JMMH_3-4_p264-271 Improving patient satisfaction R.H. Koop

264 © W. S. Maney & Son Ltd. 2010. Journal of Management & Marketing in Healthcare. VOL. 3 NO. 4. PP 264–271. DECEMBER 2010
DOI: 10.1179/175330310X12918040319694
R. H. Koop
Started his career as a ostomy
care nurse. Five years ago he
registered as a nurse
practitioner after the master
advanced nursing practice.
Specialities are patient
education, colonic surgery
and proctology.
J. M. Klaase
is an oncology/gastro-
enterology/proctology surgeon
at the Medisch Spectrum
Twente (hospital).
J. van der Palen
Phd epidemiology, clinical
epidemiologist, professor
evaluation and assessment in
healthcare research at the
University of Twente.
P. A. M. Kommers
His interest is media, learning
and visual communication.
His Master study in 1980
formulated algorithms for
adaptive learning. In his PhD
study he questioned how
conceptual representations
may support the cognitive
integration in learning. He
was Scientific Director of
NATO Advanced Research
Workshop: ‘Cognitive
Technologies’ in 1989.
http://users.edte.utwente.nl/ko
mmers.
A. J. Sanders
University of Twente.
J. Jonker
University of Twente. Introduction
Patients that have to undergo a large bowel operation for cancer are in a
vulnerable period of their life. As a consequence, a surgical intervention
will entail a number of reactions.1
Fear of the unknown, about the
operation and the outcome of the operation, plays a significant role.
Often there are concerns about the psychological, social and physical
consequences of the operation. To meet these concerns, patients often
want as much information about the operation as possible. They gladly
get involved in decisions that must be made about the treatment.2
Information is essential, especially in the period before the treatment.
Nevertheless, many patients diagnosed with colon cancer do not receive
adequate information.3
Health literacy and coping behaviour are important aspects in
information transfer which are sometimes underestimated.4
Patient
information has to be tailored to the learning capacity of the individual
patient, taking into account already existing knowledge, fear and stress,
the learning need and their capacity to absorb information.5–6
Using a web application to
improve satisfaction among
patients undergoing surgery
R. H. Koop, J. M. Klaase, J. van der Palen,
P. A. M. Kommers, A. J. Sanders and J. Jonker
Abstract
The study explores whether patient satisfaction is increased when
a web application is used to inform patients about a surgical
intervention. A randomised single centre study was conducted.
The study population consisted of 32 patients that underwent an
elective colon resection for colon cancer (15 in the experimental and
17 in the control group; patient characteristics were equally divided
between both groups). The study group got the information with the
web application from the nurse practitioner at least 10 days before
surgery; the control group was given the standard oral information by
the nurse practitioner. Satisfaction level was measured with a
validated patient satisfaction questionnaire directly after giving the
information and two weeks after the surgical intervention. The results
indicate that patients are more satisfied when information is given by
means of a web application. Given that expectations regarding
hospital admission are more realistic when information is given in
the optimal manner, this has consequences for the use of multimedia
information techniques in healthcare in the near future.
R. H. Koop
Department of Surgery
Medisch Spectrum Twente
Postbus 50.000
7500 KA Enschede
E-mail: r.koop@mst.nl
Keywords: patient satisfaction,
web application, colon
resection, information provision,
PATSAT32

Using a web application to improve patient satisfaction
© W. S. Maney & Son Ltd. 2010. Journal of Management & Marketing in Healthcare. VOL. 3 NO. 4. PP 264–271. DECEMBER 2010 265
Information can be transmitted in several manners to the patient. Most
commonly, information is given orally. Folder material is frequently used
to support the oral information. The frequency of information given
using a computer and animations is rising. However, information transfer
is not always well coordinated and sometimes the patient even hears
contradictory information from different care workers. While some
patients seek further information through the internet, this information
is not tailored to the individual and, in certain cases, is simply incorrect.
According to Marple, the absence of unmet expectations increases the
level of patient satisfaction.7
In 2005, we started developing and testing an individualised
programme to inform patients with colon cancer using a web
application.8
Patients and methods
After obtaining informed consent, 32 patients aged 40–85 years (mean
age 67), without serious audiovisual or mental handicaps, were included
in the study between May 2006 and December 2007 (see Table 1). All
patients had to undergo elective colon resections (a right or left
hemicolectomy for large bowel cancer). Patients were randomised to an
experimental group and a control group. Fifteen patients were allocated
to the experimental group, and 17 patients to the conventional group.
Patient satisfaction was measured with the EORTC PATSAT32, a
validated ordinal questionnaire9
of 32 items with scores of 1–5 by item.
There are 32 topics in this questionnaire, ranging from satisfaction with
information to satisfaction with speed for medical tests. The instrument
has been developed speciﬁcally to measure the satisfaction of
oncological patient. Local ethical committee approval was obtained.
Experimental group
The experimental information consisted of an initial interview
conversation with the surgeon, in which minimal information about the
diagnosis and operation was given. The surgeon requested informed
Experimental group Conventional group
Number 15 17
Gender
Male 9 6
Female 6 11
Mean age: 67 years
Level of education
No education 0 1
Basic education 4 7
Practice oriented education 9 9
University 1 0
Knowledge of illness
Present 3 3
Not present 12 14
Table 1: Patient characteristics

Koop, Klaase, van der Palen, Kommers, Sanders and Jonker
consent from the patient. Having provided this consent, the respondent
attended an extra outpatient appointment to receive the information.
The information was given by means of a web application with an
information path through which several information items were passed
(see Figures 1 and 2). The information was given by the nurse
practitioner.
The experimental information consisted of a number of animations,
texts and images related to the patient’s disorder. The information items
Figure 1: Screenshot animations from the web application
Figure 2: Screenshot animations from the web application

were the same for all patients, but the information content was tailored to
the individual patient, for example, a patient undergoing a left
hemicolectomy received different information from patients undergoing a
right hemicolectomy. Afterwards, a print-out of the discussed information
was given to the patient. The patient received the first questionnaire
immediately after the information was given. Because the first
questionnaire had to be completed before the operation, a number of the
PATSAT32 questionnaire items were not appropriate. We therefore used a
modified version of the PATSAT32. At first measurement, we also asked
about satisfaction concerning the information material used. Following
the operation and discharge, patients received the second questionnaire
consisting of the original PATSAT32. In addition to the questionnaire, we
asked for a general judgment concerning the information that was given
on an ordinal scale of 0–5. The web application used for the study was
developed by the University Twente. Development was informed by the
available literature on the use of web applications and with the assistance
of a multidisciplinary expert panel. The present study commenced
following a pilot study to test a prototype of the web application.8
Conventional group
Patients in the conventional (control) group underwent an initial
interview with the surgeon. The surgeon requested informed consent
from the patient. Having provided this consent, the respondent attended
an extra outpatient appointment to receive the information. The oral
information was given by the nurse practitioner. Patients in the
conventional information group received the same questionnaires
as the patients in the experimental group.
Questionnaires and analysis
The satisfaction of the patients in the experimental group was compared
with the satisfaction of patients in the conventional group. For ongoing
normal divided variables, this was done using a t-test. For not-normal
divided variables, a Wilcoxon’s Rank Sum test was used. All items on the
questionnaires were transformed linearly to a scale of 0 to 100, with 100
representing the highest level of satisfaction. The questionnaire was
subdivided into a number of multi-item scales. This made it possible
to evaluate the social and technical skills, information provision and
availability of the doctor and nurse, kindness, helpfulness and information
supply by other hospital staff, waiting times and accessibility, exchange of
information (communication between departments/care workers), hygiene
and comfort in the hospital and general satisfaction.
Results
Of the 35 patients approached, three refused to participate in the study,
citing insufficient time to complete the questionnaires. Of the 32
participants, 30 (94 per cent) returned the first questionnaire. After the

intervention and discharge from the hospital, the second questionnaire
was sent. Twenty-six (81 per cent) of the second questionnaires were
returned. Of the 32 patients, one died due to postoperative complications.
With regards to patient characteristics, there were no significant
differences between both groups.
Patient education
Patients in the experimental group spent an average of 45 minutes (range
32–60 minutes) at the computer. For a number of items in the web
application, additional oral information was given by the nurse when
requested. These items were mainly ‘pathology’ and the item ‘after the
dismissal from the hospital’. Questions regarding the practical aspects of
discharge and pathology arose frequently; such questions included timing
of the pathology report and care at home after discharge. These items
were not discussed in the web application and patients indicated that they
needed more information about these items. Thirteen patients were able
to launch the web application without any problems, but two patients
found the web application did not function properly due to a technical
problem (no connection with internet and/or problems with the server of
the web application). Communicating the conventional information took
an average of 60 minutes (range 45–90 minutes). In most instances, an
anatomical drawing was used.
Results of the first questionnaire
Patient satisfaction was measured directly after the intervention by means
of a modified PATSAT32 questionnaire in both groups. There was a
significantly higher satisfaction in the experimental group with respect
to information supply by doctor and nurse (p ϭ 0.03 and p ϭ 0.01
respectively). In addition, kindness and helpfulness were judged higher
in the experimental group (p ϭ 0.001).
The judgment concerning the appliances used for information provision
was significantly higher in the experimental group (p ϭ 0.04) (Table 2).
Results of the second questionnaire
The second questionnaire (PATSAT32) was completed up to three weeks
after discharge from the hospital. In the experimental group, information
provision by the doctor (p ϭ 0.04) was again judged significantly higher
(Table 3). The information provision of the nurse showed no significant
difference (p ϭ 0.22). At the second test point, however, the nurse’s
technical skills, such as measuring blood pressure and handling the
computer, were judged significantly better (p ϭ 0.05). General
satisfaction scored higher in the experimental group (p ϭ 0.04).
Discussion
The present study shows that the use of a web application with tailored
information results in higher patient satisfaction compared with the use

of conventional oral information alone. In general, it seems that the
optimal use of information techniques makes patients’ expectations about
the planned hospital admission and surgical intervention become more
realistic, leading to improved patient satisfaction. Patient satisfaction will
become a more important outcome measure in the near future.10,11
Studies with the PATSAT32 questionnaires have shown that patient
satisfaction with hospital care is independent of morbidity, treatment
type, and quality of life outcomes. It may therefore be used to generate
feedback to providers of healthcare to improve patients’ experiences of
Mean score SD Mean score SD
(%) (%) (%) (%) p-value
Doctors
Social skills 71.4 16.9 58.9 21.2 0.09
Technical skills 75.6 15.8 62.2 20.4 0.06
Information provision 78.3 16.3 60.6 27.1 0.03
Availability 68.3 19.4 63.5 15.7 0.47
Nurses
Social skills 70.5 17.2 64.4 19.8 0.39
Availability 70.0 22.0 59.3 23.5 0.21
Other personnel
Kindness and helpfulness 71.7 18.6 55.0 14.0 0.01
Waiting time
Waiting time and speed 66.7 25.7 52.3 15.3 0.07
Access
Ease of access hospital 51.7 21.0 52.3 27.5 0.94
Exchange of information 55.4 22.3 51.7 24.0 0.67
Cleanness and comfort 55.0 19.4 56.3 25.0 0.87
Opinion of used 70.0 19.4 57.8 19.8 0.04
education material
Table 2: Results ﬁrst measurement (modiﬁed questionnaire)
Mean score SD Mean score SD
(%) (%) (%) (%) p-value
Doctors
Social skills 62.1 26.4 56.4 20.5 0.56
Availability 68.8 19.6 56.3 22.3 0.16
Nurses
Social skills 70.5 16.4 57.7 24.4 0.16
Availability 69.3 19.7 57.1 23.4 0.18
Other personnel
Kindness and helpfulness 66.7 21.5 50.0 24.7 0.10
Waiting time
Waiting time and speed 61.4 22.0 51.8 16.9 0.23
Access
Ease of access hospital 51.0 21.6 48.1 26.4 0.76
Exchange of information 54.2 17.9 46.2 30.4 0.44
Cleanness and comfort 52.1 16.7 46.4 27.5 0.54
General satisfaction 79.2 20.9 62.5 19.0 0.04
Table 3: Results of the second measurement (PATSAT32)

treatment. Web-based information provision may become an obligatory
aspect of the preoperative setting.
The concept of computer-based information is not new. Within the
healthcare system, the use of web applications for information provision is
rising. In most studies, a web application is used as a decision tool.12
In the
present study, the web application was developed to tailor the information
to the individual situation. The function of the nurse practitioner is thus of
paramount importance as they structure the information path so that the
patient is not overwhelmed with irrelevant data.
The nurse practitioner function is relatively new in The Netherlands.
The EORTC PATSAT32 questionnaire is not ready for this new function
as only the performance of doctors and nurses is requested. It was highly
interesting to observe that patients did not know whether they were being
informed by a nurse or a doctor. This begs the question: how does the
patient see the nurse practitioner? A super-nurse or a mini-doctor? In any
case, the information provision skills of both healthcare workers were
judged better in the experimental group, suggesting that some patients
viewed the nurse practitioner as a nurse and some as a doctor.
The advantage of information provision using a web application is that
the information can be easily adapted to new insights in the disease or new
operative techniques. One must bear in mind, however, that the development
of a web application (especially one with animations) costs a lot of time and
money. The web application will also require an administrator to adapt the
information items. Financial support is therefore essential.
In the present study, we observed that the animations used within the
web application seemed to give patients much more clarity concerning
the planned operation. Further research is needed to look at factors like
health literacy and coping behaviour which could influence how patients
appreciate the animations. Other factors to be studied include the specific
influence of age and level of education. As translations of spoken
language in the web application have been developed, the impact of the
web application on information provision in other languages should
also be studied.
Ultimately, we can consider the possibilities of combining patient
information with the multidisciplinary electronic patient file, thus giving
tailored information to the oncological patient in the appropriate amount
and at the right moment by different healthcare workers.
Acknowledgment
The development of the web application was made possible by a grant
from Sanofi Aventis.
References
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