Patient satisfaction in a Riyadh

Tertiary Care Centre

Nesreen A. Alaloola
Quality Management, National Guard Health Affairs, Riyadh,
Saudi Arabia, and
Waleed A. Albedaiwi
Quality Management and Health System Administration,
King Saud Bin Abuulaziz University for Health Sciences Riyadh,
Riyadh, Saudi Arabia
Abstract
Purpose As one of the healthcare organizations striving to reach optimum quality level,
King Abdulaziz Medical City staff believed that knowing the patients service perspective is one core
service quality indicator. This article aims to spotlight the level of patient satisfaction or
dissatisfaction in one Riyadh tertiary centre.
Design/methodology/approach Cross-sectional survey involving 1983 inpatient, outpatient and
emergency care patients at King Abdulaziz Medical City, Riyadh using a self-developed patient
satisfaction questionnaire.
Findings There was a signicant satisfaction with room comfort (88.5 percent), room temperature
(78.1 percent), room call button system (87.9 percent), room cleanliness (79.6 percent) and respectful
staff (87.4 percent). Patients were signicantly dissatised with phlebotomists not introducing
themselves (74 percent), not explaining procedures (57.2 percent) and physicians not introducing
themselves (59.1 percent).
Research limitations/implications Only the overall satisfaction dimensions were studied in a
socio-demographic context. Not every service was studied separately, so the patients answers may not
represent the hospital.
Practical implications It is recommended that service standards in the areas in which patients
were signicantly dissatised should be raised by involving senior leaders. Areas for which patients
were signicantly satised will need to be sustained or even improved.
Originality/value So far no similar service quality and patient satisfaction based studies from
Saudi health care systems are reported in international peer reviewed journals.
Keywords Customer satisfaction, Patient care, Saudi Arabia
Paper type Research paper
Introduction
Patient satisfaction has always and will be a fundamental requirement for clinical and
nancial success of any organization providing health care, regardless of specialty.
Monumental changes in health care delivery systems have focused attention on more
affordable, more available, more efcient and higher quality health care. Traditionally,
managing quality in health care processes entail such activities as measuring outcomes
(Do the patients get better?), checking providers credentials (Are providers well
qualied?), auditing clinical activities (Are clinical guidelines and protocols being
followed?) and auditing medical records. But, care quality is more than good outcomes
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0952-6862.htm
IJHCQA
21,7
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Received 30 March 2007
Revised 6 July 2007
Accepted 7 September 2007
International Journal of Health Care
Quality Assurance
Vol. 21 No. 7, 2008
pp. 630-637
qEmerald Group Publishing Limited
0952-6862
DOI 10.1108/09526860810910113
and cost-effective processes; it must also give rise to satised patients, loyal to the
health care organization. Patient satisfaction surveys are vital to a dynamic healthcare
industry where many care providers are faced with cutting costs while maintaining
high-quality services. Patients, employers, business groups, health plans and
insurers are scrutinizing care delivery from both a quality and cost perspective.
In todays shortened length of stay and increasing outpatient procedures, healthcare
providers are competing to maintain a strong patient base. Patient satisfaction is
therefore instrumental when monitoring the hospitals quality of care in relation to
costs and services.
There have been a number of Saudi Arabian studies on this topic. It is obvious that
hospital patient satisfaction is a top priority in Saudi Arabiaa care system that is a
mix of public and private facilities. As a result, many of the studies distinguish
between public and private facility performance. The Ministry of Health oversees the
system and operates 77 percent of the whole countrys health system (World Health
Organization (2004), www.who.int). Of the remaining hospitals and clinics, the
majority is operated by the private sector or facilities are run by separate government
departments such as the military. The functions of these facilities and staff training are
supervised and supported by the Ministry of Health. The following studies cover both
hospital-based and primary care. In our setting, primary care is considered part of
ambulatory carecovered in this study.
One study we reviewed focused on people selecting private hospitals. Twenty-eight
percent of patients chose medical services as the highest inuencer on their reason
for selecting a Riyadh hospital (Al-Doghaither et al., 2003) interesting because patient
satisfaction was not the top reason for selecting a hospital. Although, according to
results from additional studies, patient satisfaction is also a highly considered measure
when selecting a hospital. A similar study was conducted in Jeddah primary health
services, which found that communication skills were the most important patient
satisfaction-determining factor. Additionally, this study found that when an
interpreter was needed to translate between Arabic and English, patient satisfaction
levels remained steady (Al-Doghaither and Saeed, 2000). In another Jeddah primary
health care study, researchers found that staff communication could have a strong
impact on satisfaction scores:
The summary satisfaction score was 3.77 points and the mean satisfaction with the services
provided by physicians was 2.56 points out of a maximum ve points. The highest
satisfaction was for discussing psychological aspects of patients problems (2.96 points) and
the lowest was for attentive listening to patients complaints (2.22 points). (Saeed et al., 2001,
p. 262).
Not listening to patients complaints is a theme among several Saudi hospital patient
satisfaction studies. Another study of cancer patients in eight Riyadh hospitals showed
that the lowest level of satisfaction on a ve-point scale was attentive listening to
patients complaints, which received only 2.22 points (Ibrahim et al., 2002). An earlier
Saudi health care study revealed that cancer patients were more satised with their
care and their care was more successful when the physician took the time to
communicate clearly with the patient (Al-Alwal, 1998). Clear communication from the
physician resulted in the patients ability and willingness to follow prescribed
treatment, which led to higher levels of success in ghting diseases. With this in mind,
it is obvious that communication and proper medical treatment are mutually
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dependent in determining patients ability/willingness to follow treatment and achieve
acceptable satisfaction levels. Another study conducted at household level in primary
health care in Qateef found other factors were important to patients:
The factors that showed the greatest association with satisfaction were the type of the
primary health care centre building (purpose-built or rented), household heads literacy status
(literate or illiterate), the extent of the primary health care centre utilization (regular or
infrequent) (Al-Qatari and Haran, 1999, p. 529).
This study reveals two major variables that determine patient satisfaction: type of
facility and frequency of use. Health education is another patient satisfaction aspect
that has been scrutinized in Saudi Arabia. In a recent study, satisfaction levels with
health care education were low:
The mean satisfaction regarding health education services was low. This nding is similar to
that shown by other workers and can be accounted for by the lack of health education
resources as well as poor doctor/patient communication (Makhdoom, 1997, p. 528).
Patient satisfaction is closely linked to communication between doctor and patient.
This means that even if a doctor is a competent physician, he may generate low levels
of patient satisfaction if he is not a good communicator. Finally, another Saudi Arabian
health care study revealed that there are three main areas that are important to patients
and their levels of satisfaction:
They [patients] cited three main requirements: (1) looking for more experienced physicians or
specialists; (2) accessibility to doctors; and (3) availability of investigations (tests) and drugs.
(Al-Faris et al., 1996, pp. 16).
According to this study, experience and accessibility to doctors are what patients
found most important. Consistent with other surveys that found patient-physician
communication important; these patients consider access or ability to
communicateto doctors to be essential. After reviewing all information on patient
satisfaction in Saudi Arabian hospitals, two conclusions can be made: rst, patient
satisfaction is a major concern to health care institutions in Saudi Arabia. The amount
of research on health care satisfaction reveals that it is important and that providers
consider it a top priority. The second conclusion derives from the diversity of methods
and results found in Saudi Arabia patient satisfaction research. The problem with
this second conclusion is that the authors have not described their methods. Although
results can be helpful to hospitals, individually the lack of uniformity makes
aggregated data less useful. For example, questions asked were measured on different
scales, different sample groups were used and questions were worded in a variety of
ways. Statistically, it is not safe or sensible to compare these studies. Consequently,
there needs to be a uniform system in Saudi Arabia for measuring patient satisfaction.
Results can then be used to compare satisfaction between hospitals and not just within
individual hospitals.
There are some primary health care centers and hospitals that have adopted total
quality management (TQM) programs that could be applied to other Saudi Arabian
hospitals (Hoskins et al., 1994). Total Quality Management includes measuring patient
satisfaction as a thorough and calculated process. If more hospitals adopted this type
of system then satisfaction research could be formalized and therefore be more
valuable for Saudi Arabia hospital comparisons. As one of the healthcare organizations
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that strive to reach optimum quality, King Abdulaziz Medical City staff believe that
knowing the patients perspective is an important service quality indicator. Therefore,
we spotlight the level of patient satisfaction or dissatisfaction in a tertiary healthcare
center in Riyadh.
Methods
A multidisciplinary team was formed to develop a standardized patient satisfaction
survey throughout King Abdulaziz Medical City (KAMC) for Outpatient, Inpatient as
well as Emergency Care. We used the survey method. The study population consists of
all inpatients, outpatients and emergency care patients who presented to
KAMCRiyadh during October 2003. Data were obtained from questionnaires
designed by the Patient Satisfaction Team. Three questionnaires (approximately fty
eight questions on four pages) were used to collect data. To assure research
questionnaire validity, the Patient Satisfaction Team reviewed relevant literature and
conducted a pilot study. Alpha coefcients were used to nd out the questionnaires
reliability: 0.8, 0.7, 0.9, and 0.79 for inpatient, outpatient and emergency care
questionnaire, respectively. Questionnaires were coded, fed into and processed by the
Statistical Package for Social Sciences (SPSS). We used frequencies, percentages and
the independent sample t-tests to calculate the results of this study.
Results
Inpatient satisfaction survey
In total, 365 patients replied of which 40 percent were male. There was a signicant
satisfaction with room comfort (88.5 percent), room temperature (78.1 percent), room
call system (87.9 percent, room cleanliness (79.6 percent) and with the person who
cleaned their rooms being respectful (87.4 percent). For nursing staff there was a
signicant dissatisfaction with nurses not introducing themselves to patients
(76.1 percent), while patients were signicantly satised with nurses respect and
dignity (96.1 percent), answering the call button (85.9 percent), addressing their needs
(93.3 percent) and providing them with privacy (96.4 percent). While for assistant and
interpreter staff, patients were signicantly satised with respect and dignity they
showed (79.9 percent). From the physicians side, there was a signicant satisfaction
with physicians introducing themselves to patients (80.2 percent), treating them with
respect and dignity (96.4 percent), the time spent with them (84.3 percent) and
involving them with their treatment plan (70.1 percent).
Patients were signicantly dissatised with the phlebotomist not introducing
him/her self to the patient (74 percent) and not explaining the procedure (57.2 percent).
They were signicantly satised, on the other hand, when blood was drawn quickly
and with minimal pain (75.5 percent), treating them with respect and dignity
(86.6 percent). Also patients were signicantly satised with X-ray technicians treating
them with respect and dignity (68.9 percent). Patients were signicantly satised with
social workers introducing themselves (55.5 percent). Also they were satised with
patient relations ofcer introducing him/her self to patients (89.2 percent), visiting
them on a daily bases (excluding weekends) (73.2 percent), their solutions (57.5 percent)
and the idea of seeking help from patient relations in the future if patients have a
problem (74.2 percent). For dietary and food services, there was a signicant
satisfaction with meals delivered on time (89.1 percent), food temperature (77.5 percent),
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respectful food services staff (91.1 percent), tray and utensil cleanliness (92.2 percent).
There was a signicant dissatisfaction with dietary explanations (55.1 percent) and the
lack of food choice (66.6 percent). Patients also were signicantly satised with visitors
nding it easy to get to their rooms (86.7 percent), that visiting hours were adequate
(82.9 percent) and that staff were respectful toward their visitors (91.9 percent). Finally,
there was a signicant satisfaction with the staff being respectful to the Saudi culture
(96.6 percent), and nding it easy to communicate with them (97.6 percent).
Outpatient satisfaction survey
In total 382 patients responded, 55 percent were male. There was a signicant
satisfaction with registration staff helpfulness (71.6 percent); informing patients about
documents needed for treatment eligibility at King Abdulaziz Medical City (73 percent),
answering questions (72.5 percent) and waiting area comfort (68.9 percent). Also, there
was a signicant satisfaction with appointment desk staff helpfulness (88.6 percent),
answering patients queries (85.7 percent) and with appointment booking processes
(68.4 percent). For unit assistants and interpreters, patients were signicantly
dissatised with interpreters not introducing him/her self (75.7 percent), while they
were signicantly satised with interpreters respect and dignity (85.1 percent).
Patients were signicantly dissatised with nurses not introducing themselves
(89 percent), while they were signicantly satised with the way nurses treating them
with respect and dignity (90.4 percent), addressing their needs (86.1 percent),
explaining tests, treatments and expectations (66.7 percent) and providing them with
privacy (86 percent). Patients were signicantly dissatised with physicians not
introducing themselves (59.1 percent), while they were signicantly satised with the
time spent with physicians (88 percent), treating them with respect and dignity
(95.9 percent), involving them in their treatment plan (86.9 percent) and keeping them
informed about their medications (82.8 percent).
Patients were signicantly dissatised with the phlebotomist not introducing
him/her self (66 percent), while they were signicantly satised with the way their
blood was drawn quickly and with minimal pain (66.8 percent) and being treated by the
phlebotomist with respect and dignity (71.9 percent). Patients were signicantly
satised with the way the pharmacist treated them with respect and dignity
(90.9 percent), explaining how to use their medications (85.1 percent), their prescribed
medications available in the pharmacy (59.3 percent) and the medications dispensed
according to the prescription (78.6 percent). Finally, patients were signicantly
satised with nding their way around the clinics (92.2 percent), the way staff were
respectful to Saudi culture (91.1 percent) and the ease of communicating with staff
(93.9 percent).
Emergency care satisfaction survey
In total, 1131 patients completed the questionnaire; 84 percent were male. Patients were
signicantly satised with the privacy provided during the triage processes at the
emergency care center front desk (90.6 percent) and with the way they were treated
with respect and dignity (96 percent). At the emergency care center registration ofce,
patients were signicantly satised with the desk persons helpfulness (94.8 percent),
the respect and dignity with which they were treated (96.1 percent), providing them
with privacy during the registration process (93.9 percent) and informing them of the
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documents needed for eligibility for treatment at King Abdulaziz Medical City
(71.4 percent) and the waiting area being comfortable (64.3 percent). Also patients were
signicantly satised with the triage nurses who treated them with respect and dignity
(90.5 percent). Physicians respect and dignity were also highly rated (90.6 percent).
Patients were signicantly dissatised with nurses not introducing themselves
(92.7 percent). They were, on the other hand, signicantly satised with the way nurses
treated them with respect and dignity (89.8 percent), addressed their needs
(76.9 percent), time he/she spent with them (67.7 percent), test and treatment
explanations (52.5 percent), drawing patients blood quickly and with minimal pain
(52.6 percent) and providing them with privacy (90.5 percent).
Patients were signicantly satised with treatment room cleanliness (90 percent).
They were signicantly dissatised, on the other hand, with the interpreters failure to
introduce him/her self (57.6 percent). Medical services patients were signicantly
dissatised with nurses not introducing themselves (83.9 percent), while they were
signicantly satised with the time he/she spent with doctors (90.1 percent) and the
way they were treated with respect and dignity (74.8 percent). Also, patients were
signicantly satised with emergency care staff allowing relatives to accompany
patients undergoing treatment (60.9 percent). Discharge medication and related
information was well rated (67.1 percent) and post discharge care information
generally (56.4 percent). There was signicant satisfaction with pharmacists treating
patients with respect and dignity (79.4 percent), explaining how to use their
medications (78.1 percent) and that all prescribed medications were available from the
pharmacy (60.7 percent). Finally, patients were signicantly dissatised with
emergency care staff information (52.7 percent), while they were signicantly satised
with the military police being available to provide directions if needed (77.6 percent),
staff respecting the Saudi culture (82.8 percent) and communicating ease (82.1 percent).
Discussion
The F test showed that while inpatients report high satisfaction, outpatients and
(especially) emergency care patients were the most satised. However, emergency
patients mean parking satisfaction scores were two points lower than those for
inpatients and outpatients. The mean score for the emergency care visits may not be
entirely indicative of their overall satisfaction because the standard deviation for
emergency patients was higher than inpatient and outpatient groups, which reects
patients volatile responses.
Another difference between the three datasets was that women have a signicantly
higher mean satisfaction score than their men in all test groups. For inpatient and
outpatient services, women report a higher mean score in all categories, but women in
the emergency test group only had higher mean scores in four categories. The means
show the same relationshipswomen have lower means in inpatient and outpatient
services, but have a higher one in emergency services. The results also show
trendswhile women report higher degrees of satisfaction after their hospital visits,
both sexes feel different about their care. Women averaged 4.47 for inpatient care, 4.07
for outpatient care and 3.3 for emergency care. Male means show the same downward
trend but were lower 3.95 for inpatient, 3.77 for outpatient, and 3.08 for emergency
care. There are two obvious conclusions. First, women signicantly feel more satised
than men with their hospital experience. Second, while inpatient means are high,
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outpatient means are relatively lower and emergency service means are lower still.
To discover why, we need to look to other statistics to gain a clearer picture. When we
compare inpatient and outpatient results, there exists a positive relationship between
the means of these two groups. Inpatient and outpatient males had a higher mean than
women: 0.72 to 0.63 for inpatients and 0.83 and 0.57 for outpatients. This relates the
trends between genders for these two groups, but then when we look at the emergency
group, this trend is reversed. Women have a higher mean than men. The reason is the
positive relationship that exists between the inpatient and outpatient groups, which
reverse when we compare them to the emergency group. For example, women have
lower mean for waiting time in the inpatient and outpatient groups but a higher one in
the emergency group. A negative relation in the emergency group is apparent in two
other categories as well satisfaction scores for parking area and direction signs
also have higher standard deviations for women. The reason for this is unclear. One
possible explanation is that while women constitute a higher percentage of inpatient
respondents, men outnumber women almost seven to one in emergency visits. The
result of our survey accords with the literature that showed a general higher level of
satisfaction with health services in female gender (Al-Doghaither et al., 2003 and
Al-Doghaither, 2004).
It appears that womens higher standard deviation indicates a more varied response
to emergency room experiences. But this is not applicable to all seven categories. For
example, there are two categoriessatisfaction with medical services and paramedical
servicesin which men have larger standard deviations. Therefore, although the
overall standard deviation for women may be higher, this does not automatically
trickle down to the each individual inpatient, outpatient or emergency care category.
But the overwhelming relationship in our survey is that regardless of gender, the
degree of satisfaction decreases from inpatient to outpatient to emergency room.
Although the lowest mean scores for both groups are emergency room parking
services, the consistently lower emergency room overall mean scores in all seven
categories indicates that the emergency room experience is unsatisfactory.
Our study has limitations. First, questionnaires were distributed only to KAMC,
Riyadh. They were not distributed to National Guard hospitals in other regions;
therefore the results cannot be generalized to all Riyadh hospitals or to National Guard
Health Affairs Hospitals. Second, only the overall satisfaction dimensions were
studied. Socio-demographic data were not studied in detail. However, detailed
socio-demographic dimensions could be the subject of future research. Third, answers
provided by patients may not be accurate since there is a percentage who might have
understood the question differently thereby providing answers that do not reect their
real satisfaction. Consequently, we recommend that the patient satisfaction
dissatisfaction issues we highlight should be raised at the highest leadership and
organizational levels so that they can be sustained or improved.
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Corresponding author
Waleed A. Albedaiwi can be contacted at: bedaiwiw@ngha.med.sa.
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