Exploring the dynamics between different organizational culture types and patient satisfaction in Dutch hospitals

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Exploring the dynamics between different organizational culture types and

patient satisfaction in Dutch hospitals

Master Thesis, MSc Business Administration

Organizational & Management Control

University of Groningen

Faculty of Economic and Business

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ABSTRACT

Patient satisfaction has become an important influence on financial performance. The current financial environment in where the Dutch hospitals operate in is tough. Improvements in the patient satisfaction depend on the organizational culture within the hospital. This study examines the influence of each organizational culture type captured in the Cultural Value Framework on patient satisfaction. Data gathered from five hospitals in the Netherlands, three general hospitals and two university medical centers are used to explore this relationship. Results show that different dimensions within the hierarchy culture and market-oriented culture are positively and negatively related to patient satisfaction. This suggest that hospitals creating a highly divers organizational culture is likely to be influencing patient satisfaction most beneficial.

Key words: organizational culture, patient satisfaction, organizational culture types, cultural value

framework, Dutch hospitals

Supervisor: dr. E.G. van de Mortel

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1. INTRODUCTION

1.1 Topical matter

The health care industry is currently changing towards a more competitive and market-sensitive entity (Newman, 1991; Bellou, 2008). The Netherlands made a switch in 2006 by replacing the hospital funds in a regulated market. The health care providers are facing, because of these changes, new challenges. Like the increasing competition between health care providers, health insurances and other care institutions. Furthermore, the health care providers are nowadays under constant pressure to reduce costs while maintaining the quality of care. Besides, the services they delivered must be organized around the consumer’s preferences, according to Bellou (2008). Research of Frings and Grant (2005) and Rider and Perrin (2002) support these findings.

Naidu (2009) mentioned several researchers in his article who related patient satisfaction with financial performance of hospitals. According to Devlin and Dong (1994) high quality services are directly linked to increased market share, profits and savings. In addition, research of Buttle (1996) added that one of the financial performance drivers is service quality. To be more accurate, patients’ quality perceptions account for 17-27 percent of variation in hospital’s financial measures (Nelson, Rust, Zahorik, Rose, Batalden, and Siemanski, 1992). In addition, a hospital can lose $6,000 - $400,000 dollars in revenue over one patient’s lifetime by negative word of mouth (Strasser, Schweikhart, Welch, and Burge, 1995). Hence, for the Dutch hospitals it is of particular interest to pay attention to patient satisfaction to reduce costs, since financial performance and patient satisfaction is directly linked to each other. This conclusion is of particular interest for the Dutch hospitals, since the tension between the rising costs in the health care sector and the more demanding patients are increasing. The CPB (2011) predict that in 2040, at most, 31% of the gross domestic product will be spending on collective financed care. This will lead to an increase of the care premiums to at least 30% of the income and could rise to 45% of the income of the citizens.

The above literature shows an abound of evidence of the influence patient satisfaction has on the financial performance. It is therefore of interest to investigate which factors influences patient satisfaction to be able to reach optimum performance.

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5 out that when hospitals wish to increase the quality of patients’ services in a cost effectively manner changes in the organizational culture are needed.

Zafer Acar and Acar (2014) did research on the effect of organizational culture on the performance of Turkish hospitals and according to them there is an abound of evidences in the literature that the organizational culture is one of the most important factors that affect performance. In where patient satisfaction is part of the performance. Underpinned by the research of Greenslade and Jimmieson (2011) who pointed out that patient satisfaction is critical outcome indicator, hence part of the performance. Furthermore, the health care service belongs to the service industry in where there is a lot of one-to-one customer contact. The customers experience and customers’ performance perceptions are therefore largely dependent on the organizational culture (Zafer Acar and Acar, 2014). Concluding, the organizational culture has a significant influence on the patient satisfaction.

Hence, patient satisfaction influences the financial performance (e.g. Naidu, 2009; Devlin and Dong, 1994; and Buttle, 1996). Many factors influence patient satisfaction. According to Bellou (2008) to reach optimum patient satisfaction, the organizational culture needs to adapt accordingly. Therefore, it is for Dutch hospitals interested to know how their organizational culture influences the patient satisfaction.

1.2 Research question and sub questions

The purpose of this research lies in understanding the impact of organizational culture on patient satisfaction of the Dutch hospitals. Organizational culture is divided in four types (Quinn and Rohrbaugh, 1981, 1983), which will be explained in more detail in chapter three, and the purpose of this research is to identify what effect each type of organizational culture has on patient satisfaction. The main research question of this research is therefore set as follow:

How do different types of organizational culture effect patient satisfaction within the Dutch hospitals?

In order to answer the main research question several sub questions are established: 1. What is the context in where Dutch hospitals operate?

2. What is patient satisfaction?

3. Which variables influence patient satisfaction? 4. What is organizational culture?

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1.3 Academic relevance

This research will contribute to the literature by investigating in the question how the mechanism between organizational culture and patient satisfaction in Dutch hospitals works. The theoretical approach adopted is the Competing Value Framework (hereafter: CVF) developed by Quinn and Rohrbaugh (1981, 1983). This approach classifies organizational in four types. Using this approach is of particular interest since mixed results occur in the literature regarding the relation between patient satisfaction and each type of organizational culture. The research of Zafer Acar and Acar (2014) shows positive results between one type of organizational culture and patient satisfaction, while research of Ancarani, Di Mauro, & Giammanco (2009) shows in this case a negative relation. Moreover, both researchers did a quantitative study and confirm a relationship between those two variables. However, it does not explain how organizational culture influences the patient satisfaction. Using a qualitative approach was recommended by Wagner, Mannion, Hammer, Groene, Arah, Dersarkissian and Suñol (2014), according to them a qualitative approach, or using mixed methods, could help to understand the impact of culture on quality improvement in hospital settings. This research is indirectly focused on quality improvements, since patient satisfaction is influenced by the delivered quality (Naidu, 2009). Qualitative research is according to Eisenhardt (1989:542) “useful for understanding why or why not emergent relationships hold”. Furthermore, the dynamics underlying the relationship are revealed by qualitative data, it provides a good understanding of the why of what is happening (Eisenhardt, 1989). This research is therefore of theoretical interest since quantitative research only seems to be too limited.

1.4 Managerial relevance

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1.5 Outline of the research

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2. SECTOR DESCRIPTION

According to the Dutch dictionary, health care entails all agencies who are working together on the health of people. In the Netherlands, the health care sector is divided in three different levels. The first level, called primary care and provided care is directly accessible, a reference from a health care provider is not required. In the Netherlands, the general practitioner, part of the primary care, is functioning as “gatekeeper” for the hospitals, the secondary care. The emergencies are, of course, an exception on the rule. Hence, health care institutions that can only be accessed after referral from the health care providers of the primary care outline the secondary care. Professional can rely on the tertiary health care for their care provision. It entails the service provided by e.g. expertise centers. Hence, the three different levels represent the health care sector in the Netherlands. The next paragraph entails a description of the financial context in where the Dutch health care sector needs to operate.

2.1 Financial context

In the last couple of years the costs in the health care sector remains increasing. The graph below shows the increases over the past years in the Netherlands.

Figure 1: The rising health care costs of the past years, source: CPB, CEP 2012:appendix 9

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9 According to the CPB (2011) in 2040, at the most, 31% of the gross domestic product will be spend on collective financed care. According to the expectations of the CPB, the care premiums will increase to at least 30% of the income and could rise to 45% of the income of the citizens. Comparing to the 25% at this moment, the rising expenditures could lead to a rising pressure in the solidarity in the care between young and old and rich and poor (CPB, 2011).

The graph below was published in a document of the Ministry of Health, Welfare and Sports in 2012 called The health care: how much extra is it worth to us? and shows the increase in health care spending’s in three different scenarios for the coming years.

Figure 2: Three different scenarios for increasing health care spending’s, source: document of the Dutch Government in 2012:7.

As mentioned above, according to the CPB (2011) the most likely scenario is, unfortunately, the one who expect that 30% of the BBP in 2040 will be spend on health care. In 2013 94,2 billion euros is spend on health care, an increase of 1,6 percent compared to 2012 (CBS). About a quarter of the total expenses are from the hospitals and medical specialists, this is an increase of 4,9 percent compared to 2012 (CBS). Hence, from these figures it is obvious that something needs to be done to reduce the increasing costs in the health care sector.

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10 same time. The second reason for the increase in costs is due to the higher expectations of the patients regarding medical care. Patients can choose between different care providers and are therefore more critical towards the delivered care. People’s standards of care and caregivers are increased and they are less willing to accept less. The third reason, mentioned by the Dutch government for the increase in costs is due to the major investments made for extra guidance for people who have troubles to participate in the society at full capacity. And the last reason is the aging problem, although it is not a quarter of the increasing costs of care, hence without aging the health care costs will still increase tremendously.

Most reasons are obvious causes of the increase in health care spending’s, since innovations, investments and aging will always exist and have always occurred. The second reason is of particular interest, since the change in society is something which was developed recently and has a major influence on the rising health care spending’s. This change is the consequence of the increasing market forces in the health care sector caused by a modification made in 2006.

2.2 The switch to a regulated market

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2.3 Quality of care

The IGZ is the inspection for health care, supervised by the government. They will judge the quality of care in cooperation with NVZ (Hospitals Association), NFU (Dutch Federation of University Medical Centers), OMS (Order of Medical Specialists), and V&VN (Nurses and Cares Netherlands). The following information is gained from the report of the Inspection for the Healthcare Basic set of quality indicators for hospitals in 2014. The IGZ used quality indicators in order to determine which care processes in the hospitals need extra attention or ask for further investigation. The indicators are determined annually by the IGZ with the help of NVZ, NFU, OMS, V&VN and professionals supervised by the IGZ directly. Hence, the IGZ monitors the quality of care in Dutch hospitals with the help of quality indicators.

The quality of care is also judged by the patients. On for instance zorgkaartnederland.nl patients can express their experience of a particular health care organization. Several factors are given by the website to be judged by the patient on the scale of 1-10, in where 10 is excellent and 1 is very poor. The factors are appointments, accommodation, listening, employees, information and treatment.

2.4 The Dutch hospitals: facts and figures

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Total 143

General Hospitals 83

University Medical Center 8

Specialized hospitals consisting of: Audiologiscle centers Dialysis centers Epilepsy centers Integral cancercenters Radiotherapy centers Asthma center Others 22 2 3 2 2 5 3 5 Rehabilitation institutions 30

Table 1: Hospitals in the Netherlands, end 2012, source NVZ, NFU.

Between 2008 and 2012 the general hospitals are clustered in three different sectors distinguishing the hospitals based on size. The following table gives a better view of the scope of the different hospitals within the Netherlands (Panteia/EIM, 2012).

Number of beds in general hospitals

< 300 beds 300 – 400 beds 400 – 600 beds > 600 beds UMC’s > 600 beds 25 19 20 19 8

Table 2: Size hospitals Netherlands in number of beds.

This research will focus on the general hospitals and the University Medical Centers. Since, it is interest to know if the size of the hospital has an influence on the organizational culture and thereby on the patient satisfaction. The University Medical Centers are the biggest hospitals, and therefore the inclusion of those hospitals is of significant value for this research. Furthermore, by including two types of hospitals a broader picture of the organizational culture within Dutch hospitals can be formed.

2.5 Conclusion

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13 regulated market together with the increasing competitive environment hospitals are working in the following proposition is of interest.

Proposition 1: “The movement from hospital funding to a regulated market creates a competitive

environment and results therefore in a market oriented organizational culture in hospitals in the Netherlands”.

Investigating in this proposition is also supported by Senić and Marinković (2012) since they advised further researchers to elaborate on the question if non-for-profit health care providers are market-oriented. Hospitals investigated in this research are part of the non-for-profit health care providers.

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3. THEORETICAL FRAMEWORK

This part of the research discusses the organizational culture and its influence it has on patient satisfaction. Hospitals face financial pressure due to external factors. Patient satisfaction influences positive patient behavior, such as loyalty (Naidu, 2008). Hence, loyal patients are positively related to an increase in financial performance. Patient satisfaction and the factors influencing patient satisfaction clarifying in paragraph 3.1. The healthcare industry experienced one-to-one contact with their patients and organizational culture has therefore a large impact on customers’ performance perception, according to Zafer Acar and Acar (2014). Paragraph 3.2 describes organizational culture and the different types of organizational culture. The interaction between organizational culture and patient satisfaction in the non-profit sector discusses in paragraph 3.3.

3.1 Patient satisfaction

In the research of Zafer, Acar and Acar (2014) the performances of the hospitals distinguishes service performance, financial performance and perceived performance. Patient satisfaction is part of the service performance.

When examining patient satisfaction several definitions came across. The definitions relevant for this research are given below in where the customers represent the patients. The expectations of a product and the delivered performance is a function of satisfaction (Oliver, 1980). According to Lam and Zhang (1999) customer satisfaction is reached when the service delivered exceeds the expectations of the customers. In the study of Naidu (2008) a definition of patient satisfaction is given by Linder-Pelz (1982) who defined patient satisfaction as an evaluation of different health care dimensions. It is a reaction of the customer to a single or a number of consecutive service encounters (Hu, Kandampully, and Juwaheer 2009). Westbrook (1981) defines customer satisfaction as an emotional reaction on the evaluation given by the customers on the received service. Another definition of patient satisfaction is given by Brennan (1995:250): “Patient satisfaction is the appraisal, by an individual, of the extent to which the care providers has met that individuals’ expectations and preferences”. Hence, from the definitions mentioned above the conclusion could be drawn that patients are satisfied when their expected needs are fulfilled or even exceeded.

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15 doctors. As a result, competitive advantage positively influences the financial performance. Therefore, it is of particular interest to know which factors influence patient satisfaction.

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16 Figure 3: Factors influencing patient satisfaction

The variance in factors could be explained by the individual differences in patients (Greenslade and Jimmieson, 2010). Age, gender, social status, ethnic origin, client health status and client expectations are variables causing differences in patient satisfaction (Mangelsdorff and Finsteun, 2003; Braunsberger and Gates, 2002; and Etter and Perneger, 1997). According to Jackson and Kroenke (1997) and Hall and Dornan (1990) those variables only explain a small proportion of the variances in patient satisfaction, they are a minor predictor of satisfaction. In several studies (e.g. Ancarani et al., 2009 and Zahr, William, & El-Hadad, 1991) only the patient characteristic age shows a positive effect on patient satisfaction. They concluded that younger people are less satisfied than older people with health care.

From the literature mentioned above it becomes clear that patient satisfaction is influenced by multiple factors, shown in figure three. Furthermore, geographic characteristics could be of influence, although they are a minor predictor according to several studies. It remains clear that patient satisfaction is complex and probably not uniform among all patients. Hence, for this research it is of interest to investigate in the question if patient satisfaction is unambiguously measurable. To

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17 explore the mechanism between organizational culture and patient satisfaction it is of interest to outline the contours of patient satisfaction. Therefore, the following proposition is established:

Proposition 2: “Is patients satisfaction unambiguously measurable?”.

3.2 Organizational culture

It is of concern to know how to influence the factors that are taken into account when patients evaluate the hospitals to increase patient satisfaction. Since, satisfied patients are more likely to continue utilizing health care services (Hill and Doddato, 2002). This can contribute to positive financial results (Hall, 2008). According to Zafer, Acar and Acar (2014) the literature shows an abound of evidence that organizational culture is one of the most important factors influencing performance. According to Greenslade and Jimmieson (2011) patient satisfaction is a critical health care outcome indicator, hence part of the performance. Several definitions of organizational culture exist in where the following are relevant for this research, since these definitions applied in the context of this research. According to Wagner et al. (2014) organizational culture represents the shared beliefs, values, attitudes, norms of behavior of people in an organization and the established organizational routines, traditions, ceremonies and reward systems. Jones (2010) had a similar definition and described organizational culture as a set of shared values and norms that control organizational members’ interactions with each other and with people outside the organization. Another well-known definition is given by Schein (1997), he defined organizational culture as an outline of mutual basic assumptions that the group learned as it solved its problems that has worked well enough to be considered valid and is passed on to new members as the correct way to perceive, think, and feel in relation to those problems. Hence, the organizational culture provides the “social glue” that gives organizations coherence, identity, and direction (Lok, Rhodes and Westwood, 2011:508).

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18 economic and corporate objectives. Hence, clinical freedom arises. Finally, the most visible level within organizational culture is those artefacts that represent the concrete appearances of culture. For instance, in the medical care issues like dress codes, standard ways of running services, or methods of performance assessment (Davies et al., 2000). Hence, by unravelling the organizational culture in hospitals each level should be taken into account.

3.2.1 Organizational culture types

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19 Table 3: The Competing Value Framework, adapted from Cameron and Quinn (2011).

In the research of Quinn and Rohrbaugh (1983) the family/clan culture is called the human relations model and is described as a model who had a great emphasis on flexibility and internal focus. The clan culture is often characterized by a flat organizational structure and acting more autonomously. Furthermore, people are bonded by loyalty and tradition (Wagner et al., 2014). Hence, hospitals with this type of organizational culture focusses on teamwork, creating personal places and trusts their employees by giving them the freedom to take own decisions.

The entrepreneurial or adhocracy oriented culture is called the open system model by Quinn and Rorhbaugh (1983) and has a flexibility and external focus. In the literature of Wagner et al. (2014) this is called the development culture and is characterized by creativity, has an adaptive leader as risk-taker. In comparison to the clan culture who has a more participative leader as mentor. Furthermore, the development culture bonded by entrepreneurship and put an emphasis on innovation (Wagner et al., 2014). The behavior of people is typically risk taking for this type of culture (Kaarts-Brown et al., 2004). This type of organizational culture is likely more present in University Medical Centers, since the focus of those hospitals is on development and try to find break through innovations. Emphasize is placed on flexibility, out of the box thinking, external look and coming up with innovations to increase quality of care.

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20 and regulations. It is likely that all hospitals in the Netherlands will have an organizational culture in where a characteristic of this culture type is shown.

The market culture is characterized by his external and results oriented focus (Kaarts-Brown et al., 2004). According to Quinn and Rohrbaugh (1983) this is the rational goal model and therefore in some articles also called the rational oriented culture type (Wagner et al., 2014). The rational goal model or market oriented culture is a competitive culture where the leader is goal-oriented and emphasize the winning mentality (Wagner et al., 2014). Hence, this organizational culture type exists in hospitals where the focus lies on the results, a result-oriented environment.

3.2.2 Organizational sub-cultures

Health care organizations in the public sector are described as typically large, complex and diverse organizations. It is therefore over simplistic to consider culture as uniform among all employees (Brunetto and Farr-Wharton, 2006: Detert, Schroeder, and Mauriel, 2000). Several sub-cultures exist in health care organizations. Sub-cultures is defined by Van Maanen and Barley (1985) as the subgroups of organizational members who interact regularly with one another, identify themselves as a distinct group within that organization, share the same problems, and take action on the basis of a common way of thinking that is unique to the group. This definition is also used by Bellou (2008) who identified organizational culture and sub-cultures within Greek hospitals. Hence, different cultures may arise within different professional groups (Davies et al., 2000). Especially in hospitals existing of different departments sub-cultures arises, since each department has their own specialism. Although several cultures can be present within one organization, the so-called sub-cultures, hospitals have always a tendency towards one particular culture type according to Wagner et al. (2014). Hence, conflicting results arises from the literature. It is therefore of particular interest to investigate in the following proposition.

Proposition 3: “In Dutch hospitals there are subcultures inherent in the main organizational culture”.

The relationship between the characteristics of each organizational culture and the factors influencing patient satisfaction will be discussed in the next paragraph.

3.3 Organizational culture and patient satisfaction in the non-profit sector

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21 in the research of Scholz (1987) who argued that the perceived role that organizational culture can play in generating competitive advantage and thereby claiming that organizational culture could be directly linked to organizational performance. In hospitals, patient satisfaction is part of the performance. Hence, showing a link between organizational culture and patient satisfaction.

Bellou (2008:497) argues: “hospitals that wish to offer their patients services of increased quality in a cost effectively manner, need to form employees’ values, priorities, attitudes and behaviors accordingly”. The values, priorities, attitudes and behaviors are part of the organizational culture. Hence, to influence patient satisfaction, which is influenced by the quality of care delivered, it is interesting to explore the dynamic between organizational culture and patient satisfaction.

Research was done by Zafer Acar and Acar (2014) on the influence of organizational culture on the business performance in Turkish hospitals. Business performance was divided in service performance, financial performance and perceived performance. Under service performance the patients’ satisfaction level was incorporated herein. In their research, they made a distinction between public and private hospitals. The public hospitals are particularly interested for this research since this research focus on the public hospitals in the Netherlands, therefore only the results of the public hospitals will be discussed. Two hypotheses are fully supported by their results. Those are (Zafer Acar and Acar, 2014:21): “Hierarchy culture has direct and positive effects on business performance” and “Market culture has direct and positive effects on business performance”. According to Zafer Acar and Acar (2014) it is hard to reach superior performance in service and financial aspects with clan and adhocracy culture. The hypotheses related to clan and adhocracy culture were only partially supported by their results. These results were partly contradicting the results of the research done by Ancarani et al. (2009) in hospitals in Italy. They could only validate three CVF models, namely the clan, adhocracy and market culture. The clan culture and adhocracy culture are positively associated with patient satisfaction (Anacarani et al., 2009). Hospitals with a dominant market oriented culture shows negative results in their patient satisfaction (Anacarani et al., 2009). Hence, contradicting results occur in quantitative data if certain organizational culture types have a positive or negative influence on patient satisfaction.

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22 and McDermott, 2011). Hence, for this research it means relating elements of each organizational culture type to factors regarding patient satisfaction.

Organizational culture has an influence on the performance, since the organizational culture controls the way members make decisions (Jones, 2010). Following Jones (2010) the organizational culture influences the behavior of their members of the hospital and thereby the decisions made. These decisions will influence patient satisfaction. Hence, for this research it means exploring the decisions following from each culture type and relate this to patient satisfaction.

In a clan culture the focus lies on flexibility and the internal organization. According to Cameron & Quinn (2006) and Denison & Spreitzer (1991) the core values of a clan culture is trust and participation. According to Gregory, Harris, Armenakis & Shook (2009) and Meterko, Mohr & Young (2004) patient satisfaction is positively associated with a culture of teamwork and cohesion. Teamwork, employee participation and involvement are typical characteristics of the clan culture. Employees are bonded by loyalty (Quinn and Rohrbaugh, 1983). According to Greenslade and Jimmieson (2007) a hospital related examples include staying late to help patients and providing additional care beyond their job duties. Hence, the existing relationship between clan culture and patient satisfaction could probably be explained by the underlying assumption that patients value attention, caring and personal relationship. For this research it means the following proposition is of particular interest relating clan culture with patient satisfaction: “Are the elements teamwork, employee participation and involvement of the clan culture positively influencing patient satisfaction?”.

In a hospital with an adhocracy culture as the dominant culture, the focus lies on flexibility, and on the external environment (Quinn and Rohrbaugh, 1983). Searching for new process innovations, creativity, resource acquisitions and risk-taking behavior are typical characteristics of this culture type. Moreover, listening to patients is one of their core values (Cameron and Quinn, 2011). Searching for the opinion of the patients and based on patients preferences and feedback new innovations can be developed and adapted. Patients are for the adhocracy culture a source of information. Since, patients value communication, which include listening, and judge their satisfaction based on, among other things, communication the positive relationship between adhocracy culture and patient satisfaction could be explained. More precisely, an emphasis on innovations and listening to patients, as characteristics of the adhocracy culture, could lead to positive patient satisfaction. This proposition is therefore of particular interest for this research: “Are the elements process innovations and listening to the patient of the adhocracy culture positively influencing patient satisfaction?”.

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23 and efficiency (Cameron & Quinn, 2006; Denison & Spreitzer, 1991). Efficiency has influence on the process of care. Kirigia, Emrouznejab, Cassoma, Asbu and Barry (2008) state that efficiency means minimizing the use of available resources while producing a given level of service required by the hospital. Alternatively, providing maximum services out of obtainable resources (Kirigia et al., 2008). Furthermore, a significant characteristic of the hierarchy culture is the value attached towards formal rules and procedures. The hierarchy culture is bonded by rules and procedures. According to Ancarani et al. (2009) patient satisfaction is, among other things, influenced by the responsiveness. In where responsiveness is the information provided about the current health state and protocols to be followed (Ancarani et al., 2009). Hence, the underlying assumptions of the relationship between hierarchy culture and patient satisfaction could be caused by the emphasis on efficiency and rules and procedures. Therefore, the following proposition is of particular interest: “Are the elements efficiency and working according to formal rules and policies of the hierarchy culture positively influencing patient satisfaction?”

Competition and the focus on the external environment are characteristics of the market-oriented culture (Quinn and Rohrbaugh, 1983). According to the research of Zafer Acar and Acar (2014) the market culture is positively related towards patient satisfaction, while the research of Anacarni et al. (2009) shows the opposite. A hospital with the market-oriented culture stimulates working towards results and emphasizes the importance of competition. Quality of care influences, among other things, patient satisfaction (Naidu, 2009). Hence, this is in line with the results-oriented view of the hospital, since hospital strategy is uniform among all hospitals and focusses on the improvement of quality of care. Hence, this could be the underlying assumption in the relationship between market oriented culture and patient satisfaction. Emphasizing competition could probably contribute to the improvement of the quality of care. To explore if this relationship is indeed positively influences patient satisfaction by emphasizing competition and working results-oriented the following proposition is of particular interest: “Are the elements competition and results-oriented of the market oriented culture positively influencing patient satisfaction?”

It is important to note that not all characteristics of each culture are taken into account in exploring the relationship between organizational culture and patient satisfaction. To the knowledge of the researcher, only those dimensions seen as most influential towards patient satisfaction are investigated.

Hence, taking the most significant characteristics of each culture type together with the components valued by the patients the following propositions are of interest.

Proposition 4A: “Are the elements teamwork, employee participation and involvement of the clan

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Proposition 4B: “Are the elements process innovations and listening to patients of the adhocracy

culture positively influencing patient satisfaction?”.

Proposition 4C: “Are the elements efficiency and working according to formal rules and policies of the

hierarchy culture positively influencing patient satisfaction?”.

Proposition 4D: “Are the elements competition and results-oriented of the market oriented culture

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4. METHODOLOGY

4.1 Research type

This study aims to find an answer on the main research question: “How do different types of organizational culture effect patient satisfaction within the Dutch hospitals?”. Performing a qualitative research in order to answer this question, because this type of research tries to point out how the mechanism between the concepts works and gain an understanding of the underlying reasons of the link between those concepts. This study will investigate in the casual relationship between organizational culture and patient satisfaction which is already in the quantitative research of Zafer Acar and Acar (2014) and Ancarani et al. (2009) shown and will now be explained in this research. Bartunek and Seo (2002) did research on the added value of qualitative research on quantitative research and argued that qualitative research can give extra meaning to the latter one. They argue that qualitative research is helpful and sometimes necessary to explore the meanings and the interactions that creates the meanings between different phenomena.

4.2 Data collection

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Hospital Date Number of Beds (2013) Position

A 04-12-2014 Small hospital (<300) Managing director

B 02-12-2014 Small hospital (300-400) Team leader

02-12-2014 Small hospital (300-400) Team leader C 22-12-2014 Middle-size hospital (>600) Team leader

D 04-12-2014 UMC’s (>1000) Manager

10-12-2014 UMC’s (>1000) Manager

E 26-11-2014 UMC’s (>1000) Financial Controller

26-11-2014 UMC’s (>1000) Manager

05-12-2014 UMC’s (>1000) Team leader

11-12-2014 UMC’s (>1000) Manager

Table 4: Interview schedule

4.3 Interview method

Ten interviews were conducted in different hospitals (see table four for an overview). All the interviews were face to face and were audio-taped. Of each interview a transcript is written. The interviews were held in Dutch, and the associated transcripts are written in Dutch as well. The interviews had a length of approximately 30 minutes up to 60 minutes. The interviews were semi-structured, because this allows the researcher to adapt on the answers given by the respondent and ask additional questions (Corbetta, 2003). In this way, the opportunity to explore issues that arise spontaneously remains by being flexible and asking open-questions (Berg 2009; Ryan, Coughlan, & Cronin, 2009). Further research on semi-structured interviews was done by Hand (2003) and Dearnley (2005), they pointed out that the open nature of the questions encourages depth and help to emerge new concepts. During the interviews novel insights were gained. Due to the pop-up of these unexpected insights during the interviews, the interviews deviated from the original planning. Noonan (2013) mentioned that this would increase the validity of the study. Two interviews were held with two managers of the same hospital at the same time. This was due to time limitations of the interviewees.

4.4 Interview questions

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27 The first question was related to the first proposition. The current financial situation was discussed with the interviewee and the questions followed contain the influence of this situation on the organizational culture. Hence, the first question asked discussed if the hospital was forced to work within a market oriented culture due to the external pressure.

The article of Kaarts-Brown et al. (2004) declares that the CVF is one strategy to examining the characteristics of an organizational culture that may affect its organizational effectiveness and success (Quinn and Rohrbaugh, 1981, 1983; Cameron and Quinn, 1999). To evaluate which organizational culture is dominant in the hospital the Organizational Culture Assessment Instrument (OCAI) developed by Cameron and Quinn (1999) was used. Based on six aspects with four answer categories representing the different culture types the dominant organizational culture type could be determined within the hospital (Wagner et al., 2014). Since this research is qualitative, the questions where slightly changed to interview question and adapted towards the hospital industry. The six aspects hospital characteristics, leadership style, management of employees, organizational glue, strategic emphasis and criteria for success remains (Kaarts-Brown et al., 2004).

The second part of the interview contains questions about the patient satisfaction. First questions were asked about the measurement systems the hospital uses to gain information about their patient satisfaction level. Next, two questions were asked about zorgkaarnederland. Zorgkaartnederland is an initiative of the Dutch Patient Consumer Federation representing a complete and independent overview of all health care providers. Patients have the opportunity to review their health care provider. The interviewees were asked what their opinion is about this development. The information gained from zorgkaartnederland was presented to the interviewee. To get a deeper understanding about what patients value further “why” and “how” questions were asked about the rates and feedback given. Besides, a question was asked if this score is representative for the satisfaction rate measured by the hospital itself. The last question of this category concerned the factors influencing patient satisfaction.

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4.5 Data analysis

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5. RESULTS

This part of the research represents the results gained from the interviews in five hospitals in the Netherlands. The results will be organized per category.

5.1 Patient satisfaction

The second part of the interview contained questions about patient satisfaction. Those questions were asked to be able to support or reject proposition two.

5.1.1 Measuring patient satisfaction

Three questions about measurement systems regarding patient satisfaction were asked. As mentioned in the paragraph 4.4 the first question (question six in the interview) remained if hospitals measure their patient satisfaction. The following results occur.

From the interviews, it became clear that patient satisfaction is not measured on every department. In one of the bigger hospitals the board of directors decided to measure the satisfaction level only on the outpatient departments. Besides, in two interviews it became clear that patients are not always able to fill in a questionnaire or answer questions. Reasons for this could be the state of illness or the age of patients (babies). In those cases and on those departments the focus lies on family satisfaction. Hence, patient satisfaction level contains not only patients but also entails family. The information of the two interviews reviewing family satisfaction was included in the results below. Since, it became clear that family and patients are interrelated according to those two interviewees. Hence, the following information about patient satisfaction is gained from nine interviews.

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30 academic hospitals to gain more information of specific patients often use the latter one. The mirror reflections were done in two of the hospitals. Those reflections were organized for doctors, nurses, other staff members and patients. In the last two years, almost twenty reflections were held. In those reflections, patients were asked to answer several questions. The staff was not allowed to interrupt or to talk; they only listen to the patients. According to the interviewees, this way of reflection results in new improvement points for the hospital. Patients feel free to talk and support each other in their opinion.

“The mirror reflections are valuable for the doctors and nurses; it is an excellent tool, a genuine mirror that is held in front of them. …. They gain knowledge about their way of communication. There could be difference in how something comes across and how it was actually meant”.

Hence, from the first question it can be concluded that the hospitals uses several measurement instruments to gain more insight in the factors valued by the patients. Table 5 stretches an overview of the measurement systems used and by how many hospitals.

Measurement system Number of hospitals

CQ-index general 5

CQ-index applied for each department 5

Different review-forms 5

Mirror reflections 2

Small research questionnaires 2

Focus interviews 1

Table 5: An overview of the measurement systems and the number hospitals performing those measurement systems.

The next two questions asked regarding patient satisfaction (question seven and eight in the interview) were about zorgkaartnederland. The interviewees were asked what their opinion is about those kinds of websites and if the results are representative for the scores measured by the hospital itself.

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31 the last couple of years. First, they all agreed that transparency is a positive development. Those kinds of websites create more insights in hospitals. However, all of the interviewees agreed that opinions given on those websites are very subjective. Since, it is only the opinion of one patient. Unfortunately, all the interviewees noticed that the reviews given on those websites could indeed influence the image of the hospital. Therefore, they are trying to find the balance between reacting or ignoring the comments. On some serious comments, the hospital reacts and asks the patient to contact them to learn from their experience to improve their hospital. This is uniform among all the five hospitals.

The reviews given on the hospital in general is a realistic representation of the scores measured by the hospital himself according to six of the interviewees. The other three find it hard to say something about this topic.

Hence, from those two questions an important conclusion could be drawn. The hospitals are all aware of the trend came up in recent years to share experience on the internet. All the hospitals agreed that the analyzing the results of the measurement systems regarding patient satisfaction performed is not enough. If hospitals want to improve their patient satisfaction level, they should keep record of the reviews given on those websites. Not only on zorgkaarnederland.nl, but also on the reviews published on independer.nl and kiesbeter.nl.

5.1.2 Factors influencing patient satisfaction

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Factors valued by the patients Number of interviewees

Personal contact 9

Attention 9

Information 9

Communication 9

Kindness and friendliness of personnel 9

Quality of care 9

Treatment 7

Costs 5

Waiting time 4

Scale of the hospital 2

Distance to hospital 2

Customization 1

Table 6: An overview of factors influencing patient satisfaction mentioned by the interviewees

All the nine interviewees mentioned the factor personal contact with the patients as very important to improve patient satisfaction level. This factor is closely related to attention. Every patient should have the feeling that he/she is heard, that sincere attention is paid to his or her disease. Thereby is listening to the patient is essential. Furthermore, in order to meet those needs of the patient communication between doctor and patient is critical. A patient communication manager is hired to make the transition from doctor to patient. The patient communication manager guides the patients in their treatment process by thinking along with the patients. Furthermore, improvements are made in already two hospitals by introducing electronic boards in the waiting room mentioning waiting times for each doctor.

“Contact is highly valued by patients. They often say: ‘I do understand that I have to wait, but as long as I get informed it is fine’.”

The last factor that is mentioned by all the interviewees is quality of care. Quality of care is vital to reach optimum patient satisfaction. However, patients are not able to judge the quality of care, due to a lack of knowledge. Hence, patients judge the quality of care due to the preconditions around him or her. However, they used the term quality of the hospital for this.

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33 patients should be taken into account. Two interviewees mentioned a theory in where the patients were divided in four types, each with their own color. The so called knowledge seeker, the blue patient who wanted to be fully informed about his or her disease and wanted to think along. The yellow patient is called the cozy patient, appreciating an atmosphere in the hospital like if they are at home. He or she likes to chat in the waiting room with fellow patients. The holistic patients view everything from the inside. And for the last patient an ‘Ikea concept’ would fit perfect according to the interviewee. Two other interviews mentioned the knowledge seeker patient as well, but in different words. Both mentioned the influence of the educational level of patients as influence on the patient satisfaction level. Another interviewee was aware of the theory mentioned above as well, but considered it as a hype from a couple of years ago and not used anymore. However, the latter interviewee mentioned that the location of the hospital is important to consider. One hospital was located in a densely population area. As opposed to the other hospital which was located in another part of the Netherlands. The interviewee mentioned this as an important difference, because the diversity of the patient is consequently influenced by the diversity of cultures present in an area.

Furthermore, the state of illness of the patient needs to be taken into account when considering which factors they value. According to all interviewees the patient who struggle the most with their disease, the less value they attached towards irrelevant factors. Like distance near the hospital and costs of the treatment were examples mentioned by two interviewees. They are only concerned about their health and healing process.

Hence, the factors mentioned above are important to consider by the hospitals to reach optimum patient satisfaction. However, the extent to which the factors are valued by the patients depends on several factors. First, patients are divers and could be categorized in four types. Each patient attaches different weight to each factor. Second, the state of illness of the patient is important to consider. The heavier the disease they face, the less weight they attach to some factors. Finally, the area in where the hospital is situated is of influence. Since the cultural diversity in a particular area causes an increase in the diversity of patients.

Variables influencing patients criteria Number of interviewees

State of illness 9

Type of patients 4

Area in where the hospital is situated 1

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34 Hence, proposition 2: “Is patient satisfaction unambiguously measurable?” could be supported. All interviewees admit that patient satisfaction is complex and influenced by several variables. Hence, for this research it means that the relationship between organizational culture and patient satisfaction is not so simple at it seems. Since, first of all patient satisfaction is a complex and divers concept. In the next paragraph, the results will be presented regarding the organizational cultures within Dutch hospitals.

5.2 Organizational culture

The organizational culture in Dutch hospitals is undoubtedly divers. Diversity between hospitals and within the hospitals. The organizational culture present in the hospitals consists of the main culture and several sub-cultures. The main culture is discussed in paragraph 5.2.1 and the sub-cultures in 5.2.2. The core culture dimensions that exist in the Dutch hospitals are presented in table eight. In table eight, the horizontal axis represents the hospitals. Hospitals needs to remain anonymous, therefore called A,B,C etcetera. The vertical axis represents the organizational culture types. In the far left column the characteristics are mentioned per organizational culture type. The rest of the columns represent the organizational culture present in the hospital accordingly. Hence, each column represents the main culture existing in the hospital.

5.2.1 Organizational main culture

The following information is an explanation off table eight. Hospital A is the only one who shows characteristics of the clan culture. The interviewee described the hospital as cozy and family like. Furthermore, characteristics of the hierarchy and market culture were shown in this hospital. The interviewee mentioned the top-down structure in the hospital, and the increase amount of rules and procedures the hospital is obliged to follow. Besides, hospital A wanted to prove that the quality delivered is of high standard. Hence, they focus on accreditation and rewards. NIAZ (Dutch Institution for Accreditation in the Health Care), JCI (Joint Commission International) and NFU (Dutch Federation of the University Medical Centers) are accreditations gained. The hospitals with an accreditation create a culture of professionalism, consequently working according to rules and procedures are inescapable according to all interviewees. As shown in table eight the characteristics of the hierarchy culture are present in all the hospitals (A, B, C, D and E) of this research. The hierarchy culture is furthermore present in the existence of a strong order from doctor to nurse.

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35 Some interviewees mentioned that the hierarchy is not equally strong among all departments. See paragraph 5.2.1 Organizational sub-cultures. However, the strong hierarchy is highly valued among the personnel, especially by the specialist. The communication between doctor and nurse is formal. The rest supported the quote of one of the interviewees. Terms related to medical staff and mentioned by the interviewees were ‘other type of people’, ‘overruling the hospital’, and ‘stately’ were interpreted by the researcher as a strong form of hierarchy between doctor and nurse. Notable is the difference between the hierarchy from the medical staff towards nurses and towards members outside the medical staff. Other staff members experienced far less the distance between them and the medical staff. Communication is direct and more informal, experienced by the financial controller and two other managers.

Furthermore, the main culture of hospital A shows besides the characteristics of the clan and hierarchy culture, also features of the market oriented culture. The focus of the hospital lies in the continuous improvement of the quality of care and patient safety. This results-oriented view is part of the market-oriented culture and is shared by all hospitals as shown in table eight. Furthermore, all the interviewees mention the increase in negotiations and competition between hospitals and insurances. The bigger hospitals have separate departments responsible for the negotiations with the insurances. In one smaller hospital, this is still done by the board of directors. Competition is distinctive for the market-oriented culture. As shown in table eight these characteristics are uniform among all hospitals (A, B, C, D and E).

Hospital D and E are the academic medical centers, the bigger hospitals. As shown in table eight, the adhocracy culture is present in hospital D and E. One of their core values is education and research. The adhocracy culture, also called the development or entrepreneurial culture focuses on developments and innovations. The medical centers work together to search for new developments to increase the quality of care. The focus on education is present in practice since almost every doctor guide a student.

“Innovations are very important in our hospital. We as managers stimulate being innovative in our employees. Education is therein also very important. Doctors are used to having students around them and explaining everything in detail. Innovation, research and education are very present in our culture and in the end it is all very result-oriented”.

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Table 8: An overview of the characteristics of the main organizational culture present in each hospital Hospital Org. C. A (small hospital) B (small hospital) C

(medium size hospital)

D

(bigger hospital, academic medical center)

E

(bigger hospital, academic medical center)

Clan Culture Internal and Flexible - Family atmosphere, cozy Adhocracy Culture External and Control - Focus on research - Education - Focus on research - Education Hierarchy Culture Internal and Control - Top-down approach - Bonded by rules - Focus on accreditations - Top-down approach - Bonded by rules - Focus on accreditations - Top-down approach - Bonded by rules - Focus on accreditations - Top-down approach - Bonded by rules - Focus on accreditations - Top-down approach - Bonded by rules - Focus on accreditations Market Oriented Culture External and Control - Result-oriented view towards quality of care and patient safety - Negotiations and competition between health insurances - Focus on financial results - Result-oriented view towards quality of care and patient safety - Negotiations and competition between health insurances - Focus on financial results - Result-oriented view towards quality of care and patient safety - Negotiations and competition between health insurances - Focus on financial results - Result-oriented view towards quality of care and patient safety - Negotiations and

competition between health insurances

- Result-oriented view towards quality of care and patient safety - Negotiations and

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However, mixed results occurred during the interviews if the financial external pressure caused the tendency towards the market-oriented culture. Most of the hospitals admit that a shift towards market oriented organizational culture arises. The peripheral hospitals, also called the general hospitals, noticed a tendency from clan culture towards market-oriented culture.

“Our hospital went through a development from small oriented view, almost family like, we know each other, and we know how it went, if there is a problem we solve it together. Towards a more professional, quality focused culture, which is accountable, register more, an increase in transparency towards the outside world. This change occurred the last two/three years”

Hospitals introduced accreditations, as mentioned above. This was done, according to the interviewee, to make sure not to lag behind other hospitals and increase transparency. One of the bigger hospitals noticed an increase in competition with peripheral hospitals. However, in this interview the interviewee said that they lag behind the smaller hospitals, because they did not feel the financial pressure so tough. The other interviewees of the bigger hospitals underpinned this. The smaller hospitals felt the financial pressure earlier and harder compared to the bigger hospitals. The market oriented view started therefore earlier in the smaller hospitals. This resulted in an increase in cooperation between peripheral hospitals. A merger between hospitals arises to combine their strengths and share the financial pressure. Furthermore, the smaller hospitals focus on the basic care and abandoned the complex care, because of financial reasons. The result-oriented view by focusing only on the basic care shows a shift towards a market-oriented culture. In addition, as mentioned before, the result-oriented view is one of the characteristics of the market-oriented culture. One hospital that was not involved in the merge between the peripheral hospitals noticed a swift in patients’ referrals. Because the merged hospitals send their patient to each other and not towards hospitals outside the merge. The interviewee mentioned that it is hard to influence patients’ choice due to these mergers. Moreover, this is also influenced by external factors, as the arrangements made with the health insurances. However, the hospital still tries to influences as much as possible by working together with general practitioners.

“We make general practitioners aware of our hospital and the care we can deliver to the patients to attract patients”.

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39 In one interview, the interviewee did not notice the competition when it comes to patients. They only noticed the competition between health insurances. The competition had increased the last couple of years, and became more complex.

Hence, from the interviews it becomes clear that all the hospitals became more market oriented because of the shift towards a regulated market. They became more aware of their external environment and competition increases. This is shown in the different activities they underwent, like the gaining NIAZ accreditation and the cooperation with general practitioners. Furthermore, they became more result oriented, especially the smaller hospitals who abandoned the complex care and focus only on the basic care. However, the bigger hospitals lag behind the smaller hospitals regarding the competition between hospitals. Because they do not feel the financial pressure that tough. However, in general the conclusion could be drawn that the regulated market created a competitive environment. For some hospitals only between them and the health insurances, for other hospitals also between hospitals. Hence, proposition 1: “The movement from hospital funding to a regulated market creates a competitive environment and results therefore in a market oriented organizational culture in hospitals in the Netherlands” is supported. Important to mention, besides the main market oriented culture, features form the hierarchy culture have a strong presence.

5.2.2 Organizational sub-cultures

Although some characteristics are uniform among the whole hospital, several sub-cultures are present in the hospital according to all interviewees. Hence, a diversity of cultures exists in each hospital, since every interviewee indicated this. It was beyond the scope of this research to investigate in each culture separately. However, since all interviewees admit that the sub-cultures could be very dominant, it is of interest to say something about it. Some reasons for the existence of the sub-cultures pop up during the interviews and are mentioned below.

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40 Hence, the first reason for the creation of sub-cultures lies in the existence of different specialisms. Eight of the ten interviewees declared this.

The second factor creating sub-cultures is the way the hospital is structured. Doctors can work in different ways for the hospital. They could be hired by the hospital and are then employed by the hospital. Or, they are part of a partnership. In the first case, the doctors received a fixed salary per month, in the latter case they are entrepreneurs. Hence, the incentive is different and brings another culture with itself. In some hospitals, all the doctors are employed, but in most cases, there is a mix of both cases. However, this structure is about to change from the 1ste of January 2015. This change would probably influence the organizational sub-cultures within the hospital. Eight of the ten interviewees mentioned the influence of the structure on the existence of sub-cultures.

The last factor creating sub-cultures is the influence of the manager from the department. Every manager has his/her own management style according to the interviewees. This brings a sub-culture with itself. Some managers are very focused on the financial results, some are very open and focused on own responsibility, and others are more guiding. Hence, the managers create a sub-culture within the main sub-culture. However, for this reason there is not enough evidence to confirm the influence it has on the creation of sub-cultures, since only one interviewee mentioned it.

Hence, from the results presented above the conclusion could be drawn that sub-cultures are inherent in the main organizational culture. Therefore, proposition 3: “In Dutch hospitals there are subcultures inherent in the main organizational culture” is supported. However, no further questions were asked about the content of the sub-cultures. Only several reasons for the existence did occur.

5.3 Organizational culture and patient satisfaction

In paragraph 5.2 the main organizational culture present in the hospitals are declared, and the existence of sub-cultures inherent in the main culture is confirmed. Since, the sub-cultures could be very dominant each organizational culture type and there relation with patient satisfaction is discussed in this paragraph.

5.3.1 Clan culture and patient satisfaction

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41 The following results did pop up during the interviews investigating in the dynamic between clan culture and patient satisfaction. The clan culture was only partly visible in one smaller hospital. Because of the small scale, there is more room for personal contact between the doctor and patient according to the interviewee. According to the interviewee, the hospital is the hospital of the area. People consider it as their hospital; it feels familiar and well known for them. This atmosphere positively relates towards patient satisfaction according to the interviewee.

“The hospital is relatively small, close by, familiar, quickly aided, less waiting time. These elements are important and valued by our patients”.

According to the interviewee, the patients compare ‘their’ small hospital with the bigger hospitals in the environment and they feel at home in ‘their’ small hospital. Because in the bigger hospital they get the feeling to be lost and being a number instead of being you. The hospital received that respond from their patients. In another interview, the characteristics of a clan culture were also visible on departmental level. This resulted in a culture in where the doctor and nurses could call each other by the first names. Some jokes were made around the bed of the patients. Patients noticed this and give positive feedback on this atmosphere. They felt comfortable and at ease according to the interviewee. Furthermore, the clan culture could be created due to the smaller scale of the hospital. According to the interviewees of the smaller hospitals the smaller the size of the hospital the more satisfied patients are. Since, the small scale creates more room for personal contact between the doctor and patient according to the interviewee. However, the interviewees of the bigger hospitals do not confirm this statement. They believe that the size of the hospital has no direct influence on the patient satisfaction level. The personal contact can still exist in bigger hospitals, but depends on the treatment of the patient. One interviewee mentioned that her patients always receive a treatment consisting of 30 appointments. This results in an intense personal relationship between the doctor and patient. Scale has than no influence on the personal contact between doctor and patient, but it is about the amount of times they see each other. Hence, contradicting results occur relating to the scale of the hospital and their influence on the personal relationship between doctor and patient. In where the smaller hospitals believe that size and personal contact are interrelated.

5.3.2 Adhocracy culture and patient satisfaction

Exploring the dynamics between different organizational culture types and patient satisfaction in Dutch hospitals