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ARTíCULOS DE INVESTIGACIÓN
Or ganizat ional climat e: Comparing pr ivat e and
public hospit als wit hin pr ofessional r oles
Diana Roj as
a,bChiara Seghier i
aSabina Nut i
aa Scuol a Superior e Sant ’ Anna,Labor at orio Management e Sani t à, Ist it ut o di Management
Piazza Mar t iri del l a Libert à 33 – 56127 Pisa (It al y)
Email : c.seghieri@sssup.it ; d. roj ast orres@sssup. it ; s.nut i @sssup.it .
b Fundación Universit aria Konrad Lorenz,Direct ora Grupo de Invest igaciones Escuel a de Negocios.
Recibido el 15 de oct ubre de 2014 Acept ado el 30 de oct ubr e de 2014
Palabras clave Salud publica y privada, clima organizacional, salud en la Toscana Resumen
Est e est udio compara las dif erencias de clima organizacional en los roles prof esionales de hospit ales públicos y privados. Nos hemos cent rado en cómo los médicos, administ rat ivos, personal sanit ario y no sanit ario, ya sea en público o en el privado perciben el ent orno de t rabaj o, para cada dimensión clima organizacional. La inf ormación proviene de cuest ionarios de clima aplicados en 2010 y 2012 para 19616 y 1276 empleados de salud en hospit ales públicos y privados, respect ivament e, de la Región Toscana. Se aplicó un análisis f act orial explorat orio para veriÀcar la validez y consist encia int erna ent re punt os del cuest ionario y la prueba t , de un solo sent ido el análisis de varianza para comparar signiÀca percepciones respect o a las dimensiones a t ravés de diferent es grupos de encuest ados.
Keywor ds
Public healt hcare, privat e healt hcare, organizat ional climat e, Tuscan healt hcare.
Abst ract
This st udy compares t he organizat ional climat e diff erences wit hin prof essional roles in privat e and public hospit als. We focused on how physicians, administ rat ive, healt hcare and non-healt hcare st af f eit her in t he public or in t he privat e perceived t heir work environment and each organizat ional climat e dimension. Dat a came f rom organizat ional-climat e quest ionnaires administ ered in 2010 and 2012 t o 19616 and 1276 healt h employees in public and privat e hospit als in t he Tuscany Region respect ively. We applied explorat ory f act or analysis t o verif y t he validit y and int ernal consist ency bet ween it ems in t he quest ionnaire and t -t est , one-way analysis of variance t o compare mean percept ions regarding t o t he dimensions across dif ferent groups of respondent s. We measured f our dimensions: “ t raining opport unit ies” , “ managerial t ools” , “ organizat ion” and “ management & leadership st yle” and overall j ob sat isfact ion. Hospit al st at us in t he professional roles was f ound signiÀcant in t he st af f’s percept ions (p≤0. 05).
Suma de Negocios
Int roduct ion
It has been ident iÀed import ant element s f or healt hcare st af f’s commit ment and loyalt y t oward t he organizat ion, examples of t his element s are: cont inuing t raining and educat ion (Spat h, 2002), leadership st yle, proj ect man-agement , st af f recognit ion, dedicat ed t ime, and resources f or improvement proj ect s (Thomson et al. 2003). But , or-ganizat ional climat e seems t o depend also on t he part icu-lar charact erist ics of t he work environment (Tovey et al. , 1999; Cumbey et al. , 1998).
Organizat ional climat e is deÀned as t he shared percep-t ions of percep-t he work environmenpercep-t (Jones and James, 1979). This concept can be t raced back t o several st udies, f or example, Lewin et al. , (1939) analyse t he relat ionship bet ween t he leadership st yle and climat e; Kof f ka (1935) f ocuses on “ behaviour environment ” ; Lewin (1936) st ud-ies t he “ lif e space” ; and Phillips (1996) invest igat ed how women and men perceived t he organizat ional climat e. Some st udies have shown t he ef f ort s made t o bet t er un-derst and t hose f act ors which cont ribut e t o improve t he work environment (or climat e) and mot ivat e all employ-ees, regardless of t heir posit ion, st at us and gender, t o be commit t ed and ef f ect ive perf ormers (Clark, 1997; Ger-shon, 2007; Nembhard, 2006)
In t he present st udy we were able t o analyze t he hos-pit al st at us (public or privat e) and prof essional roles wit h respect t o organizat ional climat e dimensions like t raining opport unit ies, managerial t ools, organizat ion and man-agement & leadership st yle and j ob sat isf act ion inside t welve public general hospit als and eight een accredit ed privat e hospit als. Our st udy included physicians, admin-ist rat ive st af f , healt hcare employees and non healt hcare employees of t he Tuscan healt hcare syst em. There have been no recent st udies of t his phenomenon, and none have compared and cont rast ed organizat ional climat e and prof essional roles at t he hospit al st at us. This paper is an at -t emp-t -t o address -t his gap in -t he li-t era-t ure.
The general hypot heses developed were whet her public and privat e hospit als wit hin prof essional role would dif f er signiÀcant ly on how t hey perceived t he organizat ional cli-mat e and j ob sat isf act ion. By st udying a count ry like It aly wit h a part icular healt h syst em we hope t o give an insight t o bet t er underst and t he persist ent barriers rest rict ing t he organizat ional climat e in t he prof essional roles at hospit al st at us.
Wit h regard t o It aly, independent ly if public or privat e hospit al is import ant t he use of perf ormance measurement t o promot e a more ef Àcient and ef f ect ive administ rat ion. Wit h t his premise, t he Tuscany region wit h MeS laborat ory in 2005 developed it s own Perf ormance Evaluat ion Syst em valued as a part icularly innovat ive and comprehensive syst em (Carinci 2011; Censis2008) it was implement ed in order t o f ollow up t he regional obj ect ives based on t he needs of t he Regional Healt h Councillor. The PES measured t he qualit y of services provided and t he abilit y t o meet t he needs of cit izens in order t o achieve bet t er healt h and qualit y of lif e st andards and t o preserve Ànancial st abilit y. The 130 indicat ors are classiÀed in six dimensions: Popula-t ion healPopula-t h sPopula-t aPopula-t us; capaciPopula-t y Popula-t o pursue regional sPopula-t raPopula-t egies; clinical perf ormance; pat ient sat isf act ion; organizat ional
climat e and Ànally ef Àciency and Ànancial perf ormance. (Nut i, 2011; Nut i, 2012).
Every year each publ ic Healt h Aut horit y receives it s own report expl aining if it was able t o reach t he obj ec-t ives during ec-t he year and doing a benchmarking com-parison. PES is compulsory f or public inst it ut ions and opt ional -volunt ary f or privat e ones. In 2012 PES has been adopt ed by eight een privat e hospit als as a decision sup-port t ool at managerial l evel. In 2012 was possibl e ap-pl ied t he organizat ional cl imat e quest ionnaire t o privat e inst it ut ions, get t ing int erest ing resul t s t o compare wit h t he public cont ext .
We report ed a cont ribut ion on t he debat e of diversit y in management of healt hcare by highlight ing t he way in which st af f perceived t he organizat ional climat e and t he variat ion addressed in t he prof essional roles and hospi-t al shospi-t ahospi-t us. The implicahospi-t ions of hospi-t his shospi-t udy can be usef ul hospi-t o policy makers, managers and prof essionals underst anding how t he percept ion of t he organizat ional climat e Àt as predict or of good perf ormance.
The cont ext
The It alian healt h care syst em is a Nat ional Healt h Ser-vice (Beveridge-like model) accessible t o t he f ull popula-t ion providing prevenpopula-t ive and curapopula-t ive services (Beveridge 1942). The syst em is organized at t hree levels: nat ional, regional and local. The nat ional level is responsible f or en-suring t he general obj ect ives and f undament al principles of t he Nat ional Healt h Service. The regional government s are responsible f or ensuring t he delivery of t he healt h care t hrough a net work of populat ion-based healt hcare organizat ions (healt h aut horit ies).
In It aly during t he past t wo decades, t he st rong decen-t ralizadecen-t ion policy, in decen-t he line widecen-t h “ New-Public-Manage-ment ” (NPM) philosophy (Ket t l, 2000; Pollit , 1995) which aims is t hat public organizat ions should import manage-rial processes and behaviour f rom t he privat e sect or (Box, 1999; Boyne, 2002). Wit h t his argument t he government have gradually t ransf erred several import ant administ ra-t ive and organizara-t ional responsibilira-t ies f rom ra-t he sra-t ara-t e ra-t o t he 21 It alian regions wit h t he aim of making regions more sensit ive t o t he communit y needs, t o cont rol expendit ure, promot e ef Àciency, qualit y, and cit izen sat isf act ion but specially it has st art ed t o f ocus on more ef f ect ive man-agement (Mourit sen et al. , 2005).
This model provided regions wit h signiÀcant aut onomy in organizing healt hcare services, allocat ing Ànancial re-sources t o t heir Local Healt h Aut horit ies (LHAs), monit or-ing and assessor-ing perf ormance (Nut i 2008, Ant onini 2009). Whereas, t he cent ral government ret ains overall respon-sibilit y f or ensuring t hat services, care and assist ance are equit ably dist ribut ed t o cit izens across t he count ry.
The Tuscany region have 3. 7 beds f or each 1000 inhabit -ant s of which 95% correspond t o public beds and only 5% are privat es. The healt hcare syst em works t hrough a net -work of sevent een public healt h aut horit ies of which Àve are t eaching hospit als (THs) and t welve are Local Healt h Aut horit ies (LHAs) and eight een privat e hospit als wit h ac-credit at ion.
In 1999, t he Region of Tuscany began t he accredit at ion syst em (LR 8/ 1999, LR 51/ 2009). Inst it ut ional accredit at ion is t he recognit ion by t he Region of hospit als t hat are au-t horized au-t o provide and develop healau-t h services according t o t he Nat ional Healt h Service (NHS). Accredit at ion is com-pulsory f or public inst it ut ions and opt ional-volunt ary f or privat e ones, but if privat e inst it ut ions does not have t he accredit at ion cannot provide beneÀt s on behalf of t he NHS. However, obt ain accredit at ion, does not allow t o perform services on behalf of t he NHS, is compulsory an agreement bet ween subj ect and accredit ed Local Healt h Aut horit ies t hat speciÀc t imes, cost s, t erms and amount s of beneÀt s payable in agreement wit h t he NHS (Lenzi, 2012).
Dat a and Met hods
In 2010 t he Laborat ory of Management e Sanit à (MeS) wit h Tuscany region administ ered t he organizat ional climat e sur-vey t o healt h care professionals in 16 Tuscan Healt h Aut hor-it ies (12 General Hosphor-it als and 4 Teaching Hosphor-it als), whor-it h a t ot al populat ion of 2407 managers and 47903 st af f . In 2012 t he survey was administ ered t o healt hcare prof essionals in 18 privat e hospit als wit h accredit at ion.
The organizat ional climat e is part of t he six dimension wit hin Perf ormance Evaluat ion Syst em (PES). Regarding t o t he procedures for compiling and sending t he survey; we provided t he quest ionnaires on-line using t he Comput er As-sist ed Web Int erviewing (CAWI) syst em; each employee had a login and password t hat allowed him/ her access t o t he web plat f orm for collect ing dat a. Secure connect ion guar-ant eed t he anonymit y of responses and saf et y of dat a t rans-mit t ed. (Pizzini and Furlan, 2011).
Independent ly f rom t he quest ionnaire, all quest ions had a 5-point likert scale f ormat , ranging f rom 1 ext remely un-sat isÀed t o 5 ext remely un-sat isÀed. The analysis ext ract ed inf ormat ion on t he survey sample, j ob sat isf act ion and or-ganizat ional climat e dimensions like management & leader-ship st yle, managerial t ools (i.e. budget ), hospit al organi-zat ion and t raining opport unit ies. We t ast ed and validat ed bot h quest ionnaires and we assure t he validit y and reliabil-it y of t he inst rument .
We applied Fact or Analysis t o quest ionnaires t o obt ain t he percept ion of managers and employees in t erms of t he dimensions ment ioned above. We perf ormed descript ive st at ist ics, f act or analysis, and t wo-t ailed t est t o examine gender dif f erences in t he General hospit als. We used STATA soft ware for st at ist ical analyses (Version12, St at a Corp, College St at ion, TX).
Analysis
Respondent s’ charact erist ics
Table 1 shows descript ive st at ist ic. In public hospit als 17424 of t he 34686 st af f (50.2%) ret urned t he quest ionnaire while in privat e hospit als only 1276 employees ret urned it .
Table 1. Descript ive st at ist ics wit hin hospit al st at us. Public (%) (n=17424) Privat e (%) (n=1276) Gender Men Women Age (years) 18-34 35-49 >50 Seniorit y (years) <2 2-5 6-10 11-20 Af Àl iat ion Administ rat ive Physicians Healt h employees Non Healt h employees
28.0 72.0 8.5 50.6 40.9 18.2 18.5 28.8 34.5 11.7 16.9 56.3 15.0 37. 4 62. 6 24. 5 44. 0 31. 5 16. 9 23. 0 21. 8 38. 3 14. 8 22. 8 58. 8 3. 8
Or ganizat ional climat e dimensions
Applying f act or analysis t o t he dat a we obt ained overall j ob sat isf act ion and f our organizat ional climat e dimensions: 1. Sat isfact ion wit h managerial t ools was measure by four
it ems (α=0.94). Test ing t he manager performance con-cerning t o t he budget responsibilit ies and cont rol syst em. 2. Sat isf act ion wit h t raining opport unit ies was measure by f our it ems (α=0.86). Test ing t he correspondence bet ween t raining needs of employees and hospit als’ st ruct ure, it means t he eff ect iveness of t he perf ormed t raining and t he dif f usion of inf ormat ion relat ed t o educat ional op-port unit ies off ered by hospit als.
3. Sat isf act ion wit h t he organizat ion was measure by seven it ems (α=0. 89). Test ing t he hospit al organizat ion and st ruct ure.
4. Sat isf act ion wit h management & leadership st yle by Àf-t een iÀf-t ems (α=0.95). Test ing t he managerial abilit ies of t he CEO, seniors and managers.
Overal l j ob sat isf act ion dimension: Measure how cont ent an individual is wit h his or her j ob.
Fact ors were obt ained using Principal Component s Fact or Analysis, wit h varimax rot at ion of t he ort hogonal axes and in bot h cases t he percent age of explained variance was about 65%. We calculat ed for each dimension Cronbach’s α reliabil-it y coefÀcient above 0.8 conÀrming t he validreliabil-it y and int ernal consist ency bet ween it ems on t he scale of each fact or.
Prof essional r oles in public and privat e hospit als in t he percept ion of Or ganizat ional Climat e Fact or s
Subsequent ly we used t -t est t o compare mean percept ions regarding t o t he dimensions obt ained across different groups
of respondent s. The probabilit y level for all hypot hesis t est s was set at p<=0.05.
Table 2 shows t he signiÀcant dimensions of organizat ional climat e in public and privat e hospit als analyzing prof ession-al roles. It was not ed t hat t he dimensions of organizat ionession-al climat e are import ant depending on t he professional role; f or example for t he administ rat ive st af f is only signiÀcant t he managerial t ools and t his is underst andable because t heir priorit y is t he budget . However, climat e percept ion at hospit al st at us reveals signiÀcant dif ferences among physi-cians t han t he rest of employees.
Table 2. Public vs. Privat e diff erences at prof essional roles of perceived climat e and j ob sat isfact ion.
LHAs
Pr of essional roles Administ rat ive Organizat ion Training Management & leadership st yle Job sat isfact ion Physicians Managerial t ools Organizat ion Management & leadership st yle Job sat isfact ion Healt h employees Organizat ion Training Management & leadership st yle Non healt h employees Managerial t ools Organizat ion Management & leadership st yle Job sat isfact ion
Public (n=17424) Privat e (n=1276) Mean sd mean sd 0.0338 -0. 2985 0.0248 -0. 1317 0.3329 0.0252 0.1998 0.0566 -0. 0779 0.7335 -0. 0819 -0. 1660 -0. 1142 -0. 1177 -0. 0396 0.9940 1.0310 0.9987 1.0731 0.9027 1.0134 1.0339 0.9826 0.9555 0.9926 0.9697 1.0021 0.9406 0.9680 0.9579 0.8287 -0. 8346 0.4263 0.1135 0.4356 0.9341 0.6685 0.3287 0.6002 -0. 0264 0.2414 0.2202 0.8440 0.5712 0.3773 1.1208 0.8331 1.0170 1.0802 0.9977 1.0906 0.9625 1.0416 1.1281 0.8585 1.0709 1.0989 1.1765 1.0394 0.9459 p>0. 05
In general, st aff s working in privat e hospit als are more likely t han t hose working in public hospit als. Management & leadership st yle and organizat ion are signiÀcant in all pro-f essional roles regardless opro-f t he hospit al st at us, but privat e hospit als st af f are more sat isfy wit h bot h of t hem.
Sat isf act ion wit h t he organizat ion is t he most signiÀcant -ly f act or in privat e hospit als, but at t he same t ime t he most crit ical one because of t he higher gap bet ween t wo hospit al st at us. Dif f erences bet ween public and privat e organiza-t ions have been discussed broadly. The Àrsorganiza-t dif ference is t hat privat e organizat ions are owned by privat e part ners while t he nat ion is t he owner of public organizat ions. Pub-lic sect or organizat ions are cont rolled mainly by t he po-lit ical f orces, not market f orces. For t his reason t he main const raint s are imposed by t he polit ical syst em, while in privat e organizat ions, t he owners have a direct monet ary incent ive t o mot ivat e managers t o provide bet t er perf or-mance. Similarly, t he managers t hemselves are likely t o beneÀt f rom improved perf ormance, because t heir pay-ment is linked wit h t he proÀt .
The lit erat ure point ed out t hat t here are several ex-t ernal aspecex-t s ex-t haex-t make dif f erenex-t managing public orga-nizat ions (Boyne, 2002; Arrow, 1974; Angelopoulou, 1998; Bhat ia, 2004). Public hospit als are complex organizat ions; Met calf e (1993) argues t hat ‘ government operat es t hrough net works of int erdependent organizat ions rat her t han t hrough independent organizat ions which simply pursue t heir own obj ect ives’ . Moreover, in t he public sect or t here is more bureaucracy compared t o t he privat e one, also po-lit ical condit ions impact s t he policy makers changing t he short -t erm out look and pressing t o achieve result s so f ast , result s t hat can help only for polit ical purposes, whereas privat e organizat ions should pursue t he goal of proÀt .
The result s wit h respect t o Managerial & leadership st yle are signiÀcant in all prof essional roles. Lit erat ure has shown t hat managerial & leadership st yle dif f er signiÀcant ly be-t ween privabe-t e and public organizabe-t ions, managers in pri-vat e organizat ions are mot ipri-vat ed more by t heir economic well-being (Khoj ast eh, 1993) and public managers are more obj ect -orient ed and t hey have a desire t o serve t he public int erest and st rongly orient ed t owards t he ‘ common good’ . Nevert heless, t hese result s support some st udies t hat have found t hat public sect or employees are less sat isÀed wit h t heir work (Buchanan, 1974; Lachman,1985).
Highly specialized st aff responded more posit ively all it ems. Physicians and administ rat ive employees were more posit ive about how t hey perceived t heir hospit al, part icu-larly t he quest ion about t he adequacy of inf rast ruct ure and physical environment .
Training opport unit ies is signiÀcant ly less ef f ect ive in privat e hospit als. Moreover employees perceived t hat ca-reer opport unit ies are not equally guarant eed f or all and t here is a lack of inf ormat ion about t raining opport unit ies provided by t he hospit al. It seemed t o be t he most crit ical issue t o be t aken up.
We f ound t he exist ence of a discreet dif ference in t he percept ion of t he managerial t ools among physicians and a large dif ference among non healt h employees. The higher gap bet ween professional roles concerned t o t he exist ence of a professional hierarchy in healt hcare well est ablished in t he lit erat ure.
Conclusions
The result s of t he present st udy support t he hypot hesis t hat t here are dif f erences in how t he organizat ional climat e is perceived by employees wit hin prof essional roles and hos-pit al st at us in t he Tuscan healt hcare organizat ions (General hospit als).
The analysis showed t hat t he Tuscan organizat ional cli-mat e quest ionnaire is a reliable inst rument used as a mea-surement t ool for evaluat ing working condit ions and det er-mining t he f act ors which sat isÀes and mot ivat es employees in t he healt hcare sect or. The f our dimensions det ect ed showed high variabilit y and dif ferent signiÀcance along di-verse organizat ional st ruct ures, prof essional roles and hos-pit al st at us.
This st udy shows t hat t here are maj or dif f erences be-t ween public and privabe-t e hospibe-t als in be-t erms of how be-t hey
perceive t he int ernal climat e where t he employees in pri-vat e hospit als are more sat isÀed t han employees in public ones. On t he ot her hand, our result s suggest t hat in t erms of j ob sat isf act ion physicians in privat e inst it ut ions are in general more sat isÀed.
Training processes, however, wit hin t hese organizat ions, are loosely coupled wit h t he rest of t he organizat ional pro-cesses and oft en depend on t he employee’s abilit y and will-ing t o ask f or t arget ed t rainwill-ing courses.
Finally t he use of an organizat ional climat e survey can help management t o ident if y t he crit ical point s in t he f ac-t or dimensions and communicaac-t e more ef fecac-t ively wiac-t hin t he st ruct ures improving t he eff ect iveness of t ot al qualit y management programmes.
In f act , a valid int ernal climat e survey can be a usef ul t ool in support ing t he management t o make eff ect ive in-novat ion process. Moreover, in order t o assure it s ef f ect ive-ness it is import ant t o share and discuss t he result s of t he int ernal climat e survey wit h all t he prof essionals being t his t he most import ant prerequisit e t o support t he organiza-t ional changes and iorganiza-t is whaorganiza-t organiza-t he Tuscan healorganiza-t h managers are used t o do not only wit h regards t o t he int ernal climat e result s but also t o all t he performance measures.
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