Method

From September 1995 to June 1996, a series of 40 one day workshops were organised with an aim of training all the medical and senior medical officers in Hong Kong.

As most of the frontline doctors (75%) of the EDs were trained during this period, the effect of the workshops on patient's satisfaction was assessed retrospectively in two ways:

1. Number of complaints related to communication skills and attitude of medical staff before and after the series of workshops.

   Standard proformas were sent to all EDs in Hong Kong asking their numbers of written complaints on doctors' attitude or communication problem during the nine months before (1 January 1995 to 30 September 1995) and after (1 July 1996 to 31 March 1997) the series of workshops. The total number of complaints received by the EDs during the same period was also recorded as a reference. Handling and classification of complaints in these hospitals were done independently by public relation officers using standard criteria throughout the study period (with the exception of one hospital, which was thus excluded from the study).

2. Satisfaction rate on doctor's attitude and explanation before and after the series of workshops.

   There are regular patient satisfactory surveys in most EDs in Hong Kong. For seven consecutive days in each of the past five years, questionnaires were distributed to all ED patients after their registration. Patients were encouraged to return the questionnaires to the collection box in EDs or by mail after the visit. The data collected in four public hospitals before and after the workshops were collected for comparison.

Results

Nine hospitals responded out of a total of 12. The result of one hospital was excluded as it included all cases handled by the patient relation officer, some of which were inquiries but not complaints.

After the series of workshops, there was a 42% reduction (from 26 to 15 cases) in the number of complaints against doctors' attitude. This occurred despite the increased attendance from 724 000 to 898 000 in the eight hospitals. The reduction was of statistical significance (p = 0.05 χ² test). The number of complaints against EDs as a whole was more or less the same (increase from 75 to 77 cases, p = 0.38).

A total of 633 and 480 questionnaires were collected from four EDs before and after the series of workshops in the patient satisfaction surveys.

For the 633 returns before the workshops, 559 patients (88.3%) were satisfied with the attitude of the doctors and 505 patients (79.8%) were satisfied with the explanation and advice provided by doctors. After the workshops, out of 480 returns, 470 patients (98%) were satisfied with the attitude of the doctors and 450 patients (93.8%) were satisfied with the explanation and advice provided by doctors. The improvement of satisfaction rate in both aspects studied was statistically significant with p<0.001 by χ² test.

Discussion

With the introduction of modern management concepts into the medical world, EDs nowadays are more concerned with patient satisfaction.

Numerous studies have been done on factors affecting patient satisfaction in EDs.^1–3 These studies focus on perceived technical quality of care,¹ perception regarding waiting time, information delivery and expressive quality,² ED information received, physician's attitude, physician's explanation of illness and treatment, and ease and convenience of care.³

EDs are also concerned about dissatisfied patients, who are prone to make complaints. In his review of 122 complaints over seven years, Hunt noted that the commonest cause of complaint was on attitude (37.7%), while poor communication accounted for 11.5%.⁴ He suggested that training in interpersonal skills might reduce complaints on staff attitude. This view was also held by Simpson.⁶ In Hong Kong, although we have a much lower complaint rate of 0.1 per thousand attendance,⁷ more than half of the complaints were directed to attitude and communication problems.⁷ Our patient centred communication skills workshop for medical staff, designed to train all the doctors in the public hospitals in Hong Kong, is one of the most ambitious attempt to install a concept of patient centred care to some 3000 doctors to improve their communication skills in managing patients. With a capital investment of about US$80 000 in developing the course and US$100/set of workbook for each doctor, we would like to see whether the money was well spent by assessing the outcomes.

As most of the doctors in emergency rooms had attended the workshop, the number of complaints as well as the satisfaction rate on doctor's attitude and explanation should be improved. These were shown to be the case.

It can also be seen that although the complaints on doctors' attitude decreased, the total number of complaints did not reduce. It is probably attributable to the increase of attendance. It is shown in many studies^{3, 5} that patient satisfaction is associated with increasing future patronage. With the introduction of patient centred concept in accident and emergency care, more and more of our patients are satisfied with our service, and we are attracting more patients from the private sector to the public hospitals.⁸ Without a corresponding improvement in manpower, clinical competence in EDs may be jeopardised resulting in an increase of complaints.

One major limitation of the study was that we presumed the only difference between these two periods were the attendance of the workshops, which changed the doctors' behaviour. Other things might have changed during the study period, however, which might improve patient satisfaction. For example, further improvement in physical environment and reduction of waiting time, are among such possible factors. However, as major improvement in physical environment had been achieved early in the reform and it is difficult to improve the waiting time as the attendance to the public hospitals has been increasing, the improvement in patient's satisfaction was very probable because of this intervention of communication skills training.

Conclusion

This study supports our belief that communication skills workshops can improve the doctors' communication skill with a corresponding increase in patients' satisfaction and decrease in patients' complaints towards ED doctors.