Intellectual model for analyzing and anaging patient trust in medical staff of primary healthcare institutions

2024 Vol.30 No.1 POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 98 INTELLECTUAL MODEL FOR ANALYZING AND MANAGING PATIENT TRUST IN MEDICAL STAFF OF PRIMARY HEALTHCARE INSTITUTIONS Gavurova B., Smolanka V., Polishchuk V. Abstract: In the work, research was conducted on the development of an intellectual analysis model for determining the level of trust of patients in the medical staff of a primary medicine institution, for effective strategy and management on the example of the countries of the Visegrad Group (Czech Republic, Hungary, Poland, Slovakia). The research uses modern knowledge collection and presentation methods, applied in fuzzy set theory, system analysis, and expert evaluation. The main value of the model lies in the fact that it examines the question of evaluating the effectiveness of the management of primary medicine medical institutions, taking into account the level of trust of patients in the medical staff. The model provides an opportunity to comprehensively analyze the region and develop recommendations for state authorities to create strategies for improving the quality of medical medicine in outpatient facilities. At the level of primary medicine institutions, managers should develop strategies to create conditions in which patients' trust in medical personnel will grow. The developed model was verified and tested on real data of primary medicine patients in the countries of the Visegrad Group. An example of evaluation on fragments of data in four regions is illustrated. Key words: trust of patients, primary medicine, management efficiency, intellectual analysis of knowledge, fuzzy modeling DOI: 10.17512/pjms.2024.30.1.06 Article history: Received September 02, 2024; Revised October 14, 2024; Accepted November 06, 2024 Introduction Trust in medical personnel is one of the key factors in the successful provision of medical services and the overall level of patient satisfaction. Patients who trust the medical staff are more likely to return to the same institution for services, which increases loyalty and positively affects the reputation of the medical institution. Also, patients who trust their doctors are more likely to leave positive reviews and  Beata Gavurova, prof. Ing. PhD., MBA, Tomas Bata University in Zlin, Faculty of Management and Economics;  Corresponding author: gav[email protected], ORCID: 0000-0002-0606-879X Volodymyr Smolanka, prof. DrSc., Uzhhorod National University, Faculty of Medicine;  emails: [email protected], ORCID: 0009-0003-5583-3341 Volodymyr Polishchuk, prof. DrSc., Technical University of Košice, Faculty of Aeronautics; Uzhhorod National University, Faculty of Information Technology.  email: volodymyr.polishch[email protected], ORCID: 0000-0003-4586-1333 POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 2024 Vol.30 No.1 99 recommend the facility to others, contributing to the influx of new patients. Measuring the level of trust of patients in medical personnel can be part of strategic planning. This allows management to identify problem areas and develop measures to eliminate them. Trust in medical staff allows for more efficient planning and allocation of resources, including the time of doctors and nurses, as satisfied patients are less prone to conflict and complaints. Also, patients' trust in medical staff helps reduce stress and burnout among employees, reducing staff turnover. Thus, trust in medical personnel is a critically important factor affecting the effectiveness of medical facilities. The strategy and management aim to create conditions in which patients' trust in medical personnel will grow, which in turn will contribute to the general improvement of the quality of medical services and the level of patient satisfaction. The main goal of the conducted research is to develop a model of intellectual analysis for determining the level of trust of patients in the medical staff of a primary medicine institution, for effective strategy and management based on the example of the countries of the Visegrad Group (Czech Republic, Hungary, Poland, Slovakia). Trust represents a construct that can be affected by many factors. It can be altered over time and can be perceived by the various population groups in a differentiated way, depending on previous experience with the healthcare service provided as well as the demand for it, the patients' health status, the sociodemographic indicators, and so on. Patients' confidence can also be influenced by the enforced healthcare policy of the countries, related to the availability of resources and insurance financial schemes (Gerhards et al. 2017). People can be concerned about the lack of healthcare sources as well as unavailability of healthcare depending on age, comorbidities, social and economic situation, and so on. Hence, investigation of the confidence factors and their changes is rudimentary for efficient management of healthcare facilities and for construction of optimal management strategies aimed at higher quality, healthcare service efficiency and sustainability of the healthcare system (Sousa‐Duarte et al. 2020). These aspects are the basement of patients' satisfaction and loyalty necessary to ensure effective healthcare policy in the countries (van Dijk et al. 2021). Effective healthcare policies of the countries will enable reduction of regional health disparities not only within the individual countries, but also between the countries and thus, to ensure fulfillment of global health goals, including sustainable development goals (SDGs). Literature Review Investigating patients' confidence and its impact on quality and efficiency of healthcare has been in the attention of many research teams around the world for decades and the importance of this issue has been increasing. This is related not only to the increasing life expectancy of the population, but also to technological development in healthcare, an increase in morbidity and emergence of new diagnoses, epidemics, and pandemics. Although there are many research studies in this field, their comparison is considerably comprehensive for the methodological 2024 Vol.30 No.1 POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 100 aspects as well as the difference in the healthcare policies that are applied in the individual countries. Nevertheless, they provide a valuable platform to justify the need for investigating factors and development of systems that would help not only measure confidence, but also to implement information about status and development of confidence in management and the decision-making mechanisms in healthcare facilities. The following selected research studies also declare the difference in the impact of factors related to confidence and satisfaction. For instance, Dayan et al. (2022) suggest that service quality, speech form, and relationship to outpatient physician positively influence patient satisfaction and indirectly influence patient loyalty. According to the authors, satisfaction with the waiting time has no impact on the outpatients' satisfaction. An increase of the costs of switch to other healthcare providers can prevent patients from switching to other providers and thus, it creates the potential for false loyalty or so-called status of customer hostage. Shie et al. (2022) point to the relationship between the four variables: quality of health services, accessibility to services, trust, and loyalty. Their findings show that the higher the quality of health services, the higher the trust, promoting enhancement of the health services level and followingly, increasing the loyalty between physician and patient. Development of the tools to self-manage own health care can raise enthusiasm for maintaining own health and contribute to greater satisfaction with own treatment plan. The sociodemographic indicators also influence change in patients trust and loyalty to physician in healthcare facilities. Some studies confirm that elderly patients, more educated, married, living in urban regions, in better health condition and with a contract with a family physician, show higher patient trust to physician (Li et al. 2022). Age, marital status, education, region, where they live, health status, and a contract with a family physician is a significant predictor of patient's trust. In many studies, the interconnectedness between trust and perceived quality of the provided healthcare services is visible that are directly related to the patient's expectations. For instance, Thom et al. (2002) confirmed that patients with a lower trust level in their physician are more likely to list unfulfilled requests for healthcare services. In the recent period, communication has also played an important role in building trust between patient and physician. According to Chandra et al. (2018) both trust and communication are positively related to patient satisfaction and perceived quality of healthcare services. A patient-centered approach with effective communication skills and trust promotes better healthcare management that results in higher patient satisfaction. Trust in physicians needs to be investigated in the other causal relationships as well. Oguro et al. (2021) confirmed that the family member's negative experiences with healthcare services have a long-term impact on patients' attitudes and emotions and hence, it is necessary to investigate the impact of family members' experiences on patients' trust in their own and general practitioners. POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 2024 Vol.30 No.1 101 Although many studies point to a direct relationship between patients' trust in physicians and satisfaction with the health care provided (Adriansyah et al. 2021), enhancing a physician to patient interaction does not automatically guarantee higher trust and higher satisfaction. Shan et al. (2016) confirm that the patient's trust as the most significant predictor of his satisfaction is shaped by the perceived high quality of the services provided, empathetic and caring interpersonal interactions. Similarly, Abbasi-Moghaddam et al. (2019) consider consultations with physician the most significant predictor of patient satisfaction, how they are provided with information and in what environment they receive healthcare. According to the authors, the highest difference in service quality was related to the perception of the sensitivity dimension by patients and managers. The appropriate training programmes for employees aimed at creating effective interactions and ensuring timely healthcare services are mentioned in the studies as frequent recommendations for enhancing healthcare quality. Some authors also recommend investments in the physical environment and technical equipment of outpatient department that can contribute to the perceived satisfaction of patients with the quality of the provided health services (Alrubaiee and Alkaa'ida, 2011; Thom et al. 2002). The sociodemographic characteristics can be an important aspect in the differentiated perception of the healthcare services that is also related to a higher potential need for healthcare in elderly age. Trust in healthcare can be related to age, education, employment, income, existence of household, residence, and the various ideological aspects (Durmus and Akbolat, 2020; Farrokhi et al. 2023). Usta and Korkmaz (2020) confirm that people over sixty years, with low education, unemployed, with low income, and people from rural areas have higher trust in the healthcare system. Trust in the healthcare system may also be related to a higher need for healthcare information in the periods of illness or elderly age, as well as social and economic uncertainties. These aspects are also intensively investigated in a relation to the health systems of the developing countries, where social and economic indicators play a significant role (Amankwah et al. 2019). Kim et al. (2017) consider the treatment effectiveness to be an important factor in patients' satisfaction with the healthcare quality. According to the authors, the effectiveness of treatment had a more significant impact on patient satisfaction compared to facilities and environment, indirectly influencing satisfaction and directly influencing the intention to repetitive visit of a particular physician. New models of healthcare service delivery also point to the importance of examining waiting times, clinical contact period, trust, empathy, communication, and expectations when evaluating specialist healthcare service (Waters et al. 2016). Nguyen et al. (2021) explain the differential weight and strength of patient satisfaction factors such as emotion, function, social influence, and trust. According to these authors, emotions do not significantly affect customer perceived value and function does not significantly affect patient satisfaction. 2024 Vol.30 No.1 POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 102 The various perceptions of patient satisfaction can be influenced not only by the regional characteristics, but also by the healthcare facility type (private versus state healthcare providers). This fact is confirmed by the research studies conducted within public healthcare providers (Liu et al. 2021) as well as private ones (Pathak, 2017; Fatima et al. 2018). Public hospitals can show significant deficiencies in the quality of services provided (Majele et al. 2024), and failure to address them can lead to increased patient dissatisfaction, increased infections, longer recovery times, and higher mortality rates. The ambition of healthcare policies in the individual countries is to reduce the differences in the healthcare service quality provided by state and private health care providers and thus, to improve the regional and economic availability of healthcare service. Various insurance mechanisms play an important role in the healthcare policies of the individual countries. System efficiency, the introduction of standard operating procedures, as well as increasing investments in electronic healthcare service systems, which have an impact on the timely provision of health services, including the reduction of waiting times, have been increasingly promoted in the recent period. Patients' satisfaction and their trust in the medical staff also impact the willingness to pay for an abovestandard health service and engagement (Ai et al. 2022). Many other aspects of the healthcare service quality are also investigated in the research studies that can reveal new causal relations in the processes of improving the healthcare service quality. For instance, it was found that the exterior design of healthcare facilities is not associated with patient satisfaction or trust, while interior decoration and cleanliness as well as atmosphere is directly associated with them in healthcare services (Ai et al. 2022). The patients often associate the different types of healthcare facilities with the different levels of the healthcare services provided. Cho et al. (2020) pointed out the differences in the evaluation of the healthcare service quality by patients within university healthcare services, community clinics and hospitals. Patients perceived a higher quality of healthcare services in community primary care facilities than in hospitals. According to Manulík et al. (2016), patients from state healthcare facilities had higher expectations from contacts with medical personnel than patients from private healthcare facilities. Chegini et al. (2022) confirmed that patients of private health facilities trust physicians more as those ones living in rural areas. The authors also confirm the relationship of decreasing trust of patients in physicians if communication between physicians and patients is erroneous. Nevertheless, AlNeyadi et al. (2018) confirm that the perceived patients' satisfaction with the provided service quality does not differ between private and state healthcare facilities. The most important evaluation dimension for the both types of healthcare facilities is security. High-quality healthcare services lead to satisfied patients. Hence, the differences between types of healthcare facilities in the perception of the healthcare services quality should be minimal in healthcare systems (Singh and Dixit, 2020). POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 2024 Vol.30 No.1 103 Healthcare providers may perceive healthcare quality attributes differently than patients that may be related to the different levels of expectations (Campos et al. 2017). Knowing the perception of the quality of services by patients makes it possible to examine their potential loyalty as well. According to Lin et al. (2004), potential loyalty is related to tangibility, reliability, responsiveness, assurance, and empathy. The importance of these factors is also confirmed by Jonkisz et al. (2022). The patient treatment type can also influence the different perceptions and evaluations of the healthcare service quality (Lee and Kim, 2017). The perception of the healthcare quality can also vary depending on the environment and state (Mohammed et al. 2016). Hence, it is important to investigate the impact of patients' experiences on the perception of the healthcare service quality and interventions that influence patients' decision-making processes and their loyalty to healthcare facilities. Information technologies can also influence the perceived healthcare service quality. Kisekka and Giboney (2018) examined how privacy concerns reduced the frequency of patient access to health records that may impact the perceived healthcare service quality. Healthcare facilities should implement optimal security measures to increase trust and thus, to reduce privacy concerns that will have an impact improving healthcare service quality. The effectiveness of the information exchange for patients can be supported by various innovations in health information technology. Xie et al. (2020) point to the interconnectedness of health information technology and patient satisfaction and trust with these trajectories, possessing many complex relationships that need to be further explored. The outcomes of the mentioned research studies allowed us to define the elementary research platform for the analytical processes, whose aim was development of an intellectual analysis model for determining the level of trust of patients in the medical staff of a primary medicine institution, for effective strategy and management on the example of the countries of the Visegrad Group. Based on the above, the scientific hypothesis of this study focuses on the functional capabilities of the proposed tool and the predicted results of its implementation. It can be formulated as follows: the developed model of intellectual analysis is functional and effectively assesses patients' trust in primary care medical personnel; in the selected region there is a relationship between the overall degree of effectiveness of management of primary care institutions and patients' trust in medical personnel. 2024 Vol.30 No.1 POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 104 Research Methodology Consider some region 𝑅 to evaluate the general level of trust of patients in the medical staff of primary medicine. The set of patients 𝑃={𝑝1;𝑝2;…;𝑝𝑛} are the respondents of the research questionnaire who expressed their attitude regarding trust in the medical staff according to some set of evaluation criteria 𝐾= {𝐾1;𝐾2;...;𝐾𝑚}. This model is presented in the form of an operator: 𝛴(𝑅,𝑃,𝐾)→𝑓(𝑙𝑡,𝐷𝐸). (1) As a result of the operator's work, based on the input data, the initial values of 𝑓 are obtained, namely: 𝑙𝑡 – a generalized quantitative assessment of patients' trust in the medical staff of primary medicine in the studied region; 𝐷𝐸 – linguistic assessment of the effectiveness of the management of primary medicine institutions within the studied region. To present the intelligence analysis model, two management subjects are introduced: the system analyst is the person responsible for setting up all assessment processes; a decision-maker (DM) is a person who, based on the obtained results, concludes (recommendations, scenarios) regarding increasing the trust of patients in the medical staff of primary medicine at the regional level. The model of intellectual analysis processes the opinions of patients and moves from individual knowledge to collective knowledge at the regional level. Therefore, first, based on the set of criteria 𝐾={𝐾𝑗;𝑗=1,𝑚       }, which is classified into l groups 𝐺1;𝐺2;...;𝐺𝑙, data is collected from respondents according to various aspects of trust in medical personnel. This set is open, so the model does not depend on their number, which makes it adaptive. Data collection from patients takes place in the form of an integer score 𝐸∈[0;10], which is obtained based on the answer to the question about the trust of patients in the medical staff of primary medicine. Based on theoretical-multiple generalization, the formation of a set of evaluation criteria was carried out, and they were classified into groups. 𝐺1 – Quality of medical services: 𝐾11 – How would you generally rate the work of the medical staff who treated you? (from 0 – “Worst rating” to 10 – “Best rating”). 𝐾12 – Did you have the opportunity to participate in the decision-making about your health as you wished? (from 0 – “I did not participate at all” to 10 – “I was involved as much as possible”). 𝐺2 – Empathy and communication: POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 2024 Vol.30 No.1 105 𝐾21 – Did you have enough time to discuss your health issues with health professionals? (from 0 – “There was not enough time at all” to 10 – “There was enough time”). 𝐾22 – Did you feel enough respect and empathy when communicating with the medical staff? (from 0 – “Did not feel” to 10 – “Feeled”). 𝐾23 – Did the medical staff respect your cultural or religious beliefs? (from 0 – “Not respected at all” to 10 – “Respected and given a lot of respect”). 𝐾24 – Did the medical staff treat you politely? (from 0 – “They were not polite at all” to 10 – “They were very polite”). 𝐺3 – Convenience and availability of medical services: 𝐾31 – How convenient was it to make an appointment with a doctor? (from 0 – “Very difficult” to 10 – “Extremely comfortable”). 𝐾32 – Was the state of your health easily explained by medical workers? (from 0 – “It was not clear” to 10 – “Everything was clear”). 𝐺4 – Security and privacy: 𝐾41 – Did you feel enough privacy when discussing your health with the medical staff at the outpatient clinic? (from 0 – “I did not feel privacy” to 10 – “I needed privacy”). 𝐾42 – Did you feel enough trust in the medical staff? (from 0 – “Did not feel trust” to 10 – “Trust was necessary”). Based on the expressed impressions of patients according to the above criteria, a set of input data 𝐸 is obtained, within the proposed groups for the researched region 𝑅. First, a convolution of the obtained scored points takes place in the section of patients 𝑝𝑖, 𝑖=1,𝑛: δ𝑢(𝑝𝑖)=∑𝐸𝑗𝑖 𝑚𝑢 𝑗=1 . (2) 𝑚𝑢 − the number of criteria in the group 𝑢, 𝑢=1,𝑙, δ𝑢(𝑝𝑖)∈[𝑎𝑢,𝑏𝑢]. In the second step, data is compared using intelligent knowledge analysis based on membership functions. This will reduce the subjectivity of the data received from patients. According to the research logic, it is proposed to apply membership functions to uncertainties of the "high level" type. They are used to blur decision 2024 Vol.30 No.1 POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 106 boundaries and are described in terms of S-shaped membership functions. Such functions are easily parameterized, allowing them to be configured to reproduce different forms and gradations of belonging. For example, a quadratic S-spline is as follows: 𝜇𝑢(𝑝𝑖)= { 0, 𝑖𝑓 δ𝑢(𝑝𝑖)≤𝑎𝑢; 2(δ𝑢(𝑝𝑖)−𝑎𝑢 𝑏𝑢−𝑎𝑢)2,𝑖𝑓 𝑎𝑢<δ𝑢(𝑝𝑖)≤𝑎𝑢+𝑏𝑢 2; 1−2(𝑏𝑢−δ𝑢(𝑝𝑖) 𝑏𝑢−𝑎𝑢)2,𝑖𝑓 𝑎𝑢+𝑏𝑢 2<δ𝑢(𝑝𝑖)<𝑏𝑢; 1, 𝑖𝑓 δ𝑢(𝑝𝑖)≥𝑏𝑢. (3) For the proposed criteria groups 𝐺1,𝐺3,𝐺4 the membership function will look like this: 𝜇1,3,4(𝑝𝑖)= { 0, 𝑖𝑓 δ1,3,4(𝑝𝑖)≤0; 1 200(δ1,3,4(𝑝𝑖))2,𝑖𝑓 0<δ1,3,4(𝑝𝑖)≤10; 1− 1 200(20−δ1,3,4(𝑝𝑖))2,𝑖𝑓 10<δ1,3,4(𝑝𝑖)<20; 1, 𝑖𝑓 δ1,3,4(𝑝𝑖)≥20. (4) For a group with four criteria 𝐺2, the membership function is as follows: 𝜇2(𝑝𝑖)= { 0, 𝑖𝑓 δ2(𝑝𝑖)≤0; 1 800(δ2(𝑝𝑖))2,𝑖𝑓 0<δ2(𝑝𝑖)≤20; 1− 1 800(40−δ2(𝑝𝑖))2,𝑖𝑓 20<δ2(𝑝𝑖)<40; 1, 𝑖𝑓 δ2(𝑝𝑖)≥40. (5) Thus, normalized scores 𝜇𝑢(𝑝𝑖)∈[0;1] are obtained for patients 𝑝𝑖 within the criteria groups regarding their trust in the medical staff of primary medicine. In the third step, the DM introduces weighting factors {𝜔1,𝜔2,...,𝜔𝑙} to each group of criteria from the interval [1; 10]. Since the calculation takes place in the evaluation space [0;1], normalized weights are derived: 𝜔𝑢     =𝜔𝑢 ∑𝜔𝑢 𝑙𝑢=1 ,𝑢=1,𝑙; 𝜔𝑢     ∈[0;1]. (6) In the fourth step, using a convolutional approach, an aggregated quantitative assessment of trust in the medical staff of primary medicine is derived by patients. DM can choose one of the convolutions for calculation: POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 2024 Vol.30 No.1 113 Groenewegen, P. P., Hansen, J. and De Jong, J. 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POLISH JOURNAL OF MANAGEMENT STUDIES Gavurova B., Smolanka V., Polishchuk V. 2024 Vol.30 No.1 115 INTELEKTUALNY MODEL ANALIZY I ZARZĄDZANIA ZAUFANIEM PACJENTÓW DO PERSONELU MEDYCZNEGO PLACÓWEK PODSTAWOWEJ OPIEKI ZDROWOTNEJ Streszczenie: W pracy przeprowadzono badania nad opracowaniem modelu analizy intelektualnej w celu określenia poziomu zaufania pacjentów do personelu medycznego instytucji podstawowej opieki zdrowotnej, dla skutecznej strategii i zarządzania na przykładzie krajów Grupy Wyszehradzkiej (Czechy, Węgry, Polska, Słowacja). W badaniach wykorzystano nowoczesne metody gromadzenia i prezentacji wiedzy, stosowane w teorii zbiorów rozmytych, analizie systemowej i ocenie eksperckiej. Główna wartość modelu polega na tym, że bada on kwestię oceny efektywności zarządzania placówkami medycyny podstawowej, biorąc pod uwagę poziom zaufania pacjentów do personelu medycznego. Model daje możliwość kompleksowej analizy regionu i opracowania zaleceń dla władz państwowych w celu stworzenia strategii poprawy jakości medycyny w placówkach ambulatoryjnych. Na poziomie placówek medycyny podstawowej menedżerowie powinni opracować strategie tworzenia warunków, w których zaufanie pacjentów do personelu medycznego będzie rosło. Opracowany model został zweryfikowany i przetestowany na rzeczywistych danych pacjentów podstawowej opieki zdrowotnej w krajach Grupy Wyszehradzkiej. Zilustrowano to przykładem ewaluacji na fragmentach danych w czterech regionach. Słowa kluczowe: zaufanie pacjentów, medycyna podstawowa, efektywność zarządzania, intelektualna analiza wiedzy, modelowanie rozmyte