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ISLAMIC MEDICAL EDUCATION RESOURCES 04

0304-PAHANG HOSPITAL QUALITY ASSURANCE PROJECT

By Professor Omar Hasan Kasule sr.

ABSTRACT

This paper describes the conceptual and methodological background of hospital quality assurance programs. It then presents an implantation plan for the Pahang Hospital Quality Assurance Project (PHQAP), a joint project of the Pahang Department of Health and the Kulliyah of Medicine, International Islamic University Malaysia. The project will be piloted at Jengka Hospital for a period of 10 months after which a decision will be made about its extension to other hospitals in the state.

 

1.0 CONCEPTUAL BACKGROUND

DEFINITION OF TERMINOLOGY

Quality assurance and peer review are control tools in the health care industry. They involve assessing quality of medical care by structure and outcome. Quality assurance (QA) is formal and systematic identification, monitoring, and overcoming problems in health care delivery. Quality improvement (QI) is a management philosophy to improve organizational performance. Total Quality Management (TQM) is a participatory and systematic approach to planning and implementing continuous improvement in quality. The term audit is sometimes used to refer to quality review. Benchmarking is establishing targets based on leading performance indicators of the industry concerned.

 

Quality is different from the perspective of the patient and that of the caregiver. The definition and measurement of quality are still a dilemma. Quality in consumer economics is easy to measure since it is based on consumer satisfaction. Quality in industry can be quantified easily and its determinants can be identified and can be incorporated into the worker training and service delivery systems. Quality in medicine is seen more as what is wrong and not what is right. Outcome measures of quality have the disadvantage that they are probabilistic with no consistent relation between health intervention and health outcome. The price of a health intervention can be measured but not its value. There is no consensus on what is appropriate intervention. Generally assessment of quality covers personnel, facilities, processes, and outcomes. An exact definition of quality of health services is elusive. It may be defined as maximizing patient well-being, improvement of life, or desired health outcomes. To avoid confusions, quality in any specific discussion must be defined empirically and contexually.

 

HISTORY OF QA

The concept has evolved through 3 stages: Quality control (QC) through Quality assurance (QA) to Quality improvement (QI). Wide-spread use of computers in hospitals has increased the need for and ability to carry out quality reviews since data is readily available. TQM started in industry and was then applied to the medical field.

 

PURPOSES OF QA

QA is normally part of good clinical practice being a continuous monitoring tool to make sure that care given is up to expectation. It is also required in some situations of accreditation and even licensure.

 

PRINCIPLES OF QA

The 4 major principles of QA are intrinsic motivation, review of systems (problems are in systems and not individuals, use of the scientific method (hence the involvement of epidemiology), and adult learning to change behavior in view of the findings of the quality process.

 

COMMON QUALITY PROBLEMS IN QA

The common problems in medical quality are: insufficient knowledge, defects in the system, behaviors & performance, and documentation. Recording of the clinical data is the corner-stone of QA reviews. The QA reviewer can not attend all medical procedures and will have to rely on the records for evaluation. The records must be a faithful representation of what actually happened. Data problems are usually: incomplete data, inconsistent data, and data without record of time. Uniform reporting of data facilitates quality reviews.

 

PROCESS OF QA

Quality assurance involves planning, action, checking, action, and returning to planning. The processes of QA can be summarized by the mnemonic: FOCUS-PDCAE. Finding a process to improve. Organizing a team. Clarifying current knowledge. Understanding the process and causes of the problem. Selecting procedures to improve. Planning data collection & determining what data to collect. Data collection and analysis. Checking data to see opportunities for improvement. Acting to improve the process. Evaluation

 

QUALITY INDICATORS, CRITERIA and GUIDELINES

Quality indicators are mortality, morbidity, patient satisfaction, and various rates. The indicators must be assessed for validity, reliability (precision), and acceptability because of random and systematic errors. 

 

Consensus guidelines must be developed for each clinical situation to be a bench-mark against which clinical performance can be evaluated. Good Clinical Practice (GCP) is a set of guidelines that have been developed and they undergo continuous revision. They are not a universal prescription since each situation will have to be treated differently. Clinical protocols are developed for dealing with specific diagnostic categories of specific procedures.

 

2.0 METHODS and PROCEDURES of QA REVIEW

TYPES OF QA REVIEWS

QA review may be concurrent or retrospective. Concurrent review occurs when the reviewer attends and directly observes health care delivery such as attending a ward round, an operation, or an out-patient clinic. Retrospective review normally depends on review of records or interview of patients and health care providers. Quality review may be discipline specific (e.g. surgery or obstetrics) or site specific (heart, and lung).

 

THE QA REVIEWERS

The QA reviewers may be independent clinical auditors from outside or may be part of the health care team assigned the special function of QA. In most cases QA review by a committee gives best results. Many institutions train nurses to be QA reviewers and they report to the institutional or departmental QA committee. Peer review is when a person of persons of equivalent professional status carries out the review.

 

WHAT IS REVIEWED

QA in hospitals centers around review of the patient charts. The following records are reviewed: physician notes, nursing notes, pharmacy records, dental records, etc. Additional documents may be reviewed as necessary. Other aspects reviewed are morbidity and mortality figures, waiting times, the ratio between primary and secondary care. Physician performance is assessed based on knowledge and skills, observation, and clinical audit.

 

METHOD OF REVIEW

The aim of QA review is to ascertain compliance with the given guidelines. If a deviation is found, it is documented as well as its surrounding circumstances. It is discussed at the departmental QA committee. The committee will suggest actions to be taken to alleviate the deficiency and map out an implementation plan.

 

FOLLOW-UP

The QA review process is cyclical. The QA reviewers must follow up on the recommendations of the QA committee and ascertain that they have been followed.

 

EPIDEMIOLOGICAL METHODS USED IN QA PROGRAMS

Epidemiology provides data and to provide comparison tools used in quality studies. It studies the impact of quality on health outcome by comparing rates (incidence, prevalence, and risk). It also deals with issues of validity and reliability in quality measurements. Data can be obtained from routinely collected data or from special studies (cohort, case control, and cross-sectional). For certain quality problems the usual methods of documenting a deficiency, discussing it, and suggesting solutions may not be suitable. Specific epidemiological studies are used to investigate the causative factors of the problem and to evaluate the impact of interventions. Case control, cross-sectional, cohort, randomized, and quasi experimental studies are used. A sampling plan is made. Variables to be investigated are selected. The reliability and validity of the instrument are determined. Data collection may be in person, by mail, or by telephone. Incidence, prevalence, odds ratio, and risk ration are epidemiological measures that can be used to describe QA phenomena.

 

3.0 IMPLEMENTATION

 

THE STATE QA COMMITTEE

A QA committee will be set up in the Pahang State Health Department to monitor the project and receive QA reports that will be submitted every 3 months. The committee will also oversee the implementation of Quality Improvement (QI) measures that will be recommended. The committee should be chaired by a senior official and will include members of the QA team.

 

HOSPITAL QA COMMITTEE

Each hospital will set up a QA committee whose membership will consist of senior management in the various sectors of the hospital. This committee will liaise with the external QA team.

 

THE EXTERNAL QA TEAM

A multi-disciplinary QA team will be assembled by IIUM and should include 1-2 representatives from the State Health Department.

 

Members of the team from IIUM shall be as follows:

 

Prof Tahir Azhar, Dean of IIUM Kulliyah of Medicine will be responsible for auditing clinical management. Prof Tahir is an internist with over 25 years of clinical experience.

 

Prof Kamaruzaman, Deputy Dean Kulliyah of Medicine, IIUM will audit hospital administrative procedures that have a direct bearing on clinical care of patients. Prof Kamaruzaman had experience as a hospital director in Kelantan and has taught medical management.

 

Assoc Prof Dato’Mahathevan will audit hospital support services that have a bearing on quality. Dr Mahathevan has had extensive experience as State Health Director in Pahang and Sarawak and has held other administrative positions in the Ministry of Health.

 

Professor Omar Hasan Kasule, Sr. will be the overall team coordinator and will write the QA report. He had experience conducting QA reviews in US hospitals for a period of 5 years during which he developed several guidelines for quality care. In addition to overall coordination he will conduct indepth review of samples of charts.

 

IMPLEMENTATION SCHEDULE

 

February 2003: Joint meeting of the QA team with the State QA Committee to agree on objectives and procedures

 

            Preparation of guidelines and QA review forms to be used by members of the QA team

 

            Visit of the QA team to Jengka and meeting members of the hospital QA committee. During the meeting the concepts, objectives, and procedures of QA review will be explained.

 

March 2003:    1st QA review at Jengka Hospital. The QA team will brief the Hospital QA team of their findings and get input before writing and finalizing the 1st quarterly QA report.

 

June 2003:        2nd QA review at Jengka Hospital. The QA team will check on the implementation of the QA recommendations from the 1st quarterly QA report.

 

September 2003:          3rd QA review at Jengka Hospital

 

December 2003:           4th QA review at Jengka Hospital

 

January 2004:   Seminar in Kuantan with representatives of all hospitals in Pahang to present the experience of QA at Jengka and discuss the extension of the program to other hospitals in the state.

 

 

ACTIVITIES DURING THE QA VISIT

 

Each QA visit will last 1 day. The QA team will arrive early in the morning and will have a brief meeting with the Hospital QA committee. Then the members will disperse to review their respective sections.

 

Prof Tahir will conduct a ‘ward round’ covering a random sample of patients accompanied by physicians and nurses who will be available. He will talk to patients, review records and may be examine some patients. He will also visit the outpatient department and specialized clinics held on that day to observe actual clinical care.

 

Prof Kamaruzaman will visit various administrative units and discuss with the officials concerned various management issues related to patient care. He will also review various administrative reports and records.

 

Dato’ Mahathevan will visit and check on the following support services: pharmacy, kitchen, medical records etc and meet the people concerned.

 

Prof Omar will draw a random sample of various medical records such as patient charts, outpatient registration, theater lists, pharmacy records etc and conduct a quality chart review according to professional standards. He may also visit any other sections of the hospital to verify issues identified from the records.

 

The QA team will have lunch together and review their separate findings. They will then meet the hospital QA committee for an exit discussion. They will present preliminary findings and get feed-back.

 

The coordinator of the QA team will prepare a professional QA report and send a draft to the Hospital QA committee for comments before the report is submitted to the State QA Committee.


GUIDELINES FOR THE QUALITY REVIEW AT JENGKA HOSPITAL

 

OVERVIEW

The first visit will be a general observation and getting a feel of what is going on. The following simple guidelines will be used. After understanding the current situation more elaborate guidelines will be used for subsequent visits.

 

CLINICAL REVIEWS

The objective of clinical review will be to identify main issues in the health care process starting from admission, examination, management, and follow-up. The review will look at the ‘total’ picture in order to identify, if any, structural and functional problems and challenges. The review will be carried out in 2 parts: in-patient review and outpatient reviews.

 

In the in-patient review, Prof Tahir will conduct a ‘ward round’ covering a random sample of patients accompanied by physicians and nurses of the hospital who will be available. He will talk to patients, review records and examine some patients as appropriate. He will talk to the doctors, nurses, patients and attendants to obtain a picture of health care activities. He may also request additional information from the pharmacy, the laboratory, and the radiology sections. He will also visit the outpatient department and specialized clinics held on the day of the visit to observe actual clinical care. The results for each patient will be presented in the following way.

 

Clinical Review: Individual Cases

Problem/Issue

Elaboration

Comments & Suggestions

 

 

 

 

 

 

 

 

 

 

 

 

 

For statistical purposes a general assessment will be made for each subject reviewed indicating overall assessment of all aspects of management and the results will be tabulated as follows

Clinical Review: Overall assessment (on a scale of 1-10 where 1=very poor 10=excellent)

Serial Number

1

2

3

4

5

6

7

8

9

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REVIEW OR ADMINISTRATIVE PROCESSES

Prof Kamaruzaman will visit various administrative units and discuss with the officials concerned various management issues related to patient care.  He will also review various administrative reports and records.

 

The following will be the criteria used in the administrative evaluation:

Statement of the Objective: Is the objective of the hospital clearly stated? Is the objective understood by the staff?

Organizational structure: Is the organizational structure clearly drawn? Are the relationships between departments/units clearly demonstrated in the organizational structure

Managerial roles and functions: Do the managers have written roles and functions?, Do they know/understand their roles and functions?

Work process: Is there a desk file for every administrative  staff? Is there a ‘work procedure manual’ for every work process?

Management functions: who are responsible for the following functions: planning, controlling, and organizing. Have they attempted to do a situational analysis in order to redesign the organization and implement new rules?. Are there any quality control groups (QCC) among the workers?. Are there any specific methods used in analyzing data to improve management (such as program evaluation review techniques PERT)?

Hospital Information Systems used for management: is there am annual report (assess the quality of the report)?, Do they use the data collected to improve the management process?. Do they disseminate information down to the subordinate staff?. Is ICT used in collecting and compiling data/information?

Quality Assurance Programs (QAP): Do they use the National Indicator Approach (NIA) in QAP?. What NIA indicators are used in this hospital? How many outliers are detected?

Management Issues  Is the hospital budget adequate?. Are the hospital facilities adequate?. Is the hospital staff adequate?. How do they handle complaints?. Is there any informal organization in the hospital?. Are there internal politics in the hospital?:

 

He will summarize results as follows:

 

Administrative Review: Individual Issues

Problem/Issue

Elaboration

Comments & Suggestions

 

 

 

 

 

 

 

 

 

 

 

 

 

The results of the administrative review will be summarized as follows:

 

Administrative Review: Overall assessment (on a scale of 1-10 where 1=very poor 10=excellent)

 

Unit of Function

1

2

3

4

5

6

7

8

9

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REVIEW OF PATIENT SATISFACTION

Prof Kamaruzaman select a random sample of patients (inpatient and outpatient) and administer the attached patient satisfaction questionnaire and summarize results as follows:

 

Summary of patient satisfaction questionnaire: Overall assessment (on a scale of 1-10 where 1=very poor 10=excellent)

Item

1

2

3

4

5

6

7

8

9

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REVIEW OF SUPPORT SERVICES

Dato’ Mahathevan will visit and check on the following support services:

 

Para-medical facilities

Radiology

Pharmaceuticals (outpatient, ward, drug storage: poison and non-poison)

Pathology (out patient laboratory, in patient ward laboratory, and mortuary)

Hospital Engineering/maintenance

Hospital information and records

CSSD

Laundry and linen

 

Non-medical facilities

Building Maintenance

Environmental: ground maintenance, landscaping, waste disposal (clinical and non-clinical),

Catering: kitchen/pantry, food storage (wet ration, dry ration), staff canteen

Transport: ambulances & other vehicles

Hospital security

Counseling services

Almone

Dietitian

Professional education services (health promotion and health education)

Special clinics

Diabetic clinic

Hypertension clinic

Geriatric clinic

Well Women clinic

Well Men clinic

Baby friendly

Cottage for accompanying relatives

Surau

Hearse

 

 He will summarize problems identified as follows:

 

Support Services Review: Problem identification

Problem/Issue

Elaboration

Comments & Suggestions

 

 

 

 

 

 

 

 

 

 

 

 

 

For statistical purposes a general assessment will be made for each section / service as follows

 

Support Services: Overall assessment (on a scale of 1-10 where 1=very poor 10=excellent)

Unit of Function

1

2

3

4

5

6

7

8

9

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHART REVIEW

Prof Omar will draw a random sample of various medical records such as patient charts, outpatient registration, theater lists, pharmacy records etc and conduct a quality chart review according to professional standards. He may also visit any other sections of the hospital to verify issues identified from the records. He will summarize findings on each chart as follows:

    Chart Review: Individual chart

 

Problems / Issues identified

Comments

Identifying information

 

 

Clerking on admission

 

 

Dates and times

 

 

Signatures

 

 

Vital Signs Monitoring

 

 

Medication Orders

 

 

Drug administration

 

 

Dietary orders

 

 

Lab investigations

 

 

Radiological investigations

 

 

Discharge notes

 

 

 

As an overall summary he will score charts as follows:

 

Chart Review: Overall Assessment (on a scale of 1-10 where 1=very poor 10=excellent)

Unit of Function

Total Charts

1

2

3

4

5

6

7

8

9

10

Identifying information

 

 

 

 

 

 

 

 

 

 

 

Clerking on admission

 

 

 

 

 

 

 

 

 

 

 

Dates and times

 

 

 

 

 

 

 

 

 

 

 

Signatures

 

 

 

 

 

 

 

 

 

 

 

Vital Signs Monitoring

 

 

 

 

 

 

 

 

 

 

 

Medication Orders

 

 

 

 

 

 

 

 

 

 

 

Drug administration

 

 

 

 

 

 

 

 

 

 

 

Dietary orders

 

 

 

 

 

 

 

 

 

 

 

Lab investigations

 

 

 

 

 

 

 

 

 

 

 

Radiological investigations

 

 

 

 

 

 

 

 

 

 

 

Discharge notes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Charts

Poor

Satisfactory

Excellent

Identifying information

 

 

 

 

Clerking on admission

 

 

 

 

Dates and times

 

 

 

 

Signatures

 

 

 

 

Vital Signs Monitoring

 

 

 

 

Medication Orders

 

 

 

 

Drug administration

 

 

 

 

Dietary orders

 

 

 

 

Lab investigations

 

 

 

 

Radiological investigations

 

 

 

 

Discharge notes

 

 

 

 

 


INTERNATIONAL ISLAMIC UNIVERSITY, MALAYSIA

KULLIYAH OF MEDICINE

 

 

 

 

 

 

 

QUALITY REVIEW AT JENGKA HOSPITAL

 

 

 

 

 

 

QUALITY REPORT #1

 

 

 

 

 

 

 

April 18, 2003

1.0 OBJECTIVES OF THE REVIEW

This is the report of the first quality review at Jengka Hospital. The main objectives of these reviews is to help the hospital administration identify quality problems and to take necessary measures to correct them. In most cases there are no current quality problems but there is a need to improve the services. It is therefore expected that with each subsequent review the quality of services will improve. This is therefore a continuous process that requires joint effort by all involved.

 

2.0 METHODOLOGY OF THE REVIEW

This was the first review with the main objective of general observation and getting a feel of what is going on. Subsequent reviews will delve deeper into specific quality issues based on the preliminary findings. The following simple guidelines will be used. After understanding the current situation more elaborate guidelines will be used for subsequent visits.

 

Three types of reviews were carried out: clinical reviews, administrative reviews, chart reviews, and review of supporting services.

 

The objective of clinical review was to identify main issues in the health care process starting from admission, examination, management, and follow-up. It looked at the ‘total’ picture in order to identify, if any, structural and functional problems and challenges. The review was carried out in 2 parts: in-patient review and outpatient reviews.

 

In the in-patient review, Prof Tahir conducted a ‘ward round’ covering a random sample of patients accompanied by the medical officer. He talked to patients, reviewed records and examined some patients as appropriate.

 

3. RESULTS OF THE REVIEW

 

3.1 CLINICAL REVIEWS

Attachment #1 shows the results of clinical review at the male adult ward. A total of 18 cases were reviewed. The information was summarized in three columns: sociodemographic information, clinical status, and comments & suggestions.

 

3.2 REVIEW OF ADMINISTRATIVE PROCESSES

Attachment #2 shows the results of administrative review.

 

3.3 REVIEW OF SUPPORT SERVICES

Attachment #3 shows results of review of support services.

 

3.4 REVIEW OF CHARTS

Attachment #4 shows results of chart reviews

 

 

4. GENERAL RECOMMENDATIONS

This initial review proceeded smoothly. There were no major systematic problems discovered. The isolated problems that were identified have been documented. The next review will check on whether the problems have been dealt with and will also explore new quality areas.

 

ATTACHMENT #1:

Clinical Reviews

 

ATTACHMENT #2:

Administrative Review

 

ATTACHMENT #3:

Support Services Review

 

ATTACHMENT #4:


Chart Review

Case 1: Industrial accident in which a grinder cut the index finger

All items in the record were in order with the exception of the medical officer who did not write the time at which the records were written.

 

Case 2: Traffic accident with bleeding

All items in the record were in order except that there was no report of laboratory investigations. In such a case a hemoglobin determination was necessary in view of the report of bleeding

 

Case 3: Patient admitted with hypertension and uncontrolled diabetes mellitus

All items in the chart were in order

 

Case 4: Patient not known to be a diabetic before was admitted with a hypoglycemic attack, put on a neurological observation chart, and finally referred to Mentakab Hospital

All items were in order with the exception of the medical officer handwriting that was difficult to read

 

Case 5: Child admitted with diagnosis of possible viral fever

All items were in order except the clerking on admission by the medical officer that was found to be inadequate – too skimpy and perhaps done in a hurry

 

Case 6: Patient admitted with provisional diagnosis of ?acute appendicitis

All items were in order with the exception of (a) lack of a report of radiological investigation (b) the date of discharge was not recorded

 

Case 7: Admitted with hypertension, hemoptysis, and ?PTB

The patient was discharged to be followed up in the outpatient department. All items were in order except the incomplete admission checklist and misleading order of laboratory examination. The medical officer ordered sputum culture and sensitivity and the results came back as Klebsiella. What should have been ordered specifically is an AFB test in view of the suspicion of PTB

 

Case 8: Post-gastrectomy patient admitted with ?bleeding Peptic ulcer

The patient was anemic and had a transfusion. All items were in order with the exception of the incomplete nursing admission check list, illegible medical officer handwriting, and lack of any record on testing stool for occult blood in view of the suspicion of peptic bleeding.

Case 9: Mild cardiomyopathy with bradycardia

The patient was referred to HTAA for specialist care. All items were in order with the exception of an incomplete nursing admission check list and the medical officer’s handwriting that was difficult to read

Case 10: 6-year old child with ?measles

All items were in order with the exception of the medical officer hand writing that was not legible.

 


4. CONCLUSIONS AND RECOMMENDATIONS

 

1 check list on admission and not 2

 

REPORT ON ADMINISTRATIVE PROCESS

 

Statement of Objective

The mission and vision statements were clearly stated and understood by the administrative staffs interviewed.

 

Organizational Structure

The organizational structure was clearly drawn and the line of responsibility was clearly demonstrated.

 

Managerial roles and functions

The managers interviewed had written roles and functions. They were clearly written in their desk files.

 

Work Process

Each administrative staff had individual desk file.Each work procedure was described clearly in work procedure manual. These files and manuals were kept neatly in a file cabinet. All the staffs interviewed understood these work process and they were followed deligently.

 

Management function

The director had done the management function fairly well. Planning, organizing and controlling were done through committees. There were some quality control circles (QCC) existed but the effectiveness of these groups was not evaluated. These groups had made substantive progress in inventing new inovations to improve quality of services.

 

Use of hospital information system

Although there was a hospital annual report produced, but it could not be used effectively to improve management process. There were some pamphelets produced to inform customers on the services of the hospital.

 

Quality Assurance Programs (QAP)

National Indicator Approach (NIA) was used as a measure of QAP. From the NIA record, this hospital had complied with almost all NIA standards except in four indicators namely:

Incidence of physical food contamination : 1 (std. 0)

Delay in preparation of medical report:  94.3% (std. Not less than 95%)

Timeliness in dispatching medical records: 60.9% (std. Not less than 95%)

Readmission of asthma patient to the hospital within 28 days after discharge: 1 (std. 0)

Necessary actions were taken by the management to improve services and to prevent future occurance of the above incidence.

 

REVIEW OF PATIENTS SATISFACTION SURVEY

 

All units in the hosoital except Pathology Unit had done patients satisfaction survey in 2002-03. Majority (90%) of the customers were satisfied with the services in general. Some units for example Food Catering unit, 18 – 21% of the customers were not satisfied with the food provided. In the Phamacy uint, 12.5% of the customers expressed that the services needed to be improved. The other unit where substantial proportion of the customers was not satisfied was the ambulance services.

 

COMMENT ON THE PATIENTS SATISFACTION SURVEY

 

These surveys were not done using proper scientific method. The questionnaires were not standardised and not validated.The sample taken was not randomly taken and hence they were not representative of the entire customers. It is difficult to compare the result between various units because different aspect of satisfaction was measured.

 

SUGGESTION ON A STANDARD SATISFACTION SURVEY

 

It is suggested that the hospital should use a standard questionnaires called SERVQUAL (short for “service quality”) as in the appendix.

ęCopyright Professor Omar Hasan Kasule, Sr April 18, 2003