University Malaya Medical Centre (UMMC) Service Quality: A Pilot Study on Transformational Leadership and Empathy

Article Information ABSTRACT Received: November 12, 2020 Revised: November 20, 2020 Online: December 01, 2020 This pilot study observed the correlation between transformational leadership and a healthcare service provider's service quality. The research used two sets of crosssectional questionnaire surveys designed to measure the Consumer Assessment of Healthcare Providers and Systems and a Leadership Inventory Index of the services rendered by the University Malaya Medical Centre (UMMC) to their patients to classify the quality of services delivered to patients at UMMC. The results emphasized a significant correlation between transformational leadership and empathy but no significant relationship between leadership effectiveness and service quality because of a lack of consensus and empirical support around which leadership types are significant. Transformational leadership has empirical support and is principles-based, relationship-oriented, intuitively appealing, and potentially “transformative. The study further stressed that the patients were pleased with the services rendered by UMMC staff. Also, additional education for physicians and physicians in training in transformational leadership is warranted.


INTRODUCTION
When leaders have a high level of responsive intellect, they are considered transformational in their leadership style (Goleman, 2017). Nurturing and identifying the talents of individuals is seen as a trait of transformational leadership. Handling conflicts and disagreements effectively and efficiently is a trait leader possesses universally (Holt et al., 2017). Another trait that is regularly used to identify transformational leaders is associated with high social awareness skills and the ability to make the subordinates feel vital and valued.
When someone can put themselves in another person's shoes and experience their anxieties and opinions and express them, that is empathetic towards others. It is a relatively powerful motivation that binds the relationship of patients with the medical team. This gesture enhances the patient treatment plan, increases motivation for participating, and ultimately uplifts the patients' satisfaction level. Not to mention, empathy can also prevent medical errors and lawsuits, thus improving the quality of care rendered to patients in the hospital (Zenger & Folkman, 2017).
According to Seppala (2017), the healthcare industry's main challenges in Malaysia are to sustain the professional services rendered to their patients. With the rising cost of healthcare maintenance and low healthcare personnel quality, there is a severe need for fundamental change in today's customerdriven market. With this, it is crucial to ensure healthcare institutes execute sustainable strategies in IJAE Page 189 open more robust channels for discussion with the management and subordinates, leading to organizational goals.
Some of the rudimentary features of transformational leadership are inspirational, in that the leader can inspire workers to find better ways of reaching a goal; mobilization because leadership can mobilize people into groups that can get work done; and morale, in that transformational leaders raise the well-being and motivation level of a group through excellent rapport. They are also good at conflict resolution (Goleman, 2006). Empathy is a concept that is ingrained in the leadership style of every leader. It has been proposed by many leadership theories that empathy is the bedrock of leadership. If a leader does not care for their followers' needs and achievement, this is not the essence of transformational leadership. Transformational leaders motivate their followers with a vision that is greater than themselves. They inspire, set clear goals, have high expectations, stir emotions, and get people to look beyond their self-interest to achieve something meaningful. They inspire followers consistently.
Researchers like Joireman et al. (2006) noted that leaders who can feel empathy for their subordinates better understand and guide them to achieve the organizational goals. In turn, they can go down to their followers' level to motivate, uplift them, and use persuasive skills and psychology to manage their feelings and emotions. This trait is particularly inherent in transformational leadership as the leaders with empathy can look at issues from a more comprehensive and different angle to solve problems effectively. They then motivate the followers to use positive ways to help solve their predicaments and ultimately meet the organizational goals. These traits and leadership styles lead to higher productivity, reduced absenteeism, and greater job satisfaction (Kellet et al., 2006). Bass (1985) also stated that leaders who possess these traits are much more adventurous in engaging with their followers and ultimately lead to the company's' objective being meet consistently. One of the key traits that were highlighted by Mete (2007) also suggested that the leaders have emphatic feelings towards their subordinates whereby they listen to the follower's grievances, spend considerably long time engaging with their concerns, and would, if the need arises, coach them to attain success in their tasks. It essentially creates passion and commitment towards the organizational goals, thus boosting the follower's capability and obligation to effectively and efficiently achieve the goals set by their leaders.
According to Pillai et al. (1999), transformational leaders do not use coercion to control and handle the situation negatively. It will create discomfort and chaos among subordinates, which will lead to unhappy followers and create a wedge between the management and subordinates. Transformational leaders insist on only using motivation and positive reaffirmation to engage with the followers to create harmony, increase motivation, interactive dialogue to achieve the organizational goals. They also have been known to use soft skills and persuasiveness to stimulate the followers to streamline the organizational objectives and goals, thus eliminating undue biases or discrimination. It motivates the followers to work towards a better culture, engage in highly organized communication via dialogue and innovative problem-solving techniques to achieve the company's goals more resourcefully.
All transformational leaders recognize that empathy is a soft skill that is worth nurturing to motivate subordinates to increase the productivity of the company and ultimately lead them to acknowledge the follower's abilities and emotional stability as part of the work environment that enhances the leader-subordinate relationship (Silvester et al., 2007). Leaders who approach a problem from a different angle use positive coercion, motivate followers relentlessly to achieve their personal goals, and aim that these ground-breaking problem-solving highly modernized techniques will ensure the subordinate's individual goals complements the organizational overall objectives and goals.

Service Quality
With the advancement in technology, health care service quality has taken a vital step to position patients' quality, medical care, and notably the overall service rendered to the patients in a hospital setting. With the upsurge in importance in health care for patients, the service quality, according to Trompenaars and Hampden-Turner (1998), has taken the medical world to the next level with their medical claim that directly enhances the patient's well-being with the application of medical innovation and science that maximizes its benefit with no-risk or risk-free notion. Van Velsor and Leslie (1991) describe the quality of healthcare provided to patients as the utmost priority of every hospital and IJAE Page 190 should meet the latest clinical guidelines and standards set by the healthcare industry in a country, thus meeting the patients' needs satisfies stakeholders.
Only while maintaining high-quality behavior with a keen interest in patients care and protection can lead to increased life expectancy, reduced mortality, and achieving the healthcare industry's overall objective and goals. As in the case of transformational leaders who build a strong relationship with their healthcare providers, the followers are infused with strong motivation, clear vision, and soft skills that give them a sense of significant impact towards their patients that ultimately lead to a better working environment and patient care (Wolf et al., 2002). Andrew et al. (2008) referred to approachability, efficacy, enhancement of quality care for patients, and continuous support and caregiving as the penultimate epitome of service quality in the healthcare industry. Leaders with sociable nature develop a network of people who work diligently to augment open communication among patients and caregivers while maintaining scheduled tasks, instructions, emphasizing deadlines, and collectively working toward the hospital's goals.
In one of the UAE's studies, hospitals revealed leaders with a passion for the five service quality dimensions, reliability, responsiveness, tangibles, assurance, and empathy, identified a strong positive relationship with service quality and performance (Bass, 1985). The majority of the studies conducted in the healthcare sector have identified inputs such as hospital resources comprising of staff, medical equipment, medicine, innovative technology, competent staffs, courteous communication, collaboration, caring nature, accessibility, and patient outcomes as the most vital properties to achieve a steady healthcare patient relationship. These programs build bonds between the patient and healthcare provider and help boost retention, as does a dual incentive program, with rewards for both quality service care providers and teams. Building morale, promoting cohesion and supporting team members all create a sense of spirit that helps maintain empathy when a patient in need calls in for help (Davis, 1980). Another observation identified from this program is the healthy customer/patient satisfaction achieved from implementing the quality of service provided through appropriate responsiveness, intangible, reliability, empathy, and assurance in carrying out their daily work. Ultimately, this could also lead to better patient loyalty or retention level in the healthcare industry.

Empathy
Motivating followers to achieve organizational goals and objective is paramount to leaders who are viewed as emphatic (Nettle, 2007). The bond creates an innate relationship between leaders and followers and helps the problem-solving process in the workplace. If there is no vision and clear transparency in the communication between the management and employees, disruptions can occur that can side-track the goals. In this instance, empathy is viewed as the savior grace for critical success in the organization. Plutchik (1987) believes that the higher the empathy a leader possesses, the more vibrant and successful his or her leadership becomes. Without the essence of empathy, the organization will seem less likely to achieve their goals and shared vision. In some societal relations between employees and leaders, empathy is a controlling variable for success. According to Huang et al. (2006), leaders' traits include empathy, understanding, farsightedness, mindfulness, managing emotions, receptiveness, and harmonization with a wide variety of people.
A leader with empathetic ability can decipher various signals and codes from the followers and manage their emotions professionals without resorting to biases or discrimination. Empathy is recognizing another person's emotion and dealing with it in a manner that binds ethics and encourages motivation. A good leader might raise the followers' level by acting and indulging in situations arising from his/her experiences. It helps identify the leader with the subordinate and brings them closer to one another, thus increasing the motivation and performance. A study by Meyer et al. (2002) concluded that the higher level of empathy portrayed by the leader, the higher the efficacy and effectiveness of the service received by patients in a hospital setting. When leaders encourage positive feelings towards their followers, they lead by example (Schein, 2004). Creating reverberation among subordinates releases positive feelings and emotions that bind the followers, propelling them to achieve the organizational goals and objectives. This fundamental nature of showing emotions and feeling towards followers is the core of leadership. In the absence of emotional intelligence, chaos surpasses, leading to discomfort and dysfunctional unity in business management. In a study conducted by Yahaya and Ebrahim (2016), he believed that a leader's essence is traits inherent in his vocation to increase IJAE Page 191 followers' self-esteem and create a feeling that will lead them into a harmonious working environment and culture. In some studies, Rubin et al. (2005) have stressed that leaders who are empathetic towards their subordinates maintain an apparent directional authority. Sometimes in exceptional situations, empathy can backfire to be counter-productive in decision-making. When the followers are contented with the leader, this circumstance might lead to disunity between then leaders and followers in making decisions that affect the organization's smooth running. Hence, getting too personally involved with followers can lead to disruptions and create disharmony in the relationship. In this kind of situation, empathy can be a cacophony that will not be effective when leaders give orders or expect them to obey their instructions. Past researchers have concluded that without empathy, the leaders will not instruct and coordinate the follower's emotions and perform critical leadership activities (Stein et al., 2009).

METHODS
The study used a cross-sectional questionnaire survey design. Participants were asked questions about their self-efficacy, team efficacy, health, and well-being and asked to rate their immediate manager (line manager) on various leadership behaviors. Transformational leadership has been shown to operate and be critical at this managerial level (Bass, 1999). Questionnaire research in Denmark does not require approval by ethic committees, and thus, approval was not sought. However, the study was approved by the Danish Data Protection Agency and followed the regulations for data storage and protection. Also, before completing the questionnaire, participants received information about the study, and it was made clear that participation was voluntary. Also, participants returned their completed questionnaires directly to the research group. In this study, we used two types of structured questionnaires. The first questionnaire used was the leadership inventory index (LPI) to measure their leaders' perceptions. The second one was the Consumer Assessment of Healthcare Providers and System (CAHPS), used to measure the service quality rendered to the patients at UMMC. A five-point Likert scale was used to gauge the relationship between the variables identified in the study. The respondents were mainly from UMMC's patients and staff. The data collected were analyzed using SPSS version 21.0. The results of the study are presented in the following section.

RESULTS
The total number of respondents in this study was 540, and most of the employees who participated in this study were females (77.8%), while most of the patients who participated in this study were also females (82.3%). The majority of the respondents have at least a diploma, unlike the patients from a sedentary background to high school leavers. The Kaiser-Meyer-Olkin (KMO) and Bartlett's Test of Sphericity tests were used to measure factor analysis. According to Table 1, the result for the KMO test was 0.887, and the result of Bartlett's Test of Sphericity showed that the data did not have multicollinearity problems, and the correlation between the items was enough to perform the factor analysis, where p < 0.05. .000 Reliability analysis was carried out to ensure that the instruments used in the study were stable and consistent. Table 2 shows that the alpha value was .89 for leadership and .91 for service quality. The mean score and standard deviation are shown in Table 3. The score for leadership effectiveness, service quality, and overall service quality was perceived as high by the respondents. Overall, the study concluded that the patients were satisfied with the level of service they received from the UMMC staff. The study also found that transformational leaders and empathy do have a significant relationship with employee behavior. The study findings contribute to existing studies on transformational leadership and service quality (Weberg 2010) and add new knowledge about the associations between transformational leadership style and positive perceptions of service quality and work-life balance. A leader who successfully empowers staff develops a climate of mutual trust increases job satisfaction, and fosters a commitment to the organizational goals, culminating in delivering highquality patient care (Sheldon & Parker 1997).

DISCUSSION
In an organization, the managers are armed with the right traits to instill the followers to achieve the organizational goals. Many leaders use motivation, mobilization, inspiration, goal setting, positive mindsets, harmony, enthusiasm, and courteous communication, to name a few, to achieve the organizational objectives. From the study, we can conclude that empathy can benefit service quality in hospital settings. Using empathy helps leaders achieve better understanding among the staff, customers, and the organization itself. Combining transformational leadership with service quality in the hospital environment positively impacts the service rendered to patients. Good quality of service will ultimately lead to patient satisfaction and repeat patient enrollment in the same hospital.
Enhancing quality of service care for the patients will lead to higher revenue for the hospital with added satisfaction, reduced turnover, increased patient outcome, increased efficiency, and sustained reputation (Bellingkrodt S., & Wallenburg, 2015). The patients were treated with respect and professional conduct by the staff of UMMC. Good leaders embrace the high service quality treatment given to the patients by the staff. Many of the patients were satisfied and overwhelmed. Effective leadership involves formulating a clear understanding of what the followers want and how to embrace this connection to achieve organizational goals. In many cultures, the ability to connect empathy with performance is highly desirable for leaders (Clemes et al., 2011). The empathetic leaders are the assets in an organization that binds the followers and the broader communities by effectively building a critical relationship to maintain a culture of compassionate understanding for organizational success.

CONCLUSION
The study of leadership and the approach to leadership training in the health care environment has suffered because of a lack of consensus and empirical support around which types of leadership are effective. Transformational leadership has empirical support and is principles-based, relationshiporiented, intuitively appealing, and potentially "transformative." Additional education for physicians and physicians in training in transformational leadership is warranted.