2.1 Flexibility rhetoric and practices

The concepts of flexibility have received significant attention from scholars and practitioners in several management disciplines (Buzacott & Mandelbaum, 2008; Chakraborty & Sengupta, 2014; Golden & Powell, 2000; Mishra et al., 2014; Shukla & Sushil, 2020; Vredenburg & Bell, 2014; Zhang, 2005). The academic literature has accepted the crucial role of flexibility in dealing with environmental uncertainties and a firm's ability to adapt (Idris, 2012; Upton, 1994). Flexibility has been observed as a multidimensional concept, reflecting the ability to cope with environmental uncertainties and increased responsiveness (Brozovic et al., 2016; Koste et al., 2004; Sushil, 2001). Many authors argue that flexibility is required as an inbuilt mechanism to facilitate improvements in firm processes (Jain et al., 2013; Lu et al., 2017; Mishra et al., 2014; Sushil, 2017; Zhang, 2005). Numerous researchers have examined the correlations of flexibility practices with new idea generation, firm performances, and customer satisfaction (Singh et al., 2020; Thakur et al., 2012). Furthermore, many ensuring studies argue that flexibility rhetoric and practices are essential to generate market responsiveness (Gerwin, 1993; Volberda, 1996). Das and Elango (1995) suggest that firms essentially need to develop flexible capacities for improved performance. Luangsakdapich et al. (2016) have represented flexibility as an effective mechanism to alter the quality requirements, introduce new products and services, and modify the existing products. In subsequent works, researchers develop various frameworks for modeling and analyzing flexibility (Alessandra et al., 2020; Liu et al., 2019). According to Ivens (2005), flexibility is crucial in turbulent environments, and the firm devotes resources and capabilities to exhibit flexibility. Previous studies (Koste et al., 2004) argue that flexibility has three significant elements as “range: mobility and uniformity.” These authors further suggest investigating how these elements in a particular region affect performance outcomes.

With the increasing importance of a service-based economy, scholars suggest exploring the dynamics of flexibility in services (Dumont et al., 2017; Lin et al., 2015; Vredenburg & Bell, 2014). Brozovic et al. (2016) posit that flexibility in services refers to adapting and creating customer values. A significant number of studies argue that flexibility in services is crucial for developing value propositions and therefore suggest identifying the dimensions of flexibility (Jin & Oriaku, 2013; Shukla & Sushil, 2020; Slack, 2005). Morgan et al. (2014) developed the conceptual model of flexibility in services and established its linkage organizational climate and culture. Previous studies proposed the significant role of flexibility with service quality and satisfaction (Da Silva et al., 2015; Idris, 2012; Powers & Jack, 2008). Many studies across service businesses (e.g., tourism, healthcare, software industries, and telecommunications) accept that flexibility practices are essential to strengthen the service orientation of the firms (Alessandra et al., 2020; Chakraborty & Sengupta, 2014; Liu et al., 2019; Shukla & Sushil, 2020). Gronroos and Gummerus (2014) opine that flexibility is an essential strategy for creating value and improving performance. The implications for developing flexible capabilities in services are more meaningful than the manufacturing sector (Brozovic et al., 2016; Luangsakdapich et al., 2016). These authors acknowledged that flexibility offers a rapid response for customized services and thus affects performance outcomes (e.g., customer satisfaction and loyalty). Liu et al. (2019) accept that several adjustments made by the service providers are the precise mechanism that influences value creation processes. Thus internal organizational processes and resources are reconfigured by the service providers to create new value propositions. Accordingly, Brozovic et al. (2016) suggest that service providers adjust their resources and capacity to deliver customized services. Recent studies have identified the role of flexibility to understand customer requirements and redesign services (e.g., (Alessandra et al., 2020; Lin et al., 2015). The service delivery systems in general and healthcare, in particular, are arguably faced with similar challenges to develop the capabilities to exhibit flexibility.

In recent years, the importance of flexibility from a market driving perspective has received significant attention in different contexts, which emphasize that providers act to redesign their services implying innovations (Glandon & Jaremski, 2019; He, 2019; Shukla & Sushil, 2020; Skålén et al., 2015). As a response to demand uncertainty, healthcare organizations are concerned about developing strategies to make them flexible. Vredenburg and Bell (2014) contend that healthcare flexibility is a competitive instrument that firms respond to environmental uncertainties and changes. Many healthcare studies suggest that flexibility affects clinical and business performance (Nair et al., 2013). Early studies on flexibility in a healthcare context involve decisions on facilities, equipment, and employees (Jack & Powers, 2006; Powers & Jack, 2008; Timothy, 2000). More recent research explored various operational issues and their linkages with patients' experience and satisfaction (Da Silva et al., 2015; Ponsignon et al., 2015). Powers and Jack (2008) argue that volume flexible capabilities are essential in a healthcare organization to cope with demand variability. Some studies have highlighted the importance of clinical flexibility in healthcare to deliver a range of services and increase responsiveness (Al-quaness et al., 2020; Nair et al., 2013). Evidence suggests that flexibility is essential in healthcare to deliver convenient services and handle a wide range of complaints (Flieger, 2017; Tuzovic & Kuppelwieser, 2016). Moreover, flexibility provides mechanisms to adjust to the changes and introduce new services or improve existing services (Gronroos & Gummerus, 2014). Despite the evolving paradigm of flexibility in healthcare, empirical studies that focus on different facets of market-focused flexibility and their crucial link to design new services are still scarce. Recent perspectives on value creation suggest that flexible disposition affects innovativeness differently (Heinonen et al., 2013). The critical appraisal of the existing literature reveals that the dynamics of market-focused flexibility and their influence on innovative services are unclear. Given the need for further knowledge about responsiveness and innovative performance, understanding market-focused flexibility is crucial.

2.2 Market-focused flexibility

Johnson, Lee, and Grohmann (2003) define market-focused flexibility as the firm's intent to configure the resources and capabilities to facilitate new value creation services. Rajshekhar et al. (2006) posit that market-focused flexibility represents the capability of adaptation to the changes to customize the services and hence closely related to customers. Consistent with this, market-focused flexibility attempts to customize the services at the mass and individual levels by utilizing a firm's resource portfolio. In this way, market-focused flexibility generates market responsiveness through adaptive capacity and introducing new services. Although considerable literature on flexibility exists across management disciplines, the critical issues to link the conceptualization with market-oriented services and customized deliveries are overlooked. In light of the current turbulent situations faced by healthcare firms due to COVID-19, the time is appropriate to explore the dynamics of market-focused flexibility and specify the facets (Jones & Comfort, 2020). Therefore, the study intends to explore the proactive view of market-focused flexibility that a firm needs to generate by utilizing its resource base and identifying the higher-order dynamic capabilities that form the market driving perspective.

Skålén et al. (2015) argue that executing flexibility in firm practices without a market focus will not help redesign services. Therefore, the conceptualization of market-focused flexibility in service organizations must consider market-linking activities and understanding customer idiosyncrasies (Brozovic et al., 2016; Lin et al., 2015; Morgan et al., 2014). Although many researchers focus on the market-focused perspective of flexibility (Johnson, Lee, Saini, et al., 2003; Morgan et al., 2014; Raj et al., 2006), there is limited knowledge on the factors that facilitate them to drive the market under the emergent conditions (e.g., changing service delivery models, new working methods, and advanced clinical processes). In healthcare, the direct implication of market-focused flexibility is that the composition of medical resources and capabilities are the foundation for developing new services, entering new markets, and surviving under dynamic conditions. Public healthcare organizations are particularly challenged to create the potential to serve a high volume of patients and provide new and unique services to them. Therefore, public healthcare needs to develop flexible capabilities by adjusting service capacity and introducing innovativeness.

Theorists on the resource-based view (RBV) suggest that firms can be viewed as a bundle of valuable resources and capabilities utilized to create various options for the firms to operate (Teece, 2014). The acquisition and utilization of valuable resources provide an infrastructure to develop the capabilities which generate operational flexibility and design news services (Amit & Schoemaker, 1993). RBV argues that organizations exhibit flexibility by treating resources as central consideration (Bhardwaz, 2000). The organization's skills and competencies utilize the resources that undergo an action to create value for the customers. Prahlad and Hamel (1990) contend that service operations should develop capabilities by which superior services are generated and delivered to create customer value propositions. The flexible capabilities allow customization of services and understanding the customers' context, facilitating the adaptive delivery systems (Brozovic et al., 2016). Therefore, customers can access new and customized services with ease. However, the extant literature does not indicate whether market-focused flexibility affects the innovative performance of the firms.

2.3 Innovative performance in public healthcare

Innovative performance is referred to as creating value through a set of practices, including improvements or new service proposals, service processes, and service delivery models. According to Lin and Chen (2012), innovative performance indicates greater achievements through new services. Some studies advocate that firm innovative performance is realized through the changes in current service offerings and thus affect customer emotions and attitudes (Lusch & Nambisan, 2015; Snyder et al., 2016). As a prerequisite of service innovation, it is crucial to close the gap between service design and standards to understand customer expectations. It creates a necessity for service organizations to adapt to environmental changes and respond to customer expectations. Service blueprints are better portrayed with service processes and aligned with customers' changing needs by executing a high degree of flexibility (Baier et al., 2015; El-kassar & Kumar, 2017).

The innovative performance as a strategic lever has been widespread in healthcare. Public healthcare organizations are concerned about their ability to remain competitive and create strategic values through innovativeness (Omachonu, 2010). Innovative performance in public healthcare is essential for sustainable performance and to create value. The rigid service delivery model and the scarcity of medical resources are significant challenges for public healthcare (Saha & Ray, 2019). Moreover, limiting services to the patients may have severe consequences, including death. Therefore, public healthcare organizations are focusing on flexibility in their process of care and generating market responsiveness. Researchers accept that public healthcare in emerging economies needs to develop market responsiveness in several ways to continuously renew their service portfolio and delivery models (Fletcher-Brown et al., 2018; Singh & El-kassar, 2019). Healthcare provisions, particularly public healthcare, have a central concern with keeping pace with new ideas and approaches that can be objectively defined for integrating extended service lines and improved offerings (Hou et al., 2019; Salge & Vera, 2009). As a key driver of public healthcare success, the emphasis on the skills, professionalism, working methods, and technologies should be scaled up to match with new and innovative services that benefit the customers. In this scenario, public healthcare organizations can be positioned in a successful innovation system, providing quality customer experience, and affecting customer emotions. While the public value of innovativeness in healthcare is significant, it is imperative to investigate how flexible mechanisms affect innovative performance.

2.4 Methodology

2.4.5 Data analysis and coding

The study first analyzed the facets of market-focused flexibility in public healthcare and then examined their role in improving innovative performance. The analysis relied on the elements of flexibility, as suggested in the literature (Koste et al., 2004): range, mobility, and uniformity. The qualitative data analysis was done using NVIVO 10 software (Welsh, 2002). All the responses were transcribed and fed into the NVIVO 10 package. The primary reason to select the NVIVO for data analysis over other packages was its simplicity to use and allowed the document extraction directly from the word package (c.f., Acharya & Mishra, 2017). Thematic analysis was employed to analyze the findings during the qualitative case study. The six-step process of analyzing the patterns of meaning within data was followed (Braun & Clarke, 2006). First, the familiarization of all the interviews and other types of data was done. The next step included organizing the data in a systematic and meaningful way. Further, significant patterns were identified and collated into initial themes. These patterns were further reviewed and grouped to converge into the themes. The fifth step of the thematic analysis process included the identification of the essence of the themes and their nomenclature. Finally, the process was documented and reported. The flow chart of the coding process is depicted in Figure 1. The emergent themes were demarcated within the raw data by the coders. Three coders (two professors and one research scholar) were requested to participate and help in the coding process. The coders started from the initial data corpus and generated initial codes to reduce them into small chunks. Based upon the questions of research, the coding process was concerned with capturing the relevant and meaningful text from each segment of data. There was no pre-set code but developed and modified as the coders worked through the coding process, called open Coding (Braun & Clarke, 2006). The recommendations of Fleiss (1971) were utilized to ascertain the inter-coder reliability. Fleiss's kappa (k = 0.93) was interpreted by the extent to which the observed value of agreement exceeded the expected value while all the coders made their random ratings. Further, percentage agreements on the presence of themes (c.f., Acharya & Mishra, 2017) between the coders were calculated. As recommended by the Boyatzis (1998) formula, a minimum threshold of 50% was considered for agreement on the presence of the particular theme (Table 2). The findings suggest the different facets of market-focused flexibility and explain their innovative performance in public healthcare settings (Figure 2).

TABLE 2. Summary of findings

Sl. No.	Market-focused flexibility and percentage of agreement between coders	Elements of market-focused flexibility			Innovative performance
		Range	Mobility	Uniformity
1.	Volume flexibility (65.96%)	Improving service quality, accommodating a large number of patients, lower mortality rates	Reduced waiting time, managing discharge rates	Uniform services to the admitted patients	Improvements in the registration process, computerized processes, forecasting, new delivery models, alliances with other hospitals to increase service lines
2.	Clinical flexibility (71.45%)	Quality of services offered, the productivity of services	Quick response for different services	Variety of clinical and diagnostic services	Technology-based equipment, increase in service lines, improvement in treatment modalities
3.	Service convenience flexibility (62.84%)	Quality services across locations, ability to serve at different timings, to offer a range of payment methods	Responsiveness to the preferences, delivery schedules, location, and offering new services	Uniform performance at various, Delivery schedules, Payment methods, number of new services offered	On-line services, digital delivery of diagnostic reports, home care, digital payment methods, telemedicine facility
4.	Patient recovery flexibility (70.55%)	Quality of support services, efficiency in complaint handling	Attentiveness and carefulness to the complaints, quick acknowledgment of problems, willingness to serve	Number of support channels, the speed of complaint handling or re-admittance	Complaint handling mechanisms, analysis of patient opinion, tracking of patient feedback, and recovery

3.1 Volume flexibility

Public healthcare delivery systems are faced with challenges to develop the potential to serve a high volume of patients. The current outbreak of COVID-19 has transformed the public healthcare systems into an operational crisis due to extended admittance and a high rate of patient arrival. Volume flexibility is referred to as a response to fluctuations in the volume of demand (Powers & Jack, 2008). For many Indians, these challenges are further exacerbated by increasing concerns about access to healthcare, availability of beds, and less waiting time. Volume flexibility represents the inherent capability to leverage its resources to manage the discharge rate from a particular medical unit with the best possible treatment quality. Respondent R4 describes, “We have made significant investments in healthcare technology at various levels, including HMIS. This has improved patient throughput and quality of care. The patient load is increased manifold during COVID, which we are managing with the help of various technologies.” Therefore, volume flexibility in a public healthcare organization is a market-focused perspective that aims at mass customization by reducing waiting time, accommodating the maximum number of patients, and maintaining a consistent performance to the admitted patients in a particular medical unit. Therefore, the proposition is.

3.2 Clinical flexibility

Clinical flexibility refers to a quick response to the uncertain clinical conditions of the patient and providing a range of healthcare services (Nair et al., 2013). Clinical flexibility concerns the capability to offer a wide range of service-mix and promptly fulfill several requirements. The healthcare delivery system is expected to reduce variability induced by heterogeneous patient requirements in clinical care. Hence, it is likely to generate responsiveness if it can handle a range of possibilities by offering broad service lines. Respondent R10 states, “the hospital maintains a wide portfolio, be it clinical or non-clinical. The range of services helps a lot to manage COVID and other patients.” Public healthcare organizations need to adjust service capacity to provide a range of services to the patients, which manifests clinical flexibility. The particular medical unit exhibits flexibility to deliver a range of related clinical services, and hence, clinical flexibility affects the redesign of services or introducing new services.

3.3 Service convenience flexibility

Service convenience flexibility refers to the capability to provide convenient services and adapt to patient preferences for convenience (Upton, 1994). Despite the complexities of service design, patients demand convenience and continue to value those non-health outcomes (Harvey et al., 1997). Patients covet convenience for a range of health interventions, for example-service location, delivery schedule, payment methods, admittance and discharge procedures, or new services. Therefore, public healthcare organizations must focus on convenient services to patients. During the COVID outbreak, non-health-related outcomes have gained momentum like telehealth, mobile-app-based services, digital payment methods, and electronic medical reports delivery. Respondent R6 explained, “So we have introduced new activities and healthcare programs to provide convenience to the patients in terms of delivery schedules, locations. Those options include virtual visits to the hospital through the website, the electronic delivery of reports, and payment methods of debit/credit cards or net banking- in other words, convenience.” Public healthcare organizations develop the capabilities to provide non-health outcomes to the patients and increase responsiveness toward them. The flexible capabilities to adapt to the varying needs and introduce new mechanisms for convenient deliveries affect innovative performance.

3.4 Patient recovery flexibility

Patient recovery flexibility is defined as the service delivery system's ability to respond to patients' complaints and recover them quickly after something wrong has happened (Correa & Gianesi, 1994). It refers to the attentiveness in handling patient complaints, willingness to serve, and participation-based service orientation. After-service support and managing complaints (recovery) are becoming crucial in public healthcare to improve the social image and enhance services' experience. Respondent R8 said, “We have redesigned our service process and programs to meet individual patient demand and help in services to them. COVID patients have observed re-occurrence of disease or other complaints—to which carefulness and attentiveness is very important for care givers.” Therefore, flexibility strategy in service operations is important to specify the significant changes that enable listening to patients' voices more effectively even after discharge. Consequently, public healthcare organizations shift toward a service-oriented culture and increase responsiveness to the patients. The flexibility to handle various service situations allows to improve existing services and introduce new services.

4.1 Implications for theory

The present study has several implications for the theory. Previous studies suggest exploring the dynamics of flexibility in services which improve the capabilities of adaptation (Lin et al., 2015; Luangsakdapich et al., 2016; Slack, 2005). Recent studies advocate that service deliveries must exhibit flexibilities that are market-focused (Alessandra et al., 2020; Liu et al., 2019; Shukla & Sushil, 2020). The findings thus identified the essential practices that encompass a market-focused perspective. The current research findings address the literature gap documented in recent studies (e.g., Brozovic et al., 2016; Liu et al., 2019; Shukla & Sushil, 2020) to explore the dimensionality of market-focused flexibility in services. The existing service literature has implicitly portrayed the notions of flexibility (Gronroos & Gummerus, 2014; Javalgi et al., 2005; Johnson, Lee, Saini, et al., 2003). This study's findings delineate several kinds of market-focused flexibility in public healthcare that generate responsiveness in divergent ways.

Second, a group of studies has outlined the role of firm-based resources and capabilities to exhibit flexibility (Agarwal & Selen, 2009; Gronroos & Gummerus, 2014; Makadok, 2001). The proponents of RBV theory (Barney, 1991; Kaleka & Morgan, 2019; Teece et al., 2016) argue that flexible mechanisms function several resources and capacities. The current study's findings further clarify the role of resources and capabilities in the execution of a multitude of flexibility at various levels of service operations. The current study contributes to the extant literature (Bhardwaz, 2000; Johnson, Lee, & Grohmann, 2003; Teece, 2014) by identifying the specific capabilities and justifying the four dimensions of market-focused flexibility in the context of public healthcare.

Third, many studies on flexibility suggest exploring the industry-specific dynamics (Alessandra et al., 2020; Liu et al., 2019; Shukla & Sushil, 2020; Singh et al., 2019). Healthcare, in particular, is faced with several uncertainties (Da Silva et al., 2015; Eric & Thomas, 2004; Fox & James, 2020; Sturmberg & Lanham, 2014), and therefore, flexibility is required as an inbuilt mechanism. This study explores flexibility dynamics in public healthcare and explains how healthcare firms exhibit multiple flexibilities at various levels. The findings explore how healthcare firms acquire resources to respond to market uncertainty and introduce new services. Thus, consistent with some previous studies on the role of valuable resources to generate flexible capabilities (Amit & Schoemaker, 1993; Kaleka & Morgan, 2019; Nair et al., 2013; Powers & Jack, 2008), the current study's findings support that organizations utilize valuable resources to develop market-focused flexible capabilities.

Fourth, the study is a first step to establish the linkage of the organizations' market-focused flexibility and innovative performance. Prior studies (Brozovic et al., 2016; Johnson, Lee, Saini, et al., 2003; Toni & Tonchia, 2005) merely mention that the service providers must exhibit flexibility in their processes to create value for the customers. For example, Powers and Jack (2008) argue that healthcare organizations must develop volume flexibility for improved performance. Additionally, Nair et al. (2013) posit the role of clinical flexibility for improved responsiveness and satisfy the patients. This study combines various flexibilities and unearths the underlying dynamics while simultaneously explaining their market-focused perspective. Moreover, the results illustrate that adjustment in the service capacity generates market responsiveness through mass customization (volume flexibility and clinical flexibility) (Brozovic et al., 2016).

Finally, recent studies on value creation perspectives (Heinonen et al., 2013; Jones & Comfort, 2020; Ponsignon et al., 2015; Skålén et al., 2015) argue that service organizations must react to customers changing demands. Some studies accept that organizations must exhibit flexibility to develop value propositions.(e.g., Brozovic et al., 2016; Gronroos & Gummerus, 2014). The current study extends this notion and proposes the market-focused dimensions flexibility that creates value through innovative performance. This study established the linkages of the elements of flexibility (range, mobility, and uniformity) and clarified how they facilitate new and innovative performance (Khan & Zaman, 2021; Koste et al., 2004; Skålén et al., 2015). Thus, the findings of this study are also consistent with the previous studies on flexibility and performance outcomes (Nair et al., 2013; Powers & Jack, 2008; Vredenburg & Bell, 2014) by establishing a linkage between market-focused flexible capabilities and innovative performance.

4.2 Implications for practice

The findings of this study have several implications of interest to practitioners and policymakers of public healthcare. The policymakers in India are concerned about the innovative performance in public healthcare (MOHFW, 2020). Additionally, given limited capacity and infrastructure, a market-oriented view in public healthcare is largely missing (Saha & Ray, 2019). The various reports opine that public healthcare deliveries in India need to introduce new service models and multiple changes on multiple fronts (Srinivasan, 2014). The proposed framework could be used in practice-oriented research to develop flexible strategies for transforming the service delivery models in the public healthcare domain. Implying the results, public healthcare organizations must invest in resources and capabilities to attain services' flexible operation. Public healthcare practitioners and policymakers can use the framework to support their further development regarding the design of care and provisioning of services. In a public healthcare setting, strategists and planners develop internal competence to respond to patients' needs. The use of internal and external resources can help to instigate flexibility in organizational culture.

The framework advice the healthcare practitioners to respond as flexibly as possible in emergency situations like COVID-19 pandemic (WHO, 2020). This study suggests filling the gap of non-availability of a comprehensive framework to enhance flexibility. This study may lead to the establishment of dedicated functions (e.g., managing bed capacity, reducing long waiting times, and increasing line of services) to increase the flexibility maturity (Shukla & Sushil, 2020) of healthcare organizations. Volume flexibility and clinical flexibility support the health delivery systems to achieve mass customization through the ability to serve a high volume of patients and provide a range of service offerings. This study explains the various methods of attaining volume flexibility in a medical unit. For example, the management of bed-occupancy ratio, managing admittance and discharge, training of medical employees to handle a larger volume. Further, the study guides how inter-departmental responsiveness can be increased to attain clinical flexibility. The study also suggests that the administrators may selectively deploy and manage the service convenience flexibility strategies like digital reports during COVID, teleconsultation, on-line registration, cashless payment methods. In this way, more focus can be given to the different aspects of convenience for better responsiveness and hence, increased patient satisfaction. Appropriate management of after-service support is critical to the success of public healthcare delivery systems.

Furthermore, healthcare practitioners should be mindful of the existing service capacity that healthcare resources (medical equipment, employees, and materials) may offer flexible execution and avoid underutilization (Kringos et al., 2020; MOHFW, 2020). The service providers have the opportunity to inform and train how to appropriately improve and redesign the existing services to create new value propositions. This study has outlined a flexibility strategy to meet a critical national need, like India, for personalized care and improve the public healthcare domain's innovative performance. Public healthcare organizations must carefully evaluate their use of medical resources to minimize the wastage or develop inter-firm relationships (e.g., alliance higher medical centers and collaboration with external medical specialists) to exhibit flexibility (Liu et al., 2019; Saha & Ray, 2019). Thus, the policymakers can utilize the findings to design innovative services in public healthcare, which is a critical demand of the current pandemic (WHO, 2020). With an informed understanding of both patients' needs and expectations and the capabilities to deliver, the public healthcare system will better improve the existing services and introduce new services to help the patients achieve enhanced quality and experience of care. Public health policies that facilitate market-focused flexibility and allow innovative solutions to emerging at various delivery levels will generate the community's best possible healthcare outcomes.