A Research Study on the Patient Experience (PX) in the Philippines: Journey towards Optimal Health

Harold James Doroteo^*, Fely Marilyn Lorenzo, Angelito Obillo and Davidson Teh
^*Correspondence: Harold James Doroteo, USAID-Human Resources for Health in 2030 Philippines, Manila, Philippines, Tel: +639427416323, Email:

Keywords

Patient experience • Philippines • Human resources for health • Health systems • Case study • Metro Manila • PX Framework

Introduction

This study adopted the definition of PX of the Beryl Institute as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care”. The World Health Organization (WHO) defines universal health coverage “as ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship”. These points considered, PX serves as a lens upon which the effectiveness of UHC in the Philippine health system, particularly for facilities and providers may be evaluated and improved upon.

The research stemmed from evidence from studies conducted among patients, associated with both the facility and the provider, of persistent problems in the Philippine health systems including long wait times, lack of information about services, services needed are not available, privacy and confidentiality taken lightly, dirty bathrooms, lack amenities, overcrowding, among others.

The PX journey of USAID’s HRH 2030/Philippines began with case study research from 10 health facilities to develop a PX Framework that is contextual to the Philippine local setting which can be applied to both public and private institutions, and in different levels of care. From these case studies and a cross-case analysis, elements of the patient experience framework were derived. Observations across the 10 cases presented 6 Facility Capacities and 6 Provider Competencies that affects the 4 phases in the Continuum of Care leading to Health Outcomes in the Filipino Patient Experience Framework.

Certain thematic areas are of particular focus in this cross-case analysis. Patient experience between primary and higher level of care facilities is compared. Similarities and differences in the practice of patience experience within the health sector are discussed. Finally, lessons learned in patient experience are covered, both, in addressing tuberculosis and in support of family planning in the Philippines showcase PX best practices in TB and FP, and to spur more conversation and build partnerships for improving PX resulting to better services and optimal health for Filipinos.

Based on the findings of the case studies and framework, USAID’s HRH2030/Philippines designed a PX Assessment Tool comprised of an HRH competency tool and a facility tool to assess levels of PX implementation and identify areas for improvement. From the results of using the tools, PX improvement plans can be developed by the facility to improve PX and sustain PX efforts within their locality/province appropriate to the Philippine context.

Philippine Health Sector’s Human Resource and Px

Patient Experience becomes a valuable concept to consider and operationalize to deliver upon the Strategic Goal 2 of the National Objectives for Health 2017-2022 of a “ more responsive health system ” and more specifically described as, “The quality of health goods and services as well as the manner in which they are delivered to the population will be improved to ensure people-centered healthcare provision. This may be done through instruments that routinely monitor and evaluate client feedback on health goods used and services received.” The relationship of the concept of Patient Experience is therefore closely related to the access to quality health services provision by health workers who are highly skilled and motivated.

Goals

Some of these notable persistent problems in the Philippine context that impact Patient Experience, based on research published in the Philippines Health Systems Review include [1,2]:

• Understaffing and lack of local capacity to manage devolved health facilities

• Lack of operational funds to operate and maintain health infrastructure

• Breakdown of the referral system and loss of distinction between different levels of care (i.e. patients go to hospital even if their illness can be and should be addressed at the primary level)

• Fragmented and unharmonized health financing by the three biggest health funders: DOH, PhilHealth and LGUs where some programs/areas are over-funded and other areas are financially neglected

• Regulatory gaps, such as in the areas of health technology, private health insurance, outpatient services and free-standing clinics.

Challenges

In related studies conducted among patients, the following are the more common findings associated with both the facility and the provider [3,4].

• Long wait times

• Lack of information about services

• Services needed are not available

• Privacy and confidentiality taken lightly

• Dirty bathrooms, lack amenities

• Overcrowding, among others

Review of Related Literature

Patient satisfaction

Patient experience is linked with, but conceptually different from, patient satisfaction [5]. Patient satisfaction is highly subjective and dependent on the patient ’ s expectations with the provider and type of service. Patient satisfaction may simply measure a point in a continuum of care, whereas patient experience measures the whole continuum, assessing not only one department or provider but the whole system or organization and how they work together. Patient satisfaction is, largely, subjective but surveys are commonly used as a measuring device in an attempt to translate subjective results into meaningful, quantifiable, and actionable data.

Patient-centered care

Patient-centered care is often explained as part of patient experience and is often used interchangeably [6]. Elements of patient-centered care are similar to elements used to describe patient experience such as collaborative and coordinated care. Emotional well-being is part of the focus in addition to physical well-being and the patient and family are part of the decisionmaking. Patient-centered care involves customizing treatment appropriate to the patient’s condition and circumstances; it spans the onset of a visit to a health facility to the time an illness or disease has been treated or resolved and would thus involve several visits and entail developing relationships [7].

Patient experience

Patient experience is more than a single visit or a series of visits to resolve or treat an illness. Patient experience starts not at the point of the visit to a health facility, but at the point when an illness or a symptom of a disease is recognized. It proceeds to when a decision is made to seek consultation, to the consultation/s or confinement, the treatment process, and whether there is compliance to the treatment. Patient experience affects the health seeking behavior and the health literacy of a patient and their families. Ultimately it can drive the attainment of patient health outcomes and collectively affects health outcomes of a populace. Compared to the usual understanding of quality health care that focuses mainly on effectiveness and safety of care, patient experience includes several aspects of health service delivery that patients value highly when they seek and receive care, such as getting timely appointments, easy access to information, and good communication with health care providers (Figure 1) [8-10].

Existing patient experience frameworks

Several frameworks have been developed to describe the important principles of patient experience and potentially provide a structure within which patient experience is considered.

Warwick PX Framework (WaPEF): According to the The Warwick Patient Experience Framework (WaPEF), there are seven key generic themes that are important for a high-quality patient experience:

• Patient as active participant,

• Responsiveness of services,

• An individualized approach,

• Lived experience,

• Continuity of care and relationships,

• Communication,

• Information and support.

In addition, the WaPEF informed the development of the National Institute for Health and Care Excellence (NICE) guidance and quality standard in Adult NHS services.

The seven generic themes mentioned in the WaPEF have similarities with the conceptual framework of patient centered care discussed by Hudon, et al. For example, the patient-as-person concept in the conceptual framework is aligned to the Responsiveness of Services theme of the WaPEF since they both point to having individualized care for each patient. The generic theme of Patient as Active Participant in WaPEF is similar in concept of sharing power and responsibility in the framework of Hudon. The limitation though of the PCC framework mentioned is that it only captures the physician-patient relationship but not the whole continuum of care.

NHS National Quality Board (NQB) PX Framework: Improving patient experience is a key aim for the NHS. The framework provides a common evidence-based list of what matters to the patients and can be used to direct efforts to improve service. Unlike a graphical framework, the NHS provided a working definition of patient experience to guide measurement of patient experience across their organizations. It is as follows:

• Respect for patient-centered values, preferences, and expressed needs, including: cultural issues; the dignity, privacy and independence of patients and service users; an awareness of quality-of-life issues; and shared decision making;

• Information, communication, and education on clinical status, progress, prognosis, and processes of care in order to facilitate autonomy, self-care and health promotion; Emotional support and alleviation of fear and anxiety about such issues as clinical status, prognosis, and the impact of illness on patients, their families and their finances;

• Welcoming the involvement of family and friends, on whom patients and service users rely, in decision-making and demonstrating awareness and accommodation of their needs as care-givers;

• Transition and continuity as regards information that will help patients care for themselves away from a clinical setting, and coordination, planning, and support to ease transitions;

• Access to care with attention for example, to time spent waiting for admission or time between admission and placement in a room in an inpatient setting and waiting time for an appointment or visit in the outpatient, primary care or social care setting.

Aneurin Bevan Health Board PX Framework: Under the National Health Services (NHS) in Wales, the Aneurin Bevan Local Health Board aspires to continually provide quality and excellent patient care. With this, the board has designed a framework towards achieving their aim and mission which is as follows: “Working with you for a healthier community, Caring for you when you need us, Aiming for excellence in what we do” Their framework revolves around patient centered services which are then reinforced by • Improving public health (eliminating inequalities in health status through partnership, ownership and empowerment),

• Empowering staff and providers (upgrade the skills of workforce and trusting them to deliver excellence),

• Focusing on safety, excellence and quality (provide quality and evidence based patient experience at all times), and

• Achieving better use of resources (reduce waste and variation). The Local Health Board has also provided a list of strategic principles that is embedded in the organization and that should adopted by all staff to ensure a positive patient experience outcome. They are as follows:

• The organization’s culture must be one of valuing every person and ensuring that they are treated with dignity and respect.

• – The key purpose is to provide direction, gain commitment, facilitate change (develop the culture and attitude that facilitate work with patients and service users to bring about change) and achieve results through the efficient, creative and responsible deployment of people and other resources.

• – to do no harm to patients by ensuring that the environment is safe, clean and by reducing avoidable harm. It also means that we give patients more control over their own care, and care for every patient in the way we would want our family, friends and loved ones to be cared for.

• – Upgrade the skills of the staff to enable them to deliver excellence. Also, to trust them, value them and their contribution.

• – to listen to the patients and cares, as individuals and collectively, to understand how to better provide patient centered services.

On the other end, the health board recognizes that to improve patient experience, the health staff should be inspired and motivated, as the way to achieve transformation is through their mobilization to drive change. The staffs needs to have

• A clear vision,

• Training and assurance that they are safe, confident and empowered to resolve problems and change practice or escalate to an appropriate person if resolution or improvement cannot be achieved, and

• A culture of pride in the service delivered and with the staff who deliver it.

While all of these frameworks are useful, they provide generic guidance on the concept of Patient Experience. In order to facilitate a meaningful and appropriate implementation of the concept in the Philippines, an acceptable and feasible Philippine framework needs to be crafted. USAID’sHRH2030 began with a documentation of Patient Experience in selected hospitals and communities in the country to determine what current Patient Experiences prevail and to derive a Philippine PX framework and tool that may be used to measure status of PX in health care facilities at the primary care level. Hence case studies were developed to describe and analyse the prevailing PX practices and what interventions may be mounted to improve Patient Experience.

Patient experience in the Philippines

There is a scarcity of studies on and documentation of good practices in patient experience in the Philippines. A First Asian Patient Experience Meeting was spearheaded by St. Luke’s Medical Center in 2017 but the proceedings are not available online. St. Luke’s Medical Center a private owned company, has a patient experience group headed by its vice president and patient experience officers who can assist patients and their family members with their medical and personal concerns as described in its website. Dr. Wolf of The Beryl Institute visited SLMC and noted the organization’s commitment to engagement through SLMC’s Patient and Family Engagement Council, commitment to access through expansion of its concierge services to include those who may not have readily available resources by aligning insurance needs with care, etc., commitment to all touchpoints whether it be the outpatient unit or the laboratory. Aside from St. Luke’s Medical Center, the other JCI accredited hospitals in the Philippines are Makati Medical Center, The Medical City and Asian Hospital Medical Center Makati Medical Center does not explicitly have a patient experience office but has a patient relations office which facilitates the communication between the healthcare team and the patients to ensure that their concerns are properly addressed. The Medical City emphasizes measurement of the overall experience of admitted patients and the overall satisfaction of patients consulting in the outpatient unit. It also has the Center for Patient Partnership whose services include health education and promotion and patient clubs, as well as management of special programs for quality improvement through patient experience survey, patient satisfaction survey, FGD for patients among others.

There are a number of studies on related concepts – patient satisfaction and patient centered approach, which are worth looking into. One case study is the transformation of Love Yourself HIV screening center into a quality TBHIV care one stop shop. Previously, people living with HIV and who were also presumptive TB patients were referred to TB DOTS facilities with the NGO being unaware of the outcome of the referral because follow up was not part of the protocol. Through the “Building Models for the Future” project, an intersectoral collaboration among national agencies and local government unit and NGOs, the facility was provided technical assistance and equipment which enabled it to screen for TB, conduct GeneXpert testing, and initiate anti TB treatment. Related as well to patient experience is cultural sensitivity. This was demonstrated in the maternal health services in Lapuyan, Zamboanga del Sur wherein the consultation of the mayor with the Subanen tribal leader resulted to allowing relatives and tribal leaders in the delivery room to perform rituals before and after giving birth. This along with the other innovations in Lapuyan contributed to the improvement of facility based delivery from 3% in 2009 to 60% in the first half of 2012. Critical to the change process is the improved health leadership of the mayor and the municipal health officer. A private public partnership between the Makati Medical Center Foundation and the DOH owned Rizal Medical Center was made with the latter’s officers and personnel coached by the MMCF in improving its patient processes. While there may be positive cases found related to patient experience, the concept remains largely unrealized in Philippine health facilities whose patients still struggle with more basic issues such as out of pocket payments which in 2017 was at 54.5%. A health system responsiveness study was done in the Philippines across 6 of the 8 WHO domains. Health system responsiveness was defined as “a measure of how well the health system fulfills the non-medical expectations of the people interacting and participating in the services provided by the health sector - essentially the non-health outcomes of a health system’s performance” Some of the key findings were that social class (81% or respondents) and capacity to pay (75% of respondents) were perceived as the greatest barriers to health care and that those from lower socioeconomic classes, D1, D2 and E, also perceived that they were less frequently treated with respect by health care providers with those belonging to D2 being the highest at 27%, compared to those from class ABC at 6%.

Patient experience and the universal Healthcare Act

A landmark legislation that will significantly improve the delivery of health services is the Universal Health Care Act 2018 which is already waiting signing of the President. This is a significant policy because it aims to address the fragmentation of the health system which results to discontinuity of care. Essentially, the law mandates the contracting by PhilHealth of a network of health care provider for individual based health care and contracting by DOH of the province-wide or city-wide health system for population-based services. The policy defines a health care provider network as “a group of primary to tertiary care providers, whether public or private, offering people-centered and comprehensive care in an integrated and coordinated manner with the primary care provider acting as the navigator and coordinator of health care within the network”. The operationalization of this Act is hinged on the UHC principles of an integrated and comprehensive approach to health, a health care model providing comprehensive, quality care service with financial risk protection, a whole of system, whole of government and whole of society approach and as stated in Sec.2 d of the Act, a “people oriented approach for the delivery of health services that is centered on people’s needs and wellbeing, and cognizant of the differences in culture, values and beliefs”. The funding to operationalize the UHC will come from PhilHealth reimbursements, internal revenue allotment and other sources which will be pooled in a special health fund under the management of the provincial health board or city health board. Since the integration of a province-wide and city-wide health system is within the mandate of the governors and city mayors and their health officers, there is an opportunity for interested organizations to partner with provincial and city governments to improve patient experience not just in individual facilities but in the entire service delivery network.

Case Study Approach

The case study method utilized and involved up-close, in-depth, and detailed examination of patient experience practices or practices related to patient experience such as patient-centered care, as well as its related contextual conditions. The case study included a Systems analysis or the process of studying a procedure or process to achieve intended goals and purposes (effectiveness) in the most efficient way possible to enable the suggestion of solutions to steps/processes that hinder efficiency and effectiveness (Figure 2).

The case studies have the flavor of a phenomenological approach as the patient experience or patient journey focuses on subjective experiences and understanding the structure of the lived experiences. Phenomenology is a qualitative research method used to describe how human beings experience a certain phenomenon, encompassing their feelings, thoughts, reactions and responses. In the study’s interest, the phenomenon under examination is the patient experience. Through phenomenology, the research is afforded a glimpse into the respondents’ knowledge, attitudes, and practices pertaining to health, wellness, and illness.

The case study method falls under the Grounded Theory approach for qualitative studies. Grounded theory is a systematic methodology involving the construction of theories/concepts through methodical gathering and analysis of data, which was done using multiple case studies for this research.

The research tools used are key informant interview (patient, companion, health provider), community facilitated interview, focused group discussion, and observation. All key informant interviews, FGDs, FGIs were transcribed and form part of the primary data gathering.

In the context of the research, the following measures were used to establish the validity of the qualitative research tools:

• The OD PX Tools were conceptualized based on the research protocol previously developed by the researchers. Prior to implementation, the tools were tested in two health facilities which followed the general categories of the sample: primary health care and hospitals. The pilot testing of tools was arranged with the City Health Office of Manila and the tools were tested in Atang de la Rama and Ospital ng Maynila Medical Center. The pilot testing surfaced inputs on improving the tools to ensure their appropriateness in both settings. Gender sensitivity questions were added to the developed tools.

• In a health facility, the following sources are used: patients, patient’s companion, nurses, nursing aides/orderlies, officers (chief of clinic, PETRO, physician-in-charge, others), Barangay Health Workers (BHWs)/ midwives, administrative officers, Pastor/Chaplain, others. For the health centers, a community group facilitated interview was conducted. A separate section lists the research’s respondents.

• After the case studies are finalized, they would be presented informally to the approving officer of the health facility. For the LGU-attached health facility, the case studies would be presented to the City Health Office (CHO). Inputs would be solicited and incorporated into the final draft of the case studies. All health facilities included in this study have approved the publication of their case studies.

The sample universe of the case study encompasses the health care continuum from primary health care to tertiary hospitals (Table 1). The sample case study units are concentrated in Tondo, Manila with the exception of the Philippine General Hospital (PGH) and St. Luke’s Medical Center-QC (SLMC-QC).

The rationale for identifying Tondo as the focal geographic area is because of its dense and largely very poor population of more than 600,000 people crammed into an 8.8 square kilometer land area at close to 70,000 people per square kilometer. Close to the garbage disposal site Smokey Mountain and the poverty in the area, the poor sanitation and environment promote the spread of diseases. The area also remains underserved in relation to health services.

The two hospitals located outside Tondo are the PGH and SLMC-QC. PGH is an apex hospital; its inclusion in the study is necessary to fully explore and understand patient experience in the Philippines. On the other hand, SLMC-QC has its own Patient Experience Department and is considered to be one of the best healthcare institutions in the Philippines, having been accredited by the Joint Commission International.

For each health facility, various data collection methods were applied:

• Key Informant Interviews were conducted for patients, companions and various Health Providers.

• Focused Group Discussions were conducted among nurses in all hospitals.

• Facilitated Group Interviews were conducted among Nursing Aides and Orderlies in all hospitals.

• Facilitated group interviews were conducted in the community/catchment area of the health centers.

The study used purposive sampling to acquire a representation of different patients from different departments, with particular attention to TB patients, Family Planning recipients, and Maternal and Child Care patients.

Cross-case analysis and the Filipino patient experience framework

The development of the Filipino Patient Experience Framework reconciled evidence across the ten cases, the types of data, and between cases and literature. Thus, below is the proposed Filipino Patient Experience Framework (Figure 3) and the discussion of its elements and as a whole, citing specific cross-case analysis follow.

The literature indicates that patient experience is a function of the organization as a whole more than individual health care providers. Organizational elements that facilitate patient centered care in healthcare organizations well known for good patient experience are

• Strong, committed senior leadership,

• Clear communication of strategic vision,

• Active engagement of patient and families throughout the institution,

• Sustained focus on staff satisfaction,

• Active measurement and feedback reporting of patient experiences,

• Adequate resourcing of care delivery redesign,

• Staff capacity building,

• Accountability and incentives and

• A culture strongly supportive of change and learning.

Interviewees reported that changing the organizational culture from a ‘provider-focus’ to a ‘patient-focus’ and the length of time it took to transition toward such a focus were the principal barriers against transforming delivery for patient centered care. With which, this cross-case analysis identified similar facets of an organization that affects patient experience and is name in the Filipino Patient Experience Framework as “ Health Care Facility Capacities”.

Health care facility capacities

Health Care Facility Capacities refers to the wide range of capabilities, practices, resources, systems, and other factors that are within the scope of a health care organization that contribute to Patient Experience through the Continuum of Care. The following are the elements, their definitions.

Governance: Capacity to administrate and manage with the existence of an organizational vision and strategic direction combined with effective oversight, transparency, responsiveness, integrity, and accountability.

Information and communication capacity: To manage and utilize information for records keeping, data generation, research, policy crafting and decision making.

Financing: Capacity to provide appropriate financing options to patients set the right financial incentives to providers and ensure revenue generation for optimal operations.

Human resources: Capacity to recruit, manage, train, motivate, and support its human resource possessing appropriate skills and competency, with adequate number of HRH matched to proper workloads.

Medicines, technologies, and infrastructure: Capacity to provide access to quality medical products, equipment, facilities, and technologies assuring safety and efficacy.

Service delivery: Capacity to deliver comprehensive, effective, organized, responsive and patient-centered quality care to its clients through efficient processes leading to desired health care outcomes.

Health care provider competencies

Health Care Provider Competencies is the combination of observable and measurable knowledge, skills, abilities and personal attributes of the health care practitioner that contribute to Patient Experience through the Continuum of Care. These competencies are mostly taken from the competency clusters for coordinated/integrated health services of the WHO. The addition of Technical Proficiency complements the social and emotional intelligenceassociated competencies prescribed by WHO. The following are the elements, their definitions.

Patient advocacy: Ability to promote patients’ entitlement to ensure the best quality of care and empowering patients to become active participants of their health.

Effective communication: Ability to quickly establish rapport with patients and their family members in an empathetic and sensitive manner incorporating the patients’ perceived and declared culture.

Teamwork: Ability to function effectively as a member of an interprofessional team that includes providers, patients and family members in a way that reflects an understanding of team dynamics and group/team processes in building productive working relationships and is focused on health outcomes.

People-centered care: Ability to create conditions for providing coordinated/integrated services centered on the patients and their families’ needs, values and preferences along a continuum of care and over the life course.

Continuous learning: Ability to demonstrate reflective practice, based on the best available evidence and to assess and continually improve the services delivered as an individual provider and as a member of an interprofessional team.

Technical proficiency: Ability to apply the technical knowledge and skills required in the specialist and professional job role and responsibilities in order to achieve the expected outputs.

Patient experience assessment across the phases in the continuum of care

The assessment of the presence and practice of both the facility performance indicators and provider behavioural indicators for each of the 4 phases in the Continuum of Care when tallied and presented in percentages will indicate the areas where Patient Experience requires attention for the facility or the provider (Figure 4). The results are given as a table shown below (Table 2).

The findings, as presented, highlight areas for improvement and may be used in the process of planning. Specific targets may be set by the leadership of the facility, and in so doing, enumerate interventions to be implemented within a given timeline and by identified owners and allocated resources.

Cross-Case Analysis of Thematic Areas

Certain thematic areas are of focus in this cross-case analysis. Patient experience between primary and higher level of care facilities are compared. Similarities and differences in the practice of patience experience within the health sector are discussed. Finally, lessons learned in patient experience are covered, both, in addressing tuberculosis and in support of family planning in the Philippines.

Primary vs. higher level of care

Health misconceptions are still rampant within communities that surround primary care facilities and one of the ways to address this is to strengthen their communication and information capacity through community visits, health classes, lectures, demonstrations, and IEC material distribution. Take the experience of Fugoso HC as an example where some members of the community still resist the facility’s efforts to convince them of the benefits of staying updated about their current personal health status. The residents prefer to rely on what they see and experience, and the opinions and suggestions of people in their confidence, such as their family members and friends, despite the inaccuracy of their information. In the same way, higher level facilities should maximize opportunities to improve knowledge on disease and health seeking behaviors of their patients, along with companions or family members. As with the case of PGH, it has the capacity to set-up mechanisms that can repetitively relay information such as infomercials which can be used by health providers to remind patients about their rights and responsibilities in the facility. This can also be utilized to educate patients and open an avenue for the patient and health provider to discuss health related topics. Amidst this opportunity, available resources for communications in the said facility are left underutilized.

As for disease prevention, such activities are not limited within the facilities but are also mostly seen down in the communities especially among primary care facilities. Barangay Health Workers (BHWs) are considered to be the main drivers of these extended services. They conduct home visits to monitor patients who are chronically ill and those that are pregnant and encourage them to visit the health centers to get their regular check-ups. Citing as an example, Fugoso LIC developed a program called the Community Prenatal Care (ComPreCare) where health workers go directly to the community to assist pregnant women on their health journey and encourage them to undergo pre-natal check-ups as early and as consistently as possible.

Regarding medical check-ups and treatment, it was observed that providers from both primary care and higher-level facilities exhibit effective communication skills and are able to properly engage patients, alleviate their worries and respond politely to their queries. For one, St. Luke’s Medical Center has a Patient Experience Group with a Patient Relations Department which solely handles patient complaints and a Patient Care Department that ensures that patients’ needs are met. In addition, Health providers try to treat their patients according to their uniqueness, individuality and with sympathy while maintaining a professional relationship with them and exhibiting a high level of technical competency. One of the case reports describes how Fugoso LIC treats a patient: “During her labor, the health providers made sure she was comfortable, monitored her condition closely, and encouraged her, boosting her confidence to pursue a normal delivery, the patient emphasized that the concerned and caring manner with which health providers treated her are what led to her patronizing the facility, on top of their skills, knowledge, and capabilities. Fugoso Lying-in health providers are very friendly and encouraging; they treated her like family during her labor and until her discharge”.

Furthermore, teamwork and flexibility are essential competencies that health providers should possess to provide better experience for patients. As observed, most of the primary care facilities are understaffed and the only way to cope up with varying workloads is to back each other up and be flexible in terms of task sharing. Providers from Foreshore HC acknowledge the fact that they are understaffed and they need to cope with it by working efficiently and by supporting each other.

Health sector effects (Public-private patterns)

Lack of human resources is a perennial problem for both public and private health facilities. In most of the public health facilities, providers admit that they are severely understaffed and that they are working beyond their capacity to provide positive patient experience and promote prevention of disease. Providers from Foreshore HC believe that they could do better, provide more satisfactory services, and implement more health programs if the problem of understaffing is addressed.

Another struggle of public health facilities is their capacity to sustain communication and information efforts in health promotion. Most of the said facilities have few to none IEC materials and they are unable to produce more due to lack of budget. In the case of Fugoso HC, their IEC materials were lost and damaged during the facility’s renovation and beside budget constraints, heavy workload prevent providers from gathering and disseminating new IEC materials. In contrast, private facilities are well supported in terms of IEC material production.

On the other hand, effective communication is seen in both private and public health providers. They are able to support and make the patients feel at ease to go through procedures and treatments. Trust and confidence is built by reassuring the patient that his or her safety is guaranteed. Such is the case at Metro Doctors LIC where clinic staff members listen to the patients, giving them appropriate attention. Patients characterized the staff as cordial, good natured, chatty and capable of allaying their fear and worries making them at ease during their visits.

It is also good to note that financing for public facilities heavily relies in the budget given by the government and the reimbursements they receive from social insurances. The challenge, however, is that most of the public facilities had issues in terms of PhilHealth accreditation thus are unable to receive funds from them. This has been the case with Fugoso HC, Fugoso LIC and Foreshore HC where the said facilities failed to renew their PhilHealth accreditation due to issues on structural design requirements It greatly affects patient experience as to the supposed delivery of services are impeded due to lack funding and resources. Conversely, private facilities have more financing options as they are receiving payments from patients and also partner various health maintenance organizations (HMOs) to sustain their operations. Some private facilities are also able to be flexible in their payment scheme and are willing to give bigger discounts to their patients without compromise to the services that they are giving. Setting St. Luke’s Medical Center as an example, it has a business strategy that is financially viable and fully capable of allowing it to provide significantly discounted services, medicines and supplies to social service patients, which contributes to positive patient experiences.

Lastly, it is observed that there are differences in terms of training prospects for both the public and private sector. As seen in the cases of Fugoso HC and Foreshore HC, public health providers have limited opportunities given that permanent positions are prioritized over contractual staff. While, for the private sector, all of their providers are required to undergo training which are mostly in-house. St. Luke’s Medical Center for one requires their Health and non-health workers to undergo capability building in the form of interventions such as in-house trainings, on-the-job supervision, and seminars. It is to be said that continuous learning is an important element in providing positive patient experience within facilities. This ensures providers are updated and are able to improve the services that they deliver.

Tuberculosis and patient experience

Despite numerous multi-stakeholder efforts in the past two decades, tuberculosis (TB) remains to be a leading cause of mortality and morbidity in the Philippines. While diagnostic methods and total notifications are improving, significant gaps remain between total numbers of TB cases annually, and the number that are notified. More notable is the everincreasing number of Multi-Drug Resistant (MDR) and Extreme-Drug Resistant (XDR) cases. Globally there is a growing interest not only in the total number of patients diagnosed and treated for TB, but the quality of TB related healthcare service delivery.

Based on the case studies, a large proportion of the community is still unaware of health services available (whether free or not) especially in public healthcare facilities. TB services (TB-DOTS) and medication, are well supported in government health centers and hospitals. In one case in Fugoso HC, a patient is still unwilling to go and be treated due to the belief that he still need to pay for the health service. Good information and communication practices are the key to avoid such situations and properly promote services. It is also a key in improving patient experience in facilities.

In cases where patients are well-informed, and services are wellpromoted, health-seeking behavior among patients was observed to increase. Results of a study on the quality of TB care implemented by Epimetrics with the Department of Health reported that of the patients interviewed, eleven percent reported that cost (e.g., transportation) affected their ability to come to the health facility. Cost was a concern for 17 percent of the DR-TB patients compared with eight percent of the DSTB patients (although patients received free medicines); 30 percent paid for blood tests and 64 percent paid for X-rays. Seventeen percent said that they had to pay to see the provider and a smaller number (9%) paid for sputum tests. Typically, DS-TB patients were more likely to pay for these health services compared with DR-TB patients, especially in the case of payment for X-rays (71% compared with 26% respectively).

On another note, it was observed that infection and prevention control is being judiciously practiced in the delivery of TB services; but the constraints come in the infrastructure. This was the case in Fugos HC where patients use a separate entrance and are accommodated at a separate waiting area within the building to avoid infecting other patients. However, due to the increasing number of both TB patients and patients seeking consultation, the space provided has become insufficient, hence, patient queues overflow onto the adjacent barangay road. Likewise, the room assigned for TB program activities is not well ventilated and is too small to accommodate sputum collection, drug dispensing and administration, and TB program orientation and counseling. Increase in patients being served should entail improvement and upgrades to infrastructure (ventilation, needed space for counselling, dispensing of medicine) as well to accommodate them properly. These facilities should also respond to the need to ensure privacy and confidentiality in treating TB patients, especially when stigma on TB is still an evident issue despite health promotion initiatives on TB as a non-fatal and curable disease. On the same Epimetrics’ study, reported privacy was almost the same for facilities and patients. Eighty-one percent of facilities offered privacy for counseling and diagnosis, with a private room available for individual counseling. An equally high percentage of the patients interviewed felt that they had privacy during counseling and diagnosis.

Mobilizing the support of the family is another crucial element of compliance. Furthermore, the presence of case handlers (BHWs or health providers) who are assigned patients also helps motivate patients. This labor-intensive arrangement, coupled with other interventions, achieves the desired results: TB patients completing their treatment. The role of a community health worker (CHW) or volunteer can be quite important in TB care and prevention efforts. Similar to Family planning, effective communication with the patient is a key element in improve patient experience in the delivery of TB services-- Giving the patient the right information and right motivation to pursue treatment and be cured from his illness. Also, securing commitment from TB patients in psychological and spiritual ways will strengthen their resolve to be consistent In Canossa’s case, patients formalizes their willingness and consent to participate in the Lingap Lusog TB-DOTS Program of the facility through a treatment contract. The provision of the contract states that the patient understands and subscribes to the objective of the program to improve not only the health of his/her body but also the entirety of one’s personhood.

Financing is also an integral element in improving patient experience in facilities. TB services and medicines are given for free in all public facilities and in some private institutions. However, resources are limited and there are instances where the stock of drugs runs out. For private facilities, the key is to sustain its operations and finding viable sources of funding to serve both their paying and charity clients. Moreover, the approach and direction of both public and private facilities ensures that patients are able to cope up in their recovery and their life after treatment. Follow-ups are being made, TB stigma is being addressed, and patient’s livelihood is taken into consideration.

In addition, it was observed in most of the case reports that various elements of patient experience are woven together. For the facility, it was pointed how the staff or the health human resources has been one of the major reasons for having a positive patient experience throughout the duration of their TB treatment. Effective communication is being practiced and the technical competencies of the personnel in terms of the quality of services they are providing have been observed.

Lastly, Patient-centered care is a key component of WHO’s End TB Strategy. As part of patient-centered care and depending on needs, all patients should receive educational, emotional and economic support to enable them to complete the diagnostic process and full course of required treatment. All persons with TB should also be screened for diabetes. Depending on local epidemiology, they should also be assessed for other comorbidities and related risk factors such as smoking and alcohol or drug abuse.

Family planning and patient experience

Effective communication is reported as one of the important elements of improving patient experience in promoting family planning health services. This has seen to be applied in family planning counselling sessions, family planning classes, or the integration of Family planning in maternal and child health teachings. Taking Fugoso LIC as an example were family planning information is also provided to mothers who have given birth. In addition, effective communication by providing comprehensible and complete information of family planning services allows the patient to make informed choices. Having them make informed and voluntary decisions, the patient is less likely to drop-out in the program or suddenly discontinue the use of family planning commodities

In terms of prevention activities, a well-known intervention, the USAPAN series, among primary care facilities provides useful and correct maternal and child health information and encourage the use of family planning services specially among pregnant women To make it effective, these sessions are conducted by trained USAPAN Facilitators. As noted in the cases, competent human resource is an integral element that affects patient experience within facilities.

Efforts are also being made to identify community family planning needs. In this case, activities are also directed in encouraging male clients to participate in the program. Such efforts were seen in the case of Mary Johnston Hospital were their case workers go into the community to conduct health teaching sessions which includes counselling efforts to encourage vasectomy candidates to undergo the procedure. ” A similar inclusive approach would benefit other facilities in ensuring that services can reach the grass roots.

It is also observed that gender awareness and sensitivity is still a lingering issue that needs to be addressed in the provision of family planning services. Decisions related to family planning largely depend on the male partner. More so, family planning programs target women as recipients of awarenessraising as they are oftentimes the frequent visitors of a primary health care facility. On the other hand, the husband plays his traditional role of earning income and rarely is they encouraged to become acceptors. Sadly, there is no sustained proactive communication campaign to encourage men to participate more fully in family planning, pre- and postnatal, child birth, and child rearing. Service delivery is also seen as important capacity of facilities in improving patient experience. However, there are instances that some health services will not be available. Service Delivery Networks (SDNs) or referral systems address this gap. It is also a means to connect private sector facilities to public sector facilities or viceversa.

Similarly, financing plays a role in improving patient experience in facilities. Optimizing the use of both private and social insurance to cover cost of service allows patient to avail health care without worry. Cost has been observed to be a deterrent for patients to seek medical consult or service.

Conclusion and Recommendations

These recommendations were provided to DOH and related institutions based on the findings drawn from the process of case study, cross-case analysis, Filipino PX Framework development, and PX Assessment Tool Design:

1. The Adoption and Application by DOH of the Filipino PX Framework and the PX Assessment Tool. Through this effort, Strategic Goal 2 of the National Objectives for Health 2017-2022 of a “more responsive health system” and more specifically described as, “The quality of health goods and services as well as the manner in which they are delivered to the population will be improved to ensure people-centered healthcare provision which may be done through instruments that routinely monitor and evaluate client feedback on health goods used and services received ” will be better approached and operationalized. More so, in the advent of UHC goal of “ ensuring all Filipinos are guaranteed equitable access to quality and affordable health care goods and services, and protected against financial risk”, a renewed focus towards positive patient experience by health facilities, providers and institutions may be realized.

2. Local Government Units (LGUs) to Support the Improvement of Patient Experience in Health Facilities. Without policies to improve patient experience in all health facilities from primary health care to hospitals articulated by the local government and reinforced by local leaders with corresponding budgets, the state of patient experience would not receive the emphasis it requires. Certifications from PhilHealth, DOH, ISO, and other certifying bodies – in which facility improvement is crucial – need the support of LGUs. The improvement of the credibility and image of LGU-governed health facilities may be achieved when financial support is available to upgrade skills and health facilities. Financial support is also necessary to launch media campaigns to inform the public about the primary health facilities’ services and counter some of the wrong perceptions about the facilities’ services. Together with DOH, LGUs could significantly contribute to increasing health literacy at the community level and invest in changing health seeking behaviors of people.

3. Department of Health (DOH) to Support LGU governed Facilities in Addressing Elements of Patient Experience. Asking LGU-governed health facilities to initially undertake Continuous Quality Improvement (CQI) programs with financial, administrative, and logistical support coming from DOH that would significantly improve patient experience within those facilities. Moreover, DOH must direct the Health Facility Development Bureau to set standards on health facility improvements for enhancing patient experience and ensure compliance. Lastly, DOH could provide more support to increase general public awareness about navigating the health system and raising/improving health literacy of the public.

4. PhilHealth and other Institutions to Ensure Social Safety Nets for Health are Continuously Provided. These, as the cases present, are crucial to the provision of the patient experience in the Philippines. Enrollment to PhilHealth may have to be free for all cases, and more incentives for at least biennial medical check-ups might be needed to encourage the health seeking behaviors of Filipino patients. Extension of coverage to outpatient services might have to cover laboratory tests, and transportation costs could be provided to enable patients to comply with their follow up check-ups.

5. DOH to Continue Analyzing PX across Thematic Areas. Learnings obtained from this research already gathered various best practices and key issues in the Philippine Health System such as:

• Strengthening communication and information capacity through community visits, health classes, lectures, demonstrations, and IEC material distribution by all levels of care.

• Improving HRH distribution to manage severely understaffed facilities and strained health care providers working beyond their capacity to provide positive patient experience and promote prevention of disease across the sector.

• Offering training for the public and private sector health providers to ensure continuously updated sets of technical competencies.

• Build greater awareness among TB and FP patients of there is broad set of services available in the public health care facilities that are free.

• Invest in facilities of TB and FP programs to address issues of privacy, comfort, and safety. DOH may benefit from further research in these areas and others using the view of PX to surface common challenges and to obtain more best practices with the interest of implementing solutions nationwide.

6. DOH to Validate the Philippine PX Framework and PX Assessment Tool. DOH may proceed with a step of validating both the framework and the assessment tool to find ways to improve both.

References

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