SSESSING THE SATISFACTION LEVELS OF OLD AND NEW PATIENTS IN OPD – AN OBSERVATIONAL CROSS-SECTIONAL STUDY OF OPD PATIENTS IN PUSRAWI HOSPITAL, MALAYSIA

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Fall 2015
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CHAPTER I. INTRODUCTION
1.1 Background of Study
Healthcare industry across the globe is striving towards optimal quality of care, which has emerged as the central goal of various public and private organizations. Malaysian healthcare system caters to the health of the population via public and private services. Disparity in wealth has created divisional provision of public and private entities in the healthcare system. While the private hospitals’ general focus lies in providing opulent services to the palatial population with a key idea of increasing their revenues, public hospitals are run by the Ministry of Health, Malaysia. Despite the disparity, the goal of Malaysian government is to ensure optimal health to its population by fulfilling patients’ expectations through services and care. However, consistent healthcare restructuring, advancements in technology medical or otherwise, demand for healthcare practitioners coupled with high competition, have created disturbances in the equilibrium of the global healthcare system on perpetual basis (Turris, 2005).
Apart from demand for quality of services and care from government segments, a general demand among the consumers of healthcare or patients in simplistic terms, has viably made its way into the healthcare system. Patients’ experiences with the hospital’s quality of care define their satisfaction with the hospital, and patient satisfaction with the obtained quality of services and care is considered as an important indicators of healthcare quality itself (Othedal et al., 2007). The experiences of the patients in addition to patients’ expectation and perceptions have a direct impact on health outcomes (Wilde et al., 2009). Since excellent care for patients is the primary goal of hospitals, ensuring physical and psychological well-being of the patients emerges an inevitable need.
Measuring patient satisfaction through quality of service and care from a Malaysian perspective shall ensure hassle-free and quick resolution for patients. Since OPD is considered as the window of the hospital, it is important to ensure virtuoso experiences for not only new patients but also each and every old patient that visits the hospital. Such an experience requires patients’ feedback with the services received; measuring patient satisfaction in each and every regional and national healthcare divisions of Malaysia is inevitably important.
1.2 Statement of Problem
The current study addresses the anomalistic problem of patient satisfaction definition and measurement since the inception of the concept in healthcare history. There exists spasticity in patient satisfaction conceptual and theoretical discussions, which view patient satisfaction either as attitude to measure, or perception to be aware of or as supposition of healthcare or towards life in general excluding the services provided in the hospitals (Merkouris, et al., 2004). In addition, a common consensus towards the definition and outlook of patient dissatisfaction does not exist in literature studies (Biering et al., 2006). While some researchers signify the unprecedented use of dissatisfaction as a distinct concept and build theories around it (Coyle & Williams, 1999), certain researchers insist on considering patient satisfaction as a subjective concept, given its qualitative dimensionality alike any satisfaction index (Linder-Pelz, 1982; Merkouris, et al., 2004). Recent studies have added new dimension to this pandemonium and have insisted on considering patient satisfaction from patients’ perspective (Johansson et al., 2002) significantly highlighting the need for patient centeredness.
Patient centred care (PCC) is synonymous to a healthcare system which revolves around the physical, social and psychological well-being of patients around the pillars of compassion, concern, communication, respect and shared decision-making. An epitome of morality, PCC integrates the physical, process and people aspects of the healthcare system, and insists on strong professional practices across healthcare providers to ensure optimal quality of care and services and patient satisfaction, while reducing costs (Pelzang, 2010). Patient centeredness ensures measurement of experiences from patients’ point of view.
“There is a growing interest in measuring patients’ experiences in health care” (Delnoij, 2009: 355). Patient satisfaction ensures compliance of physical and people attributes in the healthcare system as per patients’ expectations (Ganasegeran & Al-Dubai, 2014). It evaluates the quality of care and patients’ perceived positive or negative outlook defines the essence of quality of care and outcome of the healthcare feature/s using key functionalities such as process, people and procedures (Narimah et al., 2006).
Lately, numerous oddity among the healthcare organizations, increasing pressures of patient management and varied quandaries related to service delivery (Troyer et al., 2004) have challenged the stability and semblance of the healthcare system. High competition in the healthcare market, aging population, lack of insurance, coupled with increasing patient demands for quality of services and care, amidst declining earnings, have created complexity in the healthcare system itself (Savage, et al., 1997). Continued presence of such issues can result in loss of stakeholder and public interest in healthcare and government itself (Health Research and Educational Trust, 2007). Therefore, need exists in providing optimal features to the users and ensure efficient survival and growth for organizations. Continual studies amalgamating the concepts of service quality and patient satisfaction from patients’ perceptions to ensure optimal patient centred care is critically essential.
1.3 Purpose and Rationale of the Study
The purpose of the study is to assess the satisfaction levels of old and new patients with the quality of healthcare services provided by the Outpatient Department (OPD) of Pusrawi hospital at Kuala Lumpur, Malaysia. Conducted from an aggregate and waiting time perspective, the current study applies the SERVQUAL model to divulge into the inter-relationship between quality of care and services and patient satisfaction. Understanding patients’ perception is crucial for healthcare providers given the importance of patients as direct consumers of healthcare. Satisfaction of healthcare consumers yields optimal physical and psychological health outcome for the patients and optimal survival and growth for the organizations. While numerous theoretically based research have defined critical measurements for patient satisfaction through service quality, the conditions that encompass the two constructs create discrepancies not only pertinent to the relationship between them, but also about methodological and structural measures that define the two constructs. Each study is an individual representation of the interaction between intrinsic, person-related an extrinsic, environment-related factors, which minimizes a common applicative standard across all local, regional and global levels. Continuous studies shall not only identify the satisfaction levels of patients in the given setting, but also enable in conducting trend analysis in the particular setting over a period of time. In addition, most studies identified in the literature reflect univariate analysis of the collect data in most cases and bivariate in certain others, with minimal amalgamation of the three analytical methods in a single study. Using the three types of analysis, the outcome of the subject subjected to rigorous iterative analysis shall better the understanding of relationship between quality of care and services and patient satisfaction from patients’ perspective. Using SERVQUAL model as the theoretical model, the current study eventually aims at drafting steps for optimal patient satisfaction levels with the quality of care and services among all patients that visit the OPD of Pusrawi hospital.
1.4 Conceptual Framework
The current study aims to validate the theoretical model based on SERVQUAL approach, considering its five dimensions, tangibility, assurance, responsiveness, reliability and empathy as independent variables. The impact of these variables in addition to intricate analysis on another crucial independent ‘responsiveness’ variable ‘waiting time’, on patients’ satisfaction levels across Pusrawi hospital’s OPD is figuratively defined in the figure below. Intertwined with demographic indicator, patient status’ perception of quality of care and the impact of this perception on dependent variable ‘patient satisfaction’ is indicated in the conceptual framework. The framework concurrently establishes the relationship of three crucial healthcare constructs – patients’ perception, quality of care and services and patient satisfaction, and symbolizes the materialization of the current study from dual perspective, an aggregate SERVQUAL dimensional perspective and explicit responsiveness perspective.

1.5 Research Objectives and Questions
The objectives of the current study can be delineated as follows:
1. To identify the existence and degree of variation in the satisfaction levels of old and new OPD patients with the quality of care and services in Pusrawi hospital from an aggregate and waiting time perspective.
2. To identify the crucial factors that impact the satisfaction levels of old and new OPD patients with the quality of care and services in Pusrawi hospital from an aggregate and waiting time perspective.
3. To outline plausible steps for effective OPD management to ensure high satisfaction levels with the quality of care and services among all patients that visit the OPD of Pusrawi hospital.
Conforming to the research objectives and from an aggregate and waiting time perspective, the following research questions can be outlined:
1. Does a variation exist in the satisfaction levels of old and new OPD patients in Pusrawi hospital with the quality of care and services? If yes, that is the degree of variation in the satisfaction levels of old and new OPD patients?
2. What are the crucial factors that impact the satisfaction levels of old and new OPD patients in Pusrawi hospital with the quality of care and services?
3. What are the plausible steps for effective OPD management to ensure high satisfaction levels with the quality of care and services among all patients that visit the OPD of Pusrawi hospital?
1.6 Nature of the Study
The study used cross-sectional quantitative approach based on survey strategy (Bryman & Bell, 2007) to identify the interaction between patients’ perception, quality of care and services and patient satisfaction from a SERVQUAL and waiting time perspective. Considered as the nature of the study, this approach with the applicative use of self-administered questionnaire used simple random sampling method to collect data from 150 OPD patients that visited Pusrawi hospital. The collected data post statistical analysis (univariate, bivariate and multivariate analysis) using SPSS aimed at identifying the relationship between independent variables of the SERVQUAL dimension and waiting time, and dependent variable, patient satisfaction attributed with willingness to reuse the services. Conducted within the perspective of patient status (demographic indicator), the study aimed segmental analysis to ensure optimal patient satisfaction among new and old patients that visit the Pusrawi hospital’s OPD.
1.7 Definition of Terms
This section covers the commonly used terms in the current paper. Each of the terms mentioned below are defined from researcher’s point of view accumulated through literary analysis.
Patient Status: Standing of the patient in terms of number/frequency of visits to the hospital. Patient status can be viewed from new and old patients’ perspective.
New patients: Patients that have never availed OPD services from the hospital before.
Old patients: Patients that have availed OPD services from the hospital before.
SERVQUAL: SERVQUAL is service quality acronym developed by Parasuraman et al. (1985). Defined by a dimensional gap, it is the difference between consumers’ expectations (E) and consumers’ perception of performance (P).
Patient perception: The continual cognition of the services availed by the patients with respect to environmental, people and processes of the hospital.
Patient expectation: The anticipants of patients. Patient expectations could revolve around the environmental, people and processes of the hospital.
Patient satisfaction: Fulfilling experiences of the patients with respect to environmental, people and processes of the hospital and the willingness of the patients to use the services again; attributed by the minimization and gradual reduction of the gap between consumers’ expectations (E) and consumers’ perception of performance (P).
Waiting time: Time taken by the patients to avail services in each area of the OPD
Waiting area: Areas of OPD such as registration, consultation, waiting room and dispensary
1.8 Assumptions and Delimitations
The study was conducted on the basic assumption that patients’ perception did not vary with socio-demographic indicators such as age, gender, employment, educational status, availability of health insurance and many more. Socio-demographic dimension was kept as constant and patient satisfaction variation with demographic indicator patient status was only considered. This is not only the current study’s assumption but also an important delimitation. The second delimitation of the study lies in the study’s intention. The study is delimited towards understanding the relationship between patient satisfaction and service quality. The further impacts of satisfaction with service quality or satisfaction itself such as patient loyalty and financial benefits or people-related intrinsic factors such as behavioural intentions or employee performance and motivation was not included in this study. For instance, a quantitative study was conducted by Aliman & Mohamad (2013) identified partial mediating effect of satisfaction on service quality and behavioural intentions. Thus, an inclusion of satisfaction in any study along while predicting behavioural intentions could yield weak results associated with quality-behavioural constructs. Considering this, patients’ behavioural intentions were not considered in this study and the study was delimited towards SERVQUAL dimensional perspectives.
1.9 Organization of the Study
The following chapters of the study are organized as follows. Chapter two critically analyses the already existing literature on service quality, patient satisfaction and waiting time. This chapter provides the necessary secondary resources for developing fundamental measures for collecting and analysing the data. Chapter three provides an overview of the research methodology used in the current study. While chapter two laid the theoretical foundation, chapter three developed necessary hypotheses and instrumentation to collect patients’ perception on service quality and to extract concurrent satisfaction levels. Chapter four deals with presentation of the univariate, bivariate and multivariate analysis conducted on the collected data to discuss the relevant findings and connect it to the research objectives and hypotheses, which is achieved in chapter five. Chapter six concludes the current study with necessary recommendation for further research. The next chapter conducts a critical analysis of the literature on service quality, patient satisfaction and waiting time from a demographic and patients’ perception perspective.

CHAPTER II. LITERATURE REVIEW
2.1 Introduction
Chapter two provides a critical analysis of the available literature on patient satisfaction with healthcare quality. The chapter is divided into nine sections. The first section provides an introduction to the second chapter of the current study. The second section highlights the strategy used to collect the critical literature for the study. The third section provides a dichotomous discussion on the concepts of satisfaction and patient satisfaction from general and hospital services perspective and introduces the various factors that influence satisfaction levels. The fourth section focuses on the relationship between patient status and patient satisfaction. Various studies on the two aspects are covered in this section. The fifth section provides a comprehensive view of quality of care. The following section focuses on the time spent in the OPD. The next section provides an overview of the relationship between waiting time and service quality. The chapter culminates with summary points of the analytical chapter on the available literature on patient satisfaction and service quality.
2.2 Search Strategy
A systematic search using key constructs of the current study, patient satisfaction, and SERVQUAL instrument, waiting time and patient visits from a global, regional and local levels across key databases such as Google Scholar, Emerald, Pub-Med, BioMed Central, Science Direct, ProQuest which produced artices relevant and critical for the current literature. To ensure the applicative use to recent studies, the timeline for the studies was filtered between 2004 and 2015. Only studies published since 2004 were thus explored and used in the current literature review. While certain references regarding the theoretical origin or evolution of certain concepts such as patient satisfaction and healthcare quality required the use of studies prior to the filtered timeline; however, care is taken to ensure the use to recent studies while drafting the relationship of demographics, service quality and waiting time with patient satisfaction.
2.3 An insight patient satisfaction in the healthcare system
The role of patient satisfaction in healthcare system is vital and gauging patient satisfaction from local, regional, national and global levels is correspondingly quintessential. In line with this, understanding the importance of patient satisfaction in the healthcare system from a historical and theoretical perspective is crucial. Patient satisfaction is commonly used to guide research into patients’ experiences of healthcare (Gut, Gothen, & Freil, 2004; Danielsen, Garratt, Bjertnes, & Pettersen, 2007). An insight to the historical evolution of consumer rights provides sufficient information of the development of patient satisfaction as a practical and political indicator in the current healthcare system. The roots of patient satisfaction lie in the sociological interests of researchers towards interpersonal relationships such as patient-personnel relationship. Patients’ point of view began to contrive in the research studies such as that of Cartwright (1964, 1967) and Locker & Dunt (1978). Studies since then began to stress the importance of considering patients view to improve healthcare quality, and the pressure exerted on healthcare providers in UK to incorporate patients’ decisions in enhancing UK health services in the 1980s highlight the stress on patients view (Jones et al., 1987).
Griffiths report (DHSS, 1984) laid the foundation for: a) consumer-service oriented culture, b) quality management philosophies and theories, and c) patient satisfaction movement. A general shift in the healthcare paradigm was observed, where the providers shifted their focus from ‘processes only’ management towards ‘processes and people’ integrative systems. Studies conducted by (Hopkins, 1990), Williams & Calnan (1991) and Cox et al., (1993) began to be considered patients as consumers of healthcare in the late early 1990s. Patient satisfaction functions as a qualitative indicator of healthcare system and enables the healthcare system to discern the behavioural traits of patients to develop appropriate regional frameworks. Consistent evaluation of patient satisfaction shall provide an overview of existing medical treatment and processes of healthcare providers, modes of utilization of services by patients and interpersonal relationship between patients and healthcare personnel (Ganasegeran & Al-Dubai, 2014). Such informative studies shall strengthen the stance of patients as crucial entities in the healthcare system.
From a powerless entity in the healthcare system, studies in the past 25 years have robustly considered patients as the central entity of the healthcare system. What followed since then is the ingrained and circadian analysis of patient satisfaction across various global, regional and local arenas. For instance, studies conducted in Europe and America on evaluating patient satisfaction with quality of care insist on three crucial insights: a) measuring patient experiences with varied qualitative aspects rather than mere overall experience, b) integrated internal quality measurement and external reporting, and c) standardized questionnaire and models to measure patient satisfaction with quality of care (Delnoij, 2009). While the concept of standardizing patient satisfaction measurement is utopian in nature, the demand for standardization can only be met with continued regional and local studies to understand the applicative nature of various indicators such as quality of care.
On the perspective of identifying various indicators, a secondary study based on World Health Survey (WHS) analysed the experiences of 2352 patients to assess the degree of responsiveness of healthcare system from public and private perspectives. The results of the study showcased great co-relation between access, communication and autonomy and outpatient patient satisfaction, followed by dignity, confidentiality and basic amenities quality and solution and outpatient patient satisfaction. The study highlighted priority areas for improving responsiveness in South African healthcare system (Peltzer, 2009).
Another review of 33 patient satisfaction surveys conducted in Asia aimed at identifying factors that define patient satisfaction from a generic perspective. The results of the study identified the influence of demographic factors, technical and functional aspects and environment on patient satisfaction. Variation in satisfaction indicators was observed across the countries and the study eventually stressed on conducting national level satisfaction countries to identify and develop standardized healthcare system for each and every country (Dayasiri & Lekamge, 2010).
In line with this, cross-sectional survey conducted in Kedah, Malaysia reflects the importance of conducting studies on patient satisfaction to predict health-related behaviours. With the help of self-administered questionnaires, the study used a convenience sampling of 435 patients to primarily understand the satisfaction of the patients with current healthcare services. With a discovery of satisfaction rate of 45.5%, the study highlighted waiting time and time spent in consultation and registration as influential factors of patient satisfaction. Thus, highlighting the need for developing strategies to minimize waiting time, the study also identified patient satisfaction as an indicator of quality of healthcare provider (Hassali el at., 2014).
The above studies validate the periodic and continuing studies on patient satisfaction across different continents including Malaysian perspective and emphasize on the innate need for unremitting assessment of patient satisfaction from local fronts in each and every region across the continents, to identify the factors that ensure patient satisfaction and prepare a region specific action plan to ensure optimal patient-centred care.
Patients are consumers in healthcare systems (Prakash, 2010) and various analytical studies have qualitatively or quantitatively established the significance of PCC in any healthcare system. For instance, a concept-analytical study conducted by Jayadevappa & Chhatre (2011) assesses 143 multidisciplinary studies that addressed PCC between 1910 and 2010 across various countries to highlight the importance of PCC. The results of the study established a strong connection between PCC and quality of care, patient satisfaction and reduction in healthcare costs. Another longitudinal study conducted by Lee & Lin (2010) in Taiwan used quantitative research approach to collect questionnaire data from 614 patients with type II diabetes. With an aim to understand the relationship between PCC and patient-practitioner relationship and health outcomes, the study signified the autonomous preferences of patients in healthcare system. A strong relationship was found between PCC and concepts such as communication, care and power and the study eventually signified the importance of PCC as a deciding factor of health outcomes and patient satisfaction. A non-experimental evaluative study conducted by Sidani (2008) on 320 patients in Canada identified the effects of PCC on patient satisfaction. The results of the study identified an indirect effect of PCC on self-care ability and patient satisfaction and established a significant relationship between healthcare professionals such as nurses and patient satisfaction. An overview of these studies eventually highlights the need for ensuring PCC as a critical factor for the holistic development of the healthcare system of the nation.
Systematic measurement of patient satisfaction is one of the critical factors that ensure the materialization of PCC at any organizational level (Shaller, 2007) and optimal patient satisfaction ensures reduction in divisional gap between patient satisfaction and dissatisfaction. Numerous behavioural and cognitive theories have been propounded to measure satisfaction levels of consumers. The dynamic nature of patient satisfaction provides the flexibility for researchers to measure satisfaction levels: a) quantitatively or qualitatively (Al-Abri & Al-Balushri, 2014), b) from a subjective perspective (Linder-Pelz, 1982), c) from a patient’s current psychological standing or from dissatisfaction perspective (Merkouris, et al., 2004). Patient satisfaction is measured through patient experiences and in the recent years various qualitative and quantitative approaches such as department or unit level surveys, focus groups, interviews, forums and third-party intervention through advocacy groups or service organizations have been rigorously employed (LaVela & Gallan, 2014).
From a subjective perspective, the value-expectancy model developed by Linder-Pelz (1982) can be reviewed. The value-expectancy model highlights patient satisfaction from the different dimensions of healthcare. Importance is given to patients’ evaluative experience through a single visit or setting or healthcare system in general (Linder-Pelz, 1982). The model fails to define patient satisfaction from a ‘value perspective’ (Williams, 1994) and the uncertain nature of patient expectations is brought into forefront, rendering the futility of such a model. Given the changing expectations of patients with experiences (Williams, 1994), it is important to gauge patients experiences using patients’ current psychological standing to understand the definition of patients’ perception of satisfaction and dissatisfaction.
Larsson & Wilde-Larsson’s (2010) psychological framework for understanding patient satisfaction reflects the possible derivatives of patient satisfaction or dissatisfaction. Conducted from patient’s perspectives, the criteria of analysing patient satisfaction influencers from cognitive and psychological standing clarifies the interplay between patient’s intrinsic and extrinsic factors that define patient satisfaction, unique to each patient’s experience. Patient satisfaction is an emotional outcome of patients’ experiences (subjective) and is dependent on patients’ external objective conditions, socio-demographic characteristics and personality (person-related conditions). It is cognitive in nature and need for viewing patient satisfaction from patients’ perspective as an emotional process rather than mere technical or functional is critical. Considering this, the current study considers patient satisfaction as an emotional response of patients towards the actual experience and not as a difference between their expectations and preferences unlike value-expectancy model. Focus in this study is given to patient’s preferences and the outcome of their emotional response towards their current experiences can either be satisfaction or dissatisfaction with the services offered. The emotional response eventually decides with patients’ intentions towards visiting the ward or hospital again (Wilde, Larsson & Larsson, 2009).
Intrinsic and extrinsic factors satisfaction/ dissatisfaction revisiting / rejection of ward/hospital
This direct outcome-based relationship indicated above enables the inclusion of question in the study’s questionnaire:
? Are you willing to use the OPD services again?
Most studies on patient satisfaction literature identify patient-related factors, rather considered as socio-demographic factors such as age, gender, ethnicity, socioeconomic status and health status, physician-related factor such as expectations, communication, control, decision-making, time spent, technical skills and appearance, and system-related factors such as the clinical team, referrals and continuity of care as divisional indicators of patient satisfaction (Thiedke, 2007). Another important indicator that has received wide attention since the inception of studies conducted by Donabedian is quality of care. Studies conducted by Donabedian (1966, 1980, 1992), establish a crucial link between patient satisfaction and quality of care, allowing various academicians and researchers to divulge into the intricate relationship between the two concepts from an individual patient perspective and integrated healthcare system perspective. Irrespective of the distinction in the measurement tangents, measuring satisfaction levels from patient’s perspective is highlighted across various research studies. The current study focuses on understanding patient satisfaction from demographic, quality of care and waiting time perspective. The aspect of quality of care is measured from a patient’s perspective and the following sections focus on: a) understanding the relationship between patient status (demographic indicators) and patient satisfaction, b) service quality from a patient’s perspective, c) understanding the relationship between service quality and patient satisfaction, d) waiting time from a patient’s perspective, and e) understanding the relationship between waiting time and patient satisfaction.
2.4 Relationship between patient status and patient satisfaction
The role of demographic factors such as age, ethnicity, gender, occupation and employment status, health insurance status, patient status and many more has received attention across several quantitative studies conducted on quality of care and patient satisfaction.
Conflicting review and minimal studies on patient status (patient visits/frequency of visits) reflect the need for identifying the influence of patient status on their experience. For instance, quantitative studies conducted by Mahdzir et al. (2013) in Malaysia did not establish significant difference in patient satisfaction among patients with =3 visits and =3 visits; however, the study established statistically significant influence of number of visits on patient satisfaction (p=0.030). On similar lines, study conducted by Hasyimah et al. (2014) in Malaysia did not establish significant differences among the categorical variables with respect to frequency of visits, second time and more than three times; however, the study established statistical relationship between frequency of patient visits and total patient satisfaction (p=0.025). Another quantitative study conducted by Ezat et al (2010) in Malaysia established an interesting implication regarding patient visits and satisfaction. The study indicated that patients that visited the health clinics (HCs) more than three times were more satisfied than one time visitors. Another study conducted in Mongolia by Chimed-Ochir (2012) identified higher satisfaction levels among patients that visited hospitals more than 12 times (M=3.5, SD=0.707) in comparison with patients that visited the hospitals once. Another quantitative study conducted in Pakistan by Ali et al (2014) indicated significantly higher satisfaction levels among patients that visited the hospitals three or more times (p<0.05) than those that did not. This clearly implied the high satisfaction rates among old patients than new patients.
Contrarily, study conducted by Udonwa & Ogbonna (2012) in Nigeria did not establish statically significant relationship between frequency of patient visits and patient satisfaction (p>0.25) and statistically contradicted the popular belief of patients’ preference towards particular physician impacted their satisfaction levels (p>0.05). Another study conducted by Al-Sakkak et al (2008) identified an interesting relationship between patient satisfaction and frequency of visits. The study established in inverse statistical relationship between patient satisfaction and frequency of visits (p=0.015).
In line with the above literary analysis, conflicting views on the relationship between patient satisfaction and patient status, whether a relationship between the two constructs exists or not, presents a need for determining the role of patient status in patient satisfaction. Additionally, discrepancies on whether patients visiting the healthcare centre for the first time (new patients) or patients visiting the healthcare centre more than once (old patients) are more satisfied required intricate analysis to prepare necessary measures to ensure optimal patient satisfaction across both the groups. The presence of such a duality on the role of patient status in patient satisfaction emphasizes a need for considering patient status as a definitive independent variable in assessing patient satisfaction with quality of care and services in Pusrawi hospital. While other studies have used terms such as frequency or number of visits, the current study has used patient status (old patients and new patients) as the demographic indicator that requires assessment.
2.5 Comprehensive view of quality of care
The central thesis of World health organization (WHO), the public health arm of United Nations, considers health as an amalgamation of physical, mental and psychological well-being of the society apart from disease prevention (WHO, 2015). In line with this, the Malaysian Ministry of Health envisions citizens that work in tandem with each other for better health. The mission of the Ministry thus revolves around principle objectives: a) facilitating and supporting the citizens to be responsible for their individual health, uphold health as a valuable asset and achieve optimal health, b) develop high quality health system with focus on professionalism, human dignity and citizen partnership (Ministry of Health Malaysia, 2015).
Defining the importance of quality in primary healthcare on a general scale is complex in itself and assumes a multidimensional form (Heath, 2009). A review of literature since the 1960s shall assert the multidimensional anatomy of quality and reflect gradual rise of quality as a prominent healthcare indicator. Quality in health system is dynamic and has manifold denotations based on the frame of references, cultural significances and social stratums. Quality can thus be defined and understood through: a) the viewpoints of personnel such as patients, relatives, healthcare staff and administrators within the confinements of time and personal experiences, b) from a process, structure or outcome perspective, and/or c) from a social or individual perspective (Donabedian, 1966, 1980, 1992; Wilde, 1994; Pettersen et al., 2004).
While measuring the structure, process and outcome of the medical care received, the structural aspect of the quality of care measures the physical setting and resource availability of the healthcare provider. The ‘process’ aspect of the quality of care measures the procedures involved in the actual providing-availing interaction between the personnel and the patient, and the ‘outcome’ aspect of the care measures the consequences of the said processes within the healthcare structure (Donabedian, 1966). An understanding of the actual functionality of the system is the final goal of measuring the structure, process and outcome of the quality of care. Thus, quality of care eventually measures the satisfaction of patients with the received care, which ultimately signifies the goal of any healthcare system (Donabedian, 1980).
Quality of care defines the satisfaction of patients (Zastowny et al., 1995) and establishes the importance of the direct approach of collecting patients opinions about the care received. For instance, an insight to patients’ perception of quality of care provides sufficient insight towards their perception towards hospital wards (Crow, et al., 2002). In addition, understanding the resource-structure of the healthcare organization along with the patients preferences and expectations shall enable the direct and indirect stakeholders of the healthcare system to: a) understand the experiences and expectations of patients and formative process that shape the norms and beliefs of patients, b) prioritize patients wants and needs (Wensing et al., 1998), and c) bridge the gap between patients expectations and healthcare systems provisional aspects and definitions of quality of care (Wilde, et al., 1993). Periodic understanding of the uniqueness of each patient’s aggregate experience within the confinements of a patient-centred care model for each organization shall provide a rational yet sensitive framework towards optimal care quality. Thus, the normative requirement of conducting research studies from patients’ perceptions can be understood (Wilde et al., 1993) and the importance of measuring quality of care as a patient satisfaction indicator can be confirmed.
Measuring service quality from a patient’s perspective involves assessment of various concerns related to the service quality (Groves & Wagner, 2005). An ideal healthcare comprises of fundamental qualities. It should be safe, effective, patient-centred, timely, efficient and equitable (Institute of Medicine (IOM), 2001). With focus on avoiding injuries to patients, with its fundamentals based on scientific knowledge and balanced services to the patients, with its central ideal on patient’s preferences, with its reduction on waiting times and delays, with its effective waste management skills and with its quality in providing care irrespective of socio-demographic characteristics of patients, an ideal healthcare system is respectively safe, effective, patient-centred, timely, efficient and equitable (IOM, 2001). With an intention to provide optimal service quality to the patients, several notable frameworks have been developed for healthcare practitioners and management. Based on patients perceptions frameworks on service quality are structured either on patients’ perceptive notions on hospital performance in specific and healthcare system in general (Isaac et al., 2013) or on patient’s experiences and health outcomes (Manary et al., 2013), or on) or on generic value-creation based on the process-structure-outcome approach (Porter, 2010).
When research studies focus on patients’ perceptive notions on hospital performance in specific and healthcare system in general, the centrality of the studies lies in the technical and functional quality of the hospitals. The study conducted by Grönroos (1982) defines technical quality as the service quality provided in its actuality; the question ‘what’ is provided is answered in this aspect, and functional quality is defined as the means in which the service quality is provided; the question ‘how’ is answered in this regard. Enunciated by Lam’s (1997) study, measuring the two dimensions of service quality is equally essential, given patients’ limited knowledge towards the management procedures. Thus, gauging the functional or non-clinical aspects of the service quality from a qualitative perspective (Nekoei-Moghadam & Amiresmaili, 2011) is essential for the hospitals to maintain a competitive edge.
When research studies are conducted on patient’s experiences and health outcomes, two crucial aspects are highlighted on generic basis. Centred on the technical and interpersonal aspects of patients’ perceptions, the focus of the studies are either on structure-process-outcome approach of the service quality, or on bridging the gap between patients’ perceptions and expectations. An insight to each of these aspects shall provide an understanding of various methods to measure service quality.
An overview of the structure-process-outcome approach highlights the research studies conducted by various researchers since 1966. Donabedian’s (1966, 1982, and 1990) research studies reflect technical and interpersonal processes as measurements of service quality. While the technical aspect is a signature of medical and updated technological application in the care of the patient, the interpersonal aspect is a reflection of interaction between the service quality provider and patient. In line with Donabedian’s (1996, 1982 and 1990) works, Brook and Williams (1975) insight reflect technical and interactive measurements as measurements of service quality. While the technical aspect measures the application of diagnostic and remedial processes, the interactive aspect measures the behavioural interaction between the service quality provider and patient. Ware et al (1978, 1983) identified technical and interactive measurements of service quality in addition to environment. The three measurements along with administrative aspects were identified as service quality indicators that ensured patient satisfaction (Dagger et al., 2007). Periodic studies that followed have eventually enabled the creation of a list of indicators which can be termed as service quality characteristics. The qualitative nature of service quality has eventually received a tangible nature. For instance, McDougall & Levesque (1994) identified outcome, process, environment and enabling as dimensions of service quality which offer easy service experiences to patients. A tri-dimensional model developed by Rust and Oliver (1994) measures service quality through functional interaction, physical environment and technical quality.
Theories such as Donabedian’s systems theory enables the measurement of outcomes associated with process and procedures from a patients’ perspective, it follows a one-dimensional approach. However, service quality requires assessment of non-clinical aspects revolving around patient care to identify extrinsic and intrinsic factors (Heiby et al., 2014). Such a holistic identification will enable organizations to develop step-by-step interventions that bridge the gap between patients’ perceptions and expectations. In line with this, a SERVQUAL measurement scale was developed by Parasuraman et al. (1988).
With an intention of standardizing measuring scale with flexibility to modify the indicators based on varied service sectors, the SERVQUAL scale enables the materialization of multi-dimensional scale. With its roots in the structure-process-outcome approach, the SERVQUAL scale amalgamates the environmental and administrative aspects of quality of care supplied to the patients along with the technical and functional aspects. While the items in the SERVQUAL dimensions are flexible to change, SERVQUAL measures service quality through five common dimensions – tangibility, reliability, responsiveness, assurance and empathy (Parasuraman et al. 1988).
Quality in the service sector is defined on the basis of consumer perception-expectation interaction. Applying to the healthcare quality, a strong relationship exists between the patients perceptions of the quality of care and the satisfaction received (Cronin & Taylor, 1994; McAlexander et al., 1994). For instance, when the patients perceptions of wait time in hospitals is measured in line with the seating arrangement, space availability and other physical environment aspects, the satisfaction or dissatisfaction at each waiting points either with the hospital personnel or with the documentation (hospital structure or process) process shall decide the continuation or discontinuation of further patient visitations to the hospital (outcome). Thus, a large portion of the service management considers that quality can be defined by discerning patient’s needs and wants, and that there is a relationship between the impression of the customers on the nature of the administrations and their fulfilment. Service quality has synonymously viewed with patient satisfaction in certain other studies (Hadorn, 1991; Derose et al., 2001; Rakin et al., 2002), and the extent of patient satisfaction with the providers eventually determines the extent of health care utilization and behaviour of patients. These studies highlight that patient satisfaction is a noteworthy quality result in itself and the degree of patient satisfaction by the providers can be viewed as key variable that identifies their wellbeing and conduct with healthcare itself. Administration quality observations are by and large characterized as a consumer’s impression around a substance’s general predominance (Parasuraman et al., 1985, 1988), and patients’ perception of service quality can be defined as their overall impression about the provider’s supremacy.
This overall perception is regularly portrayed as the contrast between purchasers’ expectation with the services and the actual attainment of the said services. In most cases, studies that gauge the overall perceptions of the consumers part utilize the SERVQUAL scale to gauge the service quality or consumers overall satisfaction. Service quality, according to the SERVQUAL scale is the difference between consumers’ expectations (E) and consumers perception of performance (P) and consumer is considered satisfied if the consumers perception of performance is greater than consumers’ expectations (Kopalle & Lehman, 2001). Consumers under the influence of past experiences and experiences of others develop certain expectations with a particular service, which eventually defines their definition of service quality.
While the SERVQUAL model measures technical, functional, service environment and administrative aspects, there exists a shift of locus towards the functional aspect at greater levels. Nevertheless, given the dynamicity of the model to address patients’ perceptions along with their expectations provides necessary grounds for conducting a research study based on the SERVQUAL model. Additionally, the current study is conducted from patient’s viewpoint and from an individual perspective. It applies a model based on the structure-process-outcome approach with strong focus on the functional aspects, since it aims to understand the satisfaction levels of old and new patients in Pusrawi hospital, Malaysia.
2.6 Relationship between service quality and patient satisfaction
A quantitative study conducted across ten different hospitals in Dhaka City, Bangladesh attempted to identify the service quality factors that influenced patient satisfaction. Using a self-administered questionnaire, the study signified the existence of relationship between service quality factors and patient satisfaction. The study identified the positive impact of eight service quality dimensions on patient satisfaction. From an impact perspective, the eight service quality dimensions were ranked as: reliability, responsiveness, empathy, assurance, communication, process, features, tangibles and cost. Patients in this study desired prompt response, quick diagnosis of diseases, care, attention and understanding from the service providers. Their trust and confidence is based on knowledge, skills and credentials of the practitioners. Patients also desired clear explanation and response to queries to eliminate feelings of uncertainty. The appearance of physical facilities, technologically advanced equipment and cleanliness also played an important role in defining patient satisfaction. The study ultimately provided necessary foundation for private hospitals in Dhaka City to draft measures to increase the satisfaction of their patients. The study concluded with an assertion – an increase of overall satisfaction of patients will provide agility and competitiveness to providers (Rahman & Kutubi, 2013).
With an aim to revive customers’ confidence with the service quality of private nursing homes and to understand its equation with corporate image and customer satisfaction, a quantitative study was conducted across private nursing homes in the Bangkok, Thailand metropolitan region. Using the structural equation modelling approach to the data collected via self-administered questionnaire, the study identified direct effects of service quality on customer satisfaction. The importance of service quality as a reflector of corporate image was also established in the study. The study eventually identified variables such as alertness, polite attitude, possessing able skills, understanding, quickness in responding and expression of care as possible areas in personnel development that the private hospitals could focus on to ensure satisfactory experiences. Lack of direct relationship between corporate image and customer satisfaction asserted that irrespective of good corporate image, customer satisfaction is largely dependent on service quality. The importance of service quality to ensure satisfaction of patients and need for healthcare personnel to possess good attitude towards care of patients was reflected in this study (Satsanguan et al., 2015)
A quantitative study was conducted to test the relationship between quality, satisfaction and loyalty from six Chinese public hospitals in Shanghai. Using the structural equation modelling approach to the data collected via self-administered questionnaire the study identified the distinctiveness of two concepts of the model- quality and satisfaction. The mediating effect of satisfaction in the quality-satisfaction-loyalty model was established from a Chinese healthcare perspective. While the study significantly identified that improvement in quality fails to improve customer loyalty on a direct basis, customer loyalty can be improved when customer satisfaction with quality of care is improved. The study clearly signified the need for measuring patient experiences with quality and satisfaction to ensure customer loyalty (Lei & Jolibert, 2012).
A quantitative research study was conducted to assess patients’ satisfaction in the Sunyani Regional Hospital in Ghana using the SERVQUAL instrument. Using a self-administered questionnaire, the study utilized the SERVQUAL gap model which defines customer satisfaction as a dimensional gap between patients perception of performance and patients expectations. Given that a positive score indicated patient satisfaction and negative score indicated patient dissatisfaction, the study concluded the existence of patient satisfaction with tangibility and empathy constructs and dissatisfaction with assurance, reliability, responsiveness and communication/interpersonal relationship. The study eventually highlighted the constructs and variables that healthcare management could focus to ensure optimal patient satisfaction (Peprah & Atarah, 2014)
A quantitative exploratory study conducted for tertiary-level health-care services across multispecialty hospitals located in northern India aimed to identify the factors that affected patient satisfaction in the healthcare sector. Using a self-administered questionnaire and TQM metrics, the study identified clinical requirements, affordability and convenience, healthcare personnel, behaviour of healthcare practitioners, registration and administrative processes, physical amenities, behaviour of doctors and reception facilities and services and OPD area as influential factors of patient satisfaction. The study also highlighted significant variation in health insurance and demographic variables across the identified factors. The outcome of the study can eventually help various healthcare providers and the system itself in enhancing the quality of care to maintain loyal customers (Kamra et al, 2015)
A quantitative research study was conducted to assess patients’ satisfaction pertinent to various OPD services across various public healthcare facilities such as district and civil hospitals, community and primary health centres of the eight selected districts of Madhya Pradesh, India. The study identified that most OPD patients consisted of youth and had low levels of education. Through frequency analysis, the study highlighted the presence of maximum percentage of patients at district hospitals (DH), followed by civil hospitals (CH) and community health centre (CHC) and primary healthcare centres (PHC). Patients’ choice of healthcare facility largely depended on the cost of the facility, infrastructure and proximity of the healthcare facility. A comparison analysis of patients across higher health facilities (DH and CH) and lower level facilities (CHC and PHC) identified higher levels of patient satisfaction across higher levels than lower levels with respect to basic amenities. Contrarily, patients at lower levels expressed higher satisfaction than higher level facilities with respect to doctor and staff behaviour. Demographic factors such as gender, age and educational level of the OPD patients were assessed to understand the load of patients across each level of hospital and distribute necessary infrastructure and other facilities across each level (Sodani et al, 2010)
A cross-sectional quantitative study attempted to identify patients’ satisfaction with various service quality dimensions across the government hospitals in the western districts of Tamil Nadu. The study identified the presence of low satisfaction levels among the patients and the need for government hospitals to improve their performance. Given the high expectations of patients’ factors under each SERVQUAL index such as cleanliness of premises, ward working system, nurse-patient interaction and availability of healthcare practitioners played an important role in patient satisfaction. The outcome of the study eventually validated the distinctiveness among the two constructs – perceived service quality and patient satisfaction. A statistically significant relationship existed between tangibility, reliability, assurance, responsiveness and empathy with patient satisfaction. Each of the five dimensions emerged as indicators of patient satisfaction. The survival and growth of hospitals eventually depend on the service quality dimensions which in turn define patient satisfaction. The study emphasized the need for superintendents to focus on improving quality of service even at a small scale of one percent to begin with (Deepa et al, 2015)
A cross-sectional quantitative study eight private general hospitals in Tehran, Iran was conducted to understand the relationship between service quality perceptions and patient loyalty and identify service quality factors that impacted patient loyalty. A self-administered questionnaire based on SERVQUAL dimensions on performance of services was drafted. Based on service performance (SERVPERF) scale, the study identified process quality (QP), interaction quality (QI), environment quality (QE) and costing as aggregate determinants of patient loyalty. These determining factors proved as crucial factors for healthcare providers to improve service quality, retain customers and increase market share through positive word of mouth and willingness of patients to reuse and recommend the service to others. The study established a direct relationship between service quality and patient loyalty (Arab et al., 2012).
A quantitative research study was conducted across several public and private hospitals in the Malaysian Klang Valley. The study aimed at understanding the relationship between hospital service quality and patient satisfaction and behavioural intention. Using five dimensions, the study established the relationship between service quality and patient satisfaction. The study identified admission, medical service, overall service, discharge and social responsibility as significant indicators of service quality, by identifying the relationship between each construct with service quality. The study ultimately established the relationship between service quality and patient satisfaction along with behavioural intention. The study ultimately implied the need for considering service quality and patient satisfaction as techniques for exit strategy and increase long-term relationship and patient loyalty in the process (Amin & Nasharuddin, 2013)
A quantitative cross-sectional study which aimed at assessing patient satisfaction levels and physiotherapy service quality across teaching hospitals in the Klang Valley identified patient satisfaction measure as 62.4% in the region. While patients attributed high satisfaction with SERVQUAL dimension ‘assurance’, patients’ experience with ‘caring services’ emerged as lowest satisfactory dimension. The study highlighted the significant relationship between demographic indicators such as age, education status, employment status and number of visits to the hospitals and patient satisfaction. The study establish the relationship between SERVQUAL index, ‘outcome’ and ‘corporate culture’ and patient satisfaction with a strong need of focusing on corporate culture variable, ‘caring services’ to ensure and increase patient satisfaction (Mahdzir et al., 2013)
A quantitative study based on survey strategy focused on an implicative research study for policy makers, and hospital personnel and directors. With an aim of understanding the progress of patient satisfaction across Ministry of Health (MOH) hospitals, the study focused on understanding patient satisfaction based on perception from a single question, multiple questions and SERVQUAL gaps. Findings of the study identified an increase in patient satisfaction by 1% based on single satisfaction question, by 2.1% based on multiple questions and by 2% based on SERVQUAL index. While improvements were specifically observed in tangibility, assurance and responsiveness, the study identified lowest patient satisfaction scores based on SERVQUAL gap across tangibility, reliability and responsiveness. The study eventually implied the need for using SERVQUAL dimensional gap as patient satisfaction measurement tools given their diagnostic capabilities to produce practical scores, and the need for collecting patients’ opinions to create substantial improvement in the service quality (Ang et al, 2012).
A quantitative survey study aimed at identifying patient satisfaction as an indicator of service quality across 23 State level hospitals, National Referral Centre and selected district hospitals, primarily identified two dimensions of service quality, clinical and physical. Conducted from an outpatient and inpatient perspective, the comparative study identified higher satisfaction levels among both the groups with the clinical dimension than the physical dimension, and across smaller district hospitals than rather larger state hospitals. With respect to clinical and physical dimension, the study highlighted higher satisfaction levels with respect to services of doctors and nurses and cleanliness of facilities respectively. A positive correlation existed between waiting time and patient satisfaction. The study concluded with a strong need for considering patients’ reluctance towards their true feelings about the received care to avoid bias (Manaf & Nooi, 2009).
A quantitative cross-sectional survey study aimed at measuring patient satisfaction and discerning the factors that affected the outpatient satisfaction levels at University Kebangsaan Malaysia Medical Centre (UKMMC) 41% as overall satisfaction levels of patients. The study failed to identify significant relationship between demographic indicators and patient satisfaction. Nevertheless, patient satisfactory measurements with respect to descending order of importance were ascertained. Patients were satisfied with interpersonal relationships, followed by registration process, technical quality, communication, physical facilities, accessibility and financial aspects (Hasyimah et al., 2014).
A quantitative cross-sectional comparative survey study aimed at understanding the satisfaction levels across 54 rural and urban public health clinics (HCs) in nine districts belonging to the State of Selangor, Malaysia. The study identified 86.1% as the satisfaction rate of the patients and bivariate analysis identified demographic indicators of satisfaction levels. Comparative analysis highlighted Indian and Chinese population as satisfied respondents compared to Malays, along with lesser educated population, patients belonging to >33 years age bracket and male population. Significant associations were found between old patients that visited the hospitals more than 3 times than new patients. With respect to ‘clinics corporation’ dimension which was used to ascertain the satisfaction rate along with the ‘SERVQUAL’ index, the study identified similarity in the satisfaction levels (high satisfaction levels) among the rural and urban population with respect to treatment outcome and low satisfaction levels with respect to caring and professionalism of the personnel. Differences in satisfaction levels were observed with respect to ‘working as a team’ aspect of the ‘clinics corporation’ dimension. Urban areas exhibited higher satisfaction scores than rural area in regard to this aspect. Patient satisfaction in urban areas with overall SERVQUAL dimensions was higher. Nevertheless, both the groups exhibited almost similar satisfaction levels, indicating the need for evaluating and ensuring high patient satisfaction across urban and rural areas (Ezat et al., 2010).
A quantitative study was conducted in a private health care in Malaysia to identify the role of service quality perceptions on patient satisfaction and behaviour. Through statistical analysis, the study identified association between tangibility, assurance and empathy (SERVQUAL dimensions) and behavioural intentions. The study also established the three SERVQUAL dimensions as predictors of patient satisfaction. Using the mediating effect process, the study ultimately established relationship between service quality, patient satisfaction and behavioural intentions (Aliman & Mohamad, 2013).
A quantitative study conducted in a hospital in Padang City, West Sumatra Province, aimed at identifying the influence of service quality on patient satisfaction. The results of the study when subjected to statistical analysis identified significant relationship between service quality and patient satisfaction. The study identified the need for doctors to provide sufficient time in explaining the diagnosis and need for punctuality in doctors. The study eventually stressed on increase hospital’s service quality to enhance user satisfaction (Frinaldi & Embi, 2015)
A cross-sectional quantitative descriptive study conducted at Indira Gandhi Memorial Hospital’s OPD in the Maldives, focused on assessing patients’ satisfaction through patients’ service quality expectations and perceptions’. Using a modified SERVQUAL instrument the study identified only 18.4% patient satisfaction with the OPD service quality. The study identified significant service quality dimensional gap between patients’ perceptions and expectations across all SERVQUAL dimensions. The study also identified that young patients were three times more satisfied than adult patients, and patients with low or moderate perceived needs were more satisfied than those with high perceived needs. The study ultimately stressed on additional research studies on other departments with respect to service quality and employee performance to ensure optimal patient satisfaction by meeting the expectations of the patients (Zaid et al., 2013)
A quantitative study conducted across three district hospitals in Ulaanbaatar, Mongolia, aimed at identifying service quality elements that significantly influence patient satisfaction. Conducted from patients’ perceptions, the study identified gap in the empathy dimension of service quality with respect to patients’ perception and expectation. The study identified quality of nursing care, respectful attitude of nurses towards patients, helpful attitude of nurses and extent of doctors’ attention towards patients as significant service quality influencers of patient satisfaction (Chimed-Ochir, 2012)
A cross-sectional quantitative study conducted across four public district hospitals in Pakistan aimed at identifying the service quality dimensions that influenced the public hospitals and also identify the indicators of patient satisfaction. Statistical analysis revealed significant five service quality dimensions namely discipline, communication, responsiveness, personal contacts and access as influencers of public hospitals. With respect to indicators of patient satisfaction, the study identified provider communication as most powerful indicator, followed by responsiveness and discipline. While validating the SERVQUAL framework as a flexible yet powerful tool in measuring service quality and patient satisfaction, the study stressed on interventions that ensure better communication between providers and patients for higher satisfaction and patient continuity (Ali et al., 2014).
While certain studies have used TQM constructs, most studies used the SERVQUAL instrument to measure patients’ satisfaction. These studies have validated the role and importance of SERVQUAL instrument as a direct indicator of service quality and as a measurement of patient satisfaction and indirect indicator of customer loyalty. Discrepancy exists relationship between satisfaction and quality of care. A quantitative study conducted across two 1Malaysia clinics in Selangor, Malaysia, aimed at understanding the relationship between service quality and patient satisfaction using the SERQUAL questionnaire. The study identified significant negative relationship between service quality and patient satisfaction. The negative correlation between the two constructs indicated lower satisfaction with higher service quality across the healthcare clinics (Yunus et al., 2013)
2.7 Summary
The fifth section highlights the definitions of quality of care and service quality across varied contexts. The historical evolution of service quality measurements is indicated in this section.

CHAPTER III. METHODOLOGY
3.1 Introduction
First section of the third chapter outlines the methodology used in the current study. The second section focuses on the methodology selected which is cross-sectional survey design and quantitative approach. The third section highlights the research questions and hypothesis attached to each question and the following section provides an overview of the population, sample and sampling process used in the current study. The fifth section identifies the ethical considerations of the current study, followed by an insight towards the instrumentation, data collection and analysis process. The next section discusses the validity and reliability tests applied in the current study and the chapter culminates with a short summary of the chapter.
3.2 Methodology Selected
3.2.1 Research Design
Research method can be defined as set of techniques employed by the researcher/s in collecting the data for any empirical study. It involves the applicative use of a well-defined and structured research instrument. A supportive functionality of research method, research design can be defined as a systematic framework that enables the researcher to collect and analyse the data. It is a reflection of priority decisions towards the nomothetic dimensional ranges across the varied research processes (Bryman, 2008). Given the presence of varied perceptions in conducting a research study, five types of research designs such as experimental, case study, longitudinal, cross-sectional and comparative designs aid the researcher in materializing the aims of the study (Bryman & Bell, 2007). While an experimental research design clarifies that relationship between two or more variables in a controlled setting, case studies focus on a particular subject or phenomena in a particular setting or time and identifies the interact (Collis & Hussey, 2009). In longitudinal design, data is collected across various points and comparison and trends are observed across time (Johnson & Christensen, 2012), and in comparative design two varied cases are compared and data is collected separately to resolve the research problem.
Cross-sectional design involves data collection on “more than one case and at a single point in time in order to collect a body of quantitative or quantifiable data in connection with two or more variables, which are then examined to detect patterns of association” (Bryman & Bell, 2007, p. 55). Cross-sectional design enables in collecting data from various units of the given sample across a short period of time on several variables (Johnson & Christensen, 2012). It provides sufficient basis for collecting data that is quantitative or numerical in nature from a given sample (Fowler, 2009). In line with this, relevant hypotheses are developed based on the available literature and the study is thus deductive in nature. Quantitative measurements through the questionnaire tool are used to collect data in cross-sectional research design. The current study aims to identify the predictors of patient satisfaction from an aggregate and waiting time perspectives; it attempts to collect data from various independent variables at a single point. Patterns of association between the variables are discerned and the outcome of the study is dependent on the opinions of the participants at the instance of answering the questionnaire or interview at a particular point in time rather than change over time (Johnson & Christensen, 2012). Trend analysis is seldom done in cross-sectional. Since the current study aims to understand patient satisfaction at a particular juncture in time rather than opinions over a period of time, the current study applies cross-sectional research design to collect data.
3.2.2 Research Approach
Two main research approaches that enable the researcher to define and structure the relevant data collection methods and instruments are qualitative and quantitative (Kekäle et al., 2009). Qualitative approach focuses on attaining in-depth understanding of the cause of a particular process, subject or phenomenon and involves techniques such as interviews, protocol analysis, grid technique and many more to collect primary data (Cooper & Schindler, 2006). Contrarily, if the focus of the research study is to discern ‘how often’ things occur or ‘why’ things occur, then the measurement is quantifiable and quantitative approach is apt (Cooper & Schindler, 2006). While quantitative approach involves measurements that can be quantifiable, measurements involved in qualitative approach are non-quantifiable in nature (Bryman & Bell, 2007). Since qualitative studies are most applicable for exploring and understanding a particular concept rather than generalizing the outcomes of the study (Creswell, 2009). Quantitative approach enables in generalization of the research outcomes (Swanson & Holton, 2005), and the survey method to collect data via the quantitative approach is economic and less time consuming in nature (Creswell, 2009; Coughlan et al., 2009). Given the advantages of the quantitative studies, the current study has applied quantitative approach and survey strategy to collect data on patient satisfaction.
Patient satisfaction is evaluated through either qualitative or quantitative approaches, and quantitative approach provides accurate measurements in comparison with the qualitative approach (Al-Abri & Al-Balushri, 2014). Standardized questionnaires that are self-administered or interview-based are most commonly used to measure patient satisfaction (Linda, 2002; Jose et al., 2006). Available literature that measure patient satisfaction either have privately developed unpublished questionnaire, whose reliability and validity is questionable, or have standardized instruments with good reliability and validity; however with limited scope, or are generated for a specific study based on available literature and pervious standardized questionnaires (Al-Abri & Al-Balushri, 2014). Irrespective of the origin of the measurement tools, patient satisfaction measurement tools need to be reliable and valid and practically functional in collecting patients’ feedback on their experiences with the healthcare provider (Linda, 2002). Considering this, survey strategy with self-administered questionnaire tool is used to collect quantifiable data for the current study based on the research questions and hypotheses.
3.3 Research Hypotheses
H01: There is no difference in the satisfaction levels old and new OPD patients with the quality of care and services in Pusrawi hospital
HA1: There is a significant difference in the satisfaction levels old and new OPD patients with the quality of care and services in Pusrawi hospital
H02: There are no significant predictors that impact the satisfaction levels of old and new OPD patients with the quality of care and services in Pusrawi hospital
HA2: There are significant predictors that impact the satisfaction levels of old and new OPD patients with the quality of care and service in Pusrawi hospital
H03: There is no relationship between SERVQUAL dimensions and patient satisfaction Pusrawi hospital
HA3: There is a significant relationship between SERVQUAL dimensions and patient satisfaction Pusrawi hospital
H04: There is no relationship between waiting time and patient satisfaction in Pusrawi hospital
HA4: There is a significant relationship between waiting time and patient satisfaction in Pusrawi hospital
3.4 Population and Sample
Population for the current study comprised of all patients above the age of 18 years that visited the OPD in the Kaula Lampur region. The choice for Pusrawi hospital among the numerous public and private hospitals in Kaula Lampur was the presence of only 30% satisfied OPD patients. An initial simple outpatient survey was conducted across 5 hospitals the Kaula Lampur region with the following criteria: a) participants were above 18 years of age b) participants agreed to voluntary participation for an additional survey for the current study c) participants provided personal information for follow-up on additional survey if their opinions were required. Random patients for a two-day period across the five hospitals were asked to answer a single question: ‘Would you use the services of the hospital again?’ with Likert scales ranging from strongly agree to strongly disagree. Based on the collected data, 512 respondents in Pusrawi hospital highlighted 30% satisfaction rate, 30% moderate satisfaction and 30% dissatisfaction reflecting the need for conducting a study on OPD patient satisfaction levels in Pusrawi hospital.
On an average level, OPD in Pusrawi hospital has about 500 total visits from new and old patients on a daily basis. Considering this as the population for cross-sectional studies, where data on multiple variables are collected at one single point (Johnson & Christensen, 2011), the sample for the current study is extracted based on the single population proportion formula: n= Z2pq/d2, where n is the estimated sample size, Z2 is the critical value for the distribution (for confidence level of 95%, the critical value is 1.96 given that a= 0.05, p and q account to the proportion of patients that are respectively satisfied and dissatisfied with the overall service quality and care (p=0.788 as obtained from a study conducted by Aniza & Suhalia (2011) and q= 0.212) and d is the margin of error (0.05 in this case) (Kerns, 2010). Based on this calculation and accommodating a 20% non-response rate (Mahdir et al., 2013), the recommended sample size for the study was 170.
Simple random sampling method was applied to select the sample. Considered as the most basic types of probability sample design, simple random sampling provides the opportunity for each and every unit of the population to be included in the sample (Marsden & Wright, 2010), unlike non-probability sampling designs such as purposive, quota and convenience sampling (Sarantakos, 2005). With an unbiased approach, this sampling technique is most effective for small-scale survey sampling as opposed to large-scale survey (Marsden & Wright, 2010). Given the sampling frame of 166 and given the need for including all patients above the age of 18 visiting the OPD at a single point of frame, the current study used simple random sampling method to accommodate 166 patients to the current study.
3.5 Instrumentation
The process of instrumentation in the current study involved the development of valid and reliable patient satisfaction measurement tool. Based on the systematic and schematic process developed by Radhakrishna (2007), associate professor at The Pennsylvania State University, the current section highlights the background, conceptualization of the questionnaire, format and data analysis, and establishing of validity and reliability measurements. A schematic representation of the process in provided in figure below and each of the processes involved in instrument development is discussed below:
3.5.1 Background
As the first step of the instrumentation process, the background section proposes the researcher to establish fundamental grounds regarding research aim and objectives, hypotheses development and an idea about the research audience and respondents (Radhakrishna, 2007). The first two chapters of the current study and previous sections of the current chapter aided the researcher to progress further into the conceptualization of the questionnaire.
3.5.2 Conceptualization of the questionnaire
Literature review analysis enabled the researcher to design a structured questionnaire based on crucial constructs such as SERVQUAL index, waiting time and patient status (demographic indicator). A self-administered questionnaire based on SERVQUAL studies, studies on patient visits and waiting time under the guidance of research advisors aided in the item-generation process for the current study. Based on the research objective the questionnaire was divided into three parts along with a small introduction. The following table outlines the sections of the questionnaire, along with their corresponding rationale, measurement, and research objective and item number.
Questionnaire Section Rationale Measurement Scale Research Objective Item number
Introduction Provides a background of the research study, the aims and objectives are discussed and the target group is ensured of its confidentiality and anonymity
Part A collects demographic indicators such as age, gender and patient status Patient demographics play an important role in understanding the mix of the sample population that is being surveyed to: a) variation in perception pertinent to the demographic indicator, and b) draft required steps catering to the needs of particular group. Close ended-questions with categorical variables with coding values of:
Age – 18-25 years =1, 26-45 years = 2, 46-65 = 3, >65 = 4
Gender – male = 0 and female = 1
Patient status – new patients = 0, old patients = 1 Objective one-to identify variation in patient status, it is important to sort data between new and old patients 1=Age
2=Gender
3=Patient Status
Part B collects information on satisfaction with OPD quality of care and services. Based on the SERVQUAL model, literature identifies the relationship between service quality and patient satisfaction, and the need for conducting studies from patients’ perspective to achieve optimal patient centred care. Each question belonging to the five SERVQUAL dimensions, tangibility, responsiveness, reliability, assurance and empathy, have been picked based on critical literature analysis. Identifying the questions that influence patient satisfaction enables the healthcare provider to maintain the standards to ensure continued patient satisfaction. Considered as predictors, each dimension’s influence on patient satisfaction shall enable generalizability of the study across OPD areas in Kuala Lumpur area All questions begin with ‘How satisfied are you’ to gauge patient satisfaction on SERVQUAL dimensions.
Five-point Likert scale with ordinal variables and coding values of 1= strongly agree, 2=agree, 3=neutral, 4=disagree, 5=strongly disagree was used to measure patient satisfaction
Objective two Tangibility = 4,5,6,7,8
Reliability = 9,10,11,12,13
Responsiveness = 14,15,16,17
Assurance = 18,19,20,21
Empathy = 22,23,24,25
Part C collects information pertinent to patients’ satisfaction levels from waiting time perspective Assessing patients’ satisfaction with waiting time and waiting area is crucial in identifying the co-relation between the two constructs to: a) clarify any discrepancies in the relationship between the two variables as reflected in the literature, and b) identify areas and time segments that have potential impact on patient satisfaction to either maintain the time segment in the case of positive satisfaction or reduce the waiting time in the particular waiting area in case of negative patient satisfaction ‘How satisfied are you’ question was used to gauge patient satisfaction with respect to waiting time and waiting area. Categorical variables with coding values 1 = =14 minutes, 2 = 15-29 minutes, 3 = 30-59 minutes and 4 = 60 minutes were used to identify waiting time in each individual area. Five-point Likert scale with ordinal variables and coding values of 1= strongly agree, 2=agree, 3=neutral, 4=disagree, 5=strongly disagree was used to measure patient satisfaction Objective two Waiting time in individual areas = 26,28,30,32
Waiting time satisfaction = 27,29,31,33

3.5.3 Format and data analysis
Data has not been re-coded since re-coding the data will affect the response-order of the original data and affect the raw scores collected during data collection. There exists a significant difference between raw scores collected and data obtained through reversal of order responses (Chan, 1991). For example, the raw scores for questions that ask the customers to rate their satisfaction with hospital services remain as 1=strongly agree, 2=agree, 3=neutral, 4=disagree and 5=strongly disagree even during data analysis. Flipping or reversal of raw scores is avoided in the study. Having understood the impracticality of recoding or flipping response scale of negatively worded items, given its adverse impacts on the raw-score means, factor analysis and related analysis that follow (Chan, 1991), the current study has: a) avoided the use of negative questions in the questionnaire, and b) maintained consistency in the response scale with not only during data collection process, but also while subjecting the data to iterative analysis.
Data analysis for the current study amalgamated univariate, bivariate and multivariate analysis depending on the number of variables. Based on the research hypotheses relevant statistical tests were used to understand the relationship between identified independent variable and dependent variable/s. The following table represents the same.
Research Hypotheses Variables Associated Statistical Tests
H01: There is no difference in the satisfaction levels old and new OPD patients with the quality of care and services in Pusrawi hospital IV = Patient Status DV=patient satisfaction
Mann-Whitney U Test

H02: There are no significant predictors that impact the satisfaction levels of old and new OPD patients with the quality of care and services in Pusrawi hospital IV= Tangibility variables, Reliability variables, Responsiveness variables, Assurance variables, Empathy variables DV= Patient Satisfaction Separate binomial regression for new and old patients
H03: There is no relationship between SERVQUAL dimensions and patient satisfaction Pusrawi hospital IV= Tangibility, Reliability, Responsiveness, Assurance, Empathy DV= Patient Satisfaction Separate binomial regression for new and old patients
H04: There is no relationship between waiting time and patient satisfaction in Pusrawi hospital IV= Waiting time, waiting area DV= Patient satisfaction Spearman rank-order correlation
3.5.4 Validity and Reliability of the Questionnaire
Validity can be defined as a differential gap found in the research instrument. It measures the extent to which the research instruments measures what it is supposed to measure, and is calculated through varied dimensions such as face, content, criterion-related and construct validity which comprises of convergent and discriminant validity (Polit & Beck, 2012). Content and construct validity was obtained through expert opinion, where 5 different versions of the research instrument inclusive of the operational definitions was sent to experts and a modified research instrument (Appendix ) was obtained with an 85% acceptance level. Face and content validity provided necessary substratum for developing a questionnaire in congruence with existing literature and based on expert validation. Criterion validity which measures the outcome of the questionnaire with a standard measurement obtained or standardized based on prior studies. Given the varsity in the patient satisfaction measurement tools, a definitive measurement for patient satisfaction is seldom present. In such cases construct validity can be used.
Construct validity measures ‘how well’ a research instrument measures the underlying construct; for instance, how well the SERVQUAL instrument measures the quality of care and services in a healthcare sector and patients’ willingness to use the service again. Exploratory factorial analysis (EFA) was used to measure the construct validity in the current study.
3.5.5 Reliability
Reliability ensures consistent results and common measures of reliability are measures of internal consistency and test-retest reliability. Internal consistency checks the regularity in the measurability of the items in the questionnaire. Cronbach’s alpha (a) is a common method of measuring internal consistency and questionnaire’s items with minimum value of 0.70 is considered as reliable (Kline, 2000). Test-retest is another measure of ensuring reliability. While internal consistency checks the reliability for a particular situation or time, test-rest reliability checks the reliability of the questionnaire over a period of time. Alike Cronbach’s alpha’s (a) minimum value test-retest’s minimum reliability value is 0.70 (Fitzpatrick et al., 1998).
3.5.6 Data Collection
Data collection is a systematic and crucial process. It functions as the link between research objectives and implications, and provides relevant information based on the objectives. An obvious process that provides substratum for the data analysis process, data collection can be divided into two processes, primary data collection and secondary data collection. Primary data refers to original data and is specific to the research objectives, hypotheses and variables of the study. It is unique to a research study given the explicitly of the study’s sample and setting. Secondary data refers to already existing data, which aids the researcher in either developing theoretical framework or in some cases extract implications and conclusions itself. Common primary data collection processes include interviews, observations, experiments and surveys using questionnaire tool, and common secondary data collection sources include books, journals, web-based data sources and many more (Ghauri & Gronhaug, 2005).
The current study has utilized both primary and secondary data collection processes. Secondary resources provided the necessary framework for constructing relevant objectives and drafting hypotheses, along with providing necessary aid in understanding the processes involved in research methodology. Each and every resource that has aided the author is mentioned in the ‘Reference’ section of the current paper.
Primary data through self-administered questionnaires was used and data was personally collected by the researcher within the time extent of 15-20 minutes for each survey, with the help of two collectors who were apprised of the aim and importance of the study and process of informed consent. Questionnaires avoid researcher bias, since they are constructed prior to the actual data collection process and are convenient for respondents. However, missing data and frivolous responses could function as possible disadvantages of this process (Bryman, 2008). Considering this, missing data and other errors were significantly rectified and the researcher personally conducted random quality checking to clean and prepare the data for iterative analysis.
The response rate of the study was 88.23% and is considered as very good (Babbie, 1992). Several reasons can be attributed towards this good response rate: a) commitment of Pusrawi hospital towards optimal patient satisfaction, and b) researcher’s personal and individual collection of responses from each survey while maintaining anonymity, clarifying any questions to avoid bias and instilling confidence in the OPD patients. With the reduction in sample size to 150 patients that visited OPD services, the current study collected responses from 150 patients, which constituted as sample size for the current study. The responses collected from these participants represented as primary data for the current study and enabled the researcher to conduct statistical analysis and extract relevant inferences within the boundaries of research ethics.
3.6 Summary
Cross-sectional survey design is used in the study and quantitative approach towards data collection and analysis provides necessary basis for extracting relevant information on patients’ satisfaction with the OPD services. Univariate, bivariate and multivariate statistical methods are employed in identifying the variance in satisfaction levels between new and old patients and predictors of satisfaction from an aggregate and waiting time perspective for both new and old patients separately.

CHAPTER IV. FINDINGS AND ANALYSIS
4.1 Introduction
The current study has used univariate, bivariate and multivariate analysis to test the hypotheses identified in section 3.3. The current section provides an overview of each of the statistical test is essential to understand the variation in each test and reason for using separate tests for the hypotheses. The table below indicates the same.
Type of Analysis Analysis Method Definition and Application in current study
Univariate Analysis Frequency distribution A tabular summary of the number of items in each category of the non-overlapping classes (Anderson et al., 2007). In the current study, frequency of the demographic indictor and Likert scale categorical distribution is represented as numerical counts in tabular form.
Cumulative percentage frequency distribution A tabular summary of the items in each category in the form of percentages, with values that are less than or equal to the upper limit of each distribution class (Anderson et al., 2007). In the current study, frequency of the frequency of the demographic indictor and Likert scale categorical distribution is cumulatively represented as percentages next to counts in tabular form.
Mean Average value of the selected data. Central location of the selected data obtained by adding the values of the selected data and dividing it by the number of counts or observations (Anderson et al., 2007). In the current study, mean value is calculated for each question in Part B of the questionnaire (SERVQUAL dimension) and PART C (responsiveness dimension).
Bivariate Analysis Mann Whitney-U Test A non-parametric test which assumes ordinal measurement level for DV data, categorical measurement levels for IV, along with non-normal distribution (Anderson et al., 2007). In the current study, Mann Whitney-U Test is used to test hypothesis 1, the existence of variance among the satisfaction levels of new and old patients. Given the non-normal distribution of data, and ordinal level of DV = patient satisfaction along with categorical levels of IV=patient status, old patients and new patients, Mann Whitney-U Test was applied and represented in tabular form with relevant significant indicators of variance across patient willingness to use the services, SERVQUAL dimensions, and waiting time.
Spearman rank-order correlation A non-parametric test which assumes ordinal measurement levels for both DV and IV along with a monotonic relationship between the two variables (Anderson et al., 2007). In the current study, Spearman’s correlation was used to test hypothesis 4, the relationship between waiting time/waiting area and patient satisfaction. Given the ordinal scale of measurement between DV=patient satisfaction and IV=waiting time/waiting area and the existence of monotonic relationship between the two variables, Spearman rank-order correlation was used. The test was applied to test the relationship between: a) waiting time and patient satisfaction from an overall and patient status (new and old patients) perspective, b) time taken in each waiting area and patient satisfaction with each area from an overall and patient status (new and old patients) perspective, and c) patients’ willingness to use the services again and waiting time in each area from an overall perspective. The results of the analysis were presented in tabular form with statistically significant identification.
Multivariate Analysis Binomial Logistic Regression A statistical test in which the DV assumes two discrete outcomes as signified in the name, ‘binary/binomial’, along with categorical/nominal IV with independence of observation (Anderson et al., 2007), can be used to test predictability of occurrence of events in any given applicative setting. In the current study, logistic regression was used to test hypotheses two and three. DV= patient satisfaction (willingness of patients to use the services again) indicators were predicted through IVs = SERVQUAL individual and aggregate dimensional levels along with waiting time satisfaction from patient status, old and new patients’ perspective. Logistic regression constitutes of dichotomous responses for dependent and independent variables. The odds ratio were computed using the mathematical form:
n
p/1-p = ß0 + ? ßi Xi , where
i=1

p is the DV= probability of patient satisfaction (willingness of patients to use the services again), ß0 is the intercept/constant, ßi is the coefficient of independent variables and Xi is the independent variable itself (Kleinbaum et al., 1994). The study collected data in ordinal measurement scale. Since logistic regression demands DV to be in binary form, the mean score for the ‘willingness of patients to use the services again’ was calculated. Since the current study used decreasing satisfaction level scale with strongly agree coded as 1, patients with values greater than mean were considered as patients with low willingness coded as 0 and patients with values lesser or equal to mean were considered as patients with high willingness coded as 1. On similar lines to predict patient satisfaction with each SERVQUAL dimensional variable and waiting time, mean score for individual SERVQUAL dimensional variable and waiting time was taken. Values greater than mean were considered as patients with low satisfaction coded as 0 and patients with values lesser or equal to mean were considered as patients with high satisfaction coded as 1. In addition, to predict patient satisfaction from aggregate SERVQUAL dimensional and waiting time perspective, the mean values for the entire dimension or waiting time patient experience is computed and Values greater than mean were considered as patients with low satisfaction coded as 0 and patients with values lesser or equal to mean were considered as patients with high satisfaction coded as 1. The analysis was conducted from patient status (new and old patients) perspective, where high satisfaction is compared with low satisfaction.
While these statistical analyses enabled in testing and validating the outlined hypotheses, another important analysis predicted the satisfaction levels of new and old patients with respect to each SERVQUAL dimension and waiting time. The mean value for each SERVQUAL dimension and patients’ satisfaction with waiting time was calculated. Given that the current study used decreasing satisfaction level scale with strongly agree coded as 1, patients with values lesser or equal to mean were considered as patients with high satisfaction, and patients with values greater than mean were considered as patients with low satisfaction. Satisfaction levels for each SERVQUAL dimension and waiting time is tabulated and represented from an overall and patient status (old and new patients) perspective. The following sections outline the empirical findings of the study in line with the hypotheses and research objectives and the chapter concludes with a summary of findings.
4.2 Empirical Findings
4.2.1 Demographic Characteristics of the Patients
The demographic characteristics in the current study included the age, gender and status of the patients that availed the OPD services at Pusrawi hospital. The results from the table below indicate that majority (45.33%) of the patients were between 26 and 45 years of age. 30% of the patients belonged to 18-25 years age bracket and 18.67% belonged to 46-65 years age bracket. Only 6% of the patients belonged to the >65 years age bracket. 65.33% of the patients were female and 34.67% of the patients were male. More than half of the patients (55.33%) were new patients and remaining (44.67%) were old patients. A graphical representation of the demographic characteristics of the patients that availed OPD services at Pusrawi hospital is provided in figure below.
Table 1 Demographic Characteristics of the Patients availing OPD services at Pusrawi Hospital. N=150
Demographic Variables Count N=150 Percent
%
Age 18-25 45 30.0%
26-45 68 45.3%
46-65 28 18.7%
>65 9 6.0%
Gender Male 52 34.7%
Female 98 65.3%
Patient Status New patients 83 55.3%
Old patients 67 44.7%
Figure 1 A) Age break-up of patients B) Gender break-up of patients and C) status of patients availing OPD services at Pusrawi Hospital
4.2.2 Willingness
Willingness of patients Patient Status Mann Whitney U test statistic p-value
New patients Old patients
Strongly Agree 6(7.2%) 4(6%) -5.118 0
Agree 10(12%) 28(41.8%)
Neutral 20(24.1%) 29(43.3%)
Disagree 39(47%) 3(4.5%)
Strongly Disagree 8(9.6%) 3(4.5%)
Mann Whitney U test mean rank 91.2 56.05

Patient Willingness to use services again Mean & SD New patients Old patients
Willingness to use services again Mean 3.4 2.6
SD 1.059 0.854

SERVQUAL factor Percentage of satisfaction Overall New patients Old patients
Willingness Percentage of patients with low willingness 54.67% 56.72% 52.24%
Percentage of patients with high willingness 45.33% 43.28% 47.76%
4.2.3 OPD patient satisfaction with quality of care and services at Pusrawi hospital

4.2.3.1 OPD patient satisfaction from tangibility perspective
Tangibility Variables Patient Status Mann Whitney U test statistic p-value
New patients Old patients
Cafeteria Strongly Agree 12(14.5%) 0(0%) -1.892 0.058
Agree 9(10.8%) 2(3%)
Neutral 47(56.6%) 56(83.6%)
Disagree 12(14.5%) 9(13.4%)
Strongly Disagree 3(3.6%) 0(0%)
Mann Whitney U test mean rank 70.55 81.63
Drinking Water Strongly Agree 4(4.8%) 4(6%) -3.4 0.001
Agree 17(20.5%) 25(37.3%)
Neutral 43(51.8%) 37(55.2%)
Disagree 13(15.7%) 1(1.5%)
Strongly Disagree 6(7.2%) 0(0%)
Mann Whitney U test mean rank 85.34 63.31
Toilets Strongly Agree 12(14.5%) 1(1.5%) -0.562 0.574
Agree 32(38.6%) 33(49.3%)
Neutral 17(20.5%) 22(32.8%)
Disagree 22(26.5%) 7(10.4%)
Strongly Disagree 0(0%) 4(6%)
Mann Whitney U test mean rank 73.81 77.6
Magazines/TV Strongly Agree 0(0%) 2(3%) -0.237 0.812
Agree 22(26.5%) 10(14.9%)
Neutral 12(14.5%) 15(22.4%)
Disagree 17(20.5%) 20(29.9%)
Strongly Disagree 32(38.6%) 20(29.9%)
Mann Whitney U test mean rank 76.23 74.6
Cleanliness of OPD Strongly Agree 10(12%) 2(3%) -0.554 0.58
Agree 34(41%) 31(46.3%)
Neutral 15(18.1%) 20(29.9%)
Disagree 24(28.9%) 10(14.9%)
Strongly Disagree 0(0%) 4(6%)
Mann Whitney U test mean rank 73.83 77.57
Cleanliness of OPD personnel Strongly Agree 9(10.8%) 3(4.5%) -0.293 0.769
Agree 33(39.8%) 28(41.8%)
Neutral 25(30.1%) 28(41.8%)
Disagree 16(19.3%) 8(11.9%)
Strongly Disagree 0(0%) 0(0%)
Mann Whitney U test mean rank 74.62 76.59
Queue System Strongly Agree 5(6%) 9(13.4%) -1.142 0.254
Agree 32(38.6%) 23(34.3%)
Neutral 18(21.7%) 16(23.9%)
Disagree 20(24.1%) 18(26.9%)
Strongly Disagree 8(9.6%) 1(1.5%)
Mann Whitney U test mean rank 78.99 71.17
Waiting area and space availability Strongly Agree 6(7.2%) 1(1.5%) -0.382 0.702
Agree 35(42.2%) 31(46.3%)
Neutral 20(24.1%) 27(40.3%)
Disagree 14(16.9%) 5(7.5%)
Strongly Disagree 8(9.6%) 3(4.5%)
Mann Whitney U test mean rank 76.64 74.08
Dispensary Strongly Agree 15(18.1%) 5(7.5%) -1.586 0.113
Agree 34(41%) 28(41.8%)
Neutral 27(32.5%) 27(40.3%)
Disagree 5(6%) 6(9%)
Strongly Disagree 2(2.4%) 1(1.5%)
Mann Whitney U test mean rank 70.76 81.87
Registration area Strongly Agree 2(2.4%) 12(17.9%) -0.593 0.553
Agree 19(22.9%) 17(25.4%)
Neutral 36(43.4%) 11(16.4%)
Disagree 22(26.5%) 15(22.4%)
Strongly Disagree 4(4.8%) 12(17.9%)
Mann Whitney U test mean rank 77.33 73.23

Mann-Whitney U test was run to identify the presence of variation in tangibility index between new and old patients. Distributions of the variables of tangibility for new and old patients were not similar, as observed by visual inspection. Variation in the frequencies across the two groups with respect to each tangibility variable was evident. For instance, statistically significant difference between new and old patients was evident with respect to drinking water. Satisfaction scores of new patients (mean rank = 85.34) with respect to drinking water was statistically significantly higher than that of old patients (mean rank = 63.31), z = -3.4, p = 0.001. Contrarily, significant statistical variation between new and old patients was absent with respect to cafeteria (z = -1.892, p = 0.058), toilets (z = -0.562, p = 0.574), magazines/TV (z = -0.237, p = 0.812), cleanliness of OPD (z = -0.554, p = 0.58), cleanliness of OPD personnel (z = -0.293, p = 0.769), queue system (z = -1.142, p = 0.254), waiting area and space availability (z = -0.382, p = 0.702), dispensary (z = -1.586, p = 0.113) and registration area (z = -0.593, p = 0.553).
However, differences in mean ranks between the two groups and variation in frequencies towards the five ordinal scale measurements towards each of the tangibility variable were present. For instance, distribution of mean ranks among new patients with respect to cafeteria (mean rank = 70.55), toilets (mean rank = 73.81), magazines/TV (mean rank = 76.23), cleanliness of OPD (mean rank = 73.83), cleanliness of OPD personnel (mean rank = 74.62), queue system (mean rank = 78.99), waiting area and space availability (mean rank = 76.64), dispensary (mean rank = 70.76) and registration area (mean rank = 77.33) and old patients with respect to cafeteria (mean rank = 81.63), toilets (mean rank = 77.6), magazines/TV (mean rank = 74.6), cleanliness of OPD (mean rank = 77.57), cleanliness of OPD personnel (mean rank = 76.59), queue system (mean rank = 71.17), waiting area and space availability (mean rank = 74.08), dispensary (mean rank = 81.87) and registration area (mean rank = 73.23) recorded variation in the satisfaction experiences.
Most of the new and old patients expressed similar and neutral experience with cafeteria (new patients = 56.6%, old patients = 83.6%), drinking water (new patients = 51.8%, old patients = 55.2%), expressed satisfactory agreement with their experience with toilets (new patients = 38.6%, old patients = 49.3%), cleanliness of OPD personnel (new patients = 39.8%, old patients = 41.8%), queue system (new patients = 38.6%, old patients = 34.3%), waiting area and space availability (new patients = 42.2%, old patients = 46.3%) and dispensary experience (new patients = 41%, old patients = 41.8%). However, majority of the patients recorded dissimilarity towards their experience with magazines/TV, cleanliness of OPD and registration area. While majority of the new patients (38.6%) expressed strong disagreement with magazines/TV, majority of the old patients either expressed disagreement (29.9%) or strong disagreement (29.9%). On similar lines, majority of the new patients (28.9%) expressed disagreement with cleanliness of OPD, majority of the old patients expressed agreement (46.3%). Majority of the new patients (43.4%) expressed neutrality with registration area, while majority of the old patients either expressed agreement (25.4%).
The table below provides detailed information on variation in frequencies and Mann-Whitney U test results between new and old patients.
Tangibility Mean & SD New patients Old patients
Cafeteria Mean 2.82 3.1
SD 0.977 0.394
Drinking Water Mean 3 2.52
SD 0.924 0.636
Toilets Mean 2.59 2.7
SD 1.036 0.905
Magazines/TV Mean 3.71 3.69
SD 1.235 1.144
Cleanliness of OPD Mean 2.64 2.75
SD 1.031 0.959
Cleanliness of OPD personnel Mean 2.58 2.61
SD 0.926 0.758
Queue System Mean 2.93 2.69
SD 1.124 1.062
Waiting area and space availability Mean 2.8 2.67
SD 1.113 0.824
Dispensary Mean 2.34 2.55
SD 0.928 0.822
Registration area Mean 3.08 2.97
SD 0.886 1.392

SERVQUAL factor Percentage of satisfaction Overall New patients Old patients
Tangibility Percentage of patients with low satisfaction 54.13% 51.49% 56.12%
Percentage of patients with high satisfaction 45.87 48.51% 43.88%

4.2.3.2 OPD patient satisfaction from reliability perspective
Reliability Patient Status Mann Whitney U test statistic p-value
New patients Old patients
Number of personnel to assist Strongly Agree 7(8.4%) 2(3%) -1.343 0.179
Agree 36(43.4%) 31(46.3%)
Neutral 8(9.6%) 30(44.8%)
Disagree 25(30.1%) 4(6%)
Strongly Disagree 7(8.4%) 0(0%)
Mann Whitney U test mean rank 79.53 70.51
Services and drug availability Strongly Agree 4(4.8%) 6(9%) -0.56 0.576
Agree 27(32.5%) 16(23.9%)
Neutral 4(4.8%) 16(23.9%)
Disagree 44(53%) 22(32.8%)
Strongly Disagree 4(4.8%) 7(10.4%)
Mann Whitney U test mean rank 77.18 73.42
Delivery of services within stipulated time Strongly Agree 8(9.6%) 0(0%) -1.612 0.107
Agree 20(24.1%) 16(23.9%)
Neutral 8(9.6%) 14(20.9%)
Disagree 39(47%) 20(29.9%)
Strongly Disagree 8(9.6%) 17(25.4%)
Mann Whitney U test mean rank 70.58 81.6
Delivery of promised services Strongly Agree 1(1.2%) 4(6%) -2.148 0.032
Agree 29(34.9%) 27(40.3%)
Neutral 19(22.9%) 23(34.3%)
Disagree 26(31.3%) 7(10.4%)
Strongly Disagree 8(9.6%) 6(9%)
Mann Whitney U test mean rank 82.05 67.39
Documentation and filing process Strongly Agree 3(3.6%) 4(6%) -1.865 0.062
Agree 36(43.4%) 33(49.3%)
Neutral 11(13.3%) 18(26.9%)
Disagree 31(37.3%) 10(14.9%)
Strongly Disagree 2(2.4%) 2(3%)
Mann Whitney U test mean rank 81.06 68.61
First visit resolution Strongly Agree 7(8.4%) 2(3%) -1.422 0.155
Agree 35(42.2%) 35(52.2%)
Neutral 9(10.8%) 22(32.8%)
Disagree 25(30.1%) 6(9%)
Strongly Disagree 7(8.4%) 2(3%)
Mann Whitney U test mean rank 79.75 70.23

Mann-Whitney U test was run to identify the presence of variation between new and old patients across the reliability index of the SERVQUAL index. Distributions of the variables of reliability for new and old patients were not similar, as identified by visual inspection. Variation in the frequencies across the two groups with respect to each reliability variable was evident. For instance, statistically significant difference between new and old patients was evident with respect to delivery of promised services. Satisfaction scores of new patients (mean rank = 82.05) with respect to delivery of promised services was statistically significantly higher than that of old patients (mean rank = 67.39), z = -2.148, p = 0.032. Contrarily, significant statistical variation between new and old patients was absent with respect to number of personnel to assist (z = -1.343, p = 0.179), services and drug availability (z = -0.56, p = 0.576), delivery of services within stipulated time (z = -1.612, p = 0.107), documentation and filing process (z = -1.865, p = 0.062) and first visit resolution (z = -1.422, p = 0.155).
However, differences in mean ranks between the two groups and variation in frequencies towards the five ordinal scale measurements towards each of the reliability variable were present. For instance, distribution of mean ranks among new patients with respect to number of personnel to assist (mean rank = 79.53), services and drug availability (mean rank = 77.18), delivery of services within stipulated time (mean rank = 70.58), documentation and filing process (mean rank = 81.06) and first visit resolution (mean rank = 79.75), and old patients with respect to number of personnel to assist (mean rank = 70.51), services and drug availability (mean rank = 73.42), delivery of services within stipulated time (mean rank = 81.6), documentation and filing process (mean rank = 68.61) and first visit resolution (mean rank = 70.23), recorded variation in the satisfaction experiences.
Majority of the new and old patients expressed similar and satisfactory agreement towards their experience with number of personnel to assist (new patients = 43.4% old patients = 46.3%), delivery of promised services (new patients = 39.49%, old patients = 40.3%), documentation and filing process (new patients = 43.4%, old patients = 49.3%) and first visit resolution (new patients = 42.2%, old patients = 52.2%). Most of the patients expressed similar and expressed disagreement towards their experience with delivery of services within stipulated time (new patients = 47%, old patients = 29.9%). The table below provides detailed information on variation in frequencies and Mann-Whitney U test results between new and old patients.
Reliability Mean & SD New patients Old patients
Number of personnel to assist Mean 2.87 2.54
SD 1.187 0.659
Services and drug availability Mean 3.2 3.12
SD 1.102 1.162
delivery of services within stipulated time Mean 3.23 3.57
SD 1.203 1.118
delivery of promised services Mean 3.13 2.76
SD 1.045 1.031
documentation and filing process Mean 2.92 2.6
SD 1.027 0.922
first visit resolution Mean 2.88 2.57
SD 1.183 0.821

SERVQUAL factor Percentage of satisfaction Overall New patients Old patients
Reliability Percentage of patients with low satisfaction 52.11% 53.98% 48.76%
Percentage of patients with high satisfaction 47.89% 46.02% 51.24%

4.2.3.3 OPD patient satisfaction from responsiveness perspective
Responsiveness Patient Status Mann Whitney U test statistic p-value
New patients Old patients
Quickness Strongly Agree 4(4.8%) 26(38.8%) -4.835 0
Agree 27(32.5%) 16(23.9%)
Neutral 27(32.5%) 21(31.3%)
Disagree 17(20.5%) 3(4.5%)
Strongly Disagree 8(9.6%) 1(1.5%)
Mann Whitney U test mean rank 90.39 57.06
prompt attitude to help Strongly Agree 24(28.9%) 25(37.3%) -0.705 0.481
Agree 23(27.7%) 10(14.9%)
Neutral 20(24.1%) 25(37.3%)
Disagree 8(9.6%) 4(6%)
Strongly Disagree 8(9.6%) 3(4.5%)
Mann Whitney U test mean rank 77.66 72.82
providing immediate attention Strongly Agree 6(7.2%) 23(34.3%) -1.985 0.047
Agree 14(16.9%) 6(9%)
Neutral 39(47%) 21(31.3%)
Disagree 18(21.7%) 5(7.5%)
Strongly Disagree 6(7.2%) 12(17.9%)
Mann Whitney U test mean rank 81.57 67.98
actual time to avail services Strongly Agree 8(9.6%) 26(38.8%) -4.145 0
Agree 21(25.3%) 9(13.4%)
Neutral 30(36.1%) 30(44.8%)
Disagree 11(13.3%) 1(1.5%)
Strongly Disagree 13(15.7%) 1(1.5%)
Mann Whitney U test mean rank 88.14 59.84

Mann-Whitney U test was run to identify the presence of variation between new and old patients across the responsiveness index of the SERVQUAL index. Distributions of the variables of responsiveness for new and old patients were not similar, as observed by visual inspection. Variation in the frequencies across the two groups with respect to each responsiveness variable was evident. For instance, statistically significant difference between new and old patients was evident with respect to quickness, providing immediate assistance and actual time to avail services. Satisfaction scores of new patients (mean rank = 90.39) with respect to quickness was statistically significantly higher than that of old patients (mean rank = 57.06), z = -4.835 p = 0.00. On similar lines, satisfaction scores of new patients (mean rank = 81.57) with respect to providing immediate assistance was statistically significantly higher than that of old patients (mean rank = 67.98), z = -1.985 p = 0.047. Satisfaction scores of new patients (mean rank = 88.14) with respect to actual time to avail services was statistically significantly higher than that of old patients (mean rank = 59.84), z = -4.145 p = 0.00.
Contrarily, significant statistical variation between new and old patients was absent with respect to prompt attitude to help (z = -0.705, p = 0.481).
However, differences in mean ranks between the two groups and variation in frequencies towards the five ordinal scale measurements towards each of the responsiveness variable were present. For instance, distribution of mean ranks among new patients (mean rank = 77.66) with respect to prompt attitude to help and old patients (mean rank = 72.82) recorded variation in the satisfaction experiences.
Majority of the new and old patients expressed similar and neutral experience with actual time to avail services (new patients = 36.1% old patients = 44.8%). Most patients expressed dissimilarity in their experience towards quickness, prompt attitude to help and providing immediate assistance. While majority of the new patients (32.5%) expressed neutrality with quickness, majority of the old patients expressed strong agreement (38.8%). On similar lines, majority of the new patients (28.9%) expressed strong agreement with prompt attitude to help, majority of the old patients expressed either strong agreement (37.3%) or neutrality (37.3%). Majority of the new patients (47%) expressed neutrality with providing immediate assistance, while majority of the old patients either expressed strong agreement (34.3%).The table below provides detailed information on variation in frequencies and Mann-Whitney U test results between new and old patients.
Responsiveness Mean & SD New patients Old patients
quickness Mean 2.98 2.06
SD 1.059 1.013
prompt attitude to help Mean 2.43 2.25
SD 1.271 1.159
providing immediate attention Mean 3.05 2.66
SD 0.987 1.472
actual time to avail services Mean 3 2.13
SD 1.189 1.013

SERVQUAL factor Percentage of satisfaction Overall New patients Old patients
Responsiveness Percentage of patients with low satisfaction 55.33% 63.06% 47.39%
Percentage of patients with high satisfaction 44.67% 36.94% 52.61%

4.2.3.4 OPD patient satisfaction from assurance perspective
Assurance Patient Status Mann Whitney U test statistic p-value
New patients Old patients
Display of SME and knowledge, resolution skills Strongly Agree 2(2.4%) 24(35.8%) -4.144 0
Agree 15(18.1%) 15(22.4%)
Neutral 36(43.4%) 12(17.9%)
Disagree 20(24.1%) 8(11.9%)
Strongly Disagree 10(12%) 8(11.9%)
Mann Whitney U test mean rank 88.34 59.59
information received Strongly Agree 16(19.3%) 6(9%) -1.361 0.174
Agree 12(14.5%) 7(10.4%)
Neutral 20(24.1%) 23(34.3%)
Disagree 23(27.7%) 19(28.4%)
Strongly Disagree 12(14.5%) 12(17.9%)
Mann Whitney U test mean rank 71.28 80.72
privacy protection Strongly Agree 15(18.1%) 24(35.8%) -2.077 0.038
Agree 12(14.5%) 10(14.9%)
Neutral 54(65.1%) 29(43.3%)
Disagree 2(2.4%) 2(3%)
Strongly Disagree 0(0%) 2(3%)
Mann Whitney U test mean rank 81.46 68.12
Courteousness Strongly Agree 33(39.8%) 27(40.3%) -0.036 0.971
Agree 11(13.3%) 8(11.9%)
Neutral 32(38.6%) 27(40.3%)
Disagree 3(3.6%) 2(3%)
Strongly Disagree 4(4.8%) 3(4.5%)
Mann Whitney U test mean rank 75.61 75.37

Mann-Whitney U test was run to identify the presence of variation between new and old patients across the assurance index of the SERVQUAL index. Distributions of the variables of assurance for new and old patients were not similar, as observed by visual inspection. Variation in the frequencies across the two groups with respect to each assurance variable was evident. For instance, statistically significant difference between new and old patients was evident with respect to displaying SME, knowledge and resolution skills and privacy protection.
Satisfaction scores of new patients (mean rank = 88.34) with respect to displaying SME, knowledge was statistically significantly higher than that of old patients (mean rank = 59.59), z = -4.144 p = 0.00. On similar lines, satisfaction scores of new patients (mean rank = 81.46) with respect to privacy protection was statistically significantly higher than that of old patients (mean rank = 68.12), z = -2.077 p = 0.038. Contrarily, significant statistical variation between new and old patients was absent with respect to information received (z = -1.361, p = 0.174) and courteousness (z = -0.036, p = 0.971).
However, differences in mean ranks between the two groups and variation in frequencies towards the five ordinal scale measurements towards each of the assurance variable were present. For instance, distribution of mean ranks among new patients (mean rank = 71.28) with respect to information received and old patients (mean rank = 80.72), and distribution of mean ranks among new patients (mean rank = 75.61) with respect to courteousness and old patients (mean rank = 75.37) recorded variation in the satisfaction experiences.
Majority of the new and old patients expressed similar and neutral experience with privacy protection (new patients = 65.1% old patients = 43.3%) and courteousness (new patients = 38.6% old patients = 40.3%). Most patients expressed dissimilarity in their experience towards displaying SME, knowledge and resolution skills and information received. While majority of the new patients (43.4%) expressed neutrality with displaying SME, knowledge and resolution skills, majority of the old patients expressed strong agreement (35.8%). On similar lines, majority of the new patients (27.7%) expressed disagreement with information received, majority of the old patients expressed neutrality (34.3%). The table below provides detailed information on variation in frequencies and Mann-Whitney U test results between new and old patients.
Assurance Mean & SD New patients Old patients
Display of SME and knowledge, resolution skills Mean 3.25 2.42
SD 0.973 1.394
information received Mean 3.04 3.36
SD 1.338 1.164
privacy protection Mean 2.52 2.22
SD 0.817 1.071
Courteousness Mean 2.2 2.19
SD 1.156 1.145

SERVQUAL factor Percentage of satisfaction Overall New patients Old patients
Assurance Percentage of patients with low satisfaction 53.33% 57.09% 46.27%
Percentage of patients with high satisfaction 46.67% 42.91% 53.73%

4.2.3.5 OPD patient satisfaction from empathy perspective
Empathy Patient Status Mann Whitney U test statistic p-value
New patients Old patients
personal attention Strongly Agree 18(21.7%) 27(40.3%) -3.091 0.002
Agree 13(15.7%) 7(10.4%)
Neutral 27(32.5%) 29(43.3%)
Disagree 18(21.7%) 2(3%)
Strongly Disagree 7(8.4%) 2(3%)
Mann Whitney U test mean rank 84.93 63.82
sense of concern Strongly Agree 13(15.7%) 19(28.4%) -2.06 0.039
Agree 18(21.7%) 16(23.9%)
Neutral 28(33.7%) 20(29.9%)
Disagree 16(19.3%) 6(9%)
Strongly Disagree 8(9.6%) 6(9%)
Mann Whitney U test mean rank 81.87 67.6
sense of well-being and interest Strongly Agree 14(16.9%) 12(17.9%) -0.181 0.856
Agree 22(26.5%) 15(22.4%)
Neutral 31(37.3%) 32(47.8%)
Disagree 13(15.7%) 3(4.5%)
Strongly Disagree 3(3.6%) 5(7.5%)
Mann Whitney U test mean rank 76.02 74.82
expression of understanding Strongly Agree 13(15.7%) 19(28.4%) -1.953 0.051
Agree 21(25.3%) 10(14.9%)
Neutral 26(31.3%) 32(47.8%)
Disagree 13(15.7%) 4(6%)
Strongly Disagree 10(12%) 2(3%)
Mann Whitney U test mean rank 81.48 68.1

Mann-Whitney U test was run to identify the presence of variation between new and old patients across the empathy index of the SERVQUAL index. Distributions of the variables of empathy for new and old patients were not similar, as observed by visual inspection. Variation in the frequencies across the two groups with respect to each empathy variable was evident. For instance, statistically significant difference between new and old patients was evident with respect to personal attention and sense of concern
Satisfaction scores of new patients (mean rank = 84.93) with respect to personal attention was statistically significantly higher than that of old patients (mean rank = 63.82), z = -3.091 p = 0.02. On similar lines, satisfaction scores of new patients (mean rank = 81.87) with respect to sense of concern was statistically significantly higher than that of old patients (mean rank = 67.6), z = -2.06 p = 0.039. Contrarily, significant statistical variation between new and old patients was absent with respect to sense of well-being and interest (z = -1.181, p = 0.856) and expression of understanding (z = -1.953, p = 0.051).
However, differences in mean ranks between the two groups and variation in frequencies towards the five ordinal scale measurements towards each of the empathy variable were present. For instance, distribution of mean ranks among new patients (mean rank = 76.02) with respect to sense of well-being and interest and old patients (mean rank = 74.82), and distribution of mean ranks among new patients (mean rank = 81.48) with respect to expression of understanding and old patients (mean rank = 68.1) recorded variation in the satisfaction experiences.
Majority of the new and old patients expressed similar and neutral experience with personal attention (new patients = 32.5% old patients = 43.3%), sense of concern (new patients = 33.7% old patients = 29.9%), sense of well-being and interest (new patients = 37.3% old patients = 47.8%), and expression of understanding (new patients = 31.3% old patients = 47.8%). The table below provides detailed information on variation in frequencies and Mann-Whitney U test results between new and old patients.
Empathy Mean & SD New patients Old patients
personal attention Mean 2.8 2.18
SD 1.247 1.1
sense of concern Mean 2.86 2.46
SD 1.191 1.247
sense of well-being and interest Mean 2.63 2.61
SD 1.056 1.072
expression of understanding Mean 2.83 2.4
SD 1.228 1.06

SERVQUAL factor Percentage of satisfaction Overall New patients Old patients
Empathy Percentage of patients with low satisfaction 57.17% 56.72% 53.36%
Percentage of patients with high satisfaction 42.83% 43.28% 46.64%

4.2.4 OPD patient satisfaction with waiting at Pusrawi hospital
Waiting Time across various OPD areas Patient Status Mann Whitney U test statistic p-value
New patients Old patients
Time taken in registration >60 0(0%) 6(9%) -5.222 0
30-59 6(7.2%) 12(17.9%)
15-29 15(18.1%) 27(40.3%)
<14 62(74.7%) 22(32.8%)
Mann Whitney U test mean rank 90.39 57.05
time taken in waiting room >60 8(9.6%) 27(40.3%) -4.584 0
30-59 19(22.9%) 16(23.9%)
15-29 22(26.5%) 13(19.4%)
<14 34(41%) 11(16.4%)
Mann Whitney U test mean rank 89.68 58
time taken for consultation >60 16(19.3%) 8(11.9%) -1.041 0.298
30-59 23(27.7%) 27(40.3%)
15-29 22(26.5%) 27(40.3%)
<14 22(26.5%) 5(7.5%)
Mann Whitney U test mean rank 78.68 71.56
Time taken in dispensary >60 4(4.8%) 3(4.5%) -5.207 0
30-59 8(9.6%) 21(31.3%)
15-29 19(22.9%) 32(47.8%)
<14 52(62.7%) 11(16.4%)
Mann Whitney U test mean rank 91.06 56.22

Mann-Whitney U test was run to identify the presence of variation waiting time between new and old patients. Distributions of the scores across different waiting areas for new and old patients were not similar, as observed by visual inspection. Variation in the frequencies across the two groups with respect to each waiting area was evident. For instance, statistically significant difference between new and old patients was evident with respect to time taken in registration, time taken in waiting room and time taken in dispensary. Satisfaction scores of new patients (mean rank = 90.39) with respect to time taken in registration was statistically significantly higher than that of old patients (mean rank = 57.05), z = -5.222 p = 0.00. On similar lines, satisfaction scores of new patients (mean rank = 89.68) with respect to time taken in waiting room was statistically significantly higher than that of old patients (mean rank = 58), z = -4.584 p = 0.00. Satisfaction scores of new patients (mean rank = 91.06) with respect to time taken in dispensary was statistically significantly higher than that of old patients (mean rank = 56.22), z = -5.207 p = 0.00.
Contrarily, significant statistical variation between new and old patients was absent with respect to time taken for consultation (z = -1.041, p = 0.298).
However, differences in mean ranks between the two groups and variation in frequencies towards the four waiting time demarcation were evident. For instance, distribution of mean ranks among new patients (mean rank = 78.68) with respect to time taken for consultation and old patients (mean rank = 71.56) recorded variation in the waiting time.
Most patients expressed dissimilarity in their experience towards all the four waiting areas. While majority of the new patients (74.7%) recorded <14 minutes waiting time in the registration area, majority of the old patients (40.3%) recorded 15-29 minutes waiting time. On similar lines, majority of the new patients (41%) recorded <14 minutes waiting time in waiting room, majority of the old patients (40.3%) recorded >60 minutes waiting time. Majority of the new patients (27.7%) recorded 30-59 minutes as consultation time, while majority of the old patients either recorded 30-59 minutes (40.3%) or 15-29 minutes (40.3%) as consultation time. Majority of the new patients (62.7%) recorded <14 minutes as time taken in dispensary, while majority of the old patients recorded 15-29 minutes (47.8%). The table below provides detailed information on variation in frequencies and Mann-Whitney U test results between new and old patients with respect to waiting time.

4.2.4.1 OPD patient satisfaction with the waiting time
Waiting experience Patient Status Mann Whitney U test statistic p-value
New patients Old patients
Registration experience Strongly Agree 33(39.8%) 22(32.8%) -2.116 0.034
Agree 31(37.3%) 15(22.4%)
Neutral 10(12%) 16(23.9%)
Disagree 9(10.8%) 9(13.4%)
Strongly Disagree 0(0%) 5(7.5%)
Mann Whitney U test mean rank 69.05 83.49
waiting room experience Strongly Agree 13(15.7%) 12(17.9%) -2.053 0.04
Agree 20(24.1%) 10(14.9%)
Neutral 28(33.7%) 9(13.4%)
Disagree 14(16.9%) 24(35.8%)
Strongly Disagree 8(9.6%) 12(17.9%)
Mann Whitney U test mean rank 69.11 83.42
Consultation experience Strongly Agree 14(16.9%) 1(1.5%) -2.009 0.045
Agree 13(15.7%) 9(13.4%)
Neutral 8(9.6%) 12(17.9%)
Disagree 32(38.6%) 27(40.3%)
Strongly Disagree 16(19.3%) 18(26.9%)
Mann Whitney U test mean rank 69.36 93.11
Dispensary experience Strongly Agree 10(12%) 28(41.8%) -7.365 0
Agree 9(10.8%) 33(49.3%)
Neutral 18(21.7%) 3(4.5%)
Disagree 33(39.8%) 2(3%)
Strongly Disagree 13(15.7%) 1(1.5%)
Mann Whitney U test mean rank 98.33 47.22

Mann-Whitney U test was run to identify the presence of variation between new and old patients across the waiting areas. Distributions of scores across the waiting areas for new and old patients were not similar, as observed by visual inspection. Variation in the frequencies across the two groups with respect to each waiting area variable was evident. For instance, statistically significant difference between new and old patients was evident with respect to all four waiting areas, registration, waiting room, consultation and dispensary. Satisfaction scores of new patients (mean rank = 69.05) with respect to registration was statistically significantly lower than that of old patients (mean rank = 83.49), z = -2.116 p = 0.034. On similar lines, satisfaction scores of new patients (mean rank = 69.11) with respect to waiting room was statistically significantly lower than that of old patients (mean rank = 83.42), z = -2.053 p = 0.04. Satisfaction scores of new patients (mean rank = 69.36) with respect to actual time to consultation was statistically significantly lower than that of old patients (mean rank = 93.11), z = -2.009 p = 0.045. Satisfaction scores of new patients (mean rank = 98.33) with respect to actual time to dispensary was statistically significantly higher than that of old patients (mean rank = 47.22), z = -7.365 p = 0.00.
Variation in frequencies towards the five ordinal scale measurements towards each waiting area variable was present. Majority of the new and old patients expressed similar and expressed strong agreement with their experience towards registration area (new patients = 39.8% old patients = 32.8%), and similar and disagreement towards their experience with consultation (new patients = 38.6% old patients = 40.3%). Most patients expressed dissimilarity towards their waiting room and dispensary experiences. While majority of the new patients (33.7%) expressed neutrality with waiting room, majority of the old patients expressed disagreement (35.8%). On similar lines, majority of the new patients (39.8%) expressed disagreement towards their experience with dispensary; majority of the old patients expressed agreement (49.3%). The table below provides detailed information on variation in frequencies and Mann-Whitney U test results between new and old patients.
Waiting time Mean & SD New patients Old patients
Registration experience Mean 1.94 2.4
SD 0.98 1.28
waiting room experience Mean 2.81 3.21
SD 1.184 1.388
Consultation experience Mean 3.28 3.78
SD 1.391 1.042
Dispensary experience Mean 3.36 1.73
SD 1.226 0.809

SERVQUAL factor Percentage of satisfaction Overall New patients Old patients
Experience with
Waiting time Percentage of patients with low satisfaction 45% 45.15% 43.66%
Percentage of patients with high satisfaction 55% 54.85% 56.34%

Spearman’s rho Waiting experience
Correlation Coefficient p-value [Sig. (2-tailed)] N
Time taken Overall .692** 0.000 600
New patients .776** 0.000 332
Old patients .695** 0.000 268
**. Correlation is significant at the 0.01 level (2-tailed).

Spearman’s rho Waiting experience
Correlation Coefficient p-value [Sig. (2-tailed)] N
Time taken Overall Registration .832** 0.000 150
Waiting Room .855** 0.000 150
Consultation .677** 0.000 150
Dispensary .199*

0.015 150
New patients Registration .703** 0.000 83
Waiting Room .917** 0.000 83
Consultation .871** 0.000 83
Dispensary .771** 0.000 83
Old patients Registration .954** 0.000 67
Waiting Room .831** 0.000 67
Consultation .338**

0.005 67
Dispensary .567** 0.000 67
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).

Waiting time in each area
Correlation Coefficient p-value [Sig. (2-tailed)] N
Spearman’s rho Willingness to use services again Registration .217** 0.008 150
Waiting Room .241** 0.003 150
Consultation 0.089 0.281 150
Dispensary .226** 0.006 150
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).

4.2.5 Factors that affect OPD patients satisfaction
4.2.5.1 New patients
The logistic regression performed to predict the factors that influenced new patients’ willingness in using the service again
Factors that influence new patients’ willingness to use the hospital services again
B S.E. Wald df p-value Odds Ratio 95% C.I. for Odds Ratio
Lower Upper
Constant 11.16 7.13 2.45 1 0.118 70284.995
Cafeteria 1.74 1.38 1.59 1 0.208 0.175 0.012 2.628
Low satisfaction, [High satisfaction] Drinking Water 1.655 1.25 1.76 1 0.185 0.191 0.017 2.211
Low satisfaction, [High satisfaction] Toilets 2.135 1.05 4.16 1 0.042* 0.118 0.015 0.921
Low satisfaction, [High satisfaction] Magazines/TV 1.989 1.01 3.9 1 0.048* 7.309 1.014 52.67
Low satisfaction, [High satisfaction] Cleanliness of OPD 0.52 1 0.27 1 0.604 0.594 0.083 4.245
Low satisfaction, [High satisfaction] Cleanliness of OPD personnel 1.444 1.13 1.63 1 0.202 0.236 0.026 2.169
Low satisfaction, [High satisfaction] Queue System 0.06 0.94 0 1 0.949 0.942 0.149 5.961
Low satisfaction, [High satisfaction] Waiting area and space availability 2.981 1.35 4.9 1 0.027* 19.709 1.408 275.87
Low satisfaction, [High satisfaction] Dispensary 1.527 1.08 2.01 1 0.156 0.217 0.026 1.791
Low satisfaction, [High satisfaction] Registration area 1.713 1.08 2.52 1 0.113 0.18 0.022 1.498
Low satisfaction, [High satisfaction] Number of personnel to assist 0.014 1.03 0 1 0.989 1.014 0.135 7.604
Low satisfaction, [High satisfaction] Services and drug availability 2.035 1.07 3.65 1 0.056 0.131 0.016 1.055
Low satisfaction, [High satisfaction] delivery of services within stipulated time 1.5 1.03 2.11 1 0.146 0.223 0.029 1.687
Low satisfaction, [High satisfaction] delivery of promised services 0.484 1.11 0.19 1 0.661 1.622 0.186 14.144
Low satisfaction, [High satisfaction] documentation and filing process 1.097 1.04 1.1 1 0.293 0.334 0.043 2.584
Low satisfaction, [High satisfaction] first visit resolution 2.669 1.05 6.5 1 0.011* 14.425 1.854 112.26
Low satisfaction, [High satisfaction] quickness 1.863 1.17 2.55 1 0.11 0.155 0.016 1.529
Low satisfaction, [High satisfaction] prompt attitude to help 0.842 1 0.71 1 0.398 2.321 0.329 16.354
Low satisfaction, [High satisfaction] providing immediate attention 0.089 1.25 0.01 1 0.943 0.915 0.079 10.545
Low satisfaction, [High satisfaction] actual time to avail services -0.47 0.97 0.24 1 0.626 0.625 0.094 4.147
Low satisfaction, [High satisfaction] Display of SME and knowledge, resolution skills -1.86 1.23 2.29 1 0.13 0.156 0.014 1.73
Low satisfaction, [High satisfaction] information received 2.194 1.07 4.2 1 0.04* 8.97 1.1 73.128
Low satisfaction, [High satisfaction] privacy protection -1.12 1.05 1.14 1 0.287 0.327 0.042 2.555
Low satisfaction, [High satisfaction] Courteousness 1.786 0.96 3.5 1 0.062 5.966 0.917 38.794
Low satisfaction, [High satisfaction] personal attention 0.976 0.92 1.12 1 0.289 2.653 0.436 16.136
Low satisfaction, [High satisfaction] sense of concern 1.087 1.09 1 1 0.318 2.964 0.352 24.953
Low satisfaction, [High satisfaction] sense of well-being and interest 0.863 0.96 0.8 1 0.37 2.37 0.359 15.623
Low satisfaction, [High satisfaction] expression of understanding 0.856 1.18 0.52 1 0.47 2.353 0.232 23.906
Low satisfaction, [High satisfaction] Registration experience -3.17 1.77 3.23 1 0.072 0.042 0.001 1.333
Low satisfaction, [High satisfaction] waiting room experience 3.346 1.67 4.03 1 0.045* 28.383 1.081 745.31
Low satisfaction, [High satisfaction] Consultation experience 1.535 1.43 1.16 1 0.282 4.643 0.283 76.278
Low satisfaction, [High satisfaction] Dispensary experience -0.79 1.32 0.35 1 0.553 0.456 0.034 6.112
Low satisfaction, [High satisfaction] *significant at p<0.05
4.2.5.2 Old patients
Factors that influence old patients’ willingness to use the hospital services again
B S.E. Wald df p-value Odds Ratio 95% C.I. for Odds Ratio
Lower Upper
Constant 11.16 7.134 2.447 1 0.118 70284.995
Cafeteria -4.135 19.9 0.043 1 0.835 62.459 0 5.43391E+18
Low satisfaction, [High satisfaction] Drinking Water 4.476 2.786 2.581 1 0.108 0.011 0 2.678
Low satisfaction, [High satisfaction] Toilets 4.513 3.188 2.003 1 0.157 0.011 0 5.676
Low satisfaction, [High satisfaction] Magazines/TV 5.398 2.676 4.069 1 0.044* 0.005 0 0.858
Low satisfaction, [High satisfaction] Cleanliness of OPD -1.831 2.697 0.461 1 0.497 6.242 0.032 1233.46
Low satisfaction, [High satisfaction] Cleanliness of OPD personnel 1.726 2.663 0.42 1 0.517 0.178 0.001 32.915
Low satisfaction, [High satisfaction] 4Queue System 0.12 4.589 0.001 1 0.979 0.887 0 7143.249
Low satisfaction, [High satisfaction] Waiting area and space availability 4.116 4.069 1.023 1 0.312 0.016 0 47.443
Low satisfaction, [High satisfaction] Dispensary 2.001 3.639 0.302 1 0.582 0.135 0 169.336
Low satisfaction, [High satisfaction] Registration area 4.152 3.364 1.524 1 0.217 0.016 0 11.483
Low satisfaction, [High satisfaction] Number of personnel to assist 7.411 3.018 6.029 1 0.014* 1653.831 4.461 613182.766
Low satisfaction, [High satisfaction] Services and drug availability 5.231 5.142 1.035 1 0.309 0.005 0 127.36
Low satisfaction, [High satisfaction] delivery of services within stipulated time -2.101 2.536 0.687 1 0.407 8.175 0.057 1177.163
Low satisfaction, [High satisfaction] delivery of promised services 3.957 3.615 1.198 1 0.274 0.019 0 22.828
Low satisfaction, [High satisfaction] documentation and filing process -0.753 1.928 0.153 1 0.696 2.124 0.049 92.922
Low satisfaction, [High satisfaction] first visit resolution 3.636 2.229 2.66 1 0.103 37.958 0.48 2999.323
Low satisfaction, [High satisfaction] quickness 8.568 3.784 5.127 1 0.024* 0 0 0.316
Low satisfaction, [High satisfaction] prompt attitude to help 2.791 3.329 0.703 1 0.402 0.061 0 41.83
Low satisfaction, [High satisfaction] providing immediate attention -4.455 3.356 1.761 1 0.184 86.029 0.12 61898.63
Low satisfaction, [High satisfaction] actual time to avail services 3.146 2.823 1.242 1 0.265 0.043 0 10.886
Low satisfaction, [High satisfaction] Display of SME and knowledge, resolution skills -4.468 3.578 1.56 1 0.212 87.163 0.079 96746.686
Low satisfaction, [High satisfaction] information received 6.933 3.644 3.621 1 0.047* 0.001 0 1.232
Low satisfaction, [High satisfaction] privacy protection 5.621 4.378 1.649 1 0.199 0.004 0 19.29
Low satisfaction, [High satisfaction] Courteousness -1.09 3.299 0.109 1 0.741 2.974 0.005 1913.345
Low satisfaction, [High satisfaction] personal attention 0.099 2.047 0.002 1 0.961 0.906 0.016 50.042
Low satisfaction, [High satisfaction] sense of concern 2.016 2.675 0.568 1 0.451 0.133 0.001 25.171
Low satisfaction, [High satisfaction] sense of well-being and interest 4.606 2.73 2.846 1 0.032* 0.01 0 2.107
Low satisfaction, [High satisfaction] expression of understanding 2.165 2.634 0.675 1 0.411 0.115 0.001 20.045
Low satisfaction, [High satisfaction] Registration experience -2.455 1.812 1.836 1 0.175 11.648 0.334 406.079
Low satisfaction, [High satisfaction] waiting room experience 3.88 2.171 3.194 1 0.047* 0.021 0 1.455
Low satisfaction, [High satisfaction] Consultation experience 9.576 4.125 5.39 1 0.02* 0 0 0.225
Low satisfaction, [High satisfaction] Dispensary experience -17.14 7.426 5.325 1 0.021* 27676797.7 13.23 5.79225E+13
Low satisfaction, [High satisfaction] *significant at p<0.05
High satisfaction is compared with low satisfaction
4.2.6 SERVQUAL dimensions that affect OPD patient satisfaction
4.2.6.1 New patients
SERVQUAL dimensions that influence new patients’ willingness to use the hospital services again
B S.E. Wald df p-value Odds Ratio 95% C.I. for Odds Ratio
Lower Upper
Constant 2.795 4.24 0.43 1 0.51 16.36
Tangibility -0.02 0.04 0.19 1 0.661 0.982 0.908 1.063
Reliability 0.1 0.03 8.55 1 0.003* 1.106 1.034 1.183
Responsiveness 0.014 0.03 0.29 1 0.589 1.014 0.965 1.065
Assurance 0.075 0.03 5.79 1 0.016* 0.928 0.873 0.986
Empathy -0.02 0.02 0.89 1 0.345 0.978 0.933 1.024
Waiting experience 0.04 0.02 7.53 1 0.006* 0.961 0.934 0.989
*significant at p<0.05
Average weighted values

4.2.6.2 Old patients
SERVQUAL dimensions that influence old patients’ willingness to use the hospital services again
B S.E. Wald df p-value Odds Ratio 95% C.I. for Odds Ratio
Lower Upper
Constant 1.082 3.04 0.13 1 0.722 2.952
Tangibility 0.127 0.06 4.07 1 0.044* 0.88 0.778 0.996
Reliability -0.01 0.06 0.01 1 0.916 0.993 0.879 1.123
Responsiveness 0.037 0.05 0.65 1 0.421 1.038 0.948 1.137
Assurance 0.022 0.05 0.21 1 0.647 1.022 0.931 1.122
Empathy 0.023 0.04 0.32 1 0.047* 1.023 0.945 1.107
Waiting experience 0.022 0.03 0.61 1 0.436 1.022 0.967 1.08
*significant at p<0.05
Average weighted values
4.3 Summary
Three crucial interpretations can be extracted from the study’s findings. A significant variation exists in the perceived patient satisfaction experiences with respect to demographic indicator patient status. New and old patients’ satisfactory levels with each SERVQUAL index and waiting time/area indicated significant variation. Mann-Whitney U test validated the first hypothesis associated with this variation. Significant predictors for patient satisfaction through service quality index exist from individual variable perspective and SERVQUAL dimensional perspective with respect to demographic indicator patient status. Predictors of new and old patients’ satisfactory levels with each SERVQUAL index and waiting time/area were identified through separate binomial logistic regression tests which validated the second and third hypotheses. A significant relationship exists between waiting time and patient satisfaction with respect to overall and demographic indicator patient status. Spearman’s rank order correlation test validated the last hypothesis and established a correlation between waiting time and patient satisfaction.
CHAPTER V. CONCLUSION
5.1 Epilogue
Three crucial interpretations can be extracted from the study’s findings. A significant variation exists in the perceived patient satisfaction experiences with respect to demographic indicator patient status. New and old patients’ satisfactory levels with each SERVQUAL index and waiting time/area indicated significant variation. Mann-Whitney U test validated the first hypothesis associated with this variation. Significant predictors for patient satisfaction through service quality index exist from individual variable perspective and SERVQUAL dimensional perspective with respect to demographic indicator patient status. Predictors of new and old patients’ satisfactory levels with each SERVQUAL index and waiting time/area were identified through separate binomial logistic regression tests which validated the second and third hypotheses. A significant relationship exists between waiting time and patient satisfaction with respect to overall and demographic indicator patient status. Spearman’s rank order correlation test validated the last hypothesis and established a correlation between waiting time and patient satisfaction.
5.2 Ethical Considerations
Ethical concerns in any research could arise while collecting information, processing the information, storing the data and presenting the research findings under the principles of morality in an unbiased and responsible manner (Saunders et al., 2007). Obtaining consent letters and providing special care while questioning the participants on their experiences required adherence towards principles of autonomy, beneficence, non-maleficence and justice (Beauchamp & Childres, 2001; Williams, 2008). In this study consent letters were obtained from the Institutional Review Board (IRB) and Pusrawi Hospital. Apart from the institutions, informed consent in the form of covering letters was attached to each questionnaire which insisted on patients’ reviewing prior to responding to any questions. The covering letter provided a short description of the aim and objectives of the study and informed the participants about protecting their privacy and confidentiality, voluntary participation and allowed the participants to withdraw from the study at any given point of time. The participants were also informed about the use of data for academic purposes and destruction of data post 2 years of approval and publishing from any written or computerized records.
Post obtaining consent special care was taken to ensure that no participant was potentially harmed in the process of collecting data. Any participant can be potentially harmed not only physically but also mentally and emotionally while recollecting any negative experiences associated with the questions. Such questions can result in either creating shame in the respondents and result in internal drop-out (Japec et al., 1997) or can force the respondents to modify their answers, creating unnecessary bias (Japec et al, 1997; Trost, 1994). To avoid such situations, the questions in the current study aimed at a five-point rating scale and used positive questions rather than negative questions. Each participant was notified to contact the researcher in case of any clarifications or support.
5.3 Limitations of the Study
Limitations of the study lie in the study’s research methodology. The cross-sectional nature of the study prevents the study from extracting causal inferences and conducting any trend analysis of Pusrawi hospital’s OPD patients’ perception on service quality and patient satisfaction. The second limitation is the study’s setting. Conducting the study from one hospital only has its own limitations. It prevents heightened generalizability of the study across all Malaysian OPDs. This could have been overcome with larger and representative sample size. The final limitation of the study is in the data analysis procedure employed to conduct regression. The current study used mean values to categorize data into binary categories. Given the limitations of using mean values, median values could have been used to achieve reliable scores. Time pressure prevented the researcher from re-doing the entire research analysis, given the complexity involved in the process.
5.4 Recommendations for Further Research
The current study has used SERVQUAL model to measure patient satisfaction in the Pusrawi hospital. Further studies can be conducted on other patient satisfaction measurement tools from a mixed-methodology perspective to obtain deeper insight towards the aspects of patient satisfaction and quality of care and services. Further studies can also be conducted on people-related intrinsic factors such as behavioural intentions or employee performance and motivation, or on governance related aspects to achieve a holistic balance between people, process and procedures in any healthcare organization. Other extrinsic aspects such as impact of other patients and socio-demographic aspects on patient satisfaction needs further exploration and further studies can focus on the same. Continued efforts starting from each hospital could eventually include multiple hospitals individual and collective departments, to achieve patient satisfaction trend across each region in Malaysia. Such studies shall eventually impact the healthcare system and ensure optimal quality of care and satisfactory experiences for patients that visit any hospital in the nation.
CHAPTER VI. REFERENCES
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Oman Medical Journal (2014) Vol. 29, No. 1:3-7
DOI 10. 5001/omj.2014.02
Received: 30 Aug 2013 / Accepted: 23 Oct 2013
c OMSB, 2014
Patient Satisfaction Survey as a Tool Towards Quality Improvement
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CHAPTER VII. APPENDIX- STUDY QUESTIONNAIRE
The purpose of the study is to assess the satisfaction levels of old and new patients with the quality of healthcare services provided by the Outpatient Department (OPD) of Pusrawi hospital. Kindly read each question carefully and provide answers that you feel are most appropriate to the questions. If a scale of 1-5 is provided for any question, 1 indicates that you are strongly satisfied with the indicated quality of healthcare services at the OPD and 5 indicate that you are strongly dissatisfied. You can circle any number in between. Please note that there are no correct or incorrect answers to this survey.
This survey is purely conducted for academic purposes and shall highlight your opinions or perceived satisfaction on quality of healthcare services. By participating in this survey you are agreeing to voluntary participation and any information hereby used will be considered as indicators of patient satisfaction of Pusrawi hospital’s OPD facility. The survey is divided into three parts: Part A, Part B and Part C. Part A shall collect your demographic indicators: your age, gender and patient status will be collected. Part B consists of questions related to your satisfaction with OPD quality. Part C consists of questions pertinent to your satisfaction levels from a waiting time perspective. Kindly be open and honest and we value your feedback. Here we begin…all the best!
Part A
1. Age :
2. Gender:
3. Patient Status:
Part B
Tangibility
1. On a scale of 1-5 how satisfied are you with the physical facilities such as:
a. Seating arrangement
b. Cafeteria
c. Drinking water
d. Toilets
e. Magazines/TV etc
2. On a scale of 1-5 how satisfied are you with the cleanliness of:
a. OPD
b. OPD personnel
3. On a scale of 1-5 how satisfied are you with the queue system of the OPD
4. On a scale of 1-5 how satisfied are you with the waiting area and space availability
5. On a scale of 1-5 how satisfied are you with the
a. Dispensary
b. Registration area
Reliability
6. On a scale of 1-5 how satisfied are you with the availability of:
a. Number of personnel (doctors, staff and nurses)
b. Services and drugs
7. On a scale of 1-5 how satisfied are you with the delivery of services within the stipulated time
8. On a scale of 1-5 how satisfied are you with the delivery of promised services
9. On a scale of 1-5 how satisfied are you with the documentation and filing process of the OPD
10. On a scale of 1-5 how satisfied are you with the provided resolution – was it provided in the first visit itself?
Responsiveness
11. On a scale of 1-5 how satisfied are you with the quickness of OPD process and personnel in providing services
12. On a scale of 1-5 how satisfied are you with the personnel’s prompt attitude of helping
13. On a scale of 1-5 how satisfied are you with the immediate attention provided
14. On a scale of 1-5 how satisfied are you with the response given by the personnel regarding the actual time to avail the services
Assurance
15. On a scale of 1-5 how satisfied are you with the personnel’s display of subject matter expertise, knowledge and issue resolution skills
16. On a scale of 1-5 how satisfied are you with the information received on relevant questions
17. On a scale of 1-5 how satisfied are you with the privacy protection
18. On a scale of 1-5 how satisfied are you with the expressed courteousness of the personnel
Empathy
19. On a scale of 1-5 how satisfied are you with the received personnel attention
20. On a scale of 1-5 how satisfied are you with the sense of concern exhibited by the personnel
21. On a scale of 1-5 how satisfied are you with the sense of well-being and interest exhibited by the personnel
22. On a scale of 1-5 how satisfied are you with the expression of understanding and willingness of personnel to apologize for inconveniences
Part C
1. How long did you wait in the registration department?
2. On a scale of 1-5 how satisfied are you with the waiting time in the registration department?
3. How long did you wait in the waiting room department?
4. On a scale of 1-5 how satisfied are you with the waiting time in the waiting room?
5. How long did your consultation time take?
6. On a scale of 1-5 how satisfied are you with the time taken for consultation?
7. How long did you wait in the dispensary?
8. On a scale of 1-5 how satisfied are you with the waiting time for getting drugs?

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