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Journal of Health Organization and Management The role of learning and customer orientation for delivering service quality to patients Victoria Bellou

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The role of learning and customer orientation for delivering service quality to patients Victoria Bellou


Department of Economic Studies, University of Thessaly, Greece

The role of learning

383 Received 11 February 2009 Revised 17 October 2009 Accepted 18 October 2009

Abstract Purpose – This study seeks to investigate the impact that learning orientation, internal and external customer orientation have on quality of care delivered to patients. Additionally, given the differences between managerial and non-managerial employees regarding organizational value perception and focus on the needs of internal customers and patients, the study aims to examine potential variations in these relationships. Design/methodology/approach – The study took place in ten out of 31 public hospitals operating in the five largest districts in continental Greece. Hospitals were chosen on a random basis. Out of 800 questionnaires that were personally administered, 499 usable responses were gathered. Findings – The extent to which employees create and use knowledge and focus on satisfying the needs of both internal customers and patients is indicative of the quality of care provided. In addition, only managerial employees believe that learning orientation reinforces quality of care. Research limitations/implications – The fact that employees rated quality of care delivered to patients and that most employees had extended tenure should be taken into consideration when interpreting these findings. Practical implications – Top management needs to create a strong and clear culture that emphasizes learning, as well as internal customer and patient orientation, and infuse them among all organizational members. Moreover, human resource management policies should be aligned to meeting or exceeding patients’ requests and expectations. Originality/value – The paper enhances existing knowledge with regard to the antecedents of offering medical care of high quality. Keywords Customer orientation, Workplace training, Customers, Hospitals, Greece Paper type Research paper

Introduction Learning and market orientation are two organizational values that have attracted considerable attention with regards to both their interrelationship (Baker and Sinkula, 1999; Slater and Narver, 1995) and their separate and combined effect on innovation and organizational performance (Dickson, 1996). Evidence suggests that emphasis on gathering and disseminating market information along with the ability to develop, share, and utilize knowledge are the basis for designing internal processes which produce superior values to customers, yielding in turn a competitive advantage (Baker and Sinkula, 1999). This also appears to be the case for the health care industry. Kaissi et al. (2004) claim that the culture of organizations influences the quality of care to a great extent while Hendricks et al. (2002) suggest that the patient-centered operation is currently more critical then ever before.

Journal of Health Organization and Management Vol. 24 No. 4, 2010 pp. 383-395 q Emerald Group Publishing Limited 1477-7266 DOI 10.1108/14777261011064995

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Having taken these issues into consideration, the present study investigates customer orientation, one of the three market orientation dimensions proposed by Narver and Slater (1990), and learning orientation within Greek hospitals, from a service quality perspective. Yet, building strong relationships with patients necessitates adopting an internal marketing strategy and embracing a patient-focused perspective, as well (Yoon et al., 2007). Besides, internal and external customer orientation allows an examination of both internal and external capabilities, just like learning orientation does. Of course, within the health care setting, customers are no others than patients, paying – directly or indirectly – for and receiving the medical services offered. Participants in this study were employees, who evaluated not only internal and external customer and learning orientation but also quality of care offered to patients. Concerning internal customer and learning orientation it is quite obvious that they are the most appropriate source of information, since they are the ones to embrace or reject organizational values. Regarding quality of medical care, however, although patients are the obvious source of information, previous evidence has shown that employee surveys are also valid when trying to predict customer perceptions of satisfaction and service quality, as employee and customer perceptions of service quality are positively related (Schneider et al., 1996). Furthermore, since there is evidence on the different way that managerial and non-managerial employees perceive organizational values (Schneider et al., 1998) and the extent to which they focus on customers’ needs (Martin and Fraser, 2002), this study also looked for possible variations in the aforementioned relationships, based on the job position that participants held. The study took place in Greece, among public hospital employees, in a different setting than the usual British or American. Greek public hospitals, as most hospitals in developing countries, are currently greatly challenged by the fact that they have to confront both domestic and international competition (Andaleeb, 2001). In addition, certain particularities of Greek public sector, including operation under monopolistic conditions for long, increased bureaucracy, existence of permanent employment relationships, and political interference (Makrydimitris, 2008), seem to withhold public hospitals from offering health care of superior quality (Bellou, 2008). Greek public sector characteristics Makrydimitris (2008) has concluded that bureaucratic and monopolistic operation is the basic reasons why organizations within the Greek public sector fail to achieve effectiveness and efficiency. Despite the fact that the Politia Reform Act of 2001 demanded goal setting, measurement of performance, and reporting on accomplishments, Greek public organizations have still a long way to go, as most of their managers and employees were recruited and socialized under the previous order (Bellou, 2008). Moreover, the organizations that operate within the Greek public sector have some particularities that need to be taken into consideration when studied. In particular, first of all there are permanent employment relationships, which ensure employees lifelong employment regardless of their performance or even their respect for norms and policies (The Greek Ombudsman, 2003). Second, there is evidence that political parties tend to interfere in organizational operation, allowing thus room for political discriminations (Makrydimitris, 2008). Finally, increased centralization does not leave


much room for managerial initiatives within each organization, as Human Resource Management policies and practices are either formed and/or executed by central authorities (Joumard and Mulonas, 1999). Regarding the organization of the Greek health care system in specific, this comprises the National Health Service (NHS), a social insurance (compulsory) and a private health insurance system (voluntary). All Greek citizens have equal access to health care services and only 8 percent have complementary health insurance coverage on the private health market. Both the overall health policy and the national strategy for health are set by the Ministry of Health and Social Cohesion. The implementation of these falls within the responsibility of the 17 regional health authorities that exist, although full financial responsibility has not been given yet (World Health Organization, 2006). Theory and conceptual framework Quality in the health care industry The health care service context is a multifaceted one. Pascoe (1983, p. 189) defined patient satisfaction as the “patients’ emotional reaction to salient aspects of the context, process, and result of their experience” while Bogner (1994) suggested that health care organizations need to coordinate several interrelated subsystems before being able to deliver health care of high quality and satisfy the needs of their patients. This complexity stems from several reasons. First, the production and consumption phases are inseparable, making the process of quality control difficult. Patients are usually active participants in the medical act, since care is consumed as soon as it is produced. Based on this argument, Babakus and Mangold (1992) argued that patients’ experience is the only way to verify that medical care provided has met quality anticipation. Second, assuring quality in health care is hard, as the “production process” of medical care involves patient-employee interaction, making it hard to ensure consistency and reliability (Jun et al., 1998). Third, in health care systems the service comprises a number of interacting elements, including technology and interpersonal interactions with health professionals and administrative staff (Darby and Daniel, 1999). Still, given that patients cannot adequately assess the values of the technology used, they tend to stress interpersonal interactions (Yoon et al., 2007). In addition, patients’ inability to evaluate medical treatment per se makes them rely on attitudes toward caregivers and the facility itself when assessing their experience. Consequently, patients’ satisfaction with health care offered depends highly on health care providers. Since most health care providers offer similar services, service quality is critical in the eyes of the patients. In fact, Desombre and Eccles (1998) argued that organizations should emphasize quality management in the years to come to survive. The increased competition has forced hence health care organizations to become more market-oriented (Vandamme and Leunis, 1992), as perceptions of care of high quality tend to strengthen patient patronage behavior (John, 1991). On the contrary, a bad service experience is likely to cause multiple problems. Other than dissatisfaction and negative word of mouth, underutilization, use only for minor ailments or as a last option, replacement with another hospital, as well as legal action may occur (Andaleeb, 2001; Cho et al., 2004). Furthermore, the constantly and rapidly changing technology used by health care institutions, new medicines, medical tests, and approaches stress the importance of gathering information as well as promoting and applying new knowledge constantly to ensure high quality of medical services in the long-run.


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Internal and external customer orientation According to Deshpande´ et al. (1993, p. 27) customer orientation is “. . . the set of beliefs that put the customer’s interest first, while not excluding those of other stakeholders such as owners, managers and employees, in order to develop a long-term profitable enterprise”. The concept has been approached in two distinct ways. Some researchers suggest that it is a set of organizational behaviors devoted to attaining and utilizing customer information for the purpose of achieving customer satisfaction (i.e. Jaworski and Kohli, 1993) while others that it is a philosophy included in organizational culture (i.e. Narver and Slater, 1990). In any case, customer orientation focuses primarily on realizing customers’ interests and needs and delivering appropriate solutions. In the case of the health care sector, where patients are the customers, Daniel and Darby (1997) defined the term as the ability of service providers to adjust their service, in a way that reflects patients’ reality. As a result, successful health care organizations should have the interest of patients at the heart of their operation. Stressing patient satisfaction is likely to promote the generation and dissemination of market-related information among organizational members, enabling the organization to deliver medical care of high quality in a consistent and immediate manner (Hallums, 2008). Although being patient-focused is essential, effective customer orientation presupposes that internal customers’ needs are also identified and fulfilled. The importance of internal customers is emphasized by the theory of internal marketing. According to this theory, because internal customers (employees) provide services to external customers (patients), their role is vital for delivering care of high quality and satisfying patients. As Yoon et al. (2007) indicate, employees will be willing to do their best in order to satisfy the needs of patients only after effective internal exchanges at their level have taken place. For this reason, unless an organization focuses on internal operational excellence, other than the market, continuous achievement and organizational effectiveness cannot be achieved (Vera and Kuntz, 2007). Learning orientation Although trying to gather as much information as possible on patients is important for matching their needs, it is not enough for predicting new needs, trends, and changes to come. So, this is where learning orientation comes in. As Hamel and Prahalad (1991) insist, market-oriented organizations can only learn in an adaptive way. Nevertheless, in a complex business setting, organizations are expected to go a step further than increasing adaptability, improving efficiency, and adjusting strategies. It is also essential that they identify challenges and generate new knowledge. For this reason, Baker and Sinkula (1999) argued that market orientation should always be coupled with learning orientation. As Senge (2006, p. 14) indicates: . . . the basic meaning of a “learning organization” (is) an organization that is continually expanding its capacity to create its future . . . But for a learning organization, “adaptive learning” must be joined with “generative learning”, learning that enhances our capacity to create.

Learning orientation refers to the “organization-wide activity of creating and using knowledge to enhance competitiveness” (Calantone et al., 2002, p. 516) and reflects the extent to which an organization is committed in challenging fundamental knowledge, beliefs, and practises on a systematic basis. In fact, it is indicative of the importance an organization places on its responsiveness to changes and challenges. Learning


orientation includes three dimensions, namely commitment to learning, shared vision, and open-mindedness (Sinkula et al., 1997). The benefits reported for organizations oriented towards learning are numerous, including increased performance (Calantone et al., 2002) and market share (Baker and Sinkula, 1999), the production of higher-order learning and innovations (Slater and Narver, 1995) and successful design and implementation of Total Quality Management initiatives (Kumar and Sankaran, 2007). As Dickson (1996) claims, processing information that is provided by a strong market orientation is easy for competitors to copy, but the learning environment in which processing takes place is not. Although learning orientation has not received enough attention within the health care industry, there is evidence for its importance. In particular, Yourstone and Smith (2002) argued that to the extent that health care organizations focus on learning from prior errors, their operation will be refined while Rangachari (2008) recently found that senior administrators need to create knowledge networks within health care organizations, in order to enhance knowledge sharing among their members and achieve improved performance. Yet, based on the findings from other industries, it is quite normal to believe that health care organizations which first gather and disseminate information that relate to patients, the competition, the market and the overall external environment and second foster values that question existing knowledge and promote new approaches are more likely to fulfil the needs and expectations of their patients. The conceptual framework Nowadays, organizations need to manage a dual challenge: adapt to the external environment and also make effective adjustments on the inside. In the case of health care organizations, external customer orientation obviously focuses on patients, ensuring that the hospital is more ready to respond to their changing needs, desires, priorities, and expectations and thus more likely to make effective adjustments. Learning orientation, however, has both an internal and an external focus. Externally, a learning-oriented health care organization not only seeks to gather patient and market related information, but any kind of information that could be helpful in improving its operation and outcomes in the present and future. Internally, it fosters shared mental models, organizational vision and open-minded approaches in organizational policies, practices and procedures. By the same token, internal customer orientation ensures that the hospital realizes the contribution of every single employee in producing the desired medical care for patients. Combining all the aforementioned issues, the expectation in terms of this study is that: H1. Patient orientation is positively related with the quality of care delivered to patients. H2. Internal customer orientation is positively related with the quality of care delivered to patients. H3. Learning orientation is positively related with the quality of care delivered to patients. H4. Learning orientation along with internal customer orientation and patient orientation are positively related with the quality of care delivered to patients.


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Methods Sample and procedures The present study sought to create a general view of the way that employees in Greek public hospitals perceive antecedents of quality of care. Still, since no employee database was available to allow random sampling on an individual basis, all employees were approached through their employing hospitals. The Greek National Health-Care System is organized in 17 Administrative Health Districts, 12 of which operate in continental regions. Hospitals operating in insular Greece were excluded for cost and time reasons. The present study took place in ten out of the 31 public hospitals that operate in the five largest districts in continental Greece, chosen randomly after excluding those that were significantly different (larger or smaller) in terms of size, as size may significantly affect organizational structures, responses to the environment, managerial styles and the ways they compete with other organizations (Man et al., 2001). The researcher contacted the head of departments within each hospital and asked for permission to conduct this study among employees that have direct contact with patients. After explaining the importance of the study and guarantying full anonymity for participants, questionnaires were randomly handed to individuals. Overall, 800 questionnaires, approximately 80 per hospital, were distributed roughly proportionately among doctors, nurses and administrative staff that were on shift at the time of the researcher’s visit. Out of these, 532 (66.5 percent) were returned and 499 (62.3 percent) were fully and correctly completed and therefore incorporated in the study. Administrative staff was a little more eager to participate in the study than doctors and nurses, as their responses comprised 40.2 percent (201) compared to 159 (31.9 percent) and 139 (27.9 percent) respectively. In terms of sample composition, 69 percent of the participants were female, 71.8 percent had attended at least a four year undergraduate program, and 51.9 percent had children. 77.3 percent worked under a permanent employment relationship and 35.2 percent held a managerial job position. Concerning tenure in the current hospital, 9.3 percent had been working there for less than one year, 17 percent for one to three years, 17 percent for four to six years, 14.5 percent for seven to ten years, and 42.2 percent for more than 15 years. Finally, 127 individuals (25.4 percent) held managerial job positions. Measures Learning orientation. In order to measure organizational learning, this study adopted the 15-item instrument developed by Sinkula et al. (1997). Sample items include “The basic values of this organisation include learning as key to improvement” and “We are not afraid to reflect critically on the shared assumptions we have made about our customers”. Despite the fact that previous researchers have identified three distinct learning orientation dimensions, the factor analysis did not confirm its multidimensionality in the present study. As a result, it was operationalized as a single factor concept (a ¼ 0:92) Internal customer orientation. This study adopted Conduit and Mavondo’s (2001) instrument for measuring the extent to which employees were oriented towards satisfying their internal customers’ needs. Sample items include “Our hospital stresses the importance of treating other sections as customers” and “In interdepartmental dealings, we treat each department as a customer” (a ¼ 0:91).


External customer orientation. The six items introduced by Narver and Slater (1990) were adjusted to assess employees’ concern regarding patients’ needs. Sample items are “Our hospital objectives are driven by the patient satisfaction” and “We frequently measure patient satisfaction” (a ¼ 0:78). Service quality. Employees’ perception regarding service quality offered to customers was measured through a single item (Overall, my hospital provides its patients with services of high quality). Although there is some dispute over the use of single-item measures, Bergkvist and Rossiter (2007) used the predictive validity to demonstrate that they are as valid as multiple-item measures. Control variables. Participants were asked to note their gender (1 ¼ male, 2 ¼ female), and job position (1 ¼ managerial, 2 ¼ non managerial). They were grouped in five age groups (1 ¼ 18 2 24, 2 ¼ 25 2 34, 3 ¼ 35 2 44, 4 ¼ 45 2 54, 5 ¼ 55 2 64), three job position groups (1 ¼ administrative staff, 2 ¼ nurses, 3 ¼ doctors), and three educational levels (1 ¼ university, 2 ¼ technological institute, 3 ¼ high school). Moreover, they were asked to write their years of tenure in an open-ended question. The scale adopted for all measures other than the control variables was 7-point, Likert type, ranging from “not at all” (1) to “a great extent” (7). The rationale for choosing measures for the present study was their wide acknowledgement and incorporation in previous studies, in an attempt to ensure reliability and validity to the greatest possible extent. This need was greater in this study compared to others because all measures not only were tested in a different setting, but they also had to be translated into the Greek language. For this reason, the approach proposed by Bhagat and McQuaid (1982) was followed. Initially, independent groups of Greek citizens, fluent in English, translated the list of organizational obligations into Greek. Then, the researcher took their suggestions into consideration and selected the terms to be used in the Greek language. Finally, the Greek version was given to an official independent translator, who did not know the English one – to translate it back to English. The procedure was repeated until reaching an agreement. A group of 20 employees aged between 18 and 64 tested the translated questionnaire, to ensure that it would be fully and correctly understood by participants.


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Results Descriptive statistics and correlations for all variables appear in Table I. As apparent, the mean scores of all three orientations are moderate, indicating that the hospitals Mean External customer orientation Internal customer orientation Learning orientation Service quality Gender Age Job position Notes: *p , 0.05; * *p , 0.01

4.48 4.22 4.08 3.83 1.68 2.65 1.34

SD

1

2

3

4

5

6

1.56 1.34 0.66 * * 1.61 0.69 * * 0.60 * * 1.75 0.63 * * 0.56 * * 0.55 * * 0.51 0.06 0.11 * 0.01 0.02 0.93 0.11 * 0.16 * * 0.09 * 0.07 0.07 0.51 2 0.04 20.07 2 0.16 * * 20.03 0.01 2 0.05

Table I. Descriptive statistics and Pearson correlations for all variables

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examined have failed to infuse these values among their employees effectively. Regarding the interrelationships of the concepts examined, although service quality correlates positively with customer orientation, both external and internal, and with learning orientation (R ¼ 0:63, p , 0.01, R ¼ 0:56, p , 0.01 and R ¼ 0:55, p , 0.01 respectively) it does not correlate significantly with any of the demographic variables examined, suggesting that the perceptions of the level of quality of care offered to patients are quite uniform among employees. However, age does correlate positively with all forms of orientation (R ¼ 0:11, p , 0.05 for external customer orientation, R ¼ 0:16, p , 0.01 for internal customer orientation and R ¼ 0:09, p , 0.05 for learning orientation), implying that as employees grow old they are more likely to acknowledge the importance focusing on continuous learning, internal customers’ needs and patients’ requests. Last but not least, it is obvious that individuals holding non-managerial job positions are less likely to stress learning orientation within their organizations as job position correlates negatively with learning orientation (R ¼ 20:16, p , 0.01). Stepwise regression analyses were incorporated to test the hypotheses stated, regarding the effect of internal and external customer orientation and learning orientation on employees’ view of quality of care delivered. Four regression analyses were conducted for all employees, regardless of job position. In particular, as apparent in Table II, in all cases, the first step included gender, age and employment state (permanent employment relationship versus contractors). Then in the second step, patient service orientation, internal customer orientation and learning orientation were examined initially separately and afterwards combined. The results suggest that none of the demographic variables entered were significant service quality antecedents. The opposite case applies to patient orientation (b ¼ 0:60, p , 0.001), internal customer orientation (b ¼ 0.55, p , 0.001) and learning orientation (b ¼ 0.51, p , 0.001) both on the separate and on the combined basis (b ¼ 0.34, p , 0.001, b ¼ 0:22, p , 0.001, and b ¼ 0:16, p , 0.001 respectively). As a result, support has been provided for all four hypotheses. These findings indicate that employees tend to identify learning and customer orientation as factors that are important for improving patients’ health care experience. Managerial employees

All employees Step 1 Gender Age

Table II. Regression analyses for service quality

2 0.02 2 0.03

20.05 20.03

0.02 20.01

Step 2 Patient service orientation 0.60 * * * Internal customer orientation 0.55 * * * Learning orientation 0.51 * * * Adjusted R 2 0.36 0.30 0.26 F-ratio 240.83 * * * 185.12 * * * 149.76 Notes: *p , 0.05, * *p , 0.01, * * *p , 0.001

20.04 20.03

2 0.02 2 0.01

Non-managerial employees 2 0.06 2 0.09

0.34 * * *

0.23 * *

0.38 * * *

0.22 * * *

0.33 * *

0.29 * * *

0.16 * * * 0.41 81.83 * * *

0.18 * 0.43 52.44 * * *

0.09 0.50 32.59 * * *


Stepwise regression analysis was also adopted to identify potential differences in the factors that influence perceptions of quality of care, based on the job position that participants held within their hospital. For this reason, employees were split in two groups: those holding managerial job positions (n ¼ 372) and those holding non-managerial job positions (n ¼ 127). It was interesting to find out that individuals holding managerial positions are the only ones to believe that, other than internal and external customer orientation, learning orientation is also crucial for the quality of services rendered (b ¼ 0:23, p , 0.01, b ¼ 0:33, p , 0.01, and b ¼ 0:18, p , 0.05 respectively). Conclusions and implications Owing to sharp competition, quality of care offered to patients is decisive for the organization’s performance (Kim et al., 2008). The realization, hence, of the quality of care antecedents is nowadays imperative. For this reason, this study sought to understand the role that learning, internal and external customer orientation has on quality of care provided. As Deshpande´ et al. (1993) have claimed, and in accordance with the expectations of this study, individuals do believe that trying to understand and satisfy the need of both internal customers and patients enhances the level of service quality. It appears that satisfying internal customers enables them to perform their tasks, creating in turn a network of employees that can work effectively towards delivering care of high quality (Rangachari, 2008). Likewise, when employees realize that their hospital regards patient needs as a priority, they are more likely to do their best in order to provide care of high quality (Cardello, 2001). Besides, since the quality of care lies in the eyes of patients, providing care that reflects their preferences is critical (Ramachandran and Cram, 2005). In terms of learning orientation, employees recognize its significance for quality of medical care. Gathering market-related information, developing new knowledge and spreading it across all organizational members helps the organization not only keep up with but also lead the market. This way, patient need fulfillment, even over-fulfillment can happen (Ward et al., 2005). This study also checked for possible variations in the way that employees at different hierarchical levels view the impact that learning and customer orientation have on the quality of services offered to patients. Results show that managers are the only ones to believe that organizational learning can boost quality of care. Although this is a quite surprising finding, such a divergence may be attributed to the fact that managers are more likely to have a holistic and long-term view of what it takes to ensure organizational survival and success (Martin and Fraser, 2002). Another possible explanation could be the fact that, according to a survey conducted by Hofstede (1998), which compares international populations based on their values in the workplace, Greeks have been identified as the most risk-avoidant people. It is likely, hence, that Greeks underestimate the importance of developing revolutionary approaches and challenging the status quo. Additionally, as Sinkula et al. (1997) have argued, this finding also implies that although customer and learning orientation have synergistic effects, they are distinct concepts, indeed. The fact that learning as well as internal and external customer orientation are values only moderately accepted by individuals in Greek public hospitals suggests that top management has a lot of work to do in terms of creating a strong patient-centered


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culture and infusing it among all employees. For this reason, behaviors creating superior value for internal and external customers, such as Organizational Citizenship Behavior and prosocial behavior, need to be actively promoted among employees. This way, both existing employees and newcomers will be more likely to have consistent standards and objectives for service quality. Of course, promoting employee involvement requires that individuals are not only empowered but also encouraged to take initiatives and experiment, even when there is risk to be taken. Additionally, as Hammer (1990, p. 111) claimed, “putting the decision point where the work is performed” is needed to improve employees’ responsiveness to the needs of both the internal and the external customers. To enhance learning orientation among employees, top management needs to show commitment to learning, try to create a learning climate and form a clear and inspiring organizational vision linked to continuous advancement. Moreover, stressing the need for sharing intra-organizational knowledge among organizational members will enable employees to handle patients’ requests more effectively and to improve their own performance (Rangachari, 2008). Because employees that focus on satisfying customers’ needs are an asset to their organization, it is essential that human resource management policies and practices are formed in a way that can attract, motivate and retain such employees. First of all, organizations need to recruit and select individuals that realize the importance of customer satisfaction. This way, it is more likely that newcomers fit the operating culture and embrace its values. Second, since both customer and learning orientation are cultural value systems, the socialization process can help managers infuse the aforementioned values among newcomers. Third, it is important that managers openly communicate their expectations. Creating a clear picture of organizational priorities and aims helps employees avoid future psychological contract breach and amplifies their trust in management (Rousseau, 1995). Finally, appraisal and reward systems need to be tied to patient-focused behaviours. Managers also need to realize that those subordinates who do not understand the significance of learning orientation may resist change and any kind of information, decision, or practices that differ from the established one (Baker and Sinkula, 1999). Given that in health care organizations employees are determinative of the quality of care produced and offered, it is imperative that everyone involved comprehends the need for constant transformation, based on continuous scanning of the external environment. Like any study, this one has some limitations that need to be taken into consideration when interpreting its findings. First of all, employees were asked to rate quality of care delivered to patients. Even though this is not atypical of analogous studies – because of the practical considerations related to undertaking research in organisations – ratings by actual patients other than employees could offer more thorough insight. Second, given the fact that in terms of this study the attitudinal data were collected from self-reports, it is possible that common method variance biased the findings. Third, the fact that more responses came from administrative staff than from doctors and nurses and from employees with tenure greater than 15 years may have affected the results of the present study. Consequently, future researchers could examine the role of the exact job position as well as tenure for the relationships under investigation.


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