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ORGANIZATIONAL LEARNING AND SERVICE QUALITY IN HEALTHCARE INDUSTRY

Thilageswary Arumugam (Corresponding author)

University Putra Malaysia (UPM)-Malaysia E-mail: [email protected]

Khairuddin Idris

University Putra Malaysia (UPM)-Malaysia

E-mail: [email protected]

Zoharah Omar

University Putra Malaysia (UPM)-Malaysia


Komati Munusamy University Putra Malaysia(UPM)-Malaysia


ABSTRACT The aim of this work is to establish the relationship between organisational learning and service quality in the public healthcare industry. Unit of analyses consists of clinical and clinical support departments in public hospitals. Service quality perception is obtained from patients and organizational learning assessed by the head of departments. Utilizing the AMOS Structural Equation Modelling and SPSS, data were analysed. The hypothesised model has provided a model fit between the constructs contributing to the theoretical body of knowledge. Study reports that the level of organizational learning and service quality are at the moderate level among public hospital departments. Findings reveal that the hypothesis is supported. Organizational Learning

Action has significant and positive relationship with Service Quality. Keyword: Organizational Learning Systems Model, Organizational Learning, Learning Action, Service Quality

1. INTRODUCTION Public health care is part of the key areas of national economic growth. However, one

significant problem encountered here is the increase of aging population in Malaysia

(Economic Intelligence Unit, 2014) despite the data highlighting that Malaysia’s

healthcare quality is progressing (Human Development Index, 2015). The GDP for

healthcare expenditure in Malaysia is 4.03 in 2013 according to World Bank. The Malaysian population is estimated 30 million in beginning 2015. The age dependency ratio

of population in Malaysia is 52.9% which is relatively high based on United Nation, 2015.

Based on Malaysian population distribution is pyramid is an expanding type. The

pyramid indicates relatively short life expectancy, low level of education and poor

healthcare (United Nation, 2015). Public hospitals in Malaysia have excess demand

where demand for subsidy exceeds the supply highlighting significant problem like longer waiting time of patients to obtain treatment (Pillay, et al., 2011). Thus, the

challenge is uprooted to sustain the hospital care progressively. Adversely, there have been

steady increases in admission rate, outpatient attendance, pathology workload and

inadequate human resource skilled workforce (Yusof, 2014). From the patient's

perspective, there is an increase of population, especially aging population, burden of diseases and dependency on hospital facility (Yusof, 2014). MOH shows an increase in

non-communicable diseases which is 250% increase from year 2002 to 2012 (EIU, 2014).

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One problem claimed by the President of Malaysian Medical Association is attention needed to improve healthcare service and especially public healthcare that faces brain

drain (Star, 2015). Another factor that contributes to poor service is also due to

inefficient process, time wastage, over- processing imbalance of bed utilization, lack of

specialist care, and so on (Pillay et al., 2011; Rose, Uli, Abdul, & Ng, 2004). Notably, the

government has looked into the concept of lean management rooted since 2013 as a way

to tackle these issues (Lani, 2014). This new approach is swayed towards patient centered to avoid congestion, waiting time, long process, etc. (Yusof, 2014). Looking into this

scenario, there seem to be more to be done from the administration and the

management part in order to deliver a quality service to the patients in public hospitals.

The Malaysian healthcare issue is also seen along this trail of literature whereby numerous studies had been done to measure the level of quality service delivery or patient

satisfaction in Malaysian public and private healthcare in the past (Manaf, 2005; Pillay et

al., 2011; Rashid, & Jusoff, 2009; Suki, Lian, & Suki, 2011). However, specifically in the

research conducted, Malaysian healthcare has found service quality in some aspects

needs improvement (Lam, 2010; Manaf, 2012; Pillay, et al. 2011; Rose, et al., 2004;

Sohail, 2003). One of the improvement needed is to achieve patient satisfaction which has always been an important method to measure in quality aspects ( Chakravarty, 2011;

Kapoor 2011; Rasiah, Wan Abdullah, & Tumin, 2011).Hence, customers [patients] play

an important role in measuring quality service delivery of healthcare in the organization

(Babakus & Mangold,1992; Bakar, Akgün, & Assaf,2008; Elluech, 2007; Kapoor,2011;

Pillay et al., 2011; Rad, 2005; Rose et al., 2004;).

Service quality is generally measured by customer satisfaction that reflects the

organizational performance (Ramayah, Samat, & Lo, 2011). Quality service is a perceived

quality which means a customer's judgment about a service (Cuiberg & Rojšek, 2010).

Quality is the service that occurs during delivery of intangible, heterogeneous and

inseparable service delivery during and interaction between customer and provider (Zeithaml, Parasuraman, & Berry, 1990).This is crucial especially in healthcare industry

where patients’ perception on the service are significant (Brahmbahatt,2011) because

hospitals’ service is highly prone to errors compared to other industries (Natarajan,

2006). There has been an increase in quality in the healthcare sector. This is an

important question to adhere in hospitals and has been supported empirically by numerous studies (Pillay et al., 2011;Bakar, et al. 2007; Elluech, 2007; Kapoor, 2011;

Manaf, 2012; Rad, 2005; Rose et al,. 2004). Service quality output has been measured

from vast paradigm; customer experience, customer satisfaction, number of errors,

customer awareness, people management, waiting time, quality management empirically

(Bakar et al., 2008; Elleuch, 2008; Elluech, 2007; Kapoor, 2011; Manaf, 2012;Pillay et

al., 2011; Raja, Deshmukh, & Wadhwa, 2007; Rad, 2005; Rose, 2004;) and customer dissatisfaction (Jamali,2008). This is evident empirically that there is significant and

positive relationship between quality and customer satisfaction (Boulding, et al., 1993).

Service quality based on patient satisfaction of public hospital, which consists medical

services and overall service (Aagja & Garg, 2010). This service quality dimensions are designed for public hospitals. The root work is based on (Parasuraman, 2010) (There are

two dimensions used here. Medical service is defined as having knowledgeable doctors,

nurses, staff and prevent acquired disease. The second dimension is overall service which are defined below (Aagja & Garg, 2010): Tangible. This term refers to the use of modern

equipment, appealing material and facilities and professional appearance of staff (Sohail, 2003); Reliability. This term refers to the ability of the hospitals to provide promised

service and error-free record (Sohail, 2003); Responsiveness. This term refers to prompt services given and willingness to help patients (Sohail, 2003); Assurance. This term refers

to the ability to handle patients’ problems, instil confidence, courteous and knowledgeable

(Sohail, 2003).

On the other hand, studies indicate organizational is lacking in organizational learning

(Maden, 2011) and that many studies have ascertain the importance of learning in healthcare delivery (e.g. Damschroder, et al., 2009; Lipshitz, & Popper, 2000; Tucker,


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Nembhard, & Edmondson, 2007). Organizational learning important in the healthcare industry mainly to overcome mistakes and errors (Kim, Newby-Bennet, Song,2011) and to

face the various pressure in public healthcare (de Burca, 2000).Numerous empirical

research focuses on how organizational learning works in action at workplace through

learning (Gorelick, 2005; Johnson,2000; Lakhani, 2005; Mauchet, 2011). Although

some theories of learning had been studied only in workplace learning, some have

identified learning transferred into action. This approach is the sociological perspective. Comprehensively, OLSM identifies workplace learning into learning actions (Johnson &

Bailey, n.d). Schwandt & Marquardt (2000) adopted this sociological perspective of

organizational learning in their systemic model to reconcile several of the dissimilitude

extent in previous theories. Schwandt’s OLSM underpins Parson’s (1956) social action

theory. The learning model consists of four subsystem acquisitions, creation, sharing and retention and reuse of knowledge based on Parsons Adaptation (A), Goal attainment

(G), Integrative (I), Latent (L) which referred as AGIL. The study attempts to look into

the Organizational Learning perspective by applying the OLSM (Schwandt, 1997) which is

grounded from Parsonion Social Action theory (Johnson, 2000) to understand the gap in

the quality of service provided by hospital staff.

It is comprehensible that the service quality concept is a significant performance output

(Brady, Cronin & Brand, 2002). Past literature has taken tremendous effort in measuring

the delivery of quality service to patients as an indicator of performance level (Cronin &

Taylor, 1994). On the other hand, learning in the workplace has been quite significant in

improving this type of organizational performance (Maden, 2012) along with the current popular approach to innovation concept. Further to what have been discussed,

it is judicious to study the link between organizational learning and service quality.

This research contributes to fill the gap in the public healthcare in Malaysia, as this

industry plays the role as a key economic area to the nation’s growth and progress. In

order to fill the service quality gap, the study objective examines whether organizational

learning has relationship with service quality. The proposed research framework comprises of exogenous variables Organizational Learning while the endogenous Service

Quality. As a result, this model has second order construct and based on this, the

following four research hypothesis have been formulated:

H1: There is a positive relationship between Organizational Learning and Service Quality

2.0 LITERATURE REVIEW 2.1 Service Quality Definitions and Models

Service quality generally means ‘perceived serviced quality’ and evaluation should

come from the ‘customer perspective’ (Padma, Rajendran, & Sai, 2009). Parasuraman et

al. (1985) defined service quality as ‘the global evaluation or attitude of overall excellence of service’. (Wang & Shieh, 2006) defined ‘service quality is the difference between customers’ expectation and perceptions of services delivered by service firm’.

In a review of service quality models it has been identified that about 19 existing service quality models (Seth, Deshmukh, & Vrat, 2005); some to name are technical

and functional quality model by Gronroos, (1984), GAP model by Parasuraman et al.,(1984), synthesised model of service quality by Brogowicz, Delene, & Lyth, (1990).

(Cronin & Taylor, 1992). Most studies rely on several service quality model namely,

technical and functional quality model by Groonroos, (1984), and GAP model by

Parasuraman et al.(1985). Performance only model developed by Cronin and Taylor (1992), Rashid and Jusoff, (2009) and Seth et al., (2005).

2.2 Quality Service in Healthcare

Defining quality and even the scale used in healthcare is difficult as there are so many subjective meaning. Quality in healthcare as stated by Joint Commission is ‘the degree to which patient care services increase the probability of desired outcome and reduce the probability of desired outcome’ which is similar to Washington Institute of Medicine

(WIM) (Kapoor 2011). Kapoor (2011) however defined quality in healthcare as ‘degree of adherence to pre-established standards based upon prevailing knowledge and practices’.


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‘Service quality’ in healthcare refers to all other aspects of the patient experience such as hospital comfort and patient can judge service quality more accurate than clinical

quality (e.g. surgical skill) (Bakar et al., 2008). It broadly defined by the authors as

meeting customer expectations or providing perfect service and ability of an

institution to meet or surpass customer expectations.

Quality is used in every organization to meet the standard performance of the internal and external requirement of an organization. Nevertheless, the external standards need like

the customers seemed to be more important. Additionally what need to be met in

‘quality’ differs from one industry to another or rather what aspects. In the era of

beginning of industrialization, quality attention was directed towards manufacturing

the goods. Then later, organizations swayed its interest in quality in providing service and it has become a sensitive term over the years. Though service quality is significant

for many countries, and is significant in many industries, but healthcare services is

always as its high risk involvement (Rashid & Jusoff, 2008). Service quality is not only

seen as technical quality but also functional quality is seen as on how service is

delivered to customer (Rashid & Jusoff, 2008). Customers in healthcare are the patients

who to be the focus, who carries different values and views (Duggirala, Rajendran, & Anantharaman, 2008). Though efforts taken on quality improvement in healthcare but

shortcoming in the delivery of effective and reliable care remain (Boyer, Gardner, &

Schweikhart, 2012; Carman 1990). The extent of importance of service quality in the

healthcare setting can be viewed in Table 1. There been numerous service quality scale

development by many researchers to suit the countries healthcare setting. The dimensions use/developed by researchers are generally have some similarity. With regards

to this, it is notable that SERVQUAL (see Table 2) becomes the underlying model for the

instrument and studies conducted. Some of common analyses can be grouped into

services and empathy by hospital staff (doctors, nurses, etc.), amenities and facilities.

Some have gone for detail in developing scale precise for hospital setting.

Recently, Aagja and Garg (2010) attempted to adapt the measurement for public

hospitals which partly based on Duggirala’s work. The authors developed a scale for

measuring service quality from the patient perspective. Standard scale development

research procedure was followed based on experts. A reliable and valid scaled called

public hospital service quality (PubHosQual) measuring 5 dimension of hospital service quality; admission, medical service, overall service, discharge process and social

responsibility. However, it is emphasize that the dimensions are mainly grounded from

the work of Parasuraman, Cronin and Taylor. The dimensions were adapted from Carman

(1990) and (Rust & Oliver, 1993) on admission, medical service, overall service and

discharge.

Some research find SERVQUAL is reliable in healthcare but some doesn’t capture

healthcare dimension (Babakus & Mangold, 1992). SERVQUAL scale is important to tailor

to sector specific needs, culture or nation (Butt & Run, 2010; Parasuraman et al. 1991).

Critics argue that performance based measure is more appropriate for measuring service

quality (Sureshchandar et al., 2001). Many researchers has discarded the expectation in measuring service quality through SERVQUAL is still a preferred model in many sectors

(Butt & Run, 2010; Parasuraman, Zeithaml, & Berry, 1985). Andaleeb, (1998). Bowers

et al (1994) human interaction and relief from pain and suffering following treatment

not included in SERVQUAL. Many of the item adapted based from SERVQUAL,

SERVPERF and functional and technical quality. Based on these scales studies are

conducted in the healthcare industry. These studies have contributed to the development of quality clinical service and setting and identification of patient needs and expectations

or demands. In fact, customer satisfaction has an important outcome of service quality.

Bowers, Swan and Koehler (1994). In this notion, patient satisfaction and/or expectation

is examined to determine the level of service quality. Thus as many empirical evidence

have used patients or family members or friends to determine quality level (Padma et al.,

2009; Prasanna, Bashith, & Sucharitha, 2009). Patient or customer is important in Asian context because countries like India, Malaysia always accompanied by their family

members.


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Similar to other developing countries, Malaysia has been keen in managing service quality in the healthcare industry (Rose et al., 2004). Since, complaints has been prolonging

like long wait hours, unfriendliness, apathetic and uncaring attitude of staff are some

issues in Malaysia (Yusof, 2002). In comprehensive national study conducted found

issues on average lengthy waiting time employee attitude and work process, heavy

workload, management and supervision problems and adequate facilities are some

issues highlighted as problems in public hospitals in Malaysia(Pillay et al., 2011). Other service quality problem is intangibility of nature of service, maintaining the variability of

customer-employee relationship, educating patients of service provided (Rashid & Jusoff,

2009). It was found that medical staffs play an important role in determining customer

quality evaluation (Elleuch, 2008).

In 23 public hospitals Malaysian study, physical and clinical dimensions measured.

Results found that inpatient and outpatient were more satisfied with clinical dimensions

(Manaf & Nooi, 2007). The measure used was adaption of Institute Health Malaysia.

Similarly in another Malaysian context used SERVQUAL measure private healthcare

quality (Butt & Run, 2010). The instrument was based on modified for Malaysian context

but capture the five service dimensions. There was negative gap found between perception and expectation especially in service reliability

In healthcare setting patients rely on functional aspects like facility, food quality and

employee attitude, etc. (Rashid & Jusoff, 2009). Sohail (2003) analyzed patient expectation

and perception of the quality service using SERVQUAL in Malaysian setting. Results indicate that patients perceived value of service exceed expectations for all variables

unlike countries like Hong Kong (Sohail, 2003). On the other hand (Butt & Run, 2010)

used modified SERVQUAL to measure Malaysian private healthcare quality. Results

shows moderately negative quality gap on each service quality scale dimension. Seven(7)

point likert scale used in assessing the patients in private hospitals. It is found that

SERQUAL is robust for Malaysian context. However, the results indicate expectations are higher than the perception thus giving a negative gap in private hospitals. Service

‘reliability’ and ‘responsiveness’ indicates highest negative score. Malaysian healthcare is

still in need to find solution to solve problem not on ad hoc but long term.

Service quality is a complex performance construct (Young, Meterko, Mohr, Shwartz, & Lin, 2009). Employees may not be best in assessing the service quality that they tend to

assess lower than the customers. This study is about investigating of whether and to what

degree employees assess their service quality of their organization similar to their

customers. However employees tend to underestimate the service quality as compared

to patients. Longer tenure was associated with greater congruency, suggesting employee

more experience in organization gain skill in interpreting customer related cues about quality. Organization with stronger customer service oriented work climates presumably

have an infrastructure for collecting, analyzing, disseminating to employees information

about their customers attitude and opinions concerning service quality. Physicians

assessment of service quality were more congruent with customer assessments than

were the assessment of other employees. This is because they may have first-hand information about the quality issues. Thus, the connectivity physician and customer is

important.

As to meet this research context, adapts Aagja and Grag (2010) measurement on two

dimension; medical service and overall service. So far this is the preferred scale for this

study justifying that; the two dimension has got the validity and reliability test and most suitable for the Malaysian patients, has got lesser number of question as per field

experts concern, measures has SERVPERF & SERVQUAL context in more short and

concise manner except for ‘empathy’ as Aagja and Grag derive in separate dimension, and

finally the scale is meant for the Asian context. The other three dimensions (medical

service and overall service) were not adapted because it is non-feasibility; some

questions are not suitable for outpatient that violates the study methodology. Next, the section discusses the antecedent variable for the service quality study. Organizational

learning from the Parsons Social Action theory is elaborated.


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2.3 Parsons Action Theory

Talcott Parson has based his work from Pareto, Durkheim, Weber and Compte (Parsons,

1966), Shills and Bells (Schwandt & Marquadt, 2000). This is called system of social

action (Schwandt & Marquardt, 2000). Some of the other theorists whom have used the

Parsons theory are like Denison(1990), Silverman(1973), Burrell and Morgan (1979) and

Schwandt (2009). However Parsons theory used as foundation study is the Schwandt Organizational Model as the sociological perspective.

Action in Parsons theory is dependent on situation of goal oriented: situation of means

and condition, end/goal, norms and values, relating end to situation (Rocher, 1975).

The subsystem of actions is necessary for the social subsystem to function (AGIL). The

AGIL has mutual exchange:

1. Adaptation to environment(A)

2. Allocation of resources and goal attainment(G)

3. Interaction of systems Action(I)

4. Latent motivation patent (L)

The four functions of Parsons General Theory of Social Action are applicable at all level of

analysis with integration of social, psychological and cultural element of organizational

dynamics depicted in Figure 1 (Gorelick, 2005; Johnson & Bailey, n.d.; Schwandt and

Marquardt, 2000). 2.4 Organizational Learning Systems Model

The Organizational Learning System Model is dependent on the collective learning for

change to take place. Schwandt & Marquardt (1990) finds that organizations are social

system that change based on performance and learning (Gorelick, 2005). This is

because on the Parsonion Theory of Social Action. Social Action Theory of Parsons is based on four integrated elements of social action (Gorelick, 2005; Johnson & Bailey,

n.d.; Schwandt,1997).

1. Actor/subject: an individual, group or collective

2. Situation: the physical and social objects which actor relates 3. Symbols: the means through which the actor relates to different situation and assigns

meaning to them, and

4. Rules, norms, values: the guiding factors for the actors relations with the

social objects in his/her environment.

Each subsystem has its functional prerequisites. Then the functional perquisites is interacts through the medium of interchange (input and output). With this the

subsystem continuously interacted with each subsystem. This is illustrated in Figure 2.

Later Schwandt (1997) emphasize the learning aspect of change in Parsons General

Theory of Social Action based in Figure 2 and described further in Table 3.

1. Environmental Interface Subsystem (adaptation): information obtained requires to

secure, filter and expel information [output: new information]

2. The Action/reflection subsystem (goal attainment): creation of valued knowledge from

new information, goal of learning system [output: goal referenced knowledge]

3. Dissemination/Diffusion (Integration): transfer the information and knowledge within

organization through informal and formal way [output: structuring] 4. The Meaning and Memory Subsystem (culture or pattern maintenance):

establishment of criteria for judgment, selection, focus, control of Organizational

Learning system. Beliefs, values, assumptions and artifacts - cultural component of

organization.[output: sensemaking]

The interchange medium for the learning subsystems are new information, goal reference knowledge, structuring and sensemaking (Schwandt and Marquardt, 2000).

OLSM signifies empirical evidence from sociological perspective reconciles the gap of


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organizational theories (Lakhani, 2005). Action is can be associated with performance, or only with learning or both simultaneously as in Table 3. It should be understood that

any change occur through learning and performance actions. For the purpose of

analysis in this research these actions are separate to two independent system

(performance and learning). The analogy of performance and learning reflects in the

actions of organizations. It is actually difficult to see the learning act, however to

understand learning which may be seen in cognitive or behavior changes (performance). OLSM focuses on Organizational Learning as a social system and how it learns to

survive in the environment (Schwandt & Marquardt, 1990). It is grounded from

Parsonian theory which rooted from works of Pareto, Durkheim and Weber (Parsons,

1966). The OLSM comprise of subsystem, functions and output for each tabled as

below. The symbolic patterning, performance defined as maintaining the system structure while the physical and social objects are acquired as possessions, used as

facilities possibility consumed, created or change in the system values (Johnson and

Bailey, n.d, p.3). Learning from symbolic perspective is processes of change in the

symbolic-meaning pattern of the system. Based on parsons work and Schwandt work

organizational performing action and organizational learning action:

“…Learning action complex social system of actions, actors, symbols and

process that enables an organization to transform information into valued

knowledge, which in turn increases its long run adaptive capacity.”

(Johnson 2000, p.57)

Studies through confirmatory factor analysis found organizational learning action are

valid through the OAS measurement (Johnson, 2000; Krishna 2008; Doiron, 2012;

Mauchet, 2011). Johnson (2000) found the reliability for the four dimensions ranging from 0.64 to 0.78.

2.5 Organizational Learning and service quality as performance outcome

Parson(1966) general theory of social action has performance and learning element.

Schwandt and Marquadt (2000) views learning process as integrated with performance

and learning. Unlike other scholars like Argris & Schön(1978), Huber(1991), Garvin

(1985) views learning as a process only. To sustain performance in organization performance and learning is important (Gorelick). In comparison with Schwandt’s

learning concept though it is integrated performance and learning but not sufficient to

ensure the organizations sustainability (Gorelick, 2005). Customer satisfaction is seen

as important provision in measuring health system performance (Brambhat et al., 2011). Customer performance is positively link to business performance (Peltier, Zahay,

& Lehmann, 2013). It is evaluated from customer retention for a long time and customer satisfaction, providing services. Scholars argue that performance based measure is more

appropriate for measuring service quality because is basically measure the consumer

attitude (Sureshchandar, Rajendran, & Anantharaman, 2002). Better service quality is

positively related to organizational performance. Service quality also has mediating effect

between market orientation and endogenous organizational performance (Ramayah,

Samat & Lo, 2011). Full involvement of entire workforce and continuous improvement is achieved for customer satisfaction (Evans & Lindsay, 2006).

Learning evidence-based decision support system in healthcare organization has

resulted in recognition of data quality improvement as key area of both strategic and

operational management in US healthcare. Managers are being to understand the

importance of formal, continuous data quality assessment in health services delivery and quality management (Lorence & Jameson, 2002). Learning error is to the extent of

frequency, severity, understanding, awareness of errors has improved their hospital during

last 3 years. On a particular factor of creating safety climate for patient to error learning

has shown significant and positive relationship indicating the structural model fit (Boyer

et al., 2012).

Quality healthcare can be achieved when task is refocused on learning organization (de Burca, 2000). Thus, having superior performance requires innovation to strengthen this

value chain, greater learning in organization is most needed (Weerawardena, 2003). This


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can be supported by generative learning (March, 1991) that learning internally and externally is prerequisite to generative learning (Weerawardena, 2003). Lifvergren,

Docherty, & Shani (2011) argues sustainability of healthcare system depends on one of

learning mechanism to meet the dynamic challenges. Learning mechanism at cognitive

based (practice based) are concepts, values, frameworks expressed in the value

statement, strategy and policies of the organization. The other two is procedural based

(routines, tools, etc.) and structural (organizational infrastructure).

Organizational Learning is sequential information processing activities with assumption

that any process of knowledge socialization and collective learning is based on the

relationship that consist of building and sharing (Morrison& Sandmeier, 2008). OLSM

conceptualizes this notion of creating and sharing knowledge. Fiol & Lyles (1985) sees

this as process of Action (Morrison& Sandmeier, 2008). Companies make more profit

when integrated the customer know how into innovation process as Fiol & Lyles (1985) sees this as process of Action (Morrison & Sandmeier, 2008).

There is abundance of conceptual literature that concerns the relationship between

learning and performance (Chonko, Dubinsky, Jones, & Roberts, 2003). There is still

confusion in the organizational learning as yet to have appropriate measurement

development (Jyothibabu, Farooq, & Pradhan, 2010). There have been numerous study linked with organizational learning and organizational performance. However, both the

concepts are very wide in nature as there have been many theories and models pertaining

to it in the literature. This has been discussed above. Since the study is on healthcare,

performance of this industry is very much based on quality service delivery. Therefore,

further discussion highlights the possible type of relationship between organizational

learning and service quality. Organizational learning evidently enhance organizational performance (Kim, Newby-Bennett, & Song, 2013). The creation of a quality healthcare

when a task is refocused to creation of learning (de Burca, 2000).

Action learning is another concept that part of Schwandt’s organizational learning model.

Action learning able to create inquiry, share and create problem solving culture among

individuals and groups. Action learning able to measure return on investment, which

relates directly to workplace and impacts on organizational performance (Pounder, 2009). Peltier et al. (2013) finds that customer retention has positive link to business

performance. The business performance is evaluated from return on investment from

customer basis.

In South West London hospital study the term on evidence-based practice shows positive

effect on service provided in the hospitals. Learning can be obtained through library

information, problem or error based. An empirical analysis by Manaf (2005) in Malaysian public hospitals which sampled 23 hospitals studied in quality management practice.

Continuous improvement, strategic planning, quality assurance, teamwork, leadership

and management commitment, employee involvement and training and management by

fact and supplier partnership are aspects studied under the quality management aspect.

It was found that physicians as the important contributor of hospital is perceived lowest

among other category of staff.

One research on Indian power plant tried to identify an integrated scale for Organizational Learning through learning enablers, learning outcome achieved and

performance outcome (Jyothibabu, Pradhan, & Farooq, 2011). They argued that there is

yet to have appropriate scale to be developed for organizational learning which leads to

conceptual confusion. In their study they used Watkins & Marsick’s to measure the

facilitator of Organizational Learning. Organizational size studied as control variable in

past literatures as its large number of employees have more difficult time to share knowledge. Organizational level dimensions are employee empowerment, embedded

system, system connection and leadership for learning which found closely associated

with each other. Organizational Learning also directly contributes to performance than at

an individual or group. The OLSM model used focusing on Action/reflection (goal

referenced knowledge) and meaning/memory (sensemaking) (Schwandt & Marquardt, 2000).


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Based on Raja, Deshmukh, & Wadhwa (2007) some healthcare problem identified in India as lack of competence, low technical quality and response to patient needs and lack

of evaluation. It was found that relationship, resource management, people management

and customer satisfaction has shown positive influence on service quality in India.

Similar issues is highlighted by Hulton et al., (2007) and his associates like inappropriate

procedures, lack of professional attendance and delay.

Kuo (2011) use Delaney and Huselid, (1996) performance measure service quality and

customer satisfaction from seven elements. In this Taiwanese study, the organizational

learning consists of goal setting, flexibility of HR requirement, providing clear guideline,

team and cross-cultural interaction. Organizational learning was found to positively

influence to organizational performances. This reported the same by (Ruiz-Mercader, Meroño-Cerdan, & Sabater-Sánchez, 2006). In team learning also influence performance

(Zellmer-Bruhn & Gibson, 2006). (Hanvanich, Sivakumar, & Hult, 2006) finds learning

orientation and organizational memory related to organizational outcome. In Kuo (2011)’s

study, organizational learning is measured in terms of information sharing, inquiry

climate, learning practices and achievement mindset based on Huber (1991) theory.

In one study on knowledge sharing is not only able to improve organizational

performance but also considered to enhance patient safety (Kim, Newby-Bennet & Song,

2011). Knowledge sharing concept by (Srivastava, Bartol, & Locke, 2006) team members

share idea, information and suggestion’. It is emphasis that hospital should have

learning system to improve patient safety which through knowledge sharing. In a study in Chinese public healthcare system found unsatisfactory delivery of services highlighted by

Lee, Ng and Zhang (2007). In order to overcome this as solution on performance

management tool like Balance Scorecard able to achieved to improve accountability

among employees. Based on Schwandt’s model, this consists of Integrative Performance.

The link between input and the resulting outcome can be rather complex in healthcare industry. Lack of knowledge here is important because it involves diverse specialization

group, e.g. doctors and nurses. Thus according to (Natarajan, 2013) the making of

systems thinking is complex. Some of the serious obstacles identified among employees

lack of awareness on problems, responsibility, understanding on the work process that

undermines the healthcare system. This actually notifies the need of performing and learning action aspects. Some of the healthcare performance are safety, effectiveness,

patients-centeredness’, timeliness and efficiency (Natarajan, 2013).

Organizational learning scale by (Hult, Ferrell & Hurley, 2002) used. The four factors

measurement model includes team orientation learning orientation, memory orientation

and learning system orientation. The study sampled managers of purchasing units in one of Fortune 500 multinational corporations. This is tested on the effect of cycle time

performance (time taken from initiation to completion). This is positively with learning

seminars which has direct and significant effect.

The greater organizational and individual learning, greater the change success e.g. customer satisfaction (Chonko et al., 2003). Their empirical evidences measure

specifically on sales volume of salesperson. This is because traditional performance

measure in general may not be adequate. It has to be outcome based like sales volume

or service quality level.

In a study on learning orientation consist of creating and using knowledge to enhance competitiveness (Calantone et al., 2002; Baker & Sinkula, 1999). This consists of

obtaining and sharing information about customer needs, market changes and competitor

actions, new technology development. In this study learning orientation is a reflective

construct commitment to learning, shared vision, open mindedness and intra knowledge

sharing (Calantone et al., 2002). It works as stores knowledge and takes feedback from

customers and develop core competency. We can understand that numerous studies identified the effect between learning and performance (competitive advantage, financial,

non- financial, customer satisfaction, etc.). However, what we infer so from empirical


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researches is, whether any learning model link directly with organizational performance by integrating customers understanding on service or product. OLSM from a social

action perspective to be tested the relationship from learning and performing action

perspective. As conclusion, though is rather wide in scope the relationship relating to

the two constructs, there is yet fill the gap in this relationship. Of note, it is

comprehensible that past literature scope is mainly on the common performance outcome

rather than specifically on service quality.

3. METHODOLOGY

The study aims to examine the correlation between Organizational Learning (OL) and

Service Quality (SQ). It contains a description on philosophy of research, research design,

population and sampling, instrument, validity and reliability, data collection procedure and data analysis (Zikmund, Babin, Carr, & Griffin, 2012).

It involves collecting and analyzing numerical data and applying statistical test

(Creswell, 2007). The research attempts to obtain information on the characteristics of the

problem and predicting action on the basis of hypotheses. Thus, the study is grounded on

descriptive and predictive research type (Hussesy & Hussey, 1997; Sekaran, 2003). The research is based on a non-experimental survey study using self-administered

questionnaires. For the purpose of this study, structural equation modelling (SEM) was

conducted in order to verify the degree to which organizational learning is associated with

service quality in the medical industry. Samples were obtained from the public hospitals

in Peninsula Malaysia. Questionnaires were administered among two dissimilar groups of respondents; patients and head of departments in the selected hospitals. Drop and pick

method was used for the paper based surveys whereas SPSS 19.0 and Analysis of a

Moment Structures (AMOS) 21.0 have been used as statistical tools. Structural

Equation Modelling (SEM) is use to test hypotheses about a particular factor structure,

which produces goodness- of-fit measure using AMOS software (Albright, Myoung & Park,

2009).

The samples consist of multi-specialty hospitals such as maternity, orthopaedic and other

specialties which managed by the government (Aagja & Garg, 2010) as in Table 4. There

is total of 87 multi-specialist government hospitals situated in Peninsula Malaysia

(Ministry of Health, 2013). There are 55 hospitals which have a bedding capacity of more than 100 beds and been selected for the purpose of this study. Thus, with a total of

825 departments, 488 questionnaires were distributed to 23 hospitals upon the

approval received. from the Ministry. The study uses disproportionate stratified

random sampling procedure (Israel, 1992; Awang, 2014). Since the study covers an

exclusive and selected number of respondents from Peninsula Malaysia, drop and pick

and also self-administered survey method was used to obtain sufficient response form. 3.8 Measurement Instruments

Organizational Learning instrument were administered to the head of departments’ of

clinical and clinical support department as in Table 5 . All items uses the seven (7) point

likert scale. The likert scale also acceptable to assess patient perception measure (Butt & Run, 2010). The questionnaires consist of two major parts for patient and head of

department participants where the dimension items displayed in Table 6 and Table 7: Questionnaire A (respondent: head of department)

1. Organizational learning

2. Demographic profile (gender, age, frequency of visit, education level, treatment expenses and ethnic group) Questionnaire B (respondent: patients)

1. Demographic profile (job category, department, age, education, position, years of

working experience, years in current position)

2. Service quality The OAS instrument is owned by George Washington University, in which validated

further by Johnson (2000). The OAS measure Organizational Learning from the


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learning action and performing action. The instrument rooted from the theoretical grounds of Schwandt’s (1997) dynamic social Action learning. OAS consists of 15

items from two sub-constructs organizational performing action and organizational

learning action used for this study from which four items dropped. Each serves with

four subsystems. Each question items begins with ‘To what extent…’ and followed

by a seven(7) point Likert scale from strongly agree to strongly disagree. However,

only the Learning Action is measured for purpose of measuring Learning Action.

This instrument however, was not plausible based on the experts’ opinions from

Malaysian public hospitals as a short and concise instrument was recommended. Thus, a

similar grounded instrument was adapted. The instrument from PubHosQual was adopted from the scale developed by Aagja & Garg (2010). It has four dimensions namely,

admission, medical service, overall service, social responsibility. Two relevant dimensions

(medical services, overall service) consisting of 13 items were adopted as shown in Table 7.

One (1) item dropped from medical service. The other dimensions were not adopted

because it was considered unfit for this research as it involves both outpatient and

inpatient and the time consideration to not disturb the patients. The advantage of this scale is that it is more specifically designed for public hospitals (Aagja & Garg, 2010)

though its grounded from ‘gap model’ of service quality by Parasuraman (1994), Carman

(1990) and Rust & Oliver (1994). Based on the exploratory, the coefficient alpha scores for

scale validation of medical service was 0.5880 and overall service was 0.8194.

4. DATA ANALYSIS

This segment discusses the result for dimension Learning Action and Service Quality.

The mean, maximum, minimum, standard deviation, skewness and kurtosis for all

constructs in Table 12. The total score of the respondents for the scales computed to

determine the levels of the constructs in the study. Subsequently, the level for the scales

of seven(7) point likert scale is categorized to three levels; high, moderate and low.

Learning Action scale comprises of four subcontract; Adaptive learning, Goal Learning,

Integrative Learning and Adaptive Learning. The mean ratings for Learning Action

dimensions and its subscales are also presented in Table

12. The integrated learning scored highest (µ=4.0400, σ=0.82758). Next the goal oriented learning scale (µ= 4.0226, σ=0.92659) and followed by Latent Learning (µ= 3.9898,

σ=0.87969) and Adaptive Learning has (µ= 3.9661, σ=0.86601). It is notable that the

mean values are not far distinct among the subscales which is less than 0.1. The overall

mean score for Learning Action was computed in determining the level of Learning Action

in hospitals. Overall high mean score of Learning Action indicated 4.00 which is above the

midpoint. The summary of descriptive statistics is shown in Table 4.2. Standard deviation is 0. 56519. Based on 7 point likert scale, minimum Learning Action is 2.33 and

maximum of 6.33. These values implies that the overall level of mean score indicate at

moderate level based on Table 13.

The overall mean score for Service Quality scale was computed in determining the level of Organizational Innovativeness in hospitals. Overall mean score of Service Quality is 3.9749

which is above the moderate level as in Table 12. The summary of descriptive statistics is

shown in Table 12. Standard deviation is 0.78753. Based on seven(7) point likert scale,

minimum Service Quality is 1.85 and maximum of 6.08. These values implied that the

overall level of Service Quality mean is moderately high. An examination of the values for

skewness and kurtosis indicates that the assumption about normality of the distribution is not violated. Likewise, service quality in public hospitals is perceived at a moderate

level by patients, consists of 79.19%. Though score indicate 175 aggregated respondents

falls in moderate level, the actual number of frequency score that represents is

(N=175x4)700 out of 884 respondents. The low level contributes to 23(10.41%)

respondents and equivalent score at the high level score as well.

The CFA results showing fitness indexes and factor loading for every item is presented in

Figure 3. The text output explaining the results in Figure 3 are presented in Table 8,9,10


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and 11. Item would be deleted if factor loading less than 0.6 is achieved or check Modification Indices (MI) if model fit is not achieved. High value of MI (more than 15)

indicate redundant item in the model (Awang,2014). The indexes RMSEA, GFI, CFI

and Chisq/df were assessed in this study as it is frequently reported in literatures as in

Table 8 (Hair, et al.2010; Awang, 2014). Table 10, output is based on individual CFA on

the constructs. The items that have low factor loading were dropped. Two items dropped

in service quality dimensions and 2 items in learning action dimensions. Based on the measurement model for this study; the uni-dimensionality, validity and reliability have

been assessed. The construct validity, convergent validity and discriminant validity meet

the model fit requirement. The reliability of the model is met based on the assessing of

composite reliability (CR) and Average Variance Extract (AVE) in Table 11. It can be

assumed that data for all constructs for Leaning Action and Service Quality are approximately normally distributed in terms of skewness and kurtosis based on

calculated z value is within -1.96 and +1.96. An examination of the values for skewness

and kurtosis indicates that the assumption about normality of the distribution is not

violated as shown in Table 9.

Figure 4 presents the Standardized Regression Weight and Figure 5 presents the Regression Estimate. Based on the Standardised Regression Weight in Figure 4,

standardised beta estimate for Learning action (LA) effect to Service Quality(SQ) is 0.47 as

in Table 15. The value of coefficient of determination R2 is 0.22 in Table 16. It indicates the contribution of the exogenous constructs LA estimating SQ is 22%. The fitness index

assessment for the structural model is presented in Table 14. The standardised beta

estimate in Table 15, when LA goes up by 1 standard deviation, SQ goes up by 0.466

(SQ = 0.466LA). The probability of getting on critical ratio is 4.164 in absolute value is

less than 0.001 as in Table 15.

Hypothesis H1 findings reveals that Learning Action is found to have significant and

positive relationship with Service Quality. This implies that the higher the Learning

Action leads to higher Service Quality. This hypotheses was supported based on strong

path coefficient (β=0.376, t=2.625, ρ<0.05). When Learning Action goes up by 1 unit,

Service Quality goes up by 0.376. The regression weight for LA in the prediction of

Service Quality is significantly different from zero at the 0.05 level (two-tailed). Thus,

Learning Action has significant and positive effects on Service Quality. The result of hypothesis is presented in Table 17.

5. DISCUSSION

Organizational Learning to Service Quality is explained further since performing action

and learning action is a reflection of organizational learning. Both hypotheses H1 is

supported the study suggests that level of organizational learning has a substantial

criteria in defining their growth and success. It is being confirmed that the benefit of learning is through understanding patterns of behavior (Gillies & Maliapen, 2008)

Therefore, hospitals show a greater organizational learning, the higher the service

quality offered by the employees. At a time when quality and safety outcome of

healthcare institutions in limelight and sensitivity of the nature of services provided

(Jamali, Hallal, & Abdallah, 2010), calls for better management approach and increase responsibility is unlikely to be denied. Other factors in the organizational learning in the

systems model identified like structured, formalized incentives, team, collective individual

work and in collaboration shows quality healthcare is achieved through this (Ezziane,

Maruthappu & Wan, 2012) seems supporting the study. This represents the

action/reflection subsystem. The supports the finding that collaborative learning in team

improve patient safety and employee rewards improve as they identify critical mistakes (Goh, Chan, kuziemsky, 2013). It also agreeable that stronger group oriented culture

leads to better problem solving. Learning at work that generate actionable learning in

understanding organizational learning and provides change in work environment like

awareness on patient safety (Sujan, 2015). The influence of excellence care delivery,

ethical values, involvement, professionalism, value for money, commitment to quality and strategic thinking determines quality service delivery (Carney, 2013).


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6. THEORETICAL AND PRACTICAL IMPLICATION These findings suggest that the theories may benefit from the incorporation of other constructs as suggested by the organizational learning scholars. The study examines specifically on one phase of performance outcome that is service quality. It evaluated the level of service quality based on employment actions that transformed from the hospital employees. This at once provides the value of planning and experience gained in the work and how it transforms to provide a total service to the patients. As discussed above, this research revealed the central role to deliver effectively and efficiently service to the patients. The research breaks a new ground by studying learning activities in healthcare context and by empirically distinguishing learning and performing action oriented, although the processes are the same (Gorelick,2007; Schwandt & Marquadt,2000;). In addition to advancing empirical understanding and methodological approach, this research also contributes to the development of the literature. The implication of this model fit suggests that knowledge based practices should

be carried out.

Lastly, the research suggests that future studies may consider a broader dimension of service quality recommended by service quality scholars in the healthcare industry. As the present study found lack of time, tedious procedures involve and need monetary aid for the current query. The organizational innovativeness measure was not being able to adopt at the wider scope based on dimensions developed by Wang and Ahmed (2004). This, however, can be carried out by the Clinical Research Centers in each state of Malaysia. Other than that, this study also provides several implications to the healthcare practices and MOH. On a practical ground, this work provides a stepping stone for hospitals seeking for better performance in servicing the outgrowing number of patients. Department heads can set up departments to act jointly and get along as a team to serve the patients. This helps to cut down on unnecessary processes. The learning organizational cultivation can be a source to improve quality of services provided. More generally, the departments will get to understand the factors that facilitate deliberate efforts to improve work practices, thus overcoming barriers to service output.

The study also provides insights for the practical field whereby practitioners and head of departments are able to connect the importance of creating a learning organization that subsequently affects the performance outcome. In fact, organizational learning enables them to cite the laggings in terms of competency among their department staff, which probably been a crucial thing to solve. The HRD professional and the Clinical Research Centers in every district and hospitals can create relevant interventions to tackle problems associated with providing quality service. This can be facilitated for competency training by MOH as well as in the performance management and quality management practice. To sum up, the findings help to understand better on the mechanism by which learning affect service quality. This reflects the need for combining clinical and administrative perspective in future research studies. It is hoped that the findings will lead to hospital administration and practices by the Ministry of Health and also future research that delves more deeply into these constructs.

7. RECOMMENDATION FOR FUTURE RESEARCH

This research is theoretically acceptable and practically applicable by presenting a model fit that links between the constructs. Future study should focus on the proposed practical model that clarifies more on the linkage of the constructs. The result of the study is directed to future research. As recommended by Babakus and Mangold(1992), functional quality isn’t just enough, besides the technical quality for long term quality management. Quality service recognition should not be the means to solve public hospitals’ problems, but organizational learning which should be the means that meets the ends for the hospitals. Organizational Learning System Model(OLSM) can also studied innovativeness as mediating effect. The cross-sectional nature of data gathered imposes the first methodological limitation. For this reason the other research design such as experimental and longitudinal are desirable when testing the causal study relationship between variable or in-depth case study. This probably gives a richer apprehension of the relationship of the constructs proposed in the model and serve further to examine the applicability and utility from a pragmatic tip of opinion.


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8. STUDY LIMITATION The study had both theoretical and methodological limitations. Although the empirical

effects of this study largely support the proposed research model, at least a few limitations

should be counted. The use of cross-sectional sample with questionnaires is a limitation.

Many similar studies find this methodology as a limitation (Rhee et al., 2010; Jiménez-

Jimenez, et al. 2008).Longitudinal may be more appropriate to study the linkage among

innovativeness, organizational and service quality established over time. The study was unable to consider all the departments, e.g. cardiology or psychiatry as it is highly

sensitive to approach patients and more time is require for that. Results may differ

pertaining to this. In addition the service quality measurement is more specific and,

not subjective based performance since performance has many different factors. The study

cannot be generalized to other industries as its focuses on public hospitals and caution should be taken when conducting research on private hospitals in Malaysia. Respondents

for service quality assessment are from mixed group; inpatient and outpatient, thus some

dimensions of the instrument were not able to be measured. In order to obtain

maximum response from all the departments without biasness and respondent

limitations, ‘attendants’ of patients were accepted for the questionnaire administration

e.g. Pediatrics department.

9. CONCLUSION

The result suggests that the organizational learning positive and significant effect on

service quality in the Malaysian public hospitals. This implies that, the governmental

policies and practice by MOH should aim more on creating learning organization that can stimulate more on learning and performing simultaneously. Given the growing

attention in healthcare problems (e.g. waiting hours, errors, treatment and

procedures) in service delivery in Malaysian public hospitals, this study provides

practical solutions for MOH in terms of facilitating learning and providing effective in

the service delivery to patients. Importantly, the study has contributed to the integration

of social system with organizational learning concept which this leads to path on future empirical enquiry.

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Author Measurement/Model/Framework Dimensions

Ramsay et al.(2000) General Practice Assessment

Survey

(GPAS)

Access, technical care,

communication, interpersonal care,

trust, knowledge of patient, nursing

care, receptionist, continuity of care.

Grol & Wensing (2000) European Society for Quality in

Family Practice (EQuiP)

Technical care, doctor patient

relationship, information and

support, availability and

accessibility.

Baker & Whitfield

(1992)

Consultation Satisfaction

Questionnaire (CSQ)

General satisfaction, professional

care, depth of relationship, length of

consultation

Duggirala Modified SERVQUAL Infrastructure, personnel quality,

process of clinical care,

administrative procedures, safety

indicators, overall experience of

medical care received, social

responsibility

Aagja & Garg(2010) Modified GAP MODEL and Carman

1990, Rust and Olivers(1994)

called as PubHosQual

Admission, medical service, overall

service, discharge, social

responsibility

Andaleed,1998 Modified SERVQUAL Communication, cost, facility ,

competence, demeanor

Raduan et al. 2004 Modified SERVQUAL Security, performance, aesthetics,

convenience, economy, reliability.

Tomes & Ng (1995) Modified SERVQUAL Empathy, understanding of illness,

relationship of mutual respect,

dignity, food, physical environment,

religious needs.

Padma et al. 2009 Several models and factor Infrastructure, personnel quality,

process

of clinical care administrative

procedure, safety indicator,

corporate image,

trustworthiness of the hospital

Rust & Oliver(1994) modified SERVQUAL Service product, service

environment,

service delivery

Donabedian(1980) Framework structure, process

and outcome

Efficiency, effectiveness, optimality,

acceptability, legitimacy & equity.

Carman(1990) Admission, tangibles

accommodation, tangible food,

tangible privacy, nursing,

explanation visitor access,

courtesy, discharge planning, and

patient accounting perception.

Masachuttes Health

Quality

Partneship

(MHQP)

Massachusetts Health Quality

Partners

Quality of doctor (patient

interaction,

communications, integration of

care, knowledge of the patient,

health promotion), organization

features of care

(organizational access, visit

based continuity, clinical

team, staff

Table 1 Summary of healthcare dimensions for service quality from past literature


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Figure 1 Parsons Four Functions (Schwandt, 1994)

Organizational Learning

Subsystem

Function Output/input(Interchange

Media)

Environmental Interface

Memory/Meaning

Dissemination and

Diffusion

Action/Reflection

Adaptation

Pattern Maintenance

Integration

Goal Attainment

New Information

Sensemaking

Structuring

Goal Reference

Organizational Performance

Subsystem

Function Output/input(Interchange

Media)

Acquisition of Resource

Production/Service

Management Control

Reinforcement

Adaptation

Pattern Maintenance

Integration

Goal Attainment

Instrumentality

P/S Quality

Management Philosophy

Performance Standard

Table 2 The subsystems, functions and outputs of Organizational Learning Subsystems

Figure 2 Media of Interchange in Schwandt Learning System (Gorelick,2005; Schwandt & Marquadt, 2000)


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SERVQUAL Dimensions

(Original Dimensions)

Definition

Tangibles(tangibles) Appearance of physical facilities, equipment,

personnel, and communication materials

Reliability (reliability) Ability to perform the promised service

dependably and accurately

Responsiveness (responsiveness) Willingness to help customers and provide prompt

services

Assurance (competence,

courtesy, credibility, security)

Knowledge and courtesy of employees and their

ability to convey trust and confidence

Empathy (access, ommunication,

understanding the customer)

Caring, individualized attention the firm

provides its customers

Table 3 Correspondences between SERVQUAL dimensions with original five(5) definitions for evaluating service quality

Source: Babakus & Mangold (1992), Elluech (2008)

CLINICAL SERVICE CLINICAL SUPPORT

1. Dermatology Dietetics & Catering

2. Emergency & Trauma Imaging Diagnostics

3. General Medicine Nursing Service

4. General Medicine Occupational Therapy

5. General Surgery Pharmacy

6. Hemodialysis Physiotherapy

7. Neurology/Nephrology Psychiatry & counselling

8. Obstetrics & Gynecology

9. Oncology

10. Ophthalmology/Optometry

11. Oral Surgery (Dental)

12. Orthopedics & Traumatology

13. Otorhinolaryngology

14. Out-patient

15. Psychiatry & mental

16. Pediatric Dentistry

17. Pediatric Medicine

18. Radiology (Diagnostic Imaging)

19. Rehabilitation

20. Rheumatology

21. Specialist Clinic

22. Traditional & Complementary

Table 4 Sampled Departments

No. Measure No. Items

Source Respondent

1 Organizational Learning Action (15 items)

15 (Johnson & Bailey, n.d.-a); George Washington University; Mauchet,2011) (OL1-OL15)

Head of department

2 Service Quality (SQ) Medical Service (4 items), Overall ServiceDimension (9 items)

13 (Aagja & Garg,2010) (SQ1-SQ13)

Patients

Table 5 Constructs, Items, Sources and Respondent Type


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Environmental Interface (AdaptLrng)

OL1... do members of your organization share external information? OL2...does your organization

predict the changes occurring in the industry?

OL3...does your organization continuously track how your competitors improve their products,

services and operation?

OL4...does your organization deliberately reflect upon and evaluate external information?

Action Reflection (GoalLrng)

OL5... does your organization have set goals for researching and developing new products and/or

services?

OL6 ... do members of the organization effectively use organizational structures (e.g., chain of

command, personal networks) when sharing ideas and innovations?

OL7 ...this organization has clear goals for individual and organizational development.

Dissemination and Diffusion (IntgLrng)

OL8 ...does your organization provide opportunities for employees to develop their knowledge, skills,

and capabilities?

OL9 ...do your organization's leaders support quick and accurate communication among all

employees?

OL10 ...there are established ways to share new operational processes and procedures throughout

the organization.

OL11 ...this organization has established work groups, networks, and other collaborative

arrangements to help the organization adapt and change.

Meaning and Memory (LatentLrng)

OL12 ...does your organization use ideas and suggestions from its employees?

OL13 ...this organization believes that continuous change is necessary.

OL14 ...people in this organization believe that evaluating what customers say is critical to reaching

organizational goals.

OL15 ...this organization has a strong culture of shared values that support individual and

organizational development.

Table 6 Organizational learning items Medical service

1. … knowledgeable and experienced physicians. 2. … knowledgeable and experienced nurses. 3. … knowledgeable and experienced staff members. Overall service 4. … Materials associated with the service (such as pamphlets or statements) will be visually 5. … appealing in a hospital. 6. … visually attractive and comfortable facilities. 7. … clean washrooms, clean rooms/wards without foul smell. 8. …When patients have problems, excellent hospitals will show a sincere interest in solving it. 9. … Service providers in hospitals are dependable. 10. … give prompt service to customers.

11. … always be willing to help patients. 12. …will never be too busy to respond to patient’s request. 13. … have the patient’s best interests at heart.

Table 7 Service quality items

Minimum Maximum

Mean Std. Deviation

Skewness Kurtosis Std.

Error Std. Error

Learning Action AL 2.0

0 6.50

3.9661

.86601

.137 .164

-.194

.326 GL 2.0

0 7.00

4.0226

.92659

.098 .164

.020

.326 IL 1.5

0 6.50

4.0419

.82758

.034 .164

.218

.326 LL 1.5

0 6.25

3.9898

.87169

.071 .164

.151

.326 Overall LA 2.3

3 6.33

4.0087

.60638

.246 .164

.691

.326 *Service Quality 1.8

5 6.08

3.9749

.78735

.160 .164

.144

.326 *Score based on aggregated data from 884 cases to 221 cases

Table 8 Descriptive Statistics of Learning Action and Service Quality Scales

(N= 221)


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Construct Score Level Frequency

Percent Learning 12-36

Low 11 4.98%

Action 37-60 Moderate 198 89.59% 61-84 High 12 10.86%

221 100%

Service Quality 13-39 Low 23 10.41% 40-65 Moderate 175 79.19% 66-91 High 23 10.41%

221 100%

Table 9 Determining the Level of Construct Score

Figure 3The Measurement Model for Pooled CFA Note: AL=Action Learning, GL=Goal Learning, IL= Integrative Learning, LL=Latent Learning, LA=Learning Action , SQ= Service Quality

Fitness Index LA SQ Overall

Comment RMSEA 0.05

1

0.000 fit indexes achieved GFI 0.96

1

0.968 fit indexes achieved CFI 0.96

9

1.000 fit indexes achieved Chi-square/df 1.57

9

0.935 fit indexes achieved

Table 8 Fitness Index for Revised CFA Model for Each Construct


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Variable min max skew c.r. kurtosis c.r.

SQ3 2.000 6.000

.079 .477 .170 .514 SQ13 2.000 6.00

0 .009 .055 -.230 -.699

SQ12 1.000 7.000

.140 .848 -.359 -1.089 SQ10 2.000 7.00

0 .114 .694 -.067 -.202

SQ9 1.000 7.000

-.038 -.228 .376 1.140

SQ8 1.000 7.000

.105 .637 .886 2.687 SQ7 1.000 6.00

0 -.286 -1.735 .223 .676

SQ6 1.000 6.000

-.054 -.327 .145 .440 SQ5 2.000 7.00

0 .077 .467 -.065 -.198

SQ2 2.000 6.000

-.003 -.016 -.439 -1.333 SQ1 1.000 7.00

0 .120 .728 -.109 -.332

LL2 1.000 7.000

.114 .694 -.034 -.104 LL3 2.000 7.00

0 -.020 -.120 .266 .807

LL4 1.000 7.000

.005 .031 .046 .138 IL2 2.000 7.00

0 .222 1.349 .731 2.218

IL3 2.000 7.000

.196 1.187 .110 .334 IL4 1.000 7.00

0 -.127 -.771 .060 .181

GL1 2.000 7.000

.198 1.199 .300 .911 GL2 1.000 7.00

0 -.108 -.658 -.398 -

1.208 AL1 2.000 7.000

.081 .494 -.078 -.235 AL2 2.000 7.00

0 .003 .018 .176 .536

Multivariate 2.142 .512

Table 9 Assessment of Normality Distribution for Items in the Respective Constructive

SQ Factor Loading LA Factor Loading

SQ1 .696 AL2 0.674

SQ2 .711 AL1 0.581

SQ5 .735 GL2 0.677

SQ6 .674 GL1 0.629

SQ7 .668 IL4 0.685

SQ8 .651 IL3 0.763

SQ9 .705 IL2 0.58

SQ10 .730 IL1 Dropped

SQ12 .590 LL4 0.82

SQ13 .716 LL3 0.752

SQ3 .620 LL2 0.729

SQ4 Dropped LL1 Dropped

SQ11 Dropped

Note: LA=Learning Action; SQ=Service Quality

Table 10 Standardized Estimate based on Figure 3

Item Unstandardized Estimate

S.E. C.R. P Standardized Estimate

CR (≥0.6)

AVE (≥0.5)

AL .476

.081 5.844 *** .684

0.774 0.462 GL .44

4 .078 5.707 *** .72

5

IL .586

.088 6.658 *** .712

LL .51

5 .078 6.625 *** .59

6

SQ13 1.000

.716

0.938 0.733 SQ12 1.01

4 .121 8.374 *** .59

0

SQ10 1.068

.103 10.361 *** .730

SQ9 1.02

7 .103 10.018 *** .70

5

SQ8 .867

.094 9.252 *** .651

SQ7 .89

0 .094 9.484 *** .66

8

SQ6 .915

.095 9.579 *** .674

SQ5 1.06

0 .102 10.437 *** .73

5

SQ3 .805

.091 8.804 *** .620

SQ2 1.05

2 .104 10.101 *** .71

1

SQ1 1.016

.103 9.879 *** .696 Table 11 CFA Results for Measurement Model


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Figure 4 Standardised Regression Weight for Learning Action and Service Quality Note: AL=Action Learning, GL=Goal Learning, IL= Integrative Learning, LL=Latent Learning, LA=Learning Action , SQ= Service Quality

Figure 5 Regression Weights Estimate Learning Action and Service Quality Note: AL=Action Learning, GL=Goal Learning, IL= Integrative Learning, LL=Latent Learning, LA=Learning Action , SQ= Service quality


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Variable Estimate (R2)

Service Quality 0.22

Name of category Name of Index Index Value Comments

Absolute value RMSEA 0.030 The required level achieved (≤ 0.08)

GFI 0.917 The required level achieved (≥0.80)

Incremental Fit CFI 0.977 The required level achieved (≥ 0.90)

Parsimonious fit Chi/square 1.197 The required level achieved (< 3.00)

Table 12 The fitness Indexes Assessment for structural model for Learning Action and Service Quality

Path Standardized Standard Critical P value Unstandardized

Deviation Ration SQ <--- LA 0.466 .169 4.164 *** .706 Note:***Sig. at 0.001

Table 13 Testing the causal effect of LA and SQ

Table 14 Squared Multiple Correlations (R2)

Hypothesis Statement of Path Analysis Estimate P-value Results on hypothesis

H1 : There is a positive relationship between Learning Action and Service Quality

0.706 *** Supported

Note:***Sig at 0.001

Table 15 Hypotheses Statemen

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