The satisfaction of the consumer of health service is recognized as a powerful tool for quality assurance,1–3 since more emphasis is placed on outcome than process and structure evaluation.4 To be effective, the quality assurance should be evaluative and continuous.45 The health service provided to patients in the Kingdom of Saudi Arabia (KSA) has improved a great deal over the past two decades.46 Nevertheless, to consolidate what has been achieved, there is a need for continuous monitoring of both quantity and quality of the service6 Consultation plays an important role in determining both the quality of care and patients’ satisfaction.
Studies have been carried out on the subject of the consultation and doctor-patient encounter in Saudi primary, secondary and tertiary care establishments.46–10 However, most of these studies are limited and their results are unique to the facility studied. Indeed, almost all of them lack the comparison of the different levels of health care facilities. The objective of this study was to assess factors including consultation time, completeness of physical examination, laboratory investigations, prescriptions and patients’ satisfaction with the consultation provided at the Ministry of Health Hospitals and Primary Health Care Centers (PHCCs) in Jeddah. We hope that the results will help the concerned planners, administrators and decision makers at the Ministry of Health (MOH) to rectify any shortcomings in patients’ satisfaction and care.
This cross-sectional study was conducted in 11 PHCCs and the outpatient clinics of King Fahad, and King Abdulaziz hospitals in Jeddah, Saudi Arabia. These two hospitals were randomly selected from a total of 8 MOH hospitals in Jeddah. The eleven PHCCs (30.6%) were randomly selected from the 36 PHCCs in Jeddah. Their distribution was as follows: (1) Three from the 11 PHCCs serving the North Eastern district, (2) Two from the 8 PHCCs serving the North Western district, (3) Three from the 11 PHCCs serving the South Eastern district, (4) One from the six PHCCs serving the South Western districts and (5) Two from the 8 PHCCs serving the Jeddah city center district.
The selection of these health facilities was planned in accordance with the minimum requirements of ten PHCCs recom mended by the International Network of Rational Use of Drugs (INRUD) when evaluating patient care.11 At the hospitals, five outpatient speciality clinics were randomly selected. Twelve patients were subsequently randomly selected from each clinic at the two hospitals, giving a total sample of 120 patients.
Twenty patients were selected randomly from each PHCC, giving a total of 220 patients. Each patient was registered and interviewed on leaving the clinic by one of the investigators using a pre-tested and pre-coded questionnaire and a checklist designed for the purpose. Patients’ medical files were also reviewed to collect the necessary data. Information included basic demographic characteristics, monthly income in Saudi Riyals, and patient type: whether new or for follow-up. The type of physical examination (none, partial, or complete) offered to patients was also noted. Partial (minimum) physical examination was defined as only recording body temperature and pulse rate.11 Information obtained from the patient included the degree of satisfaction on care provided in the facility, laboratory investigations requested, prescription and number of drugs on the prescription. Data about physicians included age, Arabic speaking or not, gender, nationality (non-Saudi, Saudi), professional status (consultant, specialist, resident), and length of experience. The time from each patient entering to leaving the clinic was noted and the overall consultation time was computed.
A reliability test was conducted on 20% of the sample by telephone or personal encounters 8-12 days after the initial survey. The test indicated a reliability of 92%.
Data were entered and analyzed on a personal computer using Epi-Info version 5 and SPSS-PC+ statistical packages.1213 Chi-squared test was used to assess the level of significance of the differences between proportions. Multiple regression was used to assess the factors predicting patient care in the health facilities. The outcome (dependent) variables analyzed (one at a time) were mean consultation time at PHCCs and hospitals, and completeness of physical examination (coded 1 = none, 2 = partial, 3 = complete) at both PHCCs and hospitals. The independent factors were patient's age, education, gender (coded as 1 = male, 2 = female), nationality (1 = non-Saudi, 2 = Saudi), patient type, mean consultation time, type of physical examination, and degree of patient's satisfaction (0 = not satisfied, 1 = satisfied). Other variables included were: investigations, prescriptions, number of drugs prescribed, physician's age, mother tongue ( 1 = non-Arabic, 2 = Arabic), gender (1 = male, 2 = female), nationality (1 = non-Saudi, 2 = Saudi), physician's status (1 = consultant, 2 = specialist, 3 = resident), experience (1 = 0-5 years, 2 = more than 5-10 years, 3 = more than 10 years), and overall mean consultation time.
1. Sample characteristics
Saudis represented 39.1% of the total sample. Slightly more than half (51.5%) of the patients were females. Under a third (30%) of the patients received no medication. Slightly less than half of the sample (47.1%) were illiterates, while only 15.6% had college degrees. Of the 59 physicians interviewed, 25 (42.4%) were males and 21 (35.6%) were Saudis. Eight (13.6%) of all physicians were consultants working in hospitals, 11 (18.6%) were specialists, and 40 (67.8%) were residents. There was a significant inverse correlation between mean consultation time and number of drugs prescribed during consultation (r = 0.15,p < 0.01).
2. Primary Health Care Clinics
Between the PHCCs the mean (± SE) consultation time showed a significant variation ranging from 0.5 ± 0.1 minutes to 7.8 ± 0.3 minutes (p < 0.04). The degree of patient's satisfaction was found to be related to the completeness of the physical examination offered (p < 0.0001). The degree of completeness of physical examination offered at the PHC centres was not significantly different one from another (p < 0.49), neither was the level of patients’ satisfaction (P < 0.5)(Table 1). Other significant multiple logistic regression analysis results are summarized in Table 2.
3. Hospital Clinics
Similar to the findings at all facilities, the mean consultation time at hospitals was significantly inversely correlated with the number of drugs prescribed per consultation (r = 0.21, p < 0.05). However, no significant variation was found between the two hospitals (p < 0.05). Regarding patient's satisfaction no differences were found among the hospitals’ clinics (p < 0.3) (Table 1).
The patients’ sample was almost equally represented by both genders. Non-Saudi patients constituted the majority of the sample, a fact that may reflect the size of this group of patients attending MOH facilities.
A. Consultation time
The significant variation of mean consultation time between PHCCs (5.94 ± 0.2 minutes) and hospitals’ clinics (8.62 ± 0.3 minutes) in this study could be explained by the system being followed at these facilities. PHCCs are essentially walk-in clinics and physicians, therefore, see a large number of patients. Consequently, consultations are brief. This has been shown to be true in both developing1415 and developed countries16–18 with some exceptions.19 However, the mean consultation time in PHCCs in this study is much better than what was reported earlier from rural PHCCs in Saudi Arabia7–9 and is close to that reported by Al-Shaman in 1991.6
On the other hand, physicians working at hospitals do see their patients, who are limited in number, according to an appointment system. Even with this, the mean consultation time was less than 10 minutes. Generally, studies have shown that consultations of less than 10 minutes duration have little impact on health promotion.20
An alternative explanation for short consultation may be related to the practice methods of physicians in Saudi Arabia. In some hospitals and PHCCs, physicians may not offer the basic patient's management during consultation even if the patient is the last on the list.
In the present study, the mean consultation time at PHCCs was inversely correlated with the number of drugs prescribed, and this supports similar findings reported by other investigators.19 At hospitals, mean consultation time was inversely correlated with increased experience and female doctors but positively correlated with the physician's status. Others have reported the same results earlier.2122 The gender of female patients in our study was shown to correlate positively with mean consultation time. This was reported in studies both from Saudi Arabia and from Western countries, indicating that female patients demand more elaborate explanation from physicians than males.1023 Patients’ level of education was not shown to affect the mean length of consultation as shown by others.2425 Differences in socio-cultural backgrounds of the two communities may have led to this variation. Arabic language speaking physicians had, on average, longer consultation time. This might show the effect of cultural background of patients on physicians. This is especially so in the community from which this sample with an illiteracy rate of 47% was drawn. It is known that physicians communicate better if they have adequate consultation time.6 Other research has shown that patient satisfaction is well related to good doctor-patient communication.26–28
B. Physical Examination
At all facilities, the degree of completeness of physical examination correlated positively with the degree of patient's satisfaction. This is in agreement with other researchers.2 Generally, complete physical examinations performed in this study were much fewer than those reported from other developing countries.19
C. Laboratory investigations and prescriptions
In this study, prescriptions were issued to 70% of the patients, while laboratory investigations were requested for 91% of the sample. The rate of prescriptions issued at PHCCs in this study (66.8%) was less than that reported from similar studies in Saudi Arabia629 and elsewhere.1419 At hospitals, the rates of both prescriptions issued (75.8%) and laboratory investigations requested (97%) were much more than what was previously reported from Saudi Arabia.10
D. Patients’ satisfaction
The finding of a 76.5% rate of patients’ satisfaction in this study in all facilities with no significant variations among them supports that of similar studies from Saudi Arabia .410 The figures reported for inpatients ranged from 74% - 93%4 and for outpatients from 66.4% - 95.2%.10 However, our rate was far below the expected figure.30 This indicates the need for remedial action.
In conclusion, the results of this study revealed a low rate of patient's satisfaction in all the MOH facilities studied. Certain aspects relating to patient care need to be improved. A reduction in the number of patients at hospital outpatient clinics and the introduction of an appointment system at least for follow-up patients at PHCCs should be attempted. Arabic-speaking physicians should be preferred to work at these health facilities in order to improve patient-doctor communication. The provision of more time for consultation and complete physical examination, as well as better communication with patients, will definitely improve patients’ satisfaction and the outcome of consultation. Moreover, there is a need to revise the current practice and training of our physicians so that they can master the necessary consultation skills.3132 Quality assurance departments at these health facilities should monitor this process through the continuous auditing of patients’ care. Therefore, the need for studies like these to evaluate the success and the impact of any reform measures undertaken will remain.
1. Kibbe DC, Bentz E, Maclaughlin CP. Continuous quality improvement for continuity of care J Fam Pract. 1993;36:304–6
2. Hill J, Bird HA, Hopkins R, Lawton C, Wright V. Survey of satisfaction with care in a rheumatology outpatient clinic Ann Rheum Dis. 1992;51:195–7
3. Peck DF. Survey of out-patient satisfaction in a general hospital Health Bull Edinburgh. 1993;51:63–66
4. AI-Umran K, Albar A, Al-Awdah S, Al-Jaber S, Wosornu L. Patient satisfaction survey in a teaching hospital: Preliminary results Journal of Family and Community Medicine. 1995;2:14–20
5. Vuori HV Quality Assurance of health services. 1982 Copenhagen WHO Publications
6. AI-Shammari SA. Factors associated with consultation time in Riyadh Primary Health Care Centres, Saudi Arabia
Saudi Medical Journal. 1991;12:371–5
7. Sebai ZA The health of the family in a changing Arabia. 1983 Jeddah Tihama Publications
8. Sebai ZA. Health profile of selected communities Health in Saudi Arabia
. 19851st ed Riyadh Tihama Publications:39–130
9. Banoub SNSebai ZA. Primary health care in the Qasim Region Community Health in Saudi Arabia
. 1982 Riyadh The Riyadh Al-Kharj Hospital Programme:59–70
10. Al-Dawood KM, Elzubier AG. Patient's expectations and satisfaction in a teaching hospital outpatient clinic, Al-Khobar, Saudi Arabia
Saudi Medical Journal. 1996;17:245–250
11. . Anonymous. Proposed methods for prescribing and patient care indicators INRUD News. 1991;2:9–10
12. Dean AG, Dean JA, Burton AH, Dicker RC Epi-Info, Version 5; a word processing, database, and statistics programme for epidemiology and computers. 1990 Georgia USD, Incorporated, Stone Mountain
13. . SPSS-PC+ Statistical Package (Computer Program), Version 4.0, SPSS Inc 1984-1990
14. Bimo. Field testing of the drug use indicators INRUD News. 1991;2:9
15. . Anonymous. Results of indicators studies carried out since 1990 INRUD News. 1992;3:12
16. Evans BT. A communication skills programme for increasing patient satisfaction with general practice consultation Br Med J Psychol. 1987;60:373–8
17. Morrell DC, Evans ME, Morris RW, Roland MD. “The five minutes” consultation: Effect of time constraints on clinical content and patient satisfaction BMJ. 1986;292:870–3
18. Knight R. The importance of list size and consultation length as factors in general practice J R Coll Gen Pract. 1987;27:19–22
19. Tomson G. Pilot study of drug use indicators in Sweden INRUD News. 1992;3:3
20. Morell DC, Roland MO. How can good general practitioner care be achieved BMJ. 1987;294:161–2
21. Cooke M, Ronalds C. Women doctors in urban general practice: The doctors BMJ. 1985;290:755–58
22. Wilson AD. Consultation length: general practitioners’ attitudes and practices BMJ. 1985;290:1322–24
23. Harris J. You can’t ask if you don’t know what to ask: a survey of the information needs and resources of hospital outpatients NZ Med J. 1992;934:199–202
24. John F Trends in general practice. 1979 London Published for the Royal College of General Practitioners by BMJ, Devonshire Press
25. Tuckett D, Boulton M, Olson C, Williams A Meetings between experts: An approach to sharing ideas in medical consultations. 1985 London Tavistock Publications
26. Sanchez-Memegay C, Hudes ES, Cummings SR. Patients’ expectations and satisfaction with medical care for upper respiratory tract infection J Gen Intern Med. 1992;7:432–4
27. Kincey J, Bradshaw P, Ley P. Patients’ satisfaction and reported acceptance of advice in general practice J Coll General Prac. 1975;25:558–66
28. Treadway J. Patient satisfaction and the content of general practice consultations J Coll General Pract. 1983;33:769
29. A1-Dawood KM. Evaluation of rational drug prescribing in a postgraduate primary health care teaching set-up, Saudi Arabia
Journal of Family and Community Medicine. 1994;1:41–5
30. Vuori H. Patient satisfaction - Does it matter? Qual Assur in Health Care. 1991;3:183–189
31. Stott NCH, Davis RH. The exceptional potential in each primary care consultation J R Coll Gen Pract. 1979;29:201–5
32. Middleton JF. The exceptional potential of the consultation revisited J R Coll Gen Pract. 1989;39:383–6