Lean leadership: the key to stimulate the relation between lean maturity and second-order problem solving?

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Lean leadership: the key to stimulate the relation

between lean maturity and second-order problem

solving?

Master’s thesis SCM MSc Supply Chain Management

University of Groningen, Faculty of Economics and Business The Netherlands January 30, 2017 Pauline Vinks Student number: 2363267 Email: p.m.vinks@student.rug.nl Supervisors/ university: prof. dr. ir. C.T.B. Ahaus

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2 Abstract

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1. Introduction

In recent years, the performance of the healthcare sector has come under attack. While expenses for healthcare keep rising, the medical errors and patient satisfaction have not improved (Dahlgaard, Pettersen, & Dahlgaard-park, 2011). Many healthcare organizations have started implementing lean practices in an attempt to enhance their performance.

Although lean practices seem promising to continuously improve processes by eliminating the activities that do not add value to the customer (Iris & Cebeci, 2014), the success rate of lean initiatives in healthcare is low (Burgess & Radnor, 2012). Furthermore, the several cases of success of lean in healthcare that do exist in literature lack in explanation, prediction and replication of these successes (Holden, Eriksson, Andreasson, Williamsson, & Dellve, 2015). One of the aims of lean is to increase the learning ability of the organisation and its

employees (Tortorella, Marodin, Fogliatto, & Miorando, 2015). Tucker and Edmondson (2003) indicate that a dimension of organisational learning, second-order problem solving, could be the key to increase the performance in hospitals, which has triggered this research.

In the context of organisations, problem solving can be classified as one of the two types: first-order or second-order problem solving (Tucker & Edmondson, 2003). According to Meijboom, Gemmel, and Beveren (2016), organisations apply a second-order problem solving approach when they attempt to unveil the causes to their problems by questioning their current work practices and theories. Second-order problem solving differs from first-order problem solving in that first-first-order problem solving only resolves the immediate issues at a specific time, but does not prevent these issues to re-occur in the long run (Ghosh & Sobek II, 2015). In contrast, second-order problem solving is a cognitive approach in organisational learning that not only solves the issues at a certain period in time, but also tackles the underlying causes of the issues (Meijboom et al., 2016), which matches the lean principles of continuous improvement. Therefore, second-order problem solving behaviour of employees could significantly improve the performance of healthcare organisations.

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5 second-order problem solving. Erskine et al. (2013) mention that the people who lead the changes are central to the success of a transformational change program, such as lean improvement initiatives. A leader can stimulate employees to create, develop and sustain a culture of improvement (White, Wells, & Butterworth, 2014), which matches the idea behind the second-order problem solving approach. Furthermore, leadership is considered to be crucial to sustain lean initiatives in an organisation (Smith & Rudd, 2010). Currently, the role of a lean leader in a healthcare environment is not clearly defined. Therefore, this research aims to identify the characteristics and activities that belong to lean leadership.

This research investigates what constitutes the term lean leadership and how this concept influences the relation between lean maturity and second-order problem solving, and in the end on performance. The term lean leadership and the influence of lean leadership on the relation between lean maturity and second-order problem solving have not previously been studied, and will complement the existing literature. In addition, the relation between second-order problem solving and the performance of lean programmes is investigated, since second-order problem solving is suggested as key to improve the performance. Summarizing this leads to the following two research questions: (1) what constitutes the term lean

leadership? and (2) how does lean leadership affect the relation between lean maturity and second-order problem solving and in the end on the performance of nurse teams?

This research contributes to the leadership literature by extending the three elements of lean leadership founded by Aij, Visse, and Widdershoven (2015) and the four lean leadership tasks of Poksinska, Swartling, & Drotz (2013). Analyses of two Dutch Hospitals provide evidence for the existence of fourteen dimensions that describe lean leadership. In contrast to Aij et al. (2015) and Poksinska et al. (2013), this research does consider the existing

leadership styles, mentioned by Bass and Riggio (2006). Finally, this research shows that lean leadership positively influences the relation between lean maturity and second-order problem solving and provides empirical support for this conclusion.

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2. Theoretical background

This section describes the theoretical framework of the research. First, the concept of lean is shortly discussed and lean in healthcare organizations are described. Next, lean maturity and second-order problem solving is explained in-depth. Thereafter, the concept of lean leadership and the influence on the relation between lean maturity and second-order problem solving is discussed. Finally, the conceptual model is presented.

2.1. Lean in healthcare

The concept of lean started with the introduction of the Toyota Production System (TPS), which was developed as a method to remove all kinds of waste in the production process (Powell, Riezebos, & Strandhagen, 2013). Due to the success of TPS this concept was globally recognized in the whole manufacturing industry and later also absorbed in other industries under the name ‘Lean Production’ (Jasti & Kodali, 2015). The paper of Jasti and Kodali (2015) provides a systematic overview of the development of lean production. One of the industries in which lean is also widely applied is the healthcare sector (Gao & Low, 2014). This sector is under great pressure since expenses are rising, while the patient satisfaction does not seem to improve (Dahlgaard et al., 2011). To spend the budget more efficiently and effectively and to improve patient satisfaction, healthcare organizations start implementing lean principles. Lean healthcare is a management philosophy, which tries to increase patient and other stakeholder satisfaction through continuous improvements in which employees have to identify and eliminate all non-value adding activities (Doğan & Unutulmaz, 2016).

Many different lean programs have been developed, one of them being the ‘Productive Ward Releasing Time to Care’ (PW) programme, which is designed by the NHS and was initiated in England in 2007 (Van Bogaert, Van Heusden, Somers, & Tegenbos, 2014). The programme consists of thirteen modules of which three foundation modules have to be

implemented first: ‘Knowing How We are doing’, ‘Well Organised Ward’ and ‘Patient Status at a Glance’ (Wright & Mcsherry, 2013). The aim of the PW programme is to provide staff with more time to direct patient care, to improve the staff and patient satisfaction, and to change the use of ward spaces permanently in order to improve performance (Morrow,

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2.2. Lean maturity

The level of lean maturity in an organization indicates the adoption and progress of a lean programme. Assuming that a higher level of lean maturity is associated with a higher level of organisational learning in an organisation, it seems to be necessary to indicate the level of lean maturity first. Maturity models appear to be of great value to performance improvement approaches (Verrier, Rose, & Caillaud, 2015), as they provide organisations with information and direction to prioritise their improvement actions and can be useful for initiating a cultural change (Nesensohn, Bryde, Fearon, & Ochieng, 2013).

Malmbrandt and Åhlström (2013) have developed a lean adoption assessment model that can be used in a service environment, such as a healthcare organisation. This model identifies three types of items that can be measured:

1. Enablers of lean adoption: these type of items are related to employees, managers and infrastructural elements that can play an important role in lean adoption.

2. Lean practices: these type of items focus on the way of working according to the lean

principles in a service context.

3. Performance: items to measure the operational performance with the focus on the results

of lean adoption.

The three types of items are measured on a five-level scale, see Table 1.

Generic definition of maturity level

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

Level 2 General awareness: start of searching for proper tools and methods, problem solving is becoming more structured. Informal approach in few areas with varying degrees of effectiveness

Level 3 Systematic approach: most areas involved, but at varying stages. Experimenting using more and more tools and methods and employees start following-up work using metrics

Level 4 On-going refinement: all areas involved, but at varying stages. Improvement gains are sustained

Level 5 Exceptional, well-defined, innovative approach: all areas are involved at the advanced level. Improvement gains are sustained and challenged systematically. Innovative solutions to common problems, recognized as best practice/role model

Table 1: Levels of lean maturity. Retrieved from Malmbrandt and Åhlström (2013), inspired by Nightingale & Mize (2002)

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8 organization, the enabling items of lean adoption and the lean practices have to be translated to healthcare specific items, which is done in this research.

2.3. Second-order problem solving

Second-order problem solving is a cognitive approach in organizational learning theory that aims to find the root causes of problems by in-depth questioning of the work-practices and theories (Tucker & Edmondson, 2003). Like mentioned before, this approach differs from first-order problem solving, which does not focus on preventing issues to re-occur, but only resolves the issues at that particular time (Ghosh & Sobek II, 2015).

A problem can be defined as a ‘disruption in a worker's ability to execute a prescribed task because either (1) something the worker needs is unavailable in the time, location, condition, or quantity desired and hence, the task cannot be executed as planned, or (2) something is present that should not be, interfering with the designated task’ (Tucker & Edmondson, 2003, p.3). Problems can be categorized according to five types: (1) missing or incorrect information, (2) missing or broken equipment, (3) waiting for a (human or

equipment) resource, (4) missing or incorrect supplies, and (5) simultaneous demands on their time. Using a first-order problem solving approach, a nurse would solve only the problem without considering the underlying cause of the problem, which appears to be successful at first glance, but does not prevent the problem to re-occur in the future (Tucker & Edmondson, 2003). This problem solving approach is mostly used for problems in healthcare settings, due to two rules of thumb in this sector: ‘do what it takes to continue the patient-care task’

(Tucker & Edmondson, 2003, p. 10) and if the tasks cannot be completed without help, this help will be asked from people that are socially close instead of the best equipped people for this problem (Tucker & Edmondson, 2003). These two rules of thumb prohibit nurses from conducting a more successful approach for the long-term: second-order problem solving. Second-order problem solving behaviour does address the underlying causes of the problem, which reduces the likelihood of reoccurrence of a problem. Tucker and Edmondson (2003) have identified five actions that can be categorized as second-order problem solving behaviour, see Table 2.

There are different options to stimulate second-order problem solving. First, managers must be aware of problem re-occurrence and have to support nurses with problem solving. Second, nurses need to be able to talk about their problems without being criticized. Third, nurses need to be stimulated to come up with boundary-crossing suggestions for

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Action 1 Communicating to the person or department responsible for the problem

Action 2 Bringing the problem to the attention of the manager or the head nurse

Action 3 Sharing ideas about the cause of the situation and how to prevent recurrence with someone in a position to implement changes

Action 4 Implement changes

Action 5 Verify that changes have the desired effect

Table 2: actions of second-order problem solving (Tucker & Edmondson, 2003)

This research complements to literature by testing the problem solving behaviour of nurses after the implementation of a lean programme. Meijboom et al. (2016) already investigate whether the implementation of lean tools stimulates second-order problem solving behaviour by nurses. However, they do not consider the extensiveness of lean implementation and order problem solving. They also mention that the supportive dimensions for second-order problem solving, such as the behaviour of management need more in-depth studying. Therefore, this research extends on Meijboom et al. (2016) by considering different levels of lean maturity and second-order problem solving. Furthermore, the effect of lean leadership on second-order problem solving behaviour of nurses is investigated.

2.4. Lean leadership

Stimulating followers to achieve certain goals requires a particular leadership style (Hamstra, Van Yperen, Wisse, & Sassenberg, 2014). Nevertheless, there is still no consensus about the leadership style and competences that are important when organizations experience change, for example when implementing lean (Aij et al., 2015). The two general leadership styles that are distinguished in literature are transformational and transactional leadership.

Transformational leadership can be defined as ‘a motivational leadership style which

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Transformational leadership Transactional leadership

Idealized Influence: leaders behave in ways that allow them to serve as role models for their followers.

Contingent Reward: leader assigning or obtaining follower agreement on what needs to be done with promised or actual rewards offered in exchange for satisfactorily carrying out the agreement

Inspirational Motivation: leaders behave in ways that motivate and inspire those around them by providing meaning and challenge to their followers’ work.

Active Management-by-Exception: leader arranges to actively monitor deviances from standards, mistakes and errors in the follower’s assignments and to take corrective action as necessary.

Intellectual Stimulation: leaders stimulate their followers’ efforts to be innovative and creative by questioning assumptions, reframing problems, and approaching old situations in new ways.

Passive Management-by-Exception: leader waits passively for deviances, mistakes and errors to occur and then taking the corrective action

Individualized Consideration: leaders pay special attention to each individual follower’s needs for achievement and growth by acting as a coach or mentor.

Table 3: components of transformational and transactional leadership retrieved from Bass and Riggio (2006)

Because lean has become indispensable in manufacturing (Shah & Ward, 2007) and of growing importance in services, including healthcare (Matthias & Brown, 2016), research on successful lean leadership seems crucial. Aij et al. (2015) start to investigate what defines lean leadership. They execute an ethnographic study that results in three common characteristics of lean leaders:

- Going to the Gemba: leaders must be on the work floor and see the problems

themselves. They have to experience what is going on, instead of primarily focusing on measurement of outcomes.

- Empowerment and trust: leaders have to assign responsibility to nurses, which fosters trust.

- Modesty and openness: leaders have to be able to express uncertainty on the work floor, which promotes others to show sincerity. Also, understanding the patient perspective and cooperation of leaders are crucial.

In addition, Poksinska et al. (2013) argue that a lean leader has four main tasks: - Be committed to development: leaders must have commitment to

self-development and develop themselves first before they can teach others. They must have in-depth understanding of the work, the ability to lead people and have to be respected in terms of their technical knowledge as well as their leadership abilities. - Coach and develop others: leaders have to understand and live the organisational

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11 learning and knowledge sharing should be promoted in the organisation to encourage employees to solve problems themselves.

- Support daily Kaizen and encourage participation and engagement for improvement

activities: leaders should help their employees to realize that they have to improve

their own operations and provide the necessary resources to do so.

- Create the vision and align goals: the vision should describe the objective and long-term goals of the organisation.

While Aij et al. (2015) and Poksinska et al. (2013) start to determine lean leadership, a

uniform definition is still lacking. Furthermore, they do not reflect on the existing components of transformational and transactional leadership. Therefore, this research investigates which transformational and transactional components pertain lean leadership. According to Dun and Wilderom (2016) organizational learning and root-cause analysis could be stimulated by lean leadership. This would imply that lean leadership has a positive influence on second-order problem solving. Acknowledgement of this assumption will be examined in this study.

2.5. Conceptual model

This research investigates the relationship between lean maturity and second-order problem solving, and the influence of lean leadership on this relation. Next to that, the relation between second-order problem solving and the performance of lean programmes is examined. Based on previous literature this study assumes that a higher level of lean maturity leads to a higher degree of conducting second-order problem solving behaviour and in turn to a higher

organizational performance. Lean leadership may act as a moderator that positively influences the relation between lean maturity and second-order problem solving. This means that a higher level of lean leadership makes the relation between lean maturity and second-order problem solving even more positive. Figure 1 summarizes the conceptual model.

Lean maturity -+- _{problem solving}Second-order -+- Performance Lean leadership

+

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3. Methodology

Since there is little knowledge about the term lean leadership, and how this concept influences the relation between lean maturity and second-order problem solving and in the end

performance, a multiple case study approach has been chosen. According to Karlsson (2009), a case study is suitable for explorative investigations in which the variables and relations are not clearly defined or understood. The explorative case study approach enables rich data gathering from semi-structured interviews and makes it possible to get a better understanding of the nature and the complexity of the complete phenomenon (Karlsson, 2016) whereby how and why questions could be answered. In this way, the definition of lean leadership and the relations between the variables can be inferred.

3.1. Sample selection

The data were collected at two Dutch hospitals that have implemented the PW programme. In total, fifteen teams were selected based on their expected diversity in level of lean maturity. This level was determined by the duration of implementing PW, which was measured in number of months from the start date. The duration of the sample can be found in Table 4. The cases are selected using replication logic. In this way cases with the same duration are selected, which are expected to yield similar results. In addition, cases with different start dates should produce contrary results based on expectations from the literature, because low mature teams are expected to perform less second-order problem solving than high mature teams. Next to that, the pilot teams of both hospitals are compared to identify consistent lean leadership elements. The multiple-case study improves the external validity, compared to a single case study (Karlsson, 2016).

Scale Duration Teams

1 0 – 6 months L, N

2 6 – 12 months H, I, J, K

3 12 – 18 months D, E, F, G, M, A2

4 18 – 24 months B, C

5 24+ months A1

Table 4: duration of the sample

3.2. Data collection

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13 leader, one nurse of the core team and one nurse that is not part of the core team. Each

interview was conducted with two interviewers to reduce observer bias. The interviews lasted on average 40 minutes and 10 seconds and were recorded to provide accurate rendition of the data as recommended by Karlsson (2009). The shortest interview lasted 24 minutes and 48 seconds and the longest interview time had a duration of 1 hour, 8 minutes and 37 seconds. In total, the transcripts compromise 416 pages and 305567 words. Background data of the sample can be found in Table 5. Because of the diversity in duration and the fact that no irregularities have been found in the sample, the 15 teams are expected to provide a good representation of nursing teams. The rest of this section clarifies the data collection per concept.

Table 5: background data of the sample

Lean maturity

The collected data about lean maturity includes the information about the start dates of the teams in order to select cases. Data about the start dates of teams were provided by the hospitals. Since a start date does not have to ensure lean mature behaviour of the team

members, interviews have also been used to collect data about lean maturity. The questions in the interview are based on the enablers and practices identified by Malmbrandt & Åhlström (2013). They have identified 9 enablers and 19 practices to assess the level of lean maturity. However, these enablers and practices are not related to a healthcare context and due to constraints on the length of the interviews, not all of these enablers and practices are used. Three enablers and three practices have been selected which are assumed to be influenced by

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14 implementing PW. These enablers and practices are translated to a healthcare context and are shown in Table 6.

Assessment instruments What is measured?

Enabler 1 Understanding of Lean by nurses The extent to which nurses are able to describe what their ideal process looks like and how they work toward that process in their everyday work

Enabler 2 Use of infrastructural elements The extent to which nurses experience time allocation to work on improvements (e.g. meetings)

Enabler 3 Transfer of information The extent of bottom-up and top-down information sharing in an organisation

Practice 1 Identification of value for the patient The extent to which the identification of value for the patient is a central element and constantly refined

Practice 2 Measures the continuous flow The extent of information and resource allocation to smooth process flow

Practice 3 Visualisation of information and improvements The extent to which information and improvements are visualized at the ward

Table 6: enablers and practices to determine lean maturity, based on Malmbrandt & Åhlström (2013)

For further validation of the level of lean maturity the data of the ‘10-point checklist’ were collected. These checklists estimate the progress of the PW programme per module. A module is completed when all the 10-points are checked. Unfortunately, these lists were recorded inaccurately and contain a lot of missing data. Therefore, the ’10-point checklist’ is not used to determine lean maturity.

Second-order problem solving

The level of second-order problem solving of the team members is determined based on the interviews. Meijboom et al. (2016) have composed five scenarios that examine the level of second-order problem solving of nurses. These scenarios try to determine whether a

respondent performs a second-order problem solving action. These scenarios are translated to Dutch and used in the interviews, see Appendix A. Besides this, an open question is used that offers nurses the possibility to describe their problem solving behaviour separately from the scenarios. This question was: ‘Can you give an example of a problem that has occurred and how you have solved it?’.

Lean leadership

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15 Performance

The level of performance is based on the time that could be spent on direct patient care, the aim of the programme. To determine the performance level of each team, data of the ‘multiple moment recordings’ were collected, as well as the ‘perceived performance’ of nurses. The ‘multiple moment recordings’ were executed by one nurse who had followed another nurse the whole day and measure his/her time spent on direct patient care with the use of a customized application. After receiving the data about the recordings of the hospitals it appeared that some of the teams had not performed the recordings at all or infrequently. Next to that, there was much missing data, which made the data impossible to use. However, the data collected in the interviews about ‘perceived performance’ could still be used to

determine the performance levels. In this way, the level of performance is determined based on the feeling of the nurse about the performance in the ward. These data were collected by asking the question: ‘how would you describe the influence of Productive Ward on the time that can be spent on patient care?’.

3.3. Data analysis

The data analysis is guided by the two research questions: (1) what constitutes the term lean

leadership? and (2) how does lean leadership affect the relation between lean maturity and second-order problem solving and in the end on the performance of nurse teams?

For the first research question the data collected by the interviews was used. First, the pattern of data within the cases was analysed (Karlsson, 2016). The interviews were coded in an inductive way, which allows deep and rich understanding of a phenomenon (Gioia, Corley, & Hamilton, 2012). According to Gioia, Corley, & Hamilton (2012) the first-order codes have to be close to the informant terms. Thereafter, second-order codes were formulated which try to capture similarities between the many categories. For further reduction of the second-order codes, aggregate dimensions were formulated. This has also been done inductively. The resulting first-order codes, second-order codes and dimensions are displayed in the coding tree in Appendix B. This visualization makes it possible to discover unique patterns and in-depth understanding of concept, which could be useful to analyse across cases.

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16 results to guarantee objectivity. In each interview three enablers and three practices of lean maturity were questioned, and to test if these items all measure lean maturity and could be combined, first a factor analysis is performed. The factor analysis results in one-dimensional solution with high factor loadings (see Table 7). This indicates that all the enablers and practices measure only one construct, which will be defined as lean maturity. Secondly a reliability analysis is performed to investigate whether it is possible to create a single scale variable of lean maturity. The inter-item correlation scores between each of the enablers and practices are above or close to .40 and below .70 (see the inter-item correlation matrix in Appendix C), which shows a high internal consistence between the items with a Cronbach’s Alpha of .85. These results confirm that all three enablers and three practices measure lean maturity and could be combined in a single scale variable. Thereafter, the correlation between lean maturity and duration is also tested to ensure validity of the case selection method. These two variables are significantly correlated (r =.44, p < .01). Hence, duration can be used as case selection criterion.

Lean maturity

Understanding of Lean by nurses .77

Use of infrastructural elements .73

Transfer of information .84

Identification of value for the patient .77

Measures the continuous flow .73

Visualisation of information and improvements .71

Table 7: factor loadings on the dimension "lean maturity" extracted from the component matrix

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Function Low Medium High

Team leader 0 – 2,5 2,5 – 3,0 3,0 – 5,0

Core team member 0 – 2,25 2,25 – 2,75 2,75 – 5,0

Nurse outside core team 0 – 2,0 2,0 – 2,5 2,5 – 5,0

Table 8: scale to determine Lean maturity level per function

Data from each interview about second-order problem solving, based on the scenarios of Meijboom et al. (2016), are again assessed by two researchers to guarantee the objectivity. An eight-point scale, based on the actions of second-order problem solving identified by Tucker and Edmondson (2003) is used to give each interviewee a score of second-order problem solving behaviour. Again, to yield one score per team, each score has been rescaled into a scale with three categories: high, medium and low. The data about second-order problem solving indicate no link between the function and the level second-order problem solving (see dispersion figure in Appendix D). This could be explained by the fact that all team leaders also work part-time as a nurse on the work floor, whereby they have to accomplish the same problem solving activities as the rest of the team. For this reason, the same scale for team leaders, core team members, and nurses outside the core team is adopted. The low score scale ranks from 1 until 3, medium scale from 3 until 6 and the high scale from 6 until 8. As result, the scores of each team are combined, in the same way as the lean maturity team score is determined, which results in a single score on second-order problem solving behaviour per team. Since each team has a single score on lean maturity and second-order problem solving, a cross-case analysis can be performed. Each team was assigned to a category, which results in the formation of six cases. In Table 9, the cases that are distinguished and their incidence are shown.

Table 9: cases and their occurrence

Lastly, the relation between lean maturity and performance, mediated by second-order problem solving is analysed. The data collected in the interviews, which indicates the

interviewees’ ‘perceived performance’ of the PW programme, is used to this end. The level of perceived performance per interviewee is analysed using a four-point scale, ranging from ‘1=interviewee does not perceive clear impacts of the PW programme’, ‘2=interviewee

Lean maturity Second-order problem solving Number (N) Teams

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18 perceives indirectly more time for the patient, due to an organised ward’, ‘3=interviewee perceives more time for the patient and has an idea of the effects of PW’ to ‘4=interviewee perceives more time for direct patient care and this extra time can be demonstrated’. Again, two researchers are used in the analysis to guarantee objectivity. Thereafter, the correlation between the individual lean maturity, second-order problem solving and perceived

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4. Results

This section shows the results of the elements of lean leadership and the influence of this concept on the relation between lean maturity, second-order problem solving and

performance. First, to determine lean leadership, the outcomes of the within case analysis are presented. Thereafter, the influence of lean leadership on the relation between lean maturity and second-order problem solving is shown by presenting the results of the cross-case analyses. Last, the influence of lean maturity and second-order problem solving on performance is outlined.

4.1. What constitutes lean leadership?

To gain insight into the definition of lean leadership a coding tree is constructed, which visualizes the information gathered from the interviews and provides insights into the relations between the quotes as explained in section 3.3. The analyses of the 45 interviews result in 97 first-order codes, 33 second-order codes and 14 aggregate dimensions (for the aggregate dimensions see Table 10). To gain insight into the concept lean leadership the aggregate dimensions and some of the associated quotes are mentioned. To indicate who have said what, the function of the person is indicated with the number 1, 2 or 3, where 1=team leader, 2= core team member, 3= nurse outside core team, followed by a character which indicates the team.

Aggregate dimensions

1. Leader convinces the team of the change and tries to involve everyone in early stages 2. Leader is involved and present at the work floor

3. Leader visualizes, provides insights and uses information sessions 4. Leader evolves team to become self-steering

5. Leader encourages nurses to be in the lead

6. Leader keeps an eye on progress and takes actions when necessary 7. Leader pays attention on individual level

8. Leader facilitates time and resources 9. Leader uses communication skills 10. Leader supports lean principles 11. Leader is a role model 12. Leader is a coach

13. Core team has a leading role

14. Team leader and higher management have supportive roles

Table 10: aggregate dimensions

The first dimensions convincing the team of the change and try to involve everyone in early

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20 stimulate everyone to change. So, a couple of times we have individually approached

colleagues if they are aware that the changes will improve the processes at the ward, but some of them see it as a burden.’ Quite often the interviewees mentioned that the lean leadership means that the leader is involved and present on the work floor, for example 2I: ‘Come and take a look at the work floor to see what is happening, then you are able to draw an

appropriate conclusion’. Another dimension that is distinguished in the interviews was the leader visualizes, provides insights and uses information sessions. This is supported by person 1C: ‘I try to involve my colleagues by showing areas of waste to them and asking how we could improve these areas’. In addition, leader evolves team to become self-steering is considered as lean leadership dimension: ‘He let us solve problems ourselves, that saves him time and let us invent things ourselves. I believe that we can be considered as self-steering, for example while the team leader was on holidays, we have implemented the module about patient transfers ourselves’ (2F). Additionally, a lean leader also has to encourage nurses to

be in the lead. This is supported by 3B who has said: ‘that you use your ability and try to

solve the problem first yourself and not immediately hand it over to the team leader. So the leader has to afford scope for creating own solutions, but I need to know that I can rely on her when needed.’ Next to that, lean leadership can also be described by keeping an eye on the

progress and take action when it is necessary, for example by 1K: ‘My role is to reframe and

put brakes on things occasionally, otherwise it will become a mess of improvements and the big picture will be lost’. The team leader of team N pronounces the importance of a leader

pays attention on individual level, by saying: ‘I think you have to make people aware of their

own influence and competence to improve things by showing that they could improve things themselves’. Some nurses mentioned the leader facilitates time and resources as a major task of lean leadership. One of them has said: ‘I think that our team leader has qualities like creating enthusiasm which motivates us to work on improvements if we can. She also makes time available, so that we are able to work on it’ (2E). According to 2N, it is important that a

leader uses communication skills: ‘A leader should carefully listen to others, so do not

interrupt, but are always open to everyone’s’ opinion’. As well, the leader supports the lean

principles is considered as element of lean leadership: ‘we continuously analyse our process

and try to diminish any kind of waste, supported by the team leader’ (1D). A lean leader can also be considered as leader is a role model: ‘I have to be enthusiastic myself in order to create enthusiasm at the rest of the team’ (1E). Others mentioned leader is a coach, as

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21 start and he is always willing to answer our questions’. In contrast, lean leadership can be explained by the core team has a guiding role. As said by the team leader F: ‘I am not the leader of lean at the ward, no the leadership is located at the core team and I think it has to be there’. The last dimension of lean leadership is team leader and higher management have

supportive roles: ‘the team leader is the one that talks to the manager if they could help us

when we could not fix it ourselves or be counteracted’ (2D).

4.2. Influence of lean leadership on lean maturity and second-order problem solving

To investigate if there is a relation between lean maturity and second-order problem solving, first a correlation analysis is performed. The results of this analysis show a significant and positive relation between lean maturity and second-order problem solving (r =.72, p <.001). In Figure 4 the level of lean maturity and second-order problem solving per team, as

explained in section 3.3., are shown graphically by the blue lines. The dotted red line shows the expected level of second-order problem solving of the team. This expected level is considered to be equal to the level of lean maturity of a team, since lean maturity positively influences order problem solving. Notably, no high mature teams with a low second-order problem solving level were found.

Figure 2: level of lean maturity, second-order problem solving and expected second-order problem solving per team

Based on this figure, five cross-case analysis are distinguished that are interesting to gain insights into the relation between lean maturity and second-order problem solving and the influence of lean leadership on this relation. These cross-cases are:

• High mature teams with high second-order problem solving level compared to low mature teams with a low lean maturity level (HH x LL)

The three categories that have a second-order problem solving level which deviates from the expected level of second-order problem solving:

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22 • Medium mature teams with a medium second-order problem solving level compared

to medium mature teams with a low level of second-order problem solving (MM x ML)

• High mature teams with a high second-order problem solving level compared to high mature teams with a medium level of second-order problem solving (HH x HM) The last comparison is between the pilot wards of the different hospitals. Remarkably, these are the only teams that have accomplished a high level of second-order problem solving. Insight into the necessary lean leadership elements to accomplish high second-order problem solving is investigated with:

• The two high mature teams with a high second-order problem solving level compared to each other (HH x HH)

The results of the first cross-case analysis HH x LL tries to determine the differences in lean leadership elements between low and high mature teams that have influenced their level of second-order problem solving. Table 11 shows quotes that provide a proper reflection of both categories. The HH team leader acts as a coach to provide guidance, so that the team can solve problems themselves, while teams that are assigned to the category LL need the knowledge of the core team to solve problems. Next to that, the team leader of the HH

category tries to involve the whole team by rotating the nurses that belong to the core team. In this way, the whole team is aware of PW and has to work on projects themselves. In contrast, the LL category team members need support and help from the team leader in problem solving activities. They have no confidence in problem solving on their own.

HH LL

Quotes - ‘provide guidance for people, so that they can think for themselves, that they do not come to me with a problem and that I have to solve it, no solve it together.’(1A1)

- ‘Therefore, we have switched the members of the core team to ensure that everyone feel personally involved.’(3A1)

- ‘That I can rely on her when I have a question or cannot solve the problem on my own. Because they are part of the core team and know how to tackle problems.’ (3N)

- ‘I think that they are still unsure when they have found a solution themselves. There are always people who prefer to hand over control, while they have the capabilities to do it themselves.’ (1N)

Lean leadership - leader is a coach (dimension 12)

- leader encourage nurses to be in the lead by switching the members of the core team (dimension 5)

- nurses need the core team in problem solving - nurses are unsure about their own problem solving capabilities

Table 11: quotes and corresponding lean leadership elements of cases HH and LL

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23 convince the team of the benefits of PW by telling them that they will experience the results soon. The LM category team is shown some minor improvements accomplished by PW in convincing them of the benefits. This team was also encouraged to discuss problems with each other and tried to determine what could be the best solution for them by using the

‘hairdryer model’ as a tool. The ‘hairdryer model’ is an iterative step-wise model provided by PW, which is used for continuous improvement of processes. The LL teams need the team leader in problem solving as he/she shows other ways to solve problems or provides help when the team encounters barriers.

LM LL

Quotes - ‘You have to tackle some small things first, to show the improvements that could be achieved by the project and in this way create support for it.’ (2K)

- It is important that the team learn that they have to go through all steps and discuss together what would work for them. I do not always have to give permission, no discuss it which each other. If they have used the ‘hairdryer model’ once they will experience what does not work, so do it another time and when you repeat it often enough it becomes part of your nature.’ (1K)

- ‘In the beginning we had a lot of meetings, but on the work floor nothing has been changed. Then you need to convince everyone that they have to wait, but that they will experience the results soon.’ (1F)

- That the team leader provides support when we cannot solve problems by ourselves or maybe he has other ideas to solve a problem where we did not think of.’ (3L)

Lean leadership - Team leader visualizes improvements to create support for PW (dimension 3)

- Team leader encourage nurses to be in the lead and stimulate the use of the ‘hairdryer model’ (dimension 5)

- Team leader has difficulties with convincing the team of PW

- Team leader has a decisive role in problem solving

Table 12: quotes and corresponding lean leadership elements of cases LM and LL

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24

MM ML

Quotes - ‘That we could do it together, and PW provides us tools, explains specific methods, and gives us time and ways so that we work together on problems and the team leader no longer have to do it himself.’ (1G)

- ‘We have learned to use the tool from the beginning and go through all the different steps to accomplish the desired result. Otherwise, you think that you have solved the problem but after a few weeks you see that the problem is still there and that you have missed some steps.’ (3J)

- ‘We have disregard the ‘hairdryer model’, actually we already did that at the start. Of course the ‘hairdryer model’ is widely applicable, but sometimes you can arrange it in another way without use the tool.’ (2D)

- You know the steps of the ‘hairdryer model’ and know how to use it, when you add a team member for a new project you have to teach them

everything from the beginning. These instructions will take some time, so we decided to do it with the core team only, so that you do not lose time by teaching others.’ (2C)

Lean leadership - The team leader encourages the team to solve problems themselves (dimension 5) - Team leader facilitates time and resources (tools) to solve problems (dimension 8)

- The core team solves problems themselves, instead of involving the rest of the team in problem solving

Table 13: quotes and corresponding lean leadership elements of cases MM and ML

The next cross-case analysis tries to determine which lean leadership elements may have influenced the limit score of high mature teams on second-order problem solving. This is examined by comparing high mature teams with high second-order problem solving

behaviour to high mature teams who have performed second-order problem solving behaviour on a medium level. Table 14 shows the quotes and lean leadership elements of these

categories. In the HH teams, the team leader supervises whether the team executes all the steps of the ‘hairdryer model’ in problem solving activities, and addresses the team if it has not. The team leader of HM teams also introduces the tool to the team, but when there is a limited amount of time partial use of the ‘hairdryer model is also sufficient. In the HM teams, the role of the higher management is important to enable the team to work according to PW principles and the team leader has to motivate the rest of the team. The HH teams do not need a leader to work according to PW. The leader has to contribute to the evolution of the team, so that it learns to work with PW on its own.

HH HM

Quotes - ‘Therefore, I think the new team leader has to know something about PW, but do not have to interfered. Because only we as nurses, case assistants and nutrition assistants have to work with it, the team leader has not.’ (2A2)

- ‘Follow the steps of the ‘hairdryer model’ before you undertake the change. Often, you want to do it fast and skip some steps unconsciously. Then we need a leader who lets us make an analysis of the problem, before we immediately start with solving the problem.’(3A1)

- ‘It is difficult, because we have a new team leader and our two previous team leaders who have left recently were very enthusiastic about PW. It is hard that you do not have that enthusiasm now.’ (1B)

- ‘We have reached a point where we have to give a signal to the higher management, because we are worried. We get responses from the core team members that when it continues this way they want to quit.’ (1B)

- ‘Sometimes you do not have enough time to execute all the steps of the ‘hairdryer model’, and then you try to do a short version.’ (2B)

Lean leadership - Leader evolves the team to become self-steering (dimension 4)

- The leader facilitates and stimulates the use of resources (‘hairdryer model’) (dimension 8)

- Team misses an enthusiastic team leader - Higher management has to enable the team to work according PW

- Team leader stimulates the use of the ‘hairdryer model’, though partially use of the model is also accepted.

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25 The last cross case is used to analyse the similarities in lean leadership elements between hospitals by comparing two high mature teams that both have a score that is high on second-order problem solving (Table 15). Both team leaders distribute tasks according to team members’ personal interests, resulting in a higher level of motivation across the team. These team leaders also consider the individual qualities of the team in order to accomplish goals and solve problems. In addition, the whole team is involved in the process in both hospitals, otherwise not all team members will work according to the improved rules and solutions and the project will not succeed.

Table 15: quotes and corresponding lean leadership elements of HH teams of two hospitals

Summarizing, the results of these cross-case analyses yield seven lean leadership dimensions that enhance second-order problem solving. These dimensions are mentioned in Table 11 until 15, and are respectively: leader is a coach (dimension 12), leader encourages nurses to be in the lead (dimension 5), leader visualizes the improvements (dimension 3), leader facilitates time and resources (dimensions 8), leader evolves team to become self-steering (dimension 4), leader pays attention on individual level (dimension 7), and leader convinces the team of the change and tries to involve everyone in early stages (dimension 1).

4.3. Influence of lean maturity and second-order problem solving on performance

In this research, it is assumed that the performance of teams is influenced by both lean maturity and second-order problem solving, where second-order problem solving has a mediating role. Figure 5 visualizes this assumption, where two causal paths are shown that feed into performance as mentioned by Baron and Kenny (1986): the direct effect of lean maturity on performance (path c’) and the impact of the mediator: second-order problem solving (path b). There is also a path from lean maturity to second-order problem solving

HH HH

Quotes - ‘I think that it motivates when you are assigned to tasks of your interest instead of something you are not attracted to.’ (2A1) - ‘We are a team and we need each other to accomplish goals. You only have to know who you assigned to which tasks.’ (3A1)

-Therefore, we have switched the members of the core team, such that everyone feel that they are involved.’ (3A1)

- ‘I am enthusiastic and because of that I can positively contain the message to others instead of being imposed to do something which you are not interested in.’ (3A2)

- ‘One of the elements of lean is reducing waste of talent. In a hospital the individual talents are not often considered, but with Productive Ward they suddenly are and these talents are also more appreciated.’ (1A2)

- ‘I was always tempted to ignore the people who resisted to change, but I have learned that you have to go through the process with the whole team in order to make it work.’ (1A2)

Lean leadership - The leader pays attention on individual level (dimension 7)

- The team leader convinces the team of the change and tries to involve everyone (dimension 1)

- The leader pays attention on individual level (dimension 7)

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26 (path a). The total effect of lean maturity on performance is determined by adding the direct effect (c’) to the indirect effect (a*b). If second-order problem solving has a mediating role, the indirect effect (a*b) has to be significant and larger than the direct effect (c’).

Lean maturity Second-order problem solving -a -Performance -b --c’

-Figure 3: relations between lean maturity, second-order problem solving and performance

A stepwise approach had been used to test for the mediating role of second-order problem solving. The first step is to test whether lean maturity is a significant predictor of performance (path c’). A regression analysis is performed which confirms the significance of this relation ( = .92; p =.00). The next step investigates whether the relation between lean maturity and second order problem solving (path a) is also significant, which is confirmed by the

regression analysis ( = 1.79; p = .00). Lastly, a third regression analysis is performed, which confirms that second-order problem solving is a significant predictor ( = .36; p = .00) of performance (path b). The results of the regression analyses can be found in Table 16. A mediating effect of second-order problem solving occurs when the indirect effect (a*b) is significant. This is tested with a regression analysis in which both lean maturity and second-order problem solving are included as independent variables. The results in Table 16 confirm that this indirect relation is significant. However, the direct effect also remains significant, and the indirect effect (a*b) is smaller than the direct effect (c’). This indicates that the direct effect of lean maturity on performance still exists next to the indirect effect. Therefore, performance is only partial mediated by second-order problem solving, and not fully, as was assumed. To validate the significant relation of the mediating role of second-order problem solving on the relation between lean maturity and performance, which is found using a regression analysis, a Sobel test is performed. A Sobel test is a significance test that

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27

Dependent variables Performance Second-order problem

solving

Performance mediated by second-order problem

solving Independent variables Path c’ Path a Path (a*b)

Lean maturity β Std. Error R2 .92*** (.14) .51 1.79*** (.26) .52 .56** (.18) .58 Path b

Second-order problem solving

β Std. Error R2 .36*** (.06) .49 .20* (.07) .58 Note: * p <.05, ** p < .01, *** p <.001.

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5. Discussion

The main proposition of this research is that the level of second-order problem solving is positively influenced by lean maturity and moderated by lean leadership. In this section, this assumption is discussed based on the results of the cross-case analyses. First, the results of what contains lean leadership are examined. Thereafter, the influence of this concept on the relation between lean maturity and second-order problem solving is discussed and the consequences for performance are explained. Finally, the current conceptual model is adjusted.

5.1. Lean leadership

The explorative research into the definition of lean leadership discerns fourteen dimensions (Table 19, retrieved from Table 10 in section 4.1.) that compromise the required leadership style of a lean programme. When looking at these dimensions some of them correspond to the transformational and transactional leadership components defined by Bass and Riggio (2006) as mentioned in section 2.4. These corresponding transformational components are presented in Table 17, and in Table 18, the transactional lean leadership dimensions are shown. The remainder of this section discusses the obtained similarities and differences in leadership components.

Table 17: transformational lean leadership dimensions

Table 18: transactional lean leadership dimensions

Table 19: dimensions of lean leadership

Aggregate dimensions

1. Leader convinces the team of the change and tries to involve everyone in early stages

2. Leader is involved and present at the work floor 3. Leader visualizes, provides insights and uses

information sessions

4. Leader evolves team to become self-steering 5. Leader encourages nurses to be in the lead 6. Leader keeps an eye on progress and takes actions

when necessary

7. Leader pays attention on individual level 8. Leader facilitates time and resources 9. Leader uses communication skills 10. Leader supports lean principles 11. Leader is a role model 12. Leader is a coach

13. Core team has a leading role

14. Team leader and higher management have supportive roles

Transformational leadership Dimensions

Idealized Influence 11

Inspirational Motivation 1

Intellectual Stimulation 3, 4, 10 Individualized Consideration 5, 7, 12

Transactional leadership Dimensions

Contingent Reward -

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29 As can be seen in Table 17, all of the four components of transformational leadership are related to one or more dimensions of lean leadership. Idealized Influence for instance, matches the idea of a leader is a role model (dimension 11). Inspirational Motivation is related to the leader convinces the team of the change and tries to involve everyone in early

stage (dimension 1), since both are used to motivate and involve the whole team. The third

transformational component, Intellectual Stimulation, is related to three leadership

dimensions, where the distinction between these dimension stems from the leader’s ways of stimulating: visualizing and providing insights (dimension 3), evolve to become self-steering

(dimension 4) and support of the lean principles (dimension 10). Lastly, Individualized

Consideration is found to be associated with leader encourage followers to be in the lead

(dimension 5), leader pays attention on individual level (dimension 7) and leader is a coach (dimension 12). In all of these three dimensions of lean leadership the leader takes account of

the individuals’ qualities and needs. Although lean leadership matches especially

transformational leadership elements, one dimension matches the transactional leadership style, which is the leader keeps an eye on the progress and takes action when necessary

(dimension 6) (see Table 18). This dimension can be compared to Active

Management-by-Exception, despite the fact that a lean leader is more focused on the progress of improvements and a transactional leader on detecting mistakes and errors.

Although, a large number of the lean leadership dimensions is related to the transformational and transactional leadership components of Bass and Riggio (2006), comparison of Table 17, 18 and 19 also indicate five complementary dimensions, namely dimension 2, 8, 9, 13 and 14. First, the results show the importance of a leader that is

involved and present at the work floor (dimension 2). While this was not mentioned by Bass

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30 complementary dimension concerns the supportive role of the team leader and higher

management (dimension 14), which confirms that the leader needs to align the goals of the

organisation (Poksinska et al., 2013). However, this supporting role also means that the leader needs to ensure that the goals of the organisation can be met.

5.2. Relation between lean maturity, second-order problem solving and performance

First of all, the results of the regression analysis (see section 4.2.) confirm a significant and positive influence of lean maturity on second-order problem solving. Furthermore, the results of the cross-case analyses in section 4.2. unveil that seven of the fourteen lean leadership dimensions enhance second-order problem solving. This section discusses which and why only these leadership dimensions stimulate nurses to address the underlying causes of problems.

First, Table 15 demonstrates that second-order problem solving is positively influenced by a leader who convinces the team of the change and tries to involve everyone

(dimension 1), since the only two teams that have succeed in establishing high second-order

problem solving behaviour have done so by involving of the whole team. However, the fact that involvement of a team can be used as stimulator of second-order problem solving has not considered before. Next to that, the finding that visualization of improvements by leaders

(dimension 3) boosts the use of second-order problem solving in the early stages of a lean

programme (see Table 12) is also surprising. The reason for this boost is that nurses become aware of the advantage of solving the causes of problems in their daily work. That a leader who evolve the team to become self-steering (dimension 4) promotes root cause analyses of problems was expected, since Bass and Riggio (2006) claim that questioning assumptions and reframing of problems is related to Intellectual Stimulation of a leader. Table 11, 12 and 13 provide evidence for the statement of Tucker & Edmondson (2003) that leaders can stimulate their followers to come up with boundary crossing improvements that increase second-order problem solving behaviour themselves, described in this study as a Leader encourage nurses

to be in the lead (dimension 5). After a while, nurses will perform second-order problem

solving automatically. However, to accomplish a high level of second-order problem solving, the results in Table 15 reveal that a leader needs to pay attention on individual level

(dimension 7). That individuals’ need for growth, as mentioned by Bass and Riggio (2006),

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31 of a leader who facilitates time and resources (dimension 8). However, the results of this study (Table 13 and 14) demonstrate that lean mature organisations can only accomplish high second-order problem solving practices when nurses are provided with time and resources. Lastly, this study confirms (Table 11) that the coaching role of a lean leader (dimension 12), as mentioned by Poksinska et al (2013), stimulates organisational learning.

Although, the results show that only these seven lean leadership dimensions influence the relation between lean maturity and second-order problem solving, the remaining seven are also important for a leader of a lean programme, but do not stimulate organisational learning. This may imply that lean programmes use multiple ways to improve the organizational performance, where one of them aims to increase second-order problem solving behaviour as already mentioned by Tortorella et al. (2015). This assumption is supported by the partial mediation effect of second-order problem solving on the relation between lean maturity and performance. Therefore, lean leadership may also influence the direct relation between lean maturity and performance, or other factors that increase organisational performance may be influenced by lean leadership.

5.3. Revised conceptual model

Although the results confirm the direct relation between lean maturity and second-order problem solving and the positive influence of lean leadership on this relation as suggested, not all the dimensions of lean leadership appear to have influence. In total, section 5.2. discusses that the seven dimensions that do have influence are dimension 1, 3, 4, 5, 7, 8 and 12.

Surprisingly, six of these seven dimensions are related to a transformational leadership style, see Table 17 section 5.1. Only the facilitation role of a leader (dimension 8) has not been considered in the transformational or transactional literature. Therefore, stimulating second-order problem solving in a lean environment requires a transformational leadership style complemented by a facilitation leadership role. Furthermore, the mediating role of second-order problem solving on the relation between lean maturity and performance is only partially confirmed, and not fully, as suggested. These insights on the concepts and relations between these concepts have resulted in a revised conceptual model (Figure 6). Although the

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32

Lean maturity -+- _{problem solving}Second-order

-+

-Performance -+

-Leader convinces the team of the change and tries to involve everyone Leader visualizes the improvements

Leader evolves team to become self-steering Leader encourage nurses to be in the lead Leader Pays attention on individual level Leader facilitates time and resources

Leader is a coach

-+

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33

6. Conclusion

This research explores: (1) what constitutes the term lean leadership and (2) how does lean leadership affect the relation between lean maturity and second-order problem solving and in the end on the performance of nurse teams. Answering the first research question, fourteen dimensions of lean leadership are identified. All of the four components of transformational leadership identified by Bass and Riggio (2006) are included in the dimensions of lean leadership, and one dimension can be compared with transactional leadership. This is the first study that provides evidence that lean leadership can be seen as a form of transformational leadership that is specified to accomplish lean practices.

Regarding the second research question, the conclusion is drawn that lean leadership has a positive influence on the relation between lean maturity and second-order problem solving and in the end on the performance in nurse teams, as expected. Out of the fourteen dimensions of lean leadership that this study identifies, the cross-case analysis reveals that seven of these stimulate second-order problem solving. These seven dimensions are: leader convinces the team of the change and tries to involve everyone in early stages, leader

visualizes the improvements, leader evolves team to become self-steering, leader encourages nurses to be in the lead, leader pays attention on individual level, leader facilitates time and resources and leader is a coach. Surprisingly, this study shows that the performance of nurse teams is only partial mediated by second-order problem solving, which also implies a direct influence of lean maturity on performance. Therefore, it allows for the possibility that the remaining dimensions of lean leadership have a positive influence on this direct relation and in this way stimulate the performance of a lean organisation.

The results of this study have some theoretical implications. First, this research provides a complete overview of the dimensions of lean leadership. This is the first time that previous literature on transformational and transactional leadership is considered and

compared to enhance similarities between these leadership styles. Second, it provides several insights into the role of leadership to stimulate second-order problem solving behaviour and the performance of nurse teams. Third, it confirms and expands the lean leadership

characteristics described by Tucker and Edmondson (2003) and Meijboom et al. (2016). Next to the theoretical implications, this study has also several managerial

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34 performance. Furthermore, it provides specific lean leadership dimensions where healthcare organisations can benefit from based on their level of lean maturity.

A limitation of this research is that both the proposed quantitative measures of

performance and lean maturity: the ‘multiple moment recordings’ and the ‘10-point checklist, contain missing data and could not be used in this study. This limits the amount of objective data available for both constructs. However, the quantitative data about the duration of the lean programme still provides objective data of lean maturity. Moreover, the small sample size restricts the reliability of the statistical tests.

This research yields implications for future research. Since this is the first study that gives a comprehensive view of the term lean leadership, more in-depth study on the fourteen dimensions is suggested. In addition, the seven dimensions of lean leadership that are

identified to enhance second-order problem solving of nurses can be studied in more depth. Furthermore, this research shows that performance is partial mediated by second-order problem solving. Further research on other variables that also have influence on the relation between lean maturity and performance and how lean leadership influences this relation is recommended. Lastly, the open question about second-order problem solving carries

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35

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Lean leadership: the key to stimulate the relation between lean maturity and second-order problem solving?