Tandin Chogyel¹, Namgyel Lhendup¹, Ugyen Dema Dorji², Tshering Choeda³

¹Traditional Medicine Division, Department of Health Services, Ministry of Health, Thimphu, Bhutan.

²National Medical Service, Thimphu, Bhutan.

³Faculty of Post Graduate Medicine, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan

Corresponding author: Tandin Chogyel, Traditional Medicine Division, Department of Health Services, Ministry of Health, Bhutan.

Email: tchogyel@health.gov.bt

DOI: https://doi.org/10.47811/bsj.0003050304

ABSTRACT

Background: Assessing patient satisfaction is a vital component of any robust health service. In this study, we assessed the level of patient satisfaction with the TM services across health facilities in Bhutan in 2023..

Methods: This study was a cross-sectional study conducted among adults availing TM services between March and April 2023. Patient satisfaction was scored against given statements on a Likert scale. Data were analysed to examine the overall levels of satisfaction with TM services.

Results: There were 353 respondents surveyed across 46 TM units. Patients reported high satisfaction scores on the cleanliness of the health facility and its toilets, availability of sitting facilities in waiting rooms, clarity of direction and signage in the hospitals, and good communication skills of receptionists and TM practitioners. High scores were also recorded on the time provided by TM practitioners to patients and the ability to receive timely care. However, patients reported lower scores on the availability of all amenities for the drungtshos to provide the desired services to the patient. However, only 44.41% of participants reported adequate satisfaction with the services. The domain-wise satisfaction scores: satisfaction (44.19%), Physical environment (31.44%), Courtesy (52.12%), Quality of care (48.48%), Interpersonal (56.37%), Communication (56.37%), Time spent with health professionals (28.61%) and Accessibility and convenience (37.68%).

Conclusions: Only four in every ten participants were highly satisfied with Traditional Medicine services at various public health facilities in Bhutan. Such patient satisfaction surveys serve as a benchmark for quality improvement initiatives.

Keywords: Alternative Medicine; Health Services; Patient Communication; Patient Satisfaction; Quality of Care

The assessment of patient satisfaction is an important indicator of quality of care [1]. To improve patient experiences and patient outcomes, it is now recommended that patient satisfaction is assessed as a routine measure as per the national quality standard, Bhutan Healthcare Standard for Quality Assurance [2]. At the level of health facility, managers and administrators make use of patient satisfaction surveys to provide tailor-made services to meet the expectations of the patient’s needs [1]. At the level of policymakers, such patient outcomes serve as a benchmark of quality indicators [3].

The components of patient satisfaction assessment include convenience in availing the services, opportunities to meet doctors and get investigations done, receipt of prescribed medicines and opportunities to receive treatment and follow-up advices [3]. From a health system perspective, this includes the availability of health personnel at the centre, waiting time before consultation with doctors, waiting time for investigations and waiting time in obtaining prescribed medicines. In addition, one of the most powerful predictors of client satisfaction with government hospitals is a positive client experience such as politeness and respect while interacting with healthcare staff. In fact, this positive client interaction is perceived to be more important than the technical provider’s competence.

Traditional Medicine in Bhutan became a part of the national health care system which has been integrated into the general health care delivery system since 1967. As the healthcare system expanded to cover the population living in all 20 districts, Traditional Medicine Units are co-located with modern hospitals [3]. Such an approach not only offers a choice to people for their disease conditions, but provides opportunities to address aspects of disease prevention and health promotion. While it is generally understood that TM services are well received by the patients, it was considered to assess patient satisfaction from a quality improvement perspective.Therefore, this study was conducted to assess the satisfaction level with outpatient TM services at various health facilities in the country.

Study design

This was a cross-sectional study conducted among patients visiting 46 TM Units across the country including the National Traditional Medicine Hospital between 1 March and 30 April, 2023.

TM services are provided through a three-tier system where TM Units are co-located with modern hospitals under one roof. As of 2023, there were a total of 80 TM Units in the country. TM Units are located at 30 Primary Health Centres, 25 Ten-bedded Hospitals, 22 district hospitals and two regional referral hospitals [4]. At the apex level, the National Traditional Medicine Hospital with 20 beds, is located separately at Kawang Jangsa, Thimphu. In 2023, there were 195 TM practitioners, 56 drungtshos and 139 menpas.

This study included patients aged 18 years and above who received services at 46 TM Units across the country: 17 Primary Healthcare Centres, 12 ten-bedded hospitals, 14 district hospitals and three referral hospitals. All patients who were able to answer the questions independently and provided informed verbal consent were included. A stratified random sampling was implemented with every fifth patient registered for the day invited to participate in the study. Among the first five patients, the first participant was selected based on the lottery method.

For this study, the data collection tool was adapted from Patient Satisfaction Questionnaire Short Form (PSQ-18) [5]. The questions that were applicable to government hospitals were selected and pre-tested on 20 patients at the National Traditional Medicine Hospital for improvement of its contents, clarity and conformity in February 2023. The study tool contained 23 items under the domains such as general satisfaction, physical environment, courtesy, quality of care, interpersonal manner, time spent by health professionals, communication and accessibility and convenience Table 1.

Eight data collectors were trained by the research team on the interpretation of the study questionnaire in local language. The interviews were held by telephone call after verbal consent.

The data was collected using Google Form and exported into Google Sheet. Statistical analysis were done using STATA version 14 (StataCorp, LP, USA). Categorical variables are summarized as frequencies and percentages and continuous variables are summarized as mean and standard deviation.

Satisfaction was measured using a positively-coded five-point Likert scale (i.e., 1 = “strongly disagree”, 5 = “strongly agree”). The sum of the total score for satisfaction was divided using the 75th percentile as the cut-off point between the two groups, high satisfaction and low satisfaction. The respondents at or above the 75th percentile were considered as highly satisfied; those below the 75th percentile were in the low-satisfaction group [5].

Ethics approval was obtained from the Research Ethics Board for Health, Ministry of Health. Administrative approval was obtained from the Policy and Planning Division, Ministry of Health and respective hospital administrators. Informed verbal consent was obtained from each participant.

RESULTS

Patient satisfaction assessment themes

Some of the key items with the majority positive scores were noted in the cleanliness of the healthcare facility, having clean toilets at the facility, availability of sitting facilities in the waiting rooms and clarity of directions and sign boards.

There were majority positive scores on the hospital receptionist’s timeliness and punctuality, receptionists being friendly, and clarity of information provided by receptionists.

Health workers were available to explain the reason for medical examinations and the majority were friendly towards patients. Very few patients reported drungtshos not spending adequate time with patients. While the majority of the patients were able to receive all TM care from the hospitals they visited, it was noted that only three-quarters noted that the health workers were supplied with everything needed to provide care to them. The details of patient responses against survey statements are shown in Table 3”.

The overall assessment of patient satisfaction was 44.41%. In terms of the domains, the major positive scores were noted in interpersonal manner (56.37%), communication (56.37%) and courtesy of health workers (32.12%). However, the domains where patients reported not-satisfied were time spent with a health professional (71.39%), physical environment (68.56%), accessibility and convenience (62.32%), general satisfaction (55.81%) and quality of care (51.56%). The details of the satisfaction scores across domains are shown in Figure 1.

While patient satisfaction surveys have been done on small scales across many hospitals, this is the first assessment of data representative of all districts. In the theme-based analysis, there were high levels of satisfaction scored on the cleanliness of hospital premises and the directions and signage. This positive outcome is a result of TM Units being co-located with allopathic centres. In hospitals across the countries, Infection Prevention Control measures, 5S Continuous Quality Improvement initiatives and biomedical wasteanagement systems are well instituted [6]. As these are factors that are directly related to patient safety and patient outcomes, these have been fully adopted by the TM Units. It has been shown in a study on practices of infection prevention and control practices and patient safety measures are fully adopted in the units that deliver invasive therapy services to patients.[7]

The respondents provided high scores on the reception team in providing information and directives to patients. This reflects a positive trend in many hospital-level trainings provided to train frontline service providers in patient communication.

The patients provided positive feedback on the patient communication skills of TM practitioners and the amount of time given to each patient. This reflects that the current volume of the patient load is adequate to meet the expectations of the patients. This finding is an affirmation on the integration of TM practitioners in the provision of counselling and mental health support to patients with chronic conditions such as malignancy [8]. TM practitioners are now increasingly involved as team members in providing palliative care services, albeit in only selected districts. Given the positive time balance reflected in this study, it maybe recommended that TM practitioners may be positively engaged in hospital-level health initiatives as active team members [3].

However, only 44.41% of the respondents reported that they were satisfied with the services available through the TM Units. This metric was based on the data translation of the original Patient Satisfaction Survey Questionnaire (PSQ-18) [5]. This represents an important area of intervention to identify the domains where improvements are required. Higher levels of dissatisfaction were scored on the physical environment, accessibility and convenience in availing of TM services. These parameters need careful consideration given that TM services are more suitable in selected conditions compared to allopathic medicine. Where TM Units are co-located with allopathic medicine services, providing TM services as a viable alternative serves to reduce patient load in the allopathic medicine units [8]. From a health system perspective, improving the quality and efficiency of TM services will improve the overall efficiency of the hospitals and the health system.

This study comes with some limitations. The data were collected over telephone calls due to a lack of time and resources for field visits. The original PSQ was modified to address the requirements of the TM system and the context of Bhutan. However, formal validity testing of this questionnaire could not be done.

While a proportion of patients reported high levels of satisfaction on selected domains related to availing TM services, the overall satisfaction was quite low. This is one of the first nationwide surveys on patient satisfaction in the TM sector and serves as an important benchmark. Such surveys are required in the future to track progress and improve the quality and efficiency of TM services in Bhutan.

Acknowledgement

We express our gratitude to Dr Karma Tenzin, Khesar Gyalpo University of Medical Sciences of Bhutan and Namgay Wangchuk, Ministry of Health for their support in conducting this study.

Declarations

Ethics approval was obtained from the Research Ethics Board for Health, Ministry of Health. Administrative approval was obtained from the Policy and Planning Division, Ministry of Health and respective hospital administrators. Informed verbal consent was obtained from each participant.

Consent for publication

Not applicable

Competing interests

None

There was no funding for this article.

The data set is available from the corresponding author upon request.

Conceptualization, data curation, methodology, resources, writing – review and editing: T Chogyel, NL, UDD, T Choeda

Investigation, software, validation, visualization, formal analysis, writing – original draft: T Chogyel

Received: 21 December, 2023   Accepted: 12 April, 2024   Published online: 16 May, 2024

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