Assessing user satisfaction and hospital pharmacy practice:

application to an individualized dispensing system in a

French military teaching hospital
Claude Dussart PharmD PhD,
1,2
Sophie Dussart MD,
3
David Almeras PharmD,
1
Isabelle Camal PharmD
1
and Gilles Grelaud PharmD
1
1
Hospital Pharmacist, Military teaching hospital Desgenettes, Hospital pharmacy, Lyon, France
2
Associate Researcher, Laboratory of Analysis in Health System, Medical Research Unity 5205 CNRS, Claude Bernard University, Lyon, France
3
Epidemiologist, Centre Lon Brard, Regional Cancer Center, Biostatistic Unit, Lyon, France
Keywords
individualized dispensing system, nurse,
pharmaceutical care, physician,
questionnaire survey, user satisfaction
Correspondence
Dr Claude Dussart
Service de Pharmacie Hospitalire
Hpital dInstruction des Armes
Desgenettes
108 Boulevard Pinel
69003 Lyon
France
E-mail: dussart.claude@wanadoo.fr
Accepted for publication: 8 February 2008
doi:10.1111/j.1365-2753.2008.00990.x
Abstract
Rationale and aims Hospital pharmacy aims at optimizing pharmaceutical care practice.
Classically, assessing patients satisfaction is required. Same manner, for a service provider
such as a hospital pharmacy, it is necessary to evaluate the satisfaction of its customers:
physicians, nurses and pharmacy staff. The aim of this paper was to assess user satisfaction
with an individualized dispensing system.
Method A survey including 14 close-ended and 1 open-ended questions was repeated at
several years distance in a French military teaching hospital. Questionnaires were admin-
istered anonymously to the different actors involved: physicians, nurses, pharmacy staff.
Results Fifty-seven users of an individualized dispensing system (29 nurses, 18 physicians
and 10 pharmacy staff) were included in the survey. At the level of the establishment, users
opinion about the system was positive. None of the dimensions studied concerning the
pharmaceutical service was rated negatively. Overall user opinion about the computer
system was the only parameter rated negatively. In total, most dimensions were judged
satisfactory: condence in the individualized dispensing system, time of delivery at the care
unit, impact on cost control, quality of the presentation of unit doses and performance of
respondents. The benet for the patients was judged very satisfactory. The workload
involved, the frequency and severity of errors, the serviceability of the information pro-
cessing system and its impact on patient safety were judged fairly satisfactory. Finally, the
quality of pharmaceutical information was rated average.
Conclusions An evaluation of a service or a practice should include an assessment of how
well the service meets the needs of the user and how well the service is provided. A
comprehensive, reliable and valid instrument for assessing users satisfaction with indi-
vidualized dispensing system is then available in our hospital. This paper demonstrated the
interest of using simple and robust tools in professional practice.
Introduction
In order to improve the security of dispensing, the French military
teaching hospital Desgenettes (Lyon, France) has implemented a
prescription system with individualized daily dispensing, in use
since 1992. This system of medication distribution is a pharmacy-
coordinated method of dispensing and controlling medications in
organized health care settings. Medications are contained in single
unit packages dispensed in a ready-to-administer form. Not more
than a 24-hour supply of doses is delivered to or available at the
patient care area at any time. This system has been computerized
since 1996. Today, 280 of the 296 beds of the establishment are
served by the system. Medication distribution is the responsibility
of the pharmacy. Pharmacists must develop comprehensive poli-
cies and procedures to ensure the safe distribution of all medica-
tions. In this quest for continuous improvement of quality, the
hospital pharmacy aims at optimizing pharmaceutical care
practice.
Quality management, a concept originating in the industrial
sector over 100 years ago, has been embraced by the hospital
pharmacy Desgenettes. Quality Management is a process of
ensuring continuous quality for the customer while at the same
Journal of Evaluation in Clinical Practice ISSN 1356-1294
2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 252256 252
time keeping production efcient and cost effective. Taking into
account the customers needs and the results of current practice is
thus a prerequisite [13].
Quality management is driving health systems to identify and
incorporate services that will increase patient satisfaction, identi-
ed by many studies as being highest when patients expectations
are met [48]. Classically, surveys evaluate only patient satisfac-
tion [915] but not that of physicians, nurses and pharmacy staff.
To date, the literature measuring user satisfaction is limited [16].
Based on this observation, the pharmacy department elaborated an
instrument for measuring user satisfaction. A rst investigation
was completed by end of 2004. Since that date, a new hospital
information system has been developed, which has had some
impact on drug delivery practice. A new survey was carried out to
investigate potential changes.
The primary purpose of this study was to evaluate the user
satisfaction with an individualized dispensing system, with two
secondary objectives: to improve the quality of pharmaceutical
care practice and to facilitate its adaptation to the needs of the
users, either expressed or implicit.
Methods
Study population
The study was conducted over 10 days (June 2007). To be eligible
for the study, participants must belong to one of the following
categories: senior physician, junior physician, nurse or pharmacy
staff; be present at the time of the investigation; agree to take part
in the study.
Questionnaire
For this study, the questionnaire that had been used for the rst
evaluation was repeated, with addition of three questions about the
new information system set up in December 2006. The question-
naire was administered by an investigator. Questions covered four
areas:

participants characteristics (care unit and medical category);

the level of user satisfaction (condence in an individualized

dispensing system, quality of pharmaceutical information, time for
delivery to the medical departments, frequency and severity of
dispensation errors, impact on cost control, benet for the patient,
workload, quality of presentation and performance);

the existence of a previous professional experience with another

non-computerized system; and

user satisfaction concerning the new information system (global

satisfaction, benet for patient safety, serviceability).
Finally, opinions, suggestions or free commentaries were also
collected.
Anonymity
It was agreed to preserve the anonymity of participants.
Statistical analysis
Data were coded and stored in a computer database for statistical
analysis using SAS version 8 software. The various groups of
variables were compared using anova or KruskalWallis tests for
parametric and non-parametric data, respectively. The answers to
the open questions were categorized by topic and ranked by fre-
quency of quotation. Parameters were determined with 95% con-
dence interval and 5% accuracy.
Results
Satisfaction scores varied from -2 to +2, with 0 indicating neu-
trality.
We interviewed 57 people, including 29 nurses [51.0%], 8
junior physicians [14.0%], 10 senior physicians [17.5%] and 10
pharmacy staff [17.5%]. The study population essentially con-
sisted of individuals who had known other devices than the auto-
mated dispensing system [66.7%]. All care units functioning with
an individualized dispensing system were involved in the study.
Overall results in our series were superior to 0 for all dimensions
studied, except for global satisfaction with the new information
system [Fig. 1]. Scores varied between -0.2 and +1.4 according
to items (Table 1). On the whole, users appeared satised with the
automated dispensing system.
General satisfaction
In terms of condence in the individualized dispensing system,
participants were globally satised, with an overall score of +1.0.
No signicant differences were associated with the medical
category of the participant (P = 0.07) or with the care unit
(P = 0.42).
Regarding the quality of pharmaceutical information, all par-
ticipants were fairly satised with the service [+0.1]. These results
do not show any statistically signicant difference according to the
category of the participant (P = 0.24). Contrariwise, there were
differences according to the care unit (P = 0.043), with the least
satised services being the departments of rheumatology [-1],
pneumology and dermatology (0.33 each).
The delivery time was judged satisfactory [+1.0]. However,
differences according to the medical category (P = 0.003) and the
care unit (P < 0.05) were observed. Caregivers were moderately
satised with the delivery time (+0.2 for senior physicians, +0.9
for junior physicians and +1.0 for nurses) whereas the pharmacy
staff reported markedly higher scores [+1.7].
-2
-1
0
1
2
Confidence
Pharmaceutical information
Delivery time
Frequency of errors
Gravity of errors
Impact on cost control
Benefit for patients
Workload
Quality of presentation
Performance
Figure 1 Users satisfaction, a global view.
C. Dussart et al. Satisfaction and pharmacy practice
2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 253
The frequency of errors with the distribution of drugs in the
trolleys was considered fairly satisfying [+0.6], with no variation
according to the medical category (P = 0.06) or the care unit
(P = 0.15).
The dimension severity of distribution errors was judged fairly
satisfactory [+0.7]. Again, no difference was noted according to
the medical category (P = 0.98) or the care unit (P = 0.47).
For most participants rated the impact of an individualized
dispensing system on cost control was rated positively [+0.9]. The
medical category or the care unit of the respondent did not inu-
ence the responses (P = 0.67 and P = 0.77, respectively).
Most participants agreed that the individualized dispensing
system was benecial to the patient [+1.4]. There were signicant
differences according to the medical category (P = 0.04) and the
care unit (P = 0.05). The pharmaceutical staff was the most con-
dent in the interest of this system for the patient [+2.0].
The workload generated by the individualized dispensing
system was judged rather satisfactory [+0.7], with no difference
according to the medical category (P = 0.06) or the care unit
(P = 0.41).
The quality of presentation of the system was also judged sat-
isfactory [+1.1]. However, there were signicant differences
according to the medical category (P = 0.02) and the care unit
(P = 0.05), with the least satised units being rheumatology [-0.1]
and psychiatry [+0.25].
To the question how do you rate your own performance when
using the automated dispensing system?, the whole cohort
answered positively [+1.2], with no difference according to the
medical category (P = 0.08) or the care unit (P = 0.10).
Satisfaction with the information system
The overall perception of the information system was the only
parameter rated negatively [-0.2], without statistically signicant
difference according to the medical category or the care unit
(P = 0.3 and P = 0.47, respectively). The preservation of patient
safety when using the information system was considered average
[+0.4], again without statistically signicant difference according
to the medical category (P = 0.24) or the care unit (P = 0.29). All
respondents were fairly satised with the serviceability of the
information processing system [+0.3]. There were no signicant
differences according to the care unit (P = 0.17), but opinions
varied with the medical category (P = 0.04): the least satised
groups were the pharmacy staff [-0.3], then senior physicians
[-0.2].
Use of a system other than an individualized
dispensing system
Of the 10 dimensions studied, there was no statistically signicant
perception difference between the group of respondents with pre-
vious professional experience of an individualized dispensing
system and the others (P > 0.05, respectively, for each dimension).
Open questions
Thirty-seven respondents primarily commented on the difculty of
using the new information system, the need for information on the
matches suggested, the need to improve the integration of dose
modications during the day and the lack of availability of drugs at
night and over the weekend.
Comparison with results of the previous
investigation (Table 1)
No statistically signicant differences were reported with regard to
the distribution of the study population between medical catego-
ries (P = 0.39) or between care units (P = 0.06). The comparison
with previous results indicated similar user satisfaction, either in
terms of: condence (P = 0.92), delivery time (P = 0.56), fre-
quency of errors (P = 0.75), severity of errors (P = 0.08), cost
control (P = 0.37), benet for the patient (P = 0.11), quality of the
presentation (P = 0.06). On the other hand, the quality of informa-
tion and the workload were statistically signicantly different
between 2004 and 2007 (P < 0.01 and P < 0.05, respectively). The
quality of information was judged less favourably, contrary to the
workload which was generally perceived as lower than at the time
of the rst investigation.
Table 1 Summary of users responses in 2004 and 2007
2004 2007
Difference between
groups P-value Number mean SE Number mean SE
Condence 67 0.99 0.86 56 1.00 0.79 0.92
Pharmaceutical information 65 0.85 0.92 51 0.12 1.21 <0.01
Delivery time 65 0.86 1.00 57 0.96 0.94 0.56
Frequency of errors 53 0.62 0.81 53 0.57 0.97 0.75
Severity of errors 51 1.04 0.87 52 0.69 1.08 0.08
Impact on cost control 52 1.06 0.96 35 0.86 1.12 0.37
Benet for patients 63 1.16 1.03 55 1.44 0.81 0.11
Workload 61 0.15 1.38 54 0.74 1.07 0.01
Quality of presentation 60 1.45 0.87 56 1.11 1.09 0.06
Performance 58 0.91 0.73 50 1.18 0.75 0.06
Information system - - - 56 -0.20 1.10 -
Interest of the system for patient safety - - - 56 0.41 1.11 -
Serviceability of the system - - - 56 0.32 1.21 -
Satisfaction and pharmacy practice C. Dussart et al.
2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 254
Discussion
Many studies concerning unit dose drug distribution systems were
published during the last years. These studies indicate that indi-
vidualized dispensing systems, in comparison with other drug
distribution methods, are safer for the patient, more efcient and
economical for the organization and a more effective method of
utilizing professional resource. On the level of the establishment,
the appreciation of the users concerning an individualized dispens-
ing system is considered to be satisfactory. No studied dimension,
concerning the pharmaceutical service, is noted negatively, con-
trary to the general satisfaction of the new information system of
hospital. Pharmaceutical information is thus felt in a relatively
satisfactory way with an average of almost 0. According to the
medical category of the questioned subject, this dimension is
appreciated in a different way. Indeed, senior physicians and
nurses are most critical concerning the diffusion of pharmaceutical
information. This situation can be explained by a lack of commu-
nication by the pharmaceutical staff. It is interesting to note that
pharmacy and its customers appreciably have the same perception
of the quality of an individualized dispensing system for the major-
ity of evaluated dimensions, except for the items: delivery time,
interest for the patient and quality of presentation of the unit doses.
With regard to the quality of presentation of the unit doses, some
brief replies are proposed: the pharmaceutical staff is particularly
satised with the exhaustiveness of the information provided on
conditioning, whereas nurses note important difculties with the
opening of the blisters. In any way, to maximize the benets of a
unit dose drug distribution system, all drugs must be packaged in
single unit or unit dose packages. However, all drugs are not
commercially available in a unit dose package. Therefore, the
pharmacist must often repackage drugs. The personnel of phar-
macy have a better image of the delivery periods than those of the
medical departments. It appears that clinical departments are not
sensitized with the workload of an individualized dispensing
system. The improvement of this dimension will necessarily pass
by a better communication between pharmacy and its customers.
The general satisfaction of the information system is the only
negatively evaluated dimension. The recent change of the infor-
mation system on the level of the hospital during December 2006
explains certainly this dissatisfaction. Two other dimensions con-
cerning to the information system (safety patient and practical
aspect) are evaluated more positively. Indeed, in spite of the dif-
culties of implementation of the software, there is a real awakening
of its total interest by the whole of the hospital staff. The main
difculty lies in the training of the use of the software for which
the personnel received an initial formation. Some of them would
wish to supplement it by an adapted continuous formation.
In a general way, the tendencies of studied dimensions signi-
cantly did not vary compared with the results obtained at the time
of the preceding study. However, for two of them, of the signicant
differences are observed. The satisfaction of pharmaceutical infor-
mation strongly decreased, whereas the workload felt clearly
improved. With regard to pharmaceutical information, the clinical
services expressed their needs for information concerning the
drug, and particularly regarding substitution. Indeed, in spite of the
list of principal substitutions available, nurses encounter difcul-
ties at the time of the drugs administration. Corrective actions must
be carried out in order to attenuate this lack of information and
communication. The pharmacist must provide patient-specic
drug information and accurate and comprehensive information
about drugs to other health professionals or patients. Currently,
there is a system of follow-up of preparation for each carriage,
including a printed formulary on which are listed per day: the
name of the pharmacist technician, the name of the pharmacist
controller, the name of the nurse and all remarks emanating from
pharmacy or the service. This printed formulary, useful for the
quality control, is not adapted to the diffusion of information. For
this reason, we propose to found a specic printed formulary of
connection. No medication should be administered to a patient
unless medical and nursing personnel receiving adequate informa-
tion about its therapeutic use, potential adverse effects and dosage.
This information should include, for each patient, the list of the
specialities substituted as well as the remarks relating to the modi-
cations: posology modications, galenic formal amendment,
absence of a speciality, etc. The use of this printed formulary must
naturally be supplemented of a sensitizing of all personnel con-
cerned with his operation. In the same way, up-to-date drug infor-
mation should be available, including current periodicals and
recent editions of textbooks in appropriate pharmaceutical subject
areas.
The workload is the second dimension having signicantly
changed. It would seem today that the whole of the personnel of
pharmacy accepted the additional workload related to an individu-
alized dispensing system. Thus, the workload is distributed better
in the hospital. The pharmacist must continue to take care that
other dimensions such as condence, the deadlines and the errors
continue to give satisfaction. Then, the survey allowed to identify
organizational weaknesses.
Every health profession seeks recognition and compensation
for its unique skills and contributions to the quality of a patients
life [17,18]. There exists a need to conceptualize and understand
the roles that pharmacists serve to help convince others such as
patients, prescribers and payers to value their contributions and to
plan for the roles they could serve in the future within the health
care system [19]. In November 2004, the Joint Commission of
Pharmacy Practitioners developed a consensus position on the
future vision of pharmacy and described how pharmacy practice
will benet society [20]. Part of this document stated that phar-
macists should achieve public recognition that they are essential
to the provision of effective health care by ensuring that [1]:
medication therapy management is readily available to all patients
[2], desired patient outcomes are more frequently achieved [3],
overuse, underuse, and misuse of medications are minimized [4],
medication-related public health goals are more effectively
achieved, and [5] cost effectiveness of medication therapy is
optimized.
No single standard measure of user satisfaction is applicable
to all pharmacy situations and therefore other measures should be
used. No quality programme has proven to be superior to others,
and quality improvement probably requires various approaches.
Quality-managed process can provide a quality-nished product.
Recently, in health care, the focus has gone from simply evaluating
the content of care. In pharmacy specically, the focus has gone
from making good quality drugs to ensure the security of the entire
medication process. A cornerstone of quality management is
evaluation, which includes third party: assessments, surveys and
statistical indicators. Quality management emphasises patient
C. Dussart et al. Satisfaction and pharmacy practice
2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 255
safety by including medication and risk management standards
and focus on improvement rather than just quality attainment.
Signicant quality-of-care gaps are well documented, specially in
the USA. These reports have focused mostly on underuse of per-
formance measures of important processes of care and some out-
comes of care [21]. Recently, a performance model proposed a
combination of four primary elements: quality of care, cost of care,
access to care and satisfaction [22].
Conclusion
Drug control (of which drug distribution is an important part) is
among the pharmacists most important responsibilities. There-
fore, adequate methods to assure that these responsibilities are met
must be developed and implemented.
An evaluation of a service should include an assessment of
how well the service meets the needs of the user and how well the
service is provided. A comprehensive, reliable and valid instru-
ment for assessing users satisfaction with individualized dispens-
ing system is then available in our hospital. The pharmacists
responsibility in the medicine usage chain does not end after
delivering medications. Quality links are installed to ensure the
best usage of medicines at each stage in the process.
The measuring instrument presented within the framework of
this work appears, with the experiment, adapted to the laid down
objectives. Hospital pharmacy practice can then evolve according
to the implicit and explicit users needs.
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