The influence of leadership behavior on the implementation process of a lean program. A single case study in the healthcare sector.

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The influence of leadership

behavior on the

implementation process of a

lean program

A single case study in the healthcare sector

Bo Heijkoop (s4351827)

Nijmegen, 23-08-2018

Supervisor: dr. R.L.J. Schouteten

Second examiner: dr. Y.G.T. van Rossenberg

Master Thesis Business Administration – Strategic Human Resource Leadership Nijmegen School of Management

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Preface

In front of you lies the thesis ‘The influence of leadership behavior on the implementation of a lean program’. The research for this thesis into leadership behavior was carried out at the Policlinic Urology of Alrijne Zorggroep. This thesis was written in the context of my graduation of the Master’s program Strategic Human Resource Leadership at the Radboud University Nijmegen. From February till August, I have been busy with the research and writing of the thesis.

Without the help of several people I was not able to do this research and therefore I would like to thank them. First of all, I would like to thank my supervisor Roel Schouteten for his guidance during this project. Next, I really would like to thank Robert van Kleeff for all his help and support during my research and for introducing me at Alrijne and the Policlinic Urology. Additionally, I would like to thank everyone at Policlinic Urologywho helped me with gathering data, and especially Annet van Kesteren, who gave me this opportunity. And finally I want to emphasize my gratitude towards my parents and my friends, who have always supported me and motivated me to finish this thesis successfully.

I hope you enjoy this thesis and that you will benefit from the insights it gives. Bo Heijkoop

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Management Summary

For this Master Thesis research is conducted to the influence of leadership behavior on the implementation of a lean program in a hospital. The research was carried out at the Policlinic Urology of Alrijne Zorggroep. The policlinic started December 2016 with the implementation of the so called program ‘SamenBeter’. The aim of this program is to implement lean thinking and working at the work floor in order to improve work processes and to deliver good and efficient care to their patients.

In existing literature is often written how team leaders should behave in order to implement the organizational concept lean successfully. However, we know little about how team leaders really behave during the implementation process and what the consequences are of their behavior. Therefore this research provides an answer to the question: ‘How does the behavior of leaders influence the implementation process of a lean program in a hospital?’

Qualitative research is conducted to formulate an answer to the question. Real-time observations and open semi-structured interviews are held to better understand the role of leaders in a lean implementation process. Also, several relevant documents are consulted. The data showed that leaders have both a positive as well as a negative influence on the implementation process of lean in this case. The most striking finding is that leaders have to be apparent and that some kind of top-down, active steering is beneficial for the lean implementation process.

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4.1 Observation 1 ... 87 4.2 Observation 2 ... 87 4.3 Observation 3 ... 88 4.4 Observation 4 ... 92 4.5 Observation 5 ... 92 4.6 Observation 6 ... 92 4.7 Observation 7 ... 93 4.8 Observation 8 ... 93 4.9 Observation 9 ... 93 4.10 Observation 10 ... 94 4.11 Observation 11 ... 94 4.12 Observation 12 ... 95 4.13 Observation 13 ... 96 4.14 Observation 14 ... 96

Appendix 5: Documents overview ... 98

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1. Introduction

The last decades there is a growing attention for implementations of the organizational concept lean in different sectors. The concept lean was first used by the Japanese car company Toyota to describe their new approach to production and is characterized by a radically new approach to manufacturing whereby creating maximum value for customers is central for organizations and trough the elimination of waste with a culture of continuous improvement better outcomes for customer and organization can be reached (Womack & Jones, 1996). Lean thinking may be described as: “an integrated system of principles, practices, tools, and techniques focused on reducing waste, synchronizing work flows, and managing variability in production flows” (de Koning et al., 2006, p. 5). Lean thinking is based on five process optimization principles: (1) define value as perceived by the customer, (2) identify the value adding activities and eliminate the others, (3) create flow, (4) react on customer demand (pull), and (5) continuously strive for perfection (continuous improvement) (Aij, 2015; van Loenen & Schouteten, 2016). Womack and Jones (1996) already highlighted the possibility for lean to be useful in other sectors as well to improve processes and to reduce waste. One of those sectors is the healthcare sector.

Lean healthcare literature started to appear in 2001 (Robinson, Radnor, Burgess & Worthington, 2012). Lean healthcare is about simplifying processes by identifying what adds value and eliminating waste. It is often emphasized that current healthcare systems consist of fragmented processes that require a shift in how the flow of patient care delivery is perceived and organized (Poksinska, 2010). Patients should be considered as primary customers and the application of the lean principles seems to lie in eliminating delays, repeated encounters, errors and inappropriate procedures (Aij, 2015). Dahlgaard, Pettersen and Dahlgaard-Park (2011) define lean healthcare as: ‘a management philosophy to develop a hospital culture characterized by increased patient and other stakeholder satisfaction through continuous improvements, in which all employees (managers, physicians, nurses, laboratory people, technicians, office people etc.) actively participate in identifying and reducing non-value-adding activities (waste) (p.677).

Despite similarities between healthcare and manufacturing organizations some people are skeptical about translating the organizational concept lean, with its roots in a manufacturing company, to the complex healthcare sector (Aij, 2015). Arguments like ‘people are not automobiles’ are often used (Kim, Spahlinger, Kin & Billi, 2006). Within lean creating

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6 customer value is essential and in healthcare different customers can be identified. The patients are often seen as main customers, because they are the recipients of care. However, Health Insurance organizations and practice-based commissioners, as purchasers of care, and central political organizations, as regulators, can be identified as customers as well. Having different customers can make it difficult to define the customer value (Aij, 2015). Furthermore, the professional environment of hospitals can be characterized as highly complex with a unique and embedded culture among employees (Aij, 2015). Implementing the organizational concept lean in hospitals and other healthcare organizations can be challenging. Aij (2005) identified several challenges: resistance to change, a need for evidence that lean initiatives will work, lack of time to undertake both improvement projects and routine daily activities and interdepartmental friction if patients move between parts of a hospital that have not fully adopted a lean philosophy (p. 12). To be able to deal with those challenges and to implement lean successfully in such a complex environment leadership is essential. Effective leadership is necessary in order to make the lean implementation and transformation sustainable over the long run (Aij, 2015; Mann, 2009).

As shown by van Loenen and Schouteten (2016) management plays a key role in successful lean implementation processes. It is important that managers are trained to perform as servant leaders, because in theory this type of leadership stimulates employees to improve continuously. Managers define guidelines and give employees space to use their own knowledge and experience to improve their work continuously. Managers are seen as facilitators in the lean implementation process (van Loenen & Schouteten, 2016). According to Al-Balushi, Sohal, Singh, Al Hajri, Farsi and Al Abri (2014) a decentralized management style is directly related to a successful lean implementation in the healthcare sector.

When implementing an organizational concept, such as lean, it is possible that the intended idea differs from the way that the idea is implemented and perceived by employees. Nishii and Wright (2008) and Purcell and Hutchinson (2007) describe this mechanism. As first, organizations design a policy to contribute to the achievement of business strategy. Then, the idea is implemented and this implementation, in this case lean, is influenced by the method or style of leadership behavior from front line managers. Leadership behavior aims to influence employees’ attitude and behavior and give direction (Purcell & Hutchinson, 2007). For a successful implementation it is important that a leader behaves in a way that the actual implementation of the concept is as close as possible to the intended idea. This study focusses

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7 on the leadership behavior and its role in the implementation process of the organizational concept lean. Previous literature already showed the important role of leaders during implementation processes of organizational concept (Purcell & Hutchinson, 2007), but regarding the concept lean we know little about how leaders really behave in practice. That is why there is chosen to focus on leadership behavior.

To the best of my knowledge in existing studies real-time observational data about leadership behavior during lean implementations is lacking. Graban (2012) and Jorma, Tiirinki, Bloigu and Turkki (2016) recognize in their articles that there is a need for real-time observational data about lean thinking in healthcare management in order to find out the deeply rooted causes of implementation problems. Aij and Teunissen (2017) conducted a systematic literature review about lean leadership attributes based on articles published from 2000-2016. They refer to many qualitative articles, but almost all those articles are based on interview data and this data is mostly retrospective (Aij & Teunissen, 2017). Real-time observational data can complement the existing retrospective literature.

The goal of this master thesis is to conduct an explorative study to research the influence of leadership behavior on the implementation process of a lean program in a hospital. This is necessary because although we have all the prescriptive literature about how leaders should behave to implement lean, lean implementations are still experienced as difficult (Jorma et al., 2016) and we know little about how leaders really behave during the implementation process and what the consequences are of their behavior. In order to understand the behavior better it is necessary to really dive into the implementation process and to do real-time observations to reveal what is really going on during the implementation process. Possibly there are several reasons why the lean implementations are difficult, but to give this study any direction it is chosen to focus on leadership behavior, because previous research showed the important role of leaders during the implementation of lean and that is why first this leadership role is explored. Maybe the leadership behavior is hampering the implementation process. To research this, real-time observations are done to reveal underlying dimensions of leaders’ behavior in such implementations and to stay really close to the reality and what happens at the work floor. In this way, by gaining real-time, explorative data, real behavior can be revealed and this can help us to better understand the role of leaders in lean implementation processes. The study goes further than existing studies, whose data is mostly retrospective. In order to reach the goal of the study the following central question is formulated:

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8 ‘How does the behavior of leaders influence the implementation process of a lean

program in a hospital?’

By answering this question, this study contributes to existing literature about lean management in healthcare by providing an insight into the implementation process from the inside and to understand the role of leadership behavior better. This study tries to reveal what leaders really do in the implementation process and why they do that instead of only what they say they do. This can possibly be different.

Answering this question can be of practical relevance as well. The department researched in this study can learn from the insights gained in this study and can possibly improve their lean implementation by adjusting their leadership behavior. Depending on the outcomes, it could be possible to translate the results to other contexts as well, for example to other departments or other hospitals.

Chapter 2 of this thesis consists of an explanation of the theoretical framework and describes the existing prescriptive literature where this study builds further on. In chapter 3 the methodological part will be outlined, the data collection and data analysis methods will be explained. This study is based qualitative research. Interviews are conducted with employees and leaders of a hospital and real-time observations are done to observe the behavior of leaders in interaction with their employees. Next, in chapter 4 the results will be presented and in chapter 5 a conclusion will be drawn together with a discussion and recommendation part.

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2. Theoretical framework

This research tries to contribute to literature about lean management in healthcare by focusing on leadership behavior. When searching for literature about leadership roles and behavior during lean implementations in the healthcare context it is observable that most literature is highly prescriptive. Many authors wrote about how leaders should behave when implementing lean. Dombrowski and Mielke (2013) developed a conceptual model for an integrated lean leadership system. Aij and Teunissen (2017) built further on this model by providing specific attributes and behavior of successful lean leaders in healthcare organizations. Other authors argue that traditional leadership styles are effective when implementing lean, namely transformational and servant leadership (Den Hartog et al., 1997; Stone et al., 2004; Grove et al., 2010; Poksinska et al., 2013). They describe important qualities and ways to behave for leaders during lean implementations. There are also authors that recognize the change character of lean implementations and they see lean leaders as change agents and they describe what those leaders should do during changes. The work of Flinchbauch et al. (2008), Fine et al. (2009), Mann (2009), Mazur et al. (2012), Studer (2012) and Aij and Lohman (2013) about lean and leadership can be characterized as prescriptive as well. In general they all describe guidelines and essentials for leaders how to act and behave when implementing a lean program. In the mechanism of Nishii and Wright (2008) and Purchell and Hutchinson (2007) this leadership behavior takes place in the phase where the intended practices are implemented by front line managers.

This above mentioned prescriptive literature about lean and leadership behavior will be further explained in the next sections of this chapter in order to get an overview about what is known at this moment of the topic. The overview will serve as a starting point for this explorative study and the ideas and concepts will be kept in mind when doing the real-time observations and interviews.

2.1 Lean leadership

According to Dombrowski and Mielke (2013) lean leadership can be defined as: ‘a methodical system for the sustainable implementation and continuous improvement of lean production systems. It describes the cooperation of employees and leaders in their mutual striving for perfection. This includes the customer focus of all processes as well as the long-term development of employees and leaders’ (p. 570).

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10 Dombrowski and Mielke (2013) developed a conceptual model for an integrated lean leadership system, which includes five core principles of lean leadership: improvement culture, self-development, qualification, gemba, and hoshin kanri. The model of Dombrowski and Mielke (2013) is not industry specific. Aij and Teunissen (2017) applied the model to the healthcare sector and came up with several attributes for lean leaders.

The first principle, improvement culture, is about all attitudes and behaviors regarding an ongoing strive for perfection. For a lean leader it is important to involve employees in lean initiatives and to believe in the concept itself. Furthermore a leader has to be able to honestly recognize failures and see them as opportunities for improvement (Aij & Teunissen, 2017). When an employee notices a failure in the work process a lean leader should support the employee to improve the process.

The second principle is self-development. To become a successful leader during lean implementation, leaders have to develop themselves because lean leadership asks for new leadership skills. Self-development asks leaders to show interest, facilitate resources, emotional intelligence, visualize greatness, be aware of one’s status, and have the skills to motivate, inspire, stimulate, and facilitate (Al-Balushi et al., 2014; Hopkins et al., 2011). Moreover, lean leaders have to behave as role models and have to learn to use different lean tools, for example plan-do-check-act cycles and value stream mapping (Aij & Teunissen, 2017).

The third principle is called qualification. During the lean implementation leaders have to support their employees to establish daily routines and to develop a sustainable continuous improvement environment. Some attributes which enable managers to support their employees’ development are empowerment, trust, communication, governance and consistency (Steed, 2012).

A key factor in lean is the daily presence of management on the work floor and this reflects to the fourth principle, gemba. In Japanese, gemba means actual place. In the lean context, especially in healthcare, it refers to the place where value is created for the patient (Fine et al., 2009). For leaders, going to the gemba means that they should frequently go to the work floor in order to really understand the processes where their employees create value and to be able to make the right decisions (Aij, 2015; Dombrowski & Mielke, 2013). The leader gains trust

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11 of employees by demonstrating engagement and showing himself to be honest, benevolent, and express well-intentioned behavior (Aij & Teunissen, 2017).

The fifth and last principle of the conceptual model of Dombrowski and Mielke (2013) is hoshin kanri. Hoshin kanri is a method of aligning goals with customer focus on all levels. The task for lean leaders is to develop long-term strategies and goals and to coordinate the work of all teams within the hierarchical structure of the healthcare organization. Dombrowski and Mielke (2013) assume and expect that a leader can influence the process and contribute to the success of a lean implementation by executing all those five principles.

2.2 Transformational and servant leadership

According to Grove, Meredith, Macintyre, Angelis and Neailey (2010) transformational leadership is necessary for a successful and sustainable implementation of lean in healthcare. Idealized influence, inspirational motivation, intellectual stimulation and individualized consideration are some characteristics of a transformational leader that are appropriate for a leader during a lean implementation (Poksinska, Swartling & Drotz, 2013). Transformational leaders inspire their employees to do more than expected before and within transformation leadership there is an emotional attachment between leader and employee. Those leaders can broaden the interests of their employees, generate awareness and acceptance among employees of the purposes and mission of the group and motivate employees to go beyond their self-interests for the good of the group (Den Hartog, Muijen & Koopman, 1997). A transformational leader is able to transform an organization, which is needed when implementing lean healthcare, by defining a specific need for change, creating new visions and mobilizing commitment to those visions (Den Hartog et al., 1997).

Another leadership theory that can be linked to lean leadership is the servant leadership theory (Poksinska et al., 2013, van Loenen & Schouteten, 2016). According to the servant leadership theory a leader can be seen as a servant. The primary goal and highest priority of a servant leader is to serve and meet the need of others. Within lean the primary focus is on the customer, that is the one who decides whether an activity is value adding. Therefore a leader alone cannot add value, it is the employee on the work floor who does that (Dombrowski & Mielke, 2013). By knowing this, it is important for leaders to be aware of this and to serve their employees.

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12 Stone, Russell and Patterson (2004) recognize that transformational leadership and servant leadership are quite similar and that is why both can be linked to lean leadership. Both theories put emphasis on the consideration and appreciation of individuals and on the importance of teaching, supporting, involving, coaching, developing and empowering employees, which are all necessary for lean leaders in the healthcare sector as well (Poksinska et al., 2013) and which can be found in the conceptual model of Dombrowski and Mielke (2013). Moreover, according to both theories the leader and employee have to work together and the leader is not superior to his or her employees. This is important for lean leaders as well, because leader and employee have to cooperate in their mutual strive for perfection (Dombrowski & Mielke, 2013).

2.3 Leadership during change

Successful lean conversions ask for changes in culture. The role of the leader in this context is to be open to the kind of self-development needed, to develop subordinates so that they grow and improve, to remove obstacles that prevent employees from doing their work as expected; and finally to set challenges and goals so that teams at all levels of the organization can contribute to continuous improvement and attainment of its long-term goals (Liker & Convis, 2011). For a successful transformation towards lean working it is important that managers realize that lean is not just implementing a few lean tools, it is rather a change in the behavior of the whole organization and its employees in order to get a lean culture in your organization (Mazur, McCreery & Rothenberg, 2012). This realization is important, because managers have to understand where the transformation is about and what it means for themselves, their employees and the organization. Leaders need to have the qualities to be change agents (e.g. technical skills, personal commitment and broad support in the organization) in order to make the implementation successful (Fine et al., 2009). Leadership for change requires leaders with the appropriate personal qualities, skills and methods but the authors do not specify what these are (Daft & Armstrong, 2009 in Aij, 2015). It is important that leaders support and motivate their employees for the planned change.

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2.4 Summary

Based on previous work (Flinchbauch et al., 2008; Fine et al., 2009; Mann, 2009; Studer, 2012; Aij & Lohman, 2013) Lahaye (2014) developed a list of typical behaviors of lean leaders in the healthcare sector. This list is extended with literature described in this chapter in order to get an overview of what is known about leadership behavior during lean implementations. The list can be seen as a summary of the existing, prescriptive literature described in this chapter about how leaders should behave during lean implementations in the healthcare sector in order to have a successful influence on the process.

Behavior of lean leaders

1. Motivate and inspire employees to be creative in continuously improving processes and coach them in solving problems

2. Promote the long term orientation of lean

3. Focus on the patient and ensure employees do it as well 4. Have the drive, courage and perseverance to implement lean 5. Be open, honest and vulnerable and serve employees

6. Dare to make decisions and to take the initiative 7. Trust employees and give them responsibilities

8. Show the right behavior (serve as a role model), show commitment and understand the processes where value is created (gemba)

9. Show respect, make sure that there is a two way communication between manager and employee and let employees to that it is ok to make mistakes and that it is an opportunity to learn.

10. When there is a problem, look at the process. Do not blame employees or others 11. Control the determined standards and talk with employees why the standards are

not reached

12. Give direction, set goals and define a specific need for change 13. Be supportive and approachable and create trust

14. Be ‘soft’ and patient and take time to look for root causes of a problem Table 1. Summary of existing literature about leadership in lean implementations

According to the existing literature as described in this chapter and summarized in table 1, leaders can positively influence the implementation process of lean when they show the desired behavior. Which behavior is desired, based on literature, can be found in table 1.

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14 However, although we have all this knowledge and guidelines for leaders, the implementation process is sometimes still difficult and not always successful. That is why this study tries to make a step further and research the phenomenon real-time to reveal how leaders really behave and what the consequences are for their behavior. The information in table 1 is translated into sensitizing concepts, by giving a name to every single point of information. In this way, the described literature in this chapter serves as a starting point for the study, because the sensitizing concepts are kept in mind while doing research.

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3. Methodology

3.1 Case description

This research is carried out at Alrijne Zorggroep. On January 1st of 2015 Rijnland Zorggroep and Diaconessenhuis Leiden are merged into Alrijne Zorggroep. The aim of this merge was to keep delivering the best care of the region. In the Netherlands, the rules towards quality and volume standards for hospitals are getting more and more strict. It is obligated to carry out specialist treatments regularly in order to prove your proficiency. To comply with the regulations, hospitals started working together in order to meet the quality requirements and volume standards. Together the hospitals can deliver the best care for their patients. Alrijne Zorggroep consists of three hospitals (Leiden, Leiderdorp and Alphen a/d Rijn) and two nursing homes (Leythenrode and Oudshoorn). Next to that, there are specialist consultation hours in Katwijk, Sassenheim and Lisse. At Alrijne, they believe that people will get better from good care with personal attention and they have a focus on the patient when designing a care plan. The core value of Alrijne is ‘together’. Together with patients they choose the best treatment, together with colleagues they offer care with personal attention and together with care partners they organize optimal care around the patient.

A couple of years ago Alrijne started the program ‘SamenBeter’. The aim of this program is to implement lean thinking and working in the hospital in order to improve work processes and to deliver good and efficient care to their patients. In implementing ‘SamenBeter’ Alrijne works together with Lean Instituut @ Verbeeten. Lean Instituut @ Verbeeten provides education and training about lean and gives support in change trajectories towards lean working. At Alrijne there are two different types of training to get people ready for a transformation towards lean. First of all, there is a training for ‘regular’ employees, which is about ‘how do I improve?’. A particular number of employees from a department follow the so called Green Belt training of five days. After the training the employees understand the impact of a change in the organization and are able to improve their work every day. Furthermore, the idea is that they can support and assist colleagues, who did not follow the training, at the work floor to start working lean and to improve work processes (Document 1). Besides this, there is a special training for team leaders and some doctors, which is about ‘how do I support?’. Within this training team leaders and doctors learn the basic knowledge and principles from lean management and how they can translate those principles to their own

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16 practice. Furthermore, they learn to watch differently to their own organization and which attitude and behavior is suitable in a lean transformation process (Document 2).

The data for this thesis is collected at the Policlinic Urology of Alrijne. The department started December 2016, as one of the first departments of the hospital, the Green Belt trainings and in May 2017 the Leadership trainings had started (Document 3). In total four employees followed the Green Belt training, one urologist, two nurses and a secretary and two employees followed the Lean Leadership training, one urologist and the team leader of the department (Document 4). It is noticeable that the team leader only has a functional team leader role, she do not have any medical responsibilities, or in other words she is not an urologist or a nurse.

The Urology department is chosen for this research for several reasons. First of all, the department started a while ago with the trainings and the adoption of ‘SamenBeter’, which makes it possible to follow different lean initiatives that are going on at the department at the moment. Furthermore, the department uses different lean tools. They use value stream mapping to visualize their processes and to learn where value is created and where waste can be found in the process and so, how flow can created in the process. They also use A3 reports as a systematic problem solving guide based on the plan, do check, act cycle. Next to that, the department makes its annual plan using the X-matrix. This X-matrix links the strategic long-term goals to tactical year goals for the department, which are in turn linked to operational actions, projects, A3 reports and SMART formulated results. The matrix also offers the possibility to monitor the progress (Document 5). Other lean tools used by the department are fishbone analysis and 5S methodologies. Another reason why the Policlinic Urology is an interesting case to study is the fact that the department is dispersed over different locations of the hospital, which can be challenging for a leader to motivate employees, to communicate goals and to create a common sense for an initiative like ‘SamenBeter’.

3.2 Research method and design

To understand the behavior of team leaders during the implementation of lean, detailed, in-depth and real-time information is necessary and therefore a qualitative research approach is chosen. Observational and interview data are collected and interpreted to make statements about the behavior of team leaders during the lean implementation. It is necessary to collect the data in this way, because observations and interviews offer the possibility to research the leaderships behavior during the lean implementation in depth and in real-life. Observations

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17 enable us to know and to understand what is really going on at the Policlinic Urology and interviews offer the possibility to ask further on respondents questions. In contrast to quantitative research, where respondents are limited in expressing themselves.

This study can be characterized as explorative, because this research aimed to gain new insights in the underlying dimensions of the behavior of team leaders and their influence on the implementation process of a lean program. Existing literature is mostly prescriptive and often sums up what a leader should do during lean implementations. However, although we actually know how leaders should behave, we know little about how they really behave during the implementation process and what the consequences are of their behavior. That is why this study aimed to reveal the real behavior of team leaders and in that way to contribute to existing literature. To be able to do that, it is chosen to research and explore only one department in depth and to stay within one context in order to get a good understanding of the department and to gain meaningful results, because there is time and space to really dive into the case. However, this makes it difficult and almost impossible to generalize the insights to the wider environment, due to the specific context of the department and the hospital. In this way, the external validity is low.

In this study a more inductive research approach is used, because the goal is to explore and reveal underlying dimensions of the behavior of team leaders. In an inductive research approach, the researcher has an open view and not much theoretical expectations (Bleijenbergh, 2013). Theoretical concepts about leadership behavior in lean management in the healthcare sector are translated into sensitizing concepts. At the end of the previous chapter a summary was given of the existing literature about how leaders should behave during lean implementations in order to have a successful influence on the process. The literature was summarized in a table and based on that table the sensitizing concepts are formulated. The sensitizing concepts are used to give the observations and interviews any direction and to link the empirical findings with the existing literature about lean leadership behavior. The sensitizing concepts can be found in Appendix 1.

This study is based on a single case study approach. In a single case study one organization or one department is researched, in this case the Policlinic Urology of Alrijne Zorggroep. Central is revealing specific characteristics about leadership behavior during the implementation of ‘SamenBeter’ of this department. In this way, the research is idiosyncratic rather than generalizable (Bleijenbergh, 2013). In this study real-time observations are combined with

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18 semi-structured interviews and document analyses. The combination of different data collection methods is a typical characteristic of a case study approach which enhances the validity of the study (Bleijenberg, 2013; Leung, 2015). Before observations and interviews could start, there were orientation days with a nurse and a doctor of the department in order to understand what their work is about and to learn what is going on in the department. The orientation days could be characterized as an introduction or preparation for the data collection.

The goal of the observations is to reveal the behavior of the team leaders. Fourteen team meetings are observed in order to get a comprehensive view of the situation of the department and to be part of it repeatedly and for a longer period of time. One month I was part of the department, I could walk in whenever I wanted to observe the situation. During the observations the real behavior of team leaders can be studied. The observations have an open character in order to gain in depth information. The observed meetings are recorded, notes are made during the observation sessions and pictures are taken from posters or papers in the room. It is important to make factual memos during the observation, without a personal interpretation in order to improve the reliability (Bleijenbergh, 2013). This is done by writing down everything what was really going on, without my own opinion or judgement. The observational notes can be found in appendix 4.

The interviews conducted in this study were open and semi-structured, which means that some questions are formulated in advance, but there was also room for extra questions that come up during the interview, related to the answers a particular respondent gives (Bleijenbergh, 2013). Through the semi-structured interviews, the same questions were asked to every participant, which increased the reliability of this research because the data is more consistent (Leung, 2015). Six interviews are held with several employees of the department, namely the team leader, two urologists (one with the lean leadership training and one with the green belt), one nurse with and one nurse without green belt and finally a secretary with green belt. The goal of the interviews was to gain information about the background and reasons for behavior. Since this research has an explorative character, it is very important to ask further in the interviews to reveal the underlying dimensions of the behavior of team leaders in the process of lean implementation, although this decreases the reliability. The interview is divided into different parts. First of all, an introduction is given by the researcher to explain the purpose of the interview, followed by a couple of general questions. Next, the interviewee is asked about their opinion and ideas of lean and the program ‘SamenBeter’ in order to get

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19 them into the topic of the interview. Then, questions are asked about the interviewees role in the implementation process. In this part of the interview it is important to ask further and to try to reveal (expectations of) the behavior. Thereafter, there is reflected on the observations. Finally, a conclusion is provided by the researcher and the interviewee is asked if he or she had any other suggestions or questions. The interview guides can be found in appendix 2. Open ended questions were used in the interviews to increase validity as well, because this accounted for the possibility to further explanation of the question and for additional remarks (Anderson, 2013). Furthermore, an open interview offers space to collect data about the unexpected and because of the variation in the answers, it produces varied information (Bleijenbergh, 2013). This is relevant because this is an explorative research, in which we are not only interested in the role of team leaders during lean implementation, but also in new insights about how their behavior influences the process. The interviews are recorded in order to make it possible to transcribe and analyze the interviews later.

Relevant documents were requested as well. These requested documents were used to gather information about the program SamenBeter, the hospital in general, the organizational structure of the hospital, the Policlinic Urology which is researched in order to formulate an answer to the question. An overview of documents used can be found in appendix 4.

Moreover, I had conversations with two lean coaches of the hospital to gain information of the department.

3.3 Data analysis method

The interviews and observation meetings were recorded with the permission of the interviewees and in turn have been transcribed. The transcripts of the interviews were sent to all respondents for verification, which increases the validity (Leung, 2015). I did not receive a response of the respondents and therefore I did not adjust the transcripts. The transcripts are analyzed in order to structure the collected data. I marked relevant text fragments in the transcripts. Analyzing is the breakdown of data on a particular topic in categories, naming these categories with concepts and applying and testing relationships between the concepts (Boeije, 2012). The encoding of the text is meant to select relevant fragments from the large amount of text. Then, by combining the different fragments with similar codes, the text can be interpreted (Bleijenbergh, 2013). The terms used to label fragments are called codes.

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20 Because of the inductive character of this research, inductive coding is used. The transcripts, field notes and company documents are coded. The basic assumption of inductive coding is that the beginning of the coding process is closely related to the empirical material (Bleijenbergh, 2013). Therefore, I started the coding process with the marked text fragments in the transcripts. The inductive coding process consists of three steps: open, axial and selective coding. First, within open coding each text fragment is labelled with a concept or word from the text itself, which forms a good representation of the whole fragment. The second step is axial coding and this step is about looking for connections between open codes and trying to distinguish different themes. Axial codes are called thematic codes as well. The final step in the coding process is selective coding. Within selective coding, fragments with the same themes are compared in order to recognize patterns in the social phenomenon. These codes can help to make a connection between empirical data and theory. The sensitizing concepts were used to direct the coding process and to recognize important text fragments. In order to get a structured overview I made a table, where I places the text fragments in the first column followed by the open, thematic and selective codes. The codebook can be found in appendix 3.

3.4 Research ethics

Researchers have to collect and interpret data carefully and in an appropriate way (Anderson, 2013; Symon and Cassell, 2012). Because of the involvement of people and possible consequences for the department, it is important to show acceptable and professional behavior. Therefore, I discussed with the lean coach and team leader what they expected of me, what I could do and what I could not do before the data collection process did start. The department is very busy and normally they do not work with students for research, but because this research is about ‘SamenBeter’ and they are really eager to implement and integrate ‘SamenBeter’, they decided to allow me as a researcher under the condition that I communicate everything clearly, that I take into account the workload of the department and that I only do things in accordance with the department. Before starting the observations and interviews, I was introduced to the participants in order to get to know each other, to give information about the goal of the research in the hospital and to communicate my expectations. Interviews and parts of the observational meetings are transcribed and all those texts are anonymized in order to guarantee the anonymity of participants. In some interviews employees give their opinion about the leadership behavior of their team leader. It is

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21 important to make clear and guarantee that this information is completely confidential and that team leader never hear about what is being said during the interview. I highlighted this before the interviews did start. Furthermore, participants get the opportunity to check the transcript in order to verify if their opinions and ideas are well mentioned. Moreover, it is highlighted that participants always can ask questions to make sure that everything is clear.

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4. Results

In order to be able to answer the research question, this chapter is built in two parts. First, the implementation process will be explained and second a description of the leadership behavior during the implementation process will be given. The behavior part will be complemented with results and effects of the leadership behavior.

4.1 The implementation process

During one month I was part of the Policlinic Urology to do my research. Approximately one year earlier the policlinic started the implementation of the program ‘SamenBeter’ by offering employees a lean training. The team leader and an urologist followed the Lean Leadership training and another urologist, two nurses and a secretary followed the Green Belt training. In a brochure about the Lean Leadership training is written that a lean leader has to serve his/her employees regarding lean initiatives and that they have to show respect. The leader has to activate his/her employees with an inspiring vision and has to stimulate the reduction of waste (Document 2). The green belt is the one who has to behave as an internal initiator of lean initiatives or in other words the one who has to do the work in practice supported by the lean leader. Green belts take the lead in signaling problems and improvement ideas and they help other employees with improvements initiatives (Document 1). The secretary gave a good explanation of the relationship between the team leader, who did the lean leadership training, and herself, as a green belt (appendix 3.2):

‘We examine things in the same way, she in her role as leader and I in my role as green belt, she immediately thinks about how do I have to organize this so that they are able to do their

work and I think about how can I improve this. So in this way the level of thinking and practice come together.’

The same applies to the nurses with green belt as became clear of the observations. The nurses initiate improvement ideas at the nurses department and the secretary initiates improvement ideas at the secretariat. Both are supported by the lean leaders of the department. The team leader sees the nurse and secretary with the Green Belt training as driving forces behind the lean implementation (appendix 3.4). Because the green belts also play a role in the implementation process of ‘SamenBeter’ their behavior is also observed and taken into account in this chapter.

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23 When I entered the policlinic I noticed that several lean tools and projects were running or were already implemented. First of all, there is a day start every day, where the coming day, with possible difficulties, is discussed with the whole team. Moreover, the lean leaders, together with the lean coach, are designing a X-matrix. This X-matrix links the strategic long-term goals to tactical year goals for the department, which are in turn linked to operational actions, projects, A3 reports and SMART formulated results. The matrix also offers the possibility to monitor the progress. On top of that, at the Policlinic Urology they make use of an improvement board, where improvement ideas can be placed on. Furthermore, they do or have done different A3 projects to improve the work processes, based on the plan, do, check, act method. Two projects were already implemented, namely the botox project of the continence nurses and the telephony project of the secretaries. At the moment of this study, the nephrectomy project was running in order to shorten the lead time of patients with a kidney tumor. The interviews showed that when there is a problem at the work floor, the team leader and green belts immediately think if the problem can be solved by using the lean method, so by starting an A3 project (appendix 3.1 & 3.4). The team leader explains (appendix 3.4):

‘I know that I can always use a certain lean method to solve a problem. I can always use a standard method to improve things.’

Moreover, the nurse with green belt is running a cabinets project in order to make sure that every cabinet at every location has the same content. For example, that cabinet 1 in Leiden is exactly the same as cabinet 1 in Leiderdorp.

However, I saw that the implementation process is obstructed by two main issues. First of all, the policlinic has to deal with high customer demands. An urologist told that he sees forty to fifty patients per day, that number is enormous (appendix 3.6). Next to the large number of patients, there is a relatively high level of absence of employees in time of this research, which makes the workload even higher. Patientcare is the main priority for everyone at the policlinic, which makes the implementation process difficult, because there is not enough time to undertake both improvement projects and routine daily activities. Secondly, the policlinic is dispersed over three locations, which makes that you work every day at a different location with different colleagues. It is difficult to plan group meetings because the whole team works dispersed. Also the improvement board does not function well. The improvement board is a board on which all employees can suggest points of improvement.

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24 However, if an idea is placed on the board at location A, it is not there at location B and C and it is difficult to reach the whole group, because not every employee works on every location. Moreover, during the day start, which takes place every day at every location with the team of that day, there is attention for problems that occurred the day before in order to avoid them today and to improve the daily work process. But due to the different locations it is possible that the next day there is a completely new team, that does not understand the problems from the day before and therefore the problems are not solved. That is a loss for the implementation process. During my stay at the department, nothing has changed in this situation. As well as in the beginning as in the end of my data collection period the policlinic was struggling with those issues and it seems that the situation will not improve in the foreseeable future.

4.2 Leadership behavior and consequences

In this section the behavior of leaders will be discussed, complemented by an explanation of the consequence of the behavior on the implementation process. First, the behavior of the lean leaders will be discussed, followed by the behavior of the green belts and finally two striking observations, with an important role of leadership behavior, will be explained.

4.2.1 Lean Leaders

The team leader at the Policlinic Urology acts as a facilitator in the process of implementing ‘SamenBeter’. In this case, the team leader is the one with abilities and connections to organize the side issues in order to make it possible for her team to do their work with respect to lean. For example, she gives her employees free time to work on lean projects or to organize lean initiatives and she makes sure that the right people can come together for certain projects. Also, when observing a meeting about the nephrectomy project, it became clear that the team leader does facilitate this process. Nurses and urologists have thought of new approaches for the treatment process for oncology patients in order to shorten the lead time and to make the process more efficient. The task for the team leader then was to check if the new ideas were feasible regarding the work schedule and if so, to adjust the work schedule in order to make it possible for urologists and nurses to start the new way of working (appendix 4.1).

Moreover, her responsibility goes further. During the secretary meeting, which I was observing, the team leader informed the secretaries about the nephrectomy project and what was decided during the project meeting. She explained the goal of the project and the consequential changes in the work of the secretaries, which will come as a result of the

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25 project. For example, they have to schedule the treatment process for a patient in another way and they have to call the patients on other moments in the treatment process and they have to ask them some other questions. In this part of the process the team leader took her responsibility to adjust the work schedule and to inform all other relevant employees. As a result, by being a facilitator, the team leader makes the implementation of ‘SamenBeter’, and in this case the nephrectomy project, possible.

Based on interviews with nurses and secretaries it became clear that the team leader is an open, accessible and approachable person. When there is a problem, her employees can contact her for any help. Also, one of the nurses mentioned that the team leader really does her best to understand what is going on at the work floor (appendix 3.3):

‘She is very committed. You can always ask her for help and when she does not understand something, she will make sure that she will understand it. 100%.’

During team meetings she is often asking questions to get a better understanding of the process (appendix 4.3 & 4.14) and she is always interested if everything goes well on the work floor. This is appreciated by the team. Through being open and interested the team leader can positively influence the implementation process of ‘SamenBeter’, because employees can feel themselves confident, heard and appreciated (appendix 3.2 & 3.3).

The team leader thinks that everyone is mature enough to take their own responsibilities to initiate improvement ideas and to follow up lean tasks (appendix 3.4). However, the observations made clear that urologists, nurses and secretaries do not often come up with ideas for improvement because patientcare is their main priority. As a nurse without lean training confirms (appendix 3.3):

‘I have to admit that when you are working here the whole day, you do not think quickly about let us address certain issues. You are already happy that you survived the working day.’ The team leader does not actively check and control employees regarding lean projects. There is no control in how far employees are in improvement projects. For example, the team leader said that she has no idea what one of the green belts is doing with her own A3 project (appendix 3.4). Furthermore, when I was observing the department I saw an idea for improvement at the improvement board and when I asked employees about it, I noticed that no one takes the lead over the problem written down on the board, it is unclear who is

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26 responsible. One of the nurses told me that the problem was there already for a long time and no one paid any attention to it. The team leader said (appendix 3.4):

‘I think I do not control enough, I let them free.’

The team leader, and the other lean leader as well, let move their employees freely and they do not motivate and activate their team consistently and continuously to adopt ‘SamenBeter’. I noticed that the lean leaders do not always give lean a place on the agenda actively, because they have other priorities in their daily routines. When asking them about this, one of them said (appendix 3.6):

‘There is 0.0 time during working time to start improvement projects, that is why the implementation and improvements are kind of shaky right now.’ ‘The intention is there, but

the opportunities are not, at the moment.’

Moreover, the team leader is responsible for the formation of the A3 project teams. Sometimes the formation is easy. For example, the project team of the nephrectomy project consists of the oncology urologist and the oncology nurses. However, the open projects, which cannot directly assigned to specific nurses and/or urologists, have to be filled as well and it can be experienced as difficult to motivate employees for those projects, because employees do not see the added value of projects and in their eyes the time spend in projects is detrimental to the patientcare. The team leader sends an email to her team to inform them about the project and give the possibility to sign in for the project. She said (appendix 3.4):

‘When there is an open project, I send an email and ask who would like to participate in the project. But I am not a person who really stimulates my team by asking can you please please

take place in the project team.’

The effect is that it can sometimes take a while before a project can start, because no one applies or that cases are left unattended, because no one feels responsible to sign in. The team leader is not that kind of a person who is really eager to motivate her employees. She believes that employees have to see the added value of lean projects by themselves.

As a result of the different things mentioned above the program ‘SamenBeter’ does not completely get off the ground. At the moment of the study lean is not a central topic in the department yet, according a nurse with green belt (appendix 3.1) and another nurse, who did

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27 not follow a lean training, feels not involved when it comes down to lean (appendix 3.3). This is confirmed by an urologist, who did the Green Belt training. She said: (appendix 3.5):

‘I have the idea that if I would not do it and the lean leaders and the other green belts would not do it either, than it is finished. I do not think that it flows by itself.’

The urologist with the Lean Leadership training said that the lean principle at the moment of this research is not commonly accepted and that is mostly project-based work instead of something continuous. Those examples show that they are aware of the fact that lean is not yet a central topic at the department and that the program does not got completely off the ground, but they did not take any action to change their behavior to improve the situation.

4.2.2 Green Belts

The two nurses and secretary with green belt are doing small lean tasks in the background. They are driven by internal motivation, because they know and understand the added value of lean, as became clear from observations. However, it is experienced as difficult to motivate the whole team and to create sufficient support, because the others do not understand the concept lean very well according to one of the nurses with green belt (appendix 3.1). Therefore, a common approach is necessary and desired by the nurse (appendix 3.1):

‘I am not a person who can initiate it alone, I do a lot but I cannot get the whole group along. I need more people to increase commitment and to motivate the team.’

Moreover, the nurse with green belt is humble and she does not see herself as the ‘lean captain’, which makes it difficult to stand up and motivate others and it can possibly hamper the implementation process. She is motivating others by showing role model behavior, by doing lots of work and so she hopes that others want to help her and copy her behavior. For example, she made step-by-step plans for certain practices and I saw papers on the wall and on cabinets with instructions for employees placed by her. Furthermore during the nurse meeting, which I was observing, there was a discussion about a checklist for pharmacy orders and the nurse immediately said ‘I will check tomorrow and will make sure that there is a checklist’ (appendix 4.3). During the same meeting another nurse asked her ‘Can you handle it all alone or do you need any help?’ The nurse said that she was fine, but this example implies that her motivating method can work.

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28 The secretary, who followed the green belt training as well, stated that it feels natural to take the lead in lean initiatives at the secretariat. When there is a discussion about a lean topic and colleagues try to refuse the lean way of working, she does not pay too much attention to it at that moment. However, she takes that colleague aside later to explain the idea and the purpose better in a calm environment without other stimulus and usually this works well to motivate the others (appendix 3.2), which improves the implementation process.

According to the urologist with green belt it is important to continuously name lean in order to get it on top of mind and to motivate others to start lean projects as well (appendix 3.5). Although she recognized the importance of reminding others of ‘SamenBeter’, I noticed that it is not going like that in practice. The lean team agreed that the monthly newsletter should contain a lean topic, to give the department an update about what is going on regarding lean. The urologist with green belt got the responsibility to write a small update, but she admitted that she often forgets it and that there is nothing written about lean in the newsletter. Moreover, she is not really apparent and involved in the work floor, because she also has many other responsibilities in her role as RVE chairman and as chairman of the urology professional group. She said (appendix 3.5):

‘I think that I fulfill the initiating role, which I actually want to perform, in practice too little.’ Due to this behavior, other employees are not reminded continuously of ‘SamenBeter’, which can be a loss for the implementation process.

4.2.3 Day start

Every day there is the day start, where the coming day, with possible difficulties, is discussed with the whole team. The day start takes a maximum of five minutes and takes place in a common room at the department. An information board for the day start hangs on the wall in the common room (appendix 6). On the board the problems of the day before are written down, as well as the planning and other particulars and announcements. Before the consultation hour starts, all employees meet around the board and the urologist on duty has to lead the meeting. The team leader never leads the day start, because she is not substantively involved in the patientcare. Ideally, problems of the day before, which are written down left on the board are discussed, followed by the planning of the day. The urologist has to inform if there are any bad news conversations, because if so a nurse has to support the urologist during the conversation. Then, the urologist has to communicate further particulars and has to ask if

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29 others foresee any problems or if they have something important to say. When everything is discussed, the working day starts. I observed six day starts and I noticed striking differences. The situation described above is how this lean tool is planned to go and how it should be implemented. This set-up is decided by the lean leaders and lean coach by the start of the implementation of the lean tool. When the urologist with lean leadership training has the lead, the day starts are very structured and in line with the desired situation as described above. The lean leader is very calm and clear and when people are worried, he helped them out (appendix 4.5 & 4.11). He discusses the problems of the previous day and when something is unclear he tries to figure it out later on, or he gives someone else the responsibility to do so. Moreover, he is asking questions to the team, if they have any problems, if they have something to communicate and if everything is clear. Finally, he is very enthusiastic, present and he always ends the meeting with a positive note to motivate the team (appendix 4.5 & 4.11). From those observations it became clear that the lean leader shows behavior that positively influences the implementation of the day start. However, when the lean leader is not on duty the day starts are quite different. First, I noticed that the day starts are sometimes skipped (appendix 4.8) or that they are very short (appendix 4.9, 4.10 & 4.12). When other urologists have the lead, only the planning is discussed. There is no room for problems of the previous day and also expected difficulties are not discussed (appendix 4.9). During another day start, the urologist was in a rush, she only shared her information and went back to work. One of the nurses was confused and said ‘I actually wanted to discuss something’, but everyone was almost gone and no one paid attention to her question (appendix 4.10). It also happened that the urologist did not show up for the day start and after a while one of the nurses took the lead and the nurses together discussed the planning. It is interesting to notice that they start to talk with each other and kind of copy the behavior of the lean leader, even it is not their responsibility. However, they did not pay attention to the other parts of the day start (appendix 4.12). Those examples show that there are main differences between the lean leader and other urologists with respect to the day start and implicate that there is room for improvements. The lean leader is successful in doing the day start, but he fails in completely transferring the idea of the day starts to other colleagues. During the period I was part of the department the situation did not change or improve.

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4.2.4 Lean as common activity

The name of the project ‘SamenBeter’ or in English ‘BetterTogether’ implies a common activity, the goal is to improve the work together. Only when everybody is involved you can continuously strive for perfection. The importance of teamwork is also mentioned by all employees who are lean educated during the interviews. One of them said that decisions on future measures will be taken in partnership with nurses and secretaries as well. For example, when the work of secretaries was planned to change, the urologists attended the secretary meeting to get feedback from secretaries and together they designed the new way of working (appendix 3.6). However, when observing the situation in real life it became clear that the lean leaders and also the green belts are often working on their own, without contact and therefore that they do not work always together. They are working on islands and they do not align the work with each other. During the conversations and interviews with the members of the lean team, everyone said something different about what was going on and they were not of one mind. There is still never been a meeting with all lean educated employees of the department, even though everyone desires such a meeting as became clear from the interviews. The two lean leaders try to meet every 4-6 weeks to discuss what is going on with respect to lean and what they can do to help the employees, but in practice this meeting is held only once, since the implementation started approximately one and a half years ago (appendix 3.4). They only have small conversations when they meet by chance. The nurse with green belt does not feel involved with the work of the lean leaders and at the same time the nurse who is not lean educated said that lean ideas and activities are going on and are implemented without her knowledge or without any explanation. This implies a lack of communication by lean educated people, which is a loss for the implementation process, because without knowledge and information for everyone it is difficult to improve the ways of working continuously. This is difficult because the employees without lean training are not educated in how to signal and improve the processes, so they have to be coached by the lean team in order to be able to improve work processes.

Although the lean team is aware of this behavior, they did not change their behavior during the period of research. They only said that they actually have to change the behavior, but no one took the responsibility or initiative to do so.

The influence of leadership behavior on the implementation process of a lean program. A single case study in the healthcare sector.