Evaluation of the Quality of Services in Primary Health Care Institutions

Summary. The aim of the study was to evaluate patients’ satisfaction with the quality of provided services in private primary health care institutions in Kaunas. Material and Methods. A questionnaire-based inquiry of 280 persons registered to family physicians at primary health care settings was performed. The study was carried out using 20-item anonymous questionnaires with questions about the quality of services provided in primary health care settings. Results. More than 50.0% of the respondents stated that they waited for more than 15 minutes at the physician’s office, while 17.0% of the respondents stated that the waiting time exceeded 30 minutes. More than 25.0% of the respondents positively evaluated the possibility to consult their family physician by phone. In 67.0% of patients, the family physician determined the cause of the disorder and administered treatment; in 32.0% of patients, the family physician referred them to a specialist, and 1.0% of patients were urgently sent to hospital. More than 90.0% of the respondents were satisfied with the services provided by their family physicians. Those who were dissatisfied with these services indicated that the provided treatment failed to eliminate the disorder, that they wanted to be referred to a specialist, and that they expected more diagnostic tests to be performed for more effective treatment. Conclusions. A greater part of the patients indicated that the main reason for long waiting at the physician’s office was physicians’ wish to serve too many patients. More than two-thirds (67.0%) of the patients stated that their family physicians determined the cause of the disorder and prescribed treatment. The overwhelming majority (more than 90.0%) of the patients were satisfied with the services provided by their family physicians.


Introduction
There is no doubt that it is inadequate to follow only the evaluation of professional qualifi cation of medical personnel and statistical parameters of citizens' health (mortality, morbidity, rate of complications, and unemployment) while analyzing the quality of services provided by health care. Considering this, patients' opinion about the quality of services provided by health care institutions becomes an inherent part of quality evaluation. Patients can indicate what is of the greatest importance for them and what is less signifi cant by participating in the health care process directly. Patients' evaluations can be used while determining the weak sectors of health care, which should get more attention from the heads of institutions and state politicians. Patients' participation in this process, their cooperation with family physician and other medical personnel are directly associated with the correspondence to their expecta-tions and needs while using health care services (1).
A tendency to improve the quality of the provided services without increasing the expenses is dominating in Lithuania, as in current health care systems over the world (2). One of the main objectives of the providers of health care services is optimal satisfaction of patients' needs (3,4). It is being tried to provide citizens with high-quality services at the level that requires the least of expenses by refusing the ineffective and unnecessary services at the same time (5).
While evaluating the quality of the services provided by primary health care, it is focused on patient's attitudes toward the quality of the provided services (6). However, the majority of researchers claim that satisfaction with the provided services is very subjective and depends on patient's age, sex, education, stage of disease, his/her expectations, and personal experience (3).
The objective of this study was to evaluate patients' satisfaction with the services provided by Kaunas private primary health care institutions.

Material and Methods
Four Kaunas primary health care institutions were selected for the survey: UAB "Fama Bona," UAB "Eigulių šeimos sveikatos centras," UAB "Ars Medica," and UAB "Bendrosios medicinos praktika." This survey involved randomly selected patients who were registered to a family physician in these clinics at the time of their visit to clinics. A total of 280 persons were surveyed. This survey was carried out in 2009. A 20-item anonymous questionnaire, including questions concerning the quality of the services provided by the institutions of primary health care, was used in the study; in addition, the respondents provided data about their age, sex, education, income, and the main reason for choosing a private hospital. The chi-square (χ 2 ) criterion was applied for the comparison of the distribution of the analyzed features among the clinics. The differences were considered statistically signifi cant when P<0.05. Statistical data analysis was carried out using the statistical package SPSS 15.0.

Results
A total of 280 respondents were surveyed: 94 (33.6%) men and 186 (66.4%) women. The age of respondents ranged from 18 to 70 years. Less than one-third (32.0%) of the respondents were younger than 30 years, 64.0% aged 30 to 59 years, and 4.0% aged 60 to 70 years. Every second patient (56.4%) surveyed in a private hospital had higher education; 25% of the respondents had incomplete higher or secondary education. Patients who were registered in private clinics were divided according their positions as follows: the greatest part consisted of specialists/employees (45.4%), workers/technical staff (13.2%), businessmen (12.5%), and heads of the highest/middle level (10.7%). Less than half (45.9%) of the respondents reported that they visited a family physician very rarely (once a year), and 29.4% indicated that they visited to a family physician once in three months.
While analyzing the time patients spent waiting in a queue at a family physician's consulting room, it was determined that the situation regarding this issue was different in various clinics. The majority of patients waiting for more than 30 minutes were those at a family physician's consulting room in UAB "Ars medica" (17.0%); patients spent the least time waiting in the clinic UAB "Fama Bona" (5.4%) (Fig. 1). More than half (57.1%) of UAB "Fama Bona" patients waited at a family physician's consulting room not more than 15 minutes, whereas in UAB "Ars medica", there were 34.8% of such patients (P<0.05).
More than half (57.9%) of UAB "Fama Bona," 30.8% of UAB "Bendrosios medicinos praktika," 32.1% of UAB "Ars medica," and 41.7% of UAB "Eigulių šeimos klinika" patients indicated waiting in a queue at family physicians' consulting rooms too long because hospitals want to provide services for too many patients. Less than one-third (31.6%) of UAB "Fama Bona", 38.5% of UAB "Bendrosios medicinos praktika", 40.7% of UAB "Ars medica," and 8.3% of UAB "Eigulių šeimos klinika" respondents indicated that too little time was given to physician's consultation. A half (50.0%) of UAB "Eigulių šeimos klinika" patients and only 10.5% of UAB "Fama Bona" patients indicated too short working hours of a physician as the main reason of queues at a family physician's consulting room (P<0.05).
Patients' attitudes toward the possibility to be consulted by a family physician by phone differed among the surveyed clinics (χ 2 =21.576, df=12, P=0.043). One-third (33.3%) of UAB "Fama Bona" and 22.6% of UAB "Bendrosios medicinos praktika" patients reported they would consult a family physician by phone in future (Fig. 2). Mote than one-third (38.9%) of UAB "Fama Bona" and 35.5% of UAB "Bendrosios medicinos praktika" patients evaluated such services favorably; however, they said they would continue consulting with a family physician in hospitals. These services were negatively evaluated by 28.0% of UAB "Ars medica" and 33.3% of UAB "Eigulių šeimos klinika" patients. According to their opinion, in this way a physician can provide only general recommendations and cannot take responsibility for treatment without seeing a patient. The overwhelming majority of the respondents were satisfi ed with the services provided by family physicians in all the three clinics. More than half (54.7%) of UAB "Fama Bona" patients indicat-ed that they were very satisfi ed with the services provided by a family physician, whereas in UAB "Eigulių šeimos klinika," there were only 23.1% of very satisfi ed patients (P<0.05). Only 3.5% of UAB "Bendrosios medicinos praktika" patients and 7.3% of UAB "Ars medica" patients pointed out that they were not satisfi ed with the services provided by a family physician (Fig. 3). Differences in attitudes toward the services provided by a family physician in three clinics were signifi cant (χ 2 =12.904, df=6, P=0.045).
Patients' attitudes toward treatment administered by a family physician during the last visit were surveyed. Less than one-third (27.4%) of the surveyed respondents reported that during the last visit, a family physician, having listened to patient's complaints and without performing any diagnostic tests, Very favorably. I think I will necessarily use this service in future.
Favorably. This service is necessary, but in future, I personally will try to consult a physician individually in a hospital. Neutral.
Unfavorably. In this way, a patient can be provided only with general recommendations.
Very unfavorably. This is the legalization of charlatans; a physician cannot take responsibility for treatment without seeing a patient. determined the causes of ailment and applied the treatment, 39.7% indicated that a family physician had to perform several tests after which treatment was applied, and 31.8% indicated that after performing some diagnostic tests, they were referred to a specialist. Only 1.1% of the patients were immediately sent to a hospital by a family physician. The reasons for being unsatisfi ed with the services provided by a family physician were analyzed. More than two-thirds (70%) of patients that were unsatisfi ed with the services provided by a family physician indicated that the main reason of being unsatisfi ed was their wish to be referred to a specialist, 10% of the respondents indicated that a physician had to perform more diagnostic tests for more effective treatment, and 20% of the respondents reported that treatment did not eliminate the ailments.

Discussion
The assurance of the quality of health care combines to different processes that supplement each other, i.e., quality evaluation and quality improvement. Quality improvement is impossible without quality evaluation. However, evaluation is needed in order to improve quality later. It is possible to reach high quality only when services fully satisfy users' prior expectations or exceed them (7). It is very important to know the fl ows and needs of patients who come to a sector of primary health care while evaluating the quality of health care services and planning a correct distribution of primary health care centers and the scope of their work. Patients' attitudes toward the services provided highly depend not only on the results of the services (performed tests, surgery, prescribed medications, etc.), but also on many factors related to health care personnel attitudes toward patients and their interrelations. Not always the patients can evaluate the quality of services they were provided; however, they will always pay attention to the way a hospital's personnel communicates with him/her, if he/she was heard, if his/ her questions were answered, if a strategy of diagnostic tests and treatment was discussed with him/her, and if the principle of confi dentiality was followed (6). Mainly this determines patients' satisfaction or dissatisfaction with the services provided. Therefore, all the employees of hospitals, seeking to attract as much users as possible, should care about the quality of satisfaction of patients' needs. If the satisfaction of patients' needs is suffi cient, the majority of unsatisfi ed patients will try not to use the services provided by that hospital and will inform other potential patients about poorly provided services (8).
Bankauskaitė et al. performed a study, which analyzed the reasons of persons' dissatisfaction with the Lithuanian health care. This issue was analyzed at three levels: systematic, organizational, and in-dividual. At the systematic level, the dissatisfaction with the organization of the whole health care was indicated; it was reported that patients were unsatisfi ed with health care reform since it contained a lot of bureaucracy (physicians have to fi ll in a lot of documents although they could communicate with patients at that time), it was diffi cult to get to a specialist, and medicines were expensive. At the organizational level, a long period of waiting at physicians' consulting rooms and the shortage of equipment to perform diagnostic tests were indicated. At the individual level, patients reported that personnel lacked expertise and responsibility, too little information was provided and that those who had no money were provided with low-quality services (9). A study carried out by Petrauskienė et al. analyzed the main reasons of patients' dissatisfaction with the services provided by a family physician. During the study, patients indicated the following reasons: a physician paid little attention to patients, long period spent waiting at a family physician's consulting room (34.9% of the patients waited for 10-20 min, 34.8% waited for 20-40 min, and 30.3% of the respondents waited for more than 40 min), insuffi cient family physician's qualifi cation, and a physician did not refer him/her to a specialist (10). Our analysis revealed that more than 50.0% of patients waited at a family physician's consulting room for more than 15 minutes. A greater part of the patients indicated that the main reason of queues at a family physician's consulting room was a wish to provide services to too many people. The queues at a physician's consulting room testify about drawbacks of work. According to the data of a study carried out by Vladičkienė et al., physicians acknowledged that during the time intended for a meeting with a patient was not enough to fi ll in documents and to pay suffi cient time to a patient (11).
It has been reported that family physician's consultations by phone are not common practice in the state hospitals of Šiauliai. Only 5.6% of the patients visiting state hospitals and 15.2% of the patients visiting private hospitals were consulted by phone at least once during the last two years (10). In order to improve the accessibility and quality of health care, clinics should provide such services. According to the data of our study, 25.0% of the patients responded favorably about the possibility to be consulted by a family physician by phone.
A study carried out by Petrauskienė et al. showed that 69.6% of the patients were satisfi ed with the services provided by a family physician. It was reported that patients' satisfaction with the communication of a private hospital's family physician was almost twice higher than that of a state hospital's family physician (10). A study by Misevičienė et al. reported that the majority of patients were satisfi ed with the work performed by nurses and physicians. The evaluation of physicians' work was related to the level of patients' education: patients who had higher education evaluated the work of physicians more critically. While evaluating patients' satisfaction with the behavior of nurses and physicians, it was determined that every tenth patient participating in the survey evaluated nurses' work negatively; the number of those who evaluated physicians in this way was 3.6 times lower (8). We determined that the overwhelming majority (more than 90.0%) of patients were satisfi ed with the services provided by a family physician. Those who were unsatisfi ed with the services indicated that treatment did not eliminate ailments, they were not referred to a specialist, and they expected more tests to be performed for more effective treatment.
A patient, as a recipient of services, fi nds the availability of information about a hospital, its employees, and the provided services important since such information stimulates society members to use the appropriate services provided by a health care sector optimally and strengthens the role of a specific hospital, at the same ensuring advantage over other hospitals located in the territory, i.e., strengthens hospital's competitive ability. The provision of information about health condition is important when giving the greatest part of responsibility for their own health to the patients (12). A patient has to be informed about his/her health condition, diagnosis, process of treatment, purpose and means of tests, and possible side effects of medicines (13)(14)(15). Summing up, it is possible to claim that the quality of health care services is determined not only by resources, technical possibilities (variety of the provided services, level of medical technology, possibilities of medical equipment), but also by the fl exible application of the principles of modern management in the organization of work in hospitals.

Conclusions
1. More than 50.0% of patients waited at a family physician's consulting room for more than 15 minutes. A greater part of patients indicated that the main reason of queues at a family physician's consulting room was a wish to provide services to too many patients.
2. A family physician of 67.0% of patients determined the causes of ailments and administered treatment, 32.0% were referred to a specialist, and 1.0% of patients were immediately sent to a hospital.
3. The overwhelming majority (more than 90.0%) of patients were satisfi ed with the services provided by a family physician. Those who were unsatisfi ed with services indicated that treatment did not eliminate ailments, they wanted to be referred to a specialist, and they expected more tests to be performed for more effective treatment.