Evaluating visit quality in plan of health sector evolution in Iran: A local survey from Tabriz

INTRODUCTION

Quality of health care is a main domain of services delivery in health services organizations and it is one of the original rights of patients. Regarding this, each patient has the right to benefit from the best facilities, the best treatment and the best physician.^1-3

Also, Consultation time is an important resource in health primary care (PHC), and it is important to understand whether a longer visit results in better consequences in morbidity and mortality, and patients' and doctors' satisfaction.⁴ Both physician-patient relationship is important determinants of quality in the outpatient health care setting. Good interaction is essential to a safe and
top-quality consultation.^1-4

On the other hand, quality assurance of health care in high rate is a permanent challenge confronted by every health care sector. The patient-physician relationship and availability of health care high quality are important components in the outpatient care context.^5-8

Availability is the ease with which
a patient may receive care. The
patient-physician relationship is more difficult to describe. According to Donabedian, the physician-patient relationship while listing the characteristics of a good physician-patient relationship pulls consideration to their
double role: Is not only a source of patient satisfaction, it also serves to reassure and persuade the patient.⁹ The positive dimensions of doctor-patient relationships are: facilitation of the patient's expression of feelings and expectations affiliated to his/her health care, conveyance of clear information to the patient, formation of mutually beneficial agreed upon goals, progression of an intense role for the patient in achieving a positive outcome, and provision of unanimity and persuasion.¹⁰

Multiple studies aimed at assessing the quality of health care have been undertaken, generally by rating the level of patient satisfaction.^7,11,12 Good relationships are essential to a safe and high-quality consultation.¹³ Encompassing the issues of needs evaluation, quality and satisfaction decline within the role of health care professionals. The evidence shows that the physician-patient relationship is nearly related to patient satisfaction during process treatment.¹⁴

Health sector evolution emphasizes substantially to improve the health status of populations by promoting and enhancing accessibility, quality, and efficiency of the delivery of health care services.¹⁵ Health sector evolution of Iran began in 2014. One of the seven domains of this program was to improve the quality of visit services.¹⁶ In this study, program assessment was done by Donabedian framework and using the factors affecting that have been suggested health sector evolution of Iran.

The Donabedian’ model purveys an evaluation framework that helps systematic enquiry into health services. The Donabedian’ model of structure, process and outcome is a construct where through each component is influenced by the previous, making the factors dependent.¹⁷ Thus, the aim of this study was to survey visit quality at provincial level (Sheikh Al Raeis of Tabriz Province), and provides data on factors affecting it.

METHODS

A cross-sectional study was conducted in Tabriz city, during autumn (14 August to 26 September) 2015. The study population included all patients referred to the outpatient of Sheikh Al Raeis of Tabriz Province. Using the results of a pilot study, the minimum sample size was estimated 540 participants were estimated using the following formula. (d=20 second, σ=237 second and Z=1.96). Sampling method was systematic random that were classified alphabetically.

A researcher developed checklist was used to collect data. This checklist included three parts: The first part related to Structural quality of visit (9 question), second part contains process quality of visit (18 question) and the third part was outcome of visit (1 question). Also, checklist included characteristics of patients and physicians such as: Demographic variables of patients and physicians, visit length and waiting time. All variables studied were based on previous studies and expert views.

Checklist validity was measured by indicators of Content Validity Ratio (CVR) and Content Validity Index (CVI). CVI was found to be 73% and CVR was found to be 81%. Data collection was conducted by researcher. Children under 12 years old who attended with a parent were included in our study and the parent was requested to complete the questionnaire.

Descriptive statistics were used to present quantitative and qualitative variables respectively. Data entry and analysis was done using SPSS.

RESULTS

A total of 540 patients were surveyed: 231 (42.8%) males and 309 (57.2%) females. Patients were aged between 0 and 78 years. The majority of patients were female, lived in Tabriz, 63.90% were married, and 98.10% have insurance. The findings of other demographic Characteristics of patients are shown in Table 1.

Table 1: Demographic characteristics of patients (n=540) and physicians (n=46)

The results showed that the average of visit time was 8.52 (3.14) minutes and waiting time was 101.57 (50.68). There was significant difference between the mean of visit times and standard of visit time (20 minutes) among specialties. Visit time of nutrition specialists was significantly longer than others among specialties. On the other hand, waiting time of patients was significantly longer than others for general surgery 138.50 (45.68) (Table 2).

Table 2: Waiting time and visit time of patients according to specialties (n= 540)

About quality components, the results showed that the structural quality was found to be 50.82%, process quality was found to be 62.69% and outcome quality (patient satisfaction) was found to be 51.36%. Other results are shown in Table 3.

Table 3: Quality of physician visits outpatient clinics of Sheikh Al Raeis in Tabriz Province

Results showed that structural quality was longer than others for general surgery (43.75%). Process quality was longer than others specialties for nutrition (81.94%). The rate of satisfaction (outcome quality) was longer than others Specialties for Cardiology (80%).

DISCUSSION

The health evolution plan of Iran is designed to grant the public fair access to health care, increase equity, cover health expenditure and promote the quality of health services that people receive.¹⁶ On the other hand, an important part of patient satisfaction derives from a dynamic interactional process with medical personnel. Doctor-patient relationship is acknowledged as a key determinant of a successful medical consultation.^17,18

Assessment of quality components showed that the structural quality was found to be 50.82%, process quality was found to be 62.69% and outcome quality (patients’ satisfaction) was found to be 50.82%. According to the health evolution plan is expected to be much higher than evaluated rate.

Kuusela et al showed that GPs with a capitation-based contract assessed the quality of their work higher and consultation quality was good for professional skill, communication, consultation conditions, duration of the consultation and number of examinations and treatments.²⁰ The results of the factor analysis in Golan’s study identified interpersonal processes (5 items), the technical processes (12 items) and the outcomes (5 items).The results of his study showed that quality average in interpersonal processes, the technical processes and outcomes were 4.62, 4.44 and 4.18, respectively. This global perception derives from patients’ perception of the physician’s professional and interpersonal relationships as well as from the outcomes of health care.²¹

In Table 4, factors of visit services quality based on Donabedian model are shown. These factors surveyed for specialists in the plan of health sector evolution.

Table 4: Factors of visit services quality in plan of health sector evolution