Consumer Perception of Inpatient Medical Services.

Although it is currently popular to reflect consumers' perspectives to medical service management, insufficient attempts have been made to understand detailed perception of the consumer side of medical services to promote medical services' evaluation from the consumer viewpoint. The aim of this study was to descriptively reveal how consumers perceive medical services that they receive, focusing on inpatient medical services. We conducted semi-structured interviews with 10 adults who experienced hospitalization of five or more days. Constant comparative analysis was performed on the obtained descriptive data. We identified 1) medical procedures, 2) explanations from medical professionals, 3) behavior of medical service providers, 4) somatic sensations, and 5) self-perceived physical conditions as target factors that medical service consumers perceived during hospitalization. The response to the perceived target factors, "compared with the expectation that the consumer had before the hospitalization," suggests that it is an important medical service consumer reaction to check if the service met their expectations for perceived factors. The response to the medical services perception targets suggested that medical service consumers are involved in medical services and interested in various perception targets. The expectations that medical service consumers have prior to hospitalization can largely influence inpatient medical services evaluation.

Introduction

The importance of consumers’ perspectives is popular in medical service management. As noted in service management and service marketing areas [1-5], in service production, service consumer participation is essential. For medical services, patients are the consumers. The decision-making process regarding the medical services to be received by the customer usually contains the following components: judgments of health conditions, collection of information regarding optional medical service contents for the customer, and selection of the most optimal medical service for the customer. The judgment and selection involved in this process requires highly specialized medical knowledge. For general service areas that do not require highly specialized knowledge, customers play a role freely deciding as to whether service content meets their purchase motivation and objectives. On the other hand, in professional services such as medical services that require specialized knowledge, professionals are the service providers involved in the identification of consumers’ service needs, facilitating the consumers’ participation in the service production activities.

Although there are numerous research reports evaluating medical services, survey results for patient satisfaction, commonly used as a clinical assessment of consumers’ perspectives, have not contributed much to specific solutions leading to medical service improvement. Patient satisfaction has been globally used as one of the clinical indicators of structure, process and outcome, which is the framework proposed by Donabedian [6-9]. In patient satisfaction assessment, questions are generated from the medical service providers’ perspective and medical service consumers answer the questions. The limitation of the patient satisfaction survey has been pointed out to utilize as evidence for a need to improve service quality [10-12], because the measurement of patient satisfaction captures only several aspects of patients’ multifaceted experiences [11]. Since the Institute of Medicine in the USA stated patient-centered care in the area of healthcare [6], the focus and goal of medical service management has shifted from quality of care only, to both patient–centeredness and quality of care.

Consumers’ perceptions of received medical services may help service providers learn about consumers’ experiences of their services. The importance of service assessment from consumers’ perspectives has been noted in the business administration research area. Parasuraman and colleagues developed an assessment tool for service quality, SERVQUAL [13], to help understand the gap between consumers’ service expectations and of actual service quality [5, 13]. Recently, in addition to research reports of medical service assessments using SERVQUAL, an increasing number of studies have focused on patient perceptions and experiences as consumer’s perspectives [8, 14–26]. For example, in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Hospital Survey conducted in the USA, consumers answer the questionnaire that measures medical service experiences based on patient perceptions soon after they experience medical services [18-20]. The survey compared the results among participating institutions since 2008 [22-25]. The questionnaire survey focused on patients’ experiences and satisfaction, and has been used in the other countries to evaluate medical services in hospitals [27]. Patients’ perceptions regarding experienced medical services can provide useful suggestions, not only for delivering patient-centered care, but also for improving the quality of care.

Although questionnaire-based surveys have many benefits, detailed consumers’ perceptions of specialized medical services are poorly understood because it is difficult to collect information that has not been included in the prepared questionnaire. To specifically determine consumers’ perceptions of medical service, it is necessary for consumers to express perception freely from their perspectives. Therefore, this study’s objective was to investigate consumers’ perceptions of medical service. Although there are various categories of medical service, we focused on inpatient medicine where medical service consumers stay longer in the service.

Materials and Methods

In order to investigate specific consumer perceptions of inpatient medical services, we selected a descriptive qualitative research design based on personal interviews using a semi-structured interview guide (see S1 Appendix). Qualitative research is employed to understand various social processes and complex phenomena such as daily-life experiences and human interaction in healthcare settings [28, 29]. To explore consumers’ perceptions of inpatient medical services with precision, in-depth personal interviews were used. We conducted semi-structured interviews to capture vivid descriptions by our research participants, voicing their experiences of being inpatients.

Sampling

Participants were adults who were able to complete a 60-min personal interview in Japanese, experiencing hospitalizations of five days or more. We excluded patients in obstetrics, cosmetic surgery, psychiatry, and emergency hospitalization.

Participant recruitment was conducted at the study sites (two general hospitals located in an urban area of Japan). The researchers (the interviewers in the personal interview) obtained informed consent, explaining the study nature to patients who showed interest in participation, using an explanatory form. The choice of study participation was re-confirmed prior to the interview on the interview date. The patients were regarded as participants when they completed the interview after giving written consent for study participation.

Procedure

Personal interviews were scheduled at the participant’s convenience and conducted in a private room where privacy was assured. After obtaining participant age, gender, and number of hospitalizations, a semi-structured interview regarding the medical service they received during the latest hospitalization was conducted for about 60 min. During the interview, the interviewer encouraged participants to express anything that they had experienced during the hospitalization. Interviewers took note of observed gestures, body parts to which the participant pointed, and their expressions during the interview. The interview was voice recorded with participant consent and the interviewers generated a verbatim record, based on the voice recording. The notes on the participants’ observed gestures and expressions were added to the verbatim record. Specific names of persons and institutions within the voice record were recorded as alphabet letters or general nouns. The interviewer reviewed the complete verbatim record for the accuracy of the descriptions, by reading the verbatim record while listening to the voice record. The document file of the verbatim record was coded with eight number digits, indicating interview dates.

Ethical Considerations

This study was conducted according to the principles expressed in the Declaration of Helsinki. The Ethical Committee at Tokyo Medical and Dental University, Department of Medicine, approved the present study (Approval Number 1875). Participants were recruited after the approvals of the Institutional Review Board were obtained at each study site; Approval Number 925 and Approval Number 14-R169.

Explanations were provided both verbally and in writing, regarding participants’ choices taking precedence, the agreement regarding their ability to withdraw after agreeing to participate in the study, not being disadvantaged by withdrawal from the research, and the way to withdraw from the research. Information regarding hospitalization services was collected only based on the participant interview and the researchers did not access the medical records from the study sites in general hospitals.

Data Analysis

Data analysis was conducted concurrently with data collection, based on the constant comparative method, as recommended by Strauss and Corbin [30]. The generated verbatim record was analyzed for each participant in the order of the interviews.

As the verbatim record for each participant was thoroughly read, phrases in which the participants talked about inpatient medical services were highlighted by underlining, and the data were sectioned according to content. When the sectioned data included a demonstrative pronoun, the data section was labeled with a data number, adding demonstrated contents with round brackets after the demonstrative pronoun. The data number was generated by combining an alphabet letter (A–J) that indicated participants and the sequence (number) of the comments in the verbatim record, starting from 1 (e.g., A1).

During reading, a data section with the data number, a data label (a word frankly expressing the content of the description) was allocated for the section. By alternately reading the data section and data label, paying attention to when (i.e., before, during or after) the perception of the inpatient medical service occurred, we extracted data sections and labels that included contents perceived during the hospitalization. We repeatedly compared data sections, paying attention to words that described perception target input, categorized similar items into a group, and named the categories. Verbatim records for following cases were also analyzed with the same procedures and compared with the previously analyzed cases. Data collection and analysis were conducted under the supervision of one nursing researcher and one sociologist, both of whom specialized in qualitative research.

Participants

Ten adults (six men, four women) who experienced hospitalizations of five days or more participated in this study. The age range of the participants was 28–84 years old (average: 63.5 years old). The range of number of hospitalizations was 1–10 (average 4) and it was the first admission to the study site for three participants. The interview was conducted once for each participant, between February and October 2015. The day of the interview ranged from one day before to 47 days after discharge; the total interview duration time ranged from 38–93 min (average 64.5 min).

Findings

The experiences of inpatient medical services, obtained from 10 adults who experienced inpatient medical services, were categorized according to the perception target during hospitalization input and response to the perception target output (Table 1).

Table 1

Perception target of inpatient medical service during hospitalization and response after the perception.

Perception target		Response to the perception target<Output category>
{Input category}	“Input subcategory”
Medical procedures	Consultation (B C E F G I J)
	Surgery (B C D F G H I J)	Feel unpleasant (F)
		Have irresistible feelings (F)
		Compare expectations before the hospitalization (C F G H)
		Compare previous treatment experiences (C)
		Feels like a first lifetime event (F G H)
	Endoscopy (A E)	Have irresistible feelings (A)
		Compare expectations before the hospitalization (A E)
		Compare previous treatment experiences (A)
		Feels like a first lifetime event (E)
		Search for reasons (E)
	Anesthesia (B F G H J)	Compare previous treatment experiences (J)
	Examination (E)
	Nursing (B H I J)
	Medication (D)	Feels like a first lifetime event (I)
		Compare expectations before the hospitalization (I)
		Ask questions (I)
	Rehabilitation (B D I)
Explanations from medical professionals	Explanation of the treatment progress and results (A B C E F H I)	Try not to think about it (C)
		Feel unconvinced (E H)
		Search for reasons (E)
		Compare expectations before the hospitalization (B C E G H)
	Explanation of required behaviors for the treatment (C G H I J)	Follow the instructions (C H I J)
		Compare expectations before the hospitalization (G I)
		Compare previous treatment experiences (C)
		Ask questions (I)
	Explanation of nurse call (A D E F G H)	Press the nurse call (C D E H I J)
		Do not press the nurse call (D E G)
Behavior of medical service providers	Behavior of medical doctors (B D E G I)	Observe (B D E G I)
		Search for reasons (B E G)
		Think that it cannot be helped (D E H)
	Behavior of nurses (A B D E G H I J)	Observe (A B D E G H I J)
		Search for reasons (A D E G H I)
		Think that it cannot be helped (A D E H)
	Behavior of nurse assistants (E)	Observe (E)
		Search for reasons (E)
		Think that it cannot be helped (E)
Somatic sensations	Pain (B C E F G H J)	Search for reasons (C E J G)
		Compare expectations before the hospitalization (E J)
		Compare previous treatment experiences (C)
		Think that it cannot be helped (E G)
	Nausea (B E)	Search for reasons (B E)
		Compare expectations before the hospitalization (E)
		Ask questions (E)
	Trembling of the body (H)
	Malaise (C)	Compare previous treatment experiences (C)
	Sense of thirst (C J)	Compare previous treatment experiences (C)
	Sense of being connected to medical devices (G H)
Self-perceived physical condition	Operative wound (I, J)	Compare expectations before the hospitalization (I)
		Seek the reasons (I)
	Bleeding (J)	Compare expectations before the hospitalization (J)
		Ask questions (J)
	Contents of tube connected to the body (F G H)	Have unpleasant feelings (F)
		Ask questions (G)
	Body being connected to medical devices (F G H J)	Feel unpleasant (F)

Alphabet letters within brackets in the table (A–J) indicates participant ID.

The target perception input, which was the consumer’s experience of inpatient medical services, was summarized into five categories. Findings are described in the following section in sequence of the input category indicated in Table 1. Input category is shown with {}, “” for input subcategory, and < > for output category. Interview data obtained from the participants were shown in italic font and the data number is indicated in []. Round brackets () within the interview data indicate supplement provided by the researcher.

Category 1: Medical procedures

This is a group category of {medical procedures} that medical professions performed at the study site. This category included “Consultation,” “Surgery,” “Endoscopy,” “Anesthesia,” “Examination,” “Nursing,” “Medication,” and “Rehabilitation.”

For medical service consumers, “surgery” and “endoscopy” were events that led to and .

Regarding the surgery, after all, it is like being a fish on the cutting board… [A8]

I really did not want (to undergo the surgery)… Although it was exactly as it was explained, I really did not want to…But it was easier than I thought. There is not much I could do, because I was like a fish on a cutting board. It was not something I could resist. I felt “do whatever you want” after all. [F10, 16]

The {medical procedures} that the medical service consumer received for the first time are and .

I think total duration of the surgery was about the same as it was planned and explained; the surgery was 4 to 5 hours long with an extra 2 hours for the preparation and cleaning up afterwards. [G7]

(In this hospitalization), the doctor told me that the tumor should be removed as soon as possible and it became a large-scale thing. I think that to undergo surgery might always be like this. I think this is normal. This is the first surgery for me and I cannot really judge what is good and bad [H59, 69]

For the medical service consumers who received similar {Medical procedures}, {Medical procedures} they received this time were and .

When the doctor explained (the treatment) to me, thinking about the previous treatment, I can imagine what will be painful… Now I know the procedure of the surgery. After this, they will do this, this, and so on. When I remembered that this is my fifth hospitalization, I thought that I have never worried about the surgery may not work. [C50, 86,111]

The consumers who received {Medical procedures} and when they encountered unexpected situations, they .

The doctor who performed the endoscopy was different from the one I expected. I thought “What?” I thought the doctor who explained the treatment plan was the one who performed the surgery…I did not know that until I lay down and (the endoscopy) was started. I didn’t know that. The doctor who I expected to perform the surgery kept standing beside and supervising the doctor performing the surgery. The doctor kept on instructing (things) to do this and that. Is this because the surgery was not very complicated? Or is it for experience for the young doctor? I believe they should not do that (to let the young doctor perform the surgery) if the surgery is difficult. Probably because this was an easy case, the young (doctor) was performing the surgery, for a kind of practice. If it is the case, I thought that’s fine…I mean, probably it (myself) is not that difficult a case. [E55, 56, 65]

Intravenous drip was continued three days after the surgery and oral medication started afterwards instead. The daily dose of the medication was kind of maximum. I mean, a very strong dose was prescribed. I had severe constipation due to the oral medication. I had never experienced constipation before. My stomach felt heavy at four days after the surgery…I felt very nauseous and could not do anything. I did not imagine suffering that much. It was very, very hard. It was so hard that it might have been harder than the surgery. [I21, 43]

Category 2: Explanation from medical professionals

Category {Explanation from medical professionals}, conducted for medical service consumers during their hospitalization, comprised “explanation of the treatment progress and results,” “explanation of required behaviors for the treatment,” and “explanation of nurse call.”

Medical consumers who received “explanation of the treatment progress and results” .

I really think that it (undergoing the surgery) was the right decision. I should have done it earlier. (Before the hospitalization) I had a very bad impression about artificial hip joints. I was scared when I imagined how it was going to be after implanting an artificial hip joint…[B11,12]

The biggest concern about the surgery complications were incontinence and urine leakage. I was relieved after the explanation that, although there is an individual difference, those symptoms gradually improve. I had mild symptoms the first day after the surgery, while after the second day, I had no problem at all. I became a little optimistic about enjoying the rest of my life after I was told (by the doctor) that the hospitalization treatment was finished as it was planned. [G29, 30, 81]

As a result of “explanations of treatment progress and results,” medical consumers .

Well, I don’t think about it too much…you know. Rather than being worried about many things in advance, I want to cherish the feeling of fun…not exactly fun but beauty and joy…I try not to think about it too much. Rather than thinking about it (expected survival rate explained by the doctor) too much in advance, after all, I found being joyful is the most important. [C124, 131]

For medical service consumers, when “explanation of treatment progress and results” were made when they encountered an unexpected situation, they with the explanation. Furthermore, although they