Quality of Health Services and the Factors Affecting it: A Cross-Sectional Study in Pilot Hospitals for Electronic Referral System

Extended Abstract
Background and Objectives
Quality assessment is doubly important in the health sector, compared to other sectors, due to the sensitivity of services provided in this area. This study was conducted to investigate the gap in the quality of medical services provided in hospitals implementing electronic referral system in Golestan province, using SERVQUAL model.
Material and Methods
In this cross-sectional study, 384 patients were selected through stratified random sampling with allocation proportionate to each city’s population. These patients were referred to level 2 in the frame of electronic referral system and received outpatient services by a specialist physician in the clinics of hospitals implementing the electronic referral system in Golestan province in 2019. This study was conducted in the cities of Bandar-e-Turkmen, Aq-Qala and Aliabad-e-Katoul, where the electronic health referral system had been fully. The population comprised 3 groups totaling approximately 11,004 people. The sample size allocated to each city was determined in view of the ratio of patients referred to level 2 in each city. Accordingly, the sample size selected included 84 subjects from Bandar-e-Turkmen City, 203 from AqQala is 203, and 115 from Aliabad. Having referred to these centers, we collected, from the patient registration office, the record of the patients whose family physician had referred them to level 2 and who had received the desired services. Then, the subjects were systematically and randomly selected according to the referral code registered in the system and the patient list. The data were collected through a two-part questionnaire. The first part of the questionnaire revolved around demographic variables, including age, sex, marital status, level of education, occupation and clinical and medical characteristics such as the number of visits to this clinic, type of disease and type of patients' insurance. The second part of the questionnaire assessed the patients' perceptions and expectations by 30 questions which were similar in content and number but different in wording. In this study, the validity of the questionnaire was confirmed by 10 experts including senior and mid-level managers and faculty members of Golestan University of Medical Sciences. Cronbach's alpha coefficient was calculated to determine the overall reliability of the questionnaire. The data were analyzed using SPSS software version 23. The data were analyzed descriptively through tables, number, frequency percentage for qualitative data, and Mean and Standard Deviation for quantitative data. In addition, we employed analytical statistics such as nonparametric mean comparison tests, in view of the normality assumption,) including Wilcoxon test, Mann-Whitney and Kruskal-Wallis and also Spearman correlation test to determine the intensity of correlation between the study variables. In the present study, the significance level of all tests was considered 0.05.

Results

Out of a total of 402 patients studied, information on only 384 patients was fully recorded (response rate 95.5%). The majority of subjects were female (74.5%), married (81.5%), high school graduate (24.9%), housewife (64.9%). The mean age of the patients was 37.17 ± 14.54 years, so that 62.4% of the subjects fell in the age bracket of 30-60 years. 53.6% of the patients had referred to the center more than once. 56.2% had rural insurance and the highest number of referrals had been made to gynaecologist (21.4%). The relationship between expectations and perceptions of service quality in all dimensions was statistically significant (P < 0.001). The results of Wilcoxon test showed that the gap between the patients' expectations and perceptions with a 95% probability was significant (P<0.001) in all three cities and among all patients. That is, there was a difference between the patients' expectations of service quality and their perceptions in the whole sample. The highest mean score in the expectations section was related to the guarantee and confidence dimension (4.49) and it was related to the tangible dimension in the perceptions section (4.10) while the lowest score is in the expectations and perceptions section related to the empathy dimension (4.34 and 77.3 respectively). After calculating the difference between the mean scores of perceptions and expectations, in all dimensions, the level of the patients' expectations of services was found higher than the level of perceptions with a negative gap. The largest gap in service quality was related to the empathy dimension (-0.57) and the lowest quality service gap was related to the tangible dimension (-0.38). There was no significant relationship between service quality gap and age groups, marital status, occupation groups, number of visits, type of insurance and type of illness (P> 0.05). But the gap in service quality was significantly associated with the patients' gender (P = 0.005) and education level (P = 0.028). So that the biggest gap was related to women and illiterate people. Also, the quality gap was different according to the city (P = 0.028), with the largest gap related to Aq-Qala city.
Conclusion
The results showed that the studied hospitals could not meet the expectations of the patients in any of the five components of service quality, with the perceived quality always lagging behind the expected quality. This highlights need to improve the quality of services through paying more attention to people in the community in order to deliver committed services reliably, accurately and correctly in a timely manner, as well as, enhancing the knowledge, etiquette and ability of employees to build trust and confidence in customers. Since at the time of the study, only three cities, Bandar-e-Turkmen, Aq-Qala and Aliabad-e-Katoul, were implementing an electronic referral system, it was not possible to study other cities in this field and the statistical population was outpatients from level 1 to level 2. A wider study should be conducted at the provincial level to include all referrals to family physicians at level one and all inpatient and outpatient referrals. In addition, the SERVQUAL questionnaire does not cover all the expectations, perceptions and beliefs of patients, so the use of qualitative study methods along with quantitative methods in future studies could provide a better understanding of the issue of quality.

Practical implications of research
According to the results of this study, it is suggested that officials and providers of health services should prioritize: - Continuous improvement and evaluation of service quality in planning; - Equipping medical centers with efficient and new equipment; - Providing services at the promised time and in the shortest time to clients; - Availability of staff and service providers when patients are referred; - Familiarity with the knowledge and skills of the day to meet the needs of clients and - Understanding the values and emotions of clients

Ethical considerations
Study protocol, with the number IR.GOUMS.REC.1397.289, was ethically approved by the Research Ethics committee of Golestan University of Medical Sciences. At the time of data collection, respondents were assured that their information would remain confidential and the questionnaire was completed anonymously. Meanwhile, those who did not want to participate in the study were excluded from the study.

Conflict of interest
The authors state that there is no conflict of interest in the present study.

Acknowledgement
The Vice Chancellor for Research and Technology of Golestan University of Medical Sciences and the Research Center for Health Management and Social Development for approving the research plan with code 110602 and the assistance of officials and staff of selected hospitals in conducting this research plan are appreciated.