Introduction: This audit was carried out to investigate how satisfied patients are with their pharmacy and the reasons for any dissatisfaction, specifically focusing on their visit on the day they were surveyed. The intended result of this audit is to improve patient satisfaction with their pharmacy visit by gathering satisfaction ratings given by over 2242 patients in pharmacies across Greater Manchester, discovering reasons for any dissatisfaction that can be solved, and comparing the overall satisfaction ratings to the ethnicity of the patients to identify any discrepancies. NHS England requires community pharmacies that request quality payments for funding services to hand out Community Pharmacy Patient Questionnaires (CPPQ), which include satisfaction ratings, to obtain “valuable feedback” from patients about their pharmacy.1,2 This highlights the importance of collecting patient satisfaction data in an audit, as the national framework relies on this data from pharmacies across the UK to determine if they are eligible for funding based on their quality of service. Patient satisfaction is proven to yield better healthcare outcomes from improved adherence to patient treatment and prevention regimens, especially in chronic diseases which affect 15 million people in the UK (2012).3, 4 The findings and action plan for this audit have the potential to affect the pharmacy services that thousands of patients receive in the 59 pharmacies audited in Greater Manchester.
Aim: This audit aims to improve patient satisfaction with their pharmacies in Greater Manchester
Objective 1: To discover the overall patient satisfaction with their pharmacy visit and what affects it
Objective 2: To investigate the relationship between patient ethnicity and overall satisfaction with their visit to their pharmacy
Audit Standard: 100% of patients were satisfied with their visit to their pharmacy on the day they were surveyed
Methods: The primary data was derived from 2242 pharmacy patients; this generated a convenience and a self-selecting sample as patient participation was based on their willingness to answer the questionnaire when approached in their pharmacy.5 A questionnaire, written in English, was used to collect information on overall patient satisfaction, the reasons for patient satisfaction and the relationship between ethnicity and patient satisfaction. The entire questionnaire was 11 questions long, with an estimated time of 10 minutes for completion. The questions relevant to the findings of this audit included questions 5, 6 and 11.
• Questions 1 to 4 asked patients to state why they visited the pharmacy, how often they visit the pharmacy, their quality-related reasons for visiting the pharmacy and what they would do if their pharmacy was not available.
• Question 5 was a quantitative 10-point scale for overall patient satisfaction with their visit to the pharmacy, 1 being “Very dissatisfied” and 10 being “Very satisfied”.
• Question 6 contained 15 statements that the patient can agree or disagree with.
• Question 7 was a 5-point ranked Likert scale on how likely the patient was to recommend the pharmacy to family or friends, with five options ranging from “Extremely likely” to “Extremely unlikely”.5
• Question 8 was an open question that allowed patients to explain the reason for their answer to Q7.
• Question 9 and 10 asked about the patient’s gender and age.
• Question 11 collected patient ethnicity, divided into White, Asian/Asian British, and Black/Black British, Mixed/multiple ethnic groups and Chinese / other ethnic groups. Each category was further subdivided into groups such as country/continent of origin.
The questionnaires were stored securely throughout the audit. In between patient surveys, the questionnaires were stored securely in the pharmacy and removed one by one when students carrying out the survey were required to use them for a patient. The questionnaires were then handed to the tutors after completion for safe storage. Any personal information of patients was stored on the questionnaires and care was taken with the design of the questionnaire to ensure the patients could not be identified by the information they gave. As previously stated, the only information collected included patient age, gender, and ethnicity. As the patient’s names were not taken, the questionnaires were assigned ‘Questionnaire Identification Numbers’ before the audit began, ranging from 1 to 20. These numbers represented questionnaires but did not expose anything about the patient’s identity, meaning if the patient wanted to retract their questionnaire at a later date it would be impossible to do so, due to the questionnaire being anonymous. The data received from the questionnaires for this audit came from questionnaires handed out in 59 pharmacies across Greater Manchester over a 2-week period (30th Oct 2017 – 10th Nov 2017) by Manchester Pharmacy 3rd Year students; the data analysis is based on the collective results from all 59 pharmacies surveyed.
The data were analysed using IBM SPSS Statistics. For presenting the descriptive data on the overall patient satisfaction across the 59 pharmacies audited, a column frequency graph has been generated, outlining the overall satisfaction scores and the percentage of patients within each score bracket. (Figure 1) To present the inferential findings for the relationship between patient satisfaction and ethnicity, a chi-squared test has been carried out using the binary categorical data of “White” (1) and “Ethnic Minority” (2) patients and the recoded overall satisfaction ratings, separated into binary categories of “Dissatisfied (1)” and “Satisfied (2)”. A rating of 7 to 10 has been selected as the standard of satisfaction, falling into the category of “Satisfied”, meaning the standard was 100% of all patients to fall into the “Satisfied” category, rating their visit to the pharmacy between 7 and 10. (Table 1) For determining the main reason for patient dissatisfaction, the mean, median and mode values for the responses to the nominal statements of Question 6 were generated, with Table 2 presenting the results for the statement with the lowest levels of satisfaction. (Table 2)
Findings: The collated response rate for all 59 pharmacies was unavailable; however a sample response rate from an individual pharmacy was 100%, with 7 patients being asked to complete the questionnaire and all 7 agreeing to. As previously mentioned, the only patient identifying data collected was age, gender, and ethnicity, so any analysis based on patient identity was limited to these categories. Across the 59 pharmacies audited, 1806 (80.6%) of all patients were White while 436 (19.4%) were ethnic minorities. The main reason for patient’s visiting the pharmacy was Option 1 of Question 1, “I collected a prescription for myself”. This has been determined by using a frequency table which determined a mode value of 1, meaning Option 1 was the most frequently chosen answer. The line graph below outlines the satisfaction ratings of patients who completed questionnaires. (Figure 1) 55.2% of all patients rated their visit a score of 10, and 94.1% of all patients rated scores of 7 to 10, falling into the “Satisfied” category.
For this audit, the effect of ethnicity on patient satisfaction has been analysed. Cross-tabulation and chi-squared methods of analysis have been used to determine if the observed differences in categorical overall satisfaction (“Satisfied” a score of 7-10 or “Dissatisfied” a score of 1-7) across the recoded ethnic groups (“White” and “Ethnic”) are significant. (Table 2) The chi-squared table shows generated a p-value of below 0.05 (actual value of 0.022), meaning the higher proportion of satisfied white patients compared to satisfied ethnic minority patients is statistically significant and is not due to random correlation. This means that the null hypothesis, that there is no significant difference between the overall patient satisfaction in white and ethnic minority patients, is rejected.
Lastly, the main reason for patient dissatisfaction has been determined as patients feeling that others in the pharmacy could listen to their conversation (Question 6 option S15). The options for this statement ranged from “Strongly agree” (5) to “Strongly disagree” (1) with options “Neither agree nor disagree” (3) and “Not applicable” (3). The mean value for the responses this statement received was 2.96, the lowest mean of all the statements. The median and mode values for his statement were also among the lowest, both with values of 3 indicating “Neither agree nor disagree” with the statement or “Not applicable”.
Discussion: The findings of this audit were that the overall satisfaction of the patients’ visit to their pharmacy in the 59 surveyed community pharmacies was high. While the standard of 100% of patient satisfaction was not reached, the mean satisfaction score was 9.02 and the percentage of patients across all ethnicities who rated their visit a score of 7 or above was 96.3%. This shows that most patients were satisfied with their visit to their pharmacy on the day they completed the questionnaire which reflects well on the general pharmacy service provided to them on that particular day. The method used for this audit (questionnaires) limits the answers patients can give and thus makes the findings slightly more generalisable to the rest of the patient population.6 However, Manchester City Council conducted a public survey in 2014 on patient opinions of pharmacies and 91% of patients stated that overall they were “satisfied” or “very satisfied” with their pharmacy.7 This audit found a similar but slightly higher % of satisfied patients, suggesting that the findings of this audit may not be completely generalisable to the entire population.
The factors that prevent the small percentage of patients from being satisfied with their pharmacy visit must be identified and improved. This audit determined that while patient satisfaction was high, there was a slight discrepancy between white patients and patients of an ethnic minority background. While 94.6% of white patients were satisfied with their visit, a slightly lower percentage of 91.7% of ethnic minority patients were satisfied with their visit. 19.4% of the patients surveyed in this audit were ethnic minorities, compared to 14% of the UK population consisting of ethnic minorities in the latest 2011 census.8 As a higher proportion of ethnic minorities were surveyed compared to the UK population, the overall satisfaction ratings cannot be used to generalise the whole country’s opinions on pharmacies, however, the results may be a good representation of ethnic minority patient satisfaction due to the high proportion of ethnic minorities surveyed. While there are no full UK patient satisfaction statistics for ethnic minority pharmacy patients, examples of poor satisfaction ratings from ethnic minority patients among other health sectors have been identified. Lower satisfaction scores were given in the National Cancer Patient Experience Survey, suggesting that the issues that hinder satisfaction in ethnic minority patients prevail among other healthcare sectors too.9 The discrepancy in patient satisfaction between ethnic groups may suggest there is more that community pharmacies in Greater Manchester can do to engage more with ethnic minorities to reach the standard of 100% patient satisfaction across all ethnic groups.
Lastly, the lowest mean value for the responses to the statements in Question 6 was found to be for Option S15 “I felt that others could listen to my conversation”. Pharmacies by nature are public spaces and the consultation room/s do provide private space to talk if they are offered or if the patient requests it. However, if this doesn’t occur, it is highly likely a patient would feel that others could listen in to their conversation. This finding highlights the importance of pharmacy staff encouraging the use of consultation rooms as often as possible. This is supported by a 2014 study conducted in both Poland and the UK which found that British pharmacy patients were four times more likely to choose a pharmacy if it provided a consultation room for discussing health-related issues.10
2242 patients completed the questionnaires analysed in this audit. With 61.5 million (2015) people in the UK, this sample size is 0.004% of the population which may be too small to truly represent patient satisfaction across the UK.11 The audit collection technique was based on convenience due to the environment of pharmacies; most patients didn’t plan on spending more than 5-10 minutes at a pharmacy, so people may have refused the questionnaires due to time constraints. The sample response rate of 100% may be due to the small number of patients being initially asked by the pharmacist (who they knew well) if they would mind filling in a questionnaire, for this individual case the results of the questionnaire may have been biased toward patients who knowingly viewed the pharmacy favourably.
Action Plan: The findings of this audit were that the standard of 100% patient satisfaction was not met, and the discrepancy between white and ethnic minority patients have been highlighted. To rectify this issue, efforts can be made by community pharmacies in Greater Manchester to engage further with ethnic minority patients. This could include pharmacy staff completing cultural diversity training to ensure patients of all backgrounds don’t experience any inadvertent discrimination. In 2008, only 8% of pharmacy schools included cultural diversity training in their programme, below the average value for other healthcare schools, suggesting that pharmacy as a sector could benefit from an increased availability of this training.12
To improve patient satisfaction across all ethnic groups, the facilities of the pharmacy and convenient opening hours of the pharmacy have all been identified as factors that improve patient satisfaction in a study done in community pharmacies.13 Relating this to the pharmacies surveyed in Greater Manchester, ensuring that basic facilities such as chairs and toilets are available and maintained can be done. Also ensuring that “over-the-counter” medicines are consistently stocked and that the pharmacy opens and closes at the exact stated time are factors that will improve the facilities. These improvements must be made by the pharmacy owners or superintendent pharmacists and should be funded by the pharmacy itself. The physical adjustments including the regular maintenance or addition of facilities mentioned should be completed within a year, in time for a re-audit cycle. Cultural diversity training can be provided as an online course for all pharmacy staff; this should be completed within a month.
The re-audit will be carried out a year after the first audit; using patient satisfaction questionnaires that specify reasons why patients may be dissatisfied with their service relating to pharmacy staff communication, to further pinpoint what is required to improve patient satisfaction regardless of patient background. Spaces should be provided on the new questionnaire for patients to explain any issues that prevent them from being satisfied with their pharmacy service, to ensure that is the standard has still not been met, a more specific action plan can be implemented.