Patient Satisfaction with Emergency Services in Aliman Hospital in Saudi Arabia - Research Paper Example

Patient satisfaction with emergency services in Aliman Hospital in Saudi Arabia Author’s name Institutional affiliation Contents Patient satisfaction with emergency services in Aliman hospital in Saudi Arabia 1.0 Introduction Patient satisfaction is a very significant issue when it comes to healthcare in the modern era. Additionally, the Emergency Service Department (ED) acts as one of the primary gatekeepers of patient’s treatment. In this case, it is acknowledged that EDs should establish a way of satisfying its customers by offering healthcare services of the highest standards (Shelton, 2000). Moreover, according to readily recorded statistics, the patients visiting the ED is on the rise. In other words, this clearly shows that healthcare departments should always be prepared to plan effectively. To realize successful planning, comprehending the needs, views and the requirements of customers is an essential step. Moreover, the most commonly employed tool for improving the quality of services in the Emergency Service Department is performing a client satisfaction survey so as to explore the variables that may be affecting the clients’ levels of satisfaction and the common causes of dissatisfaction among patients and customers (Shelton, 2007). In simple terms, it is believed that the satisfaction level of customers is basically a key aspect that should be considered whenever a healthcare department is making recommendations to other available services. Although it is assumed that, it is almost impossible to satisfy all ED clients, it is acknowledged that customer satisfaction can be achieved through working on related satisfaction indicators and trying as much as possible to improve them. Other scholarly articles postulate that, using the findings and results from healthcare surveys can help in enhancing the quality of the emergency services (Shelton, 2007). Therefore, in this research work, the level of satisfaction of patients presented to the Emergency Service Department of Aliman hospital. The facility was one of the renowned Emergency Department centers in Saudi Arabia with over 30,000 admissions per year will be examined and analyzed to establish possible ways of improving the quality of care services so as to increase the level of patient satisfaction. 1.1 Research Objectives To investigate the waiting time by patients before being examined To determine the relationship between communication skills of and the satisfaction levels among patients To explore the challenges and problems facing patients and clients of Aliman hospital ins Saudi Arabia as far as patient satisfaction is concerned To examine the educational background and the literacy levels of the participants 1.2 Research questions What are the educational background and the literacy status of the respondents? What is the experience of the patients with the Emergency Service Department? What is the relationship that exists between communication skills and the satisfaction levels of the patients? What are some of the factors that determine the effectiveness of service emergency department? 1.3 Research design In this joint cross-sectional research work, the methodology that was adopted encompassed both qualitative and quantitative research methodology. In this case, qualitative research methodology involves a subjective technique that covers the identification of new ideas and knowledge, fieldwork participation and the employment of the person doing the research as the primary information and data source. In this case, the researcher has the responsibility of realizing the meaning of the phenomenon involved in the research and the nature of reality. In other words, the research personnel does not concentrate much on the outcome of the study, but their primary focus is on the research process. The questionnaires that were employed in this research had additional questions that enabled the respondents to provide their personal perception of the influence of the healthcare provider’s communication skills in improving the patient satisfaction. Interviews were also employed in this research work to help in establishing a trusted environment between the researcher and the interviewee making it easy to clarify and validate data and information that is collected. The mixed approach technique in this research aided in combining research methodologies in collecting the same information and data. In so doing, it helps in reducing errors and the possibility of biases when it comes to data collection. In this case, the employment of both secondary and primary data collection methods which in one way or the other ensured that the information that was collected was more credible. Additionally, the mixed research approach allowed for cross-checking and clarification as far as any ambiguity in the collection of data is concerned. Moreover, the questionnaires were administered in a manner that permitted participants to take approximately 24 hours in answering the questions. In so doing, it gave the respondents enough time and the privacy needed to respond to the questions appropriately. Besides, the interviews that were conducted consisted of structured questions that made it possible for the researchers to collect the desired information in the most efficient manner. In summary, each research interview was allocated a maximum of thirty minutes to ensure that both the researcher and the interviewee utilized the time that they were allocated in the most efficient way. 3.0 Literature review It is universally acknowledged that the Emergency Service Department is a unique context that in one way or the other, presents some challenges whenever there are attempts to improve the quality and the experience of care (Shelton, 2000). However, it is known that it is not fundamentally impossible to improve and make the healthcare experience more positive and in the process, generate a high level of patient satisfaction (Dave, 2001). If taken seriously, so many scholars believe that high level of patient satisfaction will be the backbone of many healthcare services including the ESD (Shelton, 2007). Additionally, it is believed that research work findings and results, suggestion and opinions are open to modifications and if taken with the seriousness they deserve, they are one of the crucial elements in improving the quality of the Emergency Service Department. In this case, some issues and challenges affecting the healthcare department should be divided among teams to identify and discuss organizational and behavioral changes that would help the hospital improve the level of client satisfaction. It is believed that most of the patient satisfaction factors revolve around managing the perceptions of the patients. However, the physical setting of the healthcare facility and the hospital budget as well; play a crucial role in impacting the level of patient satisfaction when it comes to Emergency Service Department though more attention is on the management of the patient’s behavior and perceptions (Shelton, 2007). Additionally, new and cheerful emergency facilities, having an efficient and high-quality radiology unit in the ED, which helps in speeding up the diagnosis and increased staffing, are also important in improving the satisfaction level of patients. However, not all hospitals can accommodate or afford to have all these improvements. Nevertheless, all institutions are in a position to implement organizational and behavioral changes that will help in enhancing the experience and the quality of care without necessarily incurring higher budgets (Shelton, 2000). In other words, regardless of how new the healthcare facilities are, the physicians technical competence, or the number of nurses and physicians. It is acknowledged that patients are difficult to get satisfied with the delivery of the Emergency Service Department. If they find it hard to perceive that the doctors, nurses, and the overall healthcare staff care a lot about their discomfort, confusion, embarrassment, anxiety and delays they experience while in the ESD (Dave, 2001). Moreover, the healthcare staff also encompasses the physicians which mean that, if they are in one way or the other not fully committed, involved, and accountable for the healthcare’s patient satisfaction, then the hospital stands no chance of improving in this area. 3.1 Some of the challenges in the Emergency service department It is believed that, in any healthcare environment, patients not only need just treatment, but they also want care. By definition, care is acknowledged as the total patient experience of both technical elements which includes treatment, diagnosis, prescriptions, tests, and personal elements which encompass things like interaction, attitudes, empathy, and explanation. In other words, the emergency environment offers many challenges for staffs responsible for managing the care experience (Shelton, 2000). Some of the problems include first, stressful environment such that, regardless of the quality and glitzy of the healthcare facility, the patients always find the ED very stressful. In this case, they are strange to the machinery used in the ED, the rituals employed, the lack of privacy and most of the patients always compete for the attention of the healthcare providers (Shelton, 2007). Second, there is an issue of divergent views such that, the patients and the staff may possess different opinions and views about the severity of the complaint at hand. In such case, those employees that are busy always find it very abusive when they are presented with minor and petty complaints from patients while simultaneously, patients who are perceiving that the healthcare providers are not considering their proposal, may feel disdained or rejected (Glick, 2008. Third, there is an issue of conflicting therapy opinions. In this case, the patients and staffs may differ from the best and appropriate technique for treating the health problem at hand. For instance, patients postulate their medical beliefs norms, systems, and treatment habits in the Emergency Service Department. In other words, this behaviors and beliefs class with significant scientific medical practices and knowledge are resulting in communication breakdown and trust between the staff and the patients (Georgopoulos & Cooke, 1980). 3.2 Reason why patient satisfaction is essential It is argued that patient satisfaction cannot be managed if the healthcare staff is not part of the team. However, not all personnel will be directly committed to this initiative unless they are made to comprehend the significance of the patient’s personal experience with the healthcare facility to departmental, individual and the institutional goals (Mayer & Cates, 2014). In other words, all Emergency Service Department’s staff must become familiar with the benefits of having highly satisfied patients. In so doing, the healthcare facility should see to it that their entire staff realizes that patient satisfaction is not only basically a measurable care outcome but also a very necessary care component (Shelton, 2000). For instance, treatment forms part of the patient care, therefore, staff must be able to convince, confront the patient, identify themselves, and explain what is going to happen to the patient. In simple terms, the process and the manner in which all these procedures are conducted as well as the interaction that exists between the healthcare professional and the patient clearly explain the care aspect of the patient treatment which plays a very crucial part in patient satisfaction (Mayer & Cates, 2014). The bottom line is that, whenever emergency patients well care for, they are satisfied and in the process, both the staff and the patient benefit. First, patient’s level of stress is reduced such that they are calmer, staff demand decreases, the likeliness of complications is also diminished, and the Emergency Department’s visits are easier and shorter to manage (Mayer & Cates, 2014). Second the level of patients trust towards the healthcare increases such that, those patients who put their confidence in the healthcare staff are likely to be more tolerant and cooperative when it comes to scary and uncomfortable procedures (Shelton, 2000). Furthermore, the patient’s chances of complying with discharge instructions are high which means minimal returns to the Emergency Department and better care outcomes. Finally, a positive patient experience with the Emergency Department helps in protecting the image and the brand of the hospital. In this case, satisfied clients are more than willing to recommend and use the hospital facility again and again for other purposes gender (Dave, 2001). It is believed that the Emergency Service Department of any healthcare facility represents the brand and image of the hospital and an individual’s first encounter with it, represents the client’s perception and opinion of that brand. In other words, if the patients were less impressed by the services at the hospital, the chances of using the hospital again shortly is minimal. Apparently, this can affect the image of the hospital in a negative way as far as their budget, the staff’s salary and jobs are concerned (Shelton, 2000). 3.3 Strategies for improving the clients experience It is universally known that most clients are unaware of the technicalities involves in treatment such as the proper antibiotics needed and the appropriate tests, the correct sutures gauges (Olson & Simerson, 2015). However, most patients recognize the level of care they are afforded which in most cases, encompass the treatment and the level of emotional context in which the aspect of treatment is delivered (Georgopoulos & Cooke, 1980). In other words, lower satisfaction levels of patients clearly indicate that there is lower-quality care regardless of how glitzy the technical capabilities of the treatment are. During the initial or early stages of service delivery, the level of patient satisfaction involves how effective the healthcare facility can manage the patient perception (Olson & Simerson, 2015). In other words, the fact that the perception of the patients is subjective does not necessarily mean that its impact is less objective or less concrete (Shelton, 2000). In simple terms, the moment that the patients enter the Emergency Service Department room, the sights, the events, sounds, and their interactions help in building their experience. Addionnaly, how patients respond to this situations plays a very crucial part on how their level of stress, cooperation, trust, patience and tolerance is impacted. In other words, the satisfaction level of patients is hence categorized as a care component of the healthcare facility and not just a healthcare outcome (Mayer & Cates, 2014). 4.0 Research Methodology This is a cross-sectional study employing a mixed research design that encompasses precise and descriptive aims. The participants of this research work were mainly clients of the Emergency Service Department. Additionally, this study took into consideration the fact that; work busy hours, personnel, shifts, type of client, the day of the week, different healthcare providers and client complaints have an implication on the level of patient satisfaction. In this case, therefore, the sample of the study was selected factoring of the above factors. Moreover, the sample distribution of 300 Emergency Service Department’s clients was conducted using quota random sampling. During the work research period, the customer’s number was 1230 in a week. During the morning shifts, the client’s number was 378, in the evening the clients population was 431 and in the night clients were approximately 421. Furthermore, because 300 emergency service department patients were chosen randomly from the sample population, the representation of the quota was 25.2 %, 37.5%, and 35.5 % respectively. Moreover, the technique was used in selecting people in different shifts was by assigning random numbers to the individuals. Besides, the questionnaires were given to the clients and patients after agreeing to complete them. In this case, no notable cases of unwillingness and in the process, it was clear that all sampled out population agreed to cooperate. The questionnaire about the level of satisfaction designed and used by the Press Ganey Institute employed in most hospitals in America with beds amounting to over 100 was implemented in this research work. According to some already established literature, it is also evident that 49 Emergence Service Departments have also used this Press Ganey institute’s survey. Additionally; the investigation of this institute has indicated the status of the satisfaction levels of patients visiting the service emergency department annually for the year 2004 using data and information collected from 50 American states. However, in this study, this questionnaire survey was employed with minor modification because Saudi Arabia’s visit, admission and the process of discharge are unique and different from those witnessed in the United States. The following were some of the research elements that were added to the questionnaire: The educational background and the literacy status of the respondents Satisfaction levels of the respondents with Emergence Service Department’s security guards behavior and courtesy The Press Ganey questionnaire was distributed to some Emergency Department specialists in order to prove its validity and viability so as to confirm its effectiveness in this research study. In this study, a highly reliable and valid questionnaire consisting of approximately twenty standard questions were subdivided and organized into four sections Physician care Waiting and identification time Physical comfort, registration process, and nursing care Overall patient satisfaction with Emergency Department In this research work, research Interviews were carried out by the research team members as far as the topic of study is concerned. Additionally, the official communication language that was employed during this research work was Arabic, which is the national language of Saudi Arabia. Moreover, those individuals responsible for interviewing the respondents did not put on any form of uniforms or badges. In other words, the interviews commenced immediately the patients were made aware of the objectives of the research and in the process, expressed their willingness to participate. The subjects or rather the respondents were interviewed whenever they exited the ESD including those who are being discharged and the ones who were hospitalized in a ward. Patient’s waiting time before being attended to for the first examination was also measured during this study. In this case, the specific patient’s arrival time was recorded in their medical reports immediately they arrived as well as the time they attended their first examination by the physician. In other words, as per the recorded waiting time records and reports, the minutes the client spent waiting to be attended to by the physician was also determined. Moreover, to deal with interview biases, all the individuals responsible for interviewing were oriented by academic members in a session as far as unifying their communication, as well as the patients' interviewing process, are concerned. Furthermore, the data that was collected was analyzed through the employment of SPSS software version 13. In this case, ordered and ranked scale data were presented in the study as comparative frequency and total, whereas on the other hand, data that was normally distributed were classified and given in the form of means standard deviations. In other words, to determine the uniqueness of groups, the data, and information that was collected was analyzed and evaluated using Chi-Square test. In this case, the odds ratio, as well as 95 percent confidence interval, was analyzed to determine the relationship that exists between all the variables that were examined during the study. In other words, P < 0.05 value was categorized as being statistically significant. 5.0 Results and findings From data analysis, it is clear that 300 patients out of the total patient’s referred to the Emergency Service Department were willing to participate in this research work. In this case, their demographic characteristics were presented in the form of a table as shown below. Additionally, a small proportion of the information and data was categorized as missing owing to the fact that some of the questionnaires were partly answered. Demographic characteristics Gender Percentage (%) female 40 male 60 Educational level diploma 30 technician 20 degree 35 Under diploma 15 Time of visit Morning examination hours 35 Evening examination and treatment hours 40 Night examination and treatment hours 25 The data clearly indicate that 10 percent of those who participated in the research were patients, 88 % were the patient relatives, and 2 % did not respond to the questionnaires completely. It was also found out that, only 35 %, 40%, and 25% of those clients who participated in this research work visited the ED of Aliman hospital during the morning examination hours, evening treatment hours, and night examination hours respectively. Those who were using the Emergency Service Department for the first time were only 37% of the participants. AS far as the association analysis between the satisfaction levels and waiting time is concerned, P=0.003 represents the dissatisfaction of those with longer waiting times. In this case, items that boasted of a higher standard of satisfaction were; the courtesy and behavior of the physicians which attained 87% votes, followed by the courtesy of security guards at 82% and finally, the courtesy and behavior of nurses obtained 81%. On the other hand, items that recorded higher levels of dissatisfaction include the efforts of caregivers in involving the patients in making the decissions that revolve around their treatment was 26%. This is followed by the time patients visiting the ED waited before being examined was 25% and finally, neatness and cleanness which represented 22% of the total votes. The average time that most clients waited before being examined or attended to by the staff of Aliman Hospital ED was approximately 21 minutes which ranged between 30 minutes representing the maximum time taken and three minutes as the minimum waiting time. From the information, it was certain that the living area either rural or urban showed no any relationship to the participant’s satisfaction levels. As far as work shifts were concerned, it was clear that most participants were satisfied with evening shifts (65%). Followed by night shifts which boasted of 63% and finally, the morning shifts which boasted of 62%. When it comes to educational level, it was clear that those individuals who had higher educational levels background represented P=0.05, which means that they were more satisfied. Additionally, whenever the respondents were asked whether they could use Aliman Hospital’s ED again or would refer others to it, 65 percent of the participants indicated that they would use and apply it to others while 18 percent indicated that they would not recommend and refer it to it again. 6.0 Discussion Satisfaction among patients is primarily one of the most significant quality indicators when it comes to Emergency Service Department (Olson & Simerson, 2015).  Additionally, measurement of the satisfaction levels of patients is very crucial in playing an increasingly important role in the ever expanding need for accountability when it comes to health care. Moreover, considering the report postulated by Press Graney Associates in the year 2009, the ESD is one of the gatekeepers that is now accounting for approximately half of Saudi Arabia’s admissions in hospitals. In so doing it has placed a significant strain on many hospital facilities because of the increasing service demand which in most cases, is inappropriate when it comes to delivery of healthcare service (Olson & Simerson, 2015). As a result, it leads to unprecedented long waiting times, ambulance diversions, crowded conditions and highly variable outcomes and care. Because Emergency Service Department is a particular department as far as medical services are concerned, comprehension of the elements affecting the level of satisfaction among patients is very essential (Olson & Simerson, 2015). According to this study, it is clear that there is a high degree of satisfaction among clients although there are also so many unmet demands and needs. For instance, according to this research work, 34 % of the ED clients indicated very high overall satisfaction as far as the performance of the Emergency Service Department is concerned. Furthermore, by analyzing the data further, it was found that 13% of the clients have low satisfaction. In other words, in total, the findings of the study indicated that 86% of the clients believed the level of satisfaction is above average. However, although it is challenging to keep all ED customers satisfied, it is acknowledged that any healthcare can realize this objective by trying to identify potential indicators and working towards improving them. According to the findings of this research work indicated what so many research works had already proced in the sense that, there is a notable relationship between clients satisfaction with the Aliman ED and their background of education, or by a matter of a person being related to the patient, residential area, and time of admission. On the other hand, further evaluation and analysis acknowledge that, apart from the interviewees themselves and their backgrounds of education as their other two factors, there is no interrelationship or meaningful association that exists between satisfaction and other factors. In this case, no relationship existed between the satisfaction level of the relatives of the patients as compared to the patient’s themselves. Moreover, the satisfaction standards of the patients that had higher education background. Gender difference, the time the patients were admitted to the ED and residential area, had no clear relation regarding patient satisfaction level. For instance, this study, those clients who were served between 2.00 pm and 8.00 pm recorded high satisfaction levels as compared to those who were served between night hours and morning hours. Nevertheless, there was no significant statistical difference between the operational hours of the day. For example, according to the Press Ganey research report, the time period that most clients were satisfied was during the morning hours and yet the influence of race, gender residential place, and educational level on the degree of patient’s satisfaction was not included in the assessment of the report (Olson & Simerson, 2015). Besides, Patient volume, staffing patterns as well as, the severity of the condition of the patient, may impact a large junk of these notable differences in the levels of satisfaction. In simple terms, during night shifts, waiting time may increase tremendously because, during the day, the patient volumes may have been on the rise. The Hall and Press study that was carried out in the year 1996 indicated that a number of notable variables which include; gender and age, have no profound influence on the levels of patient satisfaction (Olson & Simerson, 2015). Additionally, according to this study, it was also clear that an association exists with the respect and courtesy expressed by the physicians during waiting times and the level of satisfaction. Another research work acknowledged as Aragon’s study, also produced similar results in the sense that, the general patients satisfaction was the same irrespective of the clients gender (Dave, 2001). Therefore, consistent with other previous research work, the findings and the results of this research work also indicated that the gender of the client does not influence the level of satisfaction among the ESD patients in Aliman hospital in Saudi Arabia. Moreover, in another study that was conducted in the year 2004 in New Jersey at Cooper Hospital, the level of satisfaction was high in those patients with emergency needs or severe illness. In other words, this study also indicates that the less waiting time taken, by patients in Aliman Hospital, the more satisfied a patient was. Therefore, as compared with similar research works, the findings of this research work indicated that the waiting time was not much, but it was ranked as a second dissatisfaction element. Apparently, those items that reported high levels of patient’s satisfaction revolved around the respect and the courtesy of the physicians towards patients, the respect of the security guards and the courtesy and the behavior of the nurses towards patients. The findings and the results of this study reveal that a high level of client satisfaction can be realized through respect and courtesy shown to patients and customers by the healthcare staff. Additionally, effective communication also seems to be a significant factor in the management of the Emergency Service Department and may at the same time improve the satisfaction levels of the patients. To strengthen this assertion, a Hong Kong study suggested that, a workshop on effective communication can help in improving the abilities of physicians when it comes to Emergency Services and in the process, increasing the levels of patient’s satisfaction and reduction in the complaints of the patients. The findings of this study also postulate that 16% of the sample population was dissatisfied with the interventions of the students during their examination and treatment process. Thus, it is understood, for healthcare department to improve the satisfaction level of its clients, EDs need to ensure that their processes are well defined most especially those related to treatment and diagnosis, sorting emergency patients, discharge, and admission. However, Emergency Service Departments that cannot help in reducing waiting time may as well assist in improving client satisfaction levels by enhancing the comfort of the patients in the clients’ waiting room (Shelton, 2007). Moreover, Emergency healthcare Departments can improve the comfort level by listening and acting on the comments of their client’s. For instance, simple things like replacing worn out chairs and repairing air conditioners may improve the perception of the patients as far as ED is concerned. To clarify further, an Australian study; Tailors study, suggests that it is clear that the orientation of the staff through an educational film on how to improve their communication skills improves the satisfaction levels of the patients (Shelton, 2007). In simple terms, although the respect, friendliness and the ability of the health care provider are a significant attribute in satisfaction levels in any healthcare department, resources of the hospital should be employed in improving the perceptions of the clients about ED and reducing the waiting time. Additionally, as much as the frustration of the patients were evident because of longer waiting times, there was no tangible evidence on whether the difference that was noted during waiting times reflected a clear picture or rather a representation of the actual differences when it comes to clinical quality (Olson & Simerson, 2015). 7.0 Limitations of the study There were some confounding factors in this study. Additionally, it was evident that research-based innovations can be incorporated in the healthcare ED according to their results and findings. On the other hand, the survey results cannot be taken to represent the whole population because of the differences that exist in different regions. In this case, the time spent in the Emergency Service Department was not measured right from the arrival of the patients until disposition. In simple terms, this factor is also a noticeable element that can be influential to the level of patient satisfaction. In other words, satisfaction different rates may also be realized with various presentations of the patients and how serious the patient condition is (Shelton, 2007). In other words, it is acknowledged that data as far as patient satisfaction is concerned are being collected using different types of questionnaires most especially by using the Press Ganey Institute questionnaire and Picker Institute which concentrates on the care process of patients and can also be employed in related studies. In simple terms, by applying one of this questionnaires means that the research work will be more restricted to what had already been done. However, this research designed tried to curb this challenge by adding some modifying elements in the Press Ganey Institute. 8.0 Conclusion Results and findings of this research work indicated that for the Emergency Service Department of Aliman hospital in Saudi Arabia to improve on the patient’s level of satisfaction, Onr of the things that are paramount is implementation of a research-based involvements in the core healthcare areas and related aspects .Some of this areas include; nursing services, treatment of patients, staff behavior, waiting for time, physical environment, and clinical care processes. In other words, this improvement can only be achieved by institutionalizing the quality of management in healthcare services and employing the complaints, and the feedback obtained from this interventions in a systematic way. In so doing they can help in influencing patient satisfaction and the efficiency of the Emergency Service Department. Although some patients indicated a notable degree of satisfaction with Aliman hospital’s ED, it was evident that some demands of the patients were unmet. Therefore, the healthcare hospital should establish a way of incorporating patient satisfaction as one of the core values of the hospital. References Dave, P. K. (2001). Emergency medical services and disaster management: A holistic approach. New Delhi: Jaypee. Georgopoulos, B. S., & Cooke, R. A. (1980). A comparative study of the organization and performance of hospital emergency services: Selected descriptive findings and the research instruments. Ann Arbor, Mich: Organisational Behavior Program, Survey Research Center, Institute for Social Research, University of Michigan. Glick, R. L. (2008). Emergency psychiatry: Principles and practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Mayer, T. A., & Cates, R. J. (2014). Leadership for great customer service: Satisfied employees, satisfied patients. Chicago. Illinois: Health Administration Press Olson, A. K., & Simerson, B. K. (2015). Leading with strategic thinking: Four ways effective leaders gain insight, drive change, and get results. Hoboken: Wiley Shelton, P. J. (2000). Measuring and improving patient satisfaction. Gaithersburg, Md: Aspen Publishers. Shelton, P. J. (2007). Measuring and improving patient satisfaction. Gaithersburg, Md: Aspen Publishers Read More