THE INFLUENCE OF CONTINUOUS IMPROVEMENT ABILITIES ON PROBLEM SOLVING BETWEEN DIFFERENT LEAN MATURITY LEVELS

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THE INFLUENCE OF CONTINUOUS

IMPROVEMENT ABILITIES ON

PROBLEM SOLVING BETWEEN

DIFFERENT LEAN MATURITY LEVELS

Master Thesis

THOMAS FRANSEN

Student number: 2799944 t.j.fransen@student.rug.nl

MSc Supply Chain Management

30 January 2017

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ABSTRACT

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1. INTRODUCTION

Putting the patient first is a goal which every professional in the healthcare industry wants to achieve; however, with the current urgency of curbing care costs whilst attempting to improve quality, professionals are seeking for innovative solutions outside their industry boundaries (Hyer, Wemmerlöv, & Morris, 2009). One of the latest management philosophies promising to solve the mentioned dilemma and entering the healthcare sector is Lean (Mazzocato, Savage, Brommels, Aronsson, & Thor, 2010). The term lean was created to describe Toyota‘s operations during the late 1980s. It‘s also known as the Toyota Production System (TPS) and has the core idea of maximizing customer value whilst minimizing waste (Womack, Jones, & Roos, 1990). Multiple studies evaluating lean practices across a wide array of healthcare fields have shown benefits such as improved quality, access, efficiency and a reduced mortality to both patients and staff (Mazzocato et al., 2010; Wright & McSherry, 2013). According to Mazzocato et al. (2010), there are two main traditions of lean, namely: toolbox lean and lean thinking, with the former being a practical approach and the latter being a more philosophical approach. The danger with the practical approach in the public sector, however, comes from the fact that a focus on tools and techniques will be built on a foundation of sand without basic knowledge of the philosophical approach that addresses the organization‘s learning processes (Bush, 2007; Radnor & Walley, 2008; Weber, 2006). This is supported by Mazzocato et al. (2010), who mention the importance of tools, but also stress out the greater importance of developing a routinized learning capability. The focus on learning in lean initiatives, however, is not new. Spear (2005) already indicated that learning how to improve care continuously can lead to financial savings, as well as savings in lives.

Research suggests that organizational learning can occur through problem solving, as the removal of recurring problems contributes to improvement (Tucker, Edmondson, & Spear, 2002). According to Argyris (1977), organizations can either engage in single or in double loop learning. Analogous to single and double loop learning are first- and second-order problem solving. The former approach is focused on merely fixing an occurring problem, whereas the latter approach focuses on diagnosing the problem and attempting to find and correct the underlying causes of the problem. Following the research of Tucker et al. (2002), it is mentioned that front-line workers are best positioned to identify, analyse and resolve problems which contribute to organizational learning.

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5 As an organization progresses through a lean initiative, its adoption and also maturity increases. Similarly, the way problems are approached also changes as an organization‘s lean maturity increases. This research aims to address how CI capabilities influence this relationship between lean maturity (in terms of adoption of the lean initiative) and second-order problem solving in nursing teams. Research by Van Beveren (2015) has shown a positive relationship between lean maturity and second-order problem solving; however, their definition of lean maturity lacks rigor and could be enhanced by using a lean service maturity measurement instrument, as proposed by Malmbrandt & Åhlström (2013). Furthermore, Jørgensen, Boer, & Laugen (2006) conducted a critical review of the CI core abilities. They have found that not all core abilities are equally important and also mentioned that progress is achieved by targeting specific development efforts to match an organization‘s goals; however these goals differ depending on the level of lean maturity in an organization (Guimarães & Carvalho, 2014). Hence the main research question is: How do CI abilities influence the relationship between lean maturity and second-order problem solving? In order to answer this question, a multiple case study with semi-structured interviews that includes nursing teams from two different Dutch hospitals will be included. All the teams are currently at various stages of implementing a lean-based improvement program called ―The Productive Ward – Releasing Time to Care‖, which is aimed at increasing the time nurses can spend on direct patient care. The generated results aim to offer details on which CI capabilities are more important when implementing lean programs, such as Productive Ward. It also aims to address how these capabilities affect the problem solving behaviour on different maturity levels of lean implementation.

The next section will give an in-depth analysis of the theoretical background. It is followed by a methodology section that includes a conceptual framework, a research methodology, as well as the research method and how data collection is carried out. The results section will include the relevant results of this study. This is then followed by the final three sections, namely the discussion, conclusion and limitations as well as recommendations for further research.

2. THEORETICAL BACKGROUND

This section serves as the foundation of the paper. The concepts that will be expanded upon here are: lean in healthcare, lean maturity, continuous improvement capabilities and second-order problem solving. In all subsections the current state of research will be pointed out with respect to the links between all concepts. Lastly, the conceptual model is elaborated upon to create a better understanding of the relationships between the concepts and the gap this research addresses.

2.1 Lean in Healthcare

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6 way to add value, reduce waste and improve continuously. Even though improvement efforts regarding efficiency in healthcare have been around since the 1970s, the introduction of lean in healthcare is relatively new (Radnor, Holweg, & Waring, 2012). According to Brandao de Souza (2009), the inclusion of the term lean in healthcare first appeared at the National Health Service (NHS) in 2001, followed by research of Allway and Corbett in 2002. Since then, lean has been embraced and adopted by healthcare organizations and the number of publications has been growing rapidly (Brandao de Souza, 2009; D‘Andreamatteo, Ianni, Lega, & Sargiacomo, 2015; Papadopoulos, Radnor, & Merali, 2011).

Despite the increasing popularity, many researchers also address two recurring key issues that occur with implementing lean in healthcare. First, the implementation of lean initiatives remains relatively isolated (Brandao de Souza, 2009; Burgess & Radnor, 2013; Costa & Godinho Filho, 2016; D‘Andreamatteo et al., 2015; Mazzocato et al., 2010; Papadopoulos et al., 2011; Radnor et al., 2012). Many of the projects focus on a single process or department instead of implementing an integrative or system-wide approach. Recent research by Costa & Godinho Filho (2016), however, shows there‘s an increase in publications addressing a system-wide approach. Second, the implementation of lean tends to focus on the application of tools (Burgess & Radnor, 2013; Costa & Godinho Filho, 2016; Radnor et al., 2012; Radnor & Walley, 2008). Staff simply imitates a limited range of manufacturing tools, leading to a superficial implementation in which the basic conditions of lean are not in place (Costa & Godinho Filho, 2016; Radnor & Walley, 2008). This is supported by Mazzocato et al. (2010), who say tools are important, but also stress out the greater importance of developing a routinized learning capability. The focus on learning, however, is not new. Spear (2005) indicated that within the best performing organizations managers and front-line workers need coaching to learn how to continuously improve processes through experimentation and reduce systematic uncertainty in who is responsible for what, when and how.

2.2 Lean maturity

According to Hasle et al. (2016), maturity is a term used to assess the level of lean adoption in an organization. A significant amount of literature, mainly related to manufacturing, has attempted to define measurable constructs of lean (Guimarães & Carvalho, 2014), but it remains hard to define constructs as there is much conceptual confusion on the definition of lean (Shah & Ward, 2007). Both Malmbrandt & Åhlström (2013) and Guimarães & Carvalho (2014) have reviewed the literature surrounding lean adoption and found three similar dimensions, or items, that were continuously mentioned:

 Enablers or lean readiness or preconditions

 Lean practices or lean hard and soft deployment

 Performance or lean outcomes

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7 Hadid, Mansouri, & Gallear, 2016; Shah & Ward, 2007). The distinction also finds overlap with one of the mentioned key issues of lean in healthcare, in which a focus on tools is more evident, as opposed to creating learning capabilities (Brandao de Souza, 2009; Mazzocato et al., 2010; Spear, 2005).

One of the more comprehensive tools to assess the adoption of lean is the Lean Enterprise Self-Assessment Tool (LESAT), developed by the Lean Aerospace Initiative. This qualitative tool measures 54 lean enterprise practices. It is based on the Capabilities Maturity Model for software (CMM) and it defines five generic maturity levels (Nightingale & Mize, 2002). LESAT was originally intended to be used in a manufacturing setting, but Malmbrandt & Åhlström (2013) adapted the five generic levels to fit into a new, but similar instrument which addresses a service setting. Based on literature regarding lean service, their instrument consists of 34 items and focuses on enablers, practices and performance (Table 1).

Table 1 Lean Service Maturity Model (Malmbrandt & Åhlström, 2013)

Generic definition of maturity levels

Level 1 No adoption: problems are often explicit and solutions often focus on symptoms instead of causes

Level 2

Knowing Lean

General awareness: start of searching for proper tools and methods, problem solving is becoming more structured. Informal approach in a few areas with varying degrees of effectiveness

Level 3

Understanding Lean

Systematic approach: most areas involved, but at varying stages. Experimentation using more and more tools and methods and employees start following-up work using metrics

Level 4

Thinking Lean

On-going refinement: all areas involved, but at varying stages. Improvement gains are sustained

Level 5

Lean Culture

Exceptional, well-defined, innovative approach: all areas are involved at the advanced level. Improvement gains are sustained and challenged systematically. Innovative solutions to common problems, recognized as best practice/role model

2.3 Continuous Improvement capabilities

Continuous Improvement (CI) gives organizations the ability to create a planned and organized system to discover and implement process changes (Anand, Ward, Tatikonda, & Schilling, 2009). Bessant & Francis (1999) further define CI as a bundle of behavioural routines that describe how an organization approaches issues of learning, innovation and renewal. It also corresponds closely to what is more universally known as ―Kaizen‖. Two of the major contributors to this field of research have been Bessant & Caffyn (1997), who have developed the CI capability model (Table 2). This evolutionary model describes the behaviour attributed through different ―stages‖ of CI capabilities and is further elaborated upon in their succeeding work (Bessant, Caffyn, & Gallagher, 2001; Bessant & Francis, 1999). The CI capability model also uses the CMM as its foundation, from which the levels are developed. The levels are determined through establishing the most important factors and then deriving statements from these factors that characterize an organization at that specific level.

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8 organizations do not necessarily follow the linear path through the levels as described by Table 2. They have found cases in which elements of different levels are present and claimed that instead of progressing through the stages, it is important to select specific CI development efforts, or practices, which are in line with the strategic goals of an organization. This is supported by other case studies, which have shown there is no best way to implement CI and that implementation is specific to the organization (Jørgensen, Boer, & Gertsen, 2003; Kerrin, 1999; Savolainen, 1999). This is because CI is seen as a capacity that must be developed (Boer & Gertsen, 2003).

Table 2 CI Capability Model (Bessant et al., 2001)

Definition Level 1

Trying out the ideas

Interest in the concept has been triggered - by a crisis, by attendance at a seminar, by a visit to another organisation, improving the organisation etc. - but

implementation is on an ad hoc basis

Level 2

Structured and systematic CI

There is formal commitment to building a system which will develop CI across the organisation

Level 3

Strategic CI

There is a commitment to linking CI behaviour, established at ‗local‘ level to the wider strategic concerns of the organisation

Level 4

Proactive CI

There is an attempt to devolve autonomy and to empower individuals and groups to manage and direct their own processes

Level 5

Full CI capability Approximates to a model ‗learning organisation‘

The CI capability model is supported by a set of core abilities, which are deemed essential for long-term success (Table 3). These abilities are connected to key behaviours, which are shown by employees in an organization (Bessant & Caffyn, 1997). In order to evolve, an organization has to exhibit practices that enable the key behaviours. These enablers can take a variety of forms, such as management involvement, company policies and practices, resources, structures, training and procedures (Caffyn, 1999; Garcia-Sabater, Marin-Garcia, & Perello-Marin, 2012).

Table 3 Core abilities and key enablers (Caffyn, 1999)

Core abilities Key behaviours I: The ability to link CI activities to the

strategic goals of the company

1: Employees demonstrate awareness and understanding of the organization‘s aims and objectives

2: Individuals and groups use the organization‘s strategic goals and objectives to focus and prioritise their improvement activities

II: The ability to strategically manage the development of CI

3:The enabling mechanisms (e.g. training, teamwork, methodologies) used to encourage CI are monitored and developed

4: On-going assessment ensures that the organisation‘s structure, systems and procedures, and the approach and mechanisms to develop CI, consistently reinforce and support each other

III: The ability to generate sustained involvement in CI

5: Managers at all levels display active commitment to, and leadership of, CI

6:Throughout the organization people engage proactively in incremental improvement

IV: The ability to move CI across organizational boundaries

7: There is effective working across internal and external boundaries at all levels

V: The ability to learn through CI activity

8: People learn from their own and others‘ experiences, both positive and negative

9: The learning of individuals and groups is captured and deployed

VI: The ability to articulate and demonstrate CI values

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9 2.4 Second-order problem solving

The goal of lean is to add value and remove waste through continuous improvement of processes (Womack & Jones, 1996). Problem solving, in the sense of removing recurring problems, contributes to this improvement (Tucker et al., 2002). Research has distinguished two types of problem solving which are analogous to the concepts of organizational learning (Argyris, 1977, 1995; Tucker et al., 2002). One could solve the problem without looking at the underlying causes (Model I), but also solve a problem by addressing the underlying causes (Model II). Young, Corsun, & Shinnar (2004) address the former as looking at symptoms and the latter as looking at problems. Tucker & Edmondson (2003) address the same two types differently, namely as first-order problem solving and second-order problem solving. Furthermore, Tucker et al. (2002) also mention that front-line workers are best positioned to identify, analyse and resolve problems which contribute to organizational learning. When observing these front-line workers, Tucker & Edmondson (2003) could distinguish five broad types of problems that they experience (Table 4). These were most likely to surface when preparing for patient care or from a breakdown in information or material transfer to the nurse.

Table 4 Broad types of problems (Tucker & Edmondson, 2003)

Problem type

1 Missing or incorrect information 2 Missing or broken equipment

3 Waiting for a (human or equipment) resource 4 Missing or incorrect supplies

5 Simultaneous demands on their time

First-order problem solving, also dubbed ‗fire fighting‘ (Young et al., 2004), occurs during a disruption of work where compensation for the issue is needed. The root causes are not looked upon, thus the chances of the problem recurring still remain. Even though this form of problem solving is often widely celebrated (Young et al., 2004), it appears to be mostly counterproductive as it keeps communication of problems isolated (Tucker & Edmondson, 2003). In general, there are two strategies that imply first-order problem solving; do what it takes to continue the task and asking for help from those that are socially close instead of those who are best qualified for the task (Tucker & Edmondson, 2003).

Second-order problem solving occurs when besides patching the problem, the underlying causes are also addressed (Tucker et al., 2002). This type of problem solving can have positive effects for an organization due to the fact actual change is achieved; however, in healthcare, second-order problem solving accounts for only a small fraction of all solved problems (Tucker & Edmondson, 2003). According to Tucker & Edmondson (2003), three reasons contribute to the lack of second-order problem solving in healthcare, namely:

 Individual vigilance encourages nurses to take personal responsibility for solving problems immediately, without considering the impact on the system

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 Worker empowerment has left nurses to resolve problems that may originate from elsewhere in the organization; however, the immediate nature of their duties prevents them from spending time away from patient care.

Especially the first reason is of importance, as it encourages a feeling of gratification in nurses through which second-order problem solving is reduced. This feeling of gratification comes from the fact they are overcoming problems on their own (Tucker & Edmondson, 2003).

2.5 Conceptual model

Following the conclusions of Van Beveren (2015), initial research indicates there is a positive relationship between lean maturity and second-order problem solving in nursing teams (Figure 1). The research, however, lacks rigor when defining lean maturity and second-order problem solving, as they employed a binary measurement (i.e. present or not present) of either construct. Besides this relationship, it is also believed both concepts do affect performance in some way. Research by Malmbrandt & Åhlström (2013) already included performance in their lean maturity instrument, indicating there is a relation between the constructs.

This research will also determine the effects that CI capabilities, as presented by Bessant & Caffyn (1997) and Caffyn (1999), have on the degree of second-order problem solving behaviour with respect to different levels of lean maturity. Research by Bessant & Francis, (1999), Jørgensen et al. (2003, 2006), Kerrin (1999) and Savolainen (1999) have already provided critical assessments of the CI capability model. Especially their conclusion of implementing practices specific to the organization is interesting, as it indicates that the importance of specific core abilities at different maturity levels (due to different goals) is present; however, their assessments focused on performance, rather than problem solving.

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3. METHODOLOGY

The aim of this research is to study how CI capabilities affect the relationship between lean maturity and second-order problem solving as well as establishing the relationship between lean maturity, second-order problem solving and perceived performance. In order to fulfil this aim, a multiple case study method has been chosen, assessing different teams to determine the effects at both different maturity levels, as well as at different problem solving levels. According to Benbasat, Goldstein, & Mead (1987), case studies have several strengths that fit this research in particular, namely; the phenomenon can be examined in its natural setting, the complexity of the unit is studied extensively and case studies tend be useful for the ‗why‘ and ‗how‘ questions that deal with links over time instead of frequency or incidence. Meredith (1998) expands upon these strengths by adding case studies can generate meaningful and relevant theory as well as lending itself to exploratory investigations where the phenomenon is not fully understood yet. Furthermore, multiple cases were selected to augment external validity and help guard against observer bias (Voss, Tsikriktsis, & Frohlich, 2002).

3.1 Sample selection

The sample selection of cases was done by including ward teams currently pursuing the lean-based program Productive Ward. This program, originating from the NHS, was designed to free up more time for direct patient care, change the environment of the ward to improve safety, efficiency and quality of care and to improve both patient and staff experience (Wright & Mcsherry, 2013). It consists out of 13 modules that together form the ‗PW House‘. 3 of the 13 modules are known as basic modules and have to be completed prior to the remaining modules (Wilson, 2009).

Currently, ten different Dutch hospitals have wards pursuing the Productive Ward programme at various stages. Within the hospital, each ward is led by a head nurse, taking final responsibility of the entire ward. Each ward starting the Productive Ward programme is supported by a ‗core team‘ that follows the training associated with a module. This core team consists out of a head nurse and several ‗regular‘ nurses with differing levels of motivation. After training, the core team attempts to spread their acquired knowledge across the ward. For this research, three interviews per ward will be carried out, which will include the head nurse, a core-team nurse and a non-core-team nurse. Due to the fact these wards are at various stages in the Productive Ward programme it is possible to study a range of different maturity levels, as well as second-order problem solving levels.

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12 September 2013 and the last teams started in September 2016. Additional information regarding the teams can be found in Table 5.

Table 5 Research sample data

Hospital Team Introduction Productive Ward Team size Average experience interviewee

Type of care Average interview words

Average interview duration

A A1 September 2013 * 11.8 years Non-acute Care 4515 26m 21s

B January 2015 45 7.3 years Non-acute Care 6341 37m 41s

C March 2015 30 3.7 years Non-acute Care 5852 35m 39s

D June 2015** 34 7.8 years Acute Care 10383 57m 37s

E June 2015 * 5.7 years Acute Care 6715 38m 51s

F June 2015 * 2.7 years Acute Care 7278 44m 44s

G September 2015 31 17.7 years Non-acute Care 5760 36m 45s

H January 2016 * 4.3 years Non-acute Care 6123 37m 14s

I January 2016 40 18.3 years Non-acute Care 6184 37m 37s

J January 2016 30 17.7 years Non-acute Care 6365 38m 12s

K January 2016 20 2.5 years Acute Care 7128 41m 27s

L September 2016 13 14 years Non-acute Care 7738 45m 14s

M September 2015 15 6.5 years Non-acute Care 6271 37m 35s

N September 2016 13 19 years Non-acute Care 6819 43m 54s

B A2 August 2015 * 4.7 years Non-acute Care 8383 43m 36s

* The interviewees were unable to provide this information ** Currently have Productive Ward programme on-hold

3.2 Interview protocol

As mentioned in the previous sections, a series of semi-structured interviews have been carried out for data collection, requiring an interview protocol (Appendix A: Interview protocol). The interview itself is divided into three main sections, addressing the following concepts: lean maturity, second-order problem solving and the factors influencing the relationship between the aforementioned concepts (i.e. CI capabilities, engagement and leadership).

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13 of a sixth question in which the presence of second-order problem solving was asked about directly. The five scenarios, however, remained in the interview protocol as they continued to create valuable insights. The last section addresses the influencing factors. For this research in particular the questions regarding CI capabilities are important. Three open questions have been developed, with a question focusing on which capabilities are required and present, a question asking about the commitment of involved members and a question asking about the links and relations within the hospital.

The first two thirds of the interview will explore the relationship between lean maturity and second-order problem solving, as well as its impact on perceived performance, in more detail. The information collected from this part of the interview will create a better understanding on how problem solving is addressed at different lean maturity stages. The final part will be used to determine which CI capabilities play a more important role throughout the different maturity stages.

3.3 Data collection

Each participant was visited by two of the four researchers taking part in the data collection to decrease the risks of observer bias (Voss et al., 2002). The semi-structured interviews lasted on average 40 minutes and 10 seconds per participant, with a minimum of 24 minutes and 48 seconds and a maximum of 1 hour, 8 minutes and 37 seconds. Standardisation of the interviews was achieved after a reflection session which was held after the initial four interviews to further increase the inter-rater reliability (Voss et al., 2002). All interviewees gave approval to record the interviews on digital recording devices to be transcribed later. These transcripts were then worked out in verbatim to further decrease the risks of observer bias. More details about the length of the interviews and transcripts can be found in Table 5. Due to time constraints the interviewees were unable to review the drafted transcripts for increased accuracy.

In order to improve construct validity, triangulation will be used by including data of the cases from an external source. The data, coming in the form of Multi Moment Analyses and a 10-point checklist for all the completed modules, was sent to the researchers. However, upon further investigation it was decided to exclude this data due to severe inconsistencies in the way the data was measured, as well as a lot of data lacking from these measurements. 3.4 Data analysis

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14 other to end up with 19 categories. The last step, selective coding, related these categories back to the core abilities and key behaviours mentioned by Caffyn (1999).

In order to determine the relationship between lean maturity, second-order problem solving and perceived performance, a rating system was developed. This rating system was developed differently for each concept. Lean maturity was assessed on a 5-point scale (Malmbrandt & Åhlström, 2013). Second-order problem solving used an 8-point scale and was developed by the group of researchers based on the research of Tucker & Edmondson (2003). Lastly, perceived performance used a 4-point scale that was developed by the researchers as well, based on the experience gained in all the interviews (Table 6). Rating was done by each researcher individually and then later compared amongst the researchers to decrease the risks of observer bias. All scales and criteria can be found back in Appendix B: Scaling criteria.

Table 6 Item scales

Second-order problem solving scale Perceived performance scale

1 Nothing, problems are solved solely ad-hoc No clear effects of PW experienced yet 2 Problems are solved ad-hoc, but there is a distinction

based on frequency

Experiences extra time for the patient indirectly through a better organized and more peaceful ward 3 Problem is solved ad-hoc by nurse, but team leader is

informed at that moment

Experiences extra time for the patient (clarified with examples) and has a clear idea of the effects of PW 4 Communicating to the person or department

responsible for the problem

There is demonstrably extra time for the patient (percentages are quoted based on MMAs) 5 Bringing the problem to the attention of the manager

or the head nurse

6 Sharing ideas about the cause of the situation and how to prevent recurrence with someone in a position to implement changes

7 Nurse implements changes

8 Nurse verifies that changes have the desired effect

Lean maturity was based on three enablers and three practices for which a factor analysis was carried out to determine the possibility of merging these items into a single score (Table 7). The resulting KMO from this test was .733 and Bartlett‘s test was significant (p = .000). Furthermore correlations were sufficiently high with the lowest scoring .346 and the highest scoring .649. All items also related to the same construct and were carried on to the Cronbach‘s alpha test for reliability analysis. This resulted in a score of .85, meaning the 6 questions could be averaged out to a single lean maturity score.

Table 7 Factor analysis

Questionnaire item Factor 1 Alpha

[Enabler 1] Understanding of lean by nurses .77 .85

[Enabler 2] Infrastructural elements .73

[Enabler 3] Transfer of information .84

[Practice 1] Understanding value for the patient .77

[Practice 2] Continuous flow .73

[Practice 3] Visualisation .71

Eigenvalue 3.47

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15 For the cross-case analysis all teams have been ranked in high, medium or low levels of lean maturity or second-order problem solving. For this, the researchers believed the maturity levels differed depending on the function (i.e. team leader, core-team or non-core-team), due to different levels of exposure to both the lean enablers and lean practices. Separate scales were developed based on the spread of scores per function (Table 8). Second-order problem solving was rescaled regardless of function (Table 8). This resulted in individual lean maturity and second-order problem solving levels, which were then merged into a single level for each team depending on the dominant individual levels.

Table 8 Cross-case scales

Lean maturity (team leader) Lean maturity (core-team) Lean maturity (non-core-team) Second-order problem solving Low ≤ 2.5 ≤ 2.25 ≤ 2.0 ≤ 3

Medium > 2.5 & ≤ 3.0 > 2.25 & ≤ 2.75 > 2.0 & ≤ 2.5 > 3 & ≤ 5

High > 3.0 > 2.75 > 2.5 > 5

4. RESULTS

This section provides the main results of this research. First, the influence of second-order problem solving on the relationship between lean maturity and perceived performance will be shown in this section. Second, the outcomes from the capabilities in ATLAS.ti are linked with the core abilities and key behaviours of Caffyn (1999). Last, a comparison between teams with different levels of lean maturity and second-order problem solving is made to determine the effects CI capabilities have on their relationship.

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Table 9 Statistical results

Step 1 Step 2 Step 3 Variables b s.d. b s.d. b s.d.

Constant -0.334 0.362 -0.592 0.696 -0.216 0.342

Lean maturity 0.917*** 0.137 1.787*** 0.263 0.560** 0.184

Second-order problem solving 0.200* 0.074

R² 0.511*** 0.518*** 0.583***

N 45 45 45

* p < .05 ** p < .01 *** p < .001

The previous tests have shown that second-order problem solving accounts for partial mediation on the relationship between lean maturity and perceived performance. Furthermore, a Sobel test, which measures the indirect effect of lean maturity on perceived performance via the mediator, was carried out with the result being significant (Z = 2.51, p < .05).

4.2 CI capability outcomes

As mentioned in the methodology section of this thesis, the analysis has found 19 different categories of CI capabilities. Figure 2 presents this data in a visual manner. The categories were then linked to the original key behaviours and core abilities from literature, which can also be found back in the figure, as the numbers in the descriptive codes are linked with the numbers of the capabilities. The relationship between capabilities and core abilities are explained in more detail in the following paragraphs.

Step 1: In-vivo codes Step 2: Descriptive codes

(Capabilities) (Core abilities and key behaviours, Caffyn(1999))

1. Matching initiatives with hospital goals 2. Following Strategic Framework 3. Training in Productive Ward 4. Using available information 5. Using resources in initiatives

6. Approaching problems with PDCA Cycle 7. Having time to work on Productive Ward 8. Using tools to achieve improvements 9. Evaluating progress

10. Management is actively committed 11. Team is committed to improvement 12. Solving problems

13. Team characteristics

14. Being part of a cross-functional team 15. Communicating internally and externally 16. Working on own initiatives

17. Using improvement ideas / suggestions 18. Seeing results of past initiatives 19. Supporting personality traits

I: Link CI activities to strategic goals of company:

 Understanding organization‘s aims / objectives (1)  Activities focused on organization‘s aims (1, 2)

II: Strategically manage the development of CI:

 Enabling mechanisms are monitored and developed (3, 4, 6, 8)  On-going assessment of CI (4, 8, 9)

 new: Resources given to participate in CI (4, 5, 7)

III: Generating sustained involvement in CI:

 Management displays commitment to CI (10)  Proactive incremental improvement (11, 12, 17, 19)

IV: Moving CI across organizational boundaries:

 Working across internal & external boundaries (13, 14, 15)

V: Learn through CI activity:

 Learn from own and other‘s experiences (9, 15, 16, 17)  Learning is captured and deployed (3, 16)

VI: Articulate and demonstrate CI values:

 Shared set of cultural values underpinning CI (6, 15, 18, 19)

Figure 2 Within-case analysis

I: The ability to link CI activities to the strategic goals of the company

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18 improvement, efficiency, quality and more time for direct patient care. When all the elements are taken together, they do show a common goal of improving processes to improve patient care. This is indeed aligned with the hospital‘s goals, as summarized by the non-core-team nurse of team G: “Uh yeah, the goals of the hospital, we have four core values. We try in everything what we do, but mainly in Productive Ward, to focus on the patient”. The second capability, following a strategic framework, was not present in any team; however, teams did express a desire of developing such a framework. The main reason for such a framework is to align all departments to create more uniformity, as this is not always the case, like a core-team nurse from team B noted: “We changed things last year and it was all approved by the hygienic department, but now they follow JCI1 and it all has to be different”. With a strategic framework learned lessons in other wards could be more easily deployed in all wards; however, implementing a strategic framework will come with its challenges as the core-team nurse from team C noted: “So yeah, it also makes it difficult because of the large scale. When it remains within the ward it’s easier to get it done”. In essence, improving processes and patient care seem the main drivers for teams, but a strategic framework could be implemented to improve coordination, ensuring improvement initiatives are aligned with the hospital‘s goals and other wards.

II: The ability to strategically manage the development of CI

In order to strategically manage the development of CI, several capabilities are required. Training is mainly done on a monthly basis. Attendants of these trainings are first and foremost the core-team members, but the inclusion of middle management, doctors or non-core-team nurses is not uncommon. Another capability, important for all key behaviours, is the available information. The main sources of sharing information on progress are the team meetings. These meetings are held at regular intervals (ranging from weekly to once every six weeks) and also serve as a way of transferring information to nurses outside of the core-team. Besides sharing information, there are also a number of teams mentioning that information is better available at the right moment, as the non-core-team nurse from team K said: “Yes, the program has opened a lot of doors on what happens at all the other departments”. Furthermore, the PDCA cycle was used consistently within all teams, with the exception of a few non-core-team nurses. The main reason for using the PDCA cycle was to tackle problems according to its methodology. For some nurses the PDCA cycle is becoming a habit as they move through the stages quicker, like the core-team nurse of team F mentioned: “It took much longer in the beginning, but by now you’re going way quicker [in improvement activities] through the use of the hairdryer-model2”. Next, tools and aids are also used by all teams, but there is a great variety in which tools the teams employ. Examples of tools and aids are: 5S, pictures and videos, the methodology, Multi Moment Analyses (MMAs), a lean improvement board, time and distance measurements, a safety cross and a wishing tree. The main tool, however, is the lean improvement board, as this serves as the foundation of every ward. Measurements and outcomes from all the other tools are eventually reported on this improvement board to increase the spread of information on progress, as the non-core-team nurse from team F shows: “You can’t get around it. Everyone is actually staring at the board

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19 when they’re sitting down”. Some of the tools, like the MMAs, are also used in close connection with evaluation; however, audits, surveys, improvement board meetings, interviews and (core-) team meetings serve as the main pillars of assessing improvement. Most of these practices can be linked to reflecting back on how things have gone previously, but audits also assess the degree to which improvements are embedded within the team.

A new key behaviour was formed by the capabilities of giving time and resources. Resulting from the interviews, it was found that these two capabilities are too important to simply be put into the enabling mechanisms. Time was mentioned by all teams with the main conclusion being that the program is time intensive and the participating nurses do not get sufficient time to fully engage in the program.

III: The ability to generate sustained involvement in CI

In order to generate sustained involvement, management commitment was mentioned by all teams with the main reason of facilitating all the improvements of the wards. Furthermore, the teams that were visited by management saw this as a valuable addition to management commitment, as the nurse from the core-team of team N shows: “The work council also visited us. Those were really interested ladies that were here. It was a real nice conversation back then”. In general, all nurses within the ward were committed to the program, but the levels of commitment were higher for core-team nurses. Furthermore, some teams indicated they also saw commitment from other disciplines. Team commitment is also supported by specific personally traits. These supporting traits span across a wide range, but the most frequently mentioned traits are enthusiasm, motivation, thinking along, responsibility, cooperation, participation, interest and passion. Some teams specifically mentioned the capability of problem solving in which the main consensus was to tackle underlying causes through analysis. The non-core-team nurse from team A1 added to this

consensus by stating “it’s not about finding out who is guilty, but suggesting the right people to work‖. Last, the inclusion of a system for improvement ideas and suggestions is was also mentioned by the teams. The teams that did mention a system mainly asked about the voice of the entire team.

IV: The ability to move CI across organizational boundaries

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20 V: The ability to learn through CI activity

As mentioned before, evaluation mainly reflects on the improvement actions that have been carried out in the past through improvement board meetings, surveys, interviews and (core-) team meetings. These also serve as a way to learn from the experiences of others, as during such meetings all participants share their own experiences. Improvement board meetings are held either weekly or semi-monthly, whereas team meetings range from monthly to a few times per year. Most teams attempt to hold core-team meetings on a weekly basis, but regardless of the interval it can be said that frequency is important. With regard to communication, besides open and honest communication nearly all teams do send a frequent newsletter to keep everyone in the team up-to-date, regardless of their attendance to meetings. Another important factor for teams is individually working on their own initiatives. The majority of the teams mention the use of individual initiatives, which leave room for nurses‘ own ideas and suggestions, as the core-team member from team E shows: “If you think something in a room should be different, just indicate this and you can work on it”. Naturally, the inclusion of training sessions also assists learning because besides the introduction of new theory, there is also the possibility to exchange experiences with other teams during the sessions.

VI: The ability to articulate and demonstrate CI values

The last core ability is supported by four capabilities. Although the PDCA cycle has been mentioned before, it is a key component in demonstrating CI values, as the cycle serves as the foundation for the entire program. The main reason for using the PDCA cycle was its underlying methodology, which is slowly becoming a habit to nurses. As mentioned before, communication should be open and honest, but it should also include all members of the team to be most effective. Furthermore, the supporting personality traits such as thinking along, responsibility, cooperation, participation and interest further help the team to remain committed to their CI values. Last, seeing the results of past initiatives could help nurses further articulate their values. Being able to see the effects of the program definitely helps keep the team on track, as shown by a core-team nurse from team A2: “It costs us less time to

check the fluid intake lists3, so in principle you’re left with more time for direct patient care”. 4.3 Influence of CI capabilities on second-order problem solving

Figure 3 visualizes the maturity levels and second-order problem solving levels of the teams, together with the expected levels for second-order problem solving. For this research several comparisons are of interest (Table 10). First, it is interesting to see the differences between teams scoring high on both maturity and second-order problem solving and teams scoring low on both. Next, teams in the same category of maturity, but with different levels of problem solving can be compared. Finally, as the two pilot teams of both hospitals score identical, it is interesting to determine whether there are similarities in implementation and progress between the role model teams in hospitals.

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21

Figure 3 Research outcomes

Table 10 Selection of groups for cross-case comparison

Group 1 Group 2

Maturity Problem solving Maturity Problem solving Number of teams

Comparison 1 High High Low Low 6

Comparison 2 Low Low Low Medium 5

Comparison 3 Medium Medium Medium Low 6

Comparison 4 High High High Medium 4

Comparison 5 High High High High 2

High maturity and problem solving against low maturity and problem solving

When addressing the main differences between the two categories it becomes clear that teams scoring low on both aspects are at different stages in terms of duration, with the longest team using the program already between 12 and 18 months. First, both low and high scoring groups all aim to create more time for direct patient care and also share similar personality traits such as motivation and enthusiasm. Groups with a low score tend to stick to weekly meetings as prescribed in Productive Ward, but the high scoring groups also employ surveys, questionnaires and regular audits. High scoring teams also use more advanced tools

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22 such as MMAs, assign more value to training and make sure information is more readily available at the places where it‘s needed, as the team leader of team A1 noted: “We’re also

developing bed signs so patients can see who their doctor and nurse are”. There are also differences in management commitment between the two groups. High scoring groups receive regular visits whereas low scoring groups do not, thus management is showing more active involvement in the high scoring groups. Furthermore, the majority of the low scoring group does include cross-functional teams like the high scoring groups, but only do this on an ad-hoc basis. The major difference, however, is the fact all of the low scoring teams end up having disagreements with other departments, whereas the high scoring teams don‘t. High scoring teams also show more signs of individual learning and experimentation. Another remarkable difference is that low scoring teams have a fixed core-team and high scoring teams have rotating core-team members, thus exposing the entire ward to the program.

Low maturity and different levels of problem solving

Within the low scoring teams, team K stands out amongst the rest in terms of problem solving; however, the teams do share a lot of characteristics along multiple core abilities. The teams show common goals, commitment, values and learning methods, mainly because they are all in the early stages of the Productive Ward program, which has required modules. But even though it shares many of its behaviours with the other low scoring teams, team K does have some distinct characteristics that differ from these teams in terms of managing its development. The team makes use of the MMAs as a measurement tool and includes regular audits on its improvement initiatives. Furthermore, management facilitates and thinks along with the needs of the ward, as the team leader team K shows: “It’s much more useful to have a management which thinks along and matches with the needs of the ward. No ward is identical and in that sense I think they’re [management], they are controlling that”.

Medium maturity and different levels of problem solving

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23 High maturity and different levels of problem solving

Within the high maturity teams, teams B and H display lower levels of problem solving. The goals, tools, learning and values off all teams are similar. Management commitment, however, seems to be lower on teams B and H with fewer visits and difficulties in communication. Another major difference is in cross-functional teams. Whereas teams A1

and A2 easily receive support from different disciplines in their improvement efforts, teams B

and H have difficulties getting support from other disciplines, or aren‘t ready yet to receive support. The core-team nurse of team H said for example: “Physician assistants are involved in projects, but we haven’t reached the point yet where we would also need the doctors”. The core-team nurse of team B on the other hand said the following: “During big meetings our manager and doctors are present, but they don’t really have the time”. This means that although these teams are highly developed, it remains hard to move their efforts across organizational boundaries.

Comparison between hospitals

Comparing the two pilot teams from different hospitals mainly shows many similarities. This is due to the training both teams received from the same consulting company. All core abilities are developed nearly equal. For example, both teams address problems in the same way through the PDCA cycle, which has also become a habit to both teams. There is also little variation in the tools which are employed as well as the frequency they use them. In terms of training and evaluation both teams also show similarities; however, with team A1 being in the program nearly two years longer it can be seen instruction of

trainings is coming from within the ward instead of an external party. Lastly, both teams also encourage projects to be carried out individually.

5. DISCUSSION

The cases, as described in the previous sections display some common characteristics that show the development of CI capabilities as maturity progresses. Many of the enabling and inhibiting factors mentioned by Garcia-Sabater et al. (2012) are found back throughout the cases and have been linked to the key behaviours of Caffyn (1999). However, this research also found a new key behaviour ―resources given to participate in CI‖ that was not mentioned by Caffyn (1999). Even though it was not part of the original behaviours it is supported by Garcia-Sabater et al. (2012), who mention resources are required for sustained continuous improvement. They also mention the workload of these activities should be part of the daily routine, as opposed to it being done outside normal business hours. Working outside normal business hours (e.g. coming back to work for Productive Ward meetings) or working at odd hours (e.g. using night shifts for improvement activities) were mentioned frequently by nurses.

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24 used for measurement and training in how to approach problems, such as the PDCA cycle. The main enabler from level 2 that is present within the teams is the selection of processes that need improvement. The Productive Ward program deems the first three modules as mandatory, but afterwards teams are free to follow additional process modules of their own choice. Furthermore, Garcia-Sabater et al. (2012) also mention worker involvement through material incentives as a level 2 enabler to avoid resistance to change. This could be a valuable addition to the program, as it isn‘t present yet. Within level 3, an enabler that is present within the teams is the use of cross-functional teams. Even though not all teams are at the point of structurally including cross-functional teams, it is a valuable addition to shared problem solving. Examples of enablers within levels 4 and 5 could not be found in any of the teams. This is due to a limiting factor of the Productive Ward program itself, as the main focus of the program is a single ward. This is opposite of what the levels represent, as these levels are more concerned about the organisation as a whole.

Jørgensen et al. (2006) found that not all core abilities have equally strong relationships with performance. They designated the ability to strategically manage the development of CI (core ability II) as having the strongest relationship and the ability to generate sustained involvement in CI (core ability III) as having the weakest relationship with performance. All the other core abilities remained in between the extremes of core abilities II and III. In comparison, this research also found several capabilities which relate to care ability II; however, core ability III, which was the weakest in research by Jørgensen et al. (2006), was also supported by several capabilities. This difference can be explained by the fact that Jørgensen et al. (2006) focused on the effects on performance, whereas this research focuses on the effects on second-order problem solving, which is the development of a specific ability. Development of key abilities over time does involve continuity to maintain the existing CI level (Aloini, Martini, & Pellegrini, 2011).

As shown in the statistical section of the results, there is a positive relation between second-order problem solving and lean maturity. According to Tucker & Edmondson (2003) one of the main levers to change from first-order problem solving to second-order problem solving is management support. They underpin this argument by stating managers must be visible on the work floor, create a safe environment where employees are free to talk and last, give feedback and responding to initiatives. When looking at the results of management commitment from this research, it can indeed be seen that teams with higher levels of lean maturity and problem solving do receive more support in terms of facilitating improvement efforts and visibility on the work floor.

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25 between espoused theories (i.e. desirable behaviours) and theory-in-use (i.e. conventional wisdom).

A remarkable difference can be found when comparing teams in an acute care setting with teams in a non-acute care setting. 2 out of the 4 acute care teams deviate from their predicted second-order problem solving level, as opposed to only 3 out of the 11 non-acute care teams. The acute care teams also account for the longest duration within the low maturity group and partially within the medium maturity group. Little research has been carried out regarding the differences between acute and non-acute care from an operations management point of view; however, as acute care largely depends on frequent, rapid and time-sensitive intervention, the impact of both natural and artificial variability will have a larger effect on staffing and capacity (Hirshon, Risko, & Calvello, 2013; Litvak et al., 2005).

Last, the scenarios developed by van Beveren (2015) were validated by six experts with different backgrounds in healthcare; however, when presenting these scenarios to the interviewed nurses of this research, the majority of the nurses mentioned most of the scenarios do not pose a problem during the majority their daily duties. Some scenarios were already prevented or solved through protocols (e.g. simultaneous demand of doctors was tackled by assessing criticality or asking help for colleagues, but the occurrences were not prevented) and other scenarios caused confusion on their duties (e.g. nurses do not intervene in treatment plans and doctors do not intervene in how care is delivered). This gives reason to believe scenarios regarding the broad types of problems by Tucker & Edmondson (2003) need more specific fine tuning to the research setting for proper assessment.

6. CONCLUSION

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26 The results also have theoretical implications, as it confirms the findings of the development of core abilities specific to the organization (Bessant & Francis, 1999; Jørgensen et al., 2003, 2006; Kerrin, 1999; Savolainen, 1999). However, different development with respect to previous research was found. Jørgensen et al. (2006) found the ability to create sustained involvement in CI as having the weakest relationship, whereas this research found it had several linked capabilities, together with the ability to learn from CI activities. This is due to the distinction between the ‗harder‘ and ‗softer‘ sides of CI. Second-order problem solving has a stronger relation with the ‗softer‘ side of CI, as opposed to performance, which is more related to the ‗harder‘ side of CI.

Besides theoretical implications, the research also has managerial implications. Mainly, it provides managers with areas of CI capabilities which are most important to improve problem solving. Managers should also take into account the amount of resources dedicated to CI as this research has shown many teams do not get sufficient time to engage in CI.

7. LIMITATIONS AND FURTHER RESEARCH

This research has several limitations. The first limitation is the fact this research was solely based on the interviews taken from the teams. Additional sources of data were initially planned to be included, but were subsequently deemed invalid due to large amounts of lacking data. Next, all interviewed teams were operating in hospitals, thus making the results less generalizable to different sectors that embark on lean improvement initiatives. Furthermore, the total of 45 interviews is relatively small for regression analysis. Last, part of the previous case studies carried out in CI were longitudinal within a single case, as opposed to this cross-sectional multiple case study. Longitudinal studies decrease the likeliness of differences between teams, as the development of capabilities over time is assessed by a fixed sample, but do come at an additional cost.

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REFERENCES

Aloini, D., Martini, A., & Pellegrini, L. (2011). A structural equation model for continuous improvement: a test for capabilities, tools and performance. Production Planning & Control, 22(7), 628–648.

Anand, G., Ward, P. T., Tatikonda, M. V., & Schilling, D. A. (2009). Dynamic capabilities through continuous improvement infrastructure. Journal of Operations Management, 27(6), 444–461.

Argyris, C. (1977). Double loop learning in organizations. Harvard Business Review, 55(5), 115–125.

Argyris, C. (1995). Action science and organizational learning. Journal of Managerial Psychology, 10(6), 20–26.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182.

Benbasat, I., Goldstein, D. K., & Mead, M. (1987). Strategy in Studies of Information Systems. MIS Quarterly, 11(3), 369–386.

Bessant, J., & Caffyn, S. (1997). High-involvement innovation through continuous improvement. International Journal of Technology Management, 14(1), 7.

Bessant, J., Caffyn, S., & Gallagher, M. (2001). An evolutionary model of continuous improvement behaviour. Technovation, 21(2), 67–77.

Bessant, J., & Francis, D. (1999). Developing strategic continuous improvement capability. International Journal of Operations & Production Management, 19(11), 1106–1119. Boer, H., & Gertsen, F. (2003). From continuous improvement to continuous innovation: a

(retro)(per) spective. International Journal of Technology Management, 26(8), 805–827. Brandao de Souza, L. (2009). Trends and approaches in lean healthcare. Leadership in Health

Services, 22, 121–139.

Burgess, N., & Radnor, Z. (2013). Evaluating lean in healthcare. International Journal of Health Care Quality Assurance, 26(3), 220–235.

Bush, R. W. (2007). Reducing waste in US health care systems. JAMA : The Journal of the American Medical Association, 297(8), 871–874.

Caffyn, S. (1999). Development of a continuous improvement self-assessment tool. International Journal of Operations & Production Management, 19(11), 1138–1153. Costa, L. B. M., & Godinho Filho, M. (2016). Lean healthcare: review, classification and

analysis of literature. Production Planning & Control, 7287(February), 1–14.

D‘Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9), 1197–1209.

Garcia-Sabater, J. J., Marin-Garcia, J. A., & Perello-Marin, M. R. (2012). Is implementation of continuous improvement possible? An evolutionary model of enablers and inhibitors. Human Factors and Ergonomics In Manufacturing, 22(2), 99–112.

(28)

28 Guimarães, C. M., & Carvalho, J. C. de. (2014). Assessing Lean Deployment in Healthcare—

A Critical Review and Framework. Journal of Enterprise Transformation, 4(1), 3–27. Hadid, W., & Mansouri, S. (2014). The lean-performance relationship in services: a

theoretical model. International Journal of Operations & Production Management, 34(6), 750–785. https://doi.org/10.1108/IJOPM-02-2013-0080

Hadid, W., Mansouri, S. A., & Gallear, D. (2016). Is lean service promising? A socio-technical perspective. International Journal of Operations & Production Management, 36(6), 618–642.

Hasle, P., Nielsen, A. P., & Edwards, K. (2016). Application of Lean Manufacturing in Hospitals—the Need to Consider Maturity, Complexity, and the Value Concept. Human Factors and Ergonomics in Manufacturing & Service Industries, 26(4), 430–442.

Hirshon, J., Risko, N., & Calvello, E. (2013). Health systems and services: the role of acute care. Bulletin of the World Health Organization, 91(5), 386–388.

Holweg, M. (2007). The genealogy of lean production. Journal of Operations Management, 25(2), 420–437.

Hyer, N. L., Wemmerlöv, U., & Morris, J. A. (2009). Performance analysis of a focused hospital unit: The case of an integrated trauma center. Journal of Operations Management, 27(3), 203–219.

Jørgensen, F., Boer, H., & Gertsen, F. (2003). Jump-starting continuous improvement through self-assessment. International Journal of Operations & Production Management, 23(10), 1260–1278.

Jørgensen, F., Boer, H., & Laugen, B. T. (2006). CI Implementation: An Empirical Test of the CI Maturity Model. Creativity and Innovation Management, 15(4), 328–337.

Kerrin, M. (1999). Continuous improvement capability: assessment within one case study organisation. International Journal of Operations & Production Management, 19(11), 1154–1167.

Litvak, E., Buerhaus, P. I., Davidoff, F., Long, M. C., McManus, M. L., & Berwick, D. M. (2005). Managing Unnecessary Variability in Patient Demand to Reduce Nursing Stress and Improve Patient Safety. The Joint Commission Journal on Quality and Patient Safety, 31(6), 330–338.

Malmbrandt, M., & Åhlström, P. (2013). An instrument for assessing lean service adoption. International Journal of Operations & Production Management, 33(9), 1131–1165. Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean thinking in

healthcare: a realist review of the literature. Quality & Safety in Health Care, 19(5), 376– 382.

Meredith, J. (1998). Building operations management theory through case and field research. Journal of Operations Management, 16(4), 441–454.

Nightingale, D. J., & Mize, J. H. (2002). Development of a Lean Enterprise Transformation Maturity Model. Information, Knowledge, Systems Management, 3(1), 15–30.

Papadopoulos, T., Radnor, Z., & Merali, Y. (2011). The role of actor associations in understanding the implementation of Lean thinking in healthcare. International Journal of Operations & Production Management, 31(2), 167–191.

(29)

29 Social Science and Medicine, 74(3), 364–371.

Radnor, Z., & Walley, P. (2008). Learning to Walk Before We Try to Run : Adapting Lean for the Public Sector. Public Money & Management, 28(1), 13–20.

Savolainen, T. I. (1999). Cycles of continuous improvement: Realizing competitive advantages through quality. International Journal of Operations & Production Management, 19(11), 1203–1222.

Shah, R., & Ward, P. T. (2007). Defining and developing measures of lean production. Journal of Operations Management, 25(4), 785–805.

Spear, S. J. (2005). Fixing healthcare from the inside, today. Harvard Business Review, September(September 2005), 13.

Strauss, A., & Corbin, J. (1990). Basics of qualitative research: grounded theory procedure and techniques. Qualitative Sociology, 13(1), 3–21.

Tippmann, E., Scott, P. S., & Mangematin, V. (2012). Problem solving in MNCs: How local and global solutions are (and are not) created. Journal of International Business Studies, 43(8), 746–771.

Toussaint, J., & Gerard, R. A. (2010). On the Mend : Revolutionizing Healthcare to Save Lives and Transform the Industry. Lean Enterprise Institute.

Tucker, A. L., & Edmondson, A. C. (2003). Why Hospitals Don‘t Learn from Failures: California Management Review, 45(2), 55–72.

Tucker, A. L., Edmondson, A. C., & Spear, S. (2002). When problem solving prevents organizational learning. Journal of Organizational Change Management, 15(2), 122– 137.

van Beveren, S. (2015). The Impact of Lean on the Problem- Solving Behaviour of Nurses. Ghent. Retrieved from http://lib.ugent.be/fulltxt/RUG01/002/215/497/RUG01-002215497_2015_0001_AC.pdf

Voss, C., Tsikriktsis, N., & Frohlich, M. (2002). Case research in operations management. International Journal of Operations & Production Management (Vol. 22).

Weber, D. O. (2006). Toyota-style management drives Virginia Mason. Physician Executive, 32(February), 12–17.

Wilson, G. (2009). Implementation of releasing time to care - The productive ward. Journal of Nursing Management, 17(5), 647–654.

Womack, J. P., & Jones, D. T. (1996). Lean Thinking by Womack and Jones. Review Literature And Arts Of The Americas, (November), 5.

Womack, J. P., Jones, D. T., & Roos, D. (1990). The Machine that Changed the World: The Story of Lean Production. Simon and Schuster.

Wright, S., & Mcsherry, W. (2013). A systematic literature review of Releasing Time to Care: The Productive Ward. Journal of Clinical Nursing, 22(9–10), 1361–1371.

THE INFLUENCE OF CONTINUOUS IMPROVEMENT ABILITIES ON PROBLEM SOLVING BETWEEN DIFFERENT LEAN MATURITY LEVELS