A study on patient satisfaction in the outpatient department of a secondary care public hospital

Introduction: Healthcare scenario is fast changing all over the world. Health as a fundamental right, is gaining popularity over the last few decades and it has become a social goal. Patient satisfaction is one of the established parameters to measure success of the healthcare services that are provided in the hospitals. There are high expectations and demands from consumers because of improved socio-economic status and easy accessibility to healthcare. Successful monitoring of customer’s perception has become a simple but important strategy. The measurement of patient satisfaction is an important tool for research, administration, and planning. Objective of the study


Introduction
Health care scenario is fast changing all over the world (Verma A, Sarma RK.2014).Health as a fundamental right, is gaining popularity over last few decades and it has become a social goal.Patient satisfaction (PS) is one of the established parameters to measure success of the health care services that is provided in the hospitals.There are high expectations and demands from consumers because of improved socio-economic status and easy accessibility to health care.Successful monitoring of customer's perception has become a simple but important strategy (Sreenivas T, Prasad G, 2003).
A patient who is in distress is the ultimate consumer of the hospital, expecting comfort, care and cure from hospital.Patients have certain expectations prior to visit.A patient may become either satisfied or dissatisfied after coming to the hospital and experiencing the facilities (Kulkarni MV, Deoke N.2011).Patient is the one who decides the quality, who accepts the services, who makes others to accept it, who gives correct feedback about the performance of hospital and makes the programme of total quality management successful.Thus, measurement of patient satisfaction is an important tool for research, administration, and planning (Bhattacharya A, Menon P, Koushal, Rao KLN.2003).
Patient's perceptions about health care system seem to have been largely ignored by the healthcare managers in the developing countries.Human satisfaction is a complex concept that is related to a number of factors including lifestyle, past experiences, future expectations and the value of both individual and society quality of clinical services provided, availability of medicine, behaviour of doctors and other health staff, cost of the services, hospital infrastructure, physical comfort, emotional support and respect for patient preferences.Therefore, assessing patient perspectives gives them a voice, which can make public health services more responsive to people's need and expectations.
According to an article (Indian Express 2001), patients are capable of assessing the quality of care as they pay attention to all the elements of services rendered -the art of care, the science of medication and other associated amenities of care.Patient satisfaction is an indicator of how as a consumer, he/she perceives the qualitative aspects of care.It is a pre-requisite for achieving excellence in healthcare as it influences the patient's (consumer's) decision to follow the prescription and to seek professional consultation in the near future.
The measurement of patient satisfaction is an important tool for research, administration, and planning (WHO 1984).It is one of the most important parameters of quality as it helps in determining the level of services catered by the medical staff.Satisfaction with the doctor's consultation, nursing care, housekeeping, equipment, billing and in-house food services are some of the main determinants of overall satisfaction for the hospitalized patients in a hospital (Donabedian A, 1980).
Global healthcare industry is undergoing a rapid transformation to meet the needs and demands of its rising patient population.From viewing the patients as uneducated and lack of healthcare knowledge and choice, to recognizing them as educated and well-aware consumers practicing their rights and choices.Recognizing the patient's needs and wishes is the center point for any health care system (Deva SA, 2010).Traditionally, the quality of health services was based on professional practice standards, however over the last decade, patient's perception about the services rendered has been accepted as one of the most important indicators for measuring quality of healthcare and regarded as a critical component for clinical effectiveness and performance improvement (Woodring S, 2004).
Patient care and satisfying the patient by providing him quality services is the primary function of any hospital.It is one of the terms to measure the success of services that it provides.To know the effectiveness of the hospital, assessing how good its patient care is very necessary.Since patients are the primary consumers of all the incentives provided by the hospitals, it is very much necessary to satisfy the needs of every patient who is visiting the hospital.As it is said, patient satisfaction is the real testimony to efficiency of hospital administration.As the hospital serves all the members of the society, the expectation of the users differs from one individual to other because everyone carries a particular set of thoughts, feelings, and needs.
Nowadays patients are becoming aware of their health needs and rights.They are totally aware about the health care facility which provides satisfactory and quality health services to them.If the health care facilities fail to do so, they are considered unsuccessful in implementing their assigned tasks.A completely satisfied patient means that that the organization has potential in understanding patient needs and demand related to health care.
Patient satisfaction measurement adds important information on system performance, thus contributing organization's total quality management.Research on patient satisfaction with medical care can be traced back to the late 1970's.Over thirty years, an overwhelming number of publications on the topic have appeared.At first, the research used to be focused on patient satisfaction as a condition to be satisfied in order to reach desired clinical outcomes, such as appointments or compliance with recommended treatment.Gradually, the interest shifted to patient satisfaction as a dependent variable.Nowadays, hardly any hospital will fail to incorporate patient satisfaction rating into their evaluation of care.

Concept of patient satisfaction
Patients carry certain expectations before their visit to the hospital and the resultant satisfaction or dissatisfaction is the outcome of their actual experience (Andrabi Syed Arshad et al., 2012).It can also be assumed that these patients have formed a positive attitude with regard to the service performance of the provider based on prior use of services (Sharma and Hardeep Chahal, 1999).A very important aspect on which patient satisfaction depends is 'nursing care' because nurses are involved in almost every aspect of client's care in hospital (Mufti Samina et al., 2008).
In general, patient satisfaction is defined as a measure of extent to which a patient is content with the health care which they receive from their health care provider.The patients coming to hospitals in this modern era are more aware and educated about the diseases, types of treatments and health care facilities that are available.This causes increased expectations from the healthcare system.Also, there is a tremendous rise in competition among the health care providers with the rapidly growing healthcare industry.So, that makes it even more important for providers to focus on excellent outcomes in terms of both treatment and patient satisfaction.
A positive patient perception towards the service provider highly increases the chances of the patient vising the hospital facility again in future.It helps in maintaining a loyalty base consisting of the patients.Similarly, patients would spread positive feedback about the hospital services by word-of-mouth which would attract many new patients to the same hospitals in the hope of getting the same treatment as the other patients did.

Factors affecting patient satisfaction
Patient satisfaction is a multidimensional aspect.There is no one factor that could be picked up that can say that this causes high satisfaction in patients.There are various factors from both provider's and patient's sides.These factors can be broadly categorized into four main headings:  Accessibility to services: If a person doesn't find the way to the care center at the time of illness that would obviously cause frustration to the patient.It is important that the hospital is located in such a place that the patient can reach there with ease.If a hospital is in a remote location or with poor connectivity to roads and rail or poor transport facility, then the patient would prefer a more accessible provider over it.The appointment registration service should be prompt, smooth and user-friendly.The staff from the provider side should provide adequate information politely to the caller.Online appointment should be made available in this age of technology, making it easier for many patients to get in touch with the hospitals.After reaching the facility there should be appropriate signage inside hospital premises to guide the patient towards the desired destination.If patient is travelling by private vehicles, he needs to have a parking space too.There should be security personnel and patient coordinators around to assist them as and when required.Architectural design should be made keeping patient's accessibility in mind.
 Interpersonal aspects of care -'Hospital is a centre of cure and healing': That means a holistic care should be provided.Not just physical illness treatment but psychosocial needs of patients and their relatives should be fulfilled as well.Patients and their caretakers (family members or relatives) seek timely consultations, empathy, explanation about medications, detailed explanation about procedure, good communication from nurses, treating doctors visiting them not less than twice a day when they are admitted and spending enough time with them etc.This is an extremely significant part of patient care and highly influence the patients' perception toward hospital.If hospital provides good clinical outcome but very poor interpersonal communication, that may lead to fall in patient satisfaction.Some scholars say that building interpersonal relation is not always very time consuming.Sometimes just a simple gesture of a nurse saying to patient, "May I sit with you while I talk to you?" can make the patient feel important and his satisfaction level may go up drastically.So, such simple strategies could be developed where a positive relation could be developed with the patients within no time.
 Technical aspects of care: These aspects include whether clinically right history is taken, written informed consent, right diagnostics and other procedures are done, appropriate medications are given, no medical negligence has been done, proper follow up advice is given etc.In case of surgeries, right patient, right site, right surgery should be maintained.For nurses, things like correct procedure to take blood sample, no needle stick injuries, maintaining hand hygiene, no medication errors etc. are few important technical aspects.These form the basis of the treatment and adversely affect the clinical outcome.If something goes wrong here, the patients' satisfaction is very likely to fall.
 Patient education/information/ attitude: The above three mentioned aspects are from the provider's side.But the consumer's attributes too affect how satisfied he or she would be from a service that is being provided.
Patients' knowledge about treatment and procedures, educational status, socio-economic status, background, place where patient stays, some prior experience of a hospital, his own optimistic or pessimistic attitudes etc. play a major role in placing a set of expectations in his mind from the hospital.

Review of Literature
Prahlad Rai Sodani, Rajeev K Kumar, Jayati Srivastava, Laxman Sharma in a study (2015) conducted in public health facilities found that patient was more satisfied with the basic amenities at higher health facilities compared to lowerlevel facilities.It was also observed that the patients were more satisfied with the behavior of doctors and staff at lower health facilities compared to higher level facilities.As indicated by Jones in 1978, tolerant fulfillment overview serve the human services association input in regards to obtaining choices, empower proposition to rebuild benefit conveyance and can be utilized to assess the impacts of arrangement change.
Riser, in the year 1991, said understanding fulfilment is only a reality that lies between a patient's desire of perfect nursing home and his view of the genuine nursing care that he gets.Sanjib Gogoi and Bhaben Choudhury in a study conducted in (2015) highlighted that overall, the patient satisfaction was good regarding the quality of health care services like clinical care, physical facilities, and diagnostic facilities, behavior of doctors and nurses and cost of treatment.The major concern was the low level of patient's satisfaction (38.6%) towards behavior of ward boys, sweepers and ayas.Swan, in the year 1985, concocted a thought that patient fulfillment is certain passionate reaction that is sought from psychological process in which persistent contrast their individual involvement with an arrangement of subjective benchmarks.
Kashinath KR (2010) conducted a study to assess that factor affecting patient satisfaction in a Dental College in Tumkur City suggests that measures have to be undertaken in order to fulfill the void by placing signboards, explaining the treatment procedure/ or any delay to build a good rapport with the patient.But only targeting a reduction in complaints is not a sign of improvement.What is needed is an effective evaluation of the accessibility of procedures and proof of real action, to encourage and support complaints.
Patient satisfaction was mandatory in all French Hospitals in the year 1996.A study was conducted by Laurent et al.
2006 in a tertiary hospital in France aiming to access the opinions of hospital staff towards the effect of in-patient satisfaction surveys on the quality improvement process of the hospital.The study resulted in 94% of the respondents revealing that the patient was able to judge the hospital services and quality, especially in its organizational, relational and environmental dimensions.
Swan (1985) came up with an idea that patient satisfaction is positive emotional response that is desired from cognitive process in which patient compare their individual experience to a set of subjective standards.Lender and Pelz (1982) suggested that patient satisfaction is an experience of an attitude, a response which is affective, which is related to both the belief that the care possesses certain attributes components dimensions and patient evaluation of those attributes and as the individual's positive evaluation of distinct dimension of health care.Lender and Pelz (1982) proposed a definition of patient satisfaction through various analyses of satisfaction studies.There were five socio-physiological variables proposed as probable determinants of satisfaction with health care.These are occurrences which actually take place and perhaps more importantly, the individual perception of what occurred, value that is an evaluation in terms of good or bad of an attribute or an aspect of a health care encounter, expectation which is belief about the probability of certain attributes being associated with an event or object, and perceived probable outcome of that association, interpersonal comparison in which an individual rates the health care encounter by comparing with all such encounters known or to experience by him or her, entitlement that is an individual belief that she or he has proper accepted grounds of seeking or claiming a particular outcome.

Components of satisfaction
We find a number of classifications of components that have been proposed, but only few of them are valid for specific health care context.Abdellah and Levine (1965) classified the components as adequacy of facilities, effectiveness of organizational structure, competency of personnel and the effects of care on consumers with professional education.While reviewing US patient satisfaction research, Riser (1975) reported that four components emerged: cost, convenience, the provider's personal qualities and nature of interpersonal relationship, and the provider's personal competency and perceived quality of care received.

Expectation
To express fulfilment, expressions have an imperative part while communicating.Stimson and Webb (1975) were among the first to propose that fulfilment is identified with the impression of advantages of care and the degree to which these meet the patient's desire.Riser (1975) and Fitzpatrick (1984) said that some meaning of fulfilment mirrors the possibility of desires.Abramowitz et al (1987) found that patients can hold diverse desire and fulfilment with particular parts of care, and furthermore arrived at a conclusion that for foreseeing tolerant fulfilment, desire and fulfilment with particular of care assume a vital part.In assessing fulfilment desire makes more mind-boggling importance of fulfilment.
A few reviews have demonstrated that abnormal state of nature of care prompts abnormal state of fulfilment and consequently it is not wrong to state 'Quality Assurance' is one of the device or segments of fulfilment.What's more, this has been demonstrated that fulfilment can essentially be compared with nature of nursing consideration.Bond and Thomas (1992) outlined the issue concisely unique levels of fulfilment may show alternate points of view on nursing care quality as opposed to various levels of fulfilment with a similar affair.Larson and Rootman (1976) expected or guessed that at whatever point the specialist's execution meets the patient's desire, the more will be the patient happy with the administrations offered by doctors.In any case, a couple year later reviews carried on this speculation in which connection between patient desire and general fulfilment have a tendency to be more fulfilled.Stimson and Webb (1975) recognized three classes of fulfilment viz foundation, connection and activity.Foundation desire is unequivocal desire comes about because of collected learning of the interview/treatment prepare.Despite the fact that foundation desire changes with disease and specific conditions, certain example of movement or routine are normal, and much fault-finders fixate on conduct which is inconsistent with the desires.Collaboration alludes to the patient assumption with respect to the data given by the doctors.
When he is needed for some questions, did the doctor satisfied what the patient anticipated from him?Did the specialist clarified to him about his infection and treatment?Desire of activity is only the move made by the specialist, for example, solution, reference or exhortation.Out of these three desires portrayed above, Stimson and Webb (1975) arrived at a conclusion that collaboration is the most essential desire.Filton and Acheston (1979) concentrated patient fulfilment as to five regular administration moves made by General Practitioners.Also, he partitioned activities desire into Ideal and Actual desire.Perfect manages move made by specialist as per patient's desires and Actual manages the activity which the patient thinks will be taken.

Patient characteristics
Persistent qualities, for example, social class, gender, age and so on are likewise the factors in charge of the patient fulfilment.Examiners on these factors reasoned that social, prudent, and statistic factors are essential variables vital for fulfilment.Fitzpatrick (1990) and Fox and Storm (1981) are the specialists who highlighted the absence of consistency of impact of these factors in fulfilment.The most essential among the above expressed factors is age of the patient.
Various information from different nations recommends that more established individual is more fulfilled than that of youthful people.A review done via Cartwright and Anderson (1981) found that more seasoned individuals or respondent expected less data from their doctors.
Proficiency or training status is likewise considered as one of the components for fulfilment.It has been seen from a large portion of the reviews that more noteworthy fulfilment is related with lower level of training.As indicated by Anderson and Zimmerman (1993) who completed reviews in two facilities of Michigan, patients with lower level of instructions are generally fulfilled.Correspondingly, Schutz et al (1994) found that higher instructive fulfillment was firmly connected with disappointment among the patient's experiencing colonoscopy.
The Relationship amongst fulfilment and 'social class' is less predictable, an issue being that financial factors are frequently not surveyed.Lobby and Dorman (1990) saw societal position as having almost critical connection with fulfilment, however, more noteworthy fulfilments were related with higher economic wellbeing.The creator added that it was puzzling to the slightest, that outcome for economic wellbeing and instruction went in inverse bearing.
All in all, there are a smaller number of studies which reasoned that sexual orientation of patient don't influence fulfilment values.In any case, Khayat and Salter (1994) announced that men were more fulfilled than ladies with the general administrations given by the general expert.Another review in UK found that female patients will probably whine of inflexible timetables and absence of protection than men.Holding up room office included water office, seating arrangement, portable charging points, A.C usefulness and so forth.

Measuring patient satisfaction
Patient's satisfaction is a useful measure to provide an indicator of quality in healthcare and thus, needs to be measured frequently (Athar Mohd, 2014).Patient satisfaction embodies the patient's perceived needs, his expectations from the health system, and experience of healthcare.This multidimensional concept includes both medical and non-medical aspects of healthcare (Fatima Mukhtar, 2013).Measuring the quality of intangible service products has become a great challenge for managers and administrators in the health services industry (Athar Mohd, 2014).Patient satisfaction surveys have been continuously evolving and are increasingly identified as yardsticks to measure success of the service delivery system functional at hospitals.

Patient Satisfaction and Patient Experience
The terms patient satisfaction and patient experience are often used interchangeably, but they are not entirely same.To assess patient experience, one must find out from patients whether something that should happen in a health care setting (For example clear communication with a provider) actually happened or how often it happened (AHRQ, 2016).Satisfaction, on the other hand, is about whether a patient's expectations about a health encounter were met.Two people who receive the exact same care, but who have different expectations for how that care is supposed to be delivered, can give different satisfaction ratings because of their different expectations (AHRQ, 2016).Patient satisfaction refers to the level of contentment patients have for one or more aspects of care.The patient can be asked whether he or she was satisfied or dissatisfied with the hospital room.But this only implies about a small portion of service that is provided to the patient.The patient experience begins with the very first touchpoint between a patient and caregivers.This can be a phone call, access to hospital's website, parking lot, signage or facilities.The sum of all these things and many others, how they fit together, this is called patient experience.By listening to patients and working to deliver an experience that matches their wants and needs, patient satisfaction levels can be positively impacted.Good patient experience is an intrinsically valuable goal, and payers are increasingly emphasizing patient experience as part of care quality.Patient experience scores reflect factors as diverse as a hospital floor's noise level throughout the night and how well nurses and doctors communicate with patients have become key hospital performance measures.Although as easy as it sounds, it is not so to measure patient experience.Patient satisfaction on the other hand can be quantified with a scorecard rating.Patient experience needs to be narrated by the patient and the relatives in their own language and terms.Health care industry is slowly moving a step forward towards patient experience.Patient experience and satisfaction is intrinsically valuable, as strong physician-patient communication, empathy, and patient comfort require little justification.Patient satisfaction is also associated with better health outcomes and greater compliance.

Outpatient Department
Outpatient department (OPD) is the first point of contact of the hospital with patients and serves as the shop window to any healthcare service provided to the community.The care in the OPD is believed to indicate the quality of services of a hospital and is reflected by patients' satisfaction with the services being provided (Athar Mohd, 2014).Any patient that falls sick comes to either Emergency Department or to the OPD of any hospital.After being consulted from these two entry points, the patient could be sent home, could be sent for diagnostics or laboratory tests, could be admitted as in-patient, sent in ICU etc., depending on the criticality of the illness.So, we can see that all other departments of hospital are encountered at later stages.But OPD is the entry point and visited most frequently by patients.OPD encompasses the highest footfall in a hospital.So, providing best quality services in outpatient department becomes a priority.If the patient is satisfied by the OPD services (like comfortable waiting area, less waiting time, consultation by doctor, ease of information, cleanliness etc.), he or she is more likely to visit the hospital on a subsequent requirement.At the same time, patient's family members and friends are also most likely to visit by receiving positive feedback from the patient.Moreover, patient makes an opinion and perception about other services and departments of the hospital after attending OPD.

The role of OPD Department
 To provide for the community a major source of specialist diagnostic medical opinion by mixing the knowledge, skills and ability of the specialist and supported by the resources of the hospital  These include physical resources and the materials and machines, which facilitates early diagnosis with support of paramedical staff and other allied health profession. To treat on ambulatory and domiciliary basis all cases which can be treated in the OPD (e.g., surgery for hernia and varicose veins). To refer patients for admission to the hospital of those who need it.About 80% of total admissions are through OPD. To promote health of the individuals under care in the OPD by means of health education. To carry out after care and medical rehabilitation, when necessary, after discharge from hospital. To train medical students house physicians and other professional staff such as nurse and technicians with valuable and diversified clinical experiences.
 To compile, collate and analyse records of patients using outpatient services for epidemiological clinical research and for periodic assessment of clinical outcomes. To carry out preventive and promotive services through provision of immunization, screening, antenatal, well baby, counselling etc. • Then according to appointment schedule doctor's consultation and initial examination is done.

Services of OPD
• If any diagnostic/laboratory procedure is required, patient is sent to the respective area for the diagnosis or sample collection.
• Then the payment is made for at the billing counter.
• If there is need of admitting the patient, then patient is sent to the IPD right after consultation after coordinating with the admission in charge.If only medicines are prescribed by the doctor, patient goes to pharmacy, buys medicine and then go home.

Challenges of creating a high patient satisfaction: (Sara Heath, 2017)
Driving high patient satisfaction in hospitals is a challenging task.Patients are complex and unique, each with a different set of needs and preferences.Add to that the growing to-do list for today's clinicians, and supporting patient satisfaction becomes increasingly demanding.Hospitals and healthcare system are also developing towards putting the patients at the priority of care.The pay for performance model is changing to value-based care models.One of the key values of emerging healthcare facilities talk around 'patient need approach', 'patient-centric', 'patient comes first' and so on.Providers must identify the top challenges to driving high patient satisfaction levels and develop targeted strategies to overcome them to yield optimal results.

Providers and patients not on the same page
What a provider think of patients' expectations may not be same as what the patient actually expects.Hospitals may consider top priorities as friendly and accommodating staff, improving patient provider communication, easy appointment scheduling.But the patient's top priorities could be short appointment wait times, access to out of pocket estimates, not feeling rushed during appointments.It is important to find out this gap and work on it meet the patient's expectations.

Time constraints limit patient-provider communication
Creating a deep and empathetic relationship with the patient is an important strategy for building patient satisfaction.However, these relationships are lagging as nurses and physicians become more pressed for time.The patient volume is going up in all hospitals plus the nurses have to complete a lot of documentation work, which causes time crunch.However, a positive relation can be built within a few minutes of attending the patient by simple empathic gestures.

Difficulty incorporating family members in care
A patient coming to hospital to receive treatment is hardly ever alone.Generally, there is some relative or family person joining in the care encounter.These stakeholders are almost as important as the patient when it comes to satisfaction level.But many hospitals are not able to give them due support.Many times, they influence patient satisfaction nearly as much as the individual receiving treatment.Things like communicating with them pre-operatively, giving them

Study population
The study population is those patients who had visited the hospital and utilized the health services in OPD in hospital in particular month.

Data analysis
The study had been conducted in a public hospital, Bhojpur, Bihar to determine the patient satisfaction with the health care services provided at the outpatient department of the Hospital.

Sex wise distribution
The results in the table1 shows that majority of the patients were male (52.4%) from overall respondents and while female patients were only (47.6%).
Table 1 Sex wise distribution of patients attending the OPD

Sex Percent
Male 52.4 Female 47.6 Total 100

Age
Out of the 100 patients, the youngest patient was 22 years old and the oldest was 75 years old.For the convenience of analysis, the researcher divided the age into three main groups as follows: • 20 years to 40years • 40 years to 60 years • 60 years and above > 60 yrs 10.2

Education status
Education status of the respondent was classified in the following four type: • Illiterate-this category mainly included people who cannot read and write.
• School-this category included education till 10th pass or failed.
• Graduate-this category included any graduation or relevant diploma.
• Postgraduate-this category included any post-graduation The vast majority of the respondents were 10 th Pass.They basically had essential level of training and they added to around (69.6%), just a single respondent from the aggregate 150 patient was postgraduate, and among other respondent (19.2%) were graduate and rest of the other respondent were non-school going what's more, it contributes around (10.8%)

Economic Status
With respect to normal family in every month in Rupees, the least sum that wins were Rs.4000 and the most elevated sum acquired was Rs. 40000.The patients with low wage were (73.6%), direct pay was (20.4%), and high salary was (6%).Table 4 demonstrates the investigation of wage of patients.
For the comfort of investigation, the researcher partitioned the pay status into three classes as follows: • Low pay i.e., earning less than Rs.15000/month

Physical arrangement for the OPD
The levels of patient fulfillment of OPD patients demonstrates that about (14%) of the patients were not happy with building arrangement for the OPD The reactions of the patients with respect to the waiting room facility additionally uncovers that approximately one fourth of them were most certainly not fulfilled (26%).

Registration procedure
Similar trend was observed regarding satisfaction of the registration procedure (84%) as what we have seen in the attention given by the doctors  Highly Unsatisfied 8 8 100 100

X -Ray
The facilities provided in the Xray room were satisfactory as about (16%) of the patients were not happy with the services provided in that department Highly Unsatisfied 10 10 100 100

Laboratory service
In lab services, people were mildly not satisfied, similar to ECG, its satisfaction level was (76%)    Behavior of the Doctors was found to be satisfactory by the patients as 74% of the patients were more and less satisfied with the behavior of the Doctors.Same is the case with the Nurses.Behavior of the Nurses was found to be satisfactory by the patients as 74% of the patients were more and less satisfied with the behavior of the Nurses.We have divided infrastructure facilities into building arrangement facility and waiting room facility.So, if we see overall satisfaction level of the patients in the both contexts then it came about (68%) while if we look separately into building arrangement facility and waiting room facility then it was 70% and 60% respectively.
First impression that is etched in patients mind is the cleanliness of the hospital and there is scope of improvement in this aspect which amounts to 69% of overall satisfaction and we can improve its satisfaction level by another 20% at the minimum.Behavior of the staff is the most important factor of patient coming again to the hospital.But if we see the overall behavior of the staff, then the level of satisfaction is comparatively less which is 68% thus, we can see that there is scope of improvement in this aspect while on the same note, the dissatisfaction level overall towards behavior of staff is 25% which can be reduced and consequently, we can increase patient retention.If we see satisfaction level of patients towards Behavior of the doctors, Nurses, Paramedical staff, Class IV employees separately then it is 66%, 68%, 72% and 68% respectively.

Conclusion
The study concludes the overall patient satisfaction of government hospital.The results depicted in the study are highly alarming.A government hospital with such potential cannot sustain with such dissatisfying patients.The management needs to take necessary steps in order to repair its deteriorating image in the public domain.
Overall if we see the satisfactory level of the patients approximately (70%) of the patients were satisfied with the services provided by the hospitals while around (20%) of the patients were unsatisfied with the services with the hospitals and rest (10%) were undecided with the hospital services.
The hospital Infrastructure facilities has a highly dissatisfaction.Need to change the building infrastructure.One of the factors which a patient looks in the whole services provided by the hospital is that doctor patiently listens to their problems and the satisfaction level on this factor was quite good which was approximately 80% while level of dissatisfaction was only 20%.It was a good indicator that patient was feeling attended by the doctor which increase his loyalty towards hospital.Patient satisfaction from housekeeping was at the lowest.The first impression of any hospital is the behaviour of staff and general hygiene, which in this case seems to be very poor.
Behavior of the staff is the most important factor of patient coming again to the hospital.But if we overall see the behavior of the staff then the level of satisfaction is comparatively less which is 68% thus, we can see that there is scope of improvement in this aspect while on the same note the dissatisfaction level overall towards behavior of staff is 25% which can be reduced and consequently, we can increase patient retention.If we see satisfaction level of patients towards Behavior of the doctors, Nurses, Paramedical staff, Class IV employees separately then it is 66%, 68%, 72% and 68% respectively.
We have put forward few recommendations in order fulfil this gap and to gain the loosing trust and credibility of the institute.A few major changes with outsourcing the housekeeping unit along with security and assistance services should leave a positive impact.There is also a need for communication skills workshop for both doctors and nursing staff in order to be more empathetic towards patient care.

Recommendations
 The need the quality improvement and patient safety initiatives in the hospital.
 Initiate the public private partnership (PPP).PPPs could provide a good opportunity to facilitate access to health care services, especially in remote areas.Governments should consider long-term plans and sustainable policies to start such partnerships in public health hospitals.
 Major scope of improvement can be done in the cleanliness level of the hospital OPD at present after every 4 hrs cleanliness is done which we can quash and introduce the system of regular cleanliness of the hospital that an employee will cover an area and once it is completed then again, he will clean that area after an interval of 30 minutes.
 To enhance the cleanliness, we should allocate areas to the housekeeping employees and that employee is responsible towards the cleanliness of that area which will increase the accountability of the employees.
 Introduction of the Flipper for sweeping as currently it is not in use in the hospital as it will reduce the requirement of the housekeeping employees.
 Hospital waiting room facility is not enough to satisfy patients as the level of satisfaction is only 60%.Currently attendants of the patients who are in ICU are also waiting in the OPD waiting area and which crowds the area and there is no separate facility for the attendants of the ICU patients but there is a free space on the first floor which can be utilized by the patients' attendants, and we can decry the OPD waiting area.
 Human Resource Department should initiate Training program for the hospital staff enhance empathetic behavior towards patients and it should be conducted regularly

Disclosure of conflict of interest
No conflict of interest.

Statement of informed consent
Informed consent was obtained from all individual participants included in the study.

Figure 1
Figure 1 Conceptual framework of factors affecting patient satisfaction (Courtesy-Scientific research publishing)

Figure 2
Figure 2 Framework of patient satisfactionPatient satisfaction alludes to the people who goes to the outpatient division of any doctor's facility or who visits the clinic for getting social insurance administrations.Fulfilment alludes to the judgments of the patient or the component which gives him satisfaction or delight of craving.Satisfaction alludes to client level of endorsement when contrasting an item's apparent execution and his or her desires.The markers of patient fulfilment in this exploration contain openness, entomb individual way of specialist co-op, physical condition, accessibility of medicinal care assets, and nature of therapeutic care.Interpersonal manner of service provider alludes to the path in which the wellbeing specialist co-ops communicate by and by with the patients.This incorporates conduct of the staff in reception counter amid collaboration with the patient, cooperation of doctors with the patients in OPD, and conduct as far as (politeness, support, worry of disease, and uniformity in treatment) by Physicians, Nurses, Assistants, and other staff.Physical environment alludes to the components of the setting in which the wellbeing administrations are given.This incorporates loveliness of nature, clearness of sign and bearings, and cleanliness of the OPD as seen by the patients.Holding up room office included water office, seating arrangement, portable charging points, A.C usefulness and so forth.
Patient registration • Doctors consultation • Diagnostic procedures • Immunization • Well baby clinic • Physiotherapy and Rehabilitation • Speech therapy • Waiting area for patients and attendants 4.5.1.Patient flow in OPD • Patient comes to the OPD and they get a patient registration done where they receive a number.All details of patients are registered in the hospital register book.

Table 2
Age wise distribution of patients attending the OPD

Table 3
Education status of the patients attending the OPD

Table 4
• Moderate pay i.e., earning between Rs. 15000 to Rs. 25000/month.• High pay i.e., earning above Rs.25000/month Economic status of the patients attending the OPD

Table 5
Physical arrangement for the OPD

Table 6
Waiting room facility

Table 7
Registration procedureMajority of the patients were moderately satisfied with the facilities provided in the ECG Room which is about (72%).

Table 8
Diagnostic facilities-ECG Facility

Table 9
Diagnostic facilities-X -Ray Facility

Table 10
Diagnostic facilities-Laboratory serviceCleanliness level of the OPD was not as satisfactory as other services as the level of satisfaction is only (66%).

Table 12
Cleanliness-Examination room

Table 14
Behavior of hospital staff: -Doctors

Table 15
Behavior of hospital staff: -Nurses

Table 16
Behavior of hospital staff: -Paramedical Staff

Table 17
Behavior of hospital staff: -Class IV

Table 19
Cleanliness in OPD: -Comparative percentages

Table 20
Behavior of the Staff: -Comparative percentages