Sustaining Lean: lessons from a large medical care provider

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Sustaining Lean: lessons from a large medical care

provider

Jessica van Toorn

S3813088

j.c.van.toorn@student.rug.nl

+31646461189

MSc Business Administration- Change Management

Faculty of Economics and Business

University of Groningen

Supervisor: Dr. O.P. Roemeling

Co-assessor: Prof. Dr. J.D.R. Oehmichen

February 1

st

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2 ABSTRACT

Background: Lean Management (LM) has been shown to positively influence healthcare process performance. Consequently, there is a considerable research base that shows the implementation and performance implications of LM. However, the sustainability of LM efforts over time, especially in the healthcare context, has been overlooked. Therefore, this study was designed to identify how a healthcare provider with a successful LM program was able to sustain LM over prolonged periods of time.

Method: This study is conducted within a large Dutch medical care provider. In this qualitative case-study, four departments were studied and analysed. All departments were able to sustain LM over prolonged periods of time. Data for the study consisted of primary data in the form of interviews and secondary archival data.

Findings: The results indicated four categories facilitating the sustainability of LM. These categories include: (1) The role of leadership, (2) Repetition of the Lean message, (3) Education, and (4) Employee commitment. This study provides a deeper understanding on how each of these identified categories contributes to the sustainability. In addition, the results indicated barriers that hinder the sustainability of LM. These barriers include: lack of time and space, employees resistance, and fear. Based on these results, a theoretical framework has been developed that guides healthcare organizations in sustainability thinking.

Conclusion: This study provides healthcare organizations with insights into how they can sustain LM. It provides them with a comprehensive understanding of the four categories of facilitators that contribute to the sustainability of LM. In addition to these facilitators, this study also gave insights into the various barriers that hamper the road to sustain LM. This study adds to the literature by providing a framework that assists healthcare organizations to sustain LM.

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3 1. INTRODUCTION

Healthcare organizations are facing multiple challenges which include an aging population, increasing complexity of care, and the demand for more long-term care for chronic diseases (Aij & Teunissen, 2017). These challenges require healthcare organizations to improve their service performance in terms of efficiency, cost-effectiveness, affordability, and safety (Poksinska, 2010). To achieve higher performance, healthcare organizations are adopting Lean Management (Aij & Rapsaniotis, 2017).

Lean Management (LM) in healthcare is defined as: “a management philosophy to develop a hospital culture characterised 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)” (Dahlgaard, Pettersen & Dahlgaard-Park, 2011, p. 677). In essence, LM is focused on enhancing value for the patient by eliminating activities that would be considered wasteful from a LM perspective (de Souza, 2009; Poksinska, 2010).

LM delivers a comprehensive set of tools in order to achieve a successful continuous improvement (CI). However, there is no unified method to implement LM (Daaleman et al., 2018). According to Mazzocato, Stenfors-Hayes, von Thiele Schwarz, Hasson and Nyström (2016), LM is one of the most widely used approaches to quality improvement in the context of healthcare to improve the effectiveness and efficiency of care delivery.

Prior research focuses mainly on the implementation and performance implications of LM within organizations (Smith, Poteat-Godwin, Harrison & Randolph, 2012; Moraros, Lemstra & Nwankwo, 2016; Morales-Contreras, Chana-Valero, Suárez-Barraza, Saldaña Díaz & García García, 2020; Mazzocato et al., 2012). The implementation of LM has been shown to improve healthcare process performance in terms of cost savings, reduction in medical errors, reduced patient waiting times, increased productivity, and improved working conditions (Costa & Godinho Filho, 2016; Mazzocato, Savage, Brommels, Aronsson & Thor, 2010; Smith et al., 2012; Suárez-Barraza, Smith & Dahlgaard-Park, 2012). However, these positive outcomes of LM do not necessarily imply that related CI activities are sustained (Poksinska, 2010; Henrique & Godinho Filho, 2018). Indeed, many healthcare organizations are experiencing difficulties in sustaining LM (Aij & Rapsaniotis, 2017; Hallam & Contreras, 2018; Poksinska, 2010; Leite, Bateman & Radnor, 2019; Liberatore, 2013).

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In this study, we argue that the sustainment of LM does not depend solely on whether or not it is embedded in the culture, also other unknown factors might be of importance. For example, according to Aij and Rapsaniotis (2017), leadership is also a component that can contribute to the sustainment of LM. However, the question is whether these components are the only ones or whether there are also other unknown components that can contribute to the sustainability of LM.

Whilst research on the first part of LM journey (i.e., implementation and performance implications) is abundantly present, little research is devoted to the sustainability of LM over the long term, especially in the healthcare context (Poksinska, 2010; Mazzocato et al., 2012; Costa & Godinho Filho, 2016; Hallam & Contreras, 2018). This is rather remarkable given the fact that LM sustainability is typically acknowledged as a key aspect of LM implementation (D’Andreamatteo, Ianni, Lega & Sargiacomo, 2015; Lindsay, Kumar & Juleff, 2019). Therefore, more rigorous research is required on how LM is sustained in healthcare over prolonged periods of time. It is important to investigate this, because healthcare organizations do not want LM to fade away after the implementation (Poksinska, 2010; D’Andreamatteo et al., 2015). Hence, this study focuses on obtaining a better insight into what does and what does not contribute to the sustainability of LM.

This study aims to fill this gap by identifying how a healthcare provider with a successful LM program was able to sustain LM over prolonged periods of time. This results in the following research question: “How are Lean management improvement activities sustained within a healthcare context?”. Through a qualitative study, based on unique case data, we are able to identify multiple barriers and facilitators towards LM sustainability.

This research will be conducted at a large medical care provider from the Netherlands. It adds to the literature on LM, and especially the sustainability of LM, through the development of a framework to guide sustainability thinking. Moreover, this research is valuable to healthcare providers as it provides a better understanding on how LM initiatives could be sustained.

This study is structured as follows: first, we reviewed past research on the concepts LM, LM in healthcare, and the sustainability of LM. Subsequently, we described the methodology of this study. In the next section, the findings that emerge from this study are presented, followed by a discussion section. Finally, this study is summarized with an overall conclusion.

2. LITERATURE REVIEW

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5 2.1 Introduction to Lean

The concept of LM originated from the Toyota Production System (TPS) and was developed by the Japanese Toyota Motor Corporation in the 1940s (Melton, 2005). While the roots of LM can be found within the automotive and manufacturing industries, it has extended to service industries, including healthcare sectors (Moraros et al., 2016). The TPS served as the basis for the five principles of LM, which is a methodology focused on quality improvement within organizations (Womack, Jones & Roos, 1990; Mazzocato et al., 2010; Pepper & Spedding, 2010; Moraros et al., 2016). These five principles are described by Moraros et al. (2016) as follows: (1) define value from the customer’s perspective, (2) identify all stages in the value stream and remove those that are considered wasteful, (3) create a flow of seamless stages to the customer, (4) allow the customer to extract value from the producer, and (5) pursue perfection through a CI of processes. In the pursuit of companies to understand and implement LM, these principles lend themselves as a guideline.

Previous research has emphasized the difficulty of conceptualizing LM, here the absence of a universal definition is one of the major issues (Radnor, Holweg & Waring, 2012; Shah & Ward, 2007; Hopp & Spearman, 2004; Pettersen, 2009). This can lead to a lack of clarity as to what exactly is meant by the term. In this study LM is defined as: “a managerial approach for improving processes based on a complex system of interrelated socio-technical practices” (Bortolotti, Boscari & Danese, 2015, p. 182). In other words, LM is about continually improving quality by focusing on creating and delivering value to the customer and eliminating non-value added activities, also called waste or muda (Womack & Jones, 2003; Soliman & Saurin, 2017; Costa & Godinho Filho, 2016). The goal is to enhance customer value in order to generate high-value service delivery.

Since 2002, the quality improvement approach LM has been widely adopted within healthcare organizations as Lean Healthcare Management System to improve healthcare services (Poksinska, 2010; de Souza, 2009). According to de Souza (2009), the application of LM seems to be effective in improving healthcare organizations and their associated processes. In the following paragraph, LM and its application in the healthcare sector is discussed based on previous research.

2.2 Lean in healthcare

This study focuses on the sustainability of LM over time, which will be discussed in more detail after this paragraph. First, however, we provide a broader overview of the application of LM in healthcare.

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in implementing LM in healthcare to improve their service performance towards a more efficient and high quality care for patients (Poksinska, Fialkowska-Filipek & Engström, 2016; Smith, Hicks & McGovern, 2020). Yet because of their complexity, healthcare organizations should not blindly adopt LM from manufacturing. It requires adaptations to suit their needs (Radnor & Walley, 2008; Poksinska, 2010).

LM in healthcare is often described as a CI approach that consists of identifying and eliminating non-value-adding activities (waste) in the healthcare delivery to create maximum value for patients (Poksinska et al., 2016; Radnor et al., 2012; Dahlgaard et al., 2011). Some examples of activities that would be considered wasteful from a LM perspective include: long waiting times, medical errors, and lack of resources. In essence, this approach helps to improve the flow of patients, resulting in shorter waiting times and hospital stays, and lower costs.

LM is based on five principles. In recent years, the use of these principles in the healthcare sector has increased as a means to improve care processes and eliminate waste (Aij, Visse & Widdershoven, 2015). However, LM and its application in the healthcare sector is characterized by three core principles, which are the first three steps from Womack and Jones (2003): value identification, waste elimination, and generation of customer value (Poksinska, 2010). Although the principles are guiding principles to improve the effectiveness and efficiency of care delivery, there is no unified way to implement LM (Daaleman et al., 2018). There are significant variations with regard to the implementation of LM in the healthcare sector (Radnor et al., 2012).

According to Hasle, Nielsen and Edwards (2016), the implementation of LM in healthcare has not reached its level of maturity. LM in healthcare is often seen as a project and/or as an ancillary activity that is not incorporated in the day-to-day activities of employees (Hasle et al., 2016). Healthcare organizations tend to implement LM as a one-sided approach with the focus on applying LM tools to processes, rather than a system-wide approach where a CI culture needs to be developed (Poksinska, 2010; de Souza, 2009; Radnor et al., 2012). The limited adoption might be one of the reasons that LM is rarely sustained within healthcare organizations.

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7 2.3 The sustainability of Lean

The scarce evidence available on LM sustainability emphasized the difficulty of this topic, especially in the healthcare context (Aij & Rapsaniotis, 2017; Hallam & Contreras, 2018; Leite et al., 2019; Poksinska, 2010; D’Andreamatteo et al., 2015; Liberatore, 2013). The sustainability of LM is one of the least understood issues and therefore there are still unanswered questions (Proctor et al., 2015). The application of improvement tools is meaningless without efforts to sustain LM over time, because sustainability is an important implementation result (Flynn et al., 2018). There is also a risk that the improvement will fade away after the implementation. That is why it is important to ensure that LM improvement activities are sustained within organizations. In this way, LM becomes an inherent part of the organization and its employees and will therefore deliver more value to the patient (Radnor, 2011).

According to existing literature, there is a lack of a uniform definition about the concept sustainability (Moore, Mascarenhas, Bain & Straus, 2017; Proctor et al., 2015; Flynn et al., 2018). In this study, sustainability is defined as: “the continuation or the integration of new practice within an organization whereby it has become a routine part of care delivery and continues to deliver desired outcomes” (Doyle et al., 2013, p. 2). However, it does not require LM to be seen as a cultural element in order to be considered sustainable. It is reasonable to assume that a cultural change is not always required to sustain LM.

Little research is devoted to the sustainability of LM in the context of healthcare (D’Andreamatteo et al., 2015; Costa & Godinho Filho, 2016; Lindsay et al., 2019; Mazzocato et al., 2012; Poksinska, 2010). However, the scarce evidence that is available (Leite et al., 2019; Liberatore, 2013) shows that the success rate of sustaining LM is low. This has to do, among other things, with the difficulty to deal with the barriers to sustain LM over time (Moore et al., 2017; Leite et al., 2019).

Literature shows that there are ideas about the barriers that could hamper the sustainability of LM in healthcare. One of the barriers is the complexity of healthcare environments. The challenging technical, social and institutional context makes it difficult to reproduce and adapt LM. This leads to low success rates in terms of LM sustainability (Leite et al., 2019; Bateman, Hines & Davidson, 2014; Radnor & Walley, 2008). In addition, healthcare organizations tend to implement LM as a project-based approach (one-sided approach) rather than a system-wide approach.

A system-wide approach that includes a long-term strategy and a culture for CI is helpful for the sustainability of LM (Poksinska, 2010; de Souza, 2009; Radnor, 2011; Radnor et al., 2012). Other problems are: poor communication, lack of commitment of employees with regard to LM, lack of resources, and leadership failure (de Souza & Pidd, 2011; Leite et al., 2019; Grove, Meredith, MacIntyre, Angelis & Neailey, 2010). Addressing these barriers could support the sustainment of LM over the long term.

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an important role when it comes to sustaining LM (Radnor, 2011; Aij & Teunissen, 2017; Aij et al., 2015; Flynn et al., 2018). Without continuous commitment and effort from leaders, the sustainment of LM could not be realized (Poksinska et al., 2013). Moreover, whether the organization brings in LM through external consultants or whether it is much more something that takes place in the organization itself might be important. However, according to Poksinska (2010), it is difficult to sustain LM when the consultants leave the organization. In addition, appropriate communication might contribute to the sustainment of LM. According to Radnor (2011), there is a need to keep employees focused on CI until they have become accustomed to the new way of working. Furthermore, the sustainability of LM might depend on the training of employees within an organization. Such training can provide participants with skills and knowledge in the field of LM that can benefit LM sustainability (Radnor, 2011; Al-Balushi et al., 2014).

Based on previous studies, we present the underlying framework (Figure 1) of this study. For the continuation of this study, we are particularly interested in how and why the barriers and facilitators contribute and what other barriers or facilitators might play a role when it comes to LM sustainability. Therefore, the aim of this study is to investigate how a healthcare provider with a successful LM program was able to sustain LM over prolonged periods of time. The next chapter discussed the methodology of this study.

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9 3. METHODOLOGY

In this section, the methodology used in this study is discussed. The methodology is structured as follows, first, the type of research is explained. Subsequently, the case setting is discussed. Furthermore, the approaches to data collection have been outlined. Finally, this section ends with a description of how the data were analysed, followed by a figure of the coding process.

3.1 Type of research

According to Edmondson and McManus (2007), prior research could be nascent, intermediate or mature. The nascent theory is most appropriate in this study, because little is known about the sustainability of LM over the long term, especially in the healthcare context. Therefore, the following research question has been formulated: “How are Lean management improvement activities sustained within a healthcare

context?”. This research question is open-ended in which data have been interpreted for meaning that

contributed to the identification of patterns.

Because little prior research has been done on the phenomenon of interest, the sustainability of LM in healthcare, deep and rich information has been used to better understand this phenomenon (Edmondson & McManus, 2007). More detailed information supports a better understanding of the deeper stories and mechanisms involved, which are key when it comes to answering ‘how’ questions (Edmondson & McManus, 2007). That is why a qualitative case study was most suitable and therefore has been applied in this study.

Qualitative research is explanatory in nature and focuses on identifying and explaining relationships regarding the phenomenon of interest. Moreover, qualitative data were appropriate in this study, because these kind of data were beneficial for theory generation (Edmondson & McManus, 2007; Lee, Mitchell & Sablynski, 1999). Therefore, in-depth interviews have been applied in order to establish new theory.

3.2 Case setting

To select an appropriate case organization, a number of criteria were considered. First, the case organization must operate in the context of this study (i.e., healthcare) where LM improvement efforts are used. Second, interviewees need to have experience with working on LM projects. Third, the organization must have different departments with a successful LM program that have been able to sustain LM over prolonged periods of time. Based on these criteria, a major Dutch medical care provider was selected.

The organization distinguishes itself with a wide range of excellent specialists in medical care and a number of areas of expertise. In total, there are 35 different specialisms, 3.000 employees, 211 medical specialists, and 300 volunteers. The organization cooperates closely with general practitioners and other care providers in order to strive for the best care.

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improving its healthcare processes for almost 10 years. The LM approach has been used to organize the healthcare delivery faster, more pleasant or smarter for the patient. This resulted in a long history of LM improvement activities, such as reducing the length of stay and patient waiting times. That is why this organization is appropriate to examine the aforementioned research question.

The organizations offers various in-house training programs to train employees in the domain of LM. Within the organization a coding system is used, in which the different training programs are expressed in terms of colours: yellow belt (beginner), orange belt (intermediate), and green belt (advanced). These programs vary in terms of duration, complexity, and content. The yellow belt program is characterized by a four-hour training in which employees are introduced to the basic principles of LM. The orange belt program involves a more comprehensive training (20 hours), where employees are provided with more in-depth knowledge of LM and they need to work on their own improvement project alongside the training. The green belt program entails a more advanced training (64 hours), in which extensive knowledge in LM including static process analysis is offered to employees. Besides the training, employees need to work independently on an improvement project. By participating in these training programs, the organization aims to foster a learning improvement culture that allows each employee to contribute to improve value for patients. In the meantime, a large number of successful projects have been completed. By conducting research at this organization, we have gained insights into which aspects drive projects to a success and which aspects hinder this. In this way, we have discovered more about the sustainability of LM over time within the organization.

In this qualitative case study, four different departments have been examined: Pathology (Case A), Finance and Administration (Case B), Facility Management (Case C), and Neurosurgery (Case D). This is a mix of different types of departments, which are departments that focus on providing care (Case A & Case D) and departments that focus on supporting or enabling the provision of care (Case B & Case C). In other words, there is a distinction between direct care departments and support departments. All departments are aware of healthcare-related issues and are active in this context. However, in terms of content, they have different tasks. The four departments were provided by the organization and were considered successful when it comes to the sustainability of LM. By looking at the overlapping components between the departments, we have been able to discover the categories and their underlying reasons that explain how and why these departments are successful in LM sustainability. In this way, we were able to explore how LM improvement activities are sustained within a healthcare context.

3.3 Data collection

Interviews

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bring their personal experiences and perceptions into their responses. This ultimately led to deeper and richer answers. Since little is known about the sustainability of LM over time, deep and rich information was needed to better understand the phenomenon. Therefore, this type of interview was consistent with this study, as it provided the opportunity to elaborate deeply on a particular subject.

In total, 15 interviews were conducted with an average duration of 55 minutes. In this study, we applied purposive sampling and only respondents who possessed the right knowledge, skills, and expertise of working with LM in a healthcare environment have been interviewed. Therefore, two professionals per department have been selected: (1) unit head or coordinator of the department, and (2) a professional who has completed an educational LM program. Since these professionals have experience working with LM, they were expected to provide the most valuable insights.

As a consequence of Covid-19, the interviews were conducted digitally via StarLeaf. Recording equipment has been used during the interviews to allow transcriptions to be made at a later stage. The interview questions were structured in the following categories: (1) introduction, (2) LM improvement activities, and (3) the sustainability of LM. All questions were open-ended in order to guarantee deep and rich information. Examples of questions are: ‘What ensures that LM is embedded in your daily

activities?’, ‘Which stimulating factors play a role in sustaining continuous improvement through LM?’,

and ‘To what extent has your department been able to sustain LM over time?’. The entire interview protocol including all interview questions can be found in Appendix I. The protocol is checked by the case contact to guarantee that the questions and the environment are aligned. This protocol is the latest version, as it has been updated in the meantime in order to provide the best possible insights. Moreover, an overview of all interviews that have been conducted is presented in Table 1.

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Informal conversations

In addition to interviews, informal conversations with the case contact have occurred on a regular basis. These served mainly to familiarize oneself with the organization, to develop a sense of direction for this study, and to clarify ambiguities.

Secondary data

For the purpose of context- and topic familiarization, secondary archival data have been used in this study. A more specific overview of these type of data are presented in Table 2.

Table 2: Overview secondary data

3.4 Data analysis

After data collection, the data were analysed by means of a coding process in which the data were classified into codes and categories in order to find patterns (Saldana, 2012). The analysis of data extracted from interviews included transcribing, reading and encoding the transcriptions. The coding process was conducted by means of the Atlas.ti software. This program has served as a tool to structure the data in order to discover patterns.

The coding process began with the provision of codes to the transcriptions. Both inductive codes that emerge from data and deductive codes that emerge from literature have been used for this purpose. Examples of inductive codes are: ‘delegate’, ‘recurring agenda item’, and ‘take initiative’. Moreover, some examples of deductive codes that have been used in this study are: ‘leader behaviors’, and ‘employee resistance’. This first part of the coding process in which the data collected were summarized by means of codes is also known as first-order coding (Wolfswinkel, Furtmueller & Wilderom, 2013).

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This process of refining the identified codes and categories is also known as second-order coding (Wolfswinkel et al., 2013). The coding process is shown in Figure 2. Moreover, an overview of the most important codes and categories for this study is represented in a codebook, which can be found in Appendix II.

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14 4. FINDINGS

This chapter provides insights into which facilitators and barriers play a role in the sustainment of a LM approach within a healthcare provider. First, each individual department is subjected to a within-case analysis to identify the most important insights of each case. Second, we present the cross-case analysis highlighting the main insights obtained from the within-case analysis. The within-case analysis is structured as follows, per case we focus on: (1) The role of leadership, (2) Repetition of the Lean message, (3) Education, (4) Employee commitment, and (5) Barriers to sustain LM.

4.1 Case A: Pathology

4.1.1 The role of leadership

To explore the role of leadership we distinguish between leadership behaviors and leadership attitudes.

Leadership behaviors

To explore leadership behaviors, we identified two main tasks. Leaders need to stimulate and motivate, and coach and facilitate their employees.

Stimulating and motivating is expressed in the following behaviors demonstrated by leaders in Case A. Leaders need to delegate LM tasks, show results, inform, show personal interest, monitor LM activities, interact with team members, compliment, and visit the work floor. An overview of all identified stimulating and motivating behaviors is shown in Figure 3.

When leaders wish to stimulate and motivate their employees, they need to involve the employees in the process of CI through regular improvement meetings, and by delegating LM tasks providing responsibility and autonomy. Moreover, leaders need to show the results of projects, and highlight progress that has been made. In essence, leaders need to provide feedback and make gains visible. When employees are shown the results of their efforts and when they are involved in CI, this builds enthusiasm and raises awareness of the benefits of LM.

‘I like to put the responsibility with the people themselves. People are the owners. We are all professionals, we all work in medical care, so I also expect something from these people. I am not going to say: “You have to do this and you have to do that and then it all has to be done”. I am not

going to do that. The responsibility rests with the people themselves’. (Jaap)

‘That is the only way in which we can take the employees with us and where they can also give feedback. And then things are discussed, people can ask questions or submit ideas. That also has a

stimulating effect’. (Melany)

‘Try to make them enthusiastic by showing them how something becomes easier or better for the patient or clearer or less error-prone. And then they all look in the same direction, that you just want

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Figure 3: Identified stimulating and motivating leadership behaviors in quotations

Next to stimulating and motivating, coaching and facilitating employees to keep doing LM is of importance. Leaders must provide support, time, and space for employees which enables them to work with LM on an ongoing basis. In addition, leaders need to act as a role model for their employees. Their exemplary behavior provides employees with the necessary support and guidance that enables them to keep working with LM.

‘That you are supported and given resources and time. So of course you need the unit head for that as well. You need a manager who supports you. My unit head always does that. So you need time, space

and resources to be able to carry out things’. (Melany)

‘You have to act on it yourself, of course. If you are not committed, then it is not going to work. So you have to convey it [...]. You have to act on it and you have to explain what it is. You have to stimulate

and motivate people to do that’. (Jaap) Leadership attitudes

In Case A, the results show the most evidence for acknowledging the importance and usefulness of LM. In essence, leaders need to take LM seriously, since by acknowledging the importance of LM and its usefulness, they can successfully convey it to their employees. As a result, employees also take LM seriously.

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16 4.1.2 Repetition of the Lean message

In order to sustain LM over a longer period of time, it is important to keep repeating the Lean message. Repetition ensures that all employees are on board and stay involved. In Case A, message repetition took several forms which include through newsletters and during meetings. However, the newsletter (sent through e-mail) was considered a lesser effective medium as most employees do not access computers during their work. Instead, ensuring that LM is discussed during meetings was considered more effective, especially when it is a recurring agenda item.

‘You just have to keep explaining and naming it. That is really important! [...]. Otherwise, it only

becomes something for the management which is not the intention. You have to keep communicating it to the whole department to get everyone on board’. (Jaap)

‘We had a newsletter, but we considered it to be ineffective because it was not read since many people do not sit behind their PCs. They all work in the lab. So we do not do that anymore. Now we use work

meetings’. (Melany)

‘It is a fixed item on the agenda and that is why we can keep it’. (Melany)

4.1.3 Education

Education in the domain of LM is a facilitator to sustain LM over time. In Case A, the green belt training was considered to be effective. Training creates awareness and a different mindset in LM, and provides a structure to work with. This enables employees to look at their environment in a different way. Moreover, in Case A, offering training to the majority of the department was considered to be effective as this ensures that all employees possess the same knowledge about LM. This keeps them on the same page when it comes to this topic.

‘The more people understand this, the more people look at things from a different point of view. You

look at problems and alerts in a different way when you have completed an education [...]. So you get awareness of working with Lean’. (Melany)

‘Well, like I said, you give them a certain baggage. You need training to be able to keep working according to that system [...]. You need to have 60/70 percent of the employees in your department who can do that and who understands that. Then the majority knows the theory and understand what it

means and why a certain project is being tackled according to that system. And yes, then it works’.

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4.1.4 Employee commitment

To explore employee commitment we distinguish between employee behaviors and employee attitudes.

Employee behaviors

Employees in Case A exhibit initiative behavior in order to sustain LM. Employees need to take initiative by reporting problems, providing ideas for improvement, and by making improvements themselves. This raises their involvement in LM.

‘Well, by creating alerts in their work. We have a system in which we can create alerts in our daily work […]. So employees at all units create alerts and they are monitored on a monthly basis to see

how often something has happened […]. There are also people who come up with their own suggestions, like: “Well, I think we need to improve that. Because that is too messy, it needs to be

improved”’. (Melany)

‘It is about applying what you have learned […]. Just do it, make improvements!’. (Pieter) Employee attitudes

In Case A, the results show the most evidence for intrinsic motivation as the most important employee attitude to sustain LM. Employees need to have intrinsic motivation in LM. When employees have this intrinsic motivation to improve, this builds enthusiasm to keep improving. In this way, employees remain involved and focused on LM.

‘Yes, employees really need to have the intrinsic motivation to improve. Only then we will continue to do so’. (Melany)

4.1.5 LM barriers

Looking at the elements that hamper the road to sustain LM approaches, the lack of time and space as well as employee resistance were considered to be the main barriers in Case A. The cause of lack of time and space can be expressed by the fact that employees sometimes experience a certain work pressure, because of the peak moments in their work. Moreover, employees give priority to their own work, leaving less time for LM. The cause of employees’ resistance has to do with the generation gap and the preservation of existing routines. In Case A, a generation is gap is present, which translates into the older generation not being enthusiastic about LM and not understanding its usefulness and necessity. They prefer to maintain the existing routines and therefore have a hard time moving away from it.

‘Time. Of course, we just have our work here. Sometimes there are also some peaks [...]. So time is an

issue’. (Melany)

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something that is becoming more difficult. Like: “In the past it did not have to be that way, so why should it be that way now?”. So that is indeed something you run into’. (Melany)

4.2 Case B: Finance & Administration 4.2.1 The role of leadership

To examine leadership behaviors, we determined two main tasks. Leaders need to stimulate and motivate, and coach and facilitate their employees.

Stimulating and motivating is manifested in the following behaviors demonstrated by leaders in Case B. Leaders need to delegate LM tasks, show results, celebrate successes, compliment, show personal interest, visit the work floor, and monitor LM activities. An overview of all identified stimulating and motivating behaviors is shown in Figure 4.

In cases where leaders aim to stimulate and motivate their employees, they should involve employees in the CI process. In Case B, having regular improvement meetings, and delegating LM tasks are seen as important behaviors to achieve this. When employees have the autonomy and responsibility in LM activities, this results in increased motivation and job satisfaction and they are more inclined to improve again. Moreover, leaders need to demonstrate the results of projects, and highlight the improvements made. In other words, leaders need to provide feedback and make gains visible. When employees are shown the obtained results, this builds enthusiasm and raises awareness of the benefits of LM. Furthermore, leaders need to pay attention to celebrating successes as this gives employees a positive incentive to keep working with LM.

‘Involving people. So also say: “What do you think?”. Then you keep them involved in making improvements. You also have to give them the opportunity to help improve’. (Jan)

‘If they are responsible themselves and eventually implement an improvement themselves, then I think it has a positive effect on their motivation. Then he thinks: “Oh gosh I have improved that, well that

has now been resolved. I did that myself”. So then he is more inclined to do that again’. (Eva) ‘People only participate in continuous improvement when you make them enthusiastic and when they see the results, so that they can work faster and more efficiently. Next time they will think: “Hey, that is nice! We would like to do that again, because it might even get better”. So if you do that and you

bring it across enthusiastically, then people will join’. (Jan)

‘The most important thing is to celebrate successes […]. Small things and big things need to be

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Figure 4: Identified stimulating and motivating behaviors in quotations

Besides stimulating and motivating, coaching and facilitating employees in LM is important with regard to its sustainability. Leaders need to guide employees, provide support, and act as a role model. In addition, leaders need to facilitate their employees by giving them time and space for CI. These aspects encourage employees to keep doing LM over the long term.

‘Yes, but do not supervise them by solving it yourself, but guide them by saying: "Let's find out together how we can do it better" [...]. But leave the searching to the employees’. (Robert)

‘You have to show exemplary behavior yourself’. (Robert)

‘You have to give employees some time for that. The space and time to actually investigate: “Hey, what am I doing and how can I improve?”’. (Isabel)

Leadership attitudes

Leaders in Case B hold multiple attitudes in order to sustain LM. First, leaders need to acknowledge the importance and usefulness of LM. More specifically, they need to believe in LM and the benefits it provides. Second, they need to be enthusiastic about LM. Both attitudes ensure that the positivity with regard to LM is conveyed to the employees.

‘My unit head is always very focused on Lean [...]. So I think if you have someone who is enthusiastic about it from the top, then it is more likely to trickle down to the underlying departments. To the unit

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20 4.2.2 Repetition of the Lean message

Keep repeating the Lean message is deemed to be important when it comes to its sustainability. Repetition ensures that LM is eventually embedded in the department. In Case B, the repetition of the message occurred in a variety of ways, including through e-mail, feedback, during meetings and dialogues. However, e-mail was perceived as a rather less effective medium since employees receive a relatively large number of e-mails per day. Nevertheless, it is unclear which dissemination channel is most effective when it comes to message repetition. Yet, we do know it is important that LM is a recurring item on the agenda.

‘Just bring it up on a regular basis, repeatedly. This can be done by means of feedback or by means of a meeting or just a dialogue each time about: “Hey, do you see any improvements?”. And then it will

be embedded at some point’. (Isabel)

‘No, that does not work. Mails do not work [...]. Mailing is very easy. You get a lot of e-mails a day. Sometimes I also get 50 a day’. (Jan)

‘Every week we have a work meeting. So every week we talk a lot about it in our department: “How can we improve this?”’. (Jan)

‘He also made this a fixed item on the agenda, that is really important’. (Jan)

4.2.3 Education

In order to sustain LM, education in this domain is important. In Case B, both the green and orange belt were deemed to be effective. In this case, training generates awareness surrounding the concept of LM and its benefits. In essence, training gives employees a different mindset that makes them better able to improve continuously. This permits employees to behold their surroundings in a completely new manner. Moreover, training provides employees with a structure through the tools that are necessary to improve. Finally, a group training in LM for the entire department was considered to be effective in Case B. When the entire department is educated in LM, this raises their involvement around LM and ensures that everyone is on the same page and follows the same system.

‘It is more the mindset I got from the training and therefore I know how to approach certain improvement processes […]. And also the tools to tackle it. What are the right steps? What is the right

order?’. (Eva)

‘Training makes you more familiar with the concept of Lean and what you can achieve with it. And you learn how to use it [...]. It also teaches you how to start an improvement idea. How can I improve

my work? [...]. So I think training in Lean will give you the tools to implement it in your daily work’.

(Isabel)

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Two behaviors are characterized as helpful in Case B with regard to the sustainment of LM. Employees need to take initiative, and communicate with peers.

When employees want to take initiative, they need to identify and report problems, suggest improvement ideas, and implement improvements themselves. This builds enthusiasm and raises involvement in LM. Alongside taking initiative, employees need to communicate with colleagues about LM in order to increase employee involvement. In other words, when employees interact with each other about LM, it keeps everyone focused on the topic.

‘I think it has more to do with simply being able to report problems and if something goes wrong that it is identified and mentioned […]. So yes, what they are doing is reporting that something is going

wrong. Because if that does not show up, you cannot improve anything’. (Eva)

‘And that is why we are always improving, because we are constantly talking to each other about it: “Hey, how can we get it better?”’. (Jan)

Employee attitudes

In terms of employee attitudes, intrinsic motivation is cited as an important contributor in the sustainment of LM. This implies that employees should be intrinsically motivated to work with LM. Whenever employees possess this intrinsic motivation, enthusiasm for CI is developed. As a result, employees stay focused on LM and thus on improving their processes.

‘I think it is also due to the mentality of the people. We are very enthusiastic about improving [...]. So you need to like it. If you do not like it, then it will not work out’. (Jan)

‘Just like I said, I think there must already be a foundation in your own intrinsic motivation to improve’. (Eva)

‘If you have the intrinsic value in improving, “I want to do my job faster, easier and better”, that is very important. And I always find it interesting to see where the accelerations are, or improvements in

processes [...]. But what I am saying, it has to be intrinsic’. (Isabel)

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therefore prefer to maintain them. Finally, the fear of improving or making mistakes results in a negative feeling towards LM among employees. This in turn affects the sustainment.

‘You very often hear in practice: “I do not have time for this, I am so busy” or “I have to fix all the mistakes” [...]. You have to give them time and space to do so. Otherwise you will notice that people may experience extra pressure […], which can make them feel negatively about implementing Lean or

continuous improvement projects’. (Isabel)

‘Yes, I also have a couple of colleagues who are a bit older and say: “Yes, but it is going well, right? It works well how things are going now” […]. They are not very enthusiastic and they are not eager’.

(Jan)

‘I believe that the greatest barrier is intertwined in people themselves. So the fear of change is often a barrier. Fear of making mistakes. So I think it is more about culture’. (Eva)

4.3 Case C: Facility Management 4.3.1 The role of leadership

In the examination of leadership behaviors, two main tasks can be separated. Leaders need to stimulate and motivate, and coach and facilitate their employees.

Leaders in Case C exhibited the following behaviors as part of stimulating and motivating. Leaders need to delegate LM tasks, show results, interact with team members, inform, monitor LM activities, celebrate successes, visit the work floor, show personal interest, and compliment. An overview of all identified stimulating and motivating behaviors is shown in Figure 5.

Leaders need to involve employees in the process of CI in order to stimulate and motivate them. This is expressed by frequent improvement meetings where they can discuss LM. Delegating LM tasks (i.e., providing responsibility and autonomy in LM) is also considered useful for the purpose of stimulating and motivating employees. Both generate input to continue to improve, as most improvement ideas come from the work floor. In addition, leaders are supposed to present the results of projects, and emphasize the advancements that have been made. Specifically, leaders have to provide feedback and showcase the gains. This raises awareness of the benefits of LM and encourages employees to improve.

‘Most ideas come from the teams themselves. The work floor is where the ideas for improvement projects are generated. So that is where most of the profit is. And that is where you have to stimulate people to participate. So you have to involve them […]. Discussing that together is important’. (Petra)

‘Give others the responsibility and space to make improvements’. (Henk)

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Beyond stimulating and motivating, coaching and facilitating employees to keep working with LM is of importance. Leaders need to provide their employees with support in CI and act as a role model. This allows employees to eventually do it themselves and enables them to keep doing it. Moreover, leaders must accommodate their employees by granting them time and space for CI.

‘You need to guide the employees in continuous improvement, so that they can do it themselves in the long run […]. So you need to be sharp and hold up a mirror to people all the time. And not come up

with solutions yourself, but let people think for themselves’. (Maarten)

‘You may really want to improve, but if you do not have time in your work or if your manager does not give you time, you will not get anywhere’. (Jolanda)

‘You also need to act on it and convey it to the employees’. (Peter)

Leaders in Case C highlight one important attitude to sustain LM. Leaders themselves need to be enthusiastic about LM. When employees experience this enthusiasm, this also builds enthusiasm among them. In this way, LM and its benefits is conveyed to the employees. As a result, LM remains at the centre of attention.

‘I think our leader is also enthusiastic about it and this is also passed on to the managers and the

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With regard to the sustainability of LM, the results of Case C highlight that continuous repetition of the Lean message is beneficial. This allows LM to eventually be sustained in the department. In Case C, message repetition adopted different forms, including different kinds of meetings. Message repetition was considered effective, especially when it is a recurring agenda item.

‘You just have to communicate it to your employees. Communication is important all the time, so keep communicating about it. And actively express and disseminate it among employees’. (Peter) ‘It is about communication and continuing to communicate: "This is the way we do it" [...]. Yes, and

then it is perseverance. That is the sustainability’. (Henk)

‘We have our weekly meetings and we have monthly performance board meetings, so then we discuss the KPIs. And we also have quarterly meetings with the unit heads’. (Henk)

‘Yes, that is a bit the same. Just the week start. That tells you what you have to do and that makes it very easy to sustain Lean. It is also important to make it an agenda item, because then it will come

back again and again’. (Petra)

4.3.3 Education

The provision of education in LM is an important component that contributes to its sustainability. In Case C, both the green and orange belt were seen as effective. When employees participate in LM training, it increases their awareness in terms of LM principles and its benefits. In fact, training reshapes employees' mindset, making them more capable of CI. Moreover, training stimulates the intrinsic motivation of employees to improve and to keep improving. Finally, it provides employees with a structure as it allows them to work according to the same system.

‘Yes I think it is a good thing that the hospital educates their people. Then they know how to improve. And if everyone uses the same standard, that is a good thing. And you do not have to have a green belt

for that, but orange belt is also good. Then, at least, you can improve continuously’. (Jolanda) ‘This is just to make people aware of what waste is, so the basic principles. I think it is important that

everyone realizes that’. (Maarten)

‘The moment you do have to pass such a training, then you have the success of it and you are proud of it. But you also had to leave something behind or do something for it. I think that helps to stimulate the

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Multiple behaviors are manifested by employees in Case C in order to sustain LM, including: taking initiative, communicating with peers, and listening to the client.

In terms of taking initiative employees should signal and report issues, propose ideas for improvement, and initiate improvements on their own. This implies that employees need to be proactive by taking initiative in LM. Moreover, employees need to communicate with peers about LM and the associated improvement projects. This increases awareness and keeps them involved in LM. Finally, employees should listen to clients to receive feedback. Using their feedback allows employees to optimize and keep optimizing their services accordingly.

‘Well, like I said, employees themselves come up with: "Hey, but that can be done differently. Can we not do it better this way?"’. (Peter)

‘So when employees run into something, they report it’. (Peter)

‘Everyone is asking each other about: "What is the current situation? What else do you need?". So we are constantly communicating with each other. What are we doing? How do we do that? That is really

important’. (Petra)

‘Yes, in the end I think you have to listen to the customer. It is crucial that the customer says: “Hey, how satisfied are we with the service and where do we see opportunities for improvement?”. So I think

you have to be very receptive to that. So you also have to discover that and listen to them’. (Henk)

Employees in Case C specify two important attitudes in order to sustain LM. First, employees need to be intrinsically motivated in LM, and they must be interested in working with it and continuing to do so. In fact, CI by using the LM approach should be embedded in employees’ DNA. Through this intrinsic motivation, they remain focused on CI. This keeps LM at the centre of attention. Second, employees need to believe in LM and its benefits. In other words, they need to recognize its importance and usefulness.

‘The employees also like it a lot. That is the intrinsic motivation again […]. They do have that intrinsic motivation to improve’. (Peter)

‘Because it is also in my DNA to improve continuously. I am always looking for ways to do things differently, better, smarter, faster, easier’. (Maarten)

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26 4.3.5 LM barriers

In Case C, the lack of time and space, and employee resistance were considered as the main barriers to LM sustainability. With respect to the lack of time and space, this barrier derives from the fact that employees are too busy with their own work. Essentially, employees have other priorities, resulting in little to no time to think about LM and improving their operations. Moreover, employees perceive the fact that they must do this alongside their own work as difficult. As a result, they experience an increased workload, which negatively affects employees’ feelings regarding LM. In terms of employee resistance, this barrier relates to the generation gap and the maintenance of existing routines. Case C is facing a generational gap. The older generation is more reluctant to CI, because they are accustomed to a certain way of working and want to preserve this way.

‘Yes time. Just time. I do find that difficult. Just that you have to do it next to your own work, that makes it difficult […]. Everybody is busy being busy. And I can see that. And that also has a bit of an

impact on people's commitment. Because we are so busy, we do not have much time to think about improving’. (Jolanda)

‘If you do not have the time and space to do projects, then nothing will be improved’. (Petra) ‘And, of course, people who work here for a long time and who are used to a certain way of working

are more reluctant to change’. (Henk)

4.4 Case D: Neurosurgery

Two primary tasks were identified in the examination of leadership behaviors. Leaders need to stimulate and motivate, and coach and facilitate their employees.

In Case D, leaders displayed the following behaviors when it comes to stimulating and motivating. Leaders need to delegate LM tasks, show results, celebrate successes, inform, monitor LM activities, interact with team members, visit the work floor, show personal interest, and compliment. An overview of all identified stimulating and motivating behaviors is shown in Figure 6.

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‘I think that you give autonomy to the employee. Organize it yourself. That is really the most important thing: ownership, autonomy […]. Because then your intrinsic motivation is triggered. If you have control and think: “What is best for the department?”, yes then people become happy and then you get

less resistance. But you also see that it sticks quickly’. (Esther)

‘I also give examples of my previous improvements or things that have changed and then people think: “Oh that is how it works, so good!”. And that it does not necessarily require a lot of time, but it produces a lot of good results. Well if you can explain and show that, then you will notice that people

are starting to improve and continue to do so’. (Esther)

‘Celebrating successes, so that people really become aware of it: “Oh yes, this is what we do it for”. I think that is very important to be able to sustain it for a long time’. (Sophie)

Next to stimulating and motivating, coaching and facilitating employees in LM is important. Leaders need to provide employees with the necessary support in LM and show exemplary behavior. By doing so, employees are taken along in the process of CI. This in order to raise awareness of the benefits of LM and to build enthusiasm for working with LM and continuing to do so.

‘I think we have to coach them above all. Not to come up with solutions ourselves, but to take them along. So coaching them in the process to come up with their own solutions’. (Sophie)

‘I think if the leader and the coordinators among them do not convey that to the team, then I think it is doomed to fail […]. So if you, as a leader, do not believe in it and do not act on it, that you do not take

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The main attitude that leaders in Case D cite as important to the sustainment of LM is to acknowledge its importance and usefulness. This means that they must be convinced about LM and the benefits it yields to them. Subsequently, radiating this to the employees ensures that LM does not become bogged down.

‘So you also need to believe in it as a leader, otherwise it will get bogged down and then nothing happens […]. So to sustain, you need to show that you believe in it. That you have a convincing role’.

(Miranda)

4.4.2 Repetition of the Lean message

Keep repeating the Lean message is important to sustain LM over time. Repetition ensures that all employees are and remain involved in LM. The more often repetition take place, the more the employees are exposed to LM and the more positive they become about it. When employees remain involved through message repetition, LM is perceived as an integral part of the department. In Case D, message repetition includes through an improvement board and during meetings. However, it is not clear which dissemination channel is most effective. Nevertheless, it is evident that it is important for the sustainability of LM to let it come back by making it a recurring item on the agenda.

‘The power resides in repetition, that you repeat it all the time. For example, that you have a constant

improvement board or work meetings, or that you always let it come back in team meetings. As a result, improving quality, safety, becomes normal in the department’. (Esther)

‘If you regularly come into contact with something and if something is told to you on a regular basis, you will believe it more and more and you are more likely to do something with it. And then it also

becomes easier to sustain it in the department’. (Anna)

‘Continuous improvement must be on the agenda of team meetings. And in any case, I always have a heading “quality and safety”, which includes continuous improvement [...]. So because it is continuous, you also have to have a moment to give it a place and to let it come back again and

again’. (Esther)

4.4.3 Education

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employees to work according to the same system, which means they are all on the same wavelength as far as LM is concerned.

‘So we are all yellow belt educated. All nurses, all employees had to do the training. This was facilitated in a team day, which actually puts you all in a different mindset: “We work with processes

and we have to see where the waste is”. And I think that is a very good basis to look further from there: "Okay, but how can we shape this in the department?"’. (Sophie)

‘Yes, I think so. Because then you understand what the goal is and why you do something. In my entire department you have to understand the basics, so that everyone knows why you are going to do

something’. (Anna)

To sustain LM over time, two behaviors are designated as being important in Case D: employees need to take initiative, and communicate with peers.

Initiative behavior is expressed by pointing out problems, offering possibilities for improvement, and by bringing about improvements themselves. By doing so, employees’ enthusiasm and commitment to LM will be increased. Besides taking initiative, employees need to communicate with colleagues about LM. More specifically, they must encourage and support each other in LM throughout the mutual interactions they have. This keeps everyone involved in LM and ensures that the topic remains at the centre of attention.

‘That the employees themselves put things on the improvement board [...]. So especially indicating problems’. (Sophie)

‘They just make improvements [...]. And bring things up during work meetings, like: "What problems do I encounter?" [...]. And at some point, people are constantly thinking about improving: "How did I

work today? And how can things be different tomorrow?"’. (Esther)

‘Yes, that is actually the same thing I have been saying the whole time, that is just that we all keep talking about it with each other’. (Sophie)

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‘If you are intrinsically motivated in the work process of the nurses or whoever, then it affects them. And only then they enter the action mode and start to change’. (Esther)

‘I think I have colleagues who are actively engaged in thinking along and who recognize the importance of improving. They also pass this on to other colleagues’. (Anna)

‘So you have to recognize the benefits of improvement projects. Yes, if you do not see any advantage in that, then it is not going to work’. (Anna)

In Case D, the data pinpoint both lack of time and space, and employee resistance as aspects that impede the sustainability of LM. Here, employees are often too busy with their own work, which increases their workload when they also focus on LM. As a result, they do not have the time or the inclination to make improvements. Due to the lack of time and space, employees give priority to their own work, leaving less time for CI. Moreover, there are employees who are not very enthusiastic about CI as this rearranges their way of working. Therefore, they are more likely to resist changes.

‘It is often very busy in care. So you are very glad that you have finished your work, so to speak. And

then I can also imagine that a lot of people have something like: “If I have to think about that too, well I do not have time for that at all”. So that is a barrier, yes’. (Anna)

‘Some people say: “No, I have been doing this for years, I am going to do what I have always done”. And then they almost get into a fight. So that is rather difficult’. (Sophie)

4.5 Cross-case analysis

In this paragraph, the previously found insights from the within-case analysis are juxtaposed and compared. All identified insights can be found in Table 3.

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Based on the results, on the one hand, it is acknowledged that the repetition of the Lean message is very important. However, no unambiguous conclusion can be drawn regarding the most effective way to do this. From the cases, different ways of dissemination emerge, of which the use of e-mail is generally considered less effective. The use of meetings probably works, especially when it is a fixed item on the agenda. The fact that all cases are successful in sustaining LM does not exclude the other ways (e.g., improvement board or dialogues) in which dissemination is possible. Nevertheless, the power rests in repeating and continuously bringing the Lean message to the attention when it comes to the sustainability of LM.

4.5.3 Education

Drawing on the results, all different cases were unequivocal with regard to the importance of education in the sustainment of LM. For example, it was repeatedly indicated that training serves as a suitable instrument to raise employees’ awareness of LM. Moreover, training provides employees with the necessary mindset and structure, enabling them to look at their environment in a different way. However, there is no consensus on which type of training (yellow, orange, or green belt) is considered most effective, since the provided trainings varied from case to case. Yet, this did not hinder the sustainability of LM as all departments were successful in this.

All the cases were unanimous that taking initiative by employees increases commitment to LM and hence contributes to its sustainability. Important ways that were suggested from the cases to achieve this include identifying problems, suggesting ideas, and making improvements themselves. In addition, it can be concluded that if healthcare organizations want to sustain LM, it is important that employees are intrinsically motivated and interested in improving their operations. These important components of employee commitment ensure that LM remains at the centre of attention in the operational parts of the organization.

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5. DISCUSSION

Within this study, the aim was to investigate how a healthcare provider with a successful LM program was able to sustain LM over prolonged periods of time. For this purpose, we developed the following research question: “How are Lean management improvement activities sustained within a healthcare

context?”. Through this study we were able to identify multiple facilitators and barriers towards LM

sustainability and therefore we have managed to answer the research question. In this section, the main findings of this study are discussed in relation to existing literature. Moreover, theoretical contributions and managerial implications are described. Finally, the limitations and suggestions for future research are presented.

5.1 Main findings in relation to existing literature

First, this study highlights the role of leadership as a facilitator when it comes to the sustainability of LM. This is also well recognized by existing literature (Radnor, 2011; Aij & Teunissen, 2017; Aij et al., 2015; Flynn et al., 2018). The study by van Dun, Hicks and Wilderom (2017) examined the behaviors leaders should exhibit to be an effective LM leader. Yet, none of the above studies provides clarity as to which specific behaviors are appropriate for sustainability purposes. We add to these earlier findings by showing which behaviors support LM sustainability in the healthcare context. We presented two overarching tasks in terms of leadership behaviors that lend themselves as beneficial contributors to LM sustainability: (1) stimulating and motivating, and (2) coaching and facilitating. Stimulating and motivating is manifested in several ways as this study reveals. However, two concrete behaviors are considered most important in this study, which are delegating LM tasks, and demonstrating results by making gains visible. These identified behaviors related to LM sustainability are an addition to the abovementioned studies. With respect to coaching and facilitating, providing support and acting as a role model are helpful to sustain LM. Acting as a role model is in line with the findings of Aij, Simons, Widdershoven and Visse (2013) who state that exemplifying behavior and thus acting as a role model is an important facilitator. Furthermore, this study indicates that leaders need to assist employees by giving them time and space to work with LM, which supports earlier findings by Dombrowski and Mielke (2014).

Second, repetition of the Lean message is identified as a facilitator contributing to LM sustainability. The power rests in repeating the message continuously. This contradicts the findings of Radnor (2011), Hallam and Contreras (2018), and Naik et al. (2012), as they suggest that communication is an important category that contributes to the sustainability of LM. It is assumed that this difference has to do with the scope of the studies. This study focuses entirely on the sustainability of LM and takes a more practical scope, whereas the abovementioned studies do not fully focus on this topic. Instead, they describe the sustainability in a rather global and abstract way.