Rosl an J, Ang Kf Rosl i nah Al i , Si t i Zubai dah A, Nor Fi l zat un B,
Farah Muni rah RJ
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ACKNOWLEDGEM ENTS
The Edi tori al Board Journal of Heal th Management wi shes to thank al l the referees for
thei r contri buti on towards the publ i cati on of thi s i ssue
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Dr Amal Nasi r Must af f a
I nst i t ut Penyel i di kan Per ubat an
Jal an Pahang
50588 Kual a Lumpur
Dr Hj Tahi r Ari s
I nst i t ut Kesi hat an Umum
Jal an Bangsar .
50590 Kual a Lumpur
Dr Mohd Azahadi Omar
I nst i t ut Kesi hat an Umum
Jal an Bangsar
50590 Kual a Lumpur
Prof . Madya Dr Shamsul Azhar Shah
Jabat an Kesi hat an Masyar akat
Pusat Per ubat an
Uni ver si t i kebangsaan Mal aysi a
Jal an Yaacob Lat i f
Bandar Tun Razak
56000 Cher as
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Dr Ani za I smai l
Jabat an Kesi hat an Masyar akat
Pusat Per ubat an
Uni ver si t i Kebangsaan Mal aysi a
Jal an Yaacob Lati ff
Bandar Tun Razak
56000 Cher as
Kual a Lumour
Prof. Rogayah Bi nti l aafar
Jabat an Pendi di kan Kesi hat an
Pusat Pengaj i an Sai ns Per ubat an
Uni versi t i Sai ns Mal aysi a
Kamous Kesi hat an
16150 Kubang Ker i an
Kel a nt a n
Dr Jasvi ndar Kaur
I nst i t ut Kesi hat an Umum
Jal an Bangsar
50590 Kual a Lumpur
Y. Bhg Dato' Dr Si raj oon Noor SM Abdul Ghani
Depart ment of Soci al and Prevent i ve Medi ci ne
Facul t y of Medi ci ne
Uni versi t y Mal aya
50603 Kual a Lumour
Dr Ahmad Faudzi Yusoff
Uni t Epi demi ol ogi
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Jal an Pahang
50588 Kual a Lumpur
Y. Bhg Prof. Dr Awang Bul gi ba
Department of Soci al and Preventi ve Medi ci ne
Facul t y of Medi ci ne
Uni versi t y Mal aya
50603 Kual a Lumour
Prof . Madya Dr Zal eha Md I sa
Jabat an Kesi hat an Masyar akat
Pusat Per ubat an
Uni ver si t i Kebangsaan Mal aysi a
Jal an Yaacob Lati ff
Bandar Tun Razak
56000 Cher as
Kual a Lumpur
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Jabat an Per ubat an Komuni t i
Pusat Pengaj i an Sai ns Per ubat an
Uni ver si t i Sai ns Mal aysi a
Kampus Kesi hat an
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Dr Azi zah Bt. Yusoff Dati n Dr Si ti Hani za Mahmud
Pusat Pengaj i an Sai ns Pergi gi an I nst i t ut Penyel i di kan Si st em Kesi hat an
Uni versi t i Sai ns Mal aysi a Jal an Rumah Saki t Bangsar
Kampus Kesi hat an 50590 Kual a Lumpur
16150 Kubang Keri an
Kel ant an
Puan Si t i Sa' di ah Bi nt i Hassan Nudi n
I nst i t ut Pen! , el i di kan Ti ngkahl aku Kesi hat an
Jal an Rumah Saki t Bangsar
50590 Kual a Lumpur
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Knowledge of HIV Transmission among Malaysians: A Population Based Study
Jasvi ndar K
ABSTRACT
This paper assesed the level of knowledge on the risk of HIV in the Malaysian adult population.
The data is from a subset of The Third National Health and Morbidity Survey 2006, comprising of
39,910 respondents. There were a high proportion of people with knowledge on the risk of HIV
transmission when not using condom was high. However, there were key groups of people and
geographical areas where HIV knowledge was low. Respondents with poorest knowledge were
those with low income, low levels of education and living in rural areas. Targeting these groups
will help incre4se the level of HIV knowledge in the population, especially in the most vulnerable
groups.
Keywords: Immunodeficiency diseases; AIDS, HIV
/AIDS
Screening, cross sectional survey
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INTRODUCTION
Global data on HIV knowledge indicates that 40olo
of males and 38o/o of females aged 15-24 years
had accurate and comprehensive knowledge about
HIV and about how to avoid transmission (United
Nat i ons Gener al Assembl y Speci al Sessi on(
UNGASS) indicator 13). This is well below the
Global Declaration of commitment goal of ensuring
comprehensive knowledge in 95% of young people
by 2010.1 More than 70o/o of young men know
that condoms protect against HIV exposure, only
55o/o of young women cite condom use as an
effective strategy (UNGASS indicator 13).
I n Mal aysi a, t herehas i s l i mi t ed research on
knowledge and attitudes on HIV. Studies which
exist were limited to specific population groups
and is therefore not a reflection of the whole
popul at i on, The Thi r d Nat i onal Heal t h and
Morbidity Suruey (NHMSIID 2006 included a section
on sexual behaviour and this survey has given a
clearer picture of the level of knowledge on HIV
wi t hi n t he adul t Mal aysi an popul at i on. I t i s
impodant to understand the level of knowledge
and in pafticular to analyse population groups that
lack knowledge on HIV transmission, as this will
provide the basis for focussing preventative health
education programmes in a targeted way.
Public knowledge of HIV transmission is crucial in
the strategy for effective prevention and control
of HIV/AIDS. HlV-positive patients need to have
adequate HIV transmission knowledge to reduce
the risk of primary and secondary infection. The
vulnerable patients, such as those who reported
not accessing HIV medications or had a history of
sexual abuse, had lower levels of HIV knowledge
and are at an increased risk of re-infection or
transmission.2 The AIDS control programme was
initiated by the Ministry of Health in 1985 where
the public education programme is one of the key
strategies in the programme. Studies assessing
Malaysian' s understanding and knowledge of HIV
are limited. UNGASS 2008 indicators on knowledge
and health behaviour on HIV in Malaysia were not
completed,3
Thi s paper ai ms t o det er mi ne t he l evel of
knowledge on the risk of HIV transmission in the
Malaysian adult population.
METHODOLOGY
The data used was from the Sexual Behaviour
Module of the National Health and Morbidity Survey
III 2006, a cross sectional population based
survey.a This survey was conducted nationwide in
Malaysia from April to July 2006. A two stage
stratified sampling design by states and strata with
proportionate allocation were used. The sample
comprized of 39,910 respondents aged 13 years
and above, using a self administered questionnaire
in 4 main languages of Malay, English, Mandarin
and Tami l .
The question used to access knowledge of HIV
transmission was a negative response to whether
people can protect themselves from HIV solely by
a bstaining from sexual intercourse.
The data was analysed using SPSS Version 17.
The project was approved by the Medical Research
and Ethics Committee (MREC), Ministry of Health.
I nf or med consent was obt ai ned f r om t he
respondents.
RESULTS
The response rate was 69.8
o/o.(
27,864). The
mean age of the respondents was 33.1 (range
from 13 years to 80+ years). The details of the
sample are shown in Table 1.
Majority of the respondents were Malays (59.60lo)
from urban background (620/o). More than one-
fifth of the respondents (22.5%) were above 20
years. More than half of the respondents (57olo)
had attended secondary school, More than one
third (3B.Bolo) were private sector employees.
About half of the respondents (49.7olo) had
knowledge on HIV sexual transmission. Highest
knowledge on HIV sexual transmission was noted
among the Malays
[53.8
0/o
(95olo CI 52.8, 54.8)],
married
[50.5
o/o
(95olo CI 49.48,51.5)] and those
with teftiary education
[73.4
o/o
( 95o/o CI7L6,
7s. 1) 1.
The rural population
l4l.2o/o
(95olo CI 40.2,42.2)l
had less knowledge than the urban population.
I ncr easi ng knowl edge of HI V t r ansmi ssi on
corresponded with increasing education. Almost
three quafters of the respondents with teftiary
education
173.4
o/o
(95% CI 71.6, 75.1)l were
knowledge as compared to one third
130.7
o/o
(95o/o
Cl23.2, 38.0)l of those without any education.
The rural East Coast states of Terengganu
167.30/o
(95olo CI 57.6,64.9)l and Kelantan
157.4
o/o
(95o/o
C[54.2,60.6)l showed high levels of knowledge
on HIV transmission. On the other hand, the rural
East Malaysian states of Sabah
[39.3o/o
(95olo CI
37.5, 41.21and Sarawak
139.3
o/o
(95o/o C|37.0,
41.6)l had the lowest knowledge on risk of HIV
transmission.
Knowledge of HIV risk increased propodionately
with income. About one third
[30.60lo
(CI 36.4 to
a3)l who earned less than RM400 had knowledge
as compared to more than half
157.5o/o
(95o/o
CI 55. 1, 59. 9) who earned RM5000 and above.
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DISCUSSION
Overall knowledge on the potential risk of HIV
transmission is unsatisfactory. However, this study
has highlighted key groups of people and areas
where HIV knowledge is low. Respondents with
poorest knowledge were those with low income,
low levels of education and living in rural East
Malaysian states. Targeting these groups will help
i ncrease t he l evel of HI V knowl edge i n t he
population, especially in the mostvulnerable
groups.
Rural areas have'been highlighted as having lower
l evel s of HI V knowl edge t han urban areas.
Preval ence dat a i n Mal aysi a shows t hat by
occupation the highest prevalence of HIV is in long
distance drivers, followed by the unemployed or
with temporary employment and fishermen.s HIV
programmes need to focus their effotts on these
particular groups and areas for them to be most
effective. Some authors have argued that social
factors such as povefi mobility and gender equality
may be a stronger factor in sexual ill health than
promiscuity and public health interventions need to
take this into account.5 Individuals need facts and
skills to make their sexual behaviour safe but
changes to the social context are needed to support
them.
Although Kelantan showed one of the highest
preval ence on t he knowl edge of HI V sexual
transmission, new ctses in Kelantan have increased
rapidly with a 25olo increase in ages 20-29 years
and a 42o/o increase in 30-39 year age group in
2008.'Z An increasing number of cases have been
contracted though heterosexual activity, from 19olo
in 2007 to 27o/o in 2008. These figures do not
support the findings of this survey. This presents a
cl ear case f or a concert ed heal t h educat i on
programme for HIV prevention aimed atthe adult
population and especially between 20-40 years'
Si mi l arl y, Terengganu al so has a hi gh HI V
prevalence (35.9 per 100,000 population. A study
on HIV infection among fisherman in Terengganu
showed a higher prevalence amongst fishermen
than the general population (L7o/o), with higher
prevalence among those with a positive history
of drug use, single marital status and also among
unskilled workers who represent the socio-
economically poorer group of fishermen. Almost
B9o/o of respondents had heard about HIV/AIDS.
Poorer fishermen had a higher risk of being HIV
positive as well as being less knowledgeable about
AI DS. 8 Thi s research support s t he general
findings of this paper that those from lower socio
economic groups in rural areas have a lower level
of knowledge of HIV.
Although HIV affects all socio-economic
groups
some researchers have argued that the dynamics
maybe shi f t i ng and i n t he l at er st ages of
epidemics, wealthier individuals are more likely
to have access to HIV prevention information and
condoms and adopt behaviour change.e Although
poorer individuals as a group are not necessarily
at great er ri sk of i nf ect i on,
povert y and
soci oeconomi c hardshi p can cont ri but e t o
increasing risk.
Other studies have shown a range of awareness
amongst Mal aysi ans. Peri yapayyan
(2009)
conducted an intervention study on HIV/AIDS
i nf ormat i on and l evel of awareness among
students in plantation schools in Peninsular
Malaysia.lo About B5o/o of students had some
knowledge of HIV/AIDS, but many were uncetain
on its mode of spread, 660lo said there was no
way to prevent HIV
/AIDS.
This gives some
indication of the level of knowledge amongst rural
Malaysian secondary students.
Millennium Development Goal 6 is to halt and begin
to reverse the spread of HIV/AIDS by 2015.
Indicator 6.2 relates to condom use during last
high risk sexual intercourse and indicator 6.3 is
the proportion of the population aged 15-24 years
with comprehensive correct knowledge of HIV.11
The contraceptive prevalence rate for condoms
use among marri ed coupl es i n Mal aysi a was
14.3o/o, in 2004 compared to 9.Bolo in 1994.12
However, this figure is based on surveys in the
married population and does not reflect condom
use outside of marriage. It is difficult to promote
the use of condoms as the government does not
want t o be mi si nt er pr et ed as advocat i ng
promiscuity. Response rates to surveys are low,
perhaps reflecting an unwillingness to discuss
personal issues such as contraceptive use.
Increased levels of knowledge do not always
translate in a change in risky behaviour. Therefore,
any health education programme needs to be
comprehensive with a multifaceted approach based
on effective evidence of behaviour change. The
government has i mpl ement ed a l arge scal e
education programme for youths called PROSTAR,
which has reached more than 600,000 youths.li
The programme was evaluated and the study
revealed a significant increase in awareness on
the use of condoms and prevention measures.
However, t here were some mi sconcept i ons,
i ncl udi ng t he bel i ef t hat onl y dr ug addi ct s,
prostitutes and homosexuals were infected. But
the level of awareness among PROSTAR members
was higher than non members. It is recommended
to simplify messages and deliver them through
channel s wher e yout hs r espond. However
exposure to messages does not necessarily lead
to an increase in awareness. People have to
perceive and understand that they are at risk in
order to make behavioural changes.
CONCLU$ON AND RECOMMENDATIONS
The challenge that remains is to develop a multi-
pronged public health approach to combat AIDS
which includes both health education
programmes/
testing, and high quality treatment whilst also
taking a broader and longer term approach to
tackle health inequalities and social factors such
as poverty, mobility and gender discrimination.
This survey has shown low levels of knowledge
on HIV in lower socio-economic
aroups
in rural
areas. For prevent i on t o be successf ul al l
members of society need to be included and
targeted for prevention programmes. Howeveq
programmes need to be focussed on different
target groups to comprehend their needs and levels
of understanding. A HIV prevention programme
running in central KL will be different than a
programme for fishermen in rural Terengganu.
HIV prevention education also needs to cater to
different age groups. Focussing on youth is
essential to any programme, however data in
Malaysia shows the highest prevalence is in age
30-39 years. This group is more difficult to reach,
but new methods need to used, in addition to mass
media, such as interventions in the workplace or
through religious communities.
Future surveys need to ensure questions regarding
HIV are clear and understandable, using UNAIDS
guidelines for assessing sexual health behaviour
and knowledge.
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ACKNOWLEDGEMENT
The authors thank the Director General of Health, Malaysia for his permission to publish this paper. The
authors also thank the members of the National Health and Morbidity Survey 2006 teams for making
this survey a success. Funding for this research was provided by the Ministry of Health Malaysia.
Ethical approval
Medical Review and Ethics Committee (MREC), Ministry of Health, Malaysia.
NMRR
-09-824-4684
Funding
This research was funded by a Research Grant from the Ministry of Health, Malaysia.
Project Code : ( P 42-25I- 17 0000-00500 (005000099)
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REFERENCES
1. UNAIDS. Reprt on the global NDS epidem'rc 08.
Geneva:UNAIDS; 2008.
2. M. C. Smith Fawzi, P. Jagannathan, J. Cabral,
R. Banar es, J. Sal azar , P. Far mer , H.
Behforouz, (2006), Limitations in knowledge
of HI V t ransmi ssi on among Hl V-posi t i ve
patients accessing case management services
in a resource-poor setting. AIDS Care Vol.
18, Iss. 7,
3. UNAlDS.Eprdemiological fafuheets on HN and
AIDS. Core data on epidemiology and
responset Malaysia 200B update. Retrieved
on November 3rd, 2009 f rom ht t p: l l
www. u na i ds. org/ en/ Cou nt ryrespo nses/
Countries/malaysia.asp.
Ministry of Health.Ihe National Health and
Morbidity Survey III, 2006, (2008), Kuala
Lumpur: Ministry of Health.
Malaysian Aids Council. Overuiew of HIV/NDS
in Malaysia, (2008). Retrieved on November
3' d, 2009 f rom: ht t p: / / www. mac. org. myl
statitics.htm.
Wellings, K., Collumbien, M., Slaymaker, E.,
Singh, S., Hdges, 7., Patel, D., Bajos, N,,
(2008), Sexual behaviour in context: A global
perspective. The Lancet. 368:1706-1728.
Mal aysi an Nat i onal News Agency
Bernama.com.Sexually Transmitted HIV in
Kelantan Worrisome, (2009). Retrieved,
November 3' 0, 2009 f rom: ht t p:
I I
www. ber na ma, com/ ber na ma/ v5 n ews
index. php?id=449825.
Fauziah, MN., Anita, S., Shaari, N., Ahamad,
J., PratapSetian and Muhammad Amil K.,
(2002), HIV infection among fishermen in
Terrengganu. Malaysian Journal of Public
H ea lth M ed i ci n e. 2(I) :21-25.
Lopman B et al., (2007), HIV incidence and
povefi in Manicaland, Zimbabwe: Is HIV
becoming a disease of the poor? AIDS. 27
(suppl, 7): 557-566.
6.
B.
9. 4.
10. Periyapayyan, P., (2002), A study on the
availability and accessability of HIV/AIDS
information and level of awareness among
students in plantation schools, Peninsula
Malaysia. IntConf AIDS. Retrieved October
10t h, 2009 f r om ht t p: / / www. gat eway.
hlm. n i h. gov/meetin ga b stractl 102254094.
htmU.
Economic Planning Unit, (2005), Achieving the
millennium development goals successes and
challenges, Kuala
Lumpur:
Prime Ministers
Depatment.
12. National Population and Family Development
Board, (2005), Indicator 18: Condom use rate
of contraceptive prevalence rate, Malaysia.
Retrieved on November 3d, 2009 from; http:/
/ www.
st at i st i cs. gov. my/ port a
Ui m
ages/
stori es/f i les/M a laysi a I nfol nd i cato rs
I
goal6
. pdf ?phpMyAd mi n
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TABLE 1: Socio-demographic characteristics of respondents by se><, Malaysia 2006
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Citizenship
Age group
Mean (years)
Median (years)
Mode (years)
Malaysian
Non-Malaysian
Total
13-14
15-19
20-24
25-29
30-34
3s-39
40-44
4549
50-54
55-s9
60-64
65-69
70-74
75-79
B0+
Total
13,013 46.7
34.r
33.0
13. 0
12,512 96.2
501 3. 8
13,013 100.0
980 7.s
2,054 15.8
L,429 11.0
L,302 10.0
1,252 9.6
t,zlg 9.4
1, 310 10. 1
1,068 8.2
911 7. 0
698 5.4
400 3.1
236 1.8
I M O. B
4L 0. 3
9 0. 1
13,013 100.0
14,851 53.3
32.3
31. 0
14.0
14,156 95.3
695 4.7
14,851 100.0
1,057 7.L
2,r9t 14.8
187 12.7
1,851 r2.5
1,686 L1 4
1,616 10.9
r,572 10.6
L,246 8.4
uL 5.7
519 3. 5
220 1.5
125 0.8
31 0. 2
L2 0. 1
5 0.03
14,851 100.0
27$U 100.0
33. 1
31. 0
14.0
26,666 95.7
1,198 4.3
27,8ffi 100.0
2,037 7.3
4,245 L5.2
3,308 11.9
3, 153 11. 3
2,938 10.5
2,835 10.2
2,882 10.3
2,314 8.3
L,752 6.3
r,217 4.4
620 2.2
361 1. 3
135 0. s
53 0.2
14 0. 1
27,8ffi 100.0
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o
Ethnicity
Marital
Status
Residence
Religion
Malays 7,777 59.8
Chinese 2,369 18.2
Indian 994 7.6
Other bumis L,414 10.9
Others 459 3.5
,
Total 13,013 100.0
Not married 5,287 40.6
Married 7,539 57.9
Divorcee 77 0.6
Widow/Widower 48 0.4
Unclassified 62 0.5
Total 13,013 100.0
Urban 7,828 60.2
Rural 5,185 39.8
Total 13,013 100.0
Islam 8,896 68.4
Christian 1,138 8.7
Buddha 1,998 15.4
Hindu 830 6.4
Others 132 1.0
Unclassified 19 0.1
Total 13,013 100.0
B,B2B 59.4
2,625 L7.7
1,211 8.2
1,567 10.6
620 4.2
14,851 100.0
5,330 35.9
8,816 59.4
262 1.8
403 2.7
40 0.3
14,851 100.0
9,456 63.7
5,395 36.3
14,851 100.0
10,205 68.7
L,32L 8.9
2,204 14.8
973 6.6
r29 0.9
19 0. 1
14,851 100.0
16,605 59.6
4,994 L7.9
2,205 7.9
2,98r L0.7
L,079 3.9
27,864 100.0
r0,6L7 38.1
16,355 58.7
339 L.2
45r 1.6
r02 0.4
27,864 100.0
L7,2U 62.0
10,580 38.0
27,864 100.0
19,101 68.6
2,459 B.B
4,202 15.1
1,803 6.5
261 0.9
38 0. 1
27,864 100.0
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TABLE 2:HIV Knowledge by Socio-economic determinants
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Urban
Rural
Ethnicity
Malay .
Chinese
Indian
Other Burmis
Other
Education
None
Primary
Secondary
Teftiary
Unclassified
Household incomein RM
Less than RM400
RM400
-
RM699
RM700
-
RM999
RM 1000
-
RM1999
RM2000
-
RM2999
RM3000
-
RM3999
RM4000
-
RM4999
RM5000 and above
33. 5
41.2
33.2
40.2
34.6
33. 0
36.8
37.L
30.3
47.3
50.6
30. 5
t6.2
28.9
25.9
21.7
18. 9
15. 9
14.7
13. 1
L2. I
9. 8
33. 9
42. 2
36. 1
3s. B
4L. 3
40.8
36. 6
61. 5
52.9
32.0
19
42.3
30. 3
2s.3
22. 3
18. 3
TB.2
18.9
21.5
15. 9
3s.3
34.4
39.0
38.9
33.4
54.5
5L.7
31. 3
17.5
35.3
28.0
23.5
20.6
17. I
16.4
15. 8
16. 3
12. 5
Location/ residence
State
Johor
Kedah
Kelantan
Melaka
N.Sembilan
'
Pahang
Pulau Pinang
Perak
Perlis
Selangor
Terengganu
Sabah
Sarawak
W.P Kuala Lumpur
W.P Labuan
33.2
39.4
47.0
34.7
3B.4
36.3
31. 6
4L. 0
39.4
29.4
42.4
39.3
39.3
31. 6
26.6
31. 5
37.1
44.4
31. 1
35.2
33.6
29.2
38.7
33.2
28.3
39. 5
37.5
37.O
29.r
22.6
3s.0
41.7
49.5
38. s
41.6
39.0
34.1
43.2
46.0
30.7
45.5
4t.2
4L. 6
34.4
31. 0
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Improving the Rate Of Acid Fast Bacilli Sputum Screening:
Sitiawan Health Clinic Experience
Muzaffar Z, Ling HM, Sujinder S, Noriah B, Zainuddin MA, Nor Zakiah AR, Mohd Shaffari M,
Yeoh SF, Zai nal Abi di n M, Eryda Li ana AR" Ai sah M, Nabi l ah H, Noorhai da U
ABSTRACT
Sitiawan Health Clinic (HC) in Manjung District serves as PR1 (Treatment Centre 1) to deliver
services related to tuberculosis (TB) programme since 2008. In the control of disease transmission,
early detection and treatment of Pulmonary Tuberculosis (PTB) is important. The incidence of TB
in Manjung was 49.5/100000 population and smear positive TB contributed to 64.200/o of all
forms of TB cases in Perak in 2008, With the high prevalence of smear positive PTB, it is necessary
to improve the rate of screening for Acid Fast Bacilli (AFB) sputum. Perak State Health Department
had set a target of at least 3,00o/o of outpatients to be screened for TB at all health clinics,
However, Sitiawan HC screened only 1.10olo of the total outpatients,
An Action Research (AR) based project was undedaken with the prime objective to improve the
rate of AFB sputum screening at Sitiawan HC. Data was gathered through several methods, such
as meetings with stakeholders, group brainstorming, and self-administered questionnaire to
evaluate knowledge, attitude and practice (KAP) of the patients and clients in regard to TB. The
main task of this project was to empower staff to screen patients, especially symptomatic, high-
risk patients, The empowerment exercise involved increasing the number of contact screening,
promoting the screening of symptomatic diabetic patients, deploying health staff, training, and
offering more promotions and advertisements on TB. In addition, Cough Corner was introduced
for a faster and more convenient AFB sputum test.
In the end, results showed that higher number of outpatients and contacts were screened for
AFB sputum test. In average/ 5.23o/o of outpatients were screened in 2010, 6.230/o in 2011,
followed by 8.600/o in2012. The increasing rate of AFB sputum screening had subsequently led to
higher detection of positive smear cases in Manjung District, with 7,50o/o in 2010, 5.00o/o in 2011
and 71.760/o in 2072. Cough Corner was well utilized at the beginning of its implementation, but
later on the usage had reduced tremendously. Despite that, the outcomes of this project are very
encouraging, thus sustainment of the interventions is necessary, The provision of Cough Corner
should be evaluated for better utilization and enhanced self empowerment among patients.
Keywords: Tuberculosis, Detection, Action Research, Sputum Screening, Stigma, Malaysia
INTRODUCTION
World Health Organization (WHO) repoted that
Tuberculosis (TB) has killed 1.4 million people and
sickens 8.7 million more last year (WHO 2012
regional report). They also state that South East
Asia (SEA) carries approximately 40o/o of global
burden of TB. Malaysia is an intermediate TB
burden country with TB, being the second most
contagious disease, after dengue. Therefore, early
detection of TB is essential for an effective control
of TB transmission. Suspicion of clinical symptoms,
coupled with laboratory investigations such as AFB
sputum smear/ sputum Culture &Sensitivity test
and chest x-ray are needed for the confirmation
of the airborne disease (National Strategic Plan
for TB control, 2011-2015).1 WHO has targeted
that by 2015,70o/o of people with sputum smear
positive will be diagnosed, with B5o/o of them
successfully treated. Malaysia had recorded an
increase in smear positive cases from 54.2o/o to
59. 60/ o i n 2000 and 2008 r espect i vel y. t , z, r
Treatment of new smear positive sputum cases is
initiated at designated centers, namely PRl (Pusat
Rawatan 1) or literally translates to Treatment
Centre 1. Currently, Ilo/o of public hospitals and
health clinics or a total of 229 facilities ooerates
as PRl .
An excellent TB control programme must involve
good cooperation with the public and regular
supervi si on by ski l l ed heal t hcare provi ders.
Engagement of all healthcare providers such as
Public Private Mix in Directly Obserued Treatment
Short Course (DOTS) was one of the suggested
strategies to boost the rate of TB detection and
qual i t y of car e. The cooper at i on bet ween
university hospitals and Centre for Disease Control
in China had led to more detection of TB cases
among students.4 Presence of
' Cough
Officers' in
hospital was also proven benefi cial.s Misdetection
of TB may resul t i n cost l i er t reat ment and
j eopar di ze
t he heal t h of i ndi vi dual s and
subsequent l y, communi t y, due t o f ast TB
transmission.6,T Delay in diagnosis and treatment
was pr evi ousl y l i nked t o a nosocomi al TB
outbreak.s Preference for traditional medicine,e
lack of motivation and time6 and stigmalo had been
cited to be the causes for refusal or delay in health
seeking behavior. Therefore, education for public
and health providers is vital for superior healthcare
management.
Sitiawan Health Clinic (HC) is located in Manjung
district and serves as primary healthcare provider
to a population of 250,000. As PRl, it suffices the
requirement for an ideal TB clinic, which comprises
family medicine specialist (FMS), well-trained
medical offlcers (MO), dedicated staff, an x-ray
machine and laboratory facilities. The clinic has a
good collaboration with Hospital Seri Manjung
Chest Cl i ni c whi ch i s f aci l i t at ed by resi dent
physicians and a visiting chest physician. The
incidence of TB in Manjung was 49.5 in 100,000
population. In 2008, smear positive TB contributed
to 64.20/o of all forms of TB cases in Perak.
However, the percentage of outpatients screened
for TB at Sitiawan HC was only 1.10o/o. This was
below the target set by Perak State Health
Departmentto screen at least 3.00o/o of outpatients
for TB. Increased screening rate was expected to
upgrade the health status of the community in
Manjung District.
OBJECTIVES
The general objective of this project was to
improve the screening of AFB sputum atSitiawan
HC with a monthly screening target of at least
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3.00o/o of outpatients. Specifically, it aimed to
identiflT the contributing factors for the low AFB
sputum screening rate and assess the knowledge,
attitude and practice (KAP) regarding TB among
patients and staff. It also attempted to establish a
new approach, which simplified the screening
process and encouraged sel f empowerment
through the introduction of Cough Corner.
METHODOLOGY
The concept of action research was applied. It
involved a series bf spiral cycles of planning,
implementation and evaluation throughout the
whole course of this project. Data was gathered
through brainstorming, focus group discussion,
meetings, self-administered questionnaires and
interviews. Data analysis was done by Microsoft
Excel 2007.
Findings and Results
Phase 1: Planning
A committee was formed and stakeholders were
identified. The stakeholders who acted as an
advisory panel comprised district health officer,
health staff from health clinics in Manjung District,
representatives of PTB patients who had completed
the treatment, and a representative from a non-
gover nment al or gani zat i on ( NGO) , namel y
Malaysia's Association of Pulmonary Tuberculosis
(MAPTB). The concept of action research was then
explained to the stakeholders. A consensus to
explore the problems regarding poor peformance
of AFB sputum screening at Sitiawan HC was
achieved.
Phase 2: Intelligence Gathering
Several meetings with the stakeholders took place
to fufther discuss the issue. Data collected from
January until December 2008 demonstrated that
the rate of AFB sputum screening was far below
the target set by Perak State Health Depaftment.
A self-administered questionnaire to assess the
knowledge, attitude and practice (KAP) on TB was
distributed to 33 staff and 50 patients. In the
duration of two weeks, patients who refused
screening were also interviewed face to face to
identify the causes of refusal.
Phase 3: Implementation
The main intervention was to empower staff,
namely doctors and assistant medical officers to
obtain sputum samples from patients, with the
target of B samples per staff per month. Before
that, they were required to attend an intensive
course on TB. Surveillance on the disease was
conducted based on a checklist. Number of patienb
using Cough Corner, and total number of patients
and samples received for testing were included in
the monthly checklist. Other intervention included
deploying staff for TB updates and trainings.
Continuous Medical Education (CME) was given to
existing staffl, and new staff during the orientation.
Screening was also extended to symptomatic
diabetic patients in the diabetic wards and higher
number of contacts for one TB patient.
Another interuention was the introduction of Cough
Corner. The existence of the corner was promoted
through posters, pamphlets, banners and regular
education sessions in the outpatient department.
It was located at the main entrance of outpatient
department and required no registration, bills and
waiting time, The attendance at the corner was
voluntary and only one sputum sample was needed
for AFB sputum screening.
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Cough Corner was targeted to:
1) Patients who were symptomatic and
stable but could not spare the time to see
healthcare provider.
2) Symptomatic relatives who were in the
clinic, accompanying patients.
3) Patients who had seek treatment but
refused sputum test.
4) Symptomatic diabetic patients who were
screened at the diabetic counter.
A pamphlet with instruction on proper technique
of coughing to produce sputum sample was also
supplied. Contact details and existing symptoms
were to be disclosed by patients in a referral slip
and a form. Finally, a set consisted of the sample,
completed referral slip and form was to be left at
the collection counter outside the clinic. Following
the implementation of Cough Corner, a self-
admi ni st er ed quest i onnai r e t o eval uat e i t s
effectiveness was distributed to health staff and
patients. During the whole course of this project,
t he rat e of AFB sput um screeni ng, cont act
screening and attendance at Cough Corner were
constantly recorded. After few months, the use of
referral slip was abolished and the form was
modified to allow spaces for contact details and
identification for fufther follow up. The location of
Cough Corner was also shifted.
Phase 4: Evaluation
In the beginning of the project, questionnaires to
evaluate the staff KAP revealed that 91.00o/o of
them had knowledge score of > 70o/o on TB.
Among patients, 92.00o/o had heard about TB,
62.000/o were aware that TB is contagious
,20.00o/o
understood its modes of transmission and only
4.00o/o had completely understood the symptoms.
In addition, 96.000/o agreed to be screened if they
become symptomatic, 72.00o/o believed it is
curable, 96,00o/o agreed that early screening could
prevent further spread and 94.00o/o would come
for treatment if they have the symptoms. It also
reveal ed t hat government heal t h cl i ni cs and
hospitals were still preferred as the first line of
contact for the majority of respondents. Among
the reasons for test refusal were transpodation
problem, lack of time, absence of sputum (dry
cough) and personal belief of it being a normal
cough ratherthan TB.
Meanwhile, feedback on the effectiveness of Cough
Corner exhibited that 62.000/o of
patients
were not
aware of its presence,70.00o/o did not know how
to utilize the service, 44.00o/o thought that the
location was inappropriate and 30.00o/o felt that
the process was complicated. Meanwhile, all staff
agreed that the corner was a good intervention.
Figure 1 summarizes the performance of AFB
sputum screening at Sitiawan HC from 2010 until
September 2012.
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14.00%
12.00%
10. 00%
In 2010, 4.760/o of outpatients were screened for
TB in January and the rate had been stable and
remained above 3.00o/o until the end of the year,
Each month repofted screening of more than
3.00o/o of outpatients with the lowest rate in June,
3.I2o/o and highest in September,B.B2o/o.
The performance was similar in 2011. All months
recorded screeni ng of more t han 3. 00o/ o of
outpatients. February recorded the lowest rate,
3.360/o and July, the highest, atL2.B}o/o.For 2012,
data were obtained until September. Similar to
previous years, each month displayed screening
rate above 3.00o/o with the lowest at6.37o/o in April
and the highest at 11,91olo in September. The rate
of screeni ng had been i ncreasi ng si nce t he
beginning of the project in 2010. In average, 5.23o/o
of outpatients were screened for TB in 2010, 6.230/o
i n 2011 and of 8, 60% i n2072.
Contact tracing for TB followed the same pattern
with the patient: contact ratio of 1:B in 2010, 1:5
in 2011 and 1: 10 in 2012. Following the screening,
number of patients detected positive for AFB
sputum smear had also increased with 16 patients
(7.5o/o), in 2010, B patients (5olo) in 207I and27
patients (Il.760/o) in 2012. Attendance at Cough
Corner however, had been declining throughout
the years. In 2010, the corner was used by 13
patients, followed by 2 patients in 2011and none
in2012.
DISCUSSION
Several studies have highlighted early detection
as the key for good healthcare management,ll'
12'
13,14
It is a cornerstone for successful sunreillance
of disease pandemicl4 and was linked to a reduced
mortality rate in oral cancer.13 In addition, it helped
to minimize prevalence of asthma symptomsll and
reduced t he cost f or t reat ment of Chroni c
Obstructive Pulmonary Disease.
12
o 2010
r 2011
.'r,
2012
4.00%
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Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dis
Month
Figure 1: Performance of AFB sputum screening at Sitiawan HC tor 2010-2012.
Knowledge and attitude of health care providers
are equally important for better healthcare delivery.
A study had shown that patients of H5N1 were
given better care when the staff possessed
greater knowledge of the disease.ls The improved
sputum AFB screening rate at Sitiawan HC could
be attributed to staff awareness and knowledge
gained, specifically from training and CME. In
addition, a target of obtaining B samples each
mont h was al so i mposed on each heal t hcare
personnel at the clinic. This achievement could
also be catalysed Oy staff motivation to meet the
t arget set . Our f i ndi ng f urt her support s t he
association between staff motivation and better
healthcare mentioned by Manabe et al. in 2012.
Fufthermore, the duration of cough for patients
which required screening was cut down from more
than two weeks to only three days or more. This
had allowed more patients to be screened.
Contact tracing is crucial and has been used to
contain disease outbreaks such as TB,16 small
poxl7
and sexual disease.18 Ministry of Health Malaysia
has recommended the identification of ten close
contacts for one TB patient. In order to confirm
that they are TB-free, they are required to undergo
3 monthly screening in a year. In 2008, screening
of contacts revealed that they contributed 99.5o/o
of 618 cases of PTB.1 In this project, vigorous
contact tracing was carried out to screen this high-
risk group, in collaboration with health inspectors
from the District Health Office. Eventually, the
number of contacts screened was higher from year
to year.
Cough Corner was one of t he i ni t i at i ves by
Sitiawan HC to encourage the practice of voluntary
testing. It was designed to reduce waiting time
and promote the culture of self-empowerment in
healthcare. Initially, it was located at the main
entrance to attract attention from patients walking
i n and out of t he cl i ni c. Eval uat i on of i t s
effectiveness later revealed that the utilization of
the corner was not encouraging. Privacy and
conf i dent i al i t y concer n shoul d al ways be
considered since it could affect health seeking
behavi or among pat i ent s. l 0 Some pat i ent s
commented thatthe location of the cornerviolated
their privacy and made them feel uncomfotable,
Consi deri ng t hi s f eedback, t he corner was
relocated to an area in the clinic, which was neither
too exposed nor isolated.
Another reason for the low attendance at the
corner was time constraint. This was because
patients coming to the clinic usually rushed in for
shorter waiting time and they immediately left the
clinic after completing the treatment. In addition,
they usually came to see the doctor and were
reluctant to follow instruction for voluntary testing.
Besides, being instructed does not always translate
to improved knowledge.le Stigma, feeling of
disgust to produce sputum or lack of motivation
might also be responsible for the reduced number
of patients at the corner from year to year. Since
the attendance was voluntary patient motivation
was very i mport ant i n ensuri ng t he opt i mal
utilization of the area. The roles and benefits of
motivation for both patients and healthcare
provi ders were emphasi zed by Medal i a and
Saperstein in 2011. They reported that initiation
or sustainment of cetain desired action is for the
purpose of seeking reward. Nevertheless, the
impoftance of the action must first be understood
bef ore mot i vat i on can set i n. Thi s i s when
education must come into play because proper
education is the core for successful treatment.2l
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Poor knowledge on TB had also been related to
stigma.22,23 In fact, stigma was connected to delay
in health seeking behavior, hence treatment.23
However, one study did not support the notion as
it implied that clinical impact caused by stigma
was insignificant.24
Waiting time may also influence the decision for
treatment by patients. Shoter waiting time was
associated with greater patient satisfaction,
reduced feeling of vulnerability and minimized
suffering.25 It wasalso repofted to influence the
morbidity and mortality rate26 and reflect on the
quality of care delivered.2T Suggestion for another
heal t h car e pr ovi der 2s and web based
appointment2e had been addressed to solve the
issue of long waiting time. At Sitiawan HC, Cough
Corner functioned as a One Stop Centre because
it allowed for the bypassing of the usual procedure
which required patient to make an appointment
with doctor. However, since the process of
providing sample was only peformed by patients,
several issues were encountered. These included
incomplete forms, unidentified samples and leaked
containers which compromised the quality of
samples. As a solution, the use of referral slip
was abolished and the form was modified to allow
spaces to write contact details for further follow
up. The modified form was to be clipped together
with the container and plastic bag to form a
complete set and to be left at the collection counter.
This innovative method for sample collection had
greatly assisted in accelerating the process of
screening. Previously, each item was placed
separat el y on t abl e, causi ng conf usi on and
inconvenience.
CONCLUSION
In conclusion, staff empowerment had led to
higher screening rate of outpatients and detection
of positive AFB sputum smear each year at
Sitiawan HC. In contrast, despite the initially high
attendance at Cough Corner, the number of users
had been declining. These outcomes emphasize
the need for sustainment of the interventions,
therefore this study needs to be continued. The
current collaboration between public and private
healthcare sectors should be strengthened to
r educe t he spr ead of TB and enhance t he
knowledge of TB among the community. Constant
monitoring and evaluation of Cough Corner is also
i mport ant t o ensure opt i mal ut i l i zat i on and
inculcate self empowerment among patients.
ACKNOWLEDGEMENT
The authors would like to thank the Director
General of Health Malaysia for giving permission
to publish this study,
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Management of Tuberculosis, znd edition,
(2002), Ministry of Health, Malaysia.
3. Direct Smear Microscopy 1st edn. (2000),
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4. Zhang
f,,
Guo L, Zhang S, et al., (2011),
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Loh LC, Codati A, Jamil M, et al., (2005),
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Hafkamp-de Groen E, Mohangoo AD, de
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Patient Expectation on Effective Treatment: Have They been Met?
Roslan J, Ang KT, Roslinah An Mohd Idris O, Siti Zubaidah An Farah Munirah RJ
ABSTRACT
A study i nvol vi ng al l Mi ni stry of Heal th hospi tal s i n Peni nsul ar Mal aysi a was conducted to measure
the l evel of pati ent sati sfacti on and the extent of our servi ces i n meeti ng pati ent' s expectati ons. A
set of pretested self-administered questionnaires with multiple-item scale instrument for measuring
consumer percepti ons of servi ce qual i ty (SERVQUAL), were di stri buted to pati ents i n the wards.
The response rate was 82.2o/o. Among those who responded, about 92ol o of the respondents
were sati sfi ed wi th the servi ces provi ded and 650l o of them fel t that thei r expectati on on getti ng
effecti ve treatment nl d been met. Meeti ng pati ent expectati ons was si gni fi cantl y associ ated wi th
age, ethni ci ty and l evel of educati onal . However, the di mensi on "Tangi bl es" showed the l owest
percentage among the fi ve other di mensi ons under SERVQUAL. Improvi ng the physi cal faci l i ti es
i n hospi tal s and havi ng the appropri ate technol ogy and equi pment woul d meet the pati ent' s overal l
exoectation.
Keywords : Patient satisfaction, expectation, service q ua I ity, SE RVQUAL
INTRODUCTION
" individual's
positive evaluations of distinct
dimensions of health care".1
In our effort to attai n pati ent sati sfacti on, we have
t o acknowl edge and appreci at e t he f act t hat
di f f er ent peopl e have di f f er ent needs whi l e
per cept i ons al so di f f er even wi t h t he same
st i mul us. Accor di ng t o St eer s and Bl ack, 2
percepti on i s usual l y gui ded by bel i efs whi ch are
i nfl uenced by soci etal norms and i ndi vi dual val ues.
Such norms and values become standards against
which things are compared
-
whether good or bad,
desi rabl e or undesi rabl e, appropri ate or 1 pati ents;
men express more di ssati sfacti on than women;
hi ghl y educat ed pat i ent s expr ess mor e
di ssati sfacti on than those wi th l ess educati on.
Another factor to be consi dered i s the amount of
resources heal t hcare orovi ders can al l ocat e
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The heal t h car e i ndust r y has under gone
tremendous changes and improvements in recent
years, wi t h more f ocus gi ven t o heal t hcare
outcomes. The Oxford Engl i sh Di cti onary defi nes
"outcome" as a "resul t or vi si bl e effect". Outcome
can al so be seen as t he out put , ef f ect s or
consequences of ei t her t he i nput or process.
These effects can be categori sed as success or
fai l ure to achi eve the desi red goal s. In heal thcare,
there are general l y two types of outcomes, that
i s, (i ) heal th status and (i i ) pati ent sati sfacti on.
Many or gani sat i ons ar e now f ocusi ng on
conti nual l y i mprovi ng the qual i ty of the servi ces
t hat t hey pr ovi de i n or der t o at t ai n pat i ent
satisfaction. One of the earlier definitions of patient
sat i sf act i on by Li nder-Pel z i n
' 1982
was t he
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towards meei i ng cl i ents' needs, especi al l y i n the
publ i c sector whi ch are general l y very heavi l y
subsi di zed. l t i s pract i cal l y not possi bl e f or
provi ders to meet al l the requi rements of thei r
cl i ents. The l ack of manpower usual l y l eads to
work overload and results in quality of seruice being
compromi sed. Added t o t hi s, some personnel
have to perform other non-core tasks due to the
non-avai l abi l i ty of actual personnel for the
j ob.
Bymesa reported the situation whereby nurses were
burdened with non-nursing functions that included
cl eri cal work, hol sekeepi ng, transportati on and
dietary matters.
I n recent t i mes, heal t h care provi ders have
at t empt ed t o move beyond ensuri ng pat i ent
satisfaction. According to Carson et al,5 providers
can ul ti matel y del i ght consumers by meeti ng thei r
want s or unar t i cul at ed needs. " Del i ght ed"
customers are those whose expectations or needs
are not onl y met but have been exceeded. Whi l e
thi s i s a chal l enge, there can be constant fear
that pati ents mi ght have such hi gh expectati ons
that heal thcare provi ders fi nd di ffi cul t to meet.
However, patient expectations can change if they
have accurate information about the real situation.
Larson et. a16 found that pati ent sati sfacti on
increased when clinicians communicated to their
patients key information about their relevant health
probl ems.
In view of the impotance of patient satisfaction
to our healthcare goals and objectives, this study
was carried to explore the capability of the Ministry
of Health (MOH) hospitals in meeting their patients'
expect at i ons as wel l as t o at t ai n
pat i ent
satisfaction.
To measure patient satisfaction, the study utilised
a self-administered SERVQUAL?
questionnaire'
SERVQUAL stands for Service
Quality.
It is a
mul t i pl e- i t em scal e measur e on consumer
perceptions of service quality and was developed
by A. Parasuraman, Val ari e A. Zei t haml and
Leonard L. Berry in 1988.
Measuring service
quality poses difficulties for
service
providers due to the complexity and
uniqueness of healthcare service which include
intangibility, heterogeneity, inseparability and
perish ability. Earlier in 1984, Parasuraman et. al
made a subst ant i al cont r i but i on t o our
understanding of the concept of service
quality and
the factors that influence it by identifying'gaps'
that can cause
quality problems in organizations'
These problems, known as'gaps', are actually the
differences between customer expectations of
service to be provided and perceptions of the
service actually received. The authors defined this
difference as service
qualitY.
Therefore, SERVQUAL defi nes satisfaction as "the
difference between
perception a nd expectation "
or "expectation score minus perception score"'
Patients will only be considered as "satisfied" if
t hei r
per cept i on equal s or exceeds t hei r
expectations, However, this seldom occurs, and
the author would like to
phrase this statement as
"not being able to meet patient's expectations".
Therefore, we like to use the perception of the
clients as the rate of satisfaction. Patient' s
percept i ons are measure f rom t he f i rst 13
questions.
OBJECTIVES
The objectives of the study were:
(i) To determine the level of satisfaction
among patients.
(ii) To identiff how far have we meet the
patient's expectation
(iii) To formulate the recommendation to
i m prove patient expectation.
METHODOLOGY'
This was a cross-sectional study conducted in 2008
in all Ministry of Health hospitals in Peninsular
Malaysia. The sample size was calculated using
EPI INFO software based on estimated prevalence
rate of patient satisfaction of 50o/o, worst
acceptable limit of + 20o/o and non-respondent of
20o/o, giving a total sample size of 450 respondents
for each hospital. The selection of respondents
was through systematic random sampling.
This study employed SERVQUAL questionnaire, an
instrument widely used for measuring patient
satisfaction. SERVQUAL has five dimensions which
measure the following:
: Physical facilities, equipment
and appearance of personnel
: Abi l i t y t o per f or m t he
promised seruice dependably
iii' Responsiveness
il:'#::;i"r,."H:
prompt service
iv. Assurance : Knowledge and courtesy of
employees and their ability
t o i nspi r e t r ust and
v. Empathy
confidence
: Car i ng, i ndi vi dual i zed
attention
In this study, the instrument was modified to
accommodate local setting. A few additional areas
were added in the study, namely' Outcome' and
aspect of MOH Corporate Culture of Caring,
Teamwork and Professionalism.
The self-administered SERVQUAL questionnaires
were distributed to the in-patient respondents
just
before they were discharged from the ward. The
SPSS Statistics was used for the analysis.
FINDINGS
There were 32,203 responses out of 39,200
inpatients, giving a response rate of 82.2ol0. The
majority of respondents were less than 40 years
of age (64. 2o/ o), f emal e (61. 8ol o), marri ed
(76.00/o), Malays (78.7o/o), and were educated up
to secondary school level (59.2olo). (Table 1)
i. Tangibles
ii. Reliability
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Table 1: In-Patients Respondents' socio-
demographic characteristics
The rate of satisfaction using patient's perception
was 92.2"/" but howevet, 56.5"/" of the patients
fel t that Mi ni stry of Heal th hospi tal s i n peni nsul ar
Mal aysi a were unabl e to meet thei r expectati ons
(Tabl e 2).
Table 2: Rate of patient's satisfaction
o/o
Age Groupx
Less than 40 years
40
-
55 years
56 years & more
Genderx*
Female
Ethnicxxx
Malays
Chinese
Indians
Others
Marital Statusx*xx
Si ngl e
Married
Educational Levelxx**x
No formal education
Primary education
Secondary education
Teftiary education
79748
6092
4974
72224
79792
2s207
2899
2969
954
64.2
19. 8
16. 0
38. 3
61. 8
78.7
9. 1
9. 3
3. 0
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Mal e
Overall Satisfaction
-
base on Respondent
Experience
Satisfied
Not Satisfied
27,672 92.2o/o
2,340 7.Bo/o
*n=30754, **n=3201
6, "**n=32029, "***n=31 955,
"****n=3'l 933
Meeti n g Patient Expectation
-
based on KKM SERVQUAL
Met their expectation
Not met their expectation
t2,793 43.5o/o
16,630 56.50/o
Among t he f i ve SERVQUAL di mensi ons, t he
dimension'Outcome' had the highest score (Figure
l ). Thi s di mensi on had onl y one quest i on (Ql 1),
and 650lo of the patients felt that their expectation
on getting effective treatment had been met. The
worst dimension that was unable to meet their
expect at i on was
' t angi bl e' ,
There were t wo
questions (Q1 and
Q2)
for measuring
' tangible' .
The question "Hospital always has up-to-date
equi pment " scored t he l owest among al l t he
questions (Table 3). However, professionalism was
the worst among all the five dimensions. There
were four questions for professionalism (Q1,
Q2,
Q12
and
Q13)
and
Ql2
"Hospital staff work
together as a team when giving treatment"scored
the lowest.
7665 24.0
24290 76.0
6088 19.1
1BBB9 s9.2
4567 r4.3
7.5 2389
80.0%
60.0%
40.0o/o
20.0%
O.0o/o
a$'
"ttt"""..""""",r"d*$
{"..r""'n'
o"d
Figure 1: Meeting Patients'Expectation for In-patients According to SERVQUAL Domains
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Table 3: Satisfaction score for individual questions
Expectation
Met Did not
SERVQUAL Dimensions
Hospitalalways has
up-to-date equipment.
Facilities at the waiting area
are visually appealing.
Hospitals provide
their
seruices at the time they
promise to do so.
Hospital performs the seryices
right every time.
Hospital staff gives
prompt service.
Hospital staff willing to help
with sincere interest.
Hospital staff performs
their
job
competently.
Hospital staff is always polite.
61. 0
18881 60.4
19987 63.6
19163
66.4
2OL3T 64.4
39.0
12378 39.6
TI423 36.4
t2206 38.9
10431
III2T 3s.6
n
18672
o/o
59.6
n
L2678
o/o
40.4
I2L79 19088
61. 1
33.6
N
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=
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20570 65.6 10770 34.4
9 Hospitalstaff always 20232 U$ 11090 35.4
u ndersta nds pati ent's n eeds.
10 Hospital staff gives patients 20363 65.1 10913 34.9
personal attention.
LI Hospital staff provides
effedive treatment.
20250 65.0 10926 35.0
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12 Hospital staff works together 21600 68J 9819 31.3
as a team when giving treatment.
13 Hospitalstaff displays 21023 67.0 10367 33.0
good work discipline.
( I J - ,
-t!
There were significant associations between meeting patient's expectations and age, ethnicity, occupation
b and educational level (p value<0.001).
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The hospitals were less able to meet younger patients' expectations as compared to the older age
patients and were also least able to meet the expectation of Malay patients, patient with tertiary
educational as well as patients from the public sector. (Table 4)
Table 4: Meeting Patient Expectation by Socio-demographic Characteristics
Meeting Expectations Not Metthe Expectation
Characteristics n
olo
95oloCx
o/o
95o/oCJ.
Age group
Less than 40 years
i
40
-
55 years
56 years and above
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7070 40.8
2949 45.9
2168 48.2
Lower Upper Lower Upper
s8.s 60.0
s2s 55.3
50.3 53.2
40.0
44.7
46.8
41. 5
47.1
49.7
10278 59.2
3477 54.1
2327 51. 8
Ethnic
aroup
Malays
Chinese
Indians
Others
9648 41.8
1203 44.7
r47B 55.5
421 48.6
t3446 58.2
I4B7 55.3
1185 44.5
446 51.4
57.6 s8.g
53.4 57.2
42.6 46.4
48.1 54.8
4I . T
42.8
53. 6
45.2
42.4
46.6
57.4
51. 9
N
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Education Level
None
Primary
Secondary
Tediary
10BB 49.8
2832 52.0
75BB 43.9
7rB7 27.5
109s s0.2
2618 48.0
97L6 56.1
3122 72.5
48.1 52.3
46.7 49.4
55.4 s6.9
7LL 73. 8
47.7
50. 6
43.r
26.2
51. 9
53. 3
44.6
28.9
Employment Sector
Public
Private
Self-employed
Others
I74B 33.8
2061 41.8
2L4B 45.9
6613 46.6
3429 66.2
2872 58.2
2529 54.t
7578 53.4
64.9 67.5
56.8 59.6
52.6 ss.5
52.6 54.2
32.5
40.4
44.5
45. 8
35. 1
43,2
47.4
47.4
p value<0.001
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DISCUSSION
In this study, SERVQUAL defines satisfaction as
" t he di f f er ence bet ween per cept i on and
expectation". As patients will only be considered
as being satisfied if their perception equal or
exceed their expectations, achieving satisfaction
seldom occur. Hafli attributed the finding of a low
level of satisfaction to the methodology used in
the calculation of satisfaction.
Ther ef or e, i n t hi s st udy we r edef i ned
dissatisfaction as "not being able to meet patient
expectations". With SERVQUAL, it has been
quantified that our hospitals had not been able to
meet the expectation of 61.50/o of their patients
as compared to 68.3olo in a study done in 2005,
using a similar methodology.e After three years,
there was an improvement of about 7olo i n meeting
patient expectations.
In the USA, ScardinaT carried out a study using
similar instrument to measure nursing care, found
that levels of satisfaction with was low, as defined
by SERVQUAL. Similar findings were also reported
by Fayeklo in their survey of 174 patients in the UK
on the quality of National Health Service (NHS)
health care. Neveftheless, other researchers using
different sets of instruments had different findings.
In a meta-analysis of 22I studies, Hallll found
patient satisfaction to be moderately high, ranging
fromT60/otoB4o/o of all patients studied. Calnan12
found high levels of satisfaction amongst that
receiving in-patient care in hospitals in UK. Using
her own measuring instrument, Carmell3 found
that B0o/o of patients in her hospital in Israel were
satisfied with the services provided.
In our study, younger patients seemed to be more
dissatisfied that the older age groups. Our findings
were supported by those by Pascoe,la Youngls and
Breemhaa116whom all reported older patients as
being more satisfied.
Studies on the relationship between gender and
satisfaction had varying results. In this study, there
was no significant relationship between satisfaction
and gender. Similar findings to our study were
repofted also by Carmel,13 Hall11 and Weiss.17
However, Pascoela and Zastovnyls identified
women as being more satisfied than men.
Among ethnic groups/ the Malays were found to
be more dissatisfied. This is in contrast to findings
by Wei ssl T and Hal l 11 who bot h f ound no
relationship between satisfaction and ethnic group.
Our study also repofted an association between
educat i onal l evel and sat i sf act i on. Thi s
phenomenon has been fairly well-documented in
other studies. Linn,le Hallll and Anderson,2o all
came to a similar conclusion where they all found
that dissatisfaction was greatest among the better
educated, due to their better knowledge and
presumably, higher expectations.
Our study also noted thatthose seruing in the public
sector were more dissatisfied than others. This
may be probably attributed to educational status
as well as more than one-third of the workers in
the public sector possessed qualifications from
teftiary institutions. The more frequent the patient
visited the hospital, the more dissatisfied they
become as t hey may have di scover ed or
experienced more negative situations following
those previous visits.
In meeting patient expectation, the dimension
' Outcome' had
the highest score because 650lo of
the patients felt that their expectation on getting
effective treatment had been met. The dimension
"Ta n g i bles" showed the lowest percentage a mong
the five dimensions, especially in terms of physical
facilities and equipment. This is very different from
a study by Fayek et allo (1996) on NHS hospitals,
which repoted that "Tangibles" had the highest
level of patient satisfaction. An international study
conducted by Vandamme and Leunis2l also had
si mi l ar f i ndi ngs. These di f f er ences ar e
understandable considering that the two studies
were conducted in developed countries, while
Malaysia is a developing country. Nevertheless,
the comparison indicated that much more efforts
are needed to elevate ifre tevel of our hospitals up
to internationally acceptable level in terms of
"Tangi bl es". Among t he di mensi ons of MOH
Corporate Culture, "Professionalism" was the most
problematic area and had the lowest score.
RECOMMENDATION
In this study, the patients were quite happy with
the treatment received. However, Hospital Directors
should look into creative idea on how to make their
facilities especially at the waiting area more
appealing. Provision of public amenities such as
banking automated machines (ATM), Post Office,
Kiosk (cyber caf6), play area and others within
the hospital vicinity can also be considered. Apart
from physical facilities, hospital management needs
to acquire new equipment to replace the old ones.
The dimension "professionalism" had the lowest
percent age and i s an area of bi g concern.
Management must ensure that all staff members
be given the opportunity to undergo training to
improve their competencies and capabilities to
peform their daily work more effectively. Outdoor
team buihing is also necessary to foster team spirit.
CONCLUSION
About 92o/o of the respondents were satisfied with
the services provided and 650lo of them felt that
their expectation on getting effective treatment had
been met. Meeting patient expectations was
significantly associated with age, ethnicity and
educat i onal l evel . However , t he di mensi on
"Tangibles" showed the lowest percentage among
the five dimensions under SERVQUAL. Hospital
Directors should look into creative idea on how to
make t he f aci l i t i es at t he wai t i ng area more
appealing and improve the public amenities like
banking automated machines (ATM), Post Office,
Kiosk (cyber caf6), play area and others within
the hospital vicinity.
ACKNOWLEDGEMENT
We wish to thank the Director General of Health,
Malaysia for permission to publish this aticle. We
would also like to thank all hospital directors, staff
and individuals who were involved directly or
indirectly in data collection for this study.
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REFERENCES
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Measuring Hospital Pedormance : Review Of Global Measures
Ang KT, Roslan J
ABSTRACT
Hospi tal performance are measured i n many ways dependi ng on l ocal si tuati ons. Many hospi tal s
have qual i ty measures on pati ent care or servi ce del i very performance measures. However, few
have comprehensi ve whol e hospi tal performance measures that cover the whol e spectrum of
hospi tal acti vi ti es. Thi s revi ew attempts to i denti fy gl obal performance measures that had been
adopted by hospi tal s i n di fferent parts of the worl d and the i ssues rel ated to thei r i mpl ementati on.
Four di sti nct type of gl obal measures were i denti fi ed, namel y the UK Nati onal Heal th System
(NHS) hospi tal rati ri g system; Bal anced Scorecard method; WHO Performance Assessment Tool
for Hospi tal Improvement (PATH) method; and the Anal yti cal Hi erarchy Process (AHP) method.
The use of sui tabl e hospi tal performance measures that are both comprehensi ve and bal anced,
can hel p hospi tal s to be managed more effecti vel y and effi ci entl y.
Key words : Hospital Peformance, Performance measures, Peformance indicators
INTRODUCTION
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Measuring and monitoring healthcare peformance
is essential to enhance efficiency, and to ensure
services provide are effective and responsive to
meet demands of various stake holders. Escalating
healthcare cost makes it even more oeftinent as
governments are under pressure to be accountable
i n managi ng heal t hcare f i nance, especi al l y i n
countries where healthcare is largely publicly
funded.
Most hospitals have some form of performance
measures/ many of which are focused on
patient
care,1 However, not many have an integrated
whole-hospital system of performance measure
t hat r ef l ect s whol e hospi t al management .
Measuring whole hospital performance is by no
means easy due to the complexity of services
hospitals provide, and the multiplicity of stake
holders involved. It is also dependent on the
healthcare system of individual countries, and is
context dependent in that the goal, mission and
philosophy of service provision are politically
determined, especially in public sector hospitals.2
Performance measures have been in place in the
UK hospitals since the early 1990s with the Patients'
Chafter and the internal market healthcare reform.
In 2000, star rating for acute hospital trusts was
i nt roduced. 3 Thi s has si nce undergone many
changes in the way peformance is being measured
(DOH, UK).
The Balanced Scorecard (BSC) system, developed
by Kaplan and Nofton4 (1992) as a research project
in 7992, was intended to provide top management
with a set of financial and non-financial measures
as a st r at egi c management t ool f or t he
organisation, against the limitations of the lone
traditional financial peformance measures at that
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time. The product was a set of measures covering
four domain areas/ namely Financial perspective,
Cust omer per spect i ve, I nt er nal Busi ness
perspective, and Innovation, Growth and Learning
perspective. Although originally developed for the
industry this integrated performance measure
system has since been adopted by many other
types of organizations, including the healthcare
sector.
Hospital performance is dependent on a number
of f act ors i ncl udi ng hospi t al si ze, case-mi x,
competent and skilled healthcare professionals,
resources available (diagnostic and therapeutic
technologies, other supportive facilities), local
leadership, organisational culture and otherss,6,7
(WHO 1994; Grosskoph and Valdmanis 1993;
Mannion et al 2005). What then constitute the right
mi x of i ndi cat ors t o measure and compare
performance of hospitals?
This paper is aimed at identifying global measures
used by different healthcare providers in different
countries, and the issues in the implementation of
such measures. The use of a suitable set of global
peformance measures would assist hospitals to
be managed more effectively and efficiency in the
light of increasing healthcare cost and demand
for accountability.
METHOD
El ect roni c searches were conduct ed on t he
dat abases of MEDLi ne and PUBMed, Emeral d
Journal Search on management
journals,
specific
journals
like British Medical Journal and Google
Scholar. Search was conducted using key words:
hospital pedormance
I
rating, AND performance
measu re/i ndicator/rati ng. Secondary sou rces from
reference listings of primary articles were also
made, as well as hand search for grey literature,
repofts a nd conference proceedings.
Onl y art i cl es on i mpl ement ed gl obal hospi t al
performance measures for acute hospitals were
included for the extraction of parameters used in
measuring hospital performance. Performance
measures relating to patient care alone care were
excl uded. Al so excl uded were
perf ormance
measures related to a department or clinic in a
hospital, management of a condition, or relating
to non-acute hospital settings like health system,
psychi at r i c i nst i t ut i ons, nur si ng homes and
hospices.
Domain areas of performance measures were
identified in each of the implemented projects. The
number of indicators used for the measures were
also identified and implementation issues were
noted. Where an article is a review article of several
implemented projects, attempts were made to
obtain the reports of the project through internet
search to verify details of measures if they were
not clear. Issues related to the implementation of
hospi t al per f or mance measur es, i ncl udi ng
limitations of the studies were noted.
TYPES OF PERFORJYIANCE MEASURES
The review yielded many articles on the UK National
Health System hospital rating system, and 6 were
selected to track changes over the years from 2000
when star rating of hospitals was introduced. Six
more articles on other systems of measure were
f urt her i dent i f i ed. The measures used can
generally be categorised under four groups as
follows:
a) UK NHS hospital rating system
b) Balanced Scorecard system
c) Wor l d Heal t h Or gani sat i on ( WHO
Performance Tool for
Quality
Improvement in Hospitals ( PATH) system
d) Anal yt i cal Hi er ar chy Pr ocess ( AHP)
gener at ed set of measur ement s
customised for the local hospital
A summary of the various performance measures
under the four groups are shown in Table 1
UK NHS Hospital Rating System
The UK NHS star rating system was implemented
in acute hospital trusts in July 2000 under the NHS
blue-print for modernisation and reform of NHS
for the next 10 years.B The hospitals were rated
based on a combination of performance on key
target areas which typically comprised on a first
set of key hospital/service management indicators
of national and political interest; and a second
component of peformance indicators comprising
of clinical, patient, staff/capacity or capability
f ocused areas. Thi s was suppl ement ed wi t h
peformance from the CHI (Commission for Health
Improvement) Review on clinical governance, The
CHI clinical governance review covered nine areas,
namely risk management, clinical audit, research
and education, patient involvement, information
management , st af f i nvol vement , educat i on,
training and development (CHI 200212003).
Bet ween 2000 and 2010, t here were many
changes to the NHS system
-
in the performance
measures used, methodology and conducting of
rat i ngs, as wel l as body responsi bl e f or i t s
measurement . The St ar Rat i ng syst em was
abandoned in 2004 after much criticism and this
was replaced by the Annual Health Check for the
200612007 period which was being administered
by an i ndependent body, t he Heal t h Car e
Commission (HCC 2006/2007). This was again
replaced by the Care
Quality
Commission (CQC)
in 2009 under the new Health and Social Care Act
2008, a regulatory body established under the Act
to safeguard standards and safety of patient care
and social services (CQC 2009/2010).
NHS hospital performance system is still evolving
and changing, with the Depatmentof Health (DOH)
providing the policy direction on standards, and
the management of its hospitals against these
sta nda rds. The 2010
|
201 1 performa nce guidel i ne
futher consolidate peformance measures into
four areas of financial management, operational
standards and targets, service quality and patient
safety and user experience.e
Balanced Scorecard Method
Outside the NHS, the most widely used system is
the Balanced Scorecard (BSC) method. Although
relatively new in the healthcare sector, the BSC
system has been adopted by a broad range of
organizations in the health secto6 among them
heal t hcare organi zat i ons, hospi t al s, hospi t al
systems, hospital departments, long-term care
institutions, local and federal health depatments,
and pharmaceut i cal compani es. l 0 Most were
carried out with modifications to suit the healthcare
industry.
Zel man r epor t ed t wo l ar ge scal e hospi t al
organizations that utilized the BSC method, namely
the Ontario Acute Hospital Care hospitals in Canada
with 89 hospitals, and Critical Access Hospitals
(CAH) in the US with 217 hospitals. In both hospital
organizations, the domains had been modified with
an added cl i ni cal out come di mensi on f or t he
Ontario ACH, while the innovation/learning domain
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was absent for both or called by different names.
The Ontario Acute Care Hospitals had a domain
called system integration while US Critical Access
Hospitals had a domain called Infrastructure/
Governance/Com m un ity.
Gao and Gurd (2C03)11 presented the use of BSC
i n 22 heal t h care organi zat i ons, i ncl udi ng 7
hospi t al s, i n a conf erence i n Adel ai de. The
applications were identified through literature
reviews from published papers and internet sites.
In the analysis of BSC in 7 hospital settings, the
most consistent domains adopted were clinical care
quality and client/customer focus measures while
financial domain was the least adopted. The
pedormance domains for other areas were quite
heterogeneous and called by different names such
as business and development, innovation and
gr owt h, or gani zat i on heal t h, or gani zat i on
healthcare and learning and learning/innovation.
The number of indicators ranqed from 13 to 32.
The closest application of Kaplans'BSC framework
was a study comparing a Chinese and a Japanese
hospital peformance using the four domain areas
with a total of 19 indicators.12 The study was also
t o make meani ngf ul compari son across t wo
different healthcare systems and work cultures by
selecting the appropriate indicator measures.
Ni ne heal t hcare organi sat i ons i n t he US t hat
implemented the BSC did so due to external
pressures, t he most common bei ng f i nanci al
pr essur es ( managed car e) , i ncr easi ng
competiveness, and increasing consumerism.13
Their choice of BSC over other performance
measures was that BSC provided them with
performance measurements that could be linked
t o market -ori ent at ed and cust omer-f ocused
strategies, in addition to providing continual
feedback that allows adjustments to marketplace
and regulatory changes. Their perceived benefits
were man% among them were providing the
management a framework for decision making,
setting priorities and initiating changes, linking
st rat egi es t o resources, support i ng great er
account abi l i t y i n al l l evel s, and pr ovi ded a
framework for contin ual improvements.
WHO Peformance Assessment Tool for
Quality
Improvement
eAfH)
The WHO PATH toolfor
Quality
Improvements in
Hospitals was developed in 2003 through a series
of workshops by experts conducting extensive
review of literatures on hospital performance
pr oj ect s. l a Si x di mensi ons of per f or mance
measur es wer e devel oped, namel y Cl i ni cal
Ef f ect i veness, Ef f i ci ency, St af f Ori ent at i on,
Responsi ve Governance, Saf et y and Pat i ent
Centredness with a total of 24 indicators.
The final model with 18 indicators was piloted in
countries in the European region from February
2003 to August 2005. Evaluation of 37 pilot projects
wer e car r i ed out i n 2006 t hr ough onl i ne
questionnaire administered to project coordinators
at region/country and hospital level.15 The survey,
among others, looked at hospitals'experience with
the pilot implementation in general, and their
assessment of the indicators used, as well as
process of i mpl ement at i on and t he benef i t s
derived.
Although the majority of hospitals viewed the
pr oj ect as benef i ci al i n t er ms of l ear ni ng
experi ence and provi di ng a t ool f or hospi t al
per f or mance i mpr ovement , t her e wer e
implementation issues like resource support,
organisational and methodological challenges. Not
all hospitals were able to collect data for all the
18 i ndi cat ors nei t her di d any si ngl e i ndi cat or
attained 100o/o measurement by the hospitals.
There were issues on clarity of description of
indicators used, as well as burden of collecting
the necessary data.
Another study on PATH indicators was a review
comparing existing indicator projects for hospital
pedormance and the PATH framework based on
10 selected criteria, one of which is on dimensions
of hospi t al perf ormance assessed. 16 El even
hospital indicator projects were identified through
systematic literature search, consisting of 10
national indicator projects and one PATH project.
The indicators used in the national projects were
compared to the PATH project with six domain
areas.
The most common domains measured in the ten
national projects were clinical effectiveness (10
outof 10), patientcentredness (7 outof 10), safety
and efficiency ( 6 out of 10 for both). The least
was on staff orientation ( 1 out of 10), The number
of indicators measured varied from 39 to 308.
Analytic Hierachy Process Method
The Analytical Hierarchy Process (AHP), is a multi-
criteria decision-making technique developed by
Saaty (1980) to develop a set of multi-dimensional
measures customised to the local hosoital. The
process is a step-by-step consensus opinion
method by experts in the hospital, starting with
identifying critical success factors or areas,
followed by identifying su b-factors/a reas defi ni ng
t he i ndi cat or and rat i ng, and t hen assi gni ng
weightings to each of the indicators by a process
of pair-wise comparison which ultimately yield
their relative weightings.
Such a method was applied to two tetiary care
teaching hospitals in Barbados and in India to
compare their performance.lT The method yielded
t hr ee mai n cr i t i cal ar eas of Pat i ent car e,
Establishment, and Administration, with their sub-
factors and their measurements. The measures
were used to conduct meaningful comparison of
the two hospital performances.
I ssues i n I mpl ement i ng Per f or mance
Measures
Issues on performance measures depend on
whether they are meant for internal or public use.
Performance measures/ especially when used
comparatively, can result in misinterpretation and
st i gmat i sat i on of l ow perf ormi ng hospi t al s. l s
Peformance is also influenced by structuralfactors
which are outside the control of the organisation,
like infrastructures, availability of equipment and
staffing levels. There is also a belief that what
gets measured gets attention and priority, while
the unmeasured ones are neolected.le
Choice of indicators and its definition, method of
data collection and data analysis, data quality and
case- mi x can al so i nf l uence per f or mance.
Pressure to peform can also result in dysfunctional
behaviour of gaming (manipulation) of data to
produce better results. Thus, caution is needed in
t he i nt erpret at i on and use of perf ormance
measures.
Two reports from the Royal Society of Statistics2o,21
emphasi sed t he l i mi t at i ons of compar at i ve
performance measures where common statistical
issues were appropriateness or integrity of data,
methodological rigour in statistical analysis and
presentation,
and interpretation of data presented.
Managed appropriately at each level, peformance
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measures can achieve the desired intentions.
However, poor management can result in erroneous
judgement
which can have adverse effect on the
institutions under scrutiny.
Manni on et al ( 2005) 22 caut i oned on t he
dysfunctional consequences for low performing
hospi t al s whi ch can af f ect st af f moral e and
"ghettoisation" of hospitals where low performing
hospitals were unable to attract staff
joining
their
organisation due to poor image. Snelling (2003)x
argued that star rpting did not really reflect hospital
performance by illustrating it with an alternative
analysis of the same data and showed that only
41olo of the hospitals would have received the same
number of stars if the alternative set of indicators
were used, Chang (2007)24 argued that that
performance rating in the NHS was used primarily
for legitimacy seeking purposes rather than for
rational service improvements, suggesting that it
was t o demonst r at e cent r al gover nment ' s
achievements in delivering its mandate to improve
healthcare for the population.
In the implementation of BSC system, Inamdarl3
(2002) interviewed chief executives of nine
heal t hcare provi der organi sat i ons t hat had
implemented the system and identified several
chal l enges and barri ers whi l e devel opi ng and
i mpl ement i ng t he BSC, among t hem were :
getting the support and commitment of board
members and seni or management t o buy-i n;
developing appropriate measures to meet the
needs of various stake holders who sometimes
have conflicting agenda
-
the physicians, patients,
payers and regulators; getting the suppoftofthe
workforce who feared being measured; obtaining
and interpreting timely data in a cost-effective
manner and keeping the scorecard simple, and
yet compr ehensi ve enough t o achi eve i t s
objectives.
In assessing the factors contributing to the success
of hospitals that had implemented the BSC system
in Canadian hospitals, Chan and Ho (2000)' zs
similarly found that commitment and buy-ins by
senior management and clinical staff were crucial.
Other key factors were the choice of peformance
measur es, ease of dat a col l ect i on and
or gani sat i onal i nf r ast r uct ur es, especi al l y
information system. Reasons for failure were lack
of ski l l s and know- how; l eader shi p and
management commitment; time and resource
constraint in developing and implementing the BSC
and critically, the failure of hospitals to adequately
est abl i sh t hei r or gani sat i on' s mi ssi on and
strategies before embarking on the BSC system.
Zelman et al (2003)r0 showed that modifications
were needed i n i mpl ement i ng t he Bal anced
Scorecard in healthcare settings. Selection of
appr opr i at e i ndi cat or s was cr uci al i n i t s
i mpl ement at i on and some hospi t al s added
i ndi cat ors i ncrement al l y as t hey gai ned more
experience.
Hurdles encountered in the PATH projects were
related to clarity in the definitions of indicators
chosen, burden of data collection and lack of
resources as well as logistic issues. In some
hospitals, existing data system did not allow for
collection of ATH data. Adaptation processes and
continuous revisions were needed to overcome
the problem.
Adoption the Right Global Performance
Measures
The Balanced Scorecard provides a strategic
approach to measuring peformance. The PATH
model, on the other hand, is more customised to
the health sector while the NHS performance
measures are the most comprehensive but require
a very elaborate system and resources for data
collection, processing and analysis.
Selecting a basket of indicators for the various
domains of clinical effectiveness, efficiency, staff
orientation, responsive governance, safety and
pat i ent cent redness i s a chal l enge. Sui t abl e
i ndi cat ors must be val i d, rel evant , preci se,
sensitive, reliable, quantifiable and interpretable,
as well as not cause a burden to collect them.
Existing indicators should be adopted as far as
possi bl e. A syst em of st andardi sat i on, ri sk
adjustment and weightings need to be put in place.
The AHP (Analytical Hierarchy Process) method
provides opportunity for all stake holders to be
involved in developing a list of suitable local
indicators. However, they have to understand the
underlying principles and purpose of developing
this new set of global indicators. To be strategic,
key objectives of the hospital must be defined from
a broad perspective of political and economic
needs and not merely professional and customer
needs. The number of i ndi cat or s must be
manageable but comprehensive enough to cover
all perspectives. As much as possible, data from
existing management system should be harnessed
to lessen the burden of its collection.
The methodology for data collection and process
of data cleaning needs to be spelt out. The UK
model requires massive data collection which is
not a problem in UK as the governance system
has mat ured over decades of devel opment .
Nevertheless, it was pointed out that even with
such an elaborate system, ratings can still be
significantly altered by way of selective analysis
of process and outcome measures.26
Validity of pefformance measures is as good as
t he qual i t y of dat a col l ect ed. Gami ng
(manipulation) behaviour to adjust data for a more
favourable performance is something that can
happen. It depends on the integrity of the hospital
management and the clarity of indicators used.
Perhaps a random auditing system should be put
in place to discourage such behaviours. Such a
system will require putting a structure in place
with adequate resources.
Moullin (2004)27, outlined eight essentials of
peformance measures in ensuring the delivery
of cost-effective, high quality services that meet
the needs of service users. Among them were the
need to use a balanced set of measures, involve
staff in determining the measures, taking account
of the cost of measuring peformance, and having
clear systems for translating feedback from
measures into a strategy for action.
Lastly, it may be wothwhile to note the advice
given by Aguilar (1994)'z8 that complementary data
is needed in assessing and interpreting hospital
performance measures, among which are staffing
levels, facility characteristics, hospital budget,
institutional orga nisation structure, cha racteristics
of population that uses the facility, including health
status. All these factors may impact on the
performance of hospitals but may be outside the
control of the local hospital management,
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Neveftheless, having a set of hospital peformance
measures can help in improving quality of service,
efficiency, effectiveness and better customer
sat i sf act i on. Much can be l ear nt f r om t he
experi ences and pi t f al l s of t hose who have
implemented global peformance measures.
CONCLUSION
Review of literatures indicated that while there
are many examples of performance measures for
hospital services and patient care, most are stand
alone indicator system for a department, a unit or
a condition/procedure. There are few examples
of i mpl ement ed proj ect s f or gl obal hospi t al
per f or mance measur es. Kapl an' s Bal anced
Scorecard System is a more balanced approach
to measuring performance. Howevel the WHO
PATH model is more customised to the healthcare
sector while the NHS hospital rating system is the
Departmentof Health, UK. NHS
Performance Ratings
-
Acute hospital
trusts 2000/013
Departmentof Health, UK. NHS
Pedormance Ratings and Indicators,
Acute Hospita I Trusts 2001
120028
Commission for Health Improvement
2002-20042e
most comprehensive in terms of range of indicators
used, and the methodology of measurement.
Countries can learn from various approaches
adopted by hospitals that have implemented global
peformance measures to take them to the next
level of efficiency and effectiveness in managing
their hospitals.
ACKNOWLEDGEMENT
The authors wish to thank the Director General,
Ministry of Health Malaysia; the Deputy Director
General of Heal t h (Research and Techni cal
Support) and the Director of Institute for Health
Management for permission to publish the study;
and col l eagues at t he I nst i t ut e f or Heal t h
Management, Ministry of Health Malaysia for their
assistance and cooperation in the analysis of this
study.
Key management indicators (9)
Balanced-Scorecard in 3 area. The
number of indicators ( n) changed from
period to period :
a) Clinical focus areas (3), (9), (10)
b) Patient focus areas (4), (14), (19)
c) Stafffocus/ Capacity and capability
focus areas (3), (5), (6)
Table 1 : Summary Of Global Hospital Performance Measures
3.
L Performance Measurcs used in NHS hospital ratings, 2000-2011
4. Health Care Commission
(April 2004-
2009)30
Care
Quality
Commission. Criteria for
assessing core standards in 2009/2010'
Acute Trusts. July 200931
Departnentof Health, UK. NHS Petformance
Framework
-
Implementation Guide'
April 2009, and 2010
l201Le
Balanced Scorecard SYstem
Zelman et al (2003). Use of Balanced
Scorecard in Health Carelo
Annual Health checks
-
consisting of 24 core
standards and other national standards
covering :
a)
Quality
of service
b) Use of resources
Core standards in 7 domain areas :
a) Patient safety (16)
b) Clinical and cost effectiveness
(9)
c) Governance
(19)
d) Patient focus (18)
e) Accessibility & responsiveness
(5)
f) Care environment & amenities
(6)
g) Public health (9)
Financial management
(5)
Service
Quality
o
Operational standards & targets (25)
.
User experience
(B)
.
Service
quality & patient safetY
Ontario ACH ( 89 hospitals) : 38 indicators'
.
Financial
.
Patient satisfaction
.
Clinical utilization and outcome
o
System integration and Change
US CAH ( 217 hospitals) :47 indicators in
32 hospitals
,
others not sPecified
.
Financial
.
Customer
.
Process
.
Infrastructure/Governance/community
relations
5.
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1.
World Health Organisation Initiated Hospital Pedormance Measures
Gao and Gurd (2008). Managing with
Score-card in not-for-profit healthcare
settingsll
Chen et al (2006). Using balanced
scorecard to measure Chinese and
Japanese Hospital Performance12
Veillard et al (2006). A peformance
assessment framework for hospitals:
the WHO regional office for Europe
PATH projectl4
Groene O et al (2008). An international
review of projecb on hospital peformance
assessmentls
Domain areas for 7 hospital-wide
applications of BSC, called by a variety of
names with 4 to 5 domain areas and
between 13 to 32 indicators
o
Cl in ica l/q u ality
-
7
I
Thospita ls
.
Process/system
--
4/7 hospitals
.
Client/customer
-
6/Thospitals
.
Orga n isation Growth/Developmenfl
Learning
/innovation/staff-
7
/7
hospitals
.
Financial
-
3/7 hospitals
.
Financial (5)
o
Internal business processes (9)
o
Customer focus (2)
o
Learning and growth (3)
Clinical effectiveness (7)
Efficiency (4
)
Staff orientation (4)
Responsive governance (2)
Safety (2)
Patient centredness (5)
10 national indicator projects compared to
PATH project with 6 domain areas with a
total of 39 to 308 indicators :
.
Clinical effectiveness (10/10 hospitals)
o
Efficiency (61L0 hospitals)
o
Staff orientation ( 1/10 hospitals)
.
Responsive governance (2/10 hospitals)
.
SafeV ( 6/10 hospitals)
o
Patient centredness (/10 hospitals)
Analytical Hierarchy Process (AHP) derived framework
1. J Jovanovic, Z Krivokapic (2008).
Analytical Hierarchy Process (AHP) in
Implementation of Balanced Scorecardl6
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I
6
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o
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'
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169.
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indicators from all perspectives. Int. J.
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essentials of performance measure. Int. J
Health Care
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Assurance 17(3) : 1 10-1 12.
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Peformance of Hospitals and Health Centres.
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Syst ems, Di v. of St rengt heni ng Heal t h
Services. WHO/SHS/DHS
I
94.2.
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Care
Qual i t y
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ht t p : / / www. cqc. or g. uk.
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24.
25.
26.
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Patient Safety: Do Patients Participate?
Rosl i nah A, Sararaks S, Retneswari M, Farrah OA, Noor Izni MS, Look CH, Ruhai ni I'
Pati mah A, Nari mah Y, Hasnah B, Kal som M
ABSTRACT
Background: The global diversity of quality improvement efforts into healthcare management
calls for optimal patient pafticipation towards patient safety.
Aim: To assess
patients' participation in their healthcare management.
Methods: This was a questionnaire-based cross sectional study conducted among
post-operative
patients in Malaysian
public hospitals.
Results: This study revealed mixed responses on patient perception towards their safety' Two-
thirds of the respondents
perceived that patient participation played an important role in enhancing
patient safety. Respondents scored highly in their perception pertaining to their rights. Good
compliance to advice
given by healthcare personnel contributed to patient safety' Among those
respondents with health problems, only 52.8%
(95% CI: 2L.2,82.3) informed their doctors about
their condition,
Conclusion: Although patient perceived their participation played an impoftant role toward their
safety, this was not shown in the practice. It is imperative that healthcare
providers encourage
patient empowerment towards
participation leading to patient safety.
Keywords:
patient safety,
patient pa rtici pation, hea lthca re, em powerment
BACKGROUND
In today's globalisation and evolving healthcare
er a,
pat i ent par t i ci pat i on i n heal t hcar e
management is crucial. It is gradually accredited
as a key element in the redesign of healthcare
processes and is advocated to improve patient
safety. Being the consumers,
patients play an
important role in decision making related to their
health and medical care, and more importantly,
their safety.l'2'3 It is now evident that patient safety
cannot be improved merely by counting adverse
events.4 Moreover, The London Declaration,
approved by the World Health Organization World
Alliance for Patient Safety 2005, calls for a greater
role to be played by patients in the endeavour to
improve healthcare safety worldwide.s
Malaysia is a multiracial, multi-faith and culturally-
diverse nation with a population of approximately
28 million. It is a fast developing country where a
"Western-orientated" information delivery
policy
is adopted in the medical curriculum' The quality
of healthcare services emphasises on patient-
centred care, client satisfaction and accountability'
In Malaysia, many of the patients have strong
spiritual and religious beliefs that have a bearing
on their perception of illness and their preferred
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mode of t r eat ment . 6 Though i t has been
documented that respecting their beliefs and
val ues, and t reat i ng t hem wi t h di gni t y are
important aspects of doctor-patient relationship,
factors such as the patienb'rights have rarely been
dwelt with in our countrv.
Research in numerous areas of medicine reveals
that active patient participation in their overall
healthcare management results in a variety of
benef i t s. These benef i t s i ncl ude i ncreased
sat i sf act i on, l essened syst em burden, and
i mproved out comes besi des prevent i ng and
reducing medical errors. The patients have rights
and responsibilities at every point in the medical
car e pr ocess. Pat i ent s shoul d be of f er ed
i nf ormat i on about t reat ment out comes and
encour aged t o par t i ci pat e i n deci si ons on
appropriate options available.T
Patients can act as a safeguard by highlighting
unpleasantevenb, playing an active role in decision
making, and be more fothcoming in providing
rel evant heal t h i nf ormat i on t o heal t h care
providers. This allows health care providers to
have pertinent health information in providing safer
healthcare service. In Malaysia, however, there
has not been any study conducted on patient
pafticipation.
This study aims to assess patient participation in
elective operations, perception on their rights and
f act or s enhanci ng t hei r saf et y, and t hei r
recommendations towards improving patient
safety.
METHODS
A cross-sectional study was conducted in nine
randomly selected public hospitals in 2007. The
study population comprised of all post-operative
elective operation patients from surgical disciplines
except paedi at r i cs and subspeci al t i es i n
pafticipating centres. Sample size was calculated
using Epical 2000 version 1.02. The minimum
required sample size for each hospital was 170
yielding a totalof 1,530 patients. The respondents
were randomly selected from the elective surgical
operative patients' list using randomised number
table generated using EpiCalc 2000 software.
Written consent to pafticipate in the study was
obtained from the patients after the first post-
operative day. A face-to-face structured interview
was conducted using a questionnaire developed
by the study group. A five-day training session was
conduct ed f or al l coordi nat ors and research
assistants encom passing proced u res, methods of
this study, their roles and functions, incorporating
the work flow involved. Data was analysed using
survey analysis methods with STATA SE version
10. Ethicalapprovalwas obtained from the National
Medical Research Ethic Committee, Ministry of
Health.
RESULTS
One thousand three hundred and thifi-eight
(1,338) post-operative patients were approached
and 1,084 patients responded, giving a response
rate of B1o/o. Almost half were in the age group of
30-49 years (44o/o), 54.7o/o had secondary
education, and 65,9olo were females.
About 65 percent of respondents pafticipated in
their healthcare management in some form or
another. Among those respondents with health
probl ems, onl y 52. 8ol o (95ol o CI : 21. 2, 82. 3)
informed their doctors about their condition.
Among those who did not inform their health
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problems, cited reasons were: doctors did not ask (35.4olo, 95olo CI: I2.8,67.3), they thought it did not
matter (28.4o/o,95olo CI: 4.7,76.1), and they thought the doctor should have known (I4.Bo/o,95olo CI:
6.1,31.5)(Table 1). Only 64.60/o (95olo CI: 48.I,78.2) enquired why they needed to undergo operations,
57o/o (95o/o CI: 41.2,7I.6) asked concerning other possible treatments and 54.1o/o (95olo CI: 38.4,69.0)
requested explanation before giving consent. Those who did not enquire left it to the doctor to decide.
Table 1: Reasons for not informing patient's health problems
Reasons Count ( / o) LowerCI UpperCI
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Doctor did not ask
Doctor would know
Did not think it matters or it is impoftant
No oppoftunity
Afraid to ask
Others
4T
54
29
35.4
14.8
28.4
4. 9
16.2
0. 3
6. 1
4.7
1. 9
12.8 67.3
31. 5
76. r
t2.2
31. 9
6. 2
7.4
Five main factors were perceived to be related to patients' rights by more than 50o/o of the respondents
(Table 2). However, 42.7o/o (95olo CI: 32.8,53.2) responded that they should be allowed to choose the
surgeon.
Table 2: Responses on perceived patients' rights
Patients' Rights (Weighted N
=
119,080) Count
eA
LowerCI UpperCI
Should be given information concerning the operation
Should participate in decision making on the operation
to be pedormed
Should have accompanying person during
pre-and post-operation
Should be allowed to seek second opinion
Should be given privacy
Should be allowed to choose date of the operation
Should be allowed to choose the surgeon for the
operation
964 87.3 66.5 96.0
867 80.0 63.7 90.2
865 79.6 59.1 9r.4
651
612
451
432
62.5 512 72.5
53.6 40.0 66.7
47.2 34.5 60.3
42.7 32.8 53.2
The patients perceived specialised doctors (42.7o/o,95olo CI: 29.3,57.3), caring staff (39.3olo,95o/o
CI: 20.5,61.8) and experienced doctors (32.5o/o,95olo CI: 20.6,47.2) as the top three factors
contributing to their safety while undergoing surgery
fiable
3).
Table 3: Perception on factors that increase patient safety
Factors (Weighted N
=
1 19,383)
Experienced doctors
Specialised doctors
Caring staff
Clean and sterile environment
Good cooperation from patients
Monitoring by doctors
Effective drugs
Count
402
449
L94
( / o)
32.5
42.7
39. 3
15. 0
16.9
0. 3
0. 5
189
LowerCl
20.6
29.3
20.5
5. 6
9. 7
0. 2
UpperCI
47.2
57.3
61. 8
34.3
27.6
t . 2
1. 8
Note: No response from the foltowing factors: comfoftable facility, up to date technology,
good security
system, and enough staffs.
The three key factors recommended by the respondents towards improving patient safety were; following
advi ce (54.2o/o,95ol o CI: 38.3,68.8), i nformi ng al l heal th probl ems (44.60/o,95ol o CI: 29.3,61' 0) and
provi di ng ful l cooperati on to heal th staff (43.60l o
,95o/oCI:
28.5,60.0) whi l e bei ng treated i n hospi tal
ffl
However, only 24.4o/o (95olo CI: 12.2,42.7) recommended seeking clarification for doubts and 5olo (95olo
CI: 1.2,18.9) for self-care and being concerned towards patient safety improvement.
DISCUSSION
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The majorfindings in this studyshowed that patient
participation in healthcare management varied
between 32.3o/o and 64.60/o. More than B0o/o
perceived that they had the right to be given
information and participate in decision making on
theiroperations. Lessthan half of the respondents
cited specialist doctors, experienced doctors and
caring staff as contributory factors towards patient
safety. In a 2004 suruey of 2,012 adults conducted
in the United States, two-thirds
(660/o) of the
patients stated thatthey have talked to their
surgeons about the details of the surgery.8
In this study, patients cited the following reasons
for not participating in their healthcare; they did
not know what to ask, they had already being
informed and left it to the doctor. In a study done
by Ballard in 2003, patients viewed their healthcare
practitioners (physicians, nurses, pharmacists,
therapists and other providers) as'all knowing and
without questioni competent and safe.e Healthcare
workers'beliefs, attitudes and behaviours can be
ci t ed as havi ng a maj or ef f ect on pat i ent
participation. A major obstacle in empowering
patient to participate in their care is the refusal of
healthcare workers to abandon their traditional
role and delegate power.10 Neveftheless, in most
cultures, patients accept the physician's decision
or the allied health professionalb direction without
question and are not accustomed to making
decisions about healthcare management, Other
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st udi es have al so shown t hat pat i ent s are
frequently advised not to worry and to leave their
care to the healthcare providers.ll
Studies have repofted that things have changed
over the past two decades. Most healthcare
institutions and practitioners worked to assure
certain patients' rights, such as the right to
comprehensible and appropriate health education
about illnesses and treatments. Patients now often
seek opport uni t i es f or addi t i onal opi ni ons on
a ppropriate i nterventions.
e
Informed patients ca n
also help to increase the safety of their care. In
this study, patients perceived that they have the
right to be given information concerning the
operation, participate in decision making on the
operation to be peformed, have an accompanying
person with them, be allowed to seek second
opinion and be given privacy. According to surveys
conduct ed by t he Pi cker I nst i t ut e, pat i ent s
requested that they should be respected, have
access to information, emotional suppoft, physical
comfoft, the involvement of family and friends,
coordination of care, and continuity of care.12
Patients ought to be offered information about
treatment outcomes and encouraged to pafticipate
i n deci si ons on appr opr i at e opt i ons. T Such
experiences would help to encourage further
patient participation and satisfaction.
The three key factors identified by the patients in
this study in contributing towards patient safety
were having specialist doctors, caring health
personnel and experienced doctors, Lessthan 50o/o
of the respondents cited the above factors as
contributing to patient safety because of their
mindset that'doctors know best and alll Patients
have often remained as passive recipients of
healthcare in the past.e
Patient satisfaction is one of the most impoftant
indicators of service excellence.6 In this study,
majority of the patients were satisfied with the
healthcare management before and after the
operation. Being treated well and visited by
doct ors regul arl y were t he reasons st at ed.
However, the reasons given for being dissatisfied
were the long waiting time, fasting indefinitely,
ver y col d envi r onment and poor pai n
management. A postal study done in the United
Ki ngdom t o eval uat e overal l experi ence of
respondents during their inpatient care, repofted
al most 90o/ o sat i sf act i on. The maj or
determinants of patient satisfaction in the above
study were physical comfort, emotional suppoft,
and respect for patient preferences.13 Patients
can ceftainly contribute by expressing their views
on subjects such as information, communication,
coutesy, privacy and the environment.6
The response by healthcare professionals to
patients' queries can directly influence the degree
to which patients will be involved in preventing or
intercepting errors.11 Patients can serve as a
safeguard against untoward events by paying
attention to the procedures and protocols rendered
by healthcare professionals. They can also ensure
saf e car e by pr ovi di ng per t i nent heal t h
information, namely their needs and specific health
i ssues t o t he heal t hcar e pr ovi der s dur i ng
consultations. However, involving patients in the
process can be challenging. Patients may not
understand the value of their roles in preventing
errors or are reluctant to participate. They may
be hesitant to speak up or be disinclined to help
practitioners.ll Other barriers that may prevent
patients and their families from being involved
are language, literacy, cultural differences, and
emotional aspects.
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The strength in this study was the sampling
strategy which involved stratification across
di f f er ent hospi t al s and r egi ons ensur i ng
represent at i veness. Despi t e t rai ni ng of dat a
collectors, there may be variations in administering
t he quest i onnai r e
due t o t r ai ned r esear ch
assistants who resigned before and during the data
collection process. However, new research
assistants were then recruited and trained on site
by the appointed coordinators at the particular
hospitals to overcome this problem. There is a
possibility of inter-ob6erver bias in this study due
to the'face-to-face' interview questionnai re used.
CONCLUSIONS
Two-thirds of the patients in this study perceived
that patient participation played an important role
in patient safety. However, intensive health
education has to be provided to change the mindset
of patients to enhance their decision making role
towards ensuring patient safety.14 Since patients
rely completely on doctors in decision making,
REFERENCES
Vincent CA, Coulter A., (2002), Patient
Safety: What about Patient?
QualSaf
Health
Care; lI:76-80.
Meyer GS, Arnheim L., (2002), The power of
two: improving patient safety through better
physician-patient communication. Family
Pradice Managemenf. http://www.aafp.orgl
fmp1200207001 47thep. Accessed Oct 1 1,
2010.
health education and training should be extended
t o heal t hcare provi ders encompassi ng good
pat i ent - doct or communi cat i on ski l l s and
empower i ng pat i ent s col l ect i vel y i n t hei r
management. It is highly recommended that
multicentre studies covering a wider range of
states and district hospitals be carried out to
investigate fufther the issues and obstacles related
to patient safety. Future studies are recommended
to explore the influence of the internet in providing
health information to patients. Such studies may
help to identify how health information through
the internet can lead to patient empowerment and
paticipation towards patient safety.
ACKNOWLEDGEMENTS
The authors would like to thank the Director
General of Health Malaysia for giving permission
to publish this paper and Prof. Ng Kwan Hoong,
University Malaya as well as Dr Azman Abu Bakar,
Director, Selangor State Health Depaftment for
t hei r const ruct i ve cri t i ci sm and
qui dance
i n
completing this paper.
3. Awe C, Li n SJ. , ( 2003) , A pat i ent
empowerment model to prevent medication
errors. J Med SysQ,27(6):503-17.
4. Marshal l M, Parker D, Esmai l A, Ki rk S,
Cl ari dge T. , (2003), Cul t ure Of Saf et y,
Qua
I Saf H ea lth Ca re.http://www. ncbi. n I m.
n i h.
9ov/pmc/a
rticles/PMCt7 437 48
I
pdf
I
v0 12p003 1Bc. pdf. Accessed Oct 12, 2010.
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1.
2.
6.
5. World Health Organisation. (2005), World
Alliance for Patient Safety. Global Patient
Safety Challenge 2005-2006: Clean care is
safer care. Geneva, Switzerland:. World
Health Organisation http://www.who.int/
pat i ent saf et y/ event s/ 0 5G PSC_La u nch_
ENGLISH_FINAL.pdf. Accessed Oct 12, 2010.
Yousuf RM, Fauzi ARM, How SH, Akter SFU,
Shah A. , (2009), Hospi t al i sed pat i ent s'
awareness of their rights: across-sectional
survey from a,tertiary care hospital on the
east coast of Peninsular Malaysia. Singapore
Med J; 50(5): a94-a99.
Hol mes-Rovner M, Ll ewel l yn-Thomas H,
Entwistle Y et al., (2001), Patient choice
modul es f or summar i es of cl i ni cal
effectiveness: a proposal. BMJ
;322:664-
7.
Henry J. Kaiser Family Foundation., (2004),
The U.S. Agency for Healthcare Research and
QualiV
(AHRO and the Harvard School of
Public Health. http:/iwww.ktf.orglkaiserpolls/
pomr111704nr.cfm. Accessed Oct 12, 2010.
Ballard KA., (2003), Patient Safety: a shared
responsibility. Online Journal of Issues in
Nursing; B (3). http:www.nursingworld .orgl
ojin
I
topic22
|
tpc22
_4.htm.
Accessed Oct 12,
2010.
Yves L, Hugo S, Lucian L et al., (2010),
Patient participation: current knowledge
and applicability to patient safety. Mayo Clin
Proc; 85(1):53-62.
Pat r i ce LS. , ( 2004) , Radi ol ogy t oday-
bringing the patient into patient safety; 5(B):
22.
Lawrence D., (2000), Improving patient
saf et y: i mpr ovi ng t eams, t r ust and
technology. New vision for health care;2:t-
2.
Jenkinson C, Coulter A, Bruster S, Richard
N, Chandol a T. , ( 2002) , Pat i ent s'
experiences and satisfaction with health
care: results of a questionnaire study of
specific aspects of care.
QualSaf
Health
Care;1I: 335-339.
Providing Patient and Caregiver Training.,
(2010) American Association for Respiratory
Care Clinical Practice Guidelines. http:ll
rcjournal.com
lcpgsl.
Accessed Oct 12, 2010.
10.
11.
12.
13.
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9.
The Appropriate Waiting Time to Get Treatment at the Ministry of
Health Hospitals as Perceived by Patients
Roslan J
,
Ang KT, Roslinah A, Siti Zubaidah A, Nor Filzatun B, Farah Munirah RJ
ABSTRACT
Waiting for medical consultation in a hospital can be time consuming and different people have
different perceptions of the situation. The purpose of this study was to determine the average
waiting and the appropriate waiting time as perceived by patients. A cross-sectional study involving
twenty-one public hospitals from all thirteen states and 13,463 patients using self-recording of
waiting time by patients. In this study the median waiting time ranged from 60-85 minutes for
clinics and 18 minutes for the Emergency Department. This was within 10 minutes of what is
considered as appropriate by patients where appropriate waiting time ranged from 50-85 minutes
for the clinics and 15 minutes for the Emergency Department. About 40
o/o
of the patient came
more than 30 minutes earlier than their appointed time and this could upset the appointment
system resulting in longer waiting time for those who come on time for their appointments.
Although the reading materials and health information were largely available at the waiting area,
about half of the respondents felt bored while waiting, Hospitals should explore and adopt strategies
that would make waiting more pleasant and tolerable, while allowing patients flexibility to move
around and to use their time more productively while waiting.
INTRODUCTION
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Waiting for medical consultation in a hospital can
be time consuming and a test of patience for a
busy person. According to KaDman,l people are
generally impatient when it comes to waiting.
However , di f f er ent peopl e have di f f er ent
percept i ons of a si t uat i on, i n t hi s i nst ance,
perception on waiting. Perception is guided by
beliefs, where norms and values predominate.2
For some people, half an hour is a long time to
wait but for some, they can wait for 2 hours without
feeling restless. Perceptions can change over time
as value changes.3 What is perceived now as
appropriate may not necessarily be so in the
future.
Seruice literature indicates that waiting experiences
ar e t ypi cal l y negat i ve and af f ect s over al l
sat i sf act i on of consumer s i n t hei r ser vi ce
encounters4,s). McKinnon6 found that patients are
less likely to be dissatisfied if their waiting time is
within thity minutes. Meeting the thirty-minute
threshold is a daunting task, particularly for public
hospitals which are typically ovenruhelmed with too
many patients.T
The purpose of this study was to determine the
average waiting and the appropriate waiting time
as perceived by patients.
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MATERIALS AND METHOD
This was a cross-sectional study involving twenty-
one public hospitals in the country. These hospitals
were sel ect ed t hrough mul t i -st age random
sampl i ng. The sampl e si ze f or pat i ent was
calculated by using EPI INFO Version 6, taking into
consi derat i on 20o/ o preci si on and 10ol o non-
response rate. The self-ad m i n istered q uestion na i re
was developed and pretested by a research group.
Reliability and validity analyses were carried out
on the instrument.pne research coordinator from
each hospital was identified to distribute and collect
back the self-administered questionnaires. The
coordinators were given prior training on the
process of data collection. Patients were selected
t hrough syst emat i c sampl i ng based on t hei r
registration numbers, The questionnaires were
distributed to patients while they were waiting to
get treatment at the clinic, Patients were asked to
indicate the time of arrival at the registration
counter and the time when the patient was call to
be seen by a medical personnel. Waiting time was
defined as the time spent waiting from registration
until being seen by a medical personnel. The data
was analyzed using Statistical Package for Social
Sciences (SPSS).
RESULTS
Response rate to the survey was 62.9% with
2L,750 questionnaires
distributed and 73,463
questionnaires returned.
Demographic distri bution
The median age of respondents was 33 years old
with more female respondents (57.5o/o) compared
to males (42.5o/o). The majority were Malays
(66.20/o) followed by other ethnic groups (I7.t%),
Chinese (IL.6o/o) and Indians (5.1olo). Almostthree
quaders (73.7o/o) had secondary school education
and above, whi l e 10.2ol o had no or non-formal
education.
Table 1: Respondent profile
Respondent Profile Frequency (o/o)
Age Group (n= 13,071)
Less than 39
40-55
56 and above
Gender ( n=13, 325)
Male
Female
Ethnicity( n
=
13,329)
Malay
Chinese
India
Others
Educat i on Level ( n= t 2, 973)
None
InformalSchool
Primary School
Secondary School
College/University
8442(64.6)
32ss (24.e)
1374 (10.s)
s6se (42.s)
7666 (s7.s)
8826 (66.2)
1s42 ( 11. 6)
687 (s. 1)
2274 (r7. r)
1060 (B.2)
260 (2.0)
20e2 (16.r)
7326 (s6.s)
223s (r7.2)
Table 2 shows the median waiting time to get
treatment at the various clinics or Emergency
Department. This ranged from 18 minutes at the
Emergency Department to 85 minutes at the
Medi cal cl i ni c.
Table 2 : Median Waiting Time by type of ctinic
Clinic
Median (IQR)*
t i me at t he Medi cal Cl i ni cs, 90 mi nut es f or
Paedi at r i c cl i ni c, whi l e 50 mi nut es was
inappropriate to wait at the Emergency Department
(table 4).
Tabl e 4 : Medi an Wai ti ng Ti me percei ved
as
appropriate or not appropriate by patients,
and the difference (by types of clinic)
Median Waiting Time (min)
Oinic
Perceived as Perceived as
Appropriate Inappropriate
General Outpatient
Clinic
Emergency Departnent 15
Medi cal Cl i ni c
B0
General Outpatient Clinic
Emergency Department
Medi cal Cl i ni c
Surgical Clinic
Orthopedic Clinic
Obstetric & Gynaecology Clinic
Paediatric Clinic
60 min (30,90)
18 mi n (10, 30)
85 mi n (45, 135)
60 min (35,95)
Bl min (45,720)
75 mi n (45, 110)
65 mi n (35, 102)
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90
725
50
60
75
*IQR
=
Inter-quartile range
Table 3 shows that 85.9olo of the patient
felt that
the waiting time to get
treatment was appropriate.
Tabl e 3 : Appr opr i at e Wai t i ng Ti me as
perceived
by patients
Surgical Clinic
Ofthopedic Clinic
Obstetric &
Gynaecology Clinic
Paediatric Clinic
106
110. 5
90
Appropriate waiting
time
No. of patients
n(o/o)
t\o
7,726 (85.9)
1, 168 ( 14. 1)
82e4 (100)
Patient behavior on arrival time for appointment
ranged from coming more than an hour early to
appearing late. Table 5 shows that overall, 20.5o/o
of patients
came for appointment on time or later
than their appointed time while 39.2o/o of them
came 30 mi nut es or more, earl i er t han t hei r
appointed time.
Total
Appropriate waiting time as perceived
by patients
differ between clinics. While B0 minutes was
perceived
as appropriate waiting time at the
Medi cal Cl i ni cs, i t was 15 mi nut es at t he
Emergency Department. For inappropriate waiting
time, 125 minutes was the inappropriate waiting
Table 5 : Patient arrival from appointment time by types of clinic
Oinh
Ontime/later < 3O Mins 3O-6O Mins
n (o/o) n (o/o) n (o/o)
)1 Hour
Total n (o/o)
n (o/o)
Medical
Surgery
Orthopedic
o&G
Paediatric
Overall
s00 (22.6) 811 (36.6) 446 (20.r) 4s7 (20.6) 2214 (100)
2e1 (1s.8) 827 (44.9) 4s7 (24.8) 266 (r4.4) 1841 (r.00)
42r (26.2) sB4 (36.4) 302 (18.8) 2e7 (18.s) 1604 (100)
428 (24.4) 7O4 (40.r) 3se (20.4) 266 (1s.1) r7s7 (100)
212(13. 3) 7r7 (4s. 0) 360 (22. 6) 306 (1e. 1) l sss (100)
18s2 (2O.s) 3543 (40.4) L924 (2'-.4) 1s92 (17.8) eO11(10O)
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Concerning reading materials at the waiting area,
65.8olo patients found them available, while BB.1olo
f ound Heal t h Educat i on/ Heal t h I nf ormat i on
materials available (Table 6).
Tabl e 6 : Avai l abi l i ty of Readi ng and Heal th
Information Material in the Waiting Area
Material Frequency n(
o/o)
Reading Material ( n
=
11,870)
Yes
Z811( 65. 8)
No 4,059 (34.2)
Health Education/Health Information ( n
=
II,292)
9, 944 (BB. 1)
1, 348 (11. 9)
In term of friendly and helpful staff,77.5o/o agreed
that staff at the clinics provided friendly and helpful
service while waiting, while less than half (47.7o/o)
found it boring while waiting to be seen (table 7).
Tabl e 7 : Pati ents' Experi ence whi l e wai ti ng
Patients'Experience Frequency, n (o/o)
Friendly and Helpful Staff ( n
=
12,044)
Feeling Bored While Waiting ( n
=
11,861)
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
7,747 (14.5)
6,865 (57.0)
2, 388 (19. 8)
707 (s. 9)
337 ( 2. 8)
1, 430 (12. 1)
4,2L7 (35.6)
2, 553 ( 21. 5)
2,868 (24.2)
7e3 (6.7)
Yes
DISCUSSION
Although public sector hospitals are generally
over-crowded and waiting time may be long, a
big majority of patients in the study (85.9olo)
perceived that their waiting time was appropriate
(Table 3). In fact, the median waiting time at the
various clinics (Table 2) were within or not more
than 10 minutes from their expected appropriate
waiting time (Table 4) and well below perceived
inappropriate waiting time. This is an improvement
over a similar studys in,2005 where only about
630/o of patients perceived that waiting time was
appropriate.
Waiting time in this study was defined as waiting
between arrival and being seen by a medical
personnel who may not be a doctor. In the
Emergency Depatment for example, patients are
being triaged and examined by an assistant
medical officerfirst before being seen by a medical
doctor except for seriously ill or injured patients
who are being sent to the resuscitation room
direct. Hence, in the Emergency Department,
median waiting time was lowest at 18 minutes.
This is expected as the department deals with
acute emergency cases and service has to be
prompt. The national (Ministry of Health) indicator
for waiting time is 100o/o within 15 minutes for
those triaged yellow (intermediate urgency) and
not longer than 90 minutes for non-emergency
casese. In Australia, the average waiting time at
emergency departments ranged from thirty
minutes to less, while in Canada and United
Kingdom, the waiting time could go up to two
hours or more.lo
This study indicated that almost 40o/o of patients
came more than 30 minutes earlier than their
appointed time, with 17.Bo/o of them coming more
than an hour earlier. It is known that some patients
depend on their working spouse or children for
transport to the hospital, and are being dropped
off on their way to work in the morning. The
pract i ce of comi ng much earl i er t han t hei r
appointed time may upset the appointment system,
especially if patients are seen based on their queue
number rather than their actual appointed time.
This in turn would upset appointment and waiting
for other patients who come on time and gets a
later queue number. If patients are seen on their
appointed time, itwould make waiting seem longer
than what it actually was since their earlier arrival
adds on to the waiting. While education patients
on coming on time for their appointment may
change the practice in some patients, this will not
make a difference in those who come early due to
transport problem.
To alleviate boredom and engage patients during
their long waiting, clinics in hospitals provide
reading materials like magazines as well health
information materials in the waiting area. Although
two thirds of the patients found reading materials
avai l abl e and cl ose t o 90o/ o f ound heal t h
information available, about half of the respondents
(47.7o/o) felt bored while waiting. This could be
due to the fact that such materials do not interest
patients bearing in mind that over a quarter
(26.30/0) of the patients had less than primary
education. Reading materials are also subjected
to personal preferences. To cater to the likes of
different patients, other options should be explored
like having television. However, the programme
must be i nt erest i ng t o t he pat i ent s. A ni ce
ambience and comfortable waiting environment
could make waiting more bearable. Hutton and
Richardsonll stated that proper'healthscapes' or
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the health environment, have a positive effect on
t he physi cal wel l bei ng on peopl e i n t he
environment, and impact on the healing process
of patients.
Hospitals use various methods to reduce waiting
time like reengineering patient registration process,
or adopting self-service patient check-in system
to expediting treatment12,13,14. The San Diego
Medical Centrela reduced the average waiting time
in its emergency room by 24 minutes using a new
procedure to streamline registration and expedite
care. They used laptop computers to enter patient
information into a central database and this has
resulted in faster patient movement through the
Emergency Depaftment and improved quality of
care. In order to expedite treatment a new S-level
triage system was introduced.
Hospital Directors need to be resourceful and
introduce creative strategies to make waiting more
pleasant for their patient. One possible method is
by having a digital information board to inform
status of waiting time, in addition to information
about the hospital. Shot messages via mobile
phones to notify patients that their turn is coming
shortly will allow patients move about, or optimize
their time to do other chores instead of sitting and
waiting for their turn. Some bigger hospitals have
already provided banking facilities, post-office and
sundry stores in the hospital vicinity to cater to
the needs of patients who are waiting. In addition,
hospitals can also have "Customer Seruice Centre"
where patients can seek help to expedite their
waiting for unexpected urgent matters that arises
during their waiting.
CONCLUSION
In this study, the median waiting time of between
60-85 mi nut es i n cl i ni cs and 18 mi nut es f or
Emergency Depaftments were within 10 minutes
of what is expected as appropriate by the patients
-
between 50-80 minutes for clinics, and 15
minutes for Emergency Depaftment. A sizeable
proportion of patients (about 40olo) came more
than 30 minutes earlier than their appointed time.
This could upset the appointment system and
prolong waiting for those who come on time.
Although reading materials and health information
were largely available from patients' encounter in
hospitals, more innovative strategies should be
explored to make waiting more pleasant and
reduce pat i ent boredom, as wel l as al l owi ng
patients to use their time more productively while
waiting.
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Noriah, B., Nadhirah, R., (2007), Is the waiting
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Health Management;3(1) :6-14.
Medical Development Division. Ministry of
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Blendon, R.J., Schoen, C., DesRoches, C.M.,
(2004), Confronting competing demands to
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methods to reduce waiting periods, expedite
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10.
11.
12.
13.
14.
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JHM
Notices to Contributors
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The Journal of Health Management is the official
journal
of the Institute for Health Management,
Ministry of Health Malaysia. The Journal contains
afticles and research work on all aspects of hospital
and health management and related topics. The
views expressed in the articles are those of the
authors and do not necessarily reflect the views
of the Institute for Health Management.
Manuscripts : All manuscripts should be submitted
in triplicate (3) copies to :
The Editor,
Journal of Health Management,
Institute for Health Management
Jalan Rumah Sakit, Off Jalan Bangsar,
59000 Kuala Lumpur
http ://wurw. i h m. moh. gov. my
Manuscripts should be type on one side of 44 paper
and double-spaced throughout (including tables,
legends and references). The first page should
st at e t he t i t l e, appropri at e name(s) of t he
author(s), degrees, place ofwork, both postal and
email address and the contact number of the
principal author for correspondence. Papers may
be submitted in Bahasa Melayu but must be
accompanied by an abstract in English. Summary
Introduction, Materials and Methods, Results,
Discussion, Acknowledgment and References
should follow each section beginning on a fresh
pa9e.
Length:
The norm is 6000-8000 words, but both longer
and shorter articles will be considered
Typing:
A copy should be submitted in typescript Font Arial,
size 12, double spaced, with margins, carefully
checked for typing errors, spelling, punctuation etc.
Heading:
Subheadings may be used, but should be kept as
brief as possible.
Notes:
Notes should be listed at the end of the text but
should not be used excessively. They should be
numbered consecutively in the manuscript.
Fi gures:
Char t s and gr aphs ( I l l ust r at i on) shoul d be
numbered consecutively and referred to as "Figure
7.2" etc. Every figure should have a number in
Arabic numerals, a brief title and labeled axes.
Abstract:
A summary of the main substance of not more
than 200 words should be enclosed for each article
in both English and Bahasa Malaysia. Below the
abstract, provide 3 to 7 key words.
Introduction:
State the purpose of the afticle as well as the
rationale and objectives of the study.
Materials and methods :
Describe the selection of subjects. Identify the
methods, tools, apparatus and procedure of the
study in sufficient detail to allow other researchers
to repeat the study. Statistical tests used should
be given in details and the use of computer
software should also be mentioned. For studies
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with ethical consideration, the statement of
approval from relevant ethical committee has to
be mentioned.
Resul t s:
Present the results in logical sequence. Use
appropriate tables or illustrations.
Discussion:
Emphasize the new and important aspects of the
study. Discuss the implications of the findings, the
limitations and relate the findings with other
studies.
Conclusion:
Linkthe conclusions with the objectives of the study.
Avoid conclusions not suppofted by the data.
Acknowledgement:
Acknowledge grants awarded in aid of the study
(state the number of the grants/ name and location
of the institute or organization) as well as persons
who have contributed significantly to the study.
References :
Number references consecutively in the order in
which they are first mentioned in the text. Identify
references in text, tables and figures by Arabic
numerals (in parenthesis). The references must
be verified by the author(s) against the original
documents. Try to avoid using abstracts as
references.
List all authors when six or less; seven or more
list only the first six and add et al. Correct form of
references are given below:
Journals:
1, Journal afticle, one author
Harlow, H.F. (1983). Fundamentals for preparing
psychology journal
afticles . Journal of Comparative
and Physiological Psychology, 55, 893-896.
2. Journal afticle, three to six authors
Kernis, M.H., Cornell, D.P., Sun, C.R., Berry A.,
Harlow, T. (1993). There's more to self-esteem
than whether it is high or low: The importance of
stability of self-esteem. Journal of Personality and
Socia I Psychology, 65, IL90-L204.
3. Journal afticle, more than six authors
Harris, M., Karper, E., Stacks, G., Hoffman, D.,
DeNiro, R., Cruz, P. et al.(2001). Writing labs and
the Hollywood connection. Journal of Film and
Writi ng, 44(3), 213-245.
Books:
4. Personal Author(s)
Gilstrap, L.C., Cunningham, F.G., Van Dorsten JP,
editors. (2002). Operative obstetrics. 2nd ed. New
York: McGraw-Hill.
5. Chapter in Book
MelEer, P.S., Kallioniemi, A., Trent, J.M. (2002).
Chromosome alterations in human solid tumors.
In: Vogelstein B, Kinzler KW, editors. The genetic
basis of human cancer. New York: McGraw-Hill; p.
93-113.
6. Agency Publication:
Ministry of Health Malaysia (2000). Annual Report
1999. Kuala Lumpur.
7. Internet Documents
Wor l d Heal t h Or gani zat i on. Pandemi c H1N1
(2009). (cited : 30 September 2009). Available
from : http ://www. who. i nfl csr/d isease/swinefl u/
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