Insights in building a successful and sustained Lean approach – a team based perspective

(1)

Insights in building a successful and sustained Lean

approach – a team based perspective

Marlou Linde | S3252167 | MSc Change Management | 24-06-2019

Supervisor: Oskar Roemeling

(2)

1

Abstract

(3)

2

1 Introduction

These days, healthcare systems are faced with increasing pressures for realising transformational change due to aging populations, growing amounts of chronical diseases, and increasing numbers of medical technologies (Johansen, Loorbach & Stoopendaal, 2018). These pressures seem to result in an unsustainable situation, additionally complicated by the highly specialised and fragmented way our healthcare system is currently organised (Johansen, Loorbach & Stoopendaal, 2018). In a request for higher efficiency, improved quality and cost reductions (Rapsaniotis & Aij, 2017) the healthcare sector looks at continuous improvement initiatives, especially Lean Management (LM). Within the healthcare system, LM is mainly concerned with reducing waiting times, enhancing patient focus and value, and identifying waste (Toussaint, 2010). There is no uniform way of implementing a LM approach (Hung et al., 2015; Daaleman et al.,2018). However, continuous improvement is often mentioned as the underlying principle for a sustainable LM approach (Drotz & Pokinska, 2014; Toussaint, 2010; Schonberger, 2018). LM provides an extensive set of tools that can function as a means to achieve long term and successful continuous improvement.

Nevertheless, utilising a set of LM practices and tools does not necessarily result in a successful and sustained LM approach (Radnor, Holweg and Waring, 2012; Henrique and Godinho Filho, 2018; Poksinska, 2010). This implies that further studies on how LM can be successful and sustained are worthwhile. Even so, the available literature presents a first move by highlighting the essence of teams in a LM approach. Within LM, teams are often regarded as the central unit where processes receive their coordination (Drotz & Poksinska, 2014; and McFadden, Stock & Gowen III, 2014). However, the literature also describes barriers that might prevail on this practical level. For example, the

implementation of LM tools without an aligned culture and structure can hamper a sustainable flow of improvement activities (Burgess & Radnor, 2013). Next to that, lack of attention for a safety climate through appropriate leadership, might hinder the formation of improvement initiatives (Aij & Rapsaniotis, 2017; McFadden et al., 2014), as employees might feel reluctant to admit their own or other’s errors (Muzur et al.,2015). Furthermore, the hierarchical power structures and relationships within healthcare can cause a strong professional group identity, which impedes teamwork being leveraged for continuous improvement (Drotz & Pokinska, 2014).

Since the practical challenges foster our consciousness about what must be avoided, we still lack insights about the characteristics of a successful and effective team in a LM approach. Therefore, this research further delves into this subject leading to the following research question:

What characterises a successful Lean team?

- Which activities are identified to influence the effectiveness of Lean teams?

(6)

5

Within this scope, the aim is to increase insights in team activities - and accompanying ingredients that support the effectiveness of teams in LM. Hereby we intend to gain further knowledge about a

sustainable and successful LM approach. In addition, this research can enrich the literature about Lean sustainability while bridging a gap between literature and practice.

To generate the best possible insights around this research question, an embedded multi case study is performed in a Dutch rehabilitation centre that works with Lean for approximately 5 years. During the study, two interdisciplinary teams are investigated and compared.

(7)

6

2 Literature review

In this literature review we first explain the LM concept and its meaning in the healthcare sector. As this cadre is set, we outline our interpretation of a successful and sustainable LM implementation. Hereafter we elaborate on the essential role of teams and their mandatory ingredients (operating context).

While reviewing the literature, we noticed that both terminologies; ‘successful’ and ‘sustainable’ are used to explain a situation in which the Lean methodology is leveraged to its full potential. We therefore use both terminologies during this literature section. Furthermore, we end this literature section by our proposed research contribution and conceptual framework.

2.1. An introduction to Lean

Burgess & Radnor (2013) describe Lean as ‘’an integrated socio – technical system which constitutes of a set of tools, techniques and practices combined with a cultural or social system’’ (Burgess & Radnor, 2013; p.231). ‘Lean Thinking’ can best be described as creating ‘value’. A process should flow smoothly and customers should only pay for value adding activities. Therefore, Lean is about improving quality so that activities that do not add value, are eliminated (Burgess & Radnor, 2013).

Lean has its roots in the automobile industry and was developed by the Toyota Motor Corporation. The methodology (The Toyota Production System) provided an alternative to traditional ways of

manufacturing in that period of time (Bhasin & Burcher, 2006). Around 1992, ‘Lean Thinking’ found its way into the service industry and within ten years Lean appeared to be useful in the healthcare sector as well (Brandao de Souza, 2009). In 2003, Thompson and colleagues concluded that with sufficient staff preparation and involvement, the core Lean principles had the potential for continuous, lasting and accelerated improvement in patient care. These days, the Toyota methodology is widely adopted by many healthcare organisations as the Lean Health Care Management System (Poksinska, 2010). In the next paragraph, the meaning and application of LM in the healthcare sector will be further explored.

2.2. Lean in healthcare

(8)

7

Whilst the mentioned principles provide guiding towards a comprehensive Lean system, there is no uniform approach for Lean implementation or operationalisation (Hung et al., 2015; Daaleman et al.,2018). However, there is an extensive set of Lean tools that do provide a basis for Lean

implementation. Table 1 provides a limited selection of popular tools and an explanation of their content. Lean Tool Description

Kaizen (Rapid Improvement Event)

A Kaizen event, also called a Rapid Improvement Event (RIE) is a tool used to begin a Lean initiative. Kaizen events focus on improving specific processes through small, incremental changes (Aij & Rapsaniotis, 2017). The Kaizen system involves everyone in the organisation and can to a large extend, be seen as employee driven (Drotz & Poksinska, 2014).

A3 Framework (PDCA cycles)

Provides structure to the problem solving process from identification to solution. The PDCA-cycle (Plan, Do, Check, Act) by Walter Edwards Deming is used for implementing and monitoring change (Aij & Rapsaniotis, 2017).

Five Why’s Leaders use this method by asking ‘Why’ at least five times to discover the root cause of a problem (Aij & Rapsaniotis, 2017).

Gemba Walks Regular Gemba Walks are used by leaders to assess, measure and sustain changes. Leaders can plan visits to create rapport with employees, assess the impact of changes and address problems. In addition, five golden Gemba rules exist:

1) When a problem arises, go to the Gemba

2) Analyse all things that might be involved in the problem 3) Create a temporarily solution

4) Use the 5-whys method to find the root cause of the problem 5) Standardize

(Aij & Rapsaniotis, 2017)

Table 1: A selection of Lean tools

2.3. The difficulty of Lean success and sustainability

Multiple papers conclude with unanswered questions regarding a successful implementation or sustainability of Lean in healthcare. For example, Radnor, Holweg and Waring (2012) report that the application of Lean is often typified by an over-reliance on tools. The authors argue that people tend to understand Lean as a collection of stand-alone, operational tools or techniques rather than an

(9)

8

conduct Lean in a structured way, often stop possible improvements to further develop throughout the organisation (Radnor, Holweg & Waring, 2012). The ideas of Radnor, Holweg and Waring (2012) are confirmed and supported by Henrique and Godinho Filho (2018), in a recent literature review focused on Lean and Six Sigma in Healthcare. The authors conclude that Lean tools are necessary for process improvement, yet tool effectiveness depends on the ability to develop a culture where problem solving is the norm. Here, Henrique and Godinho Filho (2018) stress the necessity for further research regarding the establishment of a continuous improvement culture in practice. Also, Poksinska (2010) perceives going beyond the simple application of Lean tools to establish a Lean culture of continuous questioning and improvement, as the real challenge.

2.3.1. Continuous improvement as the core

According to Steed (2012) a sustainable system includes a mechanism for continuous performance measurement, problem solving and action planning. In addition, Drotz & Pokinska (2014), Toussaint (2010), and Schonberger (2018) perceive continuous improvement as the underlying principle for a sustainable Lean implementation. In addition, D’Andreamatteo et al. (2015) advocate for a ‘generative’ state, in which a self-sustaining approach with improvement as a continuous condition is promoted organisation-wide.

2.4. The essence of teams

The essence of teams in LM success is noted by different authors investigating Lean. Dickson et al. (2009) distinguish three key factors for successful Lean implementation, wherein frontline staff perform the protagonist role. These include: engaged frontline workers who come to own Lean, long-term leadership commitment and a flexible workforce that is open to change (Dickson et al., 2009; Aij & Rapsaniotis, 2017). According to Poksinska (2010), employees are considered experts at performing their work and their full involvement enables their professional knowledge, skill and experience to be used for the organisation’s improvement. As in healthcare, multiple professions work next to each other and a team forms the primary operating unit for managing and improving processes (Drotz & Poksinska, 2014; McFadden, Stock & Gowen III, 2014). Also, Hung et al. (2015) perceive a fully operating Lean model of continuous improvement, impossible to be sustained top-down. Therefore, Hung et al. (2015) advocate for the essential LM components such as respect for people and their knowledge of the frontline work processes, committing physicians and staff to bottom up improvements.

2.4.1. Barriers in practice

(10)

9

the professional culture that predominate healthcare. For example, hierarchical power structures and relationships lead to strong senses of identity within the professional groups, with doctors as the dominant decision makers (Drotz & Poksinska, 2014).

In addition, the initiation of improvements can also be subject to perceived barriers. Healthcare workers can be reluctant to participate in improvement initiatives because of different reasons. For example, healthcare workers do not want to admit their own errors or highlight the ones of others. Next to that, they might not see the interconnectedness of processes or feel the necessity and responsibility to voice their opinion (Muzur et al.,2015). Furthermore, the initiation of quality improvements may not always be well distributed among professional groups, with ‘the front – line staff’ (e.g. nurses) most willing to participate. Especially physicians seem more difficult to motivate due to their traditional hierarchical perspective, in which they are used to determine and oversee the workflow of others (Mazur et al., 2015). This perception closely aligns with the findings of Hung et al. (2015) who state that physician’s

individual freedom and style are often threatened as they are required to work with standardized procedures. In some cases, this even causes physicians planning to leave the organisation (Hung et al., 2015).

2.5. Successful and sustainable teams in LM

2.5.1. Leadership and interpersonal relations

Both leadership and interpersonal relations seem to be important in the functioning of teams in LM. First of all, the role of leadership is highly influential in creating an appropriate culture for continuous

improvement and the successful implementation of Lean (Aij & Rapsaniotis, 2017; Steed, 2012). Within Lean, leaders are seen as coaches who create strategy and help employees to develop their skills (Aij & Rapsaniotis, 2017). Steed (2012) identified that within Lean, healthcare leaders need to have a strong combination of personal characteristics, learned behaviours, strategies, tools and tactics to enhance the widespread adoption and successful transformation in using Lean. In addition, different leadership styles are identified to be effective within in a Lean approach. Next to Lean leadership, Servant (Aij &

Rapsaniotis, 2017) and Transformational (McFadden et al., 2014; Weberg, 2010) leadership can be effective in the maintenance of a safe patient and employee focussed climate.

From an interpersonal level, Hung et al. (2019) advocate for fundamental changes in staff identities, along with changes in corresponding assumptions about work roles and relationships to build sustainable quality improvements. For example, work relationships based on trust, collaboration and mentoring will create a context in which work redesigns are better anticipated and accepted. Time and effort is required to maintain new professional roles and identities, workflows and relationships to facilitate the

(11)

10

viability. In order to sustain practice transformations, task rearrangements and reprioritisation, enabling resources must be provided to support the sustainment.

2.5.2. Lean team effectivity

Acknowledging the essence of teams within LM, being aware of the barriers, the importance of appropriate leadership and interpersonal relations, we still wonder what it practically constitutes to leverage LM on a team level. Van Dun & Wilderom (2016), provide little direction for this exploration and mention 3 principles in their quantitative study that should determine Lean team effectivity. Van Dun & Wilderom (2016) partly based their interpretations on Dean and Bowen (1994) and Morrow (1997). Hereby, Dean and Bowen (1994) suggest that the principles relate closely to one another. The principles can be described as follows:

- Continuous improvement (CI): An organisation’s ongoing request for better work methods and

organisational processes, recognizable at the work unit and individual level. (Morrow, 1997). Examples of continuous improvement practices can be divided into two activities: process analysis (assessment) and process reengineering (improvement) (Morrow, 1997).

- Customer focus(CF): Maintaining close relationships with customers and regularly seek feedback

from them (Van Dun & Wilderom, 2016; Morrow, 1997)

- Employee participation and involvement (teamwork) (EP&I): Collectively derived solutions are

thought to be better, more creative and foster commitment to the ultimate outcome. Therefore, teams must genuinely facilitate the participation and involvement of members, overcome hierarchical power differences and culminate the actual solving of work problems (Van Dun & Wilderom, 2016; Morrow, 1997).

As the principles will fulfil a central role in our research (also see paragraph 2.7), we hereafter refer to them as the ‘Lean team effectiveness principles’.

2.6. Ingredients

As Lean teams are mostly part of an overarching organisational system, this might influence the available ingredients and operating context of a team. The literature explains some structural ingredients that might shape the operating context of a team within LM.

2.6.1. Supporting structures

(12)

11

significant healthcare improvements. Examples of effective supporting structures found in the literature are shown in table 2.

Structural activity Description Training and

education

Lean training and education, to ensure widespread knowledge about the purpose of Lean (Flynn et al., 2018)

Performance analysis The visual display, collection and analysis of performance metrics to gather input for CI (Hung et al., 2015)

Redesign training Time for training on redesigned work processes, to bring together ideas and establish new ways of collaboration between physicians and frontline-staff (Hung et al., 2015)

Redesign coaching Time for follow-up coaching to reinforce the changes made (Hung et al., 2015),

Continuous coaching CI coaches and knowledge translation (Flynn et al., 2018)

Table 2 : Examples of structures that facilitate the integration of CI

2.7. Research question and conceptual framework

Figure 1 visualises our conceptual framework and lens. Building on previous studies, we argue that a successful and sustainable implementation of Lean is obtained through an institutionalised focus on CI (Drotz & Pokinska, 2014; Toussaint, 2010; and Schonberger, 2018; D’Andreamatteo et al., 2015; Steed, 2012). In addition, we build on the fundamental idea that care teams form the core operating unit for successfully implementing and sustaining Lean (Drotz & Poksinska, 2014; McFadden, Stock & Gowen III, 2014). Hence, a successful Lean approach highly depends on the effectiveness of teams.

LM succes and sustainability Depends on Team effectiveness and succes Depends on Ingredients Continuous improvement activities Employee involvement activities Patiënt focus activities

(13)

12

However, how can this ‘effective’ collaborative context be defined more concretely? Or in other words:

What characterises a successful Lean team?

Concretely, this means we aim to identify the activities that influence their collaborative effectiveness, and thus influence the successfulness or sustainability of a LM approach. Herein, we take the Lean team effectiveness principles as a guiding format.

Which activities are identified to influence the effectiveness of Lean teams?

Furthermore, we hope to further extend our knowledge about the ingredients and resources that are necessary to effectively support successful Lean teams.

(14)

13

3 Methodology

3.1. Theoretical lens and research type

After elaborating our research question, it must be said that this research is not conducted to make judgements about the ‘effectivity’ of teams within LM. Nor is it meant to establish any definitions for a successful and sustainable LM approach. However, we do aim to identify a pattern of meaning among the studied activities and ingredients. We adopt an interpretivist and constructivist perspective, wherein we try to understand the ‘human experience’ (Mackenzie and Knipe, 2006) regarding the activities and their context (ingredients) in a LM environment. The quantitative character of the Lean team effectiveness principles provide guidance to inductively develop an underlying pattern, meaning or theory. To establish a pattern of meaning and identify the how and why behind the principles, a case study is performed (Yin, 1981). Our study design includes an embedded multi case study. Hereby, we investigate and compare two case teams (Yin, 1981) using different data collection methods to involve as much stakeholders as possible (Scholz & Tietje, 2002).

3.2. Research setting

The study will be conducted at a rehabilitation centre located in The Netherlands. Within the rehabilitation centre 470 people are employed and approximately 50 people are connected to the organisation as volunteers. Appendix 1 shows an organogram of the organisation. The following two paragraphs provide some background information of the selected teams.

3.2.1. Team Multitrauma/Orthopedie (Case A)

Case team A, is located in house, at the main location of the rehabilitation centre. The team is operating under supervision of one manager who responsible for the entire adult rehabilitation department. For any support regarding Lean, the team can make use of a Lean coach who is supporting the specific

department. The team is composed of 1 physician, and 20 to 25 front-line staff therapists. Within the team, the physician fulfils the leading role. One of the coordination mechanisms is a team meeting, which is held once per two weeks. Next to that, the team meeting is performed by the physician and a delegation of the different therapist who form the interdisciplinary team.

3.2.2. Team Boterdiep (Case B)

(15)

14

mechanisms is a team meeting, which is held once per week. Next to that, the team meeting is performed by the physician(s) and all the present therapist who form the interdisciplinary team.

A temporal component which characterises the team, is the fact that the physician who was in charge over the team has was caught by long term illness. At time of the research, the physician had just returned.

3.2.3. Table

The following table is based on available secondary data derived from the rehabilitation centre and presents several team and departmental measurements. The table shows minimal differences between the two teams, which indicates that they are comparable in the quality of their functioning. Therefore, the differences in backgrounds of the teams should provide a basis for comparative enrichment regarding team activities and ingredients.

Measurements Case team A Case team B

Number of goals being worked on (team specific)

5 6

Finished Lean training (team specific)

91% 83%

Employee satisfaction 2018 (per department)

8.1 8.2

Patient satisfaction compared to benchmark (per

department)

8.2 (8.3 benchmark) 8.1 (8.0 benchmark)

Table 3: Team and departmental measurements

3.3. Data collection

3.3.1. Team interviews

Semi structured interviews with different members of the team were conducted to find in depth

information about team activities and collaborative ingredients. The Lean team effectiveness principles formed the main subjects during the interviews. To generate the best overview of ‘within group

agreement’ about the activities and ingredients, the propositions of the Referent Shift Consensus Model of Chan (1998) were taken into account (Cole et al., 2011). This entailed that questions were also based on group level constructs (Van Mierlo, Vermunt and Rutte, 2008). For example, ‘’Can you give an example of activities that you as a team perform to.. ‘’. An overview of the different interview protocols can be found in Appendix 2.

(16)

15

therapists, social work or nurses). To prepare for the interviews, additional conversations with the Lean coaches of teams were held to derive further knowledge about terminologies and organisational routines. In total, 14 team interviews were conducted, 7 per case. In each case, one interview turned out to be unusable. With regard to case A, one interview was largely unrecorded due to a technical issue. The unusable interview of case B included an interview with a team member who appeared to be no formal employee of the rehabilitation centre. Therefore, she was not fully involved in the work procedures of the rehabilitation centre. In addition, the interview ended after 15 minutes, due to interruption. Furthermore, in case B one interview was performed with two respondents (11 and 12) since the physician just returned from long-term illness and could not explain the collaboration in detail. Table 4 provides an overview of the conducted interviews.

Respondent table

Respondent Case Function Date Location Interview

length 1 A Front-line staff 14-05-2019 Rehabilitation Centre 33.57 2 A Front-line staff 14-05-2019 Rehabilitation Centre 23.45 3 A Front-line staff 17-05-2019 Rehabilitation Centre 30.03 4 A Operational leader 15-05-2019 Rehabilitation Centre 36.37

5 A Physician 13-05-2019 Rehabilitation Centre 44.16

6 A Manager 20-05-2019 Rehabilitation Centre 46.16

7 B Front-line staff 09-05-2019 Work location of team 29.10 8 B Front-line staff 06-05-2019 Work location of team 23.58 9 B Front-line staff 10-05-2019 Work location of team 36.31

(17.17 + 19.14) 10 B Front – line staff 10-05-2019 Work location of team 33.46

11 and 12 B Operational leader (11) and Physician (12)

09-05-2019 Work location of team 37.35

13 B Manager 08-05-2019 Work location of team 56.13

Table 4: Overview of the conducted interviews

3.3.1. Survey

To complement interview insights, an online survey (Appendix 4) was conducted among the rest of the team. The survey was designed and initially sent through the SurveyMonkey account of the rehabilitation centre, minimising the possibility of the digital invitation to end up in spam boxes. The survey consisted of 23 questions, including scale, open, multiple choice and multiple options questions. Within the survey,

(17)

16

(1998). Furthermore, questions 10 and 11 were adopted from Morrow (1997).

To increase the response rate, team members were approached to fill in the survey manually (after 2 weeks). Table 5 resents an overview of the survey responses per case.

Survey response

Case Response rate Digitally collected Manually collected

A 67% 43% 24%

B 79% 62% 17%

Table 5: Survey responses

3.3.2. Field notes

In addition, field notes were used to improve the depth of the qualitative findings (Phillippi &

Lauderdale, 2017). For case A, there existed 3 note taking moments. For case B, there were 2 note taking moments. The average spend time per case was approximately equal, although the possibility to follow the team highly depended on their available time or activity. An overview of the field notes can be found in Appendix 3.

3.4. Data analysis

(18)

17

4 Results

In this section we discuss our findings of the two investigated case teams (A and B). We start both case presentations by a short oversight of the most important results derived from the survey. These results provide a ‘self – reported’ indication of the ‘Lean team effectiveness principles’, in order to give a better idea of how can interpret the activities and ingredients. Furthermore, in each case presentation we highlight the most influencing activities and ingredients. In addition, the tables provide structured explanations for them. Finally, this section ends with a cross case analysis accompanied with a figure that synthesises and summarises all findings, providing a foundation for the discussion.

We structure our identified activities according to the ‘Lean team effectiveness principles’: Continuous improvement (CI), Customer Focus (CF), Employee Involvement and Participation (EI&P). Activities that were directly linked to LM activities/tools by the respondents and/or the researcher were noted as

Lean activities. Other activities that showed their influence on the principles but were not linked or

recognised as LM activities/tools, were noted as Lean supporting activities. Furthermore, our findings were characterised as ingredients when they could not be directly identified as an activity but did contribute to the collaborative context of the team.

4.1. Case A

Case A was characterised by an interdisciplinary team, composed of different disciplines: nursery, psychology, physiotherapy, occupational therapy and psychomotor therapy. The team consisted of 23 employees. The interdisciplinary team was subjected to different interdisciplinary pilots, such as a stop smoking clinic and treatment plan discussions in presence of patients. In addition, the different

disciplines were occupied with Lean in their own way as well. The survey respondents appraised the team’s contribution to the ‘Lean team effectiveness principles’ as quite positive.

46% Of the respondents judged the level of continuous improvement to be sufficient, another 46% judged it to be good, and the remaining 8% judged it to be moderate. The level of employee involvement was judged satisfactory till good, with 70% of the respondents perceiving the involvement as good. Characteristics as trust, openness, proactive information sharing and equal relationships were

unequivocally judged to be most applicable to the interdisciplinary collaboration (57% or higher). While power relationships and mentorship seemed not applicable at all (both 0%). Furthermore, 54% percent of the respondents found that important patient feedback sometimes led to the adjustment of work

processes. The remaining 46% percent of the respondents indicated that this happens often. The latter gives an indication of CF.

4.1.1. Activities

(19)

18

at the same time. In this section we shortly discuss the activities, and highlight the main influencers. Table 6 presents the further explanation and impact of the identified activities.

Lean activities

First of all, Lean workgroups and 5s clean – up sessions seem influencing Lean activities. Furthermore, on a managerial level, Lean problem analysis tools such as brown paper sessions and A3 were perceived as useful to structure problem analysis.

Main topics

Disciplinary and interdisciplinary improvement boards (named Keek op de Week) included a 15 minute

session in front of a board. The session is meant to share information and discuss possible short - term bottlenecks in processes by sticking post-it’s on the board. This activity can be intensified during pilots and implementation phases. The improvement board session leads to involvement and participation because observations from the work floor form input for improvement. CI and further employee

involvement is assured due to ownership that is allocated to problems. In addition, the a regularity of the activity which leads to continuous evaluation. The activity can best be connected to Rapid Improvement Events (RIE).

It is only 15 minutes a week, but because you take time to evaluate, they know there is attention for the process, de leader is also involved and also contributes in thinking about the follow-up of the process. Hence, if you talk about ‘institutionalisation’, it definitely helps. By showing yourself at the work floor, by having attention for what has been thought out in theory very well, but doesn’t work like that in practice, then listen to the employees, because employees no exactly what works. (Respondent 6, manager)

Day start meetings were performed interdisciplinary, and disciplinary at the nursery department.

Interdisciplinary, this included that representatives of the different disciplines come together at the office of the planning secretary to discuss possible daily disturbances (e.g. illness of a team member).

Alternatives are sought together, to fill the gaps in treatment schedules of patients or therapists.

(20)

19 Lean supporting activities

Also other organisational activities showed to have their impact on the principles of effective Lean teams. For example, treatment plan discussions in presence of patients, mirror interviews, nursery surveys and the working with central documents enhanced customer focus. Education, team days and professional group meetings al contributed to CI. Attention for interpersonal development, such as DISC training seemed to influence CI and EI&P.

Main topic

The interdisciplinary team meetings showed to have a large influence on the interdisciplinary

coordination. During this meeting a delegation of the therapists, and the responsible physician come together for 30 minutes to discuss progress on long term goals and short-term issues, based on input of all the representatives. The week after is reserved to further work out arrangements made during the

meeting. The physician fulfils the leading role. Long term goals are derived from the year plan (agenda). The year plan includes an Excel document in which arrangements around goals are easily noted.

Respondents connected the work method of the meeting to the PDCA – cycle, especially referring to evaluation. Continuous improvement and further employee involvement are assured due to the frequency of the meetings, the work out time and the allocation of ownership to problems which ensures continuous ‘follow-up’, evaluation and necessary participation.

(21)

20

Activity Description Citations Impact

Lean

Improvement board meeting (Keek op de Week)

Rapid Improvement Events with physical board, once a week. Disciplinary and

interdisciplinary. Dedication of problem ownership and

evaluation.

10 (I) 8 (S)

CI trough frequency, monitoring

character of the meeting, and continuous evaluation. EI & P through work floor input and dedication of problem ownership.

Lean workgroup Disciplinary and

interdisciplinary, considering the meaning of Lean for their team, implementing small projects

3 (I) 2 (S)

CI trough specific attention based on role, small improvement projects may lead to undiscovered improvement potential. EI & P through

ambassadorship and involved attitude necessary for workgroup member (sense making)

Day start meetings

Disciplinary, at nursery

department (for day and night shift). Lead by one nurse. Discussion of points of

attention, and determination of coordinating roles of the day

Interdisciplinary, with

representatives of all

departments at planning office. Discussing bottlenecks of the day (e.g. illness of patients or employees).

6 (I) 4 (S) 1 (N)

CI through, the continuous monitoring and solvation of ad hoc issues.

EI & P trough, collaborative problem solving and continuous information sharing. Participation, through the different roles and tasks (e.g. day coordinator ship and disciplinary representative) that need to be fulfilled daily.

Lean clean-up sessions (5s)

Rearranging offices and therapy rooms

3 (I) CF, trough structured therapy rooms, preventing loss of equipment and thus saving time during treatments, ensuring better patient focussed treatment. Problem

analysis

A3 and brown paper sessions 2 (I) CI, through structured problem analysis (mainly management tool)

Lean supportive

(22)

21 team meeting

and working out time

meeting, next week is reserved for work out time. Discussion of urgent issues, as well as long term goals. Year plan is guiding format for goal discussion, following PDCA thoughts.

19 (S) meeting, the working out time and the dedication of ownership to problems which ensures continuous ‘follow-up’, evaluation and necessary participation.

Treatment plan discussions

Discussing treatment plans in in presence of patients.

7 (I) 1 (S)

CF through direct feedback from patients that can be taken into account. CI, through efficiency because of fine-tuning during this meeting, leaving more time for other improvement activities. DISC training Specific training (not

structural) to gather insight in personal styles of collaboration through the use of colours: Red (dominant), Yellow (interactive), Green (stable) and Blue (conscious).

2 (I) CI, EI & P trough understanding of team dynamics with regard to improvements. Mainly on leadership level.

Peer to peer coaching

Discussing improvable cases in interdisciplinary groups under supervision of an independent leader.

7 (I) 5 (S)

CI, as team members perceived this activity to contribute to development of action points and consciousness about own handling,

Meeting with own professional group

Reflecting on situations with own professional discipline.

2 (S) CI, as it al facilitated space and time to discuss bottlenecks in more depth.

Education Moments of retraining and continuing education

1 (I) 3 (S)

CI, as it al facilitated space and time to discuss bottlenecks in more depth. Team day Social activities, and the

deepening of relevant medical content such as guest speakers (for example medical

specialists)

2 (I) CI, trough in depth discussion of medical subjects.

Nursery survey Survey at the end of 24 hour nursery admission period.

1 (I) CF, through direct feedback seeking from patients.

(23)

22 interviews trough interviewing patients,

in presence of the team members. Takes place under supervision of an independent leader. Does not occur on frequent base.

limited number of clients can be heard.

Working with central documents

Working in the same documents, regarding

treatment plans and progress of patients.

2 (I) CF, as new employees or interns more easily find patient specific information necessary to perform suited therapy.

*CI (Continuous Improvement); EI & P (Employee Involvement & Participation; CF (Customer Focus) * Survey citation = (S); Interview citation = (I); Field notes = (N)

* High score

Table 6: Activities Case A

4.1.2. Collaborative ingredients

On a technical support level, ICT and facilities support were seen as process delayers. Other subjects that came to the front were: the high level of part-time employed staff, flexibility of working hours (beyond 9 to 5 mentality), liaison roles and support of Lean coaches. Furthermore, a lot of citations could be traced back to the importance of culture, wherein feedback seeking and giving was perceived as an important problem solving mechanism. Furthermore, the work pressure and limited time to meet and share

information were mentioned as a threat to CI and increasing the risk of team members to fall back in old patterns. Table 7 presents an explanation and the impact of the most frequently mentioned ingredients.

Main topic

The main topic is the attitude of the physician. Having the final responsibility over the interdisciplinary delivered care, the physician can act as a stimulator for improvement (based on 86% of survey

respondents). Team members feel the physician to value their voices which triggers initiative taking (CI) and EI & P within the team.

They come with ideas and also make appointments without me. I always like that a lot. (Respondent 5, Physician)

The physician tried to act consciously by creating a safety culture (making mistakes is allowed), being a role model in patient contact, steering to evaluation and to act as a facilitating bridge towards

(24)

23

Ingredients Citations Impact on activities

Attitude of the physician 17 (I) 1 (N)

CI, EI & P, CF – activities:

By valuing voices of the team and making and evaluating decisions together, initiative taking (CI) and involvement (EI &P) is stimulated. Conscious fulfilment of exemplary role with regard to ethical handlings for instance contributes to CF.

Flexible working hours (mentality)

2 (I) CF – activities:

Flexibility of therapy schedules beyond 9 till 5, enlarges the flexibility for patients to visit the centre as their relatives can accompany them beyond regular working hours. However, this requires accompanying

mentality within a team.

Culture:

Feedback giving and receiving to solve collaborative issues

10 (I) 3 (S)

EI &P and CI – activities:

Important problem solving mechanism, to ensure EP, & I and the proactive reflecting on improvement activities (CI). However, highly dependent on personal attitude.

Liaison roles:

Establishing information and communication sharing

responsibility through allocated roles (e.g. responsibility for

making newsletters or documenting and communicating arrangements regarding year plans)

4 (I) 3 (S)

EI&P, CI and CF - activities

As a lot of interdisciplinary meetings take place with representatives of disciplines. To monitor

improvement and maintain involvement it is extremely important that information is

communicated and shared with the rest of the team.

These tasks can be allocated and delegated (e.g. to secretary support or operational leader) facilitating therapist, physicians or nurses to focus on care tasks (CF)

Part-time employed staff 3 (I) 1 (S)

EI & P and CI – activities:

Limits the ability to share information, participate in decision-making and stay involved with the

actualities on the work floor. Technical support staff:

ICT integration, functioning and adaption.

Inadequate facility support.

4 (I) 1 (S) 1 (N)

CI activities:

(25)

24

functional applications to new work methods or the replacement of broken attributes in therapy rooms

may last long, impacting continuous improvement and patient treatment.

Lean coach:

A member of the organisational Lean department

3 (S) CI activities:

Providing a helping hand with structured process analysis, supporting process improvement. Time and meeting frequency

Moments to structurally discuss issues in depth; and meet and share information

3 (I) 16 (S)

EI & P and CI – activities:

Due to limited time to meet and share information (EI & P). Work pressure may cause employees to fall back in old patterns (CI).

* High score

Table 7: Ingredients Case A

4.2. Case B

Case B was characterised by an interdisciplinary team, composed of different disciplines like speech therapists, physicians, physiotherapists, occupational therapists, ‘orthopedagoog’ and social workers. The team consisted of approximately 25 employees. Equal to Case A, the survey respondents appraised the team’s contribution to Lean team effectiveness principles quite positive.

53% Of the respondents judged the level of CI to be sufficient, another 42% of the respondents judged it to be good and the remaining 5% judged it to be moderate. The level of employee involvement in improvement activities was judged moderate till very good, with 63% of the respondents perceiving the involvement as good and 26% as satisfactory. Characteristics as trust and openness, were unequivocally judged to be most applicable to the interdisciplinary collaboration (57% or higher). Power relationships seemed not applicable at all (0%). Furthermore, 47% percent of the respondents found that important patient feedback sometimes led to the adjustment of work processes. 35% Of the respondents indicated this to happen often, 12% very often, and the remaining 6% judged it to happen seldom. The latter gives an indication of CF.

4.2.1. Activities

(26)

25

Main topics

The weekly interdisciplinary team meeting showed to have a large influence on involvement in and coordination of improvement activities. During this meeting, all therapists (working that day) and physicians come together for 30 minutes to discuss progress on long term goals and short term issues. Arrangements are often allocated to groups of team members to work them out further, ensuring ownership and involvement. In addition, the meeting functions as a moment for evaluation, stimulating process reengineering (improvement).

Long term and short term input for the weekly meeting is derived from the year plan and the

improvement board meeting. The year plan is developed by the team at the beginning of the year and

based on the year plan of the child rehabilitation department. The year plan, includes an Excel document in which goals, goal responsible team members and goal specific arrangements are easily noted. The

improvement board meeting takes place in the morning before the interdisciplinary meeting.

Representatives of the different professional disciplines come together and discuss the yellow post – its (ad-hoc issues) on the board. Difficult issues are put on the agenda for the interdisciplinary meeting, whereas more simple issues are assigned to one of the representatives who take responsibility for it. A pitfall can be that interdisciplinary meetings become overused for short term issues derived from the improvement board meetings.

I notice, that since we have the interdisciplinary meeting, things are tackled and more clear, and yes in total we take action more soon which causes us to improve more quickly. We actually became a very autonomous team. (Respondent 8, front line staff)

We take control over what we think is important, the interdisciplinary team is one example. We preside the meeting ourselves, we come up with points ourselves, of which we think it is important and need to be discussed, it is not top-down determined. (Respondent 9, front line staff)

An important component in this circle of activities, is that the team develops own goals and delivers input for attainment, dedicates ownership to arrangements all strengthens employee involvement and

participation. Furthermore, the regularity of the meetings stimulates evaluation and monitoring of short term and long-term improvements (CI).

Remaining topics

(27)

26

mutual understanding, stimulating EI & P. With regard to CF, mirror interviews were sometimes (not frequently) exploited to achieve direct feedback. The cumbersome way of safe mailing with caretakers was perceived to hinder direct contact.

Activity Description Citations Impact

Lean

Improvement board (Rapid Improvement Events)

Meeting with representatives of disciplines in front of a board. Entire team can deliver input. Quick dedication of responsibility for addressing short term issues issues. Arrangements and more difficult issues form input for

interdisciplinary meeting in the afternoon.

6 (I) 17 (S)

EI & P, through input from work floor (all members of

interdisciplinary team). CI, as it functions as a control method to improve and evaluate short term issues.

Lean clean-up sessions For offices, therapy rooms and computers with coaching of Lean department.

3 (I) 1 (S)

CI, through evaluation of use of therapy tools and how to work with it, providing more structure (efficiency)

Lean supportive Interdisciplinary team meetings

Once a week with entire interdisciplinary team. Reference to year plan and discussions of short term improvement board issues. Dedication of problem ownership is set. In addition, the meeting can be used to evaluate or plan an

evaluation.

23 (I) 28 (S)

EI & P, because the team develops own goals and delivers input for attainment and dedicates ownership to arrangements. CI, due to the regularity of the meetings that stimulate evaluation and monitoring of short term and long-term improvements

DISC training and Neurolinguistic Programming (NLP)

Specific training (not structural) to gather insight in personal styles of

collaboration through the use of colours: Red (dominant),

(28)

27 Yellow (interactive), Green (stable) and Blue

(conscious).

NLP includes a training about feedback giving.

stimulation of feedback giving (adjusted to a person’s

behavioural style).

Peer to peer coaching Discussing improvable cases in groups, under supervision of independent leader.

9 (I) 6 (S)

CI trough evaluation moment for delivered care, (re)interpreting the meaning of ‘good’ care.

EI & P, through stimulation of feedback giving, creating more openness.

Clinical lessons and education

Education from external parties, lessons from internal colleagues.

3 (I) 3 (S)

CI, due to extra time to discuss clinical pictures more

comprehensively. Clinical lessons ensure better adjustment to the organisational context and team request (as it is derived inhouse).

Mirror interviews Generating direct feedback trough interviewing

caretakers, in presence of the team members. Takes place under supervision of an independent leader. Does not occur on frequent base.

2 (I) CF, through direct feedback from caretakers

Working with central documents and maintenance of uniformity in documentation

Ability to adjust and see same document and maintain uniformity in way of

documentation (e.g. goal setting for treatments)

3(I) 2 (S)

CI through, quick insight (same reference point through

uniformity) for every team member in the status of a

treatment progress. In addition, it stimulates team members to keep each other involved (EI & P) Contact with

caretakers

1 or 2 times a year during treatment plan discussions, writing in a booklet, in case

(29)

28 of urgent issues there is mailing or phone contact. Mailing contact is difficult due to safe mailing security Meeting with own

professional group

Monthly meeting, to discuss profession specific themes

1 (I) 8 (S)

CI and EI &P, through collective establishment of decisions about test interpretations and treatments. *CI (Continuous Improvement); EI & P (Employee Involvement & Participation; CF (Customer Focus)

* Survey citation = (S); Interview citation = (I); Field notes = (N) * High score

Table 8: Activities Case B

4.2.2. Collaborative ingredients

First of all, ICT systems, part-time contracts and inappropriate meeting space were seen as process delayers. Large distance between offices was mentioned to inhibit information sharing. The connection with external parties was mentioned to be an essential ingredient for care quality. The ability to derive coaching was perceived supportive to problem analysis, as well as process improvement activities such as the building of collaborative structures (e.g. frequent meetings). Cultural characteristics such as, feedback giving and complimenting showed to have a large influence on problem solving and institutionalising change through the high level of social control. Table 7 presents the explanation and of the most frequently mentioned components affecting team activities.

Main topics

The attitude of the physicians was most elaborately mentioned to influence CI and EI &P. At the time of the research one physician just returned from long term illness. Conversations were currently held to discuss the pillars for revival of collaboration. Team members mentioned that especially before the physician became ill, the two physicians commanded their vision to be dominant for decision making. This resulted in less initiative taking, limited support for new arrangements, long waiting times before accordance of physicians and inhibited knowledge sharing behaviour. 32% Of the survey respondents valued the physicians to stimulate improvement. The forced independence due to sickness of the physician, strengthened the development of the mentioned cultural components.

You also take less initiative if someone always tells you how to do it, that there sometimes is not being listened to a team idea but only stick to the first suggested idea. Uh, than you have

(30)

29

Lastly, time was mentioned most frequently to influence the ability to meet, work out initiatives and come to collective decisions, just like the time to practice new work methods. The production focussed character of the schedules causes the working on improvement activities to come in the last place.

Ingredients Citations Impact

Role of the physicians 14 (I) 2 (S)

EI & P, CI – activities:

Physicians strengthening each other in perception of being dominant decision maker, causing delay (CI) and frustration, inhibiting collective decisions (EI & P)

Part-time contracts 3 (S) EI & P and CI – activities:

Difficult to all meet each other, discuss and share information.

Multiple and not always well functioning ICT systems

2 (I) CI – activities:

Time consuming causing delay in the performance of activities.

Coaching availability 9 (I) 1 (S)

EI & P, CI and CF – activities:

Supporting all facets of collaboration: problem analysis, working out plans, developing collaborative structures (for meetings) and triggering different ways of reasoning. Also, supporting clean up sessions according 5S principles and giving Lean training (cultural program).

Time and meeting frequency 5 (I) 20 (S)

CI and EI & P – activities:

Perceived as most important ingredient for process analysis and improvement (e.g. practicing and learning time), due to information sharing and participation. Production focussed character of the schedules limits ability to meet.

Rooms and their facilities, and location of offices

5 (I) 1 (S) 1 (N)

CI, EI & P – activities:

Inappropriate meeting space, inhibits meeting focus and efficiency (time consuming to rebuild rooms for a meeting) influencing (CI).

(31)

30 Culture:

Openness, trust, equal

relationships, giving feedback and compliments

12 (I) CI, EI & P – activities:

Forms an important mechanism to socially control and institutionalise improvements. (CI)

Prevents escalation of collaborative issues, ensuring involvement and consensus.

Connection with external parties

5 (I) PF – activities:

Essential to deliver ‘patient specific care’. E.g. collaboration with school (one child, one plan) or communication with hospitals about surgeries and provision of medical aids.

* High score

Table 9: Ingredients Case B

4.3. Cross case analysis

The case presentations show multiple relevant activities and ingredients. Case A and B both showed Lean activities as well as Lean supportive activities to influence the principles of effective Lean teams.

Compared to Case B, Case A showed little more Lean activities. Furthermore, multiple principles were embedded in the same activity, suggesting an intertwined relationship.

In the following paragraphs we aim to identify similarities and differences, but mainly the underlying synthesis of our findings that provide a starting point for further discussion.

4.3.1. Activities: similarities and distinctions CI and EI & P

In both cases the most influential activities directly contributed EI & P and CI. The activities showed an overarching purpose, namely information sharing (meeting). Among these information sharing activities an underlying pattern came to the front, namely a structured balance between daily disturbances, short –

term and long-term process improvement information sharing.

These activities included: Lean workgroups (Case A), weekly interdisciplinary team meetings based on year plans (long-term), time to work out initiatives (Case A) weekly improvement board meetings (short- term) and day starts (daily disturbance, Case A). A structured balance rested on some important

collaborative pillars. First of all, we found that planned and frequent meeting, embedded in a team’s work routine, can function as an important facilitator for process improvement activities (CI) and EI & P. However, we noticed that in (collaboration with) a 24 hour care department a higher frequency of daily disturbance signalling meetings had a greater influence on the smooth flow of care.

(32)

31

the efficiency and effectivity. Herein an important contribution was delivered by pre-determined and routinized meeting purposes and the allocation of daily changing or fixed roles. Examples of these kinds of roles include: meeting leader, discipline representative, day coordinator, communicator, note – taker, chairman and problem-owner. Examples of pre-determined meeting purposes include a weekly

interdisciplinary meeting wherein the agenda is partly set through the year plan, ensuring progress on long-term goals. Third, the fact that the input for frequent improvement meetings was mainly derived from the work floor and directly assigned to a team member’s responsibility (problem ownership) stimulated collective solutions and further EI & P.

Other comparable Lean supportive activities influencing CI and EI & P were interpersonal development

activities such as peer to peer coaching and training (e.g. DISC or NLP methodology). These activities

contributed to better feedback giving, mutual understanding and the formulation of action points. Next to that, reflection and educational activities such as education on demand (e.g. clinical lessons), team days (Case A), professional group meeting (primarily survey answers) and problem analysis methods such as A3 and brown paper sessions (Case A) were linked to analysis and improvement (CI). Furthermore, centrally available documents and uniformity of documentation (mainly patient specific) ensured efficiency through reduced searching time (CI), better informed temporary workers (CF) and increased collective control on each other’s documentation (EI&P).

CF & CI

Fewer quoted but similar activities influenced CI and CF included 5s clean up sessions for therapy rooms, contributing to fewer loss and better monitoring of therapy equipment ensuring patient focussed therapy (CF).

Apart from occasionally conducted mirror interviews, Case A and B differed in their patient contact and

feedback activities. A logical consequence of a differing patient population (children versus adults).

Nevertheless, this comparison teaches us that treatment plan discussions in presence of the adult patients (Case A) increase direct patient feedback (CF) and save time which can be used for improvement

activities (CI). At the same time, if the system of the patient (children in Case B) forms the primary focus of contact, the effectiveness of contact can be hindered by the method. Examples of these obstructing methods include conventional book writing or cumbersome safe mailing. Furthermore, surveys were conducted at the nursery department near the end of a patient’s treatment trajectory (Case A), contributing to direct patient feedback (CF).

4.3.2. Ingredients: similarities and distinctions Culture

(33)

32

taking - and involvement. Within Case B, two physicians were in charge. One of them just returned from long term illness. The team perceived the (historical) roles of the physicians as delaying (CI) and

inhibiting collective decision (EI & P) due to dominance in decision making, creating a gap between physicians and therapists. Hence, both cases show the essence of a role conscious attitude by physicians having the final responsibility over the care process.

Nevertheless, being challenged on their collective assertiveness after a period of forced independence, Case B showed convincing feedback relationships while respondents of Case A remained more aloof on this topic. Feedback giving seemed an important mechanism to show and derive involvement, solve problems and proactively control and institutionalize improvement activities (EI & P and CI).

Furthermore, in both case teams the supporting role of Lean coaches was mentioned. In Case B this came to the front during interviews, as in Case A only some survey respondents referred to it.

In Case A, it was mentioned that therapy hours beyond 9 till 5 could contribute to patient specific care (CF). However, according to the managerial opinion this required flexibility of the teams, which did not yet exist.

Information sharing capacity

Furthermore, both case teams were likeminded about the decreased information sharing capacity, due to part-time presence of colleagues and high work pressure. This results in the difficulty to meet each other and decreased effectiveness of the meetings due to less participation (EI & P) and higher decline to old work patterns (CI). Therefore, especially in case team A the importance of allocated liaison roles came to the front. These roles ensure involvement (EI&P), organisation wide improvement monitoring (CI) and the ability for care staff to focus on their care tasks (CF). Furthermore, the role of distanced offices was also mentioned to affect information sharing (Case B).

Structural support

With regard to technical support, both teams mentioned ICT to influence the efficiency and effectiveness of their work. Both teams mentioned the mere integration of the multiple systems as time consuming. Case A, also mentioned bad functioning and adaption to new work methods and slow responsiveness of technical support staff to influence improvement (process reengineering). Case B, especially mentioned the lack of appropriate meeting rooms to hinder a focussed and efficient meeting (CI). This topic, was of no issue in case A. However, in case A the adequate support of the facility staff was mentioned to hinder CI.

Being part of the Lean department, the Lean coaches supported the teams in a broad array of

(34)

33

developing collaborative structures (EI & P), organising 5S clean up sessions (EI &P and CF), Lean training and triggering different ways of reasoning (EI & P).

Moreover, in Case B, the connection with external parties was mentioned as a perquisite the delivery of patient specific care (CF). This highlights the essence of structural integration with other care

organisations.

4.4. Figure

(35)

34

(36)

35

5 Discussion

To get more insight in LM success or sustainability, this study aimed to derive knowledge about the characteristics of effective teams within a LM approach. We identified activities that can contribute to the effective performance of teams. In addition, we found ingredients that hinder or support the effectivity of team collaboration within LM. However, both type of findings provide room for further generalisation. Furthermore, this research shows that a team operating in a Lean environment, can use Lean activities as well as supporting Lean activities to positively influence the Lean team effectiveness principles. With reference to Radnor, Holweg and Warring (2012) who warn for the overreliance on LM tools, we emphasise the importance of aligning LM tools with more regular organisational activities. Activities such as information sharing, interpersonal development, reflection and education, patient contact and feedback, and workspace clean up contribute to the effectivity of teams in LM. Furthermore, a team’s culture, information sharing capacity and structural support must be aligned in order to establish the right collaborative context. In the coming paragraphs we propose our derived knowledge reflected on the previously collected literature.

5.1. Team activities

5.1.1. The ‘Lean team effectiveness principles’ –What, How and Why

Our findings reveal that the principles of Van Dun & Wilderom (2016), Morrow (1997) and Dean & Bowen (1994) are highly interrelated through a qualitative lens. The findings show that multiple activities influence continuous improvement (CI) and employee involvement and participation (EI&P). The two principles seem to act together, suggesting an interdependent relationship. In the light of Lean team effectivity, this entails that activities ‘flourish’ if both pillars are taken into account. Involvement and participation is necessary to signal possible process improvements, even as it is needed for successful analysis and reengineering of processes through collective decisions, ensuring social consensus. In other words, employee involvement and participation ensure action for continuous improvement and can function as a means to institutionalize improvements. Hence, we agree with Dean & Bowen (1994) that the principles are closely related. We propose that effective Lean teams must perform activities that include both; whereby continuous improvement forms the meeting purpose (what), while employee involvement and participation determines the meeting context (how), also see figure 2.

The meaning of customer focus

(37)

36

5.1.2. Continuous improvement activities as information sharing activities

Morrow (1997) distinguishes: analysis and reengineering within a continuous improvement activity. Schonberger (2018), describes a continuous improvement activity as: the recording and analysis of everything that goes wrong and which can be perceived as an error or problem. Herein, an error can be understood as the inaccuracy or unnecessary action that occurs during a task, as a problem can be seen as a disruption and/or setback that upsets task completion (Schonberger, 2018).

Our findings add, that a requirement for analysis and reengineering, encompasses that team members regularly come together and share information. In other words, they should perform an ‘information sharing activity’(e.g. meeting). In terms of Schonberger (2018), we perceive the sole recording and analysis on task level important to signal daily disturbances. In addition, the necessary frequency of such daily disturbance signalling seems to be higher in an environment of 24-hour care (e.g. nursery),

compared to polyclinic care or a 9 till 5 therapy environment. 5.1.3. Balance the purpose of activities

Moreover, recording and analysis is not enough to achieve team or organisation wide process

improvement. To establish process improvement, or in terms of Morrow (1997) come to (and maintain) process reengineering, there must be a balance between the attention for daily disturbances, short term improvements and time to share information about long term team goals. One could say that they are complementary, since returning daily disturbances or short term improvements can serve as input for long term goal development. Daily disturbances can be caught through the use of (inter)disciplinary day start meetings. The development of a team year plan can function as a guiding format to describe and work on long term team goals. Improvement board meetings can function as a method to monitor short term improvements and pilots, or derive input to fine tune process improvement implementations. Weekly interdisciplinary meetings facilitate information sharing with regard to long term year plan goals and short term issues. Hence, the above concretises and supports Daaleman et al. (2018) and Drotz & Poksinska (2014), who advocate for the integration of continuous improvement activities into daily workflows. As both authors refer to ‘daily workflows’, we extend this suggestion from a contingency perspective (Burnes, 2017). Namely: dependent on the ‘character of the improvement purpose’ (long-term/short-term/daily), the frequency of the meeting must be determined (e.g. weekly or once per two weeks). For example, when working out long term goals it is important to create time for disciplinary consultations, collecting information and evaluation etc.

5.1.4. Clear team level format for activities is essential

Insights in building a successful and sustained Lean approach – a team based perspective