Dynamics of lean and risk management in Dutch hospitals
Education:
Master of Science Accountancy & Control – Control track
Faculty:
Amsterdam Business School,
Faculty of Economics and Business,
University of Amsterdam
Student:
Yvonne Hofman
Student number:
10090142
First supervisor:
Dr. Niamh A. O’Sullivan
Second supervisor:
Dr. Georgios Georgakopoulos
Date:
23-06-2014
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Abstract
The aim of this study is to gain an in-depth understanding of the dynamics between lean thinking, business risks and risk management within the hospital sector in the Netherlands. The study adopts a qualitative approach to address the research questions. 10 semi-structured interviews are conducted with lean managers in hospitals and with advisors and consultants specialized in risk management and/or implementing lean thinking. The research findings showed that implementing lean influences organizational risk as they might shift or reduce. Furthermore lean has an influence on the information and communication processes: visibility increases and communication enhances. The research findings do not show an influence of lean on control activities in Dutch hospitals, but they do show a relation between lean and the monitoring component of risk management, as visibility increases and errors are quicker identified. It canbesaid that the concepts of lean and risk management are related and it might be beneficial to integrate those concepts more in Dutch hospitals to improve effectiveness and efficiency. There is a reasonable amount of literature on risk management and as well on lean thinking. However, there is a lack of academic literature that studies the interrelationships between lean thinking and risk management. This study fills this gap. Furthermore this study is interesting from a societal point of view, as organizations are struggling with economic downturn, reduced revenue streams and less available credit and resources. This research provided a new conceptual framework (table 6) which outlines the interrelationships between lean and risk management in the Dutch hospital sector and therefore this study can help organizations when implementing lean or risk management to see where the concepts overlap and can benefit from each other, this helps organizations to more efficiently handle their resources.
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Dutch summary
Het doel van deze studie is om een diepgaand begrip te krijgen van de dynamiek tussen lean, risico’s en risico management binnen de ziekenhuissector in Nederland. Deze studie hanteert een kwalitatieve benadering om de onderzoeksvragen te beantwoorden. Er zijn 10 semigestructureerde interviews gehouden met lean managers binnen ziekenhuizen en met adviseurs en consultants gespecialiseerd in risicomanagement en / of de uitvoering van lean. De onderzoeksresultaten tonen aan dat de uitvoering van lean invloed kan hebben op risico’s, omdat deze mogelijk kunnen verschuiven of verminderen. Verder heeft lean een invloed op informatie- en communicatieprocessen: zichtbaarheid neemt toe en communicatie verbetert. De onderzoeksresultaten tonen geen invloed aan van lean op control activiteiten in Nederlandse ziekenhuizen, maar ze geven wel een verband aan tussen lean en de monitoring component van risico management, omdat de zichtbaarheid toeneemt en fouten sneller worden geïdentificeerd. Het kan worden gezegd dat de concepten van lean en risico management aan elkaar gerelateerd zijn en het kan nuttig zijn om deze concepten meer te integreren in Nederlandse ziekenhuizen om effectiviteit en efficiëntie te bevorderen. Er is een redelijke hoeveelheid literatuur over zowel risico management als lean. Echter, er is een gebrek aan wetenschappelijke literatuur die de onderlinge relaties tussen lean en risico management bestudeert. Deze studie vult dit gat. Bovendien is deze studie interessant vanuit een maatschappelijk oogpunt, omdat organisaties worstelen met de economische neergang, gereduceerde inkomstenstromen en minder beschikbaar krediet en middelen. Dit onderzoek ontwikkelt een nieuw kader (tabel 8) welke de samenhang tussen lean en risico management in de Nederlandse ziekenhuis sector schetst. Derhalve kan dit onderzoek organisatie bij de implementatie van lean of risico management helpen om te zien waar deze concepten elkaar overlappen en kunnen profiteren van elkaar; dit helpt organisaties efficiënter om te gaan met hun middelen.
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Table of contents
1.
Introduction ... 7
1.1
Background
... 7
1.2
Research objective and research questions
... 8
1.3
Theory
... 8
1.4
Research method
... 8
1.5
Research contributions and findings
... 8
1.6
Thesis structure
... 9
2.
Literature review ... 10
2.1
Lean thinking
... 10
2.1.1
Background and concept of lean thinking ... 10
2.1.2
What literature says about lean thinking ... 10
2.2
Risk management
... 12
2.2.1
Background and concept of risk management ... 12
2.3.2
What literature further says about risk management ... 13
2.3
Chapter summary
... 14
3. Theory ... 15
3.1
Introduction
... 15
3.2
Principles and tools of lean
... 15
3.3
Risks and risk management
... 17
3.4
Lean and risk management
... 18
3.5
Summary of the chapter
... 21
4.
Research methodology ... 21
4.1
Introduction
... 21
4.2
Philosophy of research
... 21
4.3
Qualitative research
... 22
4.4
Qualitative research methods
... 23
4.5
Research design
... 24
4.5.1
Interviewees ... 24
4.5.2
Interviews ... 25
4.6
Data analysis
... 26
4.7
Summary of the chapter
... 26
5.
Research findings ... 28
5
5.2
Lean in the Dutch hospital sector
... 28
5.2.1
Reasons and benefits of lean ... 28
5.2.2
Challenges ... 30
5.2.3
Current status and development of lean in Dutch hospitals ... 31
5.3
Risk management in the Dutch hospital sector
... 32
5.3.1
Motivation & benefits... 33
5.3.1
Current status of risk management in Dutch hospitals ... 33
5.3.3
Development of risk management in Dutch hospitals ... 34
5.4
Lean thinking & risk management
... 35
5.4.1
Change in risks ... 35
5.4.2
Information and communication ... 36
5.4.3
Controls and monitoring ... 38
5.4.4
Integration and relation of lean and risk management... 39
5.5
Summary of the chapter
... 41
6.
Discussion ... 42
6.1
Introduction
... 42
6.2
Influence on organizational risks
... 42
6.3
Influence on information and communication
... 43
6.4
Influence on control and monitoring
... 43
6.5
Relation lean and risk management
... 44
6.6
Summary of the chapter
... 46
1.
Conclusion ... 47
References ... 49
Appendices ... 52
Appendix A: Interview guide representatives Dutch hospital sector
... 52
Appendix B: start-of-the-day / improvement board
... 55
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List of tables and figures
Table 1: Classification of business risks. page 17 Table 2: Relationships between lean thinking and risk management page 20 Table 3: Differences between quantitative and qualitative research page 22
Table 4: Overview of interviewees page 24
Table 5: Reasons to implement lean page 28
Table 6: Relationships between lean and risk management in Dutch hospitals page 45 Figure 1: Path of post interview data analysis page 27
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1.
Introduction
1.1
Background
An increasing amount of organizations apply lean thinking in their businesses (Hines et al., 2004). Lean originated in the 1980s in the car manufacturing industry as a method for optimizing the manufacturing practices of Toyota (Womack and Jones, 1996). The main idea of lean is to maximize customer value and minimize waste (Womack and Jones, 1991). According to Womack and Jones (1996) lean consists of five principles: value, value stream, flow, pull and perfection. It is shown that lean significantly reduces the time necessary to produce new products and also reduces costs (Womack and Jones, 1994).
Lean is often associated with manufacturing. However, it is a misconception that lean thinking can be applied only in the manufacturing sector as lean is not a cost reduction or a tactic program, but a way of thinking (Arnheiter and Maleyeff, 2006). It can therefore be applied and used within both production organizations as well as service organizations. An example of a service organization that is implementing lean thinking is the health care sector. According to a survey under US hospitals 53% of all US hospitals implemented lean thinking to at least some extent (ASQ, 2009). Implementing lean in hospitals increases efficiency, however this should never be at the risk of the patient. Simons et al. (2014) researched the relation between implementing lean and door movement in the operation and showed that implementing lean can lead to a reduction of door movements and therefore risks. Therefore it is interesting to understand more about the dynamics between lean thinking and risk management in the hospital sector.
Enterprise Risk Management (ERM) increased rapidly from the mid-1990s onwards as there is a call for the adoption of ERM by professional associations, regulators and rating firms (Arena et al., 2010). Corporate financial reporting scandals also stimulate the trend that organizational stakeholders are demanding more oversight of the key risks that organizations face to make sure that stakeholder value is retained (Walker et al., 2002). The definition of ERM used throughout this thesis is the definition from a guidance document published by the Committee of Sponsoring Organizations of the Treadway Commission (COSO): ‘‘Enterprise risk management is a process, effected by an entity’s board of directors, management and other personnel, applied in strategy setting and across the enterprise, designed to identify potential events that may affect the entity, and manage risks to be within its risk appetite, to provide reasonable assurance regarding the achievement of the entity’s objectives’’ (COSO, 2004, p.2). So ERM is an approach for identifying business risks, assess risks and make intentional decisions regarding how to deal with the them and respond to business risks. Since 2010 Dutch hospitals are required to have risk management and internal control systems (Brancheorganisatie zorg, 2010).
In short, lean thinking is increasingly applied in hospitals (ASQ, 2009) and increased rules and regulations are requiring hospitals to adopt the practice of risk management. Therefore it might be interesting the explore the dynamics between these two concepts. However to date there are no academic articles that have researched the relationship between lean thinking and risk management. This thesis wants to fill this gap by exploring the interrelationships and dynamics of lean thinking and risk management in the Dutch hospitals setting.
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1.2
Research objective and research questions
The aim of this study is to gain an in-depth understanding of the dynamics between lean thinking, business risks and risk management within the hospital sector in the Netherlands. To explore the relationship between lean thinking and risk management, this study seeks to answer the following research question:
1. How does lean thinking influence risk management in the hospital sector in the Netherlands?
In order to help answer the main research question, the following sub-questions are developed on the basis of the COSO1 model (which is discussed in more depth in paragraph 2.3.1):
2. How does lean thinking influence organizational risks in Dutch hospitals?
3. How does the implementation of lean thinking influence the information and communication processes within Dutch hospitals?
4. How does the implementation of lean thinking relate to the monitoring and control activities of risk management in the hospital sector in the Netherlands?
1.3
Theory
This study will use the concepts of lean thinking and risk management as a basis for a theoretical framework. The theory section outlines the overlap between these concepts. The theoretical framework is used as a foundation for the rest of the thesis to explore interrelationships between the concepts. The researcher believes it is beneficial to look at the dynamics between the concepts instead of only one of them, as they might enhance each other: lean can make the risk management process more efficient (OCEG 2009) and implementing lean might reduce the chance of occurrence of risks related to patient quality and safety (Simons, 2014). By conducting qualitative research the researcher is going to explore the interrelationships between lean and risk management in the Dutch hospital sector and to see whether the relationships identified from literature hold in practice. The discussion chapter theorizes the findings and provides a new conceptual framework.
1.4
Research method
This thesis aims to develop an understanding of the dynamics between lean thinking and risk management within the Dutch hospital context. The study adopts a qualitative approach to address the research questions. 10 semi-structured interviews are conducted with lean managers in hospitals and with advisors and consultants specialized in risk management and/or implementing lean thinking. Data triangulation is partly achieved by conducting documentary analysis as well. The initial access to the consultants is easily gained as the researcher is enrolled in a graduation internship at EY2 Amsterdam. Therefore, the researcher was able to select those consultants with the most relevant experiences for this research. Through EY contacts and by using snowball sampling it was possible for the researcher to contact other stakeholders.
1.5
Research contributions and findings
As already stated there is an increase in academic literature on risk management. Also there is interest on lean management as more organizations are applying lean thinking (ASQ, 2009; Hines et al. 2004). However there is a lack of academic literature that studies the relationship between lean thinking and risk management. It is also interesting from a societal point of view to study this relationship, as organizations are struggling with the
1
COSO: Committee of Sponsoring Organizations of the Treadway Commission 2 Formerly known as Ernst & Young.
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economic downturn, reduced revenue streams and less available credit and resources (EY, 2013). This leaves organizations with a dilemma. On the one hand they would like to invest in for example lean management as this will increase efficiency and reduce waste, on the other hand they are required to efficiently handle their resources. This research could help organizations facing this dilemma as it provides in-depth evidence on the relationship between lean thinking and risk management in the Dutch hospital sector.This research looks at one specific sector: Dutch hospitals. There are several reasons for the choice of this specific sector. King et al. (2006) concluded that implementing lean thinking in a hospital lead to reduced waiting time, an improved patient flow and therefore a decreasing potential for overcrowding. This is supported by Holden (2011) who stated that hospitals implement lean thinking in order to fight problems such as crowding, delays, and errors. The Lean Six Sigma institute at the University of Amsterdam points out other benefits of implementing lean thinking in hospitals: shorten the hospitalization of patients, securing patients safety, and increasing the optimization of the yield of expensive equipment (IBIS UvA, 2014). The hospital section in the Netherlands is especially interesting as Dutch hospitals face increasing pressure from care insurers (Medisch contact, 2013). Dutch hospitals need to do the same with less money, therefore they face pressure to work more efficiently. One solution to work more efficiently is to implement lean thinking. Therefore it is interesting to research how the implementing of lean thinking influences risk management within Dutch hospitals. The Dutch Health Governance Code requires Dutch hospitals to have risk management in place (Brancheorganisatie zorg, 2010). This includes risk management on concerns about safety and quality of patients as well as strategic risk like financial, merger and market risks. As Dutch hospitals are now required to have certain risk management in place, it is especially interesting to see whether they related it to lean thinking.
The research findings in this study showed that implementing lean influences organizational risk as they might shift or reduce. Furthermore lean has an influence on the information and communication processes: visibility of risks increases and communication amongst, on the one hand, employees and, on the other hand, between the hospital and the patient enhances. The research findings do not show an influence of lean on control activities in Dutch hospitals, but they do show a relation between lean and the monitoring component of risk management, as visibility increases and errors are quicker identified. It can be said that the concepts of lean and risk management are related and it might be beneficial to integrate those concepts more to improve efficiency and effectiveness. This research provided a new conceptual framework (table 6) which outlines the interrelationships between lean and risk management in the Dutch hospital sector.
1.6
Thesis structure
This thesis is structured as follows: chapter two outlines the origin and objectives of the concepts of lean thinking and risk management. Furthermore it provides an overview of what the existing literature says about those concepts. Chapter three gives a deeper understanding of the concept and discusses the theoretical framework used in this study. Chapter four describes the research methodology used in this thesis. Thereafter chapter five present the research findings of this study. Chapter six is the discussion chapter and the lastly conclusions of this research, research limitations and some suggestions for further research are presented in chapter seven.
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2.
Literature review
This chapter provides an overview of the relevant literature on lean thinking and risk management. The chapter is divided in two sections: section one discusses the relevant literature on lean and section two on risk
management. Both section start with a short introduction on the origin and objective of the concept. As the aim of the research is to get an insight in the relation between lean thinking and risk management it is important for the reader to have an understanding of these concepts and the relevant literature.
2.1
Lean thinking
2.1.1 Background and concept of lean thinking
Lean is a term first coined by John Krafcik (1988) with regard to the production process in the automotive industry. Krafcik made a distinction between buffered and lean production systems. With buffered production systems he means western producers in the post-war period, as they were buffering in order to be prepared for unexpected quality problems. In contrast to buffered production organizations, Krafcik (1988) distinguishes lean organizations. Those organizations had minimum inventory levels to keep the cost of inventory low. Further quality problems were quickly identified and solved so there was no need for buffers in the assembly lines. On top of this if an employee could not make it to work, then the team would fill the gap, so there were no ‘’extra’’ employees necessary.
Until the First World War, cars were mainly assembled according to craft production processes. It was Henry Ford who, after the First World War, changed the ideas of production heavily. He introduced the mass production and he was the first who started working with assembly lines (Gerritsen et al., 2007). After the Second World War Eiji Toyoda visited Ford’s plant in Detroit in order to gain experience for his own Toyota plant (Womack et al., 1990). Toyoda was really impressed by the mass production of Ford, however he concluded that this mass production system could not work in Japan due to several differences (Womack et al., 1990):
First the native Japanese employees did not want to be treated as a variable cost and they were also not willing to do monotonous work. Furthermore, in Japan there were no "guest workers" as there were in Ford’s plant. Secondly the Japanese car market was small and the demand for variety in cars was big – e.g. small cars for the crowded Japanese cities, luxury cars for the government. Also exporting cars was almost impossible due to the presence of large car manufacturers who were defending their markets against exports. Lastly the Japanese economy was suffering because of the earlier war. Therefore, it was not possible investment massively as was the case at the Ford plant.
Due to those differences Eiji Toyoda and Taiichi Ohno introduced the Toyota Production System (TPS) and, ultimately, lean production. This is a production system that combines the benefits of both craft production and mass production (Womack et al., 1990).
2.1.2 What literature says about lean thinking
This section first discusses what the literature says in general about lean thinking. After that this section addresses more specifically what the literature says about lean thinking in the healthcare sector.
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Several authors pointed out the benefits of implementing lean thinking (Womack and Jones, 1990; Gerritsen et al. 2007; de Mast et al. 2006). Melton (2005) points out the benefits of lean thinking for the process industry. He states that implementing lean led to release of working capital, increasing speed in the supply chain and reduced manufacturing costs. Lean improves performance across the whole supply chain and therefore increases business performance.In addition, Kennedy and Widener (2008) conducted a case study in a lean manufacturing organization with lean control and accounting as well. They developed a theoretical framework based on the accounting practices, the organizational structure and the controls in a lean manufacturing organization. Their findings show that implementing lean manufacturing directly influences the organizations accounting and control practices. The lean initiative led to the implementation of four social controls, namely peer pressure, training, visualization and employee empowerment. Before the implementation of lean the case organization was a ‘batch-and-queue’ organization (Kennedy and Widener, 2008). Teamwork is critical for a lean organization and therefore four social controls were implemented. Fullerton et al. (2013) build on the framework as provided by Kennedy and Widener (2008) and researched management accounting and control practices in a lean environment. Their findings show that there is a positive relation between the extent that lean manufacturing is implemented in an organization and value stream costing, employee empowerment, a simplified reporting system and visual performance measurement information. On the other hand they find a negative relation between the extent of lean implementation and inventory tracking.
Fearne and Fowler (2006) researched construction supply chains with regard to efficiency versus effectiveness and the dangers of lean thinking in isolation, or in other words: discrete and indiscriminant implementation of lean thinking. Results show that organizations should not only focus on the cost savings but also on the effectiveness. The need for effectively delivering projects was undermined due to a focus on efficiency related to lean thinking (Fearn and Fowler, 2006). So the implementation of lean thinking should take into accounting contingencies of organizations as otherwise it makes the organization more vulnerable to uncertainties which increases the risk and organization faces.
There are also critique on lean thinking. Williams et al. (1992) point out that lean thinking is exploitative and de-humanising as they believe that it adds high pressure to the shop floor workers. Hines et al. (2004) believe it goes too far to say that lean is exploitative and de-humanising. However, they argue the importance of adding a human dimension to the principles as identified by Womack and Jones (1996). Hines et al. (2004) argue that regardless of the sector or industry it is of major importance for the long-term survival of an organization to pay attention to the motivation of employees and respect of people.
Does et al. (2011) showed the influence of lean and six sigma on the availability of infusion pumps in a hospital. In a Dutch hospital a lean six sigma initiative led to a substantial reduction of the operational cost related to infusion pumps. Furthermore the quality improved by standardizing the infusion pumps, improving of maintenance and the implementation of a tracking system for the pumps. Does et al. (2011) conclude by stating that this method – implementing lean – is applicable for similar instruments – e.g. respiratory equipment - as well.
Reijula and Tommelein (2012) conducted a literature review on lean implementation practices in healthcare. They conclude that lean implementation projects carried out so far are promising. The results of those implementations indicate improvement of safety and quality of patient treatment, work efficiency, reducing of
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waiting time and inventories. Which all lead to cost savings for the hospitals. Also empowerment of workers and enhancement of teamwork and communication between staff is noticed (Reijula and Tommelein, 2012). That implementing lean in hospitals brings benefits is confirmed by Mazzocato et al. (2010). Mazzocato et al. (2010) reviewed 33 articles related to lean thinking in health care. All of these articles show successful lean implementations. Examples of common improvements are: cost reductions, time-savings, enhancement of productivity, reduced mistakes and errors, on-time delivery of service, reduction in mortality and patient satisfaction. Furthermore the literature review on lean thinking showed that some articles stressed improvements like reduction in steps in processes, reducing of time to resolve errors, improvements in teamwork, willingness to collaborate and increasing number of signalled errors. Dickson et al. (2009) compared operational as well as value-based variables in a pre-lean and post-lean period in an emergency department of a hospital in the USA. They saw an increase in patient visits, a slight decrease in length-of-stay and a significant increase in patient satisfaction. Therefore Dickson et al. (2009) concluded that the implementation of lean improved the value of care.However there are also some drawbacks found regarding the implementation of lean in hospitals. A common limitation Mazzocato et al. (2010) found is that most healthcare organizations limited the implementation of lean to solve a problem within one department instead of implementing it in the whole organization, as was done by Toyota. Furthermore Reijula and Tommelein (2012) point out that commitment and knowledge is needed before starting with a project like lean implementation, otherwise it is possible that the whole implementation will not succeed and that it is only a waste of money. This is confirmed by Dickson et al (2009) who points out that the success of a lean implementation is contingent upon two variables: involvement of frontline staff and leadership commitment. Trip et al. (2009) conducted a case study in a Dutch hospital – University Medical Centrum Groningen – and confirm that an important element for the success of the implementation of lean was the support of the board. Their results show that the implementation of lean lead to improving financial results and also quality improvements. De Koning et al. (2006) found similar results in the Dutch Red Cross hospital.
In conclusion a lot of different benefits of implementing lean in hospitals can be found in literature. In addition the literature points also out some drawbacks and critical success factors – e.g. involvement of staff and leadership – for the implementation of lean. This provides the reader with some background of the existing literature on lean thinking.
2.2
Risk management
2.2.1 Background and concept of risk management
The implementation of enterprise risk management (ERM) increased rapidly from the mid-1990s onwards due to a call for ERM adoption by professional associations, regulators and rating firms (Arena et al., 2010). Also corporate financial scandals caused that organizations stakeholders are demanding more oversight of the key risks that organizations face to make sure that the stakeholder value is retained (Walker et al., 2002). Several definitions of ERM can be found in literature. Those definitions indicate that there are both similarities as well as differences in the views regarding ERM. All of the definitions address the integrated approach of ERM, as it ERM is applied enterprise-wide as a holistic approach for managing all kinds of business risks. The noted
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differences between the definitions is related to the goals. In the definition of COSO (COSO, 2004) the goal is the achievement of the objectives of the entity. Whereas DeLoach (2000) indicates shareholders value as the main goal. Drew et al. (2005) mentions innovation, grow and an organizations long-term success as the goal of ERM. So all of the definitions are relatively similar, however they differ somewhat in their focus. This study makes use of the widely accepted definition of ERM published by COSO ‘’Enterprise risk management is a process, effected by an entity’s board of directors, management and other personnel, applied in strategy setting and across the enterprise, designed to identify potential events that may affect the entity, and manage risks to be within its risk appetite, to provide reasonable assurance regarding the achievement of the entity’s objectives’’ (COSO, 2004, p.2) because this study also uses the risk management framework as proposed by COSO. However it is good to be aware that there are also some different viewpoints in definitions.2.3.2 What literature further says about risk management
There is a lot of literature on risk management. This paragraph provides the reader a review of relevant literature on risk management. It especially outlines the literature on risk management related to the hospital setting. In this way the reader get a better understanding of the literature available on this topic.
McShane et al. (2011) found results that show a positive relationship between increasing levels of traditional risk management (TRM) and the value of a firm. However the results do not indicate that when firms achieve a higher ERM rating – indicating applying ERM instead of only TRM – that this lead to a higher firm value.
However Samad-Kahn (2005) in his article "Why COSO is flawed" states that the COSO model is flawed in the risk assessment component as there is a focus on incidents that recently happened; so too many attention to false-positive risks and no (or too little) attention to false-negative risks. Power (2009) agrees with Samad-Kahn (2005) that ERM has some flaws. Power (2009) indicates that ERM has 3 flaws. The first flaw he mentions is that one organization with one risk appetite is not a working concept and that COSO presents the idea that a risk appetite can be expressed in financial figure. He proposed the idea that an organization consists of many actors with different interest, characteristics and risk preferences (e.g. different departments) and therefore he believes that an organization with one risk appetite is not a working concept. The second flaw Power (2009) points out is that an accounting approach suggest that risks are the result of mistakes in designed processes and can be audited. He suggested that instead risk management should be a ‘’critical imagination of alternative futures’’ (Power, 2009, p. 852) and to achieve this companies should perform scenarios and stress testing. The last flaw, according to Power (2009) is that ERM does not take into account the concept of interconnectedness (e.g. with other organization, entities, outside world) but that ERM leads to compliance-driven risk management.
Sandrick (2010) studied ERM in practice and she stating that hospitals have the idea that their risk management is good due to their strong quality monitoring, however there are also other risks that can influence the stability of a health care organization that is strategic and that hospitals are not tracking. Her evidence showed that implementing ERM helped hospitals in understanding their overall strategic risk tolerance.
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2.3
Chapter summary
This chapter provided the reader with the origin and objectives of both lean and risk management. Also relevant literature or both concept was discussed. The following chapter provide the reader with a deeper insight in the concepts of lean and risk management. Furthermore it will discuss the overlap between those concepts and propose a theoretical framework.
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3. Theory
3.1
Introduction
This chapter is divided in four parts. The first part will give the reader a deeper insight in the principles and tools of lean. Thereafter the second section outlines a common risk management framework. The third section of this chapter discusses the use of a conceptual framework and in order to gain a better understanding of the relation between lean and risk management it identifies overlaps between those concepts. The last, fourth, section provides a short summary of this chapter.
The use of theory in qualitative research is rather important. There are two ways how theory can be used in qualitative research: qualitative research uses theory as a lens to understand phenomena or it let theory emerge from the research findings. An example of the latter is the grounded theory approach (Eisenhardt, 1989). This is an approach that after an analysis of observations of a particular social phenomena let theory emerge (Eisenhardt, 1989). This study wants to make use of a conceptual framework as theoretical lens to better understand the phenomena researched. After the data are gathered and analysed the aim of this thesis is to develop a framework that can be used as a starting point for further research.
3.2
Principles and tools of lean
Lean principles
According to Womack and Jones (1996), lean thinking/lean management consists of five principles: value, value stream, flow, pull and perfection. Each of these are now described in more detail. The first principle is value. According to Bicheno (2004) organizations need identify value from the viewpoint of the customer, before applying other lean principles. Organizations need to know what a customer values and not what they think is valued by the customer or what is convenient for the organization itself. Not applying this first principle can ultimately lead to providing, efficiently, the wrong product or service (Womack and Jones, 1996).
The second principle is the value stream. A value stream is the sequence of steps and activities consisting of as well value added as non-value added activities, to deliver a product or service to a customer. So value stream is the process from raw material to customer or from product concept to market launch (Womack and Jones, 1996). This second principle is about identifying the value stream of a certain product or service. By identifying the value stream it mostly comes clear that there are non-value added activities – waste – along the value stream, such as unnecessary steps and backtracking (Womack and Jones, 1996).
The third principle identified by Womack and Jones (1996) is flow. According to them, this principle involves a new way of thinking as it consists of making sure that there is no waiting, downtime, or waste within and between the steps in the value stream. So the organization needs to make sure that it continuously adds value.
The fourth principle is pull. Pull implies that an organization only produces or services when there is a demand of the customer (Womack and Jones, 1996). So it would be possible for the customer to pull the product form the manufacturer or service provider as they need the good or services. This implies that there is no overproducing (Bicheno, 2004).
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The last principle is perfection. Perfection – in lean context – is producing or servicing exactly what a customer wants and when a customer wants it. Furthermore perfection implies producing and servicing with minimal waste and at a fair price (Womack and Jones, 1996).The concept of lean: lean tools
There are several lean tools that organizations use to implement lean (Larson and Greenwood, 2004; EPA, 2003). To get more insight on how lean works, or to put it differently: how it ensures that it optimizes value and minimizes waste, it is necessary to understand some of the tools used to implement lean thinking. The most common tools are discussed is this paragraph.
The whole idea of lean is based on the first tool: kaizen. Kaizen implies continual improvement through eliminating waste and creating value. Kaizen is a philosophy that believes that customers’ views are continuously changing and therefore continuous improvement is required (Bicheno, 2004). Kaizen also focuses on eliminating waste. To identify waste, organizations can use the second tool: value stream mapping. Value stream mapping is a process of describing the business processes and identifying waste –e.g. defects, overproduction, unnecessary processing or movements, waiting time - in those processes (Bicheno, 2004; Womack & Jones, 1996) .
A lean tool focusing on eliminating waste is ‘‘5S’’. 5S is a methodology that helps by organizing, cleaning, developing and sustaining a clean workplace and by reducing waste. The pillars of 5S are: sort, systematize, sweep, standardize, and sustain (EPA, 2003).
Another tool is the five-why technique. This is a tool that is used for finding the root cause of a problem. Finding the cause of a problem will eventually lead to a more efficient system (Gerritsen et al., 2007). An example: a machine stops producing as the fuse bust because of overload. The corrective action would be to replace the fuse. However according to the five-why method one should ask five times why. Why did the machine stop? The fuse busted. Why is the fuse busted? Because the greasing of the machine was inadequate Why was this inadequate? The lubricant pump did not function. Why did this pump not function? Because the shaft is damaged. Why that? Because of sediment in the pump. By asking five times why the root cause of the problem is found and by fixing this problem it will prevent the event from happening again (Gerritsen et al. 2007).
Just in time (JIT)/Kanban is a tool that enables the organization to produce or service what a customer wants and when a customer wants it. JIT/Kanban results in a reduction of waste because there is less inventory of raw material and overproduction (Gerritsen et al., 2007).
The last tool discussed is teamwork. At the Ford plant there were a lot of different specialized people: cleaners to clean the floor, technical employees to fix problems, quality employees to watch the quality of the products and more. However, Ohno and Toyota experimented with teams. Those teams were responsible for all tasks thereby eliminating waiting times (Gerritsen et al. 2007). If something went wrong a team first tried to fix the problem themselves and only when the team is unable to fix the problem themselves they ask for specialized employees. In summary, this paragraph first outlined the concepts, principles and tools of lean.
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3.3
Risks and risk management
According to Gordon et al. (2009) there has been a shift in the way organizations view risk management. Before the development of ERM, risks were managed from a silo-based perspective, called traditional risk management (TRM). In TRM each business unit/level identifies and manages risks separately (McShane, 2011), where ERM strives for a holistic approach of managing all kinds of business risks. ERM differs from TRM as it strives to include risk management into the strategy of an organization.
ERM is a an approach to identify business risks, assess them and make intentional decisions regarding how to deal with them and respond to the business risks. According to Barton et al. (2002) a business risk is a threat that something is able to affect an organization’s ability to execute its strategies and achieve its business objectives. This shows that an entity will be affected by business risks and that therefore business risks are able to influence an organizations performance. Miller (1992) classifies business risks into three categories: general environmental risks; industry risks and firm-specific risks.
There are other possible classifications for business risks possible as well. For example Willams et al. (1998) categorize business risks into 7 categories: physical, legal, social, political, operational, economic and cognitive. As this research focuses on Dutch hospitals it is interesting to know more about the risks hospitals face. However before exploring the area of Dutch hospitals, first the ERM framework as proposed by COSO (2004) is set out.
ERM consists of eight interrelated components (COSO 2004). Those components can influence each other and so it is a multidirectional process and not a serial process. The eight components as identified by COSO are:
Internal environment – encompasses the tone of an organization and sets the basis of how risk is viewed. This includes the risk management philosophy.
Objective setting – draws on the importance of setting objectives before being able to identify potential events that may affect their achievement.
Event identification – identifying internal as well as external events that may affect the objectives of an organization. This can be risks as well as opportunities.
Risk assessment – Analyzing risks on their impact and likelihood.
Risk response – selecting how to react to risks: either accepting, avoiding, sharing or reducing the risk.
Control activities – establishing and implementing policies and procedures in order to ensure that risk responses are effectively carried out.
Information and communication – identifying and communication relevant information in a timely manner and such a way that it is usable for people.
Monitoring – monitoring of ERM and making modification where necessary. This also involves evaluating.
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Table 1: Classification of business risks. Source: Miller, 1992.Main business risks Sub-category Examples
General environment Political uncertainties War; Revolution
Government policy uncertainties Fiscal reforms; price controls Macroeconomic uncertainties Inflation; interest rates Social uncertainties Social unrest; riots Natural uncertainties Hurricanes; earthquakes Industry Input market uncertainties Quality; shift in market supplies
Product market uncertainties Consumer taster; substitute goods Competitive uncertainties Rivalry; technology uncertainties
Firm Operating uncertainties Labor unrest; machine failure; raw
materials shortage
Liability uncertainties Emission of pollutants, product liability R&D uncertainty Uncertain results
Credit uncertainty Problems with collectibles Behavioral uncertainty Self-interested behavior
The Dutch Health Governance Code 2010 (Brancheorganisatie zorg, 2010, p. 46) states that ‘‘ the board of directors al is responsible to make sure that in the healthcare organization there is a tailored risk management and internal control system present’’. The risk management needs to concern risks like quality of the healthcare, patient safety, financial risks, market risks, image risks, construction risks and merger risks. The supervisory board of hospitals needs to supervise the strategy and related risks of the hospitals and also needs to supervise the design and operation of the risk management and control systems. Due to this code Dutch hospitals are obliged to have a risk management and control system present. Furthermore to increase and insure patient safety Dutch hospitals implemented an accredited or certified safety management system (VMS) and they implemented ten themes related to patient safety (VMS, 2014). Crucial for a good working VMS is an ongoing risk assessment (VMS, 2014) this mean continuously assessing the risk that the organization faces. The next section discusses further what literature says about risk management: the advantages and disadvantages. It also provides some literature of risk management in the hospital setting.
3.4
Lean and risk management
This thesis makes use of a conceptual framework. Miles and Huberman (1994) define a conceptual framework as a product, either visual or written, that ‘‘explains, either graphicaly or in narrative form, the main things to be studied – the key factors, concepts, or variables – and the presumed relationships among them’’ (Miles and Huberman, 1994, p. 18). According to Jabareen (2009) one of the features of a conceptual framework is that it provides an interpretative approach to social reality instead of a causal setting. Furthermore it provides understanding instead of theoretical explanation. The information earlier provided in this thesis is used to come up with a framework than can be used as a lens in the remainder of this thesis. As earlier stated there is a gap in literature with regard to the interrelationships between lean thinking and risk management. This section addresses this gap and tries to find some overlap between those concepts. Those overlaps are discussed in this section and visual displayed in table 4. This thesis looks at the combination of lean and risk management, because the researcher believes that those concepts might enhance each other and therefore it might be beneficial to explore the dynamics between those concepts. The researchers believes that continuous
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improvement, so lean, is closely related to quality and risk management. This section describes the overlaps that are found in literature.The first overlap that can be identified between lean and risk management is related to the risk identification and assessment elements of risk management, and the lean principles pull and flow, and, tools just-in-time and A3. Risk assessment is about developing assessment criteria, assessing the risks, assessing risk interaction and prioritizing the risks (Curtis and Carey, 2012) and, as previously mentioned, just-in-time is a tool that can be used by the implementation of lean thinking. Konecka (2010) researched lean supply chain management in the aspect of risk management. Her findings showed a dependency between just-in-time and the risk level as, on the one hand, an increase in stock level significantly reduces the delay of product delivery, and, on the other hand, an increase in stock level increases the risk of having inventory. It shows that implementing lean thinking led to a shift in risks - before the implementation there is the risk of having inventory and after the implementation the risk of inventory is reduced, however the risk of delay of product delivery is increased. Therefore the expectation of this study is that by implementing lean thinking the risks will shift and therefore the assessing of risks on impact and likelihood is likely to differ. Therefore this study makes the link between the lean principle pull, the tool just-in-time and risk assessment. This is supported by an article of Simons et al. (2014): there results shows that when hospitals implement the lean tool A3 this lead to a reduction in door movements of the operation room. A reduction in door movements decreases the chance that patients get surgical site infections, which is a risk at hospitals. A3 is a lean tool that uses A3 reports to promote structured problem solving based on a PDCA cycle (plan-do-check-act). The study of Simons et al. was conducted in an operating theatre in a Dutch university medical center. By eliminating door movements you reduce risk/waste and therefore the flow improves. This can also be linked to perfection, as a patient do not want to get infections during surgery. Those first overlap is described in the first row of table 2.
The second overlap is related to teamwork and controls. Kennedy and Widener (2008) showed that the empowerment and teamwork related to the implementation of lean thinking led to the implementation of four new social controls. The element control activities of the risk management framework establishes and implements policies and procedures in order to make sure that risk responses are effectively carried out (COSO, 2004). Kennedy and Widener (2008) showed that implementing lean led to different/extra controls. This link can be found in the second row of table 2.
The third overlap is related to the monitoring aspect of risk management and to the lean principle flow. By monitoring you make sure that everything goes as expected, and if not you can make the necessary adjustments. Lean is about continuously improving. Mazzocato et al. (2010) reviewed 33 articles and showed that implementing lean lead to an increased number of signaled errors and a reduction in the time necessary to resolve errors. The expectation is that when you are continuously improving your processes, you also signal errors earlier, so implementing lean lead to more conscious monitoring. This overlap is showed on row 3 in table 2.
A fourth overlap can be found with regard to the information and communication aspect of risk management. This component is about identifying and communication relevant information in a timely manner and such a way that it is usable for people. Mazzocato et al. (2010) found that implementing lean in hospitals might led to increasing willingness to collaborate and improvement of teamwork. Teamwork is a tool that can be
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used when implementing lean. Therefore, it is expected that implementing lean influences the information and communication component of risk management. This overlap can be found on the fourth row of table 2.The Open Compliance & Ethics Group (OCEG, 2009) proposes that governance, risk and compliance (GRC) practices in organizations can benefit from a lean approach. Organizations are faced with economic downturn and have therefore less revenue streams and available credit. For this reason organization sometimes cut GRC budgets while at the same time they need to ensure compliance and improve transparency. Therefore OCEG (2009) states that GRC executives need to learn how they can do more with less. OCEG (2009) proposes that a lean approach of GRC lead to improved effectiveness, efficiency and agility. They state that by applying the principle of eliminating waste this can lead to a decrease in GRC inefficiencies like duplication of controls, poor information flow and redundant processes. This shows that the concepts of lean and risk management might enhance each other. Therefore it is beneficial to explore the interrelationships between the concepts.
Table 2 shows the overlaps that the researcher identified from the literature. By conducting qualitative research the researcher is going to explore whether those relationships can be found in practice, in Dutch hospitals, or if there might be different relations.
There is chosen for those principles of lean thinking and those elements of risk management, as some overlaps could be identified from the existing literature. A relationship or link between other principles and elements could not be identified from the literature. However as this study makes use of semi-structured interviews, it allows the researcher to explore other interrelationships as well. The aim of this research is to see whether or not those linkages still relate in the Dutch hospital sector. After the data are gathered it is the intention to adjust the framework from table 2 to point out the situation in Dutch hospitals.
Table 2: relationships between lean thinking and risk management
Lean Thinking Risk Management Lean Thinking & Risk Management
Principle: pull and flow Tool: just – in – time and A3
(Womack and Jones, 1990; Larson and Greenwood, 2004; EPA 2003)
Event identification & Risk Assessment (Curtis and Carey, 2012)
Shift in risks: different risks before and after the implementation of lean Konecka (2010)
Reduction of risk due to
implementation of lean (Simons et al. 2014)
Principle: value stream Tool: teamwork
(Womack and Jones, 1990; Gerritsen et al., 2007)
Control activities (COSO, 2004)
Other controls, e.g. social controls (Kennedy and Widener, 2008)
Principle: flow Tool: kaizen
(Womack and Jones, 1990; Larson and Greenwood, 2004)
Risk Monitoring (COSO, 2004) Increase in signaling of errors and reducing of time necessary to fix errors (Mazzocato et al., 2010)
Principle: value stream Tool: teamwork
(Womack and Jones, 1990; Gerritsen et al, 2007)
Information & Communication (COSO, 2004)
Increasing willingness to collaborate and improvement of teamwork. (Mazzocato et al., 2010)
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3.5
Summary of the chapter
This chapter discussed theory that will be used in this research. First it provided deeper insight in the concepts of lean and risk management. It outlined principles and tools of lean thinking and the components of risk management. Thereafter section 3.4 looked at a combination of those concepts. The researcher was able to identify some overlaps between lean and risk management in the current literature. This framework will be used as a theoretical lens in the remainder of this thesis. The researcher will use it as a basis for the interviews.
The researcher believes it is beneficial to look at the dynamics between the concepts instead of only one of them. This because they might enhance each other: lean can make the risk management process more efficient (OCEG 2009) and implementing lean might reduce the chance of occurrence of risks (Simons, 2014). The next chapter outlines the research methodology used.
4. Research methodology
4.1
Introduction
This chapter discusses the research methodology used in this study. The first section discusses the philosophy of research. The second section outlines the choice for qualitative research in this research. Thereafter, the third section elaborates on the research methods applied in this study i.e. documentary analysis and semi-structured interviews. The fifth section outlines the research design in this study and the last section discusses the data analysis process in this research.
4.2
Philosophy of research
There are two dimensions in the field of research, namely the quantitative approach and the qualitative approach (Tomkins & Groves, 1983). Each approach builds on different ontological and epistemological assumptions. Epistemology is concerned with the knowledge about a particular phenomenon or reality. Ontology is referring to how the researcher views reality and the nature of human being in the world (Denzin & Lincoln, 2005). According to Ryan et al. (2002) those epistemology and ontology are connected to each other, because how a researcher views reality (ontology) will influence how knowledge is gained (epistemology) and this will affect the research method.
Researchers conducting quantitative research view the world as objective and taken-for-granted. Those researchers use a positivist approach to gain knowledge (Ryan et al. 2002). Following the positivist approach the researcher and the research object are viewed as independent and therefore the researcher is able to study the research object without influencing each other (Guba & Lincoln, 1994). In quantitative research theory is used to formulate hypothesis and those hypothesis are then tested by using quantitative research methods like structured interviews, experiments and statistical regressions (Gephart, 2004). This research is aimed at statistical generalisation (Gephart, 2004).
In contrast to the above, qualitative research views the world as subjective and socially constructed. Qualitative research use an interpretative approach where ‘‘the stress is on the understanding of the social world through an examination of the interpretation of that world by its participants’’ (Bryman, 2008, p. 366). This
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means that qualitative research is trying to explore and understand processes from the point of view of the participants. Qualitative research uses methods like observations, interviews and documentary analysis to get a ‘‘deeper understanding of social phenomena than would be obtained from purely quantitative data’’ (Silverman, 2000, p.8). The aim of qualitative research is not statistical generalisation but rather an in-depth understanding of the research phenomenon (O’Sullivan, 2010). For this reason qualitative research adopts ‘why’ and ‘how’ research questions (Yin, 1989).Table 3 outlines the main differences between quantitative and qualitative research. It is worth mentioning that not one approach is better than the other (Silverman, 2000). It is dependent on the research object what research approach suits better. This study adopts a qualitative research approach as the aim is to get an in-depth understanding of the dynamics between lean thinking and risk managementand for this reason the next section outlines the characteristics of qualitative research in more depth.
Table 3: Differences between quantitative and qualitative research (Source: Bryman, 2008, p.393)
Quantitative Qualitative
Numbers Words
Point of view of researcher Points of view of participants
Researcher distant Researcher close
Theory testing Theory emergent
Static Process
Structured Unstructured
Generalization Contextual understanding
Hard, reliable data Rich, deep data
Macro Micro
Behaviour Meaning
Artificial settings Natural settings
4.3
Qualitative research
Theory is used differently in qualitative research than in quantitative research. Quantitative research tests theory, but this is not the aim of qualitative research. However it is a misconception to say that qualitative research does not use theory. There are two ways how theory can be used in qualitative research: qualitative research uses theory as a lens to understand phenomena or it lets theory emerge from the research findings. An example of the latter is the grounded theory approach (Eisenhardt, 1989). According to this approach theory emerges after an analysis of observations of a particular social phenomenon (Eisenhardt, 1989).
Moreover the way how theory is used in qualitative research is sometimes questioned (Ahrens and Chapman, 2006). There are misconceptions regarding the ‘lack’ of theory in qualitative research. However Cooper and Morgan (2008) argue that in fact theory is a major aspect of qualitative research and according to Ahrens and Chapman (2006) the research question, data, theory and method used in qualitative research are related to each other as they continuously inform each other. Furthermore there are misconceptions about the level of rigour applied in qualitative research. According to Bryman (2008) this is partly the result of the subjective nature of qualitative research as the researcher is the one that conducts the research and interprets the findings. Therefore it is important that the quality of qualitative research is assessed. Lincoln and Guba (1985)
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and Guba and Lincoln (1994) proposed two criteria - authenticity and trustworthiness – to assess the quality of the research. As mainly trustworthiness is applied in this research, these criteria will be discussed in more detail. According to Bryman (2008) trustworthiness consists of four sub-criteria: credibility, transferability, dependability and confirmability. Credibility is concerned with the level of confidence in the research findings. This can be enhanced by sending the results back to the participants in the research for confirmation – respondent validation – or by using multiple research methods or data – triangulation of findings (Bryman, 2008). Theoretical transferability can been seen as external validation. This means if other researchers see the possibility to transfer the findings in other settings. Lincoln and Guba (1985) argue that when a researcher provides a thick description of the details of the research, others can judge if it is possible to transfer the findings to other settings. Dependability can be seen as reliability and relates to procedures that should be followed to show that the research is conducted, documented and analysed rigorously. In other words, the researcher needs to follow and document a detailed "audit trail". The last criterion is confirmability. Qualitative research is always in a sense shaped by the researcher and therefore not totally objective. However the researcher is able to show confirmability by searching for contradictory data and providing data triangulation (Bryman, 2008). The research methods that can be applied in qualitative research are discussed in the next section. The method used in this study is discussed as well.4.4
Qualitative research methods
Within the qualitative research approach there are several methods that can be applied: documentary analysis, observation and interviews. In this thesis documentary analysis and interview analysis are applied and therefore these methods will be discussed in more detail. Documentary analysis according to O’Sullivan (2010, p. 74) ‘‘involves the content analysis of a wide range of hard and web-based documents and texts to ensure an in-depth analysis of the social phenomenon in question’’. Examples of documents that can be analysed are: correspondence, websites, official publications, reports, financial accounts and organisational records (Patton, 2002). By applying documentary analysis in addition to interviews it assists in triangulation.
The main research method applied in this research is interviews, because the aim of this study is to get in-depth insights into the dynamics between lean thinking and risk management in Dutch hospitals. According to Patton (2002) interviewing allows the researcher to learn more about phenomena that are not possible to observe directly. By interviewing it is possible to find out more about the thoughts of the interviewees and respond to their reactions. There are three possible interview forms: structured, semi-structured and unstructured. This research uses semi-structured interviews and therefore this method is described hereafter.
Semi-structured interviews are those where the researcher prepares an interview guide with open-ended question. Emphasis should be placed that it is a guide, but that the researcher is able to deviate from this guide and ask other question that are not in the guide as well. (Patton, 2002). According to Patton (2002) semi-structured interviews allow the researcher to understand how the interviewees see a particular phenomenon and ask them about their meaning. In addition to this, Bryman (2008) points out that an understanding of a process can be achieved by conducting semi-structured interviews.
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4.5
Research design
4.5.1 Interviewees
To get an thorough understanding of lean thinking and risk management in Dutch hospitals it is important to get a multidimensional view. This can be reached by interviewing several relevant stakeholder groups – i.e. representatives of the Dutch hospital sector and advisors. Another benefit of interviewing different stakeholders is that it enhances triangulation of the findings which, as outlined earlier, enhances the credibility and confirmability of this thesis. For each of the groups five interviewees were selected, resulting in a total of 10 semi-structured interviews. Table 4 (below) gives an overview of the interviewees; first listed per interview group and thereafter in order of when the interviews took place. Different sampling methods were used to select the interviewees.
First the researcher had some informal chat with advisors who have knowledge of and experience with risk management and lean thinking. Hereby the researcher got the feeling that the chosen topic is worth to research. After those informal chats five consultants, with the most relevant knowledge and experience of risk management and lean thinking in the hospital sector, were selected for a formal interview. According to Audehoven (2007) this is a valuable way to quickly collect knowledge in a field, because those consultants have detailed and specific knowledge about a particular field.
Purposive sampling was used to gain access to experienced advisors. This means that the interviewees are not randomly selected, but that the interviewer choose the interviewees who are relevant for the research (Bryman, 2008). The researcher participates in a graduation internship at EY Advisory Services Amsterdam and therefore initial access to the advisors was easily gained. This allowed the researcher to select those advisors with the most relevant experiences for this research. To contact other stakeholders snowball sampling was used. This means that existing interviewees bring the researcher in contact with other potential interviewees through their network (Salganik and Heckathorn, 2004). Through contacts of the EY advisors, the researcher was able to get in contact with representatives of Dutch hospitals sector. Those representatives of Dutch hospital sector contain of four representatives of different Dutch hospitals and one representative of a major Dutch healthcare insurer. All of them have expertise on lean thinking and are familiar with the concept of risk management.
Table 4: Overview of interviewees Interview
number
Interviewee Function Location of
interview
Date Duration Agree with transcript Representatives of the Dutch hospital sector
I3 Representative of a Dutch hospital Manager operations Cluster Diagnostics Anonymized 7 May 2014 45 minutes No reaction I4 Representative of a Dutch hospital
Lean coach Anonymized 8 May 2014 56 minutes Yes I5 Representative of a Dutch hospital Manager Innovation & Quality Anonymized 13 May 2014 53 minutes Yes I8 Representative of a Dutch health care insurer
Program manager lean Anonymized 19 May 2014 60 minutes Yes
I10 Representative of a Dutch hospital Head of lean team Anonymized 23 May 2014 57 minutes Yes
