Professor, Internal Medicine Department, College of Medicine, Taif University and Medical director of Taif University Outpatient Clinic KSA
Khaled A. Alswat MD
Assistant Professor, Internal Medicine Department, College of Medicine, Taif University and General Supervisor of Taif University Outpatient Clinics, KSA
Abdel Hamid Serwah MD
Professor, Internal Medicine Department, College of Medicine, Taif University
Dental Specialist and Quality Coordinator at Taif University Outpatient Clinic
Objective: Primary health care involves a sustained partnership between patients and providers that addresses the patient's health needs over time. The degree of patients' satisfaction is one among the mechanisms used in assessing the quality of health care services. Hence, the aim of this study is to determine patients' satisfaction regarding the quality of medical care at the Taif University Outpatient Clinic.
Methods: An analytical observational study cross sectional was conducted at the Taif University Outpatient Clinic. A random sampling technique was employed over a five month period; February 1st to June 31st 2013. A self administered (Arabic/English) questionnaire was used.
Results: As regard patient-physician interaction, the average percent mean score for satisfaction (7 items) was (84.14 ± 7.97%) with the medication side effect explanation is the least one (68%), while, the overall patients' satisfaction with administrative efficiency and clinic setup environment (5 items) was 89.4 ± 5.64 % with opinion about care provision got least satisfaction (83%).
Conclusion: The majority of patients were satisfied with the patient-physician interaction, technical competency, administrative efficiency and clinic set up an environment at the Taif University Outpatient Clinics.
Recommendations: Continuous evaluation of patient satisfaction is to be part and parcel of the general health care delivery by Outpatient clinics of Taif University to ensure patient satisfaction.
Patient satisfaction, Medical services, Quality of medical care, Outpatient Clinic
The need for continuous improvement of quality and safety in the provision of patient care has become axiomatic. The resulting paradigm shift from an acceptance of the status quo to a drive for constant improvement in clinical practice has required the engagement of multiple monitoring and improvement strategies. Patients are the only source of data for information on the dignity and respect with which they are treated and the best source of information for patient education and management.  Patient satisfaction is not only important by itself, it has also been suggested as a care quality indicator in developed countries.  It can contribute to clinical care improvement strategies, health care services and delivery.  Nowadays, patients are looking for hassle free, high quality and quick services. This demand is only possible with optimum utility of the resources through multitasking in a single window system of the OPD. [4, 5]
Today, many patients receive much of their health care as outpatients, a trend that many see as benefiting the health system . Much of the move toward outpatient care in the USA has been driven by third-party payers in an effort to control expenses. This change has challenged health care providers to find safe and effective ways to deliver care on an outpatient basis. Patient satisfaction can be defined as the extent of an individual's experience compared with his or her expectations and is related to the extent to which general healthcare needs and conditionspecific needs are met.  Patient dissatisfaction occurs when the patients’ experience of the service falls short of expectations, while patient’s satisfaction occurs when the patients’ experience of the service exceeds their expectations.
The importance of the differentiation is needed because though satisfaction is essential for keeping high loyalty of the patient, dissatisfaction is crucial because it may lead to unwanted patient future behavior. Patient’s feedback triggers a real interest that can lead to a change in their culture and in their perception of patients.  It is difficult to measure the satisfaction and the gauze responsiveness of health systems as not only the clinical but also the non-clinical outcomes of care do influence the customer patient satisfaction.  Patients' perceptions about health care systems seem to have been largely ignored by health care managers in developing countries. Patient satisfaction depends upon many factors such as: Quality of clinical services provided, availability of medicine, behavior of doctors and other health staff, cost of services, hospital infrastructure, physical comfort, emotional support, and respect for patient preferences.  Mismatch between patient expectation and the service received relates to decreased satisfaction. 
TAIF University Outpatient Clinic (TUOC) is a place that provides a broad range of medical services to sick and injured patients. Well designed, implemented and used patient satisfaction evaluation systems are expected to help TUOC to improve both clinical and managerial activities. Therefore, assessing patient perspectives gives them a voice, which can make public health services more responsive to people's needs and expectations. [12, 13]
This study is conducted to determine the satisfaction of patients about the services provided in the TUOC.
This study employed a self-administered questionnaire that required less than 10 minutes to be completed and which has been thought to be an efficient and effective tool for collecting information (Figure 1). The patients/respondents were consecutively selected and a questionnaire was developed to evaluate their satisfaction regarding the availability, accessibility and convenience of the TUOC services, including their perception about the behavior of staff, including a list of the amenities that they feel are important to them as clients. A Random sampling technique over a five-month period was employed starting from February 1st till the end of June 2013. All patients accepted to participate in this study. The questionnaire was based designed to measure the criteria affecting patientphysician interaction (7 items) and patient’s satisfaction with administrative efficiency and clinic setup environment (5 items).
The questionnaire was drafted in the Arabic and English with a 5-point Likert response scale ranging from 1 (strongly disagree) to 5 (strongly agree). The 5-point scale was later transformed during data analysis to a 3-point response scale ranging from 1 (disagree) to 3 (agree), with 2 corresponding to ‘‘uncertain’’. Mixtures of negative and positive statements were set to ensure that there is no standard format for answering. Therefore, participants needed to read each item carefully before responding. The questionnaire used has face validity was established experts. It was pilot tested on a subset of participants with principal components analysis and revision. The somewhat irrelevant questions be dropped. It was administered in private setting with guidance. Percentages of agreement on the 2 main disciplines of satisfaction were calculated and presented; the mean percentages of satisfaction were calculated to estimate the overall ranking analysis of individual satisfaction disciplines.
The data were coded and keyed into the Statistical Package for the Social Sciences software version 19 (SPSS Inc., Chicago, IL) used in Windows 7. Descriptive analysis followed by inferential statistics was done. Percentages and means were calculated for qualitative and quantitative data. T-test and Chi-square test (X2) were performed to statistically analyze qualitative data. A P-value of 0.05 was considered. 
The Research Ethics Committee of the College of Medicine, Taif University, approved this study. The waiver of the informed consent process was approved on the basis of the questionnaire’s being anonymous and self-administered and containing no identifiers.
A total of 383 patients agreed to participate within the study. 244 patients (64%) were Saudi nationals whilst the remaining 139 patients (36%) were Non Saudis with significant statistical difference between both groups. 214 patients were female (56%), with 169 patients were male (44%) with no significant statistical difference. As regards patient’s occupation, 146 participate were University staff (38%), 134 students (35%), and 103 (27%) employees with no significant statistical difference (Table 1). It was noticed that the majority of the patients was satisfied with the patient-physician interaction as regard, respect during examination (92%), listen to you carefully (88%), explain your condition in a clear way (88%), explain the cause of medication (87%), explain medication side effects (68%), explain way of taking medication (86%) and satisfaction by way of treatment (80%) of participating patients (Table 2& 3). Tables 4 and 5 showed that most of participated patients agreed with the technical competency items, administrative efficiency and clinic setup, less waiting time (92%), medication availability (92%), cleanliness level (96%), opinion about the level of care provided (83%), and recommendation (84%).
An overall ranking of factors related to satisfaction was done by calculating the mean percentage of agreement regarding the different disciplines of satisfaction among the studied group (Table 4). The mean percentage of agreement for the 4 disciplines was 79.5% denoting a high level of satisfaction (table 6). The association between respondents’ nationality and characteristics of the two disciplines of satisfaction revealed no significant differences between Saudi and Non Saudi, gender and occupation shown by the P-values in (tables 7, 8 and 9).
Patient care quality is a major concern of health care providers all over the world. The most cited reason for seeking care in these clinics is attributed to perceptions of high quality service and concern for the patients’ well-being.  All patients agreed to participate in the study and answer the questions included in the questionnaire and share in it with a response rate 100%. 64% of participants are Saudi people. This study serves as a situation analysis of factors affecting patient satisfaction. As regard patient-physician interaction, the average percent mean score for satisfaction (7 items) was (84.14 ± 7.97%), as regard to respect during examination (92%), listen to you carefully (88%), explain your condition in a clear way (88%), explain the cause of medication (87%), explain medication side effects (68%), explain way of taking medication (86%) and Satisfaction with way of treatment (80%) of participating patients with doctor explain medication which is a very important aspect in the patient-physician satisfaction domain represented with 68% of satisfaction among the studied sample and this should be discussed carefully with clinic physician. From these findings, the participants were satisfied with the provision of information. This agrees with a similar study in which it was found that provision of information is ranked higher by patients in terms of factors contribute to satisfy.  Another study found patients’ satisfaction correlated strongly with the amount of information patients received from their physicians. Despite the high ranking of this by patients, many physicians still try to fully understand patients’ information needs.
However the overall results on satisfaction do not tell us about the weaknesses of the service or the problem encountered. Only further probing on the specific aspect of care will reveal areas of expressed dissatisfaction.  Sharma et al, concludes that the overall satisfaction regarding the doctor-patient, professional and behavioral communication was more than 80% at almost all the levels of health care facilities. In total, 55% of respondents opined that doctors have shown little interest to listen to their problems. The overall patients’ satisfaction with administrative efficiency and clinic setup environment (5 items) was 89.4 ± 5.64 % which considered very high. The least satisfaction was from the opinion about care provided 83%. Most participants (92%) were pleased with the time spent on the facility. Many studies have documented the relationship between waiting for service and overall satisfaction. Longer waiting times being associated with decreased patient satisfaction.  In another study, it was hypothesized that “time factor” (time spent on scheduling and waiting time in the clinic) is a major contributor to overall satisfaction and this factor was modified and proven that waiting times significantly correlated well with overall satisfaction. 
There is no significant statistical difference between Saudi and Non Saudi Nationalities, gender and occupation regarding the patient–physician interaction and patients’ satisfaction with administrative efficiency and clinic setup environment satisfaction. In contrast to Kulkarni et al in 2008, who found that level of satisfaction among patients was better with doctor’s behavior of (87.76%), while dissatisfaction was found to be more with administrative efficiency and clinic setup environment as cleanliness (56.01%).  Up to our knowledge and research we did not find any satisfaction study in primary health care centers inside KSA especially university centers to compare our results with them. This study will act as a guide for health care staff members on both male and female campuses to ensure patient satisfaction as an indicator for the quality of medical services, being part of the total quality management policy of the university.
This study that the majority of patients were satisfied with the patient-physician interaction and administrative efficiency and clinic setup environment at the University Outpatients Clinic, Taif University.
Continuous supervision of patient satisfaction levels should be done to deduce methods to improve health care service delivery by the outpatient clinic, Taif University, and measures should be taken to reduce and eliminate any source of dissatisfaction.
This is only a baseline study with a limited sample size, which was carried out for evaluating outpatient clinic services as it was a self-funded project. A continuous ongoing process of evaluating the services is required for getting definitive results. Also a limited number of patients included in the study, we believe that the scores obtained from the present study can serve as a baseline against which to compare the results from future surveys.
We thank the patients for the support and time provided by them. We also owe thanks to the Medical Staff of the outpatient clinic for permission to conduct the study amidst recent controversies regarding health care provider at the clinic.
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