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

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

 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

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

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

h hi

h 20 66,6

Undergraduate 8 26,7

Occu

ation

House Wife 10 33,3

ee 13 43,4

Entrepreneur 6 20,0

Unem

1 3,3

Relationship with

atients

Chil

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

(

)

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.

1 5 9 1317212529

Quality Improvement Strategy for Interns Doctor Services in the Emergency Unit

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

(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

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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