Patient Satisfaction Among the OPD Attendees at a Secondary Care Hospital in Northern India.

Patient satisfaction reflects the quality and effectiveness of healthcare. Healthcare services have become more patient-centric in today's era as patients are viewed as active consumers of healthcare services rather than passive recipients. Measuring patient satisfaction level has become an objective criterion for defining the effectiveness of these services. Feedback from patients makes healthcare services more responsive to the expectations of patients. We conducted a cross-sectional study among 200 OPD attendees of a secondary-care hospital to assess the level of satisfaction. A 5-point Likert scale was used to record the responses. For overall satisfaction with the OPD services, most common responses were "good" or "very-good", with mean (SD) score of 3.8 (0.77). Majority of the patients were satisfied with facilities such as drinking water and toilets, and with consultation time provided by the doctors. The patients were not satisfied with the time taken at the registration window and behavior of other hospital employees. This highlights the importance of reorientation training on communication and interpersonal skills for all categories of healthcare staff.

Introduction

Patient satisfaction may be defined as “the extent to which a patient is content with the healthcare provided” (1). Patients have certain expectations regarding provision of healthcare delivery when they approach a healthcare center. Patient satisfaction is a special form of attitude which reflects the extent to which a patient liked or disliked the services after having experienced them. Healthcare services have become more patient-centric in today’s era and measuring patient satisfaction level has become an objective criterion for defining the effectiveness of these services. Quality of health services has been traditionally based on professional practice standards. The concepts of patient satisfaction gained increasing importance since 1970s. Subsequently, the patients were viewed as active consumers of health services rather than passive recipients, and the patient feedback became an essential area that guided improvements in healthcare services (2).

Patient satisfaction is simultaneously multidimensional and subjective. It is influenced by a number of factors such as the quality of clinical services delivered, maintenance of cleanliness, hospital infrastructure, supply and availability of medicines, behavior of doctors and other healthcare professionals, emotionally and physically comfortable environment, and cost of services provided (3, 4). The level of patient satisfaction is a determinant of compliance to treatment, improved clinical outcomes, and improved service utilization (5).

Currently, enhanced awareness of patients' rights has greatly influenced their expectations for patient satisfaction. Assessment of patient perspectives makes public health services more responsive to the requirements and expectations of patients. Patient satisfaction surveys help in identifying potential problems, and help in establishing accountability. Thus, the present study was carried out to assess the patient satisfaction level among the out-patient department (OPD) attendees at a secondary care hospital in district Faridabad in northern India.

Methodology

Study Design: Cross-sectional study among patients attending OPD of a secondary care hospital.

Study Backdrop: The healthcare facility was a Sub-District Hospital (SDH) in district Faridabad, Haryana. This hospital was a joint collaboration between the All India Institute of Medical Sciences (AIIMS), New Delhi, and the state Government of Haryana (6).

The OPD Block was a newly constructed 2 storied building that was fully air-conditioned. An adjacent single storied old building was repurposed as patient registration counter that had a small holding area where ceiling fan was available. Patient registration had 3 windows; 1 each for male, female, and elderly. Registration for morning shift started at 8.00 AM and at 1.30 PM for evening shift of the OPD.

The hospital pharmacy dispensed a large variety (> 50) of medicines free of cost to all patients. Most of the laboratory tests were either free or charged at nominal cost.

The medical services at the OPD were provided exclusively by the AIIMS staff which included faculty members, senior and junior residents, and Interns. The para-medical staff belonged both to AIIMS as well as Haryana Government. All patients, except antenatal women and follow-up patients with hypertension/diabetes, were attended in the morning shift of the OPD. On an average about 700 patients attended morning OPD and 300 the afternoon OPD.

Sample Size

The sample size calculation was based on the study conducted by Goel et al in the health facilities in North India (7). The reported patient satisfaction was 87.8%. Considering this proportion, with absolute precision of 5% at 95% confidence interval, we calculated a sample size of 187 which was rounded off to 200.

Sampling Technique

Systematic random sampling technique was used to select the study participants. Every 10th registered patient was enrolled in the study. The study was conducted among adult patients attending the OPD.

Since majority of the patients attend the morning OPD, we included 60% of calculated sample size from there. The remaining participants were enrolled from the afternoon OPD (20% each from NCD clinic and ANC clinic).

Study Tool

The questionnaire for data collection was prepared after reviewing the existing literature on patient satisfaction studies conducted globally. The relevant guidelines and documents prepared by the Ministry of Health and Family Welfare were also reviewed (8, 9). The questionnaire included the following parameters: (i) registration process, (ii) public facilities in the waiting area such as clean toilets, drinking water, adequate space, (iii) services provided by the doctor, (iv) experience at the pharmacy, (v) experience at the laboratory, (vi) behavior of staff with patients, (vii) availability of the prescribed medicines. Demographic information of participants was also obtained.

Data Collection

Literate participant filled the questionnaire themselves. However, face-to-face interview was conducted by a trained nurse for illiterate participants.

Scoring System

Patient rated each parameter on a 5-point Likert scale. The grading ranged from 1 to 5 which corresponded to poor, fair, average, good, and excellent, respectively. Individual rating for each parameter was summated and the overall average rating by the respondent was calculated. Responses rated as “good”, “very good,” and “excellent” were later clubbed together and was considered as “acceptable,” whereas “fair” and “poor” combined were considered as “unacceptable” rating that needed improvement.

Data Analysis

Data were analyzed using SPSS version 22 for windows. For the numerical data, descriptive statistics including mean, standard deviation, and percentages were calculated.

Ethical Considerations

The study protocol was approved by the institutional Ethics Committee of All India Institute of Medical Sciences, New Delhi. Informed consent was obtained from all participants. Confidentiality of the information was maintained.

Results

A total of 187 participants completed the questionnaire. Out of these, 107 (57.2%) participants were from morning OPD, while 40 participants (21.4%) each were enrolled from the afternoon OPD. Majority (79.1%) of participants were female. The mean age of the participants was 33.17 ± 14.45 years. Most of the participants (62%) were in the age group 20 to 39 years.

Majority of the patients (72.8%) rated the overall OPD service either as “good” (28.4%) or “very good” (44.4%). The mean (SD) score for all parameters taken together was 3.8 (0.77). The mean score for majority of the parameters was 3 or more. A score less than 3 was recorded for 2 parameters viz. waiting time at the registration window, and the behavior and attitude of the hospital staff (Table 1). For the parameters “communication and explanation by the doctor” and “time given in examination” most of the participants rated “very good” (44.9%) and “good”(33.7%), respectively. Nearly half of the participants (47.6%) reported that “public facilities in the waiting area were ‘very good’”. “Availability of diagnostic facilities” and “availability of medicines” were rated “good” by majority of the participants (Table 2).

Table 1.

Distribution of Mean (SD) Scores for Various Parameters of Patient Satisfaction.

Parameter	Score, Mean (SD)
Availability of adequate information in hospital	3.7 (0.82)
Waiting time at the registration window	2.3 (0.55)
Behavior and attitude of hospital employee	2.1 (0.59)
Facilities in the waiting area	3.8 (0.74)
Communication and explanation by doctor and their attitude towards	3.5 (0.68)
Time given in examining and explaining about sickness and other things	3.3 (0.74)
Availability of investigations and diagnostic facilities inside hospital	3.3 (0.69)
Availability of medicines prescribed in the hospital	2.8 (0.66)
Promptness in drug distribution	3.0 (0.60)
Overall satisfaction	3.8 (0.77)

Table 2.

Level of Satisfaction Regarding Various Parameters Among the Study Participants.

	Unacceptable		Acceptable			Total n (%)
Parameter	Poor n (%)	Fair n (%)	Good n (%)	Very Goodn (%)	Excellentn (%)
Availability of adequate information in hospital	1 (0.5)	22 (11.8)	77 (41.2)	57 (30.5)	30 (16.0)	187 (100)
Waiting time at the registration window	6 (3.2)	89 (47.6)	52 (27.8)	26 (13.9)	14 (7.5)	187 (100)
Behavior and attitude of hospital employee	7 (3.8)	83 (44.4)	44 (23.5)	38 (20.3)	15 (8.0)	187 (100)
Facilities in the waiting area	3 (1.6)	16 (8.6)	53 (28.3)	89 (47.6)	26 (13.9)	187 (100)
Communication and explanation by doctor and their attitude towards	0 (0)	13 (7.0)	63 (33.7)	84 (44.9)	27 (14.4)	187 (100)
Time given in examining and explaining about sickness and other things	5 (2.7)	23 (12.3)	77 (41.2)	64 (34.2)	18 (9.6)	187 (100)
Availability of investigations and diagnostic facilities inside hospital	0 (0)	29 (15.5)	89 (47.6)	55 (29.4)	14 (7.5)	187 (100)
Availability of medicines prescribed in the hospital	2 (1.1)	61 (32.6)	79 (42.2)	31 (16.6)	14 (7.5)	187 (100)
Promptness in drug distribution	1 (0.5)	40 (21.4)	76 (41.2)	51 (27.3)	18 (9.6)	187 (100)
Overall satisfaction	1 (0.5)	16 (8.6)	53 (28.4)	83 (44.4)	34 (18.2)	187 (100)

Discussion

Patient satisfaction is as an important parameter for assessing the quality of healthcare services. Satisfaction regarding the attitude of providers toward these is known to affect treatment outcome and prognosis.

In our study, almost three-quarters of participants felt that OPD service were either “good” or “very good.” Similar findings have been reported by other authors as well (4, 5, 7, 10, 11). Kulkarni et al (10) reported that majority (68%) of the OPD attendees were unsatisfied with public facilities such as toilet and drinking water in the waiting area. Panda et al (12) reported that majority of the participants in their study were unsatisfied with public facilities. Goel et al (7) reported that the physical environment, including public facilities were important determinants of patient satisfaction. In contrast, most of the participants in our study rated the public facilities, including water and sanitation, as “good” and above. Geberu et al in a study conducted in OPDs in public hospitals of Ethiopia also highlighted that availability of latrines was an important determinant of patient satisfaction (13). Patients spend substantial amount of time awaiting their turn to be attended. During the waiting period patients are likely to use toilet and drinking water facility. We ensured that the toilets were cleaned on an hourly basis which could have resulted in higher rating by the patients.

Consultation time spent with doctor is another important attribute to determine satisfaction level among patients. In the present study, majority of patients in their response to communication and explanation by the doctor, and the time devoted to examining “good” or above level of satisfaction. These findings are consistent with findings of study by Panda et al (2018) (12), Gupta et al (2014) (14), and Goel et al (2000) (7). It suggests the role of communication by doctor in quality health care. Consultation time was reported to be satisfactory in studies by Mohd. et al among the armed forces in India (15), and by Poudel et al in Nepal. However, in Nepal, availability of doctors was reported as an area of concern (16).

In our study, about half the patients rated waiting time at the registration counter as unacceptable (ie, “fair” or “poor”). The possible reason for the poor rating could be due to the fact that though the registration window opened at 8.00 AM, many patients queued up much before that time so that they could be attended early. This may be addressed by streamlining the registration process, and by increasing the waiting space along with better ambience and patient amenities.

“Behavior and attitude of other hospital staff” was another parameter where the rating was “unacceptable,” that is, either “fair” or “poor.” Courteousness and communication skills of the hospital staff are the key attributes towards patient’s satisfaction (17). It is apparent that all categories of employees including paramedical staff, needed reorientation training on communication skills, and ways to improve their behavior and attitude.

Limitations

As the patients were interviewed in a health facility, so social desirability bias cannot be ruled out. The study would have offered more valuable findings with respondents of different ages and demographics, and their comparison in terms of patient satisfaction, expectations, and experiences. Majority of the patient were not satisfied with behavior and attitude of staff at the registration counter, however, a quantitative study is unable to tease out such nuances. Hence, we propose that a qualitative study should follow up the quantitative study.

Conclusions and Implications

Majority of patients using out-patient services were satisfied with the health care received, and with facilities such as drinking water and clean toilets. Majority of participants felt that the consultation time given by doctors was adequate. However, most of the patients were dissatisfied with long time taken at the registration window. The registration process needs to be streamlined to reduce the waiting period. Similarly, majority of the participants reported that behavior of hospital staff was unsatisfactory. This highlights the need of reorientation training in communication and interpersonal skills for all categories of health care staff.