QUALITY of CARE SURVEY WORKSHOP

1. QUALITY ofCARE SURVEYWORKSHOP April 23-25, 2003

2. Background • Secondary health care services are currently delivered from a renovated Primary School building with a capacity of 30 beds.

3. Background (cont’d) • Services offered on-site include • Emergency • Pharmacy • Laboratory • X-ray • Dental • Nutrition • Housekeeping • and Maintenance

4. Background (cont’d) • The Operating theatre is located about one mile away from the hospital. • Four district clinics are located at • Salem, • St. Peters, • Cudjoe Head • St. John’s.

5. Why Did We Do This Survey This initiative arose out of: • A concern that the public had no input in the provision of health services, • The constant difficulty in accurately assessing the quality of services given to the public.

6. Why Did We Do This Survey(cont’d) The lack of information on the needs of the population made it very difficult for projects like the Operating Theatre to be approved by DfID. The dwindling finances of the Ministry of Health meant that focus had to be placed on the efficient use of resources in key areas.

7. Why Did We Do This Survey(cont’d) No survey on this subject or on this scale had ever been conducted on Montserrat. Other surveys conducted were targeted to specific areas of health and were generally used as tools for problem-solving Health staff wanted to know what the public thought of the services they provided

8. Problem Statement • The quality of care offered to the people of Montserrat has never been measured and documented. • The needs of the people could not be effectively and completely addressed for improvement and continuation and also for effective use of resources.

9. Definition “Quality of Care” refers to the value, grade or class of the hands-on care, or any other service received by a person, that contributes to the health care of that person.

10. Survey Objectives Main Objectives To determine levels of satisfaction of services, both primary and secondary, provided to the general public. To assist in determining the future direction of health services to include; Development of Health Policies

11. Main Objectives (cont’d) • Establishment of Quality Assurance and Quality Control Programmes • Development of Cost Recovery Strategies • Development of adequate Health Information and Management Information System

12. Age Gender Disabled Exempt & Fee Paying Insured & Uninsured Unemployed Low Income National & Non-national Secondary Care Users – In-patient & Out-Patients Primary Care Users – Public & Private Overseas Users Private Care & Public Care National Care & Public Care Categoriesof Users Users were categorized by the following

13. Laboratory Housekeeping Diagnostic (X-ray, ECG, Ultrasound) Pharmacy Emergency/Casualty Ambulance Maintenance Dietary Nursing/Ward Mortuary Orderly Clinical (Surgical, Medical, Paediatric) Administration Reception (Telephone, Medical Records) Categories of Services Hospital Services

14. Target Areas/Groups • Private Clinics • Public Clinics • Users at Lab, Pharmacy, and other Out-Patient Departments • Geriatric Homes • Students • Government Departments (civil servants) • Statutory Body Groups • In- Patients

15. Approach A small group of senior health officials met in May 2001. A Steering Committee and a Sub- Committee was formed in June 2001 to plan and undertake this initiative. The committees met on at least seven occasions. The categories of services, users, target areas and focus groups were decided by these committees.

16. Elderly Groups Social Welfare Recipients Anglican Group Lookout Comm.Group Manjack Com. Group Drummunds Group Womens SG10 Group Davy Hill Groups Non-Nationals Hill View Home Red Cross First Aiders Brades Pentecost Grp Rotaract & Rotarians Focus Groups

17. Methodology The following represents the tools developed to carry out the survey; Main questionnaire Individually customized questionnaires for Outpatient and Inpatient Departments and Clinics Focus Groups

18. Waiting Times Frequency of Visits Reason for Visits Opening Hours Serving Methods Helpfulness of staff Rating of staff Quality of staff Effectiveness of Instructions Treatment Facility Physical Access to services Parking Confidentiality Satisfaction What kind of Information Did We Collected

19. Awareness of types of services Availability of services Choice of services Use of services on and off island Suggestions for a range of services to be offered Familiarity with regulations Referral System Affordability of Fees Criteria for quality health care Perceptions of health service Physical facilities What kind of Information Did We Collected

20. Care of the Elderly Mentally Ill Exclusion and Access to Health Care Views on Exemption Suggestions for Improvement Criticisms Key health problems on Montserrat Financing Health What kind of Information Did We Collected

21. Limitations of the Survey It is recognized that the total hands-on quality of care cannot be assessed by this survey. Further tools such as clinical audits will have to be used in conjunction with these tools. The Quality of Care survey results are expected to provide pointers to areas needing attention.

22. RESULTS

23. Response Level The response level for was 100% for all departments, with the exception of the In-patient Section which recorded a 90% response level.

24. Distribution by Gender(of respondents) Fifty-nine percent (59%) of the respondents were females.

25. Respondents By Age Group

26. Residency Status The majority of respondents were Montserrat nationals

27. Occupational Status Forty two percent (42%) of the respondents were persons in the labour force.

28. Income Levels Forty-seven percent (47%) of the respondents were either unemployed or had minimal income.

29. Source of Referrals (Clinics)

30. Our Opening Hours -How satisfactory are they?

31. Physical Access 13% of the respondents said they could not see the Casualty Department from the main road.

32. Parking • Salem: Respondents said • “they can’t do any better.” • “they can’t do anything • about it, no land.” • St. John’s: Respondents said • “Here is just temporary.” • “When they go to the new • one there may be enough.” • “For a clinic it should not • be directly on the highway.”

33. Physical Facilities(focus groups) Positive 13 groups commented very highly on the cleanliness of medical facilities generally Negatives 12 groups commented on the inadequacy of waiting areas especially when it rains particularly for Lab, Casualty and Pharmacy.

34. Physical Facilities(focus groups cont’d) Lack of proper waiting rooms with protection from the elements (6) Lack of comfort especially for the elderly (10) Not enough seating

35. Highest Frequency ofWaiting Time

36. Dissatisfaction withWaiting Time Levels of dissatisfaction ranged between 0% – 50%. The lowest levels were in the X-ray Department and the highest levels at the Pharmacy.

37. Doctor’s Waiting Time(How much time did most persons wait)

38. Seating

39. Privacy • Cudjoe Head Clinic • Could close the door • Facility is too open • St. John’s Clinic • Nurses section is not so private • Pharmacy • Persons sitting on the bench can see and hear what is taking place.

40. Privacy • Pharmacy cont’d • Everyone waiting can see what medication one received and hear instructions. • Seating is to close. • Casualty • Persons can hear or see patients being dealt with. • Screen should be closed at all times. • Dental • There should be a door instead of a curtain.

41. Privacy(Focus Groups) 12 groups talked about the privacy of the physical facilities provided. Positives Some groups (6) felt there was (some) privacy at the various facilities (Casualty, Pharmacy, Wards, Clinics) Xray was considered private, as well as the private doctors.

42. Privacy(Focus Groups cont’d) Negatives A lack of privacy on the Wards (5) No privacy at the private pharmacy when prescriptions are left (3) Lack of privacy at the Homes

43. Level of Confidentiality

44. POLITE & HELPFULNESS OF NURSES(Clinics, Casualty, Inpatients) • POLITENESS • Levels of satisfaction ranged from 73% to 100% • QUESTIONS • Levels of satisfaction ranged from 70% to 98%.

45. POLITE & HELPFULNESS OF NURSES(Clinics, Casualty, Inpatients) • TOOK TIME • 100% levels of satisfaction were recorded on the Wards and at Salem Clinic • EXPLAINED • 63% of the respondents were satisfied with the explanations given at the Casualty Department.

46. POLITE & HELPFULNESS OF NURSES(Clinics, Casualty, Inpatients) • CARING • 100% levels of satisfaction were recorded on the Wards and at Salem Clinic. • In all the categories the Casualty Department recorded the lowest levels of satisfaction.

47. Nurses Professional Service • Casualty was the only Department that had levels of poor and very poor. • Many persons thought that the resources available affected the nurse’s ability to provide the best professional service. • On the other hand, some persons commented that Nurses had resources but were unable to use it, e.g. ultrasound

48. Nurses Instructions An average of 95% of respondents for clinics were satisfied that they could clearly understand and easily carry out the nurses’ instructions and advice. Those falling into the 5% who were not satisfied made comments such as:- Information is sometimes conflicting, all should say to do things the same way (Cas) Most nurses always seem to be in a hurry as if they are not working. (Cas) Nurses are sometimes too abrupt and uncaring. (Cas)

49. Nurses Medical Treatment or Advice An average of 93% of respondents for Clinics and Casualty were satisfied that they nurse provided effective advice and treatment for their medical condition. Those falling into the other 7% made comments such as:- Whenever you ask them a question???

50. Nurses Medical Treatment or Advice (cont’d) Sometimes it helps, sometimes it does not. They can’t cure me, they can only help me. In asking those 7% how they would deal with this problem, most indicated that they would go to a doctor or return to the Clinic.