La tunisie Medicale - 2018 ; Vol 96 ( n°010 ) : 737 - 745
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Introduction: La satisfaction des patients est l'un des indicateurs les plus couramment utilisés pour l'évaluation de la qualité des services de santé. L'objectif de cette étude était de mesurer les taux de satisfaction globaux et spécifiques des patients et d'identifier les déterminants de la satisfaction à l'hôpital universitaire de Sahloul en 2015 et 2016.
Méthodes: Il s'agit d'une étude transversale comprenant un échantillon aléatoire de patients hospitalisés à l'hôpital universitaire de Sahloul entre 2015 et 2016. L'enquête a été menée à l'aide d'un questionnaire original auto-administré. Quatre dimensions spécifiques de satisfaction ont été explorées: administrative, technique, logistique et relationnelle. Les taux de satisfaction globaux et spécifiques ont été calculés, puis les facteurs associés à la satisfaction des patients ont été identifiés grâce à une analyse multivariée utilisant un modèle de régression logistique.
Résultats: Un total de 1897 patients ont été inclus dans l'étude avec un âge moyen de 42,4 ans (ET = 20,5 ans) et un sex-ratio de 0,94. Le taux de satisfaction des patients était d'environ 67%. Les éléments de satisfaction étaient principalement en rapport avec la dimension relationnelle: le respect de l'intimité du patient et la qualité de l'information donnée. Ceux d'insatisfaction étaient d’ordre logistique: L'environnement physique dans la chambre, la propreté des toilettes et les délais d'attente. Les déterminants de la satisfaction des patients étaient principalement liés à la qualité de l'accès et de la réception, aux conditions d'hébergement, aux soins techniques, à la qualité de l'information et au respect de l'intimité du patient.
Conclusion: Cette étude constitue une action pionnière de mesure de la qualité des soins en Tunisie. Elle a permis de documenter les sources d’insatisfaction des patients hospitalisés à l'hôpital universitaire de Sahloul. Des mesures d’intervention en fonction de ces insuffisances devraient être entreprises.

Mots Clés

Patient satisfaction is a way to evaluate the "perceived quality" of care, and is currently considered in all certification and accreditation manuals as a preliminary indicator used in health care service quality evaluation (1,2). It is a composite indicator and integrator of a multitude of variables exploring multiple dimensions, mainly administrative, logistic, technical and relational aspects(3-5). Measuring this indicator has become a common practice for decades in developed countries(6).
However, in Tunisia, the quality of care paradigm has only recently been introduced in our health facilities. In fact, the Tunisian health system, after a phase of health coverage, has started to support the quality of care in its hospitals in order to implement certification procedures and accreditation of its institutions(7). Unfortunately, these efforts have not yet led to a significant improvement in hospital performance because of a lack of ways to evaluate the quality of care delivery. Thus, implementing continuous surveys measuring quality indicators like patient satisfaction becomes crucial in all our health structures nowadays.
In Tunisia, as well as in many other Maghreb countries, studies focusing on patient satisfaction were rare and limited to few short-term ones(8-10). That is why we have launched an annual survey in Sahloul University Hospital since 2015 in order to continuously monitor patient satisfaction as is done in developed countries(11).
Such an annual monitoring will certainly help managers to identify the gaps between what a patient expects and what he receives(2). This will help policy makers to take decisions and implement appropriate interventions in order to improve hospital performance and patient satisfaction.
In this manuscript, we reported the findings of this survey during 2015 and 2016 which aims were: To measure overall and specific patient satisfaction rates and to identify the patient satisfaction associated factors in Sahloul University hospital during 2015 and 2016.

Study setting:Sahloul University Hospital is a tertiary-level health care institution located in Sousse governorate in Tunisia. It is considered among the best known healthcare institutions in the coastal region of the country and it admits patients from several Tunisian governorates. It includes an emergency ward, eight surgical and eight medical departments. Its Information Systems Direction (ISD) is a medico-administrative interface structure responsible for the management of hospital data and the evaluation of the level of hospital performance.
Study design:It turns about a cross sectional study conducted during two years from 1 January 2015 to 31 December 2016. It had included a random sample of 1897 patients hospitalized in the different departments of Sahloul University Hospital. The number of patients recruited in each department represented at least 10% of the number of hospitalizations per year in that department.
Data collection:The survey was conducted through an original anonymous self-administered questionnaire developed in Arabic language after a review of the literature and validated by a focus group representing the different actors of care.
It recorded socio demographic characteristics especially: age, sex, governorate, health insuranceand was composed of 12 questions and 33 items with four propositions according to the Likert scale. It explored satisfaction about four dimensions of health services: logistic, technic, administrative and relational dimensions. Overall patient satisfaction was retained if we had three positive responses to the following questions: “Are you generally satisfied with your hospitalization?”, “Do you recommend this hospital to other people?” and “If you have a choice, will you return to this hospital if necessary?” The question about overall patient satisfaction was asked in these three different ways in order to judge the perception of patients more objectively.
Statistical analysis:Data were entered and analyzed using IBM SPSS Statistics version 20.0 software. Overall and specific satisfaction rates were calculated and then patient satisfaction associated factors were identified through a multivariate analysis using a logistic regression model. Significance was accepted at the two-sided level of 0.05. All the variables that came out to be significant in the univariate analysis with a level of significance (p) ≤ 0.2 were introduced in the model of logistic regression.  
A total of 1897 patients were included in the study with a sample size of 1269 in surgical departments and 628 in medical departments. The mean age was 42.4 years (SD = 20.5 years) with a sex ratio of 0.94. Half of them were from Sousse Governorate and 60% of them had health insurance. The general population characteristics were described in table I.
Overall satisfaction rates:During the study period, more than 67% of the included patients hospitalized in Sahloul University hospital expressed a good impression on the quality of care provided (figure 1).
Specific satisfaction rates:The main items of satisfaction concerned mainly the relational dimension: the respect of the patient intimacy (77.9%, 95%CI [77.1%-78.6%]), and the quality of information given (65.5%, 95%CI [64.8%-66.1%]). Those of dissatisfaction were mainly logistic: The physical environment in the hospital room (22%, 95%CI [21.8%-22.2%]), the cleanliness of toilets (23.3%, 95%CI [23.0%-23.5%]), waiting times (37.4%, 95%CI [36.9%-37.8%]) and food service (39%, 95%CI [38.5%-39.4%]). Technical and administrative dimension were moderately appreciated (table II).
Patient satisfaction associated factors:The multivariate logistic regression analysis (table III) identified seven independent associated factors with overall patient satisfaction which were: Age over 40 years, satisfaction with quality of health care, satisfaction with the access to the hospital and its departments, satisfaction with physical environment in the hospital room, satisfaction with reception, satisfaction with the respect of the patient intimacy and satisfaction with the quality of information given.

Patient centered care has been considered since decades as a major component in the healthcare mission. This approach helps to understand patient’ problems and consequently to satisfy their needs(12). That is why, patient satisfaction evaluation becomes a necessity in all healthcare organizations in order to identify service factors that need improvement and guide policy makers to make appropriate decisions(13,14). On the other hand, the measurement of patient satisfaction is considered today as a tool towards healthcare quality improvement (15) and it becomes a systematically assessed indicator in many developed countries(16-18).In this context, Sahloul university Hospital has launched since 2015 a survey on patient satisfaction which aims to monitor through an annual report the perceived quality of care in this hospital.
This study had some limitations that should be mentioned: A selection bias is very probable due to the fact that less satisfied patients are more likely to respond to the questionnaire in order to express their dissatisfaction. This may underestimate satisfaction levels. The questionnaire was self-administered in order to minimize information bias. However this bias could be encountered when the responder was the parent and not the patient himself. That could distort the actual perception of the patient. Information bias could be also due to the misinterpretation of some questions. To overcome this problem, a pre-test was carried out on a reduced number of patients. On the other hand, many related patient characteristics that could affect patient satisfaction levels as a potential determinants or confounders like health status, level of education and socio-economic status were not collected in the questionnaire and then their relation with overall satisfaction was not studied. Length of hospital stay which was reported to be a determinant of patient satisfaction in several studies(19), was also not studied because of a lot of missing data about the date of discharge: In fact the majority of patients responded to the questionnaire during their hospitalization before discharge.
Our study showed that overall patient satisfaction was around 67% between 2015 and 2016. In France, the overall score of satisfaction for all health care institutions was 72.7 out of 100 in 2016 which was judged as passable but not extraordinary for a satisfaction score(20). Higher scores (98.7%) were recorded in a study conducted in Swiss land according Heidegger T et al (21). In Tunisia, given the available resources of the public sector health care system, we can say that the overall satisfaction rate found in this study is acceptable. It could considerably increase if a benchmarking evaluation system would be established between our hospitals and between the departments within the same hospital.
When examining the results by items of satisfaction, we find that the respect of patient intimacy, the quality of information and the access were the most appreciated items with scores higher than 60%. Technical care, discharge organization, reception and staff behavior had passable rates of satisfaction (around 50%). Those concerning waiting times and food service had scores under 40%. Scores were about 20 % for physical environment and cleanliness of toilets. According a study conducted in Demerdash University Hospital in Egypt, it was found that inpatients’ satisfaction for physicians’ care of patients, nursing care, administrative facilities and physical environment was 61, 42, 52 and 46%, respectively(22). Soufi G et al, in a study performed in Morocco, reported average satisfaction rates on the medical information dimension(23). Whereas ,the findings of the national survey conducted in France during 2016 showed significantly higher scores :(80% for technical health care, 72% for reception, 66% for food service and 62 % for discharge organization)(20). According a survey conducted in Spain, levels of satisfaction were also higher especially for: information, human care, comfort and intimacy(24).
It could be understood that patient satisfaction in developed countries especially for logistic dimension is significantly higher than less developed ones due to the low available resources of our health care system: The physical environment in the room, the cleanliness of toilets, waiting times and food service were not enough appreciated because of an enormous hospitalization rate in Sahloul University hospital: In fact the bed occupancy rate exceeds 90% in most tertiary level public hospital facilities in Tunisia(25).
Our study identified seven predictors of patient satisfaction:
Age over 40 years: That would be explained by higher tolerance rates among aged people; in fact many studies showed that older patients were more satisfied with health services than younger ones (1,17).
Technical care: Several studies(26) identified that perceived competency of health professionals had one of the most significant impact on the variations in patient satisfaction.
Access: Patients with good perception of accessibility to the hospital and its departments had significantly higher overall satisfaction levels. When reviewing the literature, we find that many studies stated that patient satisfaction was positively associated with this factor(17).
Physical environment in the hospital room: Many environmental factors were shown to be predictors of patient satisfaction especially: Cleanliness (27), pleasantness of the atmosphere, room comfort, bedding,temperature convenience and lighting convenience(17).
Reception quality: The courtesy of the receptionist was also considered as a predictive factor of patient satisfaction according to Bouaiti E et al (28).
Intimacy and privacy: Aldana JM et al(29) highlighted that privacy respect by health professionals was significantly associated with patient satisfaction in two studies conducted respectively in Turkey and Bangladesh.
Quality of information: The quality of information on illnesses, treatments, tests, and medicines by nurses and physicians(30) were strongly associated with overall patient satisfaction.

In conclusion, we can say that the levels of patient satisfaction in Sahloul University Hospital are average compared to those found in the developed countries. The lowest satisfaction rates were mainly related to accommodation conditions and waiting times. Determinants of patient satisfaction were mainly related to the quality of access and reception, the accommodation conditions, the technical care, the quality of information and the respect of patient intimacy. Taking these results into account, certain measures should be undertaken: First, to continuously monitor the levels of patient satisfaction in our health institutions in Tunisia. Second, to set up a benchmarking evaluation system between our hospitals and between the departments within the same hospital. Third, to target the least satisfactory dimensions of care and to focus on determinants of satisfaction through appropriate interventions.

Conflict of interest:
Authors declare no conflict of interest.

Ethical considerations:The study was conducted under good clinical practice conditions and according to the ethical standards collections. During the study, verbal informed consent was sought from all the respondents before answering the questionnaire.

Funding: This work was supported by the Research Unit UR12SP36 "Mesure de la performance hospitalière". Ministry of Higher Education of Tunisia.

Acknowledgments: The authors wish to express their gratitude to the administration of Sahloul University Hospital and to all department heads for permission to conduct this study.
They would also like to thank the staff of the Information System Direction for their involvement in ensuring the success of the survey particularly Jihène Hachem, Assia Assadi and Nouha Houas for their active participation in the data collection and entry.

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