Short reportHow are organisational climate models and patient satisfaction related? A competing value framework approach☆
Introduction
Early contributions (Argyris, 1957, McGregor, 1960) in the managerial literature posited that the way employees experience their work would be reflected in organizational performance. The theoretical underpinnings of the way organizational level variables, employees' perceptions and behaviour, and performance measures are intertwined is provided, among others, by the theory of emotional contagion (Barsade, 2002), and of social exchange (Blau, 1964). This assumed relationship has found empirical support in various service settings (Lanjananda and Patterson, 2009, Schneider et al., 2005, Schneider et al., 1998).
An important and widely explored construct of the way employees experience their organization is organizational climate. Climate is defined as members' perceptions of organizational policies, practices and procedures. Organizational climate is rooted in the organization's culture. Whereas climate is behaviourally oriented, culture has to do with shared values, assumptions, and beliefs inside an organization which underlie behaviour. Often, the two concepts are used interchangeably, as both describe employees' experiences of their organizations (Schneider, 2000).
The reforms of health care which many countries have undergone since the nineties have focused on new organisational arrangements and incentives schemes as ways to improve performance and service quality. However, these policy tools cannot be considered independently from the culture inside the organizations affected. This is especially true because, unlike other services, health care is based on collective actions (Shortell et al., 2001). Moreover, the fact that culture may be based on professional groups such as nurses or physicians (Gifford, Zammuto, & Goodman, 2002) implies that allowance must be made for the co-existence of multiple and heterogeneous cultures inside health organizations. In spite of these intuitively appealing statements, relatively little attention has been devoted to the exploration of the links between organizational culture/climate and hospital performance (Davies et al., 2007, Scott et al., 2003).
Even less attention has been paid to the study of the relations between climate and patient satisfaction, in spite of the fact that patient satisfaction has become an important indicator of process quality inside hospitals. Hospital care is unique since it includes a very intense relationship, involving trust, intimacy, and empathy which may develop between the patient and service providers (Meyer Goldstein, 2003). Patients typically develop expectations about these relationships, which in turn will affect their perception of service quality.
It is, therefore, of interest to identify which types of organizational climates are germane to high levels of patient satisfaction. Empirical evidence has shown that high patient satisfaction is associated with a hospital climate promoting teamwork and cohesion (Gregory et al., 2009, Meterko et al., 2004). The underlying assumption is that causality goes from organizational climate to perceived quality, although allowance has been made for alternative causal models (Schneider et al., 1998). However, very few papers use longitudinal data and are therefore capable of proving the direction of causality (Schneider, Hanges, Smith, & Salvaggio, 2003).
In the present paper the relation between different organizational climate models and patient satisfaction is analysed. This paper adds to the existing literature in several respects. First, allowance is made for the coexistence of competing climates inside each organizational unit by estimating a model in which different climates are simultaneously taken into account. Second, the link between organizational climate and individual patient satisfaction is studied using the ward as the unit of analysis, rather than the hospital. In health organizations, climate has mainly been measured at the hospital level, and only a few studies have measured climate at team/unit level, investigating the impact of the team/unit climate on innovation diffusion (Callen et al., 2007, Gosling, Westbrook, & Braithwaite, 2003). Since, in some institutional settings, such as the Italian one, hospitals exhibit a divisional structure in which wards enjoy great autonomy in the management of resources (Cabiedes & Guillen, 2001), the measurement of climate at the ward level is called for.
Finally, in order to keep the cluster nature of the patient satisfaction data into account, a multi-level latent variable approach has been adopted.
Section snippets
Study design, population and data collection
The design of the study is cross-sectional. Between November 2007 and May 2009, organizational climate and patient satisfaction questionnaires were simultaneously and directly administered to inpatients and medical staff (nurses and physicians) in 47 wards belonging to 7 different public hospitals in Italy (four medium size hospitals with around 200 beds and three small hospitals with an average of 80 beds). On average, in each ward a period of 1.5 months was spent for interviewing the
The competing value framework
One highly rated model of organizational culture/climate is the Competing Values Framework (CVF) developed by Quinn and Rohrbaugh, 1981, Quinn and Rohrbaugh, 1983. The CVF explicitly recognises that within organizations multiple competing values and cultures may coexist (Patterson et al., 2005, Shortell et al., 2000).
The organizational competing values correspond to well-known dilemmas of organizational life. The first dilemma regards the choice between a focus on the internal environment and
Methods of data analysis
The relations between the three validated models of climate and patient satisfaction were analysed using Multilevel Structural Equation Modelling (M-SEM). In conventional SEM all latent variables and indicators vary between units and are assumed to be independent across units. In multilevel settings this assumption is violated because units belong to clusters, leading to within-cluster dependence. Multi-level models are thus used when the data structure is hierarchical with units at the lower
Results
A preliminary analysis of variance has shown that the type of employee (physicians, nurses), the hospital, and the type of ward (surgical, medical) do not significantly affect organisational climate and patient satisfaction measures. Average ICC (1), ICC (2), and RWG (j) have been calculated to justify aggregation of the climate measures at the ward level (Bliese, 2000, James et al., 1993). In particular, ICC (1) is equal to 0.125 for Human Relations scale, 0.09 for Open System, and 0.083 for
Discussion and conclusion
This study extends the existing line of research which demonstrates the importance of organisational climate for the performance of hospitals by considering for the first time the relation between climate and patient satisfaction at the ward rather than at the hospital level. This is of interest because in some health care settings wards enjoy a large degree of organisational autonomy in the management of resources and service delivery. Moreover, satisfaction with the services provided by
Limitations
Some limitations of this study must be acknowledged. First, the data collected are relative to a specific institutional setting (Italian public hospitals) and the robustness of findings should be tested in other contexts. Second, an analysis using longitudinal data could clarify the causation nexus. Finally, since the wards investigated were heterogeneous with respect to specialty, an analysis using homogeneous wards may be of interest.
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We wish to thank Piergiorgio Lovaglio, Rosario D'Agata, and two anonymous reviewers for the useful suggestions which led to the improvement of the paper. We also thank Michael West for granting permission to use the OCM questionnaire for research purposes.