ORGANIZATIONAL CULTURE AND HOSPITAL SERVICE QUALITY: A MIXED-METHODS RESEARCH IN INDONESIAN PRIVATE HOSPITAL
Dominika Lepan Tukan1*, Emiliana Tarigan2, Agustinus Bandur3
Master Program of Nursing, St Carolus College of Health Sciences, Jakarta, Indonesia1
St Carolus College of Health Sciences, Master of Nursing, Jakarta, Indonesia2
BINUS Business School, Doctor of Research in Management, Bina Nusantara University Jakarta3
Email: firstname.lastname@example.org, email@example.com,
The purpose of this study is to examine and explore how organizational culture with four cultural patterns (internal process, rational goal, open system, human relations) affects the quality of service at X hospital, Bandung. This study uses a Mixed Methods design. The subjects of this study are 207 respondents as well as participants consisting of 124 respondents and hospital employees, 80 respondents and patient participants. Data are collected using questionnaires and open-ended questions. Cosstab test is used to analyze quantitative data, while thematic analysis and corss-case analysis are used to analyze qualitative data. The results of the quantitative data analysis show that organizational culture has a significant effect towards service quality at X Hospital, Bandung. This result is strengthened by the analysis of qualitative studies which states that organizational culture is oriented towards service quality. This study has proven that organizational culture can improve the quality of service aimed at a significant positive difference in service quality between patients and hospital employees.
Keywords: Organizational Culture, Organizational Culture Patterns, Service Quality.
Improving the quality of hospital services has become one of the main problems of health research in hospitals in the last two years (Rabanni et al., 2009). Service quality according to the SERVQUAl model by (Parasuraman, Zeithaml, & Berry, 1988) which is the most common approach (Rita, P., Oliveira, T., & Farisa, 2019) divided into five dimensions, namely tangible, reliability, responsiveness, assurance, and empathy (Fida, Ahmed, Al-Balushi, & Singh, 2020).
From the consumer side, service quality means how the service has met their expectations or not (Erdil & Yıldız, 2011).
Service quality is formed from a comparison between customer satisfaction before receiving service and perceived service after (Chen et al., 2012). So, it can be seen that what determines the perceived service quality is expectations and perceptions (Álvarez-García, González-Vázquez, Del Río-Rama, & Duran-Sanchez, 2019).
The results of the study of (Rabanni et al., 2009) confirm that XXI Century hospitals need to pay attention to organizational culture if they want to improve service quality. However, empirical studies on the relationship between organizational culture and service quality are still very limited (Samee, Reino, & Vadi, 2011).
Therefore, these researchers recommend the importance of studies on the relationship between hospital organizational culture and hospital service quality. Conceptually, (Bessie L. Marquis & Huston, 2012) defines organizational culture as a system of shared values and beliefs that guide the behavior of organizational members. Organizational culture has also existed for a long time in the organization rooted in the values and beliefs of its members/employees/staff (Tsai, 2011) as the right way to think and feel (Metwally, Ruiz-Palomino, Metwally, & Gartzia, 2019). Organizational culture is also called 'normative glue' which means uniting the whole organization (Shahzad, Luqman, Khan, & Shabbir, 2012). Organizational culture is also seen as a system of shared meaning held by members that distinguishes an organization from other organizations (Robbins & Judge, 2015).
(Samee et al., 2011) explained that the study of organizational culture is concerned with the analysis of the values, attitudes, and beliefs that are behind behavior in the workplace. The creation of an organizational culture that supports organizational strategy can be a competitive superior instrument. This statement was emphasized by Sutrisno (2015) that organizational culture is used as a strategic tool in dealing with change and becomes one of the pillars of competitive advantage for organizations that lead organizations to have qualified resources. This is because organizational culture serves the dual role of adapting to changes in the external environment for the company and enabling internal integration (Joseph & Kibera, 2019). Organizational culture has the potential to improve the future prospects of the organization from a managerial perspective (Bendak, Shikhli, & Abdel-Razek, 2020)
Campbell dan Go (2013) emphasizes that to gain a competitive advantage, an organization should maximize the potential of its human resources so that it cannot be imitated by competitors. An organization or company is said to have a competitive advantage when its profit level is higher than the average level of the related industry and is said to have a sustainable competitive advantage when it maintains a high level of profit for several years (Hosseini, Soltani, & Mehdizadeh, 2018). Competitive advantage is also defined as what separates an organization or company from the rest and keeps it afloat and growing (Švárová & Vrchota, 2014). Competitive advantage has an individual character and refers to a certain interval (Sołoducho-Pelc, 2014). In addition, competitive advantage refers to the ability gained through resources to perform at a higher level than others in the same industry or market (Kibaek Lee & Yoo, 2019). The reason is, it is recognized that the development of human resources has an important role in achieving sustainable organizational performance (Rasool, Samma, Wang, Zhao, & Zhang, 2019). Vice versa, performance is considered as an indicator of the welfare of human resources, society, and also organizational effectiveness (Boselie, Van Harten, & Veld, 2021)
It can be seen that human resources are an important factor for business success in general and innovation in particular (Moussa & El Arbi, 2020) . Meanwhile, the success of a hospital does not only lie in the competence of human resources but is also greatly influenced by the culture and organizational behavior that is lived by the organization itself along with all employees who work in it. This shows that there is a strong relationship between organizational culture and the quality of patient health (Alharbi, Olsson, & Ekman, 2014). In this regard, customer satisfaction is seen as important in the process of building and maintaining relationships in medical services (Wijaya, Wisnubhadra, & Sinaga, 2015). Customer satisfaction has a very strong influence on the level of competitiveness of the organization or company (Suchánek & Králová, 2019). The impact of customer satisfaction is felt on the performance and profitability of a company (Suchánek & Králová, 2018). It can be seen that customer satisfaction is a key factor for success and is highly dependent on the behavior of service providers at the forefront (Yu Cheng Lee et al., 2016). Therefore, this study tries to test and explore how the pattern of hospital culture affects the quality of hospital services and does not only concern hospital employees but also based on patient experience.
The Indonesian Ministry of Health (2018) reported that there had been a 7% increase in the growth of hospitals in Indonesia in the last 6 years. This increased growth of hospitals led to rapid competition among hospitals. This requires hospitals to have a competitive advantage in providing quality health services. Strengthening the hospital organizational culture is one of the important strategies in gaining excellence in order to improve the quality of health services at the same time so as not to be imitated by competitors.
This research was conducted at Hospital (RS) X, Bandung because this hospital already has an organizational culture that is claimed as a brand in supporting services in all service units. The brand in question is the organizational values which are derived from the spirituality of the Sisters of St. Carolus Borromeus. Brand identity is how an organization (company) is identified (Mindrut, S., Manolica, A., & Roman, 2015). On the other hand, consumers are looking for products that provide a unique and memorable experience (Sahin, Zehir, & Kitapçı, 2011). Understanding how consumers respond to brands is an important aspect of consumer research (Keller, 2020) because brand awareness plays an important role in most aspects of marketing (Xuefeng Zhang, 2020). Brand relationships can create intangible added value and enable consumers to trust the brand (Shikun Zhang et al., 2020). Meanwhile, spirituality is distinguished from all other things, such as humanism, values, morals, and mental health, by its relation to what is sacred, the transcendent (Koenig, 2012) which is also hard to interpret (Cook, 2020). Spirituality is the essence of being human (Phenwan, Peerawong, & Tulathamkij, 2019) Spirituality, as well as religiosity, were found to be positive predictors of subjective well-being, although the results were not always consistent (Villani, Sorgente, Iannello, & Antonietti, 2019). Meanwhile, studies also show a positive relationship between spirituality and health behavior with subjective well-being (Bożek, Nowak, & Blukacz, 2020)
The basic spirituality of the CB sisters is that a person's personal encounter with God becomes the person's strength to love, serve, care for, educate and develop themselves. From this Spirituality, it is then formulated in the Caring Brand service behavior. Efforts made by hospital X management in realizing CB spirituality as organizational values in order to become a differentiating brand in service with other hospitals have been started since 2015. This year the introduction and socialization of I CARE's values was carried out by conducting a spirituality deepening for all hospital employees using the retreat and recollection method. Researchers are interested in conducting research by exploring the relationship between hospital organizational culture and service quality from the perspective of hospital external stakeholders, namely doctors, nurses, hospital management and patients.
Theoretical Concepts of Organizational Culture
Organizational culture is a system of symbols and interactions unique to each organization. Unique things related to ways of thinking, behaving, and believing that are shared by members of an organizational unit (Marquis & Huston, 2012). Organizational culture is also defined as the dominant values supported by the organization, the philosophy that guides the organization's policies towards employees and customers, the way work is done in the organization, the basic assumptions and beliefs that exist among members of the organization (Robbins & Timothy, 2015).
Marquis dan Huston (2012) explain that organizational culture in an organization is usually associated with values, norms, attitudes and work ethics that are shared by each component of the organization. Value is a belief in the form of good or bad, right or wrong, valuable and important that can be associated with the ultimate goal to be achieved by the individual / organization. These elements form the basis for monitoring employee behavior, the way they think, cooperate and interact with their environment. If the organizational culture is good, it will be able to improve employee performance and will be able to contribute success to the organization (Sutrisno, 2015). A strong and healthy organizational culture can function as demands that bind employees because it is formally formulated into various organizational rules and regulations. Thus organizational culture will create increased productivity, and performance and can affect organizational effectiveness, because to achieve effectiveness it requires appropriate organizational culture, strategy, environment, and technology (Loporto, 2019).
According to Cameron & Quinn, (2011) there are four main types of organizational culture, namely: Type 1) hierarchical culture, this pattern is also known as the internal process type orientation of organizational culture with this type is how the organization controls the entire process of organizational activities. Type 2) a consumer-oriented culture (Market culture) or what is often known as the rational goal type. In this type, the main orientation displayed is competitive, where the organization is open to rapid changes in order to gain market share and focus on external positioning. Type 3) is an adhocracy culture. This type is also known as the open system type. This type of culture is oriented towards creativity and innovation to create new things in a fast time. Type 4) Clan culture. This type is also known as the human relations type. The main orientation of this type is on collaboration. Changes that occur in clan-type cultures take a long time and focus on internal maintenance.
Each type of culture above contributes differently to the effectiveness and success of an organization without ignoring the needs of the external environment and the orientation of the organization's strategy.
Theoretical Concepts of Service Quality in Hospital
Service quality is defined as a dynamic condition that affects products, services, people, processes and also the environment that meets and exceeds consumer expectations (Tjiptono, 2001). Sachdev and Verma, (2004) in (Samee et al., 2011) explain that health service quality management can be viewed from two perspectives, namely an internal perspective and an external perspective. The internal perspective focuses on zero defects / errors and the suitability of services with service requirements that should be met by service providers while the external perception is patient-centered and patient's expectations, perceptions, attitudes and satisfaction. To improve the quality of services, the health system must be more effective, efficient, accessible, patient-centred, fair and safe (Organization, 2006).
To measure service quality, since 1985 Parasuraman has developed a measurement model known as servequal (service quality). This model measures service quality with five dimensions, namely: 1) tangible, which is tangible evidence of the care and attention given by the hospital as a service provider to consumers. The importance of this dimension is to grow the image of the hospital, especially for new patients in evaluating the quality of health services. Hospitals that do not pay attention to their physical facilities (facilities and infrastructure) will damage the image of the hospital; 2) reliability, is the hospital's ability to carry out services in accordance with what has been promised in a timely manner; the same service for all patients and without error. 3) Responsiveness is the hospital's ability to be shown directly by employees in providing fast, precise and responsive services. Responsiveness of employees can provide a positive perception of the quality of services provided; 4) assurance, is the knowledge and behavior of employees to foster trust and confidence in consumers in receiving the services offered. The components included in the assurance dimension are communication, security, credibility, competence, and courtesy. This dimension is very important because it involves the patient's perception of the high risk of uncertainty regarding the hospital's inability as a service provider, and 5) empathy, namely the ability of the hospital that is carried out directly by employees to pay attention to consumers individually and specifically including as well as sensitivity to consumer needs.
In health services in hospitals, nurses are an important part of the service system itself and provide nursing services that are directly related to humans. The focus of the nursing discipline is to pay attention to the fulfillment of human needs as a whole from the integrated biological, psychological, sociocultural and spiritual dimensions; which is abbreviated as bio, psycho, social, spiritual beings (Marlaine C, 2019). Still according to Marlaine C, (2019) that nursing is inseparable from caring; which are summarized as intentions, expressions, behaviors, actions and experiences that are based on moral, ethical, spiritual foundations that maintain human relationships, health, healing and well-being.
This research uses caring theory according to (Roach & Schorey, 2002) in (Smith, Turkel, & Wolf, 2013); known as the Caring the Human Mode of Being Theory, is a theory that talks about conscience and a way of life that is born from a person's awareness of his relationship with other people, in this case the patient and family.
The theory of Caring the Human Mode of being which consists of six components, namely: First, compasion; which is explained as a way of life born of awareness of one's relationship with all living things. The second is competence; Competence is described as something that is needed and must be possessed by a professional who is devoted to knowledge, judgment, skills, energy, experience, and motivation as a condition and responsibility to provide an adequate response to a request or demand. The third is confidence; namely the quality of building a trusting relationship. The fourth component of conscience; which is related to conscience. Conscience is an important thing that reflects the holiness of a person and has the core value of every person and the center of human integrity. The fifth component is commitment, which is something complex related to the active response of the character which is characterized by combining a desire, a person's obligation and a deliberate choice to act in accordance with their wishes. The sixth component is comportment, which means to behave, behave in harmony. Dress and words are symbols of communication and they can be in harmony or not.
I Care is a behavioral competence and at the same time a work culture for Hospital X Bandung. This I Care-based competency is a service model based on the spirituality of the Sisters Carolus Borromeus. In the history of the journey of Hospitals – Catholic hospitals that joined the CB Connection, the sisters were the pioneers of this hospital. Furthermore, CB's spirituality, which contains the values of Christian virtue, becomes the basis for health and education work under CB's auspices. The formulation of these organizational values is stated in "I CARE" which stands for Integrity, Compassion, Assurance (quality), respect and embrace innovation. These values are continuously strived to become a differentiating strategy with other competitive hospitals. This I Care value is also a CB Core Competence.
The research design used for the purpose of this research is a combined quantitative and qualitative design (Mixed-Methods research), with a mixed-method convergent parallel design model. The design of this model is that the researcher collects quantitative and qualitative data on the same research topic, analyzes them separately and then compares the results to see whether the findings confirm or do not confirm each other (Creswell, 2016). The population in this study were all employees of Hospital X from seven directorates with a total of 1519 employees and all patients who were hospitalized at Hospital X during the study. The sampling technique used is the start-up random sampling technique or categorical random sample. Startified random sampling is the determination of the sample according to the category or quota (Bandur, 2013). This technique is used because the composition of the number of employees in each directorate is different.
The quantitative research data collection technique used is through a questionnaire using a Likert scale of 1-4 (1 = Strongly disagree, 2 = Disagree, 3 = Agree and 4 = Strongly agree) The Likert scale is used to measure patterns of organizational culture at home hospital X on the quality of hospital services, so that the same questionnaire can be filled out by employees and patients. The validity of the questionnaire was tested by using Principal Component Analysis (PCA). The reliability of quantitative research is carried out by a consistency test using Alpha's Cronbach or alpha coefficient. For data analysis using T-test and Cross-Tabs. thematic analysis approach and cross-case analysis assisted by Nvivo 12 software.
Result and Discussion
Characteristics of all respondents univariate test results show that there are 40.10% are patient respondents and 59.90% are hospital employee respondents. The majority of respondents are women; 73.43% and only 24.57% male. The characteristics of employee respondents also show that female gender remains the majority, namely 84.48% and male and male only 15.32%. Likewise with patient respondents where female respondents remained the majority, namely 56.63% were women and 43.37% were men. Characteristics that are also seen from the employees' respondents are the years of service. The test results show that the majority of the respondents' tenure of service is > 5 years, namely 70.16%, then 12.10% with 3-5 years of service, 11.29% with 1-3 years of service and only 3, 2% who worked < 1 year. The shorter the respondent's tenure, the smaller the composition of the number of respondents. Vice versa, the education level of patient respondents ranging from elementary to Strata 2, the majority of them have undergraduate education of 50.6% and 22.8% are educated. This shows that the average patient respondents received higher education. The majority of respondents aged 21 -30 years with a percentage of 30.12%, aged 31-40 years 25 5, aged 41-50 years 19.8%. By looking at these results, it can be concluded that the composition of the respondents is productive age.
The Differences in Significant Effects Between the Four Patterns of Organizational Culture on Hospital Organizational Culture, And Explore These Differences.
The results of the statistical test show that four cultural patterns, namely internal process type, rational goal type, open system type and human relation type, have a significant influence on the organizational culture of X Hospital. culture with an internal pattern of process type with an Aprrog Zig value of 0.000 (p < 0.05) with a strength of influence v = 0.380, on an Aprrog Zig rational goal type of 0.000 (p <0.05) with v = 0.410 on an open system type with Aprrog Zig 0.002 (p<0.05) with v = 0.302 and the human relations type with Aprrog Zig 0.000 (p<0.05) with v = 0.302.
Of the four cultural patterns above, the pattern that has the strongest influence on the organizational culture of Hospital X is the rational goal type / market culture, then followed by the internal process type / hierarchical culture and the least influential is the open system type / adhocratic type culture and the human relations type. / clain. The results of this study that the rational goal type / market type is the pattern that has the most significant influence on the organizational culture of hospitals today, indicating that hospital culture is able to become an important element in facing increasingly tough business challenges. The author assumes that hospital X shows the current organizational culture can be a competitive superior instrument (Sutrisno, 2015).
The influence of organizational culture on service quality while exploring the process of the occurrence of that influence
The results of the cross tab test in this study indicate that there is a significant relationship between organizational culture and service quality. The results of the quantitative study are supported by the findings of important themes in qualitative research which say that organizational culture has an important effect on service quality where organizational culture helps employees to work professionally, continue to learn and innovate and try to provide the best service for consumers in this case patients. The implementation of organizational culture needs to be carried out continuously in this regard related to efforts to internalize I CARE which is a hospital's flagship behavior brand because I CARE contains priority values that are the basis for health work, in this case the hospital, which is believed to be an inspiration. , guidance, direction of movement and at the same time as a motivator for anyone, especially employees who are involved in hospital health work under the auspices of CB spirituality.
Although it was found that the organizational culture of the hospital had a significant effect on service quality, when viewed from each dimension, it was seen that the organizational culture of the hospital only had a significant effect on the dimensions of tangables and the dimensions of empathy. This is supported by the results of qualitative data analysis where the participants, both patients and employees, revealed that the hospital displays courteous, friendly and clean and tidy service, and provides services sincerely wholeheartedly and voluntarily. Attitudes and behaviors related to the tangible and empathy dimensions are also the values contained in the hospital work culture, namely I CARE. One of the values of I CARE is compasionate, namely, placing oneself in accordance with the situation at hand, feeling what is experienced by the patient, the patient's family or co-workers in facing the rejection or advantages of others patiently and being a friend to others who are served. Against these two dimensions, the organization in this case the hospital gets a picture that the real elements that can be seen and felt directly by patients, both hospital facilities and the real appearance of employees in the service process are important dimensions that need to be continuously considered, improved towards a better and evaluated regularly. For elements of service quality that are not significantly influenced by the organizational culture of the hospital, namely reliability, responsiveness, assurance, it is necessary to pay special attention to the implementation of I CARE related components related to these three service dimensions.
Differences in Organizational Culture Patterns Based on Service Units
By using the Kruskal Wallis test the results were obtained that there was no significant difference related to the pattern of hospital culture simultaneously between the services / per directorate in the hospital. In three types of organizational culture patterns, namely internal process type, open system type, human relations type, there is no significant difference in responses from hospital employees based on service units except for organizational culture with rational goal type. This is indicated by an approg value of 0.025 Zig (p<0.05). These results are strengthened by comparative analysis to identify cultural patterns as an internal process, where the results of the analysis show that all participants based on status/position confirmed the socialization carried out by the X Hospital Management to ensure all rules can be implemented by all employees. Also the comparison analysis on the pattern with the open system type where the results of the comparative analysis show that all participants based on the status / service unit confirm that employees like to do new things and are open to experimentation. Likewise in the human relations type where all participants based on service units confirmed their relationship in the hospital was more felt as a family.
In contrast to these three patterns in the rational goal pattern, the results of the comparative analysis show that not all participants based on service units confirm the hospital's efforts to maximize profit. Still on the rational goal pattern in quantitative data, it can be seen that there are 32.2% of employee respondents who do not agree that hospitals are trying to increase profits. This shows that hospital employees have different opinions when talking about profit. There are still quite a large number of employees who do not agree with the hospital's efforts to make a profit. The researcher assumes that there are still many respondents and/or employee participants who hold the principle of the existence of the hospital as a social work as in the early history of the establishment of this hospital. The researcher sees that there needs to be a refresher understanding that even though the hospital is on its way to being a manifestation of social work, as an organization, it must remain oriented towards the goal of the hospital's existence, namely the welfare of employees, where that goal is achieved if the organization in this case the hospital still pays attention to profit achievement without neglecting the noble values of the organization.
Differences of Opinion Regarding Service Quality According to Patients and Hospital Employees X
The results of statistical tests with independent T-tests showed that there were significant positive differences related to service quality between patients and employees, both simultaneously with service quality with p = 0.005 (p < 0.05) or partially from each service quality dimension except the reliability dimension. and assurance; where the significance of the difference can be seen from the p value of each dimension, namely the tangible dimension with p = 0.000, the responsiveness dimension with p = 0.043, on the empathy dimension with p = 0.013. By looking at the magnitude of the p value, the tangible dimension is the dimension that most shows a significant difference between patients and hospital employees. This quantitative result is supported by important themes from the qualitative analysis where in the tangible dimension the themes found from both hospital employee and patient participants are; polite, friendly, clean and tidy.
The researcher assumes that organizational culture at hospital X has played an important role in improving the quality of hospital services, which is marked by a positive and significant difference of opinion between patients and hospital employees on the quality of hospital services. Where it can be interpreted that patients as users of health services have received health services in accordance with their expectations, while hospitals as health service providers represented by employees are still trying to provide better services than what patients currently feel.
Limitations and Implications of the Research
The shortcomings of this study can be seen from the side that first, the research is only limited to private hospitals, so the following research can be developed in government hospitals. Second, the research was only conducted in one private hospital, so it could be further developed in other private hospitals. Third, the research was only conducted in one hospital so that subsequent studies could be conducted in more than one hospital. Fourth, in-depth interviews were not conducted, participants only filled in the open questions provided on the answer sheets provided so that the researcher could not be ascertained by the researcher the understanding of the participants in answering the open questions given. Finally, the number of samples is less and does not match the results of the sample count.
While the implications of this research theoretically are at the level of leadership and management disciplines, the research results support the theory that organizational culture is an important element in creating good service quality for patients. It is important for hospital leaders to continuously develop strategies in an effort to internalize the hospital's organizational culture.
Research on differences of opinion regarding service quality according to stakeholders and patients is still limited. The results of this study can close the gap.
Regarding managerial practice, the results of the study explain that organizational culture is closely related to the quality of hospital services. Internalization of organizational culture based on caring needs to be created in a health organization so that employees have the same organizational values so that they continue to have a positive impact and increase patient satisfaction which is also meaningful for the sustainability of the institution.
Regarding nursing education, although this research does not specifically examine nursing, the results of the research are useful as information that adds insight into the relationship between organizational culture and service quality. This research can be an additional reference for other researchers who research related to organizational culture and service quality. This study provides input that in health services it is important to know the strengths and weaknesses of organizational culture so that it can provide information to improve the quality of health services.
Quantitative and qualitative research proves that based on the results of statistical tests and thematic analysis four cultural patterns (Internal process type, Rational Goal Type, Open System type and Human Relations Type) have a significant effect on the current organizational culture of the hospital. Quantitative and qualitative research proves that based on the results of statistical tests and thematic analysis of the four patterns of organizational culture, the pattern of organizational culture that has the highest level of significance is the rational goal type. Quantitative and qualitative research has proven that based on the results of statistical tests and thematic analysis of organizational culture has a significant effect on improving service quality. Quantitative and qualitative research has proven that based on the results of statistical tests and thematic analysis, the results show that organizational culture is significantly related to the empathy dimension. This study is used as information about organizational culture and its influence on the quality of health services experienced by both hospital employees as service providers and by patients as service users. This study also describes the continuity of four cultural patterns on the quality of hospital services. This information is expected to be input for the hospital in an effort to internalize organizational culture to improve the quality of hospital services.
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