“Effect of servant leadership on the performance of a regional general hospital”

Currently, leadership becomes the concern of studies in public organizations. However, studies on servant leadership and its impact on hospital performance are still limited. This study aims to identify the relationship and impact of servant leadership on organi- zational performance (hospital). A quantitative approach was used on a sample of 729 healthcare workers at the Undata Regional General Hospital in Palu. The sampling was based on the Slovin formula with an error rate of 5%, thus it involved 258 respondents. Further, the sample was selected using a random proportional sampling technique to represent each field in the hospital. The data were analyzed using descriptive statistics and simple linear regression analysis with hypothesis testing. The results of descriptive analysis on the servant leadership variable showed that the highest mean value is the item stating that leadership in the hospital has a thorough understanding of the organi- zation and its goals. Meanwhile, the lowest is the item stating that leaders sacrifice their interests less to meet the needs of healthcare workers. In the organizational perfor- mance variable, the highest mean value is the item that states that healthcare workers can work effectively every working day, while the lowest is the item of patients com- plaining about healthcare procedures. Furthermore, the results of regression analysis through hypothesis testing showed that servant leadership has a significant effect on organizational performance of hospitals with a strong level of relationships.


INTRODUCTION
The performance of hospitals in Indonesia is in the spotlight due to many complaints from the public as service users. This condition decreases public trust in health services in Indonesia, particularly in regional general hospitals. Regional general hospitals as health services in the regions have to be more responsible for the health services provided, for example, improving performance increases public trust in the hospital performance. Concerning the increase in hospital performance, the leadership role cannot be ignored. Servant leadership will be appropriate to be applied as it is service-oriented. The servant leadership style is considered appropriate as it has a service character. Servant leadership is gaining support among many healthcare workers as a unique leadership style suitable for patient care due to its focus on service, listening, empathy, and healing (Murphy et al., 2020).
Servant leadership is expected to influence subordinates to improve the performance of regional general hospitals in Indonesia, particularly Undata Regional General Hospital in Palu. In the globalization era, there is industrial competition in all fields, including the service industry in the healthcare sector such as hospitals. Public sector or-ganizations have the responsibility to provide public services. Thus, innovation and performance improvement is mandatory for organizations in the public sector (Felício et al., 2021). Therefore, the formulation of the problem is whether servant leadership has a relation and influence on organizational performance. Strong leadership is needed to solve institutional and bureaucratic problems (Poister, 2010), including organizational performance.

Servant leadership and organizational performance
In organizations, servant leadership is a management approach focusing on providing value and promoting sustainability for stakeholders (Lemoine et al., 2020). Servant leadership is a leadership concept offering scope to study this phenomenon as serving leaders focusing more on meeting the needs of followers and less satisfying their personal needs (Ghosh & Khatri, 2018). Servant leadership is characterized by an emphasis on leaders serving their followers first (Worley et al., 2020). In particular, servant leadership can establish a combination of motivation to be a leader and a need to serve others (Lythreatis et al., 2020).
In an organization, leaders play a great role in improving organizational performance ( Indeed, the health service system in general hospitals in Indonesia is poor to present (Listiyono, 2015) based on the indicator of medical personnel and hospital management who have not fully provided patient rights and showed transparency (Lestari, 2010). Many healthcare workers, both nurses and doctors, work unprofessionally and even provide unsatisfactory services. Unsatisfactory services are certainly caused by poor performance. For this reason, it is necessary for regional general hospitals in Indonesia to improve their performance through leadership styles. Leadership is closely related to organizational performance outcomes . It is expected to improve the performance of regional general hospitals in Indonesia, particularly at Undata Regional General Hospital in Palu. Based on these elaborations, this study aims to determine the relationship and effect of servant leadership on organizational performance.

Hypotheses
This study proposed the following hypotheses: H1: Servant leadership has a significant effect on organizational performance.
H2: Servant leadership has a relationship with organizational performance.

METHODOLOGY
This study used a quantitative approach. It used both primary and secondary data collected through observation, questionnaires, and doc-umentation. The questionnaire was developed using servant leadership and organizational performance variables. The servant leadership variable was adopted from the Servant Leadership Questionnaire (SLQ) (Liden et al., 2008(Liden et al., , 2015, while the organizational performance was based on the dimensions proposed by Poister et al. (2008) and Wholey et al. (2010). The questionnaire has been tested for validity and reliability.
A validity test aims to measure and determine the level of accuracy, while reliability is to determine the level of consistency of research instruments (Heale & Twycross, 2015). The validity level of the instrument was based on the correlation coefficient value. The commonly used correlation coefficient is less than 0.3 for weak correlation, 0. The target group of this study included healthcare workers at Undata Regional General Hospital in Palu, Central Sulawesi Province, with a total of 729 people. The sample was selected using the Slovin formula with an error rate of 5% and resulted in a sample size of 258 respondents. It used a random proportional sampling technique to represent each field in the hospital. The questionnaire was distributed proportionally to all health units in the general hospital in Undata, Palu. Therefore, there were representations of each sector to meet the objectives of the study. The questionnaire was distributed, collected and verified systematically. If some questions had not been filled, the respondents were asked to fill them in.
The data were analyzed using descriptive statistics and simple linear regression analysis. Descriptive statistical analysis used is as the mean value. Before performing the regression analysis, the validity and reliability of the questionnaire were tested first. The simple linear regression analysis in this study was to reveal the influence and relationship between servant leadership and organizational performance variables.

RESULTS
This study performed the descriptive statistical analysis and linear regression using Statistical Product and Service Solutions (SPSS). The statistical analysis covered validity and reliability tests, descriptive statistics, and hypothesis testing.

Results of validity and reliability tests
The validity and reliability tests used the SPSS on the item-total statistics table covering servant leadership variable (X) and organizational per-formance variable (Y). The results on the servant leadership variable (X) indicate that the questionnaire is valid and reliable (Table 1).

Results of descriptive statistics
In this study, descriptive statistics functions to describe the characteristics of each respondent's response to the question. Table 3 shows the results of descriptive statistics of the servant leadership variable. Table 3 shows that the servant leadership shown by the leadership of the Undata Regional General   Hospital in Palu indicates that the leader has a thorough understanding of the organization and its goals, is always honest, and can solve problems with new or creative ideas. However, the results also show that any decisions that are made in the workplace must be discussed with the leadership. Besides, the descriptive results show that the leadership at the Undata Regional General Hospital is less willing to sacrifice personal needs for the benefit of the healthcare workers (subordinates) in the hospital.
Meanwhile, Table 4 shows the descriptive statistical results of organizational performance variables.
The results of the descriptive statistics indicate that the performance of the Undata Palu Regional General hospital is good. It means that healthcare workers work effectively every working day, achieve success in patient care every day, manage to carry out special handling in each of their work units; and the hospital prioritizes improving the quality of service. However, some performances were considered poor as indicated by patients complaining about service costs, attitude of the healthcare worker, and healthcare procedures.

Results of hypothesis testing
In this study, the hypothesis testing used a simultaneous significance test (F-statistical test). It aims to determine the influence of the independent variable (X) on the dependent variable (Y).
The F-statistical test is to determine whether the independent variable (X) influences the dependent variable (Y).   the independent variable (X) significantly influences the dependent variable (Y). The results indicate that H1 and H2 are accepted meaning that servant leadership has a significant effect on organizational performance.
Moreover, Table 6 shows the relationship and effect of the independent variable (X) on the dependent variable (Y).

DISCUSSION
This study focuses on the effect of servant leadership on the performance of regional general hospitals in Indonesia. It was identified through hypothesis testing. Leadership is vital in all areas of the organization, including in the health sector It indicates that studies focusing on servant leadership is still limited compared to other leadership styles such as transformational. However, it is indicated that this study is highly relevant, particularly in the health sector, as there is no study focuses on servant leadership and organizational performance.
This study aims to determine the effect and relationship between servant leadership and organizational performance. The results of this study proved that servant leadership has a significant effect on organizational performance and hypotheses are accepted.  Although the hypothesis testing showed the effect of servant leadership on organizational performance, some aspects need to be considered. The effect is showed by the leader of the Undata Regional General Hospital in Palu that has a thorough understanding of the organization and its goals, is always honest, and can solve work problems with new or creative ideas. However, decision-making should be a concern as the results show that any decisions that are made in the workplace must be discussed with the leadership. Besides, the leadership at this hospital is less willing to sacrifice personal needs for the benefit of healthcare workers (subordinates) in the hospital. Regarding decision-making, the leadership must give authority to subordinates because working in hospitals needs quick responses, so all health workers must make decisions quickly without having to wait for leadership instructions.
Meanwhile, for performance, the Undata Regional General Hospital in Palu is considered good. It means that healthcare workers can work effectively every working day, achieve success in patient care every day, and manage to carry out special handling in each of their work units; and the hospital prioritizes improving the quality of service. However, some performances are considered poor indicated by patients complaining about service costs, attitude of the healthcare worker, and healthcare procedures.
In this study, servant leadership contributes to the performance of the regional general hospital. It means leadership highly determines performance improvement. Servant leadership is widely used in the health industry in which this concept grows and develops due to the complex condition, risk, and transparency needs in this sector (Mustard, 2020). The health industry is full of risks so that it needs leadership support in its management. Servant leadership is a leadership style suitable for protection/safety (Schopf et al., 2021). It shows that servant leadership is highly appropriate to be applied in hospitals, especially the government hospitals that have been in the spotlight because of their poor performance.
Servant leaders have a strong mind and heart capable of serving their subordinates (Mustard, 2020). The intended subordinates are healthcare workers at the hospital. Thus, servant leadership helps improve hospital performance. In health organizations, the quality of performance highly depends on the quality of every professional who works in it (Gaspar et al., 2021). Organizational performance covers customer service, cost management, quality, productivity, and asset management performance (Durst et al., 2019). Organizational performance needs the support of the organization in terms of providing bonuses, compensation, and incentives following the goals and utilization to enable the organization to maximize performance and continue to grow (Lovett et al., 2021). To achieve high organizational performance, a hospital needs to take advantage of some remuneration strategies, improve services and provide an affordable cost for customers (Hidayah et al., 2020).
Provision of rewards to healthcare workers indirectly affects their performance and it can be done by leaders. Servant leadership has a greater effect on employee job satisfaction (Eva et al., 2021). This leadership style can encourage and support subordinates to have high performance. Besides, leadership support is highly needed. Leadership can be developed through organizational support in communication and trust in one's ability to be an effective leader (Bush et al., 2020). The results of this study are expected to contribute to the health sector, especially for health service providers by promoting leadership behavior.

CONCLUSION
This study found that servant leadership applied in regional general hospitals is different from the character possessed by servant leadership as all decisions in implementing duties of health workers in hospitals should not all be discussed with the leader. In general, to improve hospital performance, a leader with serving character is needed, but not each health sector in a hospital fully requires such a character. For example, in making decisions related to medical performance, there is no need to involve hospital leadership. It is significantly different if it is associated with the performance of the hospital in general, which needs directions and decisions from the top leadership of the organization. The results of this study are expected to contribute to the development and improvement of hospital performance through related variables and can be applied in all health services.