INTRODUCTION

Prolong waiting time in outpatient clin­ics is one of the most frequently en­countered concerns of patients in many of the hos­pitals worldwide and has been a long standing issue that is yet to be solved by health care providers. It is still a hot topic of discussion even today among health care users, their family members and also the health care pro­viders. Patients are increasingly dissatis­fied with the “waiting time” and “duration of consulta­tion” at outpatient clinics. Sev­eral studies have ranked waiting time in outpatient clinics as their most major concerns, giving little attention to prob­lems con­cerning health care, staff com­munication, behaviour and attitude (Bursch et al. 1993). 

The various complaints received from patients are: (1) too much time is spent waiting just to be seen by a doctor, (ii) doctors not punctual and (iii) too short a consultation time. Prolong waiting time at outpatient clinics and a short duration of consultation which has been often deemed as of poor quality has also caused many patients to default treat­ment or seek outpatient treatment in pri­vate hospitals. This has resulted in many patients to voice out their grouses and dissatisfaction through letters of com­plaint to the Director of hos­pitals and to the media. Patients were also observed to become impatient and lose their tem­per, resulting in unpleasant incidences between clinic staff and pa­tients. The patient’s rapport with the phy­sician, waiting time before consultation and con­sultation length are contributing factors to the long waiting time that have been identified as possible predictors of patient satisfaction. Therefore, prolong waiting time is the main cause of dissa­tisfaction among outpatients.

Prolong waiting time does not only af­fect the patients themselves but also their family members.  Being a close-linked family and bounded with strong family ties, majority of the children showers the responsibility of taking care of the health of their aged parents and involve actively in their health care decisions. Many make a point to be around or be present when the parents are being seen by their doc­tors (during consultation time). Therefore, during every hospital visits and follow up appointments, majority of the working children accompany their aged parents to clinic and wait anxiously with their aged parent until they are seen by the doctor. The huge responsibility of sending their aged parents to hospital and then send­ing them back home safely, requires majority of the children to take time off from work, and many had to rush back to work after a long waiting time in the out­patient clinic. In fact, studies have shown that perception of waiting time by pa­tients, parents and family members are often longer than the reality (Harris et al. 2002; Thompson et al. 1996).   

Studies have shown that prolong wait­ing time in outpatient clinics could lead to dissatisfaction among patients. Prolong waiting time can lead to overcrowded clinics and extended waiting time when doctors do not arrive at the clinic at a specific time. Gourdji et al. (2003) has also identified length of time in the wait­ing room as a main element of dissatis­faction among outpatients. Activities like relocating the individual to take blood samples, attending health education class in the clinic itself has been sug­gested to provide a less stressful envi­ronment and reduce patient’s distress while waiting.

Patient satisfaction with health care services has become one of the most frequently used criteria for evaluating programs or treatment outcomes. Pa­tient’s perception of clinic waiting expe­rience was found to affect satisfaction. Patients do underestimate or overesti­mate their actual waiting time. Waiting for less than half an hour from their actual waiting time does not affect their satis­faction but waiting for more than half an hour was found to be unacceptable by patients. Bruce et al. (1998) reported that the patient’s perceived waiting time is normally more than the actual time spent waiting. However, patients are satisfied if their waiting time does not exceed more than 40 minutes after arriving on time for an appointment (Huang 1994).

Psychological factors could also influ­ence the patient’s perceptions of the clinic waiting experience. For instance, unoccupied time feels longer than occu­pied time and uncertain waiting or unex­plained waiting may be seen longer than explained waiting and known finalized waiting. The consequences of long wait­ing can directly impact patient satisfac­tion and health outcomes by generating unnecessary emotional turmoil for the person waiting (Rondeu 1998) and their family members.  

The Malaysian Ministry of Health (MOH) recognizes the problem of pro­longed waiting times and has suggested ways to improve the waiting time of all outpatient clinics. To solve this problem, the MOH has recommended the stag­gering appointment time which reduces the waiting time to a certain level and encourages hospitals to phase off the traditional system of giving appointments. The Institute of Medicine in America has also recognized the problem of prolong waiting times and has recommended that at least 90% of scheduled patients should be seen within 30 minutes of their scheduled appointment time (target time). Outpatient Clinics Managers have also introduced the patient charter stan­dard guidelines to ensure health care providers minimize waiting time of pa­tients to a satisfactory level.

Kurata et al. (1992) in his study has compared patient’s and health care pro­viders satisfaction on waiting time and identified 8% of patients and 22% of health care providers were dissatisfied with waiting time. The actual waiting time was estimated to be not more than 45 minutes of their scheduled appointment time. Fernandes et al. (1994) reported that 90% of patients were willing to wait up to one hour from the scheduled ap­pointment time. Another study by Dos Santos et al. (1994), reported that pa­tients had experienced a long waiting time of 188 minutes and 148 minutes (Bangboye & Jarallah 1994).

Services at hospitals are expanding, patients seeking health care are in­creasing but improvement in the waiting time and duration of consultation are yet to be achieved. Hospitals have also been awarded with certification of ISO 1999 - 2000, however, the quality of services has not changed and still remains the same or poor and in fact, it has deteri­orated from bad to worse, which would be due to the increasing number of patients. Nurses and doctors play an important role in ensuring that patients are satisfied with the waiting time, duration of consultation and the overall services rendered are of quality. Therefore, identifying patient satisfaction on waiting time and duration of consulta­tion and overall services of the clinic, will enable an organization to continuously improve the quality of services provided.

No study has been done locally to ex­amine the waiting time at any of the out­patient clinics in UKMMC. The present study aims to measure the waiting time and duration of consultation and examine pa­tient’s level of satisfaction towards wait­ing time and duration of consultation at the Orthopedic Clinic, UKMMC. This study also examined patient’s satisfaction towards the overall clinic services.

MATERIALS AND METHODS

A cross-sectional descriptive survey was conducted to assess patient satisfaction on waiting time and duration of consulta­tion among patients attending follow up appointments. A total of 81 patients aged between 18 and 80 years were re­cruited in this study. Patients who came to the clinic without any prior appointment are excluded from the study. Data was collected from June 2004 until April 2005. All patients completed a self-rating structured ques­tionnaire that measured waiting time and duration of consultation. Questionnaires were extracted from the previous studies of Dhanaraj (1997) and Narimah (2004) and were slightly redesigned. Question­naires consisted of five sections: Section A con­sisted of questions on waiting time that was recorded by the observer (re­searcher), Section B consisted of ques­tions on the factors that influence waiting time such as arrival time of the clinic doctor and clinic’s filing system (also rec­orded by the researcher), Section C con­sisted of questions that identify patient’s expectation of waiting time, Section D evaluated the duration of consultation experienced by the patients, and Section E examined patient satisfaction on both waiting time and duration of consultation. Questionnaires in section E were divided into two sections: Section 1 examined the level of satisfaction of waiting time and duration of consultation whereby Section 2 examined the level of satisfaction to­wards clinic services. Section C, D and E were completed by the patients them­selves.  Waiting time referred to the time patient is given the calling number till the time patient is called into the doctor’s room. Duration of consultation referred to the time the patient enters and leaves the doctor’s room.

Waiting time experienced by patients were categorized into two levels:  waiting time Level I was the waiting time expe­rienced by patients from the time of re­porting at the registration counter till a waiting number is given. Waiting time Level II was the waiting time experienced by patients from the time the patient re­ceived the waiting number till the patient was called into the doctor’s room. Direct observation of waiting time and duration of consultation was also monitored and recorded by the researcher using a timer. These data was compared to the ex­pected time of patients and the actual time reflected on the log charter main­tained in the Orthopedic clinic.

A “prolonged waiting time” was defined as when the patient’s actual waiting time which exceeded the total waiting time as reflected in the clinic log which was 67 minutes. The waiting time showed in the clinic log for level I was 5 minutes and level II was 62 minutes.  The actual dura­tion of consultation time reflected in the clinic log was 15 to 60 minutes. Duration of consultation time in this study was ca­tegorized into short consultation time (less than 15 minutes), normal consulta­tion time (15 to 60 minutes) and a pro­longed consultation time (more than 60 minutes).

The Statistical Package for Social Sci­ences (SPSS) version 12.0 was used to produce descriptive statistics. Data on satisfaction of waiting time was analyzed using a 4-point Likert scale ranging from (1) strongly do not agree to (4) strongly agree. A score of 3 and 4 was deemed as satisfactory and a score of 1 and 2 was deemed as unsatisfactory. Ques­tionnaires designed consisted of positive- and negative-based as to avoid any bias. For positive type of questionnaires, a score of (4) was deemed as strongly agree, (3) as agree, (2) as disagree, and (1) as strongly disagree. As for negative type of questionnaires, a reversed scor­ing method was used: A score of (4) strongly disagree, (3) disagree, (2) agree and (1) as strongly agree. A score of 29 was considered as an average score as total scores were 40. Therefore, total scores of 29 and above were deemed as satisfactory and scores below 29 were deemed as unsatisfactory. A chi square test was used to examine the relationship between satisfactory scores of waiting time, duration of consultation and socio-demographic factors of respondents.

RESULTS

Table 1 highlights the distribution of waiting time experienced by patients in level I. The average waiting time in level I was 16.51 ±15.99 minutes as compared to the time (5 minutes) reflected in the clinic log. The average expectation of waiting time for level I was 20.46 ±16.18 minutes. Majority (34.6%) expected a waiting time from 10-19 minutes in level I. Only seven (8.6%) patients expected a waiting time of 50 minutes and above. Majority (45.7%) of the patients waited less than 10 minutes, which was lower than their expected time but was in line with the targeted time reflected in the clinic log. The waiting time range for level I was 1 – 97 minutes, which is higher than the expected waiting time of 1 – 75 minutes. In comparison with the actual waiting time in which majority (45.7%) waited less than 10 minutes, 23.5% of patients expected such a waiting time. Analysis also indicated that only one pa­tient experienced the actual waiting time of 1 minute.

Table 2 highlights the distribution of waiting time experienced by patients in level II. The average waiting time in level II was 127.15 ± 48.65 minutes as com­pared to the time (62 minutes) reflected in the clinic log. The average expected time was 44.63 ± 30.33 minutes. Twenty-eight (34.5%) of the patients experienced a waiting time of 150 minutes and above. The waiting time range for level II was 44 – 267 minutes. In comparison with the actual waiting time, majority (34.6%)of patients expected a waiting time of 30 – 59 minutes, but in actual waiting time, only 5 patients (6.2%) experienced such a waiting time. Only one patient (1.2%) expected a waiting time of 150 minutes and above but in actual waiting time, majority of the patients, 28 (34.5%) expe­rienced such a long waiting time. It goes to indicate that the actual waiting time was significantly higher than the ex­pected time.

Table 3 highlights the distribution of consultation time experienced by pa­tients. The average duration of consulta­tion experienced by respondents were 12.79 ±6.85 minutes as compared to the time range (15 to 60 minutes) reflected in the clinic log. The length of time spent on majority (65.4%) of patients was less than 15 minutes. Only 3 (3.7%) patients experienced a lengthy consultation time between 30 – 44 minutes compared to the 25 (30.9%) that expected such a time. Majority (40.7%) expected a long duration of consultation of 60 minutes and above, and the duration of consulta­tion of less than 15 minutes is considered as short consultation. Findings indicate a significant difference in the duration of consultation between the expected and the actual duration of consultation (p<0.05).

The average total waiting time expe­ri­enced by respondents before doctor’s consultation was 143.65 ± 53.54 minutes as compared to the time (67 minutes) reflected in the clinic log (Table 4). A number of 29 patients had a waiting time of 100 – 149 minutes and the other 29 (35.8%) patients had a waiting time of 150 – 199 minutes. The minimum and maximum waiting time was 46 minutes and 300 minutes, respectively. Findings indicate a significant difference between the actual and the expected total waiting time of the patients (p<0.001) and more than twice the standard time reflected in the clinic log.

Overall satisfaction towards total wait­ing time and duration of consultation was relatively low, 29.6% (n=24) and 42.0% (n=34), respectively (Table 5). Average total waiting time was significantly longer in the dissatisfied group (p=0.014) and the duration of consultation was signifi­cantly shorter in the dissatisfied group as compared to the satisfied group. Further analysis indicated that there was no sig­nificant association between socio-de­mographic factors and patient’s overall satisfaction (Table 6).

DISCUSSION

Patient satisfaction has been used as a significant indicator to measure the qual­ity of health care (Rondeau 1998). It has become increasingly important in today’s healthcare. Therefore, this study was un­dertaken to identify the waiting time and duration of consultation and patient sa­tisfaction of waiting time and overall clinic services at the Orthopedic Clinic, UKMMC.

Long Waiting Time

The issue of waiting too long to be seen by a doctor has been a long-standing issue not only in all outpatient clinics in Malaysia but also in other countries. Several studies by Jackovitz (1999), Luther (1996), Mc Kinnon et al. (1998), Thomas & Frank (1997) and Rondeu (1998) have indicated that long waiting time in outpatient clinics had caused patient dissatisfaction of hospital services and indirectly affected the quality of health care. Findings of the above stu-dies are similar to the findings of this study as majority of patients in outpatient clinics experienced a long waiting time. Although the time duration to be given the waiting number was acceptable and fulfilled the expectation of the patients, the time duration from the time the patient received the waiting number until the pa¬tient was called into the doctor’s room was way too far from the patients’ expectation. The waiting time had also exceeded the standard waiting time that should be achieved by any government hospitals in which waiting time for patients should not be more than two hours or 120 minutes (Khalis 2005). This could probably be due to the clinic session that started later than the given appointment and the current appointment system (clustered appointment system) that was not really effective. However, hospitals in other countries have managed to rectify the problems of long waiting time by implementing the staggering time in order to provide quality health care.

Based on observations, majority of doctors came to start their clinic at 9:30 am. The earliest doctor present was rec-orded at 8:45 am and the latest was by 11:00 am. Doctors’ delay in attending their clinics was due to the tasks that they have to complete in the Orthopedic wards. All patients in the clinic were given clustered appointments, from 8:00 am to 11:00 am. This caused the patients to wait longer as registration at the counter only starts at 8:00 am.

Short Consultation Time

The findings of this study also showed that the duration of consultation did not fulfill the expectation of patients. The du-ration of consultation stated in the clinic charter, which was supposed to be between 15 to 60 mi¬nutes was not achieved. The short duration could probably be due to follow-up appoint-ments, which do not require thorough and long evaluation of the patients as compared to the new cases. It was ob-served that there was a lack of communi-cation or discussion regarding the pa-tient’s disease between the doctor and the patient. This could be due to the doctor who wanted to expedite the con-sultation process due to the large number of patients or to ensure that the clinic operation ended before lunch time.

Patients Satisfaction

The findings showed that the level of pa-tients satisfaction on waiting time and consultation time were low. A total of 70.4% and 58.0% of the respondents were dissatisfied with the waiting time and the consultation time, respectively. This is in accordance with an earlier study done by Mowen et al. (1993) in which he reported that patients who waited longer than the expected time had a lower satisfaction level as compared to the patients in which their expected waiting time was fulfilled.

Many previous studies such as by Put-nam et al. (1985), Linn and Sheldon (1982) and Hall and Dornan (1990) showed a positive relationship between satisfaction level and age. Hall and Dornan (1990) found that aged patients are less demanding and more satisfied with the services received. Meanwhile, Bar-Dayan et al. (2002) stated that young patients had lower satisfaction level as compared to the older ones. A similar trend could also be seen in this study. This could be due to frequent visits to the clinic and long involvement of patients, especially those with chronic diseases that they began to develop good rapport with the health services provider until the patients assumed that the services are channeled according to their needs. Ac¬cording to Aljunid (1995), patients who came frequently to the clinic would have a change of perception or adaptation and indirectly would follow the requirements of hospital services.

Fox and Stroms (1981) who conducted a study in several hospitals in Baltimore, United States, reported that lower income group showed higher satisfaction level with the services provided as compared to the higher income group. Alpert et al. (1970) found that people with lower in¬come levels were more satisfied with the services provided. However, there was no significant association between customers’ satisfaction and their income (Pascoe &  Atkinson 1983; Larsen et al. 1997; Korsh et al. 1968). Dhanaraj (1997) found out that women, lower-educated people, elderly, pensioners and lower-income people were more satisfied with the services as compared to their counterparts. Some pattern of associations could be seen in this study where younger age, higher education level, working and higher income group were associated with low satisfaction level. However, all of these associations were not significant.

Overall Satisfaction on Clinic Services

In general, respondents showed a mod-erate satisfaction level on the services provided by the Orthopedic Clinic, UKMMC. The mean score of satisfac¬tion was comparable to the standard score of 29, and a total of 56.8% of the respon-dents satisfied with the clinic services.
A study conducted in a Mother and Child Health Clinic in Muar, Johor (Mukhtar et al. 1995) showed a satisfaction level of 70% whereas another study done by Narimah Yusof (2004) on antenatal services in the Larut Matang District Health Clinic showed the satisfaction level to be 87.1%.  Dhanaraj (1997) also conducted a study at the outpatient unit, Sabak Bernam Hospital, reported the satisfaction level to be 36.9%. However, there were no studies done in relation to waiting time at Orthopedic Clinics. A com¬parison cannot be made here as they are just ordinary clinics and does not fall under the category of a teaching hospital.

The overall satisfaction score by eth-nicity were comparable to the standard score (29) where the Malays showed a score of 28.72 and the non-Malays showed a score of 29.82. No significant difference was noted between the two. According to Weiss (1988), the associa-tion between ethnicity and patients’ sa-tisfaction on clinic services are inconsistent, and Krol & Nord Lund (1983) also reported that many studies did not show any association between ethnicity and patient’s satisfaction.

To improve patient satisfaction in outpatient clinics, health care workers should be sensitive to patient’s grouses on prolong waiting time. Steps should be taken to reduce the waiting time. Nurses who manage the clinic have to ensure that patient’s need not wait longer to see the doctor. Doctor’s are to ensure that patient’s are not unnecessarily made to wait during the consultation period.

Prolong waiting time in outpatient clin-ics is not only an issue in Malaysian hospitals but worldwide. Other countries also face the same problem of prolong waiting time. Studies have been undertaken in outpatient clinics by many researchers and results have helped many hospitals to improve the overall outpatient clinic services tremendously by adopting the staggering appointment time.  Not many outpatient clinics in the local hospitals have adopted the staggering system of appointment recommended by the Ministry of Health of Malaysia for some un¬known reasons

CONCLUSION

Patients are dissatisfied with the waiting time in the Orthopedic Clinic as it is not in accordance with the waiting time reflected in the clinic log. This study pro-vided important information which can be helpful for nurse managers, doctors and clinic staff of Orthopedics Clinics to fur-ther reduce waiting time and duration of consultation and at the same time im-prove the satisfaction level of patients in the Orthopedic Clinic. Waiting time and duration of consultation are important components of patient satisfaction.
It is strongly recommended here that the staggering system of appointment recommended by the Ministry of Health, Malaysia, be adopted to reduce pa¬tient waiting time. Some outpatient clinics in UKMMC and other private hospitals have adopted the staggering system of ap-pointment and have successfully reduced the waiting time.

Conducting morning ward rounds be-fore attending the Outpatient Clinic has been identified as one of the main contributing factors in prolong waiting time. It is recommended that to reduce patient waiting time, only a few doctors should be as¬signed to do the morning ward round. Doctors who are not involved in the morning ward round are required to start seeing patients at the clinic at 8am. On the other hand, doctors who come down to the clinic after their morning ward round should be allowed to see patients whose appointment starts from 9.30am onwards. This recommended practice will not only reduce patients’ waiting time, but also allow doctors to finish their clinic before lunch time and allow a good rest during lunch time.  Doctors, Nurse Manager in charge of the clinic and clinic nurses should communicate effectively with each other and work hand in hand to reduce prolong waiting time of patients at the Orthopedic Clinic.