International Journal for Quality in Health Care 2006; Volume 18, Number 4: pp. 275–280 10.

1093/intqhc/mzl022
Advance Access Publication: 19 July 2006

The development and validation of the

Concise Outpatient Department User
Satisfaction Scale
IVY F. TSO, S. M. NG AND CECILIA L. W. CHAN
Centre on Behavioral Health, University of Hong Kong, Hong Kong

Abstract
Objectives. To develop and validate a concise scale for measuring outpatient satisfaction suitable across specialties and cultures.
Design & Setting. Item generation adopted a concept-driven approach, and 10 candidate items were administered together
with a battery of validation items and scales in a cross-sectional survey at a government-aided Chinese medicine specialized

Downloaded from intqhc.oxfordjournals.org by guest on February 10, 2011

outpatient department in Hong Kong.
Participants. About 344 consenting patients or their accompanying caregivers were recruited upon their first visit at the clinic
and interviewed one month thereafter.
Results. The overall response rate was 79%. After deleting one item (physician’s manner and attitude) for its redundancy sug-
gested by interitem correlations, exploratory factor analysis yielded two factors, General Service and Case Physician, explaining
75% of variance of the remaining nine items. The internal consistency coefficients of the whole scale and the two subscales
were higher than 0.90. Criterion-related validity was supported by high correlations with three anchor items, overall satisfac-
tion, intended future reutilization, and recommendation to others (r = 0.38–0.85). Significant correlations with compliance and
negative affects provided preliminary evidence for construct validity.
Conclusion. The psychometric properties of the resulting 9-item scale supported its usefulness in measuring outpatient
satisfaction. Further validation studies in various specialties and countries are suggested to make future cross-cultural compari-
sons possible.
Keywords: outpatient, scale development, user satisfaction, validation

In recent years, there has been an increasing demand of
accountability and productivity by consumers. It is now a
global trend in healthcare development toward integrating
subjective user satisfaction into the evaluation of medical
service quality [1,2]. There is evidence that patient satisfac-
tion is associated with treatment outcomes [3,4] though the
cause–effect relationship is not clear. It is possible that ill-
ness behavior plays a role in the mechanism through which
satisfaction affects clinical outcomes. Ferris and the Health
Services Research Group [5] reported that satisfied patients are
more likely than their dissatisfied counterparts to show positive
illness behaviors, e.g. complying with their medical regimens
and disclosing important medical information to their physi-
cians [6–8]. Therefore, knowledge of users’ satisfaction with
the service can serve not only as a performance indicator but
also to identify areas of improvement to provide better care
and services for the betterment of the users’ health.
There are very few user satisfaction scales that are suitable
for use in outpatient settings across different specialties.
Among the existing ones, some scales have yet to complete
the validation process [9]. Some reported satisfactory or good
levels of psychometric properties, but very often they contain
many items (typically 20–30 items) [10–12]. On the one hand,
looking at individual aspects of service (at least the most
important ones) is necessary, as most patients are not uni-
formly satisfied with all aspects even though they are gener-
ally satisfied with the service [13]. Also, it is conceivable that a
longer scale more likely yields more reliable results. On the
other hand, a user satisfaction measure with numerous items
has its own drawbacks. A long scale can lead to low motiva-
tion of patients to complete the questions and subsequently a
low response rate and biased sample as well as more missing
data. It is also difficult for many outpatient settings to incor-
porate the administration of a long questionnaire into their
busy daily operation, needless to mention that very often
other questionnaires or assessments are administered
together at the same time. Seeing this limitation, Perneger
et al. [14] derived a 16-item outpatient satisfaction survey

Address reprint requests to S. M. Ng, Assistant Professor, Centre on Behavioral Health, The University of Hong Kong, G/F
Pauline Chan Building, 10 Sassoon Road, Pokfulam, Hong Kong. E-mail: ngsiuman@hku.hk

International Journal for Quality in Health Care vol. 18 no. 4

© The Author 2006. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved 275
I. F. Tso et al.
from previously published instruments. The scale was
administered to a large sample (n = 1027) in Switzerland and
the seven dimensions of the scale showed satisfactory to
good internal consistency. An even briefer instrument (one
item of overall satisfaction and eight items of different satis-
faction aspects) was developed by Rubin et al. [15] to com-
pare outpatient satisfaction with different kinds of practices
in the United States. The authors successfully collected eval-
uation data from 17 671 outpatients and found that overall
satisfaction was associated with patients’ staying with or
leaving the physicians or systems in 6 months. However, the
relationship between different satisfaction aspects and out-
come was not examined. It would also have been helpful if
the authors could provide detailed psychometric statistics of
the questionnaire.
Another important issue of outpatient satisfaction assess-
ment is that most scales are developed in the West. These
scales often include items that are specific or applicable to
only some cultures or regions, e.g. availability of free car
parking space, multilingual information and translation, and
managed care organizations or health insurance-related ser-
vice. As such, the applicability of these scales in different
cultures is severely limited. An outpatient clinic user satis-
faction scale suitable for multinational studies is yet to be
developed.
This study aimed to develop a user satisfaction scale for use
in outpatient settings that could address the problems dis-
cussed above. The scale was expected to have the following
characteristics: (i) short—ideally within ten items, so that it is
administrable in a busy medical practice; (ii) items not spe-
cialty-specific so that the scale can be potentially applied in a
wide range of outpatient settings; and (iii) items not culture-
or region-specific so that the scale can be potentially applied
in a wide range of regions of different cultures and socioeco-
nomic development status.
Method
Subjects
Subjects of this study were 344 participants of an evaluation
study of a Chinese Medicine Specialist Outpatient Department
of a government-aided hospital in Hong Kong. They were
recruited through consecutive sampling of new cases present-
ing at the clinic during a 5-week period from September to
October 2004. The recruitment of new patients only was to
avoid or minimize possible systematic bias in sampling, as
there is evidence that satisfaction varies with visit frequency
[16,17]. Patients of all ages were included, but for those who
were aged under 13 (the entry age of high school, at which the
individual is commonly considered competent to understand
and complete questionnaires) or mentally unfit to be inter-
viewed, they had to be accompanied by a carer who could
serve as the informant. Also, all subjects (patients or their
informants) were able to communicate effectively in Cantonese
or Putonghua. Written informed consent was sought from
each subject before data collection. Subject’s confidentiality
276
and interviewer’s independency were emphasized to avoid or
minimize biased responses due to worries of loss of anonymity
and negative impact on service to be received.
The Concise Outpatient Department User
Satisfaction Scale
A scale was constructed to measure user satisfaction. The
investigators adopted a concept-driven approach for genera-
tion of items that are considered generally applicable to out-
patient settings of different specialties. The construct was
conceptualized as having three domains, namely physical
setup, clinic operation, and case physician. Specific items
were then generated under each domain. Because the scale
intends to be applicable across medical specialties, and hope-
fully across culture as well, great caution had been taken in
avoiding items that are restricted to a certain disease group or
cultural related lifestyle. The initial item pool was reviewed
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and critiqued by experienced health researchers at the Centre
on Behavioral Health, The University of Hong Kong. Even-
tually, a three-domain, 10-item scale was constructed. The
items were (i) physical environment, (ii) equipment and facilit-
ies, (iii) appointment arrangement, (iv) waiting time, (v) ser-
vice of the dispensary, (vi) support staff, (vii) case physician’s
professionalism, (viii) explanation given by the case physician,
(ix) case physician’s attitude and manner, and (x) consultation
time. Respondents need to answer each item in a response
format of a 10-point anchored numerical scale, where ‘1’ indi-
cates not satisfied at all and ‘10’ extremely satisfied.
Validation items/scales
Three additional items were created as the anchor items to
examine the criterion-related validity of the scale: overall sat-
isfaction of the clinic, intended future reutilization, and likeli-
hood of recommending the clinic to others. They were also
answered in the abovementioned 10-point response format.
Because some studies reported that patient satisfaction is asso-
ciated with clinical outcomes and compliance [3,4], the Chinese
Affect Scale (CAS; a scale of 20 items that measure positive and
negative affects common in and applicable to Chinese popula-
tions) [18] and two 10-point items of self-reported compliance
with follow-up bookings and medical regimen were added to
evaluate the construct validity of the scale.
Procedure
All new patients of the clinic were screened by the attending
nurse staff at the assessment room before seeing their physi-
cians. The attending nurse gave each new patient a printed
reminder so that he/she would report to the independent
interviewer in the specified consultation room after seeing his/
her physician. At the same time, the interviewers could moni-
tor prospective subjects’ whereabouts with a computer ter-
minal in his/her consultation room. This enabled the
interviewers to get touch with all new patients, even during the
busiest hours. There were totally six interviewers in this study,
 Concise Outpatient Department User Satisfaction Scale

each of whom was a retired registered nurse with over 20 years
of experience in public hospitals in Hong Kong and had been
trained by the investigators (S.M.N. and I.F.T.) on administer-
ing the questionnaires of the study, including the Concise Out-
patient Department User Satisfaction Scale. There were two
interviewers standing by at the clinic at any time during the
recruitment period to recruit and interview subjects.
After receiving information of the study and giving informed
consent, each subject was interviewed by an interviewer. Inter-
view instead of self-completion was employed to minimize
invalid or missing data [12] and to obtain more reliable
responses by providing instant explanations of the instructions
and items of the questionnaire to subjects when necessary. The
subjects were followed up on telephone by their corresponding
interviewers 1 month after first interview (i.e. from October to
November 2004). If the subject could not be reached at the
first attempt, then at least two more attempts were made before
he/she was considered unreachable and dropout.
systematic bias in the successfully recruited sample. Among
the 92 non-responders/dropouts, 34 (37.0%) were male and
58 (63.0%) were female. Their mean age was 45.2 years (SD =
18.1). The responders and the non-responders/dropouts
were not statistically different in terms of age (P = 0.593) and
sex (P = 0.116).
Factor structure
Inter-item correlations were examined before proceeding
to factor analysis. Item 9 (case physician’s attitude and
manner) was removed from the scale because it was too
highly correlated with items 7, 8, and 10 (r = 0.91, 0.83,
and 0.88, respectively) and thus considered a redundant
item.
The number of valid cases (i.e. those free of missing data)
for exploratory factor analysis was 305. Using principal com-
ponent analysis with criterion of eigenvalue > 1, two factors

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Statistical analysis
We used 1-month follow-up data for validation of the scale,
as we reckoned that patients were not well informed upon
their first visit at the clinic and their opinions might be prema-
ture and not very reliable. The Concise Outpatient Depart-
ment User Satisfaction Scale was firstly evaluated for its factor
structure with exploratory factor analysis (Principal Compo-
nent Analysis with Varimax Rotation) with SPSS 11.5 for
Windows. Then, the internal consistency of the refined scale
was examined with split-half reliability and Cronbach’s alpha
coefficient [19]. The scale’s criterion-related validity was
examined by looking at the correlations between the total sat-
isfaction score with the single-item overall satisfaction score,
intended future reutilization, and likelihood of recommend-
ing the clinic to others. Construct validity was examined by
correlating the total satisfaction score with compliance with
follow-up arrangement, compliance with medical regimen, as
well as positive and negative affects of the subjects.
were extracted from the nine remaining items. Visual inspec-
tion of the Scree plot also supported a two-factor solution.
The two factors explained totally 75.62% of variance. Factor
loadings after Varimax Rotation of each item and total vari-
ance explained by the factors are presented in Table 1. With
meaningful loadings set at 0.40, only item 1 (physical envir-
onment) had double loadings on the two factors. Names
were given to the two factors according to the concept
addressed by the items: factor 1 (items 1–6) was named gen-
eral service; and factor 2 (items 7, 8, and 10) was named case
physician.
Means and standard deviations of the total satisfaction
score (averaged sum of the nine items) and the two subscales
of the whole sample and by sex, age strata, and subsequent
visit after first visit and before 1-month follow up are
Table 1 Factor loadings from the Rotated Component
Matrix for the Concise Outpatient Department User Satisfac-
tion Scale: Principal Component Analysis with Varimax
Rotation

Results Concise Outpatient Department User Factor 1 Factor 2

Satisfaction Scale items
..........................................................................................................
Response rate
General service
During subject recruitment, a total of 436 patients who satis- 1. Physical environment 0.61 0.40
fied the inclusion criteria were approached, out of which 367 2. Equipment and facilities 0.81 0.31
gave consent to participate in the research, making the 3. Appointment arrangement 0.86 0.28
response rate of first interview 84.2%. All but 23 of the 367 4. Waiting time 0.84 0.17
subjects were successfully followed up 1 month later 5. Service of the dispensary 0.77 0.11
(response rate = 93.7%). The overall response rate of the 6. Support staff 0.79 0.37
study was therefore 84.2 × 93.7% = 78.9%. Case physician
Among the responders (n = 344), 98 (28.5%) were male 7. Case physician’s professionalism 0.31 0.89
and 246 (71.5%) were female. Their mean age was 44.0 years 8. Explanation given by case physician 0.22 0.90
(SD = 17.1). Efforts were made to compare the basic demo- 9. Consultation time 0.23 0.90
graphic data (sex and ages were the only information that Variance explained 60.01% 15.61%
non-responders/dropouts agreed to disclose) of the respond-
ers (who were successfully followed up) and non-responders/ Loadings highlighted in bold indicate the factor on which the item
dropouts of the study so as to check whether there was any was placed; loading underlined indicates a double loading.

277
I. F. Tso et al.
Table 2 Means and standard deviations for the Concise Outpatient Department User Satisfaction Scale
All By sex1
............................................. ..................................................................... .............................................
(n = 305)
Male Female
(n = 85) (n = 220)
[mean (SD)] [mean (SD)] [mean (SD)] [mean (SD)] [mean (SD)] [mean (SD)] [mean (SD)]
.........................................................................................................................................................................................................................
Total satisfaction 7.00 (1.15) 7.11 (1.00)
General service 7.03 (1.21) 7.14 (1.06)
Case physician 6.94 (1.45) 7.07 (1.21)
Possible range of means: 1–10.
1
No statistical differences between the two sexes and the age strata.
2
Subsequent visit(s) following first visit before 1-month follow up. Compared with those who had no subsequent visit, subjects who had sub-
sequent visit(s) rated significantly higher on case physician (P = 0.048) but not total satisfaction (P = 0.14) and general service (P = 0.37).
displayed in Table 2. T tests did not show any significant dif-
ferences between the two sexes and the three age strata, but
subjects who had subsequent visit(s) rated significantly higher
on case physician (P = 0.048) but not total satisfaction (P =
0.14) and case physician (P = 0.37) when compared with
those who had no subsequent visit. Regression analysis indi-
cated that basic demographic variables including age, sex,
marital status, and educational level did not account signifi-
cantly for total satisfaction. The final version of the Concise
Outpatient Department User Satisfaction Scale is provided in
the Appendix.
Internal consistency
By odd–even split of the nine items, the Guttman split-half
reliability was estimated to be 0.93 and the unequal-length
Spearman–Brown reliability was 0.94. The coefficient alpha
of the scale, which represents the average of all possible
split-half reliability coefficients, was 0.91, falling into the
range of ‘good’. The factor alphas were also in the good
range: 0.90 for general service and 0.93 for case medical
practitioner.
Criterion-related validity
Correlations between the satisfaction scores and validation
items/scales are summarized in Table 3. Almost all individual
items were significantly correlated with the three anchor
items: overall satisfaction (r = 0.51–0.77), intended future
reutilization (r = 0.13–0.50), and likelihood of recommending
the clinic to others (r = 0.10–0.50). The total satisfaction
score (averaged sum of all items) was also significantly corre-
lated with the three anchor items (r = 0.85, 0.38, and 0.38,
respectively, all P < 0.001), supporting the concurrent valid-
ity. The two subscale scores were also significantly correlated
with the three anchor items. For general service, the correla-
tion coefficients were 0.76, 0.26, and 0.23, respectively (all
P < 0.001). For case physician, the correlation coefficients
were 0.77, 0.49, and 0.51, respectively (all P < 0.001).
278
By age1 By subsequent visit2
<36 36–50 >50 No Yes
(n = 67) (n = 137) (n = 101) (n = 69) (n = 236)
6.95 (1.20) 6.75 (1.03) 7.02 (1.12) 7.13 (1.15) 6.80 (1.31) 7.06 (1.10)
6.99 (1.27) 6.72 (1.15) 7.09 (1.17) 7.16 (1.29) 6.90 (1.35) 7.07 (1.17)
6.89 (1.53) 6.80 (1.09) 6.90 (1.47) 7.09 (1.62) 6.58 (1.76) 7.04 (1.33)
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Construct validity
Significant but mild correlations were found between the total
satisfaction score and compliance with follow-up bookings (r
= 0.23, P < 0.001) and compliance with medical regimen (r =
0.18, P < 0.001). Although it was not associated with positive
affect as measured by the CAS (r = 0.05, P > 0.05), it was neg-
atively correlated with CAS negative affect (r = –0.26, P <
0.001) as expected. The two subscores showed similar pat-
terns as the total satisfaction score. See Table 3 for details.
Discussion
We successfully created a scale with a parsimonious number of
items that is suitable for outpatient settings across specialties.
The scale had high levels of internal consistency and validities
as suggested by alpha coefficient and the scale’s correlations
with other related measures. Factor analysis suggested that
about 75% of the variance of the items could be explained by
two latent variables, namely general service and case physician.
Contrary to expectation, physical setup and clinic operation of
an outpatient department could not be differentiated from one
another; they contributed to user satisfaction as a single factor.
In this study, a 10-point response format in which the two
ends are labeled respectively ‘not satisfied at all’ and ‘extremely
satisfied’ was adopted. The decision was based on the rationale
that giving ratings in a 10-point scale is intuitively more direct
and thus easier than, say, 4-, 5-, or 6-point scales. This
response format was also preferable to Likert scale for two
reasons: respondents can give a rating without needing to read
the description of each response choice as in Likert response
format and it offers a more sensitive measure and avoids
skewedness potentially caused by the choice of the number of
response choices (e.g. 5- versus 6-point Likert scale) [20]. The
high level of internal consistency (alpha > 0.90) and low rate
of missing data (<2%) support that the scale was easy to
understand and effective in obtaining reliable measures.
Interestingly, although the total satisfaction score was corre-
lated with the single-item overall satisfaction more strongly than
 Concise Outpatient Department User Satisfaction Scale

Table 3 Correlations between satisfaction scores and validation items/scales

Total satisfaction General service Case physician

.........................................................................................................................................................................................................................

Subscores
General service 0.941
Case physician 0.811 0.561
Anchor items
Overall satisfaction 0.851 0.761 0.771
Future reutilization 0.381 0.261 0.491
Recommend to others 0.381 0.231 0.511
Construct validity items
Compliance (follow up) 0.231 0.151 0.311
Compliance (medical regimen) 0.181 0.11 0.251
Chinese Affect Scale—positive affect 0.05 –0.05 0.201
Chinese Affect Scale—negative affect –0.261 –0.221 –0.241
1
Significant at the 0.001 level.

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the two subscores did, the case physician subscore was a better
predictor of intended reutilization, recommending to others, as
well as compliance with follow-up arrangement and medical
regimen. Because compliance with medical follow ups and regi-
men affects patients’ clinical outcomes, it is implicated that to
help enhance patients’ clinical outcomes and patients’ satisfac-
tion with their case physicians should be elevated through striv-
ing for and maintaining a high level of quality of physicians.
A limitation of the study is that the test–retest reliability of
the scale has not been evaluated. Nevertheless, the ultimate
goal of assessing patient satisfaction is to monitor the quality
of service of the clinic as a whole and identify areas for
improvement so as to improve patients’ treatment outcomes.
The scale’s predictive power is worthy of further investiga-
tion. Follow-up studies may be conducted in the future to test
whether satisfaction measured by this scale can predict
patients’ illness behavior and clinical outcomes as indicated by
objective as well as subjective measures. It is also advisable to
test the scale on outpatient departments of other specialties to
generalize its applicability and usefulness.
The Concise Outpatient Department User Satisfaction
Scale is intended for assessing patient satisfaction in outpa-
tient settings across specialties. The items included cover only
main aspects conceived to be universal across specialties. This
property of the scale enables comparisons of results from dif-
ferent specialties. The inevitable limitation is that aspects that
might be of particular importance to particular specialties are
not included, making the scale not suitable for in-depth evalu-
ation of outpatient departments of a particular specialty. Simi-
larly, this scale is intended to have potential of development
and use in other regions or countries. Thus, in generating the
item pool, precautions were taken to include only core satis-
faction items and avoid lifestyle items specific to local con-
text. Given its good psychometric properties as revealed in
this study, further scale validation in other countries and cul-
tures is worth pursuing for it would help conducting cross-
regional or -cultural studies of health care service quality.
Acknowledgements
This study was funded by the Tung Wah Group of Hospitals
(TWGHs). We thank Dr K. F. Leung, Dr K. T. Tom, Ms Rita
Li, Mr Philip Tam, Ms Suen, and Ms Kwan of TWGHs for
their relentless support throughout this study. We gratefully
thank the contributions of Ms Yun-ying Chang, Ms Sai-mei
Lau, Ms Chi-lim Chan, Ms Siu-mui Wong, Ms Mei-ngan Sin,
and Ms Sau-kam Lui in data collection. We also thank Ms Ada
Yiu for her efficiency in data coding and entry and Ms Nora
Cheng for carrying out quality assurance check of the data set.
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Appendix
Concise Outpatient Department User Satisfaction Scale
Please indicate your satisfaction with each of the following aspects of this clinic by circling a number from 1 to 10, where ‘1’
means not satisfied at all and ‘10’ means extremely satisfied.
1. Physical environment 1 2 3 4 5 6 7 8 9 10
2. Equipment and facilities 1 2 3 4 5 6 7 8 9 10
3. Appointment arrangement 1 2 3 4 5 6 7 8 9 10
4. Waiting time 1 2 3 4 5 6 7 8 9 10
5. Service of the dispensary 1 2 3 4 5 6 7 8 9 10
6. Support staff 1 2 3 4 5 6 7 8 9 10
7. Your case physician’s professionalism 1 2 3 4 5 6 7 8 9 10
8. Explanations given by your case physician 1 2 3 4 5 6 7 8 9 10
9. Consultation time 1 2 3 4 5 6 7 8 9 10

280