Palvelumittarin kehittäminen sairaalan poliklinikalla

Abstract

Tutkimuksen tavoitteena oli kehittää luotettava väline palvelun arvioimiseksi poliklinikalla. Viime vuosikymmenellä on voimakkaasti esitetty vaateita parantaa palvelua ja toiminnan laatua sairaalassa.

Tutkimuksessa kuvattiin yliopistollisen sairaalan palvelun sisältöä aikuisen potilaan kokemana, sovellettiin teollisuudessa prosessien laadunhallintaan kehitettyjä tilastollisia menetelmiä poliklinikan palvelun arvioinnissa, testattiin poliklinikan palvelun arviointia varten kehitetyn kyselylomakkeen luotettavuutta ja tutkittiin testausten tuloksena lyhennetyn kyselylomakkeen ns. palvelumittarin käyttökelpoisuutta.

Aineisto kerättiin haastatteluin, kyselyin ja mittauksin. Haastatteluista tunnistettiin palvelun sisältö, jossa oli 32 sisältöaluetta. Nämä voitiin ryhmitellä yhdeksäksi palvelun ulottuvuudeksi. Ulottuvuuksista viisi liittyi henkilöstön toimintaan, kolme potilaan osallisuuteen ja yksi hoitoympäristöön. Palveluna koettiin yhdessä hetkessä tai tilanteessa tapahtuva henkilöstön teko tai monivaiheinen vuorovaikutteinen toiminta, joiden ulottuvuuksina olivat vakuuttavuus taitavuudesta, aktiivinen huomaavaisuus, tiedon välittäminen, hyvien tapojen mukainen kohtelu ja joustava avuliaisuus. Potilaan osallisuuden ulottuvuuksia palvelussa olivat yksilöllisyys, asema sairaalatilanteissa ja potilaan kokema hallinnan tunne. Palveluun liitettiin myös hoitoympäristön mukavuus.

Haastattelutuloksista laadittiin kyselomake, jota testattiin ensin esitutkimuksessa. Tarkennetulla kyselylomakkeella tehtiin kolme kyselyä kolmella yliopistollisen sairaalan ja kahdella aluesairaalan poliklinikalla vuosina 1995 ja 1996. Näiden kyselyjen tulosten perusteella laadittiin 12 kysymyksen lomake, jota kutsutaan palvelumittariksi. Tätä mittaria on käytetty testauksen jälkeen yliopistollisen sairaalan poliklinikoilla vuosina 1997, 1998 ja 1999 yhteensä kuusi kertaa. Tutkimukseen osallistui yhteensä yli 10 000 henkilöä.

Tuloksena saatiin luotettava, helppokäyttöinen väline poliklinikan palvelun parantamiseksi. Mittarin käytön tuloksena havaittiin, että palvelun vahvuuksia poliklinikoilla olivat henkilöstön ammattitaito, kohtelu, palveluhenkisyys, potilaan asioiden salassapito ja potilaan kokema hyöty käynnistä poliklinikalla. Huonoimpia arviointeja annettiin etukäteen saadusta tiedosta käynnin kestosta, vastaanottoajan pitävyydestä ja tiedon saantiin liittyvistä asioista. Potilaat antoivat todennäköisemmin poliklinikkakäynnistään hyvän arvion, jos he kokivat hyötyneensä käynnistä, heitä kohdeltiin hyvin ja vastaanottoajat pitivät paikkaansa.

Tutkimuksen tuloksia voitaisiin hyödyntää parhaiten jos poliklinikoiden palveluprosessit tunnistettaisiin ja parannettaisiin potilaiden mahdollisuuksia ilmaista huonoja tai myönteisiä kokemuksia. Parantamistoiminnassa pitäisi puuttua tyytymättömyyden syihin ja sairaala voisi esitellä niitä parannuksia, joita on tehty potilaiden kommenttien perusteella. Huomiota pitäisi kiinnittää entistä enemmän selkeän ja tarkoituksenmukaisen tiedon antamiseen potilaille.

Jatkotutkimuksen voisi tehdä vertaamalla henkilöstön ja johdon näkemyksiä palvelun sisällöstä tai vertaamalla ison ja pienen sairaalan palvelua. Palvelukokemusta voisi kartoittaa myös koko hoitokokemuksesta ei pelkästään yksittäisestä käynnistä. Selvittää pitäisi myös millaisissa olosuhteissa ja millä menetelmillä saaduilla asiakaspalautteilla on kyetty konkreettisesti parantamaan prosesseja terveydenhuollossa.

Client perspective on developing hospital operations served as the starting point for the study. A staff survey conducted at the Tampere University Hospital in 1989, showing that only half of the staff perceived the quality of services as good, provided the background for the study. In Finland, approximately 6 million visits to outpatient departments are made yearly. Improvement of service quality in outpatient departments is of interest not only to patients but also to those who pay for the services. The fact that the assessment of action is the precondition for quality improvement is the basic tenet underlying the whole notion of quality.

In the course of the study, a patient-oriented instrument was developed to assess and improve service quality in outpatient departments. The study consists of four sub-studies. The first sub-study depicted the content of service at the University Hospital as experienced by adult patients. The second sub-study applied statistical methods of quality management to the assessment of outpatient services. The third sub-study tested the reliability of the instrument developed. The fourth sub-study tested the viability of the instrument by measuring service quality in outpatient departments of the University Hospital.

Data were collected by means of interviews, surveys and measurements. In all 10,603 persons participated in the study. The interview data were analysed using phenomenological analysis. The surveys were analysed using pareto analysis, box-and whiskers plot, control chart and logistic regression, and the measurements using control chart, logistic regression analysis and feedback system.

As a result of the interview study, the content of service was identified as consisting of 32 content areas. These were then defined more closely as nine service dimensions. Five of the dimensions were related to the staff's actions, three to patient involvement and one to care environment. Service was perceived as an act or multiphase interactive action carried out by staff in one moment or situation. The dimensions of these actions were assurance of competence, active attention, information-giving, flexible helpfulness and polite manners by staff. The components of patient involvement were individuality, position in hospital situations and sense of control perceived by patient. The comfort of the care environment was also a service feature. In the interviews, waiting for admission to the department and in the department and sufficient information were associated with emotional experiences, the staff's actions and the patient's means of control. Other patients were identified as helpers, supporters, source of information or companions.

A new version of the questionnaire was formulated based on the interview results and tested in a pilot survey. A questionnaire adjusted based on the results was used in three surveys in three outpatient departments of the University Hospital and in two departments of a regional hospital in 1995 and 1996. A 12-item questionnaire was devised as a result of the findings of these surveys. Following pilot testing, this version of the instrument has been used in the outpatient departments of the University Hospital in 1997, 1998 and 1999 altogether six times.

The clinic staff adopted the control chart ( /R -chart) as a tool for quality improvement measures. The control chart assisted in collecting and using systematic feedback perceived as important in quality improvement. A three-stage feedback system was devised to serve as the basis for improvement measures in informing the staff of the survey results.

The service quality instrument measures issues that were considered important but had received low ratings. The instrument proved to be a useful tool for assembling systematic feedback from patients. It helped detect long-term trends in the services provided by a large organisation.

The results indicate that professional skill, the staff's treatment of patients, service-mindedness, confidentiality and benefit from the visit as experienced by patients are strong points in outpatient departments' action. Information on length of visit, admission at appointed time and issues related to information-giving received the lowest ratings. The risk of a poor rating was decreased if patients perceived the visit to be useful, if they felt that they were treated adequately and were admitted at the appointed time.

In the study, follow-up of patient feedback collected in a large hospital's outpatient departments was conducted for a period of three years. During the follow-up period, access to information about the length of the visit seemed to improve due to the improvement measures. It was also evident that the instrument is sensitive enough to detect differences between the outpatient departments of different profit areas.

The study was concerned with measuring service quality in hospital outpatient departments as experienced by patients. The content of outpatient services was comparable to earlier accounts of service quality and it has many points in common with the content of caring. Service is involved in every aspect of the client-hospital staff interaction and not just in nurses' and physicians' surgeries or during nursing procedures but in all client and staff interfaces. The development process of a service quality instrument has not been reported earlier in Finnish health care.

The results of this study could be used for developing service quality in outpatient departments primarily by identifying the service process in the department in question, developing the services delivered, improving the feedback system and popularising patient information and by placing further emphasis on patient perspective.

Suggestions for further research include identification of the concept of service also from a staff and management perspective, measurement of service in a small hospital and of the client process and exploration of the extent to which the results have been deployed.