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Organizational Psychology, 2023, Vol. 13, No. 3, P. 120-130. DOI: 10.17323/2312-5942-2023-13-3-120-130
ORGANIZATIONAL PSYCHOLOGY
www.orgpsyjournal.hse.ru
Does organizational size influence the service quality of government hospitals?
Bala SUBRAMANIAN R
Birla global university, Bhubaneswar, Odisha, India
Abstract. Purpose. The purpose of the research is two-fold: first to examine whether the hospital size impacts the patient perception of service quality, and second to identify the service dimensions from the patient perception that vary by hospital size. Study design. The study has been conducted by collecting primary data from the patients who visited these hospitals using SERVPERF with an analysis ofthe variance method. The primary data was collected from 150 patients of five different hospital sizes. Findings. The findings reveal that from the patient's perception, the hospital size exerts a significant influence on the healthcare service quality level within Indian Government hospitals. Research implications. The findings of this research are expected to assist healthcare administrators in making better resource planning and implementing effective strategies that can enhance their patient satisfaction. Value of results. There is a dearth of research that applies the most widely used SERVPERF model of measurement to explore how hospital size influences the patient perception of service quality. This study fills this gap by presenting a new perspective using SERVPERF with an analysis of the variance method on primary data.
Keywords: patient satisfaction, service quality, hospital characteristics, hospital size, SERVPERF, ANOVA, healthcare.
Globally, healthcare institutions are adopting patient-centred care approaches to enhance health outcomes, operational efficiency, and patient involvement. In this context, Digital healthcare technologies are leading the edge of this shift, enabling patients to actively participate in the development of healthcare services. Accordingly, healthcare institutions acknowledge patient satisfaction as an essential pillar of healthcare service quality to stay competent in the healthcare market.
In the healthcare sector, personal attention and care from the doctors, nurses, and medical attendants make a lot of difference to the patients. It is presumed that the service quality in terms of personal care is better if the hospital is small in size and has a small number of patients to serve. Employees deliver better due to less work pressure in these hospitals resulting in better service for the patients. In recent years, a number of economic and technological advancements have significantly
Address: Rajagiri College of Social Sciences, Kochi, Kerala E-mail: bala.mbahr@gmail.com
ORCID: 0000-0002-6354-1758
Introduction
impacted the service quality in the health sector and have highlighted its importance from the customers' viewpoint. The progress in service quality in the health sector is becoming more patient-or customer-centred and not just achieving financial goals. Quality healthcare has also been defined as "a consistent effort to serve the patient by providing efficacious, effective and efficient healthcare services according to the latest clinical guidelines and standards, which meet the patient's needs and satisfies providers" (Mosadeghrad, 2013). He opined that these attributes can be of five types: efficacy, empathy, environment, efficiency, and effectiveness (Mosadeghrad, 2012). Service quality is critical in today's environment for creating an organization's image and advancing its growth.
With the day-to-day evolution of new techniques in the healthcare sector and the advent of technology, every organization (hospitals and healthcare centres) should update and enhance itself to serve better. However, many of the organizations still rely on the traditional methods of treatment or serving the patients resulting in poor quality service, ultimately slowing the productivity and efficiency of the organization and hampering its image in the market. Though the literature evidence indicates that a range of factors may affect patient satisfaction with healthcare services, only a few researchers have examined the effect of hospital characteristics on patient satisfaction. Whilst delivering patient-centred care, it is vital to realize the system-level elements that impact patient satisfaction. With this in mind, the goal of this study is to determine the effect of organizational size on service quality in Odisha's public hospitals. We have considered government hospitals for our study because the services of private hospitals are comparatively better than government-owned hospitals.
Literature review
Service quality has been defined as "the intensity of discrepancy between the customers' expectations of the service and their perception of the delivered service" (Parasuraman et al., 1998). It is also defined as ''conformance to specifications" (Berry et al., 1988). There are two schools of thinking about how service quality parameters should be defined. One is the Nordic school view and another is the American school view. According to Nordic school, quality service has two dimensions. The first is the functional quality which focuses on the process and is directly connected to the consumer, whereas the second dimension is the technical quality which is the core to bring about functional quality (Gronroos, 2000). American school of thought defines quality service in terms of five dimensions. They are tangibility, dependability, responsiveness, assurance, and empathy, among others. (Parasuraman et al., 1985; 1988).
Numerous studies have indicated that there are factors that have been recognized as antecedents that influence service quality. These factors are grouped into three categories namely customer, employee and organization. Customer factor is the demographic factor that influences service quality such as age, gender, working hours, educational level and marital status. These factors affect their perception of service quality. Employee attitudes and behaviour like job satisfaction, employee commitment, and citizenship behaviour also influence service quality. Additionally, job satisfaction was shown to be the biggest predictor of employee service quality in research examining the factors affecting the service quality of Malaysian municipal council employees (Hamli et al., 2018).
Another study inferred that organization support, quality programs, service climate and quality culture were also related to service quality (Yee et al., 2018). Reliability and responsiveness (rather than tangibility, empathy, or assurance) were identified to be the most important variables contributing to hospital service quality to ensure survival and success in the future, (Meesala, Paul, 2018). The servicescape (service environment including tangible and intangible cues on consumers) precedes service quality (Hooper et al., 2013). Comfort, reliability, personal attention, and features are all important factors that should be considered while studying quality (Dabholkar et al., 2000).
A few more organizational barriers that influence service quality (Davies, 2005) are lack of supporting values, lack of quality improvement, infrastructure and competing priorities that focus on achieving financial goals rather than customer-centric service and support goals.
Generally, service quality may be defined as the result of a customer's comparison of their presumptions about the service they want to use with their knowledge about the service organization. This suggests that the service will be considered fantastic if the insight recognitions would be much better than the desired, the service is viewed as extraordinary if the wants met are higher and the service will be seen as horrendous if the wants are not met. The organization is required to satisfy its clients and service quality ought to be linked with the perceptions and expectations of the customer in order to be considered as great (Carlsson, 2010).
Service quality can be described "as the degree to which the performance of service providers matches that of customer's expectations" (Zikmund, 1993). It has also been defined as "those essential characteristics of a service that measures its excellence". Service quality is an acknowledgement in customer dealings. A business or association with astounding administration quality will meet customer desire while can remain financially focused in the market. Instances of good administration quality incorporate customized administration, where one can get criticism or appreciation from the client as good — return policies, having the ability to address a person while calling for assistance, and using grievance work areas and hotlines. Consumer service ought to be included as a feature of a total strategy to organize enhancement, as knowledge of customer service can alter a client's overall opinion of a company.
The success of primary care organizations is determined by their policies, priorities, functions, other organizational features, and the environment in which they operate. The size of the organization is also an important component. There is no evidence that expanding primary care groups and trusts beyond 100.000 patients improves overall performance or saves money. The optimal size varies significantly for various components of primary care groups and trusts. To achieve the varied optimal sizes for distinct functions, authoritative structures, and hierarchical coalitions can be used. One size does not fit all: for some functions, bigger is better, while for others, bigger is bad (Bojke et al., 2001).
Extensive inspection, it has been argued, contributes to the validity of the metrics (Peter, Churchill 1986). According to research, SERVQUAL (from: SERVice QUALity), a standard and popular instrument for assessing practical service quality, is reliable and valid in the hospital context as well as a variety of other service sectors. It will enable scientists or researchers to evaluate the viability of quality-improvement procedures and activities across a wide range of businesses and to make predictions about these activities and strategies. For instance, researchers may believe that a certain recognition and incentive system will increase service providers' attitudes toward the responsiveness component of service quality. SERVQUAL also provides hospital management with a mechanism for assessing practical quality in their organizations. If the organization does not get a good score on at least one SERVQUAL measurement, it means that the company has a deeper fundamental problem. SERVQUAL, for example, reveals that patients do not perceive medical clinic representatives as eager to assist them.
The inability to hire and retain high-quality employees and to do proper performance appraisal followed by adequate compensation and rewards or to provide adequate training may be symptomatic of deeper issues existing within the organization. Similarly, billing errors may be a symptom of staffing concerns that prohibit the timely filing of insurance claims and proper recording of payments. As a result, one of SERVQUAL's true obligations to the healthcare business should be its ability to spot such symptoms and provide enough evidence for the investigation of hidden difficulties that obstruct the delivery of high-quality service. The measuring of patient expectations and perceptions is an important part of comprehending the process of evaluating the quality of health care services.
Administrators should be aware of the areas where wishes are predominantly so strong that the method of service delivery is tailored to satisfy those needs (Parasuraman et al., 1985).
Administrators must understand patients' opinions of the quality of service provided and how expectations and perceptions are balanced in order to spot and address service quality issues quickly. The SERVQUAL Scale for Hospital Services Expansion can also be used to measure the viewpoints of hospital management and personnel on how they believe patients perceive service quality. This can be accomplished simply by adjusting the scale's directions. The presence of another potential gap, the gap between the supplier's and client's perspectives, can then be assessed and checked (Parasuraman et al., 1985). Only utilitarian quality is measured by SERVQUAL (characterized as how the health care service is conveyed to the patients). Both useful and specialized quality must be appropriately evaluated and controlled for a medical services association's long-term success (Mangold, 1992)
Size is a major contingency that influences the way the organization functions like other factors such as technology, and the environment. Some companies focus on getting better instead of bigger and the managers consciously decide not to expand, go public, or become part of the larger firm (Burlingham, 2016). Size has both advantages and disadvantages. The larger company enables the firms to take risks and enjoy greater power in market space and stay economically healthy. Growing organizations also attract and retain quality employees because of their competitive pay structure (Week, 1989).
There are pros and cons to both small and large sizes. Large organizations have economies of scale, global connections, vertical hierarchy, mechanistic complexity, and a very stable market. Another biggest advantage is that they have funds for investing in technology and research and development (R&D). As such, only large companies can afford to take risks and invent new products or services.
A small organization has the advantage of being responsive, flexible, organic, simple, having regional reach, flat structure, and finding niches quickly in fast-changing markets. It can react to dynamic customer needs and environmental or market conditions. They also get better employee commitments. They may work on a variety of challenging tasks (job enrichment). The overall involvement of employees in smaller firms is high as they get identified with the organization. There are demerits also: they are more bureaucratic, mechanically run, and complex. This complexity generates multiple specialities within the organization. When larger companies further expand through mergers or acquisitions, their performance declines (Henry, 2002). This may be because as the organization grows, the disadvantages may overwhelm the advantages. The decision-making process is slow in bigger companies which may impede performance (Sadtler, 2007).
As the size increases, it has an impact on the effectiveness of its functioning. There will be a lot of procedures, rules, and regulations as the larger organizations are more formalized. The degree of centralization also increases (Daft et al., 2010). A study of Canadian and New Zealand enterprises indicated that smaller and larger organizations had different marketing methods in several areas, particularly in the approach to market planning, where smaller firms are shown to be more informal than larger ones. They also utilize fewer methods to assess market success than larger companies (Coviello et al., 2000).
On the basis of the above literature, we hypothesize that the service quality is better in the smaller organization in comparison to that of a bigger organization.
H0: Organization size doesn't have an influence on the service quality.
H1: Organization size has an influence on the service quality.
Research methodology
Sample
A sample of 125 responses has been collected from five different sizes of hospitals (25 bedded, 200 bedded, 300 bedded, 500 bedded, and 1000 bedded and categorized into small, medium, large, extra-large ad double extra-large) from four districts of Odisha. The data has been collected between October 2019 and 1st December 2019. The respondents selected for this study were patients who were 18 years old or above, visited these hospitals during that period, and were able to respond to the questionnaires independently.
Measures
Customers' perceptions of service quality are measured using a set of attributes. Various criteria have been used to gauge satisfaction with service quality in various businesses or tourist locations over the years. SERVQUAL, a 22-item scale, assesses attributes across five dimensions that are thought to define service quality from the perspective of the client, including consumer (customer) desire.
J. J. Cronin Jr. and S. M. Taylor used the SERVQUAL model's perception attributes to measure service quality instead of the two sets of expectation and perception characteristics that evaluate the difference between expectation and perception of service performance (Cronin, Taylor, 1992). There is a lot of evidence from researchers that SERVPERF is a better model for evaluating service quality (Yee et al., 2018). Furthermore, SERVPERF is a better fit for the concept of perceived service quality as an attitude, as well as the visitors' overall impressions after their visits (Cameran et al., 2010). Furthermore, according to Prakash and Mohanty, SERVPERF is more efficient than SERVQUAL because it just measures half of the elements and produces better results (Prakash, Mohanty, 2013). As a result, we've just used perception in this investigation.
There are five dimensions to measure service quality namely Tangibles, Reliability, Responsiveness, Assurance, and Empathy. Except for tangibles, we have used four dimensions for the study, i.e., reliability (five items), responsiveness (four items), assurance (four items), and empathy (five items). The reliability of the instrument was 0.948.
In comparison to middle and small size hospitals, the bigger hospitals have better physical facilities, equipment, and communication materials. Hence, the tangible dimension as it measures these facilities has not been used. Moreover, discovering the human aspect of the service such as individualized attention and prompt service being the objective of the study are captured by the retained four dimensions.
The questionnaire was administered among the patients who came to get the service of these hospitals. To measure the satisfaction level of the patients towards the service quality of the hospitals, the Likert Scale was adopted where the responses were denoted as follows: 'Strongly agree' = "1", 'Agree' = "2", 'Neither agree nor disagree' = "3", 'Disagree' = "4" and 'Strongly disagree' = "5".
Data analysis
The data collected has been analyzed using SPSS. We have carried out two tests: the Kruskal — Wallis Test and the Pairwise Comparison of G.
Kruskal — Wallis Test
The Kruskal — Wallis Test is a statistical procedure that is used to compare two groups of individuals. When the one-way ANOVA assumptions are violated, the Kruskal — Wallis test is used. It is a nonparametric (probabilistic) test. Both the Kruskal — Wallis test and the one-way ANOVA are used to determine if there are significant differences between continuous and categorical dependent
variables (with two or more groups). We assume in an ANOVA that the dependent variable is normally distributed and that the variance in scores between groups is about equal. When employing the Kruskal — Wallis Test, however, none of these assumptions is necessary. As a result, the Kruskal — Wallis test applies to both continuous and ordinal dependent variables. The Kruskal — Wallis Test, like most non-parametric tests, is not as powerful as the ANOVA.
The Kruskal — Wallis test was used to look at the differences in service quality amongst hospitals of various sizes. Between the five sizes of hospitals (small — less than 125 beds, medium, big, extralarge, and double extra-large), a significant difference (x2 = 53.815, p = .000, df = 4) was discovered (Table 1).
Table 1. The differences in service quality amongst hospitals of various sizes
Test statisticsa,b Average
X2 53.815
df 4
Asymp. Sig. .000
Hypothesis Test Summary
Hull Hypothesis Test Sig. Decision
1 Independe nt-The distribution of Avg is the sam£amples across categories of G. Kruskal- Wallis Test .000 Reject the null hypothesis.
Asymptotic significances a re displayed. The significance level is .05
Note: a — Kruskal — Wallis Test; b — Grouping Variable: Size
Figure 1. Hupothesis test summary
Interpretation
Because the p-value > 0.05, the null hypothesis H0, i.e., organization size doesn't have an influence on the service quality is rejected and the alternative hypothesis H1 i.e., organization size has an influence on the service quality is accepted. It was found that the service quality is significantly different according to the size of the hospitals (Table 2).
Table 2. Ranks of organizations with different sizes
Size N Mean rank
S 25 102.42
M 25 41.02
L 25 50.76
XL 25 62.32
XLL 25 58.48
Total 125
Interpretation
We have taken 125 samples in total, i.e., 25 responses each from government hospitals of 5 different sizes: small (S), medium (M), large (L), extra-large (XL) and double extra-large (XLL). We have also assigned values to each response and calculated the mean rank, i.e., 'Strongly agree' = "1",
'Agree' = "2", "Neither agree nor disagree' = "3", 'Disagree' = "4'' and 'Strongly disagree' = "5". The higher the score of mean rank, the more negative is the service quality feedback; the lower the score of mean rank, the more positive is the service quality feedback. So, from the above table 2, we can interpret that larger-sized hospital has better quality than smaller hospitals.
Findings and discussion
From the above table we can conclude that there is a significant difference between the service quality seen in four combinations, i.e., M — S (medium — small), L — S (large — small), XLL — S (double extra — large) and XL — S (extra-large — small) with significance level .000. From the Kruskal — Wallis test, it is evident that service quality is poor in small-sized hospitals in comparison to other sizes of hospitals with more than 150 beds. According to Pairwise Comparison of G also, it can be seen that there lies a significant difference in the service quality of M — S (medium — small) hospitals, L — S (large — small) hospitals, XLL — S (double extra — large) hospitals and XL — S (extra-large — small) hospitals with significance level .000 (Figure 2 and Table 2).
Pairwise Comparisons of G
XL
62 32
1 02.42
Each node shows the sample average rank of G.
Samplel San __, ■. Test nple2 Statistic Std. E rro r Std. Test Statisti c Sig. Atlj.S ■ g-
M-L -9.740 9. OSS -1 07S .282 1 ooo
M-XLL -1 7.460 9. OSS -1 .928 .054 539
M-XL -21 .300 9. OSS -2.351 .01 9 1 87
M-S 61 .400 9. OSS 6.778 ooa ODD
L-XLL -7.72 O 9 OSS -.852 394 1 OOO
L-XL -11 seo 9. OSS -1 .276 . 202 1 OOO
L-S 51 .660 9. OSS 5.703 .OOO OOO
XL L-XL 3.04O 9. OSS .4-2.4 .672 1 OOO
XLL -S 43.940 9. OSS 4.B51 OOO OOO
XL-S 4Q 1 OO 9 OSS 4.427 OOO OOO
Each row tests the null hypothesis that the Sample 1 and Sample 2 distributions are the same.
Asymptotic significances (2-sided tests) are displayed. The significance level
is CIS
Figure 2. Pairwise comparisons of G
Table 3. Pairwise comparisons of G
Simple 1 — Simple 2 Test statistic Std. erorr Std. test statistic Sig. Agj. Sig.
M — L -9.74 9.058 -1.076 .282 1.000
M — XLL -17.46 9.058 -1.928 .054 .539
M — XL -21.3 9.058 -2.351 .019 .187
M — S 61.4 9.058 6.778 0 0
L — XLL -7.72 9.058 -.852 .394 1
L — XL -11.56 9.058 -1.276 .202 1
L — S 51.66 9.058 5.703 0 0
XLL — L 3.84 9.058 .424 .672 1
XLL — S 43.94 9.058 4.851 0 0
XL — S 40.1 9.058 4.427 0 0
Note: Each row tests the null hypothesis that the sample 1 and sample 2 distributions are the same. Asymptotic siggnificances (2-sides tests) are displayed. The significance level is .05.
An important point that can be inferred from this study is that hospital size does influence four dimensions of service quality i.e., reliability, responsiveness, assurance and empathy as the bigger hospitals have better physicians, better infrastructure, trained paramedical staff and modern equipment for better diagnosis and monitoring the health of patients. Since these hospitals have better facilities, the employees of these hospitals are well-trained to be empathetic and show immediate responses to the patient's requirements. As the health professionals working in these hospitals are also responsive and empathetic, the patients can be assured of better and more reliable service in the future also. In developing countries, the majority of the patients who visit Government hospitals are from lower-income groups and they depend a lot on referring doctors. Whereas they are clueless about the facilities of the hospital, they are more concerned with the human dimensions of service quality. Patients might also assume that their physician is already sure about the tangibility, assurance, and empathy aspect of quality in hospitals (Meesala, Paul, 2018). So, they would perceive the services of bigger hospitals as better than that of smaller hospitals because these hospitals have better health workers and consultants. These findings are in line with the quality aspects of the WHO framework which says that healthcare should be patient-centric and take into account the preferences of users and the local culture (World Health Organization, 2006).
Conclusion and managerial implications
Both large and small companies carry strategic advantages and vulnerabilities. With the advent of information technology, new forms of organization are emerging: a boundary-less, team-based, flat organization with less hierarchy and a decentralized decision-making structure. Large companies can create such small independent units in their organizations that operate autonomously from the day-to-day bureaucracy such as strategic business units (SBU). It is better to design smaller and medium-sized hospitals rather than 'hyperstructures. Working in a smaller organization will help the employees in realizing their ability and potential to add value to the organization. Small and medium-sized hospitals will enable patients to have quicker access to services and the doctors, nurses, and staff of the hospitals will provide better personal attention and care to the patients. The findings will be helpful to make the offered service still better. The answer may be a mix of large and small businesses, in which larger businesses combine their resources and reach with the organic and adaptable features of small businesses. The limitation of the study is that it has been done only on Government hospitals of three districts of Odisha. The study cannot be generalized as responses for small-sized Government hospitals have been collected only from a rural area. There is also is a constraint of self-reporting biases.
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Received 06.08.2022
Влияет ли размер организации на качество обслуживания в государственных больницах?
СУБРАМАНЯН Р. Бала
Бизнес-школа Раджагири, Кочи, Керала
Колледж социальных наук Раджагири, Кочи, Керала
ЧУДХАРИ Арчана
ORCID: 0000-0002-6354-1758
Глобальный университет Бирла, Бхубанешвар, Одиша, Индия
Аннотация. Цель. Цель исследования двоякая: во-первых, выяснить, влияет ли размер больницы на восприятие пациентами качества обслуживания, а во-вторых, — определить аспекты обслуживания на основе восприятия пациентами, которые различаются в зависимости от размера больницы. Дизайн исследования. Исследование проведено путём сбора первичных данных от пациентов, посетивших эти больницы, с использованием модели (методики) измерения качества предоставляемых услуг ИСПУСЛ1 (SERVPERF) с дисперсионным анализом. Первичные данные были собраны у 150 пациентов в больницах пяти разных размеров. Выводы. Результаты показывают, что, по мнению пациентов, размер больницы оказывает значительное влияние на уровень качества медицинских услуг в государственных больницах Индии. Практическая значимость. Ожидается, что результаты этого исследования помогут администраторам здравоохранения лучше планировать ресурсы и внедрять эффективные стратегии, которые могут повысить удовлетворённость пациентов. Ценность результатов. Существует недостаток исследований, в которых применяется наиболее широко используемая модель измерения ИСПУСЛ для изучения того, как размер больницы влияет на восприятие пациентами качества обслуживания. Данное исследование заполняет этот пробел, представляя новую перспективу использования методики ИСПУСЛ с анализом дисперсионного метода первичных данных.
Ключевые слова: удовлетворённость пациентов; качество обслуживания; характеристики больницы; размер больницы; ИСПУСЛ (SERVPERF); ANOVA; здравоохранение.
1 Аббревиатура от ИСПолнение УСЛуги (англ.: SERVice PERFormance).
