Master Thesis
The Role of Leadership in Teams in Continuous
Improvement in a Healthcare Environment
June 20, 2016
University of Groningen Faculty of Economics and Business
MSc Business Administration: Change Management
B. van Elp - S2811936 Albert van Kuyckweg 44
7957 DH de Wijk +31 (0)612978845 b.van.elp@student.rug.nl Supervisor: Dr. O. P. Roemeling
THE ROLE OF LEADERSHIP IN TEAMS IN CONTINUOUS
IMPROVEMENT IN A HEALTHCARE ENVIRONMENT
University of Groningen
B. van Elp“You can dream, create, design and build the most wonderful place in the world… but it requires people to make the dream a reality”
Abstract
This study examines the influence of leadership styles on the progress of Lean teams with regard to Continuous Improvement (CI) by means of an explorative, multiple case study at a large provider of elderly care. This paper proposes that the leadership styles of managers could influence the maturity of CI in teams. Many leadership behaviors exhibited by Lean managers can be classified as transactional and transformational leadership behaviors. We show that a transactional leadership style is important in reaching the mature CI teams; whereas transformational behavior stimulates future-oriented thinking which benefits the performance and continuity of the organization. Therefore, we suggest that a blend of transactional and transformational leadership leads to mature Lean teams.
Keywords: Lean thinking, Continuous Improvement (CI), transformational leadership,
transactional leadership, Lean teams, CI maturity, health services
Table of Contents
Acknowledgements 4
1. Introduction 5
2. Literature Review 6
2.1. Continuous Improvement in the Lean Philosophy 6
2.1.1. Lean Background 6 2.1.2. Lean in Healthcare 7 2.2. Leadership Styles 8 3. Research Methodology 10 3.1. Research Setting 10 3.2. Data Collection 11 3.2.1. Interviews 11 3.2.2. Observations 12 3.2.3. Documents 13 3.3. Data Analysis 13 4. Results 15
4.1. Continuous Improvement at Reside&Care 15
4.2. Leadership Styles of Managers 20
5. Discussion and Conclusion 26
5.1. Cross-Case Findings and Propositions 26
5.1.1. Continuous Improvement at Reside&Care 26
5.1.2. Leadership Styles of Managers 26
5.2. Implications for Lean Practitioners 29
5.3. Limitations and Future Research 30
5.4. Conclusions 30
References 31
Acknowledgements
1. Introduction
Continuous Improvement (CI) initiatives such as Lean production have proliferated among manufacturing and service organizations worldwide. This emerged due to market pressures that organizations face, which causes them to lower prices while at the same time demand for services and quality increases (Voss, 2005). Therefore, more organizations are seeking process improvement in an attempt to keep up with increased demands (Marcinko & Hetico, 2013).
In the healthcare environment one of the most popular improvement methodologies is Lean. This method, with its roots at the Toyota Motor Company, focuses on organizational process flows to reduce waste and variation within the processes (D’Andreamatteoa, Iannia, Legab, & Sargiacomoa, 2015). As one of the key principles of the Lean philosophy, CI is an ongoing change process that aims to deliver accelerating performance (Aij, 2014; Spear, 2004). For instance, the lack of process standardization in laboratories leads to less than optimal quality, errors, inefficiency and increased costs. Hence, process standardization is an example of a Lean process improvement in healthcare (Raab et al., 2008). However, increased costs can also be attributed to inefficient management (Bisgaard, 2009; Joosten, Bongers, & Janssen, 2009; Poksinska, 2010).
Health organizations need to find a balance between reducing costs and improving quality due to ever-increasing expectations (Marwaha & Savas, 2012). According to Van den Heuvel, Does, and De Koning (2006) the Lean philosophy (CI) is a well-suited method to increase the quality of care, but also reduces costs. Moreover, the research of Spear (2004) provides evidence of higher-quality, safer, and more cost-effective care.
According to Radnor (2010), Robbins and Coulter (2002) and Poksinska (2010), Lean research lacks insights in regards to soft (human) aspects. Instead, the focus of applying Lean in health services has been mainly on tools and techniques. This can make it a challenge for most project managers learning how to become effective. Managers recognize the principles of the Lean philosophy, but find it difficult to manage Lean and implement the principles into their organization properly (Pearce & Pons, 2013; Womack, Jones, & Roos, 1990). In addition, Mazzocato, Savage, Brommels, Aronsson, and Thor (2011) stated that it is important to engage management in continual problem solving. However, few other academics mentioned management involvement. For example, Mazzocato and colleagues (2011) observe that when healthcare organizations involve management more, potential benefits of Lean such as quality and reliability (Fryer, Antony, & Douglas, 2007) will be realized. Therefore, management and thus leadership is an important aspect (Bessant, Caffyn, Gilbert, Harding, & Webb, 1994), especially in order to live up to the expectations of shareholders of an organization.
several leadership styles, such as autocratic, directive, participative, and transformational leadership. In this study we focus on transformational leadership. In the context of healthcare, transformational leadership is one of the most important leadership styles (Avolio, Walumbwa, & Weber, 2009; Chen, Bian, & Hou, 2015).
Pol, Swankhuisen, and Fennis (2002) and Yukl (2002) mention that the requirements of the leader and the followers are important in choosing the right influencing style. Since, in the context of CI team members are the main persons carrying out the principles, and leaders might convince their subordinates to use the Lean philosophy and provide structure and knowledge. The research of Joosten et al. (2009) claims that Lean gives an improved opportunity for team work and better communication in a team. They state that a manager’s most important task is to create an environment where the interaction between team members leads to a level of performance that cannot be achieved by individual team members alone.
This paper aims to contribute to the knowledge related to the Lean philosophy and leadership relationships. In this study, we investigate how leadership styles facilitate Continuous Improvement in a healthcare setting by focusing on a large provider of elderly care. Therefore, the main interest is the interchange between teams, leadership and CI. This research is interesting for the field of research of CI-strategies, leadership styles and change management. The aim of the paper is to make a theoretical contribution about the influence of leadership styles on the progress of Lean teams with regard to Continuous Improvement, which also benefits practice. This qualitative multi-case study will address the following research question: “How do leadership styles facilitate Continuous Improvement in
teams in a healthcare environment?”
This paper is structured as follows. In the next section, a theoretical framework is provided elaborating the major concepts of the study. After explaining the method, the results and discussion will contribute to a deeper understanding of how leadership styles facilitate CI in healthcare teams.
2. Literature Review
The aim of the literature review is to provide definitions for concepts engaged with throughout the paper. These concepts are Continuous Improvement in the Lean philosophy and leadership styles.
2.1. Continuous Improvement in the Lean Philosophy
2.1.1. Lean Background
Many definitions of the Lean philosophy can be found in the literature (e.g., Joosten et al., 2009; Krafcik, 1988; Womack et al., 1990) and the most suitable one for this research will be adopted. One of the first books about the Lean philosophy of Womack et al. (1990) stated that Lean production is about eliminating all non value adding activities in an organization. Thus, tasks and responsibilities of workers have to add value to the organization and a system has to be put in place in order to detect shortcomings that can then retrace and find the root of the problem. In Lean thinking the key concept is “value.” Value is defined as “the capability to deliver exactly the (customized) product or service a customer wants with minimal time between the moment the customer asks for that product or service and the actual delivery at an appropriate price” (Womack & Jones, as cited in Aly, 2014, p. 92). Therefore, for this research Lean is defined as the systematic removal of waste by all members of the organization from all areas of the value stream (Worley, 2004).
The goal of CI is to enhance the quality of organizations, people, processes and products (Slack & Lewis, 2002; Womack & Jones, 2003; Womack et al., 1990). Therefore, in this research the following definition for CI was used: “Improvement initiatives that increase successes and reduce failures through the involvement of people from all organizational levels” (Bhuiyan & Baghel, 2005; Juergensen, 2000; Kossoff, 1993). Thus, a transformation takes place that changes relationships among organizational members while at the same time affecting rules, roles, procedures and structures, communication and the organizational environment (McLaughlin, Bessant, & Smart, 2008; Walker, 2006). As a result of the transformation, the organization’s members have the ability to learn where mistakes occur so that they are not repeated. Repeated mistakes function as a form of waste in the Lean philosophy and should therefore be eliminated (Robinson, 1990).
2.1.2. Lean in Healthcare
Lean has emerged in industry and according to Bisgaard (2009) it was later adopted by services industries, such as the healthcare industry. The healthcare industry is a different environment than the manufacturing environment. Nevertheless, according to Van den Heuvel, Does, and De Koning (2006) the Lean philosophy (CI) is a well-suited method to increase the quality of care, but also reduces costs. This is important for healthcare organizations as they operate in a turbulent environment where patients demand high quality. At the same time health services are confronted with ever shrinking profit margins.
The literature describes various instruments used to assess CI capability and related practices. Hereby, CI capability is defined as “the ability of an organization to gain strategic advantage by extending involvement in innovation to a significant proportion of its members” (Caffyn, 1990, p. 1142). Several writers have proposed assessing quality management in terms of maturity (Caffyn, 1999). For instance, Crosby (1979) developed a quality management maturity grid which represents five stages form “uncertainty” to “certainty.” Also Cupello (1994) identifies maturity levels from “playing” to “actualized” and using a measurement-maturity matrix. This research used the “CI Capability Model” that was defined by the CIRCA team (Bessant, Burnell, Harding, & Webb, 1992), as they observed cases that show companies passing through several developmental stages, or levels of “CI maturity” as they progressed at engaging team members in making improvements. The model proposes five such levels: (1) Pre-CI interest: “Natural” or background improvement, ad hoc and short-term; (2) Structured CI: Formal attempts to create and sustain CI; (3) Goal-oriented CI: CI is directed at company goals and objectives; (4) Proactive CI: CI is largely self-driven by individuals and groups; and (5) Full CI capability: CI is the dominant way of life. Thus, their model provides clear separation between the different levels of maturity.
The model provides the basis of the research because the model can be used to determine the CI maturity of a team. The underlying assumption in our research is that the teams who have working with CI principles longest are the most mature. This analysis results in a distinction between teams as immature and mature. An immature team is less capable of continuous improving and self-management compared to a mature team. This is regardless of the fact that a mature team has already gone through a lot of improvement and therefore has less room to continuing improving.
2.2. Leadership Styles
Transformational leadership is defined as “a process of inspiring subordinates to share and pursue the leaders’ vision” and “motivating others to move beyond their own self-interests and work for the aims of the team” (Bass as cited in Andressen et al., 2012, p. 70). It enables followers to acquire the knowledge and skills they need in order to work more effectively and perform better (Yukl, 2002). Poksinska et al. (2013) stated that those leaders tend to be more forward than backward looking. Transformational leadership can be identified by four components (ElKordy, 2013; Molly & Gupta, 2015): (1) Idealized influence, this is where the leader is viewed as a role model; (2)
inspirational motivation, is when the leader inspires motivation and team spirit; (3) intellectual stimulation, is found when the leader stimulates creativity and innovation; and (4) individualized consideration, occurs when the leader mentors and supports each follower. Thus, these components of
the transformational leadership show that self-leadership practices can be influenced. Self-leadership, as the corresponding construct, is defined as “a process by which individuals control their own behavior, influencing and leading themselves by using specific sets of behavioral and cognitive strategies” (Manz as cited in Andressen et al., 2012, p. 68). The aspect of self-leadership is also an important concept as it is strongly linked with the Lean philosophy, exemplified by the ability to trust others and let go (Bhuiyan & Baghel, 2005; Poksinska et al., 2013).
The transactional leadership style is the opposite of the transformational leadership style and this style has also received considerable academic scrutiny (Gundersen, Hellesoy, & Raeder, 2012; Poksinska et al., 2013). To date, several studies (Podsakoff, MacKenzie, & Bommer, 1996; Wang, Oh, Courtright, & Colbert, 2011) have shown that effective managers combine transformational as well as transactional leadership behaviors. Both styles have been associated with the Lean philosophy or higher efficiency (e.g., Lloréns-Montes & Molina; Jung, Chow, & Wu; Poksinska et al. as cited in Van Dun, 2015). According to Davis, Bagozzi, and Warshaw (1992) transactional leadership, compared to transformational leadership, assumes that the relationship between leader and followers is solely based on extrinsic rewards. Also Sun, Xu, and Shang (2014) describe the transactional style as a “give and take” relationship rather than a relation characterized by intrinsic motivation in which work is done. In this concept the relation between leader and follower is based on a transaction (Bass & Avolio, 1994; Van Eeden, 2008). Hereby, the leader decides what followers need to do in order to receive a reward or avoid a punishment and therefore “cater to their followers’ immediate self-interest” (Bass, 1999, p. 9). This transaction has two components (Buelens, Sinding, Walstrom, Kreitner, & Kinicki, 2006): (1)
Contingent rewards, is where leaders use rewards to motivate employees; and (2) management-by-exception, which focuses on identifying and handling cases that deviate from the norm. Transactional
leaders were found to be less effective in changing environments, as they “neglect people and organizational issues” (Afshari, Bakar, & Luan, 2009, p. 238).
transactional leadership styles are present and how they influence CI because it was previously unknown which styles were present at the case organization. According to the literature, in Lean environments, we expect transformational leaders to be more effective in stimulating a team’s CI and transactional leaders to be less effective in stimulating a team’s CI.
Based on the previous literature review, it can be theorized that difference in team effectiveness regarding to CI is due to differences in leadership styles of the managers. In addition, we suppose that CI in a team context is stimulated more by the transformational leadership style than the transactional leadership style. Therefore, we expect that a manager of a mature team will show transformational behavior. These theoretical arguments will be examined in this study.
3. Research Methodology
In this empirical and qualitative research, we aim to provide an understanding of how leadership styles facilitate CI. The advantage of a case study design is that it allows the researcher to examine theoretical concepts in the daily practice of the study participants (Yin, 2003). In addition, qualitative research is well-suited to produce relevant managerial knowledge (Leonard-Barton, 1990; Silverman, 2001). Therefore, case stories were made on the basis of interviews, observations and documentation in order to find out in which cases the relationships hold and where they do not hold and why. The propositions presented in the discussion section will function to enrich the literary field (Eisenhardt, 1989; Miles & Huberman, 1994). The level of analysis in this research was teams within a healthcare provider.
The investigation of our research question has certain implications for our case selection. First of all, our study requires a case that has ample experience with CI. Second, there has to be an opportunity to look at different cases to compare them with each other. Third, the organization must have the impression that there are differences in performance, i.e. CI maturity, between the cases.
3.1. Research Setting
The case organization under study is Reside&Care, a large healthcare provider in the north of the Netherlands. The specific provider focuses on providing care for people at home or at a nursing/care home. They have adopted Lean as their preferred CI approach. This is reflected in their vision about care, managers as coaches and as role models and self-managed teams. This case was adopted because the involved company can be seen as an exemplary case (Yin, 2003). Reside&Care function as a kind of role model for other organizations, exemplified by the fact that they organized an open day and they won the first national Lean award.
standards were implemented. To be more specific, a few teams were more able to be self-managing and showed more continuous improvement than other teams. We therefore aim to answer what the origins of these differences are.
The company is a foundation and stands for the provision of care which contributes to the quality of life. Reside&Care has worked with the Lean philosophy since 2010. They call their philosophy “Improve” which is designed in association with a consultancy firm. Their philosophy has several goals: (1) Customers want to rely on Reside&Care; (2) Reside&Care wants to be proud of their work and their organization; and (3) Reside&Care remains financially healthy and they want to be there now and in the future for people who need care. The implementation of the philosophy was divided in three parts: (1) Vision and strategy: To strengthen the desired state of the vision and culture at Reside&Care; (2) leadership: The development of a leadership style that contributes to anchor their vision, strategy and Lean method; and (3) Lean method/excellent care: Implementation of the Lean method and build on the self-managing capacity of Reside&Care to do it by themselves (Reside&Care, 2013).
The employees1 of the company explained that they see the content of care as their most important task. For example they focus on quality of care, quality guarantee and coordination. In addition, they think that the well-being of their clients (or residents) is essential. What should be noted however is that a few employees find it hard to deal with the reorganization towards small-scale living, and a few others commented that they encounter high administrative burden and work pressure (Appendix D, on p. 18, provides an overview of the function related aspects of the employees at Reside&Care). These comments reflect on some of the difficulties employees face at Reside&Care and will serve to get a more complete sense of their work environment.
3.2. Data Collection
Different types of data, such as interviews, observations and documents, provide a more thorough substantiation of the constructs and propositions. The use of the triangulation of instruments can result in establishing a chain of evidence in regards to construct validity and instrument control biases (Aken, Berend, & Bij, 2012; Eisenhardt, 1989).
3.2.1. Interviews
Primary empirical data was collected using semi-structured interviews consisting of mostly open-ended questions. The open-ended questions made it possible to gather explorative responses and experiences of the respondents which suit the explorative character of the study (Cooper & Schindler, 2008).
1
Different interview protocols were used for the managers and for the team members, which can be found in Appendix A. The questions about leadership styles were based on the papers of Dabke (2016) and McCann (2008). Their questions were adjusted to this setting. In order to investigate the influence of leadership we used a 5-point Likert scale (Appendix B). At last, a “friendly stranger” has checked the interview protocols (Miles & Huberman, 1994).
A total of seventeen one-to-one interviews at eight locations were conducted to investigate how leadership styles facilitate CI. At every location the manager and one employee were interviewed. At the smallest and biggest location (First: 23 residents; Cowboy: 80 residents) two employees were interviewed in order to identify potential differences between people, teams, and the size of the location. A pilot interview with the rayon manager took place in order to acquire more knowledge about the organization and to test the interview questions (Miles & Huberman, 1994). The pilot interview verified that the interview protocols were appropriate and useful for the purposes of the case study (Yin, 2003). The interview with the Lean consultant of the organization provided contextual information such as the consultant’s vision about CI. The managers of the eight locations (five managers) and the team members with the function “residential care attendant” (nine team members) and “nurturing residential care” (one team member; in order to compare the functions residential care attendant and nurturing residential care) were interviewed. These functions were chosen as it was expected that those members would provide the most in-depth information regarding this topic. All the interviews took place in a time frame of four weeks. The interviews with the managers lasted between 35-60 minutes and the interviews with the team members between 30-55 minutes. An overview with the interviewees’ basic information is provided in table 2 on page 14.
The interviews were recorded, supplemented by note taking, and were transcribed within 24 hours as advised by Eisenhardt (1989) in order to control research biases. Each interview is anonymous which means that names of participants were not listed. The anonymity of the respondents, and the confidentially of the research, was guaranteed by giving the organization, respondents and the location names a code or a fictitious name (table 2). Each participant is asked if that person wants to receive a copy of the interview transcript to check it for accuracy and verify their responses. This check is favorable for construct validity. All the transcripts were checked which contributes to the validity of the study (Braster, 2000).
3.2.2. Observations
3.2.3. Documents
Archival data is used to contradict or confirm outcomes of the interviews. Documents of Reside&Care about Lean and CI were consulted, such as templates regarding CI, newsletters and information about the CI program “Improve.” A few models of Reside&Care were used as a frame of reference, such as a team phase model in which the progress of a team can be measured.
3.3. Data Analysis
The analysis method of in-depth interviews consists of a questionnaire, a coding scheme with deductive and inductive codes, pattern codes and the use of a “friendly stranger.” Coding is an important step interpreting a large amount of qualitative data (Miles & Huberman, 1994). Consequently, data was analyzed with a few deductive codes which are based on the literature review. Moreover, inductive coding (Yin, 1981) took place, which is based on the answers of the participants and observations. The deductive and inductive codes were combined to find out what emerged in this particular context. We have used a codebook (Appendix D) to discover those codes and categories in order to systematically process the data. This has led to data driven insights. A few of those codes as an illustration can be consulted in table 1.
We also made use of pattern matching in order to increase research’s internal validity. During this stage within-case analysis are used for each individual case, i.e. each location. Therefore, every interview was analyzed by reading, coding and interpreting them separately. The cross-case analysis compared the cases after the within-case analysis. This was done with a framework to provide an overview of the collected data (Campbell, 1975; Yin, 1981). The conclusions of the cross-case analysis were made by going back to the raw data of the individual interviews to see if the data is correctly interpreted (Eisenhardt, 1989). At last, the friendly stranger helped to see whether interpretations were accurate and to increase researcher’s reliability (Aken, Berend, & Bij, 2012).
Table 1. Overview of a Number of Codes with their Description
Code
Description
Deductive codes
Method of approach Examples of tools that are implemented in the organization
with respect to their Lean approach: “Improve”
Role model The leader serves as an ideal role model for followers;
confident and powerful
Carry out vision The leader stimulates feelings of enthusiasm
and optimism among coworkers
Appreciation Suitable positive response to desired performance
Inductive codes
Wellbeing of resident The extent to which a person physically,
mentally and socially feels good
Reorganization An overhaul of a company's internal structure
Team meeting Team meetings are usually convened to keep members informed
of any new developments and to discuss the present situation
Table 2. Overview with the Interviewees’ Basic Information2 Code Duration (min.) Gender Age Category (years) Term at Company Function Years in Function Experience with Lean (years)
Training in Lean Start of
Approach Initiator Rayon (RAY)
RAY10 40 female 50-60 medium rayon manager 5 5 on-the-job 2012 no
(at rayon)
RAY20 42 male 30-40 medium lean consultant 6 6
“Lean in healthcare” and
coaching- on-the-job
2012 yes
Omicron & Promise (OMI & PRO)
O/P10 50 female 50-60 long manager reside/care 3 3 on-the-job 2013 partly
OMI01 40 female 30-40 short residential care
attendant ¾ 0 none 2014 (?) no
PRO01 31 female 50-60 medium nurturing residential
care 3 0 none 2015 no
First & Alpha (FIR & ALP)
F/A10 35 female 50-60 long manager reside/care 2 ½ 2 ½ on-the-job 2013 partly
FIR01 54 male 40-50 medium
residential care attendant (department
assistant)
2 0 none n/a no
FIR02 41 female 40-50 medium
residential care attendant (medical
orderly)
2 0 none 2013/
2014 no
ALP01 47 female 50-60 medium
residential care attendant (care coordinator)
1 0 none 2015 no
Zap (ZAP)
ZAP10 51 male 50-60 short manager reside/care ¾ 2 white belt and
on-the-job 2014 no
ZAP01 41 female 30-40 medium
residential care attendant (nurturing
residential care)
¾ 0 none 2013 no
Forefront (FOR)
FOR10 60 male 50-60 medium manager reside/care 2 2 on-the-job 2014 (?) no (partly)
FOR01 45 female 30-40 long
residential care attendant (care coordinator)
½ 0 none 2015/
2016 no
Cowboy & Neutron (COW & NEU)
C/N10 54 female 40-50 medium manager reside/care 4 4 pilot and
on-the-job 2012 partly
COW01 35 female 50-60 medium
residential care attendant (nurturing residential care) 3 0 None 2014/ 2015 no
COW02 41 female 40-50 medium
residential care attendant (nurturing residential
care)
2 0 None 2014 (?) no
NEU01 31 female 30-40 short residential care
attendant ½ 0 None 2015 (?) no
2
4. Results
The results of the cross-case analysis will be presented in this section. First, we will address Continuous Improvement at Reside&Care to obtain an idea of their approach. This approach will be investigated by looking at the maturity of the different Lean teams as this will determine the extent to which different kinds of leadership will facilitate CI in turn providing evidence for our research question. We will also focus on the leadership styles of Reside&Care managers and analyze their efforts through a transformational and transactional leadership style lens. We will make use of those components per style in order to determine the leadership style(s) per manager reside/care.
4.1. Continuous Improvement at Reside&Care
Reside&Care works with the Lean philosophy since 2010, and their program is called “Improve.” Since September 2012 they have prepared their nursing home locations for the future. They strive to be an organization where Continuous Improvement is an essential part of their business. These improvements focus on adding value to the organization and are especially favorable and desired by the client (Reside&Care, 2013). During the interviews is became clear that most team members had never heard of the term “Lean.” Furthermore, even fewer recognized the organization’s own program name “Improve.” This is reflected by the following comments made by team members: “I do not know that term” [OMI01] and “we do not use that term” [FOR01]. Only when those team members heard a few examples of the Lean philosophy such as “a day start board3” they knew what the interviewer meant. This is in accordance with the document “Improve” of Reside&Care (2013) which shows that they see Lean as their vision. This is also supported by management: “They (the
employees) do not know all those terms” [RAY10]. Other participants (4 out of 17) have the idea that
CI has given a label/name to continuous improving as they see it as “an essential part of management” [FOR10], and not because of “the implement of “Improve” [RAY10]. The aforementioned comments demonstrate that employees of Reside&Care see CI as part of their job, as their vision, and not something separated and independent.
A majority of the participants (9 out of 17) indicated that they see Lean consultants (exclusively) within a supportive context. This is in accordance with was stated in the advice document of Reside&Care (2013). For example, one interviewee said: “When I want to consult
someone, as you work a lot alone in this job, it is a pleasure to ask feedback” [F/A10]. The comment
“it is questionable whether you need a Lean team for that” [O/P10] shows that the need for Lean consultants is challenged. However, other participants demonstrate that they are positive about the Lean consultants: “The Lean consultant has a few extra questions to stimulate us; it is nice to have a
Lean consultant” [FOR01] and “I hope that the Lean consultants stay at our organization” [F/A10].
Overall, the added value of the Lean consultants is the design of the approach, the guidance of the
3
implementation of “Improve,” the engine behind the approach and sparring partners for the team members and managers.
Participants [RAY10, RAY20 and OMI01] commented that the reason for the implementation of “Improve” was a financial reason and in order to offer quality of care (Reside&Care, 2013). A few employees of Reside&Care were introduced with the approach by the implementation of a pilot at 3 of the 8 locations in 2012 [locations Cowboy, Zap and Alpha]. This pilot resulted in an advice document (2013) which presented the conditions for the implementation of “Improve” in all dementia nursing homes. Talking about the implementation of “Improve” a manager said: “It is a kind of
cross-pollination in which initiatives from the pilot could be done better, developments of models and the interaction with employees to see what should be done next” [O/P10]. Moreover, employees have the
idea that the implementation happened to them. In essence, the implementation of “Improve” was a form of top-down management in which the change was overseen by direction.
The implementation of “Improve” into nursing homes was by implementing different tools/ elements of “Improve” at the eight locations (Reside&Care, 2013). Every participant knows the different tools, but it varies as to how familiar the employees at the different locations are with the tools. This is illustrated by the following quotes from location Neutron and Forefront: “Yes, I have
heard of it, the quality poster is in our bathroom, but I have never used it” [NEU01] and “yes, we use the day start board and the quality poster is incorporated” [FOR01]. In most cases the employees of
Reside&Care were acquainted with the approach by explaining the use of the tools of “Improve” in a team meeting. The managers of Reside&Care have different opinions about the interrelationship of the approach in the organization and their daily tasks. One manager stated that “now it is something
separate, but you should not see it like that” [O/P10] whilst another commented “it is part of the job, that is how you have to see it” [F/A10]. The implementation of the elements of “Improve” was a
practical approach which can explain the lack of shared understanding regarding the Lean philosophy which was also discussed on the previous page.
In addition, those interviewed were asked whether they think that the organization’s goals can be attained with this approach. For example questions were asked in regards to being proud of their work and the organization. Especially the team members found it hard to answer this as they reported that “I do not know much about it, when I am honest” [OMI01] and “it is something that does not keep
me busy” [FIR01]. The managers commented that they have several means to evaluate their
performance, such as audits, a team phase model and quality measurement (Reside&Care, 2013). Moreover, two team members, from locations Omicron and Forefront, said that it is important that the tools of “Improve” are effectively used in order to achieve the organization’s goals: “It can contribute
when everyone uses it (the tools) in the same way” [OMI01 and FOR01]. Hence, the former statement
The experience of the seventeen participants with the approach will be illustrated in table 3. The row “for process” refers to the job experience of the participants and the row “for residents” refers to the expected meaning of the approach for the residents. Only the most important aspects will be mentioned in this table. The extended version, other positive and negative experiences, can be found in the codebook (Appendix D, p. 29).
Table 3. Positive and Negative Experiences with the Approach “Improve”
For Process
Advantages Quotes to illustrate Locations where item is mentioned Structure
10/17 participants
F/A10: Matters are very clearly structured.
NEU01: It makes sure that there is a better day structure. Every location
Continuous quality improvement
7/17 participants
ZAP10: I really like it because you are continuously improving. ALP01: We prefer to not make mistakes, of course.
Zap, Cowboy, Neutron, First and Alpha
Short-cycle control
6/17 participants
C/N10: I am very positive, the short-cycle control. FOR01: … without doing a whole correspondence.
Rayon, Omicron, Promise, Zap, Cowboy, Neutron, Forefront
Involvement
6/17 participants
RAY10: You keep each other informed. COW02: You can discuss with each other.
Rayon, Omicron, Promise, Zap, Cowboy, Neutron
Disadvantages Quotes to illustrate Locations where item is mentioned Effective use
of the tools
4/17 participants
OMI01: It only works when it (the tools) is used properly. ALP01: When a few groups report not much, you think that is not correct, you know there happens more.
Omicron, Alpha, Cowboy and Neutron
Change of attitude
3/17 participants
ZAP10: You ask an open attitude in which you share (personal) information.
COW01: During the family arena I doubt whether family members are honest to us because personnel is present.
Zap, Omicron and Cowboy
Resistance
3/17 participants
C/N10: One team has resisted working with it for half year.
ZAP01: I was very skeptic at the beginning. Cowboy, Neutron and Zap
Administrative burden
3/17 participants
FOR10: You should not burden the employees with it.
PRO01: Work pressure, yes, especially administrative. Forefront and Promise
For Residents
Meaning for
residents Quotes to illustrate
Locations where item is mentioned Quality of care
14/17 participants
O/P10: Quality of care, competent personnel, and thus residents will benefit.
ZAP01: Improved care, improved quality of care.
Every location
Structure
5/17 participants
F/A10: Family members know what happened with their father, mother, … this gives structure.
FOR01: Yes, it gives structure.
Rayon, First, Alpha, Omicron, Forefront
Overall, the feedback from participants is more closely matched when they discuss their respective experiences in regards to their residents than it is when they discuss the experiences in their job. Thus, more different themes emerged for the process than for the residents. About the category “for residents” other participants also commented “autonomy,” “living environment” and “more contact with family members.” Only one participant from the location First thinks that the resident will not see any advantage of it. Those positive experiences are in accordance with the advice document (2013), although team members (6 out of 10 team members) mentioned that it is not always possible to be “customer-centric,” because of the administrative burden and work pressure. All in all, we can see that the participants are quite positive about the approach and they also see a positive meaning of the approach for the residents.
We will now look at the ways of interaction in order to obtain an idea of how the Reside&Care employees communicate with each other with regard to “Improve.” The ways of interaction focus on every online and offline communication between the manager and the team members. All team members (10 out of 10) mentioned that they have had formal contact with their manager during a team meeting. Informal contact is seen as an “open door” policy. This policy is mentioned in 5 out of 8 locations. The next comment illustrates this: “He4 always has his door open, he is really
approachable” [ALP01]. At the locations Zap and First participants said that the manager makes an
informal round. This term, “gemba walk,” is used to describe personal observation of work and it is known as one fundamental part of Lean management philosophy (“invoorzorg,” 2012). However, team members expressed the belief that the visibility of the manager can be increased. For example, one interviewee said “I think it is a pity that he is not frequently on the work floor, maybe this has to
do with the fact that I had manager who often came by” [COW02]. The methods that the manager uses
to communicate with their team members are the location’s newsletter, e-mail, phone and in person. Talking about the newsletter one interviewee said: “You have to read the newsletter, then you stay
informed” [C/N10]. The newsletter can be an effective communication method but participants
expressed the feeling that not every colleague reads the newsletter. This can result in uninformed team members which leads to miscommunication within the team.
We will now look at the CI maturity of the teams. The former text was needed to establish this maturity. The examination of the maturity is the end focus of this section. The degree of CI at every location of nursing homes of Reside&Care will be determined by looking at the maturity of the teams. The maturity of the teams will be based on the previous results from the interviews with the manager and team members per location. Hence, our focus will be on the following aspects: when did the team start with CI principles (adopted from table 2 and the documents of Reside&Care), the consequent integration of CI, learning behavior, short or long-term benefits, the problem-solving process and finally, the monitoring and measuring of CI.
4
The maturity of the teams will be presented in table 4 with the application of the “CI Capability Model” of Bessant et al. (1992), but first we will show a bar graph of the maturity of the teams in figure 1.
Figure 1. CI Maturity of the Teams of Reside&Care
Table 4. CI Maturity of the Teams based on the “CI Capability Model” of Bessant et al. (1992)
Location Start of Approach
Level of CI Maturity of the Team (Bessant
et al., 1992)
1 2 3 4 5
Zap
2012 3 Goal-oriented CI
Explanation: Pilot location, structure of “Improve” is not fully implemented, label
“Improve” is unknown but the tools are known, structural problem-solving
Alpha
2012 2 Structured CI
Explanation: Pilot location, different managers in short time frame, barely familiar with
every tool, not everyone at the location is informed, structural problem-solving
Cowboy
2012 4 Proactive CI
Explanation: Pilot location, CI is integrated, familiarity with “Improve” and every
tool, progressiveness, structural problem-solving
Omicron
2013 3 Goal-oriented CI
Explanation: CI can be more integrated, label “Improve” is unknown but the tools are
known, use of tools increases, structural problem-solving
First
2013 4 Proactive CI
Explanation: CI is integrated, every tool is being used, employees know how to use it,
not everyone knows the term, structural problem-solving
Promise
2015 2 Structured CI
Explanation: CI can be more integrated, label “Improve” is unknown and not every
tool is used, structural problem-solving
Forefront
2015 3 Goal-oriented CI
Explanation: CI is integrated, familiarity with “Improve” and almost every tool,
progressiveness and future-oriented, structural problem-solving
Neutron
2015 2 Structured CI
Explanation: Familiarity with structure, but not with every tool, sometimes
Contrary to our initial expectations the analysis of the data shows that there is almost no difference between the 2012 locations (Zap, Alpha and Cowboy) and locations 2013 (Omicron and First) or 2015 (Promise, Forefront and Neutron) that started implementing “Improve” later. Furthermore, few differences were found in the way problems in a team were solved. This is because almost all participants (15 out of 16) mentioned being “engaged in conversation” during a team meeting or giving mutual feedback as a problem-solving technique. Therefore, at every location the staff uses structured problem-solving processes which are also present in the document “Improve” of Reside&Care (2013). We will elaborate further on this in the next paragraph (§4.2).
To conclude, what the descriptive results show is that the maturity of the Lean teams differ throughout Reside&Care. This may have to do with different leadership styles of the managers at the eight locations. Therefore, we will focus on the leadership styles of the managers in the next paragraph. We will first show the conceptualization of the previous results in figure 2. This figure shows where the CI maturity of the teams of the eight locations is based on.
Figure 2. Conceptualization of Continuous Improvement at Reside&Care
4.2. Leadership Styles of Managers
Now that the maturity of the different teams has been established, it is possible to focus on the leadership styles of the managers reside/care. The second set of questions for the interviews is aimed at discovering the leadership styles of the managers by looking at the different components of the transformational and the transactional leadership style. Leadership style is defined as a leader's style of implementing plans whilst providing direction and motivating employees (Newstrom & Davis, 1993).
First, we will look at the different components of the transformational leadership style. Second, we will describe the components of the transactional leadership style. Third, this section will conclude with the determination of the leadership style(s) per manager reside/care.
The Reside&Care advice document (2013) shows that they see leadership as an essential factor in the adaptability of the teams and the synergy between different disciplines. Though, during the observation of the open day (April 7, 2016) the topic “leadership styles” was not addressed. What this shows is that Reside&Care see it as an important aspect but not important enough or not relevant to discuss it at an open day of the organization.
The first question of the topic “leadership style” was about the feeling being inspired/motivated to work on the basis of the “Improve” approach. This resembles the “inspirational motivation” of the transformational leadership style. The following codes in this category emerged when the data was analyzed: “Listening,” “influence,” “give confidence,” “directness,” “convey enthusiasm” and “intrinsic motivation” (Appendix D, p. 40). The following quote is a perfect example of the transformational leadership style. This is because the manager of the location Forefront works with metaphors to inspire his employees. Both the manager [FOR10] and his team member [FOR01] gave the example of a screwdriver to remove the rearview mirror which symbolizes looking at possibilities instead of looking back at what goes wrong. His team member said: “I really like how he does it” [FOR01]. We saw that almost every manager more or less uses “inspirational motivation” to motivate their team members to work with the elements of “Improve.” Also the document of Reside&Care (2013) about “Improve” describes the transformational leadership style by inspiring and motivating.
Moreover, the listening skills of the managers seem to be important in both inspiring and motivating employees. As one team member of location Zap said about listening: “He gives you the
feeling that he listens to you, that he understands you” [ZAP01]. The manager of this team, when
asked about inspiration said: “I look at how can I support in what is needed, but also the framework
around it, and the space that arises for members to give meaning to it” [ZAP10]. This behavior of the
manager [ZAP10] can be confirmed with the observation of a meeting (April 14, 2016) because he facilitates, listens and stimulates (categorized as transformational leadership). This also counts for the manager of location Forefront [FOR10]. However, the observations at meetings (April, 2016) of the other managers [O/P10, F/A10 and C/N10] showed behavior of the manager which can be classified as targeted, overseeing and rewarding (categorized as transactional leadership).
The manager’s personal vision is understood through the leader’s statement of a desired, long-term future state for an organization (Burns, 1978; House, 1977). This aspect also resembles the “inspirational motivation” of a transformational leadership style. In regards to personal vision, one of the managers of locations Omicron and Promise said, “yes, being customer-oriented is really
important, it is about the resident’s well-being, a safe environment, the family can leave him/her with confidence behind” [O/P10]. Another interviewee, manager of location Cowboy and Neutron, when
asked about carrying out a personal vision, said: “My vision that I carry out is that I stand for
Reside&Care” [C/N10]. C/N10 also commented that he sees himself as a connector: “I prefer to throw around people, “puppets,” to obtain the same structure everywhere.” Moreover, in the document
“Improve” (2013) it is about relating people: Create perception by connecting daily work with the organizational vision. The next comment illustrates this: “Yes, I think he (the manager) has
transferred the vision of the organization to us, so focus on the residents” [PRO01]. Overall, the
The next component of the transformational leadership style resembles “idealized influence” and refers to the manager as a role model. Reside&Care explains in its documents (2013) that a manager as a role model can ratify the new direction of the organization’s core values. The participants had different views on how to act as a role model because they all mentioned different aspects to achieve this. For example “communication,” “involvement,” “take seriously,” “positive image,” “determine frameworks,” “the approach of people” and “cooperate on the work floor” (Appendix D, p. 45) were mentioned. The last item, “cooperate on the work floor,” is striking and only one team member [ZAP01] mentioned it about his manager. This person explained that he [ZAP10] has cooperated once at every department to show his interest. Moreover, the leadership model in the document “Improve” of Reside&Care (2013) mentioned taking care of the performance which is about building skills. This resembles “being a preceptor,” which was mentioned by 12 out of 17 participants. For example, one interviewee said: “I have learned a lot from him, he is really my role model. When I
want to do something in his direction, I want to do it just like him” [FOR01]. Cooperation on the work
floor and being a preceptor share a large intersection with the component “idealized influence” of the transformational leadership style.
The next category, which relates to the third component of transformational leadership “intellectual stimulation,” is the degree in which the manager stimulates his team members to be creative and innovative. 9 out of 16 of those who were interviewed indicated that an open attitude contributes to taking initiative in sharing one’s ideas. As one interviewee put it: “He is open for many
issues, he takes you seriously” [OMI01]. Also stimulation, in the sense of having a critical view, is
essential according to 5 out of 16 participants. Furthermore, the pilot of the approach has focused on self-managing teams in which the manager gives confidence and freedom to his team members (Reside&Care, 2013). Talking about this issue an interviewee said: “No, let us go back, we have
agreed about the framework, you are as a team responsible” [ZAP10]. Feedback is for 4 out of 16
participants important in stimulating creativity and innovativeness. Thus, at Reside&Care creativity and innovation is stimulated in different ways, all aimed at “intellectual stimulation.”
The importance of how the approach is transferred to the team members also resembles “intellectual stimulation” of transformational leadership. According to 6 out of 16 participants, the urgency of the approach is transferred by conversations. As one interviewee put it: “Yes, going to
bring them all along, make the sense of urgency clear, and obtain to work with it” [RAY20]. Other
items that were included: “anticipate on market changes,” “customer-oriented,” “scarcity,” and “disseminating quality.” These are all in accordance with Reside&Care’s documents (2013). The manager of Forefront hoped to “anticipate on market changes:” “How can we stay in the market as
healthcare provider and what do we need for that. This also has to do with the future of the location in which it (the location Forefront) has a key position in this town” [FOR10]. Thus, the importance of the
In this paragraph, we will look at offering a supportive work environment. The focus point of our research regarding “individualized consideration” of transformational leadership goes to a manager listens to his team members. We discovered that facilitation and personal attention (listening) are the most important points in creating a supportive work environment according to the employees of Reside&Care. A team member of location First reported that “he listens to us and there is taken
action” [FIR02]. Another interviewee of location Cowboy commented: “He can serve as a critical sounding board in order to see whether it can be done better” [COW02]. The manager of the location
Cowboy and Neutron [C/N10] mentioned that the role of the nurses is essential in this because he (the manager) is more distanced from the teams than before. The role of the nurses are meant to be supportive. Every manager is able to provide a supportive work environment for his employees in which nurses have an important role to play.
Nevertheless, when we look at the observations of the meetings of the managers (April, 2016) with regard to “offer a supportive work environment” we sometimes came to different conclusions. The manager of locations Omicron and Promise [O/P10] has the idea that his attendance during a meeting is more on the background, but during an observation (April 4, 2016) it becomes clear that he is more on the foreground. This is made evident by the fact that he asks a lot of questions, he behaves goal-oriented and intervenes when he wants to have more clarity (transactional). This also applies to the manager of locations First and Alpha. The transactional style is also found in the manager of locations Cowboy and Neutron [C/N10] and he knows this himself as he is very direct and controlling. This is best exemplified during our observations (April 28, 2016) of a meeting in which he actively takes center stage.
In the previous paragraphs we have discussed the components of the transformational leadership style. We will now look at the first component of the transactional leadership style, namely the “contingent reward.” When the participants were asked whether they give a reward or appreciation to their team members or obtained it from their respective manager, the majority (12 out of 16) commented that they give appreciation. A manager’s comment illustrates this point: “Yes, I think so,
just articulate it” [ZAP10]. This behavior can be confirmed during the observation (April 14, 2016) of
the manager at location Zap. Other participants also mentioned other forms of reward or appreciation, such as a positive gesture of the manager or giving freedom. Although, at the locations First, Alpha and Forefront it becomes clear that managers see “Improve” as part of the job, as one manager illustrates: “No, I think it is part of everyone’s job to do better” [F/A10]. And another manager [FOR10] mentioned that it is not permissiveness, which is confirmed by his team member [FOR01]. Therefore, the former statement shows a more transformational leader instead of a transactional leader because those managers [F/A10 and FOR10] do not see CI as something extraordinary; instead they see it as normal to go above and beyond yourself, resembling transformational behavior.
made between active and passive management-by-expectation. The active form is when the leader watches followers closely for mistakes or rule violations and then takes corrective action. Leaders using the passive form intervene only after standards have not been met or problems have arisen (Northouse, 2007). Almost all participants (15 out of 16) mentioned “engage in conversation” as a problem-solving technique in their team. For example, one interviewee said: “First, there is a mutual
discussion, and when there does not come a solution you can discuss it with the manager in order to solve the problems” [NEU01]. This technique is also discussed in a document of Reside&Care (2013)
which focuses on giving constructive feedback and receiving feedback. Talking about this issue an interviewee said that they used a card system: “We had invented a card system, when we noted
something we wrote it on a paper and put it in each other’s pigeonholes” [COW01]. When managers
intervene in their team their methods differ between active and passive management-by-expectation. This is because few participants mentioned when it goes wrong, whilst others mentioned when the goal is not achieved (Appendix D, p. 53). In essence, every manager is familiar with management-by-expectation, but it differs how the managers cope with it and intervene in their teams. Moreover, we have the idea that passive management-by-expectation slightly resembles the transformational leadership style because those leaders are able to let go their team members and are more able to trust their members.
The final question of the interview was about the characteristics of the manager reside/care. 14 out of 17 of those who were interviewed indicated that the manager has to be a key figure. This comment illustrates this: “Thus, they have an overall view, they know who they need for what, and
they have to be a key figure” [ZAP20]. Other aspects which are mentioned and refer to “key figure”
are: “Being a role model,” “involvement,” “being recognizable,” “emphatic,” “transparency,” “visibility,” and “approachable” (Appendix D, p. 55). Also “set out the course” is in accordance with the document “Improve” of Reside&Care (2013) because it says that managers have to be clear on how/why changes are introduced and they have to link it with specific goals. These characteristics match transformational and transactional behavior.
We will now look at the leadership styles of the five managers in order to find out in which way leadership styles facilitate CI. The determination of the leadership styles of the managers are based on the information from the interviews. The observations also gave information about the style, but are considered to be less important than the information from the interviews. This is because observing one meeting per manager can be insufficient to uncover customary behavior patterns. We have also researched the influence of a leadership style and those results are in accordance with those in table 5. This is because we have seen that participants think that all components of both styles are important in regard to CI (Appendix B).
Figure 3. Overview of the Leadership Styles of the Managers Reside/Care5
Table 5. The Explanation of the Leadership Styles of the Managers Reside/Care
Manager Leadership Style Explanation
O/P10 Transactional
Direct, open, confronting, say what you see, asks many questions, customer-oriented, impose conditions, contingent reward, action-oriented, overseeing
C/N10 Transactional
(transformational)
Direct, action-oriented, asks many questions, taking decisions, apodictic, involvement, contingent reward, overseeing, connector
F/A10 Transactional
(transformational)
Action-oriented, listens, asks questions, contingent reward, passive management-by-exception, being proud, self-confidence
ZAP10 Transformational
(transactional)
Focus on feeling good, asks an open attitude, listens, learn from mistakes, facilitates, cooperation at the work floor, action-oriented, contingent reward
FOR10 Transformational
Use of metaphors, involvement, enthusiastic, future-oriented, good atmosphere, being a role model, personal attention, customer and care-oriented
Now we have examined the leadership styles of the five managers of Reside&Care, we will show the conceptualization of the previous results in figure 4. This figure shows the relationship between the different components of the leadership styles and the categories from the codebook (Appendix D) which lead to effectiveness of Reside&Care’s Continuous Improvement endeavor.
Figure 4. Conceptualization of the Leadership Styles of Managers of Reside&Care
5
Pink refers to the female managers of Reside&Care and blue refers to the male managers of Reside&Care.
convince/inspire transformational leadership style
personal vision inspirational motivation effectiveness of organization’s CI endeavor role model idealized influence desired characteristics of manager stimulate creativity intellectual stimulation approach importance transactional leadership style
individualized consideration
supportive environment contingent reward reward/appreciation management-by-exception problem solving
transactional transformational
5. Discussion and Conclusion
In this paper we explored the role of leadership styles in relationship to Lean teams with a focus on CI. The central question in this study was: “How do leadership styles facilitate Continuous
Improvement in teams in a healthcare environment?” In response to our question we find that
leadership styles facilitate CI in teams, especially a blend of transactional and transformational leadership styles will facilitate CI in healthcare teams.
In the remainder of this section, the contribution to the literature and practitioners will be elaborated upon by interpreting the analysis to draw conclusions. Furthermore, research limitations and the possibilities for future research will be discussed. Finally, major conclusions will be given to examine the research question.
5.1. Cross-Case Findings and Propositions
5.1.1. Continuous Improvement at Reside&Care
Previous research has neglected how a leadership style can facilitate CI in a Lean team. The present study adds to a deeper understanding of the role of transformational and transactional behavior of the leader in relation to continuous improving in a healthcare team. Based on previous studies (Bessant et al., 1992), we expected that the longer team members work with the CI principles, the more mature the team becomes. Especially, the locations Alpha and Forefront are striking (table 4) because we would expect that the team of location Alpha, as it started earlier, would have a higher CI maturity than other teams (such as the team of location Forefront), but this is not the case. This inconsistency may be due to the different teams at the locations, but may also have to do with different leadership styles present at the eight locations. We will elaborate on the leadership styles of the managers in the next paragraph. Though, on the individual level there is a contrast because during the interviews we discovered that team members who have worked a longer period for Reside&Care are more familiar with the term “Improve” than team members who have just started at the organization (table 2).
The examination of the CI maturity of the teams has resulted in the following proposition:
Proposition 1. The experience of teams with Continuous Improvement principles does not dictate CI maturity.
5.1.2. Leadership Styles of Managers
Figure 5. CI Maturity of the Team and the Leadership Style(s) of the Manager per Location6
This figure shows that most mature teams have a leader with the transactional leadership style as the prominent style and the transformational leadership style as subordinate. By way of contrast, authors (Afshari et al., 2009, p. 238) reported that transactional leaders were found to be less effective in changing environments as they “neglect people and organizational issues.” In this research however, it becomes clear that the transactional leadership style is important in order to reach CI maturity in a Lean team and thus does not neglect people and organizational issues.
Moreover, we can see in figure 5 that only the locations First and Cowboy have reached a high CI maturity, “proactive CI,” in which both managers have the transactional leadership style as the prominent style and the transformational leadership style as the less pronounced style. This is in agreement with Podsakoff et al. (1996) and Wang et al. (2011) who refer to a combination of transformational and transactional behavior. As well as the “ideal situation” according to the management of Reside&Care, which can be consulted in Appendix B. This result may be explained by the fact that Bass and Avolio (1994) discussed that “contingent reward” of the transactional leadership style and “individualized consideration” of the transformational leadership style both have feedback and appreciation as central features. They emphasize the difference in the approach of people because contingent reward depends on its impact on the follower’s motives and individualized consideration looks beyond expectations.
Furthermore, in our research none of the locations were able to reach the highest CI maturity level (“full CI capability”). For instance, at the locations Omicron and Promise only transactional behavior is present, which may be the reason that the maturity of the team is not higher than level 3 (“goal-oriented CI”). To reach a higher level of maturity you need high levels of experimentation and
6
TFL: transformational leadership style TAL: transactional leadership style
CI maturity: the bigger sphere the more mature the team is
Prominent Leadership Style
