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PATIENT SATISFACTION IN THE QUALITY OF SERVICE RENDERED BY RADIOLOGIC TECHNOLOGY INTERNS IN THE PUBLIC AND PRIVATE AFFILIATING CENTERS OF MEDICAL COLLEGES OF NORTHERN PHILIPPINES: A COMPARATIVE STUDY Author: C.J. Angela J. Pinugu, RRT [email protected] ABSTRACT Literatures from previous studies show that patient satisfaction has an impact with the service rendered by Radiologic technology interns in the public and private institutions. It is therefore the main objective of this study is to ascertain the patient satisfaction in the quality of service rendered by Radiologic Technology interns in the public and private affiliating centers of Medical Colleges of Northern Philippines. The descriptive-comparative Research Design design was used to 57 patients from the following hospitals, Dr. Ronald P. Guzman (RPGMC), Isabela United Doctors Medical Center (IUDMC), Isabela Doctors General Hospital (IDGH), Quirino Provincial Medical Center, and De Vera Medical Center (DVMC), Philippine Orthopedic Center and University of the East Ramon Magsaysay Medical Center (UERMMC). Structured questionnaire based on CHED Memorandum Order (CMO) 2006 was used to measure the Patient satisfaction satisfaction of the respondents in which it was also analysed using frequency count and percentage distribution, mean and Pearson r for the test of relationship. Result shows that CT scan tech (15- 42.86%) is the breading specialization followed by sonographer (14-40%) and MRI tech. (6-17.14%). In addition respondents are very satisfied in their Job satisfaction on the following: Management (3.34), employee competence (3.43), premises and technical working condition (3.33) relationship between employees (3.43), trust (3.47), responsibility (3.37) and influence (3.37) while they are satisfied with remuneration (3.14). Further analysis shows having an area of specialization is significant related to their Job Satisfaction on the following area. Premises and technical working condition (p=.041) Relationship between employees (p=.041) and trust (p=.04). Keywords: Intern, Patient satisfaction, Commnication, Procedure, Patient Care INTRODUCTION This study focuses on the quality of service rendered by the Radiologic Technology interns to their patient. A service rendered by the intern is very important especially in building up their character as future Radiologic Technologists. Patient satisfaction, while always a critical factor, has recently gained momentum in the healthcare space. In the wake of the patient-centered healthcare environment, patients are demanding a bigger role in managing their healthcare, and they expect a higher level of commitment and care from their providers. Many medical facilities are starting to pay attention to patient experience and satisfaction. According to a recent survey, more than half of healthcare practitioners admit that patient satisfaction is one of their top three priorities. Improving patient satisfaction has become one of the primary goals for a lot of healthcare providers. The reason is simple: patient satisfaction level is directly linked to key success metrics for hospitals and individual healthcare providers. Patient satisfaction impacts clinical outcomes, patient retention and reimbursement claims. As a researcher it gives an idea to conduct a research based in the literature presented to study furthermore about the level of patient satisfaction in the quality of service rendered by the Radiologic Technology Interns, and aim to determine whether there is a relationship between them. METHODOLOGY The methodology used in this study is presented which includes the research design, respondents of the study, data gathering tool, data gathering procedures and the statistical analysis for the data being collected this study. Research Design This study used quantitative type of research using a Descriptive-Comparative Research Design. Descriptive-comparative because it described the level of patient satisfaction in the quality of service rendered by the Radiologic Technology intern and compare the relationship of patients satisfaction in the service rendered by radiologic technology intern and assessment of Radiologic Technology staff in the quality of service they render. Respondent This study used a purposive sampling technique, a non-probability sample that is selected based on characteristics of a population and the objective of the study. The respondents of this study are the patients and Radiologic Technologists from the different Public and Private Hospital affiliation of the Medical Colleges of Northern Philippines. Questionnaires will be distributed to the hospitals. Data Gathering Tool A standardize questionnaire published by the Society for Human Resource Management (SHRM) was used to gather information. The first part was self-made questionnaire used to assess the profile of the respondents. The second part used four-point Likert scale to assess the impact of specialization and is composed of seven dimensions (management, employee competence, premises and working condition, remuneration, influence, relationship between employees, responsibility and trust) regarding job satisfaction. Data Gathering Procedure The researcher sent letters to the Chief Radiologic Technologist and Hospital Director of each affiliating hospital regarding the conduct of research. The letter contains permission in allowing the researcher to conduct her study. The respondents are the patients of each Radiologic Technology intern in the hospital. A purposive sampling technique will be used in this study. Purposive sampling is a non-probability sampling method and it occurs when elements selected for the sample are chosen by the judgment of the researcher. The questionnaires will be then collected, tabulated and analyzed. After the Analysis and interpretation, Conclusions and recommendations shall be produced from the data. Data Analysis The researcher will be using frequency count and percentage distribution for the demographic profile of respondents, weighted mean for the level of satisfaction of the respondents, Pearson R for the significant relationship of profile variable of patient and their level of satisfaction, and t-test independent to assess difference in the level of patient satisfaction when grouped according to type of the hospital. RESULTS The results of the gathered data were presented in the succeeding tables. Analysis and interpretations of data were done for every tabular presentation. TABLE 1.1 Frequency Count and Percentage Distribution of Respondents According to Age AGE FREQUENCY PERCENTAGE 10-15 2 3.5 16-20 12 21.1 21-25 18 31.6 25 AND ABOVE 25 43.9 TOTAL 57 100 Table 1.1 shows the profile variable of the respondents as to their age wherein 25 and above has the highest number of respondents with frequency of 25 (43.9%), followed by age bracket 21-25 with frequency of 18 (31.6%), then age bracket 16-20 with frequency of 12 (21.1%)and the age bracket 10-15 which is the lowest number of respondents with frequency of 2 (3.5%). This means that most of the respondents are adult. TABLE 1.2 Frequency Count and Percentage Distribution of Respondents According to Sex SEX FREQUENCY PERCENTAGE MALE 19 33.3 FEMALE 38 66.7 TOTAL 57 100.0 Table 1.2 shows the profile variable of the respondents as to their sex wherein majority of the respondents are male with frequency of 38 (66.7%) while female respondents have a frequency of 19 (33.3%). It means that most of the respondents are male. TABLE 1.3 Frequency Count and Percentage Distribution of Respondents According to Civil Status CIVIL STATUS FREQUENCY PERCENTAGE SINGLE 22 38.6 MARRIED 28 49.1 WIDOWED 7 12.3 TOTAL 57 100 Table 1.3 shows that most of the respondents are married with frequency of 28 (49.1%) followed by single with frequency of 22 (38.6%) and the least is widowed with frequency of 7 (12.3%). This indicates that most of the respondents are married as most of them are in adulthood. TABLE 1.4 Frequency Count and Percentage Distribution of Respondents According to Procedure PROCEDURE FREQUENCY PERCENTAGE XRAY 50 87.7 CT-SCAN 2 3.5 MRI 0 0 RADIATION THERAPY 2 3.5 NUCLEAR MEDICINE 0 0 ULTRASOUND 2 3.5 MAMMOGRAPHY 1 1.8 TOTAL 57 100 Table 1.4 shows the profile variable of the respondents as to procedure done. Most of the procedure done is xray with frequency of 50 (87.7%) followed by CT-Scan with frequency of 2 (3.5%), then Radiation therapy with frequency of 2 (3.5%), then ultrasound with frequency of 2 (3.5%) and the least of all is mammography with frequency of 1 (1.8). This implies that most of the procedure done are x-ray for in every hospital, x-ray is their initial examination to assess patient condition. TABLE 1.5 Frequency Count and Percentage Distribution of Respondents According to Highest Educational Attainment HIGHEST EDUCATIONAL FREQUENCY PERCENTAGE ELEMENTARY UNDERGRADUATE 2 3.5 ELEMENTARY GRADUATE 3 5.3 HIGH SCHOOL UNDERGRADUATE 2 3.5 HIGH SCHOOL GRADUATE 8 14.0 PhD HOLDER 2 3.5 COLLEGE UNDERGRADUATE 10 17.5 COLLEGE GRADUATE 27 47.4 WITH EARNING UNIT 1 1.8 MA DEGREE HOLDER 2 3.5 TOTAL 57 100 ATTAINMENT Table 1.5 presents the profile variable of respondents as to their highest educational attainment. The most of highest educational attainment is College graduate with frequency of 27 (47.4%), followed by college undergraduate with frequency of 10 (17.5%), then high school graduate with frequency od 8 (14.0%), then elementary graduate with frequency of 3 (5.3%), then elementary undergraduate with frequency of 2 (3.5%), then high school undergraduate with frequency of 2 (3.5%),then PhD holder with frequency of 2 (3.5%), then MA degree holder with frequency of 2 (3.5%) and lastly, the least of all is the earning unit with frequency of 1 (1.8%). This means that most of respondents are college graduate as they are of married and of age. TABLE 1.6 Frequency Count and Percentage Distribution of Respondents According to Type of Hospital TYPE OF HOSPITAL FREQUENCY PERCENTAGE PUBLIC 39 68.4 PRIVATE 18 31.6 TOTAL 57 100 Table 1.5 shows the distribution of respondents as to the type of Hospital. This represent that most of the respondents are in Public hospital with frequency of 39 (68.4%) while the rest is in private with frequency of 18 (31.6). This implies that most respondents went to the public hospital for examination. For TABLE 1.7 Frequency Count and Percentage Distribution of Respondents According to Socio Economic Status SOCIO-ECONOMIC STATUS FREQUENCY PERCENTAGE LOW CLASS 10 17.5 INTERMEDIATE CLASS 32 56.1 HIGH CLASS 15 26.3 TOTAL 57 100.0 Table 1.6 shows the profile variable according to socio economic status. Most of respondents are intermediate class with frequency of 32 (56.1%) followed by high class with frequency of 15 (26.3). TABLE 2.1 Mean Perception of Respondents on Their Level of Satisfaction as to Communication COMMUNICATION WEIGHTED MEAN INTERPRETATION 1.The intern explains the 4.44 EXCELLENT 4.39 EXCELLENT 4.35 EXCELLENT 4.42 EXCELLENT 3.61 VERY SATISFACTORILY 4.12 VERY SATISFACTORILY 4.16 VERY SATISFACTORILY 4.21 EXCELLENT 9. The intern is attentive 4.28 EXCELLENT 10. The intern does not talk 4.32 EXCELLENT procedure. 2. The intern gives clear instruction 3. The intern is aware of her words 4. The intern gives instruction after the procedure. 5. The intern asks personal question 6. The intern does not utter vulgar profanity in front of patient 7. The intern gives complete instructions. 8. the intern instructs gently from afar. TOTAL WEIGHTED 4.22 EXCELLENT MEAN Table 2.1 shows the mean perception of respondents on their level of satisfaction as to communication. The intern explains the procedure as Excellent has the highest rating of 4.95 while the intern asks personal question as very satisfactorily. Overall, the mean perception of respondents on their level of satisfaction as to communication with general total weighted mean of 4.22 with corresponding descriptive value of Excellent which means that the interns of Medical Colleges of Northern Philippines communicates properly to the patient. A recent study, conducted by Rutten et al., used a representative sample of households in the US to explore multiple factors associated with patient perceptions about communication and found no differences based on sociodemographic characteristics. Previous studies have suggested that providers communicate less effectively with racial and ethnic minorities, older patients, and those with lower educational attainment levels. After controlling for the effects of all demographic and socioeconomic characteristics in the models, disparities in patient perceptions of healthcare communication persisted. Across all four measures of communication, older patients were more likely to report positively. Not surprisingly, health insurance and a usual source of care were also consistent predictors of positive perceptions of communication. Interpersonal communication is born through the combination of verbal forms (an oral and written language), nonverbal (gestures, mimics, posture, movement, appearance) and paraverbal forms (by voice attributes accompanying the word, such as intonation, the inflection of voice, tone, rhythm, verbal flow). It can be influenced by a number of factors: – the degree of closeness or spatial proximity; the limits and the extent of physical contact in these relationships; the friendly or authoritative style of communication; the exchange of glances that form visual communication;the volume and pace of the interactions; the dynamics of reciprocal self-development. TABLE 2.2 Mean Perception of Respondents on Their Level of Satisfaction as to Procedure PROCEDURE WEIGHTED MEAN INTERPRETATION 1. The intern is prepared of 4.16 VERY SATISFACTORILY 2. The intern is bossy. 2.86 SATISFACTORILY 3. The intern is 3.95 VERY SATISFACTORILY 4.09 VERY SATISFACTORILY 5. The intern is flexible. 4.09 VERY SATISFACTORILY 6. The intern atends to my 3.95 VERY SATISFACTORILY 4.18 VERY SATISFACTORILY the procedure. approachable 4. The intern is knowlegdeable need 7. The intern is careful in handling patient. 8. The intern positions 4.21 EXCELLENT 9. The intern is skilled 4.30 EXCELLENT TOTAL WEIGHTED 3.97 VERY SATISFACTORILY expertly MEAN Table 2.2 On mean perception of respondents on their level of satisfaction as to procedure, the intern is skilled has the highest mean rating of 4.30 with descriptive value of excellent while the intern is bossy has the lowest mean rating of 2.86 with descriptive value of satisfactorily. This means that the interns of Medical Colleges of Northern Philippines, when it comes to procedure are equipped with the right knowledge. During the internship previous studies identified stress, a theory-practice gap and a feeling of uncertainty of how to act. The effects of stress, distress and the absence of understanding among the health care team have been enumerated. Despite the many studies regarding negative experience during internship, positive experiences have been identified that have resulted into better patient care. In addition they address intern’s desire to be supervised and taught during their internship. The goal of Radiologic Technology Education is to provide the country with dynamic, competent, sociallyconscious, and ethical Radiologic Technologists concerned with the application of state-of-the-art scientific techniques in medical imaging and therapy.The program is designed to prepare students for employment as radiographers, sonographers, nuclear medicine technologists or radiation therapy technologists in hospitals, medical offices, cancer centers, community health agencies or industrial concerns where radiation is used for quality control. CMO No. 18-s 2006, Article 3 Program of Specification Section 4. TABLE 2.3 Mean Perception of Respondents on Their Level of Satisfaction as to Patient Care PATIENT CARE WEIGHTED MEAN INTERPRETATION 4.58 EXCELLENT 4.56 EXCELLENT 4.47 EXCELLENT 4. The intern is alert 4.54 EXCELLENT 5. The intern is corteous. 4.60 EXCELLENT TOTAL WEIGHTED 4.55 EXCELLENT 1. Intern behaves professionally 2. The intern assists in positioning 3. The intern does not palpate without asking persimission MEAN Table 2.2 On mean perception of respondents on their level of satisfaction as to patient care. The intern is courteous has the highest mean rating of 4.60 with descriptive value of excellent while the intern does not palpate without asking permission has the lowest mean rating of 4.47 with descriptive value of excellent. This implies that the interns of Medical Colleges of Northern Philippines provide utmost patient care to their patient. The department of Radiologic Technology of the Medical Colleges of Northern Philippines conducts revalida and praticals which has been of help to the preparation of interns to their training. Patients must be treated with compassion, kindness, and consideration. Patient’s information must be handled with utmost confidentiality. Interns must avoid undue familiarity and intimacy with patients and staff of affiliation hospitals. Interns shall maintain harmonious working relationship with fellow interns and other personnel of the affiliation hospitals. Interns are not allowed to accept fees, gifts, or presents in any form from patients. Interns are bound by the Code of Ethics in the practice of Radiologic Technology profession. CMO No. 18-s 2006, Appendix A Guidelines for Radiologic Technology Clinical Education Training Program VII. Duties and Responsibilities of Interns 1. TABLE 3.1 RELATIONSHIP BETWEEN THE PROFILEOF THE RESPONDENTS AS TO THEIR LEVEL OF SATISFACTION PROFILE OF THE RESPONDENTS AGE SEX CIVIL STATUS PROCEDURE HEA Type of Hospital SOCIO Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Communication .052 Procedure .214 Patient care -.006 .704 57 -.246 .109 57 .041 .963 57 -.024 .065 57 -.207 .762 57 -.105 .857 57 .087 .123 57 -.085 .437 57 -.133 .522 57 .125 .531 57 .197 .325 57 .072 .354 57 .012 .142 57 -.039 .593 57 -.314* .928 57 .110 .773 57 .034 .017 57 .053 .415 57 .150 .804 57 .697 57 .267 57 *. Correlation is significant at the 0.05 level (2-tailed). Table 3.1 shows therelationship between the profile of the respondents to their level of satisfaction. Age has positive relationship r value to communication (.052) and procedure (.214) while negative relationship r value to patient care (-.006). Sex has negative r value to communication (-.246) and patient care (-.024) and positive r value to procedure (.041). Civil status has negative r value to communication (-.207) and procedure (-1.05) and positive r value to patient care (.087). Procedure done has negative r value to both communication (-.085) and procedure (-.133) and positive r value to patient care (.125). Highest Educational Attainment has positive r value to communication (.197), procedure (.072) and patient care (.12). Type of hospital has negative r value to communication (.039) and procedure (-.314*) and positive r value to patient care (.110). Lastly, the socio economic status has positive r value to communication (.034), procedure (.053) and patient care (.150). There is a significant relationship between type of hospital and procedure. There is no significant relationship between the Age,Sex, Procedure, Highest Educational Attainment, and socio-economic status to their level of satisfaction. A recent study, conducted by Rutten et al., used a representative sample of households in the US to explore multiple factors associated with patient perceptions about communication and found no differences based on sociodemographic characteristics. Previous studies have suggested that providers communicate less effectively with racial and ethnic minorities, older patients, and those with lower educational attainment levels. Other studies, however, have not been consistent in reporting these sociodemographic associations. et al. have suggested that more research is needed into this area.Satisfaction literature has identified potential demographic and clinical characteristics that may also be relevant to communication, but these studies have also yielded conflicting results with respect to the magnitude and direction of association between patient satisfaction and individual factors. After controlling characteristics in the for the models, effects of disparities all in demographic patient and perceptions socioeconomic of healthcare communication persisted. Across all four measures of communication, older patients were more likely to report positively. Not surprisingly, health insurance and a usual source of care were also consistent predictors of positive perceptions of communication. Interestingly, public insurance was significantly associated with better communication experiences, rather than private insurance, in three of the four cases. While associations with race varied, patients of Hispanic origin reported better perceptions of communication across all four measures. A closer examination of each of the remaining factors revealed that the poorest patients were less likely to report that providers always explained things so that they understood. Different levels of family income were not significantly associated with the other three outcomes. Male patients were more likely to report that providers always spent enough. TABLE 3.2 Difference in the Level of Patient Satisfaction When Grouped According to Type of the Hospital VARIABLE TYPE OF HOSPITAL COMMUNICATION PUBLIC PRIVATE PROCEDURE PUBLIC PRIVATE PATIENT CARE PUBLIC PRIVATE N MEAN 39 18 39 18 39 18 4.24 4.20 4.09 3.70 4.51 4.63 TVALUE .290 df 55 Sig. (2 tailed) .773 2.456 55 .017 -.822 55 .415 Table 3.2 presents the test of difference between level of patient satisfaction in Public and Private affiliating hospital of Medical Colleges of Northern Philippines. In communication, there is .290 difference while on Procedure there is 2.456 difference and lastly, in patient care there is .415 difference. DISCUSSION Based on the tabulated data of respondents as to their age wherein age bracket of 20-30 has the highest number of respondents (31=88.6) this means that majority of the Radiologic Technology respondents are in early adulthood stage. Majority of the respondents are female with a frequency of 22 which corresponds to (62. 9%), it tells that there is more female radiologic technologist in Region II than male radiologic technologist based on the data that was gathered. Based on data gathered one reason why female Radiologic Technologist is dominant is due to specialization where Ultrasonographer that best suit for them and is very popular in Region II and almost all hospitals that are part for this study have ultrasound machine.The result of the Civil status of the respondent among radiologic technologists are single in civil status with a frequency of 19 which corresponds to 54.3% followed by 14 frequency of radiologic technologists who are Married which has a percentage of 45.7%. As to the type of hospital they are working, based on the data gathered there are a higher number of the respondents working in a Private Hospital than Public/ Government Hospital. 27 respondents with a percentage of 77.1% are working in a private hospital while only 8 radiologic respondents that participate in the study with a corresponding percentage of 22.9% are working in only in public/ government hospital. Majority of radiologic technologists has rendered years in service ranging from 1-3 years with a frequency and percentage of 20-57.1%, followed by radiologic technologists with years in service of ranging from 4-6 years and percentage of 28.6% respectively and respondents working as a radiologic technologists for at least 10 years and above garners a frequency of 3 with a corresponding percentage of 8.6%. While Radiologic Technologist working below 6 months and in service ranging from 7-9 years have a garner the lowest frequency of 1 which correspond to a percentage of 2.9%. As to their area of specialization where sonographer has the highest frequency of 11 equivalents to a percentage of 31.4%, others which represent the general radiography has a frequency of 10 and an equivalent percentage of 28.6%. And based on the gathered data CT scan Technologist has a frequency of 8 and an equivalent percentage of 22.9%, while the data shows that Radiologic Technologist with more than 2 specialization has a frequency of 4 and percentage of 11.4% followed by MRI tech with a frequency of 2 and a percentage of 5.7%, and was supported by the study of Toshio Wagaithat shows the Ultrasound has a great advantages over other imaging modalities, the most popular advantage of diagnostic ultrasound is that it does not harm the human body or cause any pain to patients. Diagnostic ultrasound has recently been widely used in diagnosing cancer and cardiovascular disease and scanning fetuses as well as routine clinical examinations in hospitals. Result of the tabulated data shows that Specialization had an Impact on the job satisfaction of the respondents. Where Trust convey to be number 1 whereas the general mean average is (3.47) with a descriptive value of strongly agree. It means that trust is the most influencing factors that have a great impact to the job satisfaction of the Respondent. The study Jacob et. al (2014) shows in that interpersonal trust has a positive effect on job satisfaction. And remuneration convey to be the least whereas the general mean average is (3.14) with a descriptive value of Agree. This data show that in Region II salary is not that important as long as the Radiologic Technologist are happy inside their environment.Study of Ali Mohammad Mosadeghrad 2014 showed that healthcare quality can be improved by supportive visionary leadership, proper planning, education and training, availability of resources, effective management of resources, employees and processes, and collaboration and cooperation among providers.Inside the radiologic department, job satisfaction is one of the vital components in making the organization sustain their good job performance. This claim was supported by the study conducted by Push pakumari (2011) in which he revealed that there is a positive correlation between job satisfaction and job performance of the employee The test of relationships between the profile variables of the respondent as to their job satisfaction, shows that there is a correlation between age of respondent as to their Premises and technical working condition which is equivalent to (.03) and a correlation between the type of hospital as to their influence which has an equivalent value of (.046), also the area of specialization as to their premises and technical working condition with an equivalent value of (.013) and to relationship between employees with a value of (.04) are all correlated to job satisfaction. And for the test relationships between the profiles of the respondent and their area of specialization, shows that there is a correlation between the area of specialization as to their Premises and Technical Working Condition with a value of (.01*), and a correlation between area of specialization as to their trust with a value of (.04*), and the area of specialization as to trust with a value of (.03*). CONCLUSION Specialization has a great impact to the job satisfaction of Radiologic Technologist as stated and confirmed by this present study. It also supported by different researchers that specialization is very important in every Radiologic Technologist inside the hospital. RECOMMENDATIONS This research provides evidence on the existence of a positive relationship between the specialization of the Respondent to their job satisfaction. Result from this study serve to provide some recommendation for the Future Researchers. 1. Researcher recommend for the future researchers to conduct a study related to the present study to have a larger number of respondents to expand the results of the present study. Making this study a basis or source of review can help the future researchers to improve the study to be conducted, and to show more accurate result. 2. Based on the finding’s researchers recommend the hospitals to encourage their Radiologic technologist to undergo training to have specialty to promote and establish a good relationship between them and to maintain their jo satisfaction. 3. MoreRadiologic Technologist are encourage to participate to have a better result and encourage them to be more honest in answering Future questionnaire to have a better result. REFERENCES 1. shttps://www.practicebuilders.com/blog/patient-satisfaction-why-it-matters-andhow-to-improve-it/ 2. https://www.ncbi.nlm.nih.gov/books/NBK221227/-Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century.Washington (DC): National Academies Press (US); 2002. -Jo Ivey Boufford, M.D.Christine K. Cassel, M.D. The Future of the Public’s Health in the 21st Century. 3. https://www.ncbi.nlm.nih.gov/books/NBK221233/-Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century.Washington (DC): National Academies Press (US); 2002- Kaye W. Bender, Ph.D., R.N., F.A.A.N. Lisa Berkman, Ph.D. . The Future of the Public’s Health in the 21st Century. 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4918748/-Health Expect. 2009 Mar; 12(1): 70–80.- Jennifer E. DeVoe, MD, DPhil, 1 Lorraine S. Wallace, PhD, 2 and George E. 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Heathfield (2016) Employee Satisfaction: Make Employee Satisfaction Surveys Successful https://www.thebalance.com/employee-satisfaction-1918014 Susan M. Heathfield (2016) 5 Recommendations to Improve Employee Satisfaction Surveys https://www.thebalance.com/employee-satisfaction-survey-recommendations1918010
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