In a Hospital Clinic in the Health Sector, patients from the Preventive Orthodontic Service express their dissatisfaction due to the long waiting time to receive care, long time to make an appointment, lack of continuity in preventive orthodontic treatment, non-compliance institutional norms, the lack of office space, instruments and supplies. To improve quality, it is proposed to carry out a study of user satisfaction with the Orthodontic service.
Its design is based on being a descriptive, analytical and purposeful study of the satisfaction that the users of the Orthodontic service had in 2004 and 2005. For this reason, the orthodontic service leads to the creation of proposals that allow monitoring of the fundamental actions for the optimization of this service, in accordance with the observed results.
Keywords: user satisfaction, quality, quality of care, Orthodontic Service.
measuring-and-improving-the-level-of-customer-service-in-the-health-sectorINTRODUCTION.
The concept of quality has evolved worldwide, where the user rates the quality of the product or service offered, its timely delivery, quality of care, reasonable costs and safety. (Melgoza, 2000, p.5). In Mexico, there is a deficient culture of quality, especially in specialized dental care, signifying changes in paradigms, constituting constant improvement or continuous improvement.
Currently, due to the process of globalization of the economy, it has as a result effects on all orders of life of nations, institutions, organizations and citizens, it has become necessary to implement strategies that allow to overcome the classic lags of government responsibility, as well as current and future challenges.
The most distinctive feature is the one that constitutes a value of the new culture.
This is the concept of competitiveness, which is based on productivity, the capacity for innovation and the quality of goods and services generated by individuals and their organizations.
Observing the following aspects:
- In our country, the result of economic and political problems is the result of insufficient and incompetent health services, accreditation of the service and certification of professionals. The patient who every day is better informed by written and electronic means. The decisions of specialized dentists are questioned due to lack of training. Lawyers take advantage of this situation and sue specialized dentists and hospitals; Due to the lack of information as much as the patient and the specialist. For this reason the Medical Arbitration Commission is created. The waiting time of the user has increased because the population pyramid has grown and the number of personnel is the same and the amount of supplies is insufficient The patient returns,due to lack of adequate indications for the use of the orthodontic appliance, by the specialized dentist. (Terres; 1998, p.245-252).
The topic that was selected is because of the importance of the quality offered in goods and services. Taking as a reference the creation of the National Oral Health Committee, whose objective is to contribute to the reduction of the frequency of oral diseases with the highest prevalence and incidence among the Mexican population. (DO 1 Nov. 1995).
And also the National Health Program 2001 - 2006, where the National Oral Health Program is inserted, in which adequate policies of primary and curative care are established, each one based on the basic needs of the population and thus achieve the goals proposed by the World Health Organization (WHO).
It is also worth mentioning that the National Committee for the Quality of Health Services was installed by President Vicente Fox Quezada. Where he mentions that quality must be total: “it must be in ourselves, it must be reflected in all aspects of our work; from the technical capacity of the service providers to the respectful, warm, loving and affectionate treatment of people and citizens. (2000, ISSSTE Newspaper).
The present study will be applied in the Hospital Clinic of San Cristóbal de las
Casas, Chiapas, of the first level, belonging to the Institute of Social Security and Social Services of State Workers, in the morning shift from Monday to Friday.
The importance of having chosen the topic called: "User satisfaction level in the Preventive Orthodontic service, in a Hospital Clinic of San Cristóbal de la Casas, Chiapas", the waiting time to be treated in the orthodontic service, the The delivery time by the laboratory was the appropriate time to the orthodontic service, if it received the appropriate indications in the use of the device, if the user knows what are the limits and scope that the institution provides in the Preventive Orthodontic service, if the training of the specialized dental surgeon is adequate, thus avoiding the iatrogenias produced.
It is important to promote the participation of personnel in continuous improvement, providing the training, responsibility, orientation, motivation, and support necessary to control these processes in order to satisfy the needs and expectations of internal and external customers. (Melgoza, 2000, p.9).
This study will make it possible to suggest an improvement of the service and implement strategies in orthodontic service, knowing the factors and processes that influence user satisfaction, according to the results obtained.
It is pertinent to point out that the impact of this study will help to improve the satisfaction of care for the beneficiary, optimizing excessive waiting times, allowing the user to assess quality, which provides a partial and complementary perspective with other forms of dental evaluation.
The present work is contained in the following chapters:
In its first chapter it addresses a description of the Hospital Clinic of San Cristóbal de las Casas, Chiapas, the place where this study will be carried out, in chapter 2 the theoretical framework of quality of care, user satisfaction. Chapter 3 will refer to the most recent studies, this will be the reference framework, chapter 4 contains the research design and as chapter 5 the results obtained in the research, this includes the description of the population under study, chapter 6 contains the conclusions and suggestions, and finally the bibliography and the annexes.
- INSTITUTE OF SECURITY AND SOCIAL SERVICES FOR STATE WORKERS (ISSSTE).
1.1 BACKGROUND.
In 1959, President Adolfo López Mateos presented to the Congress of the Union the bill for the creation of the ISSSTE. Its approval was published in the Official Gazette of the Federation on December 30. So in January 1960 the new institution began its activities.
The ISSSTE, according to its law, expanded the areas of its services, covering both health-related benefits as well as social, cultural and economic benefits, and extending these benefits to the families of workers and pensioners. The persons protected by the Institute include workers at the service of the Federation and the Department of the Federal District, workers of Public Organizations that by Law or by agreement of the Federal Executive are incorporated into the regime, as well as pensioners of said Organizations. In that same year, Section B was transformed and added to Article 123 of the Constitution, with the incorporation of the guarantees contained in the Legal Statute of State Service Workers. This placed the rights of state servants above all regulatory law.
Currently the ISSSTE protects around eight and a half million inhabitants of the country, which means that one in ten Mexicans is served by the Institution. Medical care is organized in three levels. It is organized and operated by levels of care, through 35 Regional and State Delegations distributed nationwide.
The characterization of each unit makes it possible to identify the installed physical capacity, the equipment, the supply of supplies and the allocation of personnel, particularly doctors and nurses, that guarantee the attention to the demand of the beneficiaries with modern services of high technical and human quality..
The general framework for the classification of the Institute's medical units is represented by the approach of the World Health Organization (WHO) to structure services in three levels of care:
The first includes outpatient consultation and attention to preventive medicine programs in the more than a thousand family medicine units distributed throughout the Republic. The second level offers specialty medicine in its modalities of outpatient consultation and hospitalization, through the more than eighty hospital clinics. The third level of medical care is made up of eleven regional hospitals that provide highly specialized medical services.
Institute of Security and Social Services of State Workers http://www.issste.gob.mx/website/quees/quees.html (Consultation January 4, 2003).
1.2 CLÍNICA HOSPITAL DE SAN CRISTÓBAL DE LAS CASAS, CHIAPAS.
The Hospital Clinic of San Cristóbal de las Casas, Chiapas of the ISSSTE, located in José Maria Morelos y Pavón 57 Col: Altejar, CP 29288 which was inaugurated in the year 1988. It belongs to the State Delegation of Tuxtla Gutiérrez, Chiapas of the ISSSTE.
Due to the care it provides at the Institute, it is considered a top-level clinic, with attention to 6 resolution modules such as Yajalón, Oconsingo, Palenque, Salto de Agua, Altamirano and Tila. The location is presented below .
1.3 STUCTURE.
TYPE OF HOSPITAL:
- Because of its size. It is small, with a capacity of 15 beds for adults and 3 for pediatric beds. Because of its location: It is urban. Because of its population: It serves a closed hospital.
The organizational system is linear organization chart (1.1) DISTRIBUTION BY SERVICE:
SOURCE OF HUMAN RESOURCES 2005.
INSTITUTE OF SAFETY AND SOCIAL SERVICES FOR STATE WORKERS.
CLINICA HOSPITAL DE SCLC CHIAPAS.
1.1 ORGANIZATION CHART
* In relation to the Department of Radiology.
& In relation to all departments.
= In relation to Social Work.
/ The CEYE in relation to all clinics and operating rooms.
"Warehouse" Supply with the entire clinic.
1.4 OPERATION.
The Hospital Clinic requires for its operation different departments such as the Directorate, Medical Subdirectorate, Administrative Subdirectorate, Medical Coordination, Human Resources Coordination, Head of Research and Teaching, Head of Nursing, with the following services: Family Medicine, Obstetrics, Pediatrics, General Surgery, Dentistry, Radiology and Ultrasonography, Internal Medicine, Laundry and
Wardrobe, Clinical Analysis Laboratory, Kitchen, Hospital Admission, Registration and
Validity of Rights, Pharmacy, Social Work, Anesthesiology, Clinical File, Outpatient consultation, Hospitalization, Emergencies, CEYE, Preventive Medicine, Ambulances, Conservation and Maintenance.
The Hospital Clinic has the following Human Resources: Doctors
Specialists 26, General Practitioners 132, Dental Surgeons 2, Specialized Dental Surgeon 1, Social Worker 1, General Nurses 10, Food Handlers 6.
CLÍNICA HOSPITAL DE SCLC, CHIAPAS.
HUMAN RESOURCES
MEDICAL AREA TABLE 1
| NUMBER OF STAFF PER AREA | TYPE OF PLAZA´´A´´ | TYPE OF PLAZA´´B´´ | TYPE OF PLAZA´´C´´ |
| Address | 3 | two | one |
| Medical Subdirectorate | two | one | one |
| Administrative Subdirectorate | 6 | 4 | two |
| Jef. Medical Care | one | one | |
| Coord. Of Human Rec. | 3 | 3 | |
| Warehouse | 3 | two | one |
| Statistics | two | one | one |
| Family Medicine | one | one | |
| Obstetrics and gynecology | 5 | 5 | |
| Pediatrics | two | two | |
| General Surgery | 4 | 4 | |
| odontology | 3 | 3 | |
| Radiology | 4 | 4 | |
| Internal Medicine | one | one | |
| Laundry and Clothesline | 3 | 3 | |
| Laboratory of Clinical Analysis | 3 | 3 | |
| Head of Nursing | one | one | |
| Feeding | 3 | 3 | |
| Hospital Administration | 5 | 5 | |
| Reg. And Vig. of rights | two | two | |
| Pharmacy | 4 | 3 | one |
| Social work | one | one | |
| Anesthesiology | 5 | 5 | |
| Transport | two | two | |
| Clinical File | two | two | |
| External Consultation | 22 | 22 | |
| Hospitalization | 31 | 31 | |
| Emergencies | 7 | 7 | |
| CEYE | 4 | 4 | |
| Preventive medicine | one | one | |
| TOTAL | 136 | 124 | 12 |
HUMAN RESOURCES 2005.
1.5 STATEMENT OF THE PROBLEM.
The increase in complaints as a cause of dissatisfaction on the part of users, due to the long waiting time to receive care, deferral of appointments, the lack of adequate development of orthodontic procedures, non-compliance with institutional regulations, the correct use of the appliances orthodontic and the updating of current knowledge by the specialist.
1.6 IMPACT OF THE PREVENTIVE ORTHODONTIC SERVICE.
The Preventive Orthodontic service that is provided at the Hospital Clinic of San Cristóbal de las Casas, Chiapas is preventive, that is, it controls the eruption of the primary and permanent teeth, preventing dental malpositions. which are treated through the placement of orthodontic appliances. Being in the State of Chiapas a percentage of 50% of the child population has cleft lip and palate problems, which require multidisciplinary treatment such as Plastic Surgery, Speech Therapy, Psychological, Orthodontics.
At present, the Orthodontic service provides morning care, with 1 Specialized Dental Surgeons, an average of 250 first-time and subsequent patients were attended in 2005, between the ages of 3 to 12 years old..
- THEORETICAL FRAMEWORK OF QUALITY.
2.1 BACKGROUND.
In the history of mankind it is directly linked to quality since the most ancient times, man when building his weapons, preparing his food and manufacturing his clothing, observes the characteristics of the product and immediately tries to improve it.
The practice of quality checking dates back to before the birth of Christ. In the year 2150 BC, the quality in the construction of houses was governed by the Code of Hammurabi, whose rule # 229 established that “if a builder builds a house and does not do it with good resistance and the house collapses and kills the occupants, the builder must be executed ”.
In the vestiges of ancient cultures, quality is also present, an example of this are the Egyptian pyramids, the friezes of Greek temples, etc. However, Total Quality, as a concept, had its origin in Japan where it is now a kind of religion that everyone wants to practice.
During the Middle Ages, markets emerged based on the prestige of the quality of the products, the custom of branding them became popular and with this practice the interest of maintaining a good reputation was developed (damask silks, Chinese porcelain, etc.) Given the craftsmanship of the process, the inspection of the finished product is the responsibility of the producer who is the same craftsman.
In the era of the industrial revolution, it brought with it the factory system for serial work and labor specialization. As a consequence of the high demand coupled with the spirit of improving the quality of the processes, the inspection function becomes a vital part of the production process and is carried out by the same operator (the object of the inspection simply pointed out the products that did not fit to the desired standards).
At the end of the nineteenth century and during the first three decades of the twentieth century the objective is production, man has always sought quality in services or products so that they satisfy his needs. With Taylor's contributions the inspection function is separated from production; The products are characterized by their interchangeable parts or components, the market becomes more demanding and everything converges to produce, being the measurement of the activity of the operators giving the bases to improve operation standards (Soltero, 1999 p. 1-2).
Quality control has been practiced for many years in the United States and in other countries, but the Japanese, faced with the lack of natural resources and highly dependent on their exports to obtain foreign exchange that would allow them to buy abroad what they They could not produce internally, they realized that to survive in an increasingly commercially aggressive world, they had to produce and sell better products than their international competitors such as the United States, England, France and Germany.
This led them to perfect the concept of quality. For them there should be quality from the design to the delivery of the product to the consumer, going through all the actions, not only those that include the manufacturing process of the product, but also the administrative and commercial activities, especially those that have to do with the customer service cycle including any subsequent service. (Sánchez, 2002 [email protected] Date: 7-31-2002, 7:02 pm)
2.2 THEORIES OF QUALITY.
The word quality designates the set of attributes or properties of an object that allows us to make a value judgment about it; In this sense, we speak of the null, little, good or excellent quality of an object.
When it is said that something has quality, a positive judgment is designated with respect to the characteristics of the object, the meaning of the word quality in this case becomes equivalent to the meaning of the terms excellence, perfection.
There are different definitions of quality, the use of each depends on the area in which I am working. Previously, it was believed that quality was too expensive and therefore affected the profits produced by the company. Now it is known that the pursuit of quality results in lower costs for companies and higher profits. The definition of quality has been much discussed, but the thinkers who have stood out the most on the subject are the following:(Navarro, 2001, [email protected] Date 01-13-02).
AUTHORS OF QUALITY.
2.2.1 EDWARD DEMING.
It defines quality as tangible, measurable and is the key to competitiveness since it directly affects increased productivity and cost reduction.
Deming's philosophy is characterized by the following aspects: Quality increases and therefore costs fall and savings can be passed on to the consumer.
1.- It must start in senior management.
2.- All the personnel of the organization must participate.
3.- It is based on a continuous process of improvement.
4.- It is scientifically based.
5.- Its purpose is to always serve the customer better.
Its methodology includes consumer research through periodic surveys and evaluation of market changes. Introducing the Deming Cycle (PECA).
It presents fourteen points to transform a company:
- Be consistent Adopt a philosophy Incorporate quality from the first operation Reduce cost Training Leadership Eliminate fear and uncertainty Create work groups Eliminate numerical objectives Eliminate work quotas Eliminate management by objectives Promote Responsibility in the worker and managers Develop a self-development program Improve the company through integration and continuous improvement.
He has affinities with other authors in his theory such as JURAN.
2.2.2 JOSEPH M. JURAN.
Defines quality as a server to plan quality and business strategies.
Its philosophy is understood as the absence of deficiencies that may appear as: late deliveries, failures during services, incorrect invoices, cancellation of sales contracts. QUALITY IS SUITABLE FOR USE.
In Jurán's methodology, the following Trilogy is presented:
- Quality planning, Quality control, Quality improvement.
The three processes are interrelated, it all starts with quality planning. The purpose of planning is to provide operational forces with the means to obtain products that can satisfy customer needs. It is presented graphically.
He has affinities in his theory with DEMING.
2.2.3 KAORU ISHIKAWA.
It defines the quality that must be observed and achieved not only at the product level but also in the sales area, in the quality of administration, in the company itself and in personal life.
Total Quality is when a product is achieved that is economical, useful and satisfactory for the consumer.
It presents in its philosophy the following points:
- Quality begins and ends with education. The first step in quality is to know the needs of customers. The ideal state of Quality Control is when inspection is no longer necessary. It is necessary to remove the roots and not the symptoms of the problems. Quality control is the responsibility of every organization.Means should not be confused with objectives.Quality must be put first, financial benefits will come as a consequence.Marketing is the entry and success of quality.Top Management You should not show hard feelings when the facts are presented by your subordinates.
His methodology introduces the concept of Quality Circles, he was the originator of the Cause-Effect Analysis Diagram, which is used as a tool for problem solving.
The Statistical Techniques that he performed are the following:
- Elementary Statistical Techniques.
- PARETO ANALYSIS. CAUSE-EFFECT DIAGRAM.
He presents affinities with other authors in his theory such as Deming and Juran.
2.3.4 FOURTH GENERATION: these are the continuous quality improvement processes.
Quality is aimed at continually improving and optimizing all the activities of the company towards the external customer.
Strategy and leadership.
In this generation, quality begins to return to the company the investments of the first three generations and it is until then that it can be said that quality pays. Which is a good deal.
The gap between the client's specifications and those of the company begins to narrow as a consequence of the constant improvement of the products and services offered by the company.
2.3.5 FIFTH GENERATION: REENGINEERING AND TOTAL QUALITY.
Quality is oriented to redesign the company through complete processes with value towards the customer.
Strategy and leadership.
In this generation there is a radical change in the way of conceptualizing quality. Quality processes, no matter how efficient they are, do not make the company sufficiently competitive in the face of: drastic changes in the market; new ways of doing business; the increasingly aggressive incursion of national and foreign competitors; and the response to customer needs as a recent variant of the market.
The structure of the company begins to change by changing the way of organizing the work of areas or departments and simple, specialized, and repetitive tasks to complete and harmonious processes.
2.3.6 TOWARDS A SIXTH GENERATION OF QUALITY PROCESSES.
The reengineering process was apparently working well. However, it was necessary to develop a quality strategy that would incorporate the creative and innovative thinking of all the company's collaborators and, in addition, it will present a structure that will allow reflection and freedom of action, under a centralized-decentralized scheme, oriented to continuously create value for the customer, via knowledge and intelligence. (Valdes, 1995 p.117)
2.4 CUSTOMER SATISFACTION APPROACH.
The concept of quality is associated with adequately meeting customer needs. The satisfaction of the customer is a variable that must be identified for each practice. Patients perceive the quality of the orthodontic service as communication and time, be it the treatment time or the waiting time. Time is a value and cost that must be managed effectively.
The total quality control involves diagnosis, design, implementation, and measurement of the process, people, and service.
The total quality control (CCT) is a total commitment to continuous improvement. It's a competitive advantage and investment in practice with secure income presented as profit and growth. It is not an image or public relations adventure or just talk; it is a scientific commercial process designed around the capacity of the practice, the demands and the needs of the patient.
By serving quality, excellence is being served. It is the conviction that each patient, regardless of the type of malocclusion, tries to shorten the time of the predictable result, with a lower cost and that the results achieved meet professional standards and exceed the patient's expectation. By doing the right things all the time, you are not making mistakes (Am J Orthod Dentofacial 1999, 116 p. 659).
2.5 MEXICO AND QUALITY .
The industrialization process began in Mexico at the end of the 19th century with the production of textiles, food, beer and tobacco. However, it was not until 1940 that a strong industrialization movement began based on the policy of import substitution .
The industrialization policy adopted by Mexico since 1940 has generated, among others, the following problems:
The development of an economy that offers low quality products and services that are not very competitive in price and quality in international markets.
The replacement of installed capacity in mainly industrial organizations, especially in what corresponds to small and medium-sized industry, which is always in a weak position to face economic problems such as those that occurred in 1976, 1986 and 1994.
Economic activity is mainly concentrated in three regions: Mexico City, Guadalajara and Monterrey, which accumulate 70% of the added value. Mexico has not been able to develop its own technology, and is constantly dependent on imported technology with the consequent low competitiveness.
Mexican companies grew accustomed to obtaining quick and easy profits by being able to operate protected from international competition, which, together with the price control exercised in the 1970s, reinforced their lack of interest and apathy to invest in new technologies and infrastructure. On the other hand, as the economy progressed, the demand for intermediate and capital goods increased to such a degree that it could not be met by national suppliers. By the mid-1980s, trade liberalization policies were introduced to stimulate exports. Since then, the Mexican economy has undergone a significant transformation in response to the wide range of trade policy reforms and the search for levels of international competitiveness.
However, it is important to recognize that changes towards an open economy cannot be evaluated in a short period, since they need a longer period to bring the expected benefits in terms of well-being, due to other non-economic variables such as associated political turbulence. The consolidation of democracy, improvement in the quality of education and changes in cultural values (honesty, punctuality, willingness to work and save, etc.) require perhaps 20 or 30 years to mature. The important thing is that this process has started.
The Free Trade Agreement (FTA) with the United States of America and Canada has laid the foundations for further structural changes in the economy in general; It aims to stimulate new investments and promote greater competitiveness with companies. Those organizations that are involved in total quality programs and therefore achieving higher than average productivity levels, will be able to recognize and stimulate continuous improvement with better salaries and compensation than those currently granted in Mexican companies.
A characteristic of the Mexican economy is the high degree of concentration, as large corporations dominate their respective markets. Micro and small businesses, which represent 95% of all companies in Mexico, are poorly managed, generally operate with outdated technology and can hardly compete in the international arena.
The Mexican government had no choice but to adopt a less protectionist trade policy with greater competition for national producers, who were forced to increase their efficiency, productivity and quality to international levels in order to remain in the market. The international trade organizations to which Mexico has joined are: the GATT (WTO) in 1986, the OECD in 1993, a Cooperation Agreement of the European Union in 1991, the FTA in 1993, the APEC in 1993, and others. bilateral or trilateral agreements with various Latin American countries.
In the last ten years, our country has become a strategic nation for the rest of the world, being the only one that has trade agreements with the main economic blocs. They are as follows:
| P AISES | F IRMA |
| North America FTA. 17-DEC-1992 - 1 ° -JAN-1994. | |
| FTA Mexico Chile. 17-APR.-1998 - 1-AUG. - 1999. | |
| FTA Mexico Costa Rica. 5-APR- 1994 - 1- JAN - 1995. | |
| FTA Mexico Nicaragua. DEC. 1997 - JUL.- 1998. | |
| TLC of the Group of Three 13- JUN. –1994 - 1-JAN.-1995.
(Colombia, Venezuela and Mexico). |
|
| FTA Mexico European Union. 1st - JULY-1995. | |
| FTA Mexico Bolivia. 10-SEPT.-1994 - 1 ° -JAN- 1995. | |
| FTA Mexico Israel. 6-MAR.-2000. |
Source: (www.monografias.com.mx 16-Feb-2006, 9:00 pm).
Negotiations with Uruguay, Peru, Argentina and Brazil.
The Strategic Total Quality Management (TQM) is a cultural concept and not a set of procedures that can be easily installed in an organization, like a computer program.
(Sánchez, 2001 [email protected] Date 31-Jul -2002, 7:02 pm).
- FRAMEWORK.
3.1 QUALITY IN HEALTH (DONABEDIAN).
Avedís Donabedian exposes a quality model that unifies technical and interpersonal components of quality and its consequences in the public and private sectors according to economic approaches and political programs.
It defines that quality is a property that medical - dental care possesses to varying degrees; it encompasses three basic points to define it: Relationship between the evaluation of quality and the evaluation of the programs within their technical and interpersonal components. Concepts of accessibility, continuity and coordination with their implications on the content, quantity and costs of care, to achieve the satisfaction of patients and professionals.
Assessing the quality of health care is a difficult judgment to measure; There is a tendency to evaluate medical care in a package of poorly defined attributes that are used to define quality, being perceived in different ways based on:
- Single attribute Functionally related attributes Heterogeneous combination of attributes.
Allowing quality judgments to be made not about health care itself, but directly about the people who provide it and the systems where it is delivered.
Treatment provided by a doctor or other healthcare professional in a clearly defined episode of illness to a patient during care.
It begins with the treatment that the doctor gives the patient, dividing into two types of treatment: technical and interpersonal. The technical application of the science and technology of medicine and other sciences in the management of a personal health problem (science of medicine) and the interpersonal one that is the social interaction between the client and the practitioner (art of medicine). The other element is the amenities incorporated into the care itself.
When analyzing the technical treatment of the disease as well as, the interpersonal treatment can somehow be divided as science or art. For Donabedían they are considered as an imperfect representation within medical care, however, they are intimately related: applying a technical treatment to a disease involves both science and art, as well as, the interpersonal relationship has an important influence on the success of treatment technical. The term amenities encompasses characteristics of the intimate aspects of the places where care is provided, being described in an abstract way by the patient and perceives them as components of medical care, whether in private practice or in the organization where they are delivered.
The amenities are those intimate aspects of care that the patient conceives as signs of goodness that make the patient measure the level of quality through the interpersonal relationship and the degree of attachment to their values, norms, expectations and aspirations, without considering much that, quality of care consists of the application of science and technology in such a way that it yields the maximum benefits for your health without increasing its risks. In this process the success or failure will depend on the signs of comfort, privacy, courtesy and acceptability by the patient.
Both the patient and the professional responsible for the care must unify a concept in which the application of medical science and technology, the interpersonal relationship and the "amenities" yield the maximum benefits for health without increasing its risks. To the extent that the dental medical care provided is capable of achieving the balance that provides the patient with the maximum and most complete well-being.
We must ask ourselves if dental medical care has any measure and what judgments are considered to be received, as well as if these quality quantities are sufficient to provide health and well-being to the patient:
- Not receiving care in cases where it should be received, it is evident that it denotes a failure in the quality of care and in the patient when accepting it Care received for a long period of time, fails at some point or is insufficient, denotes a lack of quality Unnecessary or excessive quality does not contribute to the well-being of the patient and can be detrimental. By spending time and money on unprofitable medical care, the patient has less to spend on other things that are valuable to him. From a social point of view, excessive attention to one group unprotects another that needs it more, this is judged by Donabedían as carelessness, lack of judgment or ignorance on the part of the professional even when it is considered as not harmful because it does not bring risks in the health, but it does not provide benefits,reducing individual and social well-being through the inappropriate use of resources.
Quality and its cost are related: quality costs money and is expensive, the cost involved in the technical equipment of a hospital and its other infrastructure, salaries of nurses and other personnel, and the amenities to operate efficiently make costs grow Therefore, the care is excessive and harmful, it is expensive and of poorer quality. If you waste your resources it is ineffective and expensive.
Both unnecessary and harmless care and inefficient care result in loss of individual and social benefits because they waste their available resources.
Including costs in the definition of quality is to balance the expected benefits and losses in technical quality.
- Quality costs money, but if useless services are eliminated and more efficient services are produced, it is possible to obtain a higher quality for the money spent on care, well, achieve the same quality at a lower cost (Donabedian 1990, p. 9).
3.2 QUALITY OF DENTAL CARE.
Its intention is to provide timely care to the user, in accordance with current ethical dental and / or medical knowledge, with satisfaction of the health needs and the expectations of the user, the service provider and the institution.
When analyzing the concepts that make up this definition, it is necessary to specify the following terms:
- Timely care, provide care at the time the patient requires it. In accordance with current medical comments through the availability of trained health personnel, based on a process of permanent updating, in congruence with the standards that the experts in the operational area have issued and kept up to date. The current ethical principles include "first, do no harm", equity in the provision of services offered to each patient, the care that their condition requires; humanism, privacy, individualized treatment, respect for professional secrecy, offering the maximum benefit with minimal exposure to risk during your care and with informed consent to carry out studies and treatment, as well as for your participation in research projects, keeping up to date.Satisfaction of health needs implies the achievement of the objective of care based on the establishment of a diagnosis, a study and treatment program and a prognosis. In this context, the objective of medical care can be: cure, control, improvement of the patient, palliation of symptoms, moral support to the patient, family members and a dignified death in accordance with current legal, moral and religious principles, in congruence with the health problem in question At the public health level, the satisfaction of health needs implies an improvement in the health level of the population, a decrease in morbidity, mortality, sequelae, complications and disabilities, and an increase in the time and quality of life of individuals.Satisfaction of user expectations includes accessibility to services, opportunity for attention, courteous treatment, process of care carried out without obstacles, enough properly trained health personnel, availability of equipment, material and medications that are required; solution of the health problem that motivated the care in congruence with the objective to be achieved, sufficient and timely information about the study and treatment program, its results and prognosis; comfort during the care process, including air conditioning, noise control, adequate lighting, absence of bad odors and harmful fauna Satisfaction of the service provider's expectations refers to the availability of the necessary resources to carry out the job,recognition by their superiors for having done it with quality, remuneration consistent with the characteristics of unemployment, job security, opportunities for improvement and training facilities The expectations of the institution correspond to the quality of medical care based on the compliance with current norms issued by the institution itself, equity in access to care required by users, regardless of the patient's health problem; opportunity for care in terms of waiting time and deferrals, improvement in the population's health level, acceptable cost benefit in the provision of services based on a rational administration of resources; adequate productivity and absence of complaints and demands.
(Echenique 2000, notes).
Other basics:
- Effectiveness: is the ability to meet established goals. Efficiency: is to achieve goals with available resources. Effectiveness: ability to solve problems. (Pastrana 2001).
3.3 IDENTIFICATION OF THE FIVE FACTORS IN WHICH THE QUALITY SUPPORT:
In quality, the results produced by any organization depend on five factors. These factors are design, equipment, materials, schedules, and performance. Their combination determines both the accuracy or acceptance of the results and the opportunity in which such results are offered.
- DESIGN:
The quality of what is produced does not only depend on the design of the product; It is also due to the design of the systems that are required to produce such goods or services.
With regard to goods and services, in general there are two factors that govern the quality of their design.
The first is the market in which the organization tries to compete. Is it a luxury, mid-level or budget market?
The second, influencing design, is based on what direct competition does. A lower quality than what the competitor is offering for the same price will result in fewer repeat purchases. On the contrary, producing a much higher quality than your competitors, charging the same as them, will generally result in higher costs and lower profit margins.
- TEAMS:
The ability with which the equipment, tools and machinery available can accurately and reliably produce desired items has a strong effect on quality, the success of the organization depends largely on the selection of suitable equipment and tools.
- MATERIALS:
Organizations use a wide variety of materials in their processes to achieve planned results. It is essential that the qualitative characteristics of such materials conform to the technical requirements or specifications. The best design - coupled with excellent equipment, a highly trained workforce and scheduling that provides adequate time for the process - all too often cannot overcome the negative effect that defective materials have on product quality. or of inferior quality to the standards defined by the SSA.
- PROGRAMMING:
If the quality of the service is equated with the satisfaction of the users, and within the latter the timely reception of what is demanded is included, it is possible to recognize the enormous importance that, for quality, an optimal programming can have. It is obvious that improper scheduling impairs the timeliness of delivery by production; however, it is no longer so obvious that poor scheduling can affect how production conforms to standards. By checking delivery dates and realizing that they already have the time required to carry out the normal invoice process, management faces the dilemma, depending on the pressures to which it has committed to fulfill its promises,to take certain shortcuts that may result in deliveries to users of the product of lower quality than the contracted standard.
- PERFORMANCE:
Human performance has an important effect on the quality of the goods that are produced. Performance depends on two factors: expertise and motivation.
Performance = expertise + motivation.
Expertise in turn depends on two factors: training and experience.
Expertise = training + experience.
Motivation also depends on two factors: attitude and environment.
Motivation = attitude + environment.
The definition of oral health of individuals and the population is the result of a complex and dynamic set of factors, known as the health-disease process; therefore, the care model for oral diseases should be based on the recognition of this and on the management of prevention for the correct conservation of the structures and functioning of the stomatognathic apparatus that allow, in the medium and long term, to reduce the incidences of the most frequent oral diseases in the Mexican population (Domínguez 1998, p. 1).
The prevention regulations for dental practice, public and private at the national level, is the most effective action strategy to improve the current state of oral health of the Mexican population.
With the application of the Official Mexican Standard for the Prevention and Control of Oral Diseases and those derived from it, it is intended to optimize and update the country's dental services, increase their quality and equity with emphasis on prevention, reduction of costs and reducing, to the greatest extent possible, the problems of malpractice; all this, with the purpose of improving the level of oral health of the Mexican population, and creating a new culture of health. (Official Gazette of the Federation 01-21-1999).
Another important aspect is the creation of the National Oral Health Committee, by Agreement Number 132 where it is mentioned that from the epidemiological point of view, the Mexican population currently suffers from the effects of dissatisfaction in the field of oral health; As can be seen, from this provision, the ISSSTE does not escape, since it is a Decentralized Organism Integrated to the Health System. (Official Gazette of the Federation 1- Nov.- 1995).
3.4 THE PERCEPTION OF QUALITY IN ORTHODONTIC TREATMENT.
Orthodontic treatment in health services are of the highest expectation. Orthodontics must be identified and served according to the needs of the patients. Who are our clients? They are the suppliers, the internal customers, and the external customers. All must be integrated into the quality control process.
PROVIDERS. One has to build a faithful relationship with suppliers that ensure delivery on time. But if you share your interest with them, they can share that interest which will further your effectiveness. One should not select materials only based on price, low cost material will contribute to poor quality both in time and in patient perception. High-quality materials from a reputable supplier are a benefit, not a cost. High technology does not ensure high quality since the process integrates materials, methods, mechanics and people.
INTERNAL CUSTOMERS. Internal customers are the internal workforce. To serve your external customers well, your internal customer must learn to identify quality defects early in the process and help you correct them. An orthodontist must refine the individual performances of internal clients through the following activities:
- Train, educate, motivate, and reward team workers Establish cross functional utilization where we all do everything, rather than one person for each role. Support teamwork that encourages excellence Effective time management in addition to effective planning. Mix motivation and order operating system to reduce waiting time and maximize return on active time. More for less. Share decisions with everyone, not just some. Avoid having the orthodontist as a bottleneck. Induce healthy tension in practice to encourage interim competition and ensure continuous quality improvement.
THE EXTERNAL CUSTOMERS. For new users, one must have a competitive line, through comfort, convenience, communications. We are in the information age, where the majority of users are oriented to quality and affordable prices. They perceive quality as value for money. Value is a set of benefits that they exchange for a price. In a competitive market, those who serve the needs of the patient will grow and win. Time, be it waiting time or active time, is seen as added value. Communication and time are perceived as quality in the consultation, regardless of the fees paid or the culture of the clients. (Am J Orthod Dentofacial Orthop 1999; 166: 659).
3.5 QUALITY PROCESSES IN SPECIALIZED DENTISTRY.
3.5.1 CONTINUOUS IMPROVEMENT OF THE QUALITY OF SPECIALIZED DENTAL CARE.
In specialized dentistry, continuous quality improvement is a set of strategies carried out in a constant, systematic and procedural way with the purpose of increasing the quality and efficiency in the presentation of dental care.
The actions aimed at the best quality and efficiency in the provision of specialized dental care are:
- Strategic planning for the continuous improvement of processes whose results can be exceeded in terms of quality and efficiency until reaching the level of excellence Recognition of achievements after identification of the person responsible for the process, through a predetermined system of stimuli, applied continuously that includes Actions verbally, in writing, in kind (scholarships, licenses, etc.) or financial incentives Solving problems that affect the quality with which dental care is provided through the following steps:
- Registration of problems Establishment of priorities for addressing problems based on their magnitude, significance, feasibility and vulnerability Identification of the person responsible for the process where the problem is located Verification in a participatory manner with the person responsible for the process of the conditions of the structure and characteristics of the process that gave rise to unacceptable results, in order to determine the best option to solve it. Giving advice to the person responsible for the process, based on knowledge and comparison with similar processes that generate results with higher quality and efficiency (benchmarking).Establishment of commitments in a participatory manner with the person in charge of the process, for the solution of the problem in time and magnitude. Follow-up of these commitments of the advances in the solution of the problem.The obstacles that prevent the solution of the problems constitute a new problem and be subject to the same solution procedure (spiral of continuous improvement). Verification of the solutions of the problem and their discharge from the list of current problems.
3.5.2 STRATEGIC PLANNING.
It is the determination of the general lines of action aimed at continuous improvement of the processes through their analysis, identification of strengths, intrinsic weaknesses, opportunities, threats to the environment and reengineering of those processes that require modification.
- Identify strengths and weaknesses inherent to the process, both in physical resources and procedures; the efficiency and satisfaction of users, service providers and institutions, to promote the development of strengths, determine the causes of weaknesses and promote their correction. Locate opportunities and threats in the process environment to take advantage of the former and nullify the second, allowing their development with quality and efficiency. Submit to reengineering processes whose results are lower than expected.
3.5.3 PROCESS REENGINEERING.
It is defined as the reprogramming of processes capable of being improved in their structure and in the procedures that comprise them, in order to achieve the expected results, in order to incorporate them into the continuous improvement of quality and efficiency.
3.5.4 REFERENCE COMPARATIVE INFORMATION SYSTEM.
(BENCHMARKING).
It is the continuous improvement of the quality and efficiency in the development of the processes, by means of the comparison with other similar processes and the application to the desired process of those procedures that would have shown better results in quality and efficiency.
3.5.5 EVALUATION AND MONITORING.
It is considered as the methodological analysis of the conditions in which specialized dental care is provided, through the integration of a situational diagnosis that allows knowing the structural conditions for its provision, the characteristics of the process and the achievement of the expected results, implying the identification of the processes that need to be improved. Achievements and problems are necessary to solve.
3.5.6 FEEDBACK TO THE SYSTEM.
Of the expected results, they refer to the achievement of the objective of specialized dental care, provided with efficiency and effectiveness, which allows meeting the expectations of the user, service providers and institution. Including continuous improvement in the oral health of the population, and in general a higher level of quality of life.
3.5.7 ACCREDITATION OR CERTIFICATION. (Echenique 2000, notes).
- DESIGN OF THE INVESTIGATION. PROBLEM STATEMENT.
The increase in complaints as a cause of dissatisfaction on the part of users, due to the long waiting time to receive care, deferral of appointments, the lack of adequate development of orthodontic procedures, non-compliance with institutional regulations, the correct use of the appliances orthodontic and the updating of current knowledge by the specialist.
- COURSE:
It is possible to know the quality of Orthodontic services by asking users their opinion about their satisfaction with the service received.
- GENERAL OBJECTIVES.
Know the satisfaction of the users of the Orthodontic Service and propose its improvement.
- SPECIFIC OBJECTIVES.
- Design a quality assessment instrument through the user that allows us to know their satisfaction Conduct an opinion survey to the user in the Orthodontic Service, which will contain 21 items Choose the sample size Analysis of the evaluation results Suggest recommendations.
EFFINITION: Quality Assurance (QA) is understood as a systematic, planned and continuous method to monitor, evaluate and improve the quality of health services with existing resources.
The GC receives various names such as Total Quality, Clinical Audit, Quality Circles or Continuous Quality Improvement.
Quality of care has different meanings depending on the different parties involved in the process, such as doctors and patients. However, a QA system must encompass three quality perspectives:
- Clinical standards Management performance User satisfaction
The appropriation of QA programs by health personnel is an essential part of this culture change.
The fundamental philosophy of the Health with Quality Project is based on the fact that the design and implementation of Quality Assurance systems must reflect in each country a particular way to organize both health care and the values and beliefs of the users of the services. and its suppliers.
OBJECTIVES OF THE MODEL.
| 1. Establish a regional QA system, integrated into the management and information system in a region of each country to: »improve the efficiency of services”, »reduce differences in quality”, »improve staff responsibility for the quality they offer ”,» improve the confidence of the population in health services ”. |
| 2. Foster a culture of quality at all levels of the health systems that responds to the needs of clients. |
| 3. Generate basic knowledge and experiences in each region to facilitate the development of QA systems in other countries. |
- TYPE OF STUDY.
Descriptive, analytical and purposeful.
- STUDY AREA OR GEOGRAPHICAL SCOPE.
Stomatology Area of the First Level Hospital Clinic in San Cristóbal de las Casas, Chiapas.
- POPULATION TO STUDY.
Users of the first level Hospital Clinic of San Cristóbal de las Casas, Chiapas, in the morning shift.
- SELECTION CRITERIA: INCLUSION, EXCLUSION AND ELIMINATION .
- Inclusion Criteria: Users of the Hospital Clinic in the morning shift, in the period 2004-2005. Having received a consultation in the Preventive Orthodontic Service. That the family member agrees to participate in the study (answer the questions). Exclusion criteria. All those users who are satisfied with the care provided by the Orthodontic Service, and who have not come without an appointment. Elimination Criteria. All those users who do not wish to participate in filling out the survey or fill it out wrong.
- TECHNIQUES AND INSTRUMENTS FOR COLLECTING INFORMATION.
In this study, a survey will be applied, which will allow us to collect information through a questionnaire, and be able to measure user satisfaction in the Orthodontic Service. (Appendix 1).
- INFORMATION ANALYSIS METHODS AND PROCEDURES.
The method and procedure of analysis to be applied is descriptive statistics.
- RESULTS
5.1 USER OPINION SURVEY. (CONSULTATION OF PREVENTIVE ORTHODONTICS). APPENDIX 1.
INSTRUCTIONS FOR THE APPLICATION OF THE SURVEY
Carrying out the application of the survey according to what is indicated in the Quality Assurance Model, being the same person who surveyed the user, numbered consecutively and entering the date.
Following the procedure for the interview:
The user was asked if he could be interviewed.
Briefly explaining why the interview was being conducted, reading the indications at the top of the questionnaire.
By asking questions exactly as they are written and others that were adapted to the Preventive Orthodontic Service.
They were clear questions that allowed the user to decide on the answer.
REMEMBERING THAT USERS ARE GIVING INFORMATION
OF DIFFICULT ASPECTS TO MEASURE. It is about “ sensitizing” patients (learning).
The pollster provided the user with a pencil, while continuing to answer a single question. If for some reason a question is left unanswered, the interviewee for refraining from answering must be marked in NA (which means “DOES NOT APPLY”), in this way when the results are tabulated, there will be no problems to write it down as NA.
TABLE OF VALUES.
- QUESTIONS OPENED WITH THE NUMBER:
2.- How long do I wait to get an orthodontic appointment?
4.- How much time passed from the time you were given the appointment until you were attended.
THE FOLLOWING VALUES ARE ESTABLISHED:
| S EMANA
1 to more |
D IAS
1 day |
H ORAS
1 enough |
M INUTES
1 to 2 minutes |
||
| Inadequate = Insufficient
Value of 2 Value of 1. |
= Sufficient Value 3 | = Excellent =
Value 4. |
- CLOSED QUESTIONS GROUPED WITH THE FOLLOWING NUMBERS:
Condition 7,8,9,10,11.
Hygiene Measures of the Specialist 12 and 13.
Treatment of Personnel 6,15,16,20.
Institution Hygiene 17,18 and 19.
THESE ARE GROUPED AND EACH WILL BE EXPLAINED IN ITS OBJECTIVE.
| E XCELLENT GOOD REGULAR DOES NOT APPLY BAD
Satisfaction, Negative, Negative and Negative Questions Totality of Positive remainder remainder plus damage or Positive Answers . positive problem. Positive with |
| E XCELLENT P OSITIVE = Excellent and Good
V ALOR 5 V ALOR OF 5 AND 4 N EGATIVE = Regular, Not Applicable and Bad V ALUE D E 1 A 3 |
- In the case of Yes and No, how many were counted. (Doyle 2001, p. 1-5)
5.2 DETERMINATION OF THE SAMPLE.
The sample was determined using the following equation:
Being:
s 2
n '= knowing that: σ2
σ 2 is the variance of the population with respect to certain variables.
s 2 is the variance of the sample, which can be determined in terms of
probability as s 2 = p (1 - p) is the standard error that is given by the difference between (µ− x) the mean
population and the sample mean.
(se) 2 is the squared standard error, which will help us determine σ 2, so that σ 2 = (se) 2 is the population variance.
Substituting values I have to:
N = 150 (Population) se = 0.015 (Standard error) p = 90% = 0.90 (Reliability rate)
D I evelopment
σ 2 = (se) 2 = (0.015) 2 = 0.000225
s 2 = p (1 - p) = 0.9 (1 - 0.9) = 0.09
s 2 0.09
so n '= = = 400
σ 2 0.000225
n '400
n = = = 109
1+ n ' N 1+ 400 150
(Ms.C: Celorrio Sánchez Arcenio, 2003)
The sample will be 109 people surveyed, according to the equation used, it allows us to have a lower margin of error and better reliability.
5.3 STATISTICAL ANALYSIS.
For the analysis of the data obtained according to the variance of the sample and population, being a simple probabilistic sample, it allowed the total of users surveyed to know their Satisfaction in the Preventive Orthodontic Service.
In this study, a Microsoft Excel computer package was used, applying the sample options and descriptive statistics.
5.4 DESCRIPTIVE ANALYSIS.
5.4.1 SAMPLE.
The sample was calculated using the formula for proportions of the phenomenon under study (see sample size page 47), which was only applied to the population of users, the total number of users was 109, giving 100% of the population.
5.5 GRAPHIC EVALUATION QUESTION BY QUESTION.
(See PDF)
5.6 GRAPHICAL EVALUATION GROUPED ACCORDING TO THEIR OBJECTIVE : Condition A. ILLNESS:
(See PDF)
- CONCLUSIONS AND RECOMMENDATIONS.
6.1 CONCLUSIONS.
- OF THE PROBLEM OF THE INVESTIGATION.
According to the evaluation of the proposed model to measure Patient Satisfaction, the following data were found, which are of two types:
- Immediate: These are the results obtained after the situational analysis has been carried out, which allowed the evaluation of the quality of the perception of the patients who attended the Preventive Orthodontic Service. According to the most important indicators, we found: The results grouped in the interrogation regarding the condition, the result was 94% affirmative. This shows us that the quality in the completion of the clinical history is within the Medical Record Standard 168. In the Hygiene measures of the Specialist in the grouped questions, the result was 97% affirmative. This allows the patient to have greater confidence in this Service and security in their care.With regard to the treatment offered by the specialist and in general the clinic staff,The result obtained was 84%, the user rating it as excellent. The Institution's Hygiene was rated by the patient's parents and the patient as satisfactory by 92%. Thus, indicating that the measures established in this Institution allow reliability and security in the permanence of the user in it. With respect to the results in the Company, they would be considered mediate or impact.
In the applied survey, the following requests were made by the parents of the patients.
- If they had their own office, 10% responded. For better patient comfort, that the Preventive Orthodontic Service continue to be provided, 4% responded. Since the prevalence existing in the State of Chiapas of patients with cleft lip and palate is 50% of the population and with dental malocclusions. And congratulations to the Orthodontist, 9% were obtained.
This study helped us to monitor quality from the user's perspective in the health service, being the most indicated person to describe how he was treated, the time of delay in the service, the process that was followed to treat his health problem mouth, and finally your level of satisfaction.
- OF METHODOLOGICAL ORDER .
The user satisfaction measurement instrument is of the highest reliability with a standard error of 0.015 and a reliability rate of 90%.
6.2 RECOMMENDATIONS.
According to the Model Used in the Study, allow us to continue with the evaluation of continuous improvement in the following aspects:
- It would be ideal for the preventive orthodontic professional to build their own evaluation indicators, allowing these to be reflected in the care received to the patient.The research carried out offers the hospital unit a guide to implement a systematic, planned and continuous method to monitor,
evaluate and improve the quality of the different Services in order to increase the benefits for users based on existing resources.
- Carry out this type of descriptive research and also correlate with different variables to find out: job satisfaction and seniority in the position of workers, productivity, mobility in the position, know the performance.This type of continuous improvement studies allows evaluating the Hospital Unit every 6 months, resulting in a quality of excellence in the Hospital Unit helping it to obtain its ISO 9000 CERTIFICATION These studies have been carried out in India, Ghana, Costa Rica, Panama and Honduras.
The geographical place where this study was applied presents great socioeconomic, health and communication deficiencies with the patient, since poverty is present in this place and the indigenous population is unprotected from this type of Service, waiting for this The study will serve in the future to respond to the needs of the user in all Health Sector Services in the State of Chiapas, helping to promote the culture of Quality at all managerial and personnel levels.
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