BMC Cancer BioMed Central BMC 22002, Cancer x

Background We conducted a survey to find out how patients feel about the care they receive in the outpatient chemotherapy unit of Marmara University Hospital. Methods The American College of Physicians Patient Satisfaction survey translated into Turkish was used. A meeting was held with all involved staff, before conducting the survey, to review the purpose and determine the process. The study was conducted with 100 random patients. Results Consistent with cancer frequency, most patients had either lung, colorectal or breast cancer. Their insurance was government sponsored in close to 90%. The educational levels were above Turkish median but consistent with the area the hospital is serving. They were coming to the unit on average 8.5 months. The responses were not influenced by the surveyed diagnosis, age, sex or educational status (p > 0,05). Particularly health care team's attention, trust and courtesy came forward as strong points. The weaknesses noted as difficulties in booking an outpatient doctor visit appointment because the phone line was busy or the secretary was not courteous, the excessive amount of time and effort it required to get laboratory and radiology results. Conclusion The health care system is basically a service based industry and customer satisfaction is at utmost importance just as in other service-oriented sectors. We hope this study will shed light in that area and Turkish health care providers will pay closer attention to how their patients feel about the services that they are getting.


Background
The healthcare team's goal is to provide the patient with the best health care and service possible. The service providers are in constant effort to better meet the patients' needs and expectations. In the last 20 years the old way of treating patients in the "disease centered" approach has changed to "patient centered" style. Now patients have more influence toward the care they receive and they are given opportunity to change the way the care delivered to them. Satisfaction is one of the core outcome measures for health care. It is intuitively more appealing than measures of health care effectiveness or efficiency that are more difficult to understand. Satisfaction with health care is a measure with a long history in the social sciences. Most current research is less interested in correlations between patient characteristics and satisfaction and more focused on improving the quality of care and service delivered to patients and health plan members [1].
In the last years an important change has taken place regarding doctor-patient relationships. One of its effects is that today healthcare results are measured in terms of effectiveness, efficiency, patient's perception of pain or autonomy, physical and mental well-being and, also, in terms of satisfaction with the achieved outcome. In literature it is easy to find studies on patient satisfaction with the conditions of hospitalization, emergencies, or visits. However, it is not usual, to find studies on patient satisfaction with medical outcomes, and this is the kind of information most relevant to clinical use. The concept of "patient-focused-care" obeys to this new position that is based on the recognition of patients' active role in the decision-making process and the notion that clinical decisions should take patients' views and perceptions into account [5].
There are quite a few studies measuring the patient satisfaction for other subspecialties but they are rather limited in oncology care setting. Thomas et al investigated patient satisfaction in a oncology outpatient clinic in Middlesex University in Enfield UK and reported that out of 252 patients 92% were "always" or "usually" reassured as a consequence of their visit. This study also confirmed the fact that clinical staff was most important source of satisfaction [6]. Similar Italian [7,8] and British studies [9] also reported strong and weak points of their services that brought out by patient satisfaction surveys and took measures to rectify the problem areas.
Although little is known about patients' perception of the quality of care they receive in Oncology services, one of the main difficulties is to find the appropriate way to assess this. Bredart et al attempted to develop a "Comprehensive assessment of satisfaction with care CASC" survey with 61-item questionnaire to evaluate the competence of hospital physicians and nurses, as well as aspects of care organization and hospital environment. The aims of the study were to define the structure of the CASC and assess the internal consistency and convergent and discriminate validity of its scales. They concluded that CASC forecast adequate properties for psychometric testing and suggested confirmation by repeating these analyses in cross-cultural setting [2]. Similar attempts for finding the proper way to measure service quality also reported, SERVQUAL instrument [3] from MD Anderson Cancer Center in Texas or FAMCARE scale [4] from University of Manitoba in Winnipeg. There is still no consensus developed on best method. In the last several years the American College of Physicians launched various projects on its web site to help doctors on their practise management. These services range from investment decisions to billing. Another one of these tools named "Patient Satisfaction Check Up" and geared toward measuring patient satisfaction from outpatient services the individual physician's office is offering. The survey questions the level of satisfaction at different stages during patient care and also rates ancillary services such as laboratory or radiology. Categorically the survey measures front office services, health care team's performance and services pertaining to ancillary services i.e

Methods
Turkey is a country in the size of Texas USA, but it populates 65 million people. The one third of this population lives in the Marmara region that encompasses Istanbul and cities around eastern Marmara Sea, Kocaeli and Bursa. The region is economically most prosperous part of the country and great amount of immigration from rest of the country to this region in the last 40 years makes both Istanbul and the larger Marmara region a melting pot for various cultural and religious groups.
Marmara University Hospital is a 350-bed hospital located in the Anatolian part of the Istanbul and closer to other smaller industrial cities like Izmit and Adapazari. Because of its location in a medium income neighborhood and close proximity to both richer coastal section of town and poorer highland section, it serves to a wide range of patient population with different socio-economic and cultural backgrounds.
Almost all cytostatics are available for Turkish cancer patients. Outpatient cancer care also provided in a similar fashion to western European countries, especially in metropolitan cities of Turkey. On the other hand because of population density in bigger cities and lack of adequate resources for appropriate buildings and scarcity of formally trained Medical Oncologists, the level of service may be below standards of European counterparts. It is not known to what level Turkish patients are satisfied with the care provided and where the pitfalls of the system exists since no group as yet reported the cancer patients' perception of care in a formal fashion in Turkey. We conducted a survey find that out in the outpatient chemotherapy unit of Marmara University Hospital.
The unit was established in a container with 2 beds, situated next to the hospital's parking lot, in 1995. A prefabricated building with 9 beds opened in the same location in January 1997. Since July 2000 serving in its current location, a rented floor from neighboring nursing home building, with 14 bed capacity. The unit serves mainly (70%) to oncology patients but also patients of hematology, pulmonary disease, radiation oncology and rheumatology departments get their infusional therapies there.
Two doctors, three nurses, a psychologist and a secretary are providing the care to the patients. Besides the therapies the patients get, their psychological states, the satisfaction and the trust they have for the unit are also given importance and that's why this study is conducted in this unit.
The American College of Physicians' "Patient Satisfaction Check Up" survey at "Practice Management Center" site was downloaded from Internet and translated into Turkish. Before conducting the survey, a meeting was held with all involved staff to review the purpose of undertaking the survey; determine the process for conducting the survey; determine how many surveys to be distributed and everyone prepared to answer patients' questions regarding the survey. A particular attention paid to involving everyone in the unit who has patient contact. Also everyone was included in the process of choosing the appropriate questions so some of the original questions were either tailored or eliminated on our own initiative, in order to fit to the way the health system is operating in Turkey. The translated form of survey consisted of 33 questions and 2 more questions were added to find out: "the cancer type of the patient" and "for how long he/she has been coming to the chemotherapy unit".
The staff psychologist and the externs who were having their rotations during the time of the study gave the questionnaires to all patients that pass through the unit. Doctors did not give the questionnaires on purpose, to eliminate the biases. Before the questionnaires were given the patients were informed about the purpose of the survey and were assured that their answers would be kept confidential and their names would not be written on their answer sheets.
The study was conducted with 100 consecutive patients who were visiting the unit for their treatment. All of the patients who passed through were given the questionnaires without making any discrimination according to their cancer types, however only the patients from the oncology department were included to avoid any inter-departmental conflict. One hundred percent of the patients accepted to cooperate and there was no refusal. This may partly due to the fact that sampled cohort appreciated our efforts to improve our services which is not a common occurrence in Turkey and also socio-cultural background of Turkish people in general may found it imperative to help when directly asked to.
Responses to the questionnaires scaled from '1' being poor, to '5' being excellent, and then arithmetical mean were calculated to be used in statistical analysis. The data was analyzed using Chi-square test and independent sample tests. The level of significance (alpha) was set to 0.05 for all tests and confidence intervals. SPSS 7.5 for Windows (SPSS, Inc., Chicago, IL) was the statistical software used.

Results
Consistent with cancer frequency, most patients had either lung, colorectal or breast cancer. Of note, 18% stated that they do not know the type of cancer that they have. Their insurance was government sponsored in close to 90%. The women were slightly over represented. The educational levels were above Turkish median but consistent with the area the hospital is serving. The patient characteristics including age distribution are shown in table 1.
The surveyed patients were coming to the unit on average 8.5 months. The responses were not influenced by the surveyed' diagnosis, age, sex or educational status (p > 0.05). Particularly health care team's attention, trust and courtesy came forward as strong points. The health care team's ability to carry on the treatment, taking the time for informing the patients and encouraging the patients to share their problems with the caregivers was other forthcoming strong points.
The weaknesses noted as difficulties in booking an outpatient doctor visit appointment because the phone line was constantly busy or the secretary was not courteous, the excessive amount of time and effort it required to get laboratory and radiology results. The other problems included inconvenience of outpatient appointment hours, bu-

Discussion
Although results are depicted above several findings on this study needs to be further elaborated upon, including unexpectantly high percentage of (18 %) patients reporting that they do not what type of disease they have. Majority if not all doctors and related health care providers are firm believers to share the information regarding the diagnosis and treatment options with cancer patients. Still there are certain setbacks that could explain why one of every 5 patients does not know their illnesses: 1. Family factor: The diagnosis of cancer is interpreted as a "death sentence" by most people in Turkey therefore the caretaker/s of the patient may insist on patient's not hearing the word "cancer". Although not entirely acceptable, on rare occasions the physician may opt to describe the condition in entirety without using the word "cancer" and asks the patient at the end "whether there are any other issues the patient wants to know regarding his/her condition". If the patient does not question it further then the issue may be "put at rest" for the time being.
2. Patient factor: The patient may know the diagnosis but may "play the game" and not reveal it to a stranger (interviewer) in the presence of the family who does not want the patient to know in the first place. On some other instances the patient may be altogether in the state of denial and attribute all symptoms to some health condition other than cancer.
One of the other interesting finding is that the patients' perceptions of the health care team's attention trust and courtesy reported as particularly strong points and probably reflects the clinic's dedication to superior education and constant improvement efforts on better patient care by all members of health care team including nurses but also the teaching faculty, the fellows, the rotating residents, medical students and psychologists. One may also question whether the patient to care provider ratio is higher than the average of other government sponsored outpatient chemotherapy units or other outpatient care units in the Marmara University Hospital. But, this is certainly not the case and because of the relatively new establishment of Oncology unit; it lacks resources beyond most of the other outpatient units in Marmara University and rates among the median average of similar outpatient chemotherapy units in Istanbul, Ankara, Izmir, Adana and Bursa where such services are available.
The shortcomings of the scheduling services came as one of the most problematic area where we thought some improvements were urgently due. Previously all the scheduling of Internal Medicine patients for 11 outpatient clinics was managed through 1 secretary and 1 internal phone line. It required the patients to reach the already busy hospital operator first and then forwarded to the sole scheduling line, which was also busy most of the time as well. Moreover even when reached through; this was the same secretary who is already trying to serve to a long queue of patients standing in line to make an appointment. Naturally he was not attentive and courteous enough. As a solution we withdraw from Internal Medicine appointment procedure altogether and set-up an on-site computerized appointment schedule at outpatient chemotherapy unit, managed by unit secretary. By that way we are also able to allocate particular time slots to patients other than bulk time-slots such that all morning appointments in Internal The most distressing or the least satisfying conditions: 1. When I called the office for an appointment, the length of time before the phone was answered was: 2. The length of time I spent on the phone to set my appointment was: 3. The staff's helpfulness in scheduling my appointment was: Medicine are given to 9 am and all afternoon ones to 2 pm and then patients are seen on a first come first serve basis.
Some of the other services that the patients have complained most are out of the direct control of the Oncology Department such as radiology, pathology and laboratory services. We reported patient complaints on those departments' level of service to hospital administration and hopefully our efforts somewhat influenced the many changes carried out by hospital administration in terms of staff and resource allocation (i.e. more space, more advanced computer network and educational courses for patient interaction)." Our study also shows that overall patient satisfaction is somewhere between good to very good but several areas requiring improvement that will necessitate other service providers in our hospital to cooperate. We shared this information with hospital administration and promises are made by the administration to address the problem areas.

Conclusion
The health care system is basically a service based industry and customer satisfaction is at utmost importance just as in other service-oriented sectors. Turkey is a developing country and most efforts in health services is pointed toward providing the most basic health care needs to all citizens adequately and equally. But just as in the developed world, the patients are demanding improvement in quality of services they receive.
Similar advances are constantly in the making in the US and Western Europe. Globalization of the world and boundary free European Union that Turkey is admiring to join will force Turkish Health care systems just as automotive or electronics industries to pay attention to customer demands and needs.
So far no similar service quality and patient satisfaction based studies from Turkish health care system are reported in International peer reviewed journals. We hope this study will be pioneer in that area and Turkish health care providers will pay closer attention to how their patients feel about the services that they are getting.