What about the People?
The Influence of Lean on Teams in a Healthcare Environment
Els van der Salm
S2794551
MSc BA Change Management
Supervisor: dr. O.P. Roemeling
Co-assessor: drs. H. P. van Peet
Date: 20-06-2016
Word count: 9888 (excl. references & appendices)
ABSTRACT
Table of Content
1.
Introduction
5
2.
Theory Development
7
2.1.
Lean Philosophy
7
2.2.
Teams in healthcare
8
2.3.
Teams and the Lean Philosophy
11
3.
Methodology
13
3.1.
Research approach
13
3.2.
Case selection
13
3.3.
Case description
13
3.4.
Data collection
15
3.5.
Data analysis
16
4.
Results
17
4.1.
Within-case analysis
17
4.2.
Cross-case analysis
18
4.2.1.
Communication
19
4.2.2.
Collaboration
19
4.2.3.
Coordination
20
4.2.4.
Conflict
21
4.2.5.
Decision making
22
4.2.6.
Participation
22
4.2.7.
Length of working with Lean and type of team
23
5.
Discussion
25
5.1.
Key findings
25
5.2.
Theoretical implications
26
5.3.
Practical implications
27
5.4.
Limitations and future research
27
5.5.
Conclusion
28
References
29
Appendices
31
Appendix I – Lean education among employees
31
Appendix II – Overview literature on Lean and Teams
32
4
Appendix IV - Informed Consent Form
37
Appendix V – General interview Guide
38
Appendix VI – Overview Teams and Participants
41
Appendix VII – Team Process Definitions, Sources and Survey Questions
42
Appendix VIII – Survey analysis
44
1. Introduction
In this thesis, the results of a qualitative research project are presented and provides insights into the
effect of Lean in a healthcare environment. Specifically, the focus lies on Lean and its effect on team
processes.
Lean manufacturing is a production philosophy and quality system that has been around since 1977
(Marodin & Sauri, 2013; Joosten, Bongers & Janssen, 2009). It originates from the Japanese car
manufacturer Toyota, and has been developed over the years for the application in manufacturing. Lean
management is focused on eliminating waste in the production process and strives for perfection through
continuous improvement (Womack & Jones, 2003). Nowadays, Lean is not solely a method for
production environments, but it is adapted and integrated in many other environments, such as
healthcare (Poksinska, 2010) and service industries (Lee, Olson, Lee, Hwang, & Shin, 2008). Forced by
economic pressures, healthcare institutions are also trying to find more efficient ways to deliver safe
and high quality care. Therefore, more and more cases are known where Lean management is being
applied to the healthcare environment (Joosten et al., 2009). In the case of healthcare, one could say that
the production process is the process of curing and caring for the patient.
Previous research on Lean in healthcare has, in most cases, reported positive operational
improvements, such as reduced mortality rates and length of stay (Joosten et al., 2009). However,
Poksinska (2010) mentions that there are two types of results from Lean in healthcare. The first type of
results focuses on operational improvements, the second type of results focuses on the social dimension,
such as the development of employees and their work environment.
This second type could also be referred to as the Socio-Technical side of Lean. Here, the social side
is teamwork and the technical side is Lean (Ulhassan et al., 2014). The Socio-Technical side is an
underexposed topic in Lean literature. The literature available on the Socio-Technical side of Lean often
takes time to convert to a healthcare setting (Joosten et al., 2009), since most studies are in the field of
manufacturing. Thus, there is not much literature on the social effects of Lean in healthcare
environments. The literature that is available on this topic, report vague effects such as improved team
work, improved communication in the teams or the development of specialized teams (Poksinska, 2010;
Joosten et al., 2009). These studies indicate that teams are influenced by Lean. However, these effects
are vague and underresearched. Therefore, there is no reliable evidence on how Lean affects teams
(Joosten et al., 2009). Toussaint & Berry (2013) even go further by stating that Lean is “a cultural
transformation that changes how an organization works” (p.74). In addition, D’Andreamatteo et al.
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we could argue that the social effects of Lean are underdeveloped in literature that relates to Lean in
healthcare. Subsequently, the goal of this thesis provide a clearer understanding of the social effects of
Lean.
As suggested before, the social effects of Lean seem to be especially relevant in the context of teams
within a healthcare setting. First, teams and teamwork are very important in the healthcare industry.
Human failures due to badly organized teams and poor communication, can lead to unfavourable
outcomes (Prati & Pietrantoni, 2014; Buljac-Samardzic et al., 2010). Second, teams also became more
and more important due to economic reasons, such as the more efficient use of resources (Heinemann
& Zeiss, 2002). Combining these two reasons to use teams, one could say that, in healthcare, effective
teams are important due to both the health and well-being of the patients and financial reasons (Landry
& Erwin, 2015).
Due to the importance of teams and teamwork in healthcare and the increasingly important Lean
philosophy, this research will focus of the effects of Lean on teams. The research question that will be
answered in this paper is:
2. Theory Development
2.1.
Lean Philosophy
The growing popularity of Lean has led to more and more research on application in public services
(Procter & Radnor, 2014). Procter and Radnor (2014) observe that since 2003, a new kind of Lean has
emerged, which is based on the five Lean principles as described by Womack and Jones (2003). This
‘second-wave Lean’ is different in that it can be applied to any organizational context. The Lean
principles are all based on ‘muda’, which is a Japanese term for waste. More specifically, Womack and
Jones (2003, p. 15)) describe waste or ‘muda’ as: “Any human activity which absorbs resources but
creates no value”. Examples of human activities, defined as waste, are rectifying mistakes, keeping
unnecessary inventories and the transport of people and goods without purpose. The opposite of waste
is value. According to Womack & Jones (2003), value is the starting point for Lean thinking and can
only be defined by the ultimate customer. Additionally, they mention value is only meaningfull when,
in this case a specific service, meets the customer’s needs at a specific time. In public services, one of
the main challenges of working with Lean is that defining the customer is not so straightforward (Radnor
& Osborne, 2013). Radnor and Osborne (2013) propose that the customer in public services can best be
defined as the end user.
In a healthcare environment, one could say that the added value is the treatment that improves the
patients health. However, this is only true for curement, thus excluding long term care. Examples of
value adding activities in a healthcare environment are collecting and analysing information on patients,
clinical interventions and observations. Waste activities are, for example, interventions that are not
needed or administrative time. An important distinction should be made between different types of
waiting time according to Joosten et al. (2009). Positive waiting time means that ‘the patient condition
is improving without interventions’ (p.344), and therefore is value adding. On the other hand, passive
(when there is no change in the patients’ condition) and negative (when the patients condition
deteriorates) waiting time are waste.
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Table 1 The 5 principles of Lean (based on Womack & Jones, 2003)Lean in this research, is seen as a method for teams in a healthcare environment to continuously
improve their work. This means that the teams included will use Lean and try to continuously improve
their work and tasks. Therefore, the main focus lies on the fifth principle of Lean: perfection.
According to Poksinska (2010), Lean in healthcare is ‘often perceived as a set of tools and techniques
for improving processes’. As mentioned before, the main outcomes from Lean initiatives in healthcare
are related to the performance of the system, and not so much on the development of teams. Additionally,
Procter and Radnor (2013) present three other types of difficulties when using Lean in public services.
First, there is no homogeneous focus on who the customer is, therefore it is hard to determine what
customer focus is. This difficulty is also mentioned as a main limitation by Poksinska (2010), who
suggests that the origin of this limitation lies within departmental silo thinking. A consequence of this
silo thinking is that there is no overview on the complete process a patient goes through. From a patient’s
point of view, who is the end receiver, this means that there are a lot of non-value adding activities.
Second, public services are capacity led, due to the inability to influence demand. Third, the public
sector must also consider effectiveness and equity, next to efficiency and cost reduction. Thus, Lean in
the public services is quite different from the private sector business.
Another barrier is to convince the staff that Lean can help in a healthcare environment. Most
healthcare employees feel that the healthcare industry is too different from car manufacturers. However,
Poksinska (2010) suggests that with clear communication and training, understanding can be developed
among staff. Therefore, Lean can be beneficial both in teams in terms of team work and efficiency, as
well for the patients, for example in terms of shorter waiting times or less errors.
2.2.
Teams in healthcare
A lot of research has been conducted in the field of teams and team effectiveness. Of which some
focus especially on healthcare teams (Lemieux-Charles & McGuire, 2006; Mickan & Roger, 2000)
and some even on Lean teams in healthcare such as Procter and Radnor (2014). They showed that
even though teams can be designed to work in a Lean way, teams might fail to operate in such a way
due to pressures, such as the need to meet targets. In this study, the widely used definition of team by
Cohen and Bailey (1997) is used:
Principle Definition
Value A product or service has value when the customer’s needs are met at a specific price at a specific time.
The Value Stream Is the set of all specific actions needed to bring a product or service from concept to the actual customer.
Flow Streamline all specific actions from the value stream to create a continuous flow. Pull Let the consumer ‘pull’ the product or service from you.
“A team is a collection of individuals who are interdependent in their tasks, who share responsibility
for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one
or more larger social systems (for example, business unit or corporation), and who manage their
relationships across organizational boundaries” (p. 241).
This definition implies that team members act, and that those actions are interdependent. Thus all
team members are responsible for the outcome of the process. The importance of interdependence in
and of teams is also mentioned by Heinemann & Zeiss (2002). The authors suggest that well-functioning
teams work as a feedback system, in which they develop, implement, evaluate and redesign a plan in a
recurrent way. Based on the definition of Cohen & Bailey (1997) and the work of Heinemann & Zeiss
(2002), it can be concluded that processes within teams are twofold. First, individuals within the teams
should work interdependently with each other, and second, teams should work interdependently with
other teams in the organization.
The many studies on team effectiveness show that there are specific factors that influence teams.
Most studies include organizational context/structure, task design and team processes (Cohen & Bailey,
1997; Lemieux-Charles & McGuire, 2006; Mickan & Roger, 2000; Salas et al., 2015), see Table 2.
Table 2 Influencing Factors of Effective Teams
However, only Lemieux-Charles and McGuire (2006) conducted a study on team effectiveness in a
healthcare environment. The study of Lemieux-Charles and McGuire (2006) showed that there are many
factors that directly and indirectly influence the effectiveness of teams. In addition, in their Integrated
Team Effectiveness Model (ITEM) they use a combination of most factors identified in Table 2.
Therefore, the proposed model by Lemieux-Charles and McGuire (2006) appears to be a suitable basis
for this research.
Influencing factors Authors
Environmental factors
Task design, group composition & organizational context Internal vs. external processes
Psychosocial traits
(Cohen & Bailey, 1997)
Organizational context: goals, structure, rewards, resources etc. Task design: task type, task features, team composition.
Team processes: communication, collaboration, coordination, conflict, leadership, decision making & participation.
Team psycho-social traits: cohesion, norms, efficacy etc.
(Lemieux-Charles & McGuire, 2006)
Organizational structure: clear purpose, appropriate culture, specified task, distinct roles, suitable leadership etc.
Team processes: Coordination, communication, cohesion, decision making, conflict management, social relationships and performance feedback.
(Mickan & Roger, 2000)
Influencing conditions: context, composition & culture.
Core processes: cognition, conflict, coaching, communication, cooperation & collaboration.
10
Figure 1 Integrated Team Effectiveness Model or ITEM (Lemieux-Charles & McGuire, 2006)In this paper, team effectiveness is approached as a multidimensional construct, based on three types
of outcomes; patient care, personnel and management. The ITEM (Figure 1) suggests that there are three
direct influences on team effectiveness, which are: (1) task design, (2) team psycho-social traits and (3)
team processes. The ITEM presumes that these three factors are interdependent. Task design factors can
be divided into task type, task features and team composition. The psycho-social traits can be norms and
shared mental models. Examples of team processes are communication and collaboration. As
Heinemann & Zeiss (2002) describe, team processes are related to how effectively team members work
together to complete their work. In this specific study, we are especially interested in the roles of team
processes in a Lean context. Therefore, this research focusses on the effect of Lean on team processes
and leaves task design and psycho-social traits out of scope.
Table 3 Definitions of Team Processes focused on in this research
shared leadership does also imply a limited focus on the remaining teamprocesses of: communication,
collaboration, coordination, conflict, decision-making and participation. Therefore, these processes are
at the centre in this study, definitions of these processes are provided in Table 3.
2.3.
Teams and the Lean Philosophy
As mentioned in the introduction, there is limited attention for the effects of Lean on social aspects like
teams and teamwork. However, some overlapping concepts can be found in literature.
First, Procter & Radnor (2014) mention that teams in a Lean environment are expected to operate an
indirect form of autonomy. This autonomy is based on the responsibility of the team to constantly
improve their Standard Operating Procedures (SOP). They underline this by stating that:
“a key part of the worker’s role is to contribute in this way [by improving their SOP] to the
continuous improvement of the production process” (p. 2980)
This means that the Lean philosophy requires the actors in the organization that add value to have
numerous tasks and responsibilities (Procter & Radnor, 2014). Therefore, autonomy is an overlapping
characteristic of both the Lean methodology and teams in healthcare.
Process Definition Source
Communication Communication is the vehicle through which personnel from multiple functional areas share information that is so critical to the successful implementation of projects. Without communication, project do not get implemented. There are three types of communication:
1. Internal vs external within teams or between teams 2. Formal vs. Informal communication
3. Written vs. Oral communication
Pinto & Pinto, 1990
Collaboration Collaboration can be defined as the interpersonal process in which teams behave towards a shared goal. The activities aimed at reading this goal (the collaboration) lead to increased mutual commitment.
Landry & Erwin, 2015; Pinto & Pinto, 1990 Coordination Coordination refers to a team’s ability to organize work activities, agree upon
and implement protocols and plans, and facilitate team member interaction.
Landry & Erwin, 2015 Conflict The concept of conflict is not negative until it is impossible for those
concerned to resolve or manage the conflict. There are two types of conflict. First of all, relationship conflict results from the differences and
incompatibilities between individuals. Second, task conflict arises when the individuals within a team have different opinions on the content of the tasks to be done.
Capozzoli, 1995; Cohen & Bailey, 1997
Decision-making Decision making power may be diffused among team members. A consideration should be made; decisions that are made quick and without discussion results in less participation and acceptance of decisions. However, decisions made by informing and involving team members lead to more commitment and productivity among team members. Therefore, the definition for decision making in this case, involves the level of knowledge of the team members on the topic and the level of involvement.
Green & Taber, 1980; Mickan and Rodger, 2000
Participation Participation can be defined as individual contribution (to the teamwork) and is considered a prerequisite for effective teamwork. Since Lean is mainly about continuous improvement, this will cause constant changes in the tasks and teams. Therefore, the participation to changes will be researched.
12
A second important aspect of both Lean and teams is Continuous Improvement. Effective teams
constantly improve themselves and give feedback (Heinemann & Zeiss, 2002), which is what Lean is
really all about.
3. Methodology
3.1.
Research approach
The aim of this study is to gain insight in the effects of Lean on teams in a healthcare environment.
Specifically, the focus will be on the effect of Lean on six team processes: communication,
collaboration, coordination, conflict, decision making and participation. Since there is no previous
known academic research on this topic, the research approach is a case study. Within case study
research, multiple data collection methods are allowed and the main aim is to build theory (Eisenhardt,
1989). This research makes use of both qualitative and quantitative research methods in the form of
interviews and a survey, to strengthen the validity of the study (Yin, 2011, p. 81; Eisenhardt, 1989). The
unit of analysis is teams.
3.2.
Case selection
According to Eisenhardt (1989), case selection is a crucial step in building theory from case studies. For
this research to be meaningful, the case must fulfil two main criteria. First of all, the teams in the case
study must operate in a healthcare environment. This means that the main goal of the organization is to
provide healthcare. Second, the organization must have a few years of experience with Lean. The
experience of the teams with Lean may vary to get a more complete end result. One organization that
met these criteria was a large academic medical centre in the north of the Netherlands, which will be
referred to as MedCentre from here on. During four weeks, all data was gathered within four different
teams. All of them have experience with Lean, varying from 1 year to 5 years.
3.3.
Case description
The organization in which this research will be conducted, is an academic centre. This means that
besides treating patients, the hospital educates doctors, nurses and other staff and medical research is
conducted. This particular hospital has been using Lean Six Sigma for over 8 years, which implies that
there is a lot of experience and knowledge on the methodology. In the past years, over 1.600 employees
have received training in Lean Six Sigma (see appendix I).
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more theoretical background, focused on employees that are responsible for quality improvement. The
Green belt training is an 8-day course, spread over 5 months and gives the participant a more thorough
view on how to use Lean and includes guidance for process improvement. For this research, four
different teams have been researched. The contextual background of these teams will be given next.
The first team includes the Medical Administration of the Intensive care and the Emergency
department, with a total of 22 team members. This team is responsible for the intake of patients,
processing data, gathering relevant healthcare information on the patient and the administrating the
policy once the patient is admitted. In the current situation, the intensive care units are spread along the
hospital, which means that the team members are too. The team experiences two major changes at this
moment. The first is the digitalisation of the administration, causing activities to be eliminated or
changed. The second one is the ‘Hotfloor’ project, which is a construction project where the emergency
department, intensive care units and the surgery disciplines are brought together. This change requires
the administrative teams to increase collaboration and align processes. In this team, the team leader and
a team member are finalizing a Green belt training, the other team members have finished a Yellow belt
training.
The second team is the logistic centre and distribution, consisting of 13 members and a team leader.
The logistic centre provides both the MedCentre and another hospital of supplies, ranging from coffee
to sterilized instruments. The distribution team is responsible for all transports within the hospital. This
includes waste processing, transport of materials and clothes. Team leader and the team member that
leads the logistic centre have been involved with Lean for over five years. The other team members have
recently engaged in a Green belt training. This team is influenced too by the ‘Hotfloor’ project, due to
changes in (temporary) locations for the delivery and pick up of materials.
The third team is a team of nurses on the Neurology ward. They receive a diversity of patients, some
of which need highly complex care. The team consist out of 60 members, divided into nurses, senior
nurses, supervising nurses and one team leader. All team members have received a Yellow belt training,
the supervising nurses and the team leader also completed the Orange belt training.
The fourth team is the Clinical Neurophysiology. This department consists of lab technicians,
doctors, a physician assistant, administration and a biomedical information scientist. However, the team
participating in this research, only consists out of lab technicians. The team leader of the Neurology
ward is also in charge of the lab technicians in this department. The lab technicians have all followed a
Yellow belt training recently, one team member also participated in the Orange belt training. In this
team, there have been four different leaders in the past 9 years. Besides that, the department is going to
be moved to another location, with less space.
3.4.
Data collection
Multiple sources have been used to collect data in this research. The combination of a survey, interviews
and studying relevant documents and literature provides the triangulation of research methods. This
strengthens the validity of the study (Yin, 2011, p. 81; Eisenhardt, 1989). This triangulation also
increases reliability since more standardized measurements are carried out and the number of
respondents is increased (van Aken et al., 2012).
Initially, an exploratory literature search in the common database ‘Business Source Premier’ with
the key words ‘Lean’ and ‘Team’ resulted in 654 results, which seemed promising. However, when
narrowing focus by selecting only peer reviewed academic journal articles, published within the past 10
years, the result was brought down to 175 articles. Of these 175 papers, only 12 of these articles were
fully accessible and considered both the concepts of Lean and Teams to be the subject of research. These
articles have been analysed, in appendix II there is an overview of the articles and their research focus.
As can be seen in the appendix, the research gap is quite obvious. 11 of the articles are not focused on
the team level and are also conducted with other industries in mind. The article by Procter & Radnor
(2014) is the only article really focused on team work in a healthcare environment. However, their focus
is on on how the teams work rather than on the processes within teams. Besides the academic papers,
some documents provided by the hospital were also studied.
To start with getting a better overview on how the teams function and how they perceive Lean, a
survey with 56 statements was set out among all team members of the participating teams. The survey
statements are based on three different sources for valid questions, an overview of the sources can be
found in appendix VII. The survey applied a seven point Likert scale on which the participants could
rate their responses. The scales used are included in appendix III. This way, it was possible to get a
complete insight in the processes of the team. The questions were set out in Qualtrics, a survey software
program that allows respondents to fill in the questionnaire online. In appendix III there is an overview
of the survey statements. The survey contained statements on the team processes, as defined in the theory
section, and how team members perceive Lean. These have been analysed by taking the average scores
of each team in Microsoft Excel. The same survey was sent out to all the team members, a total of
approximately 108 participants, of which 23 participants actually finished the survey. This means that
around 20% of the team members responded. Therefore, the survey will be used to create a sound
impression of the context, where the interviews are used to go into depth and figure out why certain
phenomena occur.
16
appendix V. The semi-structured approach enhances reliability because the same subjects are discussed
in every interview (Aken, Berends, & Bij, 2012). The interviews have been recorded. It is important to
note here that the interviewees should consent with recording the interview. To do so, all interviewees
signed an informed consent form (see appendix IV).
3.5.
Data analysis
The survey was sent out to all team members. The results are analysed by taking the average score
of the team on each statement. Those averages can be found in appendix VIII. The results are used to
build context in which the teams function and how the team members perceive Lean and the team
processes. These are used in the within-case analysis in the results section.
The interviews have been recorded and transcribed literally for further analysis. To increase the
recognition of results, the transcripts of the interviews have been sent back to the interviewees, when
the interviewees wished so. This is also known as member check (Aken, van, et al., 2012). Any
responses sharpen the results of the interviews. When there were no further adjustments indicated by
the interviewees, the interview was coded. The coding process started with coding one interview by the
researcher and a colleague from the same research field. Codes from both researchers were compared
and adjusted where needed. This way, the inter-rater reliability is increased (Aken, van, et al., 2012).
Codes are both inductive and deductive. The deductive codes are codes that already appeared when
studying relevant literature. Inductive codes are codes that came to mind while reading the
transcriptions. The codes are grouped together in categories, and some even in subcategories. To
enhance validity, the deductive codes were provided with definitions from literature. The categories,
subcategories and codes are found in the Codebook, see appendix IX. Some examples of codes are Lean
Training, Lean Tools, Formal Communication and Effect of Lean.
4. Results
In this section, the results from the interviews and survey will be discussed. The results will be presented
following the six team processes as described in the literature section and are based on both interviews
and surveys. In total, a number of 13 interviews with different participants of the four teams have been
conducted. The survey was sent out to all team members. Within the two weeks the survey was open,
23 participants have filled in the complete survey, including 4 members of the medical administration
team, 10 members of the logistics team, 8 members from the neurology ward team and 1 member of the
clinical neuro physiology team. First, a short within-case analysis is presented, followed by a cross-case
analysis.
4.1.
Within-case analysis
In this section, a short overview of how the teams use Lean and their interpretation of it will be discussed.
This is to make sense of the volume of data and to get to know the teams a bit better before cross-case
analysis (Eisenhardt, 1989).
The first team is the Medical Administration. As described before, they are facing major changes at
this point in time. They mainly use two types of Lean tools, the daily rounds at the beginning of the day
and the improvement board. To help guide the most immediate change, the development of the
‘Hotfloor’, a development team was set up to research the current processes and how they could be joint
together once the ‘Hotfloor’ is realized. With the initiation of Lean, a couple of years ago, some of the
team processes have improved drastically, as described by team member 2:
“You create a blind spot if you do the same things for years. And it worked all these years. And
when you let someone else take a look, things emerge that makes you think okay… So in that
way, Lean can have effect, influence.” (T1P2)
The outcomes of the survey for this team are quite positive. The outcomes imply that communication
is clear, reliable and feedback is given. They score very high on collaboration, especially when it comes
to the importance of their work and team members. This team also scores very high on coordination,
specifically where it comes to knowing what other team members’ tasks are. However, they do not feel
like they have much influence in the decision making process. On the opposite, they do think they have
some influence on the goals that are set.
The second team is the Logistics team. This team has been using Lean the longest, over five years.
This can be seen in the way some participants describe Lean as for example, team member 2 describes
Lean as “a way of life”. They mostly use the improvement board and started a weekly meeting. In this
team, Lean has put a strong focus on the client, whether it is a patient, another team or your colleague,
as described by team member 3:
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The survey implies that communication between team members is good, however there is room for
improvement when it comes to taking multiple perspectives when discussing a problem. Another
interesting outcome is that the Logistics team feels that they are dependent on other teams quite heavily.
Finally, participation in this team is quite high, as they feel that they can influence the goals most of
every other team.
The third team is the Neurology ward. Because this is a team that works with patients that need
specific and complex care, most processes and responsibilities have already been described in detail.
For this team, Lean can help to improve some of these processes and make them more efficient.
Therefore, they use the improvement board and a weekly meeting to discuss the optimization of
processes with paying special attention to the needs of the patients as described by the team leader:
“It has to be efficient and we should pay special attention to the patient. That goes before
anything.” (T3TL)
This team scores high in the survey on good in team communication. Additionally, they are very
aware that they need each other to collaborate to perform the tasks. In contrast to the logistics team, this
team indicates that they do not depend on other teams much. They also do not score very high on
decision-making, which implies that they feel like they do not have much influence.
The fourth team is the Clinical Neurophysiology. This is a team consisting of 13 lab technicians that
have had many team leaders in the past years. This has influence on how the team is now working
together, a lack of trust has been indicated by both team members and the survey. They also indicated
that nothing has changed much over the past 10 years. However, with the appointment of a new team
leader, change is on its way. The team started with following a Communication and Lean training. An
improvement board has been introduced and will be in use shortly. However, there is still a lot of distrust
and resistance towards changes. This need for change is illustrated by the following quote:
“And that is also transcended thinking. We are not fantastic. No. We can learn so much more
from others.” (T4P2)
This distrust and negative working environment is confirmed in the survey. In comparison with the other
teams, this team scored very low on communication and conflicts.
With this short within-case analysis, an attempt was made to describe the current situation and get a
grip of what is going on in the different teams. This helps to understand how Lean influences the
different team processes in ways that are different for every individual team. These effects will now be
analysed by means of the six team processes in a cross-case analysis.
4.2.
Cross-case analysis
4.2.1. Communication
All teams have both formal and informal communication. By analysing the interviews, Lean seems to
have influenced formal communication most. Formal communication is affected by adding a meeting
to discuss the issues on the improvement board or introducing the daily rounds, used by the medical
administration and the logistics team. The neurology ward team already used daily rounds before
introducing Lean, to exchange relevant patient information to the next shift. Therefore, one could say
that Lean has an influence on communication by means of more meetings, however, there is more to it.
The value of these meetings is explained by the logistics team leader, by stating:
“Lean gives a lot more focus. Thus, no generalities anymore, but improvement. Smart, this is
what I want to improve.” (T2TL)
This implies that meetings concerning the improvement board and daily rounds give more focus on what
to discuss and how to check any proceedings. This makes communication clearer and more efficient.
Another effect of Lean is a rather indirect one. When Lean influences coordination, this coordination,
in turn, seems to influence communication. Examples can be found in the logistics team and the medical
administration. Here, Lean helped indirectly to create ‘short lines of communication’, as described by a
team member of the logistics team:
“And now they know that I am working on a change project with clothing. The way the clothes
are put in the machines. Because they know now, you find each other sooner, therefore, that
line is shortened too. So, first I just communicated with a team leader, and now others are
involved and committed too, I guess.” (T2P1)
This quote implies that Lean affects the coordination and this in turn affects the communication, which
gets more intensive and more members are involved. Therefore, it does not only help to focus the subject
of communication, but also to focus on whom to communicate with. Shorter lines imply that less
trespasses are made and communication is directly with the team members involved due to clear
responsibilities and task division. Thus, team members experience greater autonomy because they can
reach the right people without asking team leaders and other teams or team members.
4.2.2. Collaboration
From the interviews it seems that Lean has an influence on collaboration. Additionally, coordination
also seems to affect collaboration. Collaboration is found to be increased within the team and across
teams.
One cause for increased in-team collaboration is the training. During the training people get together
and work on all sorts of assignments. For some assignments, certain processes need to be studied and
analysed. By doing so, the team members have to collaborate to get a clear answer as illustrated next:
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these assignments, you collaborate as a couple with other team members that lead teams. Then
you do this jointly.” (T2P1)
The cross team collaboration is also enhanced by Lean, adding the knowledge of multiple disciplines
makes the overall process more flexible. This is described in the following quotes:
“The nice thing is, we had an improvement suggestion on nutrition. And then a nutrition
assistant and a speech therapist joined us.” (T34TL)
“That is what I learned, step out of the box. That is what it’s called. But it is true. At this moment,
colleagues from the emergency department are observing and working here and are also being
introduced. And the same for us at the emergency department. This way, you can see how others
work.” (T1P1)
Also in the medical administration, in-team collaboration is enhanced. Members are more aware of
the process and the role they are playing in it. This awareness can be seen as clearer coordination of
tasks and responsibilities. It becomes easier to oversee the effects of the work one is performing. This
influence is illustrated by the following quote:
“And because you can collaborate, and exchange jobs, for example, when someone has a lot of
leaving patients and another colleague has none, I can ask if he or she wants to help out.”
(T2P1)
This collaboration is only possible when the tasks are described and known, therefore, it could be said
that a clear coordination is a prerequisite for collaboration. Most of the collaborations seem to be created
by using the improvement board or participating in a training. Therefore, one could say that Lean seem
to influence collaboration directly and indirectly, within and between teams.
4.2.3. Coordination
Coordination is influenced by Lean very differently, varying per team and circumstances. In the
Neurology ward team, all work activities are set up in protocols and plans. This was already done before
the introduction of Lean. Therefore, Lean has only a small influence in the improvement of these
protocols. The medical administration has also started to work with protocols. However, in this team,
the protocol description is part of Lean. Describing ways to work also meant that everyone had to work
in a uniform way, and thus change the way they used to work. Now that three disciplines are brought
together on the ‘Hotfloor’, more uniformity is needed, as explained by the team leader:
“Yes, at the intensive care, all is written down. And that is updated regularly. For next summer,
I would like to have mapped the processes of all three organizational parts down.” (T1TL)
“And then you can say ‘this went wrong, we encountered this, or I could not finalize this patient
file because I miss a note from the doctor’. Those things are handled during the daily rounds.”
(T1TL)
Therefore, Lean has a large influence on the coordination of this team. However, in the other teams, the
work activities seem to be less strict. The other teams rely on expertise and experience as illustrated by
the following quotes:
“Experience, at this moment, it is not clear. That is where the problem is. You were going to do
that, right? That is not clear at all.” (T2TL)
“Yes… People will have a job description that says what to do. But I think in the end, most
responsibility lies with yourself, not in the description.” (T4P2)
Another emerging subject was the extra tasks. In team 1, 3 and 4, the team members are all assigned
to extra tasks, or focus areas. This means that besides the daily job, each team member or a group of
team members is also responsible for another task. This can vary from processing protocol changes,
privacy, equipment or infection control. This is illustrated by the following quotes:
“Besides that, everyone has an extra task. It is very clear who has which extra tasks and who is
back up for this extra task.” (T1P2)
“That are the focus areas. You try to do what is relevant for your focus area. We have areas on
files, we have areas on care, we have the patient visits, the privacy… That is very broad.” (T3P2)
“And now we have our own focus area. Like infection control, work functions, protocols, echo’s,
we have a lot.” (T4P1)
4.2.4. Conflict
Conflict can be divided in two types: the personal conflict, and task conflict (Capozzoli, 1995; Cohen
& Bailey, 1997). From the interviews, it became clear that Lean does not have direct influence of the
prevention or solving of personal conflicts. This is described by the logistics team leader:
“No, you will, because there are conflicts that are not related to the process. You can just hate
someone without a good reason.” (T2TL)
However, there is clear evidence that Lean does influence process conflicts within a team. A cause for
these process conflicts is illustrated by the following quote:
“Someone can think, what is wrong with this, I have done it like this for over 20 years. And then
suddenly, it is not good enough anymore. That gives friction.” (T1P2)
There are two ways that Lean can influence conflicts, by preventing them or by solving them. First of
all, Lean helps to prevent conflicts indirectly through better supported work instructions. Here, improved
coordination again plays a great role. As a team member of the logistics team describes:
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Second, it helps to solve conflicts since it helps to directly discuss any points of problems.
Additionally, Lean can help to create a distance to look at the cause of the problem. This can be done
by means of an improvement board. The following quotes describe the conflict solving influences of
Lean:
“What is important, is that with Lean you directly get to them. In our situation, we transfer
someone to another team. {…} Lean necessitates, conflict is one of the things that can happen,
but Lean forces to go on with solving. You just have to deal with it.” (T2TL)
“I think it influences conflicts. The moment that conflicts arise in a process, when things are not
going smoothly, Lean can help you to take some distance.” (T34TL)
“If you find it hard to discuss some things, you can just write it on the improvement board.”
(T4P2)
4.2.5. Decision making
In the decision making process, Lean appears to have some influence. Team members are more involved
in decision making through Lean. This is encouraged by the team leaders. The involvement of team
members is illustrated by the following quotes of team leaders:
“I can decide how I want things to be. But that does not work. If you make it a team wise process,
it works a lot better.” (T1TL)
Involvement of team members goes through the improvement board and responsibility is given to the
different focus groups. This way, the team members are involved in the decision making process as
illustrated with the following quote:
“Yes, decision making is done with the improvement board, but also in de kaizen groups. This
way it is decided what is going to happen and what we are going to do. But prior to this, there
was a lot of communication in the team itself.” (T2P2)
Notwithstanding this involvement of team members, the team leaders seem to make the final decisions
in the end or initiate new overarching goals.
4.2.6. Participation
The participation of the teams in the current changes seem to be strongly dependent on a motivating
leader and intrinsic motivation, but do not appear to be influenced by Lean so much.
A motivating leader is described as enthusiastic, has high expectations of team members and has to
take the lead in changes. This can be done intentionally, however, it seems that some leaders are
changers by personality. This is illustrated by the following quotes:
“I think that my largest motivation is my supervisor. This person is very enthusiastic.” (T1P2)
“It has been said that I create it. However, I do not do this in a conscious way. It is something
that is already inside me.” (T34TL)
by giving attention, information and knowledge. The effect of the intrinsic motivation, or the lack
thereof is illustrated by a team member of the logistics team.
“I think that some people are more actively participating then others. What is visible in the work
groups, there are several, mostly the same people that sign up for this.” (T2P2)
4.2.7. Length of working with Lean and type of team
From the interviews and the survey, it appeared that the length of the period a team has been working
with Lean, has only little influence. Only at the clinical neurophysiology team, where they only started
working with Lean two months ago, there is an obvious difference in how well Lean is integrated in the
daily work of the teams. Since they only started using Lean recently, there are no clear effects yet. This
is illustrated by the following quote:
“It has, it will have an effect on the patients. I am very curious how and what effects. Yes, it will
have effect. Because there are certain things that are not very efficient. I am very curious about
that.” (T4P1)
There is of course difference in the use of Lean between the other teams, however, this seems to be
based on whether the team is involved in the direct care process or not. In the two teams that directly
work in the care process (neurology ward and the clinical neurophysiology), the effect of Lean seems
to be less evident. This can be explained by the clear responsibilities and task protocols of the care
process within the two teams, established without the use of Lean. Within the facilitating teams, these
responsibilities and protocols are now being studied, analysed and written down since the introduction
of Lean. Thus, the effect is more evident in the facilitating teams.
All in all, it can be concluded that Lean influences team processes to a certain extent, see Table 4. In
the next section, these results will be discussed.
Team Process Results
Communication Focused communication through formal Lean meetings and clearness of responsibilities. Collaboration Collaboration is influenced by clear overview of the process and the introduction of the
improvement board and training.
Coordination Influenced by Lean when processes are written down in protocols.
Conflict Only task or process conflicts are influenced by Lean by the development of protocols and Lean makes them more negotiable.
Decision-making Lean influences the decision making by giving the team members a chance to discuss the processes for improvement, however, it does not influence the decision making power. Participation Lean has no clear influence on the participation within teams.
Length of working with Lean The length of working with Lean seems to have no influence on how Lean affects the team processes.
Type of team The type of team seems to influence the effect of Lean. Teams directly involved in the care process seem to be less influenced by Lean then more facilitating teams, due to the level of standardisation.
5. Discussion
In this study, we set out to investigate the influence of Lean on team processes in a healthcare
environment. This research is based on the ITEM by Lemieux-Charles and McGuire (2006) and adopted
the six team processes from this model. Through interviews, a survey, and archival data, some new
insights can be presented. In this section, the results will be discussed to provide an answer to the
following research question:
‘How does Lean Influence Team Processes in a Healthcare Environment?’
5.1.
Key findings
Lean influences team processes in many ways. In Figure 2, there is an overview of the different
relationships found between Lean and the team processes, on which will now be elaborated.
First of all, Lean had the most important effect on coordination. If coordination is improved by Lean,
communication, collaboration and conflict are also influenced by Lean through coordination. However,
this effect is strongly dependent on the circumstances in which Lean is introduced. The degree that
protocols are used seem to influence the impact of Lean. For example, in the Neurology ward team, all
processes were already described in protocols without any influence of Lean. Therefore, Lean did not
have a great influence on the coordination in this team.
Second, communication tends to get more focused, in message and in communicating with the right
person. The content of communication gets more focused because of standardized meetings with
specific goals, such as the improvement board meetings. Improved coordination makes team members
aware of their own responsibilities and those of other team members, which helps people to reach the
right person the first time and therefore communication gets more efficient.
Third, Lean seemed to have impact on the collaboration between team members and teams. An
explanation for this can be found again in both coordination and Lean. By writing down all processes in
protocols, team members get a better overview of the whole process. With this overview, it is easier for
them to collaborate and improve processes, since they can oversee the effects of certain actions.
However, collaboration is mostly influenced by Lean itself through training and the use of the
improvement board.
Fourth, conflicts within teams are influenced by both Lean and coordination. They are reduced by
coordination because there are no irritations regarding responsibilities within teams. Additionally, they
are neither reduced nor increased by Lean, but rather they have become more negotiable through Lean.
However, Lean only influences process or task conflicts, not personal conflicts.
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most cases, the final decision making is still in hands of the team leader. Therefore, the influence of
Lean on the decision making is minor.
Sixth, there is not a clear relationship found between Lean and the participation of team members.
Lean does offer a possibility to influence and participate in the changes. However, this possibility does
not guarantee the level of participation among team members. The level of participation seemed to be
influenced by two other factors. Those factors are a motivating leader and intrinsic motivation. Since
Lean has no direct influence here, it will be left out of discussion any further.
All in all, there are team processes that are influenced to a certain degree by the implementation of
Lean and use of Lean tools. It should be remarked here, that for most teams, Lean comprised the tools
and the training. The influences are illustrated in Figure 2. Since no clear evidence could be found that
Lean had influence on participation, this concept is left out.
Figure 2 The relationships between the different concepts
