Determinants of Patient Satisfaction: A Study on Inpatients Care at Post Graduate Institute of Medical Sciences (PGIMS), Haryana, India

 Dr. Pankaj Kumar, Assistant Professor, Department of Management Studies, Deenbandhu Chhotu Ram University of Science & Technology, Murthal, Sonipat, Haryana. India  Dr. Indu, Master, Hospital Administration, Department of Management Studies, Deenbandhu Chhotu Ram University of Science & Technology, Murthal, Sonipat, Haryana. India The aim of present study is to examine determinants of patient satisfaction at PT. Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, and how these determinants influence patients’ overall satisfaction in the Government hospital setting. A structured questionnaire was distributed to 225 patients of twelve departments having fifteen wards. The sample patients were selected just before they were leaving the hospital on the basis of convenience sampling. Factor analysis is used to determine factors affecting satisfaction among IPD patients. Pearson correlations are measured to study the significant relationship between patients’ satisfaction and associated factors. Multiple regression is estimated to predict patients’ satisfaction from eight determinants. Mean value and standard deviation are also calculated to explain the directions of the study. The results of study conclude that patient satisfaction is significantly associated with the all eight factors: medical care, staff behaviour, facilities, welfare aspect, doctors’ behaviour, administrative procedure, operative facility, and cleanness but is most significantly correlated with medical care and staff behaviour indicating their importance in the setting of hospital services, and least significantly correlated with welfare aspect and cleanness. Out of total eight, five dimensions (medical care, staff behaviour, facilities, operative facility, and cleanness) impact significantly on patient satisfaction (dependent variable) and among these five dimensions medical care is the strongest predictor followed by facilities, staff behaviour, cleanness, and operative facility. Abstract


Introduction
India is a desired destination for medical tourism due to availability of quality treatment at lower cost here. Yet for patients of middle and lower income groups, it is very difficult to avail the valuebased healthcare facilities in private hospitals. In government hospitals, healthcare facilities are provided at very lower cost or free depending on the categories of treatment and income of the patients' family. The government of India has also Keywords: Healthcare, Patient Satisfaction, Inpatient Department, India undertaken strong efforts to improve healthcare infrastructure and facilities by starting several All India Institute of Medical Sciences (AIIMS) and super speciality hospitals in different states. Still the available of healthcare infrastructure, facilities and capacities are deficient as compared to needs arising out of changes in lifestyle and pollution related diseases such as cardiovascular diseases, diabetes, cancer, central nervous system related diseases and etc.. It is an enormous challenge for public hospitals to provide quality treatment to patients upto their levels of satisfaction. The concept of patient satisfaction has gained significant consideration among healthcare service providers in the developing countries (Cooper et al., 1979). Therefore, it is necessary to set benchmarking and performance measures for healthcare service delivery (Manaf et al., 2012). The patient's level of satisfaction needs to be measured to find how much patients are satisfied with healthcare services (Lang and Fullerton, 1992) offered by the provider. High degree of satisfaction among patients leads to loyalty towards healthcare service provider (Chahal, 2008) and increases profitability of hospitals (Ruyter et al., 1998). Loyal patients revisit the same healthcare service provider for further treatment (Choi et al., 2004). Large number of research validate that the relation between the effectiveness of treatment and the patient's satisfaction is significantly correlated (Nelson and Batalden, 1993). In the literature, it has been observed that western countries have been giving attention to research on patient satisfaction for a long time. Very few research has been done in this field in developing countries like India (Bhargava et al., 2012). Thus, there is a need to study patient's satisfaction especially on the government hospitals (Abd al Kareem et al., 1996) of developing countries. Research also points out that the construct of patient satisfaction vary across the countries due to changing of demographic scenario, culture and social environments. Patients of developing countries are ready to go to private hospitals as they feel that healthcare service quality in public hospitals is not reliable (Bellou and Thanopoulos, 2006). Also, studies in developing countries have found a linkage between external pressure influencing service quality and patients' overall satisfaction (Zineldin 2006;Rao et al., 2006). So the purpose of this study is to examine the major determinants of patient satisfaction at PGIMS and how these determinants influence patients' overall satisfaction in the government hospital setting. Bahrampour et al. (2017) study the factors affecting patient preferences towards medical centres and find that physical infrastructure is the most significant aspect of patient preferences followed by medical cleanliness, training after discharge, attention of staff, admission waiting time and attitude of staff while staff behaviour has not shown significant effect on patient preferences. Sahoo and Ghosh (2016) have shown six dimensions in healthcare service in the study on 378 respondents of private hospitals of various cities across India. Factors considered are conduct & cleanliness of service personnel, service delievery, internal ambience & facilities, appearance & location, pleasant decoration, and advanced safety service. Authors have found that the dimensions such as service delievery, ambience and facilities, appearance and location, appealing decoration impact significantly on patient satisfaction, while conduct and cleanliness of service personnel, and upgraded safety services are not significant. Mohamed and Azizan (2015) in their study on 235 patients discharged from the public hospital in Malaysia, observe a significant relationship and the effect of service quality on behavioral response of patients through their satisfaction level. The research studies dimensions of service quality such as physical infrastructure, administration procedure, interaction, nursing and medical care and all are significantly associated with patient satisfaction and behavioral compliance. Ghosh (2014) conducted a study at one hospital each among the four biggest cities in India-Delhi, Kolkata, Mumbai and Chennai over 225 patients who were hospitalised for treatment in both (public or private hospitals) for not beyond one year from the date of survey conducted and concluded that all four dimensions during their stay in hospitals( such as medical care, hospitals' internal environment, administrative consideration, and communication) had impacted positively and significantly on patient's overall perceived satisfaction level. Also, service quality related factors such as personnel quality, process of medical carefulness, hospital image and hospital's credibility significantly influence patient satisfaction whereas hospital infrastructure, safety indicators, administrative system and social responsibility do not have significant effect on patient satisfaction (Padma et al., 2010). Rao et al. (2006) developed a 23 items reliable constructs for measuring the perception of both in-patients and out-patients on service quality in healthcare sector of district hospitals, district hospitals for female, community health centres and primary health centres in Uttar Pradesh, the most biggest and populated state in India. The sample size of respondents was 2480. The study identified perceived service quality dimensions such as availability of medicines, medical information, behaviour of staff, doctors' behaviour, and hospital infrastructure. Furthermore, the staff behaviour was found to be the major determinant of patient satisfaction, followed by doctors' behaviour, availability of medicines, medical information, and hospital infrastructure for in-patients respondents. Bhattacharya et al. (2003) found that inpatient conveyed high degree of satisfaction towards the doctors' and nurses' technical quality but patient satisfaction towards nurses and staff behaviour felt diminutive, whereas Lane and Lindquist (1994) reported fourteen determinants of service quality for the choice of healthcare service provider which include medical personnel, emergency services, nursing care, complete set of services availability, recommendations of doctors, advanced equipment for treatment, personnel's courtesy, adequate physical and environmental settings, prior use of the hospital, treatment cost of patients, positive word-of-mouth by the family, and friends, nearness to patients' residence, and availability of private rooms for patients.

Research Methodology
The present study is conducted to measure the factors affecting patient satisfaction at indoor patient department (IPD) of PGIMS, Rohtak, Haryana. The institute is a research hospital of North India and providing training and health facilities in almost all specialty and super-specialty services to the patients from Haryana as well as nearby states. With the capacity of 1710 beds in 26 wards for the inpatients, institute provides adequate and best-in-class indoor care to patients of various ailments. Research data are collected from the inpatients availing healthcare services from fifteen wards of twelve departments include Medicine-I, & II, Surgery-I, II, & III, Gynaeoperation, Orthosurgery, Paediatric surgery, Paediatric intensive care unit, Chest, Burn, Skin, Cardiology, Ortho, and Neurosurgery respectively.

Generation of construct and pilot survey:
The questionnaire for survey is developed from inputs of reviewing of similar literature on patient satisfaction at indoor patient department, discussions with doctors, hospital administration and patients. The survey questionnaire consists of three sections with fifty one items, section-1 contains eleven questions 'About patient' i.e. the demographic measures by which the respondents were asked about their gender, age, qualification, marital status, nativity, occupation, average monthly income, mode of admission, types of department for admission, time taken between admission & initiation of treatment and duration of stay. Section-2 aims to examine the determinants of patient satisfaction which include thirty six items on four dimensions related to hospital experience namely "doctor's professional and behavioural communication contain nine items", "Nurses services contain five items", "staff services contain six items" and "basic amenities at IPD contain sixteen items". Section-3 aims to measure patients' overall satisfaction at IPD which contains four items. Five-point Likert Scale is used with indicating-1 for "strongly disagree" and indicating-5 for "strongly agree" to investigating the professional and behaviour communication provided of doctors, Nurses services, Staff services and basic amenities at indoor patient department. A Five-point Likert Scale reduces respondents' avoidances for reactions and also increases responses quality and rate (Lam, 1997). Prior to the full scale survey pilot study is conducted over thirty two newly discharge patients to ensure the question content, wording, order, effort in understanding the questions, appropriate scale range at PGIMS. The feedback from pilot survey was used to upgrade and confirmed the questionnaire before it was ready for distribution.

B-Full scale survey
A structured questionnaire is distributed to 225 patients of fifteen wards of twelve departments (15 questionnaires to each ward) with written prior permission from Medical Superintendent of PT. B.D. PGIMS, Rohtak. Patients of each ward were chosen using convenience sampling and prior verbal informed consents were taken from respondents. A patient himself/herself or attendants of the patients are the respondents of the study. Firstly, the aim of survey is clearly to communicate in detail to respondents with the assurance of their confidentiality and privacy. The questionnaire is self administered to each patient and for their convenience, any kind of confusion is clarified instantly for successful completion of the survey. An effort was made to get a real time feedback from respondents, just before they left the hospital. Attendants are involved in completing the survey where in cases where patient could not write themselves. For children, their parents or guardians fill the questionnaire. The respondents viewing slightly unwillingness are not included in this study. Out of 225 distributed questionnaires, 206 survey questionnaires are filled by respondents, 23 questionnaires are incomplete and not used for analysis and 183 valid questionnaires were used for final analysis; therefore the effective recovery rate is 81.33 per cent. SPSS (Version.20) is used for analysis in this study. Internal consistency analysis is used to access the reliability of measurements. The reliability of the measurement confirmed by using Cronbach's Alpha which is commonly used for this purpose and α-value must be higher than 0.70 (Nunnally, 1978 Patients' Overall Satisfaction=0.848) respectively, so Cronbach's Alpha received is higher than 0.70 which suggests acceptable reliability. Factor analysis is applied to determine the factors affecting the satisfaction among IPD patients. Pearson correlation analysis was also employed to study the significance relationship between patient satisfaction and related factors. Multiple regression is applied to measure the patients' satisfaction from eight determinants. Mean value and standard deviation are also used to explain the directions of study.

Descriptive Statistic
Out of 183 respondents, female were 57.38 per cent and male are 42.62 per cent. 68.90 per cent respondents having diploma or below qualification and 41.50 per cent having agriculture/laborers background with weak economic background having rupees 10,000 monthly income of 79.80 per cent respondents. Nativity wise it was found that 67.20 per cent were from rural back ground. 59.50 per cent of patients hospitalized through emergency mode. Regarding the types of department for hospitalised at IPD 18.60 per cent patients came for Surgery, followed by 15.30 per cent for medicine, 7.70 per cent for cardiology, and 7.10 per cent for each department which include Gynaeoperation, paediatric intensive care unit, chest and skin (table-1). Of the respondents 37.20 per cent are judgment that time taken for admission and initiation of treatment was 10 to 20 minutes and 40 per cent patients stay at hospital for 3 to 6 days followed by 33.20 per cent for more than 6 days.

Data Analysis and Results
Factor analysis was conducted on 36 items to extract factors that were meaningful. Principal component method of factor extraction with varimax rotation was used for data reduction and in the area of health care research this method was suggested by (Chahal and Kumari, 2012;Chahal and Mehta, 2013) for construct refinement. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy for eight factors found to be 0.88 (KMO⩾0.60 required to perform factor analysis) which means sample size is adequate for proceeding with principal component analysis (Hair et al., 2006). Bartlett's test of Sphericity was also found to be significant (Chisquare value is 4207.07 and level of significance is 0.000) prooving adequacy for running factor analysis. In order to retaining the items factor eigenvalues > 1.0 and rotated factor loadings of 0.50 or greater as practically significant (Hair et al., 2006). Thus, items with factor loadings below 0.50 were dropped from the analysis: such as doctors' interest & devotion, and general cleanness and the analysis was re-conducted to ensure the integrity of factor structure and the factor structure derived after rotation shows significant factor loading (> 0.50) for each item. The factor analysis with 34 items resulted in eight identified factors were named as Factor-1 Medical care (MC), Factor-2 Staff behaviour (SB), Factor-3 Facilities (F), Factor-4 Welfare aspect (WA), Factor-5 Doctors' behaviour (DB), Factor-6 Administrative Procedure (AP), Factor-7 Operative facility (OF), and Factor-8 Cleanness (CL) having 10, 6, 6, 4, 3, 2, 2 and 1 items respectively (Table-2

Associated Factors (N=183) in Appendix
Table-4 shows that the mean value of patient satisfaction is 4.07 on a Five-point Likert scale and has revealed a positive sign, being above the scale midpoint of 3.0 and point of 4.0. Among all the determinants of patient satisfaction medical care rated highest position followed by doctors' behaviour, staff behaviour, operative facility, facilities, administrative procedures, and cleanness, whereas welfare aspect placed lowest rank among all determinants of patient satisfaction. Pearson's correlation coefficient was performed to check the significance relationship between patient satisfaction and related factors and table-4 shows that patient satisfaction is most significantly correlated with medical care followed by staff behaviour, operative facility, facilities, doctors' behaviour, administrative procedures, cleanness, and welfare aspect at p < 0.01.
Here Patient's overall satisfaction is the dependent variable and predictors are Medical care, Staff behaviour, facilities, Welfare Aspects, Doctors' Behaviour, Administrative Procedure, operative Facility and Cleanliness.

Table 5: Regression Analysis to Determine the Factors Influencing Patients' Overall Satisfaction in Appendix
Table-5 shows the results of multiple regression analysis to determine the factors influencing patient satisfaction and results indicated that the overall regression model is significant at P < 0.01 (F8, 183= 25.23) and explains 53 per cent variation (R2 = 0.53) in the dependent variable. Five factorsmedical care, staff behaviour, facilities, operative facility, and cleanness explain the high percentage of variation in patient satisfaction and were found to be significant predictor, and significant at (P< *0.05 and **0.01). The standardized beta coefficient indicated that the variable having the highest impact on patient satisfaction is the 'medical care' followed by 'facilities', 'staff behaviour', 'cleanness', and 'operative facility'. However, surprisingly, 'doctors' behaviour' had negative coefficient and suggesting that when doctors explained diseases to their patients with friendly and courtesy way to make them tension free, patient satisfaction was reduced and possible reason may be the low literacy rate of patients to understand the medical terminology and effects.

Summary and Conclusion
Based on our empirical analysis several conclusions are drawn. First, the patient's level of satisfaction is significantly associated with the entire eight factors: medical care, staff behaviour, facilities, welfare aspect, doctors' behaviour, administrative procedure, operative facility, and cleanness, but most significantly correlated with medical care and staff behaviour, indicating their importance in the setting of hospital services, and least significantly correlated with welfare aspect and cleanness. The study also revealed that out of the eight dimensions of patient satisfaction, medical care was the most important dimension which received the highest mean value (m=4.21), followed by doctors' behaviour (m=4.13), and staff behaviour (m=4.04), while the patient's satisfaction level about welfare aspect was the lowest (m= 3.50). The possible reasons could be huge rush of patients & attendents, increase in demand for medicines for treatment, limited supply/availability of medicines for insufficient guidelines and procedures of drug procurements and rising costs of drugs & insufficient hospital budget. Hence, patients/attendents are forced to purchase prescribed medicines from outside the hospital which unfortunately are at higher cost. As per suggestion, prescribed medicines must be available in IPD pharmacy and on priority basis; the Government must allocate budget to strengthen the hospital care system. On the other hand the study finds that the mean value of overall satisfaction of patients is (m=4.07) with reasonable hospital charges for treatment and services, and wise judgment to come at this hospital.
Out of total eight, five dimensions (medical care, staff behaviour, facilities, operative facility, and cleanness) impact significantly on patient satisfaction and among these five dimensions medical care was the strongest predictor (coefficient of medical care is highest) for dependent variable followed by facilities, staff behaviour, cleanness, and operative facilities. The findings of the study suggest medical care as a key dimension of patient satisfaction in the government hospital settings and hospital administration should always emphasise to improve the technical quality of doctors. Hospitals must initiate professional development programme for doctors and nurses for providing them essential technical skills. Moreover, to increase the patient satisfaction, hospital administration needs to improve helpful and courteous staff behaviour through soft skills training and development so that staff should demonstrate kindness with patients and their attendents. Continuous progression in the basic facilities like: availability of tests in labs and diagnostics, drinking water, quality meals for patients and attendents, agreeable temperature and general cleanness will also improve patient satisfaction towards hospital. Surprisingly, doctors' behaviour had negative coefficient, but not significantly affect patient satisfaction suggesting that when doctors explained diseases to their patients/attendents with courtesy and friendly way to make them tension free, the patient's satisfaction could be reduced since, 67 per cent of patients have rural background and the low literacy rate to understand the medical terminology/clinical language and effects. This finding supports the prior results of the study by (Bhargava et al., 2012). Administration needs to provide effective training programme to improve interpersonal and communication skills among doctors. Finally, this study provided certain facts to hospitals managers and administration for the improvement in the patient's satisfaction level through the formulation and implementation of healthcare policies related to services quality. Even though, this study has been limited to PGIMS, Rohtak at Haryana, results may have applicability in other government hospitals. Future research may focus on entire north region with an acceptable sample size and also attempt to investigate the patient satisfaction in both the public and private hospitals.