Afternoon Clinics at Suhar Hospital: Assessment of Patient’s Satisfaction and Perceptions

Background: Afternoon clinics have gained popularity as an alternative to traditional daytime clinics, providing patients with the convenience of scheduling appointments and overcomig potential barriers such as work obligations or transportation issues. Despite their increasing prevalence, there is limited research on the impact of afternoon clinics on patient satisfaction. Therefore, this study seeks to contribute to the existing literature by exploring patient perception and satisfaction with the afternoon clinics at Suhar Hospital. Methods: This cross-sectional survey aimed to assess patient perception and satisfaction with the afternoon clinics at Suhar Hospital. The study targeted outpatients attending both morning and evening clinics during May-June 2023. A total of 100 patients aged 18 years and above participated in the study. At the clinics, patients were provided with a barcoded online self-reported questionnaire to be filled and submitted during their visits. The advances of afternoon appointments was assessed using a five-score likert scale of 11 items and found to have an excellent internal consistency of 0.957. Descriptive and inferential statistics (at 5% level of significance) were utilized to analyze the data. Results: Of the 100 patients submitted the survey, 58% were females, 73% aged 30 years and above, 53% held a university degree and 56% were employed. Most participants (67%) visited the hospital during the morning shift with 44% were visiting endocrine clinics and 68% came for follow-up visits. Overall, 83% of participants expressed satisfaction with health services received at current visits. The majority of afternoon appointments (67%) were first visit while the majority of moring appointments (85%) were follow-up visits


Introduction
Afternoon clinics have gained popularity as an alternative to traditional daytime clinics, providing patients with the convenience of scheduling appointments and overcomig potential barriers such as work obligations or transportation issues.Overcrowded outpatient departments is known to negatively affect patients experience [1].In public hospitals, clinics are crowded in morning time resulting in long waiting time [2].In addition, healthcare providers realized that some individuals are unable to seek medical attention during normal business hours due to work or other commitments [3].There is a paucity of studies looking at the effect of afternoon clinics on patient satisfaction.Patients have some expectation during and even before direct contact with health services as well as healthcare providers [4,5].Involving patient's satisfaction and expectation also fulfill the requirement of health providers to be patient-centered [6].Multiple studies have been conducted to investigate patient satisfaction and its influential factors.According to Aiken et al. (2012), several predictors of patient satisfaction including communication, responsiveness, and respectful treatment are significant predictors of patient satisfaction [3].Ogaji and Mezie-Okoye (2017) revealed that waiting length to get an appointment and the time of appointment are significant factors of satisfaction [5].Thus, the assessment of patients' satisfaction is considered an important tool to assess the quality of health services and solving its related problem for further improvement [2,7].Offering afternoon clinics is an initiative to increase patient satisfaction, which has found to successfully improve the satisfaction for certain specialties [2].Patients appreciate the flexibility of scheduling appointments after work or school, resulting in fewer missed appointments.This, in turn, reduces appointment cancellations and rescheduling, which can burden healthcare providers financially.Additionally, afternoon clinics allow healthcare providers to optimize their time and use resources effectively, leading to better care outcomes.Feeney et al. (2005) found that the majority of surveyied patients prefer attending outof working hours clinic, such as weekend clinics, due to their flexibility in terms of finding someone to accompany them to the hospital, managing family commitments and minimizing parking restrictions [8].Implementation of afternoon clinics has shown promising results in improving patient satisfaction and optimizing healthcare resources.Comparing the satisfaction of patients attending afternoon clinics versus morning clinics reveals significant differences in certain aspects.Pini et al. (2014) found that afternoon patients reported higher satisfaction rates in terms of waiting waiting time for appointments, appointment day and time, clinic workload, time spent for examination, crowd and privacy [2].These operational factors experienced by patients attending morning appointments directly impact their satisfaction with the quality of provided healthcare services.Additionally, individual factors such as patient's health condition, educational level and sex have been found to influence satisfaction levels [2].Further research is needed to explore the impact of afternoon clinics on patient satisfaction and to identify strategies for enhancing healthcare delivery in the future.Suhar hospital is the only referral hospital in North Batinah Governorate, serving a population of over 870 thousands.As part of its ongoing efforts to enhance the quality of healthcare services, the hospital initiated afternoon clinics for selected specialties (Endocrine, Cardiology, Neurology, Plastic Surgery, and Vascular Surgery) starting in May 2023.It is essential for the hospital's decision-makers to assess the satisfaction and expectations of outpatients seeking healthcare at Suhar Hospital to drive further improvements.Therefore, the aim of this research paper is to investigate the level of pateints experience and satisfaction as a result of receiving afternoon clinic services at Suhar Hospital.Methods This is a quantitative research design, utilizing a survey to assess patient perception and satisfaction with the afternoon clinics at Suhar Hospital.The study targeted outpatients attending both morning and evening clinics 92 during May-June 2023.A total of 100 patients aged 18 years and above was conveniencly participated in the survey during may-June 2023.An online self-reported questionnaire was developed with a barcode to facilitate accessing the questionnaire through cellphone of patients during their visits.The questionnaire consists of sections to gather personal and demographic data, information about the current visits and a scale of satisfaction items about the expected advantages of afternoon clinics.Participants were asked to rate their satisfaction and expectation of afternoon clinics over morning clinics on a 5-point likert scale which was developed by the researchers based on experience and based on previous findings retrieved and discussed in the literature review.A face and content validity was done by experts and researchers from the field followed by a pilot of the modified questionnaire with a small sample of patients before the actual data collection.Reliability of the satisfaction scale was assessed using Cronbach's alpha coefficient and found to have an excellent internal consistency (α=0.957).

SPSS program (version 22
) was used for data entry and analysis.Frequency, percentage, mean and standard deviation were applied as suitable to desribe variables.Chi-square test was used to assess differences between afternoon and morning patients according to related factors.One-way ANOVA and independent t-test were applied to investigate differences in the level of satisfaction scale by socid-demographics.Hypothesis testing was conducted at 5% level of significance.The informed consent was attached in the front page of the questionnaire with a brief aims and benefit from being part of the target population.Voluntary participation, privacy and confidentiality were stated and explained clearly.The ethical approval to conduct the research was obtained from the research committee.

Results
A total of 100 patients submitted the survey during the study period.Table 1 shows the distribution of participants by their socio-demographic characteristics.Of them, 58% were females, 73% aged 30 years and above, 53% held a university degree and 56% were employed.The majority of participants (67%) were visiting the hospital during the morning shift, 44% were visiting endocrine clinics.68% came for follow-up visits, 74% reported a self-evaluation of a good health condition, and 83% reported an overall satisfaction with the received health services.With a significant difference (p< 0.05), the majority of afternoon appointments (67%) were first visit while the majority of moring appointments (85%) were follow-up visits.
For the upcoming appointment, 51% of participants preferred to have a morning appointment, 34% preferred to have an afternoon appointment while the remaining 15% reported equal preference.With a significant difference (p< 0.05), patients of afternoon shift preferred a next afternoon appointment while patients of morning shift preferred a next morning appointment.
Overall, participants reported positive opinions towards afternoon clinics.The majority of them (91%) preferred to continue in providing the afternoon services in the hospital, 95% of them asked for more specialties in the afternoon and 94% asked to provide afternoon appointments for specialized clinics at extended health centers at levels of wilayats.About the afternoon shift timing, 58% preferred timing from 2:00 pm to 6:00 pm while 42% preferred the timing to be from 4:00 pm to 9:00 pm.As an overall opinion, 47% of them thought that giving appointments in the evening is better compared to 15% of them thought that giving appointments in the morning is better while 38% reported equal thought about evening versus morning appointments.Figure 1 shows that the most reported reasons for missing or rescheduling a morning appointment was suitability of the appointment timing (69%) followed by family commitments (62%), getting a release from work or study (50%), availability of a person to bring the patient (48%) and the availability of a vehicle (40%).
Participants were asked to provide their agreements regarding the benefits of the afternoon appointments  3).The mean scores indicate the average level of agreement for each benefit on a scale of 1 to 5, with a higher mean indicating a greater agreement.The scale showed excellent internal consistency (α=0.957).Overall agreements on the eleven statements was high with a mean of 4.12 (SD=0.72).Figure 2 shows that the benefits with the highest mean scores were "reduce the waiting length to get a new appointment" (mean=4.26),"will reduce the missing or rescheduling of appointment" (mean=4.21),and "facilitate the availability of relatives to bring children or old persons to the hospital" (mean=4.15).The main concern of participants was the release of study or work (Mean=3.98,SD=1.03) followed by the flexibility of the medical record staff to open the visit (Mean=4.03,SD=0.88) and the availability of transportation (Mean=4.04,SD=0.84).

Discussion
Growing body of health research has emphasized on the need to integrate patient-centered care to improve patient satisfaction [6,9] and to consider their values and needs [10].In this manner, Suhar Hospital initiated afternoon clinics as a response to patients' needs of health services accessibility and availability as well as reducing the appointments waiting list as a strategic aim of the hospital.This initiative emerged as a shortterm solution to reduce the top specialized clinic with The main purpose of the study was to provide a metric assessing patients experience and satisfaction regarding afternoon clinic initiative ability to address the concern of appointment in specialized clinics.Moreover, it aimed at identifying further recommendations to improve health services delivery.The assessment in this study was related only to specialties that started the afternoon shift before the study period.This is a recent introduced service in the referral hospitals in Oman, thus, patient experience and opinions is important for evaluation and improvement.Patient experience is increasingly implemented as a significant assessment tool of patients' perception, attitude, interaction and satisfaction towards the quality of health care and caregivers [1,7,9] as well as for further areas of improvement.It is expected that patient experience would improve medication adherence and outcomes [11].In the current study, 33% of the participants were taking care at afternoon clinics.A quite similar rate was reported by Bao et al. ( 2017) with around 27% in general hospitals and 38% in specialty hospitals taking into consideration the variation in afternoon timing between countries [1].In this study, participants preferred afternoon timing between 2:00 pm and 6:00 pm.Afternoon clinics initiated mainly to reduce the waiting list particularly new appointments.This is indicated in the findings as 67% of the afternoon visits were new visits compared to only 15% of the morning visits.This explained the overall self-reported evaluation of the current health condition with 14% of morning participants having a bad to average health condition compared to 48% among afternoon participants.Patients reported preference to afternoon clinics particularly those exposed to the services.Patients who experienced afternoon service reported preference of having a next afternoon appointment while those experienced morning service reported preference of having a next morning appointment.In addition, results showed no significant differences reported in patients' ratings and perspectives between morning appointments and afternoon appointments which can be due to the fact that majority of appointments still during the morning shift, similar findings stated by Bao et al. (2017) [1].This finding provided a clear indication to Suhar hospital decision makers to generalize the afternoon shift for the remaining specialties to increase the exposure of patient experience and acceptance to the change in the mode of health care delivery.A positive perspective on afternoon clinics was reported in the study as the majority of patients supported the continuity of the afternoon shift, suggested opening more specialties as well as expanding the evening service at the level of primary health care, polyclinics, in the six wilayats of the governorate.Overall, the findings indicated a high percentage of satisfaction (85%) with the health service received during their current visits to outpatient clinics whether at morning (85%) or evening (79%) shifts.However, this current satisfaction accompanied with some claims as an overall experience of the patient in receiving care at Sohar Hospital.Such overall satisfaction and claims has been addressed in previous findings.Moore et al. (2016) reported an overall satisfaction of patients with a request to reduce appointment length time and seeing doctors waiting time [9].Patients also would like to spend enough time with doctors to adequately addressing their concern.This is consistent with related research investigating patients' experience [2,12,13].The findings emphasized on the advantages of afternoon clinics to overcome part of patients concerns.Such concerns affect the accessibility of the patients as have been discussed in literature including scheduling appointment, availability of specialties and specialists, long waiting time, transportation, parking, release from work [3,9].The current results showed a positive perception of patients towards afternoon clinics in terms of shortening the waiting times, eliminating missed or rescheduled appointments and offering flexibility in scheduling appointments.The results showed a history of missing or rescheduling morning appointments due to suitability of the appointment timing, family commitments, getting a release from work or study, availability of a person to bring the patient and the availability of a vehicle.Similar and other reasons were indicated in the literature with variation in reasoning ranking.They found forgetting about the appointment to be the main reason for missing appointments.This reason is to the minimum in Oman due to sending a reminder before two days of the appointment.Work-related issue was a also a common reason while family commitment, e.g.childcaring, transportation issue as well as scheduling system were reported, but less common, reasons for missing appointment [14,15].In term of healthcare delivery, patients felt that afternoon shift enables a satisfactory amount of consultation time, reduces times to see doctors as well as eases the registration process.From facilities (logistical arrangement) perspectives, patients thought that afternoon time provides opportunities in terms of the availability of family members and transportation, absenteeism from work or studying, and availability of parking.The composite scale of participants' perception towards the benefits of afternoon appointments had a mean score of 4.12, indicating a generally positive perception overall.The high internal consistency of the 96 scale, as evidenced by the Cronbach's alpha coefficient of 0.957, suggests that the items included in the scale are measuring a similar construct.These findings highlight the importance of afternoon appointments in meeting the needs and expectations of patients at Suhar Hospital.The positive perceptions indicate that afternoon appointments are perceived as beneficial in various aspects of the healthcare experience, such as reducing waiting times, improving coordination with other commitments, and facilitating ease of access to healthcare services.Notable limitations need to be addressed while discussing the study results.The statistical significance was affected by the small sample size particularly for those attending the afternoon appointments.The survey was suspended by researchers within a short period of time due to a new patient's experience survey lunched by the Ministry of Health, Oman, at national level for all health inistitutions.The survey covered appointments schedualled during the study period so the results can be generalized to those patients only.Patients may feel inclined to provide positive feedback regarding the afternoon clinics particularly the study was introduced by healthcare providers, which may inflate the reported levels of satisfaction.Patinets who choosed to participate may have different perspectives compared to those who do not participate.In addition, technical issue was a concern as the survey used to be filled through cell phone.

Conclusion
The implementation of afternoon clinics at Suhar Hospital was an initiative to meet patient needs and expectations.Patients reported an overall satisfaction of afternoon time in terms of waiting times, flexible scheduling options and logistical arrangements.To further enhance patient access to specialized care, it is recommended to expand the afternoon clinics to include more specialties at the hospital level and integrate these services into primary healthcare at the six polyclinics in the region.This would provide patients with greater accessibility, convenience and satisfaction regarding the quality of healthcare by delivering the right healthcare at the right time and place [16,17].This, in turn, is expected to improve patients' medication adherence and overall health outcomes [11].The positive finings in this study underscore the importance of actively addressing patient needs and continuously seeking innovative strategies to enhance healthcare delivery and reduce patients waiting times.By this, the ministry of health (MOH) can further improve the quality of care provided to its population.

Figure 1 :
Figure 1: Reasons for being Missed or Rescheduled a Morning Appointment -score likert scale of 11 items (Table

Figure 2 :
Figure 2: Perceptions Towards the Advantages of Afternoon Appointments at Suhar Hospital from work/study flexibility of medical record… waiting time to see doctor Time with Doctor Waiting time in pharmacy long waiting list such as endocrine, neurology, cardiology, plastic surgery, and vascular surgery.