Abstract
Objective
The aim of this study is to examine the experiences of outpatients and inpatients at University of Health Sciences Türkiye, Ankara Etlik City Hospital and to investigate the factors influencing patient satisfaction in the integrated healthcare campus environment.
Methods
A cross-sectional research design was employed, and a patient experience survey was administered to both outpatient and inpatient groups. The survey assessed various dimensions of patient experience, including communication with healthcare providers, hospital environment, medication information, discharge information, and overall satisfaction. The collected data were then subjected to analysis using both descriptive and comparative statistical methods to identifying significant differences based on the demographic characteristics of the participants.
Results
The results indicate that patients generally express high satisfaction with the healthcare services provided, particularly in terms of communication with healthcare providers and the hospital environment. However, experiences were reported as average regarding appointment scheduling, waiting times, and accessibility of transportation. The analysis revealed significant disparities in patient experience based on demographic characteristics such as age, educational attainment, and general health status. Patients aged 65 and above, those with lower education levels, and those reporting better health status generally scored higher satisfaction levels.
Conclusion
The study suggests that while patient experiences at University of Health Sciences Türkiye, Ankara Etlik City Hospital are generally positive, improvements are needed in appointment systems, transportation infrastructure, and waiting area comfort. The findings of this study offer valuable insights that can inform the enhancement of healthcare quality within the context of integrated health campuses.
Introduction
The primary objective of healthcare services is to improve the health status of individuals receiving care, ensure a positive experience, and to facilitate their discharge from the hospital with satisfaction. Patient experiences, recognised as a pivotal quality indicator in the monitoring and evaluation of health systems, are instrumental in addressing patients’ needs, enhancing their satisfaction, and implementing improvements(1). Consequently, the measurement of patient satisfaction and experience is frequently favoured. These measurements provide valuable insights for the improvement of healthcare services(2). Furthermore, they serve as pivotal instruments from a patient policy standpoint, aiding in the support of healthcare delivery, the formulation and management of health policies, the fulfilment of legal obligations, and the protection of patients’ rights(3). The adequacy of the service provided is determined by the patient’s perceived level of service quality, which is developed over time in relation to the institution. This perception is also influenced by the institution’s actual performance in delivering a specific service(4).
In the contemporary healthcare sector, the implementation of strategies aimed at enhancing patient satisfaction, ensuring reliability, and fostering patient loyalty has become imperative for organisations in the market. To implement these strategies effectively, it is crucial to heed the voices of patients who directly experience the service. In the context of intensifying competition within the healthcare sector, providers are moving beyond the provision of medical treatment and care to include the delivery of a superior standard of comfort. Consequently, patient feedback, derived from their experiences, emerges as a valuable source of information for enhancing the quality of healthcare services. This information should be actively utilised as a fundamental quality indicator in the planning and management of healthcare delivery. Positive patient experiences have been shown to engender memorable impressions, thereby strengthening satisfaction and loyalty(5).
It is evident that patients who have positive experiences and are satisfied with the care they receive provide long-term benefits to healthcare providers. Their favourable behaviours, such as praising or recommending the institution, contribute significantly to enhancing the competitive advantage of healthcare organisations(6). Given that the cost of retaining existing patients is considerably lower than that of acquiring new ones, patient loyalty plays a critical role in ensuring the sustainability of healthcare institutions within the sector(6). In the context of escalating costs associated with attracting new patients and intensifying market competition, healthcare providers are progressively orienting their strategic focus towards fostering customer loyalty(7). In this context, while customer loyalty is regarded as the currency of the 21st century for businesses, patient loyalty is considered one of the most important competitive advantages for healthcare organizations(8).
Patient experience is a critical indicator of the effectiveness and efficiency of a healthcare system. Consequently, enhancing patient experience within healthcare organisations has emerged as a pivotal concern for administrators, clinical leaders, and policymakers. Patients utilising healthcare services have expectations of receiving the highest quality of care, accompanied by commensurate service standards. In this regard, the patient is the only actor who experiences the entire journey by connecting every step of the healthcare process. Consequently, hospitals can enhance the quality of services provided by discovering and understanding the individual patient journey(9). Patients who report negative experiences often exhibit delayed responses to treatment and have lower levels of adherence. The repercussions of substandard patient experiences are manifold, encompassing not only diminished patient health outcomes and treatment effectiveness but also the escalating costs of healthcare(10).
In response to the need for qualified hospitals and hospital beds in Türkiye, integrated health campuses -commonly referred to as city hospitals- have been established through the Public-Private Partnership model. The objective of these hospitals is to integrate geographically dispersed and hierarchically diverse healthcare institutions within a centralized system, harmonize fragmented administrative structures, and transfer financial responsibilities to private sector investors in order to share financial risks(11, 12). Furthermore, the intention is to enhance the delivery of healthcare services by utilising advanced technology and a highly qualified workforce, while also aiming to improve patient safety and satisfaction. The hospitals have been designed to provide a wide range of healthcare services under one roof and are structured as major regional medical centres. Türkiye’s strategic restructuring and modernisation of these large-scale healthcare facilities is driven by two key objectives: the enhancement of healthcare service quality and the attainment of a more prominent global healthcare market position(13).
The primary focus of this study is to assess the evaluations of patients who have received services from city hospitals, which were established within the framework of this objective. In this context, the study aims to evaluate the experiences of patients who received care at University of Health Sciences Türkiye, Ankara Etlik City Hospital. Specifically, the study seeks to compare the experiences of outpatients and inpatients based on their individual characteristics and reasons for admission, focusing on their general perceptions of outpatient clinics and their propensity to recommend the hospital. Another objective of the study is to examine the relationship between outpatient experience, general perception of outpatient clinics, and recommendation scores, as well as the relationship between inpatient experience and recommendation score. The evaluation of patient experiences across the continuum of care, from outpatient clinics to inpatient wards within an integrated health campus such as University of Health Sciences Türkiye, Ankara Etlik City Hospital, is of paramount importance in identifying both the strengths and areas in need of improvement at different stages of service delivery. Furthermore, the comparative analysis of experiences between outpatients and inpatients may reveal how service differences are perceived by patients and thus contribute to the development of a more equitable, effective, and sustainable healthcare delivery model.
Materials and Methods
Patients and the Study Design
The study population comprised patients who received services from University of Health Sciences Türkiye, Ankara Etlik City Hospital (decision no: 09/231, date: 22.11.2023. According to data obtained from the official website of the Ministry of Health, a total of 5.016.501 outpatient visits and 118.032 inpatient admissions were recorded at the hospital between September 28, 2022, and September 28, 2023. The minimum sample size was calculated to be 385 for outpatient surveys and 383 for inpatient surveys, based on a 95% confidence level, a 5% margin of error, and 80% power.
Patients who received services from the clinics and outpatient departments of the general hospital, neurology and orthopaedics hospital, chest and cardiovascular hospital, oncology hospital, obstetrics and gynaecology hospital, and physical therapy and rehabilitation hospital were included in the sample. however, patients from the paediatric hospital, psychiatric hospital, emergency departments, and intensive care units were excluded from the study.
A stratified sampling method was employed to ensure representativeness across the institutions within the health campus. The allocation of strata was proportional, with hospital-specific patient volumes (both outpatient and inpatient) being utilized as the basis for this calculation. Participants were selected through random sampling, with participation being a voluntary basis. The final sample comprised 421 outpatients and 406 inpatients who completed the questionnaires in their entirety. Data were collected between January and February 2024.
This descriptive cross-sectional study employed structured face-to-face questionnaires. The assessment of outpatient experiences was facilitated by items adapted from the care quality commission questionnaire, while the measurement of inpatient experiences was conducted using the hospital consumer assessment of healthcare providers and systems survey. The net promoter score (NPS) was utilised to assess the likelihood of recommending the hospital at the conclusion of each questionnaire. The collection of inpatient data occurred after discharge decisions had been made but prior to patients’ physical departure from the hospital, whereas the collection of outpatient data was undertaken immediately following clinical consultations.
The reliability of the questions used to assess the experiences of the patients who participated in the study was evaluated using the internal consistency coefficient (Cronbach’s Alpha, α).
The overall reliability level of the outpatient experience questionnaire was found to be 0.920. This indicates that the set of questions developed to evaluate patients’ outpatient experiences is internally consistent and therefore reliable.
The overall reliability level of the inpatient experience questionnaire was determined to be 0.764. This suggests that the set of questions designed to assess the inpatient experience also demonstrates internal consistency and can be considered reliable.
Statistical Analysis
The data were summarised using descriptive statistics, including frequency, percentage, mean, and standard deviation. The normality of the experience scores was assessed using histogram plots, Kolmogorov-Smirnov/Shapiro-Wilk tests, and Skewness-Kurtosis coefficients. Following the confirmation of normal distribution, independent samples t-tests, were employed for comparisons between two groups, and analysis of variance (ANOVA) was used for comparisons across more than two groups. Tukey’s honestly significant difference test was conducted for post-hoc analyses following significant ANOVA results. Pearson correlation analysis was used to evaluate relationships between variables. All statistical analyses were performed using SPSS version 23, with the level of statistical significance set at p<0.05.
Results
Results of Outpatient
Table 1 shows that the 421 outpatients participating in the study were predominantly female (60.1%) and aged between 30 and 44 (36.3%). The majority of participants had a high school diploma (38.7%) or an associate/bachelor’s degree (40.9%), with only 1.9% holding a master’s or doctoral degree. The majority of the participants were covered by SGK (98.0%), while a small proportion had private health insurance, and another small proportion used contracted institutions (1.0% each).
A perusal of Table 2 reveals that outpatients have a favourable perception at a "good" level of the hospital’s diagnostic and treatment processes, accessibility, and outpatient services.
As demonstrated in Table 3, a statistically significant discrepancy was identified in the “diagnosis and treatment processes” subdimension based on age (f=3.140, p=0.025). The 18-29 age group exhibited higher scores (4.00±0.67) compared to those aged 65 and above (3.58±0.71). Furthermore, a statistically significant discrepancy was identified in the “accessibility” subdimension based on the rationale for hospital attendance (f=2.557, p=0.014), with patients attending for postoperative follow-up (4.60±0.23) demonstrating higher accessibility scores compared to those visiting for test results (3.72±0.57).
As demonstrated in Table 4, the subdimensions “diagnosis and treatment processes” and “accessibility” of outpatient experience exhibited a strong correlation both with each other and with the “general perception of the polyclinic” variable. The relationship between these variables and NPS was found to be moderate.
Results of Inpatients
Table 5 presents the results related to the individual characteristics of inpatients. The majority of the participants were female (n=244), aged between 45 and 64 years (n=141), had received a primary school education (n=164), and had SGK social security (n=181). With regard to general health status, the majority of participants perceived their health as good (n=251).
As demonstrated in Table 6, the analysis indicates that inpatients have a favourable perception of communication with nurses and doctors, communication regarding medications, and the hospital environment. Given that the response options for discharge information were “yes” and “no,” further analysis is needed to determine if the perception of discharge information is at the desired level.
Table 7 analysis shows significant differences in hospital environment scores by age (f=2.805, p=0.040), with those aged 65 and above scoring higher than the 30-44 and 45-64 age groups. Both medication communication scores (f=2.727, p=0.044) and discharge information scores (f=2.556, p=0.048) were higher for primary school graduates compared to associate/bachelor’s graduates; NPS scores were higher for associate/bachelor’s graduates, compared to high school graduates (f=2.574, p=0.043). Furthermore, individuals who self-reported “very good” health status demonstrated significantly elevated scores across all subdimensions and the NPS.
Table 8 provides an overview of the correlation values between the sub-dimensions of the inpatient experience survey and NPS. In this context, statistically significant relationships were identified between all sub-dimensions and NPS, with the exception of the relationship between the sub-dimensions of discharge information and hospital environment. The strength of the relationship indicates a moderate correlation between “nurse and physician communication” “hospital environment”, and NPS. Conversely, the relationships between the remaining sub-dimensions and NPS were found to be weak.
Discussion
The objective of the study is to assess individuals’ experiences receiving medical care in city hospitals. Although patient satisfaction surveys have been conducted for many years in Türkiye, the measurement of patient experience is a relatively new concept. In the context of large and complex healthcare delivery environments, such as integrated health campuses, studies that evaluate patient experiences across different service levels, including outpatient and inpatient services, in a holistic manner, are quite limited. Nevertheless, such structures provide a significant foundation for exploring the impact of different departmental operations on patient perceptions.
The study examines seven dimensions of patient experience as outcome measures: diagnostic and treatment processes, ease of access, overall outpatient clinic perception, communication with nurses and physicians, communication about medications, discharge information, and hospital environment. The study also explores the potential influences on the hospital experience, including factors such as appointment and waiting times, geographical location, physical size, staff-to-patient ratio, communication, and hospitality services.
The majority of outpatients are female and belong to the middle to older age groups. A subsequent examination of their educational attainment revealed that the proportion of high school and university/graduate school graduates was comparable. These findings are consistent with those reported by Erdem and Pirinçci(14), although it is hypothesised that this congruence is attributable to the predominance of female patients and older age groups within the hospital population, and the absence of stratification by gender and education level during the sample selection process. With respect to the frequency of hospital visits, a significant proportion of patients had visited the hospital 2-8 times in the past year, which is below the national average in Türkiye(15).
Patients receiving outpatient care report satisfaction with both the quality of communication with their healthcare providers and the duration of their medical examinations. The impact of effective doctor-patient communication on the quality of care has been well-documented(16). Furthermore, patients with higher health literacy report a more positive treatment experience(17). Participants expressed high satisfaction with privacy during examination, which is consistent with findings from a study in Konya(18).
With regard to accessibility, patients expressed satisfaction with appointment scheduling, and the frequency of appointment date changes initiated by the hospital was low. The percentage of patients whose symptoms worsened while waiting was lower than a UK study(19). Nepal et al.(20) found that clear expectations reduced patients’ concerns and positively impacted their treatment experience.
Statistically significant differences were identified in outpatient diagnosis and treatment scores according to age. In contrast to the findings of this study, McFarland et al.(21) reported that younger and more educated patients exhibited lower levels of satisfaction. The overall perception of outpatient clinic services was 78.6% (3.93), a figure comparable to data from the UK(22).
Research on nurse-patient communication highlights that inpatient dissatisfaction is attributable to communication deficiencies(23). The present study yielded favourable outcomes in the communication subdimensions related to interactions with nurses and doctors. Concurrently, studies by Hitawala et al.(24) have demonstrated the efficacy of visual brochures in enhancing doctor-patient communication. Chen et al.(25) emphasized that satisfaction with healthcare staff is a significant factor influencing inpatient satisfaction.
In the context of the medication subdimension, participants expressed satisfaction with the information provided by nurses regarding their treatments. Wilkes et al.(26) found that inpatients preferred to be informed about the side effects and benefits of medications, and this knowledge positively contributed to treatment.
In the discharge information subdimension, the majority of participants expressed positive sentiments regarding discharge and subsequent care. The importance of written discharge instructions in enhancing patient satisfaction is underscored by the findings of(27). Patel and Bechmann(28) also found that patient education improves not only satisfaction but also the quality of follow-up care.
In the hospital environment subdimension, participants reported positive experiences regarding noise levels and cleanliness. Taylor et al.(29) identified noise as the predominant sleep disruptor among hospitalized patients. Pyrke et al.(30) further corroborated the efficacy of single rooms in mitigating noise disturbances and enhancing sleep quality.
Statistical analysis revealed significant variations in hospital environment scores based on age, with patients aged 65 and above demonstrating higher scores compared to younger age groups (f=2.805, p=0.040). These findings are consistent with those of(31).
A further analysis compared educational levels, with primary school graduates demonstrating higher scores in the medication communication and discharge information subdimensions. These findings are consistent with those reported by Jalil et al.(32) who found that lower levels of education were associated with poorer outcomes.
Study Limitations
The present study was subject to several limitations. The dearth of analogous studies within Türkiye and internationally impeded the establishment of direct comparisons. The research focused on a single hospital campus, so the findings may not be generalizable to other healthcare settings. The potential for selection bias arises if patients who declined participation differ significantly from those who accepted. Furthermore, the exclusion of patients who did not speak Turkish may have influenced the results. Despite the study’s objective to establish a comprehensive framework, further research is necessary to investigate potential variations related to language, ethnicity, and cultural factors. Furthermore, because patient interviews were conducted immediately prior to discharge, the accuracy of reported experiences may have been compromised since patients had not yet undergone the post-discharge process.
Conclusion
This study, which examined the experiences of patients receiving outpatient and inpatient care at Ankara Etlik City Hospital, found that patients were generally satisfied with the services provided and reported positive experiences. Nevertheless, issues such as average experiences in appointment scheduling, waiting times, and suboptimal accessibility in transportation suggest that improvements in appointment systems, transportation infrastructure, and waiting area comfort could enhance the overall patient experience.
