INTRODUCTION

Healthcare industry has seen recent movement towards continuous

quality improvement and this has gained momentum since 1990.(1)

Avedis Donabedian, often regarded as the Guru of quality

assessment in Health care ,used the idea of goodness to link three closely
interrelated components of health care and developed a basic framework
in which to think about quality improvement efforts.

These three components are:

Technical care: clinical effectiveness.

Interpersonal relationship: Relationship between patients, doctors,

nurses, other professionals and healthcare managers.

Care environment: Accessibility of the service, good appointment

systems, cheerful receptionist and accessory staff.(2)

According to Donabedian’s declaration incorporating patient perception

into quality assessment ,healthcare managers thus incorporate patient
centered care as a major component in the healthcare mission.

Although Donabedian’s theories are accepted in principle, they provide

only a broad outline of how to approach quality in the health service. It
must be remembered that doctors and hospitals do not treat disease alone;
they treat people with or without disease. People have needs other than
diagnosis and therapy. Among the issues that concern them are access to
care, time spent in the waiting room, time for referral to the specialist,
amenities, courtesy, adequate explanations and patient education. Many
of these factors lend themselves to objective measures. Monitoring them

1
is thus essential to establishing the perception of high quality programme.
(2)

The healthcare managers that endeavor to achieve excellence take patient

perception into account when designing the strategies for quality
improvement of care. Recently, the healthcare regulators shifted towards
a market driven approach of turning patient satisfaction surveys into a
quality improvement tool for overall organizational performance.(3)

Patient satisfaction survey are essential in obtaining a comprehensive

understanding of patient’s needs and their opinion of the services
received. It is a vital tool in evaluating the quality of healthcare delivery
service of the hospital.

The current study is cross sectional descriptive research about assessment

of patient satisfaction attending outpatient department of Bharati hospital
and Research Centre, Pune.

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Rationale of the study:

Patient satisfaction is one of the essential indicators of the effectiveness

and efficiencies of the organizations and staff. From that view, the patient
satisfaction survey is an instrument in monitoring the health care delivery
of the hospital in relation to cost and services. Specifically, outpatient
department is the first line healthcare consultation service that comes in
contact with the patients. Therefore the quality of care delivered in
outpatient department will indicate the quality of services of the hospital
overall, as perceived by the patients regarding various factors.

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 AIMS AND OBJECTIVES

1. To study the level of satisfaction of patient attending OPD on

various parameters.

2. To find out causes of dissatisfaction.

3. To suggest remedial measures to correct the dissatisfying causes and

improve patient centered care.

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 LITERATURE REVIEW

The concept of patient satisfaction:

There is no consensus between the literatures on how to define the

concept of patient satisfaction in health care. In Donabedian’s quality
measurement model, patient satisfaction is defined as patient reported
outcome measure while the structures and processes of care can be
measured by patient reported experiences .(4 ,5) Many authors tend to have
different perceptions of definitions of patient satisfaction.

Jenkinson C et al (2002) and Ahmed et al (2011) pointed out that patient

satisfaction appears to represent attitude towards care or aspects of care. (6)
while Mohan et al (2011) referred to patient satisfaction as patients’
emotions, feelings and their perception of delivered healthcare services. (7)
Other authors defined patient satisfaction as a degree of congruency
between patient expectation of ideal care and their perceptions of real
care received .(6)

Measurement of patient satisfaction:

Patient’s evaluation of care is a realistic tool to provide opportunity for

improvement ,enhance strategic decision making, reduce cost, meet
patients expectations, frame strategies for effective management, monitor
healthcare performance of health plans and provide benchmarking across
the healthcare institutions.(6,8,9)

In addition due to tendency of healthcare industries to concentrate on

patient centered care ,patient satisfaction reflects patients’ involvement in

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decision making and their role as partners in improving the quality of
health care services.(6).

Mohan et al also deemed the significant correlation between measuring

patient satisfaction and continuity of care where the satisfied patients tend
to comply with the treatment and adhere to the same healthcare
providers.(7) Patient satisfaction represents a key marker of
communication and health related behaviour.

In contrast some of the literature dismiss the patients’ view as a wholly

subjective evaluation and an unreliable judgment of the quality of care.
(4,5,7)

Standardized Questionnaires ,either self-reported or interviewer

administrated or by telephone, have been the most common assessment
tool for conducting patient satisfaction studies .(4)

There is a great variation in questionnaires as instrument of measuring

patient satisfaction. It should be reliable and valid in order to precisely
function and to realize the main goal of collecting patient’s feedback.
However core instrument need to be standardized and need to be
centralized for uniform information collection.(4)

Determinants of patient satisfaction:

In the increasingly competitive market of healthcare industries, healthcare

managers should focus on achieving high or excellent ratings of patient
satisfaction to improve the quality of service delivery; therefore,
healthcare managers need to characterize the factors influencing patient
satisfaction which are used as a means to assess the quality of healthcare
delivery.(4)

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In order to understand various factors affecting patient satisfaction,
researchers have explored various dimensions of the perceived service
quality, as a meaningful and essential measures of patient perception of
healthcare quality.

Kaneet et al (1997) and Markley et al stated that measuring satisfaction

should “incorporate dimensions of technical, interpersonal, social and
moral aspects of care.(3)

Many studies have stated correlation between demographic factors such

as age, gender, health status and level of education with patient
satisfaction; however the health status of the patients is an important
predictor of overall satisfaction. These factors are not modifiable and are
impractical for healthcare managers to improve patient satisfaction.

Though these characteristics should be considered for fair adjustment of

patient centered care policies; the multidimensional attributes of
healthcare settings are the most important determinants for improving the
overall patient satisfaction. Healthcare managers need to direct more
efforts towards those highly ranked attributes and initiate some
improvement strategies in other areas of health services that are
unsatisfactory from the patient’s perspective.(4)

Experience of the patients with OPD services:

Experience was defined as the feeling and self judgment the patients
gained from the involvement in the healthcare delivery process in the
OPD premises focusing on physical facilities, physician’s services,
nurses’ services, pharmacy services, registration and reception services.

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Physical facilities: Tangible facilities such as ease of location,
department’s cleanliness and tidiness, arrangement, lighting and
ventilation, waiting area, sanitary rest room and adequate area space.

Physician’s services: Referred to Physician’s communication and

consultation skills such as self-introduction, effective consultation
techniques, attentiveness, time management, physician’s punctuation etc.

Nurses’ services: Referred to the Nurses communication and assistance

skills such as polite and respectful manner towards the patients, feedback
to patient’s questions, patient referring process and nurses punctuation
and involvement in patients’ and caretakers health education.

Pharmacy services : Referred to the respect and attention shown by

pharmacy staff, drug preparation and explanation, adequate amount of
drugs and replacement policies.

Registration services: Referred to the respect and politeness shown by

registration staff and punctuation.

Accessibility of services: as the ease of access to the services resulting

from effectiveness of working time, working schedule and service
procedure designation.

Waiting time: Referred to the duration of time patients spent waiting for
receiving receipt, consultation services and drugs.

Service procedure: Referred to the effectiveness of the service process in

terms of time and good coordination between relevant departments

A remarkable outcome of four studies conducted in tertiary hospitals in

different countries revealed that the nurses care, respect, careful listening,
easy access of care was particularly the strongest driver of overall patient

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satisfaction. These aspects of nursing care are highly ranked by patients
compared to the other independent factors such as physicians’ care,
admission process, physical environment and cleanliness. (4,11) Also the
nurse work environment and patient nurse staffing ratio had statistically
significant effects on patient satisfaction and recommendations. (4)

In 2011,Otani et al surveyed 32 different large tertiary hospitals in the

USA to identify the relationship of nursing care, Physician’s care and
physical environment to overall patient satisfaction and results showed
that all attributes were statistically significant and positively related to
overall patient satisfaction. However Nursing care was the most critical to
increase patient satisfaction. The researchers also found that the courtesy
and respect of healthcare providers impact more on patient satisfaction
while communication and explanation are the second most important
aspect.(10)

A survey conducted in Ireland in 13 acute care hospitals revealed that

effective communication and clear explanation had the strongest impact
in improving the overall patient satisfaction among other attributes of
medical care.(12)

Three other studies found that interpersonal communication skills of

physicians in terms of their attitude, explanation of conditions, level of
respect for patient preferences and involving patients in decision making
are were more influential factors than clinical competence and hospital
tangibles on patient satisfaction.(9,13)

There are some other studies which make contrary comments about
patient satisfaction regarding hospital living arrangements and amenities
which scored lowest for a patient satisfaction index in a study carried out
in outpatient department in south Korea. (11) In outpatient departments, the

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long waiting time and overcrowded registration were the common
dissatisfying factors in a study carried out by Arshad et al in 2012. (14)

Impact of satisfaction surveys on hospital quality improvements:

Over past 20 years, patient satisfaction surveys have gained increasing

attention; however there is little published research on improvements
resulting from feedback information of patients satisfaction surveys.

Although feedback from patient satisfaction surveys is established

yardstick for healthcare quality improvement plans, they are still not
being systematically and extensively utilized for developing improvement
initiatives. There is a need for healthcare managers to implement
effective changes by unfreezing old behaviour, introducing new ones and
refreezing them for better healthcare.(15)

Short Form Patient Satisfaction Questionnaire (PSQ-18):

(Reference: The Patient Satisfaction Questionnaire Short Form By Grant

N Marshall, Ron D Hays.1994)

Recognizing the importance of patient satisfaction in assessing the quality

of medical care, Ware and his colleagues developed the Patient
Satisfaction Questionnaire, PSQ. in 1976. In subsequent years, revision of
the instrument has been fielded in various national surveys. The most
recent version is PSQ-III, consists of 50 items tapping global satisfaction
of all aspects of medical care.

PSQ-18 is a short form version of Patient satisfaction Questionnaire III.

The short form instrument contains 18 items tapping each of the seven
dimensions of satisfaction with medical care. This abbreviated, yet

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reliable and valid version of PSQ would increase the ease with which
patient satisfaction could be measured and encourage its assessment for
monitoring the delivery of medical care.

These questions are about how you feel about the medical care you
receive.

The PSQ-18 yields separate scores for each of these 7 subscales:

General satisfaction, technical quality, communication, interpersonal

manner, financial aspects, time spent with the doctor, accessibility and
convenience.

Some PSQ-18 items are worded so that agreement reflects satisfaction

with the medical care, whereas other are worded so that agreement
reflects dissatisfaction with medical care. All items should be scored so
that high scores reflect high level of satisfaction with medical care.

After item scoring, items within the same subscales should be averaged
together to create the 7 subscale scores. Scale scores represent the
average for all items in the scale that were answered.

Need for quality assessment in Healthcare industry:

In today’s era of internet and medical tourism, people are beginning to

judge healthcare services by comparing them to the improved services
they have come across in other sectors. If a health service responds to
patients needs and expectations, it attracts more patients and thus more
income.

The cost of dissatisfied patient is high. In competitive markets, raising

satisfaction is necessary to securing income. Actively seeking out what
patients want and providing it is essential for survival.

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This is explained by Ice-berg phenomenon.

1% of clients make a formal complaint.10% don’t complain but go

somewhere else (lost income, difficult to win clients back) Each of these
10% clients tell others of their dissatisfaction. Others prefer to go
elsewhere. (More lost income, bad reputation takes years to overcome)

Patient satisfaction is though not a clearly defined concept; it is identified

as an important quality outcome indicator to measure success of the
service delivery system. Patient evaluation of care is important to provide
opportunity for improvement such as strategic framing of health plans,
which sometimes exceed patients expectations and benchmarking .A
standardized tool needs to be further developed and refined in order to
reflect positively on the main goals of patient satisfaction survey. This
literature review provides a comprehensive understanding of
determinants of patient satisfaction either dependent or independent
variables and compares the magnitude of the effects of various healthcare
dimensions on overall patient satisfaction. Thus provides opportunity for
organization managers and policy makers to yield a better understanding
of patient’s reviews and perceptions.

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 METHODOLOGY

It is a cross sectional questionnaire based study carried out among

patients who attended various outpatient departments.

Study population : 50 patients attending various outpatient departments.

Study period: 15 days (15 Jan 2015 to 31 st Jan 2015)

Data was analyzed to determine score and dissatisfying factors.

Inclusion criteria:

1. The patients attending OPD of all departments in Bharati Hospital

2. The patients who are willing to give consent

Exclusion criteria:

1. Those patients not willing for review

2. Minor patients ( age less than 18 yrs)

3. Patients with psychiatric illness.

1. 4 .patients who needed emergency services.

A systematic random sampling technique was used to select respondents

from among outpatient departments.

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Permission to conduct such study was taken from Medical Director of the
Hospital.

All the patients were interviewed while leaving the OPD facility after
getting the consultation done.

The consulting physician and health facility staff were largely kept
unaware of the procedure to avoid bias of their behaviour with the
patient.

Bharati Hospital and research center :

It is a tertiary care hospital with Medical College under Bharati

Vidyapeeth Deemed University, Pune having Grade-A accreditation.

It has all the clinical, para-clinical departments, nursing college, well

equipped pathology laboratory, blood bank, cardiac cath- ab, different
intensive care units and rehabilitation centre.

Questionnaire:

A predesigned pretested patient satisfaction questionnaire form was

designed and filled up to evaluate several aspects of medical care. It
comprised of total 15 items, which measure different core dimensions of
outpatient care like reception area, paring facility, paramedical staff,
behaviour of healthcare providers. The Questionnaire consisted of five
point Likert scale items with 1 to 5 indicating the highest and lowest
levels of satisfaction respectively. Those who chose very poor and poor
were considered dissatisfied while those who selected average, good and
very good were considered satisfied.

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Questionnaire:

Ver Very
poo Fai Goo
No y Goo
Question r r d
. poor d
1 2 3 4 5
A Reception area
1 Appearance and convenience
at reception area
2 Parking facility
3 Ease of registration
4 How do you rate the
appearance of the Hospital
5 Staff at reception area
B Out patient department
1 Friendliness and courtesy of
care provider
2 Explanation the care provider
gave you about your problem
3 Concern the care provider
showed for your questions and
worries
4 Care providers efforts to
include you in the decisions
about your treatment
5 Information the care provider
gave you about your
medication and follow up care
6 Degree to which care provider
talked with you using the
words that you understand
7 Amount of time the care
provider spent with you
8 Your confidence in care
provider
9 Was the nursing staff and
office staff polite and helpful
10 Likelihood of you
recommending this facility to
others

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Any specific comments:

RESULTS

A total 50 patients were interviewed in this study using Questionnaire

based feedback.

In this study it was found that there was high level of satisfaction with
physician related aspects that is courtesy and respect given by treating
physician,overall time duration,skills of the doctor,care,problem solving
capacity,behaviour of treating physician; whereas comparatively low
level of satisfaction was found regarding reception staff , parking facility,
nursing care.

Table 1: Rating of Reception Area:

Ver Very
poo Fai Goo
NO y Goo
r r d
. poor d
1 2 3 4 5

A Reception area

Appearance and convenience

1 2 3 11 15 19
at reception area

2 Parking facility 9 13 10 10 8

3 Ease of registration 1 5 15 19 10

How do you rate the

4 0 3 11 27 9
appearance of the Hospital

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 5 Staff at reception area 1 2 18 23 6

A} 1) Appearance and convenience at reception area:

Out of 50 patients surveyed, 38% responded regarding the appearance of

reception area as very good, 30% responded as good and 22% responded
as fair appearance of reception area. Only 4% responded as very poor.
Appearance of reception area.

2) Parking facility:

This was the crucial factor of this study where 26% responded as poor
parking facility, 18% of the patients responded as very poor parking
facility. Only 20% responded as fair and good parking facility each while
16% of the patients gave the review as very good parking facility. Thus
suggesting that this factor needs considerable improvement so as to
maximize the patient centered care.

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3) Ease of Registration:

Out of 50 patients, 38% of the patients reviewed registration process as

a good facility without much inconvenience, 30% rated as average While
20% as very good facility of registration process. Only 10% rated
registration process as poor facility which lacks coordination and poor
behaviour of reception staff.

4) Appearance of the Hospital:

Overall appearance and amenities in the hospital were rated as very good
by 18% of patients while 54% rated as good appearance of the facilities
and cleanliness was also good. 22% rated as average appearance. Only
6% rated as poor appearance and available facilities in the hospital which
needs rectification.

5) Staff at reception area:

46% of the patients responded as good behaviour in terms of politeness

and helpful nature of the staff at reception area.12% of the patients rated
the reception staff as very good while 36% of the patients rated as
average stating the need for developing more courtesy and respect
regarding patients’ queries. Only 6% rated as poor behaviour and attitude
of the reception staff.

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Table2: Rating of Treating Physician in OPD and Nursing staff.

1 2 3 4 5
Ver
Ver Poo
B Out patient department fai goo y
y r
r d goo
poor
d

Friendliness and courtesy of care

1 1 2 12 26 9
provider

Explanation the care provider

2 3 2 10 25 10
gave you about your problem

Concern the care provider

3 showed for your questions and 2 2 12 25 9
worries
Care providers efforts to include
4 you in the decisions about your 0 1 14 25 10
treatment
Information the care provider
5 gave you about your medication 0 1 17 21 11
and follow up care
Degree to which care provider
6 talked with you using the words 0 0 7 31 12
that you understand

Amount of time the care

7 0 2 13 25 10
provider spent with you

8 Your confidence in care provider 1 3 12 24 10

Was the nursing staff and office

9 3 6 12 20 9
staff polite and helpful

Likelihood of you
10 recommending this facility to 2 1 12 28 7
others

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B} 1) Friendliness and courtesy of care provider:

Out of 50 patients 52% rated as good and 18% rated as very good
behaviour and attitude of the physicians. 24% of the patients rated as
average nature while only 6% of the patients rated as poor behaviour and
courtesy on the part of the treating physician.

2) Explanation the care provider gave about the problem:

50% of the patient responded as good and 20% as very good regarding
explanation and treatment options explained by the physician regarding
particular illness. 20% patients stated average explanation given by the
physician while only 10% rated as poor empathy by the treating physician

3) Concern the care provider showed about questions and worries of

patient:

Majority of patients that is 50% appreciated the concern shown by the

physician as good, 18% as very good. Only 24% of the patients gave the
opinion as average concern shown by the care provider and 8%of the
patients mentioned as poor concern shown by the treating physician.

4) Care provider’s efforts to include patient in decision about treatment

50% of the patients that means majority rated as good and 20% as very
good regarding the efforts of the physician to include the patient in the
decision making about the treatment and well explained the different
modalities of the treatment and possible required finances also. 28%
patients rated average performance regarding this point and only 2% as
poor efforts to include in the decision.

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5) Information he care provider gave about medication and follow up
care:

Out of 50 patients, 22% stated that information given by the physician as

very good, 42% stated as good while 34% mentioned that it was average.
Only 2% of the patients mentioned as poor rating regarding knowledge
given by the physician.

6) Degree to which care provider talked with you using words that patient
understands:

Majority that is 62% of the patients gave a good opinion about the
interaction and understanding language used by the physician, 24% as
very good while only 14% gave as average communication.

7) Amount of time the care provider spent with patient:

Regarding this point 20% of the patients opined as very good while 50 %
of the patients opined that the physician spent sufficient amount of time
with the patient. 26% of patients mentioned it was average. Only 4% of
the patients opined as not enough time was given for examination and
testing.

8) Your confidence in care provider:

48% of the patients had a good confidence in the care provider and the
hospital.20% had very good while 24% of the patients rated it as average
and opined that communication and care should improve. Only 8% of the
patients had poor confidence in the care provider and need to seek
another healthcare facility.

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9) Nursing and office staff polite and helpful:

Out of 50 patients 49% had a good opinion about the nursing staff. 18%
of the patients appreciated the nursing care while 24% rated the nursing
care as average. Total 18% of patients rated the nursing care and office
staff as poor and need for education and sensitization regarding patient
centered care.

10) Likelihood of you recommending this hospital to others:

Out of 50 patients 56% patients gave the opinion of good chances of

recommendation, 14% opined very good chances and 24% had fair
chances of recommendation of this hospital services to others. Only 6%
had very less chances of recommendation.

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 DISCUSSION

Patients as customers are capable of assessing the quality of care they

receive as they pay attention to all the components of care ,science of
medicine, art of care, amenities of care and finally the attitude of care
providers. Patient satisfaction survey is essential in obtaining a
comprehensive understanding of the patients needs and their opinion of
the services received .Patient satisfaction is an important tool for total
quality management, research and administration.

In this study we have conducted survey of 50 patients attending

outpatient department of Bharati Hospital and Research center, which is a
tertiary care hospital. It was found that there was high level of satisfaction
with physician related aspects that is courtesy and respect given by
treating physician, overall time duration, skills of the doctor, care,
problem solving capacity, behaviour of treating physician; whereas
comparatively low level of satisfaction was found regarding reception
staff , parking facility, nursing care. Out of 50 patients 33 patients were
highly satisfied (66%), 25 patients rated the hospital services as
average.44% patients were not satisfied with parking facility while 18%
patients were unsatisfied with nursing and office staff.

In the similar study conducted on a sample of outpatient Department at

Pakistan Institute of Medical Science, Islamabad by Anjum Javed in
2005 ,out of 200 randomly selected patients ,108 had high level of
satisfaction. Medical expense, registration service and nurse’s services
were perceived as good by 81%,77.5% and 76.5% respectively while
pharmacy service ,medical equipment, doctor’s service and physical

24
facilities were relatively less satisfied by 65%,65%,61.5% and 53%
respectively.(16)

In another study conducted by Gupta et al at a rural health training centre,

Bareily, out of total 354 OPD patients, majority of patients (61%) were
satisfied with doctor’s behaviour and also felt that doctors have given
sufficient time to see the patients.(17) More similar finding was also
reported by Arshad A.S. Et al (66%)(14)

25
 SUMMARY AND CONCLUSION

Patients receiving each hospital service are responsible for conveying the
good image of the hospital; therefore, securing high level of satisfaction
of patients attending the hospital is equally important for a hospital
management team.

Now a days patients are looking towards health care as health services,
which should be quick, hassel free up to date and must be of good quality.
This demand is possible with optimum utilization of resources and proper
administrative policies.

Monitoring patient satisfaction as a tool for quality assessment has some

advantages over clinical evaluation; as satisfaction indicators remain
stable over time as oppose to clinical indicators which will be changed
with technology and pace of medical progress.

In current pilot study in this particular hospital, it was found that the
majority of respondents were moderately satisfied with the services
offered but parking facility and nursing staff behaviour was found to be
poor, needs to be explored to elicit the lacunae.

It is beneficial to understand that there is a opportunity for the

improvement of the outpatient department service. Hence, it can be
concluded that the outpatient services form a vital element to draw a good
image of the hospital services and patients’ opinion are essential in
quality improvement.

As the high level of satisfaction was seen with treating physician’s

attitude and patient centered care, clinicians should be involved in policy
making by the managing authority.

26
Based on the result of this study, training of code of conduct and courtesy
should be given to both clinical and office staff. Incentives and
punishments should be carried out based on regular performance reviews.
It is also evident that the satisfaction level of patients attending the
outpatient department should be assessed periodically.

Further scope of this study can be extended to staff satisfaction, nurses

job satisfaction, inpatient satisfaction, individual department level and
different hospital services.

Recommendations:

The medical and paramedical staff including nursing staff should be

motivated frequently by conducting CMEs, seminars, sensitization
workshops periodically.

Medical and Nursing audits can be introduced to improve the quality of

medical care and to reduce the cost to the patient.

The work of Housekeeping staff should be properly supervised by the

authority.

Parking facility should be improved and should be cost effective.

Methods of getting daily feedback like creating suggestion box, hospital

website, patient information centre should be created.

Implementation of Patient centered care and relation between patient

centered care and improved patient outcome confirm that patient centered
care is expected to improve patient outcome by increasing the patient’s
self-care ability and improving satisfaction with care and quality of life.

27
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