A Survey Assessing Patient Satisfaction

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					A Survey Assessing Patient Satisfaction at Public               satisfaction between these groups and find out if there are
      and Private Healthcare Facilities in                      any correlations with the type of the facility and the
            Riyadh, Saudi Arabia                                satisfaction level of the patient.

    To the Editor: Quality is a process of meeting the
needs and expectations of the customers. One should,            Population and Sample
therefore, study the needs and expectations of customers,           The target population of this study was composed of
and every effort should be made to meet them. Although          patients attending two MOH and five private hospitals
quality has many perspectives, each customer has                (the number of private hospitals was increased because
specific needs and expectations and the goal is for these       they have fewer inpatients) and five MOH PHC centers
expectations to be fulfilled by the provider organization.      in Riyadh, Saudi Arabia.          A sample of patients
One method for the identification of customer needs and         representative of those attending the facilities were
expectations is a satisfaction survey. Any system has           selected using stratified random sampling techniques.
three components: inputs, processes and outputs. Outputs        Only inpatients with at least a 3 day stay were included
and outcomes are the results of the processes and the           in the study. A structured questionnaire was developed
activities of the system. One measure of this component         and 500 were distributed to hospitals and 500 to PHC
is the rate of satisfaction of the users of the system. In      centers. Of the 500 hospital questionnaires sent out, 392
healthcare, the ultimate user of the system is the patient      (78.4%) were returned and used in the analysis. From the
and thus, the patient survey is the method most                 PHC centers 408 questionnaires (81.6%) were returned
appropriate to measure satisfaction with outputs and            and validated.
outcomes of the system.
    The field of patient satisfaction surveying is growing.     The Instrument
With most of the accrediting bodies such as JACHO,                  The study instrument consisted of two parts. Part one
NCQA, AAAHC and URAC requiring survey results to                included questions on demographic information with one
be reported on a regular basis, mechanisms for                  satisfaction question asking whether the patient would
addressing them must be implemented and measured.               likely return to the facility a second time. Satisfaction
This emphasis on patient satisfaction has created a new         was assessed in part two by the four-point Likert scale,
type of health care customer, one who is becoming               ranging from 1 strongly disagree to 4 strongly agree.
increasingly intolerant of mediocre care and service.           The satisfaction measures assessed patients’ views about
    Several studies of patient satisfaction in both primary     a variety of important hospital and PHC characteristics,
health care and inpatient settings have shown that patient      including the availability of services, accessibility of the
satisfaction is directly correlated to patient’s expectation,   facilities to patients, the quality of the accommodation,
but not necessarily to clinical outcomes. 1,2,3,4,5 Two         affordability, the quality of facility personnel, including
studies are worthy of note relating to Saudi Arabia (El-        doctors, nurses and other staff, and the cleanliness and
Shabrawy and Mahmoud, 19936; and Mansour and Al-                appearance of the facilities.
Osimy, 19937). Both report on surveys conducted in                  The questionnaire had face validity based on health
Riyadh, Saudi Arabia with patients in primary health care       professional and patient comments, and was determined
(PHC) settings. Using interview methodology, both               to be reliable, having an 88.2% coefficient alpha from
studies collected information from a randomly selected          pilot testing on 10 inpatients and 10 outpatients.
sample of patients regarding satisfaction with care and
services received at the PHC centers.           Both studies
reported patients to be satisfied with their care in general,   Data Analysis
but they were less pleased with the waiting times and the           The analysis included logistic regression analysis to
thoroughness of their visits.                                   assess the volume and direction of the relationships
    This paper describes a study performed to assess            between the independent and dependent (dichotomous
patient satisfaction in Riyadh, Saudi Arabia. Patients          variable) variables. In addition, ordinary least square
were selected from the primary health care and the              regression was used when the dependent variable was
inpatient care sector. Additionally, representations were       continuous, i.e. the composite measure of total score of
sought from both private and public sectors of both             satisfaction. The 5% and 10% level of probability were
settings. The objectives of this paper were to measure          calculated for the inferential statistics. Data were entered
satisfaction at each of the settings and at each of the         and analyzed with the Statistical Package for Social
sectors by each variable identified in terms of service and     Science (SPSS) for Windows.
care. We also sought to measure the difference in
                         Results                               education tended to be more satisfied with factors such as
                                                               the availability of entertainment at their facility (2.24;
    Our analysis focused on assessing the relationships        1.44-3.50), the facility's proximity to their residence
between patient characteristics and level of satisfaction      (1.71; 1.10-2.68), shorter waiting times (1.48; 0.94-2.33),
and previous history with the facility from which they         cost of care (2.05; 1.24-3.40), quality of the doctors
sought care. The description of the results below              (1.57; 0.97-2.53), the cleanliness of the facility (1.72;
highlights those relationships that were found to be           1.09-2.72), and the nationality (1.50; 0.93-2.40) and
statistically significant at the 5% and 10% levels. The        religion of the staff (1.48; 0.94-2.34). Patient age made a
odds ratios and their 95% confidence intervals are             significant difference in reported satisfaction for only
presented for each statistically significant relationship.     two items. Older patients tended to be more satisfied
    The analysis revealed that whether the facility was a      with the availability of entertainment in the facility they
hospital or clinic (provider type), or publicly or privately   attended (1.02; 1.00-1.04), and the religion of the staff
owned (ownership), the source of payment for patients'         (1.02; 1.00-1.04). Living situation did not seem to make
care, and patients' level of education were the factors that   a difference with respect to patient satisfaction. Patients
often significantly impacted on their satisfaction with the    who were married as well as those who lived alone
various aspects of care investigated in the study. Patients    tended to be dissatisfied with the facilities they attended.
attending primary care clinics were more likely than           Both married patients and those living alone tended to be
those attending hospitals to be satisfied with the             dissatisfied with the availability of providers of the same
availability of providers and services and their ease of       sex, and the proximity of the facility to their residence.
access to the facility. In particular, clinic patients were    Patient family size was significantly related to only one
significantly satisfied with the availability of specialists   satisfaction item. Patients coming from large families
(odds ratio, 3.82; 95% CI, 2.22-6.57), felt the facility       tended to be more satisfied with the appropriateness of
was sufficiently high tech (4.00; 2.30-6.93), appreciated      appointments to the facility they attended (1.12; 1.04-
the presence of Saudi doctors (1.96; 1.18-3.25), were          1.20).
satisfied with the quality of the non-physician and nurse          The employment status of patients made a significant
staff (3.03; 1.71-5.39), had family living near by (1.75;      difference in reported satisfaction in six areas. Employed
1.02-3.01), and had attended the facility because they had     patients were more satisfied with how close their facility
heard good things about it from others (12.62; 1.56-4.38)      was to family living near by (2.02; 1.13-3.61), the
or a family member had a previous positive experience          technological sophistication of the facility (1.62; 0.92-
with the facility (1.66; 0.98-2.81). Specifically they did     2.85), the presence of Saudi doctors (3.16; 1.81-5.50), the
not think their facility was located sufficiently close to     quality of the nursing staff (2.27; 1.27-4.05), and felt the
their residence (0.42; 0.25-0.70), were dissatisfied with      cost of care was appropriate (1.73; 0.96-3.10). They
the scheduling of appointments (0.50; 0.30-0.84), felt         were, however, not satisfied with the religion of the staff
costs were too high (0.50; 029-0.87), and were not happy       at the facilities they visited (0.50; 0.29-0.88).
with the religious make up of the staff (0.36; 0.21-0.60).         The income level of patients as reflected by reported
Patients who attended private institutions were also           salary were significantly related to three items and all in
dissatisfied with most of the factors surveyed in the          a positive direction. Patients with higher salaries were
study. Items they were not significantly dissatisfied with     more likely to be satisfied with the quality of the nursing
included the availability of providers of the same sex, the    staff (2.02; 1.27-3.21), and had a previous positive
ease to get to the facility, the length of waiting time, the   experience as a patient (1.56; 0.97-2.50) or knew of
ease of registration and scheduling of appointments, and       family member who had a previous positive experience
the presence of Saudi doctors.                                 at the facility they attended (1.94; 1.22-3.08). In contrast
    For the most part, individuals who paid for care from      to the responses of patients with higher salaries, those
personal resources or those of family (private pay) were       who reported having a second source of income were
most dissatisfied with the facilities they attended. Private   more likely to be negative about their experiences.
pay patients were significantly dissatisfied with the          Patients with second incomes were significantly
availability of specialists (0.56; 0.34-0.94), the ease of     dissatisfied with the amount of time they had to wait for
registering (0.58; 0.36-0.94), the quality of doctors          service (0.60; 0.33-1.10), the ease with registering (0.56;
available (0.64; 0.38-1.06), the quality of manners (0.54;     0.31-1.00), and felt the cost of care was not appropriate
0.33-0.89), and the religion of facility staff (0.64; 0.39-    (0.53; 0.28-1.03).
1.05). They were satisfied with their ability to move              Patient health status was not significantly related to
around in their facility (0.64; 0.39-1.65), and the            satisfaction with specific aspects of the facilities they
presence of Saudi doctors (1.53; 0.94-2.49).                   attended. However, patients who had poor self-reported
    The relationship between education level, and facets       health status were significantly related to two ‘prior
of patient satisfaction were consistently significantly        history’ factors i.e., more likely to have had a family
positive in direction. Patients with more years of             relationship with a staff member (2.04; 1.23-3.40), and
they felt the hospital had a good reputation (2.09; 1.27-       Khalid M. Alaiban, MPA
3.46). On the other hand, patients with good self-              Badran Al-Omar, MHHA
reported health were significantly less satisfied with the      King Saud University
nationality of the staff at the facility they attended (0.64;   Riyadh, Kingdom of Saudi Arabia
0.39-1.07).                                                     Lutchmie Narine, MSc, PhD
    Of all the patient characteristics only sex did not         University of North Carolina at Charlotte
significantly affect patient responses on any of the items      A. F. Al-Assaf, MD, MPH, CQA
on the satisfaction scale.                                      Fatima Javed, BBA
                                                                University of Oklahoma Health Sciences Center
                        Conclusion                              USA

    The most crucial challenge for all those who work in                               References
healthcare organizations, including those who manage
them, is to ensure an exclusive standard of quality for         1.   Nettlemen, M. Patient satisfaction: what’s new? Clin
their customers, particularly the patients. The importance           Perform Quality Health Care 1998;6:33-7.
of having continuous quality improvement principles             2.   Sisk, J. E., et al. Evaluation of Medicaid managed
must be embedded in the framework of an organization,                care: satisfaction, access, and use. JAMA
in order to attain customer or patient satisfaction.                 1996;275:50-5.
          The study revealed that the factors that most         3.   Holmes-Rovner, M., et al. Patient satisfaction with
often impacted patient satisfaction were the source of               health care decisions: the satisfaction with decision
payment for patient care, and the patient’s level of                 scale. Medical Decision Making 1996; 16:58-64.
education, whether the facility was a hospital or clinic,       4.   O’Connor, A. M. Validation of a decisional conflict
publicly or privately owned. Employment and level of                 scale. Medical Decision Making 16:751-80.
education notably affected the degree of satisfaction, as       5.   Rubin, H. R. Patient’s rating of outpatient visits in
the employed, or more educated individuals were more                 different practice settings. Results from the Medical
satisfied. The patients that were most dissatisfied were             Outcome Study JAMA 1993;270:835-40.
the individuals who paid for their care from personal (or       6.   El Shabrawy, A., & Mahmoud, M. A study of
family) resources (private pay). In general, dissatisfaction         patient satisfaction with primary health care services
occurred in the following areas: availability of                     in Saudi Arabia. J Community Health 1993;
specialists, the ease of registering, the quality of doctors,        18(1):49-54.
the quality of manners and religion of the staff, the           7.   Mansour, A., & Al-Osimy, M. A study of
availability of providers of the same sex, the nationality           satisfaction among primary health care patients in
of the staff, the proximity of the facility to their                 Saudi Arabia. J Community Health 1993; 18(3):163-
residence, the ease of getting to the facility, and the cost         73.
of care.
    Healthcare organizations should focus on the
importance of the care process from the patient’s
viewpoint, by proclaiming patient satisfaction as their
mission, with an underlying emphasis on providing the
best possible care for their patients. To do so, the
management team must rearrange their infrastructure to
reflect patient needs and demands. Satisfaction surveys
are a stepping-stone to evaluating customer needs and
expectations, thus allowing for the formulation of a
policy to accommodate their perspectives. To tackle
dissatisfaction issues effectively, the management team
needs to establish a strategic plan for evaluating
performance. The plan should contain calculated
guidelines for each department to follow, by which they
can systematically measure their compliance levels.
Subsequently, a regular reporting mechanism should be
instituted, one that involves department heads, and in
turn the board of directors. Monitoring levels of
performance helps in understanding how the organization
is performing, and how it can operate better in the future.

Jun Wang Jun Wang Dr
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