Jobs in healthcare: the role of lean

Jobs in healthcare: the role of lean

By

Tseard Hofstra – S2596474

Supervisor: dr. O.P. Roemeling

Co-assessor: dr. J.F.J. Vos

Word count: 15581

Date: 20

_{of February, 2018}

Abstract

Purpose – The aim of this paper is to investigate the soft aspects when lean is implemented in healthcare organizations.

Design/methodology/approach – The study is based on a multi-case study carried out in three healthcare organizations in The Netherlands. The main findings are based on 12 in-depth interviews and a survey.

Findings – Results indicate that employees do not feel that lean leads to more job demands. Conversely, employees acknowledge that lean is a method to reduce work pressure that is already present. However, whilst lean is a method to reduce work pressure, already existing work pressure can inhibit employees of implementing lean. Furthermore, intrinsic and pro-social motivation are found to be the most important motivators for employees to implement lean. This study shows that improved communication and more alignment between departments or teams are ways through which lean can reduce work pressure. Lastly, senior nurses, department managers or a lean expert have been found to be important for the implementation and continuity of lean.

Practical implications – This research provides an understanding how lean in healthcare can be used, and it shows possible impacts. This study is one of the few to explicitly focus on the role of soft aspects in lean.

Index

Introduction 3

Research question 5

Literature review 6

Job demands-resources model 6

Soft aspects 7

Job resources 7

Job demands 9

Motivation towards implementation of lean and continuous improvement 10

Theoretical framework 12

Methodology 13

Data collection and procedures 13

Interviews 13

Surveys 14

Research quality 14

Analysis 16

Case selection and criteria 16

Findings 17 Within-case analysis 18 Case 1 18 Case 2 25 Case 3 30 Cross-case analysis 36 Deductive chapters 36 Additional chapters 42

Theoretical framework revisited 49

Discussion 50

Limitations 52

Conclusion 53

References 55

Appendices 61

Appendix A- Interview protocol 61

Appendix B- Survey 63

Introduction

Healthcare systems all over the world tend to focus on the well-known triple aim of healthcare. The triple aim approach consists of three main goals within healthcare systems: (1) health of the population, (2) the experience of receiving care, and lastly (3) the costs of care (Berwick, Nolan and Whittington, 2008). The triple aim is currently under pressure all over the world due to technological innovations that are expensive, and demographical changes that result into an older population that simply requires more care (de Koning, Verver, van den Heuvel and Does, 2006). For example, in the UK alone £20 billion in efficiency gains is required in the coming years (Gershon, 2004). The costs of healthcare are rapidly growing due to an aging population, and technological innovations in healthcare (de Koning et al., 2006). These technological innovations are huge cost drivers for the healthcare system. De Koning et al. (2006) stress that the aging population and rapidly developing technological changes are inevitable and beyond our control. Nevertheless, the authors also state that healthcare providers can control operational efficiencies of sites by implementing internal changes to counter the external changes. Since the 1970s and 80s several attempts in the healthcare sector have been made to improve the overall efficiency of hospitals (Ham, 1997). This paper will highlight how organizations cope with the changing environment and consequently how employees respond to these organizational changes.

A popular approach aimed to improve efficiency is the lean philosophy, commonly referred to as lean. Lean is one of the approaches to establish efficiency gains within an organization (Radnor et al., 2012). Lean was pioneered in the automotive industry by the Toyota Corporation where it focused on reducing wastes, such as inventories and non-value adding activities (Joosten, Bonkers and Janssen, 2009; Radnor, Holweg and Waring, 2012). Continuous improvement is one of the main pillars of lean (Bhuiyan and Baghel, 2005). Continuous improvement can be described as ‘a company-wide process of focused and continuous incremental innovation’ (Bessant, Caffyn, Gilbert, Harding and Webb, 1994). Furthermore, continuous improvement focuses on reduction of waste and should become imbedded in the organizational (Bessant et al., 1994). In this research, we think of continuous improvement as a form of continuous incremental change, through which organizations not only try to reduce waste but also try to improve the overall quality of the delivered good or services (Bessant et al., 1994).

and especially the healthcare sector might sound contradictory. Generally, services are focused on human beings, and these are obviously different from products produced in a factory, improving efficiency is more complex compared to factories that produce products. According to the triple aim of healthcare, human beings not only want to receive care efficiently but they also have their own experience considering the received care and the quality that is provided with the care. Lean has a clear focus on operational efficiency gains, it tries to achieve the efficiency gains with the use of eliminating non-value adding activities and focusing on value adding activities from which the patient may ultimately benefit (Abdulmalek and Rajgopal, 2006).

The possible contradictions of implementing lean in a service industry focused on delivering services to human beings have lead multiple researchers to investigate the viability of lean in the healthcare sector. One of the papers that addresses the viability of lean in healthcare is the paper of Radnor et al. (2012). In the end of the paper Radnor et al. (2012) came to a conclusion and ‘acknowledge the efficiency gains that lean has produced in healthcare’ (p14). De Koning, Does and de Mast (2005) performed a research in the Red Cross Hospital about lean and came to the same conclusion. The results of their study show that lean appeared to have a positive effect on efficiency gains. Lastly the study of Kolberg et al. (2007) concludes that lean is applicable and can be successful for healthcare organizations. In short, earlier studies underline the possible efficiency gains achievable in healthcare through the use of lean.

aspects are influenced by lean. This paper will examine how lean influences employees’ jobs and how job intensification takes place. To investigate the consequences for the job environment we adopt the job demands-resources model as a theoretical lens (Demerouti, Bakker, Nachreiner, and Schaufeli (2001). The model distinguishes between so-called job demands and job resources which are related to specific outcomes, such as exhaustion (Demerouti et al., 2001). This model lies at the heart of this study and will be discussed in the literature review.

This research will investigate whether continuous improvement in healthcare organizations changes the experienced jobs resources and demands of employees, and if these changes influence the motivation to improve. As the introduction shows, human aspects are known in the psychology field but the connection with lean in the healthcare sector is still under development. Through the integration of the field of psychology and lean, this paper adopts a multi-disciplinary approach. In turn, this should ensure contributions of the work to the academic fields of business and management, and change management. The research will be a theory development study in order to provide more insights for current and future research considering the consequences of lean for soft aspects.

Research question

The following research question has been created for this research:

‘How does lean change job demands and job resources and how does this influence the motivation to implement lean within healthcare organizations’

The outcomes of this study create more understanding in the relatively unknown area of soft aspects in lean in healthcare environments. The results of this study will assist understanding of managers working in the field of continuous improvement in hospital environments. By creating more understanding for employees that have to deal with continuous change under lean circumstances the manager can forecast and alter predicted outcomes. Hereby the manager can assure the ongoing continuous change within departments will prevail.

Literature review

In this chapter, we will first specify the job demands-resources model as a starting point for this study. Next, soft aspects are discussed. Furthermore, the elements of the job demands-resources are discussed and how they are applicable for this study. Next, motivation to implement lean is highlighted. Lastly, a suggested theoretical framework will be highlighted in order to give guidance throughout the paper.

Job demands-resources model

Soft aspects

Several authors have stressed that more research is needed on soft aspects of lean since managers are often lacking focus on those parts of lean (e.g. Joosten et al., 2009; Bortolotti et al., 2014; Waring and Bishop, 2010; Holden, 2011). Even though literature suggests that lean has a negative influence on the soft aspects, the clarification of soft aspects in literature remains unclear. Looking at lean from a more specific soft perspective, demands and resources is still a new field in the literature and therefore the outcomes remain debatable. Defining elements of hard and soft aspects are not always clear and multiple authors have stressed different categories of hard and soft aspects, such as time and costs as hard aspects and safety and social impacts as soft aspects (Crawford and Pollack, 2004). Lenka, Suar and Mohapatra (2010) tried to grasp the effects of hard and soft aspects on service quality and customer satisfaction. Interestingly, jobs and employees’ perceptions of their job were a central element in the identified soft issues (human resource management practices, employees’ affective commitment and job satisfaction) by Lenka et al. (2010). Both hard and soft aspects were found to be important for organizational outcomes such as customer satisfaction.

The soft aspects of employees dealing in a lean environment will be further examined in this paper. In this study, we think of soft aspects as the employees’ perception of their job. An example of employees’ perception of their job is the extent to which employees have the feeling that they have to work harder than they actually would like to. This paper will examine whether job characteristics influence the job redesign in such a way that employees’ perception of lean changes and therefore the implementation of lean might be in danger. Soft aspects have been found to be important for their high impact on key successors of projects (Crawford and Pollack, 2004). In this research, we focus on job characteristics from the job demands-resources model (JD-R) perspective, developed by Demerouti et al. (2001). This means that job resources and job demands are now treated as soft aspects that are central in this research.

Job resources

Therefore, job resources and job demands are connected in the suggested theoretical framework (figure 1). An example of a job resource would be autonomy. Job resources can be divided into factors; physical, psychological, social and organizational aspects (Richter and Hacker, 1998). The factors can be used in order to reach goals in the work environment. Richard and Hacker (1998) identified two categories of antecedents for job resources; organizational antecedents and individual antecedents. Just like the research of Demerouti, Bakker, Nachreiner and Schaufeli (2001) this paper will also mainly focus on the organizational antecedents because lean provides the organizational tools for change.

Prior literature has shown that a low amount of available job resources can lead to job disengagements of the employee (Demerouti et al., 2001). An interesting link between job demand and job resources has been found in the last years of research on the job demand resources model namely the fact that job resources can play a role in extending the duration of the employees’ wellbeing before reaching a certain point of physical and mental exhaustion. (Bakker et al., 2005; Xanthopoulou, Bakker, Demerouti and Schaufeli, 2007; Demerouti et al., 2001; Bakker et al., 2007). Thus, a high level of available job resources can function as a buffer for the consequences of a high job demands, i.e. exhaustion. Moreover, Bakker et al. (2007) contributed to the available literature that job resources become more important as job demands increase over time. Knowing that employees strive to protect their previously acquired resources, tension could arise when management decides to implement lean because it tries to achieve the highest possible operational efficiency, which can mean that job characteristics of employees will change because lean is part of continuous improvement which can have implications for employees’ jobs (Xanthopoulou et al., 2007; Radnor et al., 2012). An example of changing job characteristics might be the autonomy of employees whereas employees normally had more freedom to determine how much time a patient would need but now the concept of lean determines the amount of time per patient.

be one of causes regarding the limitations of the JD-R model considering context-free aspects. For example, lean environments can contribute to diminishing stress and exhaustion. For example, high levels of lean can reduce control of employees but does not necessarily lead to more stress for employees because it can provide them high utility benefits (Conti et al., 2006). After research Cullinane (2013) developed a framework that includes the most important sources for job resources in lean environments which function as a starting point for this research to examine job resources; Training, boundary control, feedback, skill variety and utilisation and social interaction.

Job demands

In order to create a better understanding of the consequences of neglecting soft aspects and emphasize on the hard side of lean, this research delves deeper in to psychological research concerning job characteristics. Authors often quote ‘management by stress’ as they refer to lean from the perspective of employees (Curry, 1993; Harrison, 1997; Lewchuk and Robertson, 1997; Parker and Slaughter, 1995; Vallas, 1999). This because lean can expect more from employees since lean is known for its job intensification (Curry, 1993; Delbridge, Turnbull and Wilkinson, 1992 Harrison, 1997; Lewchuk and Robertson, 1997; Parker and Slaughter, 1995; Radnor et al., 2012 Vallas, 1999). Radnor et al. (2012) state that the same employees should do more work than before when their jobs are compared to their previous job characteristics before the implementation of lean. Studies over the last decades have provided frameworks that give insights in how job characteristics can affect the wellbeing of the one performing the job and ultimately might result in a burnout (Bakker et al., 2005)

It is commonly known that lean aims to reduce wastes in order to improve operational efficiency, by routines and a clear order of actions with the same available sources or preferably less (Radnor et al., 2012). Multiple researches (Conti et al., 2006; de Koning et al., 2005; Kolberg et al., 2007; Radnor et al., 2012; Xanthopoulou et al., 2007) have tried to provide insights how lean has a positive or negative influence on the work environment and the job demands of employees. Most researchers in lean contexts acknowledge that lean is a demanding environment (Hasle et al., 2012; Landsbergis et al., 1999) for employees that can affect their jobs. Although negative results are dominant (Hasle et al., 2012), positive effects are also found. Jackson and Mullarkey (2000) found that lean improved the social relations, increased cognitive demands, increased skill utilization and lastly created greater breath of employee role within the organization. Seppälä and Klemola (2004) have found that social relations are improved in a demanding lean environment. After reviewing the literature Cullinane (2013) identified the most important factors for job demands in lean environments. Monitoring demands, physical demands, production pace, task independency and lastly feeling accountable are the most important drivers of job demands modified from the job resources-demands model (Cullinane, 2013). In short, mixed results are known considering job resources and job demands within a lean environment and ask for more clarification, therefore this research will try to illuminate lean from a job demands and job resources perspective in order to add more clarification about the consequences of lean for employees.

Motivation towards implementation of lean and continuous improvement

The most well-known examples of motivation in literature are intrinsic and extrinsic motivation which were referred to in over 800 papers in 1997 already (Vallerand, 1997). The former refers to ‘the desire to perform a task for own sake’ (Bénabou and Tirole, 2003) or ‘energized or activated toward an end is considered motivated’ (Ryan and Deci, 2000) or ‘perception of pleasure and satisfaction from performing behaviour’ (Vallerand, 1997). The latter refers to ‘doing something because it leads to a separable outcome’ (Ryan and Deci, 2000) or in short ‘contingent rewards’ (Bénabou and Tirole, 2003).

Vallerand (1997) provides a framework with the three most important determinants of motivation. According to Vallerand (1997) autonomy refers to the opportunity to engage in activities of own choosing and thus origin of behaviour lies at individual (decharms, 1968; Deci, 1975, 1980; Deci and Ryan, 1985). Vallerand (1997) concluded that relatedness is linked to the feeling of connectedness and ‘being part’ of a social group (Baumeister and Leary, 1995). Lastly, according to Vallerand (1997) a feeling of competence implies the feeling for employees that they interact with the environment effectively and the outcomes are desired (Connell and Wellborn, 1991; Deci, 1975; Deci and Ryan, 1985; Harter, 1978; White 1959). As motivation is found to be an important predictor of job outcomes and identification commitment which eventually can influence the overall implementation of continuous improvement (Lam and Gurland, 2008).

Luthans (1998) highlights the importance of motivation to sustain behaviour and eventually performance. From this perspective, one could argue that employees being motivated towards the change and implementation of continuous improvement is the start for successful implementation of the new management approach. However, Luthans (1998) also asserts that motivation is not the only predictor and mediator of behaviour but the environment of the employee also plays an explanatory role for behaviour. The Lean environments of the healthcare organizations may play a crucial in this research because they might influence the transition from motivation towards behaviour of employees. This paper will try to elucidate whether job characteristics influenced by lean will affect the feasibility for employees to implement continuous improvement. Therefore, the motivation to towards lean is also included in the suggest theoretical framework. To determine which kind of motivation drives the implementation of lean, extrinsic, intrinsic and pro-social motivation are included in the framework.

Theoretical framework

Figure 1- Suggested Theoretical Framework

Methodology

This next section will provide an overview of the methodology of the study. First the data collection and procedures are presented, this will give insights in how the data is collected. Next, the analysis chapter is presented which will give insights in how the data is analysed. Lastly, a chapter is devoted to the cases which will give some brief insights in the selected cases.

Data collection and procedures

Multiple case studies will be conducted since case studies are suitable for theory generating (Gersick, 1988) but also theory testing research approaches (Kidder, 1982). This research will be an exploratory research in terms of Yin (1984) because this research will enter a relatively new field of lean namely the soft aspects of healthcare organizations, the job characteristics of employees working in a healthcare organization to be more precise. The research will be conducted in three healthcare organizations. Case study designs have been accused of not being a robust research method, therefore a multiple case study design have been created in order to improve the robustness (Zainal, 2007).

Interviews

interviews are conducted in the same setting namely one on one in a private room. An example question regarding extrinsic motivation would be; ‘to what extent would a financial reward influence the motivation to implement lean?’

Surveys

Quantitative data will also be collected through a survey (appendix b). The survey will be spread on the same departments where the interviews took place. In total 75 surveys are spread around the departments. Response rate to the survey was 32 percent, a total of 24 participants responded. However, responses to the survey show a strong bias where 23 of the respondents were from case A, whereas only one response was obtained from case B, and we obtained no responses from case C. Because of this bias, we only use the surveys as a means of triangulation and refer from further testing. The survey examined job resources, job demands and motivation from the factors that were identified by Cullinane (2013), so for example ‘production pace’. In total 40 questions were used to address the job demands, job resources and motivation. A 5 point Likert scale has been used ranging from totally disagree to totally agree. Beside these questions, 6 questions have been included to understand the demographical characteristics of the participants.

The figure below presents all the collected data and when the data has been collected.

Type of data Number When collected

Interviews 12 18-12-2017 until 11-01-2018

Survey 24 06-12-2017 until 10-01-2018

Documentation of lean 3 18-12-2017 until 11-01-2018

Figure 2 – Collected data

Research quality

of lean within the organizations that will be researched, a research request has been submitted to a lean platform called LIDZ (Lean In De Zorg, meaning lean in healthcare). Through this platform multiple lean managers pronounced their interest in this research and ultimately three cases have been selected. The interviews and surveys have been spread around core employees of the healthcare organization and not the management board since the focus lies on soft aspects of core employees who deliver care. The selection of employees for the interviews and survey participants has been delegated to the contact person on site since they had the right network to contact all the individuals.

Reliability is more complex to assure, especially with qualitative studies since a level of subjectivity of the researcher but also from participants is always present. Standardization is a good way to improve the reliability of the research (Aken, Berend and Bij, 2012). This is the reason why semi-structured interviews are chosen. The interview questions will be prepared in advance which prevents the results from the influence of personal characteristics (Aken, Berend and Bij, 2012). The semi-structured interviews will be recorded which allows the researcher to listen to the interview again in order to remove hot and cold researcher biases (Goldman,1999). With triangulation (Yin, 2003) of sources through conducting interviews as qualitative data and conducting surveys, the reliability of the study will improve (Aken, Berend and Bij, 2012). Using triangulation of sources, biases can be countered and instruments can complement each other by filling the missing gaps (Aken, Berend and Bij, 2012) Moreover, quantitative research can indicate multiple relations that were not clear or identified by the researcher whereas the qualitative research can foster understanding of the theory and underlying relations (Jick, 1979). For this research, interviews, surveys but also documents of each organization will be gathered. Examples of those documents are for instance PowerPoint slides of a lean training or documents of meetings considering lean. The documents will be used to create a better understanding how lean is implemented in the organizations and which tools of lean the organisation has enhanced.

done in different hospital environments where lean is officially implemented in order to create a higher external validity and increasing the generalizability to other hospital environments (Aken, Berend and Bij, 2012). Besides the multiple case studies to improve the validity, the setting of each interview is the same; only the researcher and the participant in a room that is familiar for the participant.

Analysis

Both deductive and inductive coding will be used. The coding process starts with initial coding which will break down the large data into more compact elements (Straus and Corbin, 2008). Initial coding or open coding in this study is mainly descriptive coding. Next, axial coding will take place where initial codes are coupled under so-called categories. The same interviewer will conduct all of the interviews. Lastly tools are also enhanced to prevent the researcher to influence the results. One of the tools that will be used is Atlas ti.

Case selection and criteria

Case Description Function of participant Case A Case A is an urban located,

multi-disciplinary healthcare organization focused on elderly care. This case has 903 employees of which 59 are trainee’s in 2018.

A1- Physiotherapist A2- Occupational therapist A3- Physiotherapist A4- Physiotherapist

A5-Fysio therapist/ greenbelt /Geriatrician

Case B Case B is an urban located, multi-disciplinary hospital. This case had a total of 2800 employees in 2014.

B1- Lean practitioner B2- Department manager B3- Quality advisor B4- Quality advisor Case C Case C is an urban located,

multi-disciplinary hospital. This case has 2309 employees excluded the medical specialist in 2016.

C1- Senior nurse C2- Senior nurse

C3-Medical specialist/lean manager

Table 1- Case descriptions

Findings

In this part, the findings of the interviews will be presented. This section starts with a within-case analysis where every within-case is discussed on the basis of identified codes. This analysis will also provide a more in-depth description of the case, lean and the participants. The within-case analysis is supported by a table which presents the most important findings for each case on basis of the quotes. After the suggested theoretical framework is addressed in the table, other important findings related to change management that came to light in the interviews are presented. The table presents an example quote from one of the participants, moreover the table displays how much participants argued the same. Next, each within-case analysis will be compared with the survey results as a source of triangulation.

and the role of a manager, superior or greenbelt. These chapters can be categorised as additional findings. Lastly, the suggested theoretical framework will be adapted step by step after each chapter with exception of two chapters, (lean as a communication tool and lean to align) the reason why they are excluded will be explained after the chapters have been discussed.

Within-case analysis

Case 1

As stated before, case 1 is an urban located (high population density), multi-disciplinary healthcare organization focused on elderly care. In total five participants were interviewed; three physiotherapists (A1, A3, A4), one occupational therapist (A2) and one physiotherapist/greenbelt (A5). The case has adopted several lean aspects such as a Kanban board, the usage of brown papers, multiple employees are internally trained as a greenbelt and one black belt is active in the organization.

Job demands and job resources

All five participants were of the opinion that that lean is a method which could reduce job demands, which is in line with the initial ideas reflected in the suggested theoretical framework (figure 1). However, three of the five participants stated that their full schedule sometimes inhibits them from initiating new lean principles meaning that other activities receive higher priority (table 2). Four of the five participants stated that the improved communication is one of the ways how lean lowered the job demands (table 2). A quote of a physiotherapist (A1) displays how communication was beneficial by spending only fifteen minutes a day to discuss internally with the team what has to be done;

‘In the morning, we discuss everything. So, it only costs us fifteen minutes.’

Motivation

Looking at the theoretical framework, all of the five participants were intrinsically and pro-socially motivated to implement lean, respondents report that they are motivated to implement lean because they want to apply lean wherever possible. In addition, respondents mention that it is important that others (patients) benefit from the implementation of lean. The occupational therapist (A2) stated the following about intrinsic and pro-social motivation;

However, it should be highlighted that four of the five participants would appreciate a financial reward considering the implementation of lean (table 2). One physiotherapist (A5) stated the following about an extrinsic reward;

‘For me it would be nice, especially financially.’

It should be noted that participants stated that this was not their main motivator to implement lean but would be an additional motivator. Which is in line with healthcare industries not known for its bonuses for performance. One quote of a physiotherapist (A4) will be presented in order to illustrate this;

‘I think that a reward always works. However, I wonder if it really is a condition to get things done, I don’t think so.’

Interestingly, even though all the participants were intrinsically and pro-socially motivated, three of the five participants were not pro-active considering the implementation of lean or the initiation of new projects, according to the analysis (table 2). A reason for this attitude could be the work pressure that inhibits participants to spend more time on lean. A physiotherapist (A1) illustrated this;

‘I’m like I will hear from them if they need something.’

Additional findings

Beside the findings related to the suggested theoretical framework, some other interesting change characteristics came to light. From four of the five interviews, it became clear that lean is implemented top-down where the black belt plays an important role (table 2). The board and the black belt apparently has high expectations considering the implementation of lean. The greenbelt (A5) stated the following;

Lastly, all participants stated that the greenbelt plays an important role in the continuity and implementation of lean (table 2). The greenbelt (A5) stated the following about it;

‘As greenbelt, you see that they depend on me with solving problems.’ Apparently, a greenbelt is needed to champion the change, implementation of lean.

Case Highlighted aspect Example of participants’

quote Number of participants said the same (total participants of case)

Case 1 -Lean lowering job

demands […} if you would approach all processes from a lean perspective, I think work pressure will be much lower.

5(5)

-Work pressure inhibits

lean ‘I don’t know if every part can become lean because I face time pressure.’

3(5) -Pro-social motivation ‘That other benefit from it

and that I benefit from it, that is most important.’

5(5) -Intrinsic motivation ‘I would prefer applying

lean constantly to everything I see.’

5(5) -Extrinsic motivation ‘For me it would be nice,

especially financially.’ 4(5) -Result importance ‘I like the challenge,

especially when it has positive results.’

4(5)

-Distinct

departments/alignment

‘Other disciplines have difficulty with that, it gives resistance which clashes.’

4(5)

-Top-down ‘Let’s start with the board,

black belt and

management, they should be realistic about what to expect of a green belt.’

4(5)

-Lean improves

communication ‘In the morning, we discuss everything. So, it only costs us fifteen minutes.’

4(5)

-Greenbelt importance ‘As greenbelt, you see that they depend on me with solving problems.’

5(5) -No extra space or time for

lean ‘No. They say you get time but we have to create our own time for it, which often fails.’

2(5)

-Not proactive towards

lean ‘I’m like I will hear it if they need something.’ 3(5)

-Team importance ‘Everything depends on a

team […] 5(5)

Main findings case 1 and comparison with the surveys

In case 1 we see that lean can reduce job demands even though the busy schedule does not always allow participants to spend time on lean. In that sense, work pressure inhibits the implementation of lean. However, all participants were intrinsically motivated to implement lean since they acknowledge that lean is beneficial for them and the patient (pro-social motivation). Extrinsic motivators to implement lean, such as financial rewards, would be welcome for participants of case 1. Not all employees appeared to be pro-active to implement new elements of lean, perhaps due to their busy schedule. Moreover, a greenbelt took most initiatives to implement new lean aspects and was acknowledged to be important for the change. The greenbelt functioned as a lean champion to make the change happen. Participants stressed that lean improved communication since it was more effective and efficient now lean was implemented. Although the greenbelt was important, a top-down approach was enhanced in the organization. The greenbelt was expected to implement or try a number of projects each year.

Figure 3-Work harder under lean

Three of the five participants of case 1 stated that work pressure that was already present inhibited them from implementing lean. Looking at figure 4, the surveys suggest the same mixed results. 33% of the respondents answered that work pressure inhibits them from implementing lean, whereas 25 % of the respondents does not agree with the statement. The rest of the participants took a neutral stance towards this statement. Comparing these survey results with the case, a conclusion can be made that the findings of the interviews are in line with the findings of the survey; mixed perceptions regarding work pressure which inhibits the implementation of lean.

The five interviews in total suggested that some employees of case 1 might be interested in an extrinsic reward (4 of the 5). These findings are not in line with the mixed results that the survey had provided considering extrinsic motivation (figure 5). Figure 2 shows that some (16.67%) would be interested in an extrinsic reward whereas 50% was not interested or not interested at all. The survey shows that extrinsic rewards does not play such a role as case 1 suggests.

Figure 5- Extrinsic rewards

Figure 6-Lean is favourable for the patient

Case 2

As stated before, case 2 is an urban located, multi-disciplinary hospital. Four participants were interviewed; A lean practitioner (B1), one department manager (B2) and two quality advisors (B3, B4). This organization has implemented multiple lean aspects such as a day start board, formal lean meetings and A3 reports. The organization has invested a lot in training green belts but recently decided to switch to lean practitioner trainings. Lean itself is facilitated by a small lean team. Cross-case analysis can point out whether this plays an important role for the implementation of lean.

Job demands and job resources

The lean practitioner (B1) recalls how they changed activities which saved them three and a half hours on one dayshift;

‘So, in total three and a half hours just by doing activities differently.’

The department manager (B2) explained how communication lead to efficiency gains which lower the job demands;

‘If we as management agree that we visit each other or just call (instead of e-mail).’

Regarding the suggested theoretical framework, all four participants argued that lean is a method to reduce job demands by improving communication, creating alignment between departments and of course improving processes (table 3).

Just as case 1 the overall business of a department can inhibit the implementation of new lean aspects. Two of the four participants referred that the core business does not always have additional time to spend on lean (table 3). The department manager (B2) said the following about the full schedule of employees;

Motivation

Pro-social and intrinsic motivation were found to be the most important reason to implement lean for case 2 because all of the four participants stressed that lean is beneficial for the patient which is the reason for implementation, moreover all participants were found to be intrinsically motivated to implement lean. The department manager (B2) gave the following example of pro-social motivation;

‘It has to have added value for the patient.

Additional findings

Beside the suggested theoretical framework, it came to light that teams and their department managers were important for the implementation of lean since the organization enhanced a very much bottom-up approach where every department could determine how much lean they wanted to be (table 3). This created differences between teams in terms of level of lean implemented (table 3). It was argued that the department managers play a crucial role in the adoption and continuity of lean in a department. The lean practitioner (B1) said the following about department managers;

Case Highlighted aspect Example participants’ quote Number of participants said the same (total participants of healthcare organization) Case 2 -Lean lowering job demands ‘So, in total 3 and a half our

just by doing activities differently.

4(4)

-Work pressure inhibits lean ‘The floor is working really hard and they don’t have time for anything else, literally nothing.’

2(4)

-Pro-social motivation ‘It has to have added value for the patient.’ 4(4) -Intrinsic motivation ‘It’s my second nature.’ 4(4) -Result importance ‘That is important because

otherwise people think; we invest so much time and here we go again but eventually nothing is changing.’

3(4)

-Distinct

departments/alignment ‘Of course, we have a lot of teams here, really a lot, so there is a lot of work to do. We have to get rid of the island culture’.

4(4)

-Hierarchical integration ‘So, I think much more alignment is needed between the levels so not only departments.’

4(4)

-Bottom-up ‘The line is in the lead.’ 4(4) -Lean improves

communication ‘If we as management agree that we visit each other or just call (instead of e-mail).’

3(4)

-Department manager importance

‘The most important is commitment of the one in charge in order to facilitate everyone.’

3(4)

-Team importance ‘So, it has to be something for everyone, not only for our management.’

4(4)

Table 3- Within case analysis case 2

Main findings case 2

In this section case 2 will be compared with the survey results to identify similarities and differences. First of all, the job demands and job resources section of the suggested theoretical framework will be addressed, next motivation towards lean will be evaluated. As stated before, the interviews interestingly showed that participants did not experience lean as work intensification, moreover, participants even had the feeling that lean could reduce job demands.

Two of the four participants of case 2 stated that work pressure that was already present inhibited them from implementing lean. Looking at figure 8, the surveys suggest the same mixed results. 33% of the respondents answered that work pressure inhibits them from implementing lean, whereas 25 % of the respondents does not agree with the statement. Comparing these survey results with the case, a conclusion can be made that the findings of the interviews are in line with the findings of the survey; mixed perceptions regarding work pressure which inhibits the implementation of lean.

Figure 8-Work pressure inhibits lean

Figure 9- Extrinsic rewards

Figure 11-Overall motivated to implement lean

Case 3

As stated before, case 3 is an urban located, multi-disciplinary hospital. Three participants were interviewed; a medical specialist (C3), and two senior nurses (C1, C2) of two different departments. This organization has already implemented multiple lean aspects, such as a day start board, formal lean meetings but there is also room for own initiatives. Lean is being facilitated by a lean team and lean managers.

Job demands and job resources

Motivation

Looking at the suggested theoretical framework (figure 1), intrinsic motivation and pro-social motivation were found to be the most important motivators for all three participants whereas all participants argued that an extrinsic motivator would not play a role for them.

Additional findings

Beside the findings related to the suggested theoretical framework, some other interesting change characteristics came to light. Lean was implemented very much bottom-up where every department could define their own lean goals and lean activities (table 4). However, the medical specialist (C3) stated that lean will be approached a bit more top-down by creating a framework by setting the cadres for the implementation of lean for departments, wherein departments are still free to determine their own goals;

Yes, in that sense that you create a framework of your strategy as concrete as possible wherein everyone (departments) are free to move […].

Lastly, all three participants of case 3 stated that department managers or senior nurses play a crucial role in the implementation of lean by facilitating employees and initiating new lean projects. Besides, senior nurses make sure that lean is continued in the departments. The medical specialist (C3) said the following about the importance of senior nurses;

‘Very important because they are the constant factor and facilitate […]. It is also visible, in the departments where it (lean) goes smoothly, there is often someone who is good at it (lean) and in department where it goes less smoothly there is often someone who has less feeling with it, so they

are very important.’

Case Highlighted aspect Example participants’ quote Number of participants said the same (total participants of case)

Case 3 -Lean lowering job demands ‘Yes, and you have more time other things.’

3(3) -Work pressure inhibits lean ‘[…] on some days, it is just too

busy to have a discussion to do something.’

3(3)

-Pro-social motivation ‘I think very important because we improve our quality daily for the patient, that is the whole driver for lean […].’

3(3)

-Intrinsic motivation ‘No, I just like it to solve things that do not go smoothly or could go easier […].’

3(3)

- Culture inhibits lean - ‘Unsafe (environment). In the beginning, they laughed about the fact that you have to use smileys […]and what is the purpose of it.’

1(3)

-Distinct

departments/alignment ‘It (departments) are still small islands, that is something we need to solve.’

3(3)

-Hierarchical integration ‘They never visit us, they have no idea what we are doing.’ 3(3)

-Time and space available for

lean provided by organization ‘Yes plenty. Always. I make my own schedule.’ 3(3)

- Top-down ‘Yes, in that sense you create a framework for your strategy and make it as concrete as possible […}.’

1(3)

-Bottom-up ‘[…] so, everyone can set their own goals.’ 3(3)

-Lean improves

communication ‘Otherwise everyone was working individually and now you send each other e-mails and visit each other to see how they tackle it.’

2(3)

-Senior nurse ‘‘Yes, very important because they (seniors) are a constant factor and they facilitate […].’

3(3)

-Team importance ‘Yes, you need your team, otherwise it is flogging a dead horse.’

3(3)

Main findings case 3 and comparison with the surveys

In case 3 we see that lean can also reduce job demands. Also in this case it appeared that work pressure sometimes inhibited the implementation of lean. All participants were intrinsically motivated to implement lean since they acknowledge that lean is beneficial for them and the patient (pro-social motivation). Extrinsic motivators to implement lean did not play a role for the participants of case 3. In case 3, the senior nurses functioned as a lean champion to make the change happen. Participants stressed that lean improved communication since it was more effective and efficient now lean was implemented. Also, communication between different departments improved due to lean. A bottom-up approached was enhanced for case 3 however the organization has determined a framework for lean in the future, meaning that all departments have the same guidelines.

In this section case 3 will be compared with the survey results to identify similarities and differences. First of all, the job demands and job resources section of the suggested theoretical framework will be addressed, next motivation towards lean will be evaluated. Also in case 3 participants did not experience their job as more demanding compared to a prior situation where lean was not implemented

Figure 12-Work pressure inhibits lean

The three interviews in total suggested that none of the employees was interested in an extrinsic reward for implementing lean. These findings are clearly not in line with the mixed results that the survey had provided considering extrinsic motivation (figure 13). Figure 13 shows that some (16.67%) would be interested in an extrinsic reward whereas 50% was not interested or not interested at all. The survey results show that extrinsic rewards are slightly more appreciated than case 3 suggests.

Case 3 showed us that all participants were intrinsically motivated and pro-socially motivated to implement lean. Participants had the feeling that lean is beneficial for the patient and organization and therefore they were motivated to implement lean. The survey results show the same finding; thus, the surveys are in line with the findings of the interviews. Figure 14 and 15 show that 84.62% of the participants believe that lean is beneficial for the patient (pro-social) and 61.54 % is motivated to implement lean overall. It should be highlighted that 30.77% was neutral to implement lean overall. Overall, the survey results considering motivation are in line with the findings of the interviews with participants of case 3.

Figure 15-Overall motivated to implement lean

Cross-case analysis

Based on the coding, within-case analysis and main findings per case, the cases are compared to see where differences can be found and where similarities can be found. First the chapters derived from the deductive codes are presented: lean to reduce job demands, pro-social motivation, intrinsic motivation. Next the chapters based on the inductive coding are presented: lean leading to improved communication, alignment as ways to reduce job demands, and the role of a manager, superior or greenbelt. Lastly, a new theoretical framework will be created on the findings.

Deductive chapters

Lean as a method to reduce job demands

As the within-case analysis shows, employees in all three cases experienced lean as a method to reduce pressure and thereby the job demands, except for one. The medical specialist (C3) did not necessarily think it would reduce pressure but argued that it changes the perspective of people. On the question whether lean is a method for to reduce job pressure participants of the three different organizations stated the following;

A physiotherapist (A4) of case 1 answered;

The lean practitioner(B1) of case 2 answered the following;

‘Yes… we often put out fires… but if you do not solve it structurally you keep putting out fires the whole day…if you just solve things well and not for five minutes, not for one day but for ever you

will experience more rest doing your job.’ A senior nurse(C1) of case 3 answered the following;

Yes, I think so eventually, if you would work a bit more towards goals […].’

The medical specialist (C3) of case 3 had a slightly different opinion and answered the following on the same question;

‘It can be a resource which allows people to deal with it differently. […] so I think that you change the experience more than actually you remove pressure.’

Employees not necessarily feel that they have to work harder under lean but it resolves their inefficient or non-value adding activities. Looking at the previous paragraph it can be logically explained why employees do not feel job intensification but the opposite. This can be for two reasons, people actually reduce workload or work pressure or as the medical specialist suggests, the perspective of people changes. As the within-case analysis shows, bottom-up approach is mostly enhanced, employees are allowed to assess where the process is still inefficient and thereby employees self-assess the elements of the process that are insufficient for them. How employees reduce job demands still has to become clear.

A physiotherapist (A3) of case 1 stated the following;

‘If you have too much patients and many of them for a longer term, you simply end up with having not enough employees. In this situation, you could do as much lean management as you want to,

but it is not going to results in lower job demands.’

A quality advisor (B4) of case 2 stated that work pressure sometimes inhibits lean from being initiated for example by getting the right people together;

‘If you cannot get them round the table then it becomes difficult. It has to do with work pressure, not for us, but mainly in the organization because pathways are designed together, especially with

those who are involved.’ The medical specialist (C3) of case 3 argued;

Yes, yes lack of time. We had a really big lean team and received a lot of questions, but the next step to actually process them was never made because they did not make time and that has to be done

of course when you want to make the next step.’

Lastly, lean was not experienced to increase job demands in all three cases. In that sense lean would not influence the job demands but looking at the previous paragraphs, it would more function as a resource which eventually can reduce job demands. Only one participant (A1) of case 1 argued that one practice, cleaning the exercise room (a lean initiative), increased the work load. The same participant however also argued that lean is a method to reduce workload because eventually it is more efficient;

‘It is only a bit more work pressure, for example cleaning the exercise room yes.’

All other eleven participants of all three organizations argued that lean does not influence the job demands by increasing the work intensification.

On question whether the participant had to work harder under lean the occupational therapist (A2) answered the following;

A senior nurse (C2) of case 3 argued the following about lean not influencing the job demands;

‘There is, especially now, a constant work pressure but I think that has nothing to do with lean but with the ill patients.’

On the question whether the participant had to work harder under lean one quality advisor answered the following;

‘No, it does not feel like that.’

Theoretical framework revisited

The chapter above suggests that lean is not experienced as a job demands but only as a job resource. In this case the suggested theoretical model should be revisited and should look like figure 16, presented below. Lean implemented in a healthcare environment can improve the job resources of an individual and in their turn the job resources can diminish job demands.

Figure 16- Theoretical framework revisited

Intrinsic-, pro-social- and extrinsic motivation

their second nature to improve. Remarkably case 1 is clearly more interested in receiving an extrinsic reward such as financial rewards or additional time off as a reward for implementing lean or spending a bit more time at lean. It should however be noted that also intrinsic and pro-social motivation is present for all participants of case 1 and an extrinsic motivator was not the main motivator for the participants, however still, rewards were more welcome regarding the other cases. Table 5 presents an overview of all cases and all types of motivation regarding the implementation of lean and how many of the cases supported the statements presented.

Case Pro-social Participants that said the same (total participants of case)

Intrinsic Participants that said the same (total

participants of case)

Extrinsic Participants that said the same (total participants of case) Case 1 That others

benefit from it and that I benefit from it, that is most important.’ (A2)

5(5) ‘I would prefer applying lean constantly to everything I see.’ (A5) 5(5) ‘For me it would be nice, especially financially.’ (A5) 4(5)

Case 2 ‘It has to have added value for the patient.’ (B2)

4(4) ‘It’s my second nature.’ (B1)

4(4) ‘I think the answer is no, my motivation is that I know that this is a good way of working and it suits me, it works.’ (B4) 4(4)

Case 3 ‘I think very important because we improve our quality daily for the patient, that is the whole driver for lean

[…].’ (C2)

3(3) ‘No, I just like it to solve things that do not go smoothly or could go easier […].’ (C1)

3(3) ‘No that is not the right approach but it is about positive rewards, a compliment.’ (C1) 3(3)

Pro-social motivation appeared to be closely linked to the participants’ intrinsic motivation where pro-social motivation drives intrinsic motivation to enhance lean. Even more interesting, the data shows that lean is able to reduce job demands which can be a reason for participants to continue with lean since non-value adding activities are reduced and time could be spend on value-adding activities, for the patient for example.

The lean practitioner (B1) of case 2 stated the following about this phenomenon;

‘But the nurse has a little bit less pressure and more time for the patient. So, gain for patient’. A senior nurse of case 3 stated the following about the suggested phenomenon;

‘I think the work pressure of nurses is lower when you work with lean. Eventually this is beneficial for the patient because there is more space and time for the patient’.

In short, intrinsic and pro-social motivation was clearly visible in all three cases and extrinsic motivation only seemed to play a small role for case 1, however extrinsic rewards are clearly not their main motivator, besides, lean is also being implemented there and they do not receive anything extra for implementing lean which shows us that an extrinsic reward is not needed there, to some extent.

Theoretical framework revisited

Figure 17- Theoretical framework revisited

Additional chapters

The next chapters that are presented represent the additional findings of the within-case analysis. The chapters will highlight aspects that were not included in the suggested theoretical framework initially but came to light in the interviews.

The role of a manager, senior nurse or a lean belt

Besides the suggested theoretical framework, another important aspect came to light considering successful implementation of lean. This study has already shown that implementation of lean can positively influence day to day business in departments but besides being intrinsically- and pro-socially motivated to make it work, another important aspect that is not included in the suggested theoretical framework was illuminated. This aspect is highlighted because is related to the field of change management

lean and which aspects of lean they wanted to implement. All participants of all cases argued for a bottom-up approach considering lean.

The greenbelt (A5) of case 1 stated the following;

‘Besides that, they should give teams space in order to solve it for themselves.’

A quality advisor (B4) stated the following two things about the bottom-up approach of case 2;

‘The line is in the lead.’

‘Involve all those who are affected. Involve the basis, those who participate in processes or subjects.’ A senior nurse (C1) of case 3 stated the following about a bottom-up approach;

‘Make sure that it (lean) will be carried, make sure that all information arrives at those who are involved and also listen to those who are involved’.

All of the participants argued for a bottom-up approach. The ‘bottom’ is mostly involved in the processes where lean can achieve its efficiency gains, in terms of hard aspects. However, achieving those gains, commitment is needed to implement lean in the first place. However, all three cases compared there is reason to believe that case 1 enhances a slightly more top-down approach according to the greenbelt. The within-case analysis shows that participants argued that a top-down approach is more present whereas bottom-up is mostly favoured according to all date. The greenbelt (A5) stated the following things about the top-down approach;

‘Let’s start with the board, black belt and management, they should be realistic about what to expect of a green belt.’

‘Well it is expected by the black belt that I do a number of projects each year, which is also being monitored.’

for the implementation and continuation of lean. The manager, senior or greenbelt are often the initiators of new projects.

The greenbelt (A5) of case 1 stated the following about him, lean and new projects:

‘So, I’m one of the driving forces of the paramedical department, together with my superior.’ One of his colleagues (A1) stated the following considering new lean projects which indicates the importance of the greenbelt or his superior;

‘I will hear from them if they need me and if there is something going on I will see what I can do.’ The lean practitioner (B1) stated the following about the importance of a department manager;

‘The most important is commitment of the one in charge in order to facilitate everyone.’

Lastly, the medical specialist (C3) said the following about the importance of senior nurses;

‘Yes, very important because they (seniors) are a constant factor and they facilitate […].’ Apparently, every case had and needed a lean champion to be sure of the implementation of lean. In these three cases a manager, senior nurses and greenbelt were the lean champions of the departments. This does not mean that other organizations necessarily need a as lean champion as long as they have a lean champion to manage the change, that is the most important.

For case 2 and 3, this phenomenon was quite obvious since every department had their own ‘level’ of implemented lean. Some departments within the healthcare organization were large steps ahead of other departments due to their department manager who was interested in lean and very committed to lean in terms of lean events etcetera.

The medical specialist (C3) of case 3 stated the following about differences between departments;

This could be a risk if the organization wants to implement lean, enhances bottom-up, but is not able to get the manager moving. Implementation of lean in this scenario can be hard since the managers play a crucial role for motivating other team members and distributing information about lean.

Theoretical framework revisited

Figure 18 below presents the final modification of the revisited theoretical framework. The chapter above discussed how a manager, senior nurse or lean belt can be beneficial for the implementation and continuity of lean. Participants often referred to such a lean champion and therefore it can be concluded that they play an important role for lean. Participants often referred to other departments or teams which had not achieved the same level of lean. The chapter above suggests that an important reason for this phenomenon is the availability of a lean champion for each department or team. As figure 18 shows, the lean champion is a condition for lean itself since it can influence the level of lean per team of department.

Lean as a communication tool

Regarding the suggested theoretical framework, the influences of lean on the job demands and job resources and the motivation for employees have been discussed, but how and in what way lean was able to influence the job demands and job resources has not yet been explained. During the interviews lean has been acknowledged to function as a pair of glasses to see problems going on in the organization. Even though communication is not part of the current ideas about lean, the within-case analysis shows that communication was found to be one of those problems.

The within-case analysis has pointed out that lean is often used as a communication tool in healthcare organization. From a continuous improvement perspective, the organizations try to improve their efficiency. Apparently lot of time is wasted due to excessive communication, for example writing e-mails back and forth all the time. The within-case analysis shows that all three organization experienced that over communication is a waste-full activity. Lean was able to reduce the over communication according to the within-case analysis.

The department manager of case 2 (B2) said the following about this type of over processing;

‘We work a lot with e-mails. I sometimes call myself a mail manager, so I recently said that we should stop that too’.

Another example is boards to start the day or to start a week. All three cases enhanced the principle of starting the day with a board to briefly discuss the upcoming day as became clear from the descriptions in the within-case analysis. Participants recalled that the boards allow them to briefly discuss the upcoming day or upcoming week efficiently. The board allowed them to discuss the problems they are facing, how other could help them and how they could assist others in doing their job.

A physiotherapist (A4) of case 1 stated the following about improved communication;

‘Every day we ‘open’ the day and talk about it. Now we have discussed everything in about fifteen minutes instead of sending e-mails the whole day, however it is important to do it as a team

Case 3 has implemented a so-called ‘praatpaal’ in one of their departments which was also able to reduce inefficient communication as the senior nurse (C1) of the concerning department;

‘That is for doctors, midwives but also for paediatricians which saves us a lot of calling back and forth for not urgent cases.’

Theoretical framework revisited

The reason why this chapter is not added to the suggested theoretical framework is due to the fact that this reduction of waste through communication is one of the ways how waste can be reduced. This waste reduction is able to influence the job demands of employees, however there are probably a lot more of these ways to reduce job demands for employees waiting to be discovered. Including all these aspects would make the model unclear as research on this subject continues. The same holds for the next inductive chapter that will be presented; lean to align. Lean to align is also one of the ways how lean influences the waste reduction and job demands. Including all these aspects would make the model too extended.

Lean to align

This paragraph will closely link to the precious paragraph of communication. Lowering job demands is not only acquired through more adequate communication for each department or team but also through more alignment between different departments, hierarchical layers or teams. Looking at the within-case analysis, the data did not directly provided evidence for more alignment in case 1. The different nature of case 1 might be an explanation why alignment was less evident there. Cases 2 and 3 are both hospitals and as the within-case analysis shows, all participants argued that lean leads to more efficient alignment between different departments, hierarchical layers and teams for example through improved communication.