SECURING LEAN

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SECURING LEAN

HOW LEAN LEADERSHIP INFLUENCES THE

SUSTAINABILITY OF LEAN IN HEALTHCARE

ENVIRONMENTS

Joris Visser

University of Groningen

Faculty of Economics and Business

MSc BA - Change Management

March 21, 2018

Kastanjelaan 84

9741 CR Groningen

Tel: +31(0) 6 12870966

E-mail: j.visser.32@student.rug.nl

Student number: S2704021

Assessment:

University of Groningen

First supervisor: Dr. O.P. Roemeling

Second supervisor: Dr. I. Maris-de Bresser

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2 0 – ABSTRACT

Background: Growing evidence indicates that Lean within healthcare has the potential to improve the quality and efficiency of healthcare services. While most organizations achieve satisfactory results with their initial process improvement efforts, results tend to disappear over time. In the literature, it is argued that leadership is the key to sustain Lean. However, little is known about leaders’ role in the sustainment of Lean. Therefore, the aim of this study is to identify leader values and behaviors that help to sustain Lean.

Method: A qualitative research was conducted within a Dutch regional hospital. Two cases were analyzed: Case A was seen as a successful team, whereas Case B was seen as an unsuccessful team with respect to the sustainment of Lean. Interviews were held to let leaders reflect upon employees’ activities and vice versa. To supplement these findings, an observation in each case was conducted. Documentation and informal talks were used to get familiar with the hospital and to get a sense of direction for the research.

Findings: The results show that leader’s pointing out errors, involving employees, standards development, informing, expressing appreciation, delegating and providing ideas behaviors help most in sustaining Lean. Moreover, a shared set of values that helps in the sustainment of Lean was identified. Also, the results show implicit insights into the dynamics between values and behaviors of leader and employees. During this interplay, several barriers that hinder the sustainment of Lean were identified. Based on this, a framework was developed.

Conclusion: This framework could help leader and employees to behave in ways that support the sustainability of Lean. By providing this framework, it is hoped to provide healthcare organizations guidance to successfully sustain Lean on team-level.

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3 1 - INTRODUCTION

In this research, the focus will be on how Lean leadership influences the sustainability of Lean improvement activities in healthcare environments. This relationship will be explored through a qualitative research focussing on two teams in a regional Dutch hospital. Here, one team can be typified as a team where Lean was sustained, while the other team struggles with sustaining Lean.

Since society is aging, the demand for healthcare services is increasing. However, the financial conditions for healthcare organizations are not improving (Poksinska, 2010). Consequently, healthcare organizations are under great pressure to improve. They are challenged to be as cost-effective, accessible, safe, and affordable as possible (Poksinska, 2010). In order to accomplish this, healthcare organizations are adopting continuous process improvement methods, with Lean being the most studied approach (Radnor & Boaden, 2008; Radnor, 2010). According to Radnor, Holweg & Waring (2012), Lean is typified by a focus on customer value and by reducing non-value-added activities, process variation, and poor working conditions. There has been a growing interest in Lean in public services, in particular in healthcare environments (Radnor, 2010). According to Costa & Godinho Filho (2016), Lean already has proven its success within healthcare environments in terms of quality, patient safety, cost, waiting time and staff satisfaction. For hospitals, Lean is a methodology that helps improve patient care quality, support employees and doctors, eliminate barriers and focus on providing care (Costa & Godinho Filho, 2016). In this study, we adopt the definition of Toussaint and Berry (2013), and think of Lean as cultural commitment towards continuous improvement.

According to Poksinska, Swartling & Drotz (2013), Lean must be approached as a process of change. During this change process, Lean is implemented through a structured program that coaches and empowers employees (Fine, Golden, Hannam & Morra, 2009). However, Lean initiatives often raise resistance amongst recipients, which has a negative impact on continuous improvement activities over time (Melton, 2005). Fine et al. (2009) report that organizations often work with external consultants and coaches to overcome resistance amongst recipients. Unfortunately, the benefits of Lean often disappear shortly after the consultant or trainer leaves (Fine et al., 2009). Therefore, many authors argue that Lean entails cultural change and giving enough attention to the ‘respect of people’ principle of Lean (Bhasin, 2012; Dombrowski & Mielke, 2014).

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4 of Lean (Dombrowski & Mielke, 2013). However, since Lean is a recent phenomenon in healthcare environments, the quantity and quality of relevant literature and knowledge on the role of leadership in the sustainment of Lean is limited. This research, therefore, tries to fill this gap and provide considerable directions for future research.

Delving in the Lean literature in more detail, ‘leadership’ is a pervasive term in many books, research papers, and other scientific articles. Whether lack of leadership is listed as a key failure factor or effective leadership is listed as a key success factor, there is consensus on the role of leadership as an imperative in any Lean initiative (Ashtiani, Bhuiyan & Zanjani, 2017). According to Mann (2009), leadership is the missing link between Lean in practice and theory and little is known about Lean leaders. Therefore, the aim of this exploratory research is to know more about the leaders of Lean initiatives, especially about their role in the sustainment of Lean. As requested by Glynn & Raffaelli (2010), the behaviors and underlying values of Lean leaders will be researched in this research. Up until now, studies only analyzed Lean leadership quite superficially, without paying attention to the sustainability of Lean (Ashtiani et al., 2017). In a recent publication, van Dun, Hicks & Wilderom (2016) identified general Lean behaviors and values, based on an extensive literature review and field study by Lean leaders. Moreover, Liker & Convis (2012) designed a Lean leadership model including behaviors and values, which reflects their key to sustain Lean. However, how these values and behaviors influence the sustainability of a Lean approach in healthcare remains unclear, and requires further study.

Eventually, this research aims to explore how specific behaviors and values are applicable in healthcare environments and how these will influence the sustainability of Lean. Also, additional principles will be explored. The Lean leadership model of Liker & Convis (2012) is seen as an interesting starting point of this study, updated with current findings on Lean leadership behaviors and values. In this way, healthcare organizations are better able to sustain Lean initiatives by knowing how their leaders should behave in order to support the sustainability of Lean. Based on the above discussion, the following research question will be addressed in this research:

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5 2 - LITERATURE REVIEW

In this section, the following issues will be addressed: (1) an introduction to Lean, (2) an elaboration of the origin and recent developments of Lean leadership, and (4) a justification why it is important to research how Lean leadership influences the sustainability of Lean.

2.1 Lean

2.1.1 Lean origins

Originally, the Lean philosophy was developed by the Toyota Motor Corporation in Japan as a radical alternative to traditional mass production (Radnor et al., 2012). Within this philosophy, all steps that do not add value for the customer, also referred to as waste, have to be removed (Radnor et al., 2012). At a later stage, Womack & Jones (1997) introduced the term ‘Lean thinking’, which can be defined as follows: “Lean thinking is Lean, because it provides a way to do more and more with less and less – less human effort, less equipment, less time, and less space – while coming closer and closer to providing customers with exactly what they want.” In addition, Womack & Jones (1997) introduced 'five core principles' of Lean that serve as a guideline for implementing Lean. First, the operational processes must create value for the customer, viewed from the customer perspective. Second, for each product or service that involves value for the customer, a value stream have to be identified. In doing so, all steps that do not add value to the customer (and thus contain waste) must be removed. Third, one has to ensure that the products or services flow efficiently through the system, ideally without delay. By standardizing processes, these flows can take place more smoothly. Fourth, one must use the 'pull principle'. This implies that the process must be flexible and that the focus must be on individual customer's demands. Fifth, one must act and strive for perfection. Perfection means the integral removal of all activities that do not add value for the customer, so that the number of steps, the time needed and the information to serve a customer decreases. Furthermore, Womack & Jones (1997) showed that Lean could be applied within service environments as well. Lean found its application in healthcare environments in 2002 (Souza, 2009).

2.1.2 Lean in healthcare

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6 identified by Womack & Jones (1997), and other principles such as respect for people and committed leadership (D’Andreamatteo et al., 2015).

Accordingly, the literature shows considerable variability in the way Lean is implemented within the healthcare sector. Healthcare organizations tend to implement Lean as kind of a project-based approach instead of a system-wide approach (Radnor, 2010). According to Machado & Leitner (2010), a Lean transformation should take place by understanding the current state, defining the future state, implementing Lean, and sustaining the implementation. To reach the potential of Lean, a system-wide approach should be adopted. In this approach, Lean is included in the organization’s long-term vision, and employee development, continuous improvement, and sustainability are seen as the key pillars (Radnor & Walley, 2008). Up until now, only a small number of healthcare organizations have been able to implement Lean across their whole organization successfully (D’Andreamatteo et al., 2015).

With regard to success factors of Lean in healthcare, it is argued that support from each management level is required and that leadership is crucial (Poksinska, 2010; Holden, 2011). Moreover, creating cultural change, learning from previous experiences, adapting Lean to the local environment, including Lean in the long-term vision, and providing training courses and incentives are seen as important success factors of Lean in healthcare (Holden, 2011; Mazzocato, Savage, Brommels, Aronsson & Thor, 2010; Kollberg, Dahlgaard & Brehmer, 2006). Further, the quality of Lean projects’ definitions could be seen as a success factor; these should be defined by having the patient in mind (Niemeijer, Does, de Mast, Trip & van den Heuvel, 2011). According to D’Andreamatteo et al. (2015) however, little is known about the causes of why the application of Lean in healthcare fails.

Moreover, it has to be recognized that Lean is adopted from the manufacturing environment when translating it to healthcare (Souza, 2009). The healthcare environment is typified by powerful professional groups and regulatory systems, which make the translation of Lean in healthcare more complex (McNulty & Ferlie, 2002). For example, Souza (2009) argues that due to the complexity in healthcare environments, the adoption of Lean will not take place gradually. Souza (2009) also refers to the strong hierarchical structure of healthcare organizations. As a result, the voice of lower-ranked employees is often neglected. Also, it was identified that the success of a Lean transformation not solely depends on the technology used in healthcare environments, but also on the dynamics between social actors (D’Andreamatteo et al., 2015).

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7 2.2 Lean leadership

2.2.1 Defining leadership

Over the years, leadership has been researched from many different perspectives (Politis, 2005). Since this research will focus on the specific behaviors and values of Lean leaders only, these perspectives will not be considered in more detail. However, it is important to consider the difference between leadership and management here. According to Aij & Lohman (2016), leadership includes influencing people while management mainly focusses on the maintenance of systems and processes. According to Mann (2009), leadership is generally regarded as a critical success factor (CSF) for building a corporate, permanent culture within an organization. As new definitions of the concept leadership appear in the literature quite frequently, it is difficult to formulate leadership in a comprehensive way. Having the focus of this research in mind, Parisi-Carew, Finch & Stoner (2000) seems to be able to capture where leadership is about: “Leadership is the capacity to influence others through a dynamic, reciprocal covenant aimed at identifying and accomplishing collective purposes.”

2.2.2 Lean leadership developments

As already stated, Lean is initiated at Toyota. Toyota has exceeded its competitors for years on performance indicators such as quality, reliability, productivity, cost reduction, sales and growth in market share (Spear, 2004). Although Toyota has been studied worldwide and many large car manufacturers have tried to copy Toyota, only a few have been able to match Toyota's performance. Leaders within Toyota understand the importance of believing in their people, giving them confidence and believe investing in their people is the key to success (Liker, 2004). In line with this persuasion, Toyota has a long-term vision in which leaders encourage their people to fully participate in Toyota’s activities (Marksberry, Badurdeen & Maginnis, 2011). In this study, we refer to Lean as its own concept instead of seeing Toyota as the one best way to deal with Lean.

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8 improvement activities (Liker & Convis, 2012). According to Spear (2004), the role of a leader is to help employees understand the responsibility for improving their own activities and to provide them with the necessary resources. Spear (2004) even argued that leaders do not solve the problems themselves, but instead encourage their employees to solve the problems themselves. In line with this, it is important for leaders to support teamwork (Liker & Convis, 2012). Fourth, leaders are expected to create a vision and align the values across all levels of the organization. The aim of aligning values is to create a common goal with respect to Lean (Liker & Convis, 2012). A visualization of Liker & Convis’ (2012) Lean leadership model is presented in figure 1.

Figure 1: Lean leadership model (adapted from Liker & Convis, 2012)

According to Liker & Convis (2012), their model is the key to sustain Lean. In this study, we will adopt the same perspective as Liker & Convis (2012) and will focus on Lean values and behaviors. However, there may be new insights into Lean values and behaviors. Therefore, the model is compared to the current literature on Lean leadership to figure out whether the model has to be updated.

Leadership is seen as the missing link between Lean in practice and theory and less is known about Lean leaders (Mann, 2009). In order to fill this gap, this research will focus on the behaviors and underlying values of Lean leaders. Behavior is defined as observable verbal and non-verbal actions of leaders in interaction with their employees in an organizational setting (Szabo, Reber, Weibler, Brodbeck & Wunderer, 2001). Values are defined as desirable notions to guide a person’s behavior (Schwartz, 1999). This research will not focus on all possible connections between behavior and values, since many situational factors will probably influence this relationship, such as attributes and personal traits (Jin & Rounds, 2009). In this study, it is assumed that values and behavior affect each other directly.

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9 Dun et al. (2016) identified several Lean values and behaviors, based on an extensive literature review and field study of Lean leaders. Van Dun et al. (2016) identified a set of values, in which honesty, participation and teamwork, responsibility, openness, and continuous improvement are seen as the most important ones. In addition, Aij et al. (2015) identified trust, modesty, and openness as the most important Lean values in healthcare environments. To prevent confusion, Bhide & Stevensson (1990) argue that honesty and trust can be used interchangeably.

Next to Lean leadership values, several studies have focussed on Lean leadership behaviors (Camuffo & Gerli, 2018; van Dun et al., 2016). Based on an extensive review on Lean leadership literature, van Dun et al. (2016) identified a set of Lean behaviors, in which designing and coaching teams, visiting the work floor, getting and giving information, engaging employees, celebrating and recognizing success, and structuring and controlling are seen as the most important types of behavior. Moreover, Camuffo & Gerli (2018) also derived Lean leader behaviors from literature, with decision making, problem solving, standards development and capability development being most reviewed. Although the literature on Lean leadership reports different types of behavior, behaviors are often too broad and not actionable, for example ‘designing and coaching teams’ and ‘decision making’. Therefore, this study also takes Yukl’s (2002) behavioral taxonomy into account, which consists of five task-oriented behaviors, seven relations-oriented behaviors, and two change-oriented behaviors. According to Larsson & Vinberg (2010), the Yukl’s (2002) behavioral taxonomy represents all behaviors of an effective Lean leader, because the focus is also on human relationships and change, instead of only on task effectiveness. Furthermore, effective leaders tend to display five counterproductive behaviors (Liu, Liao & Loi, 2012). To structure all discussed behaviors, the definite list of current Lean behaviors is presented in table 1.

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10 With regard to the model of Liker & Convis (2012), not all elements do fit the identified values and behaviors in the current literature. It thus appears that Lean values and behaviors have changed over time, which may imply that our knowledge is outdated or that an expansion has to take place. In this study, the focus is on the current Lean values and behaviors. Eventually, this study will explore new Lean values and behaviors and tries to identify whether existing Lean values and behaviors do fit the healthcare environment with regard to sustaining Lean. Moreover, current literature does not mention the necessity of a fixed sequence of Lean behaviors in which Lean leaders continuously follow PDCA cycles (Camuffo & Gerli, 2018; van Dun et al., 2016), as proposed by Liker & Convis (2012).

Overall, in this study, we argue that the most important role of leadership is designing the organizational culture. The leader is in a position to shape the culture of continuous improvement and respect for people by influencing their followers, constantly challenging and coaching them and clearly aligning the values, vision, and goals of the organization (Dombrowski & Mielke, 2013).

2.3 Sustainability of Lean

As argued by D’Andreamatteo et al. (2015), the sustainability of a continuous improvement approach is influenced by external tensions to improve healthcare, and internal factors such as the willingness of employees to accept change. The implementation only accounts for 20 percent to achieve Lean transformation, whereas the other 80 percent is achieved through the effort of leaders who are faced with challenges to change the mindset of employees (Dombrowski & Zahn, 2011). At this moment, not much is known about the sustainability of Lean (D’Andreamatteo et al., 2015). However, some is known about the barriers to sustain Lean in the long run and the necessity of cultural change to sustain Lean. Therefore, these concepts will be addressed in more detail in chapter 2.3.1 and 2.3.2 respectively. 2.3.1 Barriers to Lean conversion

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11 decision-making around them (Morrow et al., 2012). Third, Lean leaders should prove that the change actually produces the desired effect. To convince the employees involved, it is important to give them insight into the expected results costs and revenues (Morrow et al., 2012). Fourth, Lean leaders should take into account how the change is embedded in the organization. For a change to sustain, old ways of working must be replaced by new working methods and policies (Morrow et al., 2012).

2.3.2 Continuous improvement culture

According to Liker & Convis (2011), the success rate of Lean attempts is only 2 percent. While most organizations achieve satisfactory results with their initial process improvement efforts, results tend to disappear over time (Radnor et al., 2012). In examining this phenomenon, the underlying reason may be explained by Liker's 4P model, which consist of four pillars: long-term thinking, waste elimination, respect for people and continuous learning (Liker, 2004). It seems that there is too much emphasis on waste elimination and less attention is paid to the other three pillars, which is consistent with the identified movement of Liker & Convis (2011). Hence, for Lean to be sustainable, it must be applied in an environment that promotes respect for people, a process-oriented way of thinking and a culture of continuous improvement (Bhasin, 2012).

A culture of continuous improvement culture encompasses all values and behaviors of both Lean leaders and their followers that result in a continuous pursuit of perfection (Dombrowski & Mielke, 2014). According to Liker (2004), culture is the shared set of beliefs, values, and behavior that define how you conduct the business. In a culture of continuous improvement, the culture must support the employees who do the work and is characterized by trust, shared responsibility and openness to experiments without fear of failure (Poksinska et al., 2013). According to Bhasin (2012), the human aspect of Lean, which is indicated by the culture of an organization, is a critical factor in the ability to sustain Lean. Mann (2012) state that Lean requires behavioral change to be sustained within the organization. This behavioral change needs leadership in order to sustain a continuous improvement culture, which is part of the behavioral change (Dombrowski & Mielke, 2013). In line with this, Schein (2004) argues that management is something that occurs within a culture, while leadership is something that creates and shapes cultures.

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12 2.4 Towards a Theoretical Framework

This research focusses on the role of Lean leadership in the sustainment of Lean initiatives in healthcare environments. The literature on Lean in healthcare indicates that organizations mostly fail to sustain Lean (D'Andreamatteo et al., 2015). Although little is known about the sustainability of Lean, it is known that barriers arise when it comes to sustaining Lean in organizations and that Lean requires cultural change in order to sustain over time. Leaders should understand these barriers and be equipped to deal with them. Furthermore, it is stated that cultural change demands leadership; the leader is in a position to shape the culture of continuous improvement and respect for people by influencing their employees, constantly challenging and coaching them and clearly aligning the values, vision, and goals of the organization (Aij et al., 2015; Mann, 2012). According to Mann (2009), leadership is the missing link between Lean in practice and theory and less is known about Lean leaders. At this moment, a Lean leadership model from Liker & Convis (2012) is available based on a sustained Lean environment. This is seen as an interesting and relevant starting point for this study. However, new Lean values and behaviors were identified in the current literature. Moreover, the model includes some intangible behaviors such as ‘daily management’, contains a certain sequence and does not take the dynamics between Lean leader and employee into account. This study is more interested in which Lean behaviors and values do influence the sustainability of Lean and into the dynamics between a Lean leader and his/her employees. Therefore, a theoretical framework is visualized in figure 2. This study will explore how leadership influences the sustainability of a Lean approach, and will adopt the presented framework as a theoretical lens.

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14 3 – METHODOLOGY

A more detailed understanding of how Lean leadership affects the sustainability of Lean is needed to move Lean in healthcare environments beyond the superficial approach of only applying tools, in which there is little attention for people and sustainability. As literature shows, the relationship between Lean leadership and the sustainability of Lean is poorly researched. Therefore, it is assumed that a theory development approach is most suitable (van Aken, Berends & Bij, 2012). To explore these concepts and further theory development, a case study was conducted. According to Eisenhardt (1989), a case study can be used for theory generating, and also for theory testing. In this research, the embedded case study approach is applied in order to establish new theory (Yin, 2014).

3.1 Research design and context

The case organization is selected on a number of criteria. First, the organization should operate in a healthcare environment where Lean activities or similar activities are actively used. Second, the organization should be of a certain size: at least 50 employees, at least a turnover of €10 million or a balance sheet total of at least €10 million (European Commission, 2003). Third, interviewees should have at least six months’ experience working with Lean in a healthcare environment. Last, there should be differences in the degree to which teams are able to sustain Lean in the organization. Based on these criteria, a regional Dutch hospital is selected.

The healthcare environment, including all environmental complexity was selected deliberately, but the research was conducted at two facilitating teams of the same cluster in a Dutch regional hospital. This had a convenience aspect: the teams were well-available and were provided by the hospital itself. The activities of these teams are related to the healthcare environment, but do not directly have a connection with the patient. As a result, these teams probably have lower complexity and therefore can bring Lean to good results.

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15 According to Zainal (2007), case studies have been accused of not being a robust research method, so a design with multiple case studies has been made to improve robustness. The similarities and differences between the selected cases, as mentioned above, display that theoretical sampling was achieved (Glaser & Strauss, 1967). As a result, the different conditions that were expected to influence the results were tackled. In this study, therefore, two cases were purposefully selected:

Table 2: Overview of studied cases 3.2 Data collection

For qualitative research to be of good quality, three criteria have been established: (1) controllability, (2) reliability and (3) validity (Yin, 2014). To ensure controllability, field notes of the research activities were written down in order to ensure that the research process is documented (Corbin & Strauss, 2008). Subsequently, several steps were undertaken to ensure reliability: (1) an interview protocol was developed to overcome the researcher bias, (2) the instrument bias was controlled through triangulation, (3) the respondent bias was controlled by interviewing both Lean leaders and employees on the real work floor, and (4) interviewing the respondents at different points of time helped to overcome the circumstances bias (van Aken et al., 2012). Last, to ensure validity, different data collection methods were combined. Case studies typically combine methods for data collection, such as archival data, interviews, surveys, and observations. This ensures triangulation, which provides stronger evidence of findings (Eisenhardt, 1989). Three different methods for data collection were used in this study: in-depth interviews, archival data, and observations. An overview of the data collection methods can be found in table 3.

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16 Interviews

Qualitative data was collected through a semi-structured interview, of which the interview protocol has been added to the appendix. The interview protocol gave the researcher guidance in conducting the interviews. A total of 12 interviews were held, 6 interviews in Case A and 6 interviews in Case B. All 12 interviews were conducted with employees who have experience working in a Lean healthcare environment. The interviews were all conducted in the same setting, namely one-on-one in a private room. Although the interview is semi-structured, there was room to ask additional questions when necessary. The semi-structured interviews are structured as follows: (1) a number of general questions, (2) questions about Lean leadership and (3) questions about the sustainability of Lean. During the interviews, there was made use of cross reflection; the leaders have been asked to reflect upon their employees, and the employees have been asked to reflect upon their leaders. Participants were randomly invited to participate in the study by the team leader. An overview of all studied respondents can be found in table 4.

Table 4: Overview of studied respondents Archival data

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17 Observations

Additional data was gained through observations in order to supplement the results of the semi-structured interviews. According to Yin (2014), observations cope with behavior in real time and the context of the case (Yin, 2014). The observed behaviors were categorized in the same Lean behaviors as proposed in Table 1. Furthermore, the observations tried to gain information about Lean values, Lean barriers, sustainability of Lean and the dynamics between Lean leader and their employees. The observations were performed during the CI sessions of Case A and Case B. The aim of these meetings was to discuss shortcomings and possible improvements. The CI sessions lasted approximately 30 minutes each. The improvement session of Case A was performed in a meeting room, whereas Case B was performed in front of an improvement board. All observations occurred in the morning within a time span of 2 weeks. The observation overview can be found in the appendix.

3.3 Data analysis

After the data collection, data was analyzed in a systemic way by using coding as a method to organize the data into consistent categories and find patterns (Saldana, 2015). Miles & Huberman (1994) identified two levels of coding during the coding process; first-order and second-order coding. First-order coding was used to summarize parts of the collected data. Within first-First-order coding, two approaches were used to create these codes. First, deductive codes have been derived from the theoretical background. Second, inductive codes were created after the data collection in order to figure out new themes.

After creating the first-order codes, the process of refining the codes and categories was repeated until patterns began to show up and a conceptual theory was visible from the analyzed data. As proposed by Corbin & Strauss (2008), the researcher constantly asked himself questions about the relationship between codes and writing down his reasoning. This process, known as second-order coding (Miles & Huberman (1994), was repeated until theoretical saturation was turned up (Glaser & Strauss, 1967). An example of the coding process structure can be found in figure 3. The data was coded in Atlas.ti.

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18 During the data analysis, a codebook was used to label, classify and categorize the collected data into first-order and second-order codes. To strengthen the controllability of the research, the codebook is included in the appendix.

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19 4 – RESULTS

In this section, an overview of the results of the research will be presented. First, a within-case analysis of both teams will be presented, after which the cross-case analysis is shown. The results will present deeper insights into the following concepts:

1. Lean values: Which values of Lean leaders and employees help to sustain Lean over time. 2. Lean behaviors: Which behaviors of Lean leaders and employees help to sustain Lean over time. 3. Lean barriers: Which barriers Lean leader and employees encounter in their daily work and how

these hinder the sustainment of Lean.

4. Continuous improvement culture: Whether a continuous improvement culture is part of Lean and how such a culture could be shaped.

5. Dynamics within teams: How values and behaviors of Lean leaders and employees interact while trying to sustain Lean.

4.1 Case A analysis

Team A has implemented Lean 5 years ago. In this research, Team A is considered as a successful team with respect to the sustainment of Lean. Team A has a weekly improving session, makes use of Brown Paper sessions and has realized many improvements since the implementation of Lean.

4.1.1 Lean values

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20 With regard to the employees, the most common employee values also appear to be continuous improvement and participation & teamwork. In total, 23 quotations indicate that the employees pursue continuous improvement and 21 quotations show that the employees value participation & teamwork. For example, an employee shares: “You have to stay sharp together and stay open for change. And always try to look at how we can do things better. That happens here. That happens almost automatic for me” (EA1). This quotation reveals that employees take the ‘team idea’ seriously, and that continuous improvement, for some, is internalized in their daily behaviors. Employees’ strive for continuous improvement was also disclosed during the observation: “Various ideas are presented for the problem with scan-purchase articles” (O1). Next to these two most common employee values, both the interviews and observation show evidence for employees’ creativity and pleasure in the sustainment of Lean. In the interviews, an employee indicates: “That people enjoy their work and be creative. From there, you perceive things that can be improved faster, I think” (EA1). During the observation, employees’ creativity was also shown: “Someone suggests to mark the scan-purchase items yellow, so that it is clear that the item has been ordered” (O1). For employees’ persuasion of unsatisfaction, trust, responsibility, openness and empathy, less evidence was found. All identified employee values are presented in figure 5.

Figure 4: Identified leader values in quotations per value

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21 To conclude, continuous improvement and participation & teamwork appear to be the most outspoken values in the sustainment of Lean for both leaders and employees. In addition, the results show that almost all values are shared. This shows that the leader is in a position to shape a culture, in which Lean can be sustained. Interestingly, both the leader and employees indicate the importance of pleasure in the sustainment of Lean.

4.1.2 Lean behaviors

With regard to the leader, involving employees and pointing out errors appear to be the most common leader behaviors in the data with regard to the sustainment of Lean. In total, 29 quotations indicate that the leader involves employees in the persuasion for continuous improvement and 19 quotations show that the leader points out errors. With regard to involving employees, an employee reveals: “He involves us a lot in improving” (EA3). This behavior was also displayed during the observation: “The team leader asks his employees for ideas to improve the processing of scan-purchase articles” (O1). In the matter of pointing out errors, an employee signals: “Things that go wrong repeatedly are taken into account during the Monday morning session. Everyone has awakened again then. In addition, LA1 points employees about their mistakes individually” (EA2). During the observation, it also became clear that the leader points out errors: “This point has already returned a number of times” (O1). Both behaviors were disclosed during one of the researcher’s informal talks at the hospital (Field notes). Moreover, standards development, informing, expressing appreciation and delegating appear to be important leader behavior to sustain Lean. The leader organizes Brown Paper sessions to improve and standardize work shifts: “As soon as it ends up in the procedure, routines arise” (EA3). This was also shown during the observation: “The team leader indicates that a standardized working method will be developed for taking the scan-purchase articles, on the basis of the Brown Paper session“ (O1). With respect to expressing appreciation and delegating, an employee shares the following about his leader: “I sometimes get a compliment, confirmation that you do your job well. That is how I am too. I often work with interns. LA1 sends them towards me” (EA5). Expressing appreciation was also displayed during the observation: “The team leader gives an employee a compliment, after answering a question from a department” (O1). With regard to informing, the leader communicates general announcements to his employees: “If there is a renovation soon, which concerns us” (EA3). This was also disclosed during the observation: “The team leader starts with the planning” (O1). More leader behaviors were identified in the context of sustaining Lean, but they appear to be less outspoken. All identified leader behaviors are presented in figure 6.

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22 the problem with the scan-purchase articles” (O1). Next to taking initiative, employees displayed behaviors in self-development, fulfilling appointments and communicating with peers. Some employees indicated that they like to develop themselves: “I like it when people call you to find out something, so you always learn” (EA5). Moreover, communicating with peers and fulfilling appointments were found to help the sustainment of Lean: “Continue to communicate with each other well. And what I said before, fulfilling appointments” (EA1). Communicating with peers was also revealed in the observation: “The team leader proposes to consult with each other how to divide the scanning shift” (O1). All identified employee behaviors are presented in figure 7.

To conclude, six main leader behaviors which help to sustain Lean were identified: involving employees, pointing out errors, standards development, informing, expressing appreciation and delegating. Moreover, employees’ imitative taking, self-development, appointments fulfillment and communication with peers were found to help sustain Lean over time.

Figure 6: Identified leader behaviors in quotations per behavior

Figure 7: Identified employee behaviors in quotations per behavior 4.1.3 Lean barriers

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23 to another indicated barrier; the willingness to change. In line with this, the leader tries to break the existing routines by developing new working procedures. The new standardized working procedures are all documented, so that employees can read this. Also, the leader sends an e-mail to all employees containing the discussed points during the weekly improvement session: “With the methods that have emerged from the Brown Paper sessions, everyone supports the working method. A guideline was developed of how we want to work and then keep it going. The Monday morning sessions enable us to implement the smaller ad-hoc improvements. If everyone agrees with this and LA1 also supports this, it will be implemented quickly. The working methods are updated and everyone receives it via mail” (EA5). Moreover, the working atmosphere was indicated as a barrier in the sustainment of Lean: “If you have a negative working atmosphere, people become laconic and do not deal with new improvements well” (EA5). In this case, there is a good working atmosphere: “There is attention for a birthday. Cake is handed out and stories about the weekend are exchanged” (O1). Furthermore, the results reveal that respondents find it difficult to give Lean priority over their daily activities sometimes: “Occasionally, LA1 wants to improve employees by showing how it works, but there is little time” (EA2). Besides, the results show that cross-team communication hinders the sustainment of Lean: “Communication from other departments is not good” (O1). Lastly, the meaningfulness of an improvement was identified as a barrier to sustain Lean, as an employee shares: “I think that an improvement should be meaningful” (EA1).

In short, seven Lean barriers that hinder the sustainment of Lean were identified. All identified Lean barriers are presented in figure 8.

Figure 8: Identified Lean barriers in quotations per barrier 4.1.4 Continuous improvement culture

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24 things go wrong, where things go well and where things can be improved. These people become more responsible and take the other people on the work floor in tow” (LA1). The shared drive is in line with the number of shared values, as already identified in chapter 4.1.1. Moreover, next to the improvement aspect of Lean, the human aspect is taken into account. For example, this is reflected in the identified leader’s behaviors, such as expressing appreciation and showing personal interest.

Based on the above, it is assumed that a continuous improvement culture is the end-goal in the sustainment of Lean. When this goal is achieved, Lean can be sustained in the long run.

4.2 Case B analysis

Team B has implemented Lean 5 years ago. In this research, Team B is considered as an unsuccessful team with respect to the sustainment of Lean. Team B has a weekly improving session, but sometimes this session is cancelled. Moreover, team B has realized only a few improvements.

4.2.1 Lean values

With regard to the leader, continuous improvement and empathy appear to be the most common leader values with regard to the sustainment of Lean. In total, 9 quotations indicate that the leader pursues continuous improvement and 7 quotations show that the leader strives for empathy. Regarding continuous improvement, an employee shares: “She always throws the improvement points into the group, despite the negative reactions of my colleagues. You know it. Everyone has their own opinion” (EB4). This quotation shows that the leader is persistent to improve continuously and tries to transfer this mindset to her employees. Another important leader value is empathy, as an employee indicates: “She knows exactly what it is to do our job. She has a feeling for our job” (EB5). Moreover, the leader strives for openness: “She is always open for a personal conversation” (EB2). This was also shown during the observation: “The team leader indicates that everyone can call her or come to her if there is something on the work floor” (O2). For the leader’s strive for trust, responsibility and participation & teamwork, less evidence was found. All identified leader values are presented in figure 9.

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25 something to improve or adjust, I will go to the leader” (EB1). Employees’ persuasion for continuous improvement was shown during the observation as well: “An employee indicates that the garbage bags are of poor quality” (O2). The results show little evidence for pleasure, trust, responsibility, openness, and empathy as employee values in the context of sustaining Lean. All identified employee values are presented in figure 10.

Figure 9: Identified leader values in quotations per value

Figure 10: Identified employee values in quotations per value

To conclude, it was identified that employees’ unsatisfaction and closedness hinder the sustainment of Lean. Despite evidence was found for values that may help to sustain Lean, it appears that employees’ unsatisfaction and closedness predominate the journey to sustain Lean in this case.

4.2.2 Lean behaviors

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26 Tuesday, I try to be as much as possible on the work floor, and then just go into conversations. I do not specifically mention that as improvement conversations” (LB1). For visiting the work floor, the findings were supplemented during one of the researcher’s informal talks at the hospital (Field notes). Furthermore, the results show that the leader displays informing and enforcing behaviors. As an employee indicates: “Well, it has been communicated to us. We cannot say that we do not want it, because it has to. LB1 explained it during the first session” (EB2). This finding was also shown during the observation: “The team leader forces the employees to clean the mops properly” (O2). Lastly, the leader displayed problem solving behavior. Interestingly, the leader does not associate problem solving with continuous improvement: “I am constantly solving. For example, we are solving for a year and a half now, instead of improving” (LB1). During the observation, it was also shown that the leader tends to cover all issues herself: “The team leader tries to involve employees in improving the work carts, but there is little input. The team leader will take care of it herself” (O2). More leader behaviors were identified in the context of sustaining Lean, but they appear to be less outspoken. All identified leader behaviors are presented in figure 11.

With regard to the employees, neglecting appear to be the most common behavior as well: “I think because we do not ask for it anymore. We will not go into this further. Take, for example, the booklet on the cart. You do not hear anyone anymore” (EB1).Contradictory, employees also displayed taking initiative behavior in this case. However, employees’ initiative taking eventually fades into neglecting behaviors, as the result of the neglecting behavior of the leader: “You have to go back a few times. Even that is not enough. If you notice that nothing is done, you will stop providing improvement points” (EB1). Besides, employees showed activity in communication with peers. In this case however, this type of behavior is more complex, since employees perform their work at other departments: “It is not only work within the Cleaning team, but you also work with staff who work at the departments and with patients. By communicating well with them, you do not build a wall and you can continue to improve” (EB2). Little evidence was found for employees’ fulfilling appointments and self-development behavior. All identified employee behaviors are presented in figure 12.

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27 Figure 12: Identified employee behaviors in quotations per behavior

To conclude, it was identified that both the leader and employees’ neglecting behavior hinder the sustainment of Lean. Moreover, it was recognized that a leader’s problem solving is not associated with continuous improvement. Despite evidence was found for behaviors that may help to sustain Lean, it appears that neglecting behaviors affect the journey to sustain Lean in this case negatively.

4.2.3 Lean barriers

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28 years, so they are stuck in their actions (EB4). Also, employees signal the place of the improvement session as a barrier to sustaining Lean: “The improvement board is in the hallway. You have seen with your own eyes that it is not a good place to talk to each other. We are constantly disturbed” (EB1). In an informal conversation, the leader told the researcher that people are more closed, as the result of the public place of the improvement session (Field notes). Besides, the results reveal the working atmosphere as barrier to sustaining Lean. An employee reveals: “As a group, we have never started to do nice things. If you do more with the group together, you want to do more for each other and improvements will come earlier” (EB5). Finally, the level of documentation was indicated as a barrier to sustaining Lean. Improvement points are only noted on the improvement board: “No logbook is sent or official mail” (EB4). Consequently, employees cannot look up the progress of an improvement point easily.

In short, eight Lean barriers that hinder the sustainment of Lean were identified. All identified Lean barriers are presented in figure 13.

Figure 13: Identified Lean barriers in quotations per barrier 4.2.4 Continuous improvement culture

All respondents indicated that a continuous culture is part of Lean. However, respondents do not indicate that they perceive a continuous improvement culture: “Some people want to improve, some do not. The right mentality is not with us” (EB3). Nevertheless, the leader tries to shape a continuous improvement culture by finding the right balance between continuous improvement and the human aspect of Lean: “We are looking for finding the right balance. For example, socializing, I am doing it only for one month now” (LB1). In this attempt however, continuous improvement is neglected while human attention predominates, as already indicated in the neglecting behavior of the leader in chapter 4.2.2. Next to this, the leader displays enforcing behavior, which blocks an important part of a continuous improvement culture; experimenting without fear for failure.

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29 4.3 Cross-case analysis

Several concepts have been identified in the internal analyses. In the cross-case analysis, the emerged concepts from each case will be compared with each other according to the same structure as the internal analyses. In this, the concepts that appear to have the strongest influence in sustaining Lean in each case will be compared with each other.

4.3.1 Lean values

In Case A, continuous improvement and participation & teamwork appear to be the most important values in the sustainment of Lean for both leaders and employees. Moreover, both the leader and employees indicate the importance of pleasure, trust, responsibility, openness, and empathy in the sustainment of Lean. Also, employees’ strive for creativity was found in both the interview and observation to help the sustainment of Lean.

In Case B, it was identified that employees’ unsatisfaction and closedness hinder the sustainment of Lean. Interestingly, evidence also has shown that both the leader’s and employees’ strive for continuous improvement, trust, responsibility, participation & teamwork, openness, and empathy. Despite these shared values however, Case B is unsuccessful in the sustainment of Lean. Therefore, it is assumed that employees’ unsatisfaction and closedness predominate the journey to sustain Lean here.

To conclude, since Case A has managed to sustain Lean, it is assumed that both a leader and employees have to pursue continuous improvement and participation & teamwork to sustain Lean in the first place. Besides, a shared persuasion of pleasure, trust, responsibility, openness, and empathy should be present. Furthermore, since employees’ creativity has only emerged in Case A, it is assumed that this also a required value for employees in the sustainment of Lean.

4.3.2 Lean behaviors

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30 In Case B, the results have shown most evidence for the leader’s neglecting, enforcing, socializing, problem solving and informing behavior in the sustainment of Lean. Interestingly, it was shown that problem solving is not associated with continuous improvement by the leader. The leader is constantly solving problems, instead of improving things. With regard to the employees, it emerged that employees’ taking initiative and neglecting behavior is most influential in the sustainment of Lean in this case. Although employees take initiative, it was identified that this eventually fades into neglecting behavior because of the neglecting behavior of the leader.

To conclude, since Case A has managed to sustain Lean, it is assumed that leader’s pointing out errors, involving employees, standards development, informing, expressing appreciation and delegating appear to be most helpful in the sustainment of Lean. Besides, employees’ taking initiative, fulfilling appointments, communicating with peers and self-development behaviors should be present. Last, since the leader’s providing ideas has only emerged in Case A, it is assumed that this also a required behavior in the sustainment of Lean.

4.3.3 Lean barriers

In both cases, cross-team communication, existing routines, level of documentation, meaningfulness of the improvement, other priorities, willingness to change and working atmosphere appear as barriers in the sustainment of Lean. In Case B, it was also indicated that the place of the improving session hinders the sustainment of Lean. In this study, all barriers will be included in the framework to provide concrete guidance which barriers should be taken into account in the sustainment of Lean. It have to be said however, Case B has to do with more complexity due to the new external party and decentralized way of working.

4.3.4 Continuous improvement culture

In both cases, all respondents indicate that a continuous improvement culture should be part of Lean. It was identified that a continuous improvement culture could be seen as the end-goal in the sustainment of Lean. In Case A, the results have shown that members perceive a continuous improvement culture. It emerged that this culture was shaped by the leader and the employees as well. It was also shown that there was attention for both the human and improvement aspect of Lean. In Case B however, a continuous improvement culture was not perceived. The leader tries to shape such a culture, but emphasizes too much on the human aspect of Lean.

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31 4.4 Dynamics within teams

Although there were no explicit questions about the dynamics within teams, the results provide some implicit insights. First, the results reveal insights in the reflection of leader values in leader behaviors and in the reflection of employee values in employee behaviors. Second, the results supply insights into the consequences of leader behaviors on employee values and behaviors.

4.4.1 Reflection of leader values in leader behaviors

In total, leaders display 15 different types of behavior in the context of sustaining Lean over both cases. All these behaviors seem to be associated with the pursued leader values. Although most reflections are quite straightforward, some reflections are interesting and therefore deserve more explanation. All identified reflections per case can be found in table 5, 6 and 7.

First, leaders’ strive for continuous improvement is reflected in expressing appreciation and socialization. With regard to the reflection of continuous improvement in expressing appreciation, the leader reveals: “Everyone is equally important in the process. I show this to everyone” (LA1). Assuming the leader of team A’s strive for continuous improvement, as indicated in the analysis of Case A, it can be argued the leader displays this behavior having continuous improvement in mind. Concerning the reflection of continuous improvement in socializing, the leader of team B thinks that socializing is necessary in her strive for continuous improvement: “Yes, because people are going to see each other differently. People will do more for each other, because the reason why someone is not comfortable is known” (LB1).

Moreover, leaders’ pleasure is reflected in expressing appreciation, showing personal interest and socializing. The leader of team A shares: “When people are happier, they also perform better. When people are in a dip, things go wrong. I see that people find it more fun to improve and do their work well” (LA1). Implicitly, the leader tries to transfer his pleasure to the employees by expressing appreciation and showing personal interest, because he notices that pleasure makes employees perform better. With regard to the reflection of leader’s pleasure in socialization, the leader of team B shares: “I am much more interested in getting to know each other first, then you will have a better team feeling. Organize a company trip to get the team spirit back. This improves the atmosphere” (LB1).

Furthermore, leaders’ persuasion for participation & teamwork is reflected in standards development: “With the Brown Paper sessions, we have improved the working procedures for several shifts, so that people can work in the same way. People will not adopt their own procedure. During the Brown Paper sessions, an agreed procedure came out” (LA1). In other words, the leader wants to develop standards not individually, but together with his whole team.

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32 Table 5: Identified guiding leader values per behavior in Case A

Table 6: Identified guiding leader values per behavior in Case B

Table 7: Identified guiding leader values per behavior in Case A & Case B 4.4.2 Reflection of employee values in employee behaviors

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33 First, employees’ pleasure is reflected in communicating with peers, fulfilling appointments, self-development and taking initiative. The leader of team A reveals: “When people are happier, they also perform better. When people are in a dip, things go wrong. I see that people find it more fun to improve and do their work well” (LA1). This quotation shows that employees’ pleasure is reflected in all productive behaviors implicitly, which is supplemented by an employee: “That everyone is cheerful and creative. From there, I think you can see improvements faster” (EA3). Although creativity may also be associated with self-development, the results do not provide insights for this reflection.

Besides, employees’ closedness and unsatisfaction are reflected in their neglecting behavior: “You have to go back a few times. Even that is not enough. If you notice that nothing is done, you will stop providing improvement points” (EB1). Since the employees are unsatisfied, they will display neglecting behavior towards Lean in the end. Moreover, most employees in team B are closed in public, which guides their neglecting behavior: “I think because we do not ask for it anymore. We will not go into this further. Take, for example, the booklet on the cart. You do not hear anyone anymore” (EB1).

Table 8: Identified guiding employee values per behavior 4.4.3 Influence of leader behaviors on employees

Ultimately, the results provide implicit insights into the influence of leaders’ behaviors on employees’ values and behaviors. In table 9,10 and 11, all these insights per case are presented. Although most reflections are quite straightforward, some are interesting and therefore deserve more explanation.

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34 demonstrates, the delegating behavior results in continuous improvement thinking and has a connection with involving employees by the leader. However, involving employees concerns improvement issues, whereas delegating only concerns a shift in responsibility in this study. Nevertheless, both involving employees and delegating seems to stimulate employees’ self-development. Concerning delegating, an employee shares: “That people are increasingly self-reliant on the work floor. I think that is a challenge. For example, I like it when people call you to find out something, so you always learn” (EA5). Regarding involving employees, an employee shares: “When I have time, I think about how we can improve services, such as walking more effective walkways” (EA3). These quotations show that employees will develop themselves as the result of a certain ‘freedom’.

Moreover, enforcing and neglecting by the leader result in unsatisfaction and closedness amongst employees. Employees even copied the neglecting behavior of their leader. An employee shares: “We simply do what is told to us, but we do not think about improvements ourselves. We did ask for new cloths a few times. Still, they are not here. If you already have asked 3 times, and they did not come, what do you do?” (EB2). Eventually, employees accept these counterproductive behaviors of their leader and will display neglecting behavior themselves.

Furthermore, employees indicated that pointing out errors by the leader works effectively in the sustainment of Lean: “LA1 points employees about their mistakes individually. If it occurs in a broader aspect, he will take into account in the Monday morning session” (EA2). The leader points out errors in the whole team, as well as individually. In this way, employees are ‘awake’ again and can communicate about their mistakes collectively.

Also, during the observation of team B, it became clear that problem solving works counterproductive. The leader tried to solve all problems during the improving session herself (O2). Because of this, employees do not have to think about solutions themselves, which eventually results in closedness and neglecting by employees.

Interestingly, in contrast to the persuasion of teams B’s leader, no insights were found on the influence of socializing in the strive for continuous improvement amongst employees. Also, no implicit insights were found of the influence of leaders’ showing personal interest and visiting the work on employees’ behaviors.

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35 Table 9: Influence of leader behaviors on employees identified in Case A

Table 10: Influence of leader behaviors on employees identified in Case B

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36 5 – DISCUSSION

The aim of this study was to figure out how Lean leaders could help healthcare organizations in sustaining Lean in the long run on team-level. In order to do so, the following research question was developed: How does Lean leadership influence the sustainability of Lean in healthcare environments? To gain more knowledge about the leader’s role in the sustainment of Lean, the behaviors and underlying values of Lean leaders were researched. Delving into the literature, it was found that there already was a leadership model available based on a successful Lean environment (Liker & Convis, 2012). Although this model was seen as an interesting starting point and some similarities with current literature were found, the model neglects the interplay between leader and employees and does not take barriers to sustain Lean into account. Therefore, a theoretical framework was developed based on the current findings in the literature on Lean values, behaviors, and barriers (Aij et al., 2015; van Dun et al., 2016; Camuffo & Gerli, 2018; Anand et al., 2012; Morrow et al., 2012). In this study, it was tried to provide a shared understanding of the values and behaviors of both the leader and employees. Moreover, several Lean barriers were indicated and the requirement of a continuous improvement culture was revealed.

When looking to Lean values, it emerged that both a leader’s and employees’ strive for continuous improvement and participation & teamwork help to sustain Lean in the first place. Besides, a shared persuasion of pleasure, trust, responsibility, openness, and empathy should be present. Furthermore, employees’ creativity was found to help sustain Lean. Literature shows only overlap for a leader’s strive for continuous improvement, participation & teamwork and openness (Aij et al., 2015; van Dun et al., 2016).

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37 When looking to Lean barriers, 8 barriers that hinder the sustainment of Lean were identified: cross-team communication, existing routines, level of documentation, meaningfulness of the improvement, other priorities, willingness to change, working atmosphere and the place of the improving session. The literature mentions that it is hard to sustain enthusiasm for a new way of working, because employees need all their time to finish their normal work (Davis & Adams, 2012; Anand,

Chhajed & Delfin, 2012). This is in line with the identification of ‘other’ priorities as Lean barrier in this study. Moreover, literature does mention the willingness to change as a barrier to sustain Lean. This barrier was also identified in this study. Furthermore, existing routines were indicated as Lean barrier here. Consistently, in literature it is argued that for a change to sustain, old ways of working must be replaced by new working methods and policies (Morrow et al., 2012). The other indicated Lean barriers are not mentioned in the literature.

When looking to the continuous improvement culture, literature mentions the requirement of a continuous improvement culture in the sustainment of Lean (Bhasin, 2012). In this study, a continuous improvement culture was identified as the end-goal in the sustainment of Lean. Lean has to become a second nature of everyone, instead of something that needs to be done next to the normal work (Aij et al., 2015). That being said however, a continuous improvement culture reaches further than the level of this study. A continuous improvement culture concerns the whole organization, instead of only two teams. The emphasis differs from one level to another (Aij et al., 2015). Within a team, Lean leaders are expected to act as role models, so employees will copy their behavior (Mann, 2009). In this study, it was found that leader behavior influences employee values and behaviors. Therefore, it can be assumed that leaders could shape an organization’s culture. However, the results of values and behaviors did not show evidence for cultural change. On higher level, the emphasis should be more on observing whether the continuous improvement culture is maintained across all teams.

5.1 Theoretical contributions and practical implications

In this study, the model of Liker & Convis (2012) was considered as an interesting starting point. After reading literature about Lean leadership and having this model in mind, the researcher created his own view and visualized this in a theoretical framework. Eventually, this research mainly supports literature about leader values and behaviors in a Lean environment. However, this research expands the current understanding of how leadership could help sustain Lean by also looking at employees’ perspective and taking the dynamics between the leader and employees into account. This shared understanding provides the basis for more extensive research about the sustainability of Lean in the healthcare environment on team-level.

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38 found as an important value in the sustainment of Lean. Moreover, the finding of employees’ taking initiative, fulfilling appointments, communicating with peers is a contribution to literature. Also, new barriers that hinder the sustainment of Lean were identified. These barriers should be taken into account by team leaders while trying to sustain Lean. Furthermore, this study showed that a continuous improvement culture is seen as the end-goal in the sustainment of Lean. Although the organization’s culture reaches further than the level of this study, it was identified that a leader could shape the organization’s culture. This brings us to the last contribution, this study provides implicit insights into the dynamics between leader and employees values and behaviors. Through reading between the lines, implicit reflections of values in behaviors were identified. Besides, implicit evidence was found for the influence of leader’s behavior on employees’ values and behaviors.

To visualize the aforementioned theoretical contributions, the theoretical framework needs to be updated. The updated framework can be explained in the same way as the original framework presented in figure 2, but includes more specific information on values and behaviors of leaders and employees that help in the sustainment of Lean. Moreover, the updated theoretical framework provides insights into the dynamics between leaders and employees. In Figure 14, the updated theoretical framework is presented.

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