IOSR Journal of Dental and Medical Sciences (IOSR-JDMS)

e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 20, Issue 3 Ser.11 (March. 2021), PP 14-27
www.iosrjournals.org

Hospital Waiting Time, Satisfaction with Services and Patient

Arrival Patterns among Primary Care Attendees in a Tertiary
Hospital: The Need for Time Specific Appointment Systems.
Abah V. O. (FWACP[FM], MHPM)
Department of Family Medicine, University of Benin Teaching Hospital, Benin city Edo State.
Corresponding author: Dr V.O. Abah
Department of Family Medicine, University of Benin Teaching Hospital, Benin city Edo State.

Abstract:
Background: Waiting time in Nigerian public hospitals is excruciatingly long with negative impact on quality of
care, client satisfaction and utilization of health care services. These factors have significant negative
consequences on the health indices of the population. Waiting time is amenable to easy objective and subjective
assessment and intervention and hence studies are required to provide evidence for quality improvement.
Aim and Objectives: to evaluate the pattern of waiting time and relationship with clients’ satisfaction with
services in the clinic.
Materials and Method: three hundred randomly selected subjects were administered a combination of
customized questionnaire and modified SWOPS questionnaire. P value was .05.
Results: majority of respondents were educated (74%), young (62%) and females (58.4%).
Most of the clients (40%) arrived at the clinic before 8am. Waiting time (WT) ranged 19-360 mins. (mean
=107minutes) and was longest at the pre consultation interval. WT varied significantly with arrival time
(X2=107.9, p=.000) and was not significantly related to perception of waiting time and satisfaction. Perception
of WT was good (mean=3.27/5) and significantly related to satisfaction with treatment (Likelihood Ratio=88.0
p=.000) and services (Likelihood Ratio=117.9, p=.000).
Conclusion: this study demonstrated that the unacceptable waiting time was caused by uncoordinated client
arrival patterns and that the dynamics between duration of waiting time and clients’ satisfaction is modulated
by satisfaction with treatment received offering a trade-off for the long duration of waiting time. Queue
management using appointment system will modify the arrival pattern of clients, improve waiting time, client
experience and satisfaction.
Keywords:waiting time, client’s perception, satisfaction, arrival patterns, appointment systems
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Date of Submission: 14-03-2021 Date of Acceptance: 28-03-2021
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I. Background:
Timeliness of health care services is a dimension of Quality of care as defined by the Institute of
Medicine of the United States.1 Waiting time in hospitals is a major concern in health systems
worldwide.2Timeliness is important because of the impact of waiting time on patient perception of quality of
care, utilization of facilities and choice of facilities to use.3 It is a determinant of health seeking behavior at
population level as it negatively impacts on decision for early presentation in any illness episode resulting in
poor morbidity and mortality indices for the nation. 4,5,6,7 Poor utilization of hospitals renders the available health
care resources inefficient at achieving desired health outcomes corroborating the World Health Organization
statement that low quality health care is expensive.8
The quality of health care has received inadequate attention in Nigeria compared to developed
countries with the consequence of slow development of the system even when compared to the available
resources.9 The lack of a quality management culture has resulted in inefficient utilization of resources and lack
of modification of service processes to improve efficiency and patient experiences. There is wide spread
negative view and lack of trust of the health sector especially public health services. 9,10,11
Studies have established that waiting time in most Nigerian hospitals is excruciatingly long, contributes
to low satisfaction, delayed presentation to hospital with increased morbidity and mortality, patient walk outs
and reduced revenues and business sustainability of the health institutions.7,9,12, Lack of timeliness also affects
the morale of workers resulting in burn out and consequent poor provider-patient relationships.13It is an
indicator of hospital performance and managerial effectiveness. 2,12,14

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
Waiting time in the hospital refers to the amount of time clients wait to access desired health services.
In an outpatient facility, waiting time is divided into several components: pre-process waiting time which is the
amount of time taken to access consultation with the doctor. The time taken to access care at other service
windows like the laboratory, radio-diagnostics units and the pharmacy are regarded as In-Process waiting time.
Through-put time is the sum of all the time taken from entry to exit from the facility. 12,14
Waiting has both psychological and physiological consequences which for the patients include anxiety,
frustration, sense of powerlessness or lack of control and stress. 15 These lead to dissatisfaction and aggressive
attitude towards the providers.13Waiting time also contributes to the cost of accessing health care as time spent
in the hospital results in loss of productivity as an opportunity cost to health. 9,12 It constitutes a major barrier to
early presentation as most people will not present to the hospital on time for what they consider to be minor
ailments which would not justify the direct and opportunity cost of a hospital visit. 7,9,10Anecdotal evidence
suggests that members of the public would rather visit chemists and other private hospitals despite knowing that
better quality and safer care exists in teaching hospitals due to the waiting time factor.
The Institute of Medicine in the USA set the benchmark of 30 minutes for pre-process waiting time in
primary care.16 Also the Patient bill of rights in Nigeria stipulates that patients are entitled to receive services
within 30 minutes of arrival at a health facility. 17 However this is far from the existing reality as studies have
shown that patients experience excruciatingly long waiting time in Nigerian hospitals.
In a tertiary hospital in Sokoto, North West Nigeria, through put time had a mean of 168minutes, in
National Hospital Abuja, the range was 10-432minutes while in a tertiary hospital in Port Harcourt, range was
80-525minutes.7,18,19
The interaction between waiting time and patient satisfaction in the Nigerian studies however
demonstrates varying dynamics. Despite the stated dissatisfaction with waiting time, satisfaction with quality of
care in those studies were mostly high. In the clinic of a tertiary educational institution in South West Nigeria,
Obamiro found that among a patient population that was 100% educated, 27% considered the waiting time
normal and adequate, 32% were satisfied with it, and 52% felt it was too long. 20 However, the study population
expressed satisfaction with the services in spite of the long waits. He attributed this to a culture of long waits in
Nigerian hospitals. The attributed causes of the waiting time were, large number of patients, late arrival of
doctors, inadequate number of doctors, lack of information and communication technology facilities, long
consultation time and lack of queue discipline.20
In Sokoto, where only 36% of the study population had tertiary education, the main causes of
dissatisfaction were the long waiting time and poor condition of the consulting rooms. The patients scored the
doctors 48.5% on communication and 65% on explanation, neatness of the hospital was scored 65%. Overall
satisfaction was scored 52%.7 In a tertiary hospital in Kano, Northern Nigeria, satisfaction was rated 83%.
Patient provider relationship, hospital facilities, in-patient services and access were good. Cost and waiting time
were the main causes of dissatisfaction.21
The significant relationship between duration of waiting time and satisfaction with services was
demonstrated in studies in tertiary hospitals in Abuja and Benin City. 18,22In both studies, more than 70% of
respondents expressed satisfaction with services but significantly more of those who experienced long waiting
times reported less satisfaction with services.18,22
In Enugu 63.9% of the patients were dissatisfied with the waiting time and 99% would be willing to
pay more to get better quality care and drugs. The author noted that these were major barriers to access and
utilization of the facility.23
The effect of the tradeoff between pre-process waiting and duration of consultation on satisfaction is
demonstrated by the study in Makurdi North Central Nigeria where it was found that a combination of long
pre-process time and short consultation resulted in the lowest satisfaction scores. 24 Other significant factors
included the amount of information from the doctors and the hospital environment.
In Calabar, prolonged waiting time was caused by inefficiency in the records unit and inadequate
staffing.25
The foregoing shows that the relationship between actual wait time, it’s perception and satisfaction
rating of services is complex. The quality of a service as perceived by the clients is adjudged from the sum of
the performance of the various components of the service. The perception of satisfaction with services is
determined by the differential between client expectations which incorporates their needs and values and their
experience of the service. The literature on quality of care has evidenced that this dynamic is complex and
influenced by factors related to the patient, their sociopolitical and economic environment. 26,27,28,29For the
Nigerian populace, the fact that tertiary hospitals have the best offer of ethical, safe and quality treatment
modulates their expectations and perception of experience and satisfaction. However, despite the satisfaction
expressed by respondents in these studies, the impact of waiting time on health seeking behavior and
productivity demands attention. This is more so as waiting time is highly amenable to objective and subjective
assessment and intervention.

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
The factors that mediate waiting time include: arrival pattern of clients, the organization of service
points, proper co-ordination between service points, efficient and adequate number of staff at the service points,
staff attitude (service orientation), information dissemination to patients, availability of information and
communication technology facilities to ease work flowetc.12,14,20 Developing countries like Nigeria share a
deficiency in these areas with consequent increase in inefficiency and cost of services to both clients and the
system. These factors make the hospital process a complex queuing system amenable to evaluation and
modification based on the queuing theory.12,20 The queuing theory explores the process of service to determine
causes of delays and inefficiency with a view to improve efficiency and minimize cost. The parameters include
source population and arrival pattern of clients, the existence of a queue and the order in which the clients are
served (queuing and queuing discipline), service mechanism (number of service points, available staff and the
length of time per serve and coordination of different units in the service chain) and exit. In developed countries
appointment systems have been used to control patient flow such that they arrive at a rate the staff and facilities
can cope with thereby reducing waiting time.30This is also evidenced in the study in a developing country,
Ethiopia where waiting time (WT) was reduced from 395 minutes to 165 minutes by use of appointment
system.31In Nigerian hospitals, with the absence of an appointment system, arrivals are usually overwhelming,
making long waiting time inevitable.18,20
Given the wide availability of mobile telephone technology in Nigeria estimated at 204 million
subscriptions and tele-density of 107.2%, time specific appointment systems are feasible and requires the
managers of the health care system at macro and micro levels to harness this to improve waiting time. 32 The
negative impact of long waiting time on patient satisfaction and health seeking behavior, makes it imperative to
prioritize interventions to achieve a minimization of waiting time and optimization of the quality of care. 12,19

Justification:
The waiting time in most hospitals in our country is unacceptably long resulting in wide spread
dissatisfaction and poses a major barrier to population utilization of health services resulting in unacceptable
morbidity and mortality rates. 4,5,6A quality management culture is required to create necessary improvements to
facilitate achievement of universal health coverage and better health outcomes.12 This requires evaluation of
quality of services including timeliness and its parameters to provide evidence to advocate for quality
improvement interventions.

Aim and Objectives: to evaluate the pattern of waiting time and relationship with clients’ satisfaction with
services in the clinic.

II. Methodology:
Study Area: The University of Benin Teaching Hospital is a tertiary hospital located in Egor Local
Government Area of Benin City, the capital of Edo State Nigeria. It is a 910 bedded hospital offering training to
a wide range of medical and paramedical professionals and all levels of care to the clients in Edo, Delta, Ekiti,
Ondo and other neighboring states. The Family Medicine Clinic is located at one extreme of the hospital. It
offers primary care services to patients every day and serves as the gateway to the secondary and tertiary care
units of the hospital. The clinic is run by the Family Medicine Department of the hospital with residency
training in situ and receives patients on a walk-in basis every day. At the time of this study about 150- 250
patients attended the clinic per day on week days and about 40-80 patients on weekends. It opened at 8am and
closed at 6pm. It has medical, nursing, records, revenue, laboratory and pharmacy units. Radio diagnostic
services are located in the main hospital within some walking distance. There is usually a minimum of ten
doctors (Consultants and Residents) available to attend to the patients. Patients are required to pay for
consultation and obtain their card from the revenue and records units respectively. Both units are adjacent to
each other in the waiting hall. A patient flow management mechanism operates such that patients take numbers
on arrival and queue discipline is maintained as much as possible in giving them access to the doctors for
consultation. There is an information /help desk in the waiting hall giving patients all information required to
facilitate their access to care in the clinic and the main hospital. There is a television set in the hall offering
programs on local channels. The clients are given a health talk every morning by the nurses. Emergency cases
are stabilized and then taken by ambulance to the emergency department in the hospital if needed. Most of the
patients are students, artisans, traders, civil servants, retirees and business owners reflective of the communities
the hospital serves.
Sample Population: This was made up of all clients that attended the clinic in the study period about 5480
patients in a month.
Selection Criteria: All Clients (patients or patient relatives) above 10 years of age who consented to participate
were recruited into the study. All patients who were too ill to participate (and their relatives) were excluded.

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
Sample Size: The Leslie Kish formula was employed for sample size calculation using prevalence of patient
satisfaction in Nigeria of 52%-91% an average of 71.5%.7,33,34 Calculated sample size was 298.6 rounded to 300
for ease of data analysis.
Research Instruments:1) The Satisfaction with Out-Patient Services Questionnaire (SWOPS)was used with
modification to include assessment of Pharmacist care. 35The SWOPS is a standardized self -administered
instrument developed by Seibert et al 1996 for measuring patient satisfaction with services in outpatient
departments. It has six sections covering, Registration process, Nursing Care, Physician care, Information,
Testing services and Overall satisfaction. The various dimensions have Cronbach alpha scores ranging from
0.84 -0.95. The parameters were rated on a 5-point Likert scale.2) A customized semi structured questionnaire
to capture sociodemographic data and time taken to access services at different windows in the clinic. The
instrument was interviewer administered for illiterate participants.
Sampling Method: Random sampling method by simple balloting was used.
Study duration: The calculated sample size of 300 was recruited over a period of October 2017 to February
2018. (December /January were skipped for logistic reasons) For the waiting time aspect of the study only 261
questionnaires were adequate for analysis.
Study Procedure: About 5 patients were recruited each day. The selected participants had the study explained
to them. Informed consent was obtained, and they filled the questionnaire at their own pace as they went
through the clinic for their care. The questionnaires were retrieved at the pharmacy which is the last service
point in the clinic. Participants who were illiterate were assisted by a trained research assistant.
Ethical Consideration:
Ethical Approval was obtained from the hospital Research and Ethics Committee. PROTOCOL NUMBER:
ADM/E 22/A/VOL.VII/1480. Informed consent was obtained from all the participants. Confidentiality was
maintained in data collection, collation, analysis and reporting.

Data Analysis:
The data was collated using Microsoft Excel and analyzed with SPSS version 21. P value was set at
0.05. The distribution of satisfaction with the various components of services was done using frequencies and
percentages. The 5-points Likert scale was scored 1-5 from poor to excellent. The mean of the scores for all the
participants on each parameter was calculated as the satisfaction score for the parameter. Spearman correlation
was used to determine the relationship between perception of service components and satisfaction. The
independent sample t test was used to test the significance of the difference in waiting time parameters for the
different arrival time groups.

III. Results:
Distribution of Sociodemographic Variables among the Respondents (Table 1).
Majority of the respondents were adolescents (24.7%) and young adults (20-40years at 37.3%). 23% were
elderly (above 60yrs) there were more females (54.8%) than males (45.2%). Majority had tertiary education
(59.8%) and were Christians (95.4%).
Distribution of Respondents by the Time of Arrival at The Clinic (Table 2).
Most of respondents (40.2%) arrived at the clinic before 8am (early morning), 30.7% between 8am and 11am
(mid-morning) and 29.1% beyond 11am (late morning).
Relationship between Sociodemographic Characteristics and Arrival Time Group among the
Respondents (Table 3).
The relationship between Sociodemographic Characteristics (gender and educational status) and arrival time of
respondents was not statistically significant.
Pattern of Waiting Time at the different Service Windows of the clinic (Table 4).
The range of throughput time for all the respondents was 19-360mins with a mean of 107mins. Mean waiting
time at service windows wasshortest at the laboratory (19.7mins) and longest at pre-consultation
interval(48.7mins) accounting for 40% of throughput time. The proportion of clients attended within 30mins at
the service windows shows that turn-over was highest at the laboratory (93%), pharmacy (86.2%), registration
(80%) and lowest at the pre-consultation window (42%).
Distribution of Through-put Time Category among the Respondents (Table 5).
Most of the respondents experienced a long waiting time (60-119 mins) to access services in the clinic while
24.1% experienced a short WT (<60mins) and 27.2% spent a very long WT (> 2hours).
The Pattern of Waiting Time segments by Arrival Time Groups (Table 6).
The mean throughput time and interval WT at all the service windows were highest for the early morning group
and least for late morning group. The registration time was significantly lower only between mid and late
morning groups (t=4.230 p=.000). Pre-consultation WT was significantly lower from early (t=2.252 p=.012) to
mid (t=5.003 p=.000) and late (t=8.094 p=.000) morning groups. For the lab, the difference in mean WT was

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
not significant between the groups. For the pharmacy there was no significant difference between early and
mid-morning groups but the difference between mid and late morning groups (t=2.744 p=.007) and between
early and late morning groups (t=2.840 p=.005) were significant. The throughput time was significantly lower
between early and mid-morning (t=3.003, p=.003) and mid and late morning groups (t=6.052 p=.000) and
between the early morning and late morning group (t=8.608 p=.000).
Relationship between Arrival Time Group and Through-put Time among the Respondents (Table 7).
There wsa a high statistically significant relationship between the arrival time of the respondents and the total
time spent accessing services in the clinic. X2=107.983 df =4, p=.000
Distribution of Perception of Waiting Time and it’s Categories among the Respondents (Table 8).
Most of the respondents perceived the waiting time as good (47.5%), and very good (37.5%). Only 14.9%
considered it poor. The mean score of perception of waiting time was 3.27/5.
Distribution of Respondents by the Perceived Level of Frustration at the Service Windows (Table 9).
Majority of the respondents (49.4%) considered the pre-consultation waiting time most frustrating. Registration
was next at 22.6% and then pharmacy. The laboratory was the least frustrating.
Relationship between Sociodemographic Characteristics and Perception of Waiting Time among the
Respondents (Table 10).
The relationship between sociodemographic characteristics (gender and educational status) and perception of
waiting time were not statistically significant.
Relationship between Arrival Time Group and Perception of Waiting Time among the Respondents
(Table 11).
The relationship between time of arrival of respondent and perception of waiting time was not statistically
significant. X2=4.542 df =4, p=.338
Relationship between Through-put Time and Perception of Waiting Time among the Respondents (Table
12).
The relationship between throughput time and perception of waiting time was not statistically significant.
X2=5.892 df =4, p=.207
Distribution of Rating of Satisfaction with Services among the Respondents (Table 13).
Most of the respondents (44.1%) rated the services as good (score of 3/5), 39.8% rated services as very good
and 8.5% as excellent. The mean satisfaction score was 3.57/5.
Relationship between Sociodemographic Characteristics and Satisfaction with Clinic Services among the
Respondents (Table 14).
There was no relationship between gender, educational status and satisfaction with clinic services.
Relationship between Arrival Time Group and Satisfaction with Clinic Services among the Respondents
(Table 15).
The relationship between time of arrival of respondents and satisfaction with services was not statistically
significant. X2=4.447 df =4, p=.349. (fishers)
Relationship between Through-put Time and Satisfaction with Clinic Services among the Respondents
(Table 16).
The relationship between throughput time and respondent’s satisfaction with services was not statistically
significant. X2=2.448 df =4, p=654 (fishers)
Relationship between Perception of Waiting Time and Satisfaction with Clinic Services among the
Respondents (Table 17).
The relationship between perception of waiting time and satisfaction with services was highly statistically
significant. X 2=117.931 df =4 p=.000, Likelihood ratio=111.430 p=.000
Relationship between Satisfaction with Treatment and Perception of Waiting Time among the
Respondents (Table 18).
The relationship between satisfaction with treatment and perception of waiting time was highly statistically
significant. X2=96.350 df =4 p=.000. Likelihood ratio=88.011 p=.000.
Correlation between Waiting Time at Service Windows and the perception of the Services at the
Windows (Table 19).
There was no significant correlation between actual waiting time at service windows and the perception of the
services experienced at the windows. However, there was a significant moderate positive correlation between
the perception of the service at various windows and the perception of waiting time and satisfaction with clinic
services.

IV. Discussion:

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
This study utilized a modified satisfaction with outpatient services questionnaire to explore the clients’
perception of service components, satisfaction with them and the dynamics between them. Three hundred
respondents were recruited but only 261 responded adequately with the complete time data, the analysis of
which is presented here.
The respondents were mostly educated (>74%) and young people under 40years in keeping with the
population that choose the clinic for their care. This demographic distribution is similar to that found in other
tertiary hospitals in Abuja, Sokoto, Kano and Port Harcourt, Nigeria. 7,18,19,21, This suggests that it is young
educated clients that seek care at the tertiary hospitals. It is also reflective of the demographic distribution of the
country.
The process map of the clinic shows the clients go through registration (including payment at revenue
unit), waiting hall pre-consultation, consultation, then laboratory and the pharmacy as needed. In this study
100% of the respondents registered and consulted the doctor while 69% visited the laboratory and 68%, the
pharmacy.
About 100 patients (40%) of them arrived at the clinic before 8am (early morning) and about 30%
arrived mid-morning (8-11 am) while the rest arrived beyond 11 am (late morning). This is similar to the
finding in National Hospital Abuja, where majority of the patients arrived before 11am with a median time of
8am.18 The reason most of the clients came so early was to ensure they got to see the doctor and also within
reasonable time. The arrival time of respondents is not significantly associated with sociodemographic
characteristics showing that the anxiety and effort to ensure access to care was not determined by education or
gender. However, this does not yield the desired outcome due to the overcrowding in the morning clinic.
The massive early arrival overwhelms the available staff. The process map of the clinic shows there are
about 10 doctors per day seeing patients at about one per 15 minutes consultation slot. At that arrival rate, ab
initio, each doctor had 10 patients who had arrived before 8am waiting. At the rate of 4 patients per hour, the
10th patient inevitably had to be seen 2.5hrs after registration. A pre- process waiting time that is unacceptably
long. This scenario is similar to that found in Abuja. 18
The registration service window had a waiting time (WT) range of 2-250 minutes with a mean of 29.2
minutes representing about 24% of the through put time. This is similar to that in National Hospital Abuja
(NHA) and University of Port Harcourt Teaching Hospital (UPTH). 18,19 About 32% of the clients received
service within 10 mins and about 80% within 30 min showing a good waiting time and confirming rapid
turnover of clients at this window. This is similar to findings in PH but better than findings in the Sokotostudy
where 74% of clients waited 60-120 mins to get registered.7
The pre-consultation WT ranged from 5-276mins with a mean of 48.7 mins. This was shorter than in
the National Hospital with a range of 0-336mins and median of 60mins and also shorter than found in UPTH
(mean of 82mins).18,19 About 4.2% of respondents accessed the doctor within 10mins and 42% within 30mins
showing that majority of the clients didn’t get to see the doctor within the 30mins recommended by the Institute
of Medicine (USA)and contrary to the stipulations of the patient bill of rights in Nigeria.16,17
Most of the respondents considered the pre-consultation interval the most frustrating in keeping with
the low responsiveness and slow turnover at that window. There was a weak negative correlation between the
length of the pre-consultation interval and satisfaction with services. This is in keeping with literature and
similar to the cited previous study in the same study site and in UPTH where this service window recorded low
satisfaction rate compared to others and had a large negative impact on satisfaction.19,36
The WT at the laboratory ranged from 2-240mins but had the lowest mean at 19.7mins. About 42% of
the clients were served within 10mins and 93% in 30mins confirming very high responsiveness and rapid
turnover at this service window. This was better than that found in UPTH where mean WT at the laboratory was
found to be 50mins. The laboratory was perceived as the least frustrating also reflecting the turn over indices at
that window but contrary to UPTH where it was rated the least satisfactory.19
The WT at the pharmacy had the shortest range at 2-75mins but the mean of 22.8mins was comparable
to registration and laboratory service windows. The 10-minute turnover was 20.2% and 86.2% at 30 minutes
confirming high responsiveness and turn over. The mean WT is similar to that in UPTH (27mins), but longer
than the mean WT of 17 minutes in the study by Afolabi and associates in Ife. 37 It is much shorter than the
55mins post-intervention found by Ndukwe and others who utilized a modification of the queuing mechanism
and improvement in queue discipline to reduce WT from 167minutes to 55 minutes in their study site. 38
The distribution of through put time (TPT)in this study population showed a range of 19-360mins and
mean of 107mins. This is shorter than in NHA (range 10-432mins, median 60mins) UPTH (range = 80-525,
mean 274mins) and in Sokoto (mean =168mins). 7,19 Most (49%) of the respondents experienced a long waiting
time (1-2 hr) and about 24% spent less than 60 minutes to complete their care process in the clinic. This pattern
is better than in Sokoto where majority spent about 3hrs or more. 7 The pattern of TPT shows that those who
arrived the clinic before 8am had a range of 21-360min and mean of 139 minutes. Only 5(4.8%) respondents
experienced a short TPT while 49 respondents (47%) experienced very long waiting time. This is in contrast to
those who came in the late morning group where 48 respondents (63%) experienced short WT and only 2
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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
respondents had very long WT. This demonstrates the impact of client overcrowding in the early morning on the
finite clinic service resources. Late morning clients had a better experience because by their time of arrival, most
of the crowd had been cleared and so queue lengths had reduced. This confirms that arrival pattern is the main
cause of long WT in this clinic. Although other factors like staff adequacy, absenteeism and service orientation
were not evaluated in this study, addressing the arrival pattern using appointment system will definitely go a
long way to reduce the excruciating long waiting time experienced in this clinic like others around the country.
This is very important given the fact that most people come early in the morning, abandon their work and spend
2-3hrs of the morning in the hospital thereby making it impossible for them to achieve meaningful productivity
on their jobs for that day. This is a major factor in the cost of health care utilization as work productivity is
rendered an opportunity cost for accessing health care therefore deterring most of the population from utilizing
the services. It is also a major factor promoting delayed presentation to hospital and use of substandard
alternatives like chemists and herbalists who offer more prompt and less cumbersome processes.10,12The
consequence on the morbidity and mortality status of the nation is evident in our poor health indices. 4,5,6
A break-down of the pattern of waiting time at the service windows showed significant variation by the
arrival time groups. Waiting time was lower across all service windows for the mid-morning and late morning
groups. The differences were highly significant for the registration, pre-consultation and through put time
especially between early and late morning groups. The difference between these arrival time groups for the
laboratory was not significant showing that client turn over did not vary significantly across the day. This is
probably because not all respondents went to the laboratory and that the service process is simpler and brief.
Also, the clients have to see the doctors first before going to the laboratory and so their arrival at the laboratory
is regulated by the doctors’ turn-over rate thereby reducing crowding and waiting time. The difference in the
Pharmacy WT between the early morning and mid-morning was not significant. However, between mid and late
morning, and between early morning and late morning groups were significant. Arrival at the pharmacy is also
determined by doctors’ turnover but the process of care at the pharmacy involves multiple service points which
probably allows for clients to back up thereby reflecting the crowding in the arrival time groups.
The 30-minute turnover rate at all the service windows was more than 80% except for the pre
consultation interval. This shows that if arrival is regulated, probably close to 100% of clients will be served
within 30minutes at each window especially in the pre-consultation window with positive run off effect on the
other windows and through put time. This provides evidence that queue management via appointment system to
modify arrival patterns will impact positively on the duration of WT for most of the clients. This will especially
impact on the pre consultation time which has proved to be the rate limiting step in the service process. An
appointment system that tailors the arrival of patients to match the critical service mechanism (available number
of doctors and the consultation time per patient) will effectively reduce the WT and patient over-crowding and
improve the turn-over rate at service windows.12, 20
The distribution of perception of waiting time shows that majority of the respondents (85%) rated the
WT as good or very good with a mean rating score of 3.27/5. There was no significant relationship between TPT
and perception of WT. The proportion of satisfied patients is higher than in Kano where 70% rated the WT as
good. The rating of perception of WT is in contrast to the distribution of through put time that showed majority
(75.9%) waited about 1-2hrs and more to access care. Majority of the respondents rated their perception of WT
as good despite the long duration. This finding is similar to that by Obamiro in South West Nigeria and in
UPTH where 77.2% were satisfied with a WT in the range of 80-525mins.19,20 In Enugu WT was a major cause
of dissatisfaction but clients expressed satisfaction with services despite this. 23
Despite the significant difference in WT between arrival time groups, there was no significant
relationship between perception of waiting time and arrival time group. This goes further to buttress the
assertion that actual length of time spent did not determine perception of WT among the respondents in this
study.
The relationship between perception of waiting time and sociodemographic characteristics was not
significant contrary to expectation that more educated persons as found in this study population may be more
discriminatory and express dissatisfaction with services especially WT.
The distribution of rating of satisfaction with services in the clinic showed majority (95.4%) of the
respondents rated the services as good or very good with a mean score of 3.57/5. This proportion of satisfied
clients is higher than in the Kano study (83%) but the rating score is lower than in Enugu(3.75). 39 There was no
significant relationship between sociodemographic characteristics and perception of satisfaction with services
contrary to expectation.
The relationship between through put time and satisfaction with services was not significant. Also,
there was no significant relationship between arrival time of clients and satisfaction with services despite the
significant differences in waiting time experience of the arrival time groups. These confirm that actual length of
time spent accessing services did not impact respondent’s rating of satisfaction with services. This is contrary to
findings in National Hospital and the cited previous research in the same study site that found a significant
relationship between satisfaction with medical care and duration of WT. Also, contrary to this study, the
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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
findings in UPTH was that of a significant negative correlation between satisfaction with services and duration
of WT at all service windows and through put time.19 This is possibly explained by the fact that in these studies,
satisfaction with other service components(staff behaviour, treatment, environment , information etc) was not
assessed and thereby eliminated the trade-off effect of satisfaction with those components. 40,41
However, the relationship between perception of waiting time (PWT)and satisfaction with services was
highly significant (X2=111.430, p=.000). This suggests that the value attached to the services received
determined respondents’ rating of the acceptability of WT. Those that were highly satisfied with the services
received considered the WT as good or very good irrespective of the actual length of time spent. This is similar
to findings in NHA and by Obamiro in Lagos. It is recognized in literature that the value attached to a service
determines how long clients are ready to wait for it.19,42 Also, perception or satisfaction is a product of complex
cognitive and affective integration of what is valued, expected and experienced.19,26 The respondents in this
study may be more disposed to wait for “valuable” health services especially in our environment where teaching
hospitals are expected to offer better quality, safe and ethical care than other facilities. Also, the prevailing
culture of long queues and poor responsiveness in most public facilities influences expectations and assessment
of service experience.20 Despite the well-known long waiting time and cumbersome protocols, those who value
the services will continue to use it and modulate their expectations to minimize the differential with experience
and so will express satisfaction.43,44 This was demonstrated in the study at NHA where perception of WT and
the degree to which patient’s expectations was met were significantly related to satisfaction with services. It
however calls to question the fact the performance of the health facilities cannot be completely adjudged from
the satisfaction ratings of service users but should factor in the perception of non-users in the community. In this
study, satisfaction with treatment was rated high (3.57/5) and the relationship with perception of WT was highly
significant (X2= 88.011, p=.000). Satisfaction with treatment is the clients’ core value and expectation for a
clinic visit and this therefore explains why respondents rated the WT as satisfactory irrespective of the duration.
This trend was also shown across the service windows. There was no significant correlation between the
duration of WT at the service windows and the respondents’ rating of perception of services at those windows.
However, the perception of services at these windows had significant positive correlation with perception of WT
and overall satisfaction with services. These results further buttress the explanations offered above for the
relationship between duration of WT, perception of WT and satisfaction with services. They also provide
evidence for perception management approach to improve quality of care and client satisfaction.42 Measures like
comfortable, aesthetically pleasant waiting rooms, entertainment and health education are useful for improving
the value of waiting time and it’s perception.42
The rating of perception of WT (PWT) in this study population was however low compared to other
service components (demonstrated in another paper). 45 It had moderate positive correlation with overall
satisfaction with services suggesting a service gap (PWT score 3.27, Correlation with Satisfaction services=
.565). This was confirmed with a high calculated service gap for WT(.503) which was higher than that for most
other service components (range .290-.577).45 This is evidence that despite the lack of significant impact of
long waiting time on satisfaction, the clients indicate that the service gap for WT (differential between the rated
importance of WT and rating of WT experienced) in the clinic is unacceptable and needs to be addressed.

V. Conclusion:
This study demonstrated that the unacceptable waiting time was caused by uncoordinated client arrival
patterns and that the dynamics between duration of waiting time and clients’ satisfaction is modulated by
satisfaction with treatment received offering a trade-off for the duration of waiting time. Queue management
using appointment system will modify the arrival pattern of clients, improve waiting time, client experience and
satisfaction.

Recommendation:
Appointment systems using mobile phones to grant clients open access to time specific consultation schedules
should be instituted in the outpatient clinics.

Limitations:
The duration of consultation time was not measured and so it’s contribution to through put time and interaction
with other parameters were not studied.

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
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Tables:
Table 1: Distribution of Sociodemographic Variables among the Respondents.
Variable Frequency Percentage
Age
10-19 74 24.7
20-29 58 19.3
30- 39 48 16.0
40-49 44 14.7
50—59 7 2.3
60—69 54 18.0
70> 10 5.0
Sex
Male 118 45.2
Female 143 54.8

Educational Status
None 4 1.5
Primary 63 24.1
Secondary 38 14.6
Tertiary 156 59.8

Religion
Christianity 249 95.4
Islam 12 4.6

Table 2: Distribution of Respondents by the Time of Arrival at The Clinic.

Arrival time group Frequency %
Early Morning (before 8am) 105 40.2
Mid-Morning (8am-11am) 80 30.7
Late Morning (11 am and beyond) 76 29.1
Total 261 100

Table 3: Relationship between Sociodemographic Characteristics and Arrival Time Group among the
Respondents.
Variable Arrival Time Group Total X2
Early Morning Mid Morning Late Morning P value

Educational status X2 =3.208

Primary 26 22 19 67 df=4
Secondary 19 12 7 38 p=.523
Tertiary 60 46 50 156
Total 105 80 76 261

Gender
Female 47 31 40 118 X2=3.046
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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
Male 58 49 36 143 df=2
Total 105 80 76 261 p=.218

Table 4: Pattern of Waiting Time at the different Service Windows of the clinic.
Waiting Time at Service Windows
Registration. Pre- Consultation Laboratory Pharmacy Through Put
Parameter (mins ) (mins ) (mins ) (mins ) Time(TPT)
Range 2-250 5-276 2-240 2-75 19-360
Mean 29.2 48.7 19.7 22.8 106.957
Std. Deviation 42.933 39.883 31.996 12.344 73.506
% Mean TPT 24.3% 40.4% 16.4% 18.9% 100%
10 -minute turnover
30- minute turnover 32% 4.2% 42% 20.2% 0%
Total Respondents
80% 42% 93% 86.2% 24.9%
261(100%) 261(100%) 180(69%) 178(68.1%) 261(100%)

Table 5: Distribution of Through-put Time Category among the Respondents.

Through-put Time Category Frequency %
Short (<60 mins) 63 24.1
Long (60-119) 127 48.7
Very Long (>120) 71 27.2
Total 251 100

Table 6: The Pattern of Waiting Time segments by Arrival Time Groups.

Waiting Time Early Mid Late t- test t- test t- test
Segment Morning Morning Morning Early vs Mid vs Early vs
Group Group Group mid morn Late morn grp Late morn grp
grp
Registration
Range 5-250 2-206 3-53 t=1.887 t=4.230 t=4.754
Mean 42.66 28.80 11.13 p=.061 p=.000* p=.000*

Pre-consultation
Range 14-242 8-276 5-120 t=2.525 t=5.003 t=8.094
Mean 65.32 49.92 24.67 p=.012** p=.000* p=.000*

Laboratory
Range 5-240 2-120 4-180 t=.456 t=1.074 t=1.346
Mean 24.15 18.89 14.00 p=.649 p=.285 p=.181

Pharmacy
Range 5-54 2-70 3-75 t=-.359 t=2.744 t=2.840
Mean 24.27 25.03 18.22 p=.721 p=.007** p=.005*

Through-put time
Range 21-360 20-332 19-305 t=3.003 t=6.052 t=8.608
Mean 139.76 107.75 57.66 p=.003* p=.000* p=.000*

**Sig <.05, *Sig <.005

Table 7: Relationship between Arrival Time Group and Through-put Time among the Respondents
Arrival time Through Put Time Total X2
Group Short Long Very P value
Long
Early -Morn 5 51 49 105 X2
Mid - Morn 10 51 19 80 =107.983
Late Morn 48 26 2 76 df =4
p=.000*
Total 63 128 70 261
*Sig <.005

Table 8: Distribution of Perception of Waiting Time and it’s Categories among the Respondents.
Perception of Freq. % Score Total Category Freq %

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
Waiting time Score
Poor 12 4.6 1 12 Poor 38 14.6
Fair 26 10.0 2 52
Good 124 47.5 3 372 Good 124 47.6

Very good 77 29.5 4 308 Very 99 37.9

Excellent 22 8.4 5 110 good
Total 261 100 Mean= 3.27 854 261 100

Table 9: Distribution of Respondents by the Perceived Level of Frustration at the Service Windows.
Frustrating Waiting Time Interval Frequency %
Registration 59 22.6
Pre-consultation 129 49.4
Laboratory 26 10.0
Pharmacy 47 18.0
Total 261 100

Table 10: Relationship between Sociodemographic Characteristics and Perception of Waiting Time
among the Respondents.
Variable Perception ofWaiting Total X2
Time P value

Poor Good Very

Good
Educational Status
Primary 6 30 31 67 X2 =4.397
Secondary 7 17 14 38 df=4
Tertiary 26 77 53 156 p=.354
Total 39 124 98 261

Gender
Female
Male 15 58 45 118 X2=.859
Total 24 66 53 143 df=2
39 124 98 261 p=.651

Table 11: Relationship between Arrival Time Group and Perception of Waiting Time among the
Respondents.
Arrival Time Group Perception of Waiting Time Total X2
Poor Fair Good P value
Early Morning 14 48 43 105 X 2=4.542 df
Mid- Morning 17 36 27 80 =4
Late- Morning 8 40 28 76 p=.338
Total 39 124 98 261

Table 12: Relationship between Through-put Time and Perception of Waiting Time among the
Respondents.
Through-put Time Perception of Waiting Time Total X2
Poor Fair Good P value
Short 6 36 21 63 X2
Long 18 56 53 127 5.892
Very Long 15 32 24 71 Df=4
Total 39 124 98 261 P=.207

Table 13: Distribution of Rating of Satisfaction with Services among the Respondents.
Rating of Satisfaction Freq % Score Total Category Freq %
with Services Score
Poor 2 0.8 1 2 Low 12 4.6
Fair 10 3.8 2 20
Good 115 44.1 3 345 Moderate 115 44.1

Very good 104 39.8 4 416 High 134 51.3

Excellent 30 8.5 5 150
Total 261 100 Mean =3.57 933 261 100

Table 14: Relationship between Sociodemographic Characteristics and Satisfaction with Clinic Services
among the Respondents.
Variable Satisfaction with Clinic Services Total X2

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
Low Mod. High P value

Gender
Female 6 54 58 118 X2=.454
Male 6 61 76 143 df=2
Total 12 115 134 261 p=.797

Educational
Status
Primary 3 29 35 65
Secondary 2 12 24 38 X2=3.400
Tertiary 7 74 75 156 df=4
Total 12 115 134 261 p=.757

Table 15: Relationship between Arrival Time Group and Satisfaction with Clinic Services among the
Respondents.
Arrival Satisfaction with Clinic Total X2
Time Group Services P value
Low Mod High
Early Morning 4 49 52 105 X2
Mid- Morning 5 39 36 80 4.447
Late Morning 3 27 46 76 df=4
Total 12 115 134 261 P=.349
(Fishers)

Table 16: Relationship between Through-put Time and Satisfaction with Clinic Services among the
Respondents.
Through-put Time Satisfaction Clinic Services Total X2
Low Mod High P value
Short 3 25 35 63 X2
Med 4 57 66 127 2.448
Long 5 33 33 71 df=4
Total 12 115 134 261 P=.654
(Fishers)

Table 17: Relationship between Perception of Waiting Time and Satisfaction with Clinic Services among
the Respondents.
Perception of Waiting Time Satisfaction with Services Total X2
Low Mod High P value
Poor 9 17 13 39 X2
Fair 2 87 35 124 117.932
Good 1 11 86 98 Df=4
Total 12 115 134 261 P=.000*

*Sig <.005

Table 18: Relationship between Satisfaction with Treatment and Perception of Waiting Time among the
Respondents.
Satisfaction with Perception of Waiting time Total X2
Treatment Poor Fair Good P value

Low 7 1 0 8 X2=96.350 df
Mod 18 84 16 118 =4
High 14 39 82 135 p=.000*
Total 39 124 98 261
*Sig <.005

Table 19: Correlation between Waiting Time at Service Windows and the perception of the Services at
the Windows.
Service Parameter Waiting Time at Service Windows Overall
Registration Pre-consultation Pharmacy Perception WT Satisfaction
WT WT WT Services
Reg Process -.093 -- -- .585 .491
.134 .000* .000*
Overall Dr Care - -- -.041 -- .355 .504
.509 .000* .000*
Overall PH care -- -- -.021 .357 .462
.780 .000* .000*
Perception WT -.101 -.086 .001 1.000 .565

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 Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among ..
.105 .164 .990 .000*
Satisfaction with -.048 -.126 -.132 .565 1.000
Services .442 .043** .079 .000*
*Sig <.005, **<.05

Dr V.O. Abah. "Hospital Waiting Time, Satisfaction with Services and Patient Arrival Patterns among
Primary Care Attendees in a Tertiary Hospital: The Need for Time Specific Appointment
Systems.”IIOSR Journal of Dental and Medical Sciences (IOSR-JDMS), 20(03), 2021, pp. 14-27.

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