PERCEPTION OF THE QUALITY OF CARE BY THE USERS IN THE GYNECOLOGY AND OBSTETRIC SERVICE OF A PUBLIC HOSPITAL OF HIGH SPECIALITY FROM VERACRUZ

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INTRODUCTION
Population growth, aging population, increasing life expectancy and the rising prevalence of chronic diseases are creating a greater demand for medical care that is contributing to rising health care costs around the world.As is the case in Australia, where as in other countries, the government is struggling to meet demands for access to sophisticated and expensive new diagnostics, long-term treatments and the growing need for hospital care with periodic claims that rising health care causes costs to be unsustainable.This has led to calls for transforming healthcare to improve efficiency, reduce costs and continue to deliver high quality performance-based care.(Ellis 2020).
On the other hand, Ukraine is reforming its health care system to improve the quality of care of medical services, causing health care managers to perceive quality as important to the ongoing reform, as well as to the improvement of the aforementioned services.(Anufriyeva 2022).
In Nigeria, more women-centered approaches to maternal health service delivery based on an adequate response to women's concerns and experiences with health care will be critical to curbing patient dissatisfaction with facility-based care, improving access to maternal health, and reducing maternal morbidity and mortality.(Okonofua 2017).
There is a high proportion of women with at least one obstetric risk factor (ORF), which corresponds to the epidemiological characteristics of Mexican women of reproductive age.The presence of ORF conditions complications for the woman and her child, and increases the risk of mortality, which is why preventive diagnosis and timely detection should be translated into actions that contribute to better health outcomes.The low level of quality observed in the processes of care, as well as the inequity, especially in those living in conditions of social disadvantage, is a cause for concern.(Brenes-Monge, 2020).
In general, the concept of service is related to intangible actions, processes and executions, without prejudice, since it may include facts and actions that are performed for and with the participation of users.These services can be valued depending on the capacity of perception and appreciation of the satisfaction experienced by the receiver.A service is therefore a set of direct and complementary benefits associated with an intangible good supported by a tangible support, which is evidenced in pág.5575 actions, processes and services oriented to the fulfillment of technical and functional specifications that provide satisfaction to the user.(Bustamante 2019).
Quality in the provision of health services is an issue of relevance for all the actors involved in this process.In this order of ideas, the user is the main character in the scenarios of service delivery, who must be attended with quality, timeliness and efficiency, to meet their expectations, since it is he who determines the level of excellence of an institution.(Cobo-Mejía 2018).
There is a lack of standardization in the methods for measuring patient satisfaction.The main problem is that satisfaction with a service, such as healthcare, is the result of a multidimensional interaction and the variables considered in the different studies are very diverse.(Valls-Martínez 2018).
The health service has been one of the fastest growing sectors in the service economy.Therefore, in recent times the relevance in health service quality is increasingly becoming a very important issue.
Thus, the quality of this service is important as a corporate strategy for many organizations in the area in order to provide a basis for competitive advantage.Consequently, local and global health service quality is a relevant research topic.(Olguín-Gutiérrez 2021).
In recent decades, researchers have turned their attention to the role of users in defining the meaning of quality in health services, making the user an integral part of the service delivery process.Service quality issues in healthcare are important to both the public and private sectors, yet there are differences in how they are absorbed and integrated into business operations in the respective sectors.Public sector organizations have been under pressure to improve efficiency as some researchers have rated the quality of private health care delivery higher than public health care services.(Olguín-Gutiérrez 2021).
In Mexico, the quality of medical care has become a growing and important indicator of health system efficiency.It has also increased pressure and demand from users, who wish to satisfy their expectations of the system.Theoretical and practical elements have been fundamental to evaluate the quality of health care using standard formulas or methods, in addition, each hospital would have to design strategies according to its resources for the identification, solution and prevention of problems that affect the quality of care.Different methodologies have been adopted, where not only user satisfaction was evaluated, but also expectations regarding services.(Juárez 2021).

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Measuring the quality of health services is of interest to many health institutions worldwide, since it is a fundamental part of the services provided to the patient.For this reason, the participation of the user is crucial to establish improvement processes and measurements of the perceived quality of these services.(Nieto 2017).
For the World Health Organization (WHO), quality of care means ensuring that the patient receives the most appropriate set of diagnostic and therapeutic services for optimal care.On the other hand, user satisfaction is any health care service provided correctly and that meets all the needs and expectations of the external user.The fundamental objective to improve the quality of care arises from the need to provide an adequate response to the real needs of the population by satisfactorily meeting their expectations.Within this framework, health institutions must guarantee the effectiveness of health care, as well as the efficiency of management through knowledge of the patients' perception of the care processes, which helps to implement improvements and redefine concepts and processes, which must be based on the parameters of quality of care and user satisfaction at the level of infrastructure, equipment, processes and care provided by health personnel.(Oliveira 2022).
The right to health is one of the fundamental principles of the Universal Declaration of Human Rights, hence the importance of quality health services provided by the government.In addition to being a universal right, health is one of the components of well-being.In addition, a person's health has been identified as a determinant of human capital by increasing each person's capacity to produce and consume, expanding their quantity and quality of life.(Treviño 2021).
When measuring quality it is necessary to consider various aspects that may be important in the way in which the user perceives a given service, specifically, four important aspects prevail: the skills of the personnel, the ease with which the different agents interact to provide the service, other aspects that are related to the way in which it is provided, such as style, environment and availability, and whether the service meets the expectations and demands of the consumer.(Treviño 2021).
Currently, there has been an increased interest in measuring the perceived quality of public health services from the users.This is due to the same statutes of public policy in Mexico, but to a large extent, to the demands of society itself.(Trujillo 2016).

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The analysis of quality of care has focused on the technical or objective dimension, rather than on the dimension from the patient's perspective, which is considered subjective.However, in developed countries, the patients' point of view regarding quality in health services, has contributed in the processes of health management acting in accordance with a total quality model, health models that today are an example of health care.(Trujillo 2016).
In the field of research, the studies that have been carried out around quality in health service have sought to determine patient satisfaction with respect to the treatment or intervention they receive from medical institutions.This satisfaction is directly related to the expectations a patient has and the service he or she actually receives.Under this premise, how satisfied a person may feel with the service they have received is determined by the difference between the expectations and ideas they have and their own perceptions regarding the quality of the service they received.(Trujillo 2016).

MATERIAL AND METHODS
A qualitative, prospective, longitudinal cohort study was conducted at the High Specialty Hospital of the Secretary of Health and Assistance (SSA) of the state of Veracruz during a period of 10 months in the hospitalization, emergency and outpatient areas of the gynecology and obstetrics service, where patients hospitalized for medical treatment, postoperative and/or awaiting surgery or interconsultation were administered the corresponding surveys of the Satisfaction Survey System of Adequate and Dignified Treatment.This was provided by the official website of the State Government: http://www.calidad.salud.gob.mx/site/calidad/encuesta_satisfaccion_trato_digno.html.It is worth mentioning that each person gave his or her point of view on each item of analysis.The survey application was carried out in the course of 10 non-consecutive months from June 2022 to April 2023 and depended a lot on the number of people who were there since some people remained hospitalized for several days.

Unit Of Analysis:
Our unit of analysis was 450 people to whom the aforementioned questionnaire was applied following the inclusion and exclusion criteria mentioned below.
During the analysis based on the sample size, a confidence level of 99% and a confidence limit of 1.7% were obtained.

Inclusion Criteria
Persons who are in the gynecology and obstetrics hospitalization area of the Hospital Del Alta Especialidad SSA de Veracruz.
Persons who are with the patient and who are not able to answer the questionnaire.
People who are waiting for the touch surgery area after having been attended and indicating subsequent reevaluation.
Patients who are in the outpatient waiting area for chronic pathologies (post-laboratory syndrome, climacteric syndrome, abnormal uterine bleeding, polycystic ovary, breast cancer and cervical cancer).

Exclusion Criteria:
Patients under 16 years of age.
Family members and/or outpatients without specific diagnosis or without pathologies mentioned above.
Non-surgical emergency consultation of less than 4 hours of stay.
Patients and/or family members whose stay in the hospital is less than 6 hours.
People who are in an area other than gynecology and obstetrics.

RESULTS
The surveys were applied to 450 people, including patients and family members in the emergency, outpatient and hospitalization areas.The results showed that 235 people in the hospitalization area reported a low level of follow-up by the attending physician, as well as poor communication in terms of indications and established treatments, 157 mentioned that the outpatient care provided by the attending physicians was somewhat deficient, with a lack of tact and humanism, 58 people commented that the service did not meet their expectations, although they did not find any inconvenience.
As for the nursing staff in the hospitalization area, 305 people indicated that they received adequate treatment, as well as the application of medications at established times; in the emergency area, 105 people reported good treatment; 40 people in the hospitalization area reported dissatisfaction with the nursing staff due to improper treatment and lack of quality.
For the reception area, 308 respondents said that the staff lacked empathy for patient care, 116 reported good treatment by this person and 26 mentioned in the same way that it was not optimal, but they had no problems (Graph 1).

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On the other hand, 350 respondents rated the clinical file service as adequate and only 100 people rated it as deficient and lacking organization.
The social work staff was mostly well qualified by 397 people and only 57 reported poor attention.
With regard to laboratory personnel, 427 people reported good treatment despite the limited interaction with these personnel and only 23 reported dissatisfactions with them (Graph 1 and 2).
In the same way, the X-ray personnel were mostly well qualified, taking into account the limited interaction with patients, 367 people rated them as optimal while 83 others rated them as deficient, referring to the time spent with them and waiting for results.
The cleaning staff was well qualified in its majority, mentioned by different patients that there was constant cleanliness in the areas they were in, as well as toilets with adequate hygiene.In general, the results are summarized in Graph 3.

DISCUSSION
Given the growing demand for health services in the different countries mentioned above by users, it is imperative that both public and private institutions are up to the situation both in terms of quantity and quality of human capital.In Mexico, health is part of human rights, including vulnerable groups, in this case, women and their various gynecological and obstetric pathologies.
So far, the most vulnerable institutions are those of governmental coverage, which is why we chose this hospital to carry out our study.
The current Mexican government has made a great effort both to improve health coverage and data transparency by making available to the general population the percentage of people with health insurance in each of the institutions, as well as making available the surveys that can and should be applied in each unit.
Women, as mentioned earlier in this study, are within a vulnerable group of the population, therefore, it is of great importance that the opinions of this group about the hospitals that are within their access be known.With the knowledge of their interests, we have the opportunity to direct our efforts to the most relevant focuses obtained through the surveys.

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So far, the present study is the first to recover and compile information on the quality of care perceived by patients in this hospital, and we hope that it will be a milestone for future studies that will help to improve our health services.

CONCLUSION
In conclusion, we note the need for transformations in the organization and management of health services to favor the use of available resources, investment in new human and material resources, simplification of procedures and greater job stability that favors the continuity of professionals.
On the other hand, we consider it necessary to generate analysis and reflection devices that redefine the relationship model between professionals and patients, considering the political, social and cultural variables in which it is framed.
Therefore, the use of a qualitative methodology has proved valuable in obtaining the users' vision and identifying areas for improvement related to satisfaction.
During the elaboration of this work, different areas of opportunity for improvement were observed within the High Specialty Hospital of Veracruz, which have a direct impact on the purpose of improving the customer's perception of the quality of the service provided.For this purpose, it is important to focus on the Hospital-Patient information flows, taking into account that the lack of accurate and truthful information can turn situations of negative quality perception into real failures in the quality of the service provided.The main recommendations found are listed below: The lack of information and disinterest on the part of the medical and administrative staff towards the family member as well as the hospitalized patient is the main risk factor for any type of discomfort or misunderstanding.Therefore, it is important that in the Hospital-Patient relationship there is an adequate flow of information; and this should be manifested not only with the doctors, but with any employee with whom the client interacts.When the patient receives correct and constant feedback on hospital procedures, on the medical protocol or on his health condition, he tends to perceive a more personalized and warm service.