Quality Improvement Strategy for Interns Doctor Services in the
Emergency Unit
R. Hartana Brataatmaja, Sri Lestari R. Nasution, Chrismis Novalinda Ginting, Ermi Girsang*
Faculty of Medical, Universitas Prima Indonesia, Indonesia
Keywords: service quality, patient satisfaction, interns doctor, emergency department
Abstract: In an effort to meet the needs of doctors and prepare good quality doctors in their fields, the government is
organizing an internal program. The level of patient satisfaction is still quite low on the services of interns
doctors. Patients assume that the intern is only a junior practitioner who is still in training and is still in the
stage of developing competencies. This study aims to improve the quality of service and customer value to
the image of services in the emergency department. This research is a quantitative research with an
explanatory research approach with a total sample of 30 people. Data collection was carried out using a
questionnaire. Data were analyzed using Pearson product moment correlation test and multiple linear
regression test. From the correlation test results obtained by the correlation coefficient (r) on the reliability
variable (r 0,701; p 0,000), responsiveness (r 0,645; p 0,000), guarantee (r 0,555; p 0,001), and empathy (r
0,529; p 0,003) . Statistically proven that there was an influence of reliability, responsiveness, assurance and
empathy of interns doctors on patient satisfaction in the ER.
1 INTRODUCTION
The quality of health services must embody the
highest level of quality as it deals with patients’ lives.
Doctors as medical personnel and contact point for
patients must be of certain quality. In addition, the
quantity of the doctors must be in proportion to the
number of patients as this is to prevent work overload
and providing quality services to the patients
(Supartiningsih, 2017).
The number of doctors in Indonesia is currently
insufficient. The 2016 Indonesian Medical Council
referenced that the ratio of doctors to residents in
Indonesia is 1 doctor to 2,770 residents. This ratio is
higher than the ideal ratio according to World Health
Organization (WHO) standards, namely 1 doctor for
2,500 population (Indonesian Medical Council,
2016). That is, one doctor in Indonesia has to cater to
an additional rough amount of 270 patients in
Indonesia.
In an effort to increase the numbers of doctors and
to prepare qualified doctors in the field, the
government represented through the Indonesian
Doctors Internship Committee (IDIC) organizes an
Internship Program. This internship program is an
apprenticeship program for doctors who have just
completed their professional education who aim to
practically apply their knowledge in an integrated,
comprehensive, independent manner). Also, by using
family medicine approach in understanding and
aligning theoretical knowledge with practice in the
field.
Countries that have already implemented this
program stated that internships are an integral part of
medical education. Internship can last from one year
to several years. It is also an initial part of education
in obtaining specialist degree or in obtaining practice
rights as a general practitioner or as a family doctor
(Binenbaum, Musick and Ross, 2007). In Indonesia,
doctors in undergoing an internship program have
duties in accordance with Doctor Competency
Standards covering seven areas, namely: 1) noble
professionalism; 2) self-awareness and self-
development; 3) effective communication; 4)
information management; 5) the scientific foundation
of medical science; 6) clinical skills and 7)
management of health problems (Indonesian Medical
Council, 2012).
The quality of health services in a health service
must almost always be able to satisfy the patient, this
is often referred to as quality service. The quality of
health services usually refers to the ability of
hospitals, to provide services that are in accordance
66
Brataatmaja, R., R. Nasution, S., Ginting, C. and Girsang, E.
Quality Improvement Strategy for Interns Doctor Services in the Emergency Unit.
DOI: 10.5220/0010287300660072
In Proceedings of the International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical (HIMBEP 2020), pages 66-72
ISBN: 978-989-758-500-5
Copyright
c
2021 by SCITEPRESS Science and Technology Publications, Lda. All rights reser ved
with the standards of the health profession and are
acceptable to their patients. Azwar (1996) defines the
quality of health services as showing the level of
perfection of health services in causing satisfaction to
every patient. The higher the satisfaction level, the
better the quality of health/ medical services
(Supartiningsih, 2017).
Satisfied patients are valuable asset to the hospital
as they may continuously uses the services and may
refer to others about their experiences. Likewise, if
patients feel dissatisfied, they will tell others twice as
great about their bad experiences. Customer
satisfaction has become a central concept in business
and management discourse (Tjiptono and Chandra,
2016; Wijaya et al, 2019). Service quality is centered
on efforts to meet the needs and desires of customers
and the accuracy of delivery to offset customer
expectations (Supranto, 2015).
The demand for high quality doctor’s services
coupled with the complexity of the medical sciences
is highly sought after. Especially in the emergency
department, within a limited time, doctors are
required to perform well under pressure. Emergency
services must be met with efficiency and
effectiveness. Doctors aim to save as many patients
who come to the emergency room within shortest
possible time. Conceptualizing theories, quick
decisions and executing actions are required during
crucial. This is of upmost importance to avoid errors
that may be detrimental.
Doctor’s quality services can be assessed through
several benchmarks, such as reliability, (work
consistency), trustworthiness (willingness or
readiness to provide services), knowledgeable,
courteous and most importantly, being able to
empathize on the patients’ situation (Parasuraman et
al, 1994; Turnip et al, 2020).
Over the years increasing patient satisfaction has
been the primary goal of a healthcare business
organization. Patients’ satisfaction affects customer
retention rate and company's market share. Thus,
achieving high levels of patient satisfaction in health
care is of high importance. Previous studies dedicated
in learning how to increase satisfaction in health care
settings focused on gaining better knowledge about
the doctor-patient relationship and how it affects
patient satisfaction (Al-Neyadi, Abdallah and Malik,
2018).
By improving the quality of doctor’s services,
higher patient satisfaction is expected to be achieved.
This may result in better image of hospital and
subsequently increases patient visits. A study
conducted by Rizal shows that service quality
influences patient satisfaction in the dimensions of
responsiveness, assurance, and direct evidence
(Rizal, Suardi and Yulihasri, 2017). The limitation of
this study is it only focuses on the quality of doctor's
services while the dependent variable is patient
satisfaction.
Maqsood's study found that better quality health
care had a positive effect on patient satisfaction and
actions. The results found that for every hospital that
provides good service, there is a higher referral rate
as patients will recommend their friends and
neighbors to visit (Maqsood, M., Maqsood, H.,
Kousar, R., Jabeen, C., Waqas, A. & Aman, 2017).
The difference with this study is it only focusses
services quality as independent variable and patients’
satisfaction level as dependent variable.
Research at Dr Kariadi Hospital Semarang found
that there was a significant positive relationship
between the quality of service for practicing
physicians and the satisfaction of outpatients using
BPJS Health card users. This means that the higher
the quality of service for practicing doctors, the
higher customer satisfaction for outpatients using
BPJS Health cards (Adelia and Nurtjahjanti, 2016).
The difference with this study lies in the subject that
is being examined. While previous study focusses on
the outpatient, the subject of this study focusses on
ER patients.
Research at a Korean hospital found that
physician performance and quality of service
procedures are positive factors that contribute
positively on effectiveness of treatments. That is,
should the patients experienced effectiveness and
satisfaction of a treatment, they are more likely to
continuously visit again (Kim et al., 2017). The
previous study only focusses on service quality as
independent variable and it’s impact on patient’s
satisfaction. In addition, the variable dependent that
the previous study focuses on is doctor’s performance
and hospital’s service procedure and its impact in
effectiveness of treatment.
Research in three hospitals in Pakistan found that
physician behavior significantly moderates the effect
of health care services on patient satisfaction
Manzoor assessed patient satisfaction on the quality
of doctor services through the doctor's behavior as a
moderator for patients (Manzoor et al., 2019).
In addition, research at Kavala General Hospital,
Greece examines the quality of physician services
based on 5 dimensions of quality (5Q) health services,
namely reliability, responsiveness, assurance,
empathy and physical evidence (tangible). It was
found that the overall five dimensions had a
significant impact on patient satisfaction in the
hospital. These dimensions are on a hierarchical
Quality Improvement Strategy for Interns Doctor Services in the Emergency Unit
67
scale: clinical care, social responsibility, staff quality,
infrastructure and hospital reliability (Vasiliki, A. G.
& Maditinos, 2017). In contrast to this study, this
paper aims to examine the quality of service based on
4 dimensions according to Parasuraman namely
reliability, responsiveness, assurance and empathy
did not include dimensions of physical evidence.
2 METHOD
This study is performed based on quantitative
research with an explanatory research approach
carried out at RSU Royal Prima Medan. Samples
were taken on30 respondents family companion
patients in the emergency unit. Data is collected
through distributing questionnaires containing 5
items each about the independent variables. That is,
(reliability, responsiveness, assurance and empathy)
with alternative answers according to the Liker Scale
ranging from strongly disagree, disagree, simply
agree, agree and strongly agree, It is also equipped
with five items about the variable dependent (family
satisfaction companion patient) with alternative
answers very unsatisfactory, unsatisfactory,
satisfying enough, satisfying and very satisfying.
Questionnaires were distributed in the first and
second week of December and validity and reliability
tests had been carried out on 30 respondents from the
accompanying patient family of Murni Teguh
Memorial Hospital Medan who visited the emergency
room. The validity test results using the Rhitung
coefficient values in the range 0.644-0.992> Rtable =
0.361, it is assumed that the data is normally
distributed. The results of the Cronbach's
Alphahitung value were in the range of 0.887-0.955>
0.7; assumed a reliable questionnaire as shown in
Table 1. V is Variable, K is Reliability, DT is
Responsiveness, J is Guarantee, E is Empathy, BP is
Item Statement, CI-CT is Corrected Item-Total
Correlation, CA is Cronbach's Alpha, and Ket is
Remarks.
Data processing through the stages of collecting,
checking, coding, entering and processing. Data were
analyzed bivariately using the Pearson product
moment correlation test and multivariately with
multiple linear regression tests. The research
procedure as in Figure 1.
Table 1. Results of Test Validity and Reliability of the
Research Questionnaire
No V BP CI –TC CA Ket
1. K 0,887 Reliabel
1 0,906
Valid
2 0,644
Valid
3 0,662
Valid
4 0,756
Valid
5 0,736
Valid
2. DT
0,955 Reliabel
1 0,910
Valid
2 0,886
Valid
3 0,918
Valid
4 0,945
Valid
5 0,747
Valid
3. J
0,939 Reliabel
1 0,902
Valid
2 0,822
Valid
3 0,777
Valid
4 0,843
Valid
5 0,862
Valid
4. E
0,945
1 0,768
Valid
2 0,785
Valid
3 0,882
Valid
4 0,992
Valid
5 0,859 Valid
Figure 1. Procedure of research process
3 RESULTS AND DISCUSSIONS
Characteristics of respondents involved were the
family of patients' companions based on age, the
HIMBEP 2020 - International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical
68
majority aged between 31-40 years, the majority were
men, the majority were high school educators, the
majority worked as employees and relationships with
patients were the majority of children from patients.
More clearly can be seen as in Table 2.
Table 2. Characteristics of respondents
Characteristics n=30 %
Age (years)
<30 2 6,7
31-40 14 46,6
41-50 9 30,0
>50 5 16,7
Sex
Female 13 43,3
Male 17 56,7
Education
Midle high 2 6,7
Hi
g
h hi
g
h 20 66,6
Undergraduate 8 26,7
Occu
p
ation
House Wife 10 33,3
Em
p
lo
y
ee 13 43,4
Entrepreneur 6 20,0
Unem
p
lo
y
e
d
1 3,3
Relationship with
p
atients
Chil
d
17 56,7
Parents 9 30,0
Sibling 4 13,3
The results of the questionnaire measurement of
research variables are the quality of health services
(reliability, responsiveness, assurance, empathy) and
family satisfaction of patient companions as shown in
Figure 2. Where, V is variables, R is reliability, RP is
responsiveness, G is guarantee, E is Emphaty, and FS
is Family Satisfaction.
Based on bivariate analysis, the relationship
between the quality of interns physician services
(reliability, responsiveness, assurance and empathy)
with patient satisfaction was analyzed using the
Pearson product moment correlation test with a
significance level (α) = 0.05. The results of bivariate
analysis obtained correlation coefficient (r) on the
reliability (r 0,701; p 0,000), responsiveness (r 0,645;
p 0,000), guarantee (r 0.555; p 0,001), and empathy
variables (r 0.529; p 0.003).
Figure 2: Recorded data from questionnaire with 30
respondent.
The independent variable has a probability value
smaller than α 0.015. This means that the quality
variables of interns physician services consists of
aspects of reliability, responsiveness, guarantee
(assurance) , and empathy related to patient
satisfaction. The strength of the relationship between
variables based on the correlation coefficient
indicates that the reliability and responsiveness
variables were strong while the guarantee and
empathy were moderate. The coefficient r was a
strong relationship with intervals of 0.600-0.799 and
moderate 0.40-0.599 (Sugiyono, 2014). More clearly,
pearson correlation and significance is shown in
Table 3
.
Table 3: Product Moment correlation test results.
Variabeles
Pearson
correlation
r
Significance (p)
Reliability
0,701 0,000
Responsiveness
0,645 0,000
Guarantee
0,555 0,001
Emphaty
0,529
*
0,003
The calculation results of the Kolmogorov-
Smirnov One-Sample Test obtained the Asymp value.
Sig. (2-tailed) Unstandardized Residual that was
0.655> 0.05, it can be said that the variables of
reliability, responsiveness, guarantee (assurance),
and empathy are normally distributed. The results of
the multiple linear regression test with the Enter
method for each internship physician service quality
variables in the form of reliability, responsiveness,
assurance, and empathy obtained that the relationship
between variables can be described in the multiple
linear regression equation in the form of:
Y = -4,396 + 0,272X1 + 0,277X2 + 0,377X3 + 0,354X4
where, Y is the family patient satisfaction; α is a
constant; β1 ... β4 are the regression coefficient; X1
is reliability; X2 is responsive; X3 is a guarantee; and
X4 is empathy. The results is shown in Table 4.
0
5
10
15
1 5 9 1317212529
FS
E
G
RP
R
Quality Improvement Strategy for Interns Doctor Services in the Emergency Unit
69
Table 4. Results of the hypothesis through Coefficients (a)
test
Variables β Sig.
Constant -4,396 0,015
Reliability 0,272 0,003
Responsiveness 0,277 0,001
Guarantee 0,377 0,000
Emphaty 0,354 0,000
The coefficient value β in Table 4 for each
variable, implies that each increase in internal
physician for each variable tested will result in an
increase in patient satisfaction by the value of the
coefficient. For example, the coefficient value of
responsiveness β was 0.277, which means that any
increase in the responsiveness of interns will result in
an increase in patient satisfaction of 0.277, and so on.
The biggest coefficient β value was the guarantee
variable, then the variable is the dominant factor
affecting patient satisfaction.
In the determination test results obtained
correlation coefficient (R) was 0.918 and the
correlation coefficient of determination (R Square) of
0.843 which means 84.3% of the variation of
independent variables (reliability, responsiveness,
guarantee (assurance) and empathy) was able to
explain the dependent variable, namely patient
satisfaction.
The coefficient of determination (R2) basically
measures how far the ability of the regression model
in explaining the variation of the dependent variable.
The small coefficient of determination (R2) means
that the ability of the independent variables in
explaining the variation of the dependent variable is
very limited. A value close to one means that the
independent variables provide almost all the
information needed to predict the variation of the
dependent variable.
The results of the bivariate analysis of the four
variables (reliability, responsiveness, assurance and
empathy) were related to patient satisfaction and all
four variables were included in the multivariate
analysis (p <0.25). The results showed that there was
a positive influence between the reliability of interns
physicians on patient satisfaction. Based on the
results of multiple linear regression tests obtained p
value 0.003 <0.05 means there was an influence on
the reliability of interns physicians on patient
satisfaction.
Based on the assessment of patients in the
emergency department that there is still a lack of
quality in doctor's service. This is evident in the
reliability aspect gathered from the respondent's
answer to the statement on the questionnaire that the
doctor did not provide clear health information
desired by the patient so that the patient was not
satisfied with the results of the service he received.
Patient also stated at certain times doctors were in a
rush while doing examination and the patient did not
dare to ask further about his condition.
Reliability relates to the ability of human
resources to provide accurate services from the first
time without any mistakes and prepare services
according to the agreed time (Lupiyoadi and
Hamdani, 2011). Research at RSUP Dr. Kariadi
Semarang shows that there is a significant positive
relationship between the quality of doctor's practice
services. This means that the higher the quality of
doctor's practice services, the higher the satisfaction
of outpatients consumers using BPJS Health cards.
The quality of doctor practice services contributes
41.4% effectively to the outpatient consumer
satisfaction of users of the BPJS Health card (Adelia
and Nurtjahjanti, 2016). Research at the Embung
Fatimah Regional General Hospital in Batam City
found reliability factors influence patient satisfaction
with specialist doctor services in the Outpatient
Installation (Vonikartika et al., 2018).
The results showed that there was an influence on
the responsiveness of interns doctors to patient
satisfaction. Based on the results of multiple linear
regression test p values obtained 0.001 <0.05 means
that there was an influence on the responsiveness of
interns doctors to patient satisfaction. In other words
the more responsive the doctor, the patient
satisfaction also increases. The result found doctors
has a poor level of responsiveness, evidenced by
respondents' answers to the statement on the
questionnaire that doctors has a limited time in
serving patients. This can be due to the high workload
of a doctor especially at night conditions.
The results of this study are similar to the research
at Dr. RSUPN Cipto Mangunkusumo Jakarta who
found that the quality of hospital services, especially
in class 2 inpatient care in building A, had a
significant influence on customer satisfaction, both at
the level of performance and level of expectation
(Jaya and Syarufuddin, 2015).
Responsiveness is doctor’s ability and willingness
in helping patients and in responding to patient
requests. This includes informing matters relating to
the patient's condition (Lupiyoadi and Hamdani,
2011). While doctor aims to provide quality services
to the patients, they are often burdened by their own
work conditions. For example, doctors are expected
to cover nightshifts in hospitals which may lead in
lower productivity. This is evidenced by the Patmoko
HIMBEP 2020 - International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical
70
(2015) which stated that lower productivity is
prevalent while working at night compared to
working during daytime. Absenteeism during
morning shifts is high if workers had to work the
night before. Work absenteeism in the second week
of work shifts on a biweekly work shift system is
higher than work shifts in the first week. Absent work
at work shifts in the afternoon and on a four-week
work shift system (Patmoko, 2015). The constant
changes in shifts affects doctor’s work performances
which consequently affects quality of services and
patients’ satisfaction.
The results showed that there was an effect of
interns' doctor's guarantee (assurance) on patient
satisfaction. Based on the results of multiple linear
regression tests obtained p value of 0,000 <0.05 means
that there is an influence of interns doctor's guarantee
on patient satisfaction. In other words the better the
guarantee given by the doctor, the patient's satisfaction
also increases. But still found doctors with poor level
of assurance, this can be caused by a high doctor's
imbalanced workload .An overload of medical staff
can also occur if the number of nurses on duty to help
in hospital emergency departments is not proportional
to the number of patients admitted. Based on the
statement of the patient in the emergency department,
the quality of the doctor was still lacking from the
aspect of collateral, as evidenced by the patient's
answer that the doctor's explanation of the actions
taken on the patient was still poorly understood by the
patient and the safety guarantee expected by the
patient was also not yet optimal.
In terms of service procedure in a hospital, patients
who will be treated will be accepted by local health
workers both inpatient care, outpatient care
(polyclinic) and in the emergency department. This
procedure is the initial key to the service of hospital
health workers in serving patients properly or not,
viewed from a friendly attitude, polite, orderly, and
full of responsibility (Ministry of Health, 2011). A
study conducted by Supartiningsih found that the
assurance variable had a positive and significant effect
on outpatient satisfaction. This can be interpreted if
the trustworthy nature of the employee increases,
patient satisfaction will also increase (Supartiningsih,
2017). The behavior of the employees in this case
interns doctors are able to foster patient confidence in
the hospital if the hospital can create a sense of
security for patients. In addition, assurance means that
doctors are always polite and master the knowledge
and skills needed to deal with patients.
The results showed that there was an empathy
effect of interns doctors on patient satisfaction in the
emergency department. Based on the results of
multiple linear regression tests obtained p value of
0,000 <0.05 means that there is an influence of
empathy interns physicians on patient satisfaction. In
other words, the better the empathy given by the
doctor, the patient's satisfaction will also increase.
However, in many cases it has been found that the
empathy level by doctors has not reached the desired
level. This may be due to high volume of patient visits
and night visits. Doctors may be overwhelmed to
serve patients especially if the number of nurses who
served in the emergency unit is not equivalent to the
needs. Based on the patient's statement in the
emergency unit that there is still a lack of quality of
the doctor's service from the aspect of empathy
evident from the patient's response that the doctor
seems less friendly to the patient and did not take time
to detail on the patient’s condition. Doctors are less
trying to calm the patient's anxiety about the illness.
Research at RSUD Dr. Achmad Darwis Padang
found that there was a significant relationship between
reliability, responsiveness, confidence, empathy and
physical evidence with patient satisfaction in the
Outpatient Polyclinic. The most influential variable is
the quality of nurse services. Suggestions for
improvement are aimed more at improving service
systems in outpatient polyclinics and improving the
quality and quantity of human resources and
renovating service buildings in outpatient polyclinics
(Rensiner, Azwar and Putra, 2018).
Patient satisfaction in the emergency unit found
that patients were dissatisfied with most emergency
services provided such as administrative services at
the front desk, service times, facilities, nursing
services, doctor services, cleaning and billing
procedures. Therefore, it is concluded that there is a
gap between perceptions and expe
zzctations of
emergency services provided to patients. The
company understands the problem
zzzzzs of its
customers and acts in the interests of consumers, and
gives personal attention to consumers and has
comfortable operating hours. Associated with services
in hospitals that interns doctors should act in the best
interests of patients and try to give personal attention
to patients.
4 CONCLUSIONS
This study found that statistically there was an
influence on the quality of interns physician services
on patient satisfaction. With each correlation
coefficient (r) the reliability variable (r 0,701; p
0,000), responsiveness (r 0,645; p 0,000), guarantee
(r 0.555; p 0,001), and empathy (r 0.529; p 0.003).
Quality Improvement Strategy for Interns Doctor Services in the Emergency Unit
71
Statistically proven that there was an influence of
reliability, responsiveness, assurance and empathy of
interns doctors on patient satisfaction in the
emergency unit. The strategy to improve the quality
of interns can be realized through increasing the
reliability, responsiveness, assurance and empathy of
doctors through supervision by hospital management
and accompanying doctors.
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