Quality Of Care In Health Facilities Research Articles

Abstract 151: Patient Decision Support in Implanted Defibrillator Care: A Human Rights-Based Assessment Model

Background: Shared decision making (SDM) is a mainstream component of cardiovascular disease care in the US. This is particularly true in light of support for SDM from the IOM, the ACA, the FDA 1-3, several professional societies, and Cochrane Review findings of improved patient-centered outcomes4. Given the complex nature of advanced CV therapies - characterized by the IOM as having “more to do, more to manage, and more people involved than ever before”5 - SDM programs are critical to patient-centered assessment of quality of care in CV. Human rights-based approaches (HRBAs)6-7 are common in evaluations of programs targeting communicable disease in developing countries, but are underutilized in CVD care in the US. HRBAs ground assessment in international human rights law, and provide a normative framework for the design, implementation, monitoring and evaluation of interventions, policy, and programs. An HRBA to health aims to realize the right to the “highest attainable standard of health”—including the availability, accessibility, acceptability, and quality of health facilities, information, goods, and services—and other health-related human rights (including autonomy and full and informed decisionmaking, the right to participation, and accountability).8-12 Approach: Using decision support regarding ICDs as a model, we created a conceptual framework highlighting synergies between HRBAs and SDM. This model of HRBA assessment of SDM programs covers four stages of design/deployment of decision aids (design of tools; implementation; use of PtDAs with patients; monitoring, evaluation and accountability), with accompanying rights-based considerations for each. The model is replicable across decision support related to other complex therapies with preference-sensitive trade-offs. Results & Implications: There is considerable synergy between HRBAs and SDM. Both empower patients, emphasize autonomy, and have potential to improve processes and outcomes. This model offers legal grounding and a normative framework through which one can evaluate SDM programming, improving decisionmaking processes and better aligning outcomes with patients’ values and goals. Research into the use of HRBA assessment of SDM is warranted; the goal being to respect, protect, and fulfill human rights obligations.

A compact implantable RFID tag antenna dedicated to wireless health care

Implantable tag antennas are an integral component of contemporary pervasive patient monitoring setups envisioned to reduce the medical errors and improve the quality of health care facilities. These tags, embedded into the human body, transmit critical patient information to the external equipment via a wireless communication link. This research article presents an implantable compact folded dipole antenna of size 10 mm × 15 mm × 2 mm, designed to operate in the industrial-scientific-medical band (2.4-2.48GHz). A three-layered phantom representing the human arm is used to evaluate the subcutaneous antenna performance. The tag antenna embedded in the middle of the fat layer offers a maximum gain of −16.3 dBi. The tag antenna performance as a function of implant position and phantom dimensions is analyzed. Link budget calculations show that with the achieved antenna gain the link power exceeds the required power by 38.37 dBm, and hence wireless communication is viable.

Job Preferences of Doctors for Working in Rural Islamabad Capital Territory, Pakistan: a Discrete Choice Experiment

Background: Developing countries are facing acute shortage of human resource in rural/remote areas. Effective management and retention of human resource for health are related to efficient financing and lucrative incentives packages. This study focused on preferred incentives of doctors for working in rural and resource constrained areas of Pakistan. Methods: This study was a Discrete Choice Experiment (DCE). Study population (N=107) included final year medical student and fresh graduated doctors in Islamabad. Questionnaire was computer based and data was collected through online database. Results were analyzed using conjoint analysis technique on Stata 11.0 to present the findings. Results: The results showed that mostly young doctors do not prefer to work in rural areas. Preference to opt for rural job posting depended largely on high salary along with study assistance for further education. Other attributes identified as attracting and retaining young doctors for rural job posting included career advancement, improved quality of health facilities, provision of housing allowance and transportation. Conclusion: Study results showed that salary is not the only deciding factor for attracting and retaining health workforce in rural areas. Further education for highly valued and the government should focus on efficient use of available budget to develop a bundle of cadre specific incentives package to attract and retain HR in rural and underserved areas.

Assessment of multi-contaminant exposure in a cancer treatment center: a 2-year monitoring of molds, mycotoxins, endotoxins, and glucans in bioaerosols.

Indoor air quality in health care facilities is a major public health concern, particularly for immunocompromised patients who may be exposed to microbiological contaminants such as molds, mycotoxins, endotoxins, and (1,3)-ß-D-glucans. Over 2years, bioaerosols were collected on a monthly basis in a cancer treatment center (Centre F. Baclesse, Normandy, France), characterized from areas where there was no any particular air treatment. Results showed the complexity of mycoflora in bioaerosols with more than 100 fungal species identified. A list of major strains in hospital environments could be put forward due to the frequency, the concentration level, and/or the capacity to produce mycotoxins in vitro: Aspergillus fumigatus, Aspergillus melleus, Aspergillus niger, Aspergillus versicolor, Cladosporium herbarum, Purpureocillium lilacinum, and Penicillium brevicompactum. The mean levels of viable airborne fungal particles were less than 30.530CFU per m3 of air and were correlated to the total number of 0.30 to 20μm particles. Seasonal variations were observed with fungal particle peaks during the summer and autumn. Statistical analysis showed that airborne fungal particle levels depended on the relative humidity level which could be a useful indicator of fungal contamination. Finally, the exposure to airborne mycotoxins was very low (only 3 positive samples), and no mutagenic activity was found in bioaerosols. Nevertheless, some fungal strains such as Aspergillus versicolor or Penicillium brevicompactum showed toxigenic potential in vitro.

Service quality influences delivery decisions: A qualitative study on maternity care in rural Tanzania

BackgroundThe relationship between utilization of quality health services and positive health outcomes is well documented, however in low resource settings there is both a shortage of quality services and low utilization of existing services. We assessed women and men's understanding of quality in health facilities and their application of this understanding in selecting place of delivery. MethodsTen focus group discussions (FGD) were held between May and December 2011 (five with women and five with men). The groups had 6–11 respondents. FGDs were conducted, recorded, and transcribed in Swahili then translated into English. Transcripts were analyzed using NVivo 9 software. Conceptual framework confirmatory analysis was conducted to compare results from FGDs with pre-existing frameworks for understanding health center quality in low resource settings. ResultsHigh education and positive attitude of delivery staff, close proximity to the health facility, availability of providers, and modern equipment were cited as reasons for facility delivery. Expectations of complications and better care led to seeking care at higher-level institutions. The one aspect of quality that men focused on more than women was disrespectful care and health worker attitude. The choice to deliver in a hospital versus a primary care clinic or at home was not always the woman's – it was greatly influenced by providers, the husband and the mother-in-law. ConclusionsThese results suggest that quality improvement efforts should focus on both technical and nontechnical aspects of care and target not just women, but those who influence their choice of delivery location. Trial registrationISRCTN17107760.

Assessing the Impact of Community Engagement Interventions on Health Worker Motivation and Experiences with Clients in Primary Health Facilities in Ghana: A Randomized Cluster Trial.

BackgroundHealth worker density per 1000 population in Ghana is one of the lowest in the world estimated to be 2.3, below the global average of 9.3. Low health worker motivation induced by poor working conditions partly explain this challenge. Albeit the wage bill for public sector health workers is about 90% of domestic government expenditure on health in countries such as Ghana, staff motivation and performance output remain a challenge, suggesting the need to complement financial incentives with non-financial incentives through a community-based approach. In this study, a systematic community engagement (SCE) intervention was implemented to engage community groups in healthcare quality assessment to promote mutual collaboration between clients and healthcare providers, and enhance health worker motivation levels. SCE involves structured use of existing community groups and associations to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements made and rewards given to best performing facilities for closing quality care gaps.PurposeTo evaluate the effect of SCE interventions on health worker motivation and experiences with clients.MethodsThe study is a cluster randomized trial involving health workers in private (n = 38) and public (n = 26) primary healthcare facilities in two administrative regions in Ghana. Out of 324 clinical and non-clinical staff randomly interviewed at baseline, 234 (72%) were successfully followed at end-line and interviewed on workplace motivation factors and personal experiences with clients. Propensity score matching and difference-in-difference estimations were used to estimate treatment effect of the interventions on staff motivation.ResultsIntrinsic (non-financial) work incentives including cordiality with clients and perceived career prospects appeared to be prime sources of motivation for health staff interviewed in intervention health facilities while financial incentives were ranked lowest. Intervention health facilities that were assessed by female community groups (Coef. = 0.2720, p = 0.0118) and informal groups with organized leadership structures like Artisans (Coef. = 0.2268, p = 0.0368) associated positively with higher intrinsic motivation levels of staff.ConclusionCommunity-based approach to health worker motivation is a potential complementary strategy that needs policy deliberation to explore its prospects. Albeit financial incentives remain critical sources of staff motivation, innovative non-financial approaches like SCE should complement the latter.

Utilization of maternal health care services and their determinants in Karnataka State, India.

BackgroundKarnataka State continues to have the highest rates of maternal mortality in south India at 144/100,000 live births, but lower than the national estimates of 190–220/100,000 live births. Various barriers exist to timely and appropriate utilization of services during pregnancy, childbirth and postpartum. This study aimed to describe the patterns and determinants of routine and emergency maternal health care utilization in rural Karnataka State, India.MethodsThis study was conducted in Karnataka in 2012–2013. Purposive sampling was used to convene twenty three focus groups and twelve individual interviews with community and health system representatives: Auxiliary Nurse Midwives and Staff Nurses, Accredited Social Health Activists, community leaders, male decision-makers, female decision-makers, women of reproductive age, medical officers, private health care providers, senior health administrators, District health officers, and obstetricians. Local researchers familiar with the setting and language conducted all focus groups and interviews, these researchers were not known to community participants. All discussions were audio recorded, transcribed, and translated to English for analysis. A thematic analysis approach was taken utilizing an a priori thematic framework as well as inductive identification of themes.ResultsMost women in the focus groups reported regular antenatal care attendance, for an average of four visits, and more often for high-risk pregnancies. Antenatal care was typically delivered at the periphery by non-specialised providers. Participants reported that sought was care women experienced danger signs of complications. Postpartum care was reportedly rare, and mainly sought for the purpose of neonatal care. Factors that influenced women’s care-seeking included their limited autonomy, poor access to and funding for transport for non-emergent conditions, perceived poor quality of health care facilities, and the costs of care.ConclusionsRural south Indian communities reported regular use of health care services during pregnancy and for delivery. Uptake of maternity care services was attributed to new government programmes and increased availability of maternity services; nevertheless, some women delayed disclosure of pregnancy and first antenatal visit. Community-based initiatives should be enhanced to encourage early disclosure of pregnancies and to provide the community information regarding the importance of facility-based care. Health facility infrastructure in rural Karnataka should also be enhanced to ensure a consistent power supply and improved cleanliness on the wards.Trial registrationNCT01911494Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-016-0138-8) contains supplementary material, which is available to authorized users.

M-education in India: an effort to improve educational outcomes with a special emphasis on Ananya Bihar

Purpose The purpose of this paper is to undermine the role of cellular technology, government and the funding agency to deliver reliable and cost-effective health services for the people living in the bottom of pyramid and remote areas of the country where quality healthcare facilities are not available. The people living in rural Bihar (India) have a limited education and are reluctant to visit the female healthcare centers. The Ananya Bihar project has employed volunteers from the same community and aid from the foundation and government to improve the maternity and neo-natal healthcare initially in eight districts of the state. Design/methodology/approach The study reviewed various m-health projects and m-education projects with a detailing of the Anaya Bihar Project initiated by Melinda Gates foundation and Government of Bihar, India. The study uncovers technical, operational aspects and methodology followed by Ananya. It has detailed the best practices followed by the project. The study also features the capability of mobile as a tool to reach the masses in most cost effective way. Findings The use of mobile application with the association from the social worker has been tremendously successful in maternity and child healthcare in the state of Bihar, India. The application includes educating the user’s about the healthcare, training for midwives, alerts related to vaccination and thereby reducing the mortality rate and improving the maternal healthcare for the people from the bottom of pyramid. The project has created awareness among the rural families and has improved the maternity healthcare in the eight districts of Bihar, India. They were also planning to expand the project in other states of India. Research limitations/implications The study is exploratory in nature and has not involved primary data collection and statistical analysis. The study has compiled the data and information available. Practical implications The present study may be used as a reference to the organization working on mobile healthcare projects to understand the best practices of m-health project. The study also explains the role of various stakeholders (as Ananya-Bihar was a collaborative effort of Social trust, Technical experts, Network service provider, Community, State Government and the People) in the success of the project. Social implications The study explains the role of technology for the benefit of people. In the present case mobile healthcare initiated by the foundation has been very effective in dealing with maternity healthcare in rural Bihar, where people cannot afford expensive healthcare facility. The only silver lining is increasing tele-density at the most affordable rate in the globe, with funding from NGOs and full support from government. Such types of m-healthcare projects will support the government in delivering quality healthcare to the people who are living below poverty line and deprived of basic healthcare facilities. Originality/value The study details the methodology and technical details of Ananya Mobile health care platform.

Difference in Satisfaction Levels of National Health Insurance Patients at Four Types of First Level Health Facilities

Backgrounds and purpose: The road map of the National Health Insurance Scheme (JKN) aims to ensure that 75% of patients are satisfied with the quality of health facilities. This study was designed to determine differences in patients’ satisfaction in general, as well as at each individual first-level health facility (FKTP) and based on dimensions of quality. Methods: Study was a cross-sectional sample survey with the respondents of 148 JKN patients selected consecutively from 4 types of FKTP. A total of 4 health centers, 3 government clinics, 4 private clinics and 4 general practitioners randomly selected from 11 health centers, 7 government clinics, 13 private clinics and 70 general practitioners in the city of Denpasar. Data were collected through interviews over March-April 2015 in each health facility using questionnaires by trained interviewers. Data were analyzed by univariate, bivariate and multivariate. Results: A total of 69,59% of JKN patients said that they were satisfied with the quality of FKTP services. This figure was lower than the target of JKN i.e. 75%. The highest satisfaction (90,00%) was in the general practitioners while lowest was in the private clinics (47,46%). Based on the dimensions of quality, JKN patients’ satisfaction in the four FKTPs was significantly different (p=0,008) in physical and empathic dimensions (p=0,013). In the multivariate analysis, variables found related to the satisfaction of the respondents were the FKTP of general practitioners (adjusted PR=1,91; 95%CI: 1,05-3,47) and health centers (adjusted PR=1,76; 95%CI: 1,04-2,97). Conclusion: In general, the patients’ satisfaction rate was still lower than the target of JKN and when viewed per care facilities, the highest satisfaction was found in FKTP of general practitioners and health centers.

Effect of Community Engagement Interventions on Patient Safety and Risk Reduction Efforts in Primary Health Facilities: Evidence from Ghana.

BackgroundPatient safety and quality care remain major challenges to Ghana’s healthcare system. Like many health systems in Africa, this is largely because demand for healthcare is outstripping available human and material resource capacity of healthcare facilities and new investment is insufficient. In the light of these demand and supply constraints, systematic community engagement (SCE) in healthcare quality assessment can be a feasible and cost effective option to augment existing quality improvement interventions. SCE entails structured use of existing community groups to assess healthcare quality in health facilities. Identified quality gaps are discussed with healthcare providers, improvements identified and rewards provided if the quality gaps are closed.PurposeThis paper evaluates whether or not SCE, through the assessment of health service quality, improves patient safety and risk reduction efforts by staff in healthcare facilities.MethodsA randomized control trail was conducted in 64 primary healthcare facilities in the Greater Accra and Western regions of Ghana. Patient risk assessments were conducted in 32 randomly assigned intervention and control facilities. Multivariate multiple regression test was used to determine effect of the SCE interventions on staff efforts towards reducing patient risk. Spearman correlation test was used to ascertain associations between types of community groups engaged and risk assessment scores of healthcare facilities.FindingsClinic staff efforts towards increasing patient safety and reducing risk improved significantly in intervention facilities especially in the areas of leadership/accountability (Coef. = 10.4, p<0.05) and staff competencies (Coef. = 7.1, p<0.05). Improvement in service utilization and health resources could not be attributed to the interventions because these were outside the control of the study and might have been influenced by institutional or national level developments between the baseline and follow-up period. Community groups that were gender balanced, religious/faith-based, and had structured leadership appeared to be better options for effective SCE in healthcare quality assessment.ConclusionCommunity engagement in healthcare quality assessment is a feasible client-centered quality improvement option that should be discussed for possible scale-up in Ghana and other resource poor countries in Africa.

Quality of antenatal and childbirth care in rural health facilities in Burkina Faso, Ghana and Tanzania: an intervention study

To assess the impact of an intervention consisting of a computer-assisted clinical decision support system and performance-based incentives, aiming at improving quality of antenatal and childbirth care. Intervention study in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania. In each country, six intervention and six non-intervention PHC facilities, located in one intervention and one non-intervention rural districts, were selected. Quality was assessed in each facility by health facility surveys, direct observation of antenatal and childbirth care, exit interviews, and reviews of patient records and maternal and child health registers. Findings of pre- and post-intervention and of intervention and non-intervention health facility quality assessments were analysed and assessed for significant (P < 0.05) quality of care differences. Post-intervention quality scores do not show a clear difference to pre-intervention scores and scores at non-intervention facilities. Only a few variables had a statistically significant better post-intervention quality score and when this is the case this is mostly observed in only one study-arm, being pre-/post-intervention or intervention/non-intervention. Post-intervention care shows similar deficiencies in quality of antenatal and childbirth care and in detection, prevention, and management of obstetric complications as at baseline and non-intervention study facilities. Our intervention study did not show a significant improvement in quality of care during the study period. However, the use of new technology seems acceptable and feasible in rural PHC facilities in resource-constrained settings, creating the opportunity to use this technology to improve quality of care.

Neighborhood Satisfaction and Colorectal Cancer Screening in a Community Sample of African Americans.

Social determinants are important to cancer screening among African Americans. To evaluate the association between social determinants (e.g., psychological characteristics, perceived social environment, cultural beliefs such as present temporal orientation) and colorectal cancer (CRC) screening among African Americans. African American adults (n = 262) ages 50-75 completed a telephone interview. Multivariate logistic regression analysis was used to identify factors having significant independent associations with CRC screening. Only 57% of respondents reported having CRC screening. The likelihood of screening increased with greater neighborhood satisfaction (OR = 1.38, 95% CI = 1.01, 1.90, p = 0.04), older age (OR = 1.75, 95% CI = 1.24, 2.48, p = 0.002), greater self-efficacy (OR = 2.73, 95% CI = 1.40, 5.35, p = 0.003), and health care provider communication (OR = 10.78, 95% CI = 4.85, 29.94, p = 0.0001). Community resources are important precursors to CRC screening and outcomes among African Americans. In addition to addressing psychological factors and patient-provider communication, efforts to ensure the availability of quality health care facilities that provide CRC screening in the neighborhoods where African Americans live are needed.

Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi.

BackgroundUnderstanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women’s groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008–2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale.MethodsBayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $.ResultsThe incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi.ConclusionsCommunity mobilisation through women’s groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.Electronic supplementary materialThe online version of this article (doi:10.1186/s12962-014-0028-2) contains supplementary material, which is available to authorized users.

Satisfaction of medical staff in primary health care of Sumadija district

Objective. The aim of this study was to evaluate different aspects of job satisfaction among employees as well as to evaluate the overall job satisfaction in health care institutions of the primary health care level in Sumadija district. Methods. Employee satisfaction survey was conducted in 10 primary health facilities in Sumadija district. We conducted a one-day survey of 1273 employees, using a uniform, anonymous questionnaire developed by the Ministry of Health of the Republic of Serbia within the program of improvement of the quality of health care facilities. Results. The data we obtained show that a little less than a half of the employees in healthcare institutions of the Republic of Serbia were satisfied with the work they performed. The results of logistic regression showed that, among the factors examined, the following had a statistically significant impact on the assessment of job satisfaction: adequacy of work equipment, possibility of professional development, support by superiors, comparison of satisfaction of 5 years ago and now. Conclusion. Job-related experience and satisfaction of the employees indicate the need for placement of employee satisfaction as a priority in the process of improving the quality of the health care system.

Can bans break bad habits? An interrupted time series analysis of the impact of the 2005 high school smoking ban on teenage smoking behavior in Chile

Structure/Method/Design: We use detailed facility-level data from Colombia, Ghana, India, Kenya, Lebanon, Zambia, and Uganda. In each country, we collected data in approximately 200 facilities over a 5-year period. In addition, 12,000 patient interviews were conducted with the aim of gathering information on consumer perception of health facility quality. We specify a production model with five inputs and seven outputs. Inputs include the number of beds as proxy for capital, and four categories for labor (doctors, nurses, other medical staff, and administrative staff). As with respect to output, outpatient visits include basic outpatient services, ART (antiretroviral treatment), malaria, antenatal care, and emergency. For inpatient services we use inpatient days, births, and surgery. To avoid biased efficiency estimates due to heterogeneous technology, we propose an innovative approach that adjust outputs across facilities. We first identify all pharmaceuticals and equipment related to the production of each output and build a score that reflects the extent to which technology is available in the facility. We then use consistent bootstrap DEA models using the adjusted outputs to compute technical efficiency scores by controlling for measurement error and noisy data. We include minimal weight restrictions to reflect the relative importance of inputs and outputs in the production process of health facilities. Weight restrictions are chosen to maintain the radial nature of efficiency valid. We finally use output weights provided by DEA to calculate the marginal rate of transformation between outputs. This information is critical to the estimation of average costs for each output. Results (Scientific Abstract)/Collaborative Partners (Programmatic Abstract): We find evidence of important inefficiency (40% on average) with massive variation across facilities. Inefficiency substantially increases average costs to produce health services (35% on average). Also, we find evidence of efficiency increases over time of about 10%, likely due to the scale-up of ART treatment and related services. Additional evidence is necessary to assess the causal relationship. Summary/Conclusion: We find evidence of potential efficiency increases. Efficiency increase of health services production in developing countries is paramount to exploit the potential of service coverage extension and fair allocation of resources. For this purpose, higher-quality data and systematic efficiency assessment analyses are needed.

Zadovoljstvo zaposlenih u zdravstvenim ustanovama Šumadijskog okruga

A satisfaction with job of employees in health institutions is a very important parameter that affects the quality of health care, as well as the employee motivation. The aim of this study was to evaluate different aspects of job satisfaction among employees in health institutions of Sumadia district. Employee satisfaction survey was conducted in 13 health facilities in Sumadia district. We conducted a one-day survey of 2.770 employees, 02.12.2013., using a uniform, anonymous questionnaire developed by the Ministry of Health of the Republic of Serbia within the program of improvement of the quality of health care facilities functioning. The results show that one third of employees is satisfied with the work they now performe, and dissatisfied is every ninth subject. There is a high degree of dissatisfaction with the work equipment in service, as well as with the available time to perform the job. Every fifth employee feels physical and emotional exhaustion associated with the work, and tiredness at the thought of the work is present at every ninth subject. 31.4% of the employees are dissatisfied with their monthly salary. The job related experience and satisfaction of the employees, indicates the need for placement of employee satisfaction on priority in the process of improving the quality of the health care system.

ANALISIS PASAR KERJA KABUPATEN BANYUWANGI

The quality of human resources is to determine a person's activities in the economy to earn income. While the number of working age population by level of education is higher but still unemploy, it should be brought to the attention of all parties concerned that higher education alone has not been enough to prepare the job search. Based on the data of structure of the population pyramid is dominated by young age, then the Government of Banyuwangi Regency should perform control of birth rates. A large population at a young age can occur due to improvements in the quality of health facilities for the mother and the child so that the level of infant mortality is dropping, just that it can increase the proportion of young population. When controlling the birth rate is not done, can trigger concerns did not materialize demographic bonus, which at the national level will be achieved by 2025-2030. Based on the data of education workers that still dominated at the level of basic education (primary and JSS finished finished) by 54,86%, then the Office of education (Dinas Pendidikan) should improve school participation rate, i.e. by increasing the number of educators and school facilities adds up to the remote region.

Patient safety management in the health services- what do patients want?

Patient safety management in the health services- what do patients want?

Why women do not utilize maternity services in Nepal: a literature review.

The structure and provision mechanism of maternity services in Nepal appears to be good, with adequate coverage and availability. Utilization of maternity services has also improved in the past decade. However, this progress may not be adequate to achieve the Millennium Development Goal to improve maternal health (MDG 5) in Nepal. This paper reviews the factors that impede women from utilizing maternity services and those that encourage such use. Twenty-one articles were examined in-depth with results presented under four headings: (i) sociocultural factors; (ii) perceived need/benefit of skilled attendance; (iii) physical accessibility; and (iv) economic accessibility. The majority of the studies on determinants of service use were cross-sectional focusing on sociocultural, economic and physical accessibility factors. In general, the education of couples, their economic status and antenatal check-ups appeared to have positive influences. On the other hand, traditional beliefs and customs, low status of women, long distance to facilities, low level of health awareness and women's occupation tended to impact negatively on service uptake. More analytical studies are needed to assess the effectiveness of the Safer Mother Programme, expansion of rural birth centres and birth-preparedness packages on delivery-service use. Moreover, it is important to investigate women's awareness of the need of facility delivery and their perception of the quality of health facilities in relation to actual usage.

Traveling Abroad for Medical Care: U.S. Medical Tourists' Expectations and Perceptions of Service Quality

The SERVQUAL scale has been widely used to measure service quality in the health care industry. This research is the first study that used SERVQUAL to assess U.S. medical tourists' expectations and perceptions of the service quality of health care facilities located outside the United States. Based on a sample of U.S. consumers, who had traveled abroad for medical care, the results indicated that there were significant differences between U.S. medical tourists' perceived level of service provided and their expectations of the service that should be provided for four of the five dimensions of service quality. Reliability had the largest service quality gap followed by assurance, tangibles, and empathy. Responsiveness was the only dimension without a significantly different gap score. The study establishes a foundation for future research on service quality in the rapidly growing medical tourism industry.