Validity of a New Questionnaire of Outpatient Service Satisfaction for Academic Medical Center Hospital

Background: Measuring outpatient satisfaction is an integral component of quality management in healthcare settings. Outpatient service is a major part in the hospital services and patient care. Objectives: This study aims to develop a valid and reliable survey toolfor measuring the quality of outpatient service in an academic medical center hospital. Design: A cross-sectional, analytical research design was conducted among outpatients. Settings: King Fahd Hospital of the University, University of Dammam, Saudi Arabia. Patients and Methods: The questionnaire was administered to 445 outpatients who attended the clinics during the period of April – June 2015 in King Fahd Hospital of the University. The questionnaire comprised of 21 items on 4 conceptual subscales: Professional care, Availability of service, Waiting time and Laboratory service. A five-point Likert scale was used to measure the level of satisfaction. Reliability was performed using Cronbach’s α coefficient. Factor analysis was done to test the validity of the survey instrument. Main outcome measures: Reliability, Validity for the questionnaire overall, and for each sub-scale. Results: Factor analysis indicated that the outpatients’ satisfaction towardsthe quality of service scale had four latent factors, which explained 82% of the variance: The four subscales measured includes: (1) professional care, (2) availability of other services, (3) waiting time, and(4) satisfaction of laboratory service. The four factors had excellent reliability coefficients, ranging between 0.821 (professional care), 0.854 (availability of service), 0.730 (waiting time) and 0.717 (laboratory service). It is also observed that the full scale had excellent internal consistency (Cronbach’s alpha = 0.868). Conclusion: This study provides evidence of reliability and validity of the new survey tool for the measurement of outpatient service satisfaction in academic medical center. Limitations: This study was conducted in an academic center medical center hospital, therefore the outcome as well the developed research tool is not suitable for non-academic Hospitals. Araştırma / Research Article INTRODUCTION Patients’ satisfaction is considered to be a measure of health care.1,2 By measuring the patients’ satisfaction, we can find out the quality of all healthcare services. Hence the patient satisfaction on the quality of service provided to them is one of the key performanceindicator in hospitals.Few studies indicates that patient satisfaction is ‘one of the most useful indicators (Ware et al., 1988; Vuori,1991; Carr-Hill, 1992; Williams, 1994; Scott et al., 1994) in the success of a hospital.3-7Another studyin the same field stated that patientsatisfaction is a major indicator of the quality healthcare and the quality of service can be assessed by mapping out the patient satisfaction with healthcare providers.8There are several studies which indicatethe importance of satisfaction studies in healthcare settings. Patient satisfaction has long been considered as an important component when measuring health outcomes and quality of care.9,10 1Associate Professor, Deanship of Quality & Academic Accreditation, University of Dammam, Kingdom of Saudi Arabia. 2Statistician, Deanship of Quality & Academic Accreditation, University of Dammam, Kingdom of Saudi Arabia. Anahtar Kelimeler: Ayakta Hasta Memnuniyeti, Güvenilirlik, Geçerlik, Akademik Tıp Merkezi Hastanesi


INTRODUCTION
Patients' satisfaction is considered to be a measure of health care. 1,2 By measuring the patients' satisfaction, we can find out the quality of all healthcare services. Hence the patient satisfaction on the quality of service provided to them is one of the key performanceindicator in hospitals.Few studies indicates that patient satisfaction is 'one of the most useful indicators (Ware et al., 1988;Vuori,1991;Carr-Hill, 1992;Williams, 1994;Scott et al., 1994) in the success of a hospital. [3][4][5][6][7] Another studyin the same field stated that patientsatisfaction is a major indicator of the quality healthcare and the quality of service can be assessed by mapping out the patient satisfaction with healthcare providers. 8 There are several studies which indicatethe importance of satisfaction studies in healthcare settings. Patient satisfaction has long been considered as an important component when measuring health outcomes and quality of care. 9,10 Al-Kuwaiti ve Maruthamuthu : Yeni bir anketin güvenilirliği ve geçerliliği A review by Crow et al. (2002) indicates that majority of patient satisfaction studies identified in the international literature used questionnaire based survey instruments, which are specifically designed for the study. 11 This is the concernand the need of testing the reliability and validity of instruments used, in terms of achieving comparability across settings.
As Hall and Dornan (1988) noted in theirliterature review on satisfaction, the aspects of the medical setting chosen for study vary that some areas (e.g., humaneness of health professionals, information about health care) are studied extensively while other aspects (e.g., outcomes) are assessed to a much lesser degree. 12 The study reports thathumaneness and technical quality of medical care were ranked near the top, while the bottom five ranks were occupied by aspects of care that reflected the provider's attention to other patient needs and the patient's relation to the system as a whole. In addition, it was demonstrated that different aspects of medical care are measured with extremely uneven frequencies in satisfaction instruments. Satisfaction is a multi-factorial construct; the patients experience different facets and dimensions of a health service episode and they make multiple evaluations about the process of care as well as the outcome. The dimensions identified in the review were: access, cost, overall quality, humaneness, competence, information supplied, bureaucracy, physical facilities, attention to psychosocial problems, continuity of care and outcome of care. , but there is no such study measuring the quality of outpatients' service in an academic medical center hospital. [13][14][15][16][17][18][19][20] Hencethis novel approach is to develop a tool to measure the quality of outpatient service in an academic medical center. The aim is to assess the reliability and validity of this new survey tool for measuring the quality of outpatient's service.

METHODS
A structured questionnaire was designed to measure the outpatients' satisfaction on quality of the service and patient care; it includes demographic variables like age, gender, education, occupation, service department and visit status. The tool consists of 21 items related to four subscales, as follows: (a) Professional care including appointment service, (b) Availability of service, (c) Waiting time and (d) Laboratory service.
Each item of the instrument used a 5-point Likert scale ranging from 1-Very Poor to 5-Excellent.
A total of 445 participants were involved in this study. The study design was cross-sectional, analytical and the sample was selected by stratified random sampling from each specialties. Care had been taken to get a wide representation of samples by covering all outpatients' clinics.
Interviewers from the patient relations department and quality center administrated the questionnaire at King Fahd hospital of University, University of Dammam, Saudi Arabia. The required sample of participants were interviewed from all specialties during the period of 1 st Aprilto 30th June, 2015.
The test of validity for the survey instrument was performed by Cronbach's alpha, which is considered the most important technique for testing the validity (Cronbach, 1951) of the instrument. 21 Exploratory factor analysis was used to assess the dimensions of the outpatients' satisfaction to the quality of service scale.
The statistical criteria Kaiser-Meyer-Olkin (KMO) and the Bartlett test of sphericitywere used to test the sampling adequacy and to examine the interindependence of the subscales of the scale. 22 Extraction method in factor analysis was a principal component of analysis. To compute loading of factors Varimax Rotation was used. Table I] showed the value of Cronbach's Alpha coefficient for the whole scale as0.868. This is more than 70%, which is an excellent internal consequence of the conceptual construction of the investigated scale. 23 The value of Cronbach's α based on standardized item was 0.892, which reveals that if the number of items are increased, Cronbach's alpha gives the value of 0.892. The four sub-scales has very good reliability coefficients, ranging between 0.821 (professional care), 0.854 (availability of service), 0.730 (waiting time) and 0.717 (laboratory service) [ Table 2].  Table 3], indicates that the raw data is suitable for factor analysis. From the values of communality [ Table  4], majority of the variables had a value more than 0.50, which indicates that the quality of the measurements are satisfactory. Based on the eigenvalues, 4 factors were extracted and these account for the total variance of 82%. Factor 1 contains 6 significant loadings, of whichthe major items were:following doctors' advice (0.808); doctor's' explanation about treatment (0.795) and examination by doctors (0.754) [ Table 5]. Factor 1 seems to represent a combination of physician's satisfaction and overall appointment service. Factor 2 contains8 significant loadings. The most important items were: friendliness and courtesy of the staff who provides your tests or treatment (0.685); convenience to reach investigation site (0.664): staffs concerns for your comfort, questions and worries (0.655) and convenience to reach appropriate OPD (0.643). Factor 3 contains3 significant loadings, which is related with time taken for registration (0.771), time taken to reach consultant in OPD (0.746) and time taken in getting medicine from pharmacy (0.775), and finally Factor 4 contained 2 significant loadings, which deals with laboratory service. Skills of the staff who provided your tests or treatment 1.000 .656

Reliability statistics [
Overall of appointment service 1.000 .599 Overall satisfaction of care received during your visit 1.000 .693 Overall satisfaction about our quality of the treatments 1.000 .734 Al-Kuwaiti ve Maruthamuthu : Yeni bir anketin güvenilirliği ve geçerliliği

DISCUSSION
We successfully developed a new survey instrument for measuring the quality of outpatients' service in an academic medical center hospital. The internal consistency and reliability was tested by Cronbach's alpha coefficients. The within-factor alpha coefficients were observed in a range 0.717 to 0.854 which is found to be acceptable when compared with other 25 studies in which the range reported was from 0.43to 0.90. 24,25 The 21 items/ variableswhich makes up our survey tool falls in an intermediate range of 13 to 100. 26,27 The number of extracted factors are modal among the reported range of 3 to 11 factors. 28,29 The explained variance of 82% is more optimal compared with other studies. [30][31][32] We developed and validated the questionnaire tool, which isa reliable survey instrument for measuring the quality of outpatient's service. Our finding justifies the recommendation of the use of this questionnaire on outpatients' satisfaction in various health care settings.

CONCLUSION
The three factors which have to be considered while developing a survey tool in an academic center hospital are: (i) explained variance of above 82% (ii) overall internal consistency of reliability 0.868 and above, and (iii) reliability for the sub scales ranging from 0.717 to 0.854. Based on these statistical measures, we can conclude that this tool is a reliable and valid survey tool for measuring the quality of outpatients' service satisfaction. A questionnaire tool with high variance, consistency and reliability can be adapted by any academic medical center hospital and health care settings as one of the means of assessing outpatients'satisfaction.