The Role of Empowerment
during Lean Change Projects in Healthcare
Master Thesis
MSc BA Change Management
Ewoud Stapersma
S3034224
Supervisor:
Dr. O.P. Roemeling
Second Assessor:
Dr. M.H.F. Van der Schueren
Word count:
18.491
0. ABSTRACT
Background: Lean is built on two pillars; continuous improvement efforts and respect to people. Although one of the cornerstones of respect to people is to empower employees to create continuous improvement, this aspect is often overlooked. Therefore, the aim of this study is to explore how employee empowerment facilitates change readiness and resistance to change within lean change projects in healthcare organizations.
Method: An explorative study was conducted within a large clinical teaching hospital in The Netherlands. Before data collection, the researcher did twelve visits at the Operating Room and nursing department to get a sense of how lean was perceived on the work-floor. Next, fifteen surveys were conducted to give initial insights into the concepts. Based on the survey outcomes, twelve semi-structured interviews were conducted. Archival data was used to obtain insights on the (preliminary) results of the lean change projects.
Findings: The results show that practices of empowerment of change agents facilitate perceived empowerment and change readiness via the mediating role of formal leaders among change recipients, whereby power-resistance relationships play an important role. Ultimately, this decreases resistance to change and enables long-term continuous
improvement efforts. Based on these findings a framework was build.
Conclusion: This study underlines the crucial role of the formal leader towards perceived empowerment and change readiness among change recipients. In addition, this study illustrates the role of power-resistance relationships between the different actors, constructing enabling and restraining behaviours of change readiness and resistance to change.
1. INTRODUCTION
This paper explores the role of employee empowerment on readiness to change and resistance to change within lean change projects in healthcare organizations. Starting in the early 2000s, the methodology of lean extended from the manufacturing industry towards service industries such as healthcare (Liker, 2004). Demands on healthcare organizations have increased due to the aging society, putting more and more pressure on healthcare services to provide high quality care and to work efficiently (Brandao de Souza, 2009; Joosten et al., 2009). Lean offers an approach to work more efficiently within an organization’s existing framework of processes, avoiding large investments to transform an organization (Poksinka, 2010). Furthermore, lean offers a double focus on patient satisfaction and employee involvement (Ballé & Regnier, 2007), matching most healthcare organizations. These aspects of lean offer an attractive approach for healthcare organizations to achieve improvements without losing the focus on the organization’s employees and its patients.
1.1 Problem definition
The methodology of lean is built on two pillars; continuous improvement efforts and respect for people (Ballé & Regnier, 2007). Within this latter aspect, one of the cornerstones is to develop a culture where staff is empowered and encouraged to create continuous
improvements (Netland, 2016). However, Radnor et al. (2012) conclude in their literature review that these aspects are often overlooked. As lean is a long-term effort, neglecting these aspects of lean within change projects ensures that past investments on lean initiatives never sustain, causing a cycle trapped in continuously improvement efforts where work returns to the status quo in between (Bhasin & Burcher, 2006; Radnor et al., 2012). To be able to move lean beyond this trap, strong leadership and employee empowerment in all parts of the system is needed (Young et al., 2004).
1.2 Introduction of subjects
Employee empowerment. Fostering employee empowerment is a key aspect within lean to create a successful lean culture over the long term (Bowen & Youngdahl, 1998). Managers have an important role in the influence of employees’ empowerment through negotiating decision-making latitude and through changing aspects of jobs of the employee to enhance greater self-management (Vogt & Murrell, 1990; Menon, 1995). This management style drives continuous improvements and nurtures self-development among employees within the organization (Poksinska, et al., 2013). Furthermore, empowered employees are more able to adapt to change initiatives and are less likely to resist (Kappelman & Richards, 1996). However, from the literature it is unclear how empowerment is perceived by employees and what role it has on resistance to change and change readiness in a lean healthcare setting. Based on these arguments, this research looks into the role of managers on strengthening employee empowerment and how this is perceived by employees in a lean healthcare setting.
Change readiness. Next to employee empowerment, change readiness is another key aspect of lean, as continuous improvement efforts requires a high change readiness due to its ongoing cycle of improvements (Bhasin, 2012). Change readiness is seen as the antecedent of resistance to change (Armenakis et al., 1993; Armenakis et al., 2007) and is described as the extent to which an individual and group is cognitively and affectively willing to accept and adopt a change project (Rafferty et al., 2013). A high change readiness results into employees being invested and engaged in the change and are expected to overcome obstacles and
2009). From the literature, it is clear that many change initiatives fail (Beer & Nohria, 2000). Probst & Raisch (2005) further conclude that many change initiatives are poorly managed and that organizational crises are looming due to these failed change efforts. Miller, Johnson & Grau (1994) argue that although change failures are attributed to many variables, employees’ attitude towards change is one of the critical aspects. However, from the literature it is unclear how the concept of change readiness impacts lean organizations in healthcare. Furthermore, van Rossum, Aij, Simons, van der Eng & ten Have (2016) explain that leadership provides the energy through enabling change readiness among employees to increase the organization’s change capacity. As change readiness is unclear within the lean healthcare literature and, furthermore, is strongly related to leadership, we therefore focus on this concept.
Resistance to change. As lean is an effort to continuously improve, this also means that organizations are in a constant flux of change. In these efforts, employees constantly need to make sense of new situations (Balogun & Johnson, 2005). During this process of sense-making, resistance of employees can come about to hinder a successful change (Piderit, 2000). This resistance to change is explained by Thomas & Hardy (2011) as an entanglement with power, as resistance and power are linked with each other to bring about change.
Relating resistance to lean healthcare, Joosten et al. (2009) conclude in their literature review that lean often leads to resistance. However, the authors neglect a further explanation on the role of power linking with resistance. Furthermore, Waring & Bishop (2010) explain in their case study that resistance to change caused difficulties for a successful lean implementation, but also fail to give an understanding how this role of resistance constrained the lean
implementation and no mention on power linking with resistance was made. Concluding, resistance plays a substantial role in implementation projects of lean. However, little is known about how resistance to change and the linkage with power of managers to create
empowerment influences lean change projects in healthcare.
1.3 Research goal
The objective of this paper is to explore the role of employee empowerment on resistance to change and change readiness during lean change projects in healthcare organizations. The main contribution of this paper to the current literature of lean healthcare is to give further insights into how these concepts relate to each other in a healthcare setting. From the
explained three concepts, the encompassing theme is that the manager or change agent plays a vital role in lean change projects. Therefore, the role of the change agent comes into the foreground during this research. Managerial implications of this research are to create a better understanding among managers how employee empowerment can be enabled and how this affects change readiness and resistance to change, ultimately supporting continuous
improvement efforts within a healthcare setting. Building on these insights, we try to answer the following research question in this paper:
How does empowerment facilitate lean change projects, and what is the role of resistance to change and change readiness during such projects?
2. LITERATURE REVIEW
In this section, the concepts and backgrounds of lean in healthcare, resistance to change, change readiness and employee empowerment are defined and elaborated. According to Blumberg et al. (2014), this first step to search in secondary literature is a great way to provide background information on the relevant concepts and creates valuable leads before conducting empirical research. This literature review was conducted in the field of human resource management, operations management, healthcare management and organizational behaviour. A conceptual framework is presented at the end of this section.
2.1 History of lean
The methodology of lean, also known as continuous improvement, first started at the car manufacturer Toyota Motor Corporation. Toyota did this by introducing the Toyota Production System (TPS), which later became known as the lean manufacturing system (Bowen & Spear, 1999). The lean manufacturing system can be best described as a set of practices that focus on maximizing the value output for customers. The lean manufacturing system involves five steps to eliminate non-value-added activities successfully; value specification, value stream identification, flow creation, use of pull systems and pursuing perfection (Womack & Jones, 1996). Defining lean in healthcare is not an easy task, as there are many definitions known within the literature. A number of studies (Shah & Ward, 2007; Pettersen, 2009; D’Andreamatteo et al., 2015) conducted a research investigating the
definitions of lean-thinking and came to the conclusion that there is no clear consensus. Based on these findings, it is therefore best to pick a definition of lean that suits its purpose and adapt the concept towards the research goal (Pettersen, 2009). As we focus on the social aspects of lean; resistance to change and change readiness within a healthcare setting, we therefore derive our definition from Shah & Ward (2007), and view lean as: “an integrated socio-technical system whose main objective is to eliminate waste by concurrently reducing or minimizing supplier, customer, and internal variability” (p. 791).
From the early 2000s, the lean approach moved away from cost and waste reduction on the shop floor in manufacturing industries towards an approach that continually sought to enhance customer value (Hines et al., 2004). This approach of lean was marked as a key development to move lean from manufacturing towards service industries. The approach began to focus on the value system of the entire organization and integration of all departments in this system to improve customer value, align organizations with its environment and decrease variability within the processes (Liker, 2004).
2.2 Lean in healthcare
As lean moved into the service industry, the approach was also introduced in the healthcare industry. The primary reason to implement lean in healthcare organizations is the continuing increase in patient demand and the associated rising costs, requiring care organizations to be highly efficient and quality-oriented (Joosten et al., 2009; Brandao de Souza, 2009).
Comparing the manufacturing with the healthcare industry, there are three main differences; Uniqueness of each patient, complexity of the healthcare sector and the vast amount of variety of medical situations (Katz-Navon et al., 2007). Therefore, applying lean in healthcare
organizations requires adaptations to fit healthcare organizations (Fillingham, 2007; Poksinska, 2010).
1997) also used parts of the lean manufacturing technologies in healthcare organizations to increase efficiency, however none of these researchers used the term ‘lean’ to describe these approaches. Starting from 2001, lean first appeared in the UK health service at the National Health Service (NHS) and, consequently, in 2002 in the USA (Radnor et al., 2012). These early reports on lean thinking focussed on the improvement of patient flow (Bushel & Shelest, 2002; Feinstein et al., 2002). However, implementation of these first lean approaches was fragmented and leaded to small ‘pockets of best-practice’, instead of a system-wide adoption of lean in healthcare organizations (Brandao de Souza, 2009; Radnor, 2010). A chronological overview of the evolution of lean from the car to the healthcare industry is represented in Figure 1.
1940s »1984 »1992 »2002
Figure 1: Evolution of lean (adapted from Laursen, 2003)
From figure 1, it is visible that there is a delay of ten years between the adoption of lean in service industries and the healthcare industry. Due to this delay, lean healthcare is still in its development phase. This is also indicated by the literature review of D’Andreamatteo et al. (2015), as research papers in the area of lean and continues improvement efforts further increases and no healthcare organization has yet fully institutionalized lean to the excellence level of Toyota (Spear, 2005; Berwick et al., 2005).
2.3 Lean and change
As explained in the previous sections, continuous improvement efforts are an inherent part of lean and therefore change is needed. Organizational change is a commonly established priority within organizations to be able to coop with changing internal and external
environments. Recent examples of major external changes are the environmental, technical and financial disturbances, which forces organizations to adapt their operations (Bennebroek et al., 2004; Bercovitz & Feldman, 2008). To be able to change healthcare organizations successfully, realign their operations and create a culture of continuous improvements within the environment, employee empowerment is required. However, resistance to change and low change readiness among employees can hinder successful change (Piderit, 2000).
2.4 Employee empowerment
Before the 1990s, the concept of employee empowerment could only be accessed through articles that discussed topics such as individual development, quality circles and participative
Car Industry: Toyota Production System (TPS)
Operations Industry: Lean Manufacturing Service Industry: Lean Thinking
management (Sullivan, 1994). However, since the 1990s, the number of articles on employee empowerment has increased rapidly (Honold, 1997). In the literature, different definitions are used to describe the concept of employee empowerment. As we focus within our study on the self-management of employees within lean change projects, we therefore base our definition on Vogt & Murrel (1990), describing empowerment as: negotiating decision-making latitude with the employee to change employee’s jobs and facilitate self-management.
Employee empowerment can be categorized into two main abilities of an empowered state; the individual’s ability and the team’s ability of an empowered state (Menon, 1995). From these two perspectives, the leader or change agent plays a critical role to give teams or individuals an empowered state during a change initiative. Linking leadership to the context of lean, leaders have the ability to empower their employees to drive continuous improvement efforts and develop self-management (Poksinska, et al., 2013). Furthermore, within the
context of organizational change, empowerment is able to fulfil the employee with a sense of control, as the larger forces of a change project are usually outside the limits of the employee (Kappelman & Richards, 1996). Based on these arguments, we therefore focus on the role of leaders to create empowerment among employees.
From the leadership perspective of employee empowerment, Kanter (1993) defines empowerment as giving power to employees who are in an underprivileged spot within the organization. According to her, empowerment can be seen on a continuum ranging from a powerless state to an empowered state. A higher empowered state leads to a higher work motivation and job satisfaction. The greater the power of an employee, the higher the work motivation and job satisfaction. Furthermore, high employee empowerment also leads to less ambiguity of the employee’s role within the organization. Consequently, it is up to the employee to take this self-power or not. Leaders create the environment and facilitate to take power, but the choice is on the side of the employee to seize it (Honold, 1997).
Leaders have a number of interventions or practices at their disposal to create an empowerment climate among employees (Vogt & Murrel, 1990). Within this context, empowerment climate is viewed as the shared perception of employees on managerial structures, policies and practices to create empowerment and to successfully implement lean change projects. On the individual/informal level, leaders can use the practices of expressing support towards employees’ high-performance expectations (House, 1977; Conger 1989), promote decision-making opportunities (House, 1977; Block, 1987) and provide job
autonomy from bureaucratic forces (Kanter, 1979; Block 1987). On the formal/organizational level, leaders are able to use the setting of challenging and inspirational goals (Bennis & Nanus, 1985; Burke, 1986), coaching and mentoring programmes, development of “win-win” reward systems and job enrichment (Vogt & Murrel, 1990). A manager can use both
formal/organizational and individual/informal level practices in tandem to strengthen the overall empowerment of employees. Formal/organizational practices can first be used to establish systems of empowerment. Next, individual/informal level practices are then used to increase the individual’s self-efficacy and, consequently, boost employee empowerment even further.
When looking into the perceived empowerment climate of employees, Seibert et al. (2004) conclude that there are three underlying aspects; information sharing, autonomy through boundaries and team accountability. Information sharing relates to providing
leader and employee. The aspect of autonomy through boundaries relates to the
formal/organizational level practices in use, explained in the previous section. Through establishing structures and practices within the organization, a climate of empowerment among employees is stimulated. Lastly, team accountability relates to the individual/informal level practices in use and is the perception of that teams are the centre of decision-making authority and accountable for their own performances within the organization, supported through individual/informal practices. Based on these insights of leader’s practices and employee empowerment climate, we developed a conceptual framework on employee empowerment in Figure 2.
Figure 2: Conceptual framework of employee empowerment (based on Vogt & Murrell, 1990; Seibert et al., 2004).
By using the concept of employee empowerment and explore the influence of leader practices on the empowerment climate perceived by employees, we are able to better understand the relationship between employee empowerment and lean. This is further
acknowledged by Bowen & Youngdahl 1998) and Buiter-Vink (Procesgericht organiseren in het ziekenhuis: Transitie van hokjesdenken naar procesdenken, 1 december 2016), explaining that empowering employees is a critical aspect within lean change projects to create a
successful lean culture over the long term (Bowen & Youngdahl, 1998). Furthermore,
Kappelman & Richards (1996) confirms that empowerment is able to create a sense of control among employees engaging in lean change projects.
2.5 Change readiness
Change readiness is another important factor to execute a change project (Boukenooghe, 2010). Change readiness is defined by Holt et al. (2007) as: “the extent to which an individual or individuals are cognitively and emotionally inclined to accept, embrace, and adopt a particular plan to purposefully alter the status quo” (p. 235). From this view, readiness for change is an antecedent of resistance to change (Armenakis et al., 1993; Armenakis et al., 2007). Holt et al. (2007) explains that through assessing the readiness for change, change agents are able to identify gaps which may exist between the expectations of the change agent and the expectations of the change recipients. When there are significant gaps and these gaps are not addressed, resistance among change recipients is expected and a successful
implementation of the change is jeopardized. Therefore, an assessment of the change Leader / Change Agent
Formal/Organizational level practices
Individual/Informal level practices
readiness among stakeholders can serve as a guide for the change agent in implementing organizational changes. Al-Balushi et al. (2014) explains that next to the common change readiness factors among change management, such as: leadership, organizational culture, training, key performance indicators, communication, and reward systems, a successful implementation of lean in a healthcare setting is the ability to implement a decentralized management style and taking an end-to-end process view in the care chain. However, these success factors are difficult to implement in healthcare, as organizations are characterised by their complexity, due to their uniqueness of each patient and variety of medical situations (Katz-Navon et al., 2007).
When looking further into the concept of change readiness, it is typified as a precursor of successful organizational change, as members seek psychological safety, a sense of identity and a sense of control (Weiner et al., 2008; Armenakis et al., 1993; Armenakis et al., 2007). Change readiness can be placed on a continuum from low to high, whereby a low change readiness is related to members of an organization being less invested in the change effort, are expected to be less engaged during the process and are less persistent to overcome obstacles during the implementation of the change. Contrary, a high change readiness relates to organizational members being invested and engaged in the change and are expected to do more effort to overcome obstacles and setbacks to successfully implement the change (Rafferty et al., 2013).
The proposed definition has two main components, the cognitive and the affective component, and focusses on the individual and the group-level Rafferty et al., 2013). We focus on these two levels of change readiness as a multi-level view on change readiness reveals the differences between individual and group level and how both are related with each other. According to Whelan-Barry et al. (2003), the group-level process of readiness for change emerges from the cognitive and affective components of the individual which become shared through social interaction and are manifested as higher order phenomena. We build our framework on the work of Rafferty et al. (2013), as their research focusses on these individual and group levels and include the two main components of change readiness.
Looking into the individual level, the cognitive component of change readiness is concerned with an individual’s belief that a change is needed, and the organization has the capacity to successfully lead the change (Armenakis & Harris, 2002). Furthermore, the affective component is concerned with the individual’s discrete, quantitatively emotion towards a change initiative (Crites et al., 1994). According to a number of researchers (Abelson et al., 1982; Breckler & Wiggins, 1989), it is important to consider both
components, as cognition and affect display different relations with the overall attitude and the overall behaviour.
Individual level Change readiness Group level Change readiness
Rafferty et al. (2013) conclude that there are three broad categories of antecedents on the individual as well as on the group level; the external organizational pressures (e.g. competition, regulatory pressures), internal context enablers (e.g. effective communication, history of previous changes), and the personal or group characteristics (e.g. individual’s personality traits, trust, mutual respect). A deeper insight into the concept of change readiness is found in Appendix 1. Based on these insights, we developed the conceptual framework of readiness for change in Figure 3.
Figure 3: Conceptual framework of change readiness (based on Rafferty et al., 2013) By using the concept of change readiness in combination with employee
empowerment in a lean healthcare setting, we focus on the two key aspects characterized by healthcare organizations; decentralized management style and taking an end-to-end view of lean change project in the organization (Al-Balushi et al., 2014). Through this focus, we are able to explore the concept of change readiness and look into the linkage of employee
empowerment and change readiness within this research. Furthermore, as change readiness is seen as the antecedent of resistance to change (Armenakis et al., 1993; Armenakis et al., 2007), we therefore also look into the concept of resistance to change.
2.6 Resistance to change
According to a wide range of scholars (Lewin, 1952; Kotter, 1995; Strebel, 1994), resistance to change is often proposed as a reason why a change initiative fails. Therefore, the literature
on change management is expansive on what the motive of resistance to change is, how to cope with it and in what ways it can be managed. Lean is often linked with resistance as it neglects the socio-technical aspects of healthcare organizations (Joosten et al., 2009). Consequently, Waring & Bishop (2010) conclude that resistance in lean healthcare focusses on the conflicting understandings between clinicians, as change recipients, and service leaders as change agents. Clinicians doubt the legitimacy, motives, evidence and knowledge of the service leaders and fear the negative consequences for the patient. These so called ‘lines of resistance’ are barriers to fully integrate lean in a healthcare organization, and therefore an understanding of resistance to change in healthcare is needed.
The primary dimension of resistance to change is behaviour (Ang & Pavri, 1994; Markus 1983; Zaltman & Duncan, 1977). The behaviours of resistance can be placed on a continuum. In this regard, the taxonomy of Coetsee (1993; 1999) is most useful, as it is a well-known and respected taxonomy within the literature. It places the behaviour of resistance on a continuum ranging from apathy, passive resistance, active resistance to aggressive
resistance. Apathy is explained as the behaviour of a lack of interest, inaction and distance. Passive resistance is seen as a form of mild resistance and include excuses, delay tactics and withdrawal. Active resistance is elaborated as strong, but not destructive resistance, and involves the forming of coalitions and voicing opposite views. Lastly, aggressive resistance is seen as disruptive resistance and includes sabotage, threatening, and strikes and could
potentially be destructive to the change initiative itself.
Thomas & Hardy (2011) propose a different view from the previous approaches of resistance in the literatures; demonizing resistance and celebrating resistance, as both demonizing and celebrating approaches “maintain a distinction between change agent and change recipient and privilege the former” (p.10). They shift the focus to power-resistance relations, building on the work of Foucault (1980; 1982). In this perspective, power and resistance entangle each other, as power relations does not exist without the presence of resistance. Based on these arguments, there is a shift to how these relations between power and resistance are linked with each other to bring about change. From this approach, change initiatives unfold from the enactment between members within an organization (Balogun & Johnson, 2005). The way a change project is viewed by an organizational member is dependent on the impact of the change and the power the member is holding. Furthermore, the course of the change project can influence a stakeholders’ perspective from a driving to a restraining force or vice versa. Therefore, change is accomplished through complex, messy practices between multiple stakeholders in and outside the organization. Based on these arguments, resistance needs to be viewed from multiple angles, including from those that initiate and resist the change.
Ford et al. (2008) reconstructed the relationship between change agent and change recipient and conclude that there are three main elements; recipient action, agent sense-making and the agent-recipient relationship. By using these three main elements, the authors do not solely focus on the perspective of the change agent, in line with Thomas & Hardy’s (2011) view of demonizing resistance. The agent-recipient relationship provides the context in which the interactions with the change agent and change recipient are shaped. The
the actions of the change recipients. According to Balogun & Johnson (2005), this aspect plays a central role in change management as it examines how shifts in individuals’ schemata occur during changes in organizations (Balogun & Johnson, 2005). Based on these insight, change agents might label change recipients as resistant. This ‘labelling’ of resistance might cause a self-fulfilling prophecy as change agents expect to foresee resistance among change recipients and therefore also label it as resistance (Ford et al., 2008). Furthermore, resistance can also come about due to breaking agreements both before and during the change and communication breakdowns on the side of the change agent. These communication breakdowns are caused by a failure to legitimize the change, misrepresenting the change (through being overly optimistic) and an inadequate focus on the changes in behaviour that are needed among change recipients (Balogun & Johnson, 2005).
However, Ford et al. (2008) neglect in their framework the actions of change agents and the sense-making of change recipients. Balogun & Johnson (2005) explain that change recipients also engage in sense-making. This occurs when change recipients respond to the actions of the change recipients as change agent for example communicate the designed change goals and change interventions. Based on these insights, we can also reason that change agents engage into action-taking to execute the change plans. The actions of the agents are not only constructed through the initial drive to successfully implement a change plan but is also driven by the actions of the change recipient. Based on these insights, we constructed a conceptual framework on resistance to change in Figure 4.
Figure 4: Conceptual framework of resistance to change (based on Ford et al. (2008) and Balogun & Johnson (2005))
Analysing lean in healthcare through resistance to change and exploring the concepts of agent-recipient, recipient action and agent sense-making is important, as lean
implementations are a highly dynamic process shaped and reshaped by the quality and nature of the relationship between change agent and change recipient and the power among each stakeholder (Ford et al., 2008). By viewing resistance through this lens, it “highlights the contingent nature of organizational change and the ways clinicians can corrupt, ‘game’ and capture attempts at reform to maintain or extend their influence or counter the interests of others” (Waring & Bishop, 2010, p. 1339).
2.7 Towards a conceptual framework
As already briefly explained in the introduction, due to the neglection of lean to see it as a long-term effort whereby employees are empowered and encouraged to create continuous improvement (Netland, 2016), lean change projects are not able to sustain over the long term. This causes a cyclical trap in continuous improvement efforts where work returns to the status
Agent-recipient relationship Recipient sense-making Agent
sense-making Agent action
quo after a lean change project (Bhasing & Burcher, 2006; Radnor et al., 2012), opposing the step-by-step improvement that should be taken in a culture of continuous improvements efforts. The cyclical step consists of the following phases: pre-change ® change ® post-change ® pre-post-change, whereby the last phase indicates the continuous cycle. In figure 5, this cyclical trap is illustrated.
Figure 5: Cyclical trap in continuous improvement efforts
To be able to overcome this cyclical trap in continuous improvement efforts,
empowerment of employees through formal/organizational and individual/informal practices of the manager is a way to stop the cyclical trap and steadily increase the climate of
empowerment and thus be able to further increase continuous improvement efforts (Young et al., 2004). Piderit (2000) explains that organizations which successfully want to change are increasingly dependent on the generation of employee support and excitement, rather than solely overcoming resistance. Through empowerment, employees are more adaptable and are less likely to resist changes, as they themselves are the ones who direct the lean change project (Kappelman & Richards, 1996). Furthermore, as change readiness is seen as an
antecedent to resistance to change (Armenakis et al., 1993; Armenakis et al., 2007), employee empowerment therefore also affects change readiness during lean change projects.
Consequently, high involvement of employees in a lean change project within a high
empowerment climate increases change readiness. Based on these arguments, we constructed an overarching conceptual framework, linking the previous frameworks together in Figure 6.
When looking into the overarching conceptual framework, there are two levels of interaction: the agent level and the individual/group level. On the level of the change-agent, we view the practices of empowerment available to the change agent to empower employees. As explained in the employee empowerment section, these are categorized into formal/organizational practices and individual/informal practices. The practices of the change agent affect both the perceived empowerment on the individual as well as on the group level (1). All three components of the perceived empowerment; information sharing, autonomy through boundaries and team accountability, are both perceived on the individual- and the group level. This is because information sharing, systems of empowerment and self-efficacy practices can both be deployed on these levels. Furthermore, practices of empowerment also affect the connection between change readiness and resistance to change (2), as an
empowering climate among employees not only affect change readiness, but also resistance to change when a lean change project is initiated (Kappelman & Richards, 1996). The link between change readiness and resistance to chance (3) illustrates the aspect that change readiness is an antecedent of resistance to change (Armenakis et al. (1993); Armenakis et al. (2007). Finally, via the concepts of employee empowerment, change readiness and resistance to change, continuous improvement efforts can be achieved among employees and a culture of lean in healthcare is sustained over the long-term (4).
Continuous High Improvement Efforts
Low
Time
Individual / Group level
Change readiness Perceived
empowerment
Figure 6: Overarching conceptual framework: Connecting employee empowerment, change readiness and resistance to change to continuous improvement efforts
3. METHODOLOGY
This chapter elaborates the methodology used in this research. First, an explanation is given on the type of study that is conducted. Second, the criteria for the case site are elaborated and information on the chosen case site is given. Next, the process of how respondents were selected, and which respondents collaborated in this research is explained. Finally, the instruments of data collection are explained, and, in the final section, data analysis is elaborated.
3.1 Type of study
As already explained in the introduction, we lack a clear idea how employee empowerment affects change readiness and resistance to change and, consequently, influences continuous improvement efforts within lean change projects in healthcare. Therefore, an explorative study is used to answer our research question and create a better understanding of these phenomena (Eisenhardt, 1989).
3.2 Case criteria
The case site is selected on a number of criteria. First, the case site should be in a healthcare setting where lean methods or similar methods are actively used within the organization. Secondly, the organization should at least be a medium-sized organization, having at least 50 employees, a turnover of at least €10 million or a balance total of at least €10 million
(European Commission, 2003). Thirdly, the interviewees need to have experience with working in a lean healthcare setting for at least six months. Lastly, the interviewees from the organization should have affinity with resistance to change, change readiness and employee empowerment within their functional role. Based on these requirements, we have selected a clinical teaching hospital, based in The Netherlands.
3.3 Case site.
The selected clinical teaching hospital consists of almost 3,000 employees and almost 900 beds. This hospital was among the first hospitals to adopt lean and is considered to be one of the best hospitals that has implemented lean throughout their business operations, according to a study by the “Financieel Dagblad” (September 20, 2011). We therefore believe that this case study is not a bad performing hospital, leading to a non-representative case study.
The hospital has a long history with lean initiatives. Only in the past year, a total of seventeen lean change projects have been executed across the whole organization, ranging from reducing length of stays to increasing inventory neatness and optimizing staff capacity through exchange between departments. Each lean change project is executed by using a predetermined structure of Define, Measure, Analyse, Implement and Check (DMAIC).
Within the hospital, there is an active training programme integrated in the hospital to train employees, voluntary and bottom-up, in the cycle of continuous improvement. In 2015, a total of 18 employees received their Orange Belts in Lean Six Sigma. This certificate proves that these employees have basic knowledge on lean change efforts to be able to continually improve their work environment. Looking into 2016, this number of employees with an Orange Belt further increased to 20 employees.
improve their own department or care chain. In this study, a total of six lean change projects were included in the research ranging from projects that started more than two years ago to projects that started a year ago. Out of the 6 projects, 2 projects are completed, 3 projects are almost finished (fall 2018) and 1 project is an overarching continuous improvement
trajectory, meaning that no hard deadline is attached to this project. We believe that this selection of projects with different starting and end dates spanning two years gives a fair representation how lean change projects are initiated by the change agents and how they are perceived by the change recipients on the organizational level.
3.4 Collecting respondents
To collect respondents, the researcher pitched his research at the weekly meeting of a staff department, consisting of change agents (i.e. project leaders) who lead lean change projects throughout the hospital. Based on this pitch, change agents signed up with a lean change project which they are currently leading or recently completed and proposed one or two project members that were open to participate in the research. As is seen in Table 1, four change agents consisting of two change recipients each and two change agents with one change recipient each participated in the research. In total, 6 projects with 6 project leaders and 10 change recipients were involved in this research. All respondents are listed below in Table 1.
Following these sign ups, we sent a customized invitation mail to each participant containing a weblink to the survey. The time of the surveys took approximately 10 minutes and was checked before the surveys were released. After a week, reminders via email and phone were made to remind employees to complete the survey. After completion of the survey, the preliminary results of the survey were used as input for the semi-structured interviews. The semi-structured interview sessions averaged around 53 minutes with the shortest interview being 44 minutes and the longest interview being 71 minutes.
Respondent Abbreviation Survey Interview
Internal Consultant 1 IC1 Yes Yes
- Manager 1 MAN1 Yes Yes
- Advisor 1 AD1 Yes Yes
Internal Consultant 2 IC2 Yes Yes
- Nurse 1 N1 Yes Yes
- Care Coordinator 1 CO1 No Yes
Internal Consultant 3 IC3 Yes No
- Nurse 2 N2 Yes No
Internal Consultant 4 IC4 Yes Yes
- Manager 2 MAN2 Yes Yes
- Care Coordinator 3 CO2 Yes Yes
Internal Consultant 5 IC5 Yes Yes
- Manager 3 MAN3 Yes Yes
- Care Coordinator 4 CO3 Yes Yes
Internal Consultant 6 IC6 Yes No
- Manager 4 MAN4 Yes No
Number of surveys/interviews completed 15 12
3.5 Instruments for data collection
In the weeks before retrieving the necessary data, the researcher visited the hospital 12 times in April and May (2018); 7 times at a nursing department and 5 times in the surgical
department, both part of the lean change projects. During these visits, the researcher engaged the whole day in formal meetings (e.g. tactical planning meetings, department meetings, cross-department meetings), informal meetings, (e.g. lunchbreaks, coffee breaks) and formal and informal conversations. After each day, the researcher logged his findings in a logbook. These visits allowed the researcher to get a sense of how lean is perceived on the work floor of these departments and how the gaps were perceived between managers, project leaders and work floor employees.
During these visits, archival data was collected on the overall strategy of the hospital and which lean change projects were executed in the past, including the approach and results of each project. From this archival data, we created a framework that gives insights into the six projects that were researched. This framework is found in Appendix 5. We remark that we intentionally did not connect Table 1 and Appendix 5 with each other, as this would make it easy to identify respondents.
Next, surveys were sent to give initial insights into the concepts and to let people think about the concepts conducting the interviews. Two different question sets were released; one set focussed on the change agents (i.e. project leaders) and the other set focussed on the change recipients (i.e. project members) (Appendix 2). To ensure valid questions, survey and interview questions on empowerment were based on Vogt & Murrel (1990) and Seibert et al. (2004), questions on readiness for change were based on Armenakis et al. (1999) and
questions on resistance to change were based on Kebapci, & Erkal (2009), Ford et al. (2008) and Metselaar (1997). Statement questions in the survey were conducted using a 5-point Likert scale, as this provides better quality of data compared to a 7 or 11-points Likert scale (Revilla, Saris & Krosnick, 2014). Four examples of used statement questions are found below in Table 2.
Change Agent Change Recipient
Sharing of information on quality of patient care, financial performances and
productivity among all employees affected by the lean change project. (part of the questions on practices of empowerment)
My project leader encouraged me to make decisions on my own. (part of the questions on perceived empowerment)
Project members had the confidence to successfully execute the lean change project. (part of the questions on change readiness)
There was a high priority among colleagues to successfully execute the lean change project. (part of the questions on change readiness)
Table 2: Examples of used statement questions in the survey
Based on differences between change recipients and change agents from the survey, semi-structured interviews were conducted to gain more in-depth knowledge on the differences of empowerment, change readiness and resistance to change. By using the survey as input for the interview sessions, a chain of evidence is created contributing to the controllability and
Change Agent Change Recipient Looking into your survey answer on sharing
of information on quality of patient care, financial performance and productivity among all employees affected by the lean change project in the survey, could you explain the reasoning behind it? (part of the questions on practices of empowerment)
Looking into your survey answer on how the project leader encouraged you to make decision on your own in the survey, could you explain the reasoning behind it? (part of the questions on perceived
empowerment)
Why do you think that project members had / had not the confidence to successfully execute the lean change project (part of the questions on change readiness)
Was there a high priority among colleagues to successfully execute the lean change project? Why? (part of the questions on change readiness)
Table 3: Examples of used questions in the interview
The interview-protocol was created in two-fold, focusing on change agents and change recipients. Both the survey and interview questions were checked together with an internal Black Belt change agent to check appropriateness. After the first interview with a change agent and change recipient, the interview protocol was slightly adapted, as a number of questions were perceived as very similar to each other. Each transcribed interview was checked with the interviewee to ensure that the written findings are in line with the intended meanings. The interview sessions were conducted using an interview protocol, included in Appendix 3. By using multiple sources of data collection, we not only create a better understanding of the phenomena, but also contribute to a stronger data triangulation to provide research validity (Eisenhardt, 1989).
3.6 Data analysis.
After data collection, the data was analysed in a systemic way by using coding as a method to find repetitive methods of consistencies and actions (Saldana, 2015). Miles & Huberman (1994) recognizes two levels of coding during this process; first-order and second-order coding. First-order coding was used to summarize parts of the collected data. Within first-order coding, two approaches were used to create these codes. From the literature review, deductive codes were formulated. Examples of these codes are: ‘sharing of information’, ‘autonomy through boundaries’, ‘need to change’ and ‘agent sense-making’. After data collection, inductive codes were created by looking into the gathered data and locate emerging themes, such as: ‘project leader as neutral party’, ‘actively listening’, ‘and ‘group feedback’.
After writing down the first-order codes, the cyclical act of refining the codes and categories was repeated until patterns began to emerge and a conceptual theory was visible from the analysed data. This was done by the researcher through asking questions to himself on the relationship between codes and writing down his thoughts on memos and diagrams during the process, as suggested by Corbin & Strauss (2008). This process, known as second-order coding (Miles & Huberman (1994), was repeated until theoretical saturation was reached (Glaser & Strauss, 1967). Examples of second order codes are ‘practices on group level’, ‘role of head of department, and ‘participation of all stakeholders’.
During data analysis, a codebook was used to label, classify and categorize the
is illustrated in Figure 7. To enhance controllability of the research, the codebook is included in Appendix 4.
Figure 7: Structure of the coding process
Central concept
Practices of empowerment
Second-order coding
First-order coding
- Setting group goals - Use of tools - Sharing of information - Coaching - Individual feedback - Educational possibilities - Rewarding employees - Use of tools - Explanation of project - Actively listening - Provide job autonomy - Appreciation on in overall vision - Group feedback - Delegating tasks individual level - Communication between - Support on high
project team and others performance expectations
4. RESULTS
In this section, an overview of the empirical findings of the research is presented. First, the practices of empowerment are elaborated, followed by the perceived empowerment. Next, the findings on change readiness are explained and, lastly, the resistance to change is explained from the perspective of the agent and the change recipient.
To illustrate the structure of this chapter and how each of these concepts relates to each other, Figure 8 is created. This figure is a simplified version of Figure 6. To guarantee anonymity, change agents and change recipients are referred to by a combination of letters and numbers. The abbreviations of each respondent are found in Table 1. After each section, lessons learned on each second-order code are presented in a table.
Figure 8: Simplistic overview of the overarching conceptual framework 4.1 Practices of empowerment.
The importance of empowerment was viewed by all change agents (IC1, IC2, IC3, IC4, IC5, IC6), as this allowed change agents to let the change stick. This importance is clearly
illustrated by IC4, who explains the consequence if she would not give empowerment: "When I am the one who would tell the employees what to do, I become the annoying authoritarian project leader and they [change recipients] then tell: “See, I told you this wouldn't work”". From the data collection on practices of empowerment, we have derived three second-order codes: 1) practices on group-level, 2) mediating role of the head of department, and 3) participation of all groups.
Practices on group-level. As explained in the theory, the practices of empowerment are split into formal/organizational practices and individual/informal practices. However, from the surveys and interviews, we saw that the formal/organizational practices of the change agent were more focussed towards groups of stakeholders, instead of the whole organization. The project team, as a formal group, was more engaged with the change agent and, therefore, received more practices of empowerment compared to the other colleagues that were also affected by the change but were not part of the project team. This is explained by AD1: "It was difficult for the project leader to share information outside the project team. After the measurement plan, it became something of the project team and the other employees weren't engaged anymore by the project leader". Furthermore, IC1 explained the focus on informal groups: "Now, when I create a project team, I try to have the right mix between people embracing and opposing the change, as these people also need to have informal power to be able to deliver the message to other groups outside the project". This illustrates that
Change-agent level
Individual/group level Practices of empowerment
Perceived
empowerment readiness Change
Resistance to change
Continuous improvement
change agents are very focussed on formal and informal groups of stakeholders to be able to successfully implement the lean change project.
In these empowerment practices on the group-level, the selection of tools played an important role to allow change recipients to be empowered. Brown-paper sessions (IC1, IC2, IC4, IC5) and executing baseline measurements (IC1, IC2, IC5) were often used as a first tool to measure the problem and, consequently, setup a goal together, as IC2 explains: “In LSS-projects, from the beginning the goal is unknown. There is only a problem and a process, and we try to solve it with all the relevant stakeholders. However, after the measuring stage, we try to define, together with the stakeholders, the goal of the project”. This shared goalsetting was also confirmed from the surveys of the change recipients, as all change recipients agreed or totally agreed on this statement. Furthermore, shared chairmanship was used to increase ownership among change recipients (IC4) and the interviewed change agents (IC1, IC2, IC4, IC5) explained that they see their role in the project as a coach. This was also perceived by NU1, explaining: “When we had questions, the project leader asked us: What would you do to solve this problem?”.
From these arguments, we can conclude that the used tools and approach to engage with change recipients was carefully selected to let change recipients take control of their own situation and let them have the responsibility within the framework setup by the change leader.
During the project, change agents rewarded their change recipients through expressing their appreciation during project meetings, conversations and in emails (IC1, IC2, IC5). IC2 explained that she put down a bag of liquorice during time measurements to increase
motivation and “give a positive twist to unpleasant work”. The enthusiasm with which project leaders engaged in the project also helped to gain momentum, as CO1 reflects: “The
enthusiasm of the project leaders also made us enthusiastic about the change, especially during the first days with intense contact". However, this enthusiasm faded, and momentum was lost when there were no follow-up meetings afterwards (CO1, NU1). Furthermore, IC1 and IC4 held group evaluation moments during the project to reflect on their past actions and ask how the project members thought it was going. IC5 reflected that it would also be better when she held these group moments to probe how the project members perceive the change so far. This was also confirmed by NU1, explaining: "I did miss evaluation moments during the project. We did not have any evaluation moments and I think this would have been beneficial".
These practices of appreciation, enthusiasm and reflective moments from the project leaders on a group level helped the project to gain momentum and help project members to build confidence in their ability to execute the change successfully. However, it is necessary to frequently check-in with change recipients in later stages of the project to help sustain this created momentum and prevent stagnation.
project”. IC4 explains that during these situations, the head of department should act as a role model. She was “buddying-up” with the head of department to gain trust and find an
appropriate balance between experimenting with the change, progressing and helping the head of department reflect on his change approach. Furthermore, it is important that the head of department not only has the formal power, but also the informal power within the department, as CO2 reflects: “As the head of department is actually also not originally from this
department, it is difficult for him to have the necessary power to change the work-floor employees”.
From these examples, we can see that a close collaboration between the head of department and project leader is necessary, as the project leader does not have the necessary knowledge on the context (e.g. knowledge on departmental culture, processes and group dynamics) and the head of departments does not have the necessary skills to execute a change project successfully and the broader view of the project within the organizational context. Furthermore, it is important that the head of department acts as a role model and has the necessary informal power within the department to be able to lead the change within the department with the change agent. When a head of department does not act as a role model or has the necessary power, this is might bring about a stagnation of the lean change project.
Participation of all groups. From the data collection, we found that it is essential to involve every stakeholder group in the process from the start of the project (IC1, IC2, IC4, IC5). This not only sets the stage to create an environment of high participation among the change recipients, but also makes them ambassadors of their own change (IC2). IC2
underestimated the power of a stakeholder group by not including them from the beginning, creating resistance during later stages of the project. Through the participation of every stakeholder during the baseline measurement, this allowed IC5 to have every stakeholder group on the same page on how the issue was perceived. From the interviews, initial participation of all stakeholders was experienced positively (MAN1, AD1, NU1, CO1, MAN2, CO2, MAN3, CO3) as they were involved in gathering the necessary information. However, when the lean change projects proceeded, stakeholders outside the project team were not kept up-to-date with information on how the project was going (IC5, CO3, MAN1). According to IC5, this was based on the assumption that project members would pass on project information to their department. However, this was not the case. This was also experienced by change recipient CO3, explaining: “I think the communication between the project team and the other colleagues could have been done more frequently, as some colleagues sometimes wondered how the project progressed, as they sometimes did not hear from it for a long time”.
reluctant or opposing the change. You notice that this individual is also representing an informal group. When they become enthusiastic, resistance from the informal group behind it also reduces”.
Based on these insights, we conclude that it is not only important to involve all stakeholders from the start to have them on the same page, but also to keep them involved throughout the project, without neglecting the stakeholders outside the project. Depending on their power to prevent the change from happening, project leaders select which formal and informal stakeholder groups should be represented in the project team. This not only creates engagement from all stakeholders but might also prevent resistance to change in later stages of the project, as initial resistant or opposing stakeholders represented in the project team slowly embrace the change due to their close engagement with the project. We have
summarized the lessons learned on the practices of empowerment together with the number of arguments that support the second-order codes in Table 2.
Second-order codes Practices on group-level Mediating role of head of department Participation of all groups
Lessons learned Select mix of
individuals within the project team
representing different formal and informal groups.
Collaborate closely with the head of department as he/she knows the group dynamics and context of the change.
Include individuals with power in the project team
representing groups opposing and
embracing the change. Select empowering
tools to empower change recipients during the project.
Head of department needs to act as a role model to push the change forward.
Keep each stakeholder group involved
continuously to prevent cynicism towards the change. Express appreciation
and enthusiasm, and setup reflective moments to gain momentum and build confidence.
Head of department needs to have the necessary formal and informal power to prevent stagnation of the change. - Number of arguments from the data 35 13 37
Table 2: Practices on empowerment - Lessons learned 4.2 Perceived empowerment
The concept of perceived empowerment by the change recipients is, from the theory and empirical research, divided into three categories; 1) information sharing, 2) autonomy through boundaries and 3) team accountability.
engaged with the project through brown paper sessions and baseline measurements (MAN1, AD1, NU1, CO1, MAN2, CO2, MAN3, CO3). However, during two lean change projects, sharing of information was limited to change recipients outside the project, as reflected by IC5, CO3 and MAN1. Through limiting the sharing of information among change recipients outside the project team, misinterpretations arise, as was experienced by the researcher during one of the visits overhearing a doctor saying: “This initiated project is very inconvenient. This is mainly something that management invented”. IC2 mitigated this problem by explaining that the project team frequently sent newsletters to all employees within the department to keep them updated. Consequently, a piece of paper with tips and tops was created to let employees within the department directly engage with the project. Furthermore, most change recipients (MAN2, IC5, MAN3, CO3) also explained that, as the project involved multiple departments, it opened up their eyes, to hear about the same perceived problems at other departments, as CO3 explained: “What was really beneficial for me was that you also heard from other departments what their problems were, and you could together discuss problems that you also experienced”.
Concluding, sharing of information was done on a large scale to give the rationale for the lean change project and by involving and sharing information during the initial stages. However, this was sometimes limited towards only sharing information with the project team when the project continued. This might have to do with the crucial role the head of
department plays in sharing of information, as previously explained, but also with the role of the other project members to act as a spokesperson towards their own formal or informal group to share information. Although resistance might have been formed due to this lack of communication, we did not interview change recipients outside the project teams and
therefore further consequences of these actions of limiting sharing of information is unknown.
Autonomy through boundaries. Second, when looking into the autonomy through boundaries, change recipients (MAN1, MAN2, NU1, CO1, AD1) perceived that the change agents only put up the framework of the project and furthermore gave the recipients control: “The project leader really gave us control: "What are you guys thinking about? Wat do you need? How do you want to change?” (MAN2). According to AD1, this was also due to the fact that the employees have the relevant knowledge and therefore the project leader was forced to give autonomy. Through this autonomy through boundaries, change recipients had the feeling that they were in control, as they had a lot of influence on the change within these boundaries, contributing to their sense of ownership. From the surveys, this autonomy
through boundaries was also confirmed by all change recipients, as there is an emphasize on own decision-making, the project leader listens carefully to project members and engages them in decisions that affect them.
Concluding, autonomy through boundaries perceived by the project members leads to shared ownership and a sense of control, reducing resistance as they are the ones proposing the ideas and therefore change agents are not able to “shoot the messenger” (IC4), reducing resistance to change and ensuring that the change sticks over the long-term after the project is completed.
leader does not extent infinitely, as IC2 continues explaining: “As we finish our support through delivering a continuous improvement board and accompanying dialogue to give them the tools to let the change stick over the long-term, not all departments have this capacity to continue with this on their own. However, as a project leader I am not the one to infinitely support this continuous improvement effort”. This is also confirmed by MAN2, as she
explains that the project leader shared the consequences of not continuing with the project but furthermore emphasized that they were the ones that have the accountability.
From these examples, it is clear that the project leaders do not feel accountable for the context of the project but limit themselves to properly guide the process of the lean change project through coaching efforts. This is done deliberately to further increase change recipient’s ownership and sense of control, decreasing resistance to change as change recipients execute their own proposed idea on how to change. The lessons learned on
perceived empowerment together with the number of arguments that support the second-order codes are summarized in Table 3.
Second-order codes Sharing of information Autonomy through boundaries Team accountability Lessons learned Explain the rationale
of the change among all stakeholder groups
Setup a framework with clear boundaries to increase ownership and a sense of controllability among change recipients. Engage in coaching efforts to further increase ownership and a sense of controllability among change recipients. Keep all stakeholder
groups informed on the progress of the change during the project. - - Number of arguments from the data 14 10 7
Table 3: Perceived empowerment - Lessons learned
4.3 Change readiness
As explained in the theoretical background, change readiness is divided into the cognitive and affective component. However, from the empirical data, we view that the 1) need to change, 2) capacity to change and 3) group dynamics stands out from the cognitive and affective components. Therefore, we focus on these second-order codes within the concept of change readiness.
member and others, reluctant or resistant to the change, do not feel engaged to participate in the project team. This is confirmed by IC1, explaining: “The project team was really positive about the project. However, there was one group, outside the project team, that was really resistant towards the change”. This statement is also supported by IC2 and AD1. Through early participation of the stakeholder groups, interviewed project leaders (IC1, IC2, IC4, IC5) tried to let the change recipients outside the project team see the rationale of the change, as IC1 explains: "During the initial stage, I let everybody engage to measure their work tasks. This resulted into the measurement that 27% of all work related to handling errors. I hoped that this would give people insides into the need to change. This early participation of stakeholder groups also resulted into project leader’s insights how other stakeholder groups outside the project team viewed the lean change project.
This perceived need to change might be related with the benefits or disadvantages that were perceived by each formal and informal group on their own tasks. Within the projects of IC1 and IC5, tasks were taken away from some groups during the project, as these tasks were not adding any value for the patients and therefore could be eliminated. However, during both projects, a lot of resistance was experienced from the groups experiencing only disadvantages from the change, as IC1 explains: “I talked with the head of department, and the underlying reason was that as the work consisted 27% of the time out of handling errors, a substantial part of their tasks would be gone after the project”. This was also emphasized by MAN1, explaining: “There was a lot of resistance from someone whose work consisted of handling errors. She feared her job and therefore resisted the change”. This resistance was expressed by delaying of project tasks, giving opposing views and convincing the group they
represented about the perceived negative consequences of the change, as IC5 explained: “This caused a lot of friction during the meetings. Therefore, we decided to let it rest and would continue with it in a new project”. During the project of IC1, this was handled by just pushing through and executing the change without the support of the groups opposing the change. This worked out fine, but only because the opposing groups did not have the power to stop the change. Reflecting on the project of IC5, it seems that they did have the power to stop (this part of) the change.
Concluding, change readiness of groups is partly dependent on the need to change and relates to the perceived benefits of each formal and informal group. Based on their perceived benefits, groups are willing to change and actively participate with the change by, for
example, taking place in the project team. However, when there is a lack of benefits, groups resist the change and, dependent on their power, are able to stop the change from happening. Therefore, change agents need to build a guiding coalition group to increase power and to be able to push through the change when needed.
Capacity to change. Next to the need to change, the capacity to change also influences change recipient’s change readiness. From the survey, five out of six change agents
experienced that the change recipients did not have the necessary capacity nor the confidence to change. However, from the surveys, the project members only indicated that they lacked the time and perceived that they had the necessary skills to execute the lean change projects. This difference might again be explained due to change recipients embracing the change have the capacity to change and therefore participate in the project team. However, change
