Investigation of Outpatient Satisfaction in a General Hospital: The Effect of Socio-Demographic Factors

: Introduction: Measuring patient satisfaction with health services in recent decades has been an important tool for assessing the quality of specific services. Purpose: The investigation of the degree of satisfaction of patients attending the Regular Outpatient Clinics of a General Hospital as well as the effect of socio-demographic factors on their satisfaction. Method: For the gathering of research data, a structured questionnaire with "closed" questions was used regarding the patients' satisfaction with the reception - environment, speed of service, clinical and laboratory examinations, impressions from the medical care, impressions from the nursing care, the administrative services and the general service. Results: The study involved 36 men (57.1%) and 27 women (42.9%) with a mean age of 56.78 years. The majority of them were insured (79.4%), Greek citizens (90.5%) and high school graduates (36.5%). Also, most outpatients evaluated very satisfactorily the services provided by the Regular Outpatient Clinics of the Hospital. Finally, there was a statistically significant correlation between socio-demographic variables (age, insurance and nationality) and patient satisfaction level (p <0.05). Conclusions: Based on the findings of this research, there is a clear effect of socio-demographic factors on the degree of satisfaction of outpatients.


Introduction
Understanding service satisfaction and quality have been recognized for several decades as critical to the development of service improvement strategies. Donabedian's seminal work on quality assurance [1] recognized the importance of patient satisfaction as providing a major foundation for research in the field of quality assurance in health care. In healthcare, the importance of measuring patient satisfaction is clearly linked to the concept of quality [2], while patient satisfaction has been extensively studied and measured as an independent construct and as a component of quality outcomes and in particular in studies evaluating the quality of care [3]. Moreover, the literature tells us that the concept of satisfaction is complex [4], regardless of the area in which it is studied. It is a multidimensional concept, not yet rigorously defined, and is part of an apparently yet to be defined complex model [5].
The desirable need to measure patient satisfaction, largely driven by the underlying politics of the "new public management" and the consequent rise of the health consumer movement, is one of the main goals of healthcare delivery care. With the emergence of the patients' rights movement [6], the debate about the relationship between patient satisfaction as an assessment of the care process versus the standard of care technique was well established. As a result, the use of patient satisfaction measures in healthcare has become increasingly widespread. For example, the evaluation of patient satisfaction is mandatory for French hospitals since 1998, which is used to improve the hospital environment, diseases and facilities in a consumer sense, but not necessarily to improve Paraskevi Theofilou 2 of 10 care [7]. While there are numerous specific patient satisfaction studies published in scientific journals, there is a smaller body of work that critically reviews the literature and analyzes the construct and its use. This work underscores the agreement that patient satisfaction suffers from inadequate conceptualization of the construct, a situation that has not changed significantly since the 1970s and there is no agreed definition [5]. Crowe et al. [8] identified 37 studies investigating methodological issues and 138 studies investigating determinants of satisfaction. They reported that there is agreement that a definitive conceptualization of health care satisfaction has yet to be achieved and that an understanding of the process by which a patient becomes satisfied or dissatisfied remains unanswered. They suggest that satisfaction is a relative concept and implies only adequate service.
Furthermore, both Crowe et al. [8] and Urden [9] separately point out that patient satisfaction is a cognitive evaluation of service that is emotionally influenced and is therefore an individual subjective perception. Crowe et al. [8] also highlight that there is consistent evidence across settings that the most important determinants of satisfaction are interpersonal relationships and related aspects of care. What is agreed is that satisfaction has become an endpoint in outcomes research and benchmarking services. Patient satisfaction is considered part of the quality of health outcomes, which also includes clinical outcomes, economic measures and health-related quality of life [4]. Health care research on patient perceptions of dimensions of service quality (distinctive service quality) shows conflicting findings [10], but studies that aim to assess the components of quality of care in health services they continue to primarily measure patient satisfaction [11]. There is no consensus as to the best design of the relationship between patient satisfaction and their perception of health care quality [12]. O'Connor and Shewchuk [13] pointed out that much of the work on patient satisfaction is based on simple descriptive and correlational analyzes without a theoretical framework. They concluded that when it comes to health services, the focus should be on measuring quality rather than patient satisfaction on technical and functional measurement [how care is delivered]. A study by Gotlieb et al. [14] demonstrated that there is a clear distinction between the perception of service quality and patient satisfaction. They found that patient satisfaction mediated the effect of perceived service quality on behavioral intentions, which included adherence to treatment regimens and provider advice. Cleary and Edgman-Levitan [15] pointed out that health care satisfaction surveys did not measure the quality of care because they did not include important aspects of the types of care, such as treatment and participation in treatment decisions. Furthermore, Taylor [16] pointed out that confusion continued in the industry regarding the differentiation of service quality from satisfaction and reported that some authors, for example Kleinsorge and Koenig [17], characterized them as synonymous terms. However, patient satisfaction is still measured as a proxy for patient assessment of service quality [10].
The aim of the present research is the investigation of the degree of satisfaction of patients who come to the Regular Outpatient Clinics (OTCs) of a General Hospital as well as the effect of socio-demographic factors on their satisfaction.

Method
The present study is cross-sectional, adopting a quantitative methodology. The dependent variable is considered the level of satisfaction with independent variables the socio-demographic factors (eg age, gender, education, nationality, etc.). The sample consisted of 36 men (57.1%) and 27 women (42.9%) and was a convenience sample. The criteria for entering the research included the patient being > 18 years old, communicating in the Greek language and visiting the morning Regular Outpatient Clinics of the Hospital. An exclusion criterion was the existence of a serious psychiatric disorder.
For the collection of research data, a structured questionnaire with 32 "closed" questions was used regarding patient satisfaction with the reception -environment, speed of service, clinical and laboratory tests, impressions of medical care, impressions of nursing care, administrative services and general service. The present questionnaire, which was sent by the Greek Ministry of Health to all the hospitals in Greece in order to measure patients' satisfaction, is under evaluation.
It should be noted that the participants were informed about their anonymity and the confidentiality of their responses and that they should answer honestly. The study was carried out in the months of May -June 2019. Qualitative variables were expressed as absolute (N) and relative frequencies (%) in each category of the variable, and quantitative variables were expressed as mean, standard deviation, minimum and maximum values. All data sets were tested for normality using the Kolmogorov-Smirnov normality test. All statistical analyzes were performed with the SPSS 25 statistical program.

Results
The sample consisted of 36 men (57.1%) and 27 women (42.9%) with a mean age of 56.78 years of life (±17.88). In Table 1, the demographic characteristics of the study patients are presented in detail. In the context of studying the reliability of the tool used to collect the research data, the Cronbach an index showed high reliability, reaching 0.895. Based on the results of Table 2, the majority of patients (49, 77.8%) characterized the behavior of the staff who examined them as very good, followed by 9 patients (14.3%) who evaluated it as quite good. Based on the results of Table 3, the majority of patients (50, 79.4%) rated the staff's level of respect for the patient as very good, followed by 8 patients (12.7%) who rated it as fairly good. Based on the results of Table 4, the majority of patients (54, 85.7%) characterized the quality of the provided medical care as very good, followed by 8 patients (12.7%) who evaluated it as quite good. Based on the results of Table 5, the majority of patients (56, 88.9%) characterized the behavior of the medical staff as very good, followed by 6 patients (9.5%) who evaluated it as quite good. Based on the results of Table 6, the majority of patients (51, 81.0%) characterized the psychological support provided by the medical staff as very good, followed by 8 patients (12.7%) who evaluated it as quite good.  Based on the results of Table 7, the majority of patients (50, 79.4%) characterized the behavior of the medical staff during the examination as very good, followed by 9 patients (14.3%) who evaluated it as quite good. Based on the results of Table 8, the majority of patients (48, 76.2%) characterized the quality of the provided nursing care as very good, followed by 14 patients (22.2%) who evaluated it as quite good. Based on the results of Table 9, the majority of patients (51, 81.0%) characterized the behavior of the nursing staff as very good, followed by 12 patients (19.0%) who evaluated it as quite good.  Based on the results of Table 11, the majority of patients (47, 74.6%) characterized the behavior of the administrative staff as very good, followed by 13 patients (20.6%) who evaluated it as quite good. Based on the results of Table 12, the majority of patients (59, 93.7%) would definitely choose to visit the hospital again, followed by only 4 patients (6.3%) who would probably choose it again. Based on the results of Table 13, the majority of patients (59, 93.7%) would definitely choose to recommend the hospital to others, followed by only 4 patients (6.3%) who would probably recommend it to others.   Based on the results of Table 16, the differences between age groups in terms of their satisfaction with the quality of nursing care are presented (pearson chi-square 0.037). People aged 51-65 were the most (19) who rated it very well. Based on the results of Table 17, the differences between age groups in terms of their satisfaction with the behavior of administrative staff are presented (pearson chi-square 0.011). People aged 51-65 were the most (18) who rated the behavior in question very well. Based on the results of Table 18, the differences between age groups are presented in terms of their satisfaction with the length of stay for their transaction in the hospital (pearson chi-square 0.033). People aged 51-65 were the most (17) who rated the time very well. Based on the results of Table 19, age was statistically significantly and positively related to the hospital's overall evaluation grade (r=0.312, p=0.013<0.05). Based on the results of Table 20, the differences between the insured and the uninsured are presented in terms of their satisfaction with the quiet that exists in the regular outpatient clinics of the hospital (pearson chi-square 0.001). People who were insured were the most (39) who rated this dimension very well. Based on the results of Table 21, the differences between insured and non-insured in terms of their satisfaction with the behavior of administrative staff are shown (pearson chi-square 0.041). People who were insured were the most (38) who rated this dimension very well. Based on the results of Table 22, the differences between Greek and other nationalities are shown in terms of their satisfaction with the behavior of the staff during the examination (Pearson chi-square 0.012). People with Greek nationality were the most (44) who rated the behavior in question very well.

Discussion
The aim of the present research is the investigation of the degree of satisfaction of patients who come to the Regular Outpatient Clinics (OTCs) of a General Hospital as well as the effect of socio-demographic factors on their satisfaction. Despite the fact that similar studies have been prepared in the past, the number of such investigations related to the field of regular outpatient clinics is limited. In addition, the effect of socio-demographic variables on the level of patient satisfaction has not been studied.
The findings from the said research study are significant and can be summarized as follows: The significant effect of age, insurance and nationality variables on the level of outpatient satisfaction is seen. This finding is in full agreement with those of similar studies that have shown that socio-demographic characteristics [age, gender, insurance, ethnicity] are the most widely used predictors of satisfaction [18][19][20][21]. Studies show that global satisfaction is influenced by many factors. In addition to quality-of-service delivery, it may include factors such as patient demographics, e.g. level of education, place of residence and occupational status [22], diagnosis [22], treatment program [22], and years disease.
Regarding the limitations of the present research, it is noted that the results obtained from the said study can be further investigated in samples from other hospital contexts, private or even public, giving the possibility to control the variables under study, to compare the results, so that more general conclusions can be drawn. However, it should be noted that this study was conducted in only one hospital and therefore, because the sample is small, the results cannot be generalized.
Patient satisfaction is a dynamic, multi-layered and complex concept, reflecting objective, subjective, macro-societal and micro-individual, positive and negative influences that interact. We would say that it is a multidimensional structure consisting of broad areas-psychological and social functioning-that are affected by disease and/or treatment. The measurement of patient satisfaction with health services has, in recent decades, been an important means of evaluating the quality of specific services. In particular, capturing the patients' view of the services provided can, in combination with clinical studies, offer safe conclusions about the operation of different health organizations and levels of health care. Of particular interest is the recording of user satisfaction with the care provided in public hospitals, as it reflects the effectiveness of the NHS. Most studies of people with various chronic conditions usually describe satisfaction as well as pain level. Measuring them without reference to a conceptual standard has limited the development of a knowledge base for research on these concepts. A conceptual model places concepts in context and guides the development of new theories. The use of theoretical conceptual models will enhance their application as reliable and valid outcome measures. Assessing the relative impact of chronic diseases on satisfaction is essential to better plan and allocate resources for research, training, and health care to further promote the well-being of chronically ill people. Consequently, collaboration between different sciences could produce better therapeutic outcomes for people suffering from chronic conditions, especially those most in need. A comprehensive framework such as the biopsychosocial model of health care will be based on a single guiding principle: that the goal of addressing the physical, social, and psychological aspects of chronic disease is to help patients with chronic conditions and the entire population, regardless of from a person's chronic illness or current state of health.