Knowledge management orientation and operational performance relationship in medical tourism (overview of the model performance in the COVID-19 pandemic and post-pandemic era)

Abstract

Despite the considerable growth of interest in medical tourism in the last decade, there is no standard procedure to measure the pivotal factors in medical tourism destinations. Medical tourism is a rising global phenomenon that is strongly dependent on innovation and knowledge management. Being both innovative and systematic in medical tourism requires thought enrichment in knowledge management in hospitals. By applying a quantitative method, “knowledge management-oriented innovation” items have been used in this study to analyze new products or services related to active hospitals in medical tourism in Iran. This study presents the positive effects of the most essential knowledge management areas such as time, cost, and quality management orientation, on operational performance through the mediating role of innovation speed. In the current study, hospitals of Iran that are active in the medical tourism area have been considered as the final destination. Additionaly, because this study coincides with the coronavirus COVID-19 pandemic as the global health crisis which has a considerable effect on medical tourism, the managerial implications have been developed to help managers and decision-makers in order to apply the obtained findings during the pandemic and post-pandemic period.

Keywords

hospital innovation knowledge management area medical tourism operational performance

Introduction

Interest in medical tourism is rapidly increasing, and medical tourists have many different alternative destinations for treatment. Hospitals that deliver services with low cost and high quality have more chance to compete in this market.^1–4 On the other hand, delivering such services taking time, cost, quality, and other related knowledge management areas into account is a complicated task for general and functional managers in such hospitals. According to the statistics reported by literature⁵ there are more than 30 countries with hundreds of hospitals and clinics around the world for delivering services to medical tourists. This information indicates the importance of being systematic, innovative in hospital management^6,7 to attract medical tourists as much as possible.

Recently, medical tourism has received attention as a serious topic for consideration. This industry is growing in Asia every year and many countries compete to attract more medical tourists by delivering high-quality and low-cost services.⁸ Many countries and companies are involved in medical tourism, but this type of tourism does not have accurate fundamental indicators. Iran is one of the appropriate destinations in the Middle East for medical tourists since it offers both touristic attractions and high-quality health care services in hospitals (e.g. fertility treatments). Many hospitals in Iran are leading destinations for medical tourism.^9,10

According to the literature, in many studies regarding medical tourism, the primary focus is on time, cost, quality, and being innovative,^2,11 but there are not any procedures or measurement indices to measure them. A study² proposed cost and quality as the fundamental factors of medical tourism but, the main concern is how to standardize the international hospitals in this area.

In addition to the main objectives of the study, the novelty of the current study is found to be laudable in different ways. For the first time in the literature, by applying “knowledge management-oriented innovation” items proposed by literature¹² we are going to examine whether time, cost, and quality management orientation (TIME, COST and QUAL) in innovation processes will increase innovation speed (IS) and operational performance (OP). Additionally, the effects of these factors on medical tourism, especially in international hospitals, in Iran are scrutinized.

Unfortunately, in 2020, the COVID-19 pandemic spread across the globe.¹³ The UN World Tourism Organization estimates that the travel industry could further decline by 60% to 80% by the end of 2020, calling it the “worst crisis that international tourism has faced since records began.”. Based on the results, in order to deliver new products and services in the pandemic and post-pandemic era, it is fundamental to consider time, cost, and quality-related factors and improve operational performance.

Tatum¹⁴ had investigated this issue, lately. The author illustrated how the growing number of COVID-19 infections affected the planning and strategies negatively. Almost there is not any open international border and the market share is expected to fall until 2021 because patients avoid unnecessary travel. Uncertain future would be appropriate to describe the future of this industry. By choosing efficient strategies and appropriate responses to the pandemic, Iran as a case country of this study has potential to be a reliable destination for future international patients. Indeed, such procedures will put Iran in a good position in the market.

As much as we may want to wish, the COVID-19 crisis will not be the last such aggregate shock. By not focusing on skills aimed at sustainable medical tourism, we have already produced several generations who may not be psychologically equipped to deal with such challenges. Because this study coincides with the coronavirus COVID-19 pandemic as the global health crisis which has a considerable effect on medical tourism, the managerial implications have been developed to help managers and decision-makers in order to apply the obtained findings during the pandemic and post-pandemic period.

The rest of the study is arranged in the following sections. The next section presents literature review by presenting the theoretical background and the conceptual framework. The third section will present the whole procedures of methodology while the fourth section defines data analysis. In the last sections, conclusion and managerial implications and also the limitations and further research are presented.

Literature review

Theoretical background

A study¹⁵ mentioned different areas as fundamental indicators in knowledge management theory. Among their specified areas including organizational behavior and strategic management, some elements like innovation, performance measurement, and quality management have been mentioned. It shows that the importance of knowledge management in innovation cannot be ignored in any organization because it leads to having a better performance, more efficient operational works, and delivering higher-quality products and services. In addition to this study, literature^16,17 examined the theory of innovation in organizations. However, considering all the constructs emphasized in the current study, knowledge management theory is the one that covers all of them.¹⁵ Knowledge management has a connection with other underlying theoretical foundations, which indicates its main role in management theories. It is developed in organizations to enhance the performance of important factors like creativity in organizations, productivity in operational work, the quality of both products and services, and etc.

One of the main concerns of managers in such organizations is how to measure knowledge management indices as it is crucial to be measured quantitatively. Since theories of quality and risk management were adapted to be used in knowledge management, thus, developing measurement items for knowledge management and its processes is fundamental in this area.¹⁵

The current study proposes a way of measuring knowledge management factors, specifically in innovation processes, for the first time. Additionally, it examines the effect of different knowledge management areas on IS and OP.

Conceptual framework

Medical tourism

There are different terms and definitions of medical tourism. According to literature¹⁸ medical tourism is a phenomenon organized through institutions rather than individuals’ own decisions to travel abroad for treatment. A study¹⁹ mentioned that medical tourism integrates both touristic and medical aspects for patients who travel to a new environment to receive services with less cost and high quality. Literature²⁰ defined it as traveling abroad with the aim of improving one’s health, or alternatively, any organized travel to other countries to enhance or restore an individual’s well-being in mind and body. Afterward, a study²¹ defined it as traveling to have treatment with high quality and more accessible services, or as the act of traveling abroad to receive medical care. According to all the definitions, the main purpose of medical tourism is the treatment in hospitals in another country and any mistake could be fatal in this case. Based on this purpose, literature²² suggested the terms of “International Patients” instead of medical tourists, and later on, a study²³ mentioned that medical tourism is not a suitable term, and “International Medical Travel” may have a better meaning in this area.

Medical tourism in Asia

As a consequence of globalization, the first world’s medical services are delivered at third-world prices in some parts of Asia.²⁴ A study²⁵ stated how destination cities and the medical tourists' markets are crucial in the medical tourism sector. According to them, among medical tourism cities, those which deliver low-cost services in less duration time have more medical travelers. As a tourism destination, there should be some factors which present its priority in comparison with the other destinations.²⁶ According to literature²⁷ the number of medical tourists is increasing every year. The number grew from 19 million travelers in 2005 to near 26 million in 2007, and the estimated statistics by the UN World Tourism Organization illustrated that the number of individuals engaged in healthcare tourism increased by 32% between 2005 and 2010, and around 42% increase in revenue. Literature²⁸ highlighted Asia’s high-quality medical services as one of the main reasons for the continent’s significant market share. Asian countries received 4.3 million medical tourists in 2010, generating over 6.7 billion dollars revenue, and became the most preferred destinations for medical treatments.²⁹

Medical tourism in Iran

Iran, as a legal country in the world, is a good destination for couples with infertility problems. Medical tourism has a considerable market share for fertility treatment, and 5% to 30% of the world’s population has been affected by primary or secondary infertility.³⁰ Thus, many couples around the world are seeking such a destination at a lower price and a higher quality. By analyzing studies related to the hospitals’ quality in Iran, between 2000 and 2016, the results emphasized on the importance of quality of services in hospitals.³¹

Many hospitals and clinics in the Middle East serve fertility treatments,³² and more than 70 clinics and medical centers deliver fertility treatment in Iran, as well. The founder of Avicenna Research Institute and Avicenna infertility clinic in Iran stated that five to ten percent of patients are international patients from different countries.³³ Iran is surrounded by Muslim countries such as Iraq, Afghanistan, Pakistan, Turkey, and Azerbaijan. With more than 7,000 years of urban settlements and many touristic places, Iran is a priority location for these countries regarding medical tourism. Reproduction technologies are illegal in some countries,^34,35 but Iran has many specialized centers for fertility treatments like “Royan Institute” in Tehran and “Fertility and Infertility Center” in Isfahan.³⁶

The active and aggressive market, developed infrastructure, international accreditation, expert doctors, and above all, having a lower cost of treatments rather than the developed countries and other Asian countries, such as Jordan, Turkey, Dubai, and Saudi Arabia, are some of the main motivators for medical tourists to choose Iran.¹⁰ Moreover, as a medical hub delivering high-quality services, Iran is a suitable destination for people from Muslim countries. The Iranian government is interested in attracting more tourists in both the medical and tourism industries, and its vision is to achieve 20 million international tourist arrivals by 2024.¹⁰ As the health care regulation may be different in each country, patients prefer to choose a country with the most cultural similarities besides geographical distance.^37–39 Therefore, most of the medical tourists are from neighboring countries such as Afghanistan, Turkey, Azerbaijan, Pakistan, Iraq, and also, countries with a coastline on the Persian Gulf like Oman, United Arab Emirates, Saudi Arabia, Qatar, Bahrain, and Kuwait prefer to come to Iran, as these countries have the same religion and also more valuable currency comparing to Iran which encourages them for medical services with less price and high quality in this country.^40–42)

Waiting time, professional doctors in different fields like transplantation of liver, heart and also cosmetic surgeries, nevertheless still there is a lack of infrastructural developments about this country.⁴³ Iran is among the best ten countries which have the most touristic attractions in the world.⁴⁴ Knowledge management areas and innovation in medical tourism

Knowledge management is a fundamental indicator of tourism destinations.⁴⁵ Recently, medical tourism has gained more market share among service industries in many countries. In short, globally, medical tourism is one of the fastest-growing tourism sectors.⁴⁶ The main concern in this industry is attracting more customers by proposing new services and products to the market. Thus, recognizing motivation factors is crucial for active destinations and hospitals in this industry.^47,48 In terms of motivating factors, many studies have been conducted to identify push and pull factors. The main push factors for choosing a destination are lack of expert doctors, low quality of services, and lack of medical technologies.^34,49,50 Another study,⁵¹ identified high costs as the main push factor, and innovation, high quality, and patient-doctor relationships as the main pull factors.

Literature²⁷ reported that Asian countries are delivering medical services with the characteristics of high quality, less waiting time, and less cost, as well as offering the best medical equipment. Time, cost, and quality management areas are crucial in innovation processes and will enhance IS in organizations.⁵² These knowledge management areas in innovation processes have some standard steps which should be followed if hospitals want to present the product or service in a correct and professional way. Innovation could be measured by two main dimensions of speed and magnitude.⁵³ IS defines that the time should be expended on the whole process of delivering any new product or service to the market. It shows the organization’s capability in the innovation lifecycle. IS is the main factor to measure innovation and presents its success in the market.⁵⁴ In fact, IS emphasizes being systematic in delivering new products and services in less time to the market. Hence, it is chosen to measure successful innovation in the current study and develop related hypotheses. This study presents how applying standard steps of TIME, COST, and QUAL in innovation processes will improve the IS, and consequently the OP of hospitals.

The main objectives in innovation processes are a reduction in time and improvements in performance while the quality is also considered. Then, time management orientation and following its standard procedures will improve successful innovation. By executing all standard steps of time management, organizations present more successful innovations.² According to the mentioned opinions and studies, the following hypothesis could be developed:

H1. TIME has a positive and statistically significant relation to IS.

Cost management is a fundamental factor regarding innovation processes, and it needs detail analysis before delivering the new product or service to the market. Cost management directly affects innovation.^55,56 By performing cost management’s standard procedures, organizations present a significant improvement in innovation.⁵⁷ The speed and cost of innovation have direct relation together and need to be analyzed for any type of innovation in organizations. According to the mentioned relationship regarding cost management and IS, the following hypothesis could be developed:

H2. COST has a positive and statistically significant relation to IS.⁵⁸ mentioned that quality is a fundamental indicator to enhance innovation. Literature⁵⁹ studied the importance of quality in innovation processes, and consequently in performance, regarding new product and service development. Later on, literature^60,61 emphasized that the quality is the main issue in delivering new products or services in less time and cost. Moreover, literature⁶² proved that without considering quality, increasing the speed of innovation does not worth indeed.

Quality in international hospitals is more complicated as patients expect better services comparing to their home country 2. Quality management means the standards should be checked from the beginning to the end of innovation processes. In sum, regarding innovation processes, the final products should meet all the required quality.⁶² By emphasizing on the importance of quality management orientation in innovation processes the following hypothesis is developed:

H3. QUAL has a positive and statistically significant relation to IS.

Innovation and operational performance

Managers working in hospitals active in medical tourism need a suitable tool for the measurement of their success level in this industry. In many previous studies, being strongly innovative and delivering high-quality services at a low price has been frequently suggested.^63–65 There are two main concerns in this area. First, ensuring the success of all innovation types by applying systematic procedures, and secondly, monitoring the outcomes of being systematic in the innovation process. If hospitals are innovation-oriented, then they have a high IS, which is the initial seed of any activity related to innovation.⁵³ Consequently, having the innovation-oriented system leads hospitals to a high OP in practice.⁶⁶

IS is an important factor to present performance and competitive advantage.⁶⁷ Organizations are encouraged to foster innovation in order to remain competitive in the market.⁶⁸ Organizations with better innovation have also better performance.⁶⁹ Innovation directly affects OP,⁷⁰ hence scholars are interested to find more about the importance of innovation in performance.⁶⁶ In other words, IS is a factor to present less time and cost by improving the performance.

Innovation improvement has different effects on different areas. It strongly improves OP as a significant result.⁷¹ Improvement in innovation leads organizations to present a better financial and OP.⁷² Therefore, the following hypothesis is considered:

H4. IS has a positive and statistically significant relation with OP.

As the necessary intangible asset for any organization, knowledge should be elaborately managed. Wang and Wang⁷³ examined the influence of knowledge sharing on IS and OP in their study. The results illustrated that different types of knowledge sharing will enhance IS and OP by emphasizing on knowledge management orientation.

In the current study, a similar model will be applied to present how chosen knowledge management areas will improve IS and OP while IS is a mediator. This model was also supported by the results of a study conducted by literature⁷⁴ which stated how improvement in knowledge management has a positive effect on OP.

Regarding time management as a subfactor of knowledge management areas, by performing it’s all standard steps in innovation processes, OP will be improved. In fact, performing time management practices have significant effects on OP;⁷⁵ and consequently, the following hypothesis could be developed:

H5. TIME has a positive and statistically significant relation with OP.

Cost management orientation and efficient analysis will improve OP in organizations.⁷⁶ By performing cost management standard steps like cost estimation and budget determination and control, absolutely organizations present a better performance.⁷⁷ By executing standard steps of cost management in organizations, OP will be increased. Cost management has a direct relation to OP.⁷⁶ The effect of cost on OP is obvious for all industries.⁷⁸ Then, by relying on cost management’s fundamental role in innovation processes, the following hypothesis is developed:

H6. COST has a positive and statistically significant relation with OP.

If organizations aim to present better OP, they should meet the required quality standards in execution.⁷⁹ In fact, there is a direct relationship between quality management and OP. Quality management is a process from the beginning to the end of delivering any new product or service, which directly affects OP. Literature⁸⁰ mentioned that without considering quality, the organization could not present a high OP in practice. Additionally, they stated how both quality assurance and quality control improve OP, which supports the following hypothesis development:

H7. QUAL has a positive and statistically significant relation with OP.

Considering knowledge management areas, this study argues that knowledge management practices not only have a direct and positive relationship with OP but also influences IS. Literature⁷³ examined the influence of knowledge sharing on IS and OP. In their proposed model, IS is the mediator between all knowledge sharing categories and OP. The chosen knowledge management areas for the current study are time, cost, and quality management. Time management has a positive relationship with both innovation and OP,⁷⁵ and IS has a positive relationship with OP too.⁷⁰ According to these relations, by emphasizing on time management orientation in innovation processes, the following hypothesis is developed:

H8. IS is a mediator between time management and OP.

Cost management has positive relationships with both innovation⁵² and OP.⁷⁸ Hence, by considering the mediation role of IS between knowledge management areas and OP, the same relationship could be applied to present how cost management orientation in innovation processes improves OP by mediating the role of IS. Therefore, the following hypothesis is developed:

H9. IS is a mediator between COST and OP.

Knowledge management practices enhance both IS and OP. It contains ten main areas, that quality management is one of them, and this relationship could be applied to each of them. Therefore, by considering the positive relationship between IS and OP,⁷⁰ and by emphasizing on quality management orientation in innovation processes, the following hypothesis is developed:

H10. IS is a mediator between QUAL and OP.

Research model

The research model in this study contains five main constructs, exhibited in Figure 1. This figure displays that TIME, COST, and QUAL have positive relations with OP. In addition, this model proposes that IS has relations with OP, and mediates the effect of TIME, COST, and QUAL on OP.

Figure 1.

Research model.

Methodology

Procedure and sample

Data collection was performed through the participation of international hospitals’ general and functional managers in Iran. The authors directly contacted to the managers for presenting the importance of the study and asking to answer the questions about measurement items in a meeting around 30 minutes for each. Data collection was conducted from June up to November 2017.

Hundreds of hospitals existed in Iran, specializing in different types of treatments forced the authors to use the convenience sampling technique, that is a type of non-probability sampling method where the sample is taken from a group of easy to contact managers. As a rule of thumb, to analyze the covariance-based Structural equation modeling (SEM), it is suggested to find around 10 respondents per question in the self-structured questionnaire.⁸¹

To minimize the common method bias, proposed by literature⁸² managers were ensured about the management support through a cover letter. The questionnaires were developed according to the project management body of knowledge, which is in English, and the official language in Iran is Persian. Thus, the back translation was performed for all the items.

The chosen cities for data collection in Iran are Yazd, Tabriz (neighboring Azerbaijan, Armenia, and Turkey), Tehran, Mashhad (neighboring Afghanistan), and Rasht. All the mentioned cities are well-known destinations for medical tourism in other countries. For instance, Tabriz contains 20 hospitals that deliver services to international patients, and it is famous for open-heart surgery, infertility, and joint surgery. In 2011, the number of international patients who visited this city was 4,680 and it increased to 5,231 in 2013.⁴³

To increase the validity and generalizability of responses using a convenience sampling method, 290 general and functional managers among 17 highly equipped hospitals related to medical tourism are considered as the sample. The questionnaires were collected two weeks after distributing them, and finally, 269 samples were retrieved.^81,83

Measurement items

The developed items are multiple-items and designed using a five-point Likert scale ranging from strongly disagree (1) to strongly agree (5) (See Appendix 1). In summary, 15 items were used to assess time, cost, and quality areas regarding innovations processes.¹² Additionally, IS was measured through five items proposed by literature.⁵³ Five items were used to assess OP according to literature^84,85 studies. The items related to measuring IS and OP are supported by the results obtained by literature.⁷³

Profile of respondents

290 questionnaires were distributed and 273 questionnaires were regained. However, four of the retrieved questionnaires were invalid, thus 269 questionnaires were analyzed (The response rate was 92.76%). The demographic information of the managers who contributed to this study has been shown in Table 1. According to the results, the majority of the respondents were males (54.65%). The largest work experience was ranged from 5 to 10 years (51.67%) and in the age interval of [35–44] (44.24%). 57.62 were married and 46.47% of respondents hold master's degrees regarding educational level.

Table 1.

Demographic information about the respondents (N = 269).

	Frequency	Percentage
Gender
Male	147	54.65
Female	122	45.35
Work Experience
<5	61	22.68
5–10	139	51.67
11–15	56	20.82
16–20	13	4.83
Age
25–34	59	21.93
35–44	119	44.24
45–54	67	24.91
55–64	19	7.06
> 65	5	1.86
Marital status
Married	155	57.62
Single	71	26.39
Divorced or widow	43	15.99
Educational level
High school or less	6	2.23
Associate degree	15	5.58
Bachelor’s degree	99	36.80
Master’s degree	125	46.47
Doctorate degree	24	8.92

Data analysis

In order to test the proposed interrelations among exogenous variables (TIME, COST, and QUAL), and the mediating variable (IS) with dependent variable (OP), structural equation modelling (SEM) was performed using analysis of moment structure (AMOS 23.0). SEM allowed us to test the causal relationships among variables of the model and to analyze the obtained measurement data to identify how well the proposed model fits the data.^86,87 SEM is a multivariate analytical approach used to simultaneously test and estimate complex causal relationships among variables, even when the relationships are hypothetical, or not directly observable.^88,89

Further, to identify the mediating effects of innovation speed (IS) in the relationship between independent variables (TIME, COST, and QUAL) and dependent variable (OP), this study followed the subsequent procedures:

Firstly, the independent variables (TIME, COST, and QUAL) need to have relations with the mediator (IS) (H1, H2, and H3). Secondly, the independent variables (TIME, COST, and QUAL) must be significantly related to the dependent variable (OP) (H4, H5, and H6). Finally, the mediator (IS) should be connected to the dependent variable (OP) (H6).

In this study, in order to test the mediation effects of IS for H8, H9, and H10, respectively, bootstrapping procedures as one of the most flexible and reliable methods are applied.^86,90

Reliability and validity of research constructs

The variables are reliable because of the results obtained from the reliability (α). All questions loaded properly on their intended factors more than 0.70 thresholds, and the overall reliability coefficient was 0.936.⁸¹

In advance of testing research hypotheses using the SEM, it is necessary to carry out confirmatory factor analysis (CFA) to examine the relationship between observed variables and their underlying latent constructs. Additionally, it must be ascertained whether the measures and components were consistent with the model, and whether the proposed model is fit or not. A range of indices is used to assess the model fit including the overall χ2 measure, Incremental Fit Index (IFI), Tucker-Lewis Index (TLI), Comparative Fit Index (CFI), Goodness of Fit Index (GFI), and Root Mean Square Error of Approximation (RMSEA). The outcomes of primary analysis before CFA display that the model fit indicators are χ2/df = 2.148 (p-value < .001); IFI = .865; TLI = .883; CFI = .872; GFI = .849; RMSEA = .086. This denotes that the research framework has partly met the criteria of the goodness of model fit.

After conducting the CFA, the computed factor loadings of all items are above 0.50 as shown in Table 2. According to this table, the final fit indicators of the overall model are χ2/df = 1.803 (p-value < .001); IFI = .947; TLI = .939; CFI = .946; GFI = .913; RMSEA = .055. This signifies that the research framework has met the criteria of the goodness of model fit.⁹¹

Table 2.

Measurement items.

Scale items	Factor loading	Mean	SD	Cronbach’s Alpha
Time management- oriented innovation (TIME)		.873	.502	.877
TIME 1	0.58
TIME 2	0.62
TIME 3	0.71
TIME 4	0.71
TIME 5	0.81
TIME 6	0.79
TIME 7	0.70
Cost management-oriented innovation (COST)		.911	.720	.910
COST 1	0.89
COST 2	0.88
COST 3	0.87
COST 4	0.75
Quality management-oriented innovation (QUAL)		.853	.592	.851
QUAL 1	0.72
QUAL 2	0.89
QUAL 3	0.77
QUAL 4	0.78
Innovation speed (IS)		.854	.545	.854
IS 1	0.87
IS 2	0.83
IS 3	0.73
IS 4	0.60
IS 5	0.61
Operational performance (OP)		.881	.599	.875
OP 1	0.83
OP 2	0.85
OP 3	0.77
OP 4	0.76
OP 5	0.64

In the following, the construct validity examines the extent to which a scale truly measures a construct of interest, including convergent and discriminant validity.⁹² We considered convergent validity or the extent to which blocks of the reflective items converge in their representation of the construct. The scale is supposed to be reliable when the construct reliability (CR) is greater than 0.7 and evidently all of the scales looked greater. Factor loadings (FL) below than 0.50 should be omitted and as it is seen all FL ranged from 0.60 to 0.89 in Table 2, exhibit satisfactory convergent validity, as factor loadings. The convergent validity test also needs the average variance extracted (AVE) numbers meet the threshold of 0.50.⁹³ All items in the research attained this threshold. Additionally, the results mentioned in Table 3 show that all construct reliability values are greater than the AVEs list between 0.502 and 0.720.⁹⁴

Table 3.

Convergent and discriminant validity criterion.

	CR	AVE	MSV	ASV	COST	TIME	OP	IS	QUAL
COST	0.911	0.720	0.412	0.268	0.848
TIME	0.873	0.502	0.486	0.378	0.642	0.706
OP	0.881	0.599	0.411	0.324	0.473	0.552	0.774
IS	0.854	0.545	0.411	0.280	0.396	0.557	0.641	0.738
QUAL	0.853	0.592	0.486	0.341	0.529	0.697	0.596	0.494	0.769

CR: construct reliability; AVE: average variances extracted; MSV: maximum squared variances; ASV: average squared variances.

Discriminant validity is present when the Maximum Shared Squared Variance (MSV) and Average Shared Squared Variance (ASV) are less than AVE. All constructs met these requirements. Moreover, literature⁹⁵ suggested that the square root of AVE in each latent variable can be used to cogitate discriminant validity if this value is greater than their corresponding inter-construct correlations values. Based on the following Table 3, in support of the discriminant validity of the measurement scales, indicating acceptable discriminant validity. Then, all MSVs and ASVs should be lower than their corresponding AVE, respectively.

Model testing results

Structural equation modeling (SEM) approach was implemented to test the hypothesized relationships in the proposed model. Figure 2 illustrates the path coefficients and the overall fit indexes:

Figure 2.

SEM analysis of research model. Model fit: χ2/df = 1.803 (p-value <.001); IFI =.947; TLI =.939; CFI =.946; GFI =.913; RMSEA =.055; *** p <.01, ** p <.05, *p<.10; Standardized coefficients are used and T-values are in parentheses.

As estimated, H1 indicated that TIME has a positive and statistically significant relationship with the IS. The result is significant (β = 0.340, p < 0.01), and thus H1 is supported.

H2 proposed that COST has a positive and statistically significant relation with IS. The findings confirmed that COST has no positive effect on IS (β = .023, p > 0.10). Thus, H2 is rejected.

H3 suggested that QUAL has a positive and statistically significant relation with IS. The results support H3 (β = 0.165, p < 0.05).

In the following, results reflect that TIME has a positive and statistically significant relation with OP (β = 0.237, p < 0.05). Thus, H4 is supported. The results are also depicting that cost management has a positive and statistically significant relation with OP (β = 0.163, p < 0.05) which is in agreement with H5. Moreover, based on the outcomes on Table 4, for H6 (β = 0.399, p < 0.01), quality management has a positive and statistically significant relation with OP thereby supporting H6. Lastly, for the direct effects, the effect of IS on OP (β = 0.870, p < 0.01) is positive and significant intensely.

Table 4.

Hypotheses (H1 to H7) testing results (n = 269, CI = 95%).

Hypothesis		Path Coefficient (β)	T-value	Support/reject
H1	TIME => IS	.340***	3.579	Support
H2	COST => IS	.023	.410	Reject
H3	QUAL => IS	.165**	2.159	Support
H4	TIME => OP	.237**	1.987	Support
H5	COST => OP	.163**	2.077	Support
H6	QUAL => OP	.399***	3.994	Support
H7	IS => OP	.870***	7.693	Support
R Square		.402

***p < .01, **p < .05, *p<.10.

According to the attained R-square, less than 50 percent of the total variance of the dependent construct (OP) is explained by predictors. Possibly, because of this matter and also the strong relation between IS and OP, the existence of IS as a mediator leads to improve the total variance explained and the power of analysis.

The model proposed that the effects of TIME, COST, and QUAL on OP are mediated by IS. In order to test the mediation effect of IS for H8, H9, and H10, respectively, bootstrapping test executed with 2000 bootstrap samples and 95% Bias-Corrected (BC) confidence level. The results are presented in Table 5.

Table 5.

Mediation test hypotheses (H8 to H10) results.

Hypothesis		Total effect	The mediator is IS		Mediation effect	Support/reject
Hypothesis		Total effect	Indirect effect	Direct effect	Mediation effect	Support/reject
H8	TIME => OP	.237**	.205***	.028	Full	Support
H9	COST => OP	.163**	.022	.143*	No	Reject
H10	QUAL=> OP	.399***	.089*	.308***	Partial	Support

R²		.402	.525
$Δ$ R²			.123***
$Δ$ F		43.156 (4, 264)

***p < .01, **p < .05, *p<.10.

According to H8 and H9, and H10, IS probably mediates the relationships of TIME, COST, and QUAL with OP. Following the bootstrapping test procedure for mediation, it is revealed that the total effect of TIME on OP (β = 0.237, p < 0.05), which met the main requirement that the independent variable relates to the dependent variables without mediation impact. Afterward, although an indirect effect, which was measured the relationship of TIME on OP through the mediator (IS), shows a positive significant relation (β = 0.205, p < 0.01), no direct connection recognized between TIME and OP at the presence of mediator (IS) (β = 0.028, p > 0.10). Consequently, H8 is supported, and IS as a highly effective mediator can fully mediate the relationship between TIME and OP.

According to H9, IS mediates COST regarding OP. Since COST doesn’t have an indirect effect on OP (β = 0.022, p > 0.10) (See Table 5), IS couldn’t play a mediator role between cost management and OP and H9 is rejected.

As stated by H10, the relationship between QUAL and OP mediates by IS. Following the above procedure, the results of the path analysis illustrate that the total effect of the relationship between QUAL and OP is positive and significant (β = 0.399, p < 0.01). As it is observable in Table 5, QUAL has a significant indirect effect on OP, thus, the required antecedent-criterion relation for the mediation effect is met. Since there is a significant direct effect from QUAL to OP at the presence of mediator (IS), IS partially mediates the relation of quality management and OP. Thus, H10 is supported.

Conclusion and managerial implications

For destination marketers, presenting a positive image is fundamental as it directly impacts the customers’ decision making and attracts potential tourists.⁹⁶ Consequently, a positive image stimulates their visiting intentions.^97–99 About medical tourism, destinations delivering low-cost services and high performance are among the main indicators.¹⁰⁰

The results of the current study present how TIME and QUAL will enhance IS and improve OP in hospitals. Additionally, the mediating role of IS between TIME, QUAL and OP was supported. By proposing a model discussing the influence of TIME, COST, and QUAL on IS and OP, this study proves that being systematic in innovation processes will increase OP in hospitals. According to literature¹⁵ in knowledge management theory it leads the organization to high innovation and high OP, which supported by the results of the current study.

COST did not show a positive relationship with IS in this case study but presented a positive effect on OP. This variable by measuring three professional terms and conditions requires professional financial managers familiar with the terms. During the meetings conducted to define the main purpose and procedures for general and functional managers, some of them were completely unaware of the standard terms, hence it could be one of the reasons for rejection of the hypothesis which stated cost management has a positive relation with IS, and IS mediates the relationship between cost management and OP. According to the results, performing standard steps of cost management will enhance OP in hospitals.

The important role of conducting standard steps of time and quality management in innovation processes in hospitals, which deliver medical tourism services, supported by the results of the current study. These results aware managers of comprehensive analysis before delivering any new product and service to the medical tourism market.

The current study is trying to aware managers active in medical tourism about the critical role of time, cost and quality management and systematic innovation processes. Additionally, relying on governmental support, this study may have a considerable effect on the growth of medical tourism in the market. The mediating role of IS between TIME and QUAL, and OP was confirmed through the SEM. In sum, all three chosen knowledge management areas contribute to hospitals’ OP, and, according to the results, TIME and QUAL have positive and direct relations with OP through the mediating role of IS.

The results of the current study provide many useful recommendations for hospital managers. Managers should consider all the standard steps regarding any new idea for any knowledge management area if they want to remain competitive in the medical tourism market. The results show how to achieve a better OP by using knowledge management areas in innovation processes.

The findings help managers to articulate implementing standard steps of time, cost and quality management to promote hospitals by delivering better OP and increased numbers of new products and services. The items related to measuring three chosen knowledge management areas,¹² expands managers’ knowledge about correct and systematic innovation with a comprehensive analysis to increase IS and OP and reach a larger market for medical tourism.

The proposed model informs hospital managers about the importance of performing detailed analysis regarding knowledge management areas to reach IS and OP. It is critical for hospital managers to know how the standard steps of each knowledge management area improve success in innovation and performance. Hospital managers are strongly recommended to write strategies for performing standard steps for each knowledge management area, and especially any new idea.

Project management has 10 main knowledge management areas. This means 10 functional managers should manage each of them, like a risk manager, cost manager, or human resources manager. Maybe one person has two duties and the human resources manager is also the stakeholder manager, but in practice, these duties need an assigned person.

Iran has some main obstacles including lack of a specific database for medical tourism, lack of international behavior training and lack of people with the necessary skills besides incapable marketing. The government has a vision of achieving 20 million international tourist arrivals by 2024¹⁰ but in practice, the governmental laws, airlines, hotels, and hospitals’ procedures do not support it. Thus, it is strongly suggested to enrich the procedures and standards for all the related organizations active in tourism, and especially hospitals active in this industry.

During data collection processes, the general and functional managers mentioned some important weaknesses of this industry. One of them was lack of a systematic and professional advertisement system. In fact, marketing procedures are not integrated and still need improvement. Such a system ensures in new product or service development, previous recorded data and lessons learned are considered in practice.

Appropriate communication channels are effective, as patients need active and friendly communication with doctors and other staff. Hence, it’s strongly suggested to the hospital managers active in medical tourism to training their doctors and staff about their English language improvement and in some cases have some staff who knows different languages like Arabic for example. This language is completely demanding because after sanctions against Iran the main focus is on regional countries and actually most of the current patients are from Arabic countries.

In Iran, medical tourism cities are experts in different fields. For example, Tehran is well known about tuberculosis and lung disorders; Yazd for infertility, Mashhad for heart surgery and orthopedics and Shiraz for kidney diseases and marrow transplants. Then in each city, there should be some special agents to promote these strengths and professions to the international market through appropriate marketing strategies. In fact, the vision of medical tourism development and its strategies are focused on developing Iran as a center for Muslim countries but still, there is a long way to prepare other connected industries.

At last, according to the additional aim of this study to adapt the implications and help managers and decision-makers for applying during the pandemic and post-pandemic period, in order to deliver new product and services, it is fundamental to consider the standards steps of time, cost and quality management in innovation processes and improve operational performance in the international hospitals. Regarding time management oriented innovation the research questions asks managers to be aware about all the involved activities; their sequences and the assigned resources for time reduction in delivering new services to international patients that play an important role in this special period. Also for cost management oriented innovation by reliable cost estimation and budget, hospitals will enhance their performance in delivering low cost services. Additionally, in quality management oriented innovation both quality assurance and quality control activities help involed hospitals to deliver high quality services. Consequently all the mentioned procedures by relying on the obtaind results leat to present high speed innovation and considerable operational performance to attract more international patients.

Limitations and further research

The results of this study have been obtained from data collection in Iran and could vary in different countries. Further, the results are reliable in the current situation of international hospitals active in this industry, and absolutely the condition of international hospitals may change in the following years.

Data collection was conducted in international hospitals in Iran, but this does not mean all of them have international accreditation certificates. Surely, they have national accreditation certificates, but when it comes to medical tourism, being globally certified and professional is necessary.^101,102

Another problem is the lack of a project management office, which is a basic requirement for systematic project management. Further, some of the functional managers were not familiar with some professional terms related to professional project management.

Regarding motivational factors for choosing a destination, there are several studies^103–105 which present the push factors for choosing a destination in another country. About Iran, some pull factors more than time, cost and quality could be discovered by performing exploratory research in hospitals.

Future researchers could define and perform suitable strategies related to implementing knowledge management areas regarding high IS and OP. It is strongly suggested to researchers to examine which knowledge management area has the largest effect on innovation in hospitals. This could differ by hospital according to the organizational structure and other factors.

In today’s competitive medical tourism environment, hospitals need specialists in both general and functional management positions. Professional project managers are familiar with all the knowledge management areas. Performing qualitative research to examine managers’ knowledge about each knowledge management area is critical for hospitals eager to remain competitive in the medical tourism market.

This study focused on variables dealing with the managerial level and points of view. For further studies, it is recommended to choose dependent variables from the medical tourists’ point of view and the received services. These variables could be word of mouth, patient trust, patient satisfaction, and patient retention.

In the current study, the main involved knowledge management areas were time, cost and quality, and focusing on stakeholder management area strongly is suggested for future studies. It is crucial in Iran, as ‘Identify Stakeholders’ the first main step of this area still needs more endeavors and plans. In addition, the current study supposed medical tourism as an isolated industry which its main concern is innovation in its new products and services but actually, other related industries have a direct effect on this industry too. The factors which are fundamental in choosing a city are medical, economic, and also culturally related factors. Additionally, government policy may affect patients’ decision making. Researchers by focusing on airlines, hotels, internal transportation, and cultural aspect can aware of the managers about their weaknesses and main requirements.

Another new term in medical tourism is hospital hotels. These hospitals offer accommodation to international patients. Gandhi hospital hotel in the capital of Iran has many international patients and could be a good center for future researches regarding its patients' point of view and main requirements.

Footnotes

Authors’ Note

Iman Aghaei is now affiliated with Faculty of Economics and Administrative Sciences, Cyprus International University, Nicosia, North Cyprus, Turkey.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Matina Ghasemi

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