Chmielewska 

et al.
BMC Health Services Research (2022) 22:7
https://doi.org/10.1186/s12913-021-07402-3

RESEARCH Open Access

Evaluating Organizational Performance

of Public Hospitals using the McKinsey 7-S
Framework
Malgorzata Chmielewska1*, Jakub Stokwiszewski2, Justyna Markowska1 and Tomasz Hermanowski1 

Abstract 
Background:  This study examined non-financial aspects of the organizational performance of public hospitals from
the perspective of hospital physicians; the obtained results were analyzed to identify the necessary improvements in
organizational performance.
Methods:  This was a cross-sectional study of multidisciplinary public hospitals on a group of 249 randomly selected
physicians from 22 in-patient departments or clinics operating in the Warsaw region. The study data was collected
using the structured World Health Organization questionnaires (to be filled out by respondents) assessing the hospi-
tal’s organizational performance variables qualified according to the McKinsey 7-S Framework.
Epidata software version 3.1 was used for data entry, and the analysis was carried out in the SPSS software, version
19. The results of the organization evaluation are presented in the McKinsey 7-S Framework diagram. Key elements of
the performance factors were grouped into ‘stens’, and the sten values were expressed as arithmetic means. Normal
distribution of the stens was validated with the Kolmogorov–Smirnov test. 95% confidence intervals were calculated.
The significance of differences between the analyzed stens was compared with the paired Student t-test. The interde-
pendence of the variables was determined using the Pearson’s correlation coefficient.
Results:  The results revealed a significant difference (p <0.05) in the respondents’ assessment of social (a mean score
of 2.58) and technical (a mean score of 2.80) organizational aspects of the hospital operation. Scores for all variables
were low. The social elements of an organization with the lowest score included ‘staff’, and in it the aspect – ‘efforts are
made to inspire employees at the lowest levels of the organization’, ‘skills’ involving the learning style followed by the
management/managerial staff, and ‘management style’ (average scores of 2.38, 2.56, 2.61, respectively).
Conclusion:  Consistently with the existing literature, social factors were shown to play a more significant role in the
management and they therefore deserve careful attention and more recognition when identifying and improving the
key aspects affecting the organizational performance of public hospitals. Technical elements (strategy, structure, sys-
tem) are important, but were demonstrated to have limited effect on the organizational operations geared towards
ensuring effective functioning of a public hospital.
Keywords:  Organizational performance, Model 7-S Framework Management, Public hospitals, Physicians

Background
Public health experts worldwide have been study-
*Correspondence: [email protected] ing organizational performance of healthcare institu-
1
Department of Forensic Pharmacy, Pharmacy Division, Medical tions, despite the inherent difficulties involved. There is
University of Warsaw, 81, Żwirki i Wigury Str, 02‑091 Warsaw, Poland
Full list of author information is available at the end of the article
a strong pressure to use quantitative indicators to assess

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Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 2 of 12

organizational performance of healthcare organizations measure most often used to assess performance. Con-
due to the increasing need for a more effective use of sidering the multidimensional nature of performance, it
resources in the health sector. Stakeholders are also inter- seems justified to adopt a critical approach to this model
ested in these analyses as they hope to gain deep insights as being based on obsolete measures, without taking
into the real-world use of public funds [1, 2]. account of non-financial measures [8–10] related to the
In-patient treatment is extremely expensive – it social aspects of performance management, e.g. human
accounts for up to 70% of the overall healthcare expendi- resources (human capital and intellectual assets) [8],
ture in some countries [3], and hence researchers turn which have so far been sidelined, perhaps because they
their attention to the performance of hospitals. In highly are difficult to quantify. An assessment based solely on
developed countries, the primary research focus is on the the outcome measures can be compared to “driving a car
operating theaters as the most cost-generating hospital with the rear-view mirrors only, without seeing the road
units [4]. Today, improving hospital performance can be through the windshield” [7]; focusing on short-term per-
challenging [5]. formance while pushing long-term planning and innova-
In this paper, we seek to examine the factors that affect tion into the background [11].
organizational performance of public hospitals using the From the perspective of public, non-profit organi-
McKinsey 7-S Framework against the background of the zations that pursue primarily social goals, the basic
management process. problem of measuring performance is to prioritize the
assessment criteria [12]. According to Donald Snow, one
Literature of the basic criterion used for assessing performance
Organizational performance of public healthcare units organizations providing public services is the degree to
H. Emerson and H. Le Chatelier are considered to be which they fulfil their mission [13]. Jay Weerawarden and
the “founding fathers” of the concept of management Gilian Sullivan Mort argue that creating greater social
by objectives, and their work was later extended by PF value for stakeholders is the underlying mission of pub-
Drucker, who is given credits for introducing the notion lic service organizations and is more important than
of organizational performance to the theory of manage- profits [14]. Therefore, to measure the performance of
ment [2]. His principles of performance remain valid to non-profit organizations in quantitative terms only raises
this day and are often referred to in the research litera- specific concerns as it does not allow for the assessment
ture. Emerson and Le Chatelier defined performance as of non-economic outcomes.
doing the right things in the right way [6]. Likewise, J.A.F Since the 1980s, performance indicators, mostly finan-
Stoner, R.E. Freeman, D.R. Gilbert argue that organiza- cial ones, have been increasingly monitored in profit-
tional performance is determine by organizational effi- oriented sectors of the economy [15], while in public
ciency and effectiveness in achieving the right objectives services, including the healthcare sector, non-financial
and building good relations between an organization and measures have been brought to the fore [16].
its environment.
In this context, M. Bielski, who closely associated the Measuring organizational performance in the social aspect
concept of performance with the essence of the organiza- – the concept of stakeholders
tion, distinguishes between two approaches to assessing The relativity of performance measurements raises an
performance [7]: important question: Who wants to improve performance
or, in other words, from whose perspective is the perfor-
– goal-oriented – performance is determined by how mance considered? [17]. It is difficult to design a universal
successfully an organization achieves its objectives, one-size-fits-all concept of organizational performance
– systemic – performance is tantamount to the volume assessment that would be suitable for all stakeholders.
of savings measured by the relationship between the Each group has its own goals, preferences and values,
outcomes achieved and the expenditure incurred which means that the various dimensions and indica-
[6]. J. Campbell and Bielski both consider these tors that make up the overall performance would not be
approaches to be complementary and put forward a assessed in the same manner [18]. The main methodo-
thesis about the multidimensionality of the category logical principle in studies concerning the organizational
of performance. This makes room for various criteria, culture is to examine an organization as a micro-com-
both numerical and descriptive, to be taken account munity [19]. If an organization wants to act strategically,
in the assessment of performance. it should take into account the needs and expectations
of stakeholders who are key to its growth and develop-
The traditional approach to performance is based on ment. Therefore, in addition to financial analysis, it is also
financial measures. Consequently, profit is the economic necessary to measure performance in the social aspect,
 Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 3 of 12

which can be based on the concept of stakeholders. The operating expenses), revenues (e.g. patient’s net revenue
stakeholder theory appears to be crucial in the efficient per bed, net revenue, patient’s net revenue per adjusted
management of organizations and addresses the short- discharge, and admission) and the use of fixed assets,
comings of earlier theories of performance measure- such as the occupancy of hospital beds) [26].
ment largely relying on financial indicators [20]. The best The non-financial dimension can be traceable to the
known definition of stakeholders is the one developed by assessment of measures such as efficiency (technical
R. E. Freeman in 1984, defining a stakeholder is an entity and allocative), productivity, and outcomes [8], provid-
or group of shareholders that has the power to impact an ing insights about the financial performance not revealed
organization, whether directly or indirectly [21]. Accord- by conventional financial measures. Technical efficiency
ing to this theory, an organization is a network of con- is an assessment of the degree of use of resources, and
nections between people or institutions. The theory of in this case, the most common indicators are: the occu-
stakeholders highlights cooperation as the essence and pancy of hospital beds, the average hospitalization dura-
foundation of the success of an organization [20]. The tion, and the amount of resources available per patient
supporters of the stakeholder concept believe that it is or service, e.g. number of medical staff, number of beds.
important to identify and meet the objectives of stake- Allocative efficiency refers to the way in which the exist-
holders in order to safeguard the proper functioning and ing resources re distributed, it determines the choice
performance of an organization [7]. However, the map of health services, patients and disease entities to be
of stakeholders should be narrowed down to those who financed. Productivity can be understood as the capac-
exhibit the most significantly impact on the organization, ity productivity (average number of patients per bed per
i.e. key stakeholders [22]. According to Frączkiewicz- year), and the manpower productivity (full-time-equiva-
Wronka et  al., the key stakeholders are those without lent employee productivity). Outcome indicators are also
whom the organization would not exist [23]. In the social used, i.e. the therapeutic outcomes that translate into the
aspect, performance means implementing the organiza- quality of the services offered [8]. Apart from quantitative
tion’s social goals to a sufficient degree. The social goals indicators, such as the mortality rate, nosocomial infec-
are determined by how much individual groups of stake- tion rates, average waiting time for a medical service, etc.,
holders are satisfied with the issues that concern them performance assessments should also include qualitative
most, of the degree to which priority needs of individual measurement, e.g. the levels of patient satisfaction.
stakeholders are fulfilled [24]. Moreover, Bryson points The research literature provides examples of studies
out that the success of an organization crucially depends assessing the behavioral dimension of hospital’s non-
on satisfying key stakeholders [20]. financial performance, in which the main emphasis is
Managements can shape the decision-making process placed on the assessment of meeting the individual needs
related to the performance of physicians. Even more so as of hospital staff [27, 28]. It is also argued that among all
there exists a simple relationship: if the executives work hospital stakeholders, healthcare professionals should
to meet the essential workplace-related needs of physi- be particularly strongly involved in designing and shap-
cians, the healthcare professionals will care more about ing the assessments of how performance indicators are
the reputation of the hospital they work in, and will be measured [29]. The widespread increase in the presence
more likely to recognize and satisfy patient needs [25]. and involvement of clinicians in the management of
health care organizations is also postulated as it believed
Measuring the organizational performance of healthcare to have a positive impact on, inter alia, the social perfor-
organizations – a hospital mance of service providers [30, 31]. In this context, the
Measuring performance in the healthcare sector at social aspects of performance management is the strate-
the microlevel can be applied to health service provid- gic focus area for hospital management. The performance
ers, including hospitals. Hospital performance can be assessment provides key information about the effective-
assessed from several dimensions and based on a mul- ness of management and the value delivered to stake-
tiple of criteria. Based on the financial dimension, the holders – it is an indicator at managerial level [32]. In
evaluation could include profitability (the hospital’s abil- order to operate in a strategic way, hospital should strive
ity to generate profit from margin and assets), financial to meet demands and expectations of those stakeholders
liquidity (the ability to timely fulfil the hospital’s financial without whom it would not be able to operate [20].
commitments), capital structure (to what extent the hos- The medical staff are the key stakeholders of a hospi-
pital uses debt service coverage and equity financing), tal, apart from patients and their families [33]. Organi-
operational performance (hospital’s ability to convert zational performance of a hospital in the social aspect
various assets or liabilities into cash or sales), costs (labor, – which corresponds to the fulfilment of social goals
hospital expenses per bed, total expenses per bed, and – can be assimilated with the degree of satisfaction of
Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 4 of 12

physicians with aspects they consider most important, accounting for both financial and non-financial
expressed with appropriate quantitative and qualitative aspects [8]. However, as the originators of the BSC
criteria [24]. Model, Dave Norton and Robert Kaplan, point out,
Meeting the needs and goals of physicians was also shown the seventh “S,” shared values, are not explicitly recog-
to be an important driver of job satisfaction, correlated with nized in the BSC model, although it complements the
the improvement of the quality of healthcare services and McKinsey Model [40].) The McKinsey 7-S Framework
patient satisfaction. Hence, work satisfaction among phy- is based on the concept of management by objec-
sicians plays a key role in the management [34–36]. Many tives. It invokes the notion of organization’s ‘health’, an
experts in human resource management agree that the level intangible category that incorporates the management
of job satisfaction among employees deserves proper recog- method and the organizational culture [39]. The 7-S
nition, and the WHO European Office for Integrated Health concept helps analyze the dysfunctions of the manage-
Care Services suggests that the focus on medical personnel ment process [38].
and management should be included in measurements and The McKinsey model specifies seven factors (7-S) as
evaluations of hospital achievements [37]. the main variables that shape the organizational perfor-
As a result, hospital performance can be examined mance [38]: shared values, strategy, structure, system,
based on feedback from physicians, using the concept of staff, style, and skills. Organizational performance in
stakeholders, i.e. to examine whether the needs of this the McKinsey’s model is a result of interactions among
professional group are met. these variables. ‘Shared values’ is the focal point in this
system (Fig. 1) [38].
McKinsey 7‑S Model of management by objectives The diagram is divided in two parts. The ‘hard’ part
The McKinsey 7-S Framework is a research tool that consists of structure, strategy, and system.
takes into account the multidimensionality of an The structure is a model of functions and positions
organization, i.e. the level of organization, team, and within an organization, often reflected in descriptions of
individual. It was designed by R. Waterman, T. Peters hierarchies, authorizations, responsibilities, and functions.
and J.R. Phillips working for the company McKinsey The systems (procedures) are defined as processes
[38, 39]. (The Balanced Scored Card model is cur- in an organization within which individual employees
rently often referred to as the model of choice to and activities are managed, coordinated and directed
examine the performance of healthcare organizations, to achieve the goals of the organization, e.g. the human

Fig. 1  Organizational Performance Variables

 Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 5 of 12

resources system determines the manner of recruit- general objectives and values are set forth; strategy - the
ment, promotion and transfer of employees. organization operates in a purposeful mode; structure
The strategy means activities of an organization geared - structures are designed based on work requirements;
towards achieving goals and objectives, e.g. a strategy to system - decisions are made based on location(s) of
improve the public health [38, 41]. information, collaboration is rewarded, the organi-
The other elements represent the ‘soft’ part of the zation is seen as an open system; management styles
model. - managers assume individuals want more responsibil-
‘Skills’ are defined as the total of individual capabili- ity, rewards are balanced, communication is relatively
ties of each employee in an organization, ‘staff’ are people open, conflict is managed, individuality and individuals
employed by the organization who have different knowl- are valued, management respects people; staff (support
edge and experience, intelligence, ability and training; ‘style’ in career development) - an effort is made to inspire
is a way of allocating rights and responsibilities within an people and skills – there is a "learning" mode of man-
organization; ‘shared values’ are beliefs, expectations and agement, feedback systems for assessing, regulating
attitudes regarding work, organization, acceptable behav- and responding to plans and actions are built in, in line
ior, shared by the majority of employees, as well as any with McKinsey’s 7-S Model. The degree to which the
communication relating to the vision, mission and values organization’s performance needed to be changed was
that define an overall goal for all employees [38, 40, 41]. assessed on the basis of a comparison of the differences
The ‘hard’ elements are related to the technical aspects between ‘as-is’ and ‘should-be’ scores.
of the organization, while the ‘soft’ ones represent its The hospital organization was assessed on a scale from
social part. In terms of management, soft factors are con- 1 (the worst) to 6 (the best). Seven stens were calculated
sidered to be more prominent [38]. as a mean value of the survey questions. A mean value
was also calculated for stens classified to either social
Methods and technical variable category. The mean status equals
Main objective 3.5. Normal distribution of the stens was validated with
Based on the literature and the proposed model, the fol- the Kolmogorov–Smirnov test. 95% confidence intervals
lowing research hypothesis was formulated: were calculated. The significance of differences between
the analyzed stens was compared with the paired Student
– H1: There is a relationship between organizational t-test. The interdependence of the variables was deter-
performance of a public hospital and the social (soft) mined using the Pearson’s correlation coefficient. The sig-
elements of an organization (according to the classifi- nificance level of 0.05 was adopted.
cation of variables in the McKinsey Framework).

Ethical considerations
Research tools and methods This study was approved by the Ethics Committee
The research tool employed in this study consisted of of the Medical University of Warsaw (Approval No.
a validated World Health Organization (WHO) ques- AkBE/116/15). The researchers duly informed heads of
tionnaire used to examine the organization of public hospital departments and medical doctors about the
hospitals from the perspective of medical staff. 22 in- study. The contact details of the researchers and research
patient clinics/departments were randomly selected information were included in the questionnaires. Partici-
from among hospitals based in Warsaw, where a sur- pation in the study was voluntary, and the questionnaires
vey was conducted on a sample of professionally active were completed anonymously.
physicians (n = 249). The physicians were randomly
selected. Detailed selection of the study sample was
described in a study by Chmielewska et  al. [42]. Only Results
general (multispecialty) public hospitals were included Organizational characteristics of hospitals
in the survey. Only over 20% of the surveyed physicians believed that
The hospital’s organizational performance fac- their organization operates in a purposeful and goal-
tors were identified and evaluated on the basis of the directed mode (a total of 5 and 6 scores (Figure  2)).
McKinsey 7-S Framework. The survey consisted of Even fewer respondents (15% to 18%) felt that managers
15 closed-ended questions concerning the ‘as-is’ and assume that individuals want to take on more responsi-
‘should-be’ status of specific organizational features of bility and provide opportunities for them to do so, and
a public hospital. The questions were divided into goal that the managerial staff respect people, and the organi-
(mission) - the organization has a set of guiding beliefs, zation has set of guiding beliefs stated.
Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 6 of 12

Fig. 2  Characteristics of the hospital organization – assessment by physicians

Only 14% of respondents believed that balanced The examined organizational variables were divided
rewarding is a strong point of the organization. into technical and social elements; the social (soft)
aspects had statistically significantly (p <0.05) lower
Organizational performance of a hospital according scores (a mean score of 2.58 (95% CI: 2.43-2.73)) com-
to the McKinsey Framework pared to technical (hard) aspects with mean score of
Strategy and shared value were ranked the highest in the 2.80 (95% CI: 2.66-2.94). The scores of both technical
survey consisting of questions assigned to the 7 organi- and social elements were significantly below the mean
zational assessment criteria according to the McKin- of 3.5. The technical and social elements were found to
sey Framework. Staff was ranked the lowest. It is worth be closely interrelated. The correlation coefficient equals
noting that all scores were relatively low or average. The 0.87. The ‘staff ’, ‘skills’ and ‘style’ elements scored the low-
mean score was 3.5 (Fig. 3). est. The overall assessment of the organization is signifi-
With the mean score of 2.71 for organizational consid- cantly reduced by the social aspects, which confirms the
erations (with the maximum score of 6) and the below- study hypothesis.
average scores for the remaining variables, it is safe to How physicians evaluate: a) the as-is status of the hos-
conclude that there is a widespread negative perception of pital organization against b) the ‘should-be’ status (ideal
the organizational performance of hospitals. All hospital organization).
organization variables scored low and very low in the sur- Unsurprisingly, according to the survey results, the
vey conducted among the hospital physicians surveyed. score of the ‘should-be’ status (ideal organization) is
This study confirms that the assumptions of the McKinsey significantly higher than the score of the ‘as-is’ status
Framework, i.e. the low score of individual variables that (Fig. 4). This is true for each of the 15 questions included
are strongly correlated with other variables and translate in the survey. Percentages of physicians who gave maxi-
into reduced organizational performance of hospitals. mum score to their own organization varies from 1.1%
 Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 7 of 12

Fig. 3  Variables of the McKinsey Framework, based on own research of hospital organizations

Fig. 4  Characteristics of the hospital organization (as-is vs. should-be) - the percentage of physicians who assigned the maximum score for the
analyzed aspects and the median value in the assessment by physicians
Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 8 of 12

for question “The organization is seen as an open sys- in the UK, respondents believed that their organization
tem” to 6.6% for “Management respects people”, while implements the following values: high quality of services,
for should-be organization adequate percentages varies meeting goals and assumptions, caring for the satisfac-
from 37.3% for “Managers assume individuals want more tion of beneficiaries, to complete effectively in the health-
responsibility” to 50.1% for “Management respects peo- care sector [48].
ple”. Medians for all questions are 6 for ideal organization Here, the hospital structure was referred to as a ‘silo’.
but for as-is organization medians ear equal 2 or 3, there- The system is considered ineffective in terms of its man-
fore each examined aspect is expected to improve. In agement mainly due to the separation between medical
terms of the ‘should-be’ scores (ideal organization), both staff and the managerial staff, which translates into an
the median and percentages of maximum score for each unclear distribution of responsibilities and difficulties
of the 15 aspects are statistically significantly higher than in quickly identifying and solving problems [49]. In this
the ‘as-is’ scores of the organization in which physicians study, the hospital structure, which determines the spe-
actually work (p <0.05). cific division of competences and responsibilities, was
also rated unfavorably by the surveyed physicians. A
Discussion score of 2.8 is below average and the ‘should-be’ score
Recently, the organizational performance of hospitals has was 5.4 (in an ideal organization). Similar findings were
received widespread interest among researchers. With reported in studies by A. Montgomery et  al. [50] con-
tight budgets and extensive restructuring, hospitals have ducted in eight European countries: Greece, Portugal,
been faced with new tasks and challenges as organiza- Croatia, Bulgaria, Romania, Turkey, Ireland, and Mac-
tions. In addition to providing high-quality healthcare edonia. Despite the diversity of the countries participat-
services, a hospital is expected to increase productivity ing in this research project, the results of interviews and
despite budget restrictions, attract highly qualified staff focus discussions among 153 physicians reveal a flawed
and promote health. The modern perceptions about how organizational structure of hospitals, which results in
a hospital should operate have inspired many models high workload (administrative tasks, large number of
designed to assess its performance, unfortunately many patients, high responsibility for decisions regarding the
of them focus only on isolated variables, and are there- treatment of many cases, shortages of human and mate-
fore inclined to produce incorrect or unsatisfactory rial resources), and poor management, particularly the
results [43]. According to literature, the operation of a lack of cooperation between departments and the hos-
hospital is multifaceted, it often exposes the challenges pital administration. In a study conducted in the US
that hospital physicians are faced with, or unsolved prob- [44], the respondents (n-816) also pointed to the exist-
lems, including issues with organizational climate, organ- ing deficiencies in the organizational structure, despite
izational structure, communication, and management the general high level of satisfaction with the working
[44]. According to E. Minvielle et  al. [43], the hospital conditions among hospital physicians. Many public sec-
performance, or the ability to effectively treat patients, tor organizations are deeply entrenched in centralized
is more important than cost control, which is a challenge bureaucracy. This problem can be addressed by establish-
for a system focused on savings. It is of equal importance ing autonomous hospital organizations and, for exam-
that a hospital is a place where members form groups ple, by delegating more responsibility for decisions to
with shared values. local administrative units, which inherently have a better
The underlying assumptions, values [45], or, as Sikor- insight into the work of hospital staff than distant central
ski claims, patterns of thinking and actions necessary to authorities [51]. In this study, the transfer of responsibil-
achieve the goals of the organization create the essence ity to lower organizational levels scored 3, which is an
of the organizational culture of a hospital [46]. A strong average rating compared to the ‘should-be’ score of 5.2.
sense of the organization’s mission is one of the key fac- The sense of control over the work environment and par-
tors that may reflect organizational performance [47]. ticipation in the decision-making were studied among
The following aspects: "The organization has a set 608 physicians from the United States. These aspects
of leading beliefs", “General goals and values have been were shown to be the main predictors of mental well-
presented" were rated at about 3, and “The organiza- being, satisfaction and professional commitment [52].
tion operates in a purposeful manner" (strategy) scored There is a scarcity of research on the possible relations
3.2. An ideal hospital in terms of organizational culture between physicians’ involvement in administrative and
was rated 5.4 (‘should-be’ score). Different results were political decision-making and the performance indicators
obtained in the study of organizational culture by Mac- of healthcare organizations. According to A. Kaissi [45],
Kenzie. In a 1995 study on a group of 120 employees, open and honest communication, especially as concerns
including physicians working at 4 NHS health centers the manager-doctor relationship, and joint commitment
 Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 9 of 12

to decision-making bring in a number of benefits: management aspects, i.e. the respect of hospital manag-
increase in the number of patients, shorter hospital stay, ers towards staff and the learning mode. Likewise, in a
and a higher hospital ranking. study by H.M. Elarabi performed in 2014 [62] in a Libyan
Researchers found that empowering employees in the government hospital, most medical staff felt disregarded
decision-making process significantly prevents the staff by the senior management. Physicians also complained
from adopting a cynical attitude towards the organiza- about the lack of or unsatisfactory level of training. This
tion [53]. Hospital leaders should take particular care has led to low job satisfaction and lower performance of
of activities facilitating the participation of physicians the hospital staff. A study by B.S. Savič and M. Pagon [63]
in decision-making concerning changes in the organi- revealed that staff development was often neglected and
zation of a department or hospital [54]. It is also note- hospitals failed to make use of the knowledge and expe-
worthy that information and knowledge management rience of the healthcare professionals, which contributed
is definitely of paramount importance for healthcare to their limited commitment to work. Research has also
organizations [55]. According to scientific sources, there found that leaders only partially fulfilled their responsi-
is a discrepancy in the management of information and bilities in terms of supporting and inspiring teamwork in
knowledge between the head of the clinic and the hos- hospitals. In general, organizations promote hierarchy.
pital administration. In the healthcare sector, most prob- Marina Kaarna [64] argues that the management and
lems arise because healthcare professionals are trained to managers in healthcare institutions should learn how
care for and prioritize patients’ needs [56]. In this study, to express their appreciation for the commitment and
the respondents gave a low score to the decision-making efforts of medical staff. In this study, the ‘as-is’ scores
based on locations of information rather than roles in the for balanced rewarding were the lowest at 2.2, com-
hierarchy scored low. There is a considerable discrepancy pared to the ‘should-be’ score of 5.4. In a study by J. Rosta
between the ‘as-is’ and the ‘should-be’ score of 5.3 con- [65] on a group of physicians in Germany (n - 1917), the
cerning this aspect. J.K. Barr [57] described the relation- ‘recognition for work’ as also considered unsatisfactory.
ship between perceived participation in decision-making According to the respondents, this factor was among the
and three indirect organizational outcomes: satisfaction five lowest rated aspects of work. Similarly, in a study by
with the work of a doctor, the staff ’s perceived consensus S. Mackenzie [48], NHS physicians did not feel fairly rec-
on daily activities, and attitudes towards patients. Physi- ognized by the organization, despite they believed they
cians who reported greater involvement in organizational were loyal and committed.
decisions were more satisfied with their work, perceived The issue of communication is perhaps one of the most
a better consensus among employees, and had better important preconditions for improving motivation. It is
attitudes towards patients. A.M. Rotar et al. of 2016 [58] most likely the key determinant of learning, coping and
conducted a study under OECD in 188 hospitals based in job satisfaction [66]. The aspect of ‘relatively open com-
7 European countries, on a sample of 1,670 respondents munication’ in this study has a low ‘as-is’ score of 2.4
from the Czech Republic, France, Germany, Poland, Por- against the ‘should-be’ score of 5.4. A comparable, or
tugal, Spain and Turkey; the results suggest that physi- even less favorable conclusions about this issue were
cians at the department and hospital level are involved in drawn from a study by B.S. Savič of 2008. It revealed a
formal decision making only to a limited extent. lack of good communication among the staff of Slovenian
The latest research underlines the need to explain the hospitals [63]. In this case, the surveyed healthcare pro-
role of leadership in the medical community as there is a fessionals pointed out that autonomy and interpersonal
difference between the traditional work environment and communication were the most important factors respon-
the healthcare environment [59]. C. Ham [60] believes sible for job satisfaction and individual well-being. In a
that the role of leadership is crucial in improving health- study by A.L. Tucker et al. of American hospitals, analyz-
care, in decision-making processes concerning the opera- ing 1,732 medical errors made between 2004 and 2006,
tion of hospital wards and all hospital patients. When the communication problems were shown to account for
leadership style is consistent with the expectations of 16% of the most common errors of medical staff in hospi-
the subordinate staff, higher job satisfaction is recorded tals [67]. Another US study on a group of 816 physicians
[61]. In this study, physicians assessed the hospital man- also indicated that communication was the main area for
agement, including its respect for hospital staff, inspiring improvement [44].
and encouraging training, conflict management, commu- Conflicts at various levels, relational, task-related
nication, and fair rewarding. The average ‘as-is’ score for and process-related, are an inherent part of the health-
these aspects is 2.6 compared to the ‘should-be’ score of care environment [45]. The effectiveness of coopera-
5.5 for an ideal organization. It is also important to note tion largely depends on how conflicts are addressed and
that the highest ‘should-be’ scores were obtained for two resolved. Interpersonal and process-related conflicts can
Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 10 of 12

lead to poor outcomes and lower job satisfaction, while of which is to facilitate the development of professional
task-related conflicts stimulate constructive criticism and competences, especially among medical students and
allow to creatively challenge ideas and opinions, lead- young graduates. Academic literature described mentor-
ing to better achievements. In a study by G. Mulvany ing programs in Sweden under which students receive
[68], organizations that dealt effectively with conflicts the support of a doctor whose function is compared to
had a high level of professional satisfaction. In this study, a ‘conductor’ and not a teacher or an examiner in charge
almost 60% of physicians surveyed had an unfavorable of assessing knowledge [71]. In this study, the ‘learning
opinion on how conflicts are managed in their organiza- mode’ of management is among worst assessed features
tion – no more than 2 on a scale of 1 to 6. The average with a score of 2.6. However, it is also one of two charac-
‘as-is’ score of conflict management is 2.4 (ranked third teristics with the highest ‘should-be’ score, i.e. in an ideal
among the lowest rated aspects of organization), and the organization, it was given a score of 5.5.
‘should-be’ score is 5.3. In a 2003 study by S. Chaudhury, In a qualitative study conducted in Stockholm using
72.7% of physicians ranked the inability to solve staff individual interviews (N = 12) of people participating
problems third most demotivating factor [69]. in the program, the results showed that having a mentor
Research by S.L. Browning published in 2014 [25] provided a sense of security and was a ‘space of freedom’
provides insights into how to develop strong healthcare in addition to the study curriculum. It offered more hope
organizations by devoting more attention to the integra- for the future and greater motivation; it helped introduce
tion of physicians in the organizational structure, which students to the new community and identify as physi-
delivers better results than paying for the treatment out- cians. S. Kalen et  al. argue that individual mentoring
comes. B. Nunberg [70] also concluded that, because the can create favorable conditions for the development of
effectiveness of promoting work motivation by paying for professional competences that are not included in med-
performance has not been confirmed, this method should ical curricula, such as reflective skills, emotional compe-
not be given priority. In fact, paying for performance can tences and a sense of belonging to a community [72]. A
have an unfavorable effect on the organizational culture study of H.M. Elarabi [62] analyzing low job satisfaction
by creating competition between physicians rather than among physicians demonstrated that there is a lack of
a sense of collaboration to achieve a common goal-vision training programs and an absence of plans to increase the
of the organization [25]. It was also found that physi- competence of hospital staff.
cians are more motivated by internal factors, and there-
fore strategies should be developed to facilitate physician Strengths and Limitation of the Study
involvement by facilitating career development and pro- The strengths of this study include random selection and
moting collaboration among healthcare professionals. relatively robust sample size coupled with the use of the
Over time, this will ensure greater job satisfaction, which WHO questionnaire and the relevant theories that frame
in turn positively shapes the behavior of physicians, the study and help to explain the results. The results of
eliminates occupational burnout and medical errors, the present study and the results of research conducted
increases patient satisfaction, and improves clinical out- in highly developed and developing countries were
comes. In this study, the ’rewarding for collaboration’ compared to confirm that the healthcare systems faced
aspect scored 2.5, significantly below the average of 3.5. similar complex problems worldwide. The results of this
Physicians felt that a hospital should undertake efforts study also confirm that more research needs to be con-
to stimulate cooperation (a ‘should-be’ score of 5.4). As ducted, including in hospitals operating outside large
shown in a study by B.S Savič in 2008 [63] conducted metropolitan areas. The use of bivariate tests of signifi-
among healthcare professionals in 14 Slovenian hospitals, cance rather than multivariate models can be counted as
physicians also complaint about the lack of good team- a study limitation as it does not allow for the inclusion of
work. The study results suggest that the current work relevant control variables.
organization, level of teamwork and leadership model do
not promote individual commitment to work, which may Conclusions
mean that employees are exposed to unfavorable pres- When identifying and improving essential aspects
sure in their work environment. It was also found that affecting the organizational performance of public hos-
those who do not work in a team show greater nervous- pitals, more attention needs to be paid to social factors
ness and lower job satisfaction compared to those who as they were shown to play a more significant role in
favor teamwork. the hospital management. This conclusion is consist-
The final aspect of the organization evaluation was the ent with the existing literature and validates the study
use of the ‘learning mode" by the hospital management. hypothesis. ‘Hard’ elements are undeniably important
Mentoring is one of its important aspects, the essence aspects of an organization, however, they determine
 Chmielewska et al. BMC Health Services Research (2022) 22:7 Page 11 of 12

the performance of management to a limited extent Author details

1
 Department of Forensic Pharmacy, Pharmacy Division, Medical University
only, i.e. organizational activities and decisions leading of Warsaw, 81, Żwirki i Wigury Str, 02‑091 Warsaw, Poland. 2 National Institute
to the achievement of the intended goals. In efforts to of Public Health – National Institute of Hygiene, 24, Chocimska Str, 00‑791 War-
improve hospital performance, the method proposed saw, Poland.
illustrates the importance of a prospective study of hos- Received: 14 May 2021 Accepted: 10 December 2021
pital organization, in which the satisfaction of the key
stakeholders is taken into account, to supplement the
most common, yet inadequate methods of retrospec-
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