Patients and quality of primary health care services. Survey of practitioners at the Bahía de Cádiz and La Janda health centers

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Survey of practitioners at the Bahía de Cádiz and La Janda health centers" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "425" "paginaFinal" => "433" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M Hernán García, JL Gutiérrez Cuadra, C Lineros González, C Ruiz Barbosa, A Rabadán Asensio" "autores" => array:5 [ 0 => array:3 [ "Iniciales" => "M" "apellidos" => "Hernán García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "JL" "apellidos" => "Gutiérrez Cuadra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "C" "apellidos" => "Lineros González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 3 => array:3 [ "Iniciales" => "C" "apellidos" => "Ruiz Barbosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 4 => array:3 [ "Iniciales" => "A" "apellidos" => "Rabadán Asensio" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Andalusia School of Public Health, Granada, Spain." 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Opinión de los profesionales de los centros de salud de la Bahía de Cádiz y La Janda." ] ] "textoCompleto" => "Introduction<hr></hr>Evaluating service quality and identifying critical factors that determine user satisfaction are challenges for client-oriented policies in primary health care services.1,2 The problems inherent in identifying the attributes of quality and evaluating services from the user´s perspective have become issues that now attract the interest of professionals, managers, politicians and researchers.3 In the health sector, different methodological approaches and models that explain service quality from the user´s perspective are currently being tested.4-6Several authors7,8 have discovered that for users, service quality does not consist simply of actions and behaviors in themselves, but also comprises the subjective manner in which these are perceived and interpreted. The complexity of measuring service quality becomes evident if we realize that it is intangible and heterogeneous, and that it is impossible to separate the moment of production from the moment of consumption.7-9In recent years a number of instruments have been used to try to measure patient satisfaction as a fundamental factor in health care outcomes.10,11 This task is not without problems. For example, it is hard to distinguish between the care process (service) and its outcomes.12Traditionally, studies designed to measure perceived service quality have been based on an analysis of the degree of user satisfaction, and have evolved from simple questionnaires to factorial studies with considerable statistical backing.12-14 Qualitative methods seek to obtain in-depth information about the phenomenon, and to produce an in-depth interpretation of opinions on quality.One of the instruments used during the previous ten years to measure quality is the SERVQUAL model,15 which is based on a definition of quality as the difference between users´ expectations and their perceptions. An adaptation of this model to the health care setting is the SERCAL model,4,6 developed from research aimed at evaluating users´ opinions on health service quality and constructed from a combination of qualitative and quantitative methods. The quality factors that the SERCAL model evaluates are access, comfort, personalized service, competence (guarantees to patients) and loyalty to the health center.Although the patients´ view is of fundamental importance in understanding their opinion about service, improving the quality of care does not seem possible without involving practitioners. Some authors8,16 consider client satisfaction to be based on the satisfaction of professionals and their concept of service quality as providers of the service. An organization must consider not only the degree to which users´ interests are satisfied; if improvement is desired, it should also serve the interests of professionals.17 From this perspective, quality can be defined in terms of professionals´ decisions and behaviors that are expected to yield the greatest benefits for patients.It is therefore of interest to determine how professionals perceive the benefits of care, and what actions they consider to contribute to patients´ perceptions of better primary health care service. Relating users´ views on quality and professionals´ perspectives may be a crucial step in designing health care processes and improving their outcomes.The aim of the present study was to report on professionals´ opinions on service quality at primary health care centers. We also set out to determine how salient the dimensions defined in the SERCAL model were in the resulting information.<hr></hr>Methods <hr></hr><img src="27v30n07-13039048tab01.gif"></img>In this cross-sectional study qualitative methods were used to obtain in-depth information on the opinions of practitioners´ working at primary health care centers.The setting was the Bahía de Cádiz and La Janda health centers in the province of Cádiz (southwestern Spain).Information was obtained with the focus group technique, based on the so-called grounded theory.18 A meeting was held with different staff members selected on the basis of similarities in their profiles, and participants were selected on the basis of their functions at the centers regarding services provided to users. The aim was to record the opinions of all professionals, and their different perspectives and views on users´ perceptions of quality.Four focus groups were studied:  Group 1: family physicians and pediatricians at both centers. Group 2: user satisfaction service staff. Group 3: social workers. Group 4: nurses. During the meeting a script was developed on the basis of the dimensions in the model (Table 1), with sufficient internal flexibility to allow exploration of new aspects and dimensions of the topic while respecting the options and terms used by participants.<img src="27v30n07-13039048tab02.gif"></img>Relations were sought between the model and three types of question: what are professionals´ views on how patients perceive quality? What opinions do professionals have on service quality at each center? What factors do professionals consider most important in defining a user-oriented quality service?The information was analyzed with the N-Vivo program, a qualitative data analysis assistant. N-Vivo19 brings together the features and applications needed to facilitate and systematize text analysis: it can be used initially to identify discourse categories in the data, and subsequently to explore existing combinations of such categories with nodes that facilitate the identification of redundant text elements.Redundancy and saturation were ensured by repeat analysis of the information by more than one investigator. The information was also checked by selecting intragroup and intergroup redundant elements.<hr></hr>Results <hr></hr>Service accessibility (Table 2)<img src="27v30n07-13039048tab03.gif"></img>Access to the service is one of the dimensions the professionals considered most important for quality service, and for which there was notable agreement regarding its influence on the user´s perception.According to professionals, users value speed in accessing the system, a feature identified as a characteristic of service quality and a positive image of the center.Participants considered that the perception of waiting times varies depending on a) the location of the health center in a rural or an urban area; b) the reason for visiting the center, and c) the level of care involved in the consultation. They believed that accessibility was related with the user´s understanding of the functions performed by certain members of the staff (user satisfaction staff), and that users consider this an obstacle that interferes with their main interest as a patient: being seen by their doctor. They also noted that telephone access generated complaints and negative views on the part of users, and that the complaints are identified by user satisfaction staff as a source of tension and problems that affect their workplace conditions, and can trigger arguments with users.With regard to routine paperwork, professionals noted confusion and lack of coordination, reflected in the need for users to visit different centers and offices and in the fact that users «need to do some running around.»Efficiency and speed of the paperwork was an element that participants said should be improved. They related excess bureaucracy with a lack of coordination between professionals and services. They also felt that inadequate training of professionals in the use of new technologies led to an increase in paperwork and often brought the system to a halt.Waiting time at the center to make an appointment or while waiting in line for other services, time spent in waiting rooms, and delays in answering the phone led to negative perceptions regarding service quality.On the other hand, when users encountered initiative, a sense of responsibility, and personal interest in their problem on the part of the professional, perceived quality was greater.Comfort of the service (Table 3)<img src="27v30n07-13039048tab04.gif"></img>This dimension was closely related to accessibility of the center´s facilities. Professionals believed that the appearance of the exterior and interior of the center and accessibility accounted for users´ first impression of the center, and were essential in creating satisfaction and an impression of quality.The participants felt that the physical conditions and comfort were relevant for users, who reach favorable or unfavorable judgments about the physical surroundings in which health care services are provided. Improvements in the physical surroundings were most clearly appreciated by users.Comfort of the facilities was considered to affect working conditions and the way users are treated.Personalized service (Table 4)<img src="27v30n07-13039048tab05.gif"></img>The greatest discrepancies between groups of staff members were found with regard to the importance of a pleasant demeanor. This was identified by all groups as a factor that influenced users´ opinions on quality, but we interpret their responses as evidence that the relevance given to this factor differed between categories of professionals. All participants agreed that recent improvements in this area were essential in offering quality service. However, physicians maintained that the main thing for users was obtaining a solution for their problem. According to physicians, technical quality is the most important aspect of service.Nurses and social workers emphasized that personalized treatment is a central component of quality. Social workers noted the importance users assign to how they are treated by physicians.«...in fact, what is most appreciated is the medical care.» The physician plays the role of the main agent of quality. Both technical quality and personal treatment are relevant for users, and social workers considered that aspects related with personal treatment of users would improve with strategies for training and adaptation to new technologies.Social workers identified as clients not only users who come to the center because of a health problem, but also the persons who accompany them and habitual clients whose main reason for coming to the center is «to pass the time.»Social workers believed the most relevant thing for these patients is to find that the staff create a pleasant, polite atmosphere.Competence (Table 5)<img src="27v30n07-13039048tab06.gif"></img>With regard to coordination between professionals and services, participants noted that this dimension is linked to others. Lack of coordination is partly responsible for long waits and excess paperwork, and has a negative influence on how users are treated. Professional competence was a secondary factor in users´ evaluations of service quality. Users assume that physicians have appropriate scientific and technical skills; in other words, the physicians´ competence is guaranteed. Physicians claimed that the user´s goal is to obtain a solution for his or her problem. On the other hand, nurses and user satisfaction staff consider their competence to be underrated by users and even by other categories of staff members.The user´s confidence in the professionals was considered another relevant factor of quality. Physicians considered this the factor that most strongly influenced users´ perceptions of quality, in comparison to other factors.Social workers expressed the opinion that the quality of the center and efforts to provide quality are perceived by users, and that this leads, on one hand, to a feeling of trust and confidence that users do not perceive in other health care settings, and on the other hand, to increased expectations and demands regarding service.The use of technology was believed to have a negative influence on other factors that influence service quality. On many occasions technology inconveniences users because professionals lack information about how it should be used, or because it does not complement or enhance previously used methods. Social workers drew attention to the inadequate training professionals received in the use of technology, particularly as regards computers for information processing.Physicians noted that deficiencies in the use of technology pointed to the need for better training of user satisfaction staff, and felt that patients do not question the physicians´ competence.User satisfaction staff members noted problems of coordination between their service and physicians. They commented on their function as «middlemen» between the patient and the consultation with the physician, and declared that despite their belief that they are the members of the center´s staff who are best informed about user satisfaction matters, their opinions are not taken into account.Nurses expressed the opinion that professionals employed at other health care services such as hospitals failed to appreciate the technical competence of professionals at health centers. Health center nurses noted that the general view of their professional competence was one of poor training and unclear functions. They noted that this view was the result of the fact that they «handle all sorts of tasks» and are not able to «sell» a clear image of their competence as a group. They felt that there ought to be a way to identify them as nurses and distinguish them from other staff members a way to create a (hitherto poorly defined) professional profile.Loyalty to the service (Table 6)<img src="27v30n07-13039048tab07.gif"></img>Participants noted that they would recommend the services provided by the health center to a relative or friend. However, they indicated that they would do so only if allowed to choose which staff members they would be seen by because of their friendliness, technical skills or ability to listen characteristics that led users to trust them. This illustrates that the professionals´ attitudes and characteristics are factors that determine users´ perceptions of the service they receive.<hr></hr>Discussion <hr></hr><img src="27v30n07-13039048tab08.gif"></img>Focal group studies make is possible to obtain extensive, in-depth information. The limitations of this technique are the same as with any qualitative technique: open questions that may be interpreted differently or elicit different degrees of insight into how and why phenomena occur. The interest of this technique, however, is not in the measurement process per se.20The categories we used generated sufficient informational redundancy and an appropriate level of saturation to consider our results an accurate reflection of the collective opinions of different professional groups in primary health care centers in our setting. The information we obtained for each participant profile is insufficient to generate reliable results for each professional collective as a whole, as we studied only one group in each professional category. This suggests that additional studies involving a larger number of groups per category would generate more complete results.The N-Vivo program, designed to analyze qualitative results, allowed us to reduce the information and make it more easily accessible by relating and grouping different categories. However, as others have noted,19,21 although these programs help with the more labor-intensive tasks of analysis and have many potential benefits, some caution is advisable as many studies claim that they increase the «power» of representativeness, as though they endowed the results with some quantitative features. This detracts from the main tenets that underlie qualitative methods.21As shown in different studies, several methods are used to obtain users´ opinions, and each method can yield information that can be compared and contrasted.22,23 Similar studies might determine which factors contribute the most to quality of the services offered by primary health care centers from the point of view of professionals and users; methods able to compare the findings24 might be used to reinforce the results obtained with focus group studies.We note that according to the professionals consulted in this study (particularly physicians), their technical competence is assumed to be beyond question by users, and is therefore guaranteed. This notion was reflected in the discourse in an implicit manner. Other factors, in contrast, appear explicitly as more important, eg, access to services, courteous treatment, the physical environment, and confidence in the professionals.Our participants also considered that waiting and problems with user access could be explained by the excess demand for care, which in turn has a negative influence on how users are treated by staff members. One factor not mentioned in the information we obtained is the size of the center and the number of users, factors that have a determining influence on how quality is judged.23 This element undoubtedly influences quality evaluations; however, our study design did not allow us to obtain more complete information on this issue.Members of the user satisfaction staff felt that many of the problems that affected users and their own work were caused by a lack of adequate means and by the limited decision-making capacity of employees who deal face-to-face with users, regarding matters that directly influence their work. Although these employees see themselves as the ones who are most often expected to take steps to ensure user satisfaction, they are not involved in higher-level decision-making processes. This reveals how the workplace atmosphere and job satisfaction of these professionals affects users´ evaluations of the quality of this service.25-27Some relationship was apparent between dimensions that constitute users´ views regarding the quality of services provided by the health centers. For example, the dimensions credibility, competence and courtesy were seen by nurses to be related. Social workers noted especially that users perceived differences between levels of care provision and care providers in the their position in the professional hierarchy. This suggests that users see the health center as a closed system disconnected from the other levels of health care. The health center is seen as being closer to the user, the lowest level in the hierarchy, where users are treated as equals. According to these opinions, this hierarchy is also perceived by users to exist among professionals at the health center, with physicians at the top of the pyramid.28As others have reported, the consequences of a bad experience with a given service are that any of the user´s previously positive perceptions disappear. A bad experience, according to professionals, affects the users' overall perception of the service as a whole.1,3The information we obtained confirms that the perception of quality is composed of multiple factors. We found that all dimensions of the SERCAL model were identified by professionals, which shows that validated models of quality assessment are useful for obtaining users´ opinions and comparing them with those of professionals.29-31It is noteworthy that the discourse we analyzed contained no explicit mention of issues such as the use of health care technology and information provided by physicians, elements which nonetheless form part of the theoretical model. Further studies are called for to explain this absence.We suggest that future studies based on this method should take into account features specific to the health centers as opposed to other services such as hospitals32, the diverse nature of users, and the different expectations of each type of user depending on sociodemographic variables and on whether the center is in a rural or an urban area.21 According to professionals, these elements weigh heavily in the user´s perception of quality.As a final point, it is interesting to note that according to professionals (particularly physicians), the essential factor for users is that the visit to the health center results in a solution to the problem that led the user to seek medical attention (ie, a problem with physical health, according to professionals). The user´s goal is to obtain a solution as quickly as possible. Therefore user satisfaction was defined exclusively as a solution to the problem. However, other elements such as treatment by staff members, waiting times and comfort also help maintain a good perception of the services offered by the center. Therefore problem-solving should be added as a component of quality. This would ensure that the professional´s commitment to and involvement in seeking a solution to the patient´s problem as quickly as possible will influence the user´s degree of satisfaction. However, our results suggest the need for further research to determine whether what professionals perceive to be the patient´s problem, and the solution they offer, actually match the patient´s own perception of the problem and the solution he or she receives from the health center. As noted by professionals in this study, health centers are organized and run in a way that is too inflexible and does not take into account users´ preferences.<hr></hr>Acknowledgments <hr></hr>We thank the staff of the Bahía de Cádiz and La Janda health centers for their cooperation and participation in this study. We also acknowledge support throughout the different phases of the research from Juan Manuel Jiménez Martín, project technician at the Andalusia School of Public Health. Correspondence: Mariano Hernán García. Escuela Andaluza de Salud Púbica. Campus Universitario de la Cartuja. Apdo. de Correos 2.070. 18080 Granada. España. E-mail: mhernan@easp.esThis report is part of research project 210559900, financed by the Spanish Fondo de Investigación Sanitaria.  Manuscript accepted for publication 27 February 2002." "pdfFichero" => "27v30n07a13039048pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec692928" "palabras" => array:4 [ 0 => "Calidad percibida" 1 => "Satisfacción" 2 => "Investigación cualitativa" 3 => "Profesionales" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec692927" "palabras" => array:4 [ 0 => "Perceived quality" 1 => "Satisfaction" 2 => "Qualitative research" 3 => "Practitioners" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Aim. To report the opinions of practitioners at health centers on dimensions of quality that affect user satisfaction. Design. Cross-sectional study of focus groups (FG). Setting. Bahía de Cádiz and La Janda health centers in southwestern Spain. Participants. We studied 4 FG whose participants were staff members of the two health centers: FG1, physicians; FG2, user satisfaction service staff; FG3, social workers; FG4, nurses. The groups were based on the different functions of staff at the two centers. Method. The analysis was based on variables in the SERCAL model (an adaptation of the SERVQUAL model for the Spanish health care system) of opinions regarding service quality: access, comfort (tangibles), personalized service (courtesy), competence, and loyalty. The data were analyzed with version N-Vivo of the NUDIST program. Results. All dimensions of the theoretical model were identified by practitioners as constructs of users' perceptions of service quality. Users' and practitioners' views contrasted with and complemented each other to generate a model that could be validated. Access, personalized service and problem-solving (responsiveness) were key variables. Conclusions. Practitioners' opinions provided information of use in improving the quality model. Differences in opinion between users and practitioners merit further study based on an understanding of these groups' values and interests, and on the care provision context. Practitioners identified access, personalized service and problem-solving as features that influenced users' opinions of the quality of the health center." ] "es" => array:1 [ "resumen" => "Objetivo. Conocer la opinión de los profesionales de los centros de salud (CS) sobre las dimensiones de la calidad que afectan a la satisfacción de los usuarios. Diseño. Estudio transversal mediante grupos focales (GF). Emplazamiento. CS de la Bahía de Cádiz y La Janda (BCJ). Participantes. Se realizaron cuatro GF con personal de los CS. GF1: médicos; GF2: servicios de atención al usuario; GF3: trabajadores sociales; GF4: enfermeras. La selección de los segmentos se realizó según las funciones desempeñadas en el CS. Método. El análisis se hizo según variables del modelo SERCAL de opinión sobre la calidad del servicio: accesible, confortable, personalizado, garantía y fidelidad. Se utilizó el programa NUDIST, versión N-Vivo. Resultados. Todas las dimensiones del modelo teórico han sido identificadas por los profesionales como constructoras de la percepción que el usuario tiene de la calidad del servicio. Las visiones de usuarios y profesionales se contraponen y se complementan, generando un modelo susceptible de validación. El acceso, el trato y la solución del problema son variables clave. Conclusiones. La opinión de los profesionales proporciona información para mejorar el modelo de calidad predefinido. Es necesario estudiar las diferencias en la opinión entre usuarios y profesionales según los valores e intereses de estos colectivos y el contexto de la atención. Los profesionales identifican la accesibilidad, el trato y la solución del problema como características que influyen en la opinión que tiene el usuario sobre la calidad del CS." ] ] "multimedia" => array:16 [ 0 => array:6 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab01.gif" "imagenAlto" => 473 "imagenAncho" => 345 "imagenTamanyo" => 13663 ] ] ] ] ] ] 1 => array:6 [ "identificador" => "tbl2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab02.gif" "imagenAlto" => 236 "imagenAncho" => 724 "imagenTamanyo" => 10371 ] ] ] ] ] ] 2 => array:6 [ "identificador" => "tbl3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab03.gif" "imagenAlto" => 368 "imagenAncho" => 728 "imagenTamanyo" => 29834 ] ] ] ] ] ] 3 => array:6 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab04.gif" "imagenAlto" => 162 "imagenAncho" => 727 "imagenTamanyo" => 12919 ] ] ] ] ] ] 4 => array:6 [ "identificador" => "tbl5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab05.gif" "imagenAlto" => 167 "imagenAncho" => 724 "imagenTamanyo" => 12597 ] ] ] ] ] ] 5 => array:6 [ "identificador" => "tbl6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab06.gif" "imagenAlto" => 536 "imagenAncho" => 739 "imagenTamanyo" => 51265 ] ] ] ] ] ] 6 => array:6 [ "identificador" => "tbl7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab07.gif" "imagenAlto" => 170 "imagenAncho" => 739 "imagenTamanyo" => 9765 ] ] ] ] ] ] 7 => array:6 [ "identificador" => "tbl8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n07-13039048tab08.gif" "imagenAlto" => 504 "imagenAncho" => 341 "imagenTamanyo" => 19239 ] ] ] ] ] ] 8 => array:5 [ "identificador" => "tbl9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 9 => array:5 [ "identificador" => "tbl10" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 10 => array:5 [ "identificador" => "tbl11" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 11 => array:5 [ "identificador" => "tbl12" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 12 => array:5 [ "identificador" => "tbl13" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 13 => array:5 [ "identificador" => "tbl14" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 14 => array:5 [ "identificador" => "tbl15" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 15 => array:5 [ "identificador" => "tbl16" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Patients Views on quality care in general practice: literature review. 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Patients and quality of primary health care services. Survey of practitioners at the Bahía de Cádiz and La Janda health centers

Los pacientes y la calidad de los servicios de atención primaria de salud. Opinión de los profesionales de los centros de salud de la Bahía de Cádiz y La Janda.

M. Hernán Garcíaa, JL. Gutiérrez Cuadraa, C. Lineros Gonzálezb, C. Ruiz Barbosab, A. Rabadán Asensiob

a Andalusia School of Public Health, Granada, Spain.

b Bahía de Cádiz and La Janda Health District, Cádiz, Spain.

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    "textoCompleto" => "<p class="elsevierStylePara">Introduction</p><hr></hr><p class="elsevierStylePara">Evaluating service quality and identifying critical factors that determine user satisfaction are challenges for client-oriented policies in primary health care services&#46;<span class="elsevierStyleSup">1&#44;2</span> The problems inherent in identifying the attributes of quality and evaluating services from the user&#180;s perspective have become issues that now attract the interest of professionals&#44; managers&#44; politicians and researchers&#46;<span class="elsevierStyleSup">3</span> In the health sector&#44; different methodological approaches and models that explain service quality from the user&#180;s perspective are currently being tested&#46;<span class="elsevierStyleSup">4-6</span></p><p class="elsevierStylePara">Several authors<span class="elsevierStyleSup">7&#44;8</span> have discovered that for users&#44; service quality does not consist simply of actions and behaviors in themselves&#44; but also comprises the subjective manner in which these are perceived and interpreted&#46; The complexity of measuring service quality becomes evident if we realize that it is intangible and heterogeneous&#44; and that it is impossible to separate<br></br> the moment of production from the moment of consumption&#46;<span class="elsevierStyleSup">7-9</span></p><p class="elsevierStylePara">In recent years a number of instruments have been used to try to measure patient satisfaction as a fundamental factor in health care outcomes&#46;<span class="elsevierStyleSup">10&#44;11</span> This task is not without problems&#46; For example&#44; it is hard to distinguish between the care process &#40;service&#41; and its outcomes&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">Traditionally&#44; studies designed to measure perceived service quality have been based on an analysis of the degree of user satisfaction&#44; and have evolved from simple questionnaires to factorial studies with considerable statistical backing&#46;<span class="elsevierStyleSup">12-14</span> Qualitative methods seek to obtain in-depth information about the phenomenon&#44; and to produce an in-depth interpretation of opinions on quality&#46;</p><p class="elsevierStylePara">One of the instruments used during the previous ten years to measure quality is the SERVQUAL model&#44;<span class="elsevierStyleSup">15</span> which is based on a definition of quality as the difference between users&#180; expectations and their perceptions&#46; An adaptation of this model to the health care setting is the SERCAL model&#44;<span class="elsevierStyleSup">4&#44;6</span> developed from research aimed at evaluating users&#180; opinions on health service quality and constructed from a combination of qualitative and quantitative methods&#46; The quality factors that the SERCAL model evaluates are <span class="elsevierStyleItalic">access</span>&#44; <span class="elsevierStyleItalic">comfort</span>&#44; <span class="elsevierStyleItalic">personalized service</span>&#44; <span class="elsevierStyleItalic">competence &#40;guarantees to patients&#41;</span> and <span class="elsevierStyleItalic">loyalty</span> to the health center&#46;</p><p class="elsevierStylePara">Although the patients&#180; view is of fundamental importance in understanding their opinion about service&#44; improving the quality of care does not seem possible without involving practitioners&#46; Some authors<span class="elsevierStyleSup">8&#44;16</span> consider client satisfaction to be based on the satisfaction of professionals and their concept of service quality as providers of the service&#46; An organization must consider not only the degree to which users&#180; interests are satisfied&#59; if improvement is desired&#44; it should also serve the interests of professionals&#46;<span class="elsevierStyleSup">17</span> From this perspective&#44; quality can be defined in terms of professionals&#180; decisions and behaviors that are expected to yield the greatest benefits for patients&#46;</p><p class="elsevierStylePara">It is therefore of interest to determine how professionals perceive the benefits of care&#44; and what actions they consider to contribute to patients&#180; perceptions of better primary health care service&#46; Relating users&#180; views on quality and professionals&#180; perspectives may be a crucial step in designing health care processes and improving their outcomes&#46;</p><p class="elsevierStylePara">The aim of the present study was to report on professionals&#180; opinions on service quality at primary health care centers&#46; We also set out to determine how salient the dimensions defined in the SERCAL model were in the resulting information&#46;</p><hr></hr><p class="elsevierStylePara">Methods  </p><hr></hr><p class="elsevierStylePara"><img src="27v30n07-13039048tab01.gif"></img></p><p class="elsevierStylePara">In this cross-sectional study qualitative methods were used to obtain in-depth information on the opinions of practitioners&#180; working at primary health care centers&#46;</p><p class="elsevierStylePara">The setting was the Bah&#237;a de C&#225;diz and La Janda health centers in the province of C&#225;diz &#40;southwestern Spain&#41;&#46;</p><p class="elsevierStylePara">Information was obtained with the focus group technique&#44; based on the so-called grounded theory&#46;<span class="elsevierStyleSup">18</span> A meeting was held with different staff members selected on the basis of similarities in their profiles&#44; and participants were selected on the basis of their functions at the centers regarding services provided to users&#46; The aim was to record the opinions of all professionals&#44; and their different perspectives and views on users&#180; perceptions of quality&#46;</p><p class="elsevierStylePara">Four focus groups were studied&#58;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#173; Group 1&#58;</span> family physicians and pediatricians at both centers&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#173; Group 2&#58;</span> user satisfaction service staff&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#173; Group 3&#58;</span> social workers&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#173; Group 4&#58;</span> nurses&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">During the meeting a script was developed on the basis of the dimensions in the model &#40;Table 1&#41;&#44; with sufficient internal flexibility to allow exploration of new aspects and dimensions of the topic while respecting the options and terms used by participants&#46;</p><p class="elsevierStylePara"><img src="27v30n07-13039048tab02.gif"></img></p><p class="elsevierStylePara">Relations were sought between the model and three types of question&#58; what are professionals&#180; views on how patients perceive quality&#63; What opinions do professionals have on service quality at each center&#63; What factors do professionals consider most important in defining a user-oriented quality service&#63;</p><p class="elsevierStylePara">The information was analyzed with the N-Vivo program&#44; a qualitative data analysis assistant&#46; N-Vivo<span class="elsevierStyleSup">19</span> brings together the features and applications needed to facilitate and systematize text analysis&#58; it can be used initially to identify discourse categories in the data&#44; and subsequently to explore existing combinations of such categories with nodes that facilitate the identification of redundant text elements&#46;</p><p class="elsevierStylePara">Redundancy and saturation were ensured by repeat analysis of the information by more than one investigator&#46; The information was also checked by selecting intragroup and intergroup redundant elements&#46;</p><hr></hr><p class="elsevierStylePara">Results  </p><hr></hr><p class="elsevierStylePara">Service accessibility  &#40;Table 2&#41;</p><p class="elsevierStylePara"><img src="27v30n07-13039048tab03.gif"></img></p><p class="elsevierStylePara">Access to the service is one of the dimensions the professionals considered most important for quality service&#44; and for which there was notable agreement regarding its influence on the user&#180;s perception&#46;</p><p class="elsevierStylePara">According to professionals&#44; users value speed in accessing the system&#44; a feature identified as a characteristic of service quality and a positive image of the center&#46;</p><p class="elsevierStylePara">Participants considered that the perception of waiting times varies depending on <span class="elsevierStyleItalic">a&#41;</span> the location of the health center in a rural or an urban area&#59; <span class="elsevierStyleItalic">b&#41;</span> the reason for visiting the center&#44; and <span class="elsevierStyleItalic">c&#41;</span> the level of care involved in the consultation&#46; They believed that accessibility was related with the user&#180;s understanding of the functions performed by certain members of the staff &#40;user satisfaction staff&#41;&#44; and that users consider this an obstacle that interferes with their main interest as a patient&#58; being seen by their doctor&#46; They also noted that <span class="elsevierStyleItalic">telephone access</span> generated complaints and negative views on the part of users&#44; and that the complaints are identified by user satisfaction staff as a source of tension and problems that affect their workplace conditions&#44; and can trigger arguments with users&#46;</p><p class="elsevierStylePara">With regard to <span class="elsevierStyleItalic">routine paperwork</span>&#44; professionals noted confusion and lack of coordination&#44; reflected in the need for users to visit different centers and offices and in the fact that users &#171;need to do some running around&#46;&#187;</p><p class="elsevierStylePara">Efficiency and speed of the paperwork was an element that participants said should be improved&#46; They related excess bureaucracy with a lack of coordination between professionals and services&#46; They also felt that inadequate training of professionals in the use of new technologies led to an increase in paperwork and often brought the system to a halt&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Waiting time at the center</span> to make an appointment or while waiting in line for other services&#44; time spent in waiting rooms&#44; and delays in answering the phone led to negative perceptions regarding service quality&#46;</p><p class="elsevierStylePara">On the other hand&#44; when users encountered initiative&#44; a sense of responsibility&#44; and personal interest in their problem on the part of the professional&#44; perceived quality was greater&#46;</p><p class="elsevierStylePara">Comfort of the service  &#40;Table 3&#41;</p><p class="elsevierStylePara"><img src="27v30n07-13039048tab04.gif"></img></p><p class="elsevierStylePara">This dimension was closely related to accessibility of the center&#180;s facilities&#46; Professionals believed that the <span class="elsevierStyleItalic">appearance of the exterior and interior</span> of the center and accessibility accounted for users&#180; first impression of the center&#44; and were essential in creating satisfaction and an impression of quality&#46;</p><p class="elsevierStylePara">The participants felt that the physical conditions and comfort were relevant for users&#44; who reach favorable or unfavorable judgments about the physical surroundings in which health care services are provided&#46; Improvements in the physical surroundings were most clearly appreciated by users&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Comfort of the facilities</span> was considered to affect working conditions and the way users are treated&#46;</p><p class="elsevierStylePara">Personalized service &#40;Table 4&#41;</p><p class="elsevierStylePara"><img src="27v30n07-13039048tab05.gif"></img></p><p class="elsevierStylePara">The greatest discrepancies between groups of staff members were found with regard to the importance of a <span class="elsevierStyleItalic"> pleasant demeanor</span>&#46; This was identified by all groups as a factor that influenced users&#180; opinions on quality&#44; but we interpret their responses as evidence that the relevance given to this factor differed between categories of professionals&#46; All participants agreed that recent improvements in this area were essential in offering quality service&#46; However&#44; physicians maintained that the main thing for users was obtaining a solution for their problem&#46; According to physicians&#44; technical quality is the most important aspect of service&#46;</p><p class="elsevierStylePara">Nurses and social workers emphasized that personalized treatment is a central component of quality&#46; Social workers noted the importance users assign to how they are treated by physicians&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#171;</span>&#46;&#46;&#46;in fact&#44; what is most appreciated is the medical care&#46;<span class="elsevierStyleItalic">&#187;</span> The physician plays the role of the main agent of quality&#46; Both technical quality and personal treatment are relevant for users&#44; and social workers considered that aspects related with personal treatment of users would improve with strategies for training and adaptation to new technologies&#46;</p><p class="elsevierStylePara">Social workers identified as clients not only users who come to the center because of a health problem&#44; but also the persons who accompany them and habitual clients whose main reason for coming to the center is &#171;to pass the time&#46;&#187;</p><p class="elsevierStylePara">Social workers believed the most relevant thing for these patients is to find that the staff create a pleasant&#44; polite atmosphere&#46;</p><p class="elsevierStylePara">Competence &#40;Table 5&#41;</p><p class="elsevierStylePara"><img src="27v30n07-13039048tab06.gif"></img></p><p class="elsevierStylePara">With regard to <span class="elsevierStyleItalic">coordination between professionals and services&#44;</span> participants noted that this dimension is linked to others&#46; Lack of coordination is partly responsible for long waits and excess paperwork&#44; and has a negative influence on how users are treated&#46; <span class="elsevierStyleItalic">Professional competence</span> was a secondary factor in users&#180; evaluations of service quality&#46; Users assume that physicians have appropriate scientific and technical skills&#59; in other words&#44; the physicians&#180; competence is guaranteed&#46; Physicians claimed that the user&#180;s goal is to obtain a solution for his or her problem&#46; On the other hand&#44; nurses and user satisfaction staff consider their competence to be underrated by users and even by other categories of staff members&#46;</p><p class="elsevierStylePara">The user&#180;s <span class="elsevierStyleItalic">confidence</span> in the professionals was considered another relevant factor of quality&#46; Physicians considered this the factor that most strongly influenced users&#180; perceptions of quality&#44; in comparison to other factors&#46;</p><p class="elsevierStylePara">Social workers expressed the opinion that the quality of the center and efforts to provide quality are perceived by users&#44; and that this leads&#44; on one hand&#44; to a feeling of trust and confidence that users do not perceive in other health care settings&#44; and on the other hand&#44; to increased expectations and demands regarding service&#46;</p><p class="elsevierStylePara">The <span class="elsevierStyleItalic">use of technology</span> was believed to have a negative influence on other factors that influence service quality&#46; On many occasions technology inconveniences users because professionals lack information about how it should be used&#44; or because it does not complement or enhance previously used methods&#46; Social workers drew attention to the inadequate training professionals received in the use of technology&#44; particularly as regards computers for information processing&#46;</p><p class="elsevierStylePara">Physicians noted that deficiencies in the use of technology pointed to the need for better training of user satisfaction staff&#44; and felt that patients do not question the physicians&#180; competence&#46;</p><p class="elsevierStylePara">User satisfaction staff members noted problems of coordination between their service and physicians&#46; They commented on their function as &#171;middlemen&#187; between the patient and the consultation with the physician&#44; and declared that despite their belief that they are the members of the center&#180;s staff who are best informed about user satisfaction matters&#44; their opinions are not taken into account&#46;</p><p class="elsevierStylePara">Nurses expressed the opinion that professionals employed at other health care services such as hospitals failed to appreciate the technical competence of professionals at health centers&#46; Health center nurses noted that the general view of their professional competence was one of poor training and unclear functions&#46; They noted that this view was the result of the fact that they &#171;handle all sorts of tasks&#187; and are not able to &#171;sell&#187; a clear image of their competence as a group&#46; They felt that there ought to be a way to identify them as nurses and distinguish them from other staff members &#173; a way to create a &#40;hitherto poorly defined&#41; professional profile&#46;</p><p class="elsevierStylePara">Loyalty to the service  &#40;Table 6&#41;</p><p class="elsevierStylePara"><img src="27v30n07-13039048tab07.gif"></img></p><p class="elsevierStylePara">Participants noted that they would recommend the services provided by the health center to a relative or friend&#46; However&#44; they indicated that they would do so only if allowed to choose which staff members they would be seen by because of their friendliness&#44; technical skills or ability to listen &#173; characteristics that led users to trust them&#46; This illustrates that the professionals&#180; attitudes and characteristics are factors that determine users&#180; perceptions of the service they receive&#46;</p><hr></hr><p class="elsevierStylePara">Discussion  </p><hr></hr><p class="elsevierStylePara"><img src="27v30n07-13039048tab08.gif"></img></p><p class="elsevierStylePara">Focal group studies make is possible to obtain extensive&#44; in-depth information&#46; The limitations of this technique are the same as with any qualitative technique&#58; open questions that may be interpreted differently or elicit different degrees of insight into how and why phenomena occur&#46; The interest of this technique&#44; however&#44; is not in the measurement process per se&#46;<span class="elsevierStyleSup">20</span></p><p class="elsevierStylePara">The categories we used generated sufficient informational redundancy and an appropriate level of saturation to consider our results an accurate reflection of the collective opinions of different professional groups in primary health care centers in our setting&#46; The information we obtained for each participant profile is insufficient to generate reliable results for each professional collective as a whole&#44; as we studied only one group in each professional category&#46; This suggests that additional studies involving a larger number of groups per category would generate more complete results&#46;</p><p class="elsevierStylePara">The N-Vivo program&#44; designed to analyze qualitative results&#44; allowed us to reduce the information and make it more easily accessible by relating and grouping different categories&#46; However&#44; as others have noted&#44;<span class="elsevierStyleSup">19&#44;21</span> although these programs help with the more labor-intensive tasks of analysis and have many potential benefits&#44; some caution is advisable as many studies claim that they increase the &#171;power&#187; of representativeness&#44; as though they endowed the results with some quantitative features&#46; This detracts from the main tenets that underlie qualitative methods&#46;<span class="elsevierStyleSup">21</span></p><p class="elsevierStylePara">As shown in different studies&#44; several methods are used to obtain users&#180; opinions&#44; and each method can yield information that can be compared and contrasted&#46;<span class="elsevierStyleSup">22&#44;23</span> Similar studies might determine which factors contribute the most to quality of the services offered by primary health care centers from the point of view of professionals and users&#59; methods able to compare the findings<span class="elsevierStyleSup">24</span> might be used to reinforce the results obtained with focus group studies&#46;</p><p class="elsevierStylePara">We note that according to the professionals consulted in this study &#40;particularly physicians&#41;&#44; their technical competence is assumed to be beyond question by users&#44; and is therefore guaranteed&#46; This notion was reflected in the discourse in an implicit manner&#46; Other factors&#44; in contrast&#44; appear explicitly as more important&#44; eg&#44; access to services&#44; courteous treatment&#44; the physical environment&#44; and confidence in the professionals&#46;</p><p class="elsevierStylePara">Our participants also considered that waiting and problems with user access could be explained by the excess demand for care&#44; which in turn has a negative influence on how users are treated by staff members&#46; One factor not mentioned in the information we obtained is the size of the center and the number of users&#44; factors that have a determining influence on how quality is judged&#46;<span class="elsevierStyleSup">23</span> This element undoubtedly influences quality evaluations&#59; however&#44; our study design did not allow us to obtain more complete information on this issue&#46;</p><p class="elsevierStylePara">Members of the user satisfaction staff felt that many of the problems that affected users and their own work were caused by a lack of adequate means and by the limited decision-making capacity of employees who deal face-to-face with users&#44; regarding matters that directly influence their work&#46; Although these employees see themselves as the ones who are most often expected to take steps to ensure user satisfaction&#44; they are not involved in higher-level decision-making processes&#46; This reveals how the workplace atmosphere and job satisfaction of these professionals affects users&#180; evaluations of the quality of this service&#46;<span class="elsevierStyleSup">25-27</span></p><p class="elsevierStylePara">Some relationship was apparent between dimensions that constitute users&#180; views regarding the quality of services provided by the health centers&#46; For example&#44; the dimensions <span class="elsevierStyleItalic">credibility</span>&#44; <span class="elsevierStyleItalic">competence</span> and <span class="elsevierStyleItalic"> courtesy</span> were seen by nurses to be related&#46; Social workers noted especially that users perceived differences between levels of care provision and care providers in the their position in the professional hierarchy&#46; This suggests that users see the health center as a closed system disconnected from the other levels of health care&#46; The health center is seen as being closer to the user&#44; the lowest level in the hierarchy&#44; where users are treated as equals&#46; According to these opinions&#44; this hierarchy is also perceived by users to exist among professionals at the health center&#44; with physicians at the top of the pyramid&#46;<span class="elsevierStyleSup">28</span></p><p class="elsevierStylePara">As others have reported&#44; the consequences of a bad experience with a given service are that any of the user&#180;s previously positive perceptions disappear&#46; A bad experience&#44; according to professionals&#44; affects the users&#39; overall perception of the service as a whole&#46;<span class="elsevierStyleSup">1&#44;3</span></p><p class="elsevierStylePara">The information we obtained confirms that the perception of quality is composed of multiple factors&#46; We found that all dimensions of the SERCAL model were identified by professionals&#44; which shows that validated models of quality assessment are useful for obtaining users&#180; opinions and comparing them with those of professionals&#46;<span class="elsevierStyleSup">29-31</span></p><p class="elsevierStylePara">It is noteworthy that the discourse we analyzed contained no explicit mention of issues such as the use of health care technology and information provided by physicians&#44; elements which nonetheless form part of the theoretical model&#46; Further studies are called for to explain this absence&#46;</p><p class="elsevierStylePara">We suggest that future studies based on this method should take into account features specific to the health centers &#173; as opposed to other services such as hospitals<span class="elsevierStyleSup">32</span>&#173;&#44; the diverse nature of users&#44; and the different expectations of each type of user depending on sociodemographic variables and on whether the center is in a rural or an urban area&#46;<span class="elsevierStyleSup">21</span> According to professionals&#44; these elements weigh heavily in the user&#180;s perception of quality&#46;</p><p class="elsevierStylePara">As a final point&#44; it is interesting to note that according to professionals &#40;particularly physicians&#41;&#44; the essential factor for users is that the visit to the health center results in a solution to the problem that led the user to seek medical attention &#40;ie&#44; a problem with physical health&#44; according to professionals&#41;&#46; The user&#180;s goal is to obtain a solution as quickly as possible&#46; Therefore user satisfaction was defined exclusively as a solution to the problem&#46; However&#44; other elements such as treatment by staff members&#44; waiting times and comfort also help maintain a good perception of the services offered by the center&#46; Therefore problem-solving should be added as a component of quality&#46; This would ensure that the professional&#180;s commitment to and involvement in seeking a solution to the patient&#180;s problem as quickly as possible will influence the user&#180;s degree of satisfaction&#46; However&#44; our results suggest the need for further research to determine whether what professionals perceive to be the patient&#180;s problem&#44; and the solution they offer&#44; actually match the patient&#180;s own perception of the problem and the solution he or she receives from the health center&#46; As noted by professionals in this study&#44; health centers are organized and run in a way that is too inflexible and does not take into account users&#180; preferences&#46;</p><hr></hr><p class="elsevierStylePara">Acknowledgments </p><hr></hr><p class="elsevierStylePara">We thank the staff of the Bah&#237;a de C&#225;diz and La Janda health centers for their cooperation and participation in this study&#46;<br></br> We also acknowledge support throughout the different phases of the research from Juan Manuel Jim&#233;nez Mart&#237;n&#44; project technician at the Andalusia School of Public Health&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Correspondence&#58; Mariano Hern&#225;n Garc&#237;a&#46; Escuela Andaluza de Salud P&#250;bica&#46; Campus Universitario de la Cartuja&#46; Apdo&#46; de Correos 2&#46;070&#46; 18080 Granada&#46; Espa&#241;a&#46;  E-mail&#58; mhernan&#64;easp&#46;es</p><p class="elsevierStylePara">This report is part of research project 210559900&#44; financed by the Spanish Fondo de Investigaci&#243;n Sanitaria&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"> Manuscript accepted for publication 27 February 2002&#46;</p>"
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            0 => "Calidad percibida"
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        "resumen" => "Aim&#46; To report the opinions of practitioners at health centers on dimensions of quality that affect user satisfaction&#46; Design&#46; Cross-sectional study of focus groups &#40;FG&#41;&#46; Setting&#46; Bah&#237;a de C&#225;diz and La Janda health centers in southwestern Spain&#46; Participants&#46; We studied 4 FG whose participants were staff members of the two health centers&#58; FG1&#44; physicians&#59; FG2&#44; user satisfaction service staff&#59; FG3&#44; social workers&#59; FG4&#44; nurses&#46; The groups were based on the different functions of staff at the two centers&#46; Method&#46; The analysis was based on variables in the SERCAL model &#40;an adaptation of the SERVQUAL model for the Spanish health care system&#41; of opinions regarding service quality&#58; access&#44; comfort &#40;tangibles&#41;&#44; personalized service &#40;courtesy&#41;&#44; competence&#44; and loyalty&#46; The data were analyzed with version N-Vivo of the NUDIST program&#46; Results&#46; All dimensions of the theoretical model were identified by practitioners as constructs of users&#39; perceptions of service quality&#46; Users&#39; and practitioners&#39; views contrasted with and complemented each other to generate a model that could be validated&#46; Access&#44; personalized service and problem-solving &#40;responsiveness&#41; were key variables&#46; Conclusions&#46; Practitioners&#39; opinions provided information of use in improving the quality model&#46; Differences in opinion between users and practitioners merit further study based on an understanding of these groups&#39; values and interests&#44; and on the care provision context&#46; Practitioners identified access&#44; personalized service and problem-solving as features that influenced users&#39; opinions of the quality of the health center&#46;"
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        "resumen" => "Objetivo&#46; Conocer la opini&#243;n de los profesionales de los centros de salud &#40;CS&#41; sobre las dimensiones de la calidad que afectan a la satisfacci&#243;n de los usuarios&#46; Dise&#241;o&#46; Estudio transversal mediante grupos focales &#40;GF&#41;&#46; Emplazamiento&#46; CS de la Bah&#237;a de C&#225;diz y La Janda &#40;BCJ&#41;&#46; Participantes&#46; Se realizaron cuatro GF con personal de los CS&#46; GF1&#58; m&#233;dicos&#59; GF2&#58; servicios de atenci&#243;n al usuario&#59; GF3&#58; trabajadores sociales&#59; GF4&#58; enfermeras&#46; La selecci&#243;n de los segmentos se realiz&#243; seg&#250;n las funciones desempe&#241;adas en el CS&#46; M&#233;todo&#46; El an&#225;lisis se hizo seg&#250;n variables del modelo SERCAL de opini&#243;n sobre la calidad del servicio&#58; accesible&#44; confortable&#44; personalizado&#44; garant&#237;a y fidelidad&#46; Se utiliz&#243; el programa NUDIST&#44; versi&#243;n <br /> N-Vivo&#46; Resultados&#46; Todas las dimensiones del modelo te&#243;rico han sido identificadas por los profesionales como constructoras de la percepci&#243;n que el usuario tiene de la calidad del servicio&#46; Las visiones de usuarios y profesionales se contraponen y se complementan&#44; generando un modelo susceptible de validaci&#243;n&#46; El acceso&#44; el trato y la soluci&#243;n del problema son variables clave&#46; Conclusiones&#46; La opini&#243;n de los profesionales proporciona informaci&#243;n para mejorar el modelo de calidad predefinido&#46; Es necesario estudiar las diferencias en la opini&#243;n entre usuarios y profesionales seg&#250;n los valores e intereses de estos colectivos y el contexto de la atenci&#243;n&#46; Los profesionales identifican la accesibilidad&#44; el trato y la soluci&#243;n del problema como caracter&#237;sticas que influyen en la opini&#243;n que tiene el usuario sobre la calidad del CS&#46;"
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                0 => array:2 [
                  "referenciaCompleta" => "Tratado de calidad asistencial en Atención Primaria. Madrid: Du pont Pharma, 1997."
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]

Article information

ISSN: 02126567
Original language: English

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Year/Month	Html	Pdf	Total

2024 November	3	0	3
2024 October	32	9	41
2024 September	68	6	74
2024 August	65	9	74
2024 July	45	8	53
2024 June	27	5	32
2024 May	31	3	34
2024 April	35	5	40
2024 March	39	5	44
2024 February	24	11	35
2024 January	39	8	47
2023 December	23	17	40
2023 November	34	18	52
2023 October	53	7	60
2023 September	31	3	34
2023 August	31	9	40
2023 July	74	7	81
2023 June	57	4	61
2023 May	87	14	101
2023 April	48	4	52
2023 March	53	6	59
2023 February	25	8	33
2023 January	17	11	28
2022 December	24	6	30
2022 November	17	9	26
2022 October	41	11	52
2022 September	44	13	57
2022 August	50	10	60
2022 July	28	17	45
2022 June	71	14	85
2022 May	56	10	66
2022 April	75	13	88
2022 March	75	15	90
2022 February	95	14	109
2022 January	88	10	98
2021 December	53	26	79
2021 November	60	16	76
2021 October	54	14	68
2021 September	46	17	63
2021 August	70	10	80
2021 July	32	6	38
2021 June	25	12	37
2021 May	47	8	55
2021 April	121	20	141
2021 March	45	17	62
2021 February	25	7	32
2021 January	32	13	45
2020 December	40	11	51
2020 November	27	9	36
2020 October	29	12	41
2020 September	19	10	29
2020 August	24	8	32
2020 July	23	14	37
2020 June	25	8	33
2020 May	32	3	35
2020 April	46	5	51
2020 March	38	4	42
2020 February	41	6	47
2020 January	38	4	42
2019 December	49	6	55
2019 November	31	10	41
2019 October	44	2	46
2019 September	40	14	54
2019 August	35	3	38
2019 July	33	5	38
2019 June	90	10	100
2019 May	176	14	190
2019 April	89	16	105
2019 March	31	12	43
2019 February	39	9	48
2019 January	23	3	26
2018 December	35	8	43
2018 November	25	5	30
2018 October	32	17	49
2018 September	28	7	35
2018 August	10	2	12
2018 July	35	3	38
2018 June	11	0	11
2018 May	11	1	12
2018 April	13	6	19
2018 March	13	2	15
2018 February	5	1	6
2018 January	12	1	13
2017 December	11	0	11
2017 November	13	0	13
2017 October	8	1	9
2017 September	7	1	8
2017 August	10	2	12
2017 July	15	3	18
2017 June	73	3	76
2017 May	31	21	52
2017 April	13	12	25
2017 March	22	1	23
2017 February	21	0	21
2017 January	23	1	24
2016 December	33	6	39
2016 November	33	3	36
2016 October	61	0	61
2016 September	35	3	38
2016 August	33	4	37
2016 July	31	3	34
2016 June	42	8	50
2016 May	29	5	34
2016 April	32	4	36
2016 March	23	3	26
2016 February	33	3	36
2016 January	26	5	31
2015 December	22	2	24
2015 November	53	4	57
2015 October	37	3	40
2015 September	27	5	32
2015 August	47	3	50
2015 July	59	0	59
2015 June	22	1	23
2015 May	21	1	22
2015 April	42	8	50
2015 March	36	3	39
2015 February	29	2	31
2015 January	30	0	30
2014 December	52	4	56
2014 November	36	1	37
2014 October	53	1	54
2014 September	45	0	45
2014 August	42	1	43
2014 July	38	1	39
2014 June	40	4	44
2014 May	24	0	24
2014 April	17	0	17
2014 March	23	1	24
2014 February	17	0	17
2014 January	17	0	17
2013 December	13	1	14
2013 November	22	0	22
2013 October	44	1	45
2013 September	18	3	21
2013 August	15	2	17
2013 July	17	1	18
2002 October	776	0	776

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