Organizational Factors and Healthcare Service Quality: A Multilevel Analysis in an Indonesian Hospital
DOI:
https://doi.org/10.26911/thejhpm.2026.11.03.05Abstract
Background: Healthcare service quality reflects hospital performance and may be influenced by individual and organizational factors. This study examined the associations of transformational leadership, organizational culture, and healthcare worker performance with service quality at Dr Soehadi Prijonegoro Regional General Hospital, Sragen, using multilevel analysis.
Subjects and Method: A cross-sectional analytical observational study was conducted among 500 patients across 25 inpatient wards at Dr Soehadi Prijonegoro Regional General Hospital, Sragen. Healthcare service quality was assessed at the individual level using the SERVQUAL instrument. Transformational leadership, organizational culture, and healthcare worker performance were assessed at the ward level using the Multifactor Leadership Questionnaire (MLQ), the Organizational Culture Assessment Instrument (OCAI), and a performance assessment instrument adapted from Mathis and Jackson, respectively. Data were analysed using multilevel mixed-effects linear regression.
Results: Transformational leadership (b = −0.15; 95% CI = −0.34 to 0.30; p = 0.101), organizational culture (b = 0.06; 95% CI = −0.05 to 0.17; p = 0.313), and healthcare worker performance (b = −0.15; 95% CI = −0.57 to 0.27; p = 0.492) were not significantly associated with healthcare service quality. The intraclass correlation coefficient (ICC) was 8.63%, indicating that only a small proportion of the variation in healthcare service quality was attributable to differences between wards, whereas 91.37% of the variation was explained by individual-level factors or other unmeasured variables. A significant likelihood ratio test (LR = 18.57; p < 0.001) supported the use of multilevel analysis.
Conclusion: Transformational leadership, organizational culture, and healthcare worker performance were not significantly associated with healthcare service quality. Most variation occurred at the individual level, highlighting the need to investigate individual-level determinants of service quality.
Keywords:
service quality, work performance, organizational culture, transformational leadership, multilevel analysisHow to Cite
References
Addo SA, Mykletun RJ, Olsen E (2026). Towards a quality care climate perspective: A systematic review of associations among patient experience, patient outcomes, and organizational climate factors in hospitals. Int J Environ Res Public Health. 23(2): 268. https://doi.org/10.3390/ijerph23020268.
Alanazi NH, Alshamlani Y, Baker OG (2023). The association between nurse managers’ transformational leadership and quality of patient care: A systematic review. Int Nurs Rev. 70(2): 175–184. https://doi.org/10.1111/inr.12819.
Almutairi RL, Aditya RS, Kodriyah L, Yusuf A, Solikhah FK, Al Razeeni DM, Kotijah S (2022). Analysis of organizational culture factors that influence the performance of health care professionals: A literature review. J Public Health Res. 13(2): 2415. https://doi.org/10.4081/jphia.2022.2415.
Bass BM, Avolio BJ (1994). Improving Organizational Effectiveness through Transformational Leadership. Thousand Oaks, CA: Sage Publications.
Boamah SA, Spence Laschinger HK, Wong C, Clarke S (2018). Effect of transformational leadership on job satisfaction and patient safety outcomes. Nurs Outlook. 66(2): 180–189. https://doi.org/10.1016/j.outlook.2017.10.004.
Braithwaite J, Herkes J, Ludlow K, Testa L, Lamprell G (2017). Association between organizational and workplace cultures, and patient outcomes: Systematic review. BMJ Open. 7(11): e017708. https://doi.org/10.1136/bmjopen-2017-017708.
Carvalho REFL, Bates DW, Syrowatka A, Almeida I, Sousa L, Goncalves J, Oliveira N, Gama M, Alencar AP (2023). Factors determining safety culture in hospitals: A scoping review. BMJ Open Qual. 12(4): e002310. https://doi.org/10.1136/bmjoq-2023-002310.
Dr. Soehadi Prijonegoro Sragen Regional Hospital Regional Hospital (2024). Laporan Survei Kepuasan Masyarakat (SKM) Tahun 2024. Retrieved from https://dindikpora.jogjakota.go.id/download/hit/13747/laporan-survei-kepuasan-masyarakat-%28skm%29-tahun-2024-13747.pdf.
Gebreheat G, Teame H, Costa EI (2023). The impact of transformational leadership style on nurses’ job satisfaction: An integrative review. SAGE Open Nurs. 9: 23779608231197428. https://doi.org/10.1177/23779608231197428.
Guan T, Chen X, Li J, Zhang Y (2024). Factors influencing patient experience in hospital wards: A systematic review. BMC Nurs. 23(1): 527. https://doi.org/10.1186/s12912-024-02054-0.
Hult M, Terkamo-Moisio A, Kaakinen P, Palonen M, Peltonen LM, Häggman-Laitila A (2023). Relationships between nursing leadership and organizational, staff and patient outcomes: A systematic review of reviews. Nurs Open. 10(9): 5920–5936. https://doi.org/10.1002/nop2.1876.
Labrague LJ (2024). Relationship between transformational leadership, adverse patient events, and nurse-assessed quality of care in emergency units: The mediating role of work satisfaction. Australas Emerg Care. 27(1): 49–56. https://doi.org/10.1016/j.auec.2023.08.001.
Mathis RL, Jackson JH (2011). Human Resource Management. 13th ed. Mason, OH: South-Western Cengage Learning.
Nantsupawat A, Poghosyan L, Wichaikhum OA, Kunaviktikul W, Fang Y, Kueakomoldej S, Thienthong H, Turale S (2022). Nurse staffing, missed care, quality of care and adverse events: A cross-sectional study. J Nurs Manag. 30(2): 447–454. https://doi.org/10.1111/jonm.13501.
Pacenko CdL, Figueiredo KC, Nunes E, Cruchinho P, Lucas P (2024). Mapping strategies for strengthening safety culture: A scoping review. Healthcare. 12(12): 1194. https://doi.org/10.3390/healthcare12121194.
Rauf A, Muhammad N, Mahmood H, Aftab M (2025). Healthcare service quality: A systematic review based on PRISMA guidelines. Int J Qual Reliab Manag. 42(3): 837–850. https://doi.org/10.1108/IJQRM-12-2023-0403.
Rosenbaum KEF, Lasater KB, McHugh MD, Lake ET (2024). Changes in patient care experiences and the nurse work environment: A longitudinal study of U.S. hospitals. Med Care Res Rev. 81(6): 444–454. https://doi.org/10.1177/10775587241282403.
Scardina SA (1994). SERVQUAL: A tool for evaluating patient satisfaction with nursing care. J Nurs Care Qual. 8(2): 38–46. https://doi.org/10.1097/00001786-199401000-00008.
Song Y, Do YK (2024). Patient experience and nurse staffing level in South Korea. Int J Qual Health Care. 36(2): mzae038. https://doi.org/10.1093/intqhc/mzae038.
Vikan M, Haugen AS, Bjørnnes AK, Valeberg BT, Deilkås ECT, Danielsen SO (2023). The association between patient safety culture and adverse events: A scoping review. BMC Health Serv Res. 23(1): 300. https://doi.org/10.1186/s12913-023-09332-8.
Vleminckx S, Van Bogaert P, De Meulenaere K, Willem L, Haegdorens F (2024). Factors influencing the formation of balanced care teams: The organisation, performance, and perception of nursing care teams and the link with patient outcomes: A systematic scoping review. BMC Health Serv Res. 24(1): 1129. https://doi.org/10.1186/s12913-024-11625-5.
Winter V, Dietermann K, Schneider U, Schreyögg J (2021). Nurse staffing and patient-perceived quality of nursing care: A cross-sectional analysis of survey and administrative data in German hospitals. BMJ Open. 11(11): e051133. https://doi.org/10.1136/bmjopen-2021-051133.
Ystaas LMK, Nikitara M, Ghobrial S, Latzourakis E, Polychronis G, Constantinou CS (2023). The impact of transformational leadership in the nursing work environment and patients’ outcomes: A systematic review. Nurs Rep. 13(3): 1271–1290. https://doi.org/10.3390/nursrep13030108.
