LEAN HEALTHCARE AND THE DYNAMICS OF RESISTANCE TO CHANGE: A SOCIO-TECHNICAL PERSPECTIVE
Student: Isaac Borghouts (S2942038) First assessor: Dr. Oskar Roemeling
Second assessor: Dr. Cees Reezigt
MSc Business Administration - Change Management
2
ABSTRACT
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INTRODUCTION
The aging society increases the demand on healthcare services while financial conditions for healthcare organizations are not improving, or even worsening (Poksinska, 2010). As a result, healthcare organizations in the 21st century are under a lot of pressure to improve. They are challenged to be as cost effective, accessible, safe and affordable as possible (Poksinska, 2010). In an attempt to achieve this, healthcare organizations are adopting continuous process improvement methodologies such as Lean thinking (Radnor & Boaden, 2008).
Lean originated from the Toyota Production System and is a management practice based on the philosophy of continuously improving processes. This is achieved either by increasing customer value or by reducing non-value adding activities, process variation and poor work conditions (Radnor, Holweg and Waring, 2012). Over the last three decades, there has been a growing interest in Lean in public services, and in particular healthcare. For example, the US institute for Healthcare Improvements and the UK Institute for Innovations and Improvement both adopted Lean principles. For the US this resulted in 53% of the hospitals implementing lean to some extent in 2009 (Holden, 2011).
According to Waring & Bishop (2010), Lean healthcare resurfaces three lines of changes in contemporary healthcare reform: (1) the reconfiguration of occupational boundaries, (2) new forms of clinical leadership, and (3) the rise of evidence based guidelines. In that spirit, they interpret Lean as the new 'frontier' of managerialisation of healthcare, in which it has the potential to transform institutionalized working practices and departmental boundaries.
This managerialisation of healthcare is not without its critiques. For example, Lozeau, Langley and Denis (2002) argue that there is a misfit between the theories underlying widely adopted managerial techniques such as quality management and the pluralistic power structures and values of public hospitals. In a similar vein, Radnor (2012) states that although Lean has a lot to offer to healthcare operations, its adaptation from private to public sector context is a great challenge. This challenge can be illustrated by findings of many authors, claiming that the current state of Lean healthcare has not achieved its level of maturity beyond the simple application of Lean tools (e.g. Poksinska, 2010; Joosten, Bongers, and Janssen, 2009; Mazzocato et al., 2010).
This is a problem, since it is widely agreed that for Lean to achieve its full potential, it needs to move beyond the application of tools, to a process view, and ideally, to a holistic understanding of pathways across healthcare organizations (Radnor et al., 2012; Ballé and Regnier, 2007; Kim, Spahlinger, Kin and Billi, 2006). On this point, the development of Lean healthcare shares common ground with the current debate on integrative care as illustrated by Drupsteen, van der Vaart and van Donk (2013).
4 the implementation of Lean healthcare is not without its barriers. Common barriers derive from the fact that healthcare organizations are usually highly political and complex, characterized by powerful professional groups and regulatory systems (Radnor et al., 2012). Other barriers relate to the healthcare workers' perception of Lean (e.g. a manufacturing philosophy is not suited for healthcare) and the current structure of fragmented care and professional practice, represented in many hospitals as functional silos (De Souza & Pidd, 2011).
Research by Radnor et al. (2006) indicate that most barriers to Lean implementation are in fact people-based. Furthermore, it appears that almost all research on the consequences of Lean healthcare is not about its impact on employees, but about the impact on the process and outcome of patient care (Holden, 2011; Mazzocato et al., 2010; Poksinska, 2010). As Holden (2011) in his critical review on Lean healthcare points out, many questions remain unclear about the impact of Lean on employees. Following this line of reasoning, Joosten et al. (2009) state that the implementation of Lean healthcare often leads to resistance. Therefore, they claim that more socio-technical research is needed, taking into account how Lean can trigger other dynamics, leading to resistance. While Joosten et al. (2009) emphasize on the importance of resistance, they do not address how this resistance evolves throughout the implementation of Lean in healthcare. To the best of the author’s knowledge, only one detailed qualitative study describes in detail how Lean interacts with the employees of an operating department, with some elaboration on resistance (i.e. Waring & Bishop, 2010). Consequently, more research on this is needed for two reasons:
(1) Up until now, studies only analyzed resistance superficially, as something that is happening 'out there' among the recipients (e.g. De Souza & Pidd, 2011) or in relation to power (i.e. Waring and Bishop, 2010). A recent reconstruction of resistance as a dynamic concept by Ford, Ford, and Amelio (2008) encourages to take a much broader perspective (see literature review).
(2) Currently, of the limited number of qualitative studies that elaborate on resistance, the cases are merely about individual departments (e.g. orthopedics). However, for providing insights regarding the debate on integration, crossing departmental could be valuable. As Poksinska (2010) states, problems with the implementation of Lean frequently appear in crossing between different departments.
5 instead, contribute to a great extent to the 21st century challenges that healthcare faces.
LITERATURE REVIEW
This chapter consists of three sections: (1) an introduction to Lean thinking and an evaluation of its application to a healthcare context, (2) an elaboration of the origins and recent developments of the concept ‘resistance to change’, and (3) a justification of why it is important to investigate how Lean healthcare influences the dynamics of resistance to change.
Lean healthcare
The management philosophy and practices of Toyota halfway the 20th century evolved in the famous Toyota Production System (TPS). Most people agree that the fundamentals of Lean thinking have its roots in this production system. However, there has been considerable development of the concept over time, whereby Womack & Jones (1996) are mostly cited as the originators of the term 'Lean' (Radnor & Boaden, 2008). Lean thinking is based on five-step process according to Womack & Jones (1996): (1) specify the value desired by the customer, (2) identify the entire value stream for each product and eliminate waste (3) make the remaining value-creating steps flow (4) design and provide what customers want only when the customers want it (5) pursue perfection.
Womack & Jones (1996) were among the first authors who claimed that translating this five-step process into healthcare organizations could be beneficial. Currently, emergency and surgery departments in hospitals are pioneering with its implementation, with results often relating to a reduction in waiting times, costs, errors, and improvements in quality (Radnor & Boaden, 2008). However, since its first introduction in healthcare at the start of this millennium, mainly the first three steps (i.e. specify the value, identify the value stream and eliminate waste, and make the value-creating steps flow) are mainly pursued, resulting in a paucity of system-wide implementations (D'Andreamatteo, Ianni, Lega and Sargiacomo; Poksinska, 2010). This indicates that implementation of Lean healthcare has not achieved its level of maturity beyond the simple application of tools, such as value stream mapping.
This limited application of Lean could hinder possible outcomes, since scholars widely agree upon that for Lean to achieve long-term sustainable goals, it is necessary to unfold in a system-wide approach (D'Adreamatteo et al., 2015; Radnor et al., 2012; Ballé and Regnier, 2007; Kim, Spahlinger, Kin and Billi, 2006). The question how Lean can become a sustainable way of working, and thereby significantly contribute to challenges healthcare faces, could not be answered in the current literature (Poksinska, 2010).
6 problematic. For example, Radnor et al. (2009) state that significant contextual differences between manufacturing and healthcare exist, resulting in two critical breaches with the core principles of Lean.
First, determining who the 'customer' is and in turn 'customer value' is problematic in healthcare. In fact, for clinical staff, the customer usually is the patient, but for other healthcare workers the customer often exemplifies other hospital departments, health purchasers or even regulatory and political organizations. This highlights the ambiguity in who Lean should be directed towards and how it should be implemented (Radnor et al., (2009).
Second, they argue that healthcare organizations are characterized by their focus on capacity and budgets. This is problematic, because possibilities to influence demand and to re-use freed-up resources are constrained and limited. Private organizations can manage demand and capacity by growing its existing businesses or entering new sectors, healthcare organizations are much more constrained (Radnor et al., (2009). To some extent, this might explain why, even though results on Lean are promising, there is currently no final conclusion to be drawn on its positive impact or challenges when translated into a healthcare setting (D'Andreamatteo et al., 2015).
Approximately seventeen years after its first introduction into health care this results in critique on its applicability into a healthcare context. It appears that almost all barriers to Lean healthcare are people based (Radnor et. al., 2012) and that resistance can be high (Joosten, et al., 2009). Joosten et al., (2009) further claim that one of the fundamental problems with Lean healthcare is the current dominant operations management perspective through which Lean is researched. Instead, they claim that another perspective (i.e. a socio-technical perspective) is needed for Lean to achieve its full potential.
7 Figure 1: conceptual framework of Lean thinking (Joosten et al., 2009)
By analyzing Lean healthcare through this socio-technical perspective, Joosten et al., (2009) emphasize on the importance of resistance. However, in line De Souza and Pidd (2011), they only address it in a superficial or anecdotal manner. In other words, the importance of resistance is acknowledged, but the concept is primarily treated as a black box. By doing this, prior research neglects the complexity and drama associated with resistance. Therefore, this study addresses Joostens et al., (2009) call to analyze Lean healthcare and how it influences resistance through this socio-technical perspective.
By taking this perspective the researcher of the present study follows the conceptualization of a socio-technical system by Lyytinen and Newman (2008). Their conceptualization is valuable since it is longitudinal, taking into account what happens to an organization, or in their terms ‘a socio-technical system’, whenever a critical incident (e.g. Lean healthcare implementation) takes place. Indeed, they state that a socio-technical system consists of four boxes (technology, actors, structure and tasks) that are in relative stability. But, as the time progresses, critical incidents take place, altering the stability of the socio-technical system. This is what Joosten et al., (2009) mean with their statement that Lean healthcare can trigger further dynamics (i.e. can unbalance the socio-technical system).
Contrary to the current dominant operational perspective, a socio-technical perspective allows us to understand the impact of Lean implementation beyond the impact for patients or processes to how and why it impacts health care workers (or ‘actors’, in terms of Lyytinen and Newman, 2008).
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Resistance to change
Scholars widely agree that the reason for failure of change initiatives often can be found in resistance to change (Lawrence, 1954; Kotter, 1995; and Strebel, 1994). Not surprisingly, the literature on change management has devoted a great deal of energy to how to cope with resistance to change, what causes it, and how it should be managed. Oreg (2003) provided four dispositional components that attribute to people reaction to change: routine seeking, emotional reaction to imposed change, short-term focus, and cognitive rigidity.
Regarding the complex nature of organizational change, insights on someone's dispositional inclination towards change can be of much practical relevance. To put this in a more business perspective, Del Val & Fuentes (2003: P:153) define resistance to change as 'any phenomenon that hinders the process at its beginning or its development, aiming to keep the current situation.' Consequently, they position resistance equally to inertia.
According to Coetsee (1993), the primary dimension of resistance is behavior, ranging from passively uncooperative behavior to engaging in aggressive destructive behavior. In addition, Coetsee (1993) provides a spectrum of these behaviors: apathy resembles inactiveness or showing a lack of interest, passive resistance, can be mild delay tactics or excuses not to cooperate, active resistance, can be voicing opposite views or forming coalitions, and aggressive resistance, which is destructive behavior such as a boycott or making threats. It is anticipated that this taxonomy is useful for analytical purpose in the present study.
It appears that the most common approach to resistance is to demonize it and thereby assume that it constitutes to some kind of problem (Thomas & Hardy, 2011). Some authors argue that this negative view on resistance stems from the observations of Charles Darwin, stating that adaptation to change is key to survival. This negative view on resistance resulted in many leading authors contributing to research on how to overcome resistance (e.g. Kotter, 1995; Lawrence, 1954; and Cummings & Worley, 1997). However, this negative approach to resistance derogates its potential to transformational efforts, and more recently resistance is also being considered as a positive aspect to change.
9 negotiation of mutually sensible meanings, whereby different positions and values are resolved in a harmonious manner (Thomas & Hardy, 2011).
While this celebrating approach to resistance seems to have a more positive view on human nature, it shares common ground with the demonizing approach. In fact, both these approaches address power relations in the same manner; the agent determines what kind of behavior can be labeled as resistance or not. It is on this specific point that Thomas & Hardy (2011) argue that it undermines our understanding of resistance to change.
Thomas and Hardy (2011) propose an understanding of organizational change whereby individuals attempt to shape meaning. Here, actors are situated in webs of power that enable or constrain them. Consequently, resistance and power are positioned at the heart of the negotiation of meaning that shape change. Hence, failing to address power-relations adequately limits our understanding of resistance.
Ford et al. (2008) provide an even more comprehensive understanding on the matter by actually reconstructing resistance to change among three elements: recipient action, agent sensemaking, and agent-recipient relationship (or the context). By doing this, they argue not to only consider resistance from the perspective of the change agent, because by doing this it is assumed that the change agent is inherently right, and the recipient is inherently wrong. Instead, they propose that very often change agents are the actual source of resistance.
For example, they argue that due to 'the expectation effect', whereby change agents are expecting resistance, they will eventually find it. In addition, they provide three more ways in which a change agent can contribute to or actually cause resistance: (1) by failing to legitimize change (e.g. providing justifications for the change) (2) by misrepresentation (e.g. being overly optimistic), or (3) by focusing too little on behavioral changes of the recipients. It is on this last point where the agent sensemaking can be crucial. To elaborate on this, employee behavior (which can be criticism) should not be labeled as resistance but instead as sensemaking.
10 Figure 2: Resistance to change based on the reconstruction by Ford et al., (2008).
Analyzing resistance to Lean through these three (relatively new) dynamic elements is important, because the implementation of Lean healthcare is likely to be a highly contested process, whereby different social actors reinterpret and reshape its form, based on their prevailing or conflicting visions (Waring & Bishop, 2010).
Reinforcing this view, Lapointe & Rivard (2005) developed a model that shows what causes resistance to IT and how resistance evolves over time. It needs to be noted. The resistance model of Lapointe & Rivard (2005) is originally developed based on technological change in a hospital. However, for two reasons this model seems fruitful for this study: (1) to the best of the author’s knowledge, no process model of resistance to Lean healthcare seems to exist in the current literature. For exploring how Lean healthcare influences the dynamics of resistance to change it seems of much value to see how and why, for example, (resistance) behaviors change over time as a Lean project progresses, (2) It provides the researcher with a valuable basis of theoretical concepts that, at least for IT change in hospitals, influence and shape resistance behaviors over time. The data of the present study was collected over a period of seven weeks, whereby the researcher was attentive to changes in resistant behaviors as the time passed.
11 This means, that dependent on whether you analyse early or late in the implementation process, resistance behaviors derive from other sources. And, more importantly, this dynamic perspective on resistance shows how early in the process resistance behaviors are characterized as compilation (i.e. individuals have independent reasons for their resistance) and later as composition (i.e. converging individual resistance to group-level resistance). The model is presented below.
Figure 3: A longitudinal process model of resistance to IT (Lapointe & Rivard, 2005)
This process model of Lapointe and Rivard (2005), the dynamic reconstruction of resistance by Ford et al., (2008), and the inherent relationship between resistance and power by Thomas and Hardy (2011) are the three dominant theoretical frameworks on which this study further builds. At the end of the literature review a conceptual model is presented which shows how the author places these three theoretical frameworks into perspective and aligned with a Lean healthcare context.
Lean healthcare and resistance
According to De Souza and Pidd (2011), one of the barriers for implementing Lean healthcare is because of resistance to change. They argue that resistance needs special attention to those implementing Lean, since engagement and empowerment are key in Lean theory. However, according to them, this resistance was not encountered based on opposition to Lean, but on 'the simple fact that changes would be required'. How and why they come to this statement is not further elaborated upon. They do claim that the Lean philosophy can be successfully applied in healthcare without major modifications.
12 they call 'the people issue' of understanding the effect and gaining buy-in from healthcare professionals in the Lean journey.
Scholars agree that achieving this can be hard (Poksinska, 2010; Radnor & Boaden, 2008). Joosten et al., (2009) suggest that this 'people issue' can be explained by the fact that Lean interventions can make jobs simple and repetitive, leading to resistance. Radnor & Osborne (2013) propose resistance to Lean healthcare merely exists because clinical specialists are in general skeptical towards process improvement initiatives aimed at efficiency gains. One of the reasons they point out is that they perceive such initiatives as in conflict with their professional values. This is in line with McCann, Hassard, Granter and Hide (2015) who state that clinical specialists in general tend to be dismissive when it comes to ‘managerial fads’ introduced in healthcare. With ‘fad’ they refer to a temporary management practice from the industry, deployed in the public domain, following a standard cycle which eventually erodes. A qualitative study performed by Waring & Bishop (2010) elaborated in a more detailed fashion on resistance to Lean healthcare in a UK NHS hospital. They analyzed how social practices at this operating unit were imbued with power and resistance. Hereby, they addressed the issue of resistance in line with how Thomas & Hardy (2011) conceptualize the concept (i.e. resistance and power operate at the heart of organizational change). What they found were three lines of resistance to Lean healthcare:
(1) The beliefs of the staff about underlying values of the group that initiated the implementation. To be more specific, the staff argued that departmental efficiency and productivity were prioritized over quality and patient experience.
(2) The staff questioned the knowledge and experience of the group that initiated the implementation. This came to the fore when changes were proposed by the initiators that deviated from national and professional guidelines. Consequently, the lack of expertise followed by a lack of legitimacy, was questioned as a line of resistance.
(3) The staff was concerned that new procedures resulted in higher degrees of standardization. As a result, they were afraid to lose skills and experience that would damage their abilities in other clinical areas.
Towards a theoretical foundation for further analysis
is a paucity of the combination of these concepts in current literature. A more detailed understanding how Lean healthcare influences resistance is needed toguide Lean healthcare beyond the application of simple tools, towards a more system wide approach.
In the preceding theoretical discussions three dominant theoretical frameworks were highlighted on which this study further builds: The longitudinal model of Lapointe and Rivard (2005), the reconstruction of resistance by Ford et al., (2008), and the inherent relationship between resistance and power by Thomas and Hardy (2011). How these three frameworks are related to one another is conceptualized in an integrated fashion in figure 4 below.
Figure 4: A theoretical starting point: Lean healthcare and resistance to change
on their claims that these could influence resistance. Conceptualizing resistance to Lean healthcare in such a way does not allow us to answer the research question but it does help as a theoretical starting point for further analysis.
METHODOLOGY
Research approach and case selection
Addressing such questions are most suited for qualitative research, since these questions require an understanding of underlying relationships and rich explanations (Eisenhardt, 1989). Furthermore, Miles (1997) suggests that data from qualitative research is much more precise when it comes to causality in organizational affairs than in (e.g.) cross-lagged correlations. The case site was selected based on the following criteria:
➢ The organization needed to have a department whose primary aim is to continuously improve hospital processes;
➢ The underlying philosophy on which the improvement projects, initiated by this department, needed to originate from Lean thinking;
➢ The data needed to be obtained from a Lean driven project which crossed departmental boundaries, thereby contributing to the integration of care.
The selected case was a Lean driven project at a peripheral Dutch hospital whereby multiple polyclinics were involved: Internal Medicine, Surgery, Gynecology, Children, and Neurology. The primary aim of the Lean driven project was to identify generic activities which all secretaries of the different polyclinics employ. Consequently, the hospital aimed to enhance the flexibility of the secretaries per polyclinic in a way that they could also (if needed) work at another polyclinic. Prior to the project, the polyclinics claimed that the work of their secretaries was too specialist in nature, and is therefore hard to execute for secretaries of other polyclinics. Based on conversations with the project leader preceding the project, it was anticipated that this could lead to resistance behavior.
Data collection
16 The observations encompassed the first four meetings of the Lean project group and two days on which the respective departments started to ‘measure’ (i.e. measuring phonecall activities and generic activities of the medical secretaries). The project followed the DMAIC quality improvement procedure, often applied in Lean projects. DMAIC is an acronym for five phases (Heuvel, Does, and De Koning, 2006):
1. Define: Define customer, problem statement, resources, stakeholders;
2. Measure: Develop data collection plan, validate measurement instrument, collect data; 3. Analyze: Define performance objectives, identify waste and variation;
4. Improve: Develop potential solutions, validate and evaluate solutions; 5. Control: Develop standards and procedures, celebrate wins, close project.
The data was collected during the Measure phase, which lasted 7 weeks. The project meetings lasted approximately one hour. At the first meeting, the researcher introduced himself shortly. Interviews were held with the project leader (PL), unit heads (UH), polyclinic coordinators (POCO), and medical secretaries (MS). An overview of the interviewees per department is presented below.
Polyclinic Interviewee Number of interviews and comments
17 Case E UH 0: This UH is the same as for case D, therefore only one interview was
done whereby she represented both polyclinics.
MS 1
Process- improvem ent
PL 2: One interview at the beginning, and one interview at the end of the project.
Total 13
Table 1: interviewees per case
According to Aken, Berends & Bij (2012), measuring for controllability, validity, and reliability enhances inter-subjective agreements of research products. In terms of controllability, the researcher kept track of dairy that described the process in such a way that it can be replicated.
For research to be reliable, potential biases need to be controlled (Van Aken et al., 2012). First, researcher bias was controlled by interviewing together with another researcher who studies the phenomenon of narratives in a continuous improvement context, and by having this other researcher also code the data (i.e. inter-rater reliability). Furthermore, three interview protocols (see appendix I, II and III) were developed: One for the project leader in the beginning of the project and one for at the end, and one for the medical secretaries, coordinators and unit heads. Second, instrument bias was controlled by triangulation. Consequently, the three data collection methods can complement or correct each other (Van Aken et al., 2012). Third, respondent’s bias was controlled by interviewing both change agents and recipients. By doing this, all crucial roles are represented in the sample (Van Aken et al. (2012). Fourth, circumstances bias is controlled by interviewing respondents at different moments in time.
For evaluating this research on validity, construct validity, internal validity and external validity need to be high (Van Aken et al., 2012). To assess construct validity, the interview questions were be based on the reconstruction of resistance by Ford et al., (2008), the primitives of resistance by Lapointe and Rivard (2005), and the notion of power and resistance by Thomas & Hardy (2011). To assess internal validity, the problem was analyzed from multiple perspectives such as sociology, operations, information technology and business administration.
18 The researcher aimed to pursue a flexible and opportunistic data collection method, by taking advantage of emergent themes in the first few interviews. After the first two interviews the protocol was slightly adapted. To elaborate on this, it appeared that resistance behavior was also present outside of the project group and among the employees at the respective polyclinics. Therefore, probing questions were added to get an understanding of resistance outside the project group. In addition, a question was added in which the interviewees were asked what ‘resistance’ meant for them. The reason for this was to be able to put their other answers into perspective.
Data analysis
According to Eisenhardt (1989) an overlap between data collection and data analysis is valuable. Therefore, field notes were a means to accomplish this. The unit of analysis for this research is on project level (Yin, 2013). The recorded interviews were first transcribed and then both coded in an inductive and deductive manner. Example deductive codes are be based on (1) the reconstruction of resistance by Ford et al., (2008) (e.g. agent sensemaking, agent-recipient relationships, agent / recipient behaviors), (2) the five primitives of resistance by Lapoint and Rivard (2005) (i.e. initial conditions, object of resistance, perceived threats, (3) power and resistance by Thomas and Hardy (2011), (4) and specific elements of Lean tools and methods (Holden, 2011). The codebook can be found in appendix 4. Observational data was be analyzed through by making use of figure 4 at the end of the literature review. Observations were structured across the five cases. It needs to be noted that all interviewees, except for the project leader, will be referred to as ‘she’ to avoid that the findings can be directed at interviewees individually.
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RESULTS
The data analysis revealed several concepts that help to explain how Lean healthcare influences the dynamics of resistance to change. These concepts will be introduced individually, whereby differences and similarities per case will be highlighted in an integrated fashion. Sub-chapters at the end of each section named ‘consequences for the conceptual model’ serve to explain how the concepts are related to each other; eventually this results in a conceptual model which integrates the analysis.
Object of resistance and conditions
Object of resistance: Project leader initial framing
As the project started, the project leader did a one hour presentation whereby the project group members were present. For the first half an hour, it was observed that most project group members looked like they did not understand what the project leader was talking about. Consequently, after some interviews it appeared that many project group members did not understand why they were doing the project or had a different interpretation of what the project leader initially said. For example, the medical secretary and coordinator of case A both stated: “I have no clue why we are doing this project”.
Interestingly, it was observed that the project leader explained why: “we are doing this project because we want to maintain continuity at the polyclinics”, he said. The meeting progressed rather mild until the project leader presented his initial measurement form. This form would eventually be used to collect the Lean data, whereby the medical secretaries had to fill in on those forms what kind of activities they did, how long it lasted, how complex the activity was, et cetera. After the project leader presented the form, many questions were raised such as: “Do you actually think that filling in this form would represent our reality?” the coordinator of case B stated. It was also anticipated that filling in such a form was too complex. From that point on it was observed that the emphasis was really on what the measurement form should look like and not on why they were doing the project.
Condition 1: Unit head framing
20 case B also linked the project for herself to this new way of working, she did not frame it like that at the polyclinic. Similar to case A, the tendency at case B was more towards having to do the project, instead of wanting to do the project such as at case D and E. As the coordinator of case C stated: “I act like an ambassador because that it my duty with regard to this project be honest I expect nothing from this project”.
Condition 2: Unit head roles
Four types of unit head roles were identified across the five cases (table 2 below).
Case Unit head role Explanation
A Observer During the interview it became apparent that there was no
communication with employees about the project, and there seemed to be no or limited understanding of the way the team members felt about the project. The unit head stated: “I think my role is that of an
observer”. Both the medical secretary and the coordinator stated that internally they never talked about the project. Furthermore, the unit head was very skeptical towards the Lean method, reflected in the following quote: “making a documentary about how the different polyclinics work would be more effective than a project like this”.
B Advisor During the interview the unit head stated that she made efforts to change the language of the measurement form. As she stated: “the resistance primarily is related to the measurement form, therefore we need to translate this into their language”. It does, however, seem that there is not alignment between how the unit head thinks about the project with her coordinator. In particular, the unit head is optimistic about the project, while the coordinator stated: “I actually expect nothing from it, hahaha”.
C Employee representative
During the interview the unit head stated that many efforts were made to make the measurement instrument comprehensible and workable for her employees: “If my employees tell me that it is not workable like this, I completely follow their judgement”. In addition, she stated that
21 format.
D & E
Ambassador During the last project meeting it was observed that she helped the project leader in discussions about the rationale of the project. In addition, in the interview she stated that she was already connected to the project when it was still in its infancy. Furthermore, it was observed that for several times she tried to extend the number of measurement days to enrich the data. This, however, did not work out eventually but it showed how strongly she believed in this project.
Table 2: unit head roles
What kind of role a unit head fulfils seems to influence the level of ambiguity among the participants. This ambiguity stems from to the project rationale, or the why, the practicalities, or the how, and the perceived project consequences. In particular, (1) the role of observer does not seem to clarify the ambiguity, and might even worsen it, (2) the role of advisor seems to help the employees with concerns related to the measurement instrument but does not appear to clarify the project rationale or project consequences, (3) the role of employee representative seems to help with clarifying ambiguity towards the practicalities and project consequences, and (4) the role of ambassador helps to clarify ambiguity towards the rationale, practicalities, and project consequences.
Consequences for the conceptual model
The interaction between the project leader initial framing (i.e. object of resistance) and the two conditions are considered the ‘start’ of the conceptual model. In turn, this interaction seems influence the level of ambiguity related to the project. In terms of unit head framing, it seems that helping the employees to place the project into perspective clarifies ambiguity, while not framing the project does not seem effective. In addition, for this project, the role of employee representative and ambassador seem to clarify most ambiguity. It needs to be noted that these roles remained constant as the project progressed. The ambiguity can take different forms and influenced the Lean projects, the next chapter explains how.
Ambiguity
22 Rationale
The first meeting commenced, and the project leader briefly stated the rationale of the project: “we want to guarantee continuity at the polyclinics” After interviewing the project group members, it appeared that some had a very good understanding of why they were doing the project, while others had not. For example, the medical secretary and coordinator of case A both stated that they did not know why they were actually doing the project. In addition, their unit head stated: “I think this project is simply to give an indication of work pressure” This understanding of the project rationale was very different from how the other unit heads had understood it. In particular, the rationale according to the other unit heads was very much aligned with how the project leader framed it.
The coordinator at case B had an even different interpretation; she thought the project was to enhance collaboration between polyclinics. In turn, this would not be needed according to her, because “they had everything under control at their polyclinic”. At case C, only the coordinator did not know why they were doing the project, the medical secretary was rather clear about that. Interestingly, the rationale of the project at cases D and E was not only very clear but was also framed as the logical consequence of their new way of ‘process-oriented working’. In that, case D and E seem to differ from the other cases.
The differences concerning the rationale of the project become even clearer, when in week six, one week before the measurement day, an intense discussion was observed about why they were actually doing the project. Even after six weeks the ambiguity was still present.
Practicalities
Ambiguity not only was directed at the rationale, but also at the practicalities (i.e. the how of the project). As the coordinator of case D stated: “up until now [week 5] the project is still searching for its identity; what are we actually going to do?” It appeared that except for the unit head at case C that all project group members shared this feeling. In addition, it seemed that the project group members had problems with comprehending the terminology on the measurement forms that the project leader provided. This made the practicalities even harder to comprehend. These forms were crucial to the Lean project, because the data would be collected by the medical secretaries filling in these forms. Therefore it needed to be workable and understandable for them. As the unit head of case B stated: “Currently, there is a discrepancy between the terminology used on the measurement forms and the language that the medical secretaries speak. If we want to make this project a success, we need to speak the language of the medical secretaries”.
23 was designed. These discussions seemed to stem not only from the terminology used, but also from the fact that the project leader designed the forms, based on documentation available per case. As the unit head of case C stated: “If you present the measurement forms in such a way, it is a very sensitive issue for the employees. They argue that it would have been much better if he had spent some time at this polyclinic to see with his own eyes what is actually happening here”.
By how this form was initially presented, the project group members did not have the feeling that the project leader knew what was actually going on at their polyclinic. Especially at cases A, B, and C, a skeptical attitude of whether filling in these forms would provide a realistic overview of what is going on at the respective cases was of primary concern throughout the whole project. As the coordinator of case C stated: “We often asked the project leader to change the measurement instrument because it did reflect our reality and was too complex to comprehend”
Perceived project consequences
It was observed that the project leader was not very explicit about the project consequences. In the beginning he stated that it was “just to get a general understanding of what is happening per polyclinic”, while later he stated: “There are a lot of organizational changes coming within the next few years”. The unit head of case D and E further stated: “The PL told me that he is very careful in framing the rationale and consequences of the project because he is afraid of unrest” Across the five polyclinics the possible consequences were interpreted in many different ways. However, staff interchangeability was often mentioned as one of the possible consequences. This means that in the future, medical secretaries could also work at other polyclinics whenever that would be needed. The project group members perceived this as desirable, undesirable or unrealistic (see table 3 below).
Perception of staff interchangeability
Perception Interviewee* Quotes
Desirable UH case B “I believe it is possible. Also, I think it is needed”
UH case C “The employees are not positive but I will make sure that they move, they have to”.
24 UH case D/E “Currently, when someone is ill we have a huge problem, staff
interchangeability could and should help”.
POCO case D “I would like it if we could interchange staff in the future, we are under a lot of pressure you know”
MS case E “If one of the outcomes is staff interchangeability I would like to do it”
Undesirable MS at case A “It would be a negative consequence if that happens”
Unrealistic UH case A “I think that only a single one might be suitable, the others are too resistant to change”
POCO case A “I have my doubts whether it will work out because we are too specialist”
POCO case B “I expect that nothing will change because of this project”
POCO case C “I do not think we can achieve staff interchangeability, we are too complex and huge”
Table 3: perception of staff interchangeability
* Abbreviations: UH unit head, MS medical secretary, and POCO polyclinic coordinator.
25 Consequences for the conceptual model
In the beginning of the project ambiguity was influenced by the interaction between conditions (i.e. unit head framing, and unit head roles) with the object of resistance (i.e. project leader initial framing). Consequently, this ambiguity seemed to influence how people behave. The next chapter will elaborate on what kind of behaviors were observed and how ambiguity influenced these behaviors.
Behavior
We see large differences in terms of behavior across the five cases. Some show constant apathy and passive resistance or adoption, while other polyclinics seem to change their behavior as the project progresses. How this research categorizes the different types of behavior is based on table 4 below (Coetsee, 1993). Consequently, behaviors per case and per period are identified in table 5.
Behaviors Description
Adoption Acting as an ambassador; constructively engaging in discussions. Apathy Being inactive; showing a lack of interest.
Passive resistance Pursuing mild delay tactics excuses not to cooperate. Active resistance Voicing opposite view; forming coalitions.
Aggressive resistance Making threats; performing destructive behavior. Table 4: spectrum of behaviors
An overview of behaviors per case and period, with explanations, is presented in table 5 below.
Case
Behaviors
Week 1-2 Week 4-5 Week 6-7
A Apathy Apathy Apathy
26 reactive role, while it was observed that the project leader asked the group several times to act as an ambassador.
B Apathy
Active resistance
Apathy Apathy
Active resistance During the project meetings it was observed that the medical secretary and coordinator often looked like they did not belief that the approach of the project leader would be fruitful. During the first meeting the coördinator did not say a word for the first 30 minutes and then said in a frustrated fashion: “would it not be way more effective just to discuss with each other about what they do per polyclinic, instead of this approach!?”. The interview with the coordinator explained her constant apathy: “I actually expect nothing from this project, and my colleagues think the same I think”. During the measurement day [week 7] one of the medical secretaries stated very frustrated: “I really doubt whether the data would be meaningful, it does not represent our reality”.
C Apathy Passive resistance
Active resistance
Aggressive resistance Adoption
During the first few meetings it was observed that the medical secretary and coordinator both did not actively voice the concerns they had. During the interviews, however, it was clear that they did have strong concerns towards the measurement day. As the coordinator stated: “In the beginning, we often asked the project leader to change the measurement instrument, but this resulted in only minor changes. We did not feel heard or understood. After we expressed our concerns more aggressively, he changed a lot and now we felt heard”. The aggressive resistance came from the unit head, as she stated: “I refuse to give my employees the form if it remains like this”. Consequently, many changes were made and the employees of case C felt finally heard, showing adoption behavior at the measurement day.
D Adoption Adoption Adoption
27 not scared of the consequences, they see it as something that could help them. This differs a lot from, for example case A, they do not see the aim or purpose”.
E Adoption Adoption Adoption
Passive resistance
Like at case D, adoption behavior was also observed at case E. However, the project leader stated: “one day before the measurement day it appeared that the medical secretary did not train all her employees with the measurement form”. Even though it appeared that she was very positive about the project, still ambiguity related to what was expected from her seem to affect her behavior: “Up until the last week it remained unclear what kind of activities we would measure”. In that, she fulfilled her role in a reactive fashion at the end,
simulating passive resistant behavior. It needs to be noted that this polyclinic was largely understaffed said the unit head, and that half of the staff during the measurement day only worked there for less than two weeks. It was anticipated that filling in the measurement forms would be too much effort for them.
Table 5: behaviors throughout the project
It seems that the ambiguity towards the rationale, practicalities and perceived project consequences is influencing the behavior of the employees. The following patterns were found: (1) employees who do not clearly understand the project rationale are more inclined to show apathy, passive resistance, or active resistance than employees who do understand the project rationale. In turn, the employees that do understand the project rationale are more inclined to show adoption behavior. (2) Employees that perceive the possible project consequence of ‘staff interchangeability’ as undesirable or unrealistic are more inclined to show apathy, passive resistance, or active resistance than employees that perceive that possible consequence as desirable. (3) Employees that have bad experiences with either Lean or other similar projects are more inclined to show apathy, passive resistance, or active resistance behavior than employees that do not. (5) Concerns towards the practicalities manifested in a perception that the measurement instrument was too hard to comprehend. Consequently, employees having these concerns seem more inclined to show apathy, passive resistance, or active resistance.
Consequences for the conceptual model
28 as he interpreted employee behavior and acted upon it, the employees changed their behavior. How this works is presented in the next chapter.
Project Leader Sensemaking
The project leader made-sense of the behavior of the project group members as the project progressed. How he did this seemed to influence the employees consecutive behavior. To elaborate on this, through his sensemaking, he tried to accommodate the ambiguity concerning the rationale, practicalities and project consequences. How he did this changed some behaviors from resistant behavior to adoption behavior (e.g. at case C). As the unit head of case D and E stated: “What we see in the project meetings is that as the measuring day comes closer, the employees become more critical. Whenever the project leader does not succeed in making the project more clear for them, this only makes their resistant behavior more intense”. The following two example are presented as illustration:
(1) The medical secretary and coordinator at case C stated: “We often asked the project leader to change the measurement instrument because it did reflect our reality and was too complex to comprehend, but this resulted in only minor changes. We did not feel heard or understood. After we expressed our concerns more aggressively, he changed a lot and now we felt heard”. As the project progressed and the measurement day came closer, the unit head of case C, showed what could be classified as aggressive resistant behavior. In particular, she threatened: “If the measurement form remains the same I will not give it to my employees”. This example shows, how because of the project leader sensemaking, the unit head felt the need to show aggressive resistant behavior.
(2) One week before the measurement day (week 6), a very intense discussion was observed during the project meeting about the rationale emerged during the project meeting. Almost all members of the project group turned against the project leader, questioning why they were actually doing the project. During the interview afterwards with the project leader he stated: “I was very surprised about that. I thought that we had that discussion already a couple of weeks ago”. Apparently he did not accommodate the ambiguity concerning the rationale as how the project group members desired. Hence, again, through his sensemaking project group members showed resistance behaviors.
Consequences for the conceptual model
29
Towards a conceptual model: Achieving a Negotiated Lean Practice
Below in figure 5, you can find a conceptual representation of, at least for this Lean project, how Lean healthcare influences the dynamics of resistance to change. This model can be considered as a framework having theoretical impact on our understanding of the application of Lean in a healthcare context. It is a conceptual representation of the findings, emphasizing how certain concepts are related to each other in the context of Lean healthcare and resistance to change.
From left to right, the start of a Lean project is characterized with the interaction between two conditions (i.e. unit head role, and unit head framing) with the object of resistance (i.e. project leader initial framing). This interaction influences the level of ambiguity regarding the project rationale, the practicalities, and the perceived project consequences. In turn, that level of ambiguity influences how participants behave. Consequently, by project leader sensemaking, the extent to which the ambiguity has been accommodated influences again their subsequent behaviors. The interaction between ambiguity, behaviors, and sensemaking takes the form of a loop.
30 Figure 5: Achieving a Negotiated Lean Practice
DISCUSSION
The purpose of this thesis was to explain how Lean healthcare influences the dynamics of resistance to change. The central concept that influences resistance to change is ambiguity regarding the rationale, practicalities, and perceived project consequences. In turn, this ambiguity is influenced by the interaction between conditions (i.e. unit head role and unit head framing) with the object of resistance (project leader initial framing) and by project leader sensemaking (see figure 5).
31
Concept Function
Conditions and object of resistance
How the interaction between conditions (i.e. unit head role and unit head framing) with the object of resistance (i.e. project leader initial framing) influences the level of ambiguity among participants.
Ambiguity How ambiguity among participants influences their behaviors.
Sensemaking How ‘Achieving A Negotiated Lean Practice’ is shaped by project leader sensemaking of behaviors.
Table 5: key concepts
In this chapter, concepts and relationship in the model are contrasted with existing literature to find out whether there are similarities or differences, placing it in theoretical perspective. The end of this chapter will encompass propositions, practical implications, suggestions for future research and limitations.
Conditions and object of resistance
Conditions
According to Thomas and Hardy (2011), power and resistance always operate in a web together. Following this line of reasoning, we see in this project variation in how unit heads frame the project and what roles they fulfil. Now, what does that mean?
First, it means that unit heads in Lean projects have the power to frame the project in such a way that it gives the employees a certain perspective (e.g. at case D and E). Lacking in providing such a perspective does not seem effective in terms of employee behaviors. By contrast, doing so seems to enhance the possibility of adoption behavior.
32 This process, whereby the unit head of department C shows aggressive resistant behavior and the project leader accommodates, exemplifies what Thomas and Hardy (2011) mean with ‘celebrating resistance’. In that, the interaction between the project leader and unit head was needed to make the project group members feel motivated to continue with the project. Without this interaction, the project leader even stated that he would not have known how the project would have progressed.
It needs to be note that the ‘initial conditions’ Lapointe and Rivard (2005) incorporate in their model are different from the ‘conditions’ in this study. In the present study no patterns were found, relating to these initial conditions and resistance behaviors. In their study initial conditions primarily refer to the work environment configuration prior to an IT implementation, while the ‘conditions’ of the present study seem to manifest because of the Lean project (i.e. the unit heads fulfil their roles and frame the project in such a way due to their affiliation with the project).
Object of resistance
In the beginning of the project, the unit head roles and framing interacted with the initial framing of the project leader. Consequently, this influenced the level of ambiguity among the participants. In that spirit, the present study shares ground and contrasts with Lapointe and Rivard (2005).
It shares ground in that that certain ‘conditions’ interact with an ‘object’ (i.e. project leader initial framing), eventually influencing behavior. Nevertheless, it contrasts in that these conditions influence ‘ambiguity’ in the present study and ‘perceived threats’ in the model of Lapointe & Rivard (2005). The concept of ambiguity includes (among others) perceived project consequences which could be the interpreted as perceived threats of Lapointe and Rivard (2005). However, in the present study these consequences could also be something that employee’s desire. Consequently, this could lead to adoption behavior.
In addition, ambiguity concerning the project rationale or project practicalities does play a central role in influencing how people behave. Lapointe & Rivard (2005), however, do not elaborate on that. Thereby, in the present study resistance is not necessarily related to perceiving the consequence of Lean as a threat, but simply because the employees do not understand why they are doing the project or how it will evolve.
Ambiguity
33 interviewed; no clinical specialists. The concept of ambiguity, however, does seem to play a central role in this study but than in a different form; it is influencing how participants behave.
Rationale
From the beginning of the project on, ambiguity towards the rationale seemed to play an important role. And, as the project progressed, for many of the project group members this ambiguity maintained. This is in line with what Ford et al., (2008) state about how a change agent (in this case the project leader) can actually be the source of resistance behavior. To be more specific, because the project leader failed to legitimize the change (the why), the project group members were more inclined to show resistant behavior.
Another explanation can be found in the term ‘interpretive flexibility’ as introduced by Waring and Bishop (2010). According to them, improvement tools and techniques such as Lean are characterized and imbued by social and cultural meaning. These improvement tools and techniques are both constructed and interpreted and they represent different things to different actors (Doherty, Coombs and Loan-Clarke, 2006). This argument shares ground with the claim of Joosten et al., (2009), stating that a healthcare context has inherent power structures that influence how Lean could be implemented. The fact that all the different polyclinics, guided by the autonomous clinical specialists, had organized their work in such a different way exemplifies this.
What both explanations have in common, is that it results in a fragmented interpretation across the project group members of why they are doing the project. In turn, it influenced how they behaved.
Practicalities
Most project group members never did a Lean project, and except for a few unit heads, their understanding of this method seemed limited. This already caused ambiguity in terms of how the project would progress. In addition, in this Lean project a measurement form was developed by the project leader. On that form, the medical secretaries and coordinators needed to fill in what kind of activities they did on a specific day. However, the perception of most project group members was that the project leader was not aware of what was actually happening at their polyclinic. Consequently, this was reflected on the measurement form in two ways: (1) it made it hard for the employees to comprehend because of unknown - or too complex terminology, and (2) the employees did not have the feeling that filling in such a form would represent their reality.
34 (2010). According to them, resistance to Lean healthcare comes from the fact that staff questions the healthcare knowledge of the project initiators.
Furthermore, in line with Joosten et al., (2009) the project was influenced by the distinct silo structure of hospital polyclinics. In turn, that seemed to enhance the complexity of achieving a ‘Negotiated Lean Practice’ because of the large differences per polyclinic; all had their own idea of what the measurement form need to look like to make it workable for them internally. This phenomenon seems to contrast the claim of De Souza & Pidd (2011), who state that resistance to Lean healthcare is similar to resistance to change in any type of context.
Perceived project consequences
Taking a sociotechnical perspective, Joosten et al., (2009) state that Lean healthcare triggers further dynamics. It can, for example, make jobs more repetitive and therefore it is needed to understand how the employees experience that. Building further on this idea, the present project showed how the perceived possible consequences of the project influenced behaviors. In the spirit of socio-technical system theory, this means that the Lean project could upset the current relative stability of the socio-technical boxes (i.e. technology, task, structure, and actor). For example, the Lean project could result in changes in structure, leading to certain actors performing alternative tasks.
The relationship between consequences and behavior seems to be rather straightforward when it comes to any type of change: if you desire the consequences of a project, you embrace the initiative, but if you do not, you show resistant behaviors. However, sharpening our analysis in terms of this Lean project allows us to understand how inherent Lean elements can be the source of resistance. Indeed, this Lean project aimed at identifying generic activities per polyclinic, which would help to start the discussion on why there are so many differences per polyclinic. Eventually, the idea behind it is to reduce variability in terms of tasks, enhancing the possibility for medical secretaries to also work for other polyclinics. Working for other polyclinics, however, does not appear to be something all medical secretaries desire or find realistic. In sum, because the inherent aim of Lean to reduce variability, employee’s show resistant behavior whenever consequences seem to evolve towards undesired ends.
35
Sensemaking
It was stated that two conditions (i.e. unit head role and unit head framing) interact with the ‘project leader initial framing’ and influence the level of ambiguity among the participants. In the following ‘loop’, the project leaders’ sensemaking seem to also fulfil a crucial role in influencing this ambiguity. Consequently, this ambiguity influenced how people behaved.
Analyzing this Lean project by the reconstruction of resistance of Ford et al., (2008) helped to recognize this crucial role of sensemaking. In that, it was the project leaders’ sensemaking that influenced indirectly how the project group members behaved. Apparently, the project leader did not accommodate the ambiguity for all of them. Except for the project group members that already showed adoption behaviors (e.g. at cases D and E), this has even resulted in aggressive resistant behaviors (at case C). This is in line with Lapointe and Rivard (2005), who state that resistance to an IT derives from other sources as a project progresses. In terms of this study, that would mean that the object of resistance initially was the project leader initial framing, while as the project progressed and for some employees the ambiguity was not accommodated, it was also directed at him because of his sensemaking. The argument of De Souza and Pitt (2011) that one of the primary boundaries to Lean healthcare comes from the current structure of fragmented care makes even raises the importance of sensemaking. The polyclinics all encompassed different characteristics that shaped different behaviors and wishes, making the sensemaking process of a project leader even harder, yet, very crucial. In particular, project leader sensemaking plays an important role in Achieving a Negotiated Lean Practice whereby eventually participant behaviors determine the Lean data reliability. By incorporating the impact of (resistant) behaviors on the Lean data reliability, this study moves beyond explaining how Lean influences resistance to what the consequences of these behaviors can be.
Propositions
Based on the preceding discussion, the following two propositions can be formulated:
❏ Proposition 1: In a project, the higher the level of ambiguity among participants regarding the rationale, the practicalities, and the perceived project consequences, the more inclined participants are to show resistant behaviors.
36
Practical implications
How could this study help hospitals which implement Lean healthcare? The conceptual model can be considered as a general overview of what kind of concepts influence how people behave in Lean healthcare projects and what kind of consequences that can have for the project. To be more specific:
(1) Acknowledging interpretive flexibility inherent to process improvement tools and techniques such as Lean (Waring & Bishop, 2010) it should not be underestimated how much effort it takes to legitimize the Lean project for project group members or other people involved. Failing to legitimize this change (i.e. provide the rationale) can even lead to resistance behavior, threatening the project survival. Therefore, a project leader should try to speak a language that the project group members understand, both verbally and on Lean measurement documents.
(2) The distinct structures of a hospital, at least for project in which multiple polyclinics are involved, should not be underestimated in terms of project practicalities (Joosten et al., 2009). It is anticipated that a Lean project leader could gain legitimacy and achieve a Negotiated Lean Practice more effectively by exploring the participating departments in detail with his own eyes preceding the project.
(3) Prior to, or in the beginning of Lean projects it appears to be helpful to spend time on past experience with Lean (or similar) projects. These experiences could help to predict behavior, making it easier to anticipate on that. Being open and clear about the possible project consequences seems a fruitful approach in this regard.
(4) By framing the project internally or taking certain roles, unit heads seem to influence employee behavior. Unit heads, or other healthcare leaders, need to be aware of that influence. In that, it seems effective to place the Lean project into a perspective that the employees understand. Furthermore, acting as an employee representative or as an ambassador (see the result section for what that exactly means) also seems effective.
(5) Since project leader sensemaking plays such a crucial role, it can be stated that more emphasis should be taken in this regard. For example, a project leader could more extensively ask participants how they feel about the project and whether they understand what is expected from them (e.g. act as an ambassador). A more proactive attitude to understand the employee's’ behavior is expected to make it more easy for a project leader to accommodate ambiguity.
Limitations and future studies
37 was collected only during the ‘Measure’ phase of Lean project. It is anticipated that an expanded scope, whereby the project had been completely finished and evaluated on, might have implications for the findings. In addition, the present study did not include any clinical specialists but exclusively unit heads, coordinators, and medical secretaries. As involvement of clinical specialists is anticipated to be problematic when it comes to the applicability of Lean, it might be valuable for future studies to include them. Future studies could also emphasize on the behavioral component which seems very crucial in terms of this Lean project. Making sense out of project group members behavior, thereby accommodating ambiguity in Lean projects seem crucial for its success. How a project leader should be triggered by employee behavior, make sense, and accommodate ambiguity has not been the focus of the present study. It seems, however, of much value to do so because implementing Lean healthcare appears to be a challenging process whereby resistance can be high and failing to accommodate resistance could threaten project survival.
CONCLUSION
The aim of this study was to explore how Lean healthcare influences the dynamics of resistance to change. Past research primarily focused on the impact of Lean on operational issues or on the patient. By taking a socio-technical perspective, the present study investigated how Lean can trigger other dynamics, emphasizing how Lean impacted healthcare workers.
It was anticipated that, during the Measure phase of a Lean healthcare project, resistance played a key role in terms of how the project progressed. A conceptual model was developed (figure 5), showing how the interaction between five dominant concepts (i.e. conditions, object of resistance, level of ambiguity, behaviors, and project leader sensemaking) opens up the black box of resistance, acknowledging its complexity and drama. And, because of that, the author claims for a change in discourse in Lean literature from ‘Measure’ to ‘Achieving a Negotiated Lean Practice’. By doing this, resistance gets a much more salient place in the conceptualization of Lean healthcare. According to the author, that is needed to withhold Lean from being just another way to reform healthcare. Thereby, the present study builds further of Waring & Bishop (2010), who argue that implementing Lean in a healthcare context is a highly contested process, whereby it is unlikely that its form remains completely intact. By acknowledging resistance as a concept that can have such a great impact on Lean projects, healthcare leaders can anticipate on that by using figure 5.
