The Influence of Team Dynamics on Continuous Improvement in a Healthcare Environment

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The Influence of Team Dynamics on Continuous

Improvement in a Healthcare Environment

By

N.R.J. Tamminga

University of Groningen

Faculty of Economics and Business

Master Thesis

MSc BA Change Management

June 2016

Multatulistraat 51

9721NG Groningen

n.r.j.tamminga@student.rug.nl

+31 6 55803833

Student number: 1613901

Word Count: 12.020

Supervisor: dr. O-P. Roemeling

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Abstract

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1. INTRODUCTION

Healthcare budgets are constantly under pressure, while the demands are increasing (Porter and Lee, 2013). This combined with evidence of poor performance have led national and local healthcare organizations to search for methods to improve quality in health service delivery (Clayton et al., 2014). One of these methods which recently gained popularity in healthcare is Lean. Lean thinking has its roots in the Toyota Production system in the 1950’s and has been further developed by Womack and Jones (1996). Lean provides organizations with principles and tools to focus on the values which drive systems (Rooney and Rooney, 2005) and refine processes or practices to cut out “waste” (e.g. delays or mistakes) and achieve the desired values (e.g. effective treatment, safe high quality care) (Womack et al., 1990; Crump, 2008). Lean can have attractive benefits such as enhanced quality and safety and it provides a basis for Continuous Improvement (Jones and Mitchell 2006). For a sustainable change and constant focus on creating value for the customer, Continuous Improvement is a necessity. A Lean organization will strive to have their employees continuously work to improve processes of their everyday activity (Houchens and Kim, 2014).

When well implemented, Lean should provide a sustainable culture of Continuous Improvement (CI). However, the implementation of Lean principles in healthcare settings is often achieved through the application of simple tools (Brandão de Souza, 2009; Radnor, 2010). The perspective on culture and people is often lost (Dahlgaard and Dahlgaard-Park, 2006; Radnor, 2010). This is remarkable because, a group-oriented culture emphasizing affiliation, teamwork, coordination, and participation appears to be associated with better implementation of continuous improvement practices (Shortell et al., 1995). Especially the focus on people is important, because the people in Lean organizations facilitate and execute the actual improvement initiatives. Ballé and Régnier (2007) emphasized that the cornerstone of Lean healthcare is developing a culture in which the staff is empowered and encouraged to make improvements. This underlines the soft side of Lean should be of importance to the healthcare environment.

Healthcare is, to a large extent, delivered by nurse work teams in different patient care units at hospitals (Kalisch et al., 2010). The importance of CI teams is reflected by a study of Imai (1986), in which the author proposes that there are three types of kaizen (CI), one of these is group-oriented kaizen. Group oriented kaizen is best represented by quality circles, which require employees to form a team, with the goal of finding and solving problems faced during their day-to-day work without any interference from management (Bhuiyan and Bagel, 2005).

Employees in teams need to initiate, execute and embrace the improvements that need to be made. Therefore it is important to know how teams function. For example Bessant et al. (2001) suggest that the experience of disappointment and failure with CI programs reported by many organizations derives in large measure from a lack of understanding of the behavioural dimension. Different behavioural dynamics play an important role in teams. In order to improve the team effectiveness in the healthcare sector CI is introduced (Clayton et al., 2014), on the other side team effectiveness depends for a large part on team dynamics (Salas, Sims and Burke, 2005).

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2. LITERATURE REVIEW

2.1 Continuous Improvement

Lean originated in the Toyota manufacturing company (Womack and Jones, 1996). Lean techniques and Lean management principles have been developing in manufacturing settings since the 1950s. After becoming prominent in the early 1980s, Lean practices have more recently been introduced into service industries, like the healthcare sector (Hayes et al. 2014).

The key principle of Lean thinking lies in the perception of value from the customer perspective. Kollberg, Dahlgaard and Brehmer (2006) state that the main goal of healthcare is to treat and cure patients. Because the patients are the end-customer in the care taking process, they should define what value is. Activities that do not add value to the product or service from the customer’s perspective are considered as non-value-added activities or waste (Shinohara 2006). Dahlgaard et al. (2011) described the following definition of Lean in healthcare which will also be used in this research:

‘Lean health care is a management philosophy to develop a hospital culture characterized by increased patient and other stakeholder satisfaction through Continuous Improvements, in which all employees (managers, physicians, nurses, laboratory people, technicians, office people etc.) actively participate in identifying and reducing non-value-adding activities (waste).’

Eliminating non-value-adding activities is an ongoing process. In CI, employees identify problems and waste in process steps during their work. Improvement ideas are depicted and implemented as a new way of performing the work. Further experimentation leads to new process methods, further refinements and implementation ultimately determine the new current state. This process repeats indefinitely in a Continuous Improvement cycle (Houchens and Kim, 2014). This description of CI is in line with the definition provided by Bhuiyan and Baghel (2005) who describe CI as a culture of sustained improvement targeting the elimination of waste in all systems and processes of an organization. This definition will be used in this research.

Changing a culture in organizations is a slow process (Boddy and Buchanan, 1992; Keuning, 1998). So a culture of sustained improvement is also not accomplished overnight. For example, ‘people are guided by a shared set of cultural values underpinning CI as they go about their everyday work’, is the description of the key behavior in the final stage of maturity (Bessant et al., 2001). The Continuous Improvement Research for Competitive Advantage team (CIRCA team) which aimed to deliver a basic methodology for implementing and maintaining CI (Bessant et al., 1992), observed cases and used experiences reported by others to show companies passing through several development stages. The CIRCA team labelled these stages as levels of “CI maturity”, as they progress towards a state where the vast majority of their members are actively engaged in making improvements focused on strategic goals and objectives (Atkinson, 1995). The model proposes five such levels as shown in Table 1. This paper will use this model to determine the maturity of CI within the different teams.

Table 1. Maturity levels

Maturity level Description of maturity level

Level 1 Pre-CI (“natural” or background improvement, ad hoc and short-term) Level 2 Structured CI (formal attempts to create and sustain CI)

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2.2 Team Dynamics

Teams are an integral part of healthcare delivery, for example through nursing work teams. These nursing work teams make up the foundation of most hospital organizations. In fact, it has been described that the function of these nurse teams is essential for efficiency within the unit (Lichtenstein, 1997). These teams also have a major impact on effective collaboration between units, and with physicians (Heinemann et al., 1999).

The effectiveness of the teams themselves depends for a large part on team dynamics (Salas, Sims and Burke, 2005). Team dynamics are referred to as the patterns of interaction between team members (Van Dun and Wilderom, 2012). Five team dynamics have proven to be of big influence of team effectiveness and are therefore known as the big five, namely: team leadership, mutual performance monitoring, backup behavior, adaptability and team orientation (Kozlowski and Ilgen, 2006; Marks, Mathieu and Zaccaro, 2001; and Salas, Sims and Burke, 2005). Literature also indicates organizational goal commitment has an important role in team effectiveness (Van Dun and Wilderom, 2012).

Table 2. Description of team dynamics.

Team dynamics Description of team dynamics

Leadership ‘To do, or get done, whatever is not being adequately handled for group needs’ (McGrath, 1962).

Mutual performance monitoring A common awareness regarding the environmental context in which the team is operating and awareness of fellow teammate performance (Weaver et al., 2013).

Backup behavior ‘The discretionary provision of resources and task-related effort to another’ (Porter et al., 2003).

Adaptability ‘The ability to recognize deviations from expected action and readjust actions accordingly’ (Priest et al., 2002).

Team orientation ‘A preference for working with others and a tendency to enhance individual performance through the coordination, evaluation, and utilization of task inputs from other members while performing group tasks’ (Driskell & Salas, 1992).

Organizational goal commitment ‘The extent to which team members are attached to or determined to reach the organizational goal, regardless of the goal's origin’ (Locke, Latham, & Erez, 1988).

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7 The team dynamic mutual performance monitoring refers to a common awareness regarding the environmental context in which the team is operating and awareness of fellow teammate performance (Weaver et al., 2013). Effective teams are comprised of members who maintain an awareness of team functioning by monitoring fellow members’ work in an effort to catch mistakes, slips, or lapses prior to or shortly after they have occurred (Salas, Sims and Burke, 2005). By measuring performance employees can indicate where problems repeatedly occur, this will provide focus on recommendations for improvements (Bond, 1999).

Backup behavior is defined as ‘the discretionary provision of resources and task-related effort to another’ (Porter et al. 2003). Marks et al. (2001) identify three means of providing backup behaviours: (1) to provide feedback and coaching to improve performance; (2) to assist the teammate in performing a task; and (3) to complete a task for the team member when an overload is detected. By providing feedback waste may be faster detected. This will have a positive influence on CI. Also Forza (1996) noted that employees in Lean organizations take their colleagues suggestions more seriously, rely more on quality feedback and were more committed to Continuous Improvements. However Bicheno and Holweg (2009) suggest a negative effect of backup behaviour as it masks underlying problems by only fixing symptoms.

Adaptability is defined as ‘the ability to recognize deviations from expected action and readjust actions accordingly’ (Priest et al., 2002). When a team continuous improves, it needs to constantly adapt to the new situation. Therefore this could be an important factor within Continuous Improvement. This is also the case according to Beale (2007) who identified labour flexibility as a factor underlying employee willingness to adopt the Lean approach. The willingness to adopt the Lean approach is also influenced by the amount of changes. When implementing Lean, Karlsson and Åhlström (1996) noticed employees found it difficult to perform new unknown tasks, when they had many new things to worry about.

Team orientation is not only a preference for working with others but also a tendency to enhance individual performance through the coordination, evaluation, and utilization of task inputs from other members while performing group tasks (Driskell & Salas, 1992). Team orientation has also been found to result in increased cooperation and coordination among team members (Eby & Dobbins, 1997). This may facilitate Continuous Improvement through increased task involvement, information sharing and goal setting (Salas, Sims and Burke, 2005).

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Figure 1. Team dynamics in relation to team effectiveness and CI. 3. RESEARCH METHODOLOGY

The nature of this research is a qualitative research. Qualitative case study methodology provides tools for researchers to study complex phenomena within their contexts (Anderson et al., 2005). When the approach is applied correctly, it becomes a valuable method for health science research to develop theory, evaluate programs, and develop interventions (Baxter and Jack, 2008). Qualitative researchers adopt a person-centered and holistic perspective. The approach helps develop an understanding of human experiences, which is of important to employees in the healthcare environment who focus on caring, communication and interaction (Holloway and Wheeler, 2013). This research will be based on a case study at a large healthcare provider in the middle of the Netherlands which we will refer to as Healthco. in the remainder of this study. Healthco. has several teams who are familiar with CI. The maturity of CI differs between the teams, while these teams experienced similar Lean programs and training. This makes Healthco. an ideal organization to perform a case study. In order to research the influence of team dynamics on CI, it was important to study teams with a different level of CI. A sample of five different departments with various stages of maturity was taken from Healthco. To ensure reliable outcomes of the study three employees of each department have been interviewed.

3.1 The Case

Healthco. is a cooperation between several hospitals in the middle of the Netherlands. In 2010 the advisory board of nurses of Healthco. received more and more signals of nurses who could not provide the care they wanted to give to their patients because of increasing regulation and the overdue of registration. The signals were taken seriously and Healthco. adopted the program named “Productive Ward” which has his roots at the NHS (Smith and Rudd, 2007). The program contained several Lean methodologies and focused on making the professionals accountable for their own tasks. At the end of the program professionals spend more of their time on patients and less on non-relevant tasks. The program was considered a success. Therefore another program started “Lean logic!”, which has a lot of the same characteristics as the first program, but in this case the central focus is the patient instead of the nurses. Another difference is the implementation of Continuous Improvement. Instead of running a project which has a fixed end date, Lean logic! is interested in implementing the Lean vision, and thereby learning the organization to continue to improve their processes. Some of the teams in the hospital try to work accordingly the vision of the program. The teams try to improve their processes by using visual boards, such as the improvement board on which improvement initiatives can be noted. At the same time other teams do not see the usefulness of the program Lean logic!, and continue with their tasks without acting on the Lean vision. A potential explanation could relate to the team dynamics, which are possibly not in line with the characteristics of Lean and CI. By taking interviews and observing other relevant data provided by Healthco., we will try to get more insight in the differences in team dynamics between these departments and the impact this has on CI.

Team Dynamics

Continuous Improvement

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3.2 Data collection

In order to provide an understanding of group dynamics and their influence on CI, this research uses different types of data, which are interviews, observations and documents. The triangulation of data sources enhances data quality based on the principles of idea convergence and the confirmation of findings (Knafl & Breitmayer, 1989).

3.2.1 Interviews

In order to collect valuable data out of interviews it is a necessity to ask well-chosen open-ended questions that can be followed up with probes and requests for more detail (Merriam, 2009). Therefore, this research will use semi-structured interviews with mostly open-ended questions. A total of fifteen one-to-one interviews were conducted in five different nursing departments. In consultation with the initiators of Lean logic! and by our own observations (e.g. documents with improvement initiatives, improvement boards), two of these departments are marked as a mature Lean team, two of the teams are marked as immature, and one team is marked in the middle of the five teams. In each team the team leader was interviewed and the interviews were conducted with team members of the different teams. Table 3 provides an overview of the maturity level of the team and the number of interviewees per team.

Table 3. Teams and their level of maturity.

Teams Level of maturity Interviewees

Team 1 High 3

Team 2 High 3

Team 3 Medium/high 3

Team 4 Low 3

Team 5 Low 3

The central focus of these interviews is to research the team dynamics and their influence on CI. All the interviews were recorded and lasted for approximately 45 minutes. In accordance with the agreements on confidentiality all the interviews are anonymized, the names of the participants will not be made public. After the interview each participant was provided the opportunity to receive a copy of the interview transcript in order check it for accuracy and verify their responses. This additional step is recommended by Burnard (1991) because it will contribute to the validity of the study.

3.2.2 Observations

To get a better insight in the team dynamics, observations will be made during visits at the different departments. To study the maturity of CI in the different teams, the improvement boards were studied, as well as the execution of some of these improvements in the departments. Behavioural dynamics were observed during regular visits sections of Healthco..

3.2.3 Documents

Secondary data will be used to examine the maturity of the Lean teams. Training documents will be studied as well as the documents of the improvement initiatives of the different teams. These documents provide information about the maturity of the Lean teams.

3.3 Data analysis

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10 study conclusions, it is best if coding begins with deductive codes. This is because analysis of these deductive codes should feed back into the original study aim or question (Neale, 2016). Therefore data was analysed through deductive coding (Table 4), based on the literature review.

Table 4. Deductive codes.

Code Description Source

Lean philosophy ‘Lean provides organizations with principles and tools to focus on the values which drive systems and realign or refine processes or practices to cut out “waste” and achieve the desired values.’

Womack et al., 1990

Continuous Improvement

‘A culture of sustained improvement targeting the elimination of waste in all systems and processes of an organization.’

Baghel and Bhuiyan, 2005

Team leadership ‘To do, or get done, whatever is not being adequately handled for group needs’

McGrath, 1962

Mutual performance monitoring

A common awareness regarding the environmental context in which the team is operating and awareness of fellow teammate performance.

Weaver et al., 2013

Backup behavior ‘The discretionary provision of resources and task-related effort to another.’

Porter et al., 2003

Adaptability ‘The ability to recognize deviations from expected action and readjust actions accordingly.’

Priest, Burke, Munim, & Salas, 2002

Team orientation ‘A preference for working with others and a tendency to enhance individual performance through the coordination, evaluation, and utilization of task inputs from other members while performing group tasks.’

Driskell & Salas, 1992

Organizational goal commitment

‘The extent to which team members are attached to or determined to reach the organizational goal, regardless of the goal's origin.’

Locke, Latham, & Erez, 1988

To complement the deductive codes, inductive coding took place, based on the answers of the participants and observations. The deductive and inductive codes are combined to analyse the data. A process that is core to the entire data analytic process is “constant comparative analysis.” This process consists of comparing data to other data within a transcript and comparing transcripts to other transcripts within the study (De Chesnay, 2015). The codebook has been added in the appendix.

4. RESULTS AND ANALYSIS

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4.1 Knowledge of Lean and CI

To provide input on the different team dynamics and especially their influence on CI, interviewees should have a basic knowledge of CI. On the question to give their interpretation of Lean and CI all the employees showed that they had a basic understanding of the main Lean and CI principles. Interviewee Team 1: “Lean is to arrange processes in a logistic way, as efficient as possible and with

as little waste as possible.”

Interviewee Team 4: “It is a methodology to make bottlenecks visible in such a way that is for

everyone clear why things should change.”

Different concepts play an important role in the definitions of Lean and CI. The number of times interviewees mentioned these concepts are presented in Table 5. Per interviewee all the concepts could be registered only one time. Therefore the maximal score per team is three.

Efficiency was considered the most valuable factor in Lean and was mentioned by almost all the interviewees. Examples of value and waste were almost exclusively given by teams with a medium/high level of maturity of CI. When asking about CI a lot of examples were given where the improvement board was mentioned. The interviewees used the improvement board to describe their problems, discuss them and find new solutions, which then could be implemented. Fewer interviewees named a culture as a part of CI, where employees should constantly look for improvements. Or as one employee described it:

Interviewee Team 3: “CI should constantly be a part of the mind-set of employees. They should

constantly think, what am I doing? Is this what I am supposed to be doing? And what can I do differently so that I will have more time in providing real care?”

Table 5. Knowledge of Lean and CI within teams.

Teams Value Waste Efficiency A culture of sustained improvement Improvement board Team 1 2 3 3 2 1 Team 2 2 2 3 1 3 Team 3 2 3 2 2 1 Team 4 1 0 3 0 1 Team 5 0 0 3 1 3

Overall, interviewees showed they had a basic understanding of the main principles of Lean and CI. The teams with a higher CI maturity enriched their definitions of Lean and CI with a lot more examples including waste and value, in comparison with teams which had a lower rate of maturity. It might be that the teams with a higher rate of maturity had a better understanding of CI and therefore mentioned more of the different concepts. Another explanation can be that the interviewees in the higher maturity teams elaborated more on Lean and CI and therefore mentioned more of the concepts. These elaborations could be the result of more CI initiatives.

4.2 Leadership and CI

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12 some major changes within their teams and had therefore no focus on CI. In teams with a less maturity of CI the following opinions were given.

Interviewee Team 5: “The head did not try to implement Lean within the team. I have not seen the

head with CI meetings.”

Interviewee Team 4: “The head was not much involved at the start of the project, I missed the head

at the start of the project. I think the head should be more involved. The head should be more on top of CI, in a leading role towards the team.”

In teams with a higher level of maturity, interviewees were more positive on the involvement of the head of the department within CI.

Interviewee Team 1: “The head is de driving force of CI. The head is the stable factor.” ”The head is

very keen on having every Thursday an improvement board meeting.”

Interviewee Team 2: “The head is at the CI meetings.”

The heads of the departments themselves thought that Leadership was of a major influence on CI. Interviewee Team 3: “I notice that CI askes a very active role as team leader and the team to keep CI

alive. It is a new way of thinking. If I do not actively ask, or if the health coordinators are not actively involved, CI would be unsuccessful.”

Leadership seems to have a significant influence on CI. Teams with a lower rate of CI maturity had team leaders who were less involved in implementing Lean. The involvement of leaders in CI and the motivation to keep employees involved in the CI process is important in creating a CI culture. In addition, the department heads are convinced leadership influences CI processes. Nevertheless, not all leaders emphasize the importance of Lean which might result in a lower maturity of CI.

4.3 Mutual performance monitoring in CI

Teams in the hospital experienced different degrees of mutual performance monitoring. Some of the interviewees in teams with a higher level of maturity experienced a low rate of mutual performance monitoring. An interviewee noted:

Interviewee Team 2: “In this department, you work much solo, everyone has his own patients.” In the departments with a lower rate of maturity people showed some more mutual performance monitoring.

Interviewee Team 5: “From the corner of my eye I look at my colleagues.” Interviewee Team 4: “Some look at their colleagues more than other.”

Overall there is not a high level of mutual performance monitoring. Some people did see the benefits of mutual performance monitoring on CI.

Interviewee Team 3: “If there is no one who sees me doing it the old way, then there is no one who

will correct me. If it is the other way around then learning and improvement will take place.”

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13 performance monitoring. Mutual performance monitoring seems to have a negative impact on CI. However when mutual performance does take place, this may lead to improvement initiatives. These are contradicting statements. One explanation can be that because the differences between the teams are not that substantial, the deviations can come from perceptions of the different interviewees, instead of a real difference in mutual performance monitoring.

4.4. Backup behavior

Backup behavior is divided in three sections: Providing positive feedback, providing negative feedback and assistance/replacement when a college is working on a task. In Table 6 the results of the different teams are shown.

Table 6. Backup behavior within teams.

Teams Positive feedback Negative feedback Assistance/replacement when a college is working on a task

Team 1 ++ + ++

Team 2 ++ +- ++

Team 3 + +- ++

Team 4 +- - +-

Team 5 ++ ++ ++

In one team the feedback does not come as smoothly as in the other teams. This is because the teams recently have been merged to one team. In a lot of departments there are groups of friends. This is one of the reasons positive feedback is easier given than negative feedback. Almost all the interviewees noted that feedback was important for CI.

Interviewee Team 3: “If you don’t always explicit mention the things that go wrong, than the way

they execute their tasks will stay the same.”

Interviewee Team 1: “I think it keeps you focused on thinking about processes. If you discuss

situations you can eventually draw conclusions about whether this is the right way or not. So I think CI will work better when you provide feedback.”

One of the respondents made another distinction on feedback.

Interviewee Team 4: “If it is about technical issues then people will provide feedback, if it is about

personal issues then providing feedback is harder. But I do not think that this last point is of influence on CI.”

In almost all the teams, interviewees noticed that team members would help each other with their tasks. Only in one team the motivation to help each other was lower because two teams had been recently merged to one team.

The relation between helping each other and CI is a difficult one. Most of the interviewees thought it would benefit CI because helping each other provided the feeling of a team, which stimulated CI. However one of the interviewees mentioned an example of overload because of the willingness to help each other.

Interviewee Team 5: “We now have on our private phone a group from work on our WhatsApp. (..) If

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pressure, she just could not say no. Maybe the care for patients is better, but you should also think about the nurses.”

This problem in the process may be earlier detected if there was not a high willingness to help each other.

The relation of backup behavior on CI is a difficult one to describe. Almost all the interviewees mentioned that feedback was important in CI. It seems that providing feedback is a necessity for CI. By providing feedback, processes and actions are discussed and this can lead to improvement initiatives. Also new procedures will be earlier adopted by the entire team when the team mates provide feedback to each other when colleagues execute the procedure according the old way. This does not mean that when a team provides more feedback, the team is more mature in CI. The team which had the highest rate of providing feedback had a low maturity on CI.

Distinction is made between negative and positive feedback. One of the interviewees however mentioned that negative feedback was easily given on technical issues, and more difficult on persons. The interviewee noted that feedback on persons did not influence CI. Feedback on technical issues did have impact on CI, because this was feedback on processes and this could lead to improvement initiatives.

The relation of supporting each other in tasks or replace each other in tasks on CI is positive because of the feeling of ‘one team’ people experience when this happens. This motivates teams to work on improvements. Only one interviewee gave an example of a negative impact of the willingness to help each other on CI. In this example a work overload was later detected because of the willingness to help each other.

4.5. Adaptability

The adaptability within teams depended on several factors. One of which is the ability to work according to different changes. For example, older team members found it more difficult to work with the electronic patient dossier (EPD). The EPD is a digital database that stores all relevant patient information and should facilitate easy access by different departments and disciplines. All the teams experienced some older people who found it difficult to work according the new ways.

Interviewee Team 3: “A change is never easy, especially for people who work here for a long time.” There was not much distinction between the teams in adaptability. Some of the interviewees noticed adaptability had impact on coping with all the different changes, and thereby impact on CI.

Interviewee Team 2: “If there are a lot of projects and a lot of changes, than people say we need to

stop with the improvement board for a couple of weeks, and after those weeks we will work again with the improvement board.”

Another factor is the willingness to make the adjustments in the actions within their work. This willingness depends on how much the team was involved in these changes and the amount of changes within the department.

Interviewee Team 4: “We had to work with less staff members, we had to merge with another team

and we had to work according Lean, because of this there was a lot of resistance.”

Interviewee Team 3: “Everyone accepts the changes made by using the improvement board because

these changes are from the team.”

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15 stated that the adaptability of a team has a positive influence on CI. When people can cope with the changes they remain open for new ideas and new improvements and remain open to provide improvement recommendations. If people cannot cope with the changes, then CI will stand still. The willingness to change has also a huge impact on CI according to the interviewees. If people do not want to change, than CI is difficult to accomplish.

4.6 Team orientation

In four of the teams there was a high level of team orientation. People wanted to work for each other and find it important that their team performs well.

Interviewee Team 3: “We want to score a 10 as a team. And we all want to contribute.”

There is one team which has a lower rate of team orientation because of the merge between two teams.

Interviewee Team 4: “This department consists of two different islands.”

Almost all of the interviewees noted that team orientation had an influence on CI.

Interviewee Team 3: “As a team we want to get better, we want to improve and in order to

accomplish that we need to work together.”

Interviewee Team 4: “If you want the same and have the same goal (..) than you understand each

other and go the right way. This was totally gone. (..) Then you are not improving, not looking for ways to make things more efficient and more practical.”

Team orientation seems to have a big influence on CI. A high level of team orientation will have a positive influence on CI. When people are team oriented, they feel the need to improve as a team, this is beneficial to CI. In fact a high level of team orientation seems a necessity for CI. If there is no team orientation there is no motivation to work on CI.

4.7 Organizational goal commitment

To relate commitment to the organizational goal it is important to know the organizational goal. The following mission is placed on the site of Healthco..

‘We want to help people to provide the care necessary to recover from a disease or enlighten the symptoms of the disease. We strive constantly to improve and innovate, by giving education and research a prominent place. We execute this in a way where we encounter people in such a way that they would recommend our hospital to others. This way we are, in the middle of the Netherlands, for patients who are not in the position to choose, not the unavoidable hospital, but for them and all the other patients, the desired hospital.’

In the annual report of 2015 the following definition in the strategy section was mentioned:

‘We stand for innovative, competent, safe and courteous. Out these core values we derived our strategy. Besides these values we make our strategic choices from durability and corporate social responsibility.’

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Table 7. Concepts of organizational goals within teams.

Concepts Team 1 Team 2 Team 3 Team 4 Team 5

Provide the care that is needed 2 2 3 2 1

Improvement and innovation

Customer friendly 1 1 1 Desired hospital 1 Courteous 1 1 Safe 1 1 1 Innovative 1 2 Competent 1 Durable

Corporate social responsible

Providing the care that is needed was mentioned the most by the interviewees. The rest of the goals of the hospital were just occasionally mentioned. Other answers which were regular mentioned, but were not mentioned in the mission and strategy of the organization, were the patient and efficiency. Interviewee Team 2: “The hospital is about patient-centered care.”

Interviewee Team 1: “To provide good quality care and besides that deliver the care to the patient as

efficient as possible.”

Interviewee Team 2: “One of the goals is cost reduction, we are still a company. It is a pity that is

works like this in healthcare. The care insurers want to save costs and they look at efficiency.”

Most of the interviewees thought that they contributed to the goal of the organization because they were responsible for good care.

Interviewee Team 1: “I do not know if the employees care that much about the goal. They are

professionals and just want to provide good care.”

Interviewee Team 1: “I do not think it is conscious, but I think it is in the nature of nurses to be kind

and patient friendly.”

It seems that most interviewees are goal committed because they seem to have the same goal in their job. According to the interviewees this goal itself gave guidance to the improvement initiatives. Team 1: “You are more conscious in your work. (..) Because you are very focused on the patient and

therefore hear what the wishes of the patients are, you know what changes need to be made. It is the guidance, the initiative to your change process.”

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5. DISCUSSION

This section will summarize, interpret and discuss the findings with regard to how the different team dynamics influence CI in a healthcare environment. Overall this research showed that team dynamics had an influence on CI. The team dynamics leadership, backup behavior, adaptability and team orientation all seem to have a positive influence on CI. Mutual performance monitoring seems to have a negative influence on CI. The teams in this study were committed to their own goal and less occupied with the goal of the organization. Having a goal, gave guidance to the improvement initiatives.

5.1 Team dynamics and CI

All the team dynamics showed to have an influence on CI. However just two of the six team dynamics were totally in line with the CI maturity of the teams, namely leadership and mutual performance monitoring. Teams with a high maturity of CI had leaders who were more involved in CI than leaders of teams with low maturity of CI. Leadership seems to have a positive influence on CI. Mutual performance monitoring seems to have a negative influence on CI. Teams which had a high level of CI maturity mentioned a low rate of mutual performance monitoring. Employees worked most of the time alone and had their own patients. Teams with a lower rate of CI maturity noted a slightly higher rate of performance monitoring.

The positive influence of Leadership on CI is in line with the literature. A lot of studies emphasized the importance of leadership on improvement initiatives (Ferlie and Shortell, 2001; Miller, 2006; Øvretveit, 2009; Barr and Dowding 2012). Also the leaders of the teams mentioned this importance, by motivating and involving employees CI could be enhanced. This is also described by Arumugam et al. (2008), who concluded that it is a Lean leader’s task to empower his or her direct reports to express their ideas.

The negative influence of mutual performance monitoring is not in line with literature. Bond (1999) stated that by measuring performance, employees can have a better understanding of recommendations for improvements. Mutual performance monitoring should therefore have a positive influence on CI. The interviewees gave a similar kind of statement. Also the interviewees thought that mutual performance monitoring should have a positive influence on CI. This positive influence was not visible in the different teams. One of the explanations might be that the influence of mutual performance measuring was relatively small in comparison to the effect of leadership on CI. The team dynamic leadership outweighs the team dynamic mutual performance. This is plausible because the differences between mutual performance measuring in teams were not that high. Another explanation could be that the perceived mutual performance monitoring was higher in teams with a low maturity on CI, instead of the real mutual performance monitoring.

There was not much differentiation between the teams when researching the team dynamic adaptability. All the teams in Healthco. experienced some team members who had difficulty to readjust when a change in the work process is made. Especially the use of more electronics was found to be difficult. If there were major changes, or a lot of changes, people found it hard to adapt. When this happened some teams put improvement initiatives on hold for the moment. On these moments the willingness to change was also very low. This is in line with Karlsson and Åhlström (1996) who noticed employees found it difficult to perform new unknown tasks, when they had many new things to worry about. When the team was adapted to the new situation, new improvements could be made. This was also mentioned by Beale (2007) who identified labour flexibility as a factor underlying employee willingness to adopt the Lean approach. When team members can adapt more easily, team members will be more willing to create a CI culture and a higher CI maturity can be reached.

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18 positive influence on CI. Salas, Sims and Burke (2005) noted that team orientation had a positive influence on CI. A higher rate of team orientation will lead to increased task involvement, information sharing and goal setting, which will benefit CI (Salas, Sims and Burke, 2005). Interviewees noticed the same influence on CI. Especially helping colleagues by assistance or completion of a task, which is an element in backup behavior, was mentioned as part of team orientation. According to the interviewees this would benefit CI because it gave motivation to work on improvements in favour of the team. A negative side of backup behaviour was stated by Bicheno and Holweg (2009), who noticed that backup behavior can be counterproductive as it masks underlying problems by only fixing symptoms. One of the interviewees mentioned such an example whereby overload was later detected because of the willingness to help each other.This had a negative influence on CI.

There was one team which had a lower level of helping other colleagues performing their tasks, this had according to the interviewees a negative influence on CI. People were not as much interested in helping each other, because of this there was a low level of team orientation and no motivation to work on improvements which would benefit the team.

Another factor which was mentioned by the team members as a result of team orientation and had an impact on backup behaviour, was an open atmosphere. An open atmosphere is important when providing feedback. The interviewees noted that feedback had a positive influence on CI. By discussing processes, it was easier to think of recommendations. This is line with Forza (1996) who stated that employees in Lean organizations took their colleagues suggestions more seriously and were more committed to CI. There was one team however that showed a high level of providing feedback but a low level of CI maturity. It seems that while providing feedback is necessary for CI, this does not mean when a team shows high levels of providing feedback, they will have a higher CI maturity. Other factors within this team may way more heavily on CI maturity than providing feedback. Such a factor could be leadership.

A factor which according to the Aloini (2011) gave guidance to CI is organizational goal commitment. Bessant et al. (2001) suggested that members of advanced Lean teams show a high level of awareness of both company goals and strategic performance measures. Between the teams there were differences between mentioning important concepts in the goal of the organization. However it was not possible to make a clear relation to CI maturity. The teams with a low maturity on CI did not mention a lot of the concepts of the organizational goal, however one mature CI team also did not mention a lot of the organizational goals. The goal of the teams was taking care of the patients. This goal has many similarities to the goal of Healthco.. This was not so much because of teams were informed about the organizational goals, but more because teams found patient care important. According to the interviewees, the goal of the teams provided guidance to the change initiatives. A goal seems to increase the improvement initiatives. However this may not always be in line with the organizational goal.

6. CONCLUSION

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19 These results provide insight in the soft side of Lean and contribute to the knowledge on the influence of team dynamics on CI. Bessant et al. (2001) suggest that the experience of disappointment and failure with CI programs reported by many organizations derives in large measure from a lack of understanding of the behavioural dimension. We hope with this study to provide a better insight in the behavioural dynamics of a team, so implementations of Lean and CI can be more successful.

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APPENDIX A: Interview protocol (in Dutch)

Interview protocol – Lean in Healthcare Naam interviewer: Niels Tamminga Naam geïnterviewde: Functie geïnterviewde: Datum: Tijd: Plaats: Introductie

Op dit moment volg ik de master, verander management aan de RUG. Om dit af te ronden doe ik een onderzoek naar het gebruik van Lean in de zorg. In het onderzoek focus ik me op de invloed van groepsdynamiek op het proces van continue verbetering.

Om hier een antwoord op te vinden, worden onder andere interviews toegepast. Deze interviews worden gehouden met werknemers van verschillende afdelingen. Om de uitkomsten zo nauwkeurig mogelijk te houden, worden de interviews opgenomen en uitgetypt. Na het uitwerken van het interview zal de transcriptie naar u worden opgestuurd, zodat u deze kunt controleren. Pas na uw akkoord kan het interview gebruikt worden voor de scriptie. De verwerking van de interviewgegevens zorgt ervoor dat u anoniem blijft, er zal dus niet te herleiden zijn wie er precies is geïnterviewd.

Het interview van vandaag duurt ongeveer een uur. In het interview zullen eerst een aantal vragen gesteld worden over de organisatie waar u werkt en wat uw functie binnen het ziekenhuis is. Vervolgens zullen er vragen gesteld worden over verschillende groepsdynamieken, zoals de rol van de teamleider, feedback geven, prestaties meten, team oriëntatie, aanpassingsvermogen en de betrokkenheid bij het doel van de organisatie. Hierna zullen er vragen gesteld worden over Lean en het continue verbeterproces en hoe het een het ander beïnvloed.

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Interview vragen

Introductie

1. Wat is uw naam en uw leeftijd?

2. Hoe lang werkt u al bij Gelre Ziekenhuizen? 3. Wat is uw functie en op welke afdeling werkt u? 4. Wat is de belangrijkste taak/doel van uw functie?

5. Uit hoeveel personen bestaat het team waar u mee werkt? 6. Heeft u ervaring met Lean?

7. Wat verstaat u onder Lean?

8. Heeft u ervaring met continue verbetering? 9. Wat verstaat u onder continue verbetering?

Vragen over groepsdynamiek

Teamleider

10. Op wat voor manier geeft uw leidinggevende leiding aan het team? 11. Laat uw leidinggevende veel beslissingen binnen het team?

12. Op wat voor manier probeert uw leidinggevende Lean over te brengen op het team? 13. Wat voor invloed heeft deze manier van leidinggeven op Lean?

14. Wat voor invloed heeft deze manier van leidinggeven op het continue verbeteren?

Feedback geven

15. Op welke manier wordt er feedback gegeven binnen het team? Kunt u een voorbeeld geven van hoe er feedback gegeven wordt?

16. Wat voor invloed heeft de manier van feedback geven op Lean?

17. Wat voor invloed heeft de manier van feedback geven op het continue verbeteren?

Prestaties meten

18. Hoe worden er prestaties gemeten op de afdeling? 19. Wat wordt er gedaan met deze resultaten?

20. Wat voor invloed hebben deze acties op Lean?

21. Wat voor invloed hebben deze acties Continue verbetering?

Team oriëntatie

22. Worden er binnen het team veel ideeën aangedragen over hoe het team beter kan functioneren? Zo ja kunt u voorbeelden geven?

23. Wat verstaat u onder teamgevoel?

24. Heerst er binnen het team het teamgevoel dat u heeft omgeschreven? 25. Hoe beïnvloed dit teamgevoel Lean?

26. Hoe beïnvloed dit teamgevoel het continue verbeteren?

Aanpassingsvermogen

27. Wat voor veranderingen zijn er geweest binnen de afdeling?

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26 30. Door verbeterprogramma’s moet u omgaan met veranderingen. Heeft dit omgaan met

veranderingen ook invloed op Lean, zo ja op wat voor manier?

31. Door verbeterprogramma’s moet u omgaan met veranderingen. Heeft dit omgaan met veranderingen ook invloed op het continue verbeteren, zo ja op wat voor manier?

Betrokkenheid bij het doel van de organisatie

32. Wat is volgens u het doel van Gelre Ziekenhuizen? 33. Hoe denkt u dat uw team daaraan bijdraagt?

34. Hoe beïnvloed het doel van het ziekenhuis Lean op de afdeling?

35. Hoe beïnvloed het doel van het ziekenhuis het continue verbeteren op de afdeling?

Afronding

36. Zijn er nog zaken die u zou willen toevoegen? 37. Heeft u nog vragen op dit moment

38. Wat vond u van het interview?

39. Zijn er dingen die ik volgende keer kan verbeteren?

Ik zal het transcript zo spoedig mogelijk naar u toesturen. U heeft een week om op het transcript te reageren. Mocht ik in deze week niets van u horen dan ga ik ervan uit dat u akkoord bent.

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APPENDIX B: Code Book

Code Description source Example (Dutch)

Lean philosophy

Lean provides organizations with principles and tools to focus on the values which drive systems and realign or refine processes or practices to cut out “waste” and achieve the desired values.

Womack et al., 1990

“Wat ik versta onder Lean is eigenlijk met de middelen die je hebt zo efficiënt mogelijk werken. Vooral de verspilling uit je processen halen. Dat je zo veel mogelijk eigenlijk directe patiëntenzorg kan leveren.”

Continuous improvement

A culture of sustained improvement targeting the elimination of waste in all systems and processes of an organization.

“Ja eigenlijk moet het dagelijks gaan ademen bij het personeel, dat ze constant gaan denken wat ben ik aan het doen. En behoort wat ik doe en wat zou daar anders in kunnen zodat we meer met het echte zorgproces bezig zijn.”

Team leadership

To do, or get done, whatever is not being adequately handled for group needs.

McGrath, 1962

“Als je naar mijn leiderschapsstijl vraagt, ik ben echt wel van het faciliterend leidinggeven. Ik ben niet iemand die alles van top down oplegt. Ik vind het juist heel belangrijk dat het team zelf dingen bedenkt, dus daar stimuleer ik ze ook wel in.”

Mutual performance monitoring

A common awareness regarding the environmental context in which the team is operating and awareness of fellow teammate performance.

Weaver et al., 2013

“Ik ben niet bewust bezig van mijn collega doet het zus of mijn collega doet het zo.”

Backup behavior

The discretionary provision of resources and task-related effort to another.

Porter et al., 2003

“Je signaleert iets, iemand heeft een drukke unit en heeft hulp nodig en je hebt het zelf vandaag rustig, en morgen heb ik misschien een slechte dag. Dat je dat dan met elkaar op lost.”

Adaptability The ability to recognize

deviations from expected action and readjust actions

accordingly.

Priest, Burke, Munim, & Salas, 2002

“Dat het soms een beetje teveel wordt al die veranderingen. Van moet dit nu, en alweer een verandering. Het kost veel energie”

Team orientation

A preference for working with others and a tendency to enhance individual performance through the coordination, evaluation, and utilization of task inputs from other members while performing group tasks.

Driskell & Salas, 1992

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28 Organizational

goal

commitment

The extent to which team members are attached to or determined to reach the organizational goal, regardless of the goal's origin.

(Locke, Latham, & Erez, 1988)

“Als ik die kernwaarden, weetje wel veiligheid hoffelijkheid vernieuwend en nog een, ik heb dat in de Keek staan, maar dat staat er elke week, dat is de layout van de keek. En dan zie je het waarschijnlijk niet meer. Maar ik weet ook niet of het zo leeft onder de medewerkers.”

Value When it is beneficial to the patient.

“Dat je zo veel mogelijk eigenlijk directe patiëntenzorg kan leveren.”

Waste Activities that do not at value. Shinohara 2006

“Ik denk dat het gewoon een manier van werken is om ja zo min mogelijk

verspilling te krijgen, dat je niet alles wat je in twee stappen kan doen, dat je dat niet in vier of vijf stappen moet doen.”

Quality An essential or distinctive characteristic, property, or attribute.

Oxford Dictionarie s, 2006

“Ze zijn min ook meer verplicht geweest om aan de kwaliteit te gaan werken.”

Time for improvements

The time people have in order to work on CI.

“De patiënt staat echt op de eerste plaats, dan worden heel veel andere dingen gewoon niet gedaan. Als je dan ook nog een project moet doen, weet ik veel Qmentum of Lean, zo zijn er wel meer dingen die we moeten doen. Ja daar is dan echt even geen tijd voor” Other parties People from other departments

or parties outside of the hospital.

“Ja, dit zijn ook brede projecten, het transferbureau, de fysiotherapeut, de arts die moeten er betrokken bij zijn, en die zijn dus ook bij dit project

betrokken.” Safety The state of being safe;

freedom from the occurrence or risk of injury, danger, or loss.

“Het teamgevoel heb ik het gevoel, zo zie ik het dan eigenlijk, dat de neuzen allemaal weer de zelfde kant op moeten en dat je gaan staan voor je patiënten en veiligheid. En daar zijn we nu, nou ja goed. Daarom zijn we ook naar de directeur geweest en hebben we een gesprekje met zorgbestuur gevraagd, geëist. Omdat we het niet veilig vonden, het te druk was”

Schooling Forms of education for employees in the hospital.

“Wij worden bijgeschoold, dat bijvoorbeeld een andere

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29 maand van de internisten. En elke week van de PA, de Physision Assistent.” Communication The imparting or interchanges

of thoughts, opinions, or information by speech, writing, or signs.

“Dus dat zegt ook wel wat rondom de communicatie en de PR, dat is ook rondom de missie en de visie van het ziekenhuis, ja daar ontbreekt wel wat aan. Dus dat heb ik ook aan mijn manager aangegeven, we moeten nog best wel wat aan communicatie en PR doen om dingen wat meer bekend te maken, ook onder de medewerkers.” Efficiency Accomplishment of or ability to

accomplish a job with a minimum expenditure of time and effort.

“Nou vooral efficiënt, efficiënt werken, dus dat je ook verspilling tegengaat.”

Improvement-board

A board were improvement initiatives can be noted and can be analyzed.

“Ja dat verbeterbord dat zijn zeg maar vaste data waarop de punten die erop staan besproken worden. Er hangt een briefje naast welke data. En dan wordt er met de betrokken mensen gekeken van welk probleem staat er op, wat zijn de oplossingen en hoe gaan we dat doen.”

CI initiatives Improvements made to reduce waste or ad value.

“We zijn met visite lopen, we zijn anders gaan visite lopen. Eerder deden we het aan bureau, nu zijn we dat op de gang aan het doen dat je de patiënt direct, dat je sneller bij de patiënt bent.

Opdrachten worden anders uitgewezen, je bent er minder tijd mee kwijt. Dat je gewoon meer tijd voor de patiënt overhoudt.”

Organizational goals

Provide the care that is needed, Improvement and innovation, Customer friendly, Desired hospital, Courteous, Safe, Innovative, Competent, Durable and Corporate social

responsible.

The Influence of Team Dynamics on Continuous Improvement in a Healthcare Environment