Bidirectional referral system between National Taiwan University Hospital medical center and Zhongxiao Branch community hospital of Taipei City Hospital: focus on patient satisfaction – Scientific Reports

The main findings of this study were as follows: the mean values of the overall satisfaction scores of medical care at the Zhongxiao campus (8.66) and bidirectional referral (9.00) were both above 0.70¹³; these are comparable with those reported in large scale researches¹⁴. Only the average of satisfaction scores of the administrative efficiency domain has a significant difference. The average of the emergent (ESI = 2) patient (mean = 3.792) is less than that of the urgent (ESI = 3) patient (mean = 4.3).Three independent variables, overall satisfaction scores of medical care at the Zhongxiao campus, waiting times for examination, treatment, and test, and the positive question on quality improvement of delivered care for patients and family, were the determinants that explained 69.3% variability (adjusted R square) of the overall satisfaction scores of bidirectional referrals.

The operational definitions of the three independent variables are as follows: waiting time is defined as the total time a patient spends in a facility from arrival at the registration desk until the time she/he leaves the facility or last service.

An overall satisfaction score is a measurement of overall satisfaction level through a one-question survey. It asks users to rate their experience with the services of hospital. Overalls answer based on a scale from “extremely dissatisfied (0)” to “extremely satisfied (10)”. Health organization can use the score to determine their satisfaction levels at crucial touchpoints like the overall evaluation with environment, administrative efficiency, service attitude, process, patient safety. Positive question on quality improvement of delivered care for patients and families means that the bidirectional referral can positively influence the quality improvement of delivered care for patients and families.

The cycle of plan-do-study-act (PDSA) can be used as the improvement guide and approach to enhancing the performance of health care organizations, using questionnaires as one kind of learning data with comprehensively statistical analyses to support improvement efforts¹⁵. Based on the theory of Nolan’s model, the cycle of plan-do-study-act (PDSA) can be used as a basis for the improvement of the bidirectional referral system between National Taiwan University Hospital and Taipei City Hospital¹⁶. In addition to traditional key performance indicators, such as morbidity and mortality¹⁷ and rate of transfer back to National Taiwan University Hospital, analyzing questionnaires dealing with patient satisfaction has become an important tool of evaluation in a specific domain of patient -centered care, leading to an improvement of the bidirectional referral system between National Taiwan University Hospital and Taipei City Hospital¹⁸. These questionnaires are multidimensional modalities and surveys that evaluate variable aspects of the delivery of health care.

There are important objective aspects of self-measuring metrics of the quality of the six dimensions (access to services, relevance to need, effectiveness for individual patients, equity, social acceptability and efficiency, and economy) of medical service¹⁹. Modalities of the evaluation of patient satisfaction include an interview in a hospital, telephone interview after discharge, traditional mails, e-mails, computer questionnaires²⁰, and document questionnaires¹⁷. Different aspects of patient satisfaction are as follows: timeliness^10,14,21, humaneness, cost²², patient-centered and shared decision making and shared informativeness^18,21,23, facilities, overall quality, outcome and quality of life²⁰, competence²⁴, continuity^21,22, courtesy and communication skills of health care providers^23,24, bureaucracy, attention to a psychological problem^14,18, cleanliness and hospital environment^17,24 and access⁹.

Although patient expectations and perceptions may be influenced by culture, characteristics of the patient²⁵, criteria of quality of patient⁷, previous experience and needs of patients, the concept of patient-centered care²⁶, and patient partnership strategy²⁷ equal patients as different medical knowledge experts and treat patients as partners. A systemic survey of patients’ perceptions, the expectation is important to improve the quality of modern health care of medical knowledge grown-up patients and their family.

Interventions to improve patient satisfaction may be important and valuable because there is evidence that satisfied patients are more likely to adhere to their health care routine. This, in turn, is related to effective treatment-related clinical outcomes¹⁴. Higher patient satisfaction means fewer demands for emergent department medical services²⁸. From the perspective of health care organizations, one of the chief reasons for surveying patient satisfaction is to find targeted information to improve delivered care under bidirectional referral processes in specific service areas. This is important because of the unpredictable nature of problems encountered in such referral programs.

Modifications must be made to achieve improvement in the determinants with a largely standardized beta coefficient in the optimization mode of overall satisfaction²⁴ among the vulnerable groups, which can represent the primary opinions of the referral patients from National Taiwan University Hospital to Taipei City Hospital, Zhongxiao campus. The average of overall satisfaction of Administrative Efficiency of the emergent (ESI = 2) patient (mean = 3.792) is less than that of the urgent (ESI = 3) patient (mean = 4.3). But, the results of determinants of multivariate regressions showed that the positive beta coefficient of waiting times for tests, examinations, and treatments represented the majority of the patients’ opinions in this referral program. Waiting times influence the perception of safety and confidence in the medical care system, which may change patients’ attitudes toward medical advice. From a management point of view, our findings may help healthcare providers organize limited resources more successfully in the patient satisfaction refinement program under the bidirectional referral between National Taiwan University Hospital and Taipei City Hospital, Zhongxiao campus. The traffic flow and each node of test, examination, and treatment of patients should be examined for improvement and modification.

Other types of waiting times, such as time spent in the waiting room, time with health providers, and consultation time with physicians, were not considered as the determinants of overall satisfaction of bidirectional referral in this study. Patient advisors can aid patients to complete survey questionnaires and thus avoid missing data¹⁷. The short duration between discharge and completion of survey questionnaires also decreases the recall bias. Other forms of satisfaction surveys, such as regular mail and telephone calls after discharge have the limitation of recall bias. Further, a hundred percent response rate after the administration of the questionnaires in this study eliminated selection bias. A previous study showed that waiting times more than 30 min may provoke low satisfaction¹⁴.

Additionally, in response to the open question, one respondent praised the medical personnel and nursing intern for their attitude. Therefore, screening items for specific domains referred to in open questions may improve the design of future questionnaires ^29,30.