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Curationis

versión On-line ISSN 2223-6279
versión impresa ISSN 0379-8577

Curationis vol.36 no.1 Pretoria ene. 2013

 

ORIGINAL RESEARCH

 

Experiences of Fast Queue health care users in primary health care facilities in eThekwini district, South Africa

 

 

Dudu G. SokhelaI; Nonhlanhla J. MakhanyaII; Nokuthula M. SibiyaIII; Kathleen M. NokesIV

IDepartment of Nursing, Durban University of Technology, South Africa
IIDepartment of Health, KwaZulu-Natal, South Africa
IIIDurban University of Technology, South Africa
IVHunter College, Durban University of Technology, South Africa

Correspondence

 

 


ABSTRACT

BACKGROUND: Comprehensive Primary Health Care (PHC), based on the principles of accessibility, availability, affordability, equity and acceptability, was introduced in South Africa to address inequalities in health service provision. Whilst the Fast Queue was instrumental in the promotion of access to health care, a major goal of the PHC approach, facilities were not prepared for the sudden influx of clients. Increased access resulted in long waiting times and queues contributing to dissatisfaction with the service which could lead to missed appointments and non-compliance with established treatment plans.
OBJECTIVES: Firstly to describe the experiences of clients using the Fast Queue strategy to access routine healthcare services and secondly, to determine how the clients' experiences led to satisfaction or dissatisfaction with the Fast Queue service.
METHOD: A descriptive qualitative survey using content analysis explored the experiences of the Fast Queue users in a PHC setting. Setting was first identified based on greatest number using the Fast Queue and geographic diversity and then a convenience sample of health care users of the Fast Queue were sampled individually along with one focus group of users who accessed the Queue monthly for medication refills. The same interview guide questions were used for both individual interviews and the one focus group discussion. Five clinics with the highest number of attendees during a three month period and a total of 83 health care users of the Fast Queue were interviewed. The average participant was female, 31 years old, single and unemployed.
RESULTS: Two themes with sub-themes emerged: health care user flow and communication, which highlights both satisfaction and dissatisfaction with the fast queue and queue marshals, could assist in directing users to the respective queues, reduce waiting time and keep users satisfied with the use of sign posts where there is a lack of human resources.
CONCLUSION: Effective health communication strategies contribute to positive experiences by health care users and these can be effected by: (1) involvement of health care providers in planning the construction of health facilities to give input about patient flow, infection prevention and control and provision of privacy, (2) effective complaints mechanisms for users to ensure that complaints are followed up and (3)encouraging users to arrive at the facility throughout the day, rather than the present practice where all users arrive at the clinic early in the morning.


 

 

Introduction

The South African government reorganised healthcare and created a Comprehensive Primary Health Care System (PHC) using the World Health Organization (WHO) principles (WHO 1978) of accessibility, availability, affordability, equity and acceptability. Sibiya (2009) described integrated primary health care as a strategy that increases health service utilisation by increasing accessibility and availability of all health services at the PHC level. The way that organisations serve clients who are waiting to be seen, impacts on the clients' perception of the organisation. Queue management is about ensuring fairness and demonstrating to clients that they are waiting in a planned environment, whilst reassuring them that they will be attended to timeously (Qmatic. com 2005). Clients want to know that their time is valued. Patient flow and actively searching for bottlenecks is necessary to ensure that patients are processed through to the fastest or shortest queue at any given time. The Fast Queue strategy was implemented to resolve challenges in a range of health care services so that patients coming for a brief, routine consultation would not be kept unnecessarily in the PHC setting for long periods.

The WHO estimates that one-third of the 40 million people living with HIV and AIDS worldwide are co-infected with tuberculosis (TB), one of the most common opportunistic infections. South Africa has one of the highest estimated TB rates in the world, ranking fourth amongst the 22 WHO-determined high-burden countries, with an estimated 461,000 new cases reported each year. The South African TB and HIV co-infection rate is also high, with approximately 55% of TB patients also testing positive for HIV. Further exacerbating the problem is the existence of drug-resistant TB, often caused by non-adherence to drug regimens (CDC 2011). One of the challenges has been that the changes in the healthcare system planned by the postapartheid government, could not anticipate the great influx of patients infected with tuberculosis and HIV who would require services in their local community.

Problem statement

Whilst the Fast Queue strategy has been instrumental in promoting access to health care services, a major goal of the PHC approach; the influx of patients as experienced by the researcher, has had adverse effects on health care delivery, with queues growing longer and patients waiting many hours for service. Although the Fast Queue strategy was introduced in 2001, there is no evidence of any systematic evaluation by South African researchers, hence the need for this study.

Background

Poorly staffed health care facilities in South Africa have been faced with the challenge of treating persons with complex health problems who present at the PHC level. Waiting times due to long queues had increased in public health clinics, which prompted the Gauteng Member of the Executive Committee for Health and Social Development, to announce that waiting times would be a thing of the past and that additional queue marshals would be introduced to assist outpatients (Mahlangu 2009:1). The Fast Queue strategy is the service for patients who need short consultations and have been seen previously in a hospital, community health centre or another primary health care facility and referred for ongoing treatment (Department of Health 2001).

Chronically ill adults, older adults and children could be referred to the Fast Queue if they had been assessed previously either at a Comprehensive Health Centre (CHC) or PHC clinic. Services provided to in the fast queue include: follow up issuing of prescribed treatment according to protocols along with routine procedures, including assessment of vital signs and basic physiological assessment parameters such as blood pressure, body mass index, heart and lung functioning, and blood glucose levels. Patients who further qualify for the Fast Queue service include those who need follow up monitoring of complications; to identify and refer people with disabilities; patients who need provision of explanation and education on treatment and general health education in group or individual format as well as for the booking of follow up visits. In addition, Fast Queue services include the treatment and follow up of patients and families of patients with mental diseases; dispensing and monitoring of medication for acute conditions for a limited period according to protocol; identification and referral for periodic reassessment; screening, counselling and referral for drug abuse, sexual abuse, child abuse and other crisis events.

Services for children in the Fast Queue include: growth monitoring and immunisation; counselling of caretakers; rheumatic heart disease prophylaxis; counselling of parents regarding the prevention, impact and follow up related to teenage pregnancies including; providing reports to the school, social welfare services or other service providers on request, and/or in agreement with parent or legal guardian. Other services included in the Fast Queue are for persons with special needs such as working clients who can visit the clinic at times suited to their working hours or patients who need to be attended to very early, before other services start - such as patients needing family planning methods, daily Directly Observed Treatment Short Course (DOTS), chronic patient medicine collection, immunisations, and other agreed upon services such as dispensing of sunscreen for people with albinism (Department of Health 2001:28). Since a significant number of chronically ill patients who visit the primary health care facility can access the Fast Queue service, it is essential that services are continuously evaluated and patient perceptions and experiences are assessed.

Aims of the study

To describe the experiences of the users of the Fast Queue in order to better understand how to more effectively implement the Fast Queue strategy and thus, improve health care delivery and enhance user satisfaction.

Objectives

To describe the experiences of the Fast Queue strategy users and to determine the level of satisfaction of users with Fast Queue strategy.

Purpose

This study explored experiences of health care users of the Fast Queue strategy to learn about their perceptions and experiences with this service.

Operational Definitions

PHC facilities are clinics within communities which are the first contact for health care.

Health care users are all people; whether sick or well, who visit the PHC facility with the purpose of seeking health care.

Health care providers are nurses working in the Primary Health Care facility.

Significance: The results of the study will assist in decision making related to patient flow management, in order to reduce patient waiting times which in turn will improve access to healthcare services and reduce overcrowding. With improved patient flow, health care providers may work more effectively and user satisfaction may increase. The study will inform policy makers who can address unnecessary long waiting times in the comprehensive health care service package for South Africa.

 

Theoretical Framework

The Kano Model of Customer Satisfaction (Kano 1984:1) is a quality management and marketing technique that was used to guide the study (see Figure 1). The Kano model of customer satisfaction classifies product attributes based on how they are perceived by customers and the effect they have on customer satisfaction. According to this model, there are six attributes, namely; basic or threshold, performance, excitement, neutral, questionable and reverse attributes however, only the basic or threshold attribute will be addressed in this article. This attribute is compulsory for any product and should not be omitted at any given time because absence results in customer dissatisfaction. One of the essentials of the basic or threshold attribute is the presence of qualified and highly skilled health care providers at the health facilities, who can make expert decisions about health care needs. Patients perceive that they are in good hands, the providers knows what they are doing and do so with agility. This will facilitate quality care and avoid delays, thus shortening patient waiting time and increasing satisfaction.

 

 

Literature Review

Customers are satisfied if the quality of goods or services of an organisation meet the specified expected requirements (Oakland 2003:4). Waiting times relate directly and form a significant component of patient satisfaction (Eilers 2004:1). Thompson and Yarnold (1995:662) found that patients were least satisfied when the waiting time was longer than expected; they were relatively satisfied when time was perceived as equal to their expectation and they were highly satisfied if the waiting time was shorter than expected. Ajayi (2002:1-7) concluded that if patients perceive that the time they have to wait is used constructively, the time was well spent and they have gained from it. Setty (2004:2) identified important principles of effective client flow in reproductive health and family planning settings, namely; balancing client load with client flow. Improving client flow can help shorten patient waiting time and thus, increase the number of patients a provider sees daily. Effectively using signs, posted or written instructions and simplified and clear directions can assist the clients' time to find service provision areas on their own and move through the system more quickly.

 

Research method and design

Design

A descriptive qualitative survey using content analysis (Burns & Grove 1999) was used to explore the experiences of the health care users served on the Fast Queue.

Sampling

In order to ensure geographic diversity, a two stage sampling plan was used. To identify the PHC setting in the three health sub-districts (south, north and west sub districts of eThekwini municipality), facilities with the highest number of attendees seen over three months (October 2008 to March 2009) were chosen. Once the clinic was selected, health care users who were in the Fast Queue on the day of the research were purposively selected. Since one of the most frequent services provided by the Fast Queue is for chronically ill patients who come monthly to collect their medications, it was decided to hold one focus group with those health care users to gain insight into their unique experiences as regular users of the Fast Queue strategy.

Data collection method

After informed consent was obtained, the same interview guide questions were used for both individual and the one focus group discussion. The researcher conducted the interviews in the languages the participants were comfortable with, mainly isiZulu and English. Responses were audio taped and transcribed in English by the researcher. Data was transcribed in the languages that interviews were done in, and those done in isiZulu were translated into English.

Context of the study

The study was conducted in the PHC facilities of eThekwini Municipality excluding mobile units. The eThekwini Municipality is situated within eThekwini district, which is one of 11 districts in the province of KwaZulu-Natal in South Africa. The municipality was formulated following the December 2000 election and is a product of seven municipalities that were amalgamated into one. It is divided into three sub-districts namely South, North and West. The Municipality has 77 PHC facilities, and 15 mobile units, with 1 CHC shared between the municipality and the provincial department of health. The catchment population ratio per clinic is 1:22570, which is above the national norm of 1:15000 (eThekwini municipality 2006/2007).

Data Analysis

Data analysis occurred in three stages namely; description, analysis and interpretation. In the description phase the researcher listened and re-listened to the interviews from the audio tape recorder. The researcher also read and re-read the transcripts to become immersed in the data with the aim to interpreting it to find meaning and make sense of it. In the analysis phase, themes and sub-themes were identified from the raw data to establish patterns and these were used to interpret data. The researcher interpreted the data according to her understanding using; themes and sub-themes identified during the analysis phase, and supported her interpretation with the use of excerpts from the interviews to eliminate subjectivity and bias. The Kano model was used to guide identification of themes into specific categories.

 

Results

Five clinics, with the highest number of attendees during a three month period, and a total of 83 health care users of the Fast Queue were interviewed. The average participant was female, 31 years old, single, and unemployed.

According to Kano, basic and threshold attributes are foundational. Positive experiences with the Fast Queue resulted in client satisfaction whilst negative experiences resulted in dissatisfaction. Two main themes: health care user flow with four sub-themes and communication with two sub-themes emerged.

Theme 1: Health Care User Flow

Good clinic organisation eliminated bottlenecks and effective health care user flow enhanced the work process and increased satisfaction. Sub-themes that emerged related to health care user flow and included: floor space, staffing patterns, waiting time, and workload.

Floor space

The clinic floor plan and structure had a direct bearing on user flow. Health care users shared their experiences in a small clinic which resulted in delays and long waiting times. Some users reported that the Fast Queue enabled quick attendance to an extent that allowed them to keep to their normal daily schedule. Mothers of young babies liked the fact that they were seated away from the sick people, thus protecting their children from possible infections.

'This queue is very fast because when I arrived here there were many of us and I thought I will leave late. When I came inside, there were many different queues that we were directed to. It was fast'. (Participant: 7, female, unemployed, 26 years)

'I am not sure. Maybe it is the load of work. This clinic used to be very full before it was moved to these new premises. Since moving to this new clinic the work seems lighter, but I think it is because this clinic is more spacious, there is more space for us to move and be separated into different specific queues'. (Participant: 22, female, unemployed, 32 years)

Staffing Patterns

Insufficient staffing contributed to dissatisfaction and resulted in increased waiting time. Although they were sympathetic, health care users still expected good and fast service. Staff shortages resulted in work starting late because of sorting out problems in other areas. This yielded high levels of dissatisfaction, which was expressed as follows:

'I am okay with it, but the staff is short, so the Fast Queue is not so fast. For an example: people with TB are not supposed to wait in the general waiting area, they are supposed to go straight to the nurses because other people can contract TB. Sometimes we are told there are only two or three nurses in the clinic.'(Participant: 17, male, unemployed, 40 years)

'[I]t's just that they start late on some days. The nurses are few sometimes only two attending to patients. At the moment there is no one; I think she is at tea. Some can say they are neglecting their work'. (Participant: 18, male, unemployed, 47 years)

Whilst there is a shortage of staff, some health care users verbalised that there were more nurses than before 'and there are definitely more nurses now.'(Participant: 37, male, unemployed, 35 years)

 

Waiting time

Government health institutions are overcrowded, with long waiting times and long delays. Long waiting was mainly experienced during the process of registration and not in the fast queue. In the fast queue waiting time was minimal as expressed by users in these quotes:

'I was very happy because it saved me a lot of time; I am going to be able to go to class at 12h00. I had even reported at school that I will be absent, but because it is organised and fast I am now going to be able to go to school'.(Participant: 47, female, university student, 20 years)

' There is no waiting after you have registered. The queue for babies is fast and I like it because you leave before the baby gets bored. It is very upsetting if you are in the clinic and the babies cry non-stop. With the fast queue it does not happen'. (Participant: 21, female, unemployed, 28 years)

Participants who experienced long waiting time had negative perceptions. A health participant, who had come for family planning, had thi