Analysing the connections between Operations Flexibility and Hospitality

Category: Accounting

Purpose - This study attempts to examine the relationship between operations flexibility and hospital performance in Jordanian accreditation hospitals using the Structure Equation Modeling (SEM) approaches.

Design/methodology/approach - This model starts with operations flexibility elements measurement scales consisting of two dimensional structures: external flexibility and internal robustness to measure operations flexibility elements in Jordanian hospitals. Hospital performance elements measurement scales consisting of four dimensional structures: patient result, staff and work system result, hospital efficiency & effectiveness results and governance flexibility performance. Respondents are the medical leaders (managers, head departments, senior offices, supervisors and residency doctors) who work in two accreditation hospitals in Jordan.

Findings - The findings suggest that the model of Jordanian hospitals consist two latent's first operations flexibility dimensions consist of the two dimensions (loading dimensions) and hospital performance consist of the four dimensions. Positive relationship was noted between operations flexibility and hospital performance.

Research limitations/implications - Further research should be considered in order to gather more information regarding operations flexibility and hospital performance dimensions in the not accreditation hospitals.

Practical implications - The four dimensions of hospital performance and two dimensions of operations flexibility represent a valid instrument to measure the relationship between total quality management and operations flexibility in Jordanian accreditation hospitals.

Originality/value - This research is an important in the line with understands the relationships between two main topics operations flexibility and hospital performance.

Keywords Performance, Operations Flexibility, Hospitals, Joint Commission International, Jordan

1. INTRODUCTION

The administration today lives an era characterized by innovation and research for more competency and creativity, whereas the developed world witnesses changes and rapid and successive developments, in all public and private sectors, so the administration found itself from time to time in front of limitations that impose dispensing the systems, principles and approaches that have been used in the past development and improvement.

Therefore, the application of the principles and modern methods on our institutions is very important in order to upgrade them to high rates of performance, quality and raise the efficiency of the services provided. Flexibility occupies singular importance in the management philosophy of contemporary organizations, global and local companies , especially in light of economic, political and technological developments witnessed by our current world along with an fierce competition for markets and resources including their various components be it physical, financial or human, which requires having a vision and holistic philosophy able to cope with environmental challenges of the present and future, and increase their own capacity to adjust and adapt to decisive changes in the competitive environment.

The need for change in the methods of administrative work has become more urgent, especially with the beginning of the new millennium, as for the accelerated growth that has an impact on both global and local institutions, as well as the rapid development in technology, the demographic structure of the labor force, the global expansion, and the increasing emphasis on quality and flexibility in the production of commodity and service delivery, all emphasize the need for change.

In an era of globalization and openness that characterizes today's world, excellence in organization has become a topic of concern and widespread debate by various researchers, because the era of knowledge and information does no longer recognize a patterned labor governed by the traditional functional specifications prevalent in the old bureaucratic pyramid. It relies on elements that are characterized by excellence and diversity of knowledge of the heads and subordinates, as the Organization would achieve excellence in performance requires its members to stay away from all that is typical and routine in the performance and behavior, and adopt effective and energetic systems (Ibrahim, 2001).

In healthcare sector the flexibility play major role to motivates the staff and increase the productivity through continuous improvement in flexibility work environment. One of the most objective for modern organizations achieve satisfaction for both internal and external customers, through strong strategies and effective plans depend on more flexibility in work. Operations flexibility has an important role in all health sectors in recent years, attention to operations flexibility in the healthcare industry started to rise as a major concern to achieve the overall quality. Operations flexibility depends on meeting the rapid changes inside and outside the organization to improve the operations of the organization. It also depends on the many factors as top management and leadership; raw materials, strategic planning and supply chain. The requirements for the application of operations flexibility within the healthcare organizations depend on the organization manager to make some changes in the staff behaviors', structure, process and system of work, with other requirements are necessary conditions for achieving the objectives of operations flexibility. To impose all the principles of the program in all aspects of the health organization there must be a very strong commitment from the seniors managers.

This study attempts to determine the relationship between operations flexibility elements and hospital performance in Jordanian hospitals accredited from Joint Commission International (JCI) by adapting and modifying hospital performance scale from Baldrige A ward Health Care Criteria for performance excellence, (2011) and operations flexibility scales from Idris (2006). This research is important to improve hospital performance in Jordanian hospital and determine the relationship between operations flexibility and hospital performance from medical leaders' perceptions in JCI accreditations hospitals to help other hospitals (many hospitals in Jordan or other countries) working hardly to get accreditation from Joint Commission International (JCI), only seven hospitals (the best hospitals) in Jordan have JCI accreditation and only three hospitals (private and government) have a doctors residency programe (doctors doing specialist study) and have JCI accreditation in the same time (JCI, 2010).

Clarify the relationship between operations flexibility of and hospitals performance the important points, especially in Arab countries because the concept of flexibility and operations flexibility is still vague and not applied in effectively way, also some leaders in the health sector do not trust the importance of flexibility in improving production and services . In addition, this study has been selected hospitals, award-winning high performance and quality, and therefore, this study is very important for the hospitals study as well to the other hospitals that work hard to get the international awards and accreditation in quality and high performance.

This is one of the few studies that shed light on the applications of operations flexibility in excellent performance hospitals, to become a reference and guide for all hospitals in Jordan, also important evidence of the importance of operations flexibility for the international accreditation in the medical sector.

2. LITERATURE REVIEW

2.1 FLEXIBILITY

Chan (2004) proposed that the flexibility manufacturing system covers spectrum of manufacturing activities, which includes machining, welding, fabricating, assembly and a number of other applications. From this definition it shows, flexibility covers all aspects of manufacturing, from the raw materials suppliers to the after sales services. The changes in market competition, and customer wants, needs on efficient, good quality, and highly flexible production and services. Flexibility is important to meet the many unexpected changes in consumer requirements. Flexibility is able to manage rapid changes in an efficient and effective manner. Strategies is based on reducing the number of workers, improving the utilization of machines, improving the operations control, and reducing both the work in process inventory and the final products inventory. All flexibility strategies have positive attitudes in all the production stages but reducing the number of workers will create social problems, by increasing the number of unemployed people which relate unfavorably on the society.

Correa and Gianesia (1994) adopted two important ways for flexibility which are related to organization manufacturing strategy. The first is response to an increasing turbulent environment. Second, flexibility can be very pervasive and can influence the performance of other organization completive criteria, such as delivery speed and dependability. The same authors defined flexibility as being able to vary and adopt the operations either, because the needs of customer alter, or because of changes in the production process, or perhaps because of changes in the supply of resources. So flexibility covers all organization services process, especially when these changes relates to the customer. The objective is to meet all changes which have an effect on customer satisfaction level.

The flexibility objective, the ability to deal effectively with effects, through unplanned changes control methods thus work as a filter to restrict the amount of change effects the system has to deal with. Emphasis on developing operations flexibility to deal with the unplanned changes effects once they have occurred, in the same study, the author proposed several dimensions for control filter; such as monitoring, forecasting, standardizing, maintaining, booking, queuing and promoting, substituting, delegating and sub contracting, focusing and coordination and integration. If unplanned changes which for some reasons, can enter through control filter, the operations flexibility must deal with it, through types of service operation. There are seven types of service operations flexibility:

1. Design flexibility, the ability to introduce new service.

2. Package flexibility, the ability to offer varied services within a period of time.

3. Delivery location services, the ability to offer the service in a variety of places.

4. Delivery time flexibility, the ability to anticipate the services delivery to requirement.

5. Volume flexibility, the ability to change services output levels.

6. System robustness flexibility, the ability to remain operation effectively despite changes affecting inputs and process.

7. Customer recovery flexibility, the ability to recover the customer after some things goes wrong. The effect of unplanned changes goes in tow way, affecting the organization only, and affecting the whole market (Correa & Gianesia, 1994).

Harvey et al. (1997) proposed the specificity of services and service delivery process as follows:

1. Services generally involve customer contact of one kind or another.

2. Customers demand increasingly that all the services required to produce a given result be bunched together and delivered in harmony with their activity cycle.

3. Services are generally consumed as they are produced.

In the same study the authors determine the source of variability, both internally and externally. External variability come from market and driven by competition, internal variability comes from aspects of the organization, such as product or process design, organization structure or administrative procedures.

Verdu and Gomez-Gras (2009) suggested that organization flexibility is the main capability that enables companies to face environmental fluctuations, as it makes the organization more responsive to change. In this century the organization must become most sensitive to changes in the environment to have a strategic organizational capability that enables them to change easily and thus to continue to maintain acceptable results without incurring high reorganization costs.

Four types of managerial flexibility adopted:

1. Strategic flexibility. This type have the potential of a company to transform itself, and propose to deal with hypercompetitive environment, and economic crises, flexibility strategy give the organization new state from engendering learning, adaptation, renewal and enhanced longevity.

2. Structural flexibility. This type from flexibility focus more on people, and tend to be less formalize, and decentralize, so that this type focus on human resource management in firms, especially some managerial practices which can affect directly on structural flexibility such as compensation system, personal selection, participation, team work, training, job design and authority system, the workers have main effect on performance especially who have polyvalence and can work different tasks and functions in a firms. Labor flexible practices like timework have a positive effect in organizational performance.

3. Operations flexibility. This type has the capability to meet the unexpected changes depend on ordinary capacities based on the organization's structures or current objectives, so that the changes in the environment. Do not involve changes in the relationship between the company and the environment. Operations flexibility can affect on cost and speed of the company operational response, and the changes as general reversible to short-term changes, these changes involve day to day or hour to hour operations.

4. Internal and external scopes, internal flexibility is the capability for organizations to adapt to the environment, and external flexibility refers to effect the environment, and thus to reduce their vulnerability. Flexible also means changing the organizational environment through actions like communication, innovation and advertisement. Internal and external flexibility are associated with offensive behavior or defensive and respectively in organization.

2.2 OPERATIONS FLEXIBILITY

Verdu´ and Go´mez-Gras (2009) explained the concept of flexibility as a broad concept that can be related to many elements in an organization such as strategy, structure, human resources, marketing, operation, and from other side the flexibility concept means also the adaptation capacity, sensibility, dynamic capability, agility and elasticity.

Organization flexibility is widely applied and used in different organizational processes, resources and functions. Dynamic capabilities are very important for firms, because the operation in environment changes rapidly.

Organizational flexibility concept returns to the overall flexibility of an organization as a system managerial function (strategizing, organizing, planning, leading, direction,…), process (operating, tasks, routines,…), structure defined by assets of resources (technology, personal, financial resources, knowledge, …), and it described as managerial task and managerial capability.

This study defines the flexibility as a strong relationship between operation, tactical and strategic, with high capabilities, response, and integration in all level of organization to meet all types of unexpected changes.

The operations flexibility defines, the capability to meet the unexpected changes depend on ordinary capacities based on the organization's structures or current objectives, so that the changes in the environment. Do not involve changes in the relationship between the company and the environment. Operations flexibility can affect cost and speed of the company operations response, and the changes as general reversible to short-term changes, these changes involve all operations (Verdu´ & Go´mez-Gras, 2009).

The operations flexibility must build strong relationship between both internal operations flexibility and external operations flexibility, with all process and work procedure in organization in all levels, this relationship will help the organization to meet unexpected changes and reduce the effect and cost of the changes if happened , also help to develop new strategy for operations flexibility in the long term, increase the effective for of continues improvement, and improve the work through the environment and market competitive changes. Every company needs strong plan, depends on the smart operations flexibility strategy, to meet different types from unexpected changes, these strategy must cover all company sections, to become more effective.

According to McFadden et al. (2006); Harvey et al. (1997); Verdu-Jovre et al. (2004) and Idris (2006) the operations flexibility consist of two important elements external flexibility and internal robustness.

2.3 HOSPITAL PERFORMANCE

The human center management system designed under the Performance appraisal in companies. Â This department may include manifest in human resource management, strategic manpower planning and total quality management (Coates, 1996).

Assess the performance of health service become an important task to public and health care industry. Recent data shows that US spend more than 14% and 38% in domestic product and hospitals accounting,   of whole budget. Their target of performance improvement is to provide quality care at low and reasonable cost (Li and Collier, 2000). Griffith et al. (2002) evaluated hospital performance through one set consisted of nine multidimensional derived from Medicare reports. The evaluation was on occupancy, change in occupancy, percent of revenue from outpatient care, cash flow, asset turnover, mortality, complications, length of inpatient stay, and cost per case.

Using hospital performance to measure the national trends of a community has faced several operations problems. First, the difficulties of finding empirical measurements about the performance of the population of community hospitals that meet the standards of validity and reliability. Second, sometimes, the data available are often reflecting only one side of hospital performance (e.g., human resource), though, provide a highly restricted picture of organizations.

Today, most researchers use and construct a standard made of nine multidimensional to find major performance dimensions in hospital covering all available Medicare reports for community hospitals including reflecting customer, financial, and operations performance (Griffith et al. 2006).

Managers cannot objectively or consistently evaluate the quality of their strategic decisions. Due to this, the performance measurement becomes crucial for performance referent.

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Nowadays, voices of people which adapting a performance measurement systems outperform in their organization are much more that those which do not have such systems in their work place or are less disciplined in this respect. Performance is considered as a dependent variable for primary interest emanating rather than a desire to understand why some organizations are more successful than others. Â This leads to consequently valid and reliable measurements of performance that are critical for both managerial and research purposes.

Yavas and Romanova, (2005) chose and identified 11 standard factors as were chosen and identified to investigate hospital performance. These factors were less tension between physicians and hospitals management, better position in negotiating with insurance companies, find and access to new markets, increased occupancy rate, decreased number of personnel per occupied bed, lower total expense per occupied bed, decrease in duplication of services and facilities, containment of operating costs, increased clinical effectiveness, lower procurement costs and shared risks (Yavas and Romanova, 2005).

JCAHO (Joint Commission on Accreditation of Health care Organizations) has focused on performance assessment and investigative methodologies directed towards improved patient care outcomes. The JCAHO (2010) defined performance improvement in health care as:

"Performance Improvement is continuous change to improve process through measuring services, identifying areas for improvement and developing improvements through multidisciplinary teamwork. The goal of PI is to promote a collaborative approach to patient centred care that focuses on improving safety, performance, patient outcomes and identifying and promoting best practices."

Abu Bakar et al. (2010) expressed that several authors have proposed performance measurement frame works, which prescribe that performance dimension organization should consider monitoring.

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2.3 CONCEPTUAL MODEL

Our conceptual model is demonstrated in Figure 1. This model starts with operations flexibility consisting of two dimensional structures: external flexibility and internal robustness, and hospital performance consisting of four dimensional structures flexibility and governance outcomes, service and process outcomes, patient-focused outcomes and workforce-focused outcomes, to explore the relationship between operations flexibility and hospital performance. Furthermore, a conceptual model of the relationship between total quality management and operations flexibility is developed based on the literature.

2.4 CONCEPTUAL THEORY AND HYPOTHESIS

The study conducted by Anand and Ward (2004) shows that, the hierarchical regressions provide evidence that flexibility is a stronger predictor of performance in more dynamic environments. Specifically, presence of the unpredictability or the volatility aspects of environmental dynamism each warrant the use of different types of manufacturing flexibility strategies. According to Kuo et al. (2003) change status of a firm's operations performance can be positively influence by a change in flexibility. Hence, in order to improve the operational performance of a company undertaking risk in an operational environment, the Flexibility must be increased.

In Toni and Tonchia (2005) the finding shows that, there exist relationship between strategic flexibility and operations flexibility. Since the strategic flexibility affects the overall performance, as a result they argued that there is a relationship between operations flexibility and performance. Furthermore, Roca-Puig et al. (2008) stressed that the relationship between external labor flexibility and firm performance can be affected by the degree of internal labor flexibility. Thus, internal labor flexibility acts as a moderating variable on this relationship, however, an increase in external flexibility can also cause both a negative and a positive effect on firm performance depending on the level of internal flexibility.

Zhang (2005) found that, information system support for product flexibility was positively related to sales growth and returns on sales. He also found a stronger association between information system support for product flexibility and return on sales, and a positive relationship between information system support for cross-functional coordination and sales growth, while information system were complemented by unique knowledge and information. In his study Jones (2005) revealed that, there is a positive relationship between performance and flexibility. In this respect performance was influenced by the interaction of flexibility with competition and structure, however, control was found to have no moderating effect on the flexibility - performance relationship.

The findings of study conducted by Kathuria and Partovi (1999) explained that, credible manufacturing managers are strongly important in demonstrating the relationship-oriented practices relating to flexibility in an organization such as team building, inspiring, supporting, networking, recognizing, etc, as well as participative leadership and delegation practices. Furthermore, as the emphasis on flexibility increases, credible manufacturing managers can delegate their traditional responsibilities, such as monitoring, problem solving, etc., to their subordinates. Thus, this subordination to employees by manufacturing managers will lead to workforce management practices, therefore creating a manufacturing flexibility in the firm or organization. On the other hand, Jack and Raturi (2002) found that, short and long-term sources of volume flexibility have a positive, although differential impact on a firm's performance. In addition, Rabinovich et al (2003) claimed that the use of operational processes, especially just-in-time (JIT) rather than the use of enterprise-wide information systems leads to improved performance as measured by inventory speculation, lead times, and turnover ratios. In Kannan and Tanb (2005) flexibility configurations based on high or low levels of volume and mix flexibility combination was found showing significant differences in terms of operational performance. However, Tan and Wang (2010) found that, firm's performance can only be impacted positively by flexibility within a certain range of applications.

Interestingly, in their study Jack and Powers (2006) stressed that, the volume flexible capability and the use of internal strategies were found to have positive influence on customer-related performance leading to a positive impact on financial and market share performance of the firm. To Verdu-Jover et al. (2004) what matters is the good fit between real and required operations flexibility which found to have more positive influence on business performance in service firms unlike the manufacturing sector. Service firms, in the day-to-day context should have the capacity to change rapidly when adopting successful operational practices in their adjoining environment of change. Similarly, Oberoi et al. (2007) revealed that, the statistical analyses of their study shows significant relationships between sourcing practices, advanced manufacturing technology and manufacturing flexibilities at different levels of manufacturing flexibility. The findings also suggest that an organization could set up specific sourcing practices or advanced manufacturing technologies to target specific manufacturing flexibility in pursuit of agility-based competitive advantages and large market share.

Based on the previous studies the researchers proposes the following hypothesis:

H1. There is a positive relationship between operations flexibility and organizational performance in hospitals.

3. RESEARCH METHODOLOGY

3.1DESIGN OF THE STUDY

The study was conducted using a quantitative research method where empirical investigation was carried out to determine the relationship and the impact of operations flexibility on hospital performance results in Jordanian hospitals. The questionnaire was adopted and modified from the previous literature included socio-demographic information of the respondents (profession, gender, age, education, name of hospital and years of working), and the items that measured the extent impact of implementing various total quality management dimensions on operations flexibility.

3.2 SURVEY INSTRUMENT

The survey instrument is composed of questions relating to the following two constructs that include operations flexibility, the extent of hospital performance results. The conceptual definition of operations flexibility was adopted from the Idris (2006) and hospital performance results adopted from the Malcolm Baldrige National Quality Award (2011-2012). Minor modifications were made to some items in the original scale to adjust for semantic meanings. Resulting in a 33-item. scale that are measured on a seven-point Likert scale ranging from "strongly disagree" to " strongly agree".

3.3 SAMPLING AND DATA COLLECTION PROCEDURE

A random sampling was used in accessing the respondents of the study. Two selected Jordanian hospitals; King Abdullah University Hospital (public owned) and Jordan Hospital and Medical centre (private). The total respondents used were 231, where 116 respondents are from king Abdullah University Hospital and 115 respondents from Jordan Hospital and Medical centre. The potential respondents consisted of manager, senior officer, head of department, supervisors, registered nurse or medical staff and residency doctors. Similarly, the respondents used were leaders who have worked in the two main hospitals in different locations in Jordan. The two hospitals chosen in this study are both having accreditation certificate from Joint Commission International (JCI). The JCI is a well known institution working in the health sector and global organizations worldwide since 1994. The JCI is focusing in improving the safety of patient care and hospital performance by using accreditation and certification services.

We choose the hospitals depending on the accreditation from (JCI) and doctors residency programme (doctors doing specialist study), there are only four hospital which have these two qualifications and the researchers select two hospitals depending on the level of cooperation from hospitals (JCI, 2010).

4. RELIABILITY

According to Joppe (2000), reliability is the extent to which results are consistent over time and an the best representation of the total population under study. A research instrument can be considered to be reliable if the result of a study can be reproduced under a similar methodology; that is the ability of instrument to be replicable and repeatable, and stability of measurement over time, Kirk and Miller, 1986; Golafshani, 2003. Therefore, the reliability scores of the constructs of the research instrument are as follows.

Table 1: Reliability scores of dimensions of operations flexibility

The reliability scores of operations flexibility as shown in Table 1 was strongly significant where the external flexibility dimension was (.95) and the internal robustness has (.92) while the overall operations flexibility has (.95), Cronbach's a was greater than 0.7 for all the dimensions, which confirmed that the items were internally consistent for each dimensions (Nunnally, 1994).

Table 2: Reliability scores of dimensions of hospital performance results

Similarly Table 2 the reliability scores of dimensions of hospital performance ranging from (.91 to .955), while the overall hospital performance out comes measured was reliable also with cronbach's alpha (.969). The above tables has demonstrated the reliability and consistent of the instrument used in this study (Nunnally, 1994)..

5. DATA ANALYSIS AND RESULTS

A total of 400 questionnaires were distributed in the two Jordanian hospitals used for this study. Out of the total questionnaires send 231 were filled and returned by respondents in which about 49.8% of respondents are working in King Abdullah University Hospital while 50.2% from Jordan Hospital and Medical Centre. Structure Equation Modeling version 16 was used for data analysis.

5.1 DESCRIPTIVE STATISTICS RESULTS

Demographic background of the respondents

Note: Total number of Respondents = 231

The demographic characteristic of the respondents was as follows:

In table 3, out of the 231 respondents used in the study, 133 (57.6%) were male while the rest of the 98 (42.4%) respondents were female. The majority of the respondents (185) which is 80.1 % were within the age range of 20 to 35 years, and 40 (17.3%) within the age range of 36 to 50. However, for those within the age range of 51 to 65 was only 6 respondents which are 2.6%.

Regarding the Education level of respondents, 111 (49.1%) respondents were Postgraduates, 100 (44.3%) were Bachelor degree holders and 15 (6.5%) were Diploma holders. Majority of the respondents 96 (41.6%) were Medical doctors, followed by 35 (15.6%) head of departments, 34 (14.7%) registered Nurses, 30 (13.0%) senior officers, 28 (12.1%) supervisors and 7 (3.0%) managers. In respect to working experience, the majority of the respondents had 6-10 years working experience with a total number of 69 (29.9%) respondents, followed by those with 2-5 years of experience with 66 (28.6%). While 64 respondents (27.7%) has less than 2 years working experience, 32 (13.8) of the total respondents has 11- 25 years working experience.

5. 2 ANALYSIS METHODS

Confirmatory factor analysis

In this study, the validation procedures for the instrument followed the method of confirmatory factor analysis (CFA). This procedure was emphasized by reputable scholars in the field of statistical analysis (Byrne, 2010; Kline, 2011), in this stage is also known as testing the measurement model, where operations flexibility and hospital performance results constructs are tested using the second order confirmatory factor model to assess construct validity using the method of maximum likelihood. The results consistently supported the factor structure for tow constructs. The confirmatory factor analysis technique is based on the comparison of variance-covariance matrix obtained from the sample to the one obtained from the model. The technique is fairly sensitive to sample size, and it is suggested to have several cases per free parameter (Bollen, 1989).

The final step in the analysis was to test the path model as shown in Figure 4.

The hypothesized structural equation model was tested using AMOS software version 16. For each of the operations flexibility and hospital performance constructs, the indicator variables were the respective dimensions (factors) as determined by the confirmatory factor analyses. Model fit determines the degree to which the structural equation model fits the sample data. The commonly used model fit criteria are chi-square (x2), goodness of fit index (GFI), adjusted goodness of fit index (AGFI), comparative fit index (CFI), Root Mean Square Error of Approximation (RMSEA) (Schumacker and Lomax, 1996).

6. DICSUSSION

In the health care sector, flexibility through the managerial practice has always been an integral part of health care delivery due to the necessity responsiveness of each patient in the clinical service process (Butler et al., 1996).The clinical flexibility is an essential method for making adjustments to achieve the best possible patient's outcomes, focusing on community satisfaction and advance market share. According to this , the main target of operations flexibility is to be capable to have a sustainable advanced research throughout operations management. The basic goal for hospitals is to change the political and economical environment to gain market advantage via focusing on flexibility. By achieving this, hospitals will be able also to win customer satisfaction and retention.

The core of this study was to observe a relationship between operations flexibility and hospital performance in the Jordanian context. The managerial tools are important tools to indicate operations flexibility in hospitals. This tool gives options for any organization to diversify its ability of new services or products. It also can provide accommodation changes ,especially environmental ones, through rapid responses of both external and internal flexibility to enhance working output with minimum cost (Verdu-Joure et al., 2004). Competitiveness of a firm highly depends on its activeness towards handling changes that happen in the business domain which includes environmental, social, market, and economical changes. Therefore, operations flexibility as a concept and practice help firms to be flexible in turning around all of its forces of change which give them competitive advantage over others. In an overview, the findings of the study were aimed at contributing to literature related to hospital service quality delivery and performance.

The first interesting finding of this study revealed a significant and positive relationship between operations flexibility and hospital performance in the Jordanian hospitals. This finding supported the findings Jones (2005); Toni and Tonchia (2005); Zhang (2005); Roca-Puig et al. (2008), in which all argued and stressed that operations flexibility has a positive and direct relationship with organizational performance.

Secondly, the results of this study also revealed that the operations flexibility as an independent variable has a positive effect on the performance of the hospital and extent that to improve the practice of flexibility in Jordanian hospitals. This will lead to an increase in the performance in general. Similarly, it was found that the external flexibility and internal robustness also have a significant effect on the hospital performance in Jordan. These results supported the results of Verdu - Jover et al (2004); Jones (2005); Jack and Powers (2006) and Tan and Wang (2010), where all the flexibility in the process have an positive relationship with organizational performance. The results showed that, the importance of operations flexibility results from achieving organizational performance, Stronger operations flexibility in the company lead to the achievement of high performance. Any change in flexibility leads to change in the level of performance and the process (Kuo. 2003). In order to improve the performance of the operations of the company, we need to promote flexibility.

In a nutshell the findings of this study is the first of its kind in the Jordanian hospitals to measure operations flexibility over the process of medical practice between senior officials and managers in the hospital and its impact on hospital performance in terms of quality delivery of health services leading to customer satisfaction and retention.

The study focused on two important dimensions in managed operations flexibility, (external flexibility and internal robustness), The study results showed that the dimensions of operations flexibility have a significant role in the influencing on hospital performance (see the results of P value and critical ratio in table 3), Therefore, the attention to operations flexibility in the hospitals have the same importance and influence, The plans to apply a high degree of operations flexibility rely heavily on integration and cooperation between the internal robustness and external flexibility. The idea of applying operations flexibility, based on the integration and cooperation in all stages of service production is to reach a high degree of satisfaction and quality in the services. Besides, the cooperation and integration between operations flexibility and total quality management or six sigma or lean will give the hospital more quality and flexibility, which will lead to improve the process, procedures and performance. Meanwhile, the study relied on important dimensions in the measurement of the performance of the hospital. These dimensions are international dimensions to measure hospital performance and adopted from Malcolm Baldrige National Quality Award (2011-2012). The study results showed that the dimensions of hospital performance have a significant role in the influence on hospital performance (see the results of P value and critical ratio in table 3),

The implication of this study is to provide little contribution on how to improve hospitals performances through the practice of operations flexibility among medical employees especially among the senior medical personals and hospital managers. However, this study has many limitations such as the sampling procedure and the respondents used in the study, as well as the sample size which can be improved in future studies. Therefore, we encourage more researches on the most vital and important topic on flexibility and operations flexibility, to reach a high level of satisfaction and productivity. This will lead to the achievement of industrial and service enterprises goals of success and excellence.

7. CONCLUSION

There is a dearth of empirical research which considers a OF and HP within the context of health sector, with previous research however largely examining these constructs either discretely or in a one way relationship. The novelty of this research while investigating the relationship between OF and HP in health sector. In this study, confirmatory factor analyses second order were used to produce empirically verified and validated underlying dimensions of OF and HP, respectively. Based on theoretical considerations, a model was proposed linking the two constructs OF and HP construct. Structural equation modeling was then applied to test the model drawing on a sample of 231 respondents in special accreditation Jordanian hospitals. The results indicated that while OF had a significant impact on extent of hospital performance results, significant direct relationship was found between OF and two OF indicators (internal robustness and external flexibility). Similarly, a strong and positive relationship was noted between the level of hospital performance results and four hospital performance indicators (patient results, staff work system results, governance flexibility performance and process outcome).