Corporate Social Responsibility: A Stakeholders Perspective Applied to the Lebanese Heart Hospital

This research aims to assess Corporate Social Responsibility (CSR) practice applied to the Heart Hospital, Tripoli, Lebanon. A stakeholders (workers, patients, the local community, and the environment) perspective is considered. The population of the research includes all workers in the target hospital, however the research sample consists of 40 employees. This research is quantitative, descriptive and analytic based on a structured questionnaire designed and distributed to the respondents. The study found that the activities related to CSR were adapted and practiced to different levels. Employees’ responses about the dimensions of CSR were varied. Findings show that the hospital does exercise its social responsibilities towards patients (Mean=3.97), it does exercise its social responsibilities towards the environment (Mean=3.96), it moderately exercises its social responsibilities towards the local community (Mean=3.36), and it weakly exercises its social responsibilities towards its workers (Mean=2.75). Therefore, it is recommended that the hospital administrators must review their CSR strategy to reinstate one of the most critical factors for the success of the institution namely the human assets besides giving more attention to its local community needs.


Theoretical Foundations
Two theories which are highly intertwined with CSR are considered in this paper namely, the neoclassical theory and the Stakeholders Theory 2.1.1 CSR and the Neoclassical Theory Neoclassical theory adopts a minimum of social responsibility, and this theory is based on the work of economist Milton Friedman, who believes that the function of the company is to maximize profits for shareholders (economic responsibility). According to Friedman (1970), -in a free society, there is one and only one social responsibility of business-to use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud‖ (p. 6). Moreover, according to O'Connell and Ward (2020), the practice of social responsibility is through decisions directed to improving the return and profitability of shareholders, and the principle of maximizing the value of shares for shareholders is the only social goal of the company. As a matter of fact, Friedman (1970) asserts that in a private free-enterprise, -the responsibility is to conduct the business in accordance with owner's desires, which generally will be to make as much money as possible while conforming to their basic rules of the society, both those embodied in law and those embodied in ethical custom‖ (p. 1). In other words, for Milton Friedman and his advocates, the only responsibility for businesses is to their shareholders.
-Companies are not required to carry out any social activity because this kind of actions concerns the Government and-if society wishes-NGOs may do it‖ (Garcia-Madariaga & Rodrí guez-de-Rivera-Cremades, 2010, p. 7). In summary, Friedman's only justification for social responsibility is --when companies could benefit by some social issue that made them more profitable by paying less tax, obtaining better access to resources, or something similar‖ (p. 7).

CSR and the Stakeholders Theory
Corporate Social Responsibility (CSR) has gained high interest among academics, professionals and business experts. Since the early years of its development, the concern for the wellbeing of the human-side of business gained more popularity amid the traditional interest on the green environment, the economic and the financial aspects of the organization. Moreover, such an interest on the human side highlighted the importance of the role of stakeholders. Carroll (1991) defines organizational stakeholders to be the groups or individuals who should be considered within CSR orientations while doing business. In fact, stakeholders deal with both internal as well as external customers or simply put the societal members who fall within a close state of urgency requiring a responsive behavior from corporations (Carroll, 1991). However, the aforementioned societal members go beyond the traditional focus on shareholders (Friedman, 1970) to include the community along the broad supply chain of the organization that is, consumers, suppliers, community, and social activist groups and NGOs (Bosch-Badia et al., 2013).
CSR has extended far more than the concept of the -triple bottom line‖ encompassing the economic, social, and environmental dimensions of business performance (Elkington, 1998;Garriga & Melé , 2004). The sought after objective is achieving sustainability through CSR projects (Elkington, 1998;Brin & Nehme, 2019). Sustainability of a business capitalizes on continuity in the market and long-term profit (Brin & Nehme, 2019;Chehimi et al., 2019). Similarly, the -triple bottom line‖ theory postulates that an organization must satisfy the surrounding society and respect its wellbeing by performing social activities (Brin & Nehme, 2019). Similarly, Hejase et al. (2017) assert that -corporations that apply CSR are actively seeking better recognition, reputation, value, growth, and relationships with consumers and other stakeholders‖ (p. 4). Thus, by having the community at large and the surrounding society as a priority, sustainability can be achieved. Finally, the broader dimension in this theory is the natural environment. An organization's interest to respect and enrich the quality of life of its human actors, for present and future generations, is fundamental and strategic as must be declared in its mission statement and then make sure that the management, conservation and the consumption of resources closely and wisely is maintained at high levels of nature safety. Nevertheless, Elkington (1998) contends that efforts in these dimensions should happen through partnerships. In this case, as Slaper (2013) asserts, the needed urgency to include the stakeholders is properly set since it is a well-established practice to achieve optimization of organizational performance and build partnerships and collaborative engagements across all dimensions.
The importance of stakeholders is actually manifested since Freeman (1984) authored his well-received book -Strategic Management: A Stakeholder Approach‖. Indeed, it became the cornerstone of his progressive work that led, after a decade, to what is currently known as the stakeholder theory (Freeman, 2010). Based on the theory, stakeholders are groups or individuals that are affected by or affect the decision-making process of an organization (Freeman & Dmytriyev, 2017). Moreover, the theory was developed in a vivid manner to also include what is presently known as stakeholder management, and how it is connected to the approach of CSR (Kotter & Heskett, 1992). On the other hand, other authors also used the theory as a descriptive tool to define the nature of firm and the corporate decision-making process that acts in the interest of its stakeholders (Brenner & Cochran, 1991). Indeed, Hejase et al. (2012a) contend that -CSR is seen as integrated corporate activities abiding by the legal regulations and going beyond compliance, and investing more in human capital, the environment and the relations with stakeholders‖ (pp. 2-3). One of the important ideas of this theory is the stakeholders' interdependence. Freeman and Dmytriyev (2017) reject the notion that value creation for stakeholders involves a tradeoff or a zero-sum game rather is a win-win situation.

Creating Shared Value
Investments enrich the creation of value. Given the large number of stakeholders involved in the process, initiating, measuring, and succeeding are relative and depend on various expectations and objectives. When it comes to corporations, financial measures justify the selection of a specific investment option over another and allow the decision-maker to track the progress in order to maximize returns and act accordingly. The concept of CSR previously discussed, integrates, to a certain extent, the societal perspective in this business process.
In 2006, Porter and Kramer redefined the bond bringing together CSR and corporate strategy (Porter & Kramer, 2006). The authors assert that the competitiveness of a corporation is inseparable from the wellbeing of the society (Porter & Kramer, 2011;Asemah, Okpanachi & Edegoh, 2013). This affirmation goes hand in hand with Freeman's approach to stakeholders' interdependence. Therefore, five years later, Porter and Kramer (2011) asserted that creating value is a common goal that had a shared effect, presented as -creating shared value‖ (CSV). In fact, the concept of CSV relocates the societal needs from the periphery to the core of the corporate strategy that organizations should implement to maximize profit, solve social problems, and enhance the wellbeing of the whole ecosystem (Kramer & Pfitzer, 2016). CSV had its opponents (Beschorner, 2013) and proponents (Bosch-Badia et al., 2013). Whereby, the first labeled it as built on a narrow consideration and the second described it as parallel evolution of the latter concept. On the other hand, Kramer & Pfitzer (2016) took CSV as a motive to claim that corporate strategy should move beyond its economic classical perspective to the ecosystem's one, giving opportunities to innovation while creating shared value (Pfitzer, Bockstette & Stamp, 2013). One key element is that creating shared value is maximized if all stakeholders collaborate together in order to combine their individual efforts, thus leading to a collective impact (Kramer & Pfitzer, 2016). In short, approaching social and environmental challenges through collaboration and engagement of all stakeholders, especially internal ones, allows corporations to achieve long term value to the business and the surroundings (Husted & Allen, 2007;Chehimi et al., 2019). That is, assessing the CSR practices of hospital institutions towards their stakeholders (workers, beneficiaries, society, the environment, supporting institutions, the local community), by analyzing the responses collected from a sample of 240 employees from various hospital institutions. Findings include: there is an inconsistency in the hospital institutions' commitment to their social responsibilities, as these institutions were very responsible towards the beneficiaries, somewhat responsible towards workers, society, and dealers, and barely responsible towards the environment. Likewise, there were no significant variations in the application of social responsibility due to personal variables such as professional experience, nature of work, age, and gender.

Review of Empirical Research
Moreover, Al-Maouchi (2016) studied CSR applications in seven Lebanese commercial banks. The research was based on assessing the triple-line and its role in the development of the Lebanese society.
Findings show that banks applied their social responsibility in all dimensions but in a limited way.
More specifically, banks had gaps in their development of the society, took CSR more as an advertising mean to attract customers and improve the bank's image. Also, the results showed the absence of a binding legal framework for the application of CSR, which constitutes the biggest challenge facing banks in playing an effective social role.
In addition, Al-Khalidi (2015) studied the impact of hospitals' commitment to social responsibility on the health services' quality perceived by patients in private hospitals located in Amman, Jordan. A descriptive and analytical approach was adopted and 463 questionnaires were analyzed distributed to patients dealing with private hospitals in Amman. Findings showed a statistically important impact of all social responsibility dimensions (Triple-Bottom line) on the perceived quality of health services.
The study also found positive perceptions regarding the quality of health services in private hospitals.
Furthermore, Tsegaw (2018) assessed the factors affecting the practices of CSR in the health sector with evidence from local hospitals in Ethiopia. This research studied the influence of government, culture, the organization, competition, clients, employees, and pressure group on the practices of social responsibility in its dimensions (the economic, the legal, the human, and the charitable) as a dependent variable. Three Ethiopian hospitals were involved and 89 questionnaires were distributed to employees in these hospitals. Findings showed a positive impact between each of the organization's culture, government policy, and pressure group on the level of application of social responsibility. It also identified a weak effect among (employees, competition, and customers) on social responsibility. The ethical dimension came first from the practice of social responsibility in the studied hospitals, and the main motivation for hospitals to adopt social responsibility was pressure groups.
Also, Lubis (2018) studied the impact of corporate social accountability in the health sector, especially government hospitals, on the hospital's reputation and customer loyalty. A descriptive and analytical approach was adopted. 200 questionnaires were analyzed and distributed to patients in four government hospitals in Indonesia. The study found an impact of social responsibility in its combined dimensions (economic, legal, and charitable) on the hospital's reputation, as well as the existence of an impact of social responsibility in its combined dimensions (economic, legal, and charitable) on the loyalty of patients.
Finally, as Gharaee et al. (2013) defined it, the social responsibility of hospitals -is the ethical obligation that requires hospitals and other health sector organizations to carry out their usual duties, ethical principles and provide services that benefit all stakeholders in society‖ (p. 843).

Research Hypotheses
The main hypothesis is as follows: H1: The hospital does not exercise its societal responsibilities towards stakeholders.
There are four other sub-hypotheses: H2: The hospital does not exercise its social responsibilities towards workers.
H3: The hospital does not exercise its social responsibilities towards patients.
H4: The hospital does not exercise its social responsibilities towards the local community.
H5: The hospital does not exercise its social responsibilities towards the environment.

Materials and Methods
This research is quantitative, descriptive and comparative. Its philosophy is based on positivism. Hejase & Hejase (2013) contend that -Positivism is when the researcher assumes the role of an objective analyst, is independent, and neither affects nor is affected by the subject of the research‖ (p. 77). The research being quantitative then the approach followed is deductive. -A deductive approach is useful if the general aim was to test a previous theory in a different situation or to compare categories at different time periods‖ (Elo & Helvi, 2008, p. 107). Moreover, the research tool is survey questionnaire administered to a sample of hospital employees. Furthermore, secondary information and data were extracted from various references and sources (books, articles, research, and previous studies) to form an integrated background of the research.

Sampling
The study population consisted of all employees working in one selected hospital, being the case under exploration. On the other hand, the study sample, chosen randomly, included 40 hospital workers chosen based on a computer generated random numbers (00-99) (Hejase et al., 2012b, p. 497). In fact, all names were numbered and then the selection was based on choosing random numbers starting with the first column counting downwards and then moving right to the next column, till the 40 employees were selected.

Research Design
The choice of the hospital was based first on selecting a Lebanese territory far from the capital Beirut.
Then, selecting one of the newly established hospitals. The reason is to explore the case of a new specialty hospital in a time where CSR has been researched in the Lebanese industry and the service sector though concentrating more on banking. Therefore, the expectation is that the top management administrators of the hospital are aware about CSR applications and have been exposed to it frequently especially that CSR conventions have been popular before the COVID-19 era.
Therefore, the chosen hospital is the Lebanese Heart Hospital located in Al-Bahsas, North Lebanon, and is the first specialized hospital for heart patients in the north. The hospital provides the necessary medical care to patients with cardiovascular disease, and its vision is to become a center of excellence in heart health care in Lebanon. The hospital aims to provide high quality care, and provide the best treatments and services to patients.
The hospital was established in 2014, and it is a 4-story building, which includes the emergency room, operating room, radiography room, in addition to the analytical laboratory. It includes 70 beds for patient care, and about 100 employees distributed in the different work functions.

Questionnaire Design
The introduction to the questionnaire consists of an opening statement about the topic, its motivation, and confidentiality. The researchers transparently and using a simple language pledge that the information is voluntary and its use is solely for academic purposes whereby no identities are disclosed whatsoever and that the anonymity of the respondents is guaranteed. The questionnaire consists of 33 questions divided into five sections. The research tool used in the current project is a systematic and structured questionnaire that is divided into five parts: 1) Section one is designed to assess the respondents' demographics with four questions (sex, age, educational qualifications, and years of experience).
2) Section two is designed to assess the respondents' attitude and behavior towards the hospital's social responsibility practices towards workers. It consists of questions 1 to 7.
3) Section three is designed to assess the respondents' views about the hospital's CSR practicing towards its patients. In this section also 7 questions explore the respondents' views about the hospital implement of CSR for their patients.
4) Section four with seven questions is designed to assess the respondents' attitudes toward the hospital CSR practices towards the local community.
5) Section five with seven questions is designed to assess the respondents' attitudes toward the hospital CSR practices towards the environment.
Finally, the questionnaire ends with one open-ended question through which respondents are free to express themselves freely regarding the research subject.

Data Analysis
Collected data were input into the Statistical Product and Service Solutions, SPSS version 25, an IBM product since 2009 (Hejase & Hejase, 2013, p. 58). Descriptive statistics were used in the form of frequencies and percentages as well as means and standard deviations. Tables of data were formed to support the analyses needed for the hypotheses. Furthermore, Internal Reliability of the questionnaire sections were studied using Cronbach's Alpha to ensure internal consistency of questionnaire statements.

Internal Reliability Analysis
The validity of the survey questionnaire was measured by calculating Cronbach's alpha. Table 1 shows that alpha coefficient is 0.924, which is higher than 0.7, which indicates that the form has the required stability.
The Internal Reliability of the 28-item scale is assessed using the Cronbach's Alpha technique. Table 1 shows that the 28-item scale produced a Cronbach's Alpha=0.924 matching the range 0.9-1.0 labeled -Excellent‖ (Burns & Burns, 2008, p. 481;Hejase & Hejase, 2013, p. 570   The five-level Likert scale was used to measure the respondents' choices to the questionnaire sections pertaining to CSR analysis. Table 2 depicts the details. Thus, the modified scores are distributed as shown in Table 3. hold a bachelor degree, and 12.5% hold a Master degree. In addition, results show that 20% of the respondents have experience of less than 5 years, 47.5% of them have experience between 5 years and less than 10 years, 7.5% have between 10 to less than 15 years of experience, while the percentage of respondents with experience of more than 15 years' is 25%.

CSR Practices towards Workers
Results in Table 4     employees support and local community support. These practices are against what researchers (Lipiec, 2001;Murphy, 2020;Hejase, 2020), are recommending on how to deal with employees. In fact, the aforementioned does not fit with the recommendation that the dimension of society under CSR must -guard for the best practices applied to employees' satisfaction mediated through empowerment, to the hospital preparedness to seasonal diseases and epidemics as well as doing an above the average work in creating awareness. Most possibly, this specific dimension as a whole lacks budgeting and/or considered of a lower priority to the hospital administration. Emirates' managers are aware of green accounting which concentrates on CSR issues of environment; Hejase et al. (2017) who asserted that Lebanese corporations concentrate their CSR activities or initiatives along two dimensions: societal philanthropic and environmental perspectives. Also, Jamali et al. (2006) concluded that -the problem faced in the Lebanese and other contexts is the absence of a precise management framework that provides for the linking of these fundamental, yet seemingly disparate pillars of sustainability and for reconciling traditional financial performance with environmental and social contributions‖ (p. 410) and finally D'Amato, Henderson, and Florence (2009) stressed the fact that, -organizations are being called upon to take responsibility for the ways their operations impact societies and the natural environment‖ (p. 1).

Discussion
This research aimed to study the extent to which the Heart Hospital practices social responsibility towards all stakeholders including workers, patients, the local community, and the environment. Based on the previous results, and to understand the extent to which the Heart Hospital in Tripoli has adopted the dimensions of social accountability and the level of importance of implementing social accountability in the hospital, the relative importance of all social responsibility dimensions has been grouped in Table 8. through the individual analysis of the dimensions, the following is observed: The hospital has its highest priority its patients who usually are insured by several Lebanese private and public bodies, which means the hospital serves its purpose of being a choice for Heart problems treatment in the northern territories of Lebanon, and at the same time it shows that the financial objectives are also satisfied. As a matter of fact, Heart problems are usually on the high-end cost and all sorts of operations are usually paid beforehand. This dimension ranked first with a mean of 3.97 (high-end of the agreement scale). In second place is the natural environment with almost an equal mean of 3.96 (high-end of the agreement scale). This choice is also typical of Lebanese institutions due to its high exposure in the media, and the hospital took special attention to the green areas in its layout besides its contribution to environmental campaigns. For example, its role in the -Clean your hand save your

Hypotheses Evaluation
Finally, it remains to assess the main hypothesis as well as the sub-hypotheses [there are four sub-hypotheses] of the research based on the findings discussed in the aforementioned paragraphs. For this purpose it is best to represent the findings in Table 9 herein: consistent with those obtained by Saeedan (2017), Al-Maouchi (2016), and Khalidi (2015), which indicated that most of the CSR dimensions were averagely applied. Nevertheless, Jamali et al. (2006) were right in their conclusion that there is an absence of a -precise management framework that provides for the linking of all CSR pillars‖ (p. 410). Similarly, Brin & Nehme (2019) ascertain that an organization must satisfy the surrounding society and respect its wellbeing by performing social activities, especially its employees and the surrounding community. Therefore, for the Hospital to attain an integrated CSR performance, that is, satisfying all dimensions, -it must seek better recognition, reputation, value, growth, and relationships with consumers and other stakeholders‖ (Hejase et al., 2017, p. 4).

Conclusion
The study offers a new insight on CSR applicability in a recently founded specialized hospital. The results are still similar to many Lebanese organizations' behavior towards the different CSR pillars, especially to what pertains to employees and workers who actually must be taken care of their welfare to a much better degree. However, this work have shown that specialized medical administrators still lack the expertise to deal with concepts like CSR and to safeguard the integrated nature of the different recommended dimensions. Nevertheless, the findings cannot be generalized for several reasons including the fact that this is a case of one hospital, few respondents, and particular to one region of Lebanon. Consequently, future research may close the aforementioned gaps in number of organizations involves, sample size and multi-territorial coverage. Researchers are invited to duplicate the research process involving the various healthcare institutions. Notwithstanding, that cross-country research is also recommended.

Recommendations
Based on the previous findings, the researchers suggest the following: -The administration of the hospital should pay more attention to its responsibilities towards the local community and to its employees in particular. For such an endeavor, the Human Resource function must pay more attention to the employees/workers wellbeing including remuneration upgrades, richer benefits, more engagement activities, and better reward and incentive system. In fact, Murphy (2020) proposed 18 different outlooks that enforce engagement that must be seriously considered to upgrade the societal dimension within CSR as it supports the positive assertiveness between employer and employees. -it goes without saying that job security, compensation and health and safety are highly important in this context‖ (Marom & Lussier, 2020).
-The hospital should diversify its programs that are concerned with its responsibilities towards its local community and try to develop them permanently. That is, job opportunities, internships, and training & development in terms of creating awareness about hospital-related jobs on one hand and from another hand, participate more in community social and sports activities beyond the green environment capacity.
-The hospital needs to intensify its social participation towards its local community, through volunteer activities and work to employ groups with special needs.
-The hospital needs to maintain its community practice towards its patients and its environment with permanent improvement and increase its social responsibilities towards them.