Modeling the
relationship between organizational culture, clinical governance, and
organizational performance: A case study of Tamin Ejtemaee hospitals in
Mazandaran Province, Iran
Taboli H, PhD1, Ayagh
Gh, PhD2, Bastami R, PhD3*, Hakimi I, MSc4
1-
Associate Prof., Dept. of Management, Payam
Noor University of Kerman, Kerman, Iran. 2- Associate
Prof., Dept. of Management, Payam Noor University of Kerman,
Kerman, Iran. 3- PhD student, Dept. of Management, Islamic Azad University of Kerman,
Kerman, Iran. 4- Faculty Member, Dept., of Management,
Payam Noor University of Kerman, Kerman, Iran.
Abstract
Received:
November 2015, Accepted: January 2016
|
Background: The quality of clinical
services is one of the main concerns around the world. Clinical governance as
a new approach to improving the quality of care provided by the health care
system plays a major role in the provision of higher quality health care services.
The success of this approach depends on the existence of a strong and
suitable organizational culture. The aim of this study was modeling the
relationship between organizational culture, clinical governance, and
organizational performance. Materials
and Methods: The
purpose of this study is practical and its data collection is descriptive, but as a
result it is an empirical study.
This study was a correlative study based on structural equation modeling
(SEM). The statistical population of this study consisted of all managers,
supervisors, educational and clinical supervisors, and nurses of Tamin
Ejtemaee (social security) hospitals in Mazandaran Province, Iran. Due to the
limitation of the study, all individuals in the target population were
selected as the study subjects. Thus, 124 questionnaires were distributed
among them, and, 113 questionnaires were received. Data analysis was
performed using SPSS and LISREL software. For data analysis, the Pearson
correlation coefficient test and confirmatory factor analysis were used for
precise measurement of the model. Results: The results show that there is
a significant and positive relationship between the components (P < 0.01).
The role of organizational culture in establishing clinical governance
estimation is desirable and the results have identified its relationship with
organizational performance. Conclusions: With the improvement of
organizational culture, the establishment of clinical governance will
increase and it will achieve optimal performance by continuation and
localization. |
Keywords: Organizational Culture, Clinical
Governance, Performance
Introduction
The
quality of clinical services is one of the main concerns around the world (1).
Many countries consider the improvement of the quality of hospitals’
performance as the main policy agenda for their health system (2). Clinical
governance was introduced as a new approach to improving the quality of care and
according to it a general reform program was created in the health system.
Clinical governance is the system by which organizations providing health care
services are constantly responsible to improve the quality of their services
and maintain high standards of care by creating an environment in which
excellence is realized in clinical care (3). *Organizational
culture, due to its impact on the different status variables within the
framework of an organization, is a specific research topic in management
knowledge which has never lost popularity in its research field. Organizational
culture is considered as a key factor for studying different aspects of
organizational life and research questions regarding its impact on the
perception of organizational goals are increasing every day (4).
Organizational
culture is used to comprehend situations that employees are faced with, and it
can affect attitudes and behaviors of employees (5). The new approach of organizational
culture excellence is based on the belief that organizational success depends
on having a strong and appropriate organizational culture and organizations
must enable themselves to create external and internal synergy for their
survival. Organizational culture can be used as a powerful lever to strengthen
organizational behavior, success in implementing any strategy depends largely
on the support of organizational culture, and any changes in the organization
cannot be effective without sufficient attention to organizational culture (6).
Organizational performance is considered as the method by which to carry out
missions, tasks, and organizational activities and their results. In another
definition, organizational performance is achieving organizational and social
goals or going beyond them and implementing organizations’ responsibilities.
Performance measurement is the process of ensuring that an organization follows
strategies which lead to achieving goals. There are two main approaches in
performance measurement (objective and subjective measures) and both approaches
have their own advantages and disadvantages. Objective measures (scales), are
more realistic; however, they are limited to financial data and do not account
for other organizational aspects. On the other hand, subjective measures
(scales), are less realistic, but they provide rich descriptions of
organizational effectiveness. These scales allow the comparison of a wide range
of organizations in different industries (7). Due to the importance of
organizational culture, clinical governance, and organizational performance in
the successful establishment of rehabilitation programs, this study
investigated the modeling of the relationship between organizational culture,
the establishment of clinical governance, and organizational performance in
Tamin Ejtemaee (social security) hospitals in Mazandaran Province, Iran. The
results can be the grounds for the successful implementation of quality
improvement programs, including clinical governance and performance at
hospitals. Moreover, executives with knowledge of the organizational culture of
their hospital can try to remove possible errors and prepare hospitals to
implement quality improvement programs and changes successfully (7).
Organizational Culture
and Clinical Governance
Conte
et al. conducted a research with the aim of understanding how clinical
governance managers in the National Health Service in England are engaging with
their organizational culture to support the improvement of quality (6). They
found that there is a clear interest in renewing culture and management among
managers, in line with the increasing attention of national policy-makers to
the promotion of alteration
as a lever to change the health system. Almost all clinical governance managers
(98%) considered the need to measure the local culture in order to promote
change for enhanced performance. Furthermore, 85% reported that culture
assessment should serve a formative (developmental) purpose, while 64% believe
that it should be followed by compaction results. Almost all managers
acknowledged the importance of understanding and shaping clinical governance.
Marshall et al. by pointing to the fact that changing the culture of
organizational health is a basic prerequisite for improving the National Health
Service, have considered the importance of culture and cultural change for the
implementation of clinical governance in public actions to distinguish
desirable and undesirable cultural attitudes (6). As a result, senior managers considered
the culture of clinical care and cultural change as fundamental aspects of
clinical governance. The desired cultural characteristics included: the
importance of liability of public responsibility by staff, their willingness to cooperate and learn
from each other, and their ability to criticize themselves and to learn from
their errors. The main obstacles for cultural change were identified as high
level of personal independence and the perceived pressure to accept rapid
measurable changes in the organization. The impacts of organizational culture
on other factors of the hospital have been identified in other studies (6). As
an example, Tessai studied the relationship between organizational cultures,
leaders’ behavior, and job satisfaction among a group of nurses in Taiwan.
Tessai concluded that culture within the organization is of great importance
and plays a major role in the establishment of a happy and healthy work
environment (5). Therefore, in communicating and promoting organizational traits
to employees, its acknowledgement and acceptance can affect their occupational
behaviors and attitudes. Tzeng et al. have evaluated the potency of
organizational culture as a good predictors of job and patient satisfaction (6). Organizational culture affects
all aspects of the organization. Studies show that culture affects development
of goals and strategies, individual behavior and employee performance,
motivation and job satisfaction, creativity and innovation, decision making,
the involvement of the staff in affairs, commitment, and discipline (6).
H1:
Organizational culture has an impact on clinical governance.
Culture
and organizational performance
Quality
should be a component of organizational values and culture of hospitals. In
addition, organizations moving toward quality care require a fundamental change
in culture, leadership, the attitude of their staff, and organizational
structure. If organizations providing health care are not successful in
changing their climate and atmosphere and their performance in order to achieve
clinical governance, they are doomed to fail. This issue is extremely complex,
especially in hospitals where people of different cultures interact with each
other (8). One of the issues that affect the performance of the organization is
organizational culture. Over the past four decades, significant studies have
focused on organizational culture and organizational performance. This volume
of theoretical framework represents the value of organizational culture.
Previous studies show the positive impact of organizational culture on
organizational performance (9). The Denison organizational culture is one of
the patterns of organizational culture as its basis is the fact that culture
affects organizational performance, and includes all dimensions of
organizational culture. This pattern considers the cultural dimensions of
organizations in four principal areas including engaging in work
(participation), consistency, adaptability, and mission (10).
H2:
Organizational culture has an impact on performance.
Clinical governance
and organizational performance
The
main aim of clinical governance is the continuous improvement of service
quality and it provides a framework within which organizations providing health
care move toward growth, development, and quality assurance of clinical
services for patients. The Balanced Scorecard is an appropriate approach to the
measurement of hospital performance of one of the models. This model suggests
that in order to assess the performance of each organization, a number of
balanced indicators must be used so that senior managers can have an overview
of the four important aspects of the organization. Responding to the four
following basic scopes will be possible through these various aspects
(dimension).
1.
Client and customer aspects
2.
The internal aspect and business
3.
Financial aspects
4.
Learning, development, and innovation aspects (11).
H3:
Clinical governance has an impact on organizational performance.
The general approach
of this study has been shown in figure 1.
Clinical Governance
Organizational Performance Organizational Culture
Figure
1: The conceptual model
The present study was conducted with the aim of
modeling the relationships among organizational culture, clinical governance,
and organizational performance in Tamin Ejtemaee hospitals of Mazandaran
Province based on data from the year 2015.
Material and Methods
This research aimed at modeling the relationship
between organizational culture, clinical governance and organizational
performance in social security hospitals of Mazandaran province. The purpose of
this study is practical and its data collection is descriptive. This was a
correlative study based on structural equation modeling (SEM).
To examine the relationship between latent and
observed variables of confirmatory factor analysis and to evaluate the
structural model (the relationship between latent variables), path analysis was
used. Data analysis was performed using SPSS and LISREL software. For data
analysis, the Pearson correlation coefficient test and confirmatory factor
analysis were used for the precise measurement of the model. The statistical
population (community) of this study consisted of all managers, supervisors,
educational and clinical supervisors, and nurses of Tamin Ejtemaee hospitals in
Mazandaran Province. Due to the limitation of the study, all individuals in the
statistical population were selected as the study subjects. After obtaining
permission from the management of the Tamin Ejtemaee hospitals of Mazandaran,
the questionnaires were distributed among the participants with the necessary
instructions and with their consent. The participants were assured that the
data would be used anonymously and collectively.
Then, 124 questionnaires were
distributed among them, and, 113 questionnaires were received. The reason
behind selecting the population was the involvement of managerial levels in
performing clinical governance. The Denison Organizational Culture Survey was
used to measure organizational culture (10).
This questionnaire emphasizes the aspects of
organizational culture that seem to influence organizational effectiveness and
focuses on four key traits of involvement (participatory), consistency,
adaptability, and mission. Each of these four attributes is measured by three
indicators. Thus, the involvement aspect is measures by the three subcomponents
of empowerment, team orientation, and capability development. The consistency
aspect is measured with the three subcomponents of fundamental values,
consensus, and coordination. The adaptability aspect is measured by the three
subcomponents of alteration,
customer orientation, and organizational learning. The mission (prophecy)
aspect is measured by the three subcomponents of strategic guidance, goals, and
objectives and vision. The main questionnaire contains 66 questions. In this
study, 36 questions were selected according to the purpose of the study.
Mirkamali Questionnaire was used to assess clinical governance (6). This
questionnaire contains 44 questions. For this purpose, specific questions were
identified based on seven aspects of clinical governance and 6 questions of organizational
performance were chosen based on the Balanced Scorecard (Table 1).
Table 1:
Components and the questionnaires of organizational culture, clinical
governance, and organizational performance
|
Number of
questions |
Components |
Subject |
|
36 questions |
Involvement
(empowerment, team orientation, and capability development) Consistency
(fundamental values, consensus, coordination) |
Organizational
culture |
|
44 questions |
Training and
management of staff Patient and
community (population) participation Risk
management and patient safety Clinical audit Data
management Clinical
effectiveness Management and
leadership |
Clinical
governance |
|
6 questions |
Financial
aspects Internal
aspect of the business (internal processes) client and
customer aspects growth and
learning aspects |
Organizational
performance |
To determine the validity of the Denison
Organizational Culture Survey (10), despite the use of domestic and foreign
research, second-order analysis validity was conducted on the questionnaire.
The root-mean-square error (RMSE) was equal to 0.09. The reliability of the
data for the entire questionnaire was approved through internal consistency
method (Cronbach's alpha = 0.95). The Mirkamali Clinical Governance
Questionnaire has been made based on the seven aspects of clinical governance
and was reviewed and modified by five experts of clinical governance in
hospitals and the Clinical Governance Committee De Guilan University of Medical
Sciences, Iran. Its validity was confirmed in this study. After the initial
implementation and modifications, in the final stage of implementation, the
indicators of estimation of the verified model obtained by the LISREL (RMSE =
0.07) software confirmed the validity of the model and the structural validity
of the questionnaire. The internal consistency of the whole questionnaire
(Cronbach's alpha = 0.97) and the organizational performance questionnaire,
using the Balanced Scorecard method, was approved (Cronbach's alpha = 0.89).
Results
The average age of participants was 37.47 ± 6.28
years and 85 had a bachelor’s degree and 28 had a master's degree. Moreover, 55
participants were supervisors of nurses, 34 were managers, 19 were supervisors,
and 5 were nursing directors. The average work experience of the participants
was 15.26 ± 7.25 years. The results presented in table 2 show that there is a
positive and significant correlation between components (P < 0.01).
Table 2:
correlation matrix of clinical governance, organizational culture and
organizational performance
|
15 |
14 |
13 |
12 |
11 |
10 |
9 |
8 |
7 |
6 |
5 |
4 |
3 |
2 |
1 |
Variable |
Row |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1 |
Training and management of staff |
1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1 |
0.75 |
Patient and community participation |
2 |
|
|
|
|
|
|
|
|
|
|
|
|
|
1 |
0.65 |
0.78 |
Risk management and patient safety |
3 |
|
|
|
|
|
|
|
|
|
|
|
|
1 |
0.81 |
0.56 |
0.74 |
Clinical audit |
4 |
|
|
|
|
|
|
|
|
|
|
|
1 |
|
0.80 |
0.54 |
0.57 |
Data management |
5 |
|
|
|
|
|
|
|
|
|
|
1 |
0.71 |
0.82 |
0.80 |
0.77 |
0.80 |
Clinical effectiveness |
6 |
|
|
|
|
|
|
|
|
|
1 |
0.62 |
0.55 |
0.57 |
0.60 |
0.51 |
0.54 |
Management and leadership |
7 |
|
|
|
|
|
|
|
|
1 |
0.46 |
0.44 |
0.37 |
0.43 |
0.39 |
0.40 |
0.38 |
Involvement |
8 |
|
|
|
|
|
|
|
1 |
0.79 |
0.68 |
0.42 |
0.42 |
0.50 |
0.49 |
0.38 |
0.44 |
Stability and integration |
9 |
|
|
|
|
|
|
1 |
0.90 |
0.76 |
0.65 |
0.47 |
0.37 |
0.52 |
0.48 |
0.43 |
0.52 |
Conformity |
10 |
|
|
|
|
|
1 |
0.87 |
0.94 |
0.85 |
0.66 |
0.46 |
0.45 |
0.49 |
0.48 |
0.44 |
0.45 |
Mission |
11 |
|
|
|
|
1 |
0.78 |
0.79 |
0.72 |
0.87 |
0.49 |
0.52 |
0.38 |
0.47 |
0.40 |
0.48 |
0.40 |
Internal processes |
12 |
|
|
|
1 |
0.67 |
0.74 |
0.81 |
0.79 |
0.61 |
0.51 |
0.32 |
0.40 |
0.36 |
0.47 |
0.43 |
0.49 |
Clients and customers |
13 |
|
|
1 |
0.75 |
0.81 |
0.78 |
0.86 |
0.77 |
0.83 |
0.50 |
0.43 |
0.34 |
0.36 |
0.36 |
0.38 |
0.43 |
Growth and learning |
14 |
|
1 |
0.57 |
0.34 |
0.51 |
0.69 |
0.54 |
0.60 |
0.77 |
0.24 |
0.21 |
0.27 |
0.30 |
0.29 |
0.16 |
0.22 |
Financial aspects |
15 |
The structural model with freedom degree of 81 (X2 /
df = 2.11) and root-mean-square error of approximation (RMSEA) of 0.09 showed
that estimation of the conceptual model of organizational culture in
establishing clinical governance is desired. Regression coefficients (R) of
each of the components of clinical governance, and organizational culture and
performance are illustrated in figure 2. Regression analysis of organizational
culture on clinical governance and performance was significant and positive.
For a better understanding, the conceptual model and coefficients of each
component are reported in figure 3. The structural model results also showed
that the estimation of conceptual model of the role of organizational culture
in the establishment of clinical governance is desired. According to figure 2,
the regression coefficient of organizational culture on clinical governance is
positive and significant.
Figure
3: Non-estimate coefficients
Discussion
Consideration of the quality of clinical services is
possible through the implementation of programs such as clinical governance.
Clinical governance is a systematic, integrated approach in which the health
care providers are responsible for continuous improvement of the output quality
and safety of patient care through revision and ensuring of clinical
responsibilities, presenting methods to prevent and reduce clinical errors, and
maintaining a high level of service standards. However, in recent decades, different
levels of organizational performance have been attributed to the type of
organizational culture. Organizational culture can act as a source for creating
sustainable competitive advantages.
Lack of attention to organizational culture and
individuals’ beliefs and values is the cause of failure and inability to
achieve the organization’s goals and vision. This lack of attention will create
numerous problems in the process of the organization’s activity and result in
the wasting of much energy to solve problems caused by the incompatibility of
predicted targets with the common culture of the organization. Organizational
culture is a complex phenomenon that has an important role in accelerating the
development and transformation of the organization.
Therefore, lack of attention to the culture of the
organization and its dimensions and parameters can cause basic problems.
Modeling the relationship between organizational culture, clinical governance,
and organizational performance in Tamin Ejtemaee hospitals of Mazandaran
Province showed that organizational culture in these hospitals is in good
condition, because their scores are higher than average. Furthermore, the
results showed that the dominant organizational culture of the studied
hospitals was cooperative or involvement culture and the establishment of
clinical governance is in good condition. Nevertheless, organizational
performance obtained a lower score compared to other components. Hence, greater
attention to this component is required in the establishment of this
relationship. In explaining this conclusion, it can be said that due to the
lack of an efficient system such level of performance was predictable. In the
case of the relationship between culture and the establishment of clinical
governance, this study confirms the results of some previous researches (12,
13). The cooperative organizational culture is recognized as the most
appropriate culture for the implementation of total quality management (TQM)
and other plans for quality enhancement. It can be stated that the
impact of organizational culture on the establishment of clinical governance is
significant. With the improvement of organizational culture, the further
establishment of clinical governance will be achieved. In addition, the relationship
between dimensions of organizational culture and clinical governance in Tamin
Ejtemaee hospitals of Mazandaran Province was positive and significant. The
overall improvement of the above results leads to more sustainable
establishment of clinical governance which causes the improvement of
organizational performance. Given that hospitals are the main organizations
that provide healthcare services in the country, establishing an appropriate
organizational culture results in hospitals' greater flexibility when
responding to the needs of clients and patients, which ultimately leads to
client satisfaction and fulfilling the core mission of hospitals.
Conclusion
In all developed and developing countries, health
systems and governments must adopt mechanisms and procedures to ensure the
quality of healthcare services. It seems that devising a national strategy to
improve health quality is not considerably difficult, yet implementing this
strategy can prove problematic. Clinical governance is the adopting of a
comprehensive strategy for continuous quality improvement of clinical services
so that everyone is accountable for providing these services. Achieving this
goal is not possible without taking into account the issues of culture and
performance.
Acknowledgments
The author would like to thank the management of
Tamin Ejtemaee hospitals of Mazandaran Province and all employees who
participated in this study.
Conflict of
interest: None declared
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*
Corresponding author: Rajab
Bastami,
Dept. of Management, Islamic Azad University of Kerman, Kerman, Iran.
Email:
Rajab_bastami @yahoo.com