e 2011 Student identity number

Eindhoven, August 2012

Managing the efficiency–quality trade-off in service oriented organizations, by applying and implementing MO and segmentation in the frontlines: a case study at GGzE by Stef Marinus

BSc Indrustrial Engineering and Management Science – TU/e 2011 Student identity number 0617505

In partial fulfillment of the requirements for the degree of: Master of Science in Innovation Management

Supervisors University of Technology Eindhoven Prof. dr. E.J. Nijssen ir. W. van der Borgh

Supervisors GGzE drs. W. van de Pol RC MAC M.E. Huffmeijer RA drs. M.G.J. van Geffen RA

TUE. School of Industrial Engineering. Series Master Theses Innovation Management

Subject headings: market orientation, customer orientation, segmentation, frontline mechanism, frontline service employee, service revenue, service productivity, quality orientation, productivity orientation, customer satisfaction, job outcomes, job satisfaction, strategic change, market orientation implementation, employee behavior, employee beliefs, frontline learning, organizational learning, empowering leadership, self-managing service teams, healthcare

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Acknowledgement Without the help of many enthusiastic people, it would be impossible for me to successfully end this Master Thesis, in partial fulfillment of my Master of Science degree. Therefore, this page is dedicated to everybody that supported me during this period. To start, I would like to thank my University supervisors Prof. dr. Ed Nijssen and ir. Michel van der Borgh. Ed, you challenged and coached me during my last moments as a student. You devoted a lot of time to support me and to provide helpful feedback. I appreciate the way you motivated me, to constantly improve my performance, but not in last place, to develop my own capabilities and expertise. Michel, your support, feedback and creative suggestions to improve this research made it possible for me to finish in time. Thank you for all the support in helping me to develop the questionnaire and analyzing the results. I realize that you both have invested a lot of time in this research too, and without your help, it would be unlikely for me to succeed in a similar way. I hope we can continue working as a team in the future, and build upon the research data to further explore this particular field of research. Willy van de Pol, Mariëlle Huffmeijer and Mark van Geffen gave me constant feedback and triggered me to dig into the practical relevance of this research. Willy, you coached me with great enthusiasm and challenged me to integrate theoretical and practical relevance. You made it possible to disseminate this research within the organization, and convinced others to join. Mariëlle and Mark, thank you for the continuing interest and helpful feedback at all times. You always stood directly by my side, and provided useful insights and enthusiastic help. Without you, it would be impossible to finish in time and to deliver such results. Furthermore I would like to thank all colleagues that participated and contributed to this research. Over 300 respondents completed an online questionnaire, which took them individually 20 minutes on average. Without your help, this research would be impossible. All other colleagues that contributed too will not be forgotten. Thank you all for making it possible for me to graduate. Finally, I would like to thank my friends and family for their support, and for understanding that I spend more time behind my laptop for the last couple of months. Mom, Dad, Pleuni and Roel thanks for all the support during my time as a student. You always supported and motivated me to develop myself and to finish my education. Last but not least, I would like to thank my girlfriend. Marthe, you remained enthusiastic about my thesis, even though I overloaded you sometimes with my research. Your inspiration and motivation helped me to successfully pass my master program! Thank you all!

Stef Marinus Eindhoven, August 2012

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Abstract In the modern era of trade-off management between efficiency and quality objectives in the service frontlines, organizations must foster market orientation (MO), but also consider other market constructs, i.e. segmentation. For service oriented organizations the challenges lay in successfully disseminating and implementing new change strategies, and facilitating frontline beliefs and behaviors in diverse ways to adopt MO simultaneously, i.e. education, leadership actions, and team processes. This study analyzes how individual MO beliefs and behaviors, in terms of customer orientation (CO), colleague information exchange, and segmentation, affect each frontline service employee’s response to organizational orientation tracks – cost containment, revenue generation, or trade-off management. Furthermore it analyzes the effect of education, management and team mediators in the process of establishing a MO-ed organizational culture, ready for change. Finally, the effect of empowering leadership on the relationship MO and outcome measures was investigated. Using survey and archival data from 268 care professionals and 58 managers, representing 42 teams with more than 3 respondents, of which 27 teams have management responses, support was found for MO to positively influenced efficiency and quality objectives. Furthermore, CO-ed training, manager beliefs and team beliefs positively facilitate the individual beliefs, and also organizational trade-off intentions positively influence the beliefs. Findings showed that empowering leadership has mixed impact on performance (i.e. positive on job satisfaction, but negative on customer satisfaction). The findings might indicate that empowerment does not help yet to disseminate the prioritization of customers to the employees, and that the organization is still in the early phases of implementing MO.

Key words: market orientation, customer orientation, segmentation, frontline mechanism, frontline service employee, service revenue, service productivity, quality orientation, productivity orientation, customer satisfaction, job outcomes, job satisfaction, strategic change, market orientation implementation, employee behavior, employee beliefs, frontline learning, organizational learning, empowering leadership, self-managing service teams, healthcare

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Management summary Changes in healthcare services and problem definition In the current healthcare settings, governmental initiatives push service organizations to meet new efficiency objectives, but in the meanwhile, to maintain (or improve) service quality levels. The shift from a solely quality focus to managing trade-offs between both organizational objectives (i.e. quality and efficiency), challenges organization to adopt alter strategies (Nembhard and Tucker, 2011). Subsequently, healthcare organizations face dynamic, rapidly changing, and uncertain complex environments, where autonomous frontline employees are directly responsible for delivering effective service. Trade-off management is therefore not only a challenge for the management, but an even bigger one for frontline service employees (Ye, Marinova and Singh, 2007; Ye, Marinova and Singh, 2011). The formulation and implementation of new strategies that combine efficiency and service quality is considered a crucial goal for future sustainability and benefits from a simultaneous implementation of market orientation (MO; e.g. Kumar, Subramanian and Strandholm, 2011). While the initial response of employees to a trade-off strategy of efficiency and revenue building may be alienation of employees (e.g. detachment: Ye et al., 2007), MO supports employees in the process to face these challenges and empowering can help overcome this “stress” effectively (Ellinger, Ketchen, Hult, Elmadag, and Richey, 2008). MO is a widely accepted concept in improving organizational performance and shows concern for the organization wide generation of market intelligence (Kohli and Jaworski, 1990; Kirca, Jayachandran, and Bearden, 2005). The concept urges to affect current and future customer needs, dissemination of the intelligence and sharing this with colleagues, and the responsiveness to it (Kohli and Jaworski, 1990; Narver and Slater, 1990). This concept should lead to an organizational culture that strives to maximize necessary behavior to maintain effectiveness and efficiency in creating superior value for customers (Homburg, Müller and Klarmann, 2011). To help the management of health service organizations, in making frontline employees responsive to strategic initiatives of their organizations, to ensure service quality, but at the same time do this in an efficient way three research questions were formulated: Research Question 1. How to manage trade-offs between efficiency and service quality in the frontlines of a service oriented organizations? Research Question 1.1. How to influence the implementation of MO as corporate culture in creating positive influences in the frontlines? Research Question 1.2. Does empowering leadership facilitate the effect of MO behavior on the dual outcome objectives – quality and efficiency?

Model to guide research To address these research questions a model was developed focusing on efficiency and quality objectives in the frontlines. Organizations that foster MO and customer orientation (CO), might consider other market constructs, i.e. segmentation, since it was expected to better respond to the changing environment. For service oriented organizations the challenges lay in successfully disseminating and implementing new change strategies and MO, and facilitating frontline beliefs and behaviors in diverse ways, i.e. educational tracks, considering manager actions, and team processes. Next, the effect of

V

empowering leadership on the relationship MO and outcome measures was investigated (see Figure 01). Finally, the model was researched empirically, which took place at a Dutch mental healthcare company: GGzE (Geestelijke Geïntegreerde Gezondheidszorg Eindhoven en de Kempen). The company was established in 1918, and the organization has 2.219 employees and about 158 million Euros of annual revenues in its current form. GGzE offers help and support to people with severe, multiple and often long-term psychiatric problems. Empowering leadership behavior

TEAM MO beliefs

Revenu orientation (quality)

H.3

H.8.a H.10.a H.6.a

H.1.a MO BELIEFS Revenu x Cost

H.11.a H.7.a

MO BEHAVIOR Efficiency / productivity

H.1

H.11 CO beliefs

CO behavior H.9

H.1.b

H.8 CO exchange beliefs

Cost containment (efficiency)

H.5

CO colleague exchange

Customer satisfaction

H.6 H.7

H.10 Segmentation CO training

Segmentation

Job satisfaction

H.2

H.4

MANAGER MO beliefs

Figure 0-1: Initial framework for empirical research

Research design - methodology Data were collected using surveys; in accord two questionnaires were developed and used (one for the individual team members and one for the managers). Constructs and measures were largely drawn from the extant literature. However, some questions (e.g. segmentation beliefs and CO-ed training) were developed specifically for this study, making use of the expert knowledge of University supervisors (experts in the field of marketing), and GGzE’s managerial input. Survey data were complemented with objective archival performance data (i.e. customer satisfaction and efficiency ratio’s). Surveys were developed online, using Qualtrics software, and following guidelines from Dillman, Smyth and Christian (2008; e.g. pre-notifications, invitations, and other contact moments). Data were analyzed using SPSS software using descriptive analysis, to make a first check of factor structure and reliabilities of constructs. Next, SmartPLS was used to analyze the data, i.e. the estimate the path model. This Structural Equation Modeling technique suits experimental designs very well. It allows flexibility in modeling and is able to provide instant solid results, even when modeling with a smaller sample size (Hair, Ringle and Sarstedt, 2011).

VI

In all, data from 268 care professionals and 58 managers, representing 42 teams with more than 3 respondents, were collected (of which 27 teams have management responses). Composite reliabilities of the constructs were good; all exceeded 0.6 (Hair et al., 2011). In all cases, the square root of the Average Variance Extracted was higher than the correlation between variables (Hair et al., 2011).

Results In general the model explained an adequate level of variance in the data (R 2’s: customer satisfaction=0.159; efficiency=0.081; job satisfaction=0.136; MO beliefs=0.494; MO behavior=0.298). Furthermore, CO-ed training, manager beliefs and team beliefs positively facilitate the individual beliefs of MO. Support was found for MO to positively influence efficiency and quality objectives. Furthermore, CO-ed training, manager beliefs and team beliefs positively facilitate the individual beliefs, where even organizational trade-off intentions positively influence the MO beliefs as well. Findings showed that empowering leadership has mixed impact on performance (i.e. positive on job satisfaction, but negative on customer satisfaction; Figure 0-2). Empowering leadership behavior TEAM MO beliefs Revenu orientation (quality) .186 ***

.132 ***

.727 * .102 *

-.202 **

.010 ns -.148 *** MO BELIEFS Revenu x Cost


.271 ***

-.165 *** CO beliefs

CO behavior

.162 ***

.150 ** .049 ns


CO exchange beliefs

.309 ***



.111 * .177 *

.087 * CO training

.309 ***

Segmentation

Segmentation

Job satisfaction

.140 ***

MANAGER MO beliefs

Figure 0-2: Results research framework (Representation of path coefficients and two-tailed significance level, where *=0.1, **=0.05, and ***=0.01)

The conclusion is that when the segmentation concept is incorporated in MO, managing trade-offs between efficiency and quality becomes realizable. Implemented MO beliefs are reflected by behavior and positively influence directly on customer satisfaction levels, and indirectly via job satisfaction on efficiency levels. Facilitators – education, team beliefs, and manager’s beliefs – in this process increase levels of MO in a positive way and make change possible to occur. Empowering leadership showed positive moderating effects on the relationship between MO behavior and job satisfaction or efficiency (although the effect of MO-ed behavior to efficiency was not significant), however it showed negative

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moderating effects on the relationship of MO behavior and customer satisfaction and job satisfaction. Empowering leadership only seemed to positively influence the negative relationship between efficiency and customer satisfaction. These findings might indicate that empowerment does not help yet to disseminate the prioritization of customers to the employees, and that the organization is still in the transition phase of implementing MO. This study furthermore showed that individual values become important in challenging business environments, where change can occur unexpectedly. Accordingly early signs of the team process effects showed heavy impact.

Recommendations For service oriented organizations, the challenges lay in successfully disseminating and implementing new change strategies, and facilitating frontline beliefs and behaviors in diverse ways, i.e. education, leadership actions, and team processes. The increasing role of frontline employees, delivering direct service and responsible for organizational performance, urges organizations to adopt alter strategies to challenge the uncertain environment. Organizations should pay more attention to the impact of organizational change and environmental influencers, at the individual employee level. From this research several implications to cope with these challenges were found. To accomplish a solid MO culture in the frontlines and based on empirical findings, the following actions can be suggested: Service organizations can manage and attack the difficulties in managing the quality-efficiency trade-off in the frontlines, by implementing MO. Values should be incorporated in the company culture and directly positively mediated by CO training programs/educational tracks, manager beliefs, and team processes and beliefs. The three way combination of those mechanisms should naturally guide organizations to attack change. The direct effect of trade-off, as perceived by the individual service employee, turned out to have a direct positive effect on MO beliefs too. Results even showed that a solely cost/financial emphasis from the organization positively influence employees MO beliefs; meaning that when the segmentation principle is added to the frontline mechanism, employees might receive right “tools” to respond adequately. These individual beliefs are reflected by MO behavior, which showed direct improvements on customer satisfaction and job satisfaction levels. And higher levels of job satisfaction deliver higher efficiency. The MO culture helps organizations to manage challenges in changing environment, and together with encouraging learning activities it should attack current challenges. Empowering leadership was not found to positively influence the relationship of MO behavior and outcome measures. Although it positively moderated the interaction between MO behavior and job satisfaction, it does negatively influence the interactions with customer satisfaction. However, this finding was consistent with the research of Hartline, Maxham and McKee, (2000) and Ellinger et al. (2008). Two reasons can be found for empowering leadership to have a negative effect: (1) empowerment does not help to disseminate the prioritization of customer services to employees yet, and (2) firms tend not to empower employees after pre-programming other educational tacks. It seemed that empowerment does not work, when organizational processes (e.g. education) are not in full support; organizations are still in the early process of implementing MO. It requires a more informal training/coaching approach, where managers strive to stimulate employees to develop themselves.

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Index Acknowledgement ................................................................................................................................ III Abstract ................................................................................................................................................ IV Management summary.......................................................................................................................... V List of Tables ........................................................................................................................................... 4 List of Figures .......................................................................................................................................... 5

1

Introduction .................................................................................................................................... 6 1.1

Problem definition and research objectives ............................................................................. 7

1.1.1

2

Research objectives .......................................................................................................... 9

1.2

The context of GGzE ................................................................................................................ 9

1.3

Thesis structure......................................................................................................................10

Conceptual background ................................................................................................................ 12 2.1

Theoretical background..........................................................................................................12

2.1.1

Implementing market orientation to manage trade-offs ................................................. 12

2.1.1.1

What is market orientation? .......................................................................................12

2.1.1.2

Why does market orientation help organizations? ......................................................14

2.1.2

Antecedents of market orientation ................................................................................. 16

2.1.3

Empowering leadership as moderator for the effect of market orientation behavior ...... 18

2.1.3.1

What is empowering leadership?................................................................................18

2.1.3.2

Why should we pay attention to the leadership-frontline mechanism? .......................19

2.1.3.3

Why could empowering leadership be a solution? ......................................................20

2.1.4 2.1.4.1

What is segmentation – the marketing context? .........................................................22

2.1.4.2

Is segmentation in the frontlines important? ..............................................................22

2.1.4.3

The role of segmentation in overcoming trade-off challenges .....................................23

2.1.5 2.2

The role of segmentation in the frontlines ...................................................................... 21

Gaps in the literature ...................................................................................................... 24

Model to guide empirical research .........................................................................................27

2.2.1

Model development ....................................................................................................... 27

1

2.2.2 3

Methodology ................................................................................................................................ 33 3.1

Research setting, sample, and procedure ...............................................................................33

3.2

Measurement ........................................................................................................................34

3.2.1

4

5

Variables ........................................................................................................................ 35

3.3

Analyses .................................................................................................................................37

3.4

Measurement validation and model check .............................................................................37

3.4.1

Manipulation checks....................................................................................................... 37

3.4.2

Construct computing ...................................................................................................... 37

3.4.3

Validity and reliability checks .......................................................................................... 38

3.4.4

Structural modeling specifications in SmartPLS ............................................................... 40

Results .......................................................................................................................................... 41 4.1

Influence of antecedents on MO beliefs and MO behavior .....................................................42

4.2

The consequences of MO behavior ........................................................................................43

4.2.1

The effect of MO behavior on Job satisfaction ................................................................ 43

4.2.2

The effect of MO behavior on Customer satisfaction ...................................................... 44

4.2.3

The consequences of Efficiency and Job satisfaction on customer satisfaction ................ 45

Discussion, managerial implications and implications for future research .................................... 47 5.1

Discussion of results ...............................................................................................................47

5.1.1

The effect of CO training, manager beliefs, and team beliefs on individual MO beliefs .... 47

5.1.2

The effect of perceived organizational orientation on individual MO beliefs ................... 48

5.1.3

The effect of beliefs on behavior .................................................................................... 48

5.1.4

The consequences of MO behavior on performance ....................................................... 48

5.1.4.1

The direct effects of MO behavior on outcome measures ...........................................49

5.1.4.2

The effect of job satisfaction and efficiency on customer satisfaction .........................50

5.1.5

6

Hypotheses .................................................................................................................... 28

General observations...................................................................................................... 51

5.2

Managerial implications .........................................................................................................52

5.3

Limitations and future research..............................................................................................54

Concluding remarks ...................................................................................................................... 56 6.1

Answer to the research questions ..........................................................................................56

2

A.

References .................................................................................................................................... 59

B.

Tables............................................................................................................................................ 64

C.

Figures........................................................................................................................................... 67

D.

Questionnaire procedure and development ................................................................................. 68

E.

Notifications, messages, invitations and reminders of the Questionnaire ....................................81

F.

Questionnaire care professionals .................................................................................................. 93

G.

Questionnaire management ....................................................................................................... 111

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List of Tables Table 2-1: Gaps in the literature are identified. Where do they come from (whence), and why are they important for future research ..................................................................................................... 25 Table 3-1: Distribution and response rate of returned surveys ............................................................... 34 Table 3-2: Construct development. Constructs provided in the first column are built upon the subconstructs, which in their turn consist of the averages of the individual items/questions. ................... 38 Table 3-3: Correlations and square root of the AVE (square root of AVE presented in the diagonal)....... 39 Table 3-4: Construct reliability and AVE’s output from SmartPLS ........................................................... 39 Table 3-5: Significance levels Bootstrapping (derived from Hair et al., 2011) .......................................... 40 Table 4-1: t-values and path coefficients................................................................................................ 41 Table 5-1: Recommendations for implementing MO and attacking the challenges for managing tradeoffs in the frontlines............................................................................................................................ 53 Table B-1: The definitions of the marketing orientation concept ............................................................ 64 Table B-2: Facts and figures GGzE .......................................................................................................... 64 Table B-3: Rotated component matrix CO beliefs and behavior. ............................................................ 65 Table B-4: Rotated component matrix colleague exchange beliefs and behavior.................................... 65 Table B-5: Rotated component matrix segmentation beliefs and behavior............................................. 66 Table D-1: Questionnaire design and specifications for development .................................................... 68 Table D-2: Questionnaire specific cycle-time procedure care professionals ............................................ 71 Table D-3: Questionnaire specific cycle-time procedure managers ........................................................ 72 Table D-4: All items included in the questionnaire (Item coding correspondents with the constructs).... 73

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List of Figures Figure 0-1: Initial framework for empirical research................................................................................ VI Figure 0-2: Results research framework (Representation of path coefficients and two-tailed significance level, where *=0.1, **=0.05, and ***=0.01) ..................................................................... VII Figure 2-1: The definitions of the MO concept (based on: Zebal, 2003) .................................................. 13 Figure 2-2: A multilayer model of MO (adopted from Homburg and Pflesser, 2000; pp.451) .................. 14 Figure 2-3: The impact of MO on performance measures ...................................................................... 15 Figure 2-4: The antecedents of MO........................................................................................................ 18 Figure 2-5: The effect of empowerment on the relationship of MO and outcome measures .................. 21 Figure 2-6: Segmentation as part of the MO concept and the effects in the frontlines ........................... 24 Figure 2-7: Initial framework for empirical research............................................................................... 28 Figure 4-1: Results research framework (Representation of path coefficients and two-tailed significance level, where *=0.1, **=0.05, and ***=0.01) ..................................................................... 42 Figure 4-2: Two-way interaction effect of MO behavior * empowering leadership and job satisfaction .. 44 Figure 4-3: Two-way interaction effect of MO behavior * empowering leadership and customer satisfaction ......................................................................................................................................... 44 Figure 4-4: Two-way interaction effect of Efficiency * empowering leadership and customer satisfaction (red line presents the interaction relationship by a direct effect of the moderator of 0.400, instead of -0.651) ..................................................................................................................... 45 Figure 4-5: Two-way interaction effect of job satisfaction * empowering leadership and customer satisfaction ......................................................................................................................................... 46 Figure C-1: Response distribution of complete questionnaires from the care professionals ................... 67 Figure C-2: Response distribution of complete questionnaires from the management ........................... 67 Figure D-1: The GGzE implemented questionnaire interface in Qualtrics ............................................... 70

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1 Introduction The mental healthcare industry has faced serious change over the past decade, specifically costs are soaring and budgets have been reduced tremendously. Since the end of 2011, the Dutch government announced major cost cutting activities in 2012, which in total equal about 600 million euro’s1. This particular sub-healthcare sector determines 10 percent of the total Dutch healthcare sector revenues, but now faces 35 percent of the cost cutting activities. The pressure rises, where governmental initiatives push organizations to strategically change, with the intention of optimizing own organizational processes to become more efficient. Additionally, the competitive market environments pressures service quality at the same time. Both opposing organizational orientations force semigovernmental organizations to adapt alter strategic practices to manage upcoming challenges and trade-offs between service quality and efficiency. In the past the healthcare industry was focused solely on service quality, and paid minimal attention to productivity and effective process management (Nembhard and Tucker, 2011; Ye, Marinova and Singh, 2011). Frontline employees assess customer needs and determined the help they had to offer, often without feedback to or consideration of actual customer satisfaction levels (Brady and Cronin, 2001) or efficiency. But things are changing. The Dutch government forces healthcare agencies to become more market and customer oriented and to cut costs similtaneously1. It implies enhancing customer quality ratings and at the same time intents to become more efficient. The rapid change urges healthcare organizations to learn new practices in order to rapidly increase knowledge about efficiency and quality performance (Nembhard and Tucker, 2011; Ye, Marinova and Singh, 2007; Marinova, Ye and Singh, 2008; Ye et al., 2011). Additionally Nembhard and Tucker (2011) state that even though the organizational knowledge base is large and growing, frontline employees still maintain a certain amount of uncertainty in their daily job. Providing healthcare service is no exact science and it involves high levels of variety, meaning that no single solution is the best. Since frontline employees often have to adapt to change unpredictably, based on for instance the changing treatment programs, time management becomes important. The challenges force top management to alter strategies. And, while there is no single best solution it is clear that it requires paying attention to cost control and finding new revenue streams at the same time (Rust, Moorman and Dickson, 2002; Ye et al., 2007). Apart from a new strategy it will require close cooperation between top management and frontline service employees, in order to optimize overall organizational performance and to satisfy customer needs (Nembhard and Tucker, 2011). While in the past management generally tried to manage (team) efficiency and frontline employees tend to focus on curing customers, the two will have to align (Ye et al., 2007). The objectives of trade-off management become an antecedent for performance, where accordingly collective cultural values should change simultaneously (Ye et al., 2007). In contrast to the old expression of “seeing change and cost reductions as threat”, it is embraced as opportunity. The formulation and implementation of new strategies that combine efficiency and service quality benefit from developing the organization’s market orientation (MO) and also fostering the marketing 1

Source (last consulted on 2012-08-03): http://www.ggznederland.nl/actueel/perslijsten/publiek-pers/ bezuinigingen-ggz-veroorzaken-waterbedeffect.html

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concept in the frontline, i.e. with frontline employees (Ye et al., 2007; Marinova et al., 2008). While change may alienate employees first (Ye et al., 2007), MO may help them cope effectively with the new, trade-off strategy, particularly when managers involve employees in the change process and empower them (Ellinger, Ketchen, Hult, Elmadag, and Richey, 2008). MO is a widely accepted concept in improving organizational performance and shows concern for the organization wide generation of market intelligence (Kohli and Jaworski, 1990; Kirca, Jayachandran, and Bearden, 2005). The concept urges to affect current and future customer needs, dissemination of the intelligence and sharing this with colleagues, and the responsiveness to it (Kohli and Jaworski, 1990; Narver and Slater, 1990). This concept should lead to an organizational culture that strives to maximize necessary behavior to maintain effectiveness and efficiency in creating superior value for customers (Homburg, Müller and Klarmann, 2011). It builds upon the earlier identified concept of customer orientation (CO), where customer interests are set first (Deshpandé, Farley and Webster, 1993), but also implies not to forget the social-cultural aspects within an organization, where managers and employees are part of (Zebal, 2003). Consequently, strategic change can be studied at the firm level (focusing on an organization’s overall MO and performance), the attention may also shift to the impact of the change on frontline activities (Ye et al., 2007; Marinova et al., 2008). Often accused of lack in CO, due to financial incentives from the market frontlines, employee training and development have been at the center stage of attention (Nembhard and Tucker, 2011; Ye et al., 2007; Ye et al., 2011). It has led to a shift in attention from optimal problem solving in a technical way to customer dimensions as “responsiveness2“ and “courteousness3“ (Homburg, Droll and Totzek, 2008; Zablah, Franke, Brown and Bartholomew, 2012). A more recent topic that has emerged is how frontline service employees can be effective and efficient at the same time (Ye et al., 2011). Confronted with budget costs, frontline employees have trouble maintaining quality. They need to learn how to deal best with trade-offs (Ye et al., 2011). This does not only directly influence the individual itself, but also reflects from or relates to management initiatives (Marinova et al., 2008) and team processes (Ye et al., 2011). After introducing the issues for not-for-profit organizations (i.e. healthcare), concerning the trade-offs between efficiency and service quality, and the increasing role of frontline employees, the next sections will further delineate the problem definition. In section 1.1 the problem definition and research objectives are formulated, then the company is introduced where empirical research is conducted, and further outline will be provided.

1.1 Problem definition and research objectives After introducing the problem context and the motives for research, the problem statement can be rephrased as follows:

2

3

Responsiveness is the ability to deliver and response to customer requirements in a timely and satisfactory manner. Courteousness is characterized by the gracious consideration towards others. It considers going beyond the ‘normal’ job description to identify customer needs.

7

Problem statement: In the current healthcare setting, governmental initiatives push service organizations to meet new efficiency objectives, but in the meanwhile, to maintain (or improve) service quality levels. The shift from a solely quality focus to managing tradeoffs between both organizational objectives, challenges organization to adopt alter strategies. Subsequently, healthcare organizations face dynamic, rapidly changing, and uncertain complex environments, where autonomous frontline employees are directly responsible for delivering effective service. Tradeoff management is therefore not only a challenge for the management, but an even bigger one for frontline service employees.

Based on this problem statement the research questions are set forward to further guide research. The general question about the effect of trade-off between quality-efficiency on frontline employees is influenced by introducing the role of MO. MO is supposed to help employees cope with the change and changing organizational strategies. MO is more than just collecting and disseminating information about the external environment (e.g. customer), since it also encompasses activities that allow individuals to act in response to threats and opportunities (Kumar, Subramanian and Strandholm, 2011; Van Raaij and Stoelhorst, 2008). It reasons from the notion of centrality of customers and affects employee’s beliefs, which are crucial for behavior. An important moderator on the relationship of MO behavior and outcome performance indicators might be empowerment (e.g. Marinova et al., 2008; Arnold, Arad, Rhoades and Drasgow, 2000); more empowered individuals use their MO knowledge more effectively and accomplish better results. Main Research question: How to manage trade-offs between efficiency and service quality in the frontlines of a service oriented organizations?

Research question 1.1: How to influence the implementation of MO as corporate culture in creating positive influences in the frontlines? performance indicators? Research question 1.2: Does empowering leadership facilitate the effect of MO behavior on the dual outcome objectives – quality and efficiency?

Here a trade-off challenge is something that can be identified in the frontlines of a service oriented organization, since they are responsible for executing activities that directly influence organizational performance. Because the research will focus on GGzE4 in particular, this organization and its market is presented in section 1.2, but first research objectives are discussed in more detail. 4

GGzE = “Geestelijke Geïntegreerde Geestelijke Gezondheidszorg Eindhoven en de Kempen”. See section 1.2 for more information about the company.

8

1.1.1

Research objectives

The objective is to approach research in analyzing and understanding the role of the frontline employee in managing trade-offs and its process facilitators. In order to attack the problem statement and to answer the research questions, one main objective is defined: Objective: Provide practical implications for GGzE to attack trade-off challenges in healthcare. Offer management drivers to design and refine a corporate (social-) culture “ready for change”, and to provide them with useful insights about the frontline employees. Furthermore this research should contribute to the scientific literature in providing useful directions for the future. It considers segmentation as part of MO in the frontline mechanism and explores the field of the effect of team processes. A questionnaire should offer means to analyze the current situation and to offer insights about solution areas for GGzE’s management. It should capture the relevance of implementing the segmentation concept of marketing simultaneously with the general principle of MO. It should be easy in use and reflect the current situation, but also frontline employee’s beliefs to determine future headings. Means: Develop a questionnaire that considers all relevant constructs, in order to get a better understanding of the frontlines and process facilitators. The questionnaire should aid in analyzing the effect of trade-off organizational orientation – efficiency vs. quality –, management and team effects, and educational tracks on individual MO-ed beliefs and behavior. To address the objective, the questionnaire was used. Additionally to the questionnaire, open questions resembling the company’s ideas, were used to gather specific frontline reactions (e.g. how to cope with the gap between management and frontline employees).

1.2 The context of GGzE This empirical research was conducted within GGzE, where management initiates to become more and more interested in how to manage change (i.e. trade-offs between quality and efficiency), and therefore it is an ideal setting for research. But before going into the details, the company is briefly introduced. GGzE was found in 1918 and is in its current organizational form since 2002 5. By the end of 2011 the GGzE had 2.219 employees at service, which count for a total of 1.799 FTE’s. The total annual revenues are 158 million Euro’s (of which 150 million euro’s is financed by the government and health insurers), which is based on 15.990 clients over the year 2011. The client quality report indicates an overall satisfaction of 7.4, on a 10-point scale (see Table B-2 for more facts and figures). Furthermore GGzE is part of the total mental healthcare sector, which in 2009 was responsible for a total sum of expenditures of 5.5 billion Euros and employed a total of 68 thousand people. 5

Source (last consulted on 2012-08-03) - Annual report 2011 of GGzE: http://www.desan.nl/net/DoSearch /downloadfile.aspx?id=610

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GGzE offers help and support to people with severe, multiple and often long-term psychiatric problems. This organization is the only one in-and-nearby Eindhoven, which offers such a professional help for people with these particular problems. Yearly, they support thousands of people ranging from young to old. And where some organizations are centered only to a specific region, GGzE offers care beyond regional boundaries (even nationwide). The majority of people they treat are called outpatients; meaning that they stay in their home environment and receive treatment. Treatment may take place by appointment, where in other cases GGzE decides to recommend them to stay under supervision. The people remain living independently at GGzE, but are under supervision where response rates increase. The supervisors can also decide to offer them stay in clinics. The final group of people is assigned to GGzE after justice has decided to provide mandatory supervision (e.g. TBS). GGzE also deals with regional and beyond regional support, where cooperation between different organizations all make sure that someone receives the best care possible and tackles problems, where afterwards the goal is to let them again participate in society. The associated treatment programs are delivered by multifunctional and functional teams. This structure has to be taken into account, where one team focuses more on treatment development and quality assurance, where the other is more related to direct client activities. Both teams have to be seen separately, since they face different performance indicators and responsibilities. GGzE has three healthcare focused departments, where approximately 50 units can be identified. GGzE’s management has reformed over the past few years, where they are now more aware of the present sector changes. GGzE’s management is actively pursuing service quality and efficiency orientation simultaneously, although the effects of cost cutting activities.

1.3 Thesis structure The structure of this thesis is as follows: The second chapter starts with elaborating on the conceptual background (section 2.1), and presents a framework for empirical research (section 2.2). First, MO implementation will be discussed in order to manage trade-offs. Afterwards the antecedents of MO are discussed, to get a better understanding of the influencers in the process of implementing and disseminating MO strategies. The third sub-section discusses the effect of empowering leadership as moderator on the relationship from employee behavior and organizational performance, e.g. financial performance, job satisfaction, and customer satisfaction. The final sub-section of chapter 2 will introduce another “part” of the marketing concept: segmentation. This particular construct has not been researched simultaneously with MO. And it may solve the issues for frontline employees to consider both performance objectives – efficiency and quality – simultaneously. It builds upon the environmental pressure (e.g. cost containment strategies and specialization of core activities) that healthcare organizations have to reconsider strategies, and is in line with optimizing healthcare processes in both ways. In section 2.2 the framework for empirical research will be presented, where hypotheses are built for empirical testing. The hypotheses draw on three main streams of historical research: MO, CO, and trade-off management literature. In chapter 3 the methodology to conduct empirical research is explained, where research setting, sample size, and research procedures are discussed first. In section 3.2 and 3.3 the measurement methodology for the questionnaire will be discussed, which is followed by the validation of the structural model. Finally the analysis section (3.4) elaborates on the software used and specifies the specific steps. Chapter 4 will present the results and provides an answer to all hypotheses. First it will elaborate on the frontline beliefs and discusses the mediators/facilitators of direct influence. Secondly it will provide results from MO behavior in

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relationship to outcome measures, where the moderating effect of empowering leadership is taken into account. Chapter (5) discusses the results and reflects the theoretical background section. Managerial implications are given, followed by directions for future research and limitations to this particular study. Finally, chapter 6 will provide an answer to the research questions as brief conclusion, and builds upon the discussion and managerial implications.

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2 Conceptual background 2.1 Theoretical background In order to get a better understanding of the impact of MO on managing trade-offs in the frontlines, the scientific literature will be reviewed first, and where gaps in the literature will be identified.

2.1.1 2.1.1.1

Implementing market orientation to manage trade-offs What is market orientation?

The MO concept and questions regarding guidelines of how to actually implement it have emerged from the marketing concept. It reflects organizational culture and behavior for making decisions “market informed” and thus sustainable. Nineteen ninety was an important year; simultaneously Kohli and Jaworski (1990), and Narver and Slater (1990) developed a “market orientation concept” in reaction to previous product and sales orientations of firms and their dissatisfaction with marketing literature development to that date (original definitions of MO can be found in appendix B, Table B-1). In general two main streams of MO thoughts exist: the (1) behavioral, and (2) cultural perspective. The behavioral perspective defines MO as follows: “MO is the organization wide generation of market intelligence pertaining to current and future customer needs, dissemination of the intelligence across departments, and organization wide responsiveness (Kohli and Jaworski, 1990; pp.6).” The intelligence generation is the starting point of MO, where it is broader conceptualized than customer needs and preferences only. Besides the analysis on customer needs and preferences, it also includes how they are affected by exogenous variables. Government regulation, technology, competition and other environmental factors require scanning activities in the market intelligence generation concept. Apart from the analyses on current needs, it is focused on the future needs as well, but therefore has to define the customers in detail. Meetings with customers and partners should be accounted for. The intelligence generation was not part of the marketing department solely, but it involves more organizational functions. It is generated collectively and mechanism should therefore stimulate and encourage the dissemination process. In order to adapt to market needs, the gathered market intelligence should be disseminated and communicated. Both, formal and informal, dissemination procedures are important for in-between departmental communication flows. It serves to coordinate individuals towards a collective organizational goal. Besides the intelligence generation and the dissemination process, responsiveness is a third element determining the level of MO. It is defined as the actions taken in response to the previously discussed elements. It focuses at target marketing selection procedures and offering products and/or services satisfying customer needs. It is the process that also includes distribution and promotion in a favorable response to the customer groups (Kohli and Jaworski, 1990). The cultural perspective defines MO as: “the business culture that most effectively and efficiently creates the necessary behaviors for the creation of superior value for customers (Narver and Slater, 1990; pp.20)…” and consists of three behavioral components “…– CO, competitor orientation and interfunctional coordination – and two decision criteria – long term focus and profitability – (Narver and Slater, 1990; pp.21).” CO and competitor orientation include activities in acquiring information gathering about buyers and competition in the target market. It also includes the dissemination

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throughout the organization. CO is the sufficient understanding of target customers and requires a proper understanding of the value chain. Both, current and future time frames are to be included. Competitor orientation includes understanding the short-term strengths and weaknesses and long-term capabilities. Inter-functional coordination follows directly from previous discussed components, by compromising the organizational coordinated efforts (e.g. other departments and marketing to create customer value). Therefore it is more than a marketing function only, since all organizational resources need to be efficiently used to create superior value. The two decision criteria include the perception on time. Long-term focus in profit and implementing the behavioral components is the objective for long term survival. Organizations must constantly discover and implement additional value to improve tactics. The second aspect is profitability and/or economic wealth. Profits are part of MO, since it is the consequence or objective of MO. For not-for-profit organizations counts, that profitability is often seen as organizational survival (Narver and Slater, 1990). Both perspectives are complementary. The behavioral perspective concerns understanding the customers and identifying (future) needs, market intelligence and actions, which reflects from the employee’s behavior. The cultural perspective concerns more of the environmental and social context, which reflects input variables for behavior to occur. If MO culture is not ready to counter challenges in changing environments (i.e. employees do not have the right tools yet), MO behavior is less likely to occur. The principles of CO, competition orientation and inter-functional coordination should lead to better performance and view opportunities on the long term. Figure 2-1 provides an overview of the entire MO concept. Customer emphasis (CO)

Intelligence responsiveness

Understanding and commitment - Markets and customers - Customers’ current and future needs Creating and providing - Superior value in the product/service - Customer satisfaction Encouraging - Customer comments and complaints - Problem solving approach

Response design - Developing and designing products and service Response implementation - Implementing designed plans - Altering products and services

Intelligence dissemination

Intelligence generation Gathering, monitoring, and analyzing information - Customers’ current and future needs - Exogenous factors Gathering and monitoring information - Formal means - Informal means

Sharing existing and anticipated information concerning - Customers and stakeholders - Exogenous or external factors Goal - Horizontal and vertical flows of communication - Ensure participation of all departments and personnel

Figure 2-1: The definitions of the MO concept (based on: Zebal, 2003)

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2.1.1.2

Why does market orientation help organizations?

“MO is more than just collecting and dissemination information about the external environment. It also encompasses those activities that allow the organization to act on such information by providing a coordinated response to environmental opportunities and threats [Kumar et al., 2011; pp.37].”

Implementing MO can help organizations to become more CO-ed and profitable by implementing the other marketing concepts, such as: colleague exchange and sharing and other marketing principles. MO is widely adopted in daily business and seen as important antecedent of organizational success (Avlontis and Gounaris, 1999; Jaworski and Kohli, 1993). Besides the behavioral aspect, social culture is an important precondition in the dissemination process, since it reflects collective’s beliefs and values, and organizational performance (Maltz and Kohli, 1996; Han, Namwoon and Srivastava, 1998). It incorporates the impact of corporate culture, where cross-functional processes and individual beliefs, norms and values became important (Despandhé et al., 1993). In general the MO concept considers the notion of centrality of customers and future expectations of customers as goal. MO turned out to be also applicable in governmental and not-for-profit service setting, since the principles of information generation, information dissemination and behavioral reactions identify the understanding of a market necessary in satisfying customers (Cevera, 1998; Kohli and Jaworski, 1990; Cevera, Molla and Sanchez, 2001). Homburg and Pflesser (2000) concluded that MO behavior can be divided into layers of MO culture. Both concepts where combined and they concluded that artifacts (i.e. stories, arrangements, rituals and language) play a crucial role in determining behavior within organizations. This resulted in a new model of MO-ed culture including: (1) shared basic values supporting MO, (2) norms for MO, (3) artifacts of MO, and (4) market-oriented behaviors (see Figure 2-2). These authors show that MO behaviors can be modeled as one of four layers in the organization culture. The consequences are based on the cultural values and behavior (See Figure 2-3), and contribute to organizational performance in three-fold: (1) market-sensing and customer-linking capabilities, (2) customer satisfaction and loyalty, and (3) individual employee’s performance (Kirca, Jayachandran, and Bearden, 2005; Zablah et al., 2012).

Market dynamism

Market-oriented behaviors - Generation of market intelligence - Dissemintation of market intelligence - Responsiveness to market intelligence Shared basic values supporting MO Examples: - Openess to internal communication - Responisiblity of the employees

Norms of MO Examples: - Openess of market-related internal communication - Market-related responsibility of the employees

Performance outcomes - Market performance - Financial performance

Artifacts of MO - Stories - Arrangements - Rituals - Language

Figure 2-2: A multilayer model of MO (adopted from Homburg and Pflesser, 2000; pp.451)

First, the marketing strategy literature posits that MO provides a firm with market-sensing and customer-linking capabilities that lead to superior organizational performance. Organizational

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performance consists of cost-based performance measures, which reflect performance after accounting for the costs of implementing a strategy, and revenue-based performance measures, which do not account for the costs of implementing a strategy (Kirca et al., 2005). It includes the perceived quality of products or services that a firm provides, customer loyalty, and customer satisfaction with the organization’s products or services (Jaworski and Kohli, 1993; customer superior value). Second, MO enhances customer satisfaction and loyalty because MO-ed firms are well positioned to anticipate customer needs and to offer goods and services to satisfy those needs (Slater and Narver, 1994; Kirca et al., 2005). Third, individual’s ability to create and implement new ideas, products and processes, and new product performance should enhance an organization’s innovativeness and new product performance because it drives a continuous and proactive disposition toward meeting customer needs and it emphasizes greater information use (Kirca et al., 2005). Kohli and Jaworski (1990) argue that by instilling a sense of pride and fellowship among employees, MO enhances organizational commitment, employee team spirit, CO and job satisfaction. MO can reduce role conflict, which is defined as the incompatibility of communicated expectations that hamper employees’ role performance and increases job satisfaction (Kirca et al., 2005; Zablah et al., 2012). When we look at the more individual consequences of (CO in particular), research showed that they are responsible for efficiency levels and generating revenue (Homburg, Müller and Klarman, 2011). But besides the (financial) performance, also the customer’s point of view should be taken into account; customer’s attitude towards the sales/service employee and to the product/service itself. These indicators are more on the quality side and therefore indirectly represent customer satisfaction too. Second, behavior also directly impacts customer satisfaction (e.g. loyalty) and resembles the overall evaluation of the interaction with the service employee, the product or service. In finding ways to improve organizational cost management and to improve quality ratings, CO’s role is critical in helping frontline employees to manage these demands.

MO

Input - Beliefs, norms, and values - Organizational culture - Social environment and context

Behavior - Knowledge generation - Market intelligence - Customer responsiveness

Performance & Output - Organizational success - Customer satisfaction - Job satisfaction

Figure 2-3: The impact of MO on performance measures

Summarized, MO consists of social-cultural and behavior sub-constructs, where in this research both are considered as part of the MO construct. They determine the environment and context, and resemble the actual behavior of individual frontline employees. The direct effects of MO improve organizational performance in three different, but related, fields. It makes organizations more aware of the landscape they are in, and provides drivers to react to change; furthermore MO positively influences individual job outcome parameters (e.g. job satisfaction) and customer satisfaction levels.

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2.1.2

Antecedents of market orientation

Important antecedents of MO are training, manager’s ability to set an example, and inter-departmental conflicts (Kirca et al., 2005). To a lesser extent, team processes may also play a role, but these have not been researched well in the MO context, but only in the context of buyer-seller (De Jong, De Ruyter and Wetzels, 2005; Van der Borg, De Jong and Nijssen., 2011). These four categories represent the antecedents at organizational, management, interdepartmental conflict, and team level processes, all directly related to MO beliefs of an individual frontline employee. First of all, organizational factors effect MO at the individual level in twofold: (1) structural, and (2) employee-related systems (Jaworski and Kohli, 1993; Kirca et al., 2005). The effect consists of formalization, concerns the definition of roles, procedures and authority through ruses, where the effect of centralization refers to a limited delegation of decision making authority in an organization. Formalization is inversely related to MO, because it inhibits an organization’s information utilization and thus the development of effective responses to change in the market place (Jaworski and Kohli, 1993). Centralization relates negatively, since it holds back the dissemination and utilization. The second factor (employee related systems) uses MO-ed behaviors as metric to reward employees, thus motivating employees actions that enhance MO (Kirca et al., 2005). Specifically, it concerns MO training augmenting employee’s sensitivity to customer needs. MO training stimulates actions that are consistent with the requirements of becoming more MO-ed. In current research (Kirca et al., 2005), MO training is seen as important antecedent of MO behavior, since it directly affects frontline employee perceptions (Ye et al., 2011). It shows strong positive relationships with MO, intelligence generation, intelligence dissemination, and responsiveness to customers (Jaworski and Kohli, 1993; Ye et al., 2011; Sinkula, Baker and Noordewier, 1997). Frontline employee’s MO knowledge mediates the influence of employees MO behavior and cognitive empathy on customer satisfaction and value (Homburg, Wieseke and Bornemann, 2009). Stimulating employees to develop capabilities and expertise to adopt MO in their normal job expands knowledge base and positively relates to overall performance (Ye et al., 2011). Finally, MO-ed training, augments employees’ sensitivity to customer needs, thus stimulating actions that are consistent with the requirements of MO (Kirca et al., 2005). Second, the role of the (top) management has emerged as one important factor in fostering MO (Kirca et al., 2005). Managers are responsible for the implementation of the concept and have to give signals regarding employee commitment and continuation of the organizational strategies (Kohli and Jaworski, 1990). Leadership studies showed the importance of leadership and the levels of employee autonomy and willingness to develop knowledge (e.g. Arnold et al., 2002; Srivastava, Bartol and Locke, 2006). It effects employee behavior and for instance increases team efficacy and knowledge sharing (Srivastava et al., 2006). The upward mobility and the two-way collaboration between employees and the management are critical in establishing a “perfect” social-cultural environment to perform in (Kohli and Jaworski, 1990). Implementing new strategies involves uncertainty and risk, which might establish failure. Low risk aversion of top managers, has a positive effect on MO support in the organization (Kohli and Jaworski, 1990). At least the combination of attitude towards change (e.g. Ye et al., 2007) and the ability to win confidence/commitment are relevant, which may results in job satisfaction (Konczak, Stelly and Trusty, 2000). The acceptance of that change determines whether the organizational change become a success or not. Another important role of managers is the one facing interdepartmental conflict, which suggests that a “marketing” manager should be able to convince others to cooperate (e.g. coaching; Konczak et al., 2000; Ellinger et al., 2008). The ability to win confidence minimizes conflict and creates trust from

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employees (Kohli and Jaworski, 1990). Second, interdepartmental conflicts include interdepartmental connectedness and conflict. Interdepartmental connectedness, or the extent of formal and informal contacts among employees various departments, enhances MO by leading to greater sharing and use of information (Kennedy, Goolsby, and Arnold, 2003). Interdepartmental conflict, or the tension between departments that arise from divergent goals, inhibits concerted responses to market needs and thus diminishes MO and may lead to ambiguity (Jaworski and Kohli, 1993). According to Kohli and Jaworski (1990) “interdepartmental conflict may stem from natural desires of individual departments to be more important or powerful, or may even be inherent in the charters of the various departments (pp.9).” These conflicts inhibit communication across departments and are likely to appear in the market dissemination process. Besides the interdepartmental conflict, connectedness is the degree of formal and informal direct contact between employees. This process, when used correctly, is required for facilitating and sharing market intelligence (Kirca et al., 2005). Reducing tensions and blame in the organization leads to shared behavior, where all employees communicate (Kennedy et al., 2003; Wieseke, Ahearne, Lam and van Dick, 2009). A final antecedent in creating MO is the one of team effects. Van Dyne, Cummings and McLean Parks (1995) showed earlier that employee behavior, which is a response on perception and attitude, is seen in the context of organization citizenship, carrying its potential to damage the performance, and therefore challenging for management controlled interventions. However, the diffusion of MO (and in particular CO) strategies may help organizations to approach change positively (Lam, Kraus and Ahearne, 2010). A more recent study of Van der Borgh et al. (2011) and De Jong et al. (2005) showed the impact of within-team effects at the performance of a sales employee. Team effects, e.g. diversity and individual position, influence the sales performance of an individual. To date, minimal research focused on the effect of team processes in creating MO. This is surprising in the healthcare context, since highly autonomous teams rely more on the direct interaction with team members, than with their manager. The leadership literature has emerged as main antecedent of MO, but in a similar way the role of team processes asks for a better understanding. Especially when MO is seen as social-cultural concept, the role of influencers directly on the process, become essential. Ye et al. (2008) add to this, by concluding that unit cohesion in managing trade-offs in one of the three (besides autonomy, and leadership) main mediators in the behavioral effects from MO on outcome indicators. With the above said, further research urges to better understand the effects of the MO concept on the individual employee level and to identify the specific role of MO in the dissemination process of change management. Important facilitators in the process of implementing MO cultural values in the organization require more attention on the team effects. Previous research focused more on top management factors, but in service oriented organizations deal with highly autonomous teams. Additionally, the knowledge updating efforts (e.g. learning) could be considered as motivator for MO, and might built a solid base for accepting frontline change, and closing the gap between management and employees. Figure 2-4 summarized the antecedents on the MO concept.

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Organizational - Centralization / formalization - Training

Management - shape values & orientation - Risk aversion - Conflict solving

MO


Inter-departmental conflict - Goal conflict - Connectedness - Communication


Team - Social support - diversity & position - beliefs and behavior

Figure 2-4: The antecedents of MO

2.1.3

Empowering leadership as moderator for the effect of market orientation behavior

An important moderator on the relationship of MO behavior and outcome performance indicators is empowerment (e.g. Marinova et al., 2008; Arnold et al., 2000); more empowered individuals use their MO knowledge more effectively and accomplish better results. Empowerment is particularly important in healthcare and other settings where chances in the market force a firm to stress frontline employees to maintain service quality and at the same time increase efficiency. Marinova et al. (2008) show that frontline autonomy moderates the positive impact of productivity and quality orientations on unit revenue and customer satisfaction and its negative impact on unit efficiency. In this process, management feedback wakens the impact of the trade-off on customer satisfaction, but also amplifies the trade-off effect for unit efficiency.

2.1.3.1

What is empowering leadership?

The change to more self-autonomous teams requires managers to be more empowering and to lay more responsibilities directly with the frontline employees. This benefits the performance in such a way that overall flexibility and efficiency increase. The shift to more autonomy in teams requires the managers to be pay attention to a new set of roles and responsibilities (Arnold et al., 2000). In general, management gives the employees self-efficacy and self-control, and removing conditions that foster a sense of powerlessness (e.g. participative decision making). Empowering leadership may be categorized into four different basic beliefs (Arnold et al., 2000):

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(1) (2) (3) (4)

Leading by example; Participative decision making; Coaching; Informing;

Those categories represent the essentials of empowering behavior. The first one refers to behaviors that show manager’s commitment to own and team members’ work. Usually managers leading by example set high standards for performance of their own behavior (Arnold et al., 2000). The second category concerns the behavior to educate team members and making suggestions for individuals to become more self-reliant. The third category refers to the use of input from team members as input to the managers’ decision making process (Arnold et al., 2000). In other words, it is the amount of effect members in a team influences the actual decisions. The fourth category refers to the capability of a manager to disseminate organizational wide information. It concerns the explanation of organizational decisions and information team members about policies and developments (Arnold et al., 2000).

2.1.3.2

Why should we pay attention to the leadership-frontline mechanism?

“In the context of service provision, empowering frontline service employees involves delegating authority to the lowest level in an organization, where a competent decision can be made by authorizing lowerlevel employees to give the customer priority over other issues in the operation (Ellinger et al., 2008; pp.4).”

This new complex business environment sitting is very demanding for frontline employees and requires a combination of professional expertise and proper management, in order to optimize service level and productivity (Ye et al., 2011). These high levels of interdependence involve coordination and collaboration between different disciplines, at the same time (e.g. seniority and learning activities). Ye et al. (2011) even found support for the effect of a seniority relationship, focused on quality and efficiency trade-offs. Updating knowledge increases not only quality levels, but also stimulates to be more efficient. The main differences are determined by employees who face variability and uncertainty, inducing high quality but lower efficiency at the same time. In this context it becomes quite relevant to further explore the trade-offs between quality and efficiency, since they seem to be opposing values and different than manufacturing settings. Nembhard and Tucker (2011) recently indicated that researchers often focus either on a quality or efficiency context, when investigating service oriented organization performance. Less research focused on the dual orientation, where trade-offs emphasize either one or the other, which in this context might be more appropriate. As discussed previously, the healthcare setting involves both business orientations. An important indicator for the dual-orientation relevance is the interesting “balance” between management, teams and frontline employees´ mindsets. Management is often more focused on providing efficiency, where employees often intent to provide quality service. Management determines the strategy for a particular period of time and frontline employees have to adapt to this situation, where they often respond negatively and see efficiency efforts as threat (Ye et al., 2007). Besides the orientation, the dissemination process therefore seems to be even more important; and managers struggle to respond. An example illustrates this point, where management and employee´s orientation clashes:

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The healthcare industry is (in the past) focused only on quality, and paid minimal attention to productivity and effective process management. In the present-day one can find an important change in this industry, where cost-cutting-activities (Rust et al., 2002; Ye et al., 2007; Raju and Lonial, 2002) influence the need for efficiency. Healthcare providers, regulators (government) and health insurers aim towards a different goal, namely: rewarding healthcare providers which possess higher quality and cost-effective care, where customers have participation in the selection procedure. These parallel market pressures require FLEs to change their own vision, beliefs and activities (Marinova et al., 2008). Frontline employees stick to their own (and old) “ways-of-working” and management cannot force them to change which eventually leads to counterproductive (compared to the cognitive schemas6) behavior (Ye et al., 2007)

2.1.3.3

Why could empowering leadership be a solution?

Especially in a changing environment, leadership is all about establishing an organization culture, where changes have no negative effect on performance. Perceived change and particularly continued change leads to change perceptions that may result in alienation. Particularly when the individual feels no control over the situation alienation is likely to occur [Ye et al., 2007]. Negative effects may be prevented by empowering leadership which involves the individual to be creative and help. Employees become more and more self-directed and receive more responsibilities than before in order to increase feelings of self-efficacy and control (e.g. participative decision-making; Arnold et al., 2000). Another relevant aspect is that less bureaucracy is faced nowadays; frontline employees feel less powerless and find themselves as being important in the organization (Arnold, et al., 2000; Shrivastava et al., 2006). Leadership may facilitate autonomy particular employee behavior, by encouraging individuals to take more responsibility, to be creative and innovative, and to provide them with trust (Hartline et al., 2000; Arnold et al., 2000; Singh, 2000). This form of empowering leadership behavior results in teams including individuals with more autonomy, self-direction and control over their own environment (Arnold, et al, 2000; Shrivastava et al., 2006; Singh, 2000). This facilitates the dissemination process and the acceptance of change. An additional dimension of empowerment is providing performance feedback (Konczak et al., 2000). The feedback employees receive impacts their performance outcome, since they are either stimulated or judged negatively on behavior. In healthcare settings, managers often have to discuss efficiency and productivity with employees, where they need system feedback as input. Often these IT supported feedback lacks in clarity and consistency, and eventually leads to misperceptions. Misperceptions of feedback, from the system or from managers, lead to poor performance (Sterman, 1989). This process may moderate the intentions of behavior from employees and the actual performance. It eventually determines the appreciation or dissatisfaction behaviors. This new management philosophy relies more on team performance, where responsibilities shift towards individual employees (Singh, 2000). Management layers lapse in order to reduce costs and to streamline the organization (Arnold et al., 2000). This change leads to the process of implementing conditions focused on increasing feelings of autonomy, self-efficacy and control (Arnold et al, 2000; Shrivastava et al., 2006; Singh, 2000). Managers should empower employees, since both organization and employee will benefit (Arnold et al., 2000). This type of leadership is seen as moderator on the 6

“The dominant schema and experience of FLEs in face-to-face service settings is based on providing highquality customer service [e.g., Donavan, Brown, and Mowen, 2004; Schneider and Bowen, 1984]”. [Ye et al., 2007, p.158].

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relationship between perception and outcome indicators (see Figure 2-5). In order to facilitate this process, mangers should possess the following items, in order to successfully stimulate employee behavior: leading by example, participative decision-making, coaching, informing and showing concern with the team (Arnold, et al, 2000; Shrivastava et al., 2006). An important activity in this form of leadership is feedback, which may facilitate the dissemination process and acceptance of change (Konczak et al., 2000). Marinova et al. (2008) indicate this effect as reducing the performance gaps, where both performance objectives may be met.

Empowering leadership - Leading by example - Participative decision making - Coaching - Informing

MO




Figure 2-5: The effect of empowerment on the relationship of MO and outcome measures

2.1.4

The role of segmentation in the frontlines

Less attention in the literature exists for the role of segmenting customers as part of MO. In the context of managing trade-offs between efficiency and quality, it is surprising that research has not yet focused on the role of segmentation, assumed that it will lead to deliver better service and efficiently management. The main premise is that for many customer similar needs and wants can be identified (Kerin, Harley, Berkowitz and Rudelius, 2006). “Market segmentation involves aggregating prospective buyers into groups, or segments that have common needs and will respond similarly to a marketing action (Kerin et al., 2006; pp.44).” The basis for this is the normal distribution that underlies most human characteristics and behavior where segmentation concerns the task of identifying communalities between customers and explores whether a targeted and well positioned product or service can be developed. Such specialization will result in a better product and higher efficiency for delivering this service. Evidence for these dual benefits in healthcare is several (Ye et al., 2011). In the past few decades several health concepts have been introduced to better address knee fractures, eye operations, and so on and so forth (e.g. Baker and Corts, 1996). However, while these specific examples refer to a specific use of the idea of segmentation and positioning here segmentation refers more to the general principle of segmentation: the way individuals are able to segment ongoing activities and beliefs in full support of the principles of segmentation at the organizational level (employee’s beliefs).

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2.1.4.1

What is segmentation – the marketing context?

In order to be a true market segment, the organizations must respond differently to variations in the marketing mix (i.e. price, promotion, distribution, and place), compared to others. Market segmentation can be generally explained from four basic criteria (Green and Tull, 1987): (1) (2) (3) (4)

Segments must exist in the environment; Segments must be indefinable (repeatedly and consistently); Segments must be reasonably stable over time; Organizations must be able to attain segments effectively (through specifically targeted distributions and communication initiatives);

McDonald and Dunbar (2004) additionally define market segmentation as follows: “Market segmentation is the process of splitting customers, ore potential customers, in a market into different groups, or segments, within which customers share a similar level of interest in the same, or comparable, set of needs satisfied by a distinct marketing proposition (MacDonald and Dunbar, 2004; pp.37).” Segmentation is powerful and a well-developed marketing tool, where a properly segmented market can improve marketing, distribution, and efficiency and provide additional profits. Senior management must be involved, and strategic decision making is required to effectively segment a market. Segmentation can be done due to several criteria. Most studies (e.g. McDonald and Dunbar, 2004; Kerin et al., 2006) focus on traditional ways to segment: geographically, demographically (i.e. age, income, and gender), and psycho-geographically (i.e. values and lifestyle). But, segmentation can also be done due to the influence of behavioral characteristics (i.e. utilization rates in manufacturing). When we look at the healthcare service setting, no research yet tried to approach segmentation from a more individual perspective; meaning that frontline employees are individually able to segment own activities in response to their customers. In this way they might be able to accept top management intentions; they perceive trade-off management positively.

2.1.4.2

Is segmentation in the frontlines important? 7

“When market segmentation is applied in the public sector, the purpose is not just the selection of target segments. Instead, the segmenting of the population should concern different services and especially different ways of serving customers in different segments. Serving the segments in the right way should help to gain efficiency improvements and advantages to allocate scarce resources [Sintonen, Hokkanen, Hallikas and Kaljunen, 2011; pp.4].

Adding customer segmentation and category specific solution to the MO concept might solve the issues in trade-off management. It relates directly to the MO concept, since it explores the segmentation and positioning elements of the marketing concept (Kerin et al., 2006). These aspects are explored at the organizational levels in marketing, but in the frontlines it might influence job outcomes positively. The concept of segmentation is widely adopted, but at the frontline employee level this should help to 7

Working paper by Sitonen et al., 2011; source (last consulted on 2012-08-08): http://www.apas.admpubl. snspa.ro/bitstream/handle/2010/409/EGPA_2011_PSG_XVI_Sintonen.doc?sequence=1

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counter the changes from solely customer focus to trade-off management; it might be that clustering complex and simpler cases offers efficient ways to improve quality. It might not directly impact by MO behavior, but relate directly to employee’s beliefs; organizational change strategy can only be adopted when individuals are able to think in the same terms and conditions. The first task in segmentation is the selection of a segment on the basis of a set of variables/characteristics used to assign homogeneous groups (Sitonen et al., 2011), but this also implies that frontline employees are able to segment processes linked to specific customer groups. Frontline employees may use the principles of segmentation to better group tasks and activities in their daily job. Taking notion of the principles of segmentation may offer individuals certain beliefs that better correspondent with quality intentions. Nowadays, the management of GGzE initiates projects at the higher levels of the organization, concerning the segmentation of customer groups on the basis of financial benefits. But, the essence of segmentation, in response, reasons from a more CO-ed belief. Thus in converging management objectives with the individual perceptions of employees, segmentation may lead to a better understanding of how to manage trade-offs. An example illustrates the point that, for instance, market segmentation (or any organizational practice) should be designed about the customer, to align management and employees: “In the service sector, and in call centers in particular, bundles of HR practices do appear to be aligned with factors such as market segment and the nature of the customer interaction. This suggests that, in some organizations at least, working practices and HR practices are being designed and implemented in a systemic and integrated manner and according to an underlying managerial orientation. However, whether organizational fit is a result of strategic or pragmatic choice needs further clarification. It should also be noted that, even where a more systemic approach is taken, working practices are often designed according to a technical and economic rationale that rarely considers employee well-being (Holman, Wall, Clegg, Sperman and Howard, 2003)”, or in my opinion customer-centered reasoning.

2.1.4.3

The role of segmentation in overcoming trade-off challenges

As quality-efficiency trade-offs in the frontlines increases (e.g. Singh, 2000; Ye et al., 2007), segmentation might offer a solution. The general principle of segmentation concerns quality and simultaneous efficiency improvements, where both positively influence organizational behavior. The reasoning from this concepts always reflects the customer interests; meaning that customers remain in the center of attention. As indicated before, segmentation is often viewed from an organizational perspective, where sub-segments are targeted as customer groups. But, no research yet tried to understand the effect of segmentation at the individual frontline employee level. Especially segmentation in service oriented contexts become relevant, since operations play a crucial role in the two-way interaction with the customer. The principles of MO and segmentation provide capabilities to reconsider the quality-efficiency trade-off, since the premise is that segmentation improves both. This way of segmentation might contribute to the organizational performance and customer satisfaction in twofold: (1) frontline employees become more aware about the way they can utilize capabilities, to better serve customers, and (2) they become aware of the bigger influence of segmentation at the organizational level. Frontline employees might better understand organizational initiatives, that mostly reflect only financial results, but the underlying idea of segmentation is that customer-orientation is essential in this process.

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MO




Segmentation (or categorization) - General principle applied in frontlines - Effect of beliefs on quality-efficiency trade-off - Reasoning from the customer

Figure 2-6: Segmentation as part of the MO concept and the effects in the frontlines

2.1.5

Gaps in the literature

The widespread use of the MO concept makes it somewhat surprising that the segmentation principle has not drawn more research attention or been investigated systematically in the frontlines. Furthermore the team and management effects in the frontlines have received minimal attention yet at the belief-level of frontline employees, next to the empowering leadership concept (e.g. Gebhardt, Carpenter and Sherry, 2006; Arnold et al., 2000). In the changing service context, where the simultaneous pressure on cost containment and qualitative service levels increases, little research has attempted at integrating the three concepts – MO, CO and trade-off management. The urge for a better understanding and identifying mediators/moderators of the challenges faced in direct service is at the order of the day in daily management. Especially the healthcare environment, where service contexts are dynamic and uncertain, seems relevant. They face often unexpected change and due to governmental initiatives change continuously occurs. These organizations posses high levels of CO-ed behavior, where unique treatment methods are often used to approach client care. The total picture of the MO concept now involves also the exchange and sharing behavior, where professionals use each other’s experience and expertise to develop collective actions. Developments do not only attract the attention of top management teams, but on all hierarchical levels of the organization, change has its effects. The individual frontline employee is responsible for final actions and emits organizational strategy. The segmentation concept is often initiated by the organization (organizational levels), where they reason more from a general business level. In marketing, no research has yet researched the beliefs and behavior (antecedents and consequences) at the individual level. This is surprising, since this particular concept has proven to be successful at the firm levels in manufacturing (e.g. Kerin et al., 2006). The concept provides quality improvements, but also positively impacts the efficiency levels of an organization. To address this gap – considering the three concepts and their effect at the individual performance and identifying the mechanisms to improve effects of their relationships – this empirical research provides evidence for previously stated areas of interest. Based on the previous sections several gaps in the literature can be identified. There were four gaps identified (summarized in Table 2-1) that received minor attention in the literature concerning the 24

frontlines: (1) the effect of segmentation in the frontlines, (2) the impact of existing team processes, (3) educational tracks to develop frontline mechanisms, and (4) the impact of employee’s beliefs. These four fields of research incite to conduct this empirical research. All are briefly explained in “where does this gap come from (i.e. relationship to current literature)” and “why is this gap an important field of research”. Table 2-1: Gaps in the literature are identified. Where do they come from (whence), and why are they important for future research

Gap 1

Adding customer segmentation and category specific solution to the MO concept. Whence? In the context of managing trade-offs between efficiency and quality, it is surprising that research has not yet focused on the role of segmentation, assumed that it will lead to deliver better service and efficiently management. The main premise is that for many customer similar needs and wants can be identified (Kerin et al., 2006). “Market segmentation involves aggregating prospective buyers into groups, or segments that have common needs and will respond similarly to a marketing action (Kerin et al., 2006; pp.44).” In the past few decades several health concepts have been introduced to better address knee fractures, eye operations, and so on and so forth (e.g. Baker and Corts 1996). However, while these specific examples refer to a specific use of the idea of segmentation and positioning here segmentation refers more to the general principle of segmentation: the way individuals are able to segment ongoing activities and beliefs in full support of the principles of segmentation at the organizational level (employee’s beliefs). Why? Adding customer segmentation and category specific solution to the MO concept might solve the issues in trade-off management. It relates directly to the MO concept, since it explores the segmentation and positioning elements of the marketing concept. These aspects are explored at the organizational levels in marketing, but in the frontlines it might influence job outcomes positively. The concept of segmentation is widely adopted, but at the frontline employee level this should help to counter the changes from solely customer focus to trade-off management; it might be that clustering complex and simpler cases offers efficient ways to improve quality. It might not directly impact by MO behavior, but relate directly to employee’s beliefs; organizational change strategy can only be adopted when individuals are able to think in the same terms and conditions.

Gap 2

Taking into account the influence of existing team processes Whence? Van Dyne et al. (1995) showed earlier that employee behavior, which is a response on perception and attitude, is seen in the context of organization citizenship, carrying its potential to damage the performance, and therefore challenging for management controlled interventions. However, the diffusion of MO strategies may help organizations to approach change positively (Lam et al., 2010). A more recent study of Van der Borgh et al. (2011) and De Jong et al. (2005) showed the impact of within-team effects at the performance of a sales employee. Team effects, e.g. diversity and individual position, influence the sales performance of an individual.

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Why?

To date, minimal research focused on the effect of team processes in creating MO. This is surprising in the healthcare context, since highly autonomous teams rely more on the direct interaction with team members, than with their manager. Especially when MO is seen as social-cultural concept, the role of influencers directly on the process, become essential. Ye et al. (2008) add to this, by concluding that unit cohesion in managing trade-offs in one of the three (besides autonomy, and leadership) main mediators in the behavioral effects from MO on outcome indicators. Also team processes like individual development and team development are relevant, since the first one is more focused on innovation, where the second one incorporates social aspects. The influences of team processes could develop or hold back individual beliefs and behavior, certainly when facing highly autonomous teams.

Gap 3

The intention to educate (learn) knowledge about trade-offs (quality vs. efficiency) Whence? It builds upon the idea that frontline learning in the frontlines about trade-offs is unique for customer service settings (Ye et al., 2011; Singh, 2000). It is critical for the organizational performance and leads to long-term financial benefits (Ye et al., 2011). Overcoming the problem, making use of educational tracks, is found to be harsh for organizations, but evidence suggests that eventually they achieve superior return on organizational objectives (Ye et al., 2011). It can be compared to the MO concept, since it generates knowledge at the individual worker level. Training and individual development strive to be more MO-ed and to evolve individual beliefs, that fit and reflect the corporate culture. Why? Training stimulates beliefs and employee development that are consistent with the requirements of becoming more MO-ed. In current research (Kirca et al., 2005), MO training is seen as important antecedent of MO behavior, since it directly affects frontline employee perceptions (Ye et al., 2011). It seems to be crucial in simultaneously improving quality and efficiency. This knowledge updating process requires organizational initiatives, management to facilitate and other team members to motivate frontline service employees. The need to cooperate with (in-) direct partners/con-colleagues, sharing behavior requires a two-way interaction between all previously discussed links.

Gap 4

The focus on changing CO beliefs and behavior should be stimulated Whence? The social culture aspect of MO is an important antecedent for performance, since it reflects collective’s beliefs and values, and organizational performance (Maltz and Kohli, 1996; Han et al., 1998). It incorporates the impact of corporate culture, where cross-functional processes and individual beliefs, norms and values became important (Despandhé et al., 1993). The changing environment pressures frontline employees to reconsider own beliefs, to incorporate the trade-off in their activities. It might not directly impact by MO behavior, but relate directly to employee’s beliefs; organizational change strategy can only be adopted when individuals are able to think in the same terms and conditions. Why? It should be stimulated, in order to improve the dissemination process. The effects of beliefs on behavior should therefore be included in research, where moderators should enhance the positive impact and exclude performance loss.

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New educational tracks (training), better system feedback and empowerment (empowering leadership behavior) are seen as main facilitators, where individual beliefs and behaviors are expected to influence organizational performance to a large extent in direct service organizations.

2.2 Model to guide empirical research This 2.2 section builds upon the introduction and the theoretical background, since it bundles findings and contextual factors into “one” model for empirical research. Besides the model development, this section will provide hypotheses and further argumentation for the proposed model.

2.2.1

Model development

Figure 2-7 shows the framework developed based on the literature to guide the empirical research at GGzE, and to get a better understanding of the challenges/problems. Subsequently, this framework was used to test this research empirically, in order to draw conclusions. The conceptual model was discussed with the with University supervisors before rolling out. Several months in advance the model was revised over and over again, until no “radical” change was found anymore. The model was considered mature after 3 months of revising, and after an interim presentation with University supervisors and GGzE’s management, which was used as “testing-ground” for this research, where it was discussed in full detail with the organization’s management. The model focused at the individual employee’s level, where MO is built in as beliefs and behavior. The antecedents are shown from three perspectives: organizational (organizational orientation and CO training), management beliefs, and team beliefs. These direct effects were expected to increase MO (second order construct: CO, colleague exchange, and segmentation beliefs). MO resembles the core values of generating knowledge, sharing behavior and viewing it from a customer’s perspective. Furthermore, the direct effect of job satisfaction on efficiency and on customer satisfaction was measured too. The final relationship viewed at is the direct effect of efficiency on customer satisfaction. This relationship was considered as most essential, since it represents the effect of trade-off at the individual level. The next section, 2.2.2, will elaborate more at the hypotheses and explains all relationships briefly.

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Empowering leadership behavior

TEAM MO beliefs

Revenu orientation (quality)

H.3

H.8.a

H.11.a H.7.a

H.10.a H.6.a

H.1.a MO BELIEFS


Revenu x Cost

H.1

H.11 CO beliefs

CO behavior H.9

H.1.b

H.8 CO exchange beliefs


H.5



H.6 H.7

H.10 Segmentation CO training

Segmentation

Job satisfaction

H.2

H.4

MANAGER MO beliefs

Figure 2-7: Initial framework for empirical research

2.2.2

Hypotheses

Based on the model several hypotheses are formulated. They are briefly discussed by making use of their underlying mechanisms/motivations and state each hypothesis for each relationship of the framework. First, organizational orientations and their effects are useful to study from an employee’s perspective, since employee’s beliefs (e.g. change perception) eventually impact performance (Marinova et al., 2008); it is what employees perceive it to be. Employees interpret and make sense of managerial actions, following naturally on the organizational orientation objectives. Employees receive organizational and managerial input and act in response (Marinova et al., 2008). Ye et al. (2007) showed that revenue- and cost containment strategies impact the change perceptions of an employee regarding change. Previous research showed that, for instance, revenue enhancement orientation positively affects autonomy (Marinova et al., 2007; Singh, 2000) and mediates the effect of negative change perceptions (Ye et al., 2007). Additionally, cost containment orientation emphasis seems to relate in a negative way to autonomy and positive change perception. These findings looked more at the effect of organizational orientation on individual perceptions, where Rust et al. (2002) concluded that revenue emphasis leads to more quality and cost containment to more efficiency. A dual emphasis (trade-off management) seems to impact the individual perception in a positive way (Rust et al., 2002; Ye et al., 2007). In this research setting the beliefs of individual employees are central and the effect of organizational orientation is predicted to impact CO beliefs, CO exchange beliefs and segmentation beliefs. For this research the following is predicted:

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H.1:

a dual emphasis – revenue orientation and cost containment orientation –positively influences MO beliefs of an individual frontline employee.

H.1.a: a revenue oriented emphasis is positively related to MO beliefs of an individual frontline employee. H.1.b: a cost containment orientation emphasis is negatively related to MO beliefs of an individual frontline employee. Second, CO training is expected to have direct effects on the beliefs of an individual. In the last two years, a study by Ye et al. (2011) explored the impact of learning in the frontlines, where they especially considered training about trade-offs. Learning in the frontlines turned out to be an important mechanism to overcome the performance loss of trade-off management in the frontlines (Ye et al., 2011). It builds upon the idea that frontline learning in the frontlines about trade-offs is unique for customer service settings (Ye et al., 2011; Singh, 2000). It is critical for the organizational performance and leads to long-term financial benefits (Ye et al., 2011). Overcoming the problem, making use of educational tracks, is found to be harsh for organizations, but evidence suggests that eventually they achieve superior return on organizational objectives (Ye et al., 2011). Nembhard and Tucker (2011) add to this, that even though the organizational knowledge base is large and growing, frontline employees still maintain a certain amount of uncertainty in their daily job. Providing healthcare service is no exact science and it involves high levels of variety, meaning that no single solution is the best. Since frontline employees often have to adapt to change unpredictably, based on for instance the changing treatment programs, time management becomes important. Training stimulates beliefs and employee development that are consistent with the requirements of becoming more MO-ed aware. In current research (Kirca et al., 2005), MO training is seen as important antecedent of MO behavior, since it directly affects frontline employee perceptions (Ye et al., 2011). Therefore, the following is predicted: H.2:

CO training has a positive direct effect on the frontline employee’s MO beliefs.

Third, team composition is another relevant aspect, which have to be taken into account in service oriented organizational settings. Differences between individuals within a team cause challenges and organizations have struggled to embrace, and manage them successfully (Harrison and Klein, 2007). According to Gebhardt et al. (2006), organizational culture allows employees to enjoy a shared understanding of problems, develop creative thinking and become appreciated in a collaborative environment. It determines the individual fit, where individuals can identify them with team norms, values and beliefs. In principle, it determines the context and environment you are working in and part of. Team composition becomes relevant as main driver for organizational and team culture (Van Dyne et al., 1995), where for instance seniority (Ye et al., 2011) can influence trade-offs and the acceptance as well. According to Harrison and Klein (2007), researchers have struggled to conceptualize and study the differences and impact of team diversity effectively. According to Anderson and West (1998), team climate can be described by the cognitive schema approach and the shared perception approach. The first one is conceptualized as “individuals constructive representations or cognitive schema of their work environments (Anderson and West, 1998; pp.236)”, which in service oriented organizational settings often refers to customer focus (Ye et al., 2007). The latter one is conceptualized as “the shared perception of the way things are around here (Anderson and West, 1998; pp.236)”, which is mainly focused at the acceptance of common policies, practices and procedures. Especially the second approach is interesting, since it is focused on four team climate factors: vision, participative safety, task orientation and support for innovation (Anderson and West, 1998).

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The impact of individual beliefs seems to be effected by team beliefs. Earlier research by Van Dyne et al. (1995) showed that individual beliefs and perception should consider the context of organizational citizenship. The social aspects carry the potential to increase the performance and to convince others to develop themselves. In a sales-context the impact of group processes is recently researched more often. De Jong et al. (2005) conclude that the relevance of group potency in a service environments impacts performance, where past research focused only on manufacturing. These principles seem applicable in the service context. Furthermore the findings of De Jong et al. (2005) suggest that interpersonal relationships among group members moderate the consequences of individual performance. Together with the previously discussed study of Van der Borgh et al. (2011), they indicate that team effects mediate the effects of individual beliefs. To date, minimal research focused on these effects from team to individuals in highly autonomous contexts. Therefore this study predicts the following: H.3:

Average team beliefs, of the same constructs as for the individual, have a positive direct effect on individual frontline employee’s MO beliefs.

Fourth, in line with the previous hypothesis, the effect of manager beliefs was considered next. The role of top managers is seen in the MO literature as one of the most important antecedents (Kirca et al, 2005). Managers are responsible for implementing MO ideas and principles (Kumar et al., 2011) and therefore are expected to directly influence individual beliefs. Implementing new strategies involves uncertainty and risk, which might establish failure. Low risk aversion of top managers, has a positive effect on MO support in the organization (Kohli and Jaworski, 1990). At least the combination of attitude towards change (e.g. Ye et al., 2007) and the ability to win confidence/commitment are relevant, which may results in job satisfaction (Konczak, 2000), might be reflected by the beliefs of mangers. Therefore, this study predicts the following: H.4:

Manager beliefs, of the same constructs as for the individual, have a positive direct effect on the frontline employee’s MO beliefs.

Fifth, MO beliefs and MO behavior are naturally related to each other; the former breed the latter. In general the logical relationship is beliefs (objective) > attitude (subjective) > behavior, thus in this case beliefs are expected to directly influence behavior. At the individual employee level, behavioral aspects consider to aim at engendering customer satisfaction levels and psychological variables (e.g. mind-set, attitude, and surface trait) that motivates to satisfy these needs (Saxe and Weitz, 1982; Zablah et al., 2012; Brown, Mowen, Donovan and Licata, 2002). This latter perspective is in line with cultural perspective, which concerns more the environment and social context. The cultural values of the MO concept relate to the psychological perspective, in a way that these individual variables are part and determine the corporate culture. Employees beliefs and behaviors represent own norms and values, which could be influenced by others and organizational culture. The reason for measuring beliefs in combination with behavior is that the segmentation aspect is not expected to be reflected into behavior yet. Furthermore the difference in beliefs and behavior is that, beliefs represent individual’s ideal service setting, where behavior depends on the surroundings and the context. This study therefore predicts the following: H.5:

MO beliefs have a positive effect on MO behavior.

Sixth, the direct relationship from MO behavior to the three outcome measures is predicted. MO behavior is expected to have a direct effect on job satisfaction, customer satisfaction and on efficiency.

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The direct positive effect on job satisfaction is expected, since Zablah et al. (2012) found that CO behavior results in higher job satisfaction. Furthermore the MO literature shows consistent evidence of the years that MO has positive overall impact on job satisfaction (e.g. Kirca et al., 2005). From several MO studies (e.g. Ye et al., 2007; Ye et al., 2011; Rust et al., 2002; Zhou, Li, Zhou and Su, 2008) it was concluded that MO behavior results in better organizational performance, regarding efficiency levels and customer satisfaction. MO behavior, including the segmentations construct, is expected to have a positive effect on efficiency. The main reason for this is that MO provide an employee drives to manage both quality and efficiency at the same time. MO enhances customer satisfaction and loyalty because MO-ed firms are well positioned to anticipate customer needs and to offer goods and services to satisfy those needs (Slater and Narver, 1994; Kirca et al., 2005). H.6:

MO behavior has a positive direct effect on customer satisfaction levels.

H.7:

MO behavior has a positive direct effect on job satisfaction levels.

H.8:

MO behavior has a positive direct effect on efficiency levels.

The direct relationships from employee measures (job satisfaction and efficiency) and the effect on customer satisfaction are discussed. Zablah et al. (2012) recently found a positive effect of job satisfaction to self-rated performance, and Zou et al. (2008) add that it directly impacts quality too (in this case, quality is seen as part of customer satisfaction). The premise that happy employees lead to better performance has been studied for several years, but the attention shifts to the strong relationship at the individual level beliefs (Zhou et al., 2008). MO contributes to the firm performance, since it is expected to increase employee job satisfaction, quality (Zhou et al., 2008) and efficiency measures. The direct relationship between efficiency and customer satisfaction is expected to relate in a negative way, which can be explained due to the trade-off principles. As already explained in the previous sections (related to H.1), this trade-off at the individual frontline employee is seen as “sweet & sour”; if efficiency goes up, customer satisfaction goes down, and vice versa. H.9:

Job satisfaction has a positive effect on efficiency.

H.10:

Job satisfaction has a positive effect on customer satisfaction.

H.11:

Efficiency has a negative direct effect on customer satisfaction.

Seventh, an important moderator considered in this process is empowering leadership. It is seen as positive influences on all MO > outcome measures relationships, as indicated by a large amount of previous research in section 2.1.3 (e.g. Ellinger et al., 2008; Hartline et al., 2000). The role of empowering leadership is especially seen as important moderator in the direct effect from efficiency to customer satisfaction, which is expected to moderate the negative effect of efficiency to customer satisfaction. It provides employees with more autonomy in their daily jobs, which perfectly suits the healthcare environment. In this research context customer satisfaction levels are seen as predicted by individual employee measures (i.e. job satisfaction) and more organizational measures (i.e. efficiency levels). This concerns the trade-off outcome measurement and resembles the dual emphasis of the organization. H.6.a: The positive relationship between MO behavior and customer satisfaction is positively moderated by empowering leadership.

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H.7.a : The positive relationship between MO behavior and job satisfaction is positively moderated by empowering leadership. H.8.a: The positive relationship between MO behavior and efficiency is positively moderated by empowering leadership. H.10.a: The effect of job satisfaction on customer satisfaction is positively moderated by empowering leadership. H.11.b: The effect of efficiency on customer satisfaction is positively moderated by empowering leadership.

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3 Methodology 3.1 Research setting, sample, and procedure The data were collected from care professional employees and managers at GGzE. The care teams contained professionals and experts who particularly focus on unique client service. These highly autonomous teams coordinate their efforts and share information about client needs, treatment processes, and performance outcomes. Since the current shift towards dual focus from the organizational point of view, the urge to combine a dual focus on maintaining/improving quality levels and efficiency measures at the individual frontline levels was increasing. Managers are responsible for daily management and pay close attention to these outcome measures. In this research setting a group of diverse management functions was investigated, since some focus more on quality assurance, where others are fully responsible for financials. The common factor in all management functions was the coordination of a specific team. The company’s care portfolio consists of a wide range of mental healthcare services, such as autism, elderly, emergency psychiatry, child psychology and forensic care for clients with a criminal tile. Its strategy is not cure clients (since this is not entirely possible), but to let clients deal with their psychological/physical handicap. The core message is to increase living standards and, if possible, to let them participate in society for the best as possible. As is common in this industry, pressure increases due to governmental cost containment strategies (Nembhard & Tucker, 2011; Ye, Marinova & Singh, 2011; Raju and Lonial, 2002), which requires also this organization/GGzE to constantly look for new strategies to tackle challenges and to survive. Particularly the past year GGzE has begun to respond to these changes and has implemented for example a project called “Process Optimization”: this project was implemented in the same time when this research was conducted. The trajectory was to determine healthcare logistic paths from departmental perspective. The goals were eventually to close the gap between NZA and DBC8 financing (governmental initiated change in financing treatment in healthcare). The project was initiated from the overhead department and also diffused to department management. Data was collected using an internet-based questionnaire (supported by the software of Qualtrics), and after 3 reminders (three-week period) 268 care professionals participated, resembling 42 teams with more than, or equal to 3 respondents. The management survey followed the same procedure, where a total of 58 managers returned complete questionnaires. Table 3-1 presents the exact distribution and response rates for the questionnaire, where the appendix (Figure C-1 and Figure C-2) provides the progress of returning complete questionnaires. Appendices represent the specific contact messages (appendix D) and full questionnaires (appendix E and appendix F). Manager’s beliefs and behaviors were excluded from team measurement, for two reasons. Most managers do not directly communicate with clients and do not perform similar tasks as care professionals. Second, this analysis aims at understanding team contexts, where these autonomous teams spend most time without direct manager. Therefore, including managers directly as team member, might bias results. Additionally to this paragraph, appendix D (Table D-1, Table D-2, and Table D-3) presents the specific procedure of gathering management data (based on the approach of Dillman, Smyth and Christian (2008). It includes initial interviews, questionnaire development, pre-tests, notifications and reminders, and briefly explains the actions during the different stages of development. 8

NZA (Nederlandse zorg autoriteit) and DBC (Diagnose behandel code) are different forms of financing, where the transaction for healthcare organizations is nowadays shifting from NZA to DBC.

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Table 3-1: Distribution and response rate of returned surveys

- All care professionals - Care professional teams with a minimal of three respondents - Care professional teams including management data - Management survey (separate)

Respondents 268 (of 1349) 227

Response rate 19,9% 16,8%

Teams

Respondents per team

42

5,4

129

9,6%

27

4,8

58 (of 113)

51,3%

Before elaborating on the measurement, demographic distributions are provided. The care professional survey contained data of 99 men and 169 women. The average experience in the mental healthcare sector was 19.6 years, within the company 13.3 years and within the team 6.9 years. The average age of all respondents is 44.3; where men are on average 48.4 years old and women are on average 42.8 years of age. Most respondents have successfully ended a HBO education (176) and 32 respondents have received a University degree. Care professionals work on average 31.3 hours per week, which equals 0.87 FTE. On average they treat about 80 patients per year, but variation is large in this particular item. The management survey contained data about 24 men and 34 women. On average they are 46.4 years of age, men 48.4 and women 45.0. The average experience in the mental healthcare sector is 22.3 years, within the company 14.9 and as manager from the team 4.5 years. 55 of the managers have a degree higher than or equal to HBO education, where 10 of them received a University degree. The average manager manages 37.4 team members and works 33.8 hours a week (= 0.94 FTE).

3.2 Measurement Interviews with the management of the company were used to get familiarized with the company. Additionally, I was already 1.5 years employed at the company, thus had early access to management, but also to the department of research and development. All pre-meetings were used to further build up upon the initial research proposal. These meetings ensured early involvement and fast word-ofmouth diffusion. My director also informed the board and directors of the entire company; they furthermore diffused the information by the management to individual employees. Before the definitive questionnaires were developed, pre-test were performed with management, quality assurers and care professionals. From the results, only minor wording adjustments were done to enhance applicability in the special context. The measures for the study constructs were adopted from the MO literature (e.g. Kohli and Jaworski, 1990; Narver and Slater; 1990; Rust et al., 2002) and as from related articles (e.g. Ye et al., 2007; Ye et al., 2011; Homburg et al., 2008; Jasmand, Blazevic and De Ruyter, 2012). In the appendix D (Table D-4) more information can be found about the actual measures and their questions (in Dutch). The original sources used are also referenced. Please note that the questionnaire included some extra questions additionally to the current model. The reason for not using all items was an overload of item-constructs to discuss in one research model. Most items were measured using a five-point Likert scale with 1=”totally agree”, 2=”agree”, 3=”neutral”, 4=”do not agree”, and 5=”do not agree at all” as anchors., but identification scales were measured using a 7-point Likert scale; overlap/identification scales (based on Bergamo and Bagozzi, 2000). Customer satisfaction and efficiency scores/data (objective data) were received directly from the organization. In association with Team Management Information, both

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constructs were used during this research9. Below independent, dependent, and control variables are described in more detail.

3.2.1

Variables

Trade-off orientation. This dual construct measured the amount of cost-containment or revenue orientation focus. Both single constructs were based on previous research. Revenue orientation was measured using three items developed by Ye et al. (2007). All focused on the implementation of initiatives to serve customers better. The cost containment orientation construct was measured using three items developed by Rust et al. (2002), and aimed that new initiatives should always encounter financial effects; when improving quality performance, initiatives are also judged regarding their financial impact. CO training. This construct was measured by four items, where one of them was new and specifically developed for this research context. The remaining three measures are based on the items of Ellinger et al. (2008). The questions focus entirely on the training that is provided to frontline employees by organizational initiative. They deal with issues like “how to cope with…” and “how to stay up-to-date about…”, and therefore impact behavior and/or beliefs. MO beliefs individual frontline employees. The MO beliefs were built out of three different subconstructs: (1) CO beliefs, (2) Colleague exchange and sharing, and (3) segmentation. The CO belief measure came from the scales of Lam et al. (2010). The questions were transformed into the Dutch language and slightly adjusted, to better represent the context. The second sub-construct also came from Lam et al. (2010), and was adjusted in a similar way. The segmentation sub-construct was new in this research context, where three questions were derived from research by Homburg et al. (2008) and three entirely new were developed. These questions were adjusted to a larger extend, since they resembled a specific situation. This last group of questions was built by the help of my University supervisors and adapted after the pre-test. Team MO beliefs & Manager MO beliefs. The MO beliefs were built out of three different subconstructs10: (1) CO beliefs, (2) Colleague exchange and sharing, and (3) segmentation. The CO belief measure came from the scales of Lam et al. (2010). The questions were transformed into the Dutch language and slightly adjusted, to better represent the context. The second sub-construct also came from Lam et al. (2010), and was adjusted in a similar way. The segmentation sub-construct was new in this research context, where three questions were derived from research by Homburg et al. (2008) and three entirely new were developed. These questions were adjusted to a larger extend, since they resembled a specific situation. This last group of questions was built by the help of my University supervisors and adapted after the pre-test. MO behavior. Similar categories, as indicated by MO beliefs, for behavior measurement were used. For CO behavior, two items were used derived from Lam et al. (2010). Two items were derived from Jasmand et al. (2010), since they better resemble behavior. They focused on the specific employee’s actions. One item was newly developed, and was built specifically for the care context. The colleague 9

10

A total overview of individual constructs and questions is provided in the appendix C. Here you can find references, original items and Dutch questions that appeared in the online questionnaire (See Table D-4). Specific methodology about converting constructs from different sub-constructs can be found in the section about “construct computing”.

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exchange construct was built of research by Kohli and Jaworski (1990) and Lam et al. (2010). This mixture resembles the construct best, since the first research is more about the individual within-team exchange and the second one is more related to outside-team exchange (competitor scale). The segmentation construct, was again, based on research by Homburg et al. (2008) and own initiative. One item was based on Kohli and Jaworski (1990) and focused on the team exchange behavior with the customer interest in mind. Empowering leadership. The leadership construct was built out of four different sub-constructs: (1) coaching, (2) informing, (3) leading by example, and (4) participative decision making. All constructs were entirely based on research by Arnold et al. (2000). These constructs/questions are widely used in by different researchers, and the measurement scale has proven its reliability. Questions were directly translated in Dutch, where slight changes linked them even more to the specific research context. Job satisfaction. Questions regarding the job satisfaction construct (three in total) were based on a proven scale, presented by Hackman and Oldham (1975). This scale is widely used as job satisfaction scale. One new question (of those three) was developed, and concerns more the satisfaction that employees get when satisfying customers. This is a particular interesting measure, since it not only resembles job satisfaction, but also specifically relates to the environment. Customer satisfaction. This scale was based on objective data sources, provided by the organization itself. Customer satisfaction scales resemble the yearly (average) customer satisfaction levels, but also presents figures at a team level. Those figures were afterwards assigned to individuals. This measure might be biased, since no direct relationships between customer satisfaction and individual respondents could be made. In healthcare this is the main issue in considering satisfaction as outcome indicator, since clients (or guardians, e.g. parents) do not judge entirely at an individual level. Nevertheless it provides the opportunity to objectively judge performance outcomes, the reason for including this data. The scale ranges from 1-10. Efficiency. The efficiency data was provided by the Management Information team within the organization. Efficiency measurement is done using the actual direct client-related time and divided by the contractual available time. It normally returns a value between 0-1, but it might be higher than 1, since some are more productive than others. These outcome data was related to the individual respondent, possible due to the link in employee number. In this research two control variables were used to correctly perform the model estimation. Innovative behavior and workload were chosen as controls. The first one was seen as important related construct, in terms of willingness to change, develop and innovate. It was also used in earlier research and turned out to have an effect (e.g. Ye et al., 2011). Furthermore the workload construct was used as control, due by the same reasoning. Employees need time to develop and to be MO-ed. In previous research by, for instance, Ye et al. (2007; 2011; Singh, 2000) these scales were also used. As noted earlier in this section, more variables were measured in the questionnaire, but not used in support for this particular research model. Although they remain interesting for future research, they are discussed in appendix D.

36

3.3 Analyses SPSS-PASW statistics 18 and SmartPLS11 were used to analyze the data. SPSS was used to perform data checks – computing averages and re-coding items –. SPSS was also used to conduct additional factor analysis to check “new” constructs; CO, colleague exchange and segmentation beliefs and behaviors. SmartPLS software was used to examine the data afterwards. This program conducts a Partial Least Squares analysis which allows simultaneously examination of theory and measures. This Structural Equation Modeling technique suits experimental designs very well. It allows flexibility in modeling and is able to provide instant solid results, even when modeling with a smaller sample size (Hair, Ringle and Sarstedt, 2011).

3.4 Measurement validation and model check 3.4.1

Manipulation checks

The returned data was checked (factor analysis and initial reliability of constructs) using SPSS. First items were re-coded, since not all data was gathered with the same scale weight. Most items were coded in a 5-point Likert scale ranging from: (1) totally agree, (2) partly agree, (3) neutral, (4) partly disagree and (5) totally disagree. These items were re-coded in opposing order (1=5, 2=4, 3=3, 4=2 and 5=1) to rate them with similar weight as the identification scales and to compare them in a right way with the objective data. The identification scales were measured using a 7-point scale, as discussed in the methodology. This scale ranged from (1) no overlap/identification at all to (7) full overlap/identification. Additionally, the construct change perception has to be considered as opposing value, since this was expected to relate negatively to the positive items; the higher the change perception, the higher the negative relationship with for instance MO behavior. Re-coding was done for both survey responses – care professionals and management. All other data is considered as complete, mainly due by the help of the Qualtrics software, since non complete surveys were filtered out directly. 269 care professional surveys returned, where one complete respondent was dropped, since only neutral answers were received. 3.4.2

Construct computing

After the manipulation check was performed, SPSS software was used to run pre-computing analysis. Those calculations were used to determine the correct construction of the on average based constructs. The following constructs were all build out of three independent sub-constructs: MO beliefs, MO behaviors, Team beliefs, Manager beliefs, and Empowering leadership (second order constructs; with reflective indicators). The following formula was used:

where Qi,k expresses the value of a question i for the sub-construct k, and n is the total number of questions of the sub-construct. Afterwards the sum is taken of all sub-constructs, where m resembles the amount of sub-constructs as part of the final construct. This formula is used to determine the constructs at the individual employee level. Table 3-2 shows how constructs how they were build specifically. Team constructs (averages) were computed only for teams with three or more respondents. 11

SmartPLS software application; free accessible beta version available at: http://www.smartpls.de/forum/

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Team averages were calculated excluding the beliefs of the respondent self. But, before even defining these combined constructs, all sub-constructs were analyzed independently using SPSS. The following formula was used:

where Ci resembles the construct value for the individual, Cj resembles the sum of all other team members and n the total members in a team. This formula was used to determine the average construct load of the team, excluding the individual itself. A factor analysis was done for the sub-constructs MO beliefs and MO behavior; this to indicate whether or not data was suitable. The factor analysis, was done to determine whether or not beliefs and behaviors were could be separately assessed. A Varimax with Kaiser Normalization component analysis was used, and showed that all care professional beliefs and behavior can be evaluated separately. Rotated component matrixes can be found in the appendix (Table B-3, Table B-4, and Table B-5). Table 3-2: Construct development. Constructs provided in the first column are built upon the sub-constructs, which in their turn consist of the averages of the individual items/questions.

Construct MO beliefs

MO behavior

Team MO beliefs

Manager MO beliefs

Empowering leadership

3.4.3

Sub-constructs CO beliefs Colleague exchange beliefs Segmentation beliefs CO behavior Colleague exchange behavior Segmentation behavior CO beliefs Colleague exchange beliefs Segmentation beliefs CO beliefs Colleague exchange beliefs Segmentation beliefs Coaching Informing Leading by example Participative decision making

Number of individual Items 3 3 6 5 5 5 3 3 6 3 3 6 5 3 4 4

Validity and reliability checks

SmartPLS was used to determine the discriminant validity, in order to determine to what extend the measures in the model are different from other measures in the model. A construct should share more variance with its measures than with other constructs in the model. This analysis was done by comparing the square root of the Average Variance Extracted (AVE) with the correlations between the variables. The correlation between the variables should be lower than the square root of the AVE (Hair et al., 2011). Table 3-3 confirms that all square roots of the AVE’s are higher in all cases than the correlations between the variables.

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Construct validity refers to which extend the variation in the endogenous latent variables is accounted for by the constructs. This was analyzed using the R-squared, where the SmartPLS model counts for 5 latent variables: Customer satisfaction (R2=0.159), Efficiency (R2=0.081), Job satisfaction (R2=0.136), MO behavior (R2=0.298) and MO beliefs (R2=0.494). Variances in the outcome constructs were relatively weak. Partially it can be explained by mixing of survey with archival data. Variance explained for the lefthand side of the model is as might have been expected. The use of second-order constructs for MO beliefs and behaviors of the individual employee might also impact R2 values (Hair et al., 2011). Table 3-3: Correlations and square root of the AVE (square root of AVE presented in the diagonal)

Construct

1

2

3

4

5

6

7

8

9

10

11

12

1.

CO training

0,83

2.

Empowering Leadership

0,13

0,82

3.

Innovation behavior

0,06

0,02

0,70

4.


0,04

0,12

-0,09

1,00

5.

Cost containment orientation

-0,08

-0,16

0,17

-0,10

0,79

6.

Efficiency

-0,17

-0,06

-0,06

-0,13

0,02

1,00

7.

Job satisfaction

0,07

0,17

-0,02

0,09

0,01

0,13

0,91

8.

Manager MO beliefs

0,06

-0,20

0,18

0,09

0,19

0,32

-0,07

0,71

9.

MO behavior FLE

0,14

-0,08

0,45

0,06

0,13

0,09

0,08

0,22

0,75

10.

MO beliefs FLE

0,26

-0,04

0,53

0,06

0,26

-0,11

-0,07

0,30

0,49

0,61

11.

Revenue orientation

0,08

0,11

0,13

0,04

0,38

0,13

0,15

0,22

0,05

0,13

0,63

12.

Team MO beliefs

0,14

0,05

0,32

0,06

0,13

-0,12

-0,09

0,23

0,21

0,39

0,06

0,63

13.

Workload

-0,28

-0,17

-0,05

-0,16

0,12

0,08

-0,28

0,16

0,14

0,05

0,14

-0,02

Construct reliability (as shown in Table 3-4) exceeds 0.6 in all cases, which indicates that constructs are reliable (0.7 in non-exploratory research; Hair et al., 2011). This alternative method of assessing the reliability was used, since Cronbach’s alpha may over or under estimate scale reliability. “Construct reliability assessment routinely focuses on composite reliability as an estimate of a construct’s internal consistency. Unlike Cronbach’s alpha, composite reliability does not assume that all indicators are equally reliable, making it more suitable for PLS‑SEM, which prioritizes indicators according to their reliability during model estimation (Hair et al., 2011; pp.145).” Table 3-4: Construct reliability and AVE’s output from SmartPLS

Construct

Composite Reliability

1.

CO training

0,901

2.

Empowering Leadership

0,890

3.

Innovation behavior

0,830

4.


1,000

5.

Cost containment orientation

0,833

6.

Efficiency

1,000

7.

Job satisfaction

0,933

8.

Manager MO beliefs

0,751

9.

MO behavior FLE

0,789

39

13

0,83

3.4.4

10.

MO beliefs FLE

0,639

11.

Revenue orientation

0,637

12.

Team MO beliefs

0,646

13.

Workload

0,865

Structural modeling specifications in SmartPLS

The hypnotized model was analyzed using SmartPLS software. This software program made it possible to test the entire model at once. Missing values in the data were all noted as “-99” values. These missing values did only concern the efficiency construct and team/manager MO beliefs. The first construct analysis showed that not all respondents had objective efficiency measurement. It depends on function and if they were allowed to register time. The missing values for the two latter constructs were present, due to the fact that teams require a minimal of three respondents and not all management data could be linked with individual respondents. The significance levels were calculated using the Bootstrapping procedure. Where the parameters were set as follows (Hair et al., 2011): (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)

Missing value settings: -99; Missing value algorithm: Case Wise Replacement; Weighting scheme: Centroid; Data metric: Mean 0, Var 1; Maximum iterations: 300; Abort criterion: 1.0E-5; Initial weights: 1.0; Sign changes: Individual changes; Cases: 268; Samples: 500;

Since the bootstrapping procedure presents t-values, they correspond with the significance levels as presented in Table 3-5. Afterwards the PLS algorithm was executed to determine path coefficients. The parameters of the Algorithm were as follows: (1) (2) (3) (4) (5) (6) (7)

Missing value settings: -99; Missing value algorithm: Case Wise Replacement; Weighting scheme: Centroid; Data metric: Mean 0, Var 1; Maximum iterations: 300; Abort criterion: 1.0E-5; Initial weights: 1.0; Table 3-5: Significance levels Bootstrapping (derived from Hair et al., 2011)

t-value > 1.645 > 1.96 > 2.576

Sig. two tailed .10 .05 .01

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In framework * ** ***

4 Results The results of the PLS estimates, i.e. path coefficients and significance levels are presented in Table 4-1. Path coefficients (can be interpreted as standardized beta coefficients of ordinary least squares regression) and are provided, calculated using the PLS algorithm in SmartPLS (Hair et al., 2011). Figure 41 additionally presents the framework results. To help link results and hypotheses also hypotheses numbers are listed (see left hand side of Table 4.1). Most relationships are significant, but a detailed discussion is presented next. Table 4-1: t-values and path coefficients

Hypothesis H.1 H.1.a H.1.b H.2 H.3 H.4 H.5 H.6 H.6.a H.7 H.7.a H.8 H.8.a H.9 H.10 H.10.a H.11 H.11.a

Relationship Revenue orientation * Cost containment orientation > MO beliefs Revenue orientation > MO beliefs Cost containment orientation > MO beliefs CO training > MO beliefs Team MO beliefs > MO beliefs Manager MO beliefs > MO beliefs MO beliefs > MO behavior MO behavior > Customer satisfaction MO behavior * Empowering leadership > Customer satisfaction MO behavior > Job satisfaction MO behavior * Empowering leadership > Job satisfaction MO behavior > Efficiency MO behavior * Empowering leadership > Efficiency Job satisfaction > Efficiency Job satisfaction > Customer satisfaction Job satisfaction * Empowering leadership > Customer satisfaction Efficiency > Customer satisfaction Efficiency * Empowering leadership > Customer satisfaction

41

t-values 5.206

Path coefficient 0.271

0.262 3.409 6.268 2.682 2.672 4.454 1.906 2.764 1.674 2.131 0.985 3.165 2.473 1.694 3.002

0.010 0.162 0.309 0.132 0.140 0.326 0.111 -0.148 0.177 0.102 0.049 0.186 0.150 0.087 -0.202

2.759 1.827

-0.165 0.727

Empowering leadership behavior TEAM MO beliefs Revenu orientation (quality) .186 ***

.132 ***

.727 * .102 *

-.202 **

.010 ns -.148 *** MO BELIEFS Revenu x Cost


.271 ***

-.165 *** CO beliefs

CO behavior

.162 ***

.150 ** .049 ns


CO exchange beliefs

.309 ***



.111 * .177 *

.087 * CO training

.309 ***

Segmentation

Segmentation Job satisfaction

.140 ***

MANAGER MO beliefs

Figure 4-1: Results research framework (Representation of path coefficients and two-tailed significance level, where *=0.1, **=0.05, and ***=0.01)

4.1 Influence of antecedents on MO beliefs and MO behavior The first part of the framework (left hand side of Figure 4-1), the relationship between organizational orientation and MO beliefs is discussed first. From the framework we can conclude that a dual orientation between revenue and cost containment is positively related to MO beliefs (H.1; =0.271); in support of H.1. From previous research it seems that revenue orientation strategies are seen superior to cost containment strategies, but this was only when considering the effect on CO and colleague exchange (Ye et al., 2011; Rust et al., 2002). This research shows that when MO is included at the individual level, cost containment even has a direct positive significant relationship towards beliefs (H.1.b; =0.162). This finding is not in support for H.1.b, but opposing. Thus, when organization’s focus on a dual emphasis or solely on cost containment it activates MO beliefs in a positive way. For the direct effect of revenue orientation on MO beliefs, H.1.a, no significant effect has been found. Frontline service employees tend to belief that they are more MO-ed, exchange and share information with colleagues and belief that segmenting customers in performing their daily activities is important in current service settings. No significant effect was found for H.1.a. From this research we cannot directly derive that revenue orientation has a positive relationship with MO beliefs. The other direct effect considered is CO training. From this research we can conclude that CO training positively influences the MO beliefs strongly (H.2; =0.309). Therefore H.2 is supported. When organizational initiate to provide CO training, it relates positively to the MO beliefs of an individual. Therefore CO training can still be seen as useful mechanism to shape individual beliefs and to eventually make them able to confront

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trade-offs between efficiency and quality. The effect also showed that training focused from the perspective of the customer, positively influences the MO construct. Furthermore we can conclude that team MO beliefs (H.3; =0.132) as manager MO beliefs (H.4; =0.140) positively influence the beliefs of frontline service employees too, which is in support of H.3 and H.4. This research incorporated the team/manager beliefs at specifically similar levels as the frontline service employee. In service settings they might be even relevant and of impact, since frontline employees often work in highly autonomous teams. They depend on and motivate each other’s. One can imagine that a team with mostly conservatives is less eager to become MO-ed. The second part of the framework (midsection of Figure 4-1) considers the direct relationship between frontline employee’s beliefs and behavior. The relationship between beliefs and behavior is rather logical, since beliefs ‘often’ directly relates to behavior. Results show that MO beliefs activate MO behavior (H.5; =0.326). Results indicate that employee’s beliefs determine behavior in large volumes, and therefore support H.5.

4.2 The consequences of MO behavior Another interesting set of relationships to look at are the actual outcome constructs (right-hand side of Figure 4-2): job satisfaction, efficiency and customer satisfaction. They determine the impact of MO on individual performance, and they reflect the organizational orientation. As derived from the framework, we can conclude that MO behavior has a positive significant effect on customer satisfaction (H.6; =0.111) and job satisfaction (H.7; =0.177), and therefore supports H.6 and H.7. No significant effect was found for the effect on efficiency, and therefore H.8 was not supported. First the direct effects of MO behavior on job satisfaction and customer satisfaction are discussed, where afterwards the indirect effects are brought to the attention.

4.2.1

The effect of MO behavior on Job satisfaction

The relationship between MO behavior and job satisfaction is positive (H.7), with a coefficient of 0.177, and therefore in support of H.7. It indicates that the second order MO construct (build from: CO behavior, colleague exchange behavior and segmentation) positively impacts the satisfaction levels of frontline service employees. This relationship is positively moderated by the effect of empowering leadership (coaching, informing, participative decision making and leading by example; H7.a; =0.102), which is in support of H.7.a. Results indicate that when managers are able to stimulate autonomy and to make individuals responsible for the care process, they become more satisfied. In order to evaluate this relationship even more in-depth, Figure 4-212 presents the two-way interaction effects of this relationship. Results indicate that high forms of empowering leadership together with high levels of MO behavior, impact job satisfaction positively. The moderating effect of empowering leadership is therefore seen as a good facilitator in the process of increasing job satisfaction due to MO behavior. The higher the MO behavior and the facilitating support by empowering leadership, the higher the levels of job satisfaction.

12

Two-way interaction effects were calculated using a template developed by Jeremy Dawson. Source (last consulted on 2012-08-12): http://www.jeremydawson.co.uk/slopes.htm - 2-way-standardized.xls.

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1,6

Job satisfaction

1,4 1,2

Low Empowering leadership

1 0,8

High Empowering leadership

0,6 0,4 0,2 0 Low MO behavior

High MO behavior

Figure 4-2: Two-way interaction effect of MO behavior * empowering leadership and job satisfaction

4.2.2

The effect of MO behavior on Customer satisfaction

The relationship between MO behavior and customer satisfaction is significant and positive (H.6), with a coefficient of 0.111. It supports H.6. It indicates that MO behavior positively impacts the satisfaction of customers. This relationship, different than expected, was negatively influenced by the moderating effect of empowering leadership (H.6.a; = -0.148). Therefore H.6.a was not supported. As Figure 4-3 shows the results of the two-way interaction, high forms of empowering leadership negatively impact the customer satisfaction levels. These results can indicate that frontline employees are not ready yet to receive empowering leadership. They do not seem to be able to behave in an autonomous way; e.g. employees do not possess the right capabilities, expertise, background, and experience. A sure thing is that employees with high levels of MO behavior and low levels of empowering leadership are able to increase customer satisfaction. When employees have high levels of MO and simultaneously experience high levels of empowerment, they have a tendency to decrease customer satisfaction in response. The assumption that can be made is that, employees do not yet know how to effectively manage optimization processes. Their knowledge is not up to date, and they are, for instance, not able to apply the principles of segmentation the right way.


2,5

2 Low Empowering leadership

1,5


1 0,5 0 Low MO behavior

High MO behavior

Figure 4-3: Two-way interaction effect of MO behavior * empowering leadership and customer satisfaction

44

4.2.3

The consequences of Efficiency and Job satisfaction on customer satisfaction

The direct effect of MO behavior and efficiency is not significant (H.8). But results from the moderator empowering leadership show significant results on this relationship, in support of H.8.a. If the relationship was viewed as being significant, empowering leadership moderates this in a positive way (H.8.a; =0.186), which implies that empowering leadership has positive impact on the relationship MO behavior to efficiency, but not to customer satisfaction. Since results in this relationship are weak, we could better focus on the direct effect of efficiency on customer satisfaction. Efficiency is directly positively influenced by job satisfaction (H.9; =0.150), indicating that satisfied employees turn out to be more efficient. This supports H.9. It seems natural, since they are likely to show less counterproductive behavior. Subsequently, efficiency has a negative significant effect on customer satisfaction. Results show that the dual performance measurement (efficiency vs. customer satisfaction) leads to friction and a negative interaction (H.11; = -0.165), which is in support of H.11. But, as expected, empowering leadership moderates this interaction more positively than on the direct effect MO behavior > customer satisfaction. It seems, according to Figure 4-4, that when employees have high levels of efficiency, customer satisfaction levels are equal independent of the impact of empowering leadership (H.11.a; =0.727). If the direct effect of empowering leadership on customer satisfaction would be less negative, than the combined high levels of empowering leadership and high levels of efficiency are of positive impact on customer satisfaction (see the red line in the Figure 4-4).


4 3,5 3

Low Empowering leadership

2,5 2


1,5 1 0,5 0 Low Efficiency

High Efficiency

Figure 4-4: Two-way interaction effect of Efficiency * empowering leadership and customer satisfaction (red line presents the interaction relationship by a direct effect of the moderator of -0.400, instead of -0.651)

Customer satisfaction is directly positively influenced by job satisfaction, in support of H.10 ( =0.087), indicating that satisfied employees turn out to have a positive direct effect on customer satisfaction. In this relationship the effect of empowering leadership was measured as well. Results in Figure 4-5 show that empowering leadership * job satisfaction has negative effects in combination with on customer satisfaction (H.10.a), opposed to the expected effect, thus no support. In all, it seems that the moderating effect of empowering leadership has a minor positive effect on customer satisfaction when it is reviewed with efficiency simultaneously. An explanation for this negative effect is assumed to be similar as explained in section 4.2.2. This particular finding asks for a better understanding of the effect of more effective and innovative management on the individual employee (e.g. informal coaching).

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3,5 3 Low Empowering leadership

2,5 2 1,5


1 0,5 0 Low Job satisfaction

High Job satisfaction

Figure 4-5: Two-way interaction effect of job satisfaction * empowering leadership and customer satisfaction

Overall results show that trade-off orientation, CO training, and team and management beliefs positively relate to the levels of MO beliefs. In turn, MO beliefs result into higher volumes of MO behavior, which concerns the CO behavior, colleague sharing and segmentation behaviors. The outcome measurement of the model showed some unexpected results about the effect of empowering leadership. This might be caused by the assumption that leadership in the organization is perceived from a more financial perspective and by the assumption that care professionals do not. Another implication might be that more factors play a crucial role in the moderating relationship from empowering leadership and outcome measures. But, these results will be reviewed and compared to other scientific literature in the next chapter.

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5 Discussion, managerial implications and implications for future research 5.1 Discussion of results The point of departure of this study was the question: how to manage the trade-off between efficiency and quality in service frontlines? To answer this main research question a model was developed to get a better understanding or how to implement MO and its effect on the frontline service employees. From the results we can conclude that there was a direct positive effect from CO training, team beliefs, and manager beliefs at the individual frontline service employee’s beliefs. Hereby they also increase MO behavior. The findings from MO behavior on performance are mixed, and interactions with empowerment can indicate that the organization is in the early stages of development; they are not ready to facilitate change, making use of empowering leadership, to implement the trade-off strategy. Results showed that the interaction between low empowering leadership and high MO led to better performance, than the interaction between high empowering leadership and high MO. High levels of empowering leadership only showed increased job satisfaction level for the frontline employee, but did not solve the challenges between efficiency and customer satisfaction measures. In the next section this will be discussed in more detail.

5.1.1

The effect of CO training, manager beliefs, and team beliefs on individual MO beliefs

Results confirmed the direct effect of CO training, manager beliefs and team beliefs on individual MO beliefs. Specifically, frontline employees that have team members with higher beliefs at MO are selftriggered to become more MO-ed. It seems that in highly autonomous environments, like in health care, rely on team impact and from the management beliefs. It is surprising that little research was done at understanding the team influences on individual behaviors in the MO and change/trade-off context. The concept of MO is often viewed from behavioral or cultural perspectives, where the latter one involves, for example, sharing behavior. Teams become increasingly important, since they are self-reliable and less influential by management; if a team includes multiple conservatives, the environment seems rather weak for change to occur. Furthermore they directly influence others negatively and hold back on the three sub-constructs of MO beliefs. When considering the efficiency – quality trade-off, managerial actions and feedback become important (Marinova et al., 2008). They deliver the organizational orientation and influence employee’s perceptions. Marinova et al. (2008) concluded that orientation of an organization only works when individual frontline employees perceive it the right way. Efficiency and quality orientation are reflected in practices of frontline employees, where besides management (Ye et al., 2008), now also team influences are found to have an effect. The MO beliefs positively increase, when teams and managers have high beliefs too. In line with previous research of Marinova et al. (2008) findings clarify and limit that direct effects of strategy and performance outcome levels, because of the frontline mechanisms. Recent research by Van der Borgh et al. (2011) identified that team composition and member’s positions influence the pro-social attitudes and behavior of frontline sales people. It strengthens findings in this research, although that it is not directly related to MO contexts. In the search to manager trade-offs at the individual worker level, recent articles focus more and more on the impact of teams (e.g. identification, team-based settings, within-team helping behavior, diversity, and individual position; e.g. Van der Borgh et al., 2011; De Jong et al., 2005). It seems naturally related to the sub-construct of CO beliefs and the colleague exchange sub-construct; if

47

workers are invited to develop/train themselves to better serve customers, they become more eager to put customer interests first and to share information in order to optimize treatment programs. Besides the original sub-constructs, it was somewhat expected to oppose with segmentation, since it might be perceived from a financial perspective. But again, this depends on the perceived long-term plans initiated by the top management. Nonetheless, the CO training construct positively influences the MO belief construct, even more than team/management perceived beliefs. Summarized, it can be concluded that CO training, team beliefs and manager beliefs all effects the individual beliefs about MO positively. This finding is consistent with Ye et al. (2011), who concluded that training at the individual level about managing trade-offs leads to better “overall” business performance. For this reason we can conclude that, trade-off management at the individual worker level can be conquered using CO training; segmentation reasoned from a customer perspective implies to increase efficiency in response.

5.1.2

The effect of perceived organizational orientation on individual MO beliefs

Results reveal that organizational trade-off orientation – cost containment and revenue orientation – can be viewed as an important antecedent for individual frontline employee’s beliefs. A trade-off orientation, as perceived from the individual frontline service employee, positively affects the MO beliefs; a dual focus improves the MO beliefs, where employees become more CO-ed, belief that exchange and sharing behavior is a mechanism and segmenting might function as solution for managing both objectives. This finding expands prior empirical work on the relationship between unit emphasis (cost containment or revenue orientation), change perceptions and frontline employee productivity and quality performance (Ye et al., 2007). From past research (Ye et al., 2007; Rust et al., 2002) it seemed that revenue orientation was the only strategy with a positive impact on business performance. But, this empirical research showed that the segmentation concept experiences positive effects, from direct cost containment strategies and a dual orientation. Backwards reasoning indicates also that larger MO beliefs easier accept the notion of cost containment strategies.

5.1.3

The effect of beliefs on behavior

The direct relationship between MO beliefs and MO behavior is found to be positive. This implies that beliefs are of direct impact on behavior, and that therefore CO training, team beliefs and manager beliefs have its impact on employee’s behavior as well. The relationship is not directly 1:1, and might be moderated by other constructs (e.g. workload, innovation beliefs, etc.). Since frontline employees are tend to cope with change, findings from theory show that perceptions about change, negatively influence behavior; the more rackety in an organization, the more an individual cannot identify him/herself, and the more counterproductive behavior will occur (Ye et al., 2007). Further research should focus on the impact of employee’s beliefs and behavior to better understand the challenges in the frontline mechanism.

5.1.4

The consequences of MO behavior on performance

As indicated before, the effects from MO behavior on the performance measures are more mixed. The direct effects of MO behavior on performance turned out to be positive. However, the interaction effect with empowering leadership showed only a positive moderating effect on job satisfaction, but not on customer satisfaction levels. The negative effects are different than expected, since earlier scientific research showed only positive effects of empowering leadership (e.g. Arnold et al., 2000; Shrivastava et al., 2006; Singh, 2000). These results may indicate that frontline employees are not ready yet to receive

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empowering leadership; in other words, the organization is still in the early phases of implementing MO and the principles of trade-off. Employees still have to adapt to the challenging situation and to learn how to use MO to become effective. This assumption is likely to occur in service organizations and is supported by earlier empirical findings (Hartline et al., 2000; Ellinger et al., 2008). A second explanation might be that the customer satisfaction measure is adequate; it resembles customer satisfaction levels on unit levels, so not directly linked to individual performance. From earlier research (e.g. Zablah et al., 2012) it seemed that customer satisfaction measures are often hard to use, since they do not fully capture individual performance. Specifically in healthcare this is the main issue in considering satisfaction as outcome indicator, since clients (or guardians, e.g. parents) do not judge entirely at an individual level. Further research should explore the measurement of customer satisfaction in these settings. Next, the direct effects of MO are discussed in more detail first, including their interaction effect with empowering leadership. Afterwards the indirect effects of MO (direct effects of job satisfaction and efficiency on customer satisfaction) are discussed in more detail. 5.1.4.1

The direct effects of MO behavior on outcome measures

The direct effects of MO behavior on outcome measures – job satisfaction and customer satisfaction – showed positive results (no significant result was found for the relationship of MO behavior and efficiency). It can be concluded that MO behavior (including the segmentation construct) influences job satisfaction and customer satisfaction directly. This confirms previous research (Zablah et al., 2012), that behavior influences organizational outcome measures at the organizational (customer satisfaction) as the individual worker level (Job satisfaction). For this explorative research, empowering leadership (coaching, participative decision making, informing, and leading by example) was reviewed as moderator, because of two reasons: (1) from past research the empowering leadership construct showed significant effects and is widely adopt in many industries (e.g Hartline et al., 2002) and (2) from practice, empowerment is seen as key moderator to performance and top management indicates their importance in facilitating trade-off management. In a context where trade-offs at the individual level becomes challenging; empowering leadership was expected to be an important moderator. The higher the MO behavior, the more important it becomes for managers to stimulate and coach frontline employees. It should help people to understand things better. It should resolve the problems with the unknown changing environment, where management makes frontlines employees ready. The interaction effect of empowering leadership and MO behavior showed positive influence on job satisfaction levels. This indicates that when employees are provided with higher levels of autonomy, they feel in control and happier. This is confirmed by recent empirical research by Ye et al. (2007); If employees participate in determining the future activities, they are more willing to adopt own beliefs; this results in more positive behavior. The effect on job satisfaction is also consistent with the findings of Zhou et al. (2008), who concluded that the quality of a leader impacts the relationship of MO behavior on job satisfaction positively. However, the moderating effect on customer satisfaction turned out to be negative. This negative relationship was unexpected (e.g. Ye et al., 2007; Srivastava et al., 2006), but might be explained due to the fact that healthcare teams are highly autonomous but not knowledgeable to cope with these challenges. Another explanation might be that segmentation, as part from the MO concept, is seen

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purely from financial perspective; at least, it is perceived as financial objective by the employees 13. Research by Hartline et al. (2000) and Ellinger et al. (2008) however confirmed this negative relationship, where they both concluded that empowerment does not help to disseminate the prioritization of customer services to employees. Besides the explanation that the positive effect of empowerment only occurs after pre-programming employees using other tracks (e.g. education), Batt (1999) concluded that employees are often empowered to focus on quality objectives, but highly “recommended” to include financial performance. This may lead to the discussion, that empowerment might not be ideal for implementing MO in the organization. On the other hand, informal management coaching 14 showed better positive relationships with MO behavior and organizational performance (Ellinger et al., 2008). Here the relationship between educational tracks and informal management is seen as unique combination to improve the performance of individual employees. It is more about the facilitation effect of providing opportunities for employees to develop capabilities, and to encourage them to do so. Coaching therefore influences the relationship of MO beliefs – MO behavior and outcome indicators. And informal forms of leadership provide them with this opportunity. This mechanism is now explored in the individual frontline context and requires more attention in the literature, to further explain exact consequences.

5.1.4.2

The effect of job satisfaction and efficiency on customer satisfaction

In line with the previous section, the effects of job satisfaction and efficiency on customer satisfaction were analyzed. “Indirect” effects of MO behavior, via the internal organizational process, impacts customer satisfaction. This is in line with the research of Zhou et al. (2008) that organizational performance is subsequent to firm performance (i.e. job satisfaction and product quality). In this research the effects of job satisfaction and efficiency were seen as internal process factors that might also influenced customer satisfaction directly. However, this assumption should be researched in the future to get a better understanding of measuring outcome and performance in service settings. Next, we continue with discussing the effects in more detail, including the moderating effect of empowering leadership. The results showed that job satisfaction directly positively influences efficiency. This finding is consistent with a small, but growing body of literature (e.g. Zhou et al., 2008). Zhou et al. (2008) confirm this relationship and concluded that happier employees are indeed more productive, thus have higher levels of efficiency. We recommend researchers to further explore the “indirect” effects of MO on customer

13

14

From practice it seemed that segmentation is now not approached from a client perspective; the organization reasons from hierarchical business structure and sketches logistic flow from financial point of view. This procedure might be perceived by the employees as efficiency mechanism, where it (according to the marketing concept) also should tend to increase customer satisfaction levels. Informal coaching is: “… the day-to-day, hands-on process of providing employees with one-on-one guidance and support to improve their knowledge, skills and abilities. Coaching has similar developmental aspirations to training but sets out to reach those aspirations in a markedly different (i.e., ongoing and informal) way. Thus, managerial coaching occurs in the workplace as part of the day-to-day relationship between employee and supervisor so that on-the-job activities and experiences can become catalysts for learning (Ellinger et al., 2008; pp.356).”

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satisfaction levels, since it seems that psychological values of individual employees relate in larger volumes than expected. Job satisfaction directly influences the customer satisfaction outcome; more satisfied employees tend to positively influence the level of satisfaction from clients. This is consistent with recent research by Zablah et al. (2012), where they found direct effects of CO on individual performance (e.g. job satisfaction, role conflict, and self-rated performance). This finding further encourages future researcher to take a more detailed look at the impact of the MO construct at individual outcome performance (Zhou et al., 2008). This empirical research might found early evidence, that no direct measurement on the customer satisfaction measure is possible, but that it first leads to efficiency and job satisfaction, and indirectly to customer satisfaction; customer satisfaction is how the customer perceives the interaction with the service employee and the quality of service. In the context of tradeoff management at the individual employee level, the relationship between efficiency and customer satisfaction is especially relevant; these outcome measures resemble the effect of dual orientation. Efficiency has a negative direct effect on customer satisfaction, indicating that higher efficiency means lower customer satisfaction. Empowering leadership moderates the negative effect of efficiency to customer satisfaction. Therefore results show that empowering leadership might be more important when considering the two-objective-trade-offs simultaneously. Management plays a crucial role, but the direct effect of leadership on customer satisfaction negatively influences the effect. It may be concluded that the higher efficiency, the more leadership is important to come into play. On the other hand, the leadership construct moderates the relationship between job satisfaction and customer satisfaction negatively. This may be explained due to the fact of autonomous teams, where every form of leadership holds back to focus on unique customer service solutions. This finding is consistent with the negative moderating effect from empowering leadership on the relationship MO behavior and customer satisfaction (Ellinger et al., 2008).

5.1.5

General observations

A general observation of this study showed from practice that organizations tried to implement strategies to benefit from customer satisfaction levels as from efficiency levels. We believe that segmentation is approached differently from the “normal” segmentation concept. From the individual frontline employee perspective it seems that segmentation is equal to financial benefits, and thus managing efficiency. Implementation challenges15 show that organizational initiative may work counterproductive, since they do not reason from the customer perspective. Especially in healthcare, all employees are expected to behave customer centered, but in practice management turns this around. They respond to abrupt to governmental change, losing grip on the situation. The gap between management and frontline employees grows and beliefs diverge, rather than converge. Differences in objectives vary even more, where management becomes more efficiency focused (also due to top management initiatives) and frontline employees show aversion.

15

Project process optimization: this project was implemented in the same time when this research was conducted. The trajectory was to determine healthcare logistic paths from departmental perspective. The goals were eventually to close the gap between NZA and DBC financing (governmental initiated change in financing treatment in healthcare). The project was initiated from the overhead department and also diffused to department management.

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MO can be seen a collective culture, ready for change. MO builds an environment, where frontline employees can cope with demanding changes. Due to external rapid change, organizations long-term goals have to be revised. We can no longer neglect the individual frontline employee, since they carryout business strategy and are responsible for efficiency and customer satisfaction. Important antecedents for creating an environment ready to change were found in the team context and from management intentions. The cultural and social aspects show significant effects and should be considered as key driver. It remains hard to deal with changing environments, where governmental initiatives change things unexpectedly. But organizations can counter this negative performance loss pathway, since internal management determines the impact of change.

5.2 Managerial implications This study provides in-depth implications for how to manage efficiency and customer satisfaction objectives in direct service settings. Furthermore it does not neglect the levels of job satisfaction, since from practice and theory (e.g. Zablah et al., 2012; Zhou et al., 2008) this is seen as important indicator for collective organizational performance. The increasing role of frontline employees, delivering direct service and responsible for organizational performance, urges organizations to adopt alter strategies to challenge the challenging environment. Organizations should pay more attention to the impact of organizational change and environmental influences, at the individual employee level. From this research several implications to cope with these challenges were found. First, the implementation of MO in the frontlines showed positive direct effects on job satisfaction, efficiency levels, and customer satisfaction levels. Top management can facilitate the MO beliefs by the providing educational tracks (i.e. CO training), which positively influences MO beliefs. Results indicate that educational tracks should reason from a customer perspective, which is profound to be supported in the literature (e.g. Homburg et al., 2008); for care professionals the central role of customers is essential in accepting organizational change. From practice this method is often not used, since organizations still reason from a more financial perspective16. In order to get a strategy accepted by frontline employees, organizations should reconsider the real meaning and effect of their objectives. Besides the effect of CO training, the direct effects of team members and manager beliefs showed positive impact. It seems relevant for organizations to pay more attention to these direct effects, where in highly autonomous teams the impact of team processes should be considered as main motivator in implementing MO beliefs. Individuals influence other team members and the higher the average team beliefs, the higher the individual beliefs turn out to be. The same counts for manger beliefs. Organizations may use this three-way-connection (i.e. CO training, team influences, and management influences) to implement MO beliefs, and to further improve individual service performance. Another implication is that adding the segmentation concept to the MO beliefs makes frontline employees aware of how to manage trade-offs. The more the principles of segmentation are included in the business culture, where they always reason from the best interest for customers, they positively respond to organizational performance indicators. Reasoning from a customer perspective remains one of the most important basic beliefs in healthcare. Recent implications show that organizations might focus on the short-term, which is understandable, since governmental initiatives urge them to do so, but organizational objectives should remain rather similar. Over time, in healthcare the problem is that cost containment strategies force them directly into full-dedicated efficiency measures, and losing grip 16

Implications are partly based on the open-question answers in the questionnaire.

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on the quality principles of CO. Top management may approach in the future more from a long-term perspective, where change is logically incorporated and mechanisms (e.g. educational tracks) are developed in advance. From practice it seems relevant to further explore closing-the-gap between management and frontline employees. This study showed that educational CO tracks can develop employees in such a way that objectives may be brought closer together. The general premise that management’s objective is efficiency, and frontline employee’s objective to deliver qualitative care; it urges organizational initiatives to converge beliefs. The responsibility that follows from this is in two-fold: (1) management should find new ways (e.g. informal coaching) to better educate employees to influence beliefs, and (2) employees should receive more autonomy to develop own beliefs. To congregate goals all layers of the organization should build upon the main principles, but also align the processes to achieve these goals. These implications result in a more soft-management-style for service oriented organizations, where an approach tends to be more humanistic. This should lead to a better social-culture, where shared beliefs converge and change can occur. In a highly autonomous environment, where professionals work closely together to fulfill customer demands, management’s task is to control the overall business performance. Therefore Table 5-1 provides drivers to consider during the implementation of change. Table 5-1: Recommendations for implementing MO and attacking the challenges for managing trade-offs in the frontlines

Recommendations 1. Implement MO

Explanation of the recommendation Implement MO in the corporate culture, to better attack change and to provide means for the frontline service employee to respond adequately. It provides organizational management drivers to implement change strategies and reduces the gaps (e.g. misperceptions of organizational objectives) with the frontline service employee.

2. Develop educational tracks

Educational tracks provide drivers for employees to better understand and accept changes, and enable them to respond positively. It forms their beliefs and expands knowledge about environmental factors. Training should reason from a customer’s perspective and should encourage individuals to exchange/share information with team members. The marketing concept, segmentation, might be considered essential in the trade-off settings, since it reasons from the customer’s perspective to improve quality ratings, but also efficiency levels.

3. Take team beliefs (processes) into account

In highly autonomous environments, where individuals are expected to manage own activities and objectives, team influencers play a crucial role. This research showed that team MO beliefs positively mediate the individual beliefs. The social-cultural values and sharing behavior enables individuals to develop themselves, as others within the team. Organizations should consider the effects of these processes and pay attention to aspects like: diversity, individual position, group potency and cohesion (as was initiated in previous research by Van der Borgh et al. (2011) and De Jong et al. (2005).

4. Take manager beliefs into account

In line with recommendation 3, manager’s beliefs tend to influence MO beliefs from the individual employee too. Employees should be able to

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identify themselves with manager beliefs, since they impact MO beliefs in a positive way. Also educational tracks (counts for team beliefs too) for the managers should intend to better implement MO in the corporate culture as at the individual level. This implies that organizations should consider softmanagement drivers to optimize the effect of MO (e.g. informal coaching). 5. (Re)Consider the effect of empowering leadership on performance

The findings in this study showed that empowering leadership has mixed impact on performance (i.e. positive on job satisfaction, but negative on customer satisfaction). These findings indicate that empowerment does not help yet to disseminate the prioritization of customers to the employees. This result is expected to be positive when organizational intentions aim at engendering MO in the corporate culture. Now it seems that employees are not ready to receive empowering leadership at this point, resulting in different performance objectives. Managers should not only pay attention to technical capabilities, but start to move towards more transformational qualities. Managers should expand their abilities to inspire and enable, rather than control. Furthermore they should build upon the understanding that the happier an employee is, the better the performance. It may also be assumed that communication issues and commitment levels increase, as job satisfaction does.

6. Implementing strategic change (trade-off)

Implementing change depends on a lot of variables, but this research showed when MO is “part” of the organization, initiatives to navigate for quality and efficiency improvements are generally accepted. But, before implementing change, organizations should consider the previous discussed recommendations, and additionally better “listen-to-the-employees”. In direct service environments they are not only the eyes of the organization, but also responsible for overall performance. They insist that “everything” is reasoned from a customer’s perspective, and segmentation can therefore provide useful opportunities to attack this problem; it indirectly considers financial consequences.

5.3 Limitations and future research In this research, some choices made, might be considered as limitations. Results and conclusions in this study were based on one industry only and in particular one organization. We used objective scale recordings from the company, which limits the generalizability of results. The nature of explorative research is to define interesting research areas, where future research can build upon. Therefore it would be helpful to conduct replication studies in other industries (e.g. commercial-sales environment, and non-profit hospital care), to increase measurement validity and support results. Another limitation is the sample size, since 27 teams with more than or equal to 3 respondents is at the lower bound. Next, the objective data of the customer satisfaction and efficiency measures might bias the research results. Customer satisfaction results were based on objective research, but only included results on unit levels. Therefore the calculation to the individual frontline employee might not fully represent actual performance outcome. This limitation is general the most common for research in MO and CO.

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The research of Zablah et al (2012) already showed outcome measurement as self-rated scaling, but these standards; do not meet the objective standards. The efficiency measure is easier to replicate from this research, it namely depends on the individual worker level and resembles the time-used versus the time-available according to contractual terms. In future research more attention should be given to objective measurement of customer satisfaction in service environments. This requires continuous measurement and might follow from ROM (routine-outcome-measurement) standards in Dutch healthcare nowadays. From 2013 onwards, healthcare providers are required to measure satisfaction levels before and after the actual treatment. If these results can be used in future research, more objective data with high quality is accessible. Future research in a more sales-context provides another solution, since more customer satisfaction measures can be directly linked to an actual service worker, where in healthcare this is more anonymous. The construct of segmentation is researched in the individual employee context. The construct is developed partly based on existing literature, but also made applicable for the specific healthcare context. Future research should further dive into the segmentation construct and the impact at the individual frontline levels and build upon the studies of Ye et al. (2007) Ye et al. (2011) and Marinova et al. (2008), since those authors closer unfold the effects of trade-off management in current business settings. The segmentation construct might add more value than expected and solves the issues in emphasizing quality and efficiency improvements simultaneously. It relates to the MO concept, since it explores the segmentation and positioning elements of the marketing concept. These aspects are explored at the organizational levels in marketing, but in the frontlines it might influence job outcomes positively. The concept of segmentation is widely adopted, but at the frontline employee level this should help to counter the changes from solely customer focus to trade-off management; it might be that clustering complex and simpler cases offers efficient ways to improve quality. It might not directly have an impact by MO behavior, but relate directly to employee’s beliefs and behavior; organizational change strategy can only be adopted when individuals are able to think in the same terms and conditions. Existing team processes need to receive more attention in relationship to service oriented contexts. Recent studies (e.g. Van der Borgh et al., 2011; De Jong et al., 2005) show concern for the impact of team processes in the sales-context, where frontline service employees are in direct connection with customers. This research indicates that in the healthcare environment, where autonomy is high, team processes do affect individual beliefs. The social aspect and cultural context may lead to better implementation and dissemination of MO. Team belies and behavior may directly impact the individuals behavior, but also impacts unit performance. New research may focus on viewing team processes as important antecedent of MO, where remarkably little research has focused on. Finally, future research should include the effects of trade-off management at the individual level even more. Especially the facilitators regarding educational tracks should receive more attention. Recent research by Ye et al. (2011) showed, consistently with this study, that establishing trade-off acceptance in the frontlines leads to better overall performance. Together with the principle of segmentation, this unique research should receive more attention.

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6 Concluding remarks It can be concluded that when the segmentation concept is incorporated in MO, managing trade-offs between efficiency and quality becomes realizable. Implemented MO beliefs are reflected by behavior and have a direct positive influence on customer satisfaction levels, and job satisfaction. In turn, job satisfaction has a positive direct influence on customer satisfaction and on efficiency. Facilitators – education, team beliefs, and manager’s beliefs – in this process increase levels of MO in a positive way and make change possible to occur. Empowering leadership showed positive moderating effects on the relationship between MO behavior and job satisfaction or efficiency (although the effect of MO-ed behavior to efficiency was not significant); however it showed negative moderating effects on the relationship of MO behavior and customer satisfaction and job satisfaction. Empowering leadership only seemed to positively influence the negative relationship between efficiency and customer satisfaction. These findings might indicate that empowerment does not help yet to disseminate the prioritization of customers to the employees, and that the organization is still in the early phases of implementing MO. To be more specifically about the conclusions, research questions are answered:

6.1 Answer to the research questions Main research question: How to manage trade-offs between efficiency and service quality in the frontlines of a service oriented organizations? Answer Service organizations can manage and attack the difficulties in managing the quality-efficiency trade-off in the frontlines, by implementing the MO. The direct effect of trade-off, as perceived by the individual service employee, turned out to have a direct positive effect on MO beliefs. Results even showed that a solely cost / financial emphasis from the organization positively influence employees MO beliefs. These individual beliefs are reflected by MO behavior, which showed direct performance improvements on customer satisfaction and job satisfaction levels. And higher levels of job satisfaction deliver higher efficiency. The MO culture helps organizations to manage challenges in changing environment. Thus, the organization should continue to implement MO, but simultaneously further develop the educational tracks to facilitate this process. Empowering leadership does impact performance in a mixed way; it negatively affects the relationship from MO behavior to customer satisfaction. The top management should persuade different ways to increase knowledge about MO and external influencers. This learning orientation should attack the problems that were found to be present. The segmentation construct might add more value than expected and solves the issues in emphasizing quality and efficiency improvements simultaneously. It relates to the MO concept, since it explores the segmentation and positioning elements of the marketing concept. These aspects were explored at the organizational levels in marketing, but in the frontlines it turns out to influence job outcomes positively. The concept of segmentation is widely adopted, but at the frontline employee level this might help to counter the changes from solely customer focus to trade-off management; it might be that clustering complex and simpler cases offers efficient ways to improve quality. It directly relates to employee’s beliefs and behavior; organizational change strategy can only be adopted when individuals are able to think in the same terms and conditions as the organization.

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In all, the organization does not master the principles of segmentation in full detail yet, which suggests that the organization is still in transition. The organization should adopt the principles of segmentation to find new ways to become effective and efficient, and to increase customer satisfaction levels. They should start with further implementing MO and led by “more informal management”, without empowerment. These recommendations build upon the managerial implications, which are discussed previously. Research question 1.1: How to influence the implementation of MO as corporate culture in creating positive influences in the frontlines? Answer MO should be incorporated in the company culture and can be directly positively mediated by CO training programs / educational tracks, team processes and beliefs, and manager beliefs. The three way combination of those mechanisms should naturally guide organizations to implement MO successfully. Thus, MO improves levels of efficiency, quality and job satisfaction. In previous research MO showed direct effects on quality and efficiency measures (Kirca et al., 2006), but this study also implies that customer satisfaction is perceived by the customer via job satisfaction and efficiency. Developing educational tracks seems to have the largest influence on individual beliefs. It develops knowledge for employees to understand organizational intents and is able to “let employees perceive change” in a positive way. Team process should receive more attention, since they directly influence individual beliefs. Aspects like, diversity, discipline-mix, conservativism, identification, individual position, group potency, and cohesion are processes that determine whether or not an individual employee is able to build MO. The generation of MO eventually provides individuals with the capacity to manage trade-offs. The same counts for leadership-style, where informal leadership stimulates employees to develop their own beliefs. Managers should belief in the top management intentions, and are responsible for making employees ready to adopt and execute in line with organizational objectives. Social-cultural aspects that play a major role in this process are the direct interaction with the team and a long term focus. Research question 1.2: Does empowering leadership facilitate the effect of MO behavior on the dual outcome objectives – quality and efficiency? Answer Empowering leadership was not found to be fully supportive as positive effect from MO behavior to outcome measures. Although it positively moderated the interaction between MO behavior and job satisfaction, it does negatively influence the interaction with customer satisfaction. This research showed that the direct effect from efficiency to customer satisfaction was positively influenced by empowering leadership, thus it seems that empowering leadership is useful for increasing efficiency levels, and simultaneously maintain service quality levels. However, this finding was consistent with the research of Hartline et al., (2000) and Ellinger et al. (2008). Two reasons can be found for empowering leadership to have a negative effect: (1) empowerment does not help to disseminate the prioritization of customer services to employees yet, and (2) firms tend not to empower employees after preprogramming other educational tacks. It seemed that empowerment does not work when other organizational processes (e.g. education) develop individual capabilities to manage trade-offs in an autonomous way. It requires a more informal training/coaching approach, where managers strive to

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stimulate employees to develop themselves. It suggests that the organization and its employees are not ready for empowerment yet, and organizations should continue with the implementation of MO first. When MO culture and education tracks are fully integrated, further actions can be taken regarding empowerment.

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A.

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Other Cervera, A. (1998). La Orientacion al Mercado: Un Modelo en el Ambito de Los Gobiernos Locales, University de Valencia, Valencia, Spain. Zebal, M.A. (2003). A Synthesis Model of Market Orientation for a Developing Country – The Case of Bangladesh, Victoria University of Technology, Melbourne, Australia.

63

B.

Tables

Definitions of the MO concept Table B-1: The definitions of the marketing orientation concept

Source Shapiro (1988)

Kohli and Jaworski (1990) Narver and Slater (1990)

Deshpandé et al. (1993) *

Day (1994)

Market orientation is… Market orientation “presents a set of processes touching on all aspects of the company. It is a great deal more than the cliché – getting close to the customer (pp.121).” Furthermore market orientation can only occur when: (1) “information on all important buying influences permeates every corporate function (pp.121)”, (2) “strategic and tactical decisions are made inter-functionally and inter-divisionally (pp.122)”, and (3) “Divisions and functions make wellcoordinated decisions and execute them with a sense of commitment (pp.123)”. “Market orientation is the organization wide generation of market intelligence pertaining to current and future customer needs, dissemination of the intelligence across departments, and organization wide responsiveness to it (pp.6).” Market orientation is defined as “the business culture that most effectively and efficiently creates the necessary behaviors for the creation of superior value for customers (pp.20).” Market orientation “consists of three behavioral components – customer orientation, competitor orientation, and inter-functional co-ordination – and two decision criteria – longterm focus and profitability (pp.21).” As part from the market orientation concept, customer orientation is introduced as important part of the definition. And customer orientation in the marketing context is defined as: “the set of beliefs that puts the customer’s interest first, while not excluding those of all other stakeholders such as owners, managers, and employees, in order to develop a long-term profitable enterprise (pp.27).” “Market orientation represents superior skills in understanding and satisfying customers (pp.37).”

* Since Deshpandé et al. (1993) discuss the MO from a CO perspective, this will also return in the next chapter, where CO is discussed.

Facts and figures GGzE Table B-2: Facts and figures GGzE

Category Clients Total number of clients over 2011 Clients in care at December 31 Production ZVW* New DBC’s Closed DBC’s Number of ambulant contacts Amount of days of clinical care Production AWBZ* Number of days of residence care Number of half days daily activity Production Justitie* New DBC’s

64

Year 2011 15.990 10.955 14.486 14.824 260.660 93.829 215.271 12.224 646

Closed DBC’s Number of ambulant contacts Amount of days of clinical care Employees Employees at December 31 Fte’s at December 31 Revenues Total revenues Legally budgeted revenues Other Satisfaction levels Clients Employees *

667 9.921 58.985 2.219 1.799 €158.0 mln. €150.1 mln. €7.9 mln. 7.4 7.0

ZVW = zorgverzekeringswet – social health insurance for the purpose of all citizens; AWBZ = Algemene Wet Bijzondere Ziektekosten – covers high medical expenses not included in the ZVW ; Justitie = forensic care financed for the purpose of citizens with a penal title.

Factor analysis of beliefs and behaviors Table B-3: Rotated component matrix CO beliefs and behavior. Rotated Component Matrix

a

Component 1

2

COBLF_0

,878

COBLF_1

,478

COBLF_2

,873

COBEH_0

,594

COBEH_1

,763

COBEH_2

,741

COBEH_3

,802

COBEH_4

,837

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. a. Rotation converged in 3 iterations. Table B-4: Rotated component matrix colleague exchange beliefs and behavior. Rotated Component Matrixa Component 1

65

2

COLBLF_0

,855

COLBLF_1

,864

COLBLF_2

,819

COLBEH_0

,485

,466

COLBEH_1

,455

,547

COLBEH_2

,714

COLBEH_3

,853

COLBEH_4

,698

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. a. Rotation converged in 3 iterations. Table B-5: Rotated component matrix segmentation beliefs and behavior. Rotated Component Matrixa Component 1

2

CATBLF_0

,817

CATBLF_1

,773

CATBLF_2

,778

CATBLF_3

,664

CATBLF_4

,527

CATBLF_5

,686

CATBEH_0

,664

CATBEH_1

,775

CATBEH_2

,666

CATBEH_3

,707

CATBEH_4

,714

Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization. a. Rotation converged in 3 iterations.

66

C.

Figures

Response rates of the care professional and management questionnaire 40 35 30 25 20 15 10 5

29-6-2012

24-6-2012

19-6-2012

14-6-2012

9-6-2012

4-6-2012

30-5-2012

0

Figure C-1: Response distribution of complete questionnaires from the care professionals

12

10

8

6

4

2

Figure C-2: Response distribution of complete questionnaires from the management

67

8-7-2012

3-7-2012

28-6-2012

23-6-2012

18-6-2012

0

D.

Questionnaire procedure and development

As indicated in the measurement section, several items left-out are discussed in this appendix after presenting the specific procedures for developing the questionnaire. This appendix section further elaborates on the specific procedures for developing and launching the online questionnaire. In the next table, Table D-1, specifications about the tailored questionnaire design are provided. Table D-2 and D-3, afterwards show the actual contact moments and actions taken during the questionnaire implementation. In Table D-4, specific questions and research topics are provided. These include questions, their references and original questions. Additionally, appendix E provides the specific invitations and reminder sent during the questionnaire procedure. Both, care professional and management specific messages are shown. Afterwards, appendix F (care professional) and appendix G (management) represent the actual questionnaires, as implemented in the Qualtrics software. Note that the specific interface is different, since these appendices are made compatible with word-format. Table D-1: Questionnaire design and specifications for development

Item Survey mode

Aspects Survey mode

Sample

Type of samples Number of samples

Contacts

Number of contacts (targets) Timing between moments of contact

Mode of each contact

Sponsorship of information

Use Web-based design, where Qualtrics software was used. Supported by the University of Tilburg, under supervision of W. van der Borgh (see Figure D-1 for interface example). Care professionals with direct contact towards clients. Their direct managers, with non (or less) direct contact. Initial sample base of 1349 care professionals (based on contract and function), which were approximately distributed over > 50 teams. Initial sample base of 113 managers (or coordinators). Based on contract as well as from early returns care professional questionnaires. 300 care professionals and 30 teams. Therefore also a minimal of 30 manager responses, directly linked to the teams. 1. Pre-notification in board-meeting and on intranet. 2. + One week: invitation 3. + One week: reminder 1 4. + One week: reminder 2 5. + One week: reminder 3 6. End of July result distribution 1. Direct communication 2. Personal email by Qualtrics 3. Personal email by Qualtrics 4. Personal email by Qualtrics 5. Personal email by Qualtrics 6. Personal direct email TU/e and GGzE

68

Incentives

Additional material and attachments

Visual design Type of incentives

Time of incentive Links Attachments

Questionnaire

Topics included Length of questionnaire Further information Questionnaire tests

Confidentiality

“Functioneel gegevensbeheerder” Key

Basic, green colored, with recurrent symbol (Figure D-1). Team check for a dinner at ‘De Gebakken Peer (GGzE)’, and a individual change on a diner check (€30,-). Both are based on a lottery. If requested, a personal benchmark of results. All afterwards (July – August). In every invitation/reminder a direct link to intranet is used, to provide additional information about the research. In every reminder a link is provided to the first email sent. Also to the personal benchmark. Please find these topics in Table D-4. Approx. 160 for care professionals Approx. 60 for managers Please find this at the end of the appendix section. Pre-test with TU/e supervisors, quality assurer GGzE, manager and care professional(s). Security officer of GGzE. Securitiy officer was the only one with the key to link ID’s and outcome measures.

69

Figure D-1: The GGzE implemented questionnaire interface in Qualtrics

70

Table D-2: Questionnaire specific cycle-time procedure care professionals

Category Pre-interviews, such as with the management.

Method Notification and presentation of the specific research. Feedback moment to delineate research and linking it with company specific environmental contexts.

… follow-up actions Director diffuses the topic towards the board, directors and the management.

Contacts Director, manager and project leader.

Timeline - Dates March – May 05 2012.

Pre-contact care professionals and management.

Notification by intranet incl. appendix with individual payoffs (benchmark) Email (by Qualtrics). Personal invitation, with attachments (additional information) and link to intranet notification. Reminder with attachments (first email and additional information) and link to intranet. Reminder 2.

-

All employees of the company.

May 23 – May 28 2012.

Additional notification about confidentiality.

1349 preselected respondents.

May 30 2012.

-

1280 respondents (non-started respondents).

June 6 2012.

-

June 12 2012.

Reminder 3.

-

Thank you and individual benchmark.

-

1194 respondents. 954 respondents. On request.

First contact care professionals.

Second contact care professionals.

Third contact care professionals. Final contact care professionals Individual feedback moment.

71

June 21 2012. June 30 2012.

Table D-3: Questionnaire specific cycle-time procedure managers

Category Pre-interviews, such as with the management.

Pre-contact care professionals and management. First contact care managers.

Second contact managers.

Third contact managers. Final contact managers.

Method Notification and presentation of the specific research. Feedback moment to delineate research and linking it with company specific environmental contexts. Notification by intranet incl. appendix with individual payoffs (benchmark) Email (by Qualtrics). Personal invitation, with attachments (additional information) and link to intranet notification. Reminder with attachments (first email and additional information) and link to intranet. Reminder 2.

… follow-up actions Director diffuses the topic towards the board, directors and the management.

Contacts Director, manager and project leader.

Timeline - Dates March – May 05 2012.

-

All employees of the company.

May 23 – May 28 2012.

-

113 preselected respondents.

June 18 2012.

-

89 pre-selected respondents.

June 26 2012.

-

July 2 2012.

Reminder 3.

Personal follow-up email, to several important respondents.

72 pre-selected respondents. 65 pre-selected respondents.

72

July 9 2012.

Table D-4: All items included in the questionnaire (Item coding correspondents with the constructs) Item code

Item - Question

COORG_0

… ligt de nadruk primair op cliënttevredenheid

Source Subin and Workman, 2004 Subin and Workman, 2004

COORG_2

… houdt men constant de mate van cliëntbetrokkenheid in de gaten … is het onderscheidend vermogen ten opzichte van andere instellingen gebaseerd op ons begrip van cliëntenbehoeften

COORG_3

… wordt men gedreven door de overtuiging hoe toegevoegde waarde voor cliënten te creëren

COORG_4

… meten we cliënttevredenheid frequent

Subin and Workman, 2004 Subin and Workman, 2004

CEORG_0

… worden verbeteringsinitiatieven altijd gekoppeld aan de mate van kostenbesparing

Rust et al., 2002

CEORG_1

… moeten initiatieven altijd leiden tot een efficiëntere manier van werken

COORG_1

Subin and Workman, 2004

Rust et al., 2002

Original item Our business objectives are driven primarily by customer satisfaction We constantly monitor our level of commitment and orientation to serving customers' needs Our strategy for competitive advantage is based on our understanding of customers' needs Our business strategies are driven by our beliefs about how we can create greater value for customers We measure customer satisfaction systematically and frequently Customer satisfaction/retention efforts should always consider the long-term impact on costs? (or vice versa) Consider the long-term effect of cost reduction efforts on customer satisfaction/retention? (rate on encouragement; or vice versa) Manage as if quality programs can increase customer satisfaction/retention and reduce costs at the same time? (rate on encouragement) Managers implement initiatives that bring new sources of revenue?

ROORG_3

… is het doel van kwaliteitsverbeteringen vaak gericht om ook kosten te reduceren … implementeren managers initiatieven om meer inkomsten te genereren … presenteren zorgprofessionals nieuwe ideeën om cliëntparticipatie en zorgkwaliteit te bevorderen … gebruikt met innovatieve projecten [bijv. Ehealth] om cliënten beter te bedienen … krijgen zorgprofessionals erkenning als zij de organisatie helpen de cliënttevredenheid te verhogen [bijv. Planetree]

TRAICO_0

… meer bewust te worden van cliëntbehoeften

Ellinger et al., 2008

TRAICO_1

… goed om te leren gaan met cliëntproblemen


Health care workers provide ideas for expanding patient care services? New Technologies are regularly adopted that allow our unit to offer new patient services? Health care workers are appropriately recognized for developing new sources of revenue? [dropped] At my company customer service contact employees receive ongoing formal training on how to serve customers better At my company customer service contact employees receive ongoing formal training on resolving customer problems


At my company customer service contact employees receive extensive formal training before they come into contact with customers

New

-

New New

-

New New

The way we do things in our unit keeps changing?

CEORG_2 ROORG_0

ROORG_1 ROORG_2

TRAIEFF_2 TRAIEFF_3

… inzichten te krijgen in cliëntenproblematiek en daardoor beter te behandelen … op de hoogte te blijven van veranderingen in de zorg en de impact hiervan op cliëntbehandelingen … informatie en discussie te hebben over het effect van kostenbesparing en bezuinigingen op mijn taken … zowel efficiënt als effectief te kunnen werken … leerinitiatieven te ontwikkelen om ‘slimmer’ te werken … te leren denken in zorgpaden

PERC_0

Alles wat we hier doen, blijft maar veranderen

TRAICO_2 TRAICO_3

TRAIEFF_0 TRAIEFF_1

Rust et al., 2002 Ye et al., 2007

Ye et al., 2007 Ye et al., 2007

Ye et al., 2007

Ye et al., 2007

73

PERC_1

Ik heb nooit het gevoel dat ik weet wanneer we gaan veranderen, het komt altijd ineens

Ye et al., 2007

You never know when your job is going to change in this unit?

IDORG_0

De criteria voor evaluatie op prestatie van ons team blijven steeds veranderen Het lijkt alsof we altijd aan het reorganiseren zijn Ik denk om te stoppen met werken bij het GGzE Het is mogelijk dat ik actief op zoek ga naar een nieuwe baan in de nabije toekomst Ik vraag mezelf wel eens af of ik op zoek moet gaan naar een baan buiten de gezondheidszorg Over het algemeen ben ik erg tevreden met mijn baan Over het algemeen ben ik tevreden met de taken die ik in deze baan uitvoer Ik haal veel voldoening uit mijn functiegerelateerde activiteiten Stel je voor dat de linker cirkel overeenkomt met jouw eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. GGzE, weergegeven door de rechter cirkel, is? (in andere woorden: in hoeverre overlappen jullie met elkaar):

COTEA_0

… kijken we veel naar cliëntbehoeften

Lam et al., 2010

COTEA_1

… is er veel aandacht voor feedback van cliënten … vindt men het belangrijker om cliëntwensen te achterhalen om behandelprogramma’s te ontwikkelen … proberen wij veel van elkaar te leren om in de cliëntbehoeften te voorzien … kijken wij veel naar wat collega’s doen om cliëntproblematiek op te lossen

Lam et al., 2010

I think customer preferences are a key factor to success of [name of the organization] I frequently survey customers to find out the products and services they would like to seen in the future

Lam et al., 2010

I try to figure out what a customer's needs are

New

I motior exactly what special actions our competitors are doing I keep a close eye on our competitors [competitors' sales people] customer retention tactics

PERC_2 PERC_3 TOINT _0 TOINT_1 TOINT _2 JOBS _0 JOBS _1 JOBS _2

COTEA _2 COLTEA_0 COLTEA_1

COLTEA_2 COCTEA_0 COCTEA_1 COCTEA_2

COCTEA_3 INNTEA_0 INNTEA_1 INNTEA_2 CAPTEA_0

… monitoren wij meer activiteiten en werkwijzen van collega’s … is er veelvuldig aandacht voor efficiënt werken voor specifieke categorieën cliënten … wordt rekening gehouden met clustering volgens zorgkenmerken … wordt regelmatig gestuurd op afgestemde zorginspanning afhankelijk het type zorg … worden cliënten vaak gedifferentieerd volgens de zorgzwaarte … zoeken wij constant naar nieuwe toepasbare ontwikkelingen en oplossingen … proberen we behandelprogramma’s steeds meer aan te scherpen … ondernemen we activiteiten om de kwaliteit van de zorg te verbeteren … hebben we de benodigde vaardigheden om een cliënt goed te helpen

Singh, 2000

Our unit keeps changing the criteria for performance evaluation and promotion? It seems like we are always reorganizing? I often think about quitting It is likely that I will actively look for a new job next year

Singh, 2000 Hackman and Oldham, 1975 Hackman and Oldham, 1975

I will probably look for a job next year Generall speaking, I am very satisfied with my job I am generally satisfied with the kind of work I do in this job

new

-

Bergami and Bagozzi, 2000

7-point scale

Ye et al., 2007 Ye et al., 2007 Singh, 2000

Lam et al., 2010

Lam et al., 2010 New Homburg et al., 2008 Homburg et al., 2008

Ye et al., 2011

Specific customers/customer segments obtain priority Customers/customer segments are served differently according to their importance The form of customer care is differentiated according to the importance of customers/customer segments I am always looking for new products and services? I always reconsider and develop the product and service offering of our company? I thought of ways to improve both productivity and quality of patient care?

New

-

Homburg et al., 2008 Lam et al., 2010 Lam et al., 2010

74

CAPTEA_1 CAPTEA_2 CAPTEA_3 CAPTEA_4 FLXEA_0 FLXTEA_1 FLXTEA_2

FLXTEA_3 TEAID_0 TEAID_1 TEAID_2 TEAID_3

IDTEA_0

GOATEA_0 HBHIND_0 HBHIND_1 HBHIND_2 HBHTEA_0 HBHTEA_1 HBHTEA_2 HBHTEA_3 EMPLBE_0 EMPLBE _1 EMPLBE _2 EMPLBE _3 EMPPDM_0

… hebben we samen een eersteklas aanpak voor de zorgproblemen van een cliënt … kunnen we uitdagende zorgproblemen doorgronden en goed behandelen … hebben we leden die zeer goed samenwerken … zijn we erg doeltreffend Binnen ons team is het eenvoudig om voor elkaar in te vallen De meeste teamleden kennen elkaars taken goed Ik heb veel vertrouwen dat mijn teamleden in staat zijn mijn activiteiten over te nemen Het uitwisselen van teamrollen en verantwoordelijkheden veroorzaakt weinig problemen De successen van mijn team zijn mijn successen Het voelt als een persoonlijke belediging als iemand kritiek uit op het team Ik ben erg geïnteresseerd in wat anderen denken van het team

New

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New New New

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De Jong et al., 2004

In our team it is easy to stand in for each other

De Jong et al., 2004 De Jong et al., 2004

Most team members know each other's tasks I have much confidence that my team members would be able to take over my activities


Exchanging team roles and responsibilities causes few problems

Jasmand et al., 2012 Vd Vegt et al., 2003 Jasmand et al., 2012

My team's success is my success When someone praises my team, it feels like a personal insult I am very intersted in what others think about my team

Ik zeg meestal “wij” in plaats van “zij” als ik praat over het team Stel je voor dat de linker cirkel overeenkomt met jouw eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. je team, weergegeven door de rechter cirkel, is? In welke mate overlappen jouw doelen [targets voor jouw functie) met die van andere teamleden]? … vaak degene die als eerste collega’s helpt … steeds bereidwillig informatie te geven aan anderen ... degene die hulp aanbiedt als iemand problemen ondervindt met werkzaamheden Teamleden proberen elkaar te helpen hoe nieuwe uitdagingen in de zorg aan te pakken Teamleden helpen elkaar om het werk beter te doen Teamleden wijzen elkaar op hoe problemen het beste opgelost kunnen worden We wisselen vaak van gedachten om zo een hoger prestatieniveau te halen met het team … stelt door middel van zijn/haar eigen gedrag hoge eisen

Jasmand et al., 2012

When I talk about my team, I usually say "we" rather than "they"


7-point scale

Bergami and Bagozzi, 2000 New

7-point scale -

New

-

New Podsakoff et al., 1997 Podsakoff et al., 1997 Podsakoff et al., 1997 Podsakoff et al., 1997 Arnold et al., 2000

"Touch base" with other crew members before initiating actions that might affect them Willingly give of their time to help crew members who have wok-related problems Provide constructive suggestions about how the crew can improve its effectiveness Are willing to risk disapproval to express their beliefs about what's best for the crew Sets high standards for performance by his/her own behavior

… werkt zo hard als hij/zij kan … werkt zo hard als eenieder binnen het team/ de afdeling … fungeert als een voorbeeld door zijn/haar gedrag … moedigt teamleden aan om ideeën en suggesties te uiten

Arnold et al., 2000

Works as hard as he/she can

Arnold et al., 2000

Works as hard as anyone in my work group Sets a good example by the way he/she behaves Encourages work group members to express ideas/suggestions

Arnold et al., 2000 Arnold et al., 2000

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EMPPDM _1

… luistert naar ideeën en suggesties van het team

Arnold et al., 2000

Listens to my work group's ideas and suggestions

EMPPDM _2

… gebruikt suggesties van teamleden om beslissingen te nemen

Arnold et al., 2000

Uses my work group's suggestions to make decisions that affect us

EMPPDM _3

… geeft alle teamleden de kans om meningen te uiten

Arnold et al., 2000

Gives all work group members a chance to voice their opinions

EMPINF_0

… legt beslissingen van GGzE uit

Arnold et al., 2000

Explains company decisions

EMPINF _1

…legt de doelen van GGzE uit … legt aan het team uit wat zijn/haar beslissingen en acties zijn … geeft suggesties hoe prestaties van teamleden te verbeteren … helpt goede relaties op te bouwen tussen teamleden … moedigt teamleden aan om problemen gezamenlijk op te lossen … leert teamleden hoe om te gaan met problemen

Arnold et al., 2000

Arnold et al., 2000

Explains company goals Explains his/her decisions and actions to my work group Suggests ways to improve my work group's performance Helps develop good relations among work group members Encourages work group members to solve problems together Teaches work group members how to solve problems on their own

Arnold et al., 2000

Helps my work group focus on our goals

IDMAN_0

… helpt het team focussen op onze doelstellingen Stel je voor dat de linker cirkel overeenkomt met jouw eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. je leidinggevende, weergegeven door de rechter cirkel, is?

AUT_0

… de volledige vrijheid in het uitvoeren van mijn werkzaamheden

Marinova et al., 2008

AUT_1

… de vrijheid mijn activiteiten uit te voeren op de manier die mij goeddunkt


… de mogelijkheid om mijn eigen oordeel te volgen in het verlenen van cliëntzorg … de ruimte om een hoge mate van initiatief te tonen in het verlenen van zorg … procedures te volgen tijdens mijn werkzaamheden


… ten alle tijde te maken met strikte protocollen … een gedetailleerde werkomschrijving waarin mijn taken staan beschreven Ik heb de benodigde vaardigheden om goed aan klantbehoeften te voldoen Ik kan uitdagende klantvragen identificeren en oplossen Ik ben goed in het achterhalen van cliëntbehoeften

Mom et al., 2009

EMPINF _2 EMPCOA_0 EMPCOA _1 EMPCOA _2 EMPCOA _3 EMPCOA _4

AUT_2 AUT_3 FORM_0 FORM_1 FORM_2 SLFEFF_0 SLFEFF_1 SLFEFF_2

Arnold et al., 2000 Arnold et al., 2000 Arnold et al., 2000 Arnold et al., 2000


New

7-point scale Employees indicate their agreement or disagreement regarding whether they had: … the freedom todo their job in the way they thought best Employees indicate their agreement or disagreement regarding whether they had: … activities that allowed for independent thought and action Employees indicate their agreement or disagreement regarding whether they had: … opportunities to do whatever was needed to provide quality patient care

Mom et al., 2009

Whatever situation arises, I have procedures to follow in dealing with it. I have to follow strict operational procedures at all times. There is a written job description for going about my tasks.

Sujan et al., 1994

I am good at selling.

Sujan et al., 1994

I know the right thing to do in selling situations

Sujan et al., 1994

I am good at finding out what customrs want

Mom et al., 2009

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ROCONF_2

Ik kan effectief omgaan met iedere voorkomende zorgvraag Ik ontvang regelmatig met elkaar conflicterende verzoeken van verschillende mensen waarmee ik in mijn werk te maken heb Ik moet in mijn werk vaak dingen doen die door de één wel, maar door de andere niet gewaardeerd worden Om voor de cliënt mijn werk goed uit te voeren moet ik af en toe de regels breken

INNBEH_0

SLFEFF_3

ROCONF_0

Sujan et al., 1994

My temperament is not well-suited for selling [R]

Rizzo et al., 1970

I receive assignments without adequate resources and materials to complete them

Rizzo et al., 1970

I receive incompatible requests from two or more people I have to buck a rule or policy in order to carry out some assignments

… onderneem ik activiteiten om de kwaliteit van de zorg te verbeteren

Ye et al., 2011

I tried different ways to improve productivity without sacrificing quality of patient care

INNBEH_1

… bedenk ik regelmatig verschillende manieren om behandelprocedures te verbeteren

Ye et al., 2011

I thought of ways to improve both productivity and quality of patient care

INNBEH_2

… probeer ik voortdurend verschillende manieren te vinden om zorgverlening te verbeteren

new

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Ye et al., 2011

I learned to deliver high level of productivity and patient care quality

ROCONF_1

Rizzo et al., 1970

INNBEH_4

… probeer ik zelf nieuwe dingen aan te leren, om de eigen productiviteit te verhogen … sta ik open voor nieuwe ideeën om veranderingen in de zorg te accepteren

COBLF_0

… cliëntvoorkeuren in ogenschouw te nemen

Lam et al., 2010

COBLF_1 COBLF_2

… regelmatig toekomstige behandelmethodieken te toetsen met mijn cliënten … uit te zoeken wat cliëntbehoeften zijn

Lam et al., 2010 Lam et al., 2010

I think customer preferences are a key factor to the success of [name of company]. I frequently survey customers to find out the products and services they would like to see in the future I try to figure out what a customer's needs are

COLBLF_0

… na te gaan wat collega’s doen om cliëntproblematiek op te lossen

Lam et al., 2010

I pay close attention to competitors' [competitors sales people] activities

COLBLF_1

… werkwijzen van collega’s te monitoren en begrijpen

Lam et al., 2010

CATBLF _0

… te leren van behandelactiviteiten van collega’s … cliënten in te schalen in subgroepen, volgens hun zorgkenmerken

Lam et al., 201o Homburg et al., 2008

CATBLF _1

… cliënten te differentiëren op zorgzwaarte

Homburg et al., 2008

I monitor exactly what special actions our competitors are doing. I keep a close eye on our competitors'[competitors sales people] activities Customers/customer segments are served differently according to their importance The form of customer care is differentiated according to the importance of customers/customer segments

New

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New

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New Homburg et al., 2008 Jasmand et al., 2012

We invest in important customers/customer segments Having identified the customers'exact problem with their products, I solve it in a reliable way


I usually listen attentively to customers in order to take appropriate action to handle their concerns regarding their products

Lam et al., 2010

I try to figure out what a customer's needs are

INNBEH_3

COLBLF_2

CATBLF _5

… in mijn werkzaamheden cliënten effectief [doeltreffend] te categoriseren … goed toegesneden efficiënte zorgpaden te hebben … onderscheid te maken in behandelmethodieken per doelgroep ...te sturen op mijn zorginspanning passend bij het type behandelactiviteit [DBC, ZZP, etc.]

COBEH_0

… staat de oplossing voor de cliënt centraal

COBEH_1

… luister ik regelmatig actief naar mijn cliënten om verbeteringen in de behandelmethodiek in overweging te nemen … probeer ik zorgvragen die nòg niet in het behandelplan staan te identificeren

CATBLF_2 CATBLF _3 CATBLF _4

COBEH_2

new

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COLBEH_2

… probeer ik cliënten een reëel beeld te geven van wat de behandeling voor hem/haar kan betekenen … probeer ik (onzekere) cliënten gerust te stellen, zodat we samen behandelingsactiviteiten goed kunnen uitvoeren … monitor ik zorgvuldig behandelmethodieken van collega’s … let ik op de slimme aanpak en werkoplossingen van collega’s … neem ik vaak deel aan interdisciplinair overleg, om ontwikkelingen in ons werk en de zorg te bespreken

COLBEH_3

… deel ik bevindingen rond effectiviteit van behandelingen met collega’s

Kohli et al., 1993

CATBEH _0

… deel ik relevante informatie samen met collega’s voor kennisontwikkeling

Kohli et al., 1993

COBEH_3

COBEH_4 COLBEH_1 COLBEH_0

CATBEH _1 CATBEH _2 CATBEH _3 CATBEH _4 CATBEH _5 WRKL_0 WRKL_1 WRKL_2 KARA_0 KARA_2 KARA_3 *

… differentieer ik cliënten op zorgzwaarte … categoriseer ik cliënten effectief [doeltreffend] … heb ik de beschikking over goed toegesneden efficiënte zorgpaden … maak ik onderscheid in behandelmethodieken per doelgroep … stuur ik op zorginspanning passend bij het type behandelactiviteit [DBC, ZZP, etc.] Door het de verandering op het werk zit ik soms dicht bij een burn-out Ik heb te veel werk, dat ik in een te korte tijdsperiode moet voltooien Ik voel mezelf vaak uitgeput na een dag op het werk Ik voel me prettig in het bijzijn van andere medewerkers Ik vertrouw collega’s zeer snel Ik geloof in de goede intenties van mijn directe collega’s

New

-

New

I monitor exactly what special actions our competitors are doing. I pay close attention to competitors' [competitors sales people] activities We have interdepartmental meeting at least once a quarter to discuss market trends and developments


Kohli et al., 1993

Homburg et al., 2008 New

Markeing personell in our buseness unit spend time discussing customers' future needs with other functional departments Data on customer satisfaction are disseminated at all levels in this business unit on a regular basis The form of customer care is differentiated according to the importance of customers/customer segments -

New

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New Homburg et al., 2008 Singh, 2000

We invest in important customers/customer segments I feel burned out from tying to meet top management's expectations

Ye et al., 2011

I have to much work and too little time to do it?

Ye et al., 2011

I often fel exhausted in my work role? I am a real team player and know how to handle social situations? I trust people very quickly and believe in their good intentions? I am open for new expierences and get excited about changing new ideas?

Via IPIP Via IPIP Via IPIP

COORG = CO level organization, CEORG = customer efficiency orientation, ROORG = revenue orientation organization, TRAICO = training in CO, TRAIEFF = training in efficiency, PERC = perception levels regarding change, TOINT = turn over intent, JOBS = job satisfaction, IDORG = identification with the organization, COTEA = CO levels of the team, COLTEA = colleague exchange level of the team, COCTEA = segmentation levels of the team, INNTEA = innovation behavior of the team, CAPTEA = capacity of the team to perform, FLXTEA = team flexibility, TEAID = identification with other team members, HBHIND = individual levels of helping behavior, HBHTEA = team helping behavior perceived by the respondent, EMPLBE = leading by example, EMPPDM = participative decision making, EMPINF = informing, EMPCOA = coaching, IDMAN = identification with the manager, AUT = autonomy, FORM = formalization, SLFEFF = self efficacy, ROCONF = role conflict, INNBEH = innovation behavior individual, COBLF = CO beliefs, COLBLF = colleague exchange beliefs, CATBLF = segmentation beliefs, COBHE = CO behavior, COLBEH = colleague exchange behavior, CATBEH = segmentation behaviors, and WRKL = workload.

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Other measures in the questionnaire As indicated before, the questionnaire contained more measures than explained previously. Since those measures are not part of the research model, they are only briefly outlined, since they might be applicable in future research. CO from organizational perspective was measured by making use of the scales from Subin and Workman (2004), and five items resembled how individuals perceived the CO of the organization. Efficiency training was measured and developed from own initiative. This scale is based on practical implications from pre-research within the organization. Those four questions resemble the aspects of learning to become more efficient. The MO beliefs were also measured at team level, i.e. individuals rated team behavior in terms of CO, colleague exchange, and segmentation behavior. Frontline change perception was used to measure the influence of change perceptions, since they can be viewed as precondition for change to occur. All three items were directly derived from Ye et al. (2007), since they viewed the perceptions of individual employees on an organizational level. They therefore resemble the impact of change, but also the perceptions about how the organization deals with change. Helping behavior was measured in two-fold, from the individual as from the team. The first measurement was done using new developed scales, and the second one was based on the scales developed by Podsakoff et al. (1997). Individual self-efficacy was measured to indicate whether or not an individual found him or herself capable for performing the activities. The scales of Sujan et al. (1994), were used. Scales were the same as at the individual levels. The next construct was individual characteristics of care professionals. The scale was based on the international personality item pool, widely used for measuring characteristics. This measure should indicate whether or not individuals are ready to perform MO behavior. Turnover intents were measured using the research of Singh (2000). It resembles the leave intention at the organization and is applicable in the same way as workload, since it holds back individual behavior. Autonomy was measured using the scales of Marinova et al. (2008) and indicate whether a team is autonomous or not. It suits very well with the measurement of empowering leadership, and was therefore included in the questionnaire as well. The formalization construct was measured using scales by Mom et al. (2009), where they resemble the formal control form the management/organization to the individual. In line with the previous construct, role conflict was measured using the scales of Rizzo et al. (1970). They resemble the conflict between trade-offs for instance, since they represent goals due to direct actions. Other team measurements were included too, team capacity (enough expertise/capabilities present to perform activities), team flexibility (can individual activities be performed by other team members; De

79

Jong et al., 2004), and team identification (Van de Vegt et al., 2003). The final constructs measured identification with the organization, team and the manager.

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E.

Notifications, messages, invitations and reminders of the Questionnaire

Pre-notification intranet Titel: Help! De impact van veranderingen (een blik op…)

De zorg verandert continu en ingrijpend! Hoe moeten we als GGzE hiermee leren omgaan? De zorgprofessional wordt steeds belangrijker en is bepalend voor ‘onze’ toekomst. Aarzel dus niet en vul binnenkort een enquête in om mee te helpen zoeken naar een oplossing…… [Lees verder] Wij vragen uw hulp bij de uitvoering van een belangrijk onderzoek van GGzE en de Technische Universiteit Eindhoven. Met dit onderzoek proberen wij de impact van veranderingen op de individuele medewerker beter te leren begrijpen, maar ook verder te zoeken naar toekomstige oplossingen. Dit is iets dat aansluit bij het gedachtegoed van GGzE, zoals jullie in het officiële jaardocument hebben kunnen lezen. Wat vragen wij van jou Binnenkort kunt u een uitnodiging ontvangen om deel te nemen aan een onderzoeksproject. We verzoeken u om een aantal vragen te beantwoorden en uw meningen, ervaringen en adviezen te delen met GGzE. Wat levert het op Dit onderzoek zal ingaan op een aantal belangrijke aspecten, waarvan het uiteindelijke doel is om: Proberen grip te krijgen op zowel zorglogistieke als financiële ontwikkelingen en prestaties [“Tradeoff management; Efficiency vs. Quality”]; Het beter leren omgaan met de invloed van veranderingen en wat hiervoor mogelijke preventieve oplossingen zijn [“Problem solving & Solution focused thinking”] ; Een effectieve oplossing zoeken voor de samenwerking tussen het management, teams en de professionals [“Bridging the gap”] ; Het zoeken naar de relatie en het effect van cultuur, opvattingen en gedrag van zorgprofessionals op de prestaties van GGzE [“Mindset & support”] ; Het ontwikkelen van de mogelijkheden om processen kwalitatief én financieel te faciliteren [“Knoppen om aan te draaien”]; Hoe een veranderstrategie te vertalen en te faciliteren naar professionals, om zowel efficiëntieals kwaliteitsprestaties te verbeteren? [“Change management”]

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Waarom hebben we jouw mening nodig? We doen onze uiterste best om de deelname zo eenvoudig en prettig mogelijk te maken. Daarmee hopen we op uw inzet, want alleen daarmee kan dit onderzoek succesvol worden afgerond. Wij vragen u binnenkort 15 minuten van uw kostbare tijd te investeren, om zo uw gedachten en meningen met ons te delen. Als blijk van waardering… Als blijk van waardering zal onder de deelnemers een geheel verzorgde teamlunch bij ‘De Gebakken Peer’ aangeboden worden. Hoe meer leden van uw team deelnemen aan het onderzoek, des te groter de kans op deze geweldige lunch. Verder wordt een diner waardebon t.w.v. €30,- verloot onder de deelnemers. Als laatste willen wij u tegemoet komen door middel van individuele feedback, in de vorm van een persoonlijk benchmark (wordt alleen aan u verstrekt; zie ook een voorbeeld). Hiermee kunt u zichzelf vergelijken met uw GGzE collega’s. Bij voorbaat dank, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

First contact care professional

Beste collega’s,

Dit bericht is een verzoek tot deelname aan een onderzoek van GGzE uitgevoerd door de afdeling technische bedrijfskunde van de Technische Universiteit Eindhoven. Met dit onderzoek proberen we de impact van veranderingen in de zorg op individuele medewerkers beter te begrijpen en een goede aanpak voor de toekomst te creëren. Iets wat in lijn is met het gedachtegoed van het jaardocument van GGzE en wat je eerder hebt kunnen lezen op intranet. Direct starten Wat is het doel? Proberen grip te krijgen op zowel zorglogistieke als financiële ontwikkelingen en prestaties; Het beter leren omgaan met de invloed van veranderingen en wat hiervoor mogelijke preventieve oplossingen zijn; Een effectieve oplossing zoeken voor de samenwerking tussen het management, teams en de professionals;

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Het zoeken naar de relatie en het effect van cultuur, opvattingen en gedrag van zorgprofessionals op de prestaties van GGzE; Het ontwikkelen van de mogelijkheden om processen kwalitatief én financieel te faciliteren; Hoe een veranderstrategie te vertalen en te faciliteren naar professionals, om zowel efficiëntieals kwaliteitsprestaties te verbeteren?; Graag willen wij jouw hulp, gedachten en mening hierbij. De vragenlijst is elektronisch en zal ongeveer 15 minuten in beslag nemen. Je deelname is vrijwillig en antwoorden worden strikt vertrouwelijk behandeld. Meedoen met het onderzoek is eenvoudig, ga naar onderstaande web-link en je kunt direct beginnen. Als blijk van waardering zal onder de deelnemers een geheel verzorgde lunch bij de gebakken peer aangeboden worden voor het hele team, de mogelijkheid worden geboden individuele feedback te ontvangen [benchmark] en eveneens individueel kans te maken op een diner check t.w.v. €30,-. Start de enquête Bij voorbaat dank, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

Attachments first contact care professionals

Beste zorgprofessional, Wij sturen u deze brief om je deelname te vragen aan een onderzoek dat we uitvoeren in samenwerking met de Technische Universiteit Eindhoven. Met dit onderzoek proberen wij de impact van veranderingen op de individuele medewerker beter te leren begrijpen, maar ook verder te zoeken naar oplossingen voor de toekomst. Dit is iets dat aansluit bij het gedachtegoed van GGzE, zoals jullie in het jaardocument hebben kunnen lezen. Een aantal belangrijke aspecten zijn: De mate van verandering en het accent van GGzE op zorgkwaliteit en/of efficiëntie; De rol van de medewerker voor de cliënt en de wijze waarop daarbij inzichten van (in)directe collega’s worden betrokken; De rol van het team en het middenmanagement in dit proces. De doelen van dit project zijn direct van toepassing op GGzE zelf. Hieronder zullen enkele onderdelen genoemd worden, om alvast een indruk te geven:

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Proberen grip te krijgen op zowel zorglogistieke als financiële ontwikkelingen en prestaties [“Tradeoff management; Efficiency vs. Quality”]; Het beter leren omgaan met de invloed van veranderingen en wat hiervoor mogelijke preventieve oplossingen zijn [“Problem solving & Solution focused thinking”] ; Een effectieve oplossing zoeken voor de samenwerking tussen het management, teams en de professionals [“Bridging the gap”] ; Het zoeken naar de relatie en het effect van cultuur, opvattingen en gedrag van zorgprofessionals op de prestaties van GGzE [“Mindset & support”] ; Het ontwikkelen van de mogelijkheden om processen kwalitatief én financieel te faciliteren [“Knoppen om aan te draaien”]; Hoe een veranderstrategie te vertalen en te faciliteren naar professionals, om zowel efficiëntieals kwaliteitsprestaties te verbeteren? [“Change management”]; De beste manier om dit soort kwesties te onderzoeken is door de medewerking van u te vagen. Uw gedachten en meningen zijn voor GGzE en daarom dit onderzoek van belang. GGzE is geselecteerd voor dit onderzoek, omdat ik als parttime medewerker P&C al enige tijd werkzaam ben binnen de organisatie. Na meerdere verdiepende gesprekken te hebben gehad binnen GGzE, hebben we besloten onze kennis te delen en gezamenlijk dit onderzoek te starten. We hopen dat u tijd neemt om de vragenlijst online in te vullen. Tegen de tijd dat u de vragenlijst volledig hebt ingevuld en aangegeven hebt om individuele feedback te ontvangen, dan zullen we over enkele weken de eigen resultaat terugsturen. Hiervoor kunt u een op maat gemaakt benchmark verwachten ten opzichte van uw gemiddelde GGzE collega’s. De vragenlijst zal ongeveer 15 minuten in beslag nemen en uw participatie is natuurlijk geheel vrijwillig. Enkele vragen zullen op elkaar lijken, maar dit is puur om de betrouwbaarheid van onderzoek te vergroten. Wel hopen wij natuurlijk op uw spontane antwoord. Antwoorden zullen vertrouwelijk worden behandeld, waar persoonlijke gegevens en antwoorden nooit gezamenlijk gepubliceerd worden en altijd geaggregeerd worden als rapportage naar het management. Hiervoor is een controleorgaan aangesteld, die waarborgt dat alle gegevens strikt vertrouwelijk worden behandeld [aanstelling van een functionaris gegevensbescherming]. Als blijk van waardering zal onder de deelnemers een geheel verzorgde lunch bij ‘De Gebakken Peer’ aangeboden worden, voor het hele team. Hoe meer leden van het team deelnemen aan het onderzoek, des te groter de kans op deze geweldige lunch. Verder kunt u individueel ook nog een diner bon t.w.v. €30,- winnen. Voor iedereen is het ook mogelijk een individueel benchmark (zie voorbeeld op de volgende pagina) te ontvangen, waarmee u zichzelf kunt vergelijke t.o.v. uw collega’s binnen GGzE. Bij voorbaat dank ik u voor alle hulp en medewerking. Als er vragen zijn tijdens en/of over het onderzoek, dan kunt u gerust contact met mij zoeken, via [email protected]. Met hartelijke groet, Stef Marinus [+ supervisors TU/e + supervisors GGzE] Voorbeeld Benchmark

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In een radarvorm/web worden zowel scores van u, als het gemiddelde van uw collega’s weergegeven. Dit is een voorbeeld, dus categorieën komen niet overeen met het geen u kunt verwachten.

Reminder 1 care professional

Beste collega, Onlangs ontving je een email met de vraag een online enquête in te vullen, om GGzE te helpen zich beter voor te bereiden op veranderingen in de zorg. Het onderzoek richt zich op de rol van de zorgprofessional, het team en de manager, bij het efficiënt leveren van de best mogelijke zorg. Jouw mening is daarbij van groot belang. Mocht je de vragenlijst reeds hebben ingevuld, dan hierbij nogmaals dank voor je tijd en reactie!!

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Direct starten Mocht je nog niet in de gelegenheid zijn geweest mee te werken, dan willen wij graag alsnog ongeveer 20 minuten van je tijd vragen. Participatie is natuurlijk geheel vrijwillig en gegevens worden strikt vertrouwelijk behandeld [er is een functionaris voor gegevensbescherming aangesteld]. Wij zouden het erg op prijs stellen als we ook een reactie van jou kunnen ontvangen. Verder hopen we op spontane antwoorden want goede en fout antwoorden bestaan niet. Ter herinnering herhalen we hier je persoonlijke enquête link: Start de enquête Het is mogelijk om de enquête tussentijds op te slaan en opnieuw [binnen twee weken] in te loggen met dezelfde link als hierboven is weergegeven. Je kunt dan verdergaan waar je gebleven was. Als compensatie kun je individuele feedback krijgen in de vorm van een benchmark in vergelijking met andere GGzE collega’s, maar alleen als je hier prijs op stelt. Voor deze zelfreflectie moet je aan het einde van de vragenlijst wel jouw e-mailadres toevoegen. Verder kun je nog steeds meedoen voor twee prijzen: de teamlunch bij ‘De Gebakken Peer’ en een diner check t.w.v. €30,-. Zie voor meer informatie intranet, de bijlage, of de eerder verzonden email. Alvast bedankt, Stef Marinus [+ supervisors TU/e + supervisors GGzE]’

Reminder 2 care professionals

Beste collega, Onlangs hebben we per email gevaagd een vragenlijst in te vullen en te reageren op de veranderingen in de gezondheidszorg… en met name binnen GGzE. Indien je de enquête al hebt ingevuld, n.a.v. onze vorige mail, dan nogmaals hartelijk dank daarvoor. Als je dit nog niet gedaan hebt, dan het verzoek dit toch te doen.

86

Direct starten Het is belangrijk zoveel mogelijk reacties te verzamelen, waarbij individueel inzicht helpt beter elkaar te begrijpen. Dit draagt bij aan een succesvolle en gezonde werkwijze van GGzE in de toekomst. Met oog op de toekomst zouden wij het fijn vinden als jij ook feedback kunt geven. De enquête is in het Nederlands geschreven en neemt ongeveer 20 minuten in beslag. Participatie is natuurlijk geheel vrijwillig en gegevens worden strikt vertrouwelijk behandeld [er is een functionaris voor gegevensbescherming aangesteld]. Onderstaande link verwijst naar de website. Het is ook nog steeds mogelijk persoonlijke feedback te ontvangen en natuurlijk mee te dingen in de twee prijzen die aan het einde verloot worden. Start de enquête Het is mogelijk om de enquête tussentijds op te slaan en opnieuw [binnen twee weken] in te loggen met dezelfde link als hierboven is weergegeven. Je kunt dan verdergaan waar je gebleven was. Elke reactie is belangrijk, dus ook die van jouw. Directe feedback krijgen van medewerkers is essentieel en waardevol om processen binnen GGzE te verbeteren. Zie voor meer informatie intranet, de bijlage, of de eerste email m.b.t. dit onderzoek verzonden email. Hartelijk bedankt, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

Reminder 3 care professionals (final reminder)

Beste collega, Hopelijk heb je nog even tijd om een online enquête in te vullen. Het duurt 20 minuten en is van groot belang voor GGzE om het onderzoek te voltooien. Mocht je de enquête al hebben ingevuld, dan willen we je hartelijk danken voor de input. Mochten we nog geen reactie hebben ontvangen, dan willen we je nog één keer bewust maken dat deze mogelijkheid er tot eind juni is. Nog maar een paar dagen dus!

87

We willen daarna starten met de analyse van de data en willen er zeker van zijn dat iedereen die nog niet gereageerd heeft, toch de kans krijgt alsnog deel te nemen. Klik op onderstaande link om direct te starten. Start de enquête Je kunt de enquête tussentijds opslaan, door het venster te sluiten. Met de link, zoals hierboven gegeven, kun je dan op een ander moment weer verder gaan. Bedankt voor je tijd en het voltooien van de enquête. Uw antwoorden zijn belangrijk en een goede bron voor inspiratie en feedback. Participatie is geheel vrijwillig en gegevens worden strikt vertrouwelijk behandeld [er is een functionaris voor gegevensbescherming aangesteld binnen GGzE]. Zie ook voor meer informatie: intranet en/of de bijlage. Met vriendelijke groeten, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

First contact managers

Titel: Enquête | Help! De impact van veranderingen (een blik op…)

Beste leidinggevende, Dit bericht is een verzoek tot deelname aan een onderzoek van GGzE uitgevoerd door de afdeling technische bedrijfskunde van de Technische Universiteit Eindhoven. Met dit onderzoek proberen we de impact van veranderingen in de zorg op individuele medewerkers beter te begrijpen en een goede aanpak voor de toekomst te creëren. Iets wat in lijn is met het gedachtegoed van het jaardocument van GGzE en wat je eerder hebt kunnen lezen op intranet. Direct starten

88

Wat is het doel? Proberen grip te krijgen op zowel zorglogistieke als financiële ontwikkelingen en prestaties; Het beter leren omgaan met de invloed van veranderingen en wat hiervoor mogelijke preventieve oplossingen zijn; Een effectieve oplossing zoeken voor de samenwerking tussen het management, teams en de professionals; Het zoeken naar de relatie en het effect van cultuur, opvattingen en gedrag van zorgprofessionals op de prestaties van GGzE; Het ontwikkelen van de mogelijkheden om processen kwalitatief én financieel te faciliteren; Hoe een veranderstrategie te vertalen en te faciliteren naar professionals, om zowel efficiëntieals kwaliteitsprestaties te verbeteren?; Graag willen wij jouw hulp, gedachten en mening hierbij. De vragenlijst is elektronisch en zal ongeveer 15 minuten in beslag nemen. Je deelname is vrijwillig en antwoorden worden strikt vertrouwelijk behandeld. Meedoen met het onderzoek is eenvoudig, ga naar onderstaande web-link en je kunt direct beginnen. De medewerkers binnen jouw team hebben ook een (andere) versie ontvangen en de respons is op dit moment goed. Echter, om het onderzoek compleet te maken heb ik ook jouw hulp nodig. Start de enquête Het is mogelijk om tussentijds de enquête op te slaan! Je kunt dan met bovenstaande link weer inloggen (binnen 4 weken) en verder gaan waar je gebleven was. Bij voorbaat dank, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

Reminder 1 manager

Beste leidinggevende,

89

Onlangs ontving je een email met de vraag een online enquête in te vullen, om GGzE te helpen zich beter voor te bereiden op veranderingen in de zorg. Het onderzoek richt zicht zich op de rol van de zorgprofessional, het team en de manager, bij het efficiënt leveren van de best mogelijke zorg. Mocht je de vragenlijst reeds hebben ingevuld, dan hierbij nogmaals hartelijk dank! Direct starten Mocht je nog niet in de gelegenheid zijn geweest mee te werken, dan willen wij graag alsnog ongeveer 15 minuten van je tijd vragen. Hierbij eenzelfde link als vorige keer. Participatie is natuurlijk geheel vrijwillig en gegevens worden strikt vertrouwelijk behandeld [er is een functionaris voor gegevensbescherming binnen GGzE aangesteld]. We zouden het op prijs stellen als we ook van jou een reactie kunnen ontvangen. Ook de medewerkers van jouw team hebben reeds deelgenomen via een eerder (uitgebreidere) uitgezette online enquête. De respons hierop is/was goed, waarbij de teller nu staat op 263 complete ingevulde enquêtes. Om het onderzoek goed af te ronden hebben we ook jouw hulp nodig. Start de enquête Het is mogelijk om tussentijds de enquête op te slaan! Je kunt dan met bovenstaande link weer inloggen (binnen 2 weken) en verder gaan waar je gebleven was. Voor extra informatie verwijzen we je naar intranet, ook kun je nog de email van vorige week raadplegen via deze link. Bij voorbaat dank, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

Reminder 2 manager

Beste leidinggevende,

90

Hopelijk heb je nog even tijd om een online enquête in te vullen. Het duurt ongeveer 15-20 minuten en is van groot belang om dit onderzoek van GGzE, i.s.m. de Technische Universiteit Eindhoven, te voltooien. Mocht je deze enquête al hebben ingevuld, dan willen we je hiervoor hartelijk danken. De respons van collega´s binnen jouw team hebben we reeds in groten getale ontvangen. We zijn echter ook benieuwd naar jouw mening, opvatting en inzicht, om zo een volledig beeld te krijgen. We willen spoedig beginnen met de data-analyse, dus hopelijk kun je alsnog tijd vrijmaken om te helpen bij dit onderzoek. Klik op onderstaande link om direct te starten. Start de enquête Het is mogelijk om tussentijds de enquête op te slaan! Je kunt dan met bovenstaande link weer inloggen en verder gaan waar je gebleven was. Voor extra informatie verwijzen we je naar intranet, ook kun je nog de eerste email (van twee weken geleden) raadplegen via deze link. Bij voorbaat dank, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

Reminder 3 manager

Beste leidinggevende, Hopelijk heb je nog even tijd om een online enquête in te vullen. Het duurt ongeveer 15-20 minuten en is van groot belang om dit onderzoek van GGzE, i.s.m. de Technische Universiteit Eindhoven, te voltooien. Mocht je deze enquête al hebben ingevuld, dan willen we je hiervoor hartelijk danken. De respons van collega´s binnen jouw team hebben we reeds in groten getale ontvangen. We zijn echter ook benieuwd naar jouw mening, opvatting en inzicht, om zo een volledig beeld te krijgen. Door jouw respons wordt het onderzoek waardevoller voor GGzE! We willen spoedig (a.s. donderdag) beginnen met de data-analyse, dus hopelijk kun je alsnog tijd vrijmaken om te helpen bij dit onderzoek. We hebben nog een aantal responses nodig van de leidinggevende functies. Klik op onderstaande link om direct te starten.

91

Start de enquête

Voor extra informatie verwijzen we je naar intranet, ook kun je nog de eerste email (van twee weken geleden) raadplegen via deze link. Bij voorbaat dank, Stef Marinus [+ supervisors TU/e + supervisors GGzE]

Additional follow-up email

Beste collega, Onlangs heb je een reminder toegezonden gekregen (afgelopen maandag om ong. 11.45; Titel: Enquête | Help! De impact van veranderingen) om mee te doen aan een online enquête. Het doel van deze enquête is om te zoeken naar oplossingen om grip te krijgen op de continue veranderingen in de zorg. Collega’s uit jouw team hebben reeds veel respons gegeven op soortgelijke enquête, maar om dit onderzoek nog waardevoller te maken zou ik graag ook jullie respons ontvangen. Dan kunnen we met de resultaten proberen grip te krijgen op zowel zorg-logistieke als financiële ontwikkelingen. Uiteindelijk hoop ik daarmee ook jouw, als leidinggevende, en de organisatie handvaten te geven om zowel op efficiëntie als kwaliteit te sturen. Het streven is dus om de best mogelijke zorg te kunnen leveren voor de cliënt, maar ook om de organisatie gezond te houden en om te gaan met veranderingen. Hopelijk hebben jullie nog even 10-15 minuten de tijd om mij te helpen. Ik wil morgen beginnen met de analyse van de gegevens en het zou fijn zijn als ik jullie input hierin nog mee kan nemen. Je kunt inloggen via de eerdere mail van afgelopen maandag, want deze link is gekoppeld aan een respondenten ID. Gegevens worden daardoor vertrouwelijk behandeld, ook middels het aanstellen van een functioneel gegevensbeheerder binnen GGzE. Zelf werk ik reeds 1,5 jaar (parttime) in dienst van Planning & Control. Tegelijkertijd probeer ik nu mijn master Innovation Management (vervolg op Technische Bedrijfskunde) aan de Universiteit van Eindhoven af te ronden. Deze twee aspecten komen nu samen en daarmee denk ik een relevant onderzoek te hebben, waarbij ook de praktische implicaties voor GGzE goed naar voren kunnen komen. Bij voorbaat dank! Met groet, Stef Marinus

92

F.

Questionnaire care professionals

Pagina 1 | enquête

“De impact van veranderingen (een blik op…)”

GGzE is volop in beweging. De uitdaging is om in de toekomst een goede kwalitatieve service te bieden maar ook oog te hebben voor efficiëntie. Dit onderzoek, in opdracht van de directie en het middenkader, probeert zicht te krijgen op de vorderingen die zijn gemaakt. Het kan helpen het veranderproces verder te verbeteren. Het onderzoek is onderdeel van mijn studie Technische Bedrijfskunde aan de TU Eindhoven en sluit aan bij andere belangrijke projecten van GGzE. Sinds eind 2010 werk ik, naast mijn studie, parttime bij de afdeling Planning & Control van GGzE. Het onderzoek biedt GGzE inzicht in organisatieprocessen en een venster op de toekomst, terwijl het mij helpt mijn afstudeeronderzoek te doen. Ik hoop op je spontane deelname. Merk op dat er géén goede en slechte antwoorden zijn. Sommige vragen zullen wat op elkaar lijken. Zij helpen de betrouwbaarheid van het onderzoek te vergroten. Jouw antwoorden worden strikt vertrouwelijk behandeld en alleen geaggregeerde gegevens worden aan het management gerapporteerd. Bij voorbaat dank ik je voor de hulp en medewerking. Als je vragen hebt over het onderzoek en de vragenlijst kun je mij te allen tijde bellen (06-41105311; b.g.g. kunt je ook mailen naar [email protected]).

Stef Marinus,

Medewerker Planning & Control Student Innovation Management (TU/e; Master opleiding van Technische Bedrijfskunde)

Eindhoven, 2012-05-21

93

Pagina 2 | enquête

Alle vragen zijn gebaseerd op een 5-puntsantwoordschaal, met het volgende bereik:

Geef aan in welke mate je het eens bent met de volgende stellingen. Ik vind dat… 1. …dit onderzoek waardevol is voor de toekomst van het GGzE 2. …iedereen binnen GGzE mee moet doen aan dit onderzoek

Helemaal mee eens

Mee eens

Neutraal

Mee oneens

Helemaal mee oneens

Je kunt nu starten met de vragenlijst. Er zijn geen goede en/of foute antwoorden. Het is van belang dat je het best passende antwoord kiest.

94

Pagina 3 | enquête

SECTIE A: "Organisatie focus, jouw perceptie en je omgang met…" In deze sectie zijn we geïnteresseerd in jouw beeld van de organisatie en haar koers. Denk hierbij aan de doelstellingen van de Raad van Bestuur en het directiemanagement. Wat valt je op aan het laatste jaar en wat zijn de ontwikkelingen? Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source

Bij GGzE…:

[Q1.0]

1.


COORG_0

2.

… houdt men constant de mate van cliëntbetrokkenheid in de gaten

COORG_1

3.

… is het onderscheidend vermogen ten opzichte van andere instellingen gebaseerd op ons begrip van cliëntenbehoeften

COORG_2

4.


COORG_3

5.


COORG_4

Subin and Workman, 2004 Subin and Workman, 2004 Subin and Workman, 2004 Subin and Workman, 2004 Subin and Workman, 2004

Bij GGzE…:

[Q1.1]

6.

CEORG_0

Rust et al., 2002

CEORG_1

Rust et al., 2002

CEORG_2

Rust et al., 2002

7. 8.

… worden verbeteringsinitiatieven altijd gekoppeld aan de mate van kostenbesparing … moeten initiatieven altijd leiden tot een efficiëntere manier van werken … is het doel van kwaliteitsverbeteringen vaak gericht om ook kosten te reduceren

Bij GGzE…:

[Q1.2]

9.

ROORG_0

Ye et al., 2007

ROORG_1

Ye et al., 2007

ROORG_2

Ye et al., 2007

ROORG_3

Ye et al., 2007

… implementeren managers initiatieven om meer inkomsten te genereren 10. … presenteren zorgprofessionals nieuwe ideeën om cliëntparticipatie en zorgkwaliteit te bevorderen 11. … gebruikt met innovatieve projecten [bijv. E-health] om cliënten beter te bedienen 12. … krijgen zorgprofessionals erkenning als zij de organisatie helpen de cliënttevredenheid te verhogen [bijv. Planetree]

Schaal: Helemaal mee eens

Mee eens

Neutraal

Mee oneens

Helemaal mee oneens

Trainingen en bijeenkomsten van het GGzE stellen mij in staat om (vb. Strategie café, cultuurprogramma’s, DBC trainingen)…:

[Q2.0]

13. … meer bewust te worden van cliëntbehoeften

TRAICO_0


14. … goed om te leren gaan met cliëntproblemen

TRAICO_1


15. … inzichten te krijgen in cliëntenproblematiek en daardoor beter te behandelen 16. … op de hoogte te blijven van veranderingen in de zorg en de impact hiervan op cliëntbehandelingen

TRAICO_2


TRAICO_3

New


[Q2.1]

17. … informatie en discussie te hebben over het effect van kostenbesparing en bezuinigingen op mijn taken 18. … zowel efficiënt als effectief te kunnen werken

TRAIEFF_0

New

TRAIEFF_1

New

19. … leerinitiatieven te ontwikkelen om ‘slimmer’ te werken

TRAIEFF_2

New

20. … te leren denken in zorgpaden

TRAIEFF_3

New

De volgende stellingen hebben betrekking op jouw perceptie van veranderingen binnen GGzE:

[Q3]

21. Alles wat we hier doen, blijft maar veranderen

PERC_0

Ye et al., 2007

22. Ik heb nooit het gevoel dat ik weet wanneer we gaan veranderen, het komt altijd ineens 23. De criteria voor evaluatie op prestatie van ons team blijven steeds veranderen 24. Het lijkt alsof we altijd aan het reorganiseren zijn

PERC_1

Ye et al., 2007

PERC_2

Ye et al., 2007

PERC_3

Ye et al., 2007

De volgende vragen hebben betrekking op je gevoel binnen GGzE en of je hier in de toekomst wil blijven werken

[Q4]

25. Ik denk om te stoppen met werken bij het GGzE

TOINT _0

Singh, 2000

26. Het is mogelijk dat ik actief op zoek ga naar een nieuwe baan in de nabije toekomst

TOINT_1

Singh, 2000

96


Mee eens

Neutraal

Mee oneens

Helemaal mee oneens

27. Ik vraag mezelf wel eens af of ik op zoek moet gaan naar een baan buiten de gezondheidszorg

TOINT _2

In welke mate ben je het eens met volgende stellingen:

[Q5]

28. Over het algemeen ben ik erg tevreden met mijn baan

JOBS _0

Hackman and Oldham, 1975

29. Over het algemeen ben ik tevreden met de taken die ik in deze baan uitvoer

JOBS _1


30. Ik haal veel voldoening uit mijn functiegerelateerde activiteiten

JOBS _2


Identificatie met het GGzE: 31. Stel je voor dat de linker cirkel overeenkomt met jouw eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. GGzE, weergegeven door de rechter cirkel, is?

[ID1]

(in andere woorden: in hoeverre overlappen jullie met IK elkaar): a.

Ver uit elkaar

b.

Dicht bij elkaar, maar wel apart

c.

Heel klein beetje overlap

d.

Beetje overlap

e.

Gemiddelde overlap

f.

Grote overlap

g.

Hele grote overlap

h. Complete overlap

SECTIE B: "De samenwerking met jouw team…" In deze sectie zijn we geïnteresseerd hoe je tegen je eigen team aan kijkt. Hoe presteert mijn team? Geef aan in welke mate je het eens bent met de volgende stellingen.

97

IDORG_0

GGzE

Singh, 2000

Bergamo and Bagozzi, 2000


Mee eens

Neutraal

Mee oneens

Helemaal mee oneens

Item-code Source

In mijn team…:

[Q6.0]

1.

… kijken we veel naar cliëntbehoeften

COTEA_0

Lam et al., 2010

2.

… is er veel aandacht voor feedback van cliënten

COTEA_1

Lam et al., 2010

3.

… vindt men het belangrijker om cliëntwensen te achterhalen om behandelprogramma’s te ontwikkelen

COTEA _2

Lam et al., 2010

In mijn team…:

[Q6.1]

4.

COLTEA_0

New

COLTEA_1

Lam et al., 2010

COLTEA_2

Lam et al., 2010

5. 6.

… proberen wij veel van elkaar te leren om in de cliëntbehoeften te voorzien … kijken wij veel naar wat collega’s doen om cliëntproblematiek op te lossen … monitoren wij meer activiteiten en werkwijzen van collega’s

In mijn team…:

[Q6.2]

7.

… is er veelvuldig aandacht voor efficiënt werken voor specifieke categorieën cliënten 8. … wordt rekening gehouden met clustering volgens zorgkenmerken 9. … wordt regelmatig gestuurd op afgestemde zorginspanning afhankelijk het type zorg 10. … worden cliënten vaak gedifferentieerd volgens de zorgzwaarte

COCTEA_0

New

COCTEA_1


COCTEA_2


COCTEA_3


In mijn team…:

[Q6.3]

11. … zoeken wij constant naar nieuwe toepasbare ontwikkelingen en oplossingen 12. … proberen we behandelprogramma’s steeds meer aan te scherpen 13. … ondernemen we activiteiten om de kwaliteit van de zorg te verbeteren

INNTEA_0

Lam et al., 2010

INNTEA_1

Lam et al., 2010

INNTEA_2

Ye et al., 2011

Focus op de situatie van het laatste half jaar en beantwoord de volgende stellingen. Binnen het team waarin ik werk …:

[Q7]

14. … hebben we de benodigde vaardigheden om een cliënt goed te helpen 15. … hebben we samen een eersteklas aanpak voor de zorgproblemen van een cliënt 16. … kunnen we uitdagende zorgproblemen doorgronden en goed behandelen

CAPTEA_0

New

CAPTEA_1

New

CAPTEA_2

New

98


Mee eens

Neutraal

Mee oneens

Helemaal mee oneens

17. … hebben we leden die zeer goed samenwerken 18. … zijn we erg doeltreffend

Geef aan in welke mate je het eens bent met de volgende stellingen m.b.t. jouw team …:

CAPTEA_3

New

CAPTEA_4

New

[Q8]

19. Binnen ons team is het eenvoudig om voor elkaar in te vallen 20. De meeste teamleden kennen elkaars taken goed

FLXEA_0


FLXTEA_1

21. Ik heb veel vertrouwen dat mijn teamleden in staat zijn mijn activiteiten over te nemen 22. Het uitwisselen van teamrollen en verantwoordelijkheden veroorzaakt weinig problemen

FLXTEA_2

De Jong et al., 2004 De Jong et al., 2004

Hoe zeer identificeer je je met je team?:

[Q9]

23. De successen van mijn team zijn mijn successen

TEAID_0

24. Het voelt als een persoonlijke belediging als iemand kritiek uit op het team 25. Ik ben erg geïnteresseerd in wat anderen denken van het team 26. Ik zeg meestal “wij” in plaats van “zij” als ik praat over het team

TEAID_1

Identificatie met het team: 27. Stel je voor dat de linker cirkel overeenkomt met jouw eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. je team, weergegeven door de rechter cirkel, is?

[ID2.0]

(in andere woorden: in hoeverre overlappen jullie met IK elkaar):

99

FLXTEA_3

Jasmand et al., 2012 Vd Vegt et al., 2003

TEAID_2


TEAID_3


IDTEA_0

Team




Mee eens

Neutraal

a.

Ver uit elkaar

b.


c.


d.

Beetje overlap

e.

Gemiddelde overlap

f.

Grote overlap

g.

Hele grote overlap

Mee oneens

Helemaal mee oneens

h. Complete overlap

Identificatie met het team: 28. In welke mate overlappen jouw doelen [targets voor jouw functie) met die van andere teamleden]? a.

Ver uit elkaar

b.


c.


d.

Beetje overlap

e.

Gemiddelde overlap

f.

Grote overlap

g.

Hele grote overlap

[ID2.1] IK

Team

GOATEA_0


h. Complete overlap

SECTIE C: "Ontwikkeling van(uit) teamleden …" In deze sectie zijn we geïnteresseerd hoe je perceptie is van ontwikkeling bij teamleden, maar ook hoe zij jou helpen ontwikkelen. Hoe probeert je team zich te ontwikkelen en hoe help jij ze daarbij? Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source

Vergeleken met teamleden ben ik…

[Q10]

1.

HBHIND_0

… vaak degene die als eerste collega’s helpt

100

New


Mee eens

Neutraal

Mee oneens

Helemaal mee oneens

2.

… steeds bereidwillig informatie te geven aan anderen

HBHIND_1

New

3.

… degene die hulp aanbiedt als iemand problemen ondervindt met werkzaamheden

HBHIND_2

New

Geef aan in welke mate je het eens bent met de volgende stellingen.

[Q11]

4.

Teamleden proberen elkaar te helpen hoe nieuwe uitdagingen in de zorg aan te pakken Teamleden helpen elkaar om het werk beter te doen

HBHTEA_0

Podaskoff et al., 1997

HBHTEA_1


Teamleden wijzen elkaar op hoe problemen het beste opgelost kunnen worden We wisselen vaak van gedachten om zo een hoger prestatieniveau te halen met het team

HBHTEA_2


HBHTEA_3


5. 6. 7.

SECTIE D: " De samenwerking met jouw leidinggevende…" In deze sectie zijn we geïnteresseerd in de samenwerking met je leidinggevende.

De volgende vragen gaan over ervaringen met het gedrag van jouw leidinggevende. Geef aan in welke mate je het eens bent met de volgende stellingen.

Wie is je directe leidinggevende [Q12.1]

--Lijst (3x)--

Wat is de naam van je leidinggevende [Q12.2]

naam Item-code Source

Mijn directe leidinggevende…:

[Q13.0]

1.

… stelt door middel van zijn/haar eigen gedrag hoge eisen

EMPLBE_0

Arnold et al., 2000

2.

… werkt zo hard als hij/zij kan

EMPLBE _1

Arnold et al., 2000

3.

… werkt zo hard als eenieder binnen het team/ de afdeling

EMPLBE _2

Arnold et al., 2000

4.

… fungeert als een voorbeeld door zijn/haar gedrag

EMPLBE _3

Arnold et al., 2000


[Q13.1]

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5.

… moedigt teamleden aan om ideeën en suggesties te uiten

EMPPDM_0

Arnold et al., 2000

6.

… luistert naar ideeën en suggesties van het team

EMPPDM _1

Arnold et al., 2000

7.

… gebruikt suggesties van teamleden om beslissingen te nemen … geeft alle teamleden de kans om meningen te uiten

EMPPDM _2

Arnold et al., 2000

EMPPDM _3

Arnold et al., 2000

8.


[Q13.2]

9.

EMPINF_0

Arnold et al., 2000

10. …legt de doelen van GGzE uit

EMPINF _1

Arnold et al., 2000

11. … legt aan het team uit wat zijn/haar beslissingen en acties zijn

EMPINF _2

Arnold et al., 2000


Q13.3]

12. … geeft suggesties hoe prestaties van teamleden te verbeteren 13. … helpt goede relaties op te bouwen tussen teamleden

EMPCOA_0

Arnold et al., 2000

EMPCOA _1

Arnold et al., 2000

14. … moedigt teamleden aan om problemen gezamenlijk op te lossen 15. … leert teamleden hoe om te gaan met problemen

EMPCOA _2

Arnold et al., 2000

EMPCOA _3

Arnold et al., 2000

16. … helpt het team focussen op onze doelstellingen

EMPCOA _4

Arnold et al., 2000

Identificatie met je manager: 17. Stel je voor dat de linker cirkel overeenkomt met jouw eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. je leidinggevende, weergegeven door de rechter cirkel, is?

[ID3]

… legt beslissingen van GGzE uit

(in andere woorden: in hoeverre overlappen jullie met IK elkaar): a.

Ver uit elkaar

b.

Dicht bij elkaar, maar wel appart

c.


d.

Beetje overlap

e.

Gemiddelde overlap

f.

Grote overlap

g.

Hele grote overlap

102

IDMAN_0

Leidinggevende


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h. Complete overlap

SECTIE E: "Autonomie…" In deze sectie zijn we geïnteresseerd in de autonomie die je als professional binnen GGzE hebt.

Hoeveel zelfstandigheid, vrijheid, verantwoordelijkheid en onafhankelijkheid ervaar je? Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source

Als zorgprofessional heb ik…:

[Q14.0]

1.

… de volledige vrijheid in het uitvoeren van mijn werkzaamheden

AUT_0


2.

… de vrijheid mijn activiteiten uit te voeren op de manier die mij goeddunkt

AUT_1


3.

… de mogelijkheid om mijn eigen oordeel te volgen in het verlenen van cliëntzorg

AUT_2


4.

… de ruimte om een hoge mate van initiatief te tonen in het verlenen van zorg

AUT_3

Mom et al., 2009

Als zorgprofessional heb ik…:

[Q14.1]

5.

… procedures te volgen tijdens mijn werkzaamheden

FORM_0

Mom et al., 2009

6.

… ten alle tijde te maken met strikte protocollen

FORM_1

Mom et al., 2009

7.

… een gedetailleerde werkomschrijving waarin mijn taken staan beschreven

FORM_2

Mom et al., 2009

Geef aan in welke mate je het eens bent met de volgende stellingen m.b.t. het geloof in eigen kunnen.

[Q15]

8.

Ik heb de benodigde vaardigheden om goed aan klantbehoeften te voldoen

SLFEFF_0

Sujan et al., 1994

9.

Ik kan uitdagende klantvragen identificeren en oplossen

SLFEFF_1

Sujan et al., 1994

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10. Ik ben goed in het achterhalen van cliëntbehoeften

SLFEFF_2

Sujan et al., 1994

11. Ik kan effectief omgaan met iedere voorkomende zorgvraag

SLFEFF_3

Sujan et al., 1994

In welke mate ben je het eens met de volgende stellingen:

[Q16]

12. Ik ontvang regelmatig met elkaar conflicterende verzoeken van verschillende mensen waarmee ik in mijn werk te maken heb 13. Ik moet in mijn werk vaak dingen doen die door de één wel, maar door de andere niet gewaardeerd worden

ROCONF_0

Rizzo et al., 1970

ROCONF_1

Rizzo et al., 1970

14. Om voor de cliënt mijn werk goed uit te voeren moet ik af en toe de regels breken

ROCONF_2

Rizzo et al., 1970

SECTIE F: "Persoonlijke ontwikkelingen en veranderbereidheid…" In deze sectie zijn we geïnteresseerd hoe je tegen veranderingen aankijkt en wat je doet om jezelf te ontwikkelen. Hoe probeer je jezelf te ontwikkelen in de dynamische gezondheidszorg setting? Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source In mijn dagelijkse werk…:

[Q17]

1.

INNBEH_0

Ye et al., 2011

INNBEH_1

Ye et al., 2011

INNBEH_2

Ye et al., 2007

INNBEH_3

Ye et al., 2007

INNBEH_4

Ye et al., 2007

2. 3. 4. 5.

… onderneem ik activiteiten om de kwaliteit van de zorg te verbeteren … bedenk ik regelmatig verschillende manieren om behandelprocedures te verbeteren … probeer ik voortdurend verschillende manieren te vinden om zorgverlening te verbeteren … probeer ik zelf nieuwe dingen aan te leren, om de eigen productiviteit te verhogen … sta ik open voor nieuwe ideeën om veranderingen in de zorg te accepteren

SECTIE G: "Jouw opvattingen over de cliënt oriëntatie…" In deze eerste sectie zijn we geïnteresseerd in een aantal specifieke opvattingen met het oog op de

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cliënt oriëntatie. Denk hierbij aan wat je zou kunnen doen om de beste zorg te leveren.

Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source

Ik vind het belangrijk om…:

[Q18.0]

1.

… cliëntvoorkeuren in ogenschouw te nemen

COBLF_0

2.

… regelmatig toekomstige behandelmethodieken te toetsen met mijn cliënten … uit te zoeken wat cliëntbehoeften zijn

COBLF_1

3.

COBLF_2

Lam et al., 2010 Lam et al., 2010 Lam et al., 2010

[Q18.1] Ik vind het belangrijk om…: COLBLF_0

Lam et al., 201o

5.

… na te gaan wat collega’s doen om cliëntproblematiek op te lossen … werkwijzen van collega’s te monitoren en begrijpen

COLBLF_1

6.

… te leren van behandelactiviteiten van collega’s

COLBLF_2

Lam et al., 201o Lam et al., 201o

4.

[Q18.2] Ik vind het belangrijk om…: 7. 8.

… cliënten in te schalen in subgroepen, volgens hun zorgkenmerken … cliënten te differentiëren op zorgzwaarte

9.

… in mijn werkzaamheden cliënten effectief [doeltreffend] te categoriseren 10. … goed toegesneden efficiënte zorgpaden te hebben 11. … onderscheid te maken in behandelmethodieken per doelgroep 12. … te sturen op mijn zorginspanning passend bij het type behandelactiviteit [DBC, ZZP, etc.]

CATBLF _0


CATBLF _1 CATBLF_2


CATBLF _3

New

CATBLF _4

New

CATBLF _5


SECTIE H: "Jouw gedrag m.b.t. cliënt oriëntatie …" In deze sectie zijn we geïnteresseerd in jouw werkzaamheden m.b.t. cliëntzorg. Denk hierbij aan de dingen die je nu doet in je functie.

Neem als referentiekader de periode van het laatste half jaar, dus vanaf ongeveer 1-jan-2012 (sinds de nieuwe doelstellingen van de Raad van Bestuur, vacaturestop, etc.) Geef aan in welke mate je het eens bent met de volgende stellingen.

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Item-code Source

In mijn huidige werk…:

[Q19.0]

1.

… staat de oplossing voor de cliënt centraal

COBEH_0


2.

… luister ik regelmatig actief naar mijn cliënten om verbeteringen in de behandelmethodiek in overweging te nemen … probeer ik zorgvragen die nòg niet in het behandelplan staan te identificeren

COBEH_1


COBEH_2

Saxe and Weitz, 1998

4.

… probeer ik cliënten een reëel beeld te geven van wat de behandeling voor hem/haar kan betekenen

COBEH_3

Lam et al., 2010

5.

… probeer ik (onzekere) cliënten gerust te stellen, zodat we samen behandelingsactiviteiten goed kunnen uitvoeren

COBEH_4


3.


[Q19.1]

6.

… monitor ik zorgvuldig behandelmethodieken van collega’s

COLBEH_1

Lam et al., 2010

7.

… let ik op de slimme aanpak en werkoplossingen van collega’s

COLBEH_0

Lam et al., 2010

8.

… neem ik vaak deel aan interdisciplinair overleg, om ontwikkelingen in ons werk en de zorg te bespreken

COLBEH_2

Kohli et al., 1993

… deel ik bevindingen rond effectiviteit van behandelingen met collega’s 10. … deel ik relevante informatie samen met collega’s voor kennisontwikkeling

COLBEH_3

Kohli et al., 1993

COLBEH_4

Kohli et al., 1993


[Q19.2]

11. … differentieer ik cliënten op zorgzwaarte

CATBEH _0

12. … categoriseer ik cliënten effectief [doeltreffend] 13. … heb ik de beschikking over goed toegesneden efficiënte zorgpaden 14. … maak ik onderscheid in behandelmethodieken per doelgroep 15. … stuur ik op zorginspanning passend bij het type behandelactiviteit [DBC, ZZP, etc.]

CATBEH _1


CATBEH _2

New

CATBEH _3

New

CATBEH _4


9.

SECTIE I: "Werkdruk en karaktereigenschappen…" Item-code Source

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De volgende stellingen hebben betrekking op de door jouw ervaren werkdruk

[Q20]

1.

WRKL_0

Singh, 2000

WRKL_1

Ye et al., 2011

WRKL_2

Ye et al., 2011

2. 3.

Door het de verandering op het werk zit ik soms dicht bij een burn-out Ik heb te veel werk, dat ik in een te korte tijdsperiode moet voltooien Ik voel mezelf vaak uitgeput na een dag op het werk

De volgende stellingen gaan in op je persoonlijke karakteristieken

[Q21]

4.

Ik voel me prettig in het bijzijn van andere medewerkers

KARA_0

Via IPIP

5.

Ik vertrouw collega’s zeer snel

KARA_2

Via IPIP

6.

Ik geloof in de goede intenties van mijn directe collega’s

KARA_3

Via IPIP

SECTIE J: "Algemene vragen…" Onderstaande vragen zijn essentieel voor het goed afronden van deze enquête. Item-code 1.

Wat is je leeftijd?

…………. Jaar

G1

2.

Wat is je geslacht?

Man:

G2

Vrouw:

Hoeveel jaar werkervaring heb je…:

G3

3.

… in de gezondheidszorg

…………. Jaar

G3.1

4.

… binnen GGzE

…………. Jaar

G3.2

5.

… in je huidige afdeling

…………. Jaar

G3.3

6.

Wat is je hoogst afgeronde opleiding?

Geen / MBO / HBO / WO / Master / Post WO/ anders

G4.a

6a. Anders, zo ja welke:

G4.b

7.

Wat is je huidig CONO beroep:

Lijst

G5

8.

Wat is jouw huidige functie

Lijst

G6

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Hoeveel uren werk je contractueel per week voor GGzE?

Helemaal mee oneens

…………. Uren

G7

10. Hoeveel maanden heb je al dezelfde leidinggevende?

…………. Maanden

G8

11. Met hoeveel mensen werk je gemiddeld in het team, waarvan je nu deel uitmaakt? 12. Hoeveel cliënten begeleid je gemiddeld op jaarbasis?

…………. Leden

G9

…………. Cliënten

G10

Hoe ziet de tijdsverdeling van je werkzaamheden eruit?

G11

13. Ik werk xx% van de tijd met vaste teamleden

10% / 20% / … / 100%

G11.1

14. Ik ben xx% van mijn tijd kwijt aan cliëntgebonden activiteiten [direct en indirect] 15. Ik sta xx% van mijn tijd direct in contact met mijn cliënten

10% / 20% / … / 100%

G11.2

10% / 20% / … / 100%

G11.3

SECTIE K: "Vragen m.b.t. specificaties van een behandelteam (focus: behandelprogramma ontwikkeling…" Onderstaande vragen hebben betrekking op het ontwikkelen van behandelprogramma's. Activiteiten zonder direct cliëntcontact. Item-code

Heb je vanaf 1-jan-2012 deelgenomen aan de ontwikkelingen van een behandelprogramma (o.l.v. de programmamanager)?

Ja:

Nee:

PDT_1

Zo ja, dan verder met 1 t/m 5

1. Ik behoor toe tot…: a. Één behandelprogrammateam b. Hoofdzakelijk één behandelteam, maar soms ook voor een aantal andere behandelteams c. Meerdere gelijkwaardige behandelteams

PDT_2

2. Welke functionele achtergrond is er binnen dit team (deze teams) vertegenwoordigd (meerdere keuzes mogelijk)? a. Psycholoog b. … c. … d. …

PDT_3

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3. Het behandelteam bestaat vooral uit…: a. Relatief vaste leden (in dienst sinds 1-jan2012) b. Enkele vaste leden, maar ook enkele die variëren (flex; parttime) c. Leden die regelmatig veranderen

PDT_4

4. Ik zou het behandelprogrammateam [waarin je het meeste participeert] omschrijven als: a. Één collectief b. Twee of meer subgroepen van medewerkers c. Een set van individuen die hun eigen werk uitvoeren 5. Hoeveel collega’s zitten er gemiddeld in het behandelteam? ____

PDT_5

PDT_6

SECTIE L: "Open vragen…" In onderstaande vragen kun je over sommige onderwerpen eventueel een korte toelichting geven m.b.t. je eigen opvattingen en mening. Hoe wil je dat GGzE komende tijd veranderingen aan gaat pakken en welk specifiek aandachtpunt wil je de directie/het management meegeven? [OPEN_0] … Hoe kunnen we management en zorgprofessionals goed laten samenwerken? [OPEN_1] … Welke rol heeft Planetree voor jou m.b.t. de goede omgang met cliënten? [OPEN_2] … Hoe denk je dat we om moeten gaan met een steeds nadrukkelijker overheersende kostenbesparingen (o.a. door de bezuinigingen)? [OPEN_3] … Als je nog andere opmerkingen of suggesties hebt, kun je die hier kwijt…: [OPEN_4] …

109

Pagina 14 | enquête = eindbericht Als deze enquête gesloten is (eind juni 2012) dan krijg je, indien je dit hieronder aangeeft, feedback op competenties. Hiervoor zal een diagram de vergelijking maken van jezelf t.o.v. het GGzE gemiddelde. Indien je persoonlijke feedback wilt ontvangen vink dan “ja” aan en vul je email in

Ik wil graag persoonlijke feedback ontvangen? Zo ja, vul dan hier je email in

Ja: Nee: ………………………………………………@ggze.nl

Pagina 15 | enquête = eindbericht

Bedankt voor je medewerking! Als je vragen en/of opmerkingen hebt kun je contact opnemen met Stef Marinus via [email protected]

G.

Questionnaire management

Pagina 1 | enquête

“De impact van veranderingen (een blik op…)” GGzE is volop in beweging. De uitdaging is om in de toekomst een goede kwalitatieve service te bieden maar ook oog te hebben voor efficiëntie. Dit onderzoek, in opdracht van de directie, probeert zicht te krijgen op de vorderingen die zijn gemaakt. Het kan helpen het veranderproces verder te verbeteren. De medewerkers van uw team hebben reeds de mogelijkheid gehad een soortgelijke enquête in te vullen, maar om het plaatje compleet te hebben vragen we ook jouw mening. Het onderzoek is onderdeel van mijn studie Technische Bedrijfskunde aan de TU Eindhoven en sluit aan bij andere belangrijke projecten van GGzE. Sinds eind 2010 werk ik, naast mijn studie, parttime bij de afdeling Planning & Control van GGzE. Het onderzoek biedt GGzE inzicht in organisatieprocessen en een venster op de toekomst, terwijl het mij helpt mijn afstudeeronderzoek te doen. Ik hoop op je spontane deelname. Jouw antwoorden worden strikt vertrouwelijk behandeld. Er is iemand aangesteld als functioneel gegevensbeheerder (FG). Bij voorbaat dank ik je voor de hulp en medewerking. Als je vragen hebt over het onderzoek en de vragenlijst kun je mij te allen tijde bellen (06-41105311; b.g.g. kunt je ook mailen naar [email protected]). Stef Marinus,

Medewerker Planning & Control Student Innovation Management (TU/e; Master opleiding van Technische Bedrijfskunde)

Eindhoven, 2012-06-13

Pagina 2 | enquête

Alle vragen zijn gebaseerd op een 5-puntsantwoordschaal, met het volgende bereik:

Geef aan in welke mate je het eens bent met de volgende stellingen. Ik vind dat… 1. …dit onderzoek waardevol is voor de toekomst van het GGzE 2. …iedereen binnen GGzE mee moet doen aan dit onderzoek

Helemaal mee eens

Mee eens

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Je kunt nu starten met de vragenlijst. Er zijn geen goede en/of foute antwoorden. Het is van belang dat je het best passende antwoord kiest. Ook heb je de mogelijkheid om de vragenlijst op te slaan (d.m.v. het sluiten van je venster) en binnen 2 weken de enquête te voltooiden. Je kunt opnieuw inloggen met dezelfde link als in de toegezonden email!!

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SECTIE A: "Organisatie focus, jouw perceptie en je omgang met…" In deze sectie zijn we geïnteresseerd in jouw beeld van de organisatie en haar koers. Denk hierbij aan de doelstellingen van de Raad van Bestuur en het directiemanagement.

Wat valt je op aan het laatste jaar en wat zijn de ontwikkelingen? Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source

Bij GGzE…:

[Q1.0]

1.


COORG_0

2.

… houdt men constant de mate van cliëntbetrokkenheid in de gaten

COORG_1

3.

… is het onderscheidend vermogen ten opzichte van andere instellingen gebaseerd op ons begrip van cliëntenbehoeften

COORG_2

4.


COORG_3

5.


COORG_4

Subin and Workman, 2004 Subin and Workman, 2004 Subin and Workman, 2004 Subin and Workman, 2004 Subin and Workman, 2004

Bij GGzE…:

[Q1.1]

6.

CEORG_0

Rust et al., 2002

CEORG_1

Rust et al., 2002

CEORG_2

Rust et al., 2002

7. 8.

… worden verbeteringsinitiatieven altijd gekoppeld aan de mate van kostenbesparing … moeten initiatieven altijd leiden tot een efficiëntere manier van werken … is het doel van kwaliteitsverbeteringen vaak gericht om ook kosten te reduceren

Bij GGzE…:

[Q1.2]

9.

ROORG_0

Ye et al., 2007

ROORG_1

Ye et al., 2007

ROORG_2

Ye et al., 2007

ROORG_3

Ye et al., 2007

… ontwikkeld het management initiatieven om meer inkomsten te genereren 10. … presenteren zorgprofessionals nieuwe ideeën om cliëntparticipatie en zorgkwaliteit te bevorderen 11. … gebruikt men innovatieve projecten [bijv. E-health] om cliënten beter te bedienen 12. … krijgen zorgprofessionals erkenning als zij de organisatie helpen de cliënttevredenheid te verhogen [bijv. Planetree]

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De volgende stellingen hebben betrekking op jouw perceptie van veranderingen binnen GGzE:

[Q3]

13. Alles wat we hier doen, blijft maar veranderen

PERC_0

Ye et al., 2007

14. Ik heb nooit het gevoel dat ik weet wanneer we gaan veranderen, het komt altijd ineens 15. De criteria voor evaluatie op prestatie van ons team blijven steeds veranderen 16. Het lijkt alsof we altijd aan het reorganiseren zijn

PERC_1

Ye et al., 2007

PERC_2

Ye et al., 2007

PERC_3

Ye et al., 2007


[Q2.0]

17. … meer bewust te worden van cliëntbehoeften

TRAICO_0


18. … goed om te leren gaan met cliëntenproblematiek

TRAICO_1


19. … inzichten te krijgen in cliëntenproblematiek en daardoor beter mijn behandelteam te leiden

TRAICO_2


20. … op de hoogte te blijven van veranderingen in de zorg en de impact hiervan op cliëntbehandelingen

TRAICO_3

New


[Q2.1]

21. … informatie en discussie te hebben over het effect van kostenbesparing en bezuinigingen op mijn taken 22. … zowel efficiënt als effectief te kunnen werken

TRAIEFF_0

New

TRAIEFF_1

New

23. … leerinitiatieven te ontwikkelen om ‘slimmer’ te werken

TRAIEFF_2

New

24. … te leren denken in zorgpaden

TRAIEFF_3

New

Identificatie met het GGzE:

[ID1]

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25. Stel je voor dat de linker cirkel overeenkomt met jouw

IDORG_0

eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. GGzE, weergegeven door de rechter cirkel, is? (in andere woorden: in hoeverre overlappen jullie met IK elkaar): a.

Ver uit elkaar

b.


c.


d.

Beetje overlap

e.

Gemiddelde overlap

f.

Grote overlap

g.

Hele grote overlap

GGzE

h. Complete overlap

SECTIE D: " De samenwerking met jouw team…" In deze sectie zijn we geïnteresseerd in de samenwerking met je team.


Als leidinggevende probeer ik …:

[Q13.0]

1.

… middels mijn eigen gedrag de lat hoog te leggen voor mijn medewerkers

EMPLBE_0

Arnold et al., 2000

2.

… met mijn werkinspanning het goede voorbeeld te geven aan mijn medewerkers

EMPLBE _1

Arnold et al., 2000

3.

… zo hard mogelijk mee te werken

EMPLBE _2

Arnold et al., 2000

4.

… een voorbeeld te zijn voor mijn medewerkers/collega’s

EMPLBE _3

Arnold et al., 2000


[Q13.1]

5.

EMPPDM_0

… teamleden aan te moedigen hun ideeën en suggesties te uiten

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6.

… te luister naar ideeën en suggesties van teamleden

EMPPDM _1

Arnold et al., 2000

7.

… hun suggesties te gebruiken om beslissingen te nemen

EMPPDM _2

Arnold et al., 2000

8.

… iedereen de kans te geven meningen te uiten

EMPPDM _3

Arnold et al., 2000


[Q13.2]

9.

EMPINF_0

Arnold et al., 2000

10. …de doelen van GGzE uit te leggen

EMPINF _1

Arnold et al., 2000

11. … het ‘hoe en waarom’ van mijn beslissingen en acties duidelijk te maken

EMPINF _2

Arnold et al., 2000


[Q13.3]

12. … suggesties te geven hoe teamleden prestaties kunnen verbeteren

EMPCOA_0

Arnold et al., 2000

13. … te helpen om tot goede onderlinge relaties op de werkvloer te komen

EMPCOA _1

Arnold et al., 2000

14. … aan te moedigen om problemen gezamenlijk op te lossen

EMPCOA _2

Arnold et al., 2000

15. … medewerkers te leren hoe om te gaan met problemen

EMPCOA _3

Arnold et al., 2000

16. … het team te laten focussen op onze doelstellingen

EMPCOA _4

Arnold et al., 2000

Identificatie met het team:

[ID3]

… beslissingen van GGzE uit te leggen

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17. Stel je voor dat de linker cirkel overeenkomt met jouw eigen normen, waarden en opvattingen. Kun je dan aangeven hoe je relatie t.o.v. je afdeling/team, weergegeven door de rechter cirkel, is? (in andere woorden: in hoeverre overlappen jullie met IK elkaar): a.

Ver uit elkaar

b.


c.


d.

Beetje overlap

e.

Gemiddelde overlap

f.

Grote overlap

g.

Hele grote overlap

IDMAN_0

afd/team

h. Complete overlap

SECTIE E: "Hoe stimuleer ik autonomie…" In deze sectie zijn we geïnteresseerd in de autonomie die je als leidinggevende geeft aan de zorgprofessionals.

Hoeveel zelfstandigheid, vrijheid, verantwoordelijkheid en onafhankelijkheid geef je? Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source

Als leidinggevende geef ik zorgprofessionals binnen mijn afdeling/team…:

[Q14.0]

1.

… de volledige vrijheid in het uitvoeren van werkzaamheden

AUT_0


2.

… de vrijheid om activiteiten uit te voeren op de manier die hen goeddunkt

AUT_1


3.

… de mogelijkheid om een eigen oordeel te volgen in het verlenen van cliëntzorg

AUT_2


4.

… de ruimte om een hoge mate van initiatief te tonen in het verlenen van zorg

AUT_3

Mom et al., 2009

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ls leidinggevende zorg ik dat zorgprofessionals binnen mijn afdeling/team…:

[Q14.1]

5.

… strikt de procedures volgen tijdens hun werkzaamheden

FORM_0

Mom et al., 2009

6.

… ten alle tijde te strikte protocollen volgen

FORM_1

Mom et al., 2009

7.

… zich houden aan hun werk-/taakomschrijving

FORM_2

Mom et al., 2009

SECTIE E_manager: "Competenties en tevredenheid" Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source

Geef aan in welke mate je het eens bent met de volgende stellingen m.b.t. het geloof in eigen kunnen.

[Q15]

1.

Ik heb alle benodigde vaardigheden om goed mijn team aan te sturen en te managen

SLFEFF_0

Sujan et al., 1994

2.

Ik kan uitdagende vragen constateren en proactief oplossen

SLFEFF_1

Sujan et al., 1994

3.

Ik ben goed in het achterhalen van behoeften binnen mijn team

SLFEFF_2

Sujan et al., 1994

4.

Ik kan effectief omgaan met iedere (zorg)vraag die op mij en mijn team/afdeling afkomt

SLFEFF_3

Sujan et al., 1994

In welke mate ben je het eens met de volgende stellingen:

[Q16]

5.

ROCONF_0

Rizzo et al., 1970

ROCONF_1

Rizzo et al., 1970

ROCONF_2

Rizzo et al., 1970

6.

7.

Ik ontvang regelmatig met elkaar conflicterende verzoeken van verschillende directieleden waarmee ik als leidinggevende te maken heb Ik moet in mijn werk vaak dingen doen die door het ene bestuurslid wel, maar door het andere niet worden gewaardeerd Om mijn werk goed uit te voeren moet ik af en toe van de richtlijnen van de directie afwijken

In welke mate ben je het eens met volgende stellingen:

118

[Q5]


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8.

Over het algemeen ben ik erg tevreden met mijn baan

JOBS _0


9.

Over het algemeen ben ik tevreden met de taken die ik in deze baan uitvoer

JOBS _1


JOBS _2


10. Ik haal veel voldoening uit mijn functiegerelateerde activiteiten

SECTIE G: "Jouw opvattingen over cliënt oriëntatie…" In deze eerste sectie zijn we geïnteresseerd in een aantal specifieke opvattingen met het oog op de cliënt oriëntatie. Denk hierbij aan wat je zou kunnen doen om de beste zorg te leveren. Denk hierbij ook aan wat jij belangrijk vindt en verwacht van zorg-professionals binnen je team!


Ik vind het belangrijk dat zorgprofessionals binnen mijn team…:

[Q18.0]

Heel Belangrijk

Heel Onbelangrijk

1.

… cliëntvoorkeuren in ogenschouw nemen

COBLF_0


2.

… regelmatig toekomstige behandelmethodieken toetsen bij cliënten

COBLF_1

3.

… uit zoeken wat cliëntbehoeften zijn

COBLF_2

Lam et al., 2010

COLBLF_0

Lam et al., 201o

5.

… na gaan wat hun collega’s doen om cliëntproblematiek op te lossen … werkwijzen van collega’s monitoren en begrijpen

COLBLF_1

6.

… leren van behandelactiviteiten van collega’s

COLBLF_2

Lam et al., 201o Lam et al., 201o

[Q18.1] 4.

[Q18.2] 7. 8. 9.

… cliënten in schalen in subgroepen o.b.v. hun zorgkenmerken … cliënten differentiëren op zorgzwaarte

CATBLF _0


CATBLF _1

… tijdens werkzaamheden cliënten effectief [doeltreffend] categoriseren

CATBLF_2


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10. … bewust zijn van goed toegesneden efficiënte zorgpaden 11. … onderscheid maken in doelgroep afhankelijke behandelmethodieken 12. … sturen op zorginspanning passend bij het type behandelactiviteit [DBC, ZZP, etc.]

CATBLF _3

New

CATBLF _4

New

CATBLF _5


SECTIE F: "Persoonlijke ontwikkelingen en veranderbereidheid…" Hier zijn we benieuwd naar jouw gedrag m.b.t. innovatie.


In mijn dagelijkse werk…:

[Q17]

1.

INNBEH_0

Ye et al., 2011

INNBEH_1

Ye et al., 2011

INNBEH_2

Ye et al., 2007

INNBEH_3

Ye et al., 2007

INNBEH_4

Ye et al., 2007

2. 3. 4. 5.

… onderneem ik activiteiten om de kwaliteit van de zorg te verbeteren … bedenk ik regelmatig verschillende manieren om behandelprocedures te verbeteren … probeer ik voortdurend verschillende manieren te vinden om zorgverlening te verbeteren … probeer ik zelf nieuwe dingen aan te leren, om de eigen productiviteit te verhogen … sta ik open voor nieuwe ideeën om veranderingen in de zorg te accepteren

SECTIE H: "Gedrag m.b.t. cliënt oriëntatie …" In deze sectie zijn we geïnteresseerd in werkzaamheden m.b.t. cliëntzorg. Denk hierbij aan de dingen die jouw teamleden doen in hun functie(s). Neem als referentiekader de periode van het laatste half jaar, dus vanaf ongeveer 1-jan-2012 (sinds de nieuwe doelstellingen van de Raad van Bestuur, vacaturestop, etc.)

Geef aan in welke mate je het eens bent met de volgende stellingen. Item-code Source In het aansturen van medewerkers in hun dagelijkse werk besteed ik veel tijd aan: Dat mijn medewerkers…:

[Q19.0]

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Veel Tijd

Weinig Tijd

1.

… de oplossing voor de cliënt centraal stellen

COBEH_0


2.

… actief naar cliënten luisteren om verbeteringen in de behandelmethodiek te vinden

COBEH_1


3.

… proberen zorgvragen, die nòg niet in het behandelplan staan, te identificeren

COBEH_2


4.

… proberen cliënten een reëel beeld te geven van wat de behandeling voor hem/haar kan betekenen

COBEH_3

Lam et al., 2010

5.

… proberen (onzekere) cliënten gerust te stellen om in overleg een behandeling goed kunnen uitvoeren

COBEH_4


Dat mijn medewerkers…: 6. … methodieken van collega’s monitoren en van elkaar leren

[Q19.1] COLBEH_1

Lam et al., 2010

7.

… letten op de slimme aanpak en werkoplossingen van collega’s

COLBEH_0

Lam et al., 2010

8.

… vaak deelnemen aan interdisciplinair overleg, om ontwikkelingen in het werk en de zorg te bespreken

COLBEH_2

Kohli et al., 1993

… bevindingen delen rond effectiviteit van behandelingen met collega’s 10. … samen met collega’s relevante informatie delen voor kennisontwikkeling

COLBEH_3

Kohli et al., 1993

COLBEH_4

Kohli et al., 1993

Dat mijn medewerkers…: 11. … cliënten differentiëren naar zorgzwaarte

[Q19.2]

12. … cliënten effectief [doeltreffend] categoriseren 13. … vastgestelde zorgpaden volgen 14. … onderscheid maken in behandelmethodieken per doelgroep 15. … sturen op zorginspanning passend bij het type behandelactiviteit [DBC, ZZP, etc.]

CATBEH _1


CATBEH _2

New

CATBEH _3

New

CATBEH _4


9.

CATBEH _0

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SECTIE I: "Werkdruk en carrière…" Item-code Source

De volgende stellingen hebben betrekking op de door jouw ervaren werkdruk

[Q20]

1.

WRKL_1

Singh, 2000

WRKL_0

Ye et al., 2011

WRKL_2

Ye et al., 2011

2. 3.

Ik heb te veel werk, dat ik in een te korte tijdsperiode moet voltooien Door de veranderingen op het werk zit ik soms dicht bij een burn-out Ik voel mezelf vaak uitgeput na een dag op het werk

De volgende vragen hebben betrekking op je gevoel binnen GGzE en of je hier in de toekomst wil blijven werken

[Q4]

4.

Ik vraag mezelf wel eens af of ik op zoek moet gaan naar een baan buiten de gezondheidszorg Ik denk om te stoppen met werken bij het GGzE

TOINT _2

Singh, 2000

TOINT_0

Singh, 2000

Het is mogelijk dat ik actief op zoek ga naar een nieuwe baan in de nabije toekomst

TOINT _1

Singh, 2000

5. 6.

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SECTIE J: "Algemene vragen…" Onderstaande vragen zijn essentieel voor het goed afronden van deze enquête. Item-code 1.

Wat is je leeftijd?

…………. Jaar

G1

2.

Wat is je geslacht?

Man:

G2

Vrouw:

Hoeveel jaar werkervaring heb je…:

G3

3.

… in de gezondheidszorg

…………. Jaar

G3.1

4.

… binnen GGzE

…………. Jaar

G3.2

5.

… in je huidige afdeling

…………. Jaar

G3.3

6.

Wat is je hoogst afgeronde opleiding?

Geen / MBO / HBO / WO / Master / Post WO/ anders

G4.a

6a. Anders, zo ja welke:

G4.b

7.

Hoeveel uren werk je contractueel per week voor GGzE?

…………. Uren

G7

8.

Hoeveel maanden geef je al leiding aan hetzelfde team/ dezelfde afdeling? Uit hoeveel collega’s bestaat het team waaraan je leiding geeft?

…………. Maanden

G8

…………. Leden

G9

9.

SECTIE L: "Open vragen…" Als je nog opmerkingen of suggesties hebt, kun je die hier kwijt…: [OPEN_4] …

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Pagina 16 | enquête = eindbericht

Bedankt voor je medewerking! Als je vragen en/of opmerkingen hebt kun je contact opnemen met Stef Marinus via [email protected]

124

e 2011 Student identity number

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