PATIENT SATISFACTION AND QUALITY OF CARE OF THE INTERNAL MEDICINE SERVICE OF HOSPITAL DANIEL ALCIDES CARRIÓN. HUANCAYO-PERU

Cite as: Richard J. Febres-Ramos, Miguel R. Mercado-Rey. Patient satisfaction and quality of care of the internal medicine service of Hospital Daniel Alcides Carrión. Huancayo Peru. Rev. Fac. Med. Hum. July 2020; 20(3):397-403. DOI 10.25176/RFMH.v20i3.3123 ABSTRACT Introduction: Patient satisfaction is an indicator of the quality of care provided in health services. Knowing the level of satisfaction will improve deficiencies and reaffirm strengths to develop a health system that provides the quality care that patients demand. Objective: To determine the satisfaction of the quality of service of patients of external Internal Medicine consultation of Hospital Daniel Alcides Carrión Huancayo, from July to November 2016. Methods: Observational, descriptive, cross-sectional study. The sample consisted of 292 patients. The quality of service in the health system according to patient satisfaction was measured using the standardized SERVQUAL questionnaire. Results: 57% of the sample was female, the ages of the participants ranged from 36 to 45 years. Similarly, 36% of users had complete secondary education and 63% were continuing patients. Overall satisfaction was 60.3%. The percentage values depended on the dimensions of safety and empathy with 86.8% and 80.3% satisfaction, respectively. The highest level of dissatisfaction was obtained by the dimension of tangible aspects with 57.1% of dissatisfied users, followed by the dimension of responsiveness of health services with 55.5% of dissatisfaction. Conclusions: the health system must implement strategies to improve care services to provide timely and quality care to users.


ORIGINAL PAPER
Article published by the Magazine of the Faculty of Human Medicine of the Ricardo Palma University. It is an open access article, distributed under the terms of the Creative Commons License: Creative Commons Attribution 4.0 International, CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/), that allows non-commercial use, distribution and reproduction in any medium, provided that the original work is duly cited. For commercial use, please contact revista.medicina@urp.pe

INTRODUCTION
One of the strategies currently used to reduce inequality in society has been the development of strategies to improve the quality of health services (1) . The concept of quality in health in general, abstract, objective, and subjective. It is explained in the function of multiple dimensions, which are influenced by the cultural process and by the actors of power. Donabedian defines quality in health as the ability of health services to provide the greatest benefits with the least risks for the user depending on the resources available and the prevailing social values (2) .
Initially, user satisfaction studies only assessed the characteristics of products as their main attribute, measuring the reward for the investment based on its effect on the health of the users who access such services (3,4) . According to this, satisfaction is considered as the result of a cognitive process of information, which mediates between the expectations of the user and what is provided by health services (perceptions). In this sense, the quality of care that a health institution must provide is perceived by the characteristics of the care process: the interpersonal relationship, the content of the query, the duration, the actions, the clinical actions of review and diagnosis; by the result in their health, by the characteristics of the physical, human and organizational structure, with and by conditions relating to accessibility (5,6) .
User satisfaction is reflected when their expectations were reached or exceeded by what was provided by health services. In this sense, quality is the ability to meet user expectations widely (7)(8)(9)(10) .
User satisfaction is a fundamental indicator in terms of quality care in health services. For this, the SERVQUAL instrument is available, which objectively measures the quality of care of health services according to the level of user satisfaction. The data obtained through this instrument will enhance the ability to respond to the demand of the Health Care Provider Institutions (11)(12)(13) .
The quality of care provided by health services measured through the level of user satisfaction is an important evaluation of the current health system. Therefore, this research aims to provide relevant data that reflects the current status of the service provided by health care providers to correct possible deficiencies and to enhance the current strengths of health services.

Design and setting
Observational, descriptive, cross-sectional study, performed in the External Internal Medicine consultation of Hospital Daniel Alcides Carrión (HDAC) in Huancayo, during the period from July to November 2016.

Population and sample
The population studied was made up of 10 726 patients who were seen by external consultation. The sample was calculated using a finite population formula, with an expected frequency of 26% (14) , obtaining a sample consisting of 292 patients.

Variables and instruments
To measure the quality of service offered by the health system, the standardized SERVQUAL questionnaire was used. The validation of the questionnaire showed a KMO sample adequacy measure of 0.975 correspondings to outpatient care and 0.957 to emergency care. Furthermore, the instrument had a Cronbach's alpha coefficient of 0.98, which makes the instrument highly reliable (15) .
The SERVQUAL survey consisted of two sections, the first assessed the user's expectations and the second survey, the perception of the service provided. The structure of the questionnaire of the SERVQUAL model consisted of 5 dimensions and 22 items in total. To determine the importance of each item, a Likert scale 3 is handled from 1 to 7, where 1 represents the lowest score, i.e., when the user is in total disagreement, and 7 represents the highest score, i.e., when the customer is very in agreement with the question (16) .
The data of the variables age, gender, educational level, type of insurance, and type of user were recorded in a data collection sheet.

Procedures
The section of the questionnaire that evaluated the user's expectation regarding the service provided was applied fifteen minutes before patient care by an external office. Once the consultation was completed, the second part of the survey was applied, which corresponded to the evaluation of the user's perception of the service received.

Statistical analysis
The data collected in the surveys were processed in Pág. 399 the Windows 10 Excel 2015 program. The descriptive results of the analysis of the variable's perception of quality, quality of care, and those corresponding to sociodemographic aspects (age, gender, educational level, type of insurance, and type of user), were evaluated using frequencies and percentages and presented in tables.

Ethical aspects
This study had the authorization of the Unidad de Docencia e Investigación del Hospital Nacional Daniel Alcides Carrión-Huancayo for its execution, it was also approved by the ethics and research committee of the Universidad Peruana Los Andes. Likewise, this research respected the ethical principles corresponding to autonomy, justice, beneficence, non-maleficence.
In this study, the confidentiality of the data collected was guaranteed by not disclosing the names of patients or companions or any data or information that may allow their identification. The data was only used for the study.

External Internal Medicine consultation of hospital Daniel Alcides Carrión
The study sample consisted of 292 patients who attended the external Internal Medicine consultation of Hospital Daniel Alcides Carrión in Huancayo. 61.0% of the total sample was female, with the most frequent ages ranging from 36 to 45 years. 34.0% of the patients had a complete secondary school, 66.0% had Seguro Integral de Salud (SIS) and 67% were continuing patients. These and other sociodemographic data are shown in Table 1. The level of satisfaction of the total sample evaluated was 60.3%, and 39.4% of the patients attended were dissatisfied with the care received. Concerning the quality of care, 86.8% and 80.3% of users showed that they were satisfied with the security and empathy provided during the time of care, respectively.
Tables 2 to 6 detail the percentages of satisfaction and dissatisfaction of the users of the HDAC internal medicine service according to the dimensions addressed in this study, and the values of notable aspects of each of the dimensions are also indicated.

DISCUSSION
The present study showed that of the 292 users of the External Internal Medicine consultation of the Hospital Daniel Alcides Carrión in Huancayo, approximately 60% were satisfied with the quality of the service received. Also, the research showed that users felt more satisfied with the perceived safety and empathy in the service received. However, more than half of the patients who used the Internal Medicine Service showed dissatisfaction with the responsiveness, reliability, and other tangible aspects (medical equipment, guidance, and user comfort) of the health system.
Attention is drawn to the high levels of satisfaction obtained in the dimensions of quality of care: safety (satisfaction: 86.80%) and empathy (satisfaction:  80.30%). Also, the study showed that the most important thing for the user of the healthcare system is the doctor-patient relationship, which implies a good deal, the interest in the pathology of the user, the management of clear and understandable information on treatments and/or medical procedures while respecting privacy, carrying out a detailed physical examination respecting the privacy of the patient, answering and solving doubts and concerns, thereby transmitting safety to patients.
In Mexico, similar results were reported by Ortiz (17) , who concluded that users of the external consultation in Hidalgo health institutions obtained 71.37% satisfaction perceived by users for the health service provided. The main contributing elements to patient dissatisfaction were excessive waiting times to receive medical attention, a poor physical examination, and a poorly planned diagnosis. Besides, the tedious and complex procedures for receiving medical care, disinterest and mistreatment of patients, increased the levels of dissatisfaction perceived by users. Ramírez-Sánchez (12) concluded that 81.2% of users perceive that health services provide good quality care due to the appropriate treatment by health personnel and the favorable evolution of the health of patients who benefited from the service; on the contrary, prolonged waiting times, inadequate physical examination and poor diagnosis were considered predictors of poor quality of service, which supports the data obtained in our study.
Some studies conducted in Peru showed a high level of dissatisfaction among users with the Health Service received. According to this, Manchón P. (18) showed that, in the emergency service of a Social Security Hospital in Chiclayo, 64.2% of users were dissatisfied with the service received. Although the health system demonstrated adequate reliability and responsiveness, aspects related to comfort, and adequate user orientation (tangible aspects) were not favorably perceived by patients who attended the service. For its part, Niño (19) reported an overall dissatisfaction of approximately 90%, with reliability and safety being the aspects perceived with the highest levels of dissatisfaction. Valerio J. (20) supported similar results in a private institution in Huancayo. These data point to the need to develop strategies to create health systems that provide high-quality services that not only contribute to the subjective satisfaction of the patient but also objective, to achieve the preservation and optimal recovery of the health of users.
The main limitation of the study is that being a single-center study, it is small-scale and therefore the results cannot be extrapolated to the health system in general of Huancayo. It is recommended that all hospitals in the Lambayeque region be replicated to determine standard levels. Also, an analytical study should be carried out to find other variables capable of identifying this cause.

CONCLUSION
The level of satisfaction with the quality of service of users in the External Internal Medicine consultation of the Hospital Daniel Alcides Carrión in Huancayo was 60.3%; the dimensions safety and empathy were the ones that had the highest level of satisfaction perceived by users, while the dimension of tangible aspects was the one that obtained the highest percentage of dissatisfaction. According to this, the health system must implement strategies to improve care services to provide timely and quality care to users.