Collaborating in a health-care process: partner, not customer

Purpose – The internal customer concept is used with different de ﬁ nitions and purposes in research and in practice – an ambiguity with implications for both scholars and practitioners. The purpose of this study is, therefore, to explore the representation of the internal customer concept in quality management literature and re ﬂ ect on how the user may affect collaboration in health-care processes, in particular between a service functionandhealth-care staff. Design/methodology/approach – A review of the internal customer concept in the literature, followed by a conceptual discussionbasedon previous studies andtheoriesof organizationaldiscourse. Findings – Three predominant types of relationships related to the internal customer concept were found. The study shows that the ambiguity in the use of the concept may have consequences for the interpretation and application of research results. Potential undesirable consequences with regard to collaboration in processes arediscussed. Originality/value – This study contributes to a new understanding of the internal customer concept in research and practice. As collaboration within and between organizations is increasingly required in many parts of health care, careful considerations become necessary regarding concepts used for relationships to avoid sub-optimization and “ us-versus-them ” thinking andto strengthen trust-basedrelationships.


Introduction
Interaction and co-creation between health-care professionals and the patients are a growing interest in health care. Many actors have common interests in increasing the value for patients and the pursuit of a sustainable system. The patient's needs, therefore, constitute the goal that holds the process together. To achieve the collaboration needed, resources and processes must be coordinated (Eriksson et al., 2020;Gibbs, 2019;Grönroos, 2019;Strokosch and Osborne, 2020;Vargo and Lusch, 2016). For example, an efficient supply process in health care depends on close collaboration between service functions and health-care staff to ensure high quality for the patient (Fibuch and Ahmed, 2015) and cross-functional collaboration in planning the facility design can contribute to higher effectiveness in the core process (Kok et al., 2015).
In quality management literature, the term internal customer is often used to define a certain relationship between actors in an organization, but the question is if there is a customer relationship with anyone besides the patient. So why then is it so important to discuss the concept as such? A statement from an actor in a study of a supply process in health care may indicate the issue (Karlsson et al., 2020).
Due to the plenitude of organizations, it is important to be equal. You may not use the customer concept too much. [. . .] We are partners.
Fundamental to sustainable collaboration is that the actors recognize each other's competence and capability, which requires interactions based on trust, respect, shared understanding and reciprocity (Adler, 2001;Li et al., 2018;Schoorman et al., 2007). On the contrary, actors who assign organizational identities to each other can contribute to a reduced understanding of the choice of activities, and thus prevent increased efficiency (Skålén, 2004). A common language including the use of concepts can, on the other hand, contribute to internal integration (Schein, 2010). Over time, a new concept, such as customer, can be included in the spoken language and should, therefore, be used consciously in research and in practice to counteract negative consequences (McLaughlin, 2009). Analysis of organizational discourse and its influence on language use and actions may, therefore, provide a deeper understanding of what motivates actions and thereby contribute to efficient improvement work (Chia, 2000;Fairclough, 2005). Furthermore, studying a discourse or a concept as an intangible object can increase the understanding of the dynamics of the collaboration (Sullivan and Williams, 2012). Using metaphors when studying a concept can provide new perspectives on the concept outside the studied context (Morgan, 2006).
In summary, in the effort to manage the entire system and achieve integration, word choice can be a powerful tool for creating action, consensus and collaboration (Lockwood et al., 2019). In contrast, concepts that describe relationships can objectify the relationship and visualize the power relationship and as a result, possibly influence the collaboration (McLaughlin, 2009).

The internal customer in research and practice
The internal customer concept is mainly used in two overlapping research areas; quality management and internal marketing (Lings, 2004;Marshall et al., 1998). Originating from the Japanese practice of quality management, the purpose of the internal customer concept was to increase efficiency in processes (Ishikawa, 1985). The use of "customer" and "supplier" denotes handovers between sub-processes and whether the actors are considered internal or external depends on the organizational boundaries (Garvare and Johansson, 2010). The use of the internal customer concept may, thus, act as an integrator in a process leading to improved quality and satisfied external customers (Gummesson, 1987). However, this view of the next process as a customer is criticized because a process is often part of a network of processes in a system (Ljungberg, 2002). Stauss (1995) argued that internal services are provided by a distinct organizational department or its employees to other departments and that the users of the service would be seen as internal customers. Another use of the internal customer concept is to describe the relationship between employee and employer, but this use is considered controversial due to the unequal relationship (Hales, 1994;Mudie, 2003).
Internal marketing may be defined as a strategy that aims to ensure that employees are service-oriented. Research has shown that internal customer satisfaction, employees' perceptions of their jobs, their colleagues and the organization and external customer satisfaction are interdependent (Heskett et al., 1994). However, this correlation is questioned and, in contrast to measurements on external customer service, there is a lack of valid and reliable instruments for measuring internal customer service (Farner et al., 2001;Lings, 2004). Instruments for measuring external customer satisfaction are, therefore, often used to measure employees' satisfaction with internal services (Al-Ababneh et al., 2018). In addition, measurements are often performed to evaluate processes without a theoretical basis and clear purpose, which can, thus, lead to incorrect decisions (Anttila and Jussila, 2017).
As a metaphor, the internal customer concept can be associated with the characteristics and perceptions of an external customer (Hales, 1994;Morgan, 2006). Intra-organizational relationships are, thus, metaphorically regarded as market-based where the supplier is assumed to fulfil the customer's wishes. However, several characteristics distinguish internal customers from external customers (Brandon-Jones and Silvestro, 2010;Marshall et al., 1998;Rafiq and Ahmed, 2000;Stauss, 1995). For example, an internal customer can rarely choose between suppliers, even if they are dissatisfied with quality or cost. Moreover, internal suppliers can seldom deliver alternative products or services or negotiate prices set by management. However, to gain power in a relationship, an actor can appeal to discursive legitimacy (Dewulf and Elbers, 2018). An example is to refer to the saying that "the customer is always right".
As a result of reforms within the framework of new public management, internal markets have been introduced in the public sector to raise financial awareness and efficiency (Gummesson, 2002;Hood, 1991). However, the reforms have proven to have unforeseen consequences in practice and by making them visible, the understanding of what actions affect the pursuit of set goals (Hood and Peters, 2004). Collaboration based on trust may, therefore, complement and balance the negative effects of market-based principles (Adler, 2001).
In summary, the theoretical discussion of the internal customer concept originates mainly from the 1980s and 1990s. Although the term is widely used in quality management literature, it is rarely defined (Cannon, 2002). The literature shows that the internal customer concept has been used with different purposes and in different contexts and as a result, the concept can be described as ambiguous. A central theme for quality management research is how to apply a system perspective on value creation, including methods for use in practice (Flumerfelt, 2020;Fundin et al., 2020). As research has pointed to the necessity of enhanced collaboration in health-care processes, more knowledge is needed as to what hinders and promotes collaboration (Schruijer, 2020;Vangen, 2017). Furthermore, studies of employees' reactions to changing governance principles in the public sector, such as the use of marketbased concepts, are limited (Sai, 2020). As far as we know, research on service functions in health-care organizations and their role in value creation for the patient is also limited.

Research aim
As the internal customer concept reflects relationships within an organization, its use may affect the actors' views of each other and, thus influence collaboration. The aim of this study is, therefore, two-folded: (1) to explore the representation of the internal customer concept in literature by identifying the way it is used and (2) to discuss the potential impact on the collaboration of the internal customer concept in health-care processes, in particular, the collaboration between service functions and health-care staff in value creation for the patient.
The study intends to contribute to research and practice by increasing our understanding of the potential consequences for collaboration in health-care processes of a market-based concept.

Methods
The understanding of a concept is influenced by the user's interpretation. The interest in the internal customer concept originates from empirical research (Karlsson et al., 2016;Karlsson et al., 2020) and the contradictions that are revealed in the presented literature.
Methods to achieve the first aim An examination of literature using the term "internal customer" was conducted. A Google Scholar search in December 2020 using the search string "internal customer" showed about 24,000 hits, more than half of these since 2012. For 2020 alone, the search resulted in approximately 1,000 hits. Accordingly, it was necessary to limit the search for papers and two new searches were performed. The first search (A) was conducted in Scopus and Google Scholar and based on papers referring to a paper by Stauss (1995), which deals with the classification of internal services in relation to quality management. For practical reasons a delimitation was made to publications in English-language scientific journals between 1996 and 2020, resulting in 50 papers after three non-retrievable papers were excluded. To explore if there were other uses of "internal customer", a second search (B) was conducted in Scopus. The search string was "internal customer" and "quality management" or "TQM" in abstracts, titles or keywords. A delimitation was made to publications in English-language scientific journals between 2000 and 2020, resulting in 31 papers after excluding one nonretrievable paper.
A summative approach to qualitative content analysis was chosen to identify and quantify words and content to understand the contextual use of "internal customer" (Hsieh and Shannon, 2005). The analysis was done in three steps: (1) the abstract was read for an overview of the purpose and context of the study, (2) the methods section was read to understand how the term internal customer was used in the paper and (3) the discussion section was read to determine if the paper discussed the internal customer concept regarding relationships.
The use of the term was then categorized according to the relationship described in the paper. The papers were then sorted by research method, the context of the study and publication year.
Methods to achieve the second aim The discussion of the potential impact of the internal customer concept on collaboration in health-care processes was based on a study of a service function in health care (Karlsson et al., 2016), a study on inter-organizational collaboration in a supply process in health care (Karlsson et al., 2020) and literature on organizational and market-based discourse. The study reported in Karlsson et al. (2016) included a service function in health care that provided services, such as cleaning, cooking, property management, purchasing and supply of materials and assistive devices. The purpose of the study was to describe the development of customer orientation in the service function. An internal customer was described as either an employee who e.g. ordered medical supplies or received information technology (IT) support or a manager who e.g. discussed premises with the service function. The study showed that there was an ongoing discussion within the management team on how to interact with health-care staff to create value for the patient, but that the introduction of an internal market had hindered collaboration.
The purpose of the study reported in Karlsson et al. (2020) was to explore what defines a perceived well-functioning collaboration in the inter-organizational supply process of providing assistive devices to disabled people. The study showed that the use of the customer concept had consequences for collaboration on equal terms because it accentuated boundaries between actors. The study also pointed to the importance of organizational collaboration in a supply process that encompasses great financial values.

IJQSS
With the support for reflections on organizational discourse and concepts (Chia, 2000;Fairclough, 2005;Morgan, 2006), a conceptual discussion was initiated on the internal customer concept in relation to collaboration in processes.

Results
In total, 81 papers, published in 65 different English-language scientific journals, were analysed. The distribution by year of publication is shown in Figure 1.
Studies from the private sector dominated with 46 papers, compared to 24 papers from the public sector and 4 papers concerned both sectors. A large majority of the papers (59) discussed service quality measurements, frequently in relation to another measurement and 22 papers discussed other quality management practices. About a third of the papers in Search B referred to other scholars' definitions of the internal customer, whilst the authors of papers in Search A often used several references to define the concept. The analysis of the papers revealed three types of relationships where the term internal customer was used, as shown in Table 1.
In about half of the papers examined, the internal customer was defined as an employee. The studies in Search A mostly concerned the relationship between the employer and the employee, for instance, the employee's perception of the manager and the working conditions. In papers in Search B, the internal customer was often assumed to be a participant in the organization's quality work. The internal customer as a recipient of service from a co-worker in the same department or process refers to a relationship between employees on equal hierarchical levels, but the actual departments or processes were not clearly stated in the papers. The papers where the internal customer was described as a recipient of services from other departments could be divided into two groups; either another department without specifying the services provided or a distinct department, such as IT services, facility management or procurement. In four papers, the employee was seen as an internal customer to both the employer, a co-worker and/or to employees at another department. The type of relationship was unspecified in three papers and one paper defined students as internal customers, although students were in other papers typically considered external customers.
Finally, 11 of the papers referred to different aspects of collaboration in the organization, such as success factors and obstacles, workflows and demands on management, but none of  Table 1.
Applications of the internal customer concept in the examined papers IJQSS the examined papers discussed the consequences for collaboration in relation to the use of the internal customer concept.

Discussion
The representation of the internal customer concept in literature The study has shown that the internal customer concept is used with different definitions in the papers examined. The study also shows that the term usually is used to describe employee respondents in service quality surveys. Differences and ambiguities in how the concept is defined can, however, hinder the user's interpretation and understanding of the specific quality that the measurement intends to highlight. This difficulty is reinforced in research on quality management where the internal customer concept is rarely well defined (Cannon, 2002) and confirmed in search B, which indicates that scholars regard the concept as well known and that it, therefore, does not need to be defined. It is also interesting to note that although all the papers in Search A referred to Stauss (1995), only about half of the papers defined an internal customer as a recipient of services from another department according to the proposed definition. To facilitate the understanding of the relationship examined, it would have been advantageous if the papers presented the questions asked; this was only done in about half of the papers that used quantitative methods.
In addition, the measurement of a recipient's satisfaction with internal services can be complicated depending on the type of service being evaluated; a single event or the overall service offering or whether the internal customer is an employee or a manager/ representative of a department (Karlsson et al., 2016;Stauss, 1995). Different methods for measuring service quality within an organization were used in the examined papers, but since there is no general agreement on methods for the measurements, standardization of measurements to enable comparisons between organizations and overtime is needed (Al-Ababneh et al., 2018;Anttila and Jussila, 2017;Farner et al., 2001;Lings, 2004). Furthermore, the point that internal customer satisfaction should not be mixed up with employee satisfaction would also be acknowledged (Stauss, 1995) and the use of the internal customer concept to describe the relationship between an employee and an employer needs to be discussed due to the unequal relationship (Hales, 1994;Mudie, 2003).
The potential impact of a market-based concept on collaboration in a health-care process The introduction of internal markets and market-based concepts in the public sector can have different purposes; to create a service culture within the organization (Gummesson, 1987) or to achieve more efficient use of resources (Gummesson, 2002;Hood, 1991). However, both purposes can have opposite consequences (Hood and Peters, 2004). Internal markets may strengthen boundaries between departments, which can lead to sub-optimization and "us-versus-them" thinking (Karlsson et al., 2016). In addition, the labelling of actors may hamper collaboration by creating imaginary boundaries in a process when the actors want to view themselves as partners (Karlsson et al., 2020). On the contrary, collaboration on service development and value creation for the patient (Karlsson et al., 2016), as well as the collaboration between organizations in supply processes that include considerable financial values (Karlsson et al., 2020), may increase efficiency and effectiveness in health care (Fibuch and Ahmed, 2015;Kok et al., 2015).
Furthermore, expectations of services associated with an external customer can, thus, possibly lead to reduced efficiency and tense relations between the parties if the expectations cannot be met (Brandon-Jones and Silvestro, 2010;Dewulf and Elbers, 2018;Marshall et al., 1998;Rafiq and Ahmed, 2000;Stauss, 1995). Viewing a care process in a network of processes, including support processes, can visualize joint value creation for patients (Eriksson et al., 2020;Flumerfelt, 2020;Gibbs, 2019;Grönroos, 2019;Ljungberg, 2002;Strokosch and Osborne, 2020;Vargo and Lusch, 2016). Awareness that service is a two-way relationship based on reciprocity (Marshall et al., 1998) and that language can help strengthen this relationship (Lockwood et al., 2019;McLaughlin, 2009) can support the pursuit of the common goal. To indicate the existence of a collaborative arrangement and a shared responsibility for the patient's quality, market-based concepts would be replaced, for example, to "partner" according to a proposal from an actor in a support process in health care (Karlsson et al., 2020).

Suggestions for scholars and management
The study shows that there is a need for more knowledge about how organizations can improve an internal collaborative culture that facilitates joint value creation, especially from a network perspective that includes support functions (Fibuch and Ahmed, 2015;Gibbs, 2019;Grönroos, 2019;Kok et al., 2015;Ljungberg, 2002;Strokosch and Osborne, 2020;Vargo and Lusch, 2016). Although it is difficult to evaluate and measure relationships and collaboration, research would take on the challenge (Eriksson et al., 2020). To contribute to a full understanding of the results of a study, researchers are encouraged to clearly define terms and measurements (Anttila and Jussila, 2017). Qualitative methods can complement surveys to a deeper knowledge of possible problems in the collaboration and highlight the reciprocity of the service (Stauss, 1995).
Both scholars and managers would be aware that internal markets and market-based discourse and concepts can emphasize certain aspects of an internal relationship. Failure to do so may mean that collaboration does not develop as expected and there is a risk that suboptimization and "us-versus-them" thinking will occur. Research can, therefore, contribute to practice with knowledge of barriers to enhanced collaboration.

Limitations
The papers examined constitute only a fragment of the literature where the term is used. The search method influenced, which publications were included in the study. There is a risk that the study may have missed relevant papers that use different terminology. Thus, the study may not provide a conclusive solution to reduce ambiguity in the internal customer concept. However, the choice of two searches with different search terms indicated saturation when no more themes were found after Search A. To strengthen the trustworthiness, the use of a summative approach to qualitative content analysis provided a non-reactive way of studying the internal customer concept. By interpreting the concept based on organizational relationships (Table 1), the analysis intended to show consistency in the interpretation (Hsieh and Shannon, 2005). The conceptual discussion of the internal customer concept in relation to collaboration in health-care processes was mainly based on reflections from previous research and literature on organizational and market-based discourse. However, this study may be an entry into further discussions and critical reflections on how market-based discourses and concepts can affect relationships and actions, in particular consequences for the integration of structures and collaboration.

Concluding remarks
The study shows that the internal customer concept can be categorized according to three different organizational relationships. The use of the concept can, thus, be described as ambiguous, which makes it difficult for a user of research to easily interpret the results without further information. Research has also shown that there is doubt as to whether methods, concepts and tools intended for external customer orientation are suitable for IJQSS achieving a service culture within the organization. The potential positive effects of the use of market-based concepts in organizational relationships cannot be assumed to be relevant today, for example, in health care due to increased organizational complexity. As collaboration in health care within and between organizations is increasingly required, discussion of concepts used for relationships becomes necessary to avoid "us-versus-them" thinking and to strengthen trust-based relationships. Systems thinking and common goals can help to shift interest from structure to processes and organized collaboration can support this endeavour. In summary, building a culture that values collaboration and promotes trust and reciprocity requires a conscious process where assumptions and organizational discourse and concepts are examined.