Assessing user satisfaction and hospital pharmacy practice:
application to an individualized dispensing system in a
French military teaching hospital Claude Dussart PharmD PhD, 1,2 Sophie Dussart MD, 3 David Almeras PharmD, 1 Isabelle Camal PharmD 1 and Gilles Grelaud PharmD 1 1 Hospital Pharmacist, Military teaching hospital Desgenettes, Hospital pharmacy, Lyon, France 2 Associate Researcher, Laboratory of Analysis in Health System, Medical Research Unity 5205 CNRS, Claude Bernard University, Lyon, France 3 Epidemiologist, Centre Lon Brard, Regional Cancer Center, Biostatistic Unit, Lyon, France Keywords individualized dispensing system, nurse, pharmaceutical care, physician, questionnaire survey, user satisfaction Correspondence Dr Claude Dussart Service de Pharmacie Hospitalire Hpital dInstruction des Armes Desgenettes 108 Boulevard Pinel 69003 Lyon France E-mail: dussart.claude@wanadoo.fr Accepted for publication: 8 February 2008 doi:10.1111/j.1365-2753.2008.00990.x Abstract Rationale and aims Hospital pharmacy aims at optimizing pharmaceutical care practice. Classically, assessing patients satisfaction is required. Same manner, for a service provider such as a hospital pharmacy, it is necessary to evaluate the satisfaction of its customers: physicians, nurses and pharmacy staff. The aim of this paper was to assess user satisfaction with an individualized dispensing system. Method A survey including 14 close-ended and 1 open-ended questions was repeated at several years distance in a French military teaching hospital. Questionnaires were admin- istered anonymously to the different actors involved: physicians, nurses, pharmacy staff. Results Fifty-seven users of an individualized dispensing system (29 nurses, 18 physicians and 10 pharmacy staff) were included in the survey. At the level of the establishment, users opinion about the system was positive. None of the dimensions studied concerning the pharmaceutical service was rated negatively. Overall user opinion about the computer system was the only parameter rated negatively. In total, most dimensions were judged satisfactory: condence in the individualized dispensing system, time of delivery at the care unit, impact on cost control, quality of the presentation of unit doses and performance of respondents. The benet for the patients was judged very satisfactory. The workload involved, the frequency and severity of errors, the serviceability of the information pro- cessing system and its impact on patient safety were judged fairly satisfactory. Finally, the quality of pharmaceutical information was rated average. Conclusions An evaluation of a service or a practice should include an assessment of how well the service meets the needs of the user and how well the service is provided. A comprehensive, reliable and valid instrument for assessing users satisfaction with indi- vidualized dispensing system is then available in our hospital. This paper demonstrated the interest of using simple and robust tools in professional practice. Introduction In order to improve the security of dispensing, the French military teaching hospital Desgenettes (Lyon, France) has implemented a prescription system with individualized daily dispensing, in use since 1992. This system of medication distribution is a pharmacy- coordinated method of dispensing and controlling medications in organized health care settings. Medications are contained in single unit packages dispensed in a ready-to-administer form. Not more than a 24-hour supply of doses is delivered to or available at the patient care area at any time. This system has been computerized since 1996. Today, 280 of the 296 beds of the establishment are served by the system. Medication distribution is the responsibility of the pharmacy. Pharmacists must develop comprehensive poli- cies and procedures to ensure the safe distribution of all medica- tions. In this quest for continuous improvement of quality, the hospital pharmacy aims at optimizing pharmaceutical care practice. Quality management, a concept originating in the industrial sector over 100 years ago, has been embraced by the hospital pharmacy Desgenettes. Quality Management is a process of ensuring continuous quality for the customer while at the same Journal of Evaluation in Clinical Practice ISSN 1356-1294 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 252256 252 time keeping production efcient and cost effective. Taking into account the customers needs and the results of current practice is thus a prerequisite [13]. Quality management is driving health systems to identify and incorporate services that will increase patient satisfaction, identi- ed by many studies as being highest when patients expectations are met [48]. Classically, surveys evaluate only patient satisfac- tion [915] but not that of physicians, nurses and pharmacy staff. To date, the literature measuring user satisfaction is limited [16]. Based on this observation, the pharmacy department elaborated an instrument for measuring user satisfaction. A rst investigation was completed by end of 2004. Since that date, a new hospital information system has been developed, which has had some impact on drug delivery practice. A new survey was carried out to investigate potential changes. The primary purpose of this study was to evaluate the user satisfaction with an individualized dispensing system, with two secondary objectives: to improve the quality of pharmaceutical care practice and to facilitate its adaptation to the needs of the users, either expressed or implicit. Methods Study population The study was conducted over 10 days (June 2007). To be eligible for the study, participants must belong to one of the following categories: senior physician, junior physician, nurse or pharmacy staff; be present at the time of the investigation; agree to take part in the study. Questionnaire For this study, the questionnaire that had been used for the rst evaluation was repeated, with addition of three questions about the new information system set up in December 2006. The question- naire was administered by an investigator. Questions covered four areas:
participants characteristics (care unit and medical category);
the level of user satisfaction (condence in an individualized
dispensing system, quality of pharmaceutical information, time for delivery to the medical departments, frequency and severity of dispensation errors, impact on cost control, benet for the patient, workload, quality of presentation and performance);
the existence of a previous professional experience with another
non-computerized system; and
user satisfaction concerning the new information system (global
satisfaction, benet for patient safety, serviceability). Finally, opinions, suggestions or free commentaries were also collected. Anonymity It was agreed to preserve the anonymity of participants. Statistical analysis Data were coded and stored in a computer database for statistical analysis using SAS version 8 software. The various groups of variables were compared using anova or KruskalWallis tests for parametric and non-parametric data, respectively. The answers to the open questions were categorized by topic and ranked by fre- quency of quotation. Parameters were determined with 95% con- dence interval and 5% accuracy. Results Satisfaction scores varied from -2 to +2, with 0 indicating neu- trality. We interviewed 57 people, including 29 nurses [51.0%], 8 junior physicians [14.0%], 10 senior physicians [17.5%] and 10 pharmacy staff [17.5%]. The study population essentially con- sisted of individuals who had known other devices than the auto- mated dispensing system [66.7%]. All care units functioning with an individualized dispensing system were involved in the study. Overall results in our series were superior to 0 for all dimensions studied, except for global satisfaction with the new information system [Fig. 1]. Scores varied between -0.2 and +1.4 according to items (Table 1). On the whole, users appeared satised with the automated dispensing system. General satisfaction In terms of condence in the individualized dispensing system, participants were globally satised, with an overall score of +1.0. No signicant differences were associated with the medical category of the participant (P = 0.07) or with the care unit (P = 0.42). Regarding the quality of pharmaceutical information, all par- ticipants were fairly satised with the service [+0.1]. These results do not show any statistically signicant difference according to the category of the participant (P = 0.24). Contrariwise, there were differences according to the care unit (P = 0.043), with the least satised services being the departments of rheumatology [-1], pneumology and dermatology (0.33 each). The delivery time was judged satisfactory [+1.0]. However, differences according to the medical category (P = 0.003) and the care unit (P < 0.05) were observed. Caregivers were moderately satised with the delivery time (+0.2 for senior physicians, +0.9 for junior physicians and +1.0 for nurses) whereas the pharmacy staff reported markedly higher scores [+1.7]. -2 -1 0 1 2 Confidence Pharmaceutical information Delivery time Frequency of errors Gravity of errors Impact on cost control Benefit for patients Workload Quality of presentation Performance Figure 1 Users satisfaction, a global view. C. Dussart et al. Satisfaction and pharmacy practice 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 253 The frequency of errors with the distribution of drugs in the trolleys was considered fairly satisfying [+0.6], with no variation according to the medical category (P = 0.06) or the care unit (P = 0.15). The dimension severity of distribution errors was judged fairly satisfactory [+0.7]. Again, no difference was noted according to the medical category (P = 0.98) or the care unit (P = 0.47). For most participants rated the impact of an individualized dispensing system on cost control was rated positively [+0.9]. The medical category or the care unit of the respondent did not inu- ence the responses (P = 0.67 and P = 0.77, respectively). Most participants agreed that the individualized dispensing system was benecial to the patient [+1.4]. There were signicant differences according to the medical category (P = 0.04) and the care unit (P = 0.05). The pharmaceutical staff was the most con- dent in the interest of this system for the patient [+2.0]. The workload generated by the individualized dispensing system was judged rather satisfactory [+0.7], with no difference according to the medical category (P = 0.06) or the care unit (P = 0.41). The quality of presentation of the system was also judged sat- isfactory [+1.1]. However, there were signicant differences according to the medical category (P = 0.02) and the care unit (P = 0.05), with the least satised units being rheumatology [-0.1] and psychiatry [+0.25]. To the question how do you rate your own performance when using the automated dispensing system?, the whole cohort answered positively [+1.2], with no difference according to the medical category (P = 0.08) or the care unit (P = 0.10). Satisfaction with the information system The overall perception of the information system was the only parameter rated negatively [-0.2], without statistically signicant difference according to the medical category or the care unit (P = 0.3 and P = 0.47, respectively). The preservation of patient safety when using the information system was considered average [+0.4], again without statistically signicant difference according to the medical category (P = 0.24) or the care unit (P = 0.29). All respondents were fairly satised with the serviceability of the information processing system [+0.3]. There were no signicant differences according to the care unit (P = 0.17), but opinions varied with the medical category (P = 0.04): the least satised groups were the pharmacy staff [-0.3], then senior physicians [-0.2]. Use of a system other than an individualized dispensing system Of the 10 dimensions studied, there was no statistically signicant perception difference between the group of respondents with pre- vious professional experience of an individualized dispensing system and the others (P > 0.05, respectively, for each dimension). Open questions Thirty-seven respondents primarily commented on the difculty of using the new information system, the need for information on the matches suggested, the need to improve the integration of dose modications during the day and the lack of availability of drugs at night and over the weekend. Comparison with results of the previous investigation (Table 1) No statistically signicant differences were reported with regard to the distribution of the study population between medical catego- ries (P = 0.39) or between care units (P = 0.06). The comparison with previous results indicated similar user satisfaction, either in terms of: condence (P = 0.92), delivery time (P = 0.56), fre- quency of errors (P = 0.75), severity of errors (P = 0.08), cost control (P = 0.37), benet for the patient (P = 0.11), quality of the presentation (P = 0.06). On the other hand, the quality of informa- tion and the workload were statistically signicantly different between 2004 and 2007 (P < 0.01 and P < 0.05, respectively). The quality of information was judged less favourably, contrary to the workload which was generally perceived as lower than at the time of the rst investigation. Table 1 Summary of users responses in 2004 and 2007 2004 2007 Difference between groups P-value Number mean SE Number mean SE Condence 67 0.99 0.86 56 1.00 0.79 0.92 Pharmaceutical information 65 0.85 0.92 51 0.12 1.21 <0.01 Delivery time 65 0.86 1.00 57 0.96 0.94 0.56 Frequency of errors 53 0.62 0.81 53 0.57 0.97 0.75 Severity of errors 51 1.04 0.87 52 0.69 1.08 0.08 Impact on cost control 52 1.06 0.96 35 0.86 1.12 0.37 Benet for patients 63 1.16 1.03 55 1.44 0.81 0.11 Workload 61 0.15 1.38 54 0.74 1.07 0.01 Quality of presentation 60 1.45 0.87 56 1.11 1.09 0.06 Performance 58 0.91 0.73 50 1.18 0.75 0.06 Information system - - - 56 -0.20 1.10 - Interest of the system for patient safety - - - 56 0.41 1.11 - Serviceability of the system - - - 56 0.32 1.21 - Satisfaction and pharmacy practice C. Dussart et al. 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 254 Discussion Many studies concerning unit dose drug distribution systems were published during the last years. These studies indicate that indi- vidualized dispensing systems, in comparison with other drug distribution methods, are safer for the patient, more efcient and economical for the organization and a more effective method of utilizing professional resource. On the level of the establishment, the appreciation of the users concerning an individualized dispens- ing system is considered to be satisfactory. No studied dimension, concerning the pharmaceutical service, is noted negatively, con- trary to the general satisfaction of the new information system of hospital. Pharmaceutical information is thus felt in a relatively satisfactory way with an average of almost 0. According to the medical category of the questioned subject, this dimension is appreciated in a different way. Indeed, senior physicians and nurses are most critical concerning the diffusion of pharmaceutical information. This situation can be explained by a lack of commu- nication by the pharmaceutical staff. It is interesting to note that pharmacy and its customers appreciably have the same perception of the quality of an individualized dispensing system for the major- ity of evaluated dimensions, except for the items: delivery time, interest for the patient and quality of presentation of the unit doses. With regard to the quality of presentation of the unit doses, some brief replies are proposed: the pharmaceutical staff is particularly satised with the exhaustiveness of the information provided on conditioning, whereas nurses note important difculties with the opening of the blisters. In any way, to maximize the benets of a unit dose drug distribution system, all drugs must be packaged in single unit or unit dose packages. However, all drugs are not commercially available in a unit dose package. Therefore, the pharmacist must often repackage drugs. The personnel of phar- macy have a better image of the delivery periods than those of the medical departments. It appears that clinical departments are not sensitized with the workload of an individualized dispensing system. The improvement of this dimension will necessarily pass by a better communication between pharmacy and its customers. The general satisfaction of the information system is the only negatively evaluated dimension. The recent change of the infor- mation system on the level of the hospital during December 2006 explains certainly this dissatisfaction. Two other dimensions con- cerning to the information system (safety patient and practical aspect) are evaluated more positively. Indeed, in spite of the dif- culties of implementation of the software, there is a real awakening of its total interest by the whole of the hospital staff. The main difculty lies in the training of the use of the software for which the personnel received an initial formation. Some of them would wish to supplement it by an adapted continuous formation. In a general way, the tendencies of studied dimensions signi- cantly did not vary compared with the results obtained at the time of the preceding study. However, for two of them, of the signicant differences are observed. The satisfaction of pharmaceutical infor- mation strongly decreased, whereas the workload felt clearly improved. With regard to pharmaceutical information, the clinical services expressed their needs for information concerning the drug, and particularly regarding substitution. Indeed, in spite of the list of principal substitutions available, nurses encounter difcul- ties at the time of the drugs administration. Corrective actions must be carried out in order to attenuate this lack of information and communication. The pharmacist must provide patient-specic drug information and accurate and comprehensive information about drugs to other health professionals or patients. Currently, there is a system of follow-up of preparation for each carriage, including a printed formulary on which are listed per day: the name of the pharmacist technician, the name of the pharmacist controller, the name of the nurse and all remarks emanating from pharmacy or the service. This printed formulary, useful for the quality control, is not adapted to the diffusion of information. For this reason, we propose to found a specic printed formulary of connection. No medication should be administered to a patient unless medical and nursing personnel receiving adequate informa- tion about its therapeutic use, potential adverse effects and dosage. This information should include, for each patient, the list of the specialities substituted as well as the remarks relating to the modi- cations: posology modications, galenic formal amendment, absence of a speciality, etc. The use of this printed formulary must naturally be supplemented of a sensitizing of all personnel con- cerned with his operation. In the same way, up-to-date drug infor- mation should be available, including current periodicals and recent editions of textbooks in appropriate pharmaceutical subject areas. The workload is the second dimension having signicantly changed. It would seem today that the whole of the personnel of pharmacy accepted the additional workload related to an individu- alized dispensing system. Thus, the workload is distributed better in the hospital. The pharmacist must continue to take care that other dimensions such as condence, the deadlines and the errors continue to give satisfaction. Then, the survey allowed to identify organizational weaknesses. Every health profession seeks recognition and compensation for its unique skills and contributions to the quality of a patients life [17,18]. There exists a need to conceptualize and understand the roles that pharmacists serve to help convince others such as patients, prescribers and payers to value their contributions and to plan for the roles they could serve in the future within the health care system [19]. In November 2004, the Joint Commission of Pharmacy Practitioners developed a consensus position on the future vision of pharmacy and described how pharmacy practice will benet society [20]. Part of this document stated that phar- macists should achieve public recognition that they are essential to the provision of effective health care by ensuring that [1]: medication therapy management is readily available to all patients [2], desired patient outcomes are more frequently achieved [3], overuse, underuse, and misuse of medications are minimized [4], medication-related public health goals are more effectively achieved, and [5] cost effectiveness of medication therapy is optimized. No single standard measure of user satisfaction is applicable to all pharmacy situations and therefore other measures should be used. No quality programme has proven to be superior to others, and quality improvement probably requires various approaches. Quality-managed process can provide a quality-nished product. Recently, in health care, the focus has gone from simply evaluating the content of care. In pharmacy specically, the focus has gone from making good quality drugs to ensure the security of the entire medication process. A cornerstone of quality management is evaluation, which includes third party: assessments, surveys and statistical indicators. Quality management emphasises patient C. Dussart et al. Satisfaction and pharmacy practice 2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 255 safety by including medication and risk management standards and focus on improvement rather than just quality attainment. Signicant quality-of-care gaps are well documented, specially in the USA. These reports have focused mostly on underuse of per- formance measures of important processes of care and some out- comes of care [21]. Recently, a performance model proposed a combination of four primary elements: quality of care, cost of care, access to care and satisfaction [22]. 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