Qual?ty and Worker Sat?sfact?on in Health Care Serv?ces: in D?yarbak?r

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INDUSTRIES. LAND USE. LABOR
HD6951−6957 UDC 341. 44
Mustafa AKSOY
Southern University (Institute of Management Business and Law)
Diyarbak? r, Tyrkey mustafaaksoy10@hotmail. com
Asena Tugba Evren SUBASI
«BORTE LTD. STI. «
Ankara, Turkey a. tugbaevrens@gmail. com
Quality and Worker Satisfaction in Health Care Services: in Diyarbak? r
ABSTRACT
Along with development of science and technology and increase of the importance given to humanity, it become necessary to deliver healthcare services at high standards of quality. In the era of increasing competition in the market conditions, the same goods or services demand a mandatory state to be in a certain format. This has revealed the requirement of quality, and for the conduction of quality in recent years it has steadyingly made the satisfaction of health sector workers a current issue in institutional organizations. Hospitals which comprise most of health care services can provide precise, consistent, high quality, transparent, well planned, fast and complete healthcare services systematically with the conduction of total quality management (TOM). To succeed in (TOM) practices, healthcare employees' satisfaction levels need to be monitored and evaluated. We based on the employees' satisfaction survey used in the performance calculations within the framework of the transformation program in health which started in 2002. In this study, related to employees' satisfaction, with the prepared survey aiming to determinate satisfaction levels of employees working in hospitals in Diyarbak? r province, answers of 100 healthcare employees to questions related to employees' satisfation were analyzed. In the employees' satisfaction questionnaire of the Ministry of Health, participants have to answer 4 demographic questions of 20 questions. Worker’s satisfaction questionnaires from a sample group of 100 healthcare workers/professionals were used and they were loaded to the Turkish Ministry of Health SPSS Statistical 20 analysis tool and then analyzed to reveal results.
Key words: Healthcare Employees, Total Quality Management, Diyarbak? r.
Introduction
Humans who keep living in a community as a social being, maintained a life which is in interaction with eachother in social situations, and they felt the necessity of keeping this interaction at a certain level. The levels of social and economic relations varied according to the times of period and, particularly after the industrial revolution, certain rules were introduced to these relations within the framework of quality and accreditation. For efficient the reflection of the increasing demands of employment and services in the market to the society, the certain criteria have been developed and within these criteria the concept of quality has been established.
With the beginning of life, with the effort of maintaining a healthy life, both environmental and personal healthcare services have started to be offered to the individuals living in the community for let them live a healthy life. Thanks to the started working of environmental and individual health services aiming for preventive, curative and rehabilitative services, standards and rules for certain health services began to be defined. The first known rule is the one in Hammurabi’s laws, which is assumed to be the oldest text of law, stated, as a law, responsibilities of a physician in result of his wrong treatment and introduced requirements of his punishment. So, starting from this framework, quality and standards of healthcare services have reached its present form with the developments.
Social and economic relations maintained as a part of life between people, and eventually, as these services are also people-oriented services, in order to maintain quality and services within certain standards, satisfaction of employees, who are the individuals offering these services, came into prominence. Employees offering services of certain quality and standards must have a standard and quality in such services- and this comes to the fore as the necessity of quality. Quality requirements should be fulfilled for the high standards in healthcare services. The condition of being able to provide healthcare services of good quality is to maintain high levels of satisfaction for employees offering healthcare services.
Although the concepts related to the quality of healthcare services and employees' satisfaction may seem different, they appear to be directly related to each other. The concepts of healthcare service, quality and employees' satisfaction which appear to be independent from eachother, are seen actually to be three main sources that are hanging together.
1. Fundamental Concepts
1.1. Definition of Healthcare Services
lust alike the definition made by the Law No. 224 dated 01. 05. 1961 concerning Socialization of Healthcare Services considered the need for investigation of protective factors in healthcare services for the factors affecting human health, another definition is maintained by the world health organization. The World Health Organization (WHO) defines healthcare services as a permanent system organized nationwide in order to perform goals changing according to society’s needs by taking advantage of different types of healthcare personnel in certain healthcare institutions and, thus, to provide healthcare to individuals and society with all kinds of protective and therapeutic activities
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(Boekholdt, 1987).
As it can be understood both from the Law No. 224 dated 01. 05. 1961 concerning Socialization of Healthcare Services and from the definition of the World Health Organization, healthcare services are not only certain services offering to patients but also the investigation of factors affecting human health covering all preventive healthcare services which are conducted with the aim of addressing all measures needed to protect influence of these factors (Akar, Ozalp, 2002). Healthcare services are activities which are carried out for to protect people from diseases, to treat them when they have illness and to prevent them from being infected again with a disease after treatment. Healthcare service includes all effective and useful activities for recovery of any patient whether by using any materials and equipment or not (Gunal, 2007).
1.2. Definition of Quality in Healthcare Services
Along the historical period many definitions of healthcare services have been made and these definitions concerned different contexts according to perspective and approach of the definition maker. For instance, according to the definition concerning quality of healthcare services in terms of medical activities, quality is a fulfillment of certain activities in a way which will at least stop any decline which may occur in individual’s health condition or in a way which will maintain a recovery as a function of any disease or condition.
Making the definition of healthcare services paves the way for improvements in quality. Definition of quality in healthcare services is an attempt of experts to make a meaningful and applicable definition in general. As in many any spheres, in the sphere of healthcare services there is not one single definition of quality. Definition of quality in healthcare services began to move forward by a continuous development. Definition of quality in healthcare services evolves constantly. Preferences and opinions of patients, public and customers who were served quality gained importance with time. Expectations of patients and competitive environment has kept the satisfaction in forefront and ensured that priority is given to quality. Revolving funds in hospitals are effective in determining patients' satisfaction. Satisfaction can be increased with the increase in quality. Patients' satisfaction need to be considered in healthcare services. And this requires services of good quality. Efforts to provide better services and to improve satisfaction maintain improvement in healthcare services. In order to provide better services priority is given to operations aiming the quality.
1.3. Systems of Quality Maintenance in Healthcare Services
Historical development of quality systems began with quality control which comprises evaluation of activities whether they meet the standards or not. Then it continued with quality assurance, which means measuring quality level of the services offered and activities of regulations according to the evaluation results. The final stage of historical development continued with total quality management which comprises continuous improvement of all activities in any organization and targeting customer’s satisfaction (Gunal, 2007, p 36).
1.3.1. Total Quality Management (TQM)
The International Standards Organization (ISO) defines Quality Control as series of operations performed by any manufacturer for to create, protect and develop quality and for to sustain services production at the most economic level in order to maintain customers' satisfaction. TQM is the management system focused on the customer. It requires a group work rather than an individual work. To maintain quality in TQM, it requires everyone in a stepwise manner, starting from top management to all employees, to fulfill their responsibilities, to work as a team and it requires a contunity in the work discipline. It requires to monitor innovation, continuous training and sense of responsibility. Total Quality Management is the system that coordinates any efforts carried out by various departments effectively in order to meet consumers' needs and desires at the most economic level for to establish quality and to ensure its development and preservation in the organization.
After taking over the management of the Social Security Authority (SSK) as one of the components of the Health Transformation Program within the scope of the Quality Assurance and Accreditation of Health Facilities, the Ministry of Health started to work with the Joint Commission International (JCI) in order to improve quality criteria applied in hospitals affiliated to the Ministry, to implement in hospitals in our country and to establish the National Health Accreditation System. Within these efforts, with the Directive of Quality Development and Performance Assessment which was prepared by the ministry and in practice, it is aimed to increase quality while measuring performance efficiency and productivity at the institutions and particularly in hospitals affiliated to the Ministry of Health. This directive was developed and changed with time, and finally published as the directive of Performance and Quality in Health. Currently, in hospitals and health institutions affiliated to the Ministry of Health, principles and procedures of this directive are in operation.
To implement the total quality management in the manufacturing sector is easier as compared with the service sector. Practices in healthcare services are more difficult and require a long-term efforts. Patient care in healthcare services should be applied with balanced skills at high standards comprising the latest information. Healthcare services should be able to meet the needs of any individual and must be able to adapt them to sensitive and variable environmental conditions. In other words, healthcare services should ensure patient’s satisfaction and it should give importance to the employees working related to patients' satisfaction. Patients' physical, psychological and medical expectations must be satisfied and their satisfaction should be maintained in every aspect (Gunal, 2007, p 46).
TQM includes various management principles, techniques and tools. These principles makes total quality management approach different from other quality management approaches. As a result, there are sufficient attention to these principles and using proper tools in corporate activities, quality results in an increase in productivity and satisfaction of customers and employees. And quality of performance is increasing as well (Kavuncubas?, 2010, p 466).
1.3.2. Hospital Quality System (HQS)
HQS, as a trademark of healthcare services, is of great importance in terms of security and satisfaction of both healthcare employees and patients. Standards aimed at providing standards of service delivery, envisaging an interrogation questioning service processes offered in hospitals, physical and technical aspects of the hospital and all processes terminating with death or jurisdiction starting from hospitalization of the patient (Sagl?kta Performans ve Kalite Yonetim).
Service Quality Standards, prepared by many experts, and concern different institutional settings, problematic areas and country conditions in accordance with national and international sources. Feedback, comments and suggestions of evaluators, hospital quality representatives and various experts from different backgrounds were evaluated and finally an assessment tool which shed light on the whole processes for our hospitals has been reached along with an extremely meticulous work by using the experiences gained so far by the presidential team (Guler, Ozturk, Haf? z Kapan, Tarhan, & amp- Suzuk, 2011).
Quality criteria constitutes the most important parameter of the work for Corporate Performance and Quality Improvement which implementation in public hospitals started in 2005. After revisions made in early 2007 the quality criteria which comprised 100 questions, turned to
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be a set of 150 questions. In the course of the revisions made in 2008, the quality criteria which included 150 questions, has been rearranged through a complete revision with regard to structural, methodological and design aspects. Quality criteria has been named as the Sevice Quality Standards and turned into a set comprising a total of 354 standards and approximately 900 sub-components. In 2009 «The Private Hospital Service Quality Standards», aiming at private and university hospitals and comprising a total of 388 standards and approximately 1450 sub-components, have been prepared and published. Besides, when examples of various countries in the world have been analyzed, we saw that studies aimed at raising the quality of health services have being carried out, to a greater extens, with respect to national quality and accreditation systems. Such reasons like needs of countries' health systems, their priorities, varied expectations and financial burden imposed by international accreditation systems enforced many countries around the world to establish their national quality systems in health. In this context, as well as the developed countries, such as Britain, Canada, France and Denmark are found among the countries with the National Quality Health System, the developing countries, such as Thailand, Egypt, India and Kyrgyzstan, can also be seen among them as well (Guler, Ozturk, Haf? z Kapan, Tarhan, & amp- Suzuk, 2011, p 3−4).
1.4. The Concept of Employee Satisfaction
Employee satisfaction is a positive and emotional situation that employees feel about their job as a result of their work or experience obtained (Kanoglu, 2007). The importance of satisfaction or dissatisfaction of any employee who uses all his power for his work is rapidly growing today. The subject which is tried to be explained in the literature with the contexts of job satisfaction or gratification, or employees' satisfaction or gratification, basicly indicates whether any individual, today and in future, is psychologically happy with his job and life or not. In other words, employee’s satisfaction is a reflection of emotional state which is emerging as a result of employee’s self-evaluations on variety of factors related to his work.
The history of scientific research on employees' satisfaction goes back to 1930s. Until today, important developments related to employees' satisfaction have been recorded both in terms of theory and practice. Since the end of 1960s, surveys have been initiated to be develop for measuring employees' satisfaction- the Minnesota Job Satisfaction Scale which has bee developed in 1967 by Weiss, Dawis, England and Lofquist and the Job Description Scale which has bee developed in 1969 by Smith, Kendall and Hulin can be mentioned as examples of such surveys. And in the early 1980s, the relation of customer satisfaction with employee satisfaction began to be investigated (Telman, 2004).
2. Research Materials and Methods
2.1. Development of Draft Criterion
On the first stage of the study, in the hospital located in Diyarbakir Province, with a questionnaire prepared for the purpose of determining satisfaction levels of healthcare employees, answers of 100 healthcare workers to the questions relating to employees' satisfaction have been analyzed. In the employees' satisfaction questionnaire of the Ministry of Health, participants had to answer on 20 questions which included 4 demographic questions.
We were based on the employees' satisfaction survey used in the performance calculations within the framework of the transformation program in health which started in 2002.
The draft criterion consisted of 20 questions. All questions, prepared in a Likert-type, have been formulated as positive statement. Options of answers to the above questions were «yes», «a little / sometimes» and «no». Moreover, questions relating to working environment and working conditions, questions related to management, employees' and patients' safety, questions about in-service training and education related to any concerned department and questions about thoughts about not leaving the place of employment have been included.
Within the prepared criterion, questions regarding demographic characteristics of patients (gender, marital status, occupation, total working time in the institution) have been also included. After pre-determination of the draft criterion, the questionnaire has obtained its final shape.
2.2. Application
Validity and reliability of the criterion has been investigated over 100 healthcare employees located in Diyarbak? r Province. From related departments have been obtained necessary permissions.
2.3. Statistical analysis
All statistical analyses in the study whave been performed using a statistical software package (SPSS for Windows, version 20: 00) which has been developed for the social sciences. Demographic data have been evaluated using parametric and descriptive statistical techniques. For reliability analysis of validity, the general demographic section has been carried out separately in Sections 2 and 3 of the survey.
2.4. Structural validity
In the reliability analysis, descriptives have been chosen as statistics, and item, scale, scale if item deleted have been chosen as for. Alfa model has been used as the model.
Pearson, pearson + spearman were used as correlation coefficients when correlation analysis has been performed. Two-tailed has been identified as Test of Significance.
In the final form of the structural validity investigation, score types have been standardized for each factor.
2.5. Scope validity
Structural validity of criteron have been evaluated by characteristics of factor analysis responses- distribution has been judged to be normally distributed or not with the calculated deviancy value (deviancy value -1 — 1).
2.6. Reliability
Reliability of criterion was investigated by calculating the coefficient of cronbeach alpha reliability. In the comparison of results of different groups, the criteria that alpha coefficient of cronbeach should be 0. 70 or above was considered.
After validity and reliability studies, relationship between criteria of cases and demographic characteristics has been investigated. Relationship between the variables which have been indicated with measurement was evaluated by calculating pearson ® — and relationship between the variables which have been indicated with counting was evaluated by the (rho) coefficients of spearman relation. Findings have been illustrated as percentage, arithmetic mean and standard deviation. In the evaluation of analysis, p & lt-0. 05 was considered as statistically significant.
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3. Research Findings and Results
Statistics
Gender Marital-Status Occupation Total working time in this institution
N Valid 100 100 100 100
Missing 0 0 0 0
Mean 1,3300 1,1600 3,9400 3,7800
Std. Error of Mean, 4 726, 3 685, 19 427, 4 163
Median 1,0000 1,0000 4,0000 4,0000
Mode 1,00 1,00 2,00 4,00
Std. Deviation, 47 258, 36 845 1,94 271, 41 633
Variance, 223, 136 3,774, 173
Range 1,00 1,00 7,00 1,00
Minimum 1,00 1,00 1,00 3,00
Maximum 2,00 2,00 8,00 4,00
In the survey at which took part 100 healthcare employees in the Province of Diyarbak? r, percantages of demographical sections are respectively as follows. From among 100 persons the number of female made 67 (67%), the number of male made 33 (33%). Concerning their marital status: 84 (84%) were married, 16 (16%) were single. Occupational groups: nurses made 31%, laborants — 24%, physicians — 15%, emergency medical technicians (EMT) made 10%, medical officers — 9%, X-ray technicians — 6%, security officers — 4% and midwives — 1%. Working time in the institution was recorded tas follows: 78% - 10−20 years and 22% -5−10 years.
The questions in two other parts of the survey related impact on reliability as of between 91% and 93. 8% in percantage. It has been found that reliability of the survey made 94. 3% with the percentaged effects and demographic data.
Significant tabled values resulted in correlation analysis results of employees' answers on questions in the survey are as follows:
Work Spaces are Organized in a Way I can Work Comfortably * My Recommendations Regarding the Functioning of the Department Where I Work are Taken into Account Crostabulation
Count My recommendations regarding the functioning of the department where I work are taken into account Total
yes a little / sometimes
Work spaces are organized in a yes 83 7 90
way I can work comfortably a little / sometimes 3 7 10
Total 86 14 100
Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 538, 000
Cramer'-s V, 538, 000
Interval by Interval Pearson'-s R, 538, 128 6,318, 000c
Ordinal by Ordinal Spearman Correlation, 538, 128 6,318, 000c
N of Valid Cases 100
There is a moderate positive relationship (0. 538) between Work spaces are organized in a way I can work comfortably and My recommendations regarding functioning of the department where I work are taken into account.
I Feel Safe at the Department Where I Work * In the Last 6 Months I Was Not Attacked Physically
Crosstabulation
Count
In the last 6 months I was not attacked physically Total
yes a little / sometimes
I feel safe at the department where Yes 86 5 91
I work a little / sometimes 3 6 9
Total 89 11 100
Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 560, 000
Cramer'-s V, 560, 000
Interval by Interval Pearson'-s R, 560, 139 6,683, 000c
Ordinal by Ordinal Spearman Correlation, 560, 139 6,683, 000c
N of Valid Cases 100
There is a moderate positive relationship (0. 560) between I feel safe at the department where I work and In the last 6 months I was not attacked physically.
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I Feel Safe at the Department Where I Work * Protective Measures Relating to Employee Safety are Taken at
the Department Where I Work Crosstabulation
Count
Protective measures relating to employee safety are taken at the department where I work Total
yes a little / sometimes
I feel safe at the department where I work Yes 86 5 91
a little / sometimes 3 6 9
Total 89 11 100
Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 560, 000
Cramer'-s V, 560, 000
Interval by Interval Pearson'-s R, 560, 139 6,683, 000c
Ordinal by Ordinal Spearman Correlation, 560, 139 6,683, 000c
N of Valid Cases 100
There is a moderate positive relationship (0. 560) between I feel safe at the department where I work and Protective measures relating to employee safety are taken at the department where I work.
Protective Measures Relating to Employee Safety are Taken at the Department Where i Work * I Never Think
of Leaving the Institution Where I Work Crosstabulation
Count
I never think of leaving the institution where I work Crosstabulation Total
yes a little / sometimes
Protective measures relating to employee safety are taken at the department where I work yes 82 7 89
a little / sometimes 6 5 11
Total 88 12 100
Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 362, 000
Cramer'-s V, 362, 000
Interval by Interval Pearson'-s R, 362, 140 3,843, 000c
Ordinal by Ordinal Spearman Correlation, 362, 140 3,843, 000c
N of Valid Cases 100
There is a low associated positive relationship (0. 362) between Protective measures relating to employee safety are taken at the department where I work and I never think of leaving the institution where I work.
The Management Finds Solutions for Failures Related to Patient and Staff Safety and Takes the Necessary Measures * Trainings Given on Reporting Cases Violating Patient and Employee Safety are Sufficient
Crosstabulation
Count
Trainings given on reporting cases violating patient and employee safety are sufficient Total
yes a little / sometimes
The Management finds solutions for failures related to patient and staff safety and takes the necessary measures yes 87 3 90
a little / sometimes 3 7 10
Total 90 10 100
Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 667, 000
Cramer'-s V, 667, 000
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Interval by Interval Pearson'-s R, 667, 127 8,854, 000c
Ordinal by Ordinal Spearman Correlation, 667, 127 8,854, 000c
N of Valid Cases 100
There is a highly associated positive relationship (0. 667) between The Management finds solutions for failures related to patient and staff safety and takes the necessary measures and Trainings given on reporting cases violating patient and employee safety are sufficient.
Management is Working to Make Corrective and Preventive Actions on Patient Safety * Related to my Department of Employment, in the Last 6 Months the Education (Logging Patient Records and Credentials, Appropriate Treatment to The Patient, Infection Prevention and so on.) I Received on Patient and Employee
Safety Issues is Sufficient Crosstabulation
Count
Related to my department of employment, in the last 6 months the education (logging patient records and credentials, appropriate treatment to the patient, infection prevention and so on.) I received on patient and employee safety issues is sufficient Total
yes a little / sometimes
Management is working to make corrective and preventive actions on patient safety yes 82 6 88
a little / sometimes 7 5 12
Total 89 11 100
Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 362, 000
Cramer'-s V, 362, 000
Interval by Interval Pearson'-s R, 362, 140 3,843, 000c
Ordinal by Ordinal Spearman Correlation, 362, 140 3,843, 000c
N of Valid Cases 100
There is a low associated positive relationship between Management is working to make corrective and preventive actions on patient safety and Related to my department of employment, in the last 6 months the education (logging patient records and credentials, appropriate treatment to the patient, infection prevention and so on.) I received on patient and employee safety issues is sufficient.
I Work in a Department Proper for my Education * I Never Think of Leaving the Institution Where I Work
Crosstabulation
Count
I never think of leaving the institution where I work Total
yes a little / sometimes
I work in a department proper for my education yes 86 8 94
a little / sometimes 2 4 6
Total 88 12 100
Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 425, 000
Cramer'-s V, 425, 000
Interval by Interval Pearson'-s R, 425, 149 4,648, 000c
Ordinal by Ordinal Spearman Correlation, 425, 149 4,648, 000c
N of Valid Cases 100
There is a moderate positive relationship (0. 425) between I work in a department proper for my education and I never think of leaving the institution where I work.
Management Informs all Employees About «Service Quality Standards (SOS)»
* I Find in-Service Trainings Sufficient Within the Past 6 Months Crosstabulation
Count
I find in-service trainings sufficient within the past 6 months Total
yes a little / sometimes
The Management informs all employees about «Service Quality Standards (SQS)» yes 83 3 86
a little / sometimes 6 8 14
Total 89 11 100
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Symmetric Measures
Value Asymp. Std. Errora Approx. Tb Approx. Sig.
Nominal by Nominal Phi, 595, 000
Cramer'-s V, 595, 000
Interval by Interval Pearson'-s R, 595, 121 7,329, 000c
Ordinal by Ordinal Spearman Correlation, 595, 121 7,329, 000c
N of Valid Cases 100
There is a moderate positive relationship (0. 595) between Management informs all employees about «Service Quality Standards (SQS)» and I find in-service trainings sufficient within the past 6 months.
Conclusion and Recommendations
While the patient satisfaction increases greatly each year as a part of the health transformation program which started in 2002 and is still going on, this study was carried out in an environment where the employees' satisfaction did not increase at the same rate- and results with regard to what should be done in order to increase employees' satisfaction have been obtained.
Proper arrangement of working place is a factor that increases employees' satisfaction. While constructing new hospitals, besides improving physical environment for patients, it is necessary to ensure a comfortable working environment for healthcare employees.
For healthcare employees in recent years being exposed to violence is one of the most important and gradually increasing problems- a positive relationship has been determined between protective measures relating to employees' safety are taken at the department where I work and I never think of leaving the institution where I work. Prevention of violence against healthcare workers and their feeling of safety will not only strengthen the institutional ties but also will increase employees' satisfaction.
Personnel who were exposed to violence and were not attacked physically during the last six months were found to feel safe. Measures taken by health managers for safety of employees make their employees to feel safe. A positive correlation has been determined between the measures taken for security and safety feeling of healthcare employees.
Solutions the Management is finding for failures related to safety of patients and staff and the process of taking necessary measures are directly correlated both with quality and employees' satisfaction. This is one of the most important factors which influences employees' satisfaction. As employees are the ones who can directly see that management values them and if the necessary measures are taken for the failing aspects, it will be seen that satisfaction will reach its highest levels when the required precautions are taken.
Employees, who are working in appropriate departments fitting their education, maintained an increase in employees' satisfaction. Employees, who are working in appropriate departments fitting their education, do not wish to leave the institution. Employing personnel, working at proper places fitting their educational background, will also contribute to the peace at work. Every employee must work in a proper place according to his education.
Management timely informing their staff about in-service trainings will resolve most of the institutional problems and also will maintain employees' satisfaction. In the organization where employees' satisfaction increases, both quality and service will get to a good point.
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