1524 International Journal of Collaborative Research on Internal Medicine & Public Health

An Assessment of Patients Satisfaction with Services Obtained

From a Tertiary Care Hospital in Rural Haryana
Syed Shuja Qadri, Rambha Pathak *, Mukhmohit Singh, SK Ahluwalia, Shveta Saini, PK
Garg
Department of Community Medicine, MMIMSR Mullana, Ambala, India

* Corresponding Author: Dr. Rambha Pathak; Assistant Professor, Department of Community Medicine,
MM Institute of Medical Sciences & Research, Mullana Ambala, India | Email: [email protected] |
Mobile: +91- 9815985227

Abstract
Introduction: Health care quality is a global issue. The health care industry is undergoing a rapid
transformation to meet the ever-increasing needs and demands of its patient population. Hospitals
are shifting from viewing patients as uneducated and with little health care choice, to recognizing
that the educated consumer has many service demands and health care choices available. The
closest most tool for measuring consumer experiences is the occasional patient satisfaction survey.

Objective: To assess patient satisfaction with services provided in a tertiary care hospital situated
in rural Haryana.

Material & Methods: A cross –sectional study was conducted among patients (aged 18-80 years).
A multistage sampling technique was used to select the respondents. A total of 450 patients
attending various outdoor and indoor departments of the MM Institute of Medical Sciences and
Research were taken for the study purpose. A self designed, pretested, semi structured questionnaire
was developed to draw the patient’s satisfaction to the health care services.

Results: Overall, 89.1% of the patients were satisfied with the services received from MMIMSR,
while the remaining 10.9% were dissatisfied. Specifically, 90.9%, 78.6% and 74.6% of the patients
were satisfied with patient provider relationship, medical care and information and support.
However, 20.7% and 13.0% of the patients were dissatisfied with organization of care and cost of
care respectively. Patients and their relatives complained about cost of drugs, delayed reports and
long appointments for ultrasound and other radiological investigations.

Conclusion: With the necessary inputs from the patients and the attendants by pointing various
drawbacks or deficiencies should always be taken care of by the hospital administration that will
turn into a good result of improvement in the hospital services to the satisfaction of the patients.

Key Words: Patient satisfaction, Hospital services, Quality care

Short Title: An assessment of patient satisfaction

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1525 International Journal of Collaborative Research on Internal Medicine & Public Health

Introduction
Health care quality is a global issue. The health care industry is undergoing a rapid transformation
to meet the ever-increasing needs and demands of its patient population. Hospitals are shifting from
viewing patients as uneducated and with little health care choice, to recognizing that the educated
consumer has many service demands and health care choices available. Respect for patient’s needs
and wishes, is central to any humane health care system.1 Quality of health services was
traditionally based on professional practice standards, however over the last decade; patient’s
perception about healthcare has been predominantly accepted as an important indicator for
measuring quality of health care and a critical component of performance improvement and clinical
effectiveness.2
Patient satisfaction has been defined as the degree of congruency between a patient’s expectations
of ideal care and his /her perception of the real care (s) he receives.3 It is a multidimensional aspect,
represents a vital key marker for the quality of health care delivery and this is an internationally
accepted factor which needs to be studied repeatedly for smooth functioning of the health care
systems.4 It has been an important issue for health care managers. The client here does not
technically assess their own health status after receiving care but the degree of satisfaction with the
services delivered.
Various dimensions of patient satisfaction have been identified, ranging from admission to
discharge services, as well as from medical care to interpersonal communication. Well recognized
criteria include responsiveness, communication, attitude, clinical skill, comforting skill, amenities,
food services, etc. It has also been reported that the interpersonal and technical skills of health care
provider are two unique dimensions involved in patient assessment of hospital care.5 Better
appreciation of the factors pertaining to client satisfaction would result in implementation of custom
made programs according to the requirements of the patients, as perceived by patients and service
providers.6
Following increased levels of competition and the emphasis on consumerism, patient satisfaction
has become an important measurement for monitoring health care performance of health plans.
Patient is the best judge since (s) he accurately assesses and provides inputs which can help in the
overall improvement of quality health care provision through the rectification of the system
weaknesses by the concerned authorities.7
Many previous studies have developed and applied patient satisfaction as a quality improvement
tool for health care providers. Thus, patient satisfaction is an important issue both for evaluation
and improvement of healthcare services.8 Keeping this in view, the present study was conducted to
assess patient satisfaction with services provided in a tertiary care hospital situated in rural part of
Northern India (Haryana).

Material and Methods

Setting and study design
This was a cross sectional study conducted in a tertiary care centre situated in the rural part of
northern India. The hospital is a centre for undergraduate and postgraduate medical teaching and
has an operational strength of 700 beds. The hospital has 17 departments and provides outpatient

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consultations and inpatient services to patients presenting to the hospital from other levels of care or
on self referral. Patients are mainly seen in the General Outpatient Department, Specialty clinics,
Emergency Pediatric Unit and Accident and Emergency unit. It receives patients from within
Haryana, and the neighboring states of India (Uttar Pradesh, Himachal, Punjab, and Chandigarh).
The majority of patients are indigenous Hindu, although the Muslim and Sikh ethnic groups also
constitute a substantial proportion of the clientele. A mixed occupational background individuals as
farmers, traders, service class and students avail the super-specialty health care facility.

Sample size and data collection

The study was carried out between January 2011 and June 2011. On the basis of previous studies of
patient satisfaction and quality of care9 and using an appropriate statistical formula for estimating
minimum sample size in descriptive health studies [n=Z pq/d], a sample size of 440 was calculated
to detect level of satisfaction among the study participants. The prevalence used for sample size
calculation was 80%. The sample size was inflated by 10% to take care of non-response, incomplete
responses and refusals. Patients between the ages of 18 and 80 years attending the outpatient
department (OPD) and admitted in various specialties of indoor patient departments (IPD) were
included in the study. However, patients referred or advised for or admitted to the Intensive care
unit / cardiac care unit / emergency with conditions related to psychiatry or maternity and those
with severe acute or chronic illness were excluded from the study since these were considered to be
exceptional circumstances.
Thus a total of 450 patients were enrolled for the study. A multistage sampling technique was used
to select study population. In the first stage seven clinical departments [Surgery, Obstetrics &
Gynecology, Pediatrics, Ophthalmology, Family Medicine, Medicine and Otorhinolaryngology]
were selected using balloting. In the second stage, a stratified sampling technique with
proportionate allocation was used to select 70, 82, 66, 56, 84, 58 and 34 patients from these
respective departments. Finally, systematic sampling technique was used to select respondents from
among out patients and inpatients in the sampled clinical departments. Every 5th patient attending
the OPD and IPD was taken for the study purpose.

Questionnaire
A semi -structured questionnaire was designed to examine several aspect of hospital care. Questions
to be included in the instrument were devised on the basis of a literature review and in depth
interviews of the patients attending the hospital. The questionnaire was standardized by a small
scaled pilot test on 50 patients. It is comprised of 40 items which measures seven core dimension of
patient satisfaction- accessibility of health care facility, perception of waiting time, availability of
basic amenities, satisfaction with cost of services, relationship between patient and health
providers, availability of laboratory, radiological and pharmacy facilities, information and
communication. It also contained questions on socio demographic characteristics of the
respondents. The questionnaire consisted of five points Likert scale items, with 1 and 5 indicating
the lowest and highest levels of satisfaction, respectively. Patients indicated their level of
satisfaction by selecting responses ranging from poor=1, fair=2, good=3, very good=4 and
excellent=5. Those who chose poor and fair were considered dissatisfied while those who selected
good, very good and excellent were considered satisfied. Patients were also asked if they had
specific complaints or recommendations regarding their encounter in the hospital. The prescribing

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doctor and the supporting staff were largely kept unaware of the survey, except in unavoidable
circumstances, to avoid the bias in their behavior with the patient.
The questionnaire was administered by trained individuals after obtaining verbal consent from all
subjects. In order to maintain complete confidentiality no names were recorded on the
questionnaire. Prior approval of the ethical board was obtained before beginning the survey.
Outpatients were interviewed during their exit from the clinics while inpatients were interviewed in
the wards.

Analysis
The surveyed questionnaires were collected and coded in a MS Excel database and analyzed by
using the SPSS statistical package, version 17.0. Descriptive statistics were performed on the socio-
demographic data, and Pearson’s chi-square test was used to examine the relationship between
satisfaction with health services, behavior of doctor and other staff, satisfaction with clinic services
and satisfaction with pharmacy services and others. Furthermore, stepwise nominal regression
model was used to identify the predictors of satisfaction with health care services.

Results
A total of 450 patients attending the various indoor and outdoor departments were included in the
study. The mean age of the respondents came out to be 39 years. Out of total, 66.4% of the study
population comprised of males. Over 87% of the respondents were more than 30 years old.
Majority of the respondents (58.9%) were Hindus belonging to rural areas. 53.55% were employed
while the rest were students, housewives, or were retired. Majority of the respondents (44%) were
illiterate. Most of the respondents (87.2%) were married. A good number of respondents belonged
to the lower socioeconomic status. (Table-1)
When asked about availability of doctors, 62% of the respondents attending OPDs did not report
any problem related to it but 76% of them were dissatisfied with timings of the hospital as OPD was
open only from 9 AM to 2 PM. Out of total, 46% reported that only junior doctors were available in
the emergency department which is only option available to the patient for half of the day and
whole of the night. The level of satisfaction regarding availability of doctors was lower (46%) in
admitted patient.
In accord with practices in all health facilities, people coming to hospital registered and waited for
their turn for consultation. The proportion of respondents indicating that waiting time was excellent,
very good and good were 18%, 32% and 20% respectively. Most patients had to wait for 15-30
minute to be called into the consultation room. 32.4% of the patients said that they did not have to
wait, but were called instantly.
When assessing the respondents satisfaction with the attitude of health care providers they were
asked to indicate if the physician / doctors were courteous, listened to their complains, took enough
time and explained what they wanted to know and gave them good advice and treatment. In this
aspect of care 66.8% of respondents were satisfied with doctors (outdoor-86.6% and indoor-46.8%
respectively) whereas 33.2% of respondents were dissatisfied (more in indoor respondents -53.5%).
(Table 2)

On asking the respondents about the attitude and behavior regarding other staff members, it was
seen that 50.0%, 59%, 60% and 45% were satisfied regarding behaviour of registration clerk,

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supporting staff, pharmacist and nurses. More (55%) of patients were dissatisfied with behaviour of
nurses than any other health care staff. Still, for further information on the behavior pattern
regression analysis was done to compute the effect of behavior of each of the health care provider
on the overall satisfaction grading by the respondents. The association between the relationship
with other health care providers and overall client satisfaction also yielded statistically significant
results. (Table2)
Concerning the infrastructure and basic facilities at the hospital, it was observed that the overall
adequacy of these facilities was 71.7%. Most of the respondents (97.4%) were satisfied with
parking facilities while 32.5% complained that water coolers were not working and areas where
drinking water facility was available were not clean. This was preventing patients from using it. On
assessing the availability of other parameters such as lighting, fans, seating facility and general
cleanliness, it was seen that the level of satisfaction varied in respect to the services obtained (92%,
78.5%, 86.5%, 94% and 74.5% respectively).
84% of the participants identified accessibility to the hospital as the commonest problem. 45% had
to walk for 1-2 kms or wait for half an hour to one hour for getting any mode of transport to reach
the hospital. 68% were of the opinion that the road connecting hospital to highway was also not
properly maintained. Out of the total respondents 35.5% were of view that hospital toilets were not
maintained and 18.25% felt food and canteen facilities required upliftment. Also 16% respondents
found it difficult to find the way to various departments owing to lack of signboards in the hospital
building. Overall, the study reports that 28.1% individuals were dissatisfied with availability of
basic amenities in the hospital. (Table-3)
The degree of satisfaction and dissatisfaction at the various service windows i.e. pharmacy stores, X
ray/USG, laboratory and health record office of the hospital was also assessed (Table 4). Majority
of the respondents (73.85%) were satisfied with pharmacy. As far as availability and quality of
drugs was concerned the respondents showed a higher level of satisfaction (72%) in contrast to the
cost of drugs which showed a relatively higher level of dissatisfaction (43.3%).
20.04% of the patients complained about services obtained from the Radiology Department. They
were of the opinion that though hospital had most of the advanced equipments in the department but
many of those were either not working or the technicians were not available to operate them. The
most frequent complaint (36.1%) included cost for the radiological investigations done in the
department followed by prolonged waiting time (24.4%).
Microbiological and Pathological laboratory services were somewhat satisfactory as only 15.77%
were not satisfied with service level. But most of the patients were unsatisfied with biochemistry
laboratory services as facilities for advanced biochemical investigations (PCR, antibody detection
techniques e.t.c) were not available in the department. 46% were referred to other private facilities
for investigations. 29.11% reported problem with timely delivery of investigation reports, while
another 22% had complaint regarding the expenses incurred for the pathological and biochemical
laboratory investigations.
On assessing the dissatisfaction regarding missing of reports only 4.44% and 9% had reported the
problem from laboratory and radiology department respectively. Overall dissatisfaction level in
relation to record keeping was reported to a level of 5.5%.

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Overall satisfaction with services

It was seen that 80.9%, 79.3%, 70.9% and 56.8% of the respondents were satisfied with information
and support, organization of care, availability of general basic facilities and doctor-patient
relationship. However there was high level of dissatisfaction (84%) as far as accessibility of health
care services was concerned. To assess the overall satisfaction, grades: - excellent, very good and
good were pooled across and it showed a high proportion of respondents (79.1%) were satisfied
with the health care services received from the hospital while only 20.9% were dissatisfied. The
overall satisfaction level was higher (86%) in patients attending outdoor than indoor patients (73%).
Level of satisfaction was significantly associated with background (p=.0032), level of education
(p=.023) and socioeconomic status (p=.016) of the participants. Level of satisfaction was
significantly higher in respondents who were illiterate, from low socioeconomic status and rural
background.

Discussion
The present study attempted to assess the satisfaction of the patients with various aspects of health
care in a tertiary care hospital of district Ambala. The results of the study indicate that most of the
respondents interviewed were satisfied with the services they received. Very few similar studies
have been done and therefore we lack the data for comparison. Yet, the findings of the survey are
quite helpful if they are transformed into actions for improving the quality of health care. However,
the high satisfaction must be put into the context of the tertiary care centre, being a referral hospital,
which receives patients who have often being shunted around between lower health facilities and
attended by auxiliaries and general practitioners.
Measuring patient satisfaction has many purposes, but there are three prominent reasons to do so.
Such interviews help to evaluate health care services from the patient’s point of view, facilitate the
identification of problem areas and help generate ideas towards resolving these problems. Despite a
pretty good level of patient satisfaction, a small, but by no means insignificant, proportion of
patients expressed dissatisfaction. The fact that patients expressed dissatisfaction with the services
indicates that hospital administration needs to do more in the drive towards improving services.
The overall satisfaction of patients with services received from this tertiary care institute came out
to be (79.3%) which is similar to the figures reported by SA Deva et al.10 in Kashmir (80%),
Kumari et al.9 in lucknow, (81.6%) and Qureshi et al.11 in Kashmir (72%) whereas it is lower than
as reported by Bhattacharya et al (88%)12, SK Jawhar et al.13 in India (90-95%) and Ofili and
colleagues (83%)14 in Benin city but higher than those reported from Mahapatra et al.15 in Andra
Pradesh (63%). Apart from variations in the way services are delivered, differences in study
population and hence patient’s expectations could affect satisfaction levels. The later could also be
affected by socio cultural differences and variations in levels of literacy. The cultural milieu and
relatively lower level of literacy of our catchment population could have altered the level of
satisfaction. In addition, variation in methodology and timing of the study could explain some of
the differences. This calls for caution for comparing our findings with previous studies.

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The satisfaction regarding listening of complaints and behavior of doctor and paramedical staff was
around 60% which is similar than as reported by kersnik et al.16, 2002 (55.3%) whereas it was less
as reported by Kumari et al.9, 2009 (73%). The dis-satisfied percentage had different view of
doctors and health care providers. 80% of them felt that doctors have no time to discuss with
patients or listen to them patiently. The fact for this dissatisfaction could be attributed to the
increasing loads of the patients.
The present study found 35.5% of the respondents were dissatisfied by the toilet facilities in the
hospital building and the similar results were found in a study by Srilata17 and Persak et al.18 2004,
who showed lowest level of satisfaction regarding toilets (3.52%).In another study by Aleena et
al.19 reported a higher level of dissatisfaction (80%).
A high proportion of patients were dissatisfied with accessibility of the hospital. This is in
concordance with findings from other studies where fewer patients were satisfied with ease of
accessing care as exemplified by 56% in Benin City by Ofili and colleagues.14
In the current study it was seen that 66.8%, 50.0%, 59%, 60% and 45% were satisfied regarding
behaviour of the doctor, registration clerk, supporting staff, pharmacist and nurses and the results
were less than in a study by Sultana et al.20, Pakistan, 2010 (95.5%, 94.5% and 93.3%). On the
other hand a study conducted by Ariba et al.21 in 2007 in a Nigerian teaching hospital, found that
most of the respondents (38.8%) were displeased with the overall quality and attitude of the health
care providers.
Our study shows a high level of dissatisfaction (18.25%) regarding canteen/food facilities, the
results of which were also found to be consistent with a study by Aleena et al (18%).19 This could
be explainable by the fact that increasing modern era demands and awareness of the health care
seekers push the medical care providers to deliver quality medical care in package with quality
hospitality and related facilities to solace them.

Limitations
The responses of patients depend upon their socio-economic profile, personality and their
perceptions; some may be satisfied with average services, while other may be dissatisfied even with
the best. In the present study, most of the respondents belonged to rural areas and middle or low
socioeconomic class. Henceforth, it implies caution while comparing results from such a survey
wherein the outcome is largely associated with the socio-demographic profile of the study
population. The study was conducted at a tertiary care centre only but the level of patient
satisfaction with different types of health providers could have given more insight into various
aspects of factors related to patient satisfaction. This could not be done due to paucity of the
resources.

Conclusion
Overall the study showed a moderate level of satisfaction of patients with services obtained from
this tertiary care centre. We have discovered a number of potential barriers and facilitators that may
influence in patient satisfaction in the northern India. Accessibility could be improved by running

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buses on paid basis. Cleanliness should be given top priority and areas with drinking water facility
should be specifically maintained properly. Certain improvements are also needed in the waiting
area by making it informative and comfortable Hospital administration should ensure that all the
equipments are working properly and well maintained. The fact that some patients expressed
dissatisfaction with the services indicates that health care providers need to do more in the drive
towards improving service windows in order to improve efficiency, minimize patient waiting times
and provide for patient comfort. Periodic patient satisfaction survey should be institutionalized to
provide feedback for continuous quality improvement.

Conflict of Interest: None declared

References
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Table 1: Socio-demographic profile of the respondents (n=450)

Characteristics Male, No. (%) Female, No. (%) Total, No. (%)

Age groups

<20 years 16(5.5) 6(3.77) 22(4.88)

20-29 years 26(8.9) 2 (1.25) 28(6.22)

30-39 years 73(25.8) 65(40.88) 138(30.66)

40-49years 94(32.3) 72(45.28) 166(36.88)

>50years 82(28.2) 14(8.80) 96(21.33)

Place of residence

Rural 167(57.4) 117(73.28) 284(63.11)

Urban 124(42.6) 42(26.41) 166(25.77)

Education

Illiterate 106(36.4) 92(57.86) 198(44)

Primary 72(24.7) 58(36.4) 131(29.11)

Secondary 95(32.6) 8(5.03) 103(22.88)

Graduate 17(5.8) 1(0.62) 18(4.0)

Occupation

Working-class 217(74.57) 24(15.09) 241(53.55)

student 30(10.30) 14(8.80) 44(9.71)

housewife 0(0) 113(71.06) 113(25.11)

Retired 50(17.1) 2(1.25) 52(11.55)

Socio-economic status

Class I 28(9.62) 32(20.01) 60(13.33)

Class II 32(10.99) 18(11.0) 50(11.1)

Class III 55(18.90) 48(30.01) 103(22.8)

Class IV 112(38.48) 35(22.01) 147(32.66)

Class V 64(21.99) 26(16.35) 90(20)

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Table 2: Patients satisfaction with the attitude and behavior of the healthcare providers
(n=450)

SATISFIED DISSATISFIED

ASPECT OF CARE Outdoor Indoor Total Outdoor Indoor Total # P-

(n=315) (n=135) (n=450) (n=315) (n=135) (n=450) value

Behavior of the 51 49 50 49 51 50 0.001

registration clerk
Behavior of supporting 68 50 59 32 50 41 0.003
staff
Behavior of the 60 59 60 40 41 40 0.06
pharmacist
Behavior of the nurse 52 38 45 48 62 55 0.036

Behavior of the doctor 86.8 46.8 66.8 13.2 53.2 33.2 0.000

# p value of <0.05 is significant

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Table 3: Availability of General basic facilities in the hospital (n=450)

ADEQUATE (%) INADEQUATE (% )

AVAILABILITY
Outdoor Indoor Total Outdoor Indoor Total
OF FACILITIES
(n=315) (n=135) (n=450) (n=315) (n=135) (n=450)

Toilets 70 59 64.5 30 41 35.5

Drinking water 74 61 67.5 26 39 32.5

Cleanliness 80 69 74.5 20 31 25.3

Canteen/food 76 81.5 24 18.5

87 13
facilities

Lighting 88 92.0 12 8
96 4
arrangement

Waiting room / 81.5 86.5 18.5 13.5

91.5 8.5
seating availability

Fans 83 74 78.5 17 26 21.5

Parking 97.3 97 97.4 2.7 3 2.8

Signboards / 79 84 21 16
89 11
locating departments

Overall rating 78 65.5 71.7 22 28.3 25.1

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Table 4:-Degree of satisfaction at various service windows (n=450)

SATISFIED DISSATISFIED
DEGREE OF SATISFACTION
No. % age No. % age

PHARMACY STORE

Availability of essential drugs 418 92.8 32 7.11

Quality of drugs 324 72 126 28

Cost 255 56.6 195 43.3

Total 997 73.85 353 26.14

RADIOLOGY / USG

Prompt delivery of services 340 75.6 110 24.4

Technically trained staff 421 93.6 29 6.4

Cost 288 64 162 36.1

Delayed reports 340 75.6 110 24.4

Missing reports 410 91 40 9

TOTAL 1799 79.9 451 20.04

LABORATORY

Prompt delivery of services 419 93.11 31 6.88

Technically trained staff 376 83.55 74 16.44

Cost 351 78 99 22

Delayed reports 319 70.88 131 29.11

430 95.55 20 4.44

Missing reports

TOTAL 1895 84.22 355 15.77

HEALTH RECORDS

Properly placed 430 95.5 20 4.44

Missing folders 420 93.33 30 6.66

TOTAL 850 94.4 50 5.55

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Table 5:-Patient’s satisfaction to health care services (n=450)

PATIENT OVERALL RATING

ASPECT OF CARE Excellent Very Good Good Fair Poor

Doctor-patient relationship 29.1 22.2 5.5 29.1 14.1

Availability of general basic 11.5

33.3 26.8 10.8 17.6
facilities

Information and support 44.6 25.3 11 13.3 5.8

Accessibility to health care 28.5

7.2 3.9 4.9 55.5
services

Organization of care 30.5 27.8 21 15.7 5

Overall satisfaction 35.8 26.3 17 14.3 6.6

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