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  Table of Contents  
Year : 2016  |  Volume : 53  |  Issue : 1  |  Page : 152-157

Perception of quality in a Radiation Oncology Department: Is it different for patients and health care providers?

Division of Radiation Oncolgy, Medanta Cancer Institute, Medanta - The Medicity, Gurgaon, Haryana, India

Date of Web Publication28-Apr-2016

Correspondence Address:
T Kataria
Division of Radiation Oncolgy, Medanta Cancer Institute, Medanta - The Medicity, Gurgaon, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.180840

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 » Abstract 

Aim: Patient satisfaction is increasingly being identified as an important benchmark in health care industry. Studies addressing patients' perceptions of quality are available but there is paucity of data regarding the perception of health care providers towards their own services. This study was undertaken to compare the satisfaction level between the patients and the staff from a Radiation Oncology Department.Materials and Methods: A common 16-item questionnaire addressing various aspects of patient care was served to 40 patients and 40 staff members. The responses were statistically evaluated to assess the satisfaction level among the two groups and the scores were compared to assess the agreement between two groups.Results: Overall, satisfaction level of both groups regarding quality of services ranged from “good” to “excellent”. A high level of agreement was observed between the two groups. The physician's ability to give an explanation to patients, helping attitude of the staff and the staff's concern for patient safety were the most satisfying features of the department while inconvenience during scheduling of appointments, billing and registration process, status of the changing rooms and inter-department coordination were the least satisfying features.Conclusion: A high level of satisfaction may be achieved from the consumers if service providers are trained to assess the needs and expectations of consumers and to critically evaluate themselves. The service provider's perception regarding their own services may serve as a preliminary indicator of overall quality. Future studies with more participants in different setting may further explore this hypothesis.

Keywords: Health care, patient, perception, quality-of-care, satisfaction, service-providers

How to cite this article:
Kataria T, Sharma K, Pareek P, Goyal S, Gupta D, Abhishek A. Perception of quality in a Radiation Oncology Department: Is it different for patients and health care providers?. Indian J Cancer 2016;53:152-7

How to cite this URL:
Kataria T, Sharma K, Pareek P, Goyal S, Gupta D, Abhishek A. Perception of quality in a Radiation Oncology Department: Is it different for patients and health care providers?. Indian J Cancer [serial online] 2016 [cited 2022 Jun 26];53:152-7. Available from:

 » Introduction Top

Health care system is a service based industry where patient satisfaction is of utmost importance.[1] Health care delivery in India is changing fast and is getting into public versus private medical care transition since early nineties.[2] These trends make it important to maintain the service quality at the highest possible standards for which it is important for health care institutions to keep a continuous check on their own quality indicators.

There is often a gap in perception of quality between patients and health care providers. While the health care provider remains satisfied with their service quality, the patients may not have the same perception at all. The continuous patient feedback and health care provider's insight into their own system may prove an efficient tool to realize the goals of modern health care systems.

Current research in health care management is focused on improving the quality of services delivered to patients.[3] In literature, it is easy to find studies on patients' (consumer) perception and satisfaction with health care services, but it is unusual to find studies where perception of service providers (health care providers) is taken into account. There is no study where head on comparison has been done using the same questionnaire served to the two groups at the same time. Moreover, most studies are from developed countries where they are mostly limited to the non-oncology settings.[1]

Thomas et al. investigated satisfaction in 252 patients of an oncology clinic in Middlesex University and reported that 92% were satisfied after their visits and showed that clinical staff was the most important source of satisfaction for patients.[4] Patient satisfaction has been correlated with the level of communication between the patients and health care providers and patient satisfaction is the most widely used outcome measure to assess a doctor's communication skills.[5] In a study, where quality of life and satisfaction questionnaire was studied simultaneously, satisfaction rates were found to be independent of the final treatment outcome.[6] Thus for a patient to be satisfied with the health care services, it is not always necessary to attain cure.

Various Italian [7],[8] and British studies [9] reported strong and weak points of their services brought out by patient satisfaction surveys and took measures to rectify their problem areas. These studies have later shown a positive impact on improving the health care services.

As of today, there is no consensus regarding the best available method to measure patient satisfaction.[1] Numerous studies have been published to find out such tools. The European Organization for Research and Treatment of Cancer IN-PATSAT32 questionnaire is one such validated and frequently used tool.[10],[11] Bredart et al. attempted to develop a “comprehensive assessment of satisfaction with care” (CASC) survey with 61-item questionnaire to evaluate the competence of physicians and nurses along with hospital care and environment.[12] Similar attempts were also reported in SERVQUAL instrument [13] from M D Anderson Cancer Center and FAMCARE scale [14] from University of Manitoba. During last few years American College of Physicians launched various projects containing different tools to assess patient satisfaction at various stages of their treatment.

These tools serve to get a firsthand feedback regarding the quality of care in a health care institution and point out the deficient areas. Such feedback becomes more important in oncology, where patients are treated over a longer time when they tend to become familiar with the system to provide a valuable feedback. Moreover, Oncology patients have longer follow-up durations and poor quality of services may result in loss of follow-up information. Thus, patients' satisfaction with health care services can have a significant impact on their overall treatment experience and the hospital's overall performance.

This study/survey was initiated to identify the overall satisfaction level among cancer patients. Another goal was to assess the perception of the health care providers regarding the same quality parameters at the same time and to correlate the perceptions of the two groups. The feedback would provide information that can be forwarded to the hospital administration to take necessary steps.

 » Materials and Methods Top

This study was conducted in the division of Radiation Oncology, an integral part of a 1600 bedded tertiary care, state-of-the-art hospital located in Haryana, India. This hospital is functional since 2009. The division of Radiation Oncology started its operation in February 2010 and provides comprehensive Radiation Oncology services. The division provides out-patient consultations, tumor boards, in-patient care, daycare facilities and follow-up services besides radiation treatments. The division is equipped with two high-end linear accelerators, a cyber-knife- (highly precise robotic linear accelerator) along with an advanced brachytherapy unit. Patients are treated on these machines on outpatient basis with prior appointments. The division has 13 doctors, seven medical physicists, 13 radiotherapy technologists along with a team of nursing staff and patient care executives.

The hospital is located in Delhi-National Capital Region. This region is economically amongst the most prosperous regions of the country and a great extent of immigration in this region makes it a melting pot for various cultural and social groups. Additionally, the hospital is a major referral center and caters to a wide range of patient population with different backgrounds. Apart from the patients of neighboring areas, the hospital receives a significant number of patients from countries outside India. The employees of this department are trained from institutions across India and are a mix of different educational and cultural background. These mixed features make this institute an ideal place to conduct unbiased surveys.

Patients receiving radiotherapy in the division of Radiation Oncology and the staff members (including radiation oncologists, radiation physicists, radiation technologists, oncology nurses and patient care executives) were invited to participate in this survey. A questionnaire in English language containing 16-items was served to 60 consecutive patients and to 40 staff members during January 2012. The sample size was selected to keep the power of the study to be more than 80%. The questionnaire was offered to the patients irrespective of their demographic features. Everyone from the department was included in the survey except the study authors to exclude any bias. The IN-PATSAT32 and CASC questionnaire were used for survey after completing the user's agreement formalities. Some of the original questions were tailored, added or eliminated, based on the feedback and concerns received from our patients in the past. The final questionnaire consisted of 16-items to measure the patient appraisal of hospital doctors and nurses along with other aspects of organizational care and services like technical competence, information provision, interpersonal skills, availability of doctors for consultation, waiting time, departmental access, comfort and overall care. The questionnaire used 5-point scale as “poor,” “fair,” “good,” “very good,” or “excellent” to rate each aspect of health care.[15]

A senior nurse explained the purpose of survey to the willing participants and assured them the desired confidentiality. Doctors did not serve the questionnaire to eliminate any possible bias. The completed questionnaires were used for data compilation and statistical analysis. Responses to the questions scaled from '1' being poor to '5' being excellent, and then arithmetic mean, median etc., were calculated for statistical analysis. Arithmetic mean and standard deviation (SD) was calculated for each item of the questionnaire for patients and service providers separately and then collectively for the entire cohort. The scores for each questionnaire were compared between two groups. The level of significance was set to 0.05 for all tests. Software SPSS version 15.0 for Windows (SPSS, Inc., Chicago, IL) was used for statistical analysis.

For the purpose of analysis, the responses rated as “excellent,” “very good,” and “good” were collectively considered as “satisfactory” and the responses “fair” and “poor” were deemed as “unsatisfactory.”

 » Results Top

Overall, 80 completed questionnaire were received,

20 questionnaires from patient group were excluded as they were either incomplete or wrongly marked. Doctors, medical physicists, technologists, nurses and patient care executives were the participants from the health care provider group. The characteristics are shown in [Table 1] and [Table 2].
Table 1: Patient characteristics

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Table 2: Health care provider's characteristics

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The mean with SD for each item of the questionnaire was calculated for each of the two groups in order to compare the satisfaction level between them. There was a high degree of agreement between the perception and satisfaction level of the two groups. There was no conflict in any item as depicted by the non-significant P value for all the responses except the question regarding the quality of nursing services (item-16). The results reflect the staff's concern towards their patients and a high-level of awareness regarding the quality of services being offered in their own department. This may be a result of an optimum level of interaction between the two groups in this department such that the staff constantly remains updates about the concerns and complaints of their patients. Another contributory factor may be the appropriate level of staff to patient ratio in the department, which increases the opportunity of such interaction. [Table 3] and [Figure 1] and [Figure 2] depict and compare the score for each item of questionnaire.
Table 3: Mean overall scores, patients' score and health care provider's score for each item of questionnaire

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Figure 1: Comparison of the mean score of each item of questionnaire as reported by the patients (blue) and the health service providers (red)

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Figure 2: Chart showing the combined mean (overall score) for each item of the questionnaire

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The arithmetic mean for each question was above '3' for both the groups separately as well as when analyzed collectively [Figure 2], which suggests that the patients and the staff members were satisfied with all aspects of services. Although, there was an overall perception of satisfaction there were certain stronger and weaker points in the system, which scored above and below the mean [Table 4] and [Table 5].
Table 4: Most satisfying points of the department

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Table 5: Least satisfying points of the department

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When studied collectively for 80 participants, the most satisfying points of the department were in the following order:

  1. Ability of doctors to explain the diagnosis, treatment and prognosis to the patients in a way that they understand (4.54 ± 0.62)
  2. General courtesy and willingness of staff to help (4.45 ± 0.65)
  3. Ability of staff to explain the procedure/treatment to patients (4.40 ± 0.69)
  4. Staff's concern for patient comfort and safety (4.40 ± 0.62)
  5. Overall appearance and layout of department (4.34 ± 0.75).

Similarly, the least satisfying points of the department were:

  1. Level of coordination with the staff members of other department/services (3.78 ± 0.93)
  2. Layout, arrangement and convenience in changing rooms (3.73 ± 0.98)
  3. Adherence to the time of scheduled appointments in the department (3.71 ± 1.0)
  4. Service provided during registration/billing (3.61 ± 1.12)
  5. Explanation offered for the long wait or other discomfort/problem (3.51 ± 1.06).

 » Discussion Top

The present study was completed well in time and there were no refusals, although there were incomplete questionnaires. This may partly be due to the fact that the sampled participants appreciated our effort to improve upon our services, which is generally an uncommon practice in Indian hospitals.

Most of our observations regarding the patients' demographic features were consistent with the general trends among Indian cancer patients. The educational levels were above the national average but consistent with the area the hospital is serving. Only one patient was illiterate in which case his attendant was given the liberty to complete the questionnaire on his behalf. Majority of the patients paid the treatment expenses from their own pocket which is consistent with the general trend in India where health insurance is still not popular among general population.[16]

There was no aspect of care where either the patients or health care providers reported “dissatisfaction.” The overall scores were better than those reported in other studies carried out in the similar settings.[4],[15] This may reflect the high level of quality being maintained in this department while providing patient services. It is unknown as to what level Indian patients are generally satisfied with the health care services in a similar setting, so it was not possible to compare our results with any background study. No group has yet reported the cancer patient's perception of health care services in formal manner in Indian context.

The questions regarding the attitude of the staff and communication between patients and staff scored very high in our survey [Table 4]. This emphasizes the importance of communication in quality patient care. It has been seen that providing adequate information to cancer patients through effective communication can reduce anxiety and improve their compliance.[17]

This study suggested that there can be a high level of agreement in perception of quality between patients and health care providers if it is analyzed in proper and transparent manner. One interesting observation was the higher level of agreement regarding the least satisfying points of the department versus the most satisfying points. This represents the critical evaluation of services by the staff, where they always try to register the weaker points reported to them by patients from time to time. The significantly higher score given by patients to the quality of nursing services as compared to that given by staff further proves this fact [Table 3]. This also reflects the department's dedication towards superior education and training in patient-care and constant efforts for improvement. Thus, the survey of the health care providers regarding their perception may reflect the overall quality of care if the surveys are conducted in an unbiased manner. Such surveys are quick and provide preliminary information regarding the quality of services being offered in any department. However, in no way they can replace the conventional form of feedback surveys completed by the patients themselves.

The reported shortcomings suggests that even after achieving high-level of satisfaction among both groups, there is still a scope for improvement in certain areas. For example, the scheduling of appointments can be made more efficient by designating permanent staff for a specific purpose rather than changing them frequently because managing patients in radiotherapy department requires training and the health care personals learn it over time. Likewise, the inter-department coordination can be improved by stressing upon a better communication among various departments. This can be achieved by wider use of computerized hospital information system and by conducting frequent cross-specialty meetings. Some of the least satisfying services are beyond the direct control of Radiation Oncology Department like the registration and billing process or the pathology, radiology and laboratory services which might have influenced the question regarding inter-department coordination. These issues may be reported to the hospital administration in terms of staff and resource allocation (i.e., more advanced software and training courses for patient interaction) and may be assessed in future again.

Although this study provided relevant observations there were certain shortcomings. Firstly, this study was conducted in a private institution generally serving higher income groups. It may not be an ideal representation of the general population in the Indian scenario. Moreover, this was a single center study and the results are representative of an urban and industrialized region.

The study was conducted in a comparatively new private hospital having all the modern facilities for patient treatment and comfort. The satisfaction level of patients in such a center is usually high because Indian patients generally do not expect such standards of hospitality and personal attention in hospitals. The perception may change in future when similar hospitals become common in India. This picture may be entirely different in public hospitals where the goal is to provide basic health care to the maximum number of patients. Thus, these results cannot be directly extrapolated to other health care services. In future, similar studies may be conducted in public hospitals to assess the trends in quality perception in those settings.

In this study, we could not include non-Indian patients as the questionnaire was available in English language only. The results may be different if non-Indian patients or the patients familiar with health care services from developed countries are included. Such patients may be included in future studies to assess the difference in their perception.

The survey was conducted in Division of Radiation Oncology, where patients are generally treated over a longer duration while they develop a rapport with the staff. This may influence their perception and reporting. The same may not hold true in other departments where patients come for shorter durations and may be having an altogether different perception.

Lastly, it was a cross-sectional study and the results may vary if the same questionnaire is tested in a longitudinal manner during a patient's treatment. Future studies should aim to assess patients' perception at different time points like before, during or after treatment. This may provide an entirely different dimension of patients' perception.

Overall, this study emphasizes the utility of feedback from the patient as well as from health care providers in the health care system. Although the results cannot be generalized to other populations, this study can be used as a guide for future studies. A follow-up study across different types of hospitals with more number of participants may be carried out in future to evaluate the impact of various parameters in perception of quality and the satisfaction levels.

 » References Top

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Di Palo MT. Rating satisfaction research: Is it poor, fair, good, very good, or excellent? Arthritis Care Res 1997;10:422-30.  Back to cited text no. 3
Thomas S, Glynne-Jones R, Chait I. Is it worth the wait? A survey of patients' satisfaction with an oncology outpatient clinic. Eur J Cancer Care (Engl) 1997;6:50-8.  Back to cited text no. 4
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Brédart A, Razavi D, Robertson C, Didier F, Scaffidi E, Fonzo D, et al. Assessment of quality of care in an oncology institute using information on patients' satisfaction. Oncology 2001;61:120-8.  Back to cited text no. 12
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Kristjanson LJ. Validity and reliability testing of the FAMCARE scale: Measuring family satisfaction with advanced cancer care. Soc Sci Med 1993;36:693-701.  Back to cited text no. 14
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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