Patient satisfaction

1. JCPSP 2006, Vol. 16 (7): 455-459 455
INTRODUCTION
In the past clinical outcome was the only parameter used to
measure the quality of health care services, however, today
there is growing recognition of the significance of patients’
perceptions of their health, quality of life and their satisfaction
with the quality of health care services. There are crucial links
between the levels of patient satisfaction and health
outcomes.1-3
Satisfaction is the extent of an individual's experience
compared with his expectations.4 Patient satisfaction is related
to the extent to which general health care needs and condition-
specific needs are met. Evaluating to what extent patients are
satisfied with health services is clinically relevant, as satisfied
patients are more likely to comply with treatment5, take an
active role in their own care6 and continue using medical care
services.7 Moreover, health care professionals may benefit
from satisfaction surveys by identifying potential areas of
service improvement and health expenditure may be
optimized through patient-guided planning and evaluation. 8
Owing to the emergence of consumer protection groups and
increasing awareness on the part of health care services
recipients, doctors and hospitals are experiencing growing
pressure of scrutiny and accountability regarding quality of
health care.9 Complaints are a double edged sword for
clinicians and may prompt either good or bad response
depending on the way these are perceived and interpreted.
Traditionally, the complaints are perceived in a negative
way10-12, however, these can be used as valuable quality
assurance tools for re-evaluation and improvement of health
care services.13,14 Such improvements in health care will not
only enhance patient satisfaction but also physicians’ own
satisfaction by declining the rate of further complaints
against them.
Physicians and hospitals are facing growing pressure to
maintain acceptable levels of patient satisfaction as these are
becoming an essential pre-requisite for accreditation and
institutional recognition.15,16
This study was undertaken to measure satisfaction among
patients receiving indoor neurosurgical care, analyse the
profile of the dissatisfied patients and collect actionable
ORIGINAL ARTICLE
PATTERN OF SATISFACTION AMONG NEUROSURGICAL
INPATIENTS
Muhammad Saaiq and Khaleeq-uz-Zaman*
ABSTRACT
Objective: To measure satisfaction among patients receiving indoor neurosurgical care and analyse the profile of the dissatisfied
patients.
Design: Cross-sectional study.
Place and Duration: This study was undertaken at the Department of Neurosurgery, Pakistan Institute of Medical Sciences ( PIMS
), Islamabad from March to April 2005.
Patients and Methods: A total of 133 patients were included in the study by convenience sampling technique. All the patients, who
received indoor care for a minimum of 24 hours and were discharged home, were included in the study . Patients who remained
hospitalized for more than 4 weeks and those not consenting to participate were excluded. A questionnaire was used for
the study that covered five fundamental areas of hospital care i.e. availability and behaviour of the staff, communication of
information, residential and management issues. A five-point response scale was used to rate responses to the questions in each of
these areas. The demographic profile of the patients and respondents, mode of admission, diagnosis, operation and duration of
hospitalization were also recorded. The average of the responses to the questions in each of the five areas was taken as the
fundamental area score ( FAS ) and the average of all these individual area scores was taken as the patient satisfaction score (PSS).
Overall satisfaction index (OSI ) was measured by calculating the average of PSS, willingness to return score and willingness to
recommend score.
Results: Response rate was 100 %. Generally, patients were satisfied with care and rated various areas favourably. Behaviour of the
staff was the highest rated area (95% score) while management was the lowest rated area ( 86.97% score). Dissatisfaction was more
frequent among the young, the educated, the male and the relatives. The PSS was 91.32 %. Willingness to return score was 97.89%
while willingness to recommend score was 95.48 %. The OSI was 94.89 %.
Conclusion: Analysis of patients’ dissatisfaction over specific aspects of health care serves to identify areas that could be improved
by simple interventions, hence, patient satisfaction surveys should be conducted on regular basis in order to utilize patients’ critical
feedback for achieving service excellence and improved quality of care.
KEY WORDS: Patient satisfaction. Patient satisfaction survey. Patient satisfaction score.
Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad.
*Department of Neurosurgery, PIMS, Islamabad.
Correspondence: Dr. Muhammad Saaiq, Medical Officer, Department of Surgery,
Pakistan Institute of Medical Sciences, Islamabad. Email:
msaaiq@yahoo..uk.com.
Received August 23, 2005; accepted May 31, 2006.

2. information to effect meaningful changes for improved
quality of health care.
PATIENTS AND METHODS
This cross-sectional study was undertaken at the Department
of Neurosurgery, Pakistan Institute of Medical Sciences
(PIMS), Islamabad during the period from March 2005 to
April 2005.
A total of 133 patients were included in the study by
convenience sampling technique. All neurosurgical patients,
who received indoor care for a minimum of 24 hours and were
discharged home, were included in the study. Patients who
remained hospitalized for more than 4 weeks and those not
consenting to participate were excluded from the study.
A comprehensive questionnaire was used for the survey that
encompassed the following five fundamental areas of hospital
services which included availability of the professional staff;
behavior of the health care personnels; communication of
relevant information to the patient/relative by the care
providers; environmental and residential aspects of care
and lastly, the management issues.
Supplemental questions regarding willingness to return to the
department and willingness to recommend the same
department to others for neurosurgical care were also asked.
Any additional suggestion for service improvement was also
invited.
Interviews to fill the questionnaires were conducted after the
patients were given discharge certificates and instructions
regarding home care and follow-up plan. Consent and re-
assurance regarding maintenance of confidentiality was
ensured before each interview. The attending relatives were
interviewed in case of head injured patients, patients with
brain lesions and children below 15 years of age . In the rest of
the cases, the patients themselves were interviewed. The
interviews were taken in English, Urdu and Pushto languages.
The demographic profile of the patients and respondents
(the one interviewed for questionnaire), mode of admission,
diagnosis, operation and duration of hospitalization were
also recorded.
A five-point response scale was used to rate responses to the
questions in each of the five fundamental areas of hospital
service. Excellent rating for 5 points, very good for 4, good
for 3, fair for 2 and poor for 1 point. No response was
considered as zero point. Results for each of the measures of
all the included patients were added up, then an average was
calculated and scaled to a score out of 100. In this way,
the respondent’s level of satisfaction was measured from
least satisfied ( 0% ) to most satisfied (100% ).
Response scale for the willingness to return and willingness to
recommend the same department to others was also of 5
points i.e. least likely (0 %) to most likely (100 %).
The average of the responses to the questions in each of the 5
fundamental areas was taken as the fundamental area score
( FAS ) and the average of all these individual area scores was
taken as the patient satisfaction score ( PSS ).
Overall satisfaction index (OSI) was measured by calculating
the average of patient satisfaction score (PSS); willingness to
return score and willingness to recommend score.
RESULTS
Majority of the patients had head injuries i.e. 49.62%, followed
by disc prolapse 11.27% (n=15), brain/spinal tumours 10.52%
(n=14), hydrocephalus 9.77% (n=13), traumatic spinal injury
9.02% (n=12), meningocele / encephalocele 5.26 % (n=7) and
miscellaneous 4.51% (n=6) .
Response rate was 100% and all the patients contacted
responded to the questionnaires. Among the 133 respondents,
94 (71 % ) were the attending relatives while 39 (29%) were the
patients themselves. There were 76(57.14%) males and
57(42.85%) females. The age range of the respondents was
15 to 63 years with a mean of 36.60 ±10.71 years. The
proportion of emergency admissions was more than that of
non-emergency admissions i.e. 79 (59.4 %) versus 54 (40.6 % ).
Sixtyseven patients underwent various surgical procedures
while 66 were managed conservatively. Nearly half of
the patients were from the twin cities of Islamabad and
Rawalpindi and the rest were from other areas. The
fundamental area scores are shown in Table I. Behaviour of
staff was the highest rated area with 95 % score while
management was the lowest rated area with a score of 86.97%.
456 JCPSP 2006, Vol. 16 (7): 455-459
Muhammad Saaiq and Khaleeq-uz-Zaman
Table I: Satisfaction scores in fundamental areas of healthcare (n=133).
Fundamental areas of hospital care Score
Staffavailability/accessibility 92.66 %
Behaviour of staff 95.00 %
Communication of information to patients/relatives 89.98 %
Environment /residential aspects of care 91.99 %
Management 86.97 %
Table II: Association of dissatisfaction with various sociodemographic
characteristics (n=133).
Variables No. of dissatisfied P-value
patients (%)
GENDER
Males (n=76) 23 (30.26%) 0.001
Females(n=57) 4 (7.01%)
AGE
Upto 40 years (n=73) 25 (34.24%0 0.000
> 40 years (n=60) 2 (3.33%)
EDUCATION
No / primary (n=97) 8 (8.33%) 0.000
Secondary and above (n=36) 19 (52.77%)
SOCIOECONOMIC STATUS
Low (n=106) 9 (8.49%) 0.000
High (n=27) 18 (66.66%)
MODE OF ADMISSION
Emergency (n=79) 11 (13.92%) 0.031
Non-emergency (n=54) 16 (29.62%)
DURATION OF HOSPITALIZATION
Upto 2 weeks (n=112) 18 (16%) 0.014
> 2 weeks (n=21) 9 (42.85%)
RESPONDENTS
Patients (n=39) 5 (12.82%) 0.000
Relatives (n=94) 22 (56.41%)
MODE OF MANAGEMENT
Operated (n=67) 21 (31.34%) 0.002
Non-operated (n=66) 6 (9.09%)

3. Generally, low satisfaction rating was more frequent with
males than females, younger than relatively older ones,
more educated than less or uneducated ones, higher
socioeconomic background than lower socioeconomic
background, non-emergency admissions than emergency
admission, longer hospital stay than short hospitalization,
relatives than patients themselves and operated patients than
those managed conservatively (Table II).
The patient satisfaction score was 91.32%. Willingness to
return score was 97.89% while willingness to recommend
score was 95.48 %. The overall satisfaction index (OSI) was
94.89 %.
DISCUSSION
Methodological issues continue to be debated in patient
satisfaction surveys. Different techniques have been employed
to conduct questionnaire surveys. Press Ganey Associates, a
large private research enterprise headquartered in South
Bend, Indiana, is using mailed satisfaction surveys.15 Griffen
Health Services Corporation avails the services of a private
company to conduct telephonic survey of 100 discharged
patients on monthly basis and a quarterly mailed survey for
all outpatients.17 More recently, South Australian’s Patient
Evaluation of Health Services (PEHS) has been using
computer assisted telephone interviews (CATI) surveys.3
In this study, the interview and completion of the
questionnaire was ensured on the day of discharge and
100% response rate was achieved as opposed to the response
rate of 65% to 80.8% reported by other studies where mail or
telephone method was used.3,18-20 Sitzia et al.21 in a meta
analysis of 210 published studies on patient response rate,
also observed that a face-to-face approach to either subject
recruitment or data collection were associated with
significantly higher response rate than those in which subjects
were recruited by mail or data were collected by mail. The
present study also emphasizes that this same day face-to-face
survey method not only ensures high participation rate but is
also cost-effective and reliable.
A variety of questionnaires have been devised by different
workers and organizations to conduct patient satisfaction
surveys in various health care contexts e.g. general inpatients,
outpatient medical practice, emergency department,
pediatrics, geriatrics, obstetrics, behavioral medicine, home
health care etc. Most of the surveys use a five-point response
scale for answering the questions and rating the various
aspects of health care. No questionnaire can be all
encompassing one and each one has its own limitations.
Moreover, any standardized questionnaire can be customized
to meet the survey objectives in a particular context.3,15,17,22
A great deal of effort and consideration went into designing
the questionnaire that was used for this survey. The aim was
to cover all important aspects of hospital care and generate
patient satisfaction data that would be a valid outcome
variable. Nevertheless, health care is a dynamic process and
there is a need to redesign it, in future, in the light of our
experience from the ongoing patient satisfaction research.
Neither any formal complaint was lodged to the hospital
administration nor any complaint proceeded to litigation
during the period of the survey. In fact there exist no culture
of litigations, particularly against doctors. Moreover, here
medical profession still continues to enjoy its centuries old
traditional status of being one of the noblest and prophetic
professions. The public seems not to appear ungrateful to
doctors who deliver the best services in spite of the inevitable
limitations of the system. In this setup, patient satisfaction
surveys become more important as they can effectively
explore the factors that would otherwise motivate patients to
complain. Surprisingly, there is disproportionately high rate
of litigations against doctors in the West.23-25
Patients’ satisfaction ratings on individual service attributes
are even more important than the overall satisfaction scores.
Analyses of the survey findings in individual areas of care
effectively point towards areas of strength as well as the areas
for potential improvement e.g. behavior and availability of the
staff remained the top rated areas in our study. Only 5%
dissatisfaction was expressed about the behavior of staff in
our study, however, misbehavior was a big issue with other
hospitals with a reported dissatisfaction rate of upto 43%.26,27
Dissatisfaction about availability/accessibility was 7.34 % in
our study while other studies have reported it to be
4-9 %.27,28
In this survey, patients expressed 8.1% dissatisfaction about
the residential aspects of care. Others have reported it to be
in the range of 7-18 % .26,27
Management was the lowest rated area about which 13.03%
dissatisfaction was noted. Most of it was about the
uncooperative attitude of admission/clerical staff and
delayed surgery. This underscores the need to increase the
sensitivity of the staff to the inconvenience and frustration
that results from their uncooperative attitude. In various
other studies, dissatisfaction over management ranged from
11.9% to 56.4%.14,27,29
Dissatisfaction about communication was 10.02% in this study
and most of it related to the paramedical and ancillary staff,
however, it was significantly low as compared to the 22-71%
reported by other studies.27-30 Satisfaction is directly
influenced by the overall effectiveness of communication
between the patient and care providers and ineffective
communication at any level will manifest as poor quality. In
this era of evidence-based medicine, effective communication
should be the buzzword of the health care team. In fact
effective communication holds the key to solve many knotty
issues of clinical practice and enhanced communication skills
of the health care providers can prevent many of the
complaints originating from poor communication. In UK,
communication skills training is becoming an integral part
of the medical curriculum.31 Furthermore, there is growing
concern about the need for even training the experienced
clinicians in this regard.32 The present results also emphasize
the need for extending the communication skills building
programme across the entire health care system to include
nursing and clerical staff as well.
In this study, females were more satisfied than male but
various Western studies have shown females to be more
demanding and less satisfied.14,19,20 Young age was associated
with more dissatisfaction in this study. Hall et al 33 also found
that greater satisfaction was significantly associated with
older age.
In this study, less educated patients were relatively more
satisfied and the same was reported by an Australian patient
JCPSP 2006, Vol. 16 (7): 455-459 457
Pattern of satisfaction among neurosurgical inpatients

4. satisfaction survey3, however, Demir et al.34 found no
relationship between educational status and satisfaction while
Tengilimoglu 35 found that low education is more associated
with dissatisfaction.
Emergency admitted patients were more satisfied than non-
emergency admissions. Thi et al 20 also had similar
observation, however, Mace26 found no association between
satisfaction and mode of admission.
Patients with low income were more satisfied than those with
high income patients. Other studies have also reported similar
findings.3 Longer duration of hospital stay was associated
with increased dissatisfaction, particularly, among those with
perceived delayed surgery. While longer waiting times
increases patient frustration, it was unclear whether large
difference in waiting time reflected actual difference in
clinical quality.
The patient satisfaction score in this series was 91.32%. Other
studies have reported it to be 89 % to 93 %.18,35,36
Patient satisfaction research is still in its infancy in Pakistan.
There is no published local data on patient satisfaction.These
surveys mark the starting point in this regard and may be
taken as the national benchmarks. The first survey was
conducted in 2003 ( unpublished data ) established a baseline
data on patient satisfaction. There is not only lack of data from
other hospitals but also an apparent lack of realization of the
potential benefits which patient satisfaction surveys may
offer. Nationwide studies are needed on patient satisfaction in
order to make strides towards improved quality, which is a
greatly desirable outcome.
Internationally, there is need for using standardized survey
instruments across the health care systems throughout the
world. Such instruments would lay the foundation of uniform
and sound methodology allowing comparability of results
from different parts of the world. This will enhance the
identification of various drivers of patient satisfaction and
hence, evolution of international strategies to improve the
quality of care worldwide.
CONCLUSION
Analysis of patients’ dissatisfaction over specific aspects of
health care serves to identify the potential areas of deficiency
that could be improved by simple interventions, hence,
patient satisfaction surveys should be conducted on regular
basis in order to utilize patients’ critical feedback for achieving
service excellence and improved quality of care .
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