Journal of Hospital & Medical Management

Keywords

Patient satisfaction; SWOPS questionnaire; SERVQUAL questionnaire; Urological care

Introduction

One of the most pressing problems facing the health care system continues to be the quality of medical services. In order to determine whether medical treatment meets health care standards, the quality of care must be evaluated. The best programme or therapy is only useful if it meets the needs of the person or group receiving it, the statement said-Avedis Donbedian. Patient satisfaction is considered by many to be a critical indicator of health care quality and is a highly desirable outcome of clinical care in hospitals. According to the Beryl Institute, the term "patient experience" now refers to the totality of contacts throughout the care process that are influenced by an organisation's culture and thus impact patient impressions [1]. Although hospitals have always been involved in patient care, the definition of successful patient care has changed with the advent of value-based purchasing. Without a thorough examination of patient satisfaction, the notion of quality healthcare is incomplete.

The ability of a health care facility to provide quality medical services is evaluated using the criterion of patient satisfaction. Patient satisfaction, along with medical outcomes and health care costs, is therefore an important consideration in evaluating health care services. Patient opinions and perceptions can be an important resource for uncovering a facility's deficiencies and inadequacies and can complement traditional health care quality measures. Patient satisfaction surveys can therefore provide valuable information about problems that need to be addressed in therapeutic facilities. These data can be used as feedback for the clinical team to identify gaps between patient expectations and reality. In this way, patients could receive the best possible care. For this reason, patient satisfaction surveys are now mandatory in developed countries and are a critical measure for assessing the quality of medical care. It could be argued that health care is evolving from simply providing services to assessing and providing the quality of those services. As a result, patient involvement in determining the quality of these services is more evident than ever. It is becoming more common to assess the quality of services from the patient's perspective, and it is widely accepted [2]. Managers can use patient’s expectations and perceptions as an important tool to identify health system vulnerabilities and to maintain and improve the quality of health care services in ways that go beyond economic considerations. Health care providers, therefore, are seeking to use customer-centred assessment procedures. This is the first study conducted with the aim of assessing the quality of health care in the urology department and identifying areas for improvement.

Materials and Methods

This prospective study enrolled a total of 220 adult patients over 18 years of age who presented to the KGMU urology department at their first visit between July 2021 and October 2022. The study was approved by the facility ethics committee (number XI-PGTSC-IIA/P6). Informed consent was obtained from all patients enrolled in this study after explaining the nature of the study to each patient.

A systematic sampling method was used, and of the patients who were eligible and agreed to participate, every fifth patient who presented to the urology consultation during the study period was recruited to the study. If the fifth patient was not willing, the next willing patients were offered participation in the study.

Adult patients registered in the urology department of KGMU between July 2021 and October 2022 was enrolled in the study. A prospective study was conducted. Data were collected using a self-administered questionnaire after explaining the meaning of the questions in the patients' preferred language.

The modified questionnaire SWOPS and the SERVQUAL questionnaire were used to analyse the data. In this study, after intra-departmental discussion with minor modifications, a subset of questions from the two questionnaires was selected and approved for implementation in the study.

The questionnaire SWOPS is a multidimensional ambulatory instrument developed by the Health Services Research Centre at the department of psychology, Royal University of Surgeons in Ireland (RCSI) for use in Irish hospitals. The generic items of the questionnaire form an overall dimension with an α-coefficient of 0.84, and the high reliability coefficient of each of these dimensions allows users to “select” questions without compromising validity. Therefore, the modified questionnaire SWOPS is a valid instrument and was used in this study [3].

All patients included in the study were asked to complete the modified questionnaire SWOPS. Sections included duration of consultation and delay, diagnosis (benign or proven malignant), and whether the consultation was led by a resident only or by a specialist. Patients were also asked to indicate their age and sex and to complete 12 of the questions on the modified SWOPS questionnaire anonymously. Data collection was performed by a separate physician, and the treating physicians were blinded to feedback throughout the study period. Patients' responses to each question were recorded in a Microsoft Excel spreadsheet. The number of responses was recorded as a percentage, and the data were further extrapolated to obtain the results.

Responses to the “scalable” questions were recorded as a percentage of the maximum score for that question. To ensure that these questions were consistently “scalable” for the calculation of “overall satisfaction," the following rules were applied: (1) For question 2, response options 4 and 5 were excluded (for the calculation of overall satisfaction); (2) For question 4, response options 4 and 5 were excluded; (3) For question 6, the response option “Don’t know” was excluded. The average percentage score, i.e., “overall satisfaction," was then calculated.

The survey used the SERVQUAL questionnaire, which is widely used by researchers and practitioners in the field of service quality and has been found useful for the health sector by many researchers. It was modified to ensure that it was suitable for meeting the study objectives in the urology clinic of a tertiary care centre in Northern India. The modified questionnaire included basic demographic information and multiple-choice questions designed to elicit patients' comments on various aspects of the functional quality of services provided at the urology clinic. Responses were based on a Likert scale. The questions aimed to assess different areas of service qualityresponsiveness, tangibility, empathy, safety, and reliability.

Statistical analysis

SPSS version 23.0 was used for statistical analysis. Data were expressed as mean (standard deviation) and percentage (%). The chi-square test was used to compare categorical variables and the independent t test was used to compare discrete variables between groups [4]. More than two groups were compared by Analysis of Variance (ANOVA). Pearson's correlation coefficient is a test statistic that measures the statistical relationship or association between two continuous variables. The p value 0.05 was considered significant.

Results

The frequencies of the age groups 18-20 years, 21-30 years, 31-40 years, 41-50 years, 51-60 years, and 61-70 years were 3.64%, 16.82%, 25.45%, 18.18%, 18.18%, and 17.73%, respectively. The mean age of the patients was 43.65 ± 14.36 years. The percentage of males and females was 78.64% and 21.36%, respectively, corresponding to a male-to-female ratio of 3.68. The percentage of renal stone, urethral stricture, bladder mass, ureteral stone, BPE, NFK, VVF, PUJO, renal mass, bladder stone, CA testis, CA penis, CA prostate and UVF were 18.64%, 12.27%, 10.91%, 9.09%, 9.09%, 8.18%, 7.73%, 7.27%, 6.81%, 3.18%, 2.73%, 2.73%, 0.91%, and 0.45%, respectively [5]. The percentage of patients who completed the questionnaire for OPD days Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday were 20.45%, 15.91%, 16.82%, 14.09%, 20.91%, and 11.82%, respectively (Table 1).

Table 1: Baseline characteristics of the patients.

Table 2 shows patients' responses to various questions on different OPD days. The average time taken for OPD registration was 18.85 minutes, although there was a statistically significant difference (P<0.001) between different OPD days. On Tuesday and Friday OPD days, >90% of patients were registered within 20 minutes, >40 minutes for registration was found on Monday and Wednesday OPD days, while no patients were registered on Tuesday and Friday OPD days. The average wait time for a consultation was 55.79 minutes, with most patients in the Tuesday and Friday OPD waiting for a consultation within 1 hour, which was statistically significant compared with the other OPD days (P<0.001). >90% of patients in the Tuesday and Thursday OPD gave a good rating for outpatient services, which was statistically significant compared with other OPD days (P<0.008). Patients in Tuesday and Friday OPD days preferentially recommended their family members/relatives, and the difference was significant (P<0.001) compared with other OPD days.

Table 2: Patients' response to different questions in different OPD day.

A total of 79.78% of patients agreed that the consultant had listened to them, whereas in comparison, only 54% of patients reported that the resident had listened to them, with the difference being statistically significant (P=0.003). 86.3% of patients had confidence and trust when seen by the consultant compared with only 56.76% of residents, a statistically significant difference (P<0.001) [6]. In addition, the specialist seemed to know the patient's medical history better than the residents, with percentages of 87.4 and 67.5, respectively, and the difference was statistically significant (P<0.001) (Table 3).

Table 3: Patients' response to different questions in consultant/resident.

Based on OPD day, patient satisfaction was statistically significantly different (P<0.001), with Tuesday and Friday having the highest overall satisfaction rates of 86.43 and 86.78%, respectively.

In addition, the satisfaction rate was significantly higher among specialists (82.29%) than residents (72.30%). However, no significant difference in satisfaction rate was found according to benign/malignant disease or gender (Table 4).

Table 4: Satisfaction rate.

OPD registration time (minutes) and consultation waiting time (approx. minutes) were significantly negatively correlated with satisfaction rate (Table 5).

Table 5: Correlation of patient satisfaction with OPD registration time (min.), consultation waiting time (approx. min.), and consultation time (approx. min.).

Discussion

Patient satisfaction is considered one of the important quality indicator(s) in the health services. Measurement of patient satisfaction stands poised to play an increasingly important role in the growing push toward accountability among health care providers. Patient satisfaction surveys are used by health care facility management to improve the facility environment and the facilities and resources available to patients. BAUS (British Association of Urological Surgeons) issued guidelines in October 2000 to help urologists, managers, and elected officials determine appropriate outpatient workloads. They were created to find a compromise between the need to provide high-quality services on the one hand and management pressures on the other [7].

In our study, most patients were over 30 years of age (79.54%) with a mean age of 43.65 ± 14.36 years. Similarly, Dharmasena, et al. reported that the majority of patients were over 35 years of age. Saginela, et al. also reported that 80% of patients were older than 30 years.

In this study total 78.64% of respondents were male and 21.36% were female, for a male-to-female ratio of 3.68. Several previous studies have reported that men are more commonly affected by urologic problems. Dharmasena, et al. reported that 78.4% of respondents were male and 21.6% were female. Saginela, et al. reported that 146 (71.2%) were men and 59 (28.8%) were women.

Studies conducted in outpatient clinics and in a variety of developing countries showed mixed results regarding overall satisfaction. The inconsistent results are not surprising, as not only are there large differences in how care is delivered in different settings, but patients also have very different experiences and expectations.

In our study, mean scores for service quality had no significant associations with demographic characteristics such as age and gender, or type of disease (benign/malignant). Similarly, studies by Bahadori M, et al. from Uganda had shown a minimal contribution of sociodemographic characteristics to patient satisfaction, whereas some previous studies had found a positive association with them.

The average OPD registration time in our study was 18.85 minutes when all clinic days were considered, with Monday and Wednesday having significantly longer average OPD registration times than the other OPD days (P<0.001). Although the overall wait time for consultations was 55.79 minutes, the wait time on OPD days Monday and Wednesday was significantly longer (81 minutes and 79.76 minutes, respectively) than on other days [8]. Our study found that higher levels of satisfaction were associated with shorter waiting time (P<0.001). Several previous studies also reported that a reduction in average waiting time was an important factor in increasing satisfaction levels. A study by Krishna, et al in Northern India also found similar results. A study by Dharmasena, et al. in Sri Lanka reported that 81.5% of patients had to wait more than an hour for a medical appointment, although 62% of respondents were satisfied with the waiting time. On the other hand, a study of 1019 patients conducted in the emergency department found that a reduction in waiting time had no effect on satisfaction. A study by Lukacs, et al. in the United Kingdom found that the average wait time in the emergency department was 33.71 minutes and in the Clerk's office was 36.48 minutes. Similar studies suggest that reducing the average wait time is an important factor in increasing satisfaction. Therefore, one of the most important areas to develop is the implementation of an appointment system based on the exact time for consultations. Although medical staff enter the clinic before the scheduled time of 9:00 a.m., there is no mechanism to assign specific time slots to individual patients.

As a result, almost all patients arrive at the clinic well before the start time. This results in long wait times for registration and consultation. Attempts to schedule appointments encounter practical difficulties because patients travel long distances and use public transportation irregularly. This makes it difficult for them to arrive at the clinic at the exact scheduled time. However, urology clinic providers need to look for a mechanism to reduce this waiting time as much as possible, as it is associated with the greatest dissatisfaction in our study. The reason for this may be that most patients present to the urology outpatient clinic and emergency admissions are relatively rare in our specialty. The majority of patients presenting to the urology outpatient clinic are men (78.64%), which would result in less time lost from a workday. This would contribute to more men attending follow-up appointments.

In our study, most patients had to wait less than an hour to see the doctor, and most of them were satisfied with this waiting time. Patients have been shown to express dissatisfaction only when extremely negative events occur. This is perhaps especially true in our country, where sociocultural traditions are such that most patients have a higher tolerance for criticism of the public health care system, which in most cases is provided at very low cost or free of charge through various government-sponsored programs, thus reducing the economic burden of health care on patients.

In the questionnaire of our study, questions G, H, I and J refer to the interaction and communication between the physician and the patient. Good communication between patients and health professionals has long been considered a cornerstone of quality from the patient's perspective. In general, physicians and health professionals are more appreciated when they are genuinely interested in what patients have to say or ask, when they provide clear explanations and examples of possible treatment options, and when they take sufficient time to interact with the patient [9].

In our study, 81.3% of patients had confidence and trust in their treating physician. In addition, 84% of patients reported that the physician was definitely knowledgeable about their health condition or medical history, suggesting that patients' perceived quality of care is generally measured by how knowledgeable physicians are about the patient's condition and disease. A higher percentage of patients who trust their treating physician increases patient adherence to treatment, which can lead to positive outcomes for the disease itself. This is particularly true for long-term treatment of serious urologic conditions such as stone disease, prostate problems, and cancer, which affected 58% of patients in our urology consultation. Therefore, measures to improve patient satisfaction will also improve treatment outcomes. This fact may be ignored by most practicing physicians who believe that only medications and surgical interventions would benefit patients. Currently, most resources are spent on improving technical quality, while little attention is paid to functional quality. Therefore, efforts should be made to balance these two aspects.

In our study, almost 84% of patients felt that the consultation was conducted appropriately and that they were fully involved in the decision-making process. 4.55% of patients did not trust their treating physician, a fact that is probably difficult to change. However, 81.36% of patients said they trusted their physician, and 14.09% said they had some level of trust in him or her. The physician's understanding of the patient's complaints and medical history is a typical indicator of how well the patient feels about the treatment they received. Further interviews confirmed that 84.09% of patients were generally satisfied with our service, but that there was room for improvement to satisfy the remaining 15.91%. Patients would like to see the same doctor and continue to receive treatment as long as the doctor they see is knowledgeable about their condition.

Overall, 83.18% were satisfied with the care they received, 14.55% found it average, but 2.27% of patients were dissatisfied (5 patients in total). The patients who found the services poor were further analyzed. Of these 5 patients, 4 would probably have been satisfied with the other area, but since the average waiting time for an appointment was more than 50 minutes, their disappointment was high. The remaining patient was dissatisfied because of the rude behavior of hospital staff at the registration desk. However, our study found that only 1.82% of patients would not recommend the department to their family members, which could indicate individual, personal, financial, or social problems and seems to be independent of the quality of care received. Although the reasons for this were not elaborated upon. In addition, there is much room for improvement, with 66.36% of patients in our study advocating for changes to further improve our services. The studies of Butt and de Run Lin, et al.; Bakar, et al.; and Arasli, et al. on CKD also concluded that there is a negative discrepancy between patients' perceptions and expectations regarding the dimensions of service quality, which is consistent with the findings of the present study. The results of the aforementioned studies suggest that the services provided in the hospitals and centers studied do not meet patients' expectations and that managers should plan and prioritize accordingly to improve the dimensions of service quality.

In the era of improved information technology, higher awareness and information about various other healthcare systems in the world through latest gadgets and easily accessible internet facilities, patients expect very high quality level of services. Therefore, listening to the voice of patients is an important tool in modern organizational management, and the studied hospital managers should redesign the processes and apply the improvement techniques in the light of patients' feedbacks and comments [10].

In our study, we also compared the satisfaction rate of patients treated by specialists or residents and found a statistically significant value (P value<0.001), which means that patients were more satisfied when treated by specialists than by residents alone.

Conclusion

The majority of patients expressed satisfaction with the length of their consultations, the support they received from staff, the contact between them and their physicians, their participation in decision-making, and their willingness to recommend the services to their relatives. Significant negative correlations were found between OPD registration time (minutes) and waiting time for a consultation (about minutes). Patients treated by a specialist were significantly more satisfied than those treated only by a resident, especially in terms of communication and decision making. Although the majority of patients (45%) thought OPD performance was good, they wished for more progress in some areas.