Patient Satisfaction with the services in the outpatient clinics of Randle General Hospital, Lagos,...

PATIENT SATISFACTION WITH THE SERVICES IN THE

OUTPATIENT CLINICS OF RANDLE GENERAL HOSPITAL,

SURULERE, LAGOS.

BY

YEKINNI, IBRAHIM OLAWALE

090705765

A PROJECT SUBMITTED TO THE DEPARTMENT OF

COMMUNITY HEALTH AND PRIMARY CARE, IN PARTIAL

FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF

THE BACHELOR OF MEDICINE, BACHELOR OF SURGERY

(MB;BS) DEGREE.

AUGUST 2013

PATIENT SATISFACTION WITH THE SERVICES IN THE OUTPATIENT

CLINICS OF RANDLE GENERAL HOSPITAL, SURULERE, LAGOS. 05/09/2013

YEKINNI IBRAHIM OLAWALE | 090705765 I

CERTIFICATION

This is to certify that this project is my own independent work. The assistance and co-operation I

received from various individuals have been duly acknowledged.

………………………………........................... …………………….

Project Supervisor Date

(Dr F.A Olatona)

………………………………........................... …………………….

Assessor Date

(Dr T.F Olufunlayo)

………………………………........................... …………………….

Student Date

(Yekinni Ibrahim Olawale)



YEKINNI IBRAHIM OLAWALE | 090705765 II

DEDICATION

This project is dedicated to the almighty God through whom all things have come to being.



YEKINNI IBRAHIM OLAWALE | 090705765 III

ACKNOWLEDGEMENT

First and foremost, I’ll love to thank my project supervisor, Dr. Olatona for her guidance. I must

confess, I have learnt a great deal from her thoroughness and her low tolerance for mediocrity;

they have indeed pushed me to mental heights I never thought I could attain.

I also want to appreciate the Department of Community Health and Primary Care for providing

such an avenue for learning the process of scientific research. For me, the project has become

much more than a partial fulfillment of a degree; I believe I have learnt a major life skill and I

can now go ahead and search for any knowledge that I require to achieve any goal.

Finally, I am grateful to all friends and family members who have helped and supported in

various ways to see this come to reality.



YEKINNI IBRAHIM OLAWALE | 090705765 IV

LIST OF TABLES

Table Page

1

2

3

4

5

6

7

8

9

10

11

Age of Respondents……………………………………………………………..

Sex, marital status, religion and tribe of respondents…………………………...

Level of education and address of respondents…………………………………

Respondents’ satisfaction with ease of getting appointment, location of

hospital and clinic opening hours……………………………………………….

Respondents’ satisfaction with simplicity of service system and waiting time…

Respondents’ satisfaction with signs, waiting area cleanliness and ventilation...

Respondents’ satisfaction with the lighting of waiting area, comfort of seats

and availability of drinking water……………………………………………….

Respondents’ satisfaction with the cleanliness of the toilets……………………

Respondents’ satisfaction with the doctors’ friendliness, attentiveness and

consultation time………………………………………………………………...

Respondents’ satisfaction with the privacy maintenance, explanation of

findings and involvement in care………………………………………………..

Respondents’ satisfaction with the conduct of other health professionals……...

29

30

31

32

33

34

35

36

37

38

39



YEKINNI IBRAHIM OLAWALE | 090705765 V

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENT

LIST OF TABLES

SUMMARY

III

IV

VI

CHAPTERS

1

2

3

4

5

INTRODUCTION

REVIEW OF LITERATURE

METHODOLOGY

RESULTS

DISCUSSION

CONCLUSION

RECCOMENDATION

REFERENCES

APPENDIX

1

5

24

29

41

48

49

50

54



YEKINNI IBRAHIM OLAWALE | 090705765 VI

SUMMARY

Introduction

Quality is a major health management concern all over the world and various measures are being

taken by healthcare managers to ensure high quality services within healthcare organizations. A

satisfaction survey is one of such measures and helps assess the responsiveness of the organization

to patient needs and expectations.

This study was conducted to evaluate the satisfaction of patients with the outpatient clinics of

Randle General Hospital, Surulere, with particular focus on; convenience/accessibility of services,

the physical environment and the delivery of care by hospital personnel.

Methodology: A crossectional descriptive survey was conducted amongst 187 patients across 5

outpatient clinics in Randle General Hospital. A multistage sampling was used and data was

collected by means of self-administered questionnaires and analyzed with EpiInfo Software.

Results: The overall level of satisfaction was 80.7%. Of all respondents, 73.7% were satisfied

with the convenience/accessibility of services, 80.9% were satisfied with the physical environment

and 87.0% were satisfied with the delivery of care by hospital personnel.

Conclusion: An approximate 80.7% of patients accessing the Randle General Hospital, Surulere

rate the services obtained in the Hospital’s outpatient departments as satisfactory.



YEKINNI IBRAHIM OLAWALE | 090705765 1

CHAPTER ONE

INTRODUCTION

Satisfaction is multidimensional and there is currently no consensus on its definition. 1,2 Patient

satisfaction would be considered as the extent to which the patients feel that their needs and

expectations are being met by the service providers and this study would be from the perspective

of a healthcare organization rather than that of a country’s health system.3 Patient satisfaction

studies are usually conducted to maintain high quality in health service delivery within

organisations. Hence, the research problem is that of service quality.

Quality is a major health management concern all over the world, developed and developing

countries alike.4 In a 2008 survey conducted by Delloite Centre for Health Solutions in the United

States, 40% of patients indicated that they would be willing to travel for care to an hospital they

perceived to be of higher quality while 20% indicated that they have already made such a choice.5

76% of the South African black population depend on public hospitals resulting in overcrowded

facilities with insufficient staff and resources and also increase in waiting time to more than 1

hour.6

In Nigeria, the quality of services received in most public facilities is poor, enough to cause protests

of healthcare professionals’ associations against the government.7 The International Medical

Travel Journal revealed that 5000 Nigerians travel abroad for Medical care in India and other

countries leading to a loss of over 30 billion dollars annually, an amount equivalent to 20% of the

2010 budgetary allocation to the healthcare sector.8

Patients who perceive the quality of service in a healthcare organization to be poor become

dissatisfied. Patients who are dissatisfied behave differently from satisfied patients. They are less




likely to comply with the prescribed medications, they do not maintain follow up appointments

and their utilization of such health facilities might decrease.9 Such patients in the lower

socioeconomic class could resort to unsafe service providers or traditional alternatives.10 Patients

who can afford to pay for private higher quality healthcare services would spend more causing

increased Out of Pocket Expenses for healthcare as opposed to saving healthcare costs with public

facilities and these trends can lead to an increase in poverty level.11 Low Quality would also result

in undesired health outcomes and consequently reduced productivity of the nation with time that

would have been spent in productive work wasted in illness and this also would have a negative

impact on the nation’s Gross Domestic Product.12

The traditional concept of healthcare relationships assumes the healthcare professional as the

expert and an ideal patient as compliant and self-reliant.13 Managing the quality of healthcare

services has thus been entirely the responsibility of the healthcare provider with the services being

largely introspective and focusing on the technical perspective of the providers.14However, a desire

to seek the patients’ perspective in improving quality came with the advent of the patients’ rights

movement and has since then been widespread.15 For example, assessing patients’ satisfaction has

been compulsory for French hospitals since 1998 and the results have been used to improve

hospital environment, patient amenities and facilities in a consumerist sense.16

A patient satisfaction research of this sort is important because our societies are in a constant state

of change. The socioeconomic conditions that characterize different populations reshuffle

frequently bringing changes in the expectations and behaviours of people as regards their health.

In dealing with these occurrences, only an evaluative measure such as a patient satisfaction survey

which inquires the patient’s own perception of the care they receive can effectively help in

monitoring the quality of care. The role of medical care is also shifting from that of just improving




the patient’s health status to that of satisfying the patient including responding to their needs and

wishes as in a consumer service.18

Furthermore, the bulk of the patient satisfaction literature consists of studies conducted in the

United States and other developed countries with very limited contributions from this part of the

world meanwhile it is a well-established fact that satisfaction ratings are context dependent i.e. the

findings are dependent on the particular mix of social and demographic factors that characterize

the population of study. Hence, it is imperative that we conduct studies in our own locality from

which we can draw practical inferences.19,20

The outpatient department of an hospital is usually considered as a 'shop-window' i.e. patients

would judge the whole institution or make decisions to continue or not continue receiving care

based on their experience in the outpatient's clinic. The outpatient clinics of hospitals is therefore

an important point from which patient satisfaction can be evaluated since patients who are satisfied

with their care at this point are more likely to continue using the hospital.21

This study would be conducted to assess the satisfaction of patients utilizing the outpatient care

services of Randle General Hospital, Surulere, Lagos.

The result of this research work would be useful to the professionals and health managers in Randle

General Hospital, Surulere for improving the quality of services they deliver and to professionals

and managers in other public health facilities. It would also be useful to policy makers in

formulating policies that would improve health outcomes.




OBJECTIVES

General Objectives

The General objective of this study would be to assess the satisfaction of patients utilizing the

outpatient care services of Randle General Hospital, Surulere, Lagos.

Specific Objectives

The specific objectives of this study would be as follows;

To determine the satisfaction of patients with the accessibility/convenience of services

delivered at the outpatient clinics of Randle General Hospital, Surulere, Lagos.

To determine the satisfaction of patients with the physical environment at the outpatient

clinics of Randle General Hospital, Surulere, Lagos.

To determine the satisfaction of patients with the delivery of care by hospital personnel.




CHAPTER 2

LITERATURE REVIEW

Quality of Care and Patient Satisfaction

The recently observed attempts at measuring patient satisfaction originated from an attempt to

measure healthcare quality. The use of patient satisfaction as a measure of healthcare quality is

usually attributed to the work of Avedis Donabedian, a notable authority in the Quality assurance

literature.

In his work (The Quality of Care; How can it be assessed?), Donabedian firstly described quality.

He expressed the fact that quality had been a somewhat difficult entity to measure in previous

times and that many individuals have either proposed methods that either oversimplified the

process of quality measurement or made it extremely difficult. He however expressed that in

defining quality, there can be many definition formulations with variations proportional to the

number of individuals defining the term and that this occurs because different individuals define

it from their own unique perspective i.e. the perspective of quality to a Physician differs from that

of a nurse, a public health practitioner or a hospital administrator. He then likened these

perspectives to be representative of the definer’s position in an imaginary spectrum of the health

system.17

Donabedian proposed that the health system or healthcare can be visualised as a set of concentric

circles around a target or a ladder with rungs and the definer describes quality with their own

context as the target of the concentric circles or the beginning rung in the ladder. He illustrated

this concept from a Physician’s point of view and represented the Physician’s art of care as the

target and subsequent levels around the target as the available facilities and equipment, the care




provided by patient families and patients themselves and on the outermost circle is the health status

of the community. He then further explained that the definition of quality is expanded with every

movement across these concentric circles and with every expansion in definition and scope comes

a whole different interplay of factors that affect the way quality is perceived.

Having explained how quality could be defined and scoped, Donabedian went further to describe

how it may be measured. According to him, in measuring quality, one could establish the whole

healthcare experience of a patient has consisting of three aspects; Structure, Process and Outcome.

He described structure has the organizational setup of the healthcare being evaluated. In evaluating

structure, one would pay attention to issues or attributes such as the availability of physicians, the

kind of organization be it private practice or a public institution, level of decision making afforded

to each health personnel, provider’s level in the overall health system i.e. whether primary health,

secondary health or tertiary health institution and such related organisational attributes.17

In the evaluation of ‘Process’, one would pay attention to the activities and factors involved in the

actual process of receiving care i.e. from the patient’s decision to come to an healthcare provider

to the actual consultation process, to payments, drug use and so on.

The ‘outcome’ aspect of the healthcare is assessed as the result of the process of care. It could be

viewed in terms of the change in the patient’s health status as a result of the care received. It is

also evaluated in terms of the increase in the knowledge of the patient regarding the particular

condition being tackled.

Donabedian explained that these three aspects of healthcare are not in isolation and that they are

closely linked together. He described the relationship between them as being similar to a kind of

cause-effect relationship i.e. the structure aspect influences the process and the process influences




the outcome. This description of his was however conceptual or theoretical and he expressed

limitations in confirming the relationships with empirical studies.

From the conceptual standpoint of structure, process and outcome, he identified that it was difficult

to find an all-embracing method of measuring the quality of healthcare. He however noted that a

viable evaluation technique or method would be one that considered at least some components of

the three aspects. It was in this process that he made mention of patient satisfaction. Here are his

statements;

“Before we leave the subject of approaches to assessment, it may be useful to say a few words

about patient satisfaction as a measure of the quality of care. Patient satisfaction may be

considered to be one of the desired outcomes of care, even an element in health status itself. An

expression of satisfaction or dissatisfaction is also the patient’s judgement on the quality of care

in all of its aspects, but particularly as concerns the interpersonal process…It is futile to argue

about the validity of patient satisfaction as a measure of quality. Whatever its strengths and

limitations as an indicator of quality, information about patient satisfaction should be as

indispensable to assessments of quality as to the design and management of healthcare systems.”

Hence, by way of inference, a patient satisfaction survey passes for a viable measure of the quality

of care especially since it reflects the patient’s perception of all aspects of the healthcare

experience.17

Another Researcher, Haslock I in 1996 further demonstrated this relationship between quality of

care and patient satisfaction. Using the structure, process and outcome framework, he gave

instances where patient satisfaction surveys have helped in evaluating patient healthcare

experience e.g. a patient satisfaction survey of rheumatology patients revealed that they had




difficulty with movement within the hospital premises and this allowed the hospital to provide

easy access to rheumatology clinics. This knowledge was transferrable to more Generalist

healthcare institutions and allowed health managers to consider easy access for such patients in

their design of a health facility. Haslock’s study supported the use of the structure, process and

outcome model in evaluation of quality of care and agreed to patient satisfaction as a valid measure

of the quality of care. 22

Definition and Theories of Patient Satisfaction

In using patient satisfaction surveys as a measure of quality of care, another issue became of

concern to researchers. There was no unanimous definition of the concept of patient satisfaction.

Different individuals defined it different ways and differences in satisfaction led to differences in

approaches of measurement.23

Hulka in 1970 was one of the first to significantly attempt to define the concept of patient

satisfaction. In her work, she described satisfaction as the attitude of the patient towards physicians

and medical care. She expressed satisfaction as a composite or global index of the patient’s

judgement of the healthcare experience. Hulka’s definition was adapted by a couple of researchers

but further studies into the subject revealed some flaws, mainly in three areas.24

Firstly, a weakness was observed in the definition of satisfaction as a global index across all

episodes, situations etc that constitutes the patient’s healthcare experience. A study by Shore B

and Franks P in 1986 identified the whole healthcare experience of a patient as having components.

They identified the consultation or a patient’s interaction with a healthcare provider as the basic

unit of healthcare. This perspective showed that patient satisfaction varied with the particular




situation or episode in the whole healthcare experience and that it was improper to measure

satisfaction as a global index across all the situations. They then proposed that patient satisfaction

should be defined as an index of the patient’s judgement of care received in a particular healthcare

situation.24

The second challenge to Hulka’s definition originated from the researchers in the Consumer

Research Literature. They believed that the definition considered satisfaction as a cognitive

process in which the patient judged the healthcare received by logical reasoning and evaluations

which was inappropriate in their own opinion. They argued that satisfaction of the patients is

instead an affective process i.e. the judgement of the healthcare received was based on emotional

processes on the part of the patients. They however did not dispute that satisfaction had cognitive

components. Their argument was mainly that Hulka’s definition omitted a major component of the

patient satisfaction concept and they proved their standing with both conceptual and empirical

studies.24

The third challenge to the definition was from the work of Ross C in 1987. She was of the opinion

that the definition focussed only on measuring the quality of the ‘medical care’ received by the

patient and that such an approach to satisfaction was inappropriate. She supported her standpoint

with multiple empirical studies that have shown that a segment of ‘satisfied but unhappy’ patients

existed. Hence, she proposed that the definition should be expanded to include other entities that

are not purely ‘medical’ e.g. Waiting times, Costs etc. Many researchers including Hulka agreed

with her position and embraced an expanded perspective of the patient satisfaction concept.24




The theories of Patient Satisfaction

In the midst of the seemingly variable perspectives and standpoints to the patient satisfaction

concept, a couple of works have been outstanding and have served as a form of conceptual

framework for many researchers in the patient satisfaction literature. This works that can be

regarded as theories were propounded in the eighties and most of the other attempts at establishing

a conceptual framework or theory for patient satisfaction in recent times have been restatements

of these initial works.23

Discrepancy and Transgression Theory of Fox and Storms (1981): this theory proposes that patient

satisfaction was dependent on the orientations or inclination of the patient and healthcare provider.

It explains that satisfaction occurs when these orientations are congruent i.e. when the conditions

made available by the healthcare provider is consistent with the orientation of the patient, the

patient is satisfied and when otherwise, the patient is dissatisfied.23

Expectation-Value Theory of Linder-Pelz (1982): this theory mainly stresses the relationship

between satisfaction and the patient’s expectation. Linder-Pelz studied the association between the

patient’s expectation and their rating of satisfaction and found a reasonable link. She therefore

proposed that the satisfaction of patients was dependent on their personal beliefs and preferences

as well as their expectations.23

Determinants and Components Theory of Ware et al (1983): this theory proposes that the

satisfaction of patients was a function of their responses to the healthcare they receive and that

these responses depended on their personal preferences and expectations.23




Multiple models theory of Fitzpatrick and Hopkins (1983): this theory is also from the perspective

that the satisfaction is strongly associated with expectations just like the preceding two theories

but its distinction is from the way it considers the source of expectation. It proposes that

expectation is socially mediated and that it reflects the patient’s health goal as well as the degree

to which healthcare or illness violates the patient’s personal sense of self.23

Healthcare Quality theory of Donabedian (1980, 1988): this theory proposes that the patient

satisfaction rating of the patients is their judgement of the quality of care in all of its aspect but

especially the art of care.23

Measuring patient Satisfaction

In the course of measuring patient satisfaction, many researchers realised that the big question for

conceptual research was more of what the patient was satisfied with rather than how patient

satisfaction should be described. Multiple studies have shown that satisfaction was a

multidimensional concept; the issue was now to determine what the dimensions were.3,24

Ware and his colleagues in 1977 did a conceptual study on the measurement and meaning of patient

satisfaction. They studied all the patient satisfaction research works in the twenty year period prior

to 1976 and were able to come up with eight distinct dimensions of patient satisfaction. They

expressed that patient satisfaction could be measured in this eight dimensions with the assumption

that these dimensions were distinct and do not overlap and that the characteristics of health

facilities and physicians in the dimensions were reasonably interrelated.




The dimensions they identified were; art of care, technical quality of care,

accessibility/convenience, finances, physical environment, availability of care, continuity of care

and efficacy/outcome of care.3

The art of care: this dimension was identified to be the most frequently measured dimension and

was also considered to be an aspect of physician conduct along with the technical quality of care.

It was described as the dimension focussed on the ‘amount of care’ shown to the patient. In the

questionnaires they studied, they reported that researchers measured patient’s satisfaction with the

art of care by asking questions relating to the friendliness of the physician, patience, concern, etc.

on the positive spectrum of evaluation and attributes such as abruptness, disrespect, degree to

which physicians embarrass, hurt, or worry their patients etc. on the negative spectrum.3

The technical quality of care: this was also an aspect of the physician’s conduct and was concerned

with the patient’s satisfaction with the provider’s actual process of care and the state of the

equipments and facilities involved in the care process. From the patient satisfaction surveys

evaluated by Ware et al in this regard, questionnaire items measured attributes or characteristics

such as the physician’s skills and abilities, thoroughness, attention to details, how effective and

modern the equipments and facilities were, potency of treatment regimen etc.3

Accessibility/convenience: this dimension focussed on the ease with which patients could receive

healthcare, it measured attributes such as the closeness of the health facility to patients, the time

during which care could be received, whether patients could receive care over the telephone.

Dimensions such as Finances and Physical environment could have been easily considered as

subdimensions of the accessibility/convenience dimension but are instead considered separately.

Opportunity costs and other non financial costs of accessing care are however considered as

components of this dimension.3




Finance: the financial cost of accessing care is also considered as a separate dimension of patient

satisfaction and in its evaluation, researchers measure the ‘dollar cost’ of receiving care. They

check the satisfaction of the patients with premiums in an insurance based health system or with

the actual fees paid in a fee for service system.3

Physical Environment: as for the physical environment dimension of care, ware and his colleagues

observed that it had longed been measure in satisfaction surveys of inpatient conditions. In the

outpatient setting, this dimension was also found to be measurable especially with attention to

particular facilities. Some of the attributes questionnaires sought to measure included; the comfort

of the waiting room, the neatness of the environment, orderliness of the environment,

attractiveness of the waiting areas, clarity of signs and directions etc.3

Availability of care: this dimensioned was found to be rarely measured and it focussed on the

availability of healthcare providers and facilities in the patient’s vicinity. It seeks to answer the

question of whether doctors, nurses or other healthcare providers are enough in a particular area.3

Continuity of care: this was another rarely measured dimension. For this dimension, researchers

mainly tried to check the consistency of the patient’s source of care i.e. whether care had been

received from the same healthcare provider or facility at every point when the patient sought care.

Rarely, attributes such as continuity of patient records could also be assessed.3

Efficacy/outcome of care: this dimension focussed on the overall outcome of the healthcare

experience of the patient. How the healthcare they received has improved their health status or

how it has been of help to them.3

Hawthorne in 2006 further reviewed the patient satisfaction literature and proposed that the patient

satisfaction construct can be assessed under six dimensions most of which were related to the




Physician’s dealings with their patient. First was the appropriate access of patients to healthcare,

including the environment within which care was delivered and the extent to which the process of

care was coordinated. Second was the amount of health information the physician relayed to their

patients. Third was the relationship between the patient and the healthcare provider. The fourth

dimension was the participation or involvement of patients in their own healthcare process. The

fifth dimension pertained to the technical quality of care and the sixth dimension dealt with the

efficacy or outcome of care; how the patient perceived the care received to be of use or significance

in their daily life.2

These researchers have been able to provide probable answers to the question of what the patient

is satisfied with or what to measure in patient satisfaction. The dimensions form the basis for

designing Questionnaires used in satisfaction surveys.

Past Research Findings on Patient Satisfaction

Various empirical studies around the world have revealed different information about patient

satisfaction with different dimensions and with satisfaction overall. A survey conducted at the

Ophthalmology outpatient in Brazil revealed that 82.4% were very satisfied although the author of

this work expressed that some of the high levels of satisfaction may be due to the nature of the

study population which consisted mainly of individuals with low literacy and lower economic

status utilizing the Brazilian public health service. It also included that a major fraction of the

participants included elderly people as would be expected for an Ophthalmology clinic and

probably had no other option to compare the service with.25




Another satisfaction survey conducted in India found 90 to 95% of patients to be generally

satisfied.6A differing result was reported by Asma Ibrahim in a Satisfaction survey conducted in

2008 at the Indira Gandhi Memorial Hospital in Maldives, Thailand where only 10.4% of the

participants were highly satisfied and 89.6% were considered to be of low satisfaction. The author

however explained that the observed deviation might be as a result of high cut off points set for

satisfaction i.e. from the questionnaire responses, only participants who rated the overall

satisfaction as excellent or very good were considered satisfied while those who considered it good,

fair, and poor were considered as dissatisfied.6

In a research conducted in Uganda in 2011 at the outpatient clinics of Mulago National and

Referral and Teaching Hospital, the authors reported a suboptimal level of patient satisfaction

amongst patients. This was deduced from the fact that only about half of the participants chose

‘strongly agree’ or ‘agree’ to being satisfied on the scale used.26

There have also been various findings in Nigeria as regards the overall satisfaction of patients. A

patient satisfaction report on the services in the general outpatients’ clinic in Ibadan, Oyo state

showed that 88.9% of participants rated the overall performance of the clinics to be very good

while 11.3% rated it as good. Another study surveyed the dental outpatient’s clinic at the Lagos

University Teaching Hospital and reported high levels of satisfaction in 53% of participants and

low levels of satisfaction in 43%. 27,28

Iliyasu Z reported 83% overall satisfaction of patients surveyed in the Aminu Kano Teaching

Hospital in Kano while Olusina et al and Eze et al reported 75% and 53% overall satisfaction in

Ibadan and Enugu respectively. Iliyasu Z however attributed the variation observed to the nature

of the study population which differed significantly from most of other researchers. The study

population (Northern Nigeria) had a different cultural mix and consisted of people with much




lower literacy levels which would have reduced the threshold for satisfaction. The manner in which

services were delivered in the Aminu Kano Teaching Hospital was also different from that of the

hospitals by other researchers. He therefore commented that the context in which the survey is

carried out might affect the patient’s rating of satisfaction with services. Similar views were also

expressed by other studies.9,27,28

Factors affecting patient satisfaction ratings

The satisfaction rating of patients is dependent on the patient characteristics and the setting of the

healthcare centre where the survey is being conducted. This means that patient satisfaction is

context or study setting dependent and the particular socio-demographic mix of the study

population might affect the ratings of patients.29

Some of the areas of association that have been found with patient satisfaction ratings are; age,

gender, socio-economic status and health problem.

The age of the respondent has been the most consistent satisfaction associated factor reported

across many studies e.g. the earlier mentioned study in the Ophthalmology outpatient clinic of

Hospital das Clinicas, Universidade Estadual de Campinas (UNICAMP) in Brazil had a higher

percentage of respondents above age 50 and the author attributed some of the high satisfaction

ratings to the age of the patients.25

The evidence on the association between gender and patient satisfaction had been somewhat

controversial. A patient satisfaction survey of particular primary healthcare services in South




Africa found disparities in the satisfaction ratings of men and women. These findings are similar

to those of other researchers in developed countries even though the reports are still mixed. Some

reports state that Women are more satisfied compared to men while others found that men are

more satisfied compared to women.30

Another study conducted in Canada found the satisfaction ratings in both males and females to be

similar i.e. 86% of males were satisfied compared to 84% of females.30 However, a meta-analysis

of 110 patient satisfaction surveys concluded that there was no difference in the rating of

satisfaction by males or females.30A more recent study reported that the frequency of patients in

the particular study setting might contribute to the male-female disparities as well as the type of

service being assessed.30 This has been further supported by the findings of a study conducted in

an oncology clinic which reported that the females rated the care aspect of satisfaction more highly

when compared to men.30 Similarly, a satisfaction survey conducted in a Tuberculosis service

centre found gender and age differences with the satisfaction ratings30

For the socioeconomic status of participants which one can consider to involve attributes such as

education or level of literacy, occupational level, income etc, the findings related to its associations

with patient satisfaction are inconsistent across literature. One study reported increase in patients’

satisfaction ratings with increasing level of education and while another explained that individuals

of educational level are sceptical of medical care.3 Reports from other studies have however

attributed high levels of satisfaction to lower socioeconomic status.25 A study conducted in the

Dental Outpatient clinics of Lagos University teaching hospital also reported that there was no

association between sex, educational status or the specific clinic attended and the satisfaction

ratings of participants.28 The trend of more recent studies especially in developing countries like

Nigeria has been an inverse relationship between socioeconomic status and satisfaction ratings.




People of higher social status usually have more knowledge and more options and consequently

more expectations compared to individuals of lower social status who mostly know little and have

the public health institutions as their only option of healthcare.25

Patient Satisfaction with Accessibility/Convenience of Health services

This earliest studies in identifying the dimensions of care have found ‘accessibility/convenience’

as one of the dimensions of medical care with which patients could be satisfied. A more recent

study also included ‘appropriate access to care’ in one of the six identified dimensions for patient

satisfaction, although the nature of the physical surroundings and the extent of coordination of the

health organization was also included.2,3

This dimension usually deals with variables such as the proximity of the healthcare institution to

patient’s residence, the time during which healthcare can be accessed, the organization of the

healthcare institution in terms of the registration process and how arrangements are made to see a

Physician, the waiting time before actual interaction with physicians etc. The financial aspect of

accessibility, specifically the financial cost of obtaining healthcare is often considered as a separate

dimension. However, costs of accessing the place of care (travel costs), and opportunity costs may

be considered as variables of the accessibility/convenience dimension.3

As with most aspects of patient satisfaction, the reports on this dimension are mixed and dependent

on the particular context of the survey. However, results from more developed countries usually

present higher satisfaction ratings. One study reported high satisfaction ratings of respondents in

the ophthalmology outpatient clinic of a public health facility in Brazil. Respondents declared an

average waiting time of 96.4 minutes with 53.9% waiting for 60 minutes or less before seeing a




physician. Respondents also expressed that it was easy to make appointments and that the cost of

visiting the institution was satisfactory. The author even explained that the high satisfaction with

the accessibility of care made it easy to properly evaluate satisfaction with the quality of care i.e.

technical quality of care since there was no interference from the accessibility dimension. Another

study on patient satisfaction in Maldives, Thailand evaluated variables such as; simplicity and

‘hassle-free’ nature of the health institution, availability of instruments, availability of doctors and

other healthcare professionals under the convenience dimension and reported that 75% of the

respondents were not satisfied. In this study also, most patients (76.5%) were not satisfied with

variables such as; out of pocket costs, affordability and level of protection against medical

problems.6,25

In developing countries including Nigeria, the reports on convenience are also mixed depending

on the particular context. However, the most frequently reported issue is that of the patient waiting

time. In a satisfaction study conducted in Uganda, in a tertiary referral centre, the author reported

the long waiting time to be a major contributor to the dissatisfaction of patients. The cause of the

long waiting time was attributed to overload from lower tier health organizations in the area and

also neighbouring cities since the hospital of study was a major national referral centre.26 For a

satisfaction survey conducted in South Africa in a Primary Health Care setting, respondents were

mostly satisfied with variables in the convenience dimension.30

In the studies done in Nigeria, most authors reported long waiting times and attributed

dissatisfaction mostly to variables from the accessibility/convenience dimension. A study

conducted in Ibadan reported that the practices associated with dissatisfaction in patients were;

long waiting times, absence of a personal list system, the large size of the institution and the fact

that the institution was a teaching practice.27 Another study conducted in a Dental Outpatient Clinic




in Lagos also reported long waiting times and other aspects of convenience as contributors to

dissatisfaction in patients.28 Reports from a study conducted in the Aminu Kano Teaching Hospital

in Kano however differed in the report on convenience since most respondents were satisfied with

the variables of the convenience dimension. The author attributed the disparity to the nature of the

study population which consisted mainly of individuals of low literacy and lower socioeconomic

status when compared to other parts of the country. Besides, the manner in which services were

delivered at the Aminu Kano Teaching Hospital was somewhat different and some of the

respondents were already familiar with the hospital processes.9 Another study that compared

Private and Public Hospitals in Lagos reported variation in waiting time; long waiting time in the

public institutions and shorter waiting time in the private institutions. The authors explained that

the disparity was due to the system of fixing appointments in the different contexts; private

institutions gave patients appointments for particular dates and times while the public institution

only gave appointment for a particular date and attended to patients based on the time they

arrived.20

Patient Satisfaction with the Physical Environment

This could be considered as one of the dimensions of interest when measuring patient satisfaction.

Hawthorne et al also included the nature of the Physical environment in the dimension that

pertained to the appropriate accessibility of the healthcare organization which was one of his

proposed six dimensions of patient satisfaction.2,3

Researchers that have tried evaluating this dimension often assess attributes such as the overall

conduciveness of the environment where healthcare is delivered, comfort of waiting areas, the




ventilation and clarity of signs and directions. Overcrowding of health facility is also usually

considered under this dimension.3

Studies from developed countries usually show high level of satisfaction of patients with the

environment so much that a study measuring patient satisfaction with incontinence treatment in

Australia considered that variables in this dimension e.g. comfort of waiting area, conduciveness

etc. could be ignored from a satisfaction questionnaire since the response of participants to such

questions were already known.2 The reports of a study conducted in Brazil also showed that most

patients were satisfied with the variables in this dimension.25 Another study that evaluated patients’

satisfaction with the Physical Environment of the Indira Gandhi Memorial Hospital in Maldives,

Thailand with variables such as clean and tidy environment, clarity of signs etc. found 58% of

patients to be dissatisfied.26

In the Primary Healthcare Clinics evaluated in South Africa, the respondents were found to be

mostly satisfied with the variable in this dimension. The researcher measured this dimension under

the heading ‘Tangibles’ under which variables such as; condition of clinic building, availability of

bench for waiting, cleanliness/condition of toilets, availability of drinking water, clarity of signs

showing consultation times etc. were assessed. As regards this dimension (satisfaction with

Physical Environment), a study conducted in the outpatient clinics of Mulago Hospital, Uganda

reported that most patients were dissatisfied with the overcrowded environment. This was because

the Mulago Hospital was a tertiary referral site.26,30

The studies in Nigeria have mostly shown dissatisfaction with this dimension with patients

complaining of Overcrowded waiting areas, inconvenient waiting environment, poor power

supply, lack of drinking water etc.27,28




Patient satisfaction with the delivery of care by Health personnel

This dimension of patient satisfaction was identified by Ware et al (1977) who subdivided it into

‘art of care’ and ‘technical quality of care’. It was also identified as the most frequently evaluated

aspect of patient satisfaction. Donabedian’s theory of patient satisfaction is based on the opinion

that the patient satisfaction ratings mainly pertain to the interpersonal process that occurs between

patients and physicians and is the major contributor to satisfaction or dissatisfaction. Hawthorne’s

proposed 6 dimensions of assessing patient satisfaction also majorly consist of items that may be

considered as aspects of the ‘physician conduct’ with items such as; the amount of information

provided to patients, the relationship between patients and healthcare provider and the quality of

care received which consists the level of skill of the physician or healthcare personnel.2,3

Across literature, high level of satisfaction with this dimension of care usually contributes a great

deal to the overall satisfaction rating. A survey conducted in Brazil showed that most respondents

were satisfied with the variables in this dimension, he however expressed that this might be due to

the fact that the respondents being of low literacy level might not want to admit that they do not

understand the Physician’s medical jargon.25

In studies conducted in Uganda in a tertiary institution and South Africa, in a Primary Healthcare

setting, respondents declared high levels of satisfaction with variables in this dimension.26,30

Studies in Nigeria also reported high levels of satisfaction with this dimension. One of the authors

however explained that the high satisfaction levels might be due to the nature of healthcare in

Nigeria where the Physician is often perceived as doing the patient a favour rather than as a

provider consumer relationship.9,27 A satisfaction survey conducted in the Dental outpatient clinics




of the Lagos University Teaching Hospital however reported that patients expressed dissatisfaction

with the practice of allowing unsupervised students attend to them.28 Another study that compared

Public and Private Institutions also found the satisfaction of patients with aspects of the physician

conduct to be similar.20




CHAPTER 3

METHODOLOGY

Description of study area

Randle General Hospital was established on the 12th of September, 1964. It is located on Randle Avenue in

Surulere; one of the 20 Local Government Divisions of Lagos State with a population of 500,000 people.

Lagos state is itself Nigeria’s commercial center and one of its most populous states. Along with the Lagos

University Teaching Hospital (LUTH), Randle General Hospital is one of the health facilities serving the

people of Surulere and it is also an important site of referral from Primary Health Care Centres and Private

Clinics.31

It is a 152 bed hospital with 91 doctors and 101 nurses in attendance and it renders services in different

specialties including; Obstetrics & Gynaecology, Paediatrics, Surgery, Accidents & Emergency, Medicine

etc and besides the outpatient clinics run by the different service departments, the hospital also has a General

outpatient clinic.

Study design

The study is a cross-sectional descriptive survey of the satisfaction of the patients accessing the outpatient

clinics of Randle General Hospital.

Study population

The study population consisted of patients who got services at the outpatient clinics of Randle General

Hospital, Surulere. This included patients from the General Outpatient Clinic, Medical Outpatient Clinic,

Surgery Outpatient Clinic, Tuberculosis Clinic and Dentistry Clinic.

Inclusion Criteria

All patients utilizing the outpatient clinics in Randle General Hospital, Surulere and who have made

at least one visit including the present one was included in the study.




Exclusion Criteria

Patients who could not speak or listen or who had mental health problems were excluded from the

study.

The Antenatal Clinic and the Paediatrics clinic which were situated at a different location from the

main Randle General Hospital premises in Randle Avenue, Surulere were excluded from the study

since the responses to the physical environment and convenience sections of the questionnaires

would be based on the assessment of a different location, environment and a different service

system which would affect the validity of the results.

Sample size determination

In calculating the sample size, report of satisfaction from a previous study in which 86% of respondent

were satisfied7 was used as well as the following statistical formula:

𝑛 =Z2pq

𝑑2

Where:

n is the estimated sample size

Z is the z-score which is 1.96 at 95% confidence interval

p is the proportion of the population possessing the characteristic of interest i.e. satisfaction which is 0.86

according to the previously conducted study.

q is 1-p which is 0.14 i.e. 1 – 0.86 = 0.14

d is degree of accuracy required setting at 0.05.

Substituting the values for the variables into the equation, we would arrive at n = 185.0115.




In order to take care of non-response, incomplete responses and refusals, the estimated sample size was

inflated by 10% arriving at a sample size of 204.

Sampling Methodology

A multistage sampling technique was used. In the first stage, a stratified sampling technique was used to

proportionate a number of respondents to the different outpatient clinics as demonstrated below:

The average total number of patients per day = 339

Estimated sample size = 204

For General Outpatient Clinic, the average number of patients per day = 149, therefore, proportionate

sample size = (149/339) x 204 = 90

For Medical Outpatient Clinic, the average number of patients per day = 59, therefore, proportionate

sample size = (59/339) x 204 = 35

For Surgery Outpatient Clinic, the average number of patients per day = 66, therefore, proportionate

sample size = (66/339) x 204 = 40

For Tuberculosis Clinic, the average number of patients per day = 17, therefore, proportionate sample size

= (17/339) x 204 = 10

For Dentistry Clinic, the average number of patients per day = 48, therefore, proportionate sample size =

(48/339) x 204 = 29

After the required number of patients from each clinic was determined by the stratified sampling

technique, the questionnaires were then distributed to the available patients who were eligible to

participate in the study.




Data Collection

The data was collected by means of self-administered questionnaires. The questionnaires consisted of

items organized into four different sections; Demographics, Satisfaction with convenience/accessibility of

services, Satisfaction with Physical environment of hospital and Satisfaction with delivery of care by

hospital personnel. The questionnaire consisted of five point likert scale items ranging from 1 = strongly

disagree to 5= strongly agree. Patients were to express their satisfaction by ticking any of 1= strongly

disagree, 2= disagree, 3= neutral, 4= agree, 5 = strongly agree and those ticking 1=strongly disagree and

2= disagree were to be considered dissatisfied. Those ticking 3= neutral, 4= agree, and 5 = strongly

disagree were to be considered satisfied with the services.

The questionnaire is an original design with the items based on the research findings of Ware et al and

Hawthorne et al.2,3 These researchers tried to deduce the dimensions of patient satisfaction and their

works (especially Ware et al.) detail particular items from diverse study questionnaires on satisfaction that

could be used in designing a study questionnaire. These details were then used to create items useful in

assessing the specific objectives of this study.

The required number of questionaires based on the proportionate sample size calculations for each clinic

was distributed on the clinic days of the different clinics, starting from the opening hours of the clinic till

the required number of questionnaires were completed.

Data Analysis

Analysis of gathered data was conducted with Epi Info Software and results were presented by use of

frequency tables and bar charts.

All patients selecting ‘Neutral’, ‘Agree’ and ‘Strongly Agree’ were considered satisfied with the

specific subcomponent being tested by the questionnaire item (e.g. waiting time, attentiveness of




doctors, tidiness and cleanliness of reception area etc.) while patients selecting ‘Strongly Disagree’

and ‘Disagree’ responses were considered dissatisfied with the services.

The rating of satisfaction for each of the subcomponents was derived by calculating the

percentage of respondents who were satisfied according to the earlier stated criterion. An average

of the percentage satisfaction for all the subcomponents or questionnaire items under a specific

dimension or section of the study (e.g. Physical environment or delivery of care by hospital

personnel) is then taken as the satisfaction rating for that section. The overall satisfaction rating

is calculated by taking an average of all the percentage satisfaction for all the three evaluated

dimensions of care.

Ethical Consideration

Ethical approval was sought from the Ethical Committee of the Lagos University Teaching Hospital and

the patients’ informed consent was sought before they were included in the study. Patient confidentiality

was also ensured by excluding their names from the questionnaires.




CHAPTER 4

RESULTS

A total of 204 questionnaires were distributed across 5 outpatient departments in Randle General

Hospital while 187 were recovered. Majority of the respondents (85; 45.5%) were from the

General Outpatient Clinic while the rest were obtained from Medical Outpatient Clinic (34;

18.2%), Surgical Outpatient Clinic (30; 16.9%), Dentistry Outpatient Clinic (28; 15.0%) and the

Chest Clinic (10; 5.3%).

The non-response rate was 8.3%, consisting mainly of patients who complained that they were too

busy to fill the questionnaires.

SECTION 1: SOCIO-DEMOGRAPHICS CHARACTERISTICS

Table 1: Age of respondents.

Age (years) Frequency Percentage (%)

<20

20 – 29

30 – 39

40 – 49

50 – 59

60 – 69

>69

Total

20

48

40

28

20

17

14

187

10.7

25.7

21.4

15.0

10.7

9.0

7.5

100.0

The age group, ’20 – 29’ was the most frequent representing 25.7% of respondents followed by

age group, ’30 – 39’ which represents 21.4% of respondents.




Table 2: Sex, marital status, religion and tribe of respondents.

Variables Frequency Percentage (%)

Sex

Female

Male

Total

112

75

187

59.9

40.1

100.0

Marital Status

Single

Married

Separated

Divorced

Total

74

109

1

3

187

39.6

58.3

0.5

1.6

100.0

Religion

Islam

Christian

Traditional

Total

135

48

4

187

72.2

25.7

2.1

100.0

Tribe

Igbo

Yoruba

Hausa

Others

Total

65

113

1

8

187

34.8

60.4

0.5

4.3

100.0

There were more females (59.9%) than male respondents (40.1%) and there were more

respondents from Yoruba (60.4%) than any other tribe.




Table 3: Level of Education and Area of Residence.


Level of Education

None

Primary

Secondary

Tertiary

Total

5

38

60

84

187

2.7

20.3

32.1

44.9

100.0

Address

Outside Surulere

Surulere

Total

66

121

187

35.3

64.7

100.0

More people (44.9%) had at least a tertiary educational level followed by a secondary level of

education (32.1%). The respondents were also mainly resident in Surulere (64.7%) which is the

location of Randle General Hospital.




SECTION 2: SATISFACTION WITH CONVENIENCE/ACCESIBILITY OF SERVICES

Table 4: Respondents’ satisfaction with ease of getting appointment, location of hospital

and clinic opening hours.


It was easy to get an appointment in this hospital

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Total

20

15

72

46

34

187

10.7

8.0

38.5

24.6

18.2

100.0

The location of the hospital is convenient for me

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

7

5

72

54

49

187

3.7

2.7

38.5

28.9

26.2

100.0

I am comfortable with the clinic opening hours

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

21

12

63

46

45

187

11.2

6.4

33.7

24.6

24.1

100.0

A total of 152 respondents (81.3%) were satisfied with the ease of getting an appointment, 175

respondents (93.6%) with the location of the hospital and 154 (82.4%) with the clinic opening

hours.




Table 5: Respondents’ satisfaction with simplicity of service system and waiting time.


The system is simple and trouble free

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

31

38

43

44

31

187

16.6

20.3

23.0

23.5

16.6

100.0

I am satisfied with the time it takes to see a doctor

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

68

32

24

35

28

187

36.4

17.1

12.8

18.7

15.0

100.0

A total of 118 respondents (63.1%) were satisfied with the simplicity of the system while 87

respondents (46.5%) were satisfied with the time taken to see a doctor.




SECTION 3: SATISFACTION WITH PHYSICAL ENVIRONMENT OF HOSPITAL

Table 6: Respondents’ satisfaction with signs, waiting area cleanliness and ventilation.


There are clear signs giving directions in the hospital

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

18

20

62

53

34

187

9.6

10.7

33.2

28.3

18.2

100.0

The atmosphere is clean and tidy

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

8

11

49

65

53

186

4.3

5.9

26.3

34.9

28.5

100.0

The waiting area is well ventilated

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

10

9

55

69

44

187

5.3

4.8

29.4

36.9

23.5

100.0

A total of 149 respondents (79.7%) were satisfied with the clarity of signs and directions in the

hospital, 167 respondents (89.7%) with the cleanliness and tidiness of the atmosphere and 168

(89.8%) with the ventilation of the waiting area.




Table 7: Respondents’ satisfaction with the lighting of waiting area, comfort of seats and

availability of drinking water.


The waiting area is well lighted

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

9

6

60

62

48

185

4.9

3.2

32.4

33.5

25.9

100.0

The seats in the waiting area are comfortable

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

13

12

60

58

44

187

7.0

6.4

32.1

31.0

23.5

100.0

Drinking water is made available in the waiting area

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

62

44

31

28

22

187

33.2

23.5

16.6

15.0

11.8

100.0

A total of 170 respondents (91.8%) were satisfied with the lighting of the waiting area, 162

respondents (86.6%) with the comfort of the seats in the waiting area and 81 (43.4%) with the

availability of drinking water in the waiting area.




Table 8: Respondents satisfaction with the cleanliness of the toilets.


The toilets are clean

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

15

13

80

51

28

187

8.0

7.0

42.8

27.3

15.0

100.0

A total of 159 respondents (85.1%) were satisfied with the cleanliness of the toilets.




SECTION 4: SATISFACTION WITH DELIVERY OF CARE

Table 9: Respondents’ satisfaction with doctors’ friendliness, attentiveness and

consultation time.


The doctor was friendly with me

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

10

7

54

62

50

183

5.5

3.8

29.5

33.9

27.3

100.0

The doctor was attentive

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

9

7

49

69

49

183

4.9

3.8

26.8

37.7

26.8

100.0

The doctor spent enough time with me

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

15

10

58

62

38

183

8.2

5.5

31.7

33.9

20.8

100.0

A total of 166 respondents (90.7%) were satisfied with the friendliness of the doctors, 167

respondents (91.3%) with the attentiveness of the doctor and 158 (86.4%) with time spent by the

doctor.




Table 10: Respondents’ satisfaction with privacy maintenance, explanation of findings and

involvement in care.


The doctor maintained privacy during examination

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

8

8

57

62

48

183

4.4

4.4

31.1

33.9

26.2

100.0

The doctor explained his findings to me

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

19

8

62

54

40

183

10.4

4.4

33.9

29.5

21.9

100.0

I was allowed to make treatment choices

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

29

13

66

38

37

183

15.8

7.1

36.1

20.8

20.2

100.0

A total of 167 respondents (91.2%) with privacy maintenance by the doctors, 156 respondents

(85.3%) with explanations made by the doctor and 141 (77.1%) with the ability to make

treatment choices.




Table 11: Respondents’ satisfaction with the conduct of other health professionals.


I am satisfied with the conduct of other health

professionals i.e. Nurses, clerical staff etc.

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

Total

18

5

67

56

38

184

9.8

2,7

36.4

30.4

20.7

100.0

A total of 161 respondents (87.5%) were satisfied with the conduct of the other health

professionals.

Overall satisfaction was calculated as described in Data Analysis of Methodology section of this

document.




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CHAPTER 5

DISCUSSION

This study was conducted to evaluate the satisfaction of patients utilizing the outpatient clinics of

Randle General Hospital Surulere and more specifically assess their satisfaction with three of the

dimensions of care being Convenience/Accessibility of services, physical environment of hospital

and the delivery of care by hospital personnel.

The questionnaire evaluated patient satisfaction by requiring respondents to select one of five

responses (Strongly Disagree, Disagree, Neutral, Agree and Strongly Agree) to specific statements

assessing various subcomponents of the relevant dimensions of care.

Overall satisfaction ratings of patients in Randle General Hospital

The overall satisfaction rating for the three dimensions in Randle General Hospital was found to

be 80.4% (i.e. 80.4% of study participants chose ‘neutral’, ‘agree’ and ‘strongly agree’ when

responding to the statements in the survey questionnaire). This is comparable with the findings of

Fornazari de Oliveira et al where the author reported an overall satisfaction rating of 82.4% for a

survey conducted in the ophthalmology clinic of a university hospital in Brazil.25 However, his

study used a higher cut-off point for satisfaction such that if the same cut-off point were adopted

in this study, the overall satisfaction rating would have been much lower. This comparatively lower

satisfaction rating could be attributed to the more heterogeneous study sample which was obtained

from five different outpatient clinics in Randle General Hospital as opposed to Fornazari de

Oliveira et al which was conducted in a single clinic. Also, their study sample consisted of elderly

citizens who had no other option of care and therefore rated the only available services highly.25




When the finding from this study is compared with a study conducted in a tertiary hospital in

Uganda, the satisfaction rating is found to be higher with the authors reporting a 50% ‘high

satisfaction’ rating amongst respondents.26 A possible explanation for the lower satisfaction rating

when compared with the study at Randle General Hospital would be the high cut-off point used

by the authors considering only those individuals choosing responses on the higher spectrum of

the response scale as satisfied. The authors also attributed the low satisfaction ratings to the context

of the study; Mulago National Hospital is a tertiary centre and a major referral site in the locality

such that the clinics are often overcrowded and this might have contributed a great deal to a

comparatively lower satisfaction rating amongst respondents. Randle General Hospital whose

patients form the study sample for this research is however a secondary health institution with

referrals mainly being from primary healthcare centres in Surulere Local Government or from

private practitioners. The hospital is also close to Lagos University Teaching Hospital which is a

tertiary referral site and is also a referral option to the primary care centres. These facts are also

reasonable explanations for the way the satisfaction rating from this study differs from the works

of Olusina et al and Eze et al who reported satisfaction ratings of 75% and 53% respectively.7,9,26

Satisfaction of patients with the convenience/accessibility of Randle General Hospital

In evaluating the satisfaction of patients with this dimension of care, their responses to various

questionnaire items representing commonly studied components of this dimension as identified by

Ware et al (1977) were evaluated. Questionnaire items involved statements regarding; ease of

getting appointment, convenience of opening hours, convenience of location, simplicity of the

process of care and the time it takes the patient to see a doctor.3

The average satisfaction rating for all the components in this dimension was found to be 73.4%

mainly contributed by the satisfaction ratings for the ‘location of the hospital’ with a satisfaction




rating of 93.6%. This high satisfaction rating for the location of the hospital can be attributed to

the high proportion of respondents who were resident in Surulere (64.7%). In the reports of other

studies conducted in Nigeria, ‘location of the hospital’ had not been reported as a contributor to

high satisfaction. This may be because their research works were carried out in Tertiary Institutions

that serve as referral sites for other lower tier health institutions in their region. This would lead to

an inflow of patients from diverse locations in the hospital some of which might not have found

the hospital location convenient and therefore rated that component of the

convenience/accessibility dimension lowly.9,27,28

The least contributor to the satisfaction ratings of patients in this dimension was found to be ‘time

taken to see a doctor’ i.e. the patient waiting time with only 46.5% of respondents giving ‘Neutral’,

‘Agree’ and ‘Strongly Agree’ as their responses. This is consistent with the findings of a study

conducted in a tertiary referral hospital in Uganda, where the researchers reported ‘patient waiting

time’ as the strongest contributor to dissatisfaction in patients.26 Another study conducted in the

Dental Clinic of Lagos University Teaching Hospital also reported ‘long waiting times’ as a major

contributor to dissatisfaction in patients. It has been reported that the practices contributing to

patient dissatisfaction were; long waiting times, absence of a personal list system, and large size

of the hospital especially if it is being used as a teaching hospital.27,28

The cause of the long waiting time in hospitals has been attributed to overload from lower tier

health institutions.26 Randle General Hospital is a secondary referral site to the primary health care

centres and general practices in Surulere. This is however not so comparable with the study sample

of other researchers who conducted their studies in tertiary referral sites that would have

experienced more overloads from lower tier health centres.9,27,28




Another reason for the long waiting times is the method of fixing appointments in the hospital. In

a study comparing Private and Public health Institutions in Lagos state, the researchers observed

that the Private institutions gave patients appointments for a specific date and time while the Public

institutions only gave appointment for a particular day and attend to them on a first come first

serve basis. This method adopted in public institutions often resulted in overcrowding and many

patients experiencing long waiting times. Randle General Hospital being a public health institution

also adopts this latter method of giving appointments and this might be considered as a contributor

to the long waiting time.20

The convenience/accessibility dimension of care was also found to be the least contributor to the

overall satisfaction of Randle General Hospital. This is consistent with the findings of other

researchers in Nigeria.27,28 Another study conducted in the northern part of Nigeria however differs

in this regard with reports of high satisfaction ratings amongst respondents. This disparity was

attributed to the socio-cultural mix of the study population consisting mainly of individuals of

lower educational achievements who also earned low incomes.9 The socio-demographic

characteristics of the respondents at Randle General Hospital revealed that more individuals had a

higher level education with 77% of respondents having at least a Secondary level of education and

44.9% with a tertiary educational level. The comparatively low levels of satisfaction with the

convenience/accessibility of care dimensions of care are therefore consistent with the findings of

recent studies where higher socioeconomic status (which is considered to include literacy level,

occupation and income) have been found to be inversely related to satisfaction.9,25,28

Satisfaction of Patients with the Physical Environment of Randle General Hospital

To evaluate the satisfaction of the respondents with the physical environment at Randle General

Hospital, their responses to various statements related to regular subcomponents of this dimension




were taken. Subcomponents of the physical environment like clarity of directional signs,

cleanliness/tidiness of atmosphere, ventilation, lighting, comfort of seats in waiting area,

availability of drinking water and cleanliness of toilets formed the questionnaire items in this

section.

The average satisfaction rating amongst respondents for all the components in this section was

found to be 80.9% mainly contributed by ‘lighting of the waiting area’ with satisfaction rating of

91.9% while the ‘presence of drinking water’ was the least contributor to satisfaction with

satisfaction rating of 43.4%. The reason for this low satisfaction rating for ‘presence of drinking

water’ is most likely because there are no arrangements for drinking water in the waiting areas of

the clinics.

The level of dissatisfaction observed in this section differs from what obtains in studies conducted

in developed countries but are not surprising when compared with results from studies conducted

in Nigeria. Other Nigerian researchers have demonstrated patient dissatisfaction with this

dimension of care especially in subcomponents like; overcrowding, power supply, comfort of

waiting area and availability of drinking water.27,28 In contrast, the foreign researchers have

recorded high levels of satisfaction with the ‘Physical Environment’ dimension so much that some

consider it not worthy of measurement. This trend was demonstrated in a satisfaction survey

amongst incontinence patience in Australia where the author wrote that the Physical environment

dimension could be exempted from the survey questionnaire since the responses to its assessing

statements were already known.2




Satisfaction of Patients with the delivery of care by Hospital personnel

In evaluating this dimension of care, subcomponents like friendliness of doctor, attentiveness of

doctor, time spent with patient, doctor’s respect for patient privacy, explanation of examination

findings to patients, ability of patients to make treatment choices, conduct of other health

professionals e.g. nurses, clerics etc. were evaluated in the study questionnaires.

After analysis of the survey questionnaires, the satisfaction rating for this dimension was found to

be 87.0% with ‘attentiveness of doctor’ being the most contributory subcomponent with

satisfaction rating of 91.3% and ‘ability of patients to make treatment choices’ being the least

contributing subcomponent with a satisfaction rating of 77.1%.

The satisfaction rating for this dimension of care is the highest of all the three dimensions evaluated

in this study and therefore contributes the most to the overall satisfaction rating. This finding is

consistent with the reports of other researchers across literature. A study conducted in Brazil

reported the ‘delivery of care’ dimension as the most contributory to overall satisfaction ratings

amongst the respondents; the author however attributed this observation to the low literacy of the

respondents explaining that the respondents would have considered the physicians satisfactory

rather than reveal their inability to understand the physician’s medical jargon.25

Studies conducted in Uganda and in Nigeria are also consistent with this findings reporting

‘delivery of care’ dimension as the most contributory to overall satisfaction ratings. This finding

might be due to the nature of healthcare relationships in Nigeria where the Physician is considered

as doing the patient a favour rather than a consumer-provider relationship. This is the most likely

explanation for the observation at Randle general hospital since a greater proportion of respondents

had at least a secondary level of education.25,26,27




The same high levels of satisfaction was observed in this dimension of care when public and

private health institutions were compared as well as in studies conducted amongst population

samples with low literacy levels.9,20

However, for a study conducted in the Dental Clinics of Lagos University Teaching Hospital,

respondents were reported to be dissatisfied especially with the practice of being attended to by

unsupervised medical students. A possible explanation for this disparity is that the Hospital in

which the study was conducted is a tertiary institution having additional training responsibilities

as opposed to just being a healthcare organization as is the case with Randle General Hospital and

the most of the other health institutions used by other researchers. 28




CONCLUSION

It can be concluded from this study that the proportion of patients satisfied with the services in the

outpatient clinics of Randle General Hospital, Surulere is 80.7%.

When the convenience/accessibility of the clinics were assessed, 73.4% of respondents were

satisfied mainly contributed by those satisfied with the hospital’s location (93.6%) while the time

they take to see the doctor was the most common reason for their dissatisfaction in this dimension

since only 46.5% of respondents rated the waiting time as satisfactory.

The proportion of respondents satisfied with the physical environment was also found to be 80.9%

with the lighting of the waiting area being the most contributory subcomponent to patient

satisfaction (91.9%) and the presence of drinking water in the waiting area being the least

contributory (43.4%).

The proportion of respondents satisfied with the delivery of care by hospital personnel was also

found to be 87.0% with the physician’s attentiveness being the most contributory component to

satisfaction (91.3%) while the ability of the patient to make treatment choices contributed the least

to patient satisfaction (77.1%).

Based on these findings, the hospital management can improve the quality of care by making

efforts to reduce patient waiting time, making services simpler and easier to navigate by patients,

providing drinking water in the patient waiting areas and ensuring doctors give more opportunity

for patients to participate in their own care. Satisfaction surveys should also be extended to

inpatient care services and be conducted on a periodic basis for quality assurance.




RECCOMENDATIONS

In view of the findings of this study and the role of an outpatient department of any hospital as one

which provides services that are easily accessible to patients while anticipating, meeting and

exceeding the needs of the patients and at the same time providing a conducive and productive

work environment for members of staff, the following actions are recommended to the

management of the Randle General Hospital, Surulere.6

i. Efforts should be made to make the hospital system simple and trouble free so that the

clinic flow is easily understood and navigated by patients in the outpatient clinics.

ii. The management should make efforts to reduce the average time it takes a patient to

see the doctor since this was the most common factor contributing to dissatisfaction

amongst the respondents in the convenience/accessibility dimension of care.

iii. The management should also make drinking water available in the different clinic

waiting areas of the hospital

iv. The hospital physicians should create more opportunities for patients to make treatment

choices and accept more responsibility over their own health.

v. More satisfaction surveys of this sort should be carried out periodically in the hospital

to ensure the outpatient clinics remain responsive to the needs and expectations of

patients.

vi. The survey should also be extended to the inpatient departments of the hospital so as

to ensure the same quality assurance benefits across all departments in the hospital.




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APPENDIX




QUESTIONNAIRE

Patient satisfaction with the services in the outpatient clinics of Randle General Hospital

Introduction

I am a 500 Level student of the College of Medicine, University of Lagos and I am conducting a

research on the satisfaction of patients with the services delivered at the Outpatient clinics of

Randle General Hospital. Results from this study would provide the Hospital management, doctors

and other health professionals with information that would help them make objective

improvements in the services delivered and the overall experience of patients in the clinic.

I therefore require your assistance in this regard. Please endeavour to be totally truthful with your

responses; the information you provide will be treated confidentially.

Yekinni Ibrahim

Do you agree to take part in this study? Yes [ ] No [ ]

SECTION 1: DEMOGRAPHICS

1. Age (in years): _________________

2. Sex: [ ]Male [ ]Female

3. Marital Status: [ ]Single [ ]Married [ ]Separated [ ]Divorced [ ]Widowed

4. Religion: [ ]Islam [ ]Christian [ ]Traditional [Others]

5. Tribe: [ ]Igbo [ ]Hausa [ ]Yoruba [ ]Others

6. Level of Education: [ ]None [ ]Primary [ ]Secondary [ ]Tertiary

7. Occupation: ________________________

8. Address: ___________________________

Please turn over




SECTION 2: SATISFACTION WITH CONVENIENCE/ACCESSIBILITY OF

SERVICES

Please tick the appropriate response in the box.

Strongly

Disagree

Disagree Neutral Agree Strongly

Agree

9. It was easy to get an

appointment in this Hospital

10. The Location of the Hospital is

convenient for me

11. I am comfortable with the clinic

opening hours

12. The system is simple and trouble

free

13. I am satisfied with the time it

takes to see a doctor

Please turn over




SECTION 3: SATISFACTION WITH PHYSICAL ENVIRONMENT OF HOSPITAL


Strongly

Disagree


Agree

14. There are clear signs giving

directions in the hospital

15. The atmosphere is clean and tidy

16. The waiting area is well

ventilated

17. The waiting area is well lighted

18. The seats in the waiting area are

comfortable

19. Drinking water is made

available in the waiting area

20. The toilets are clean

Please turn over




SECTION 4: SATISFACTION WITH DELIVERY OF CARE BY HOSPITAL

PERSONNEL


Strongly

Disagree


Agree

21. The Doctor was friendly with

me

22. The Doctor was attentive

23. The Doctor spent enough time

with me

24. The Doctor maintained privacy

during examination

25. The Doctor explained his

findings to me

26. I was allowed to make treatment

choices

27. I am satisfied with the conduct

of the other health professionals

i.e. Nurses, Clerical staff, etc.

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