Measuring Client SatisfactionMatthew Smith and Beth Engelbrecht of the Health Systems Trust assess the state of the Client Satisfaction Tool developed by S&T, and patient rights in general.
Care for the patient is the fund-amental aim of health services, and motivates many service providers. The public health system in South Africa has often been accused of inefficiency and the abuse of patientís basic rights. Consumers are now increasingly aware of their rights.
The assessment of client satisfaction forms an important part of the management of a health facility, especially after the adoption of the Batho Pele (People First) principles and the Patients Right Charter.
The main objective in undertaking our research project was to develop an instrument that would assess the satisfaction levels of clients, using two district hospitals in South Africa as pilots. The hospitals were the Gordonia hospital in Upington, and the East Griqualand and Usher Memorial Hospital in Kokstad.
What is a Client Satisfaction Tool?
The literature suggests that a CS tool should be a key instrument in any hospital/clinic management strategy, provided the tool has been well designed and is administered in a scientific manner. To ensure full participation from the client, the CS tool must be easily understood, and it must take cognisance of the clientís ability to complete the survey while maintaining confidentiality.
Taking the above into consideration it was decided to implement a two-phase research process. In the first phase, qualitative methods were used to determine the concerns of the clients in depth. In the second phase, quantitative methods were used to measure levels of satisfaction amongst clients at the two hospitals.
Developing the tool was undertaken in 4 distinct stages between June 1999 and July 2000. In each pilot, both the instrument (the Client Satisfaction Tool) and the data gathering process were tested. The methods used in this research study can be outlined as follows:
In stage one, focus group discussions were held within a framework of quality of service concerns.
In stage two, the pertinent issues that influence the perception of clients about the service they receive, together with internationally accepted norms and approaches, were used to develop a questionnaire around the main domains that influence client perceptions.
In stage three, the questionnaires were piloted. A Xhosa version of the Client Satisfaction assessment tool was piloted in Kokstad, and an Afrikaans version was piloted in Upington. In both instances training was provided to a local fieldworker, who administered the instrument.
A manual to assist hospital management to manage the client satisfaction assessment process was also developed. This phase ran parallel to stage 3 and was therefore tested as part of the third stage of developing the assessment tool.
In the final phase of the project we assisted hospital management teams make decisions based on the findings and thereby improve the quality assurance programmes in their hospitals.
The series of pilots, outlined above, led to the development of a valid and reliable CS Tool; and the pilots produced data that could be analysed and used.
The analysis of the results gathered by the CS tool illustrates that there is a strong link between the survey results and the data gathered in the focus groups. Participants in the focus groups and in responses to the questionnaire demonstrated that while they were happiest with staff, they have reservations about most of the services offered by the two hospitals. In particular, clients were especially unhappy with access to the two hospitals.
Developing a South Africa-specific instrument
The preliminary results indicated that average scores hover between 0.5 and 1.0 (on a scale between -2.0 and 2.0), which suggests that clients are more satisfied than dissatisfied with the two hospitals. In the second phase of the analysis the questions were sorted into five SERVQUAL domains, namely tangibles, reliability, responsiveness, assurance and empathy. In addition, two new domains were created: one for access and the other for general satisfaction.
Other than for access, all the domains achieved a positive score, albeit relatively low. Empathy - the ability to care and display compassion towards clients - scored the highest out of all the domains.
Although the scores from the pilot studies are low, hospital management at both hospitals could take some satisfaction from the fact that clients are not completely dissatisfied with the levels of service provided by these hospitals, as some media reports may lead one to expect. The data suggest that there are some key areas hospital management should consider, which in turn could lead to higher levels of satisfaction amongst their clients.
CS tools are by their very nature instruments which even when used properly can only assist in the gathering of information. Moreover, quantitative studies of this nature will only measure the items on the questionnaire. Alternatively, qualitative methods provide a richer and deeper understanding of what clients are thinking, but the findings are not generalisable. Using a combination of quantitative and qualitative methodology can provide a more accurate picture of the perceptions of clients. Future studies of this nature would do well to not only constantly test the reliability and validity of the CS tool, but to also explore the thoughts of the clients through periodic focus groups or by collection of comments made by respondents during the surveys.