Introduction

Patient satisfaction is defined as a subjective reaction to the context, process and result of the service experience one has received (Pascoe 1983). It is paramount and frequently used as an indicator for measuring the quality of care responsible for an equitable evaluation of the structure, process and outcome of health services (Barnett et al. 2013; Heidegger et al. 2013; Shah et al. 2015). Patient satisfaction is an integral part of service quality that leads to continuous improvement in anaesthetic service provision and it can be influenced by preoperative visit (Fung & Cohen 2001; David et al. 2004). Many factors contribute to patient satisfaction, including accessibility and convenience of services, institutional structure, interpersonal relationships, the competence of health professionals and patient’s own expectation (Myles et al. 2000).

Preoperative anaesthetic evaluation is as equally important as the actual delivery of anaesthesia during surgery. It requires an in-depth knowledge of the patient’s general health status, nature of the surgery, anaesthetic technique tailored for the surgery, as well as competency in handling anaesthesia associated complications and the subsequent expectant management (Anaesthetic Clinic Protocols 2012). Also, it is instrumental in enhancing the cost-effectiveness of the perioperative process (Pasternak et al. 2012; Olivier et al. 2016). Following the progress in the preoperative assessment clinics, this has brought to a great declination in the number of surgical cancellations, lab tests, and length of hospital stay as well as associated costs of consultations by introducing the systematically developed practice guidelines (Van Klei et al. 2002; Pasternak et al. 2012). In addition, it helps to allay anxiety, clarify any anaesthetic-related concerns and improves on the overall physical and psychological experience of a patient prior to surgery (Samuel et al. 2011; Soltner et al. 2011). However, evaluation of patient experience and satisfaction with such clinics has not been fully studied especially in our local settings despite these improvements having benefited the hospital systems. Most of the results available were evaluating patient satisfaction at the postoperative periods, which could be confounded by many factors including interaction with different health care providers as well as the outcomes of the surgery. Moreover, most of the feedbacks were obtained retrospectively via mail-back method or telephone interviews that were conducted from several days to weeks after the postoperative period and with a possibility of making the responses less precise (Fung & Cohen 2001). 

A good preoperative assessment requires more than just a medically competent anaesthetic medical officer. Effective communication and concerted team approach are vital to ensure patient’s safety and wellbeing throughout the hospital stay as well as after the patient has been discharged.  We opted for evaluation of patient satisfaction in the preoperative setting rather than postoperative assessment as the latter more often reflect on the overall perspective based on many dimensions of care delivered as well as the outcome of the surgical procedure. The use of many recognised patient satisfaction tools mostly evaluate the aspects of patient experience by means of the support and care offered by medical staff, the respect and courtesy shown by medical staff, the quality of explanation given to patients as well as other general components immediately after interaction with health care providers in the setting of preoperative assessment (Edward et al. 2007). 

The aim of this study was to determine the level of patient satisfaction with the preanaesthetic clinic (PAC) through a valid and reliable multidimensional questionnaire examining factors affecting satisfaction. These factors can be broadly categorised into provider and non-provider groups in the assessment of patient satisfaction. Non-provider assesses facilities and appropriateness of waiting time in general while for provider, they were further subdivided into doctor, counter services, nurses and supporting staff. 

Materials and Methods

This study was approved by the Research Committee of Department of Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre (UKMMC) and the Medical Research and Ethics Committee from UKMMC (FF-2018-448). Further approval was granted by Medical Research and Ethics Committee (MREC) under National Medical Research Register (NMRR), Ministry of Health Malaysia (MOH) (NMRR-16-2875-32568).

This was a cross-sectional prospective study to determine patient satisfaction with the preoperative anaesthetic evaluation that was conducted at the PAC in Hospital Kuala Lumpur (HKL) from December 2018 to January 2019. A sample size of 317 was calculated using the formula estimating the single proportion based on the prevalence of satisfaction from a previous study of 86.1% (Sharifa Ezat et al. 2010). The sample size met the precision requirements (α) of 0.05 and the confidence interval of 95%. 

Adult patients aged 18 years and above who have been scheduled for elective surgeries on the first visit to PAC, able to understand either English or Bahasa Malaysia and agreeable to participate were included in the study. Explanation and written informed consent were obtained from patients recruited into the study. We explained to the patients that their name, personal data and information taken for use of the study would not be disclosed and would be remained confidential. There was no favouritism given by the healthcare providers to those participating in the study. An independent nurse was assigned to the study would collect the questionnaire after patients have completed answering the questionnaire. The collected questionnaire would be then submitted to the principal investigator for analysis. A self-administered Patient Satisfaction Survey questionnaire was used with permission granted from the Quality Division, Centre for Strategy, Quality and Business Development Kuala Lumpur Campus UKM. The content and wording of the questionnaire were validated beforehand in both languages, English and Bahasa Malaysia to accommodate the multiracial population. 

The first section of the questionnaire was the demographics characteristics of the patients. The second section contained 17 questions to examine service quality and was further divided into non-provider and provider factors. Provider factors included services provided by the doctors, counter services and support staffs while non-provider factors were anaesthetic clinic facilities, waiting time and quality of service. Each question in the questionnaire, except the socio-demographic characteristic, was graded in a strongly agree/strongly disagree five-point Likert scale format. Question number 18 was used to assess patient’s perception on overall satisfaction with the services provided at the PAC. 

Data obtained from this investigation were analysed using IBM SPSS (Statistical Package for Social Sciences) version 25.0 (IBM Corp, Armonk, New York). A descriptive statistic of the socio-demographic characteristics was initially done to evaluate the distribution, normality and homogeneity of the data. Based on Shapiro-Wilk test, the normality distributed of data assumptions was met. Frequency and percentage were tabulated for distribution of categorical data in sociodemographic characteristic while continuous variables were reported as mean + standard deviation (SD). Pearson correlation test was used to assess the correlation between overall satisfaction with other factors which were continuous variables. Linear regression was applied to identify the relationship between patient satisfaction and all the factors studied. Statistical value was considered significant if the p-value <0.05.

Results 

A total of 304 patients’ data were collected and analysed with 13 drop-outs due to incomplete data. Data were collected across all surgical specialities including general surgery, urology, orthopaedics, otolaryngology, plastics surgery, dental surgery, neurosurgery, ophthalmology and gynaecology (Table 1). They were 125 males (41.1%) compared to 179 females (58.9%). Majority of the patients were Malays at 66.1%, Chinese at 14.5% and Indian at 13.8%. The least races seen were Others at 5.5%. Division of ranges of age into four categories showed highest response rate from the category age of 31-50 (37.2%). Almost half of the patients received secondary level of education. More than half of the patients (52%) belonged to the working group with 13.8% from the government sector and 38.8% from a private sector and self-employed (Table 1). The average of waiting time before consultancy was 29.05 + 15.96 minutes. 

  The majority of the patients in this study were satisfied with overall service provided at the PAC (98.7%) (Table 2). Mean score for provider were comparable with doctor scored highest (4.49 + 0.60) followed by counter service (4.48 + 0.61) and support staff (4.47 + 0.62). However, non-provider which examined facilities, appropriateness of waiting time and services provided by the clinic was the lowest among the 4 subscales (4.40 + 0.62) (Table 3).

All 4 domains which examined non-provider and provider (doctor, counter service and support staff) were directly proportional to overall satisfaction with a strong overall correlation (r>0.7) (Table 4).  Independent variables which showed significant association with patient satisfaction were included for multivariate analysis. Only occupation and waiting time were retained in the final model while age, gender and education level were not associated with the level of satisfaction (Table 5). During the variable selection method in the Multiple Linear Regression, only waiting time was found to be significant after adjusting for other variables. There was significant linear negative and fair relationship between waiting time and mean score of satisfaction (r=-0.48, p<0.001, adjusted B (95% CI): 0.02 (-0.019, -0.012). 

Discussion

Our results showed an overall good patient satisfaction rate of 98.7% which was comparable with a Canadian study involving 2730 patients that reported an overall anaesthesia satisfaction as high as 98.9% (Tong et al. 1997). Nevertheless, these high scores might indicate a flawed idea as some of the patients may be tinted with the impression that a lower quality of care woud be received by giving negative appraisals (Pearson et al. 1989). 

From our study, the satisfaction rate was lowest with the non-clinical elements and these included appropriateness of waiting time, basic amenities and up-to-date equipment used in the anaesthetic clinic. Our findings accentuate the importance of non-clinical aspects in enhancing patient satisfaction and can be improved by clear explanation of the purpose of the PAC visit as well as the process involved when a patient first presented at the registration counter. Also, the equipment to be used and overall cleanliness of the clinic can be improved. Lastly, longer period of waiting time was one of the most faced problems of patients in the outpatient clinic and is strongly related to overall patient satisfaction (Raja et al. 2009). Based on our findings, the average waiting time was 29.05 + 15.96 minutes which was comparable with a study of patient waiting time in a primary health care clinic (Ahmad et al. 2017). Also, there was a positive relation of waiting time and overall satisfaction with p-value<0.001. This is also observed in several studies that long waiting time in outpatient clinics had caused patient dissatisfaction of hospital services and indirectly affected the quality of health care (Jackovitz 1999; Mc Kinnon et al. 1998; Raja et al. 2009).  Therefore, further measures can be improvised to maintain patient satisfaction by means of shortening the waiting times and improving on punctuality from all the health care providers including implementation of record of time of arrival at the clinic, time to be seen by the doctor and allocation of more doctors and staff to cater for relatively large volume of patient attending the PAC. 

For the providers, ancillary health care staff, nurses and doctors each play a key role in providing a quality preoperative care to a patient. The aim of the preoperative assessment is to evaluate the patient’s condition for anaesthesia prior to surgery, to discuss in detail the anaesthetic options and postoperative pain management, to minimise anxiety and confusion of the perioperative process as well as to coordinate patient care among different discipline of medical teams in order to optimise patient’s condition prior to surgery. As the health care delivery domains were defined as the modifiable variables, refining the quality in these domains will render a better satisfaction and compliance with respective medical treatment (Fallowfield 1992). Interaction with the doctor was found to have the highest mean score from our studies and this has shown that a positive doctor-patient relationship is closely related to patient satisfaction. Therefore, we postulated the importance of communication skill and interpersonal aspects as both have an impact on measurement of patient satisfaction. Of interest, the counter service or often viewed as ‘doorkeeper’ will be taking charge found to have a higher satisfaction compared to support staff. This finding may be a result of more discernible contact with patients by providing detailed instruction and explanation. This has enabled a better understanding of what the perioperative process would involve and thus greater satisfaction.   

In term of non-modifiable factors, patients’ age, gender and level of education did not reveal a strong association with patient satisfaction. However, occupation was a significant factor in determining overall satisfaction and self-employed group had a lowest score than the rest. Our study was distributed independently of age, gender and surgical procedures with most surveyed patients scheduled to undergo general surgery, orthopaedic and urology procedures which were consistent with the overall surgical procedures in our institution. Another probable limitation is the timing of the surveys answered. The questionnaires were distributed after consultation with the doctors and were to be completed by the patients towards the end of the visit before they leave. Most of the questionnaire-based studies employed a mail-back method where patients were given more time to reflect on the experience of the clinic visit before concluding on the questionnaire. This study could be improved with incorporation of analysis of amount of contact time spent with doctors as well as the use of monthly income to determine the characteristic of occupation rather than the type of occupation.

Several measures could be implemented to improve the patient satisfaction based on our results. The duration of visit as part of the factor in influencing satisfaction could be streamlined with smooth patient flow of the clinic process, educational handout to help with better understanding of anaesthesia while waiting for consultation and minimise redundancy in medical questioning. Workshop and continuous medical education on the improvement of clinician-patient relationship and excellent customer services could be initiated to enhance overall health care quality of the clinic.    

Conclusion

Overall majority of the patients were satisfied with the preoperative evaluation provided at PAC and both non-provider and provider have a significant impact on patient satisfaction. Therefore, effective interventions and continuous medical educations to improve the overall quality of health care providers are essential in minimising medical redundancy and thus waiting time.  

Acknowledgement

The authors would like to thank the Mdm. Qurratu’ Aini Bt Musthafa from the Department of Anaesthesiology & Intensive care, Hospital Canselor Tuanku Muhriz and the Staff Nurses from Anaesthetic clinic, Hospital Kuala Lumpur for the support and assistance provided throughout this project.