F Summary and Conclusions

The Karasek and Theorell Demand/Control model of work environment, presented in Figure 6.1 appears very relevant for this study of work environment and service quality in Japanese healthcare. It has both a strong heuristic and predictive value. By combining Work Demands and Control in Table 6.1, we discovered a clear pattern where nearly one- third of the staff at these ten Japanese hospitals have Low Strain jobs, one-third High Strain jobs, while the remainder is divided between Passive and Active jobs. Table 6.2 noted that the Demand/Control model had a differential impact on different occupations. In particular, a greater proportion of doctors claimed Low Strain jobs, while more nurses claim High Strain jobs.

Table 6.3 documented the impact of the four work life or job categories on the work environment indices employed by this study, along with some additional work life indicators. A much larger proportion of the Low Strain staff scored ‘high’ on the work life indices than the High Strain staff. In particular, they have a clear impact on Service Quality - where three of five staff members with Low Strain jobs claim high Service Quality, while only one of four staff with High Strain jobs make the same claim. Table 6.4 showed that higher Discretion and Control at work leads to greater Work Satisfaction, while higher Demands have the opposite effect. It also showed that Work Satisfaction was also closely related to Service Quality. More than two-thirds of the staff that were highly satisfied said that service quality was high, while less than one-fourth of those who were least satisfied claimed high service quality. Table 6.5 documented the results of alternative perspectives on service quality by considering the staff’s evaluation of hospital standards. It showed some discrepancies with the Index of Service Quality employed in this study. However, technical issues discussed earlier prevent us from including responses about hospital standards in our Index of Service Quality.

A brief discussion of the social background of the staff and their work conditions introduced the three hospital groups at the heart of our study. Next, the Demand and Control model was revisited from the perspective of the three hospital groups employed in our study. Table 6.6 showed that the staff at Medical Co-ops were clearly over-represented among Low Strain jobs and under-represented in the High Strain category. The staff at public hospitals recorded the opposite pattern, while the Koseiren staff came in between them. After, the focus shifted to how the hospitals relate to the seven work environment indices in Table 6.7. The Medical Co-ops often rank highest in terms of positive aspects of these work environment indices, while the public hospitals ranked lowest in all but one. It also showed that staff at the Medical Co-ops rated their service quality notably higher. Half of the staff at Medical Co-ops claimed high Service Quality, while fewer than two out of five did so at public hospitals. Thus, the data demonstrate that work environment and service quality are positively related. A healthy work environment results in greater work satisfaction and it promotes better service quality. Tables 6.5 and 6.8, however, shed some light on alternative perspectives on service quality.

Finally, Table 6.G in the appendix considered hospital occupations and stress. For example, doctors at all three hospital types are overrepresented in the Low Strain category and under-represented in the High Strain category, compared with the average for all ten Japanese hospitals. This over/under-representation is most notable at Koseiren hospitals. Similarly, administrators are over-represented in the Low Strain category and under-represented in the High Strain category for the staff at Medical Co-ops and Koseiren hospitals but not the public hospitals. However, the situation is quite different for nurses and care workers. Nurses are clearly over-represented in the High Strain category and under-represented in the Low Stain category at public hospitals, somewhat over/under-represented in the same work life categories at Koseiren hospitals and more closely distributed with the average at the Medical Co-ops. Similarly, care workers are closely distributed with the average at the Medical Co-ops, but clearly over/under-represented at Koseiren hospitals, while there are too few care workers at public hospitals to comment on their over/under-representation. This suggests that the human resource departments have their work cut out for them in terms of efforts at improving the work environment of certain groups of employees. In particular, nurses and care workers at Koseiren hospitals and nurses at public hospitals are in acute need of viable plans to improve their situation and allow them more discretion in the performance of their daily tasks.

Plot of Work Environment Indices and Outcomes

Figure 6.3 Plot of Work Environment Indices and Outcomes.

Figure 6.3 provides a graphic overview of the work environment indices and outcomes for two of the work life categories - Low and High Stress - and the three hospital groups. The three hospital groups fall in between the two work life categories. The five work environment indices only report the ‘high’ scores, so anything above or below one-third is noteworthy. The Index of Service Quality is dichotomized, while the two health outcome questions report the percent of positive answers. The graph shows a stark difference among the work life categories and the three hospital groups for most of the work life categories and service quality, but almost no difference among the three hospital groups in terms of health outcome. Staff at the Medical Co-ops come closest to the Low Strain category in most respects of work life, whereas staff at the public hospitals are closer to the High Strain category, with staff at Koseiren hospitals somewhere in between.

The three main takeaways for the analysis of the Staff Study are the following. First, in spite of the clear heuristic and predictive value of the Demand and Control model, it is primarily a theoretical model about ‘the best of possible worlds’. Nevertheless, on its own, it provides little practical advice or guidance about how enlightened HR experts could proactively expand Low Strain and/or Active jobs to all or most employees and eliminate significant aspects of the toxic work environments and social pollution discussed by Pfeffer. The information gained by including the hospital groups points to notable disparities between them in terms of the Low and High Strain categories among the employees. The final table confirms that nurses and care workers are particularly subject to adverse situations in their daily work life. A general rule of thumb might be, therefore, to give all the staff more control or ‘say so’ over their everyday tasks. By considering the situation at the three hospital groups, we gain a better understanding where to begin making important improvements in the work environment of the professional healthcare staff. Exploring the situation at individual hospitals is possible, but, unfortunately, it goes well beyond the scope of this book. Moreover, discussions of governance and work environment in Chapter 9 will help to develop a better understanding of what is necessary to enrich the work environment.

Second, continuing on the previous point, we expected that if the staff was more satisfied with their work environment they would also be more satisfied with the quality of the services they provided. This was clearly the case for the work life categories in the Demand/ Control model where there was a large difference between the High and Low Strain categories. It also held true in the empirical world with respect to the hospital groups. The differences between them were not as sharp as at the theoretical level, but they were nevertheless discernable. The staff with the highest evaluation of their work environment and work satisfaction also rated their service quality higher. However, what about the patients - what do they say about service quality? Would they be willing to recommend their hospital to a friend or acquaintance? This will be explored in the next chapter on patients and co-production.

Third, direct comparisons between the hospitals in terms of work satisfaction and service quality might be somewhat misleading, since they operate in a different setting and context. This is particularly true in rural areas where there are seldom any alternative healthcare providers. Moreover, these hospitals employ different governance models, promote different social values and have different social profiles, including different approaches to patient dialog and participation. Thus, each hospital group needs to be judged by its own values, in addition to some general or abstract values related to work environment and service quality. Chapter 10 explores the social and instrumental values that the staff associate with their hospitals.

The next chapter studies issues related to patient participation and co-production and is followed by a discussion of the role of volunteers in the succeeding chapter. Data from the Patient Study and Volunteer Study can help to confirm or challenge the staff perspective on service quality. Then hospital governance models are discussed, followed by hospital social values and mission and, finally, the consideration of the impact of public administration regimes and organizational logics on co-production and healthcare.


1 The data collection was financed by the Japanese Society' for the Promotion of Science (JSPS), the Mitsubishi Foundation and Osaka University, and it was supervised by Prof. Yayoi Saito, Osaka University. The project is conducted within the framework of an established cooperation between senior researchers at Ersta Skondal Bracke University College in Stockholm (Prof. V. Pestoff and Doc. J. Vamstad) and the Faculty of Human Sciences, Osaka University (Prof. Y. Saito). This interdisciplinary group of Swedish and Japanese researchers is supported by a reference group of the relevant cooperative healthcare providers in Japan, Koseiren and the Japanese Health and Welfare Co-operative Federation HeW CO-OP JAPAN.

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