Reaching a higher potential of Lean in
nurse teams: exploring the roles of
Lean leadership and
second-order problem solving
by
Arie Bijl
University of Groningen
Faculty of Economics and Business
MSc Supply Chain Management
January 2017
Supervisor: Prof dr. ir. C.T.B. Ahaus , University of Groningen Second Assessor: Dr. G.C. Ruël, University of Groningen
Saffierstraat 196 9743LN Groningen
Abstract
This multiple case study aims to provide a better understanding of Lean leadership in healthcare through an in-depth empirical study. It also examines the relationships between Lean maturity, second-order problem solving and the performance of nurse teams, as well as how Lean leadership moderates the relationship between Lean maturity and second-order problem solving. Rich qualitative data was gathered through interviews with team leaders and nurses within different nursing departments of a Dutch hospital that has implemented a Lean-based program called: ‘The Productive Ward’. Key roles, practices and behaviours of Lean leaders are identified and positioned in relation to existing leadership theories. The results indicate that second-order problem solving partially mediates between Lean maturity and the perceived performance of nurse teams. Furthermore, five Lean leadership dimensions are found to be important for enhancing second-order problem solving of nurse teams through a moderating role. Finally, this study found that Lean leadership has a strong connection with transformational leadership theory.
Keywords: Lean in healthcare, Lean leadership, Lean maturity, second-order problem
solving, perceived performance, transformational leadership, transactional leadership
TABLE OF CONTENTS
1. INTRODUCTION………...………...1-2 2. THEORETICAL BACKGROUND………...………...3-9
2.1 Lean in healthcare……….…………...……...3
2.2 Lean maturity………..……….………...….4
2.3 Second-order problem solving………..……….…...…..5
2.4 Lean leadership……….……….…...6
2.5 Conceptual model……….……….……...8
3. METHODOLOGY.……….…….……...10-15 3.1 Choice for the case study method……….…..……...…..10
3.2 Setting………...………...…..10 3.3 Participants………..…..10 3.4 Case selection………11 3.5 Data collection……….…..11 3.6 Data analysis……….….13 4. RESULTS………...…16-26 4.1 Lean maturity, second-order problem solving and perceived performance...…….…..16
4.2 Within-case analysis………..…….…...17
4.3 Cross-case analysis……….….…..21
5. DISCUSSION………..…..27-31 5.1 Lean maturity, second-order problem solving & perceived performance……….…....27
5.2 Lean leadership roles, practices and behaviours……….……..28
5.3 The moderating influence of Lean leadership………...30
6. CONCLUSION………....……..32-33 6.1 Theoretical and managerial implications………...…32
6.2 Limitations and future research………...33
References………...34-37 Appendix A: Interview protocol………..38
Appendix B: Coding Tree………..…....…..40
Appendix C: Correlation analysis………...44
Appendix D: Interview details……….45
Appendix E: Spread of Lean maturity……….46
Appendix F: Scores of Lean maturity and second-order problem solving………...…...47
1
1. INTRODUCTION
It is now a little more than a decade ago since Lean saw some of its earliest applications in healthcare. Since then, it has received increasing attention in literature and has been implemented in a wide range of healthcare contexts (Mazzocato et al., 2012; Brandao de Souza, 2009). Benefits that successful Lean adoption in healthcare can bring about are well-documented in literature. These include a higher quality of care, increased patient and staff satisfaction and a reduction of costs and mortality (Radnor, Holweg and Waring, 2012; Morrow, Robert and Maben, 2014). However, only few hospitals that have adopted Lean have actually attained these performance improvements (Mazzocato et al., 2012). Literature suggests that this may be caused by the fact that most hospitals only focus on improving performance through the application of Lean tools, which aim to reduce direct waste. This is described as ‘Toolbox Lean’ (Dombrowski and Mielke, 2013). The problem with this approach is that it only results in minor improvements, and therefore, the full potential of Lean is not realized (Hasle et al., 2016; Poksinska, 2010). The focus on solely reducing direct waste is also prevalent in Lean healthcare literature, as this academic field is still in its infancy (Malmbrandt and Åhlström, 2013). In order for Lean to reach a higher potential in hospitals, more attention should be directed towards pursuing the real aim of Lean, which is continuously improving every process through structured problem solving (Gemmel, Meijboom and Van Beveren, 2016; Dombroski and Mielke, 2013).
Research suggests that the way that problems are solved affects the success of organizational improvement efforts (Tucker, Edmondson and Spear, 2002). Problem solving can be of the first-order and second-order kind. The first-mentioned approach is used by the majority of healthcare organizations in their effort to solve problems, but it leads to a repetition of on-going inefficiencies (i.e. waste) by only treating the symptoms of problems (Mazur and Chen, 2009). Therefore, it seems contradicting to the Lean principle of striving for perfection (Womack and Jones, 1996). Second-order problem solving is a cognitive approach which allows organisations and employees to learn by not only solving the direct problem, but also by addressing root causes and engaging in additional steps to prevent recurrence of problems in the future (Tucker, 2009; Burgess and Radnor, 2012). The importance for healthcare staff to engage in second-order problem solving has been frequently emphasized in literature, as this is crucial for continuously improving processes within organizations (Mazur, Chen and Prescott, 2008; Gemmel et al., 2016). A recent study by Gemmel et al. (2016) suggests that second-order problem solving is more prevalent than first-order problem solving in hospitals with high levels of Lean maturity. Lean maturity refers to the level of Lean adoption in an organization (Canato, Ravasi and Phillips, 2013). However, strong evidence as well as an explanation of this relationship is still lacking, as little is known about the relationship between Lean maturity and second-order problem solving. It is also not yet clear whether or not second-order problem solving mediates the relationship between Lean maturity and performance in hospitals.
2 supporting nurses to engage in second-order problem solving. The importance of managers and leadership in relation to problem solving is also emphasized by Dombrowski and Mielke (2013, p. 570), stating that “Lean leadership is the missing link between Toolbox lean and the learning and continuously improving organization.” Although the crucial role of Lean leaders during Lean implementation is frequently highlighted in literature (Aij, Visse and Widdershoven, 2015), there are only few studies that have empirically studied Lean leadership in healthcare. Moreover, most studies of Lean leadership have a weak connection to other leadership theories and are often based on ‘common sense’ (Poksinksa, Swartling and Drotz, 2013). Since leadership is a central aspect of Lean implementation (Mann, 2009), it is of great importance to explore Lean leadership in hospitals. Also, it is important to find out how Lean leaders influence the second-order problem solving behaviour of nurses. For instance, what are Lean leadership practices and behaviours that may help nurses to engage in second-order problem solving?
The most important goals of this research are to explore Lean leadership roles, practices and behaviours in a hospital setting, and to find out how Lean leadership influences the relationship between Lean maturity and second-order problem solving. Another goal is to further study the relationship between Lean maturity and second-order problem solving as suggested by Gemmel et al. (2016). Finally, this study aims to find out how the performance of nurse teams is affected by Lean maturity and to see whether or not there is a mediating role of second-order problem solving on this relationship. Therefore, the research questions are:
What are Lean leadership roles, practices and behaviours in a hospital setting?
How does Lean leadership influence the relation between Lean maturity and the
problem solving behaviour of nurse teams?
How does Lean maturity influence the problem solving behaviour of nurse teams? How does Lean maturity affect the performance of nurse teams?
3
2. THEORETICAL BACKGROUND
2.1 Lean in Healthcare
4
2.2 Lean maturity
Many researchers have made an attempt to come up with a rigorous instrument to assess the level of Lean maturity in organizations, both in the manufacturing and service environment (Malmbrandt and Åhlström, 2013). Assessing Lean maturity has proven to be a daunting task, as there is conceptual confusion surrounding the definition of Lean manufacturing (Shah and Ward, 2007) and Lean services (Pilkington and Fitzgerald, 2006). Moreover, it is difficult to define operational measures of Lean in service contexts (Hadid and Mansouri, 2014). According to Malmbrandt and Åhlström (2013), this problem can be overcome through an instrument that uses multiple dimensions to measure the extent of Lean adoption in an organization. Their instrument therefore incorporates items for assessing enablers of Lean adoption, Lean practices and performance-oriented measures. Lean enablers represent the supporting structure or preconditions of Lean, which include training of employees and dedication of time and resources for improvement work. Lean practices correspond to Lean principles, such as continuous improvement and eliminating waste, whereas performance refers to the results of Lean adoption in measures such as costs, quality and customer satisfaction (Malmbrandt and Åhlström, 2013). These dimensions are highly comparable with the dimensions suggested by Machado Guimarães and Crespo de Carvalho (2014), who have developed the Healthcare Lean Assessment (HLA) instrument. However, unlike the HLA instrument, the Lean maturity assessment tool of Malmbrandt and Åhlström (2013) has been empirically validated, and therefore it will be used for this study. As will be further explained in the methodology section, this study will only consider a set of Lean enablers and practices in order to measure Lean maturity. All performance-oriented measures will be omitted, since this relates to the dependent variable of this research. Table 1 provides an overview of five Lean maturity levels and their generic definition as given by Malmbrandt and Åhlström (2013).
Maturity
level Generic definition
1 No adoption: problems are often explicit and solutions often focus on symptoms instead of causes
2 General awareness: start of searching for proper tools and methods, problem solving is becoming more structured. Informal approach in a few areas with varying degrees of effectiveness
3 Systematic approach: most areas involved, but at varying stages. Experimentation using more and more tools and methods and employees start following-up work using metrics
4 On-going refinement: all areas involved, but at varying stages. Improvement gains are sustained
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 – Generic Lean maturity levels
Source: Retrieved from Malmbrandt and Åhlström (2013, p. 1151)
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2.3 Second-order problem solving
In hospitals, nurses have an essential role as front-line service providers, as they are in the best position to discover and eliminate root causes of problems and can thereby help their organization learn (Tucker and Edmondson, 2003). This is because nurses can develop deep consciousness of organizational problems, as they are directly involved in the details of work and are likely to experience problems frequently. Because of their position, they may also have better insights into what needs improvement (Mazur and Chen, 2009; Van Rossum et al., 2016). Tucker and Edmondson (2003, p.57) have given the following definition of a problem: “A problem is a disruption in a worker’s ability to execute a prescribed task.” Nurses experience five broad types of problems:
(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 (Tucker and Edmondson, 2003).When nurses aim to discover and tackle root causes of problems by conducting an in-depth questioning of current work practices and theories, they are engaging in second-order problem solving (Gemmel et al., 2016; Gond and Herrbach, 2006). This is a cognitive approach in organizational learning, and is also sometimes called double-loop learning or preventive control (Gemmel et al., 2016). Tucker and Edmondson (2003) have found five broad actions of second-order problem solving through observation of nurses. These are shown in table 2.
(1) Communicating to the person or department responsible for a problem (2) Bringing the problem to the manager’s attention
(3) Sharing ideas about the cause of the situation and how to prevent recurrence with someone in a position to implement changes
(4) Implement changes
(5) Verify that changes have the desired effect
Table 2 – Second order problem solving actions Source: Tucker and Edmondson, 2003, p.61
6 Although second-order problem solving is not explicitly a Lean principle, it is closely related to the Lean methodology. According to the Lean philosophy, when faced with an error, healthcare professionals should jointly investigate the situation to find and remove the root causes in order to prevent recurrence of that error (Mazur et al., 2008), which can be seen as a second-order problem solving effort. This behaviour is of great importance when pursuing perfection (Mazur and Chen, 2009), which is one of the fundamental principles of Lean (Womack and Jones, 1996). Gemmel et al. (2016) even state that a learning organization based on second-order problem solving is the ultimate goal of Lean. One of the main supportive conditions for this behaviour is the support from leaders, as they can encourage and stimulate nurses to engage in second-order problem solving (Tucker and Edmondson, 2003). Since leadership is a central aspect of the Lean methodology, it will be addressed in the next section.
2.4 Lean leadership
It is widely recognized that effective leadership is crucial for Lean initiatives to deliver sustainable improvements (Aij et al., 2015; Dombrowski and Mielke, 2013; Mann, 2009). The link between Lean and leadership has been frequently emphasized in literature, and the term ‘Lean leadership’ is increasingly mentioned (Van Dun et al., 2016ab; Aij et al., 2015). Literature suggests that effective Lean leadership is the missing link between Toolbox Lean and the learning and continuously improving organization (Dombrowski and Mielke, 2013, 2014; Mann, 2009). However, since there are only few studies that have empirically investigated Lean leadership, and even fewer that have done so in hospitals, Lean leadership is still a highly elusive concept. In this section, it will be addressed what Lean leadership could be according to existing literature.
7 follower compliance, that is, the leader clarifies performance criteria, states expectations and determines what followers receive in return (Van Rossum et al., 2016, Yammarino et al., 2005). Transactional leadership has two main components (Bass, 1999; Judge and Piccolo, 2004). Contingent reward is where the leader clarifies expectations and offers rewards when goals are achieved in order to motivate employees. Management-by-exception is the degree to which the leader takes corrective action, which may take two forms. Active
management-by-exception implies that the leader closely monitors behaviours of followers and processes in
order to anticipate problems, and it involves taking corrective actions before problems arise. It may also take the form of Passive management-by-exception, where the leader waits for problems to arise before taking action (Bass, 1999). It is argued that the most effective leaders are both transactional and transformational (Howell and Avolio, 1993; Bass, 1999). However, studies that have attempted to link Lean leadership to these two leadership theories, have only found a strong connection with transformational leadership (Van Rossum et al., 2016; Van Dun et al., 2016b; Poksinka et al., 2013).
Poksinska et al. (2013) is one of the few studies that has empirically investigated Lean leadership in a healthcare setting. They found that important aspects of transformational leadership, such as empowering employees, participation in goal achievement and the focus on learning, are also components of Lean leadership (Poksinska et al., 2013). Furthermore, a coaching style, which is an essential aspect of transformational leadership (Stone et al., 2004), was also found to be used by Lean leaders in hospitals. Through this coaching style, Lean leaders can facilitate the problem-solving and improvement processes of employees (Poksinksa et al., 2013).
Other studies (Emiliani and Emiliani, 2013; Emiliani, 2003) state that Lean leadership is characterized by being well-aligned with Lean principles, such as continuous improvement and respect for people. However, this notion does not provide real insights into the roles or characteristics of Lean leaders. In light of this, it is argued in Poksinska et al. (2013) that there are four main characteristics of Lean leaders:
(1) Commitment to self-development (2) Coaching and developing others
(3) Supporting daily Kaizen (continuous improvement) (4) Creating vision and aligning goals.
8 clarify this concept, an in-depth empirical study on the roles, practices and behaviours of Lean leadership in hospital settings is needed, and the insights need to be positioned in relation to other leadership theories, as suggested by Poksinksa et al. (2013). Furthermore, although it is argued that Lean leaders are crucial in enhancing the problem-solving abilities of health-care professionals (Aij et al., 2015; Mann, 2009), it has not yet been discovered which Lean leadership roles, behaviours or practices have a connection with second-order problem solving. This research therefore also aims to clarify this. In the next section, the conceptual model of this study will be introduced. Moreover, the expectations of the empirical results will be discussed.
2.5 Conceptual model
This research aims to further study the relationships between Lean maturity, Lean leadership and second-order problem solving and the performance of nurse teams. Gemmel et al. (2016) have found preliminary evidence that there is a positive relationship between Lean maturity and second-order problem solving of nurses. However, there is no strong empirical evidence for this link yet, and it has also not been studied how this relates to the performance of nurse teams. This research therefore aims to provide more compelling evidence of this relationship and to find out whether there is a mediating role of second-order problem solving in improving performance within nursing departments. Furthermore, since leaders are an important factor determining the success of Lean interventions in hospitals (Aij et al., 2015), and may support nurses to engage in second-order problem solving (Tucker and Edmondson, 2003), Lean leadership and its relationship with second-order problem solving will be studied. Since little empirical research has been done on Lean leadership in healthcare, this concept will be studied in an explorative way. In figure 1, the conceptual model of this study is shown.
Level of Lean maturity Lean leadership Level of second-order problem solving + (3) Level of performance + (1) + (2) + (4)
Figure 1 - Conceptual model of this study
It is expected that the relationship between Lean maturity and second-order problem solving is positive, thus, higher Lean maturity leads to an elevated degree of second-order problem-solving behaviours. This expectation is translated into the following proposition:
9 Furthermore, second-order problem solving is expected to have a mediating role between Lean maturity and the level performance, since it is argued that effective problem solving approaches are important in bringing about improvements through Lean adoption (Gemmel et al., 2016; Dombrowski and Mielke, 2013, 2014). This results in the second proposition: H2: Second-order problem solving positively mediates the relationship between Lean maturity and performance (1, 2)
With regard to Lean leadership, the expectation is that Lean leadership practices and behaviours can enhance second-order problem solving for different Lean maturity levels. This mean that a positive moderating relationship of Lean leadership on the relation between Lean maturity and second-order problem solving is expected, which results in the third proposition: H3: Lean leadership positively moderates the relationship between Lean maturity and second-order problem solving (3)
Lastly, it is expected that as the Lean implementation matures, the performance of nurse teams will reach higher levels. This is translated into the last proposition:
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3. METHODOLOGY
In this section, the choice for conducting a case study will be elaborated. It will also be discussed where this research takes place, who the participants are and how the cases have been selected. Next, it is addressed how the concepts have been operationalized in order to collect accurate data of each concept. Lastly, the methods for analysing the gathered data are discussed.
3.1 Choice for the case study method
The aim of this research has been the most important factor for choosing the case study method. According to Karlsson (2009), a case study is suitable for both theory testing and theory building research. Since prior research has been done on the relationship between Lean maturity and second-order problem solving (see Gemmel et al., 2016), a part of this study aims for so-called theory testing (Eisenhardt and Graebner, 2007). However, since in-depth knowledge about Lean leadership in healthcare is currently lacking, this study also aims to build new theory. Another reason for choosing the case study method is that it allows for studying phenomena in their natural setting with a great degree of depth (Voss, Tsikriktsis and Frohlich, 2002
),
which is particularly important for studying Lean leadership in healthcare settings. Furthermore, since multiple cases allow for making comparisons between cases (Karlsson, 2009), a multiple case study approach was chosen.3.2 Setting
This research was undertaken in nursing departments of a Dutch hospital that are currently in different phases of implementing the Lean-based healthcare program called ‘The Productive Ward – Releasing Time to Care’, from now on referred to as PW. This is an improvement program that was launched by the NHS in 2007 in the UK, and has since then been implemented in many hospitals (Wilson, 2009). Recently, countries outside the UK have also started adopting PW due to the reported successes of the program (White, Wells and Butterworth, 2014b). The main goals of the PW program are to increase the proportion of time nurses spend on direct patient care and to improve experiences for staff and patients (Morrow et al., 2014). The program consists of 13 modules and tools designed for self-directed learning at the ward level. Within the entire program, Lean is framed in language and examples that should appeal to healthcare staff (White et al., 2014b; Morrow et al., 2014). 3.3 Participants
11 team has been interviewed. The reason for this is that nurses within these teams were expected to be more involved in the Lean program than nurses outside the PW core teams. Therefore, this approach gives a more reliable view of the data, as well as insights regarding the spread of the program within each team. Furthermore, the team leaders of each nursing department have also been interviewed, in particular to gain insights into Lean leadership roles, practices and behaviours in hospitals, but also to obtain a more complete view of the other main concepts of this study.
3.4 Case selection
The 15 cases were selected on the basis of their involvement in the PW program. In order to study the relationships accurately, it was decided to select cases that were in different stages of the implementation of PW at the time the study was conducted. Thus, the duration of the Lean program is used as the selection criteria. In order to build theory, cases are selected using replication logic rather than sampling logic (Eisenhardt, 1989). Cases with different levels of durations have been selected in order to produce contrary results, but for predictable reasons (Karlsson, 2009). For instance, it is expected that cases with low duration levels will show lower levels of Lean maturity and second-order problem solving than cases with high duration levels, as the high duration teams have worked with PW a longer time. Thus, different results are expected across the cases, and thereby theoretical replication is established (Eisenhardt and Graebner, 2007). Table 4 shows the selected cases within each duration level. As shown, the amount of cases are not equally distributed across the duration levels. This research aimed to include the same number of teams in each duration level, however, many teams within hospital A had started PW around the same time after the positive experiences in the pilot department A1. Therefore, certain duration levels are less represented.
Duration Selected cases
Level 1 (0-6 months) L, N
Level 2 (6-12 months) H, I, J, K
Level 3 (12-18 months) D, E, F, G, M, A2 (hospital B)
Level 4 (18-24 months) B, C
Level 5 (24 + months) A1 (hospital A)
Table 4 – The selected cases within each duration level 3.5 Data collection
12 Lean maturity was measured based on semi-structured interviews. The interview questions are related to enablers and practices of Lean. The enablers represent the supporting structure for Lean, whereas Lean practices focus on the way of working that is seen as consistent with Lean principles. Both provide accurate insights into the progress that is made during Lean adoption (Malmbrandt and Åhlström, 2013). The specific practices and enablers that are incorporated in this study are shown in table 5.
Enabler/practice Description
Enabler 1 Employee understanding of Lean
Enabler 2 Time and resources allocated to improvement work Enabler 3 Bi-directional vertical information flow
Practice 1 Identification of patient value Practice 2 Workplace design for flow
Practice 3 Visualization of information and improvements
Table 5 – Enablers and practices that are measured in this study
Certain other Lean enablers, such as management commitment and management understanding, have not been measured. The reason is that these are too closely related to the Lean leadership variable. Certain Lean practices were also omitted, as some are too closely linked to the second-order problem solving variable, such as the degree of structured problem solving. Moreover, some Lean enablers and practices suggested by Malmbrandt and Åhlström (2013) may not be relevant for this study, as not all dimensions are incorporated in the PW program, or may be too complex to measure in healthcare organizations, such as the pull practice. These enablers and practices were therefore left out.
Next, in order to measure second-order problem solving, a set of questions in the form of scenarios of Gemmel et al. (2016) were used. Since events and problems in hospital departments cannot be imitated in a laboratory, Gemmel et al. (2016) have developed scenarios of problems that nurses face in their work. These are described as similar as possible to their occurrence in the natural setting. Five scenarios have been selected that are each related to one of the five broad types of nurse problems that have been identified by Tucker and Edmondson (2003). They were used to obtain information about the actions undertaken by nurses when facing certain problems. It was also asked through an open-ended question whether the nurses could provide an example of a problem for which they have engaged in second-order problem solving. Together, the scenarios and the open-ended question provide insights into the degree of second-order problem solving.
Lean leadership has been investigated through open and semi-structured interview questions. Since this is still largely unexplored in healthcare, this was the most feasible way to study this concept. In the interviews, different questions have been posed to team leaders and nurses in order to study Lean leadership from multiple points of view, as suggested by Karlsson (2009). Furthermore, since higher management may provide relevant insights regarding the role of leaders during Lean adoption in hospitals, the internal supervisor of PW within hospital A has also been interviewed.
13 direct patient care, as this is measured by the teams in multiple stages of the implementation. However, this data was lacking for most cases, as many teams had not yet performed this step in the program. Therefore, it was chosen to measure performance by looking at the perception of nurses and leaders of the improvements that were achieved through Lean implementation. Since the main goal of PW is to increase the proportion of time that nurses spend on direct patient care (White et al., 2014a), the respondents were asked whether they feel, notice or have any proof of improved performance in this respect.
3.6 Data analysis
This section discusses how the collected data has been analysed. All concepts that are addressed in this section have been analysed and classified by multiple researchers in order to enhance the confidence of the findings (Eisenhardt, 1989; Voss et al., 2002).
First of all, the six enablers and practices of Lean were classified into 5-point scales based on the instrument of Malmbrandt and Åhlström (2013), which are shown in Appendix G. Although the unit of analysis of this study is a nurse team, data of individual respondents was analysed in order to study the relationships between the concepts. However, first it was tested whether the levels of Lean maturity for each respondent correlated with the data that was made available by the hospitals, which is the duration of PW for each team. This analysis revealed a correlation (r = 0,57, p < 0,001), which is shown in Appendix C. Next, a confirmatory factor analysis (CFA) was performed in order to test the unidimensionality of the six Lean enablers and practices. Although the Lean enablers and practices altogether had already been validated by Malmbrandt and Åhlström (2013), the construct validity of the six selected items was not yet established, and therefore, conducting a CFA was necessary. The CFA extracted one component with all factor loadings higher than 0.7. Thus, unidimensionality is supported, since all items measure the Lean maturity concept, which is depicted in table 6.
Enabler/practice Description Lean maturity
Enabler 1 Employee understanding of Lean .77
Enabler 2 Time and resources allocated to improvement work .73 Enabler 3 Bi-directional vertical information flow .84
Practice 1 Identification of patient value .77
Practice 2 Workplace design for flow .73
Practice 3 Visualization of information and improvements .71 Table 6 - Factor loadings on the dimension “Lean maturity”
(obtained from the Component Matrix table in SPSS)
Next, the internal consistency of the Lean enablers and practices was tested. The reliability analysis returned a Cronbach’s alpha of 0,85, which points to a strong internal consistency of the six items.
14
Level Description
1 Solving problems in a fire-fighting manner
2 Solving problems in a fire-fighting manner, but distinguishing between problems based on their frequency of occurrence
3 Solving problems in a fire-fighting manner, but informing the manager or head nurse of the problem at the moment of occurrence
4 Communicating to the person or department responsible for the problem afterwards 5 Bringing the problem to the attention of the manager or the head nurse afterwards 6 Sharing ideas about the cause of the situation and how to prevent recurrence with
someone in a position to implement changes 7 Implement changes
8 Verify that changes have the desired effect
Table 7 – Second-order problem solving levels (partly based on Tucker and Edmondson, 2003, p.61) Levels 1, 2 and 3 represent a first-order problem solving approach and are inspired by Tucker and Edmondson (2003), whereas levels 4 and above are described as second-order problem solving actions (Tucker and Edmondson 2003, p.61). There is an ascending order, which means that the higher the level, the higher the degree of second-order problem solving. Lastly, the perceived performance has been categorized into a four-level scale, as shown in table 8. These levels were not deduced from literature, but were designed collectively by the multiple investigators involved.
Level Description
1 Perception that there are no clear effects of the Productive Ward
2 Perception that time is freed up for direct patient care, but only indirectly through a better organized ward
3 Perception that actual time is freed up for direct patient care and this is exemplified. 4 Time is demonstrably freed up for direct patient care, and this improvement is given in
percentages based on the outcomes of the multi moment analysis Table 8 – levels of perceived performance
For each individual interview, scores were given for the level of Lean maturity, second-order problem solving and perceived performance. Since this was done by multiple researchers, it was checked whether the scores that were given for each dimension matched and these were discussed in case there was no match. After finding an agreement for the levels of each individual respondent, the relationships between the concepts were tested using a multiple linear regression in SPSS, which is, according to Baron and Kenny (1984), the best approach to test for mediation. The outcomes will be discussed in the result section.
15 these codes in order to reduce the total amount of codes. The remaining codes have been categorized into around 30 second-order themes and these have been further categorized into 14 aggregate dimensions, as suggested by Gioia et al. (2013). The resulting coding tree is depicted in Appendix B. In the cross-case analysis, similarities and differences regarding the moderating role of Lean leadership on the relation between Lean maturity and second-order problem solving were searched. In order to distinguish cases from each other to perform the cross-case analysis, each case was classified into low, medium and high levels for both Lean maturity and second-order problem solving, as is shown in table 9.
Teamleader Nurse inside PW core team Nurse outside PW core team Lean maturity Low ≤ 2.5 ≤ 2.25 ≤ 2 Medium 2.5 ≤ 3 2.25 ≤ 2.75 2 ≤ 2.5 High > 3 > 2.75 > 2.5 Second-order problem solving Low 1, 2, 3 1, 2, 3 1, 2, 3 Medium 4, 5 4, 5 4, 5 High 6, 7, 8 6, 7, 8 6, 7, 8
Table 9 – classification of Lean maturity and second-order problem solving in low, medium and high levels
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4. RESULTS
In this section, the results of the empirical study will be discussed. First of all, it will be discussed whether or not the results support the propositions related to Lean maturity, second-order problem solving and performance that have been formulated in this study. Thereafter, the within-case analysis will discuss the data structure that has been constructed for the Lean leadership concept. Finally, the cross-case analysis compares certain groups of cases in order to examine the moderating influence of Lean leadership on the relationship between Lean maturity and second-order problem solving.
4.1 Lean maturity, second-order problem solving and perceived performance The relationships between Lean maturity, second-order problem solving and perceived performance were tested through linear regression and multiple linear regression analysis in SPSS. Table 10 shows the outcomes of these statistical tests.
Dependent variables Perceived performance Second-order problem solving Perceived performance (mediated by second-order problem solving)
Step 1 Step 2 Step 3
Independent variables
Lean maturity
β 0.92*** 1.79*** 0.56**
Std. Error 0.14 0.26 0.18
R-Square 0.51 0.52 0.58
Second-order problem solving
β 0.36*** 0.20*
Std. Error 0.06 0.07
R-Square 0.49 0.58
*** P < 0.001 Table 10 – Linear regression and multiple linear regression analysis ** P < 0.01
* P < 0.05
First of all, a highly significant positive relationship between Lean maturity and second-order problem solving was found, β = 1.79, p < 0.001. These results tell us that an increase in 1 level of Lean maturity leads to an increase of nearly 1.8 levels of second-order problem solving. Since this relationship was found to be highly significant, this seems to confirm the first proposition that Lean maturity positively influences the level of second-order problem solving by nurses.
17
Conditions for a mediating effect Outcome
(1) Lean maturity significantly influences second-order problem solving
Satisfied, β =1.79, p < 0.001 (2) Lean maturity significantly influences perceived performance Satisfied, β = 0.92, p < 0.001 (3) Second-order problem solving has a unique effect on
perceived performance
Satisfied, β = 0.36, p < 0.001 (4) The effect of Lean maturity on perceived performance shrinks
upon the addition of the mediator second-order problem solving to the model
Satisfied, the effect of Lean maturity diminishes from β = 0.92 to β = 0.56, p < 0.01 Table 11 – the conditions for a mediating effect
Source: Baron and Kenny (1986)
In table 11, it is shown that all necessary conditions for a mediating effect as suggested by Baron and Kenny (1986) are satisfied. However, it should be noted that the unstandardized coefficient of the relationship between Lean maturity and perceived performance remains quite high when controlling for second-order problem solving (a reduction of β = 0.92 to β = 0.56). Moreover, second-order problem solving has a relatively low value for the unstandardized coefficient when Lean maturity is controlled (β = 0.20, p < 0.05). Therefore, it can be concluded that there is partial mediation, rather than full mediation of second-order problem solving. The presence of a mediating effect is also supported by the Sobel test (Z = 2.64 p < 0.01), which is a statistical method for testing the significance of a mediation effect (Preacher and Hayes, 2004). Although there is only partial mediation of second-order problem solving, this partial mediation is positive and therefore, the second proposition also seems to be confirmed.
Besides a mediation effect of second-order problem solving, the effect of Lean maturity on perceived performance is highly significant, β = 0.917, p < 0.001. Therefore, the proposition that Lean maturity influences the performance of nurse teams also seems to be confirmed. 4.2 Within-case analysis
In this section, the results of the in-depth analysis of Lean leadership will be discussed. As mentioned in the methodology section, a coding tree was build using an inductive approach of Gioia et al. (2013). This coding tree is shown in Appendix B. Quotes of respondents are used to clarify the concepts of the coding tree. Respondent ‘01’ refers to the team leader, whereas respondent ‘02’ and ‘03’ refer to nurses inside and outside of the PW core team respectively. 4.2.1 Lean leadership roles
18 Figure 2 – Lean leadership roles, practices and behaviours
Coaching role
First of all, the role of the Lean leader is to coach nurses to be actively involved in the PW program and to provide help only if needed. This is illustrated by the following quote of the team leader of team I: “I think coaching leadership was the most important quality I needed to
support this program. The change should be owned by the employees, and my role as team leader is to coach and help them”. It is often mentioned that team leaders used to have a lot
more tasks and responsibility before implementation of Lean, but that leaders now employ a coaching leadership style in order to support the nurses in their work. It is also frequently mentioned that an important aspect of coaching is to relinquish tasks and responsibility, because it helps to make nurses feel that they have ownership. This is supported by the following quotes. “The leader should not solve everything himself, people on the work floor
should be coached to do this, so a leader requires some sort of coaching leadership style”
(J-03), and “The leader does not want to keep tight control of everything, they relinquish tasks
and give guidance, and that motivates to be actively involved in the program” (H-03).
Leader is a role model
Secondly, the Lean leaders are often found to be a role model for their team. The leader is generally considered as the driving force behind the Lean program. In most teams, the leader expresses this example role by being highly involved in the PW core team. The leader has an important role in keeping the nurses within the team involved and enthusiastic about the program. This is supported by the following quotes: “I notice that the leader is all the way in” (M-03), and: “The leader is a member of the core team, and is really involved, so that is very
positive” (F-03). The team leaders often feel that an important part of being a role model, is
expressing enthusiasm towards the team in order to make sure that the team remains enthusiastic towards PW. For example, the team leader of team E said it as follows: “I feel
that I have to be enthusiastic. I need to bring along the group through enthusiasm”. This is
also supported by the following statement of a nurse: “The leader motivates me through her
Lean leadership roles
Coaching role
Leader is a role model Supportive role Facilitative role
Lean leadership practices & behaviours
Convincing the team in early stages Visualizing and providing insights Going to the work floor
Considering individuals
Encouraging nurses to be in the lead Evolving the team to become self-steering Keeping track and guarding the objectives Supporting Lean principles
19
enthusiasm, and by showing that she wants it herself” (N-02). Related to problem solving, the
Lean leaders also have an example role which they should be aware of. The leader of team C described this as follows: “At moments, they will see how you solve a problem yourself, so
they will think: okay, I will go down the same path. So, as a leader you kind of have an example role”.
Supportive role of team leader and higher management
Both team leaders and higher management within hospital A were found to have a crucial supportive role of Lean implementation. The team leaders show this by being engaged in thinking about what can be changed and by giving support to the nurses on how to approach things. This is illustrated by the following comment: “If we have ideas, we can go to our team
leader and he will help us by providing input on how we can approach things, so there is certainly support” (C-03). The supportive role of the leaders is also expressed by helping the
nurses to engage in problem solving and implementing solutions. For instance, some nurses feel that if problems are beyond their level, they need support from their team leader. Moreover, since the leaders generally have more knowledge than nurses on how to propose or implement new ideas, a supportive role in problem solving is provided by the leaders by for instance making a phone call or sending an e-mail. Higher management, which are the internal supervisors of PW and the management team, are also described as being highly involved. For instance, the leader of team G stated: “When we have PW training sessions, the
manager will try to be there as much as possible, in that way she stays informed of all developments and knows what we are up to, so I am very glad that she can join these meetings”. The crucial supporting role from the internal supervisor is also supported by the
following comment: “A good point of PW is the support that we receive from the internal
supervisor, that support is indispensable” (J-01).
Facilitative role
The interviews have also revealed that Lean leaders have an important role in facilitating the team, so that enough time and resources are available to actually work on PW projects. Most leaders try to do this by freeing up the time or resources, which is illustrated by the following comment: “My task is making sure that there is enough time. That they get the time, that is
often the big motivator” (E-01).
4.2.2 Lean leadership practices and behaviours
Convincing the team in early stages
At the beginning stage, Lean leaders have the important task to convince the team of the benefits of PW and to involve everyone. Especially when the benefits of Lean implementation are not yet visible, a Lean leader is perseverant in showing that the change is beneficial. This was often achieved through starting with small projects related to structuring the ward, by for instance making materials easier to retrieve. This is reflected by the following quote: “Our
team leader tackled a few small things at the beginning, in order to demonstrate that PW leads to improvements, so that people thought: Maybe this project isn’t so bad after all”
20
Visualizing and providing insights
It is often mentioned that Lean leaders use specific practices in order to develop the team to become acquainted with Lean. This is for instance done by illustrating that PW is a team effort: “I showed my team how PW works through a game, by laying a ball on the ground
with ropes attached to it. If only one person pulls the rope, the ball will not come from the ground, but if we do it together, it is much easier and something will actually happen” (F-01).
Furthermore, Lean leaders were found to use visualization as a means to give insights to the rest of the team. For instance, video recording was mentioned in order to see how often nurses are interrupted, and process maps were mentioned as a tool to look at processes in more depth and see things that would normally not be seen. The leader of team J put it the following way:
“I try to reflect to the team as much as possible, for instance by showing photos of the results”. Besides showing the results or benefits that can be achieved through Lean, the
leaders also often demonstrated the reasons for adopting Lean and doing improvement projects: “As a leader, I try to give insights into why we have to change certain things” (D-01). Nurses mentioned that they experience this as positive, since it creates energy for being more involved in PW. Furthermore, in every department, there is an improvement board of PW that shows the latest information and visualizes the results that have already been achieved through the program. In most departments, weekly meetings are held around this PW improvement board in order to discuss the progress of PW. Moreover, leaders send out a specific PW mail to their department in order to keep everyone up-to-date. These leadership activities are supported by the leader of team G: “I try to keep them up-to-date, by organizing
board-meetings regularly, and we have a newsletter containing a PW header”.
Going to the work floor
The analysis has also revealed that Lean leaders are present at the work floor to understand what is happening there. This is expressed through their involvement and their help in improvement projects that are part of the PW program. For example, one interviewee said:
The leader would come to do some pre-work and sit with us to do things together, and that motivates” (B-02).
Considering individuals
The Lean leaders were found to pay attention on individual level. This is done by expressing appreciation, but also by looking at the individual qualities and capabilities of nurses, in order to decide how to approach them for projects. For instance, the leader of team L does this the following way: “First I look at the level of a particular employee. I know all employees well,
so I know how experienced they are. If they are not experienced at all, I will guide them, but if someone does have the experience, well, then there is little that I have to do”.
Encouraging nurses to be in the lead
Another aggregate dimension emerging from the data, is the encouragement of Lean leaders to let nurses be in the lead. Both leaders and non-leaders stated that as the Lean initiative progresses, the leaders keep taking a step back, in order to give nurses a voice and more responsibility. Furthermore, Lean leaders encourage nurses to think for themselves, which is reflected by the following comment: “There is shared responsibility, that is PW, it should not
21 encouraged, as well as ownership of new ideas and improvement projects. For instance, one of the team leaders said: “If they come to me with ideas, I immediately ask them if they want
to become the owner of their ideas” (I-01). Furthermore, some Lean leaders were found to
encourage nurses to be the chair for the weekly PW meetings, in order to further stimulate them to take the lead. Overall, encouraging nurses to take a leading role is seen as a crucial leadership practice and is necessary to create self-steering teams.
Evolving team to become self-steering
At the beginning of PW, it is important that there is a leader who navigates the team, but as the implementation progresses, many teams report that they have become more self-steering. Closely related to encouraging nurses to be in the lead, it is seen as the task of the Lean leader to create self-steering teams. This is explained by the following comment: “Through this
program, a lot of people become more responsible, and my tasks are diminished. So, we are actually becoming a self-steering team” (A1-01). In some departments, it was also found that
the PW core team is the guiding body of Lean, keeping the rest of the team involved and up-to-date, and doing this without an active role of the Lean leader.
Keeping track and guarding the objectives
Another Lean leadership practice that was found, is related to keeping the overview of the PW implementation. This involves multiple activities, such as keeping track of who does what, guarding the objectives of PW and calling nurses to account if certain commitments are not honoured. The leaders were found to take action if they felt this was necessary for guarding the objectives. As one leader said: “Sometimes I have to slow things down, otherwise it will
become a whirlpool of improvements, making it hard to keep the overview” (K-01).
Supporting Lean principles
Lean leaders also support Lean principles. They try to make sure that the nurses do their work more efficiently, by keeping in mind that an important principle of Lean is to root out waste, as the following comments illustrate: “I think Lean leadership is about setting up processes in
such a way that there is no waste” (L-01) and “I am continuously looking at our processes, the problems we encounter, so that the team can root out every type of waste” (D-01).
Using communication skills
Finally, the majority of the respondents argued that most Lean leaders use communication skills in order to motivate employees for Lean. They are often addressed as highly important, for instance: “My leader motivates my through being really open in communication. Because
of that, I myself am investing more energy in the program” (L-02). 4.3 Cross-case analysis
22 Figure 3 – Results of each case concerning Lean maturity and second-order problem solving The above figure shows that many cases corroborate with the proposition. However, cases B, C, D, H and K deviate from the expected level of second-order problem solving. In order to search for cross-case patterns, groups of cases were formed on the basis of the levels of Lean maturity and second-order problem solving, as is shown in table 12.
Group Lean maturity Second-order
problem solving Number of cases
1 H H 2 2 H M 2 3 M M 4 4 M L 2 5 L M 1 6 L L 4
Table 12 – Categorization of cases in groups
Multiple groups of table 12 have been compared. In particular, groups of cases that are in accordance with the proposition have been compared to groups of deviating cases, in order to discover whether the different degrees of second-order problem solving can be ascribed to the Lean leadership moderator. Also, the PW pilot teams within hospital A and B have been compared, which are the only teams where a high degree of second-order problem solving was found.
4.3.1 Comparison of groups 1 and 6 (HH*LL)
23 In cases A1 and A2, nurses have the responsibility, but also the possibility to tackle root causes of problems themselves, both as a team and individually. This is explained by the feeling of these nurses that they are in the lead. The leaders of teams A1 and A2 play a crucial role in empowering and giving a sense of trust to nurses, so that they are able to engage in second-order problem solving. The following response emphasizes this: “The leader gives us
the opportunity to think about problems ourselves, and people are stimulated through that. They are not stimulated if leaders keep solving problems themselves” (A2-03). Furthermore,
the Lean leaders want to make the nurses take ownership over their solutions, since this further stimulates the nurses. As one interviewee put it: “Solutions to problems are not
imposed upon us, we think about them ourselves” (A2-03). Thus, related to Lean leadership
practices and behaviours, it seems that promoting nurses to feel ownership and to be in the lead, and thereby stimulating the team to become self-steering, is something that contributes to second-order problem solving.
The analysis of group 6 shows differences concerning Lean leadership. Within three of the four cases, the leaders have a very active role in problem solving and thinking about solutions. For instance, they were found to provide more directions, and a lot of attention was focused on giving the nurses support on how to approach problems. This active support may be necessary in these teams, as these nurses are less experienced with second-order problem solving and continuous improvement. The analysis also revealed that the nurses within these lower Lean maturity teams do not have the same possibilities to tackle problems and implement solutions, as illustrated by the following comment: “A lot of things are not
possible, but the leaders have larger possibilities and know which budgets are needed. So, we need a bit of support” (F-03). Thus, this is in contrast with cases A1 and A2, where the Lean
leaders have given the nurses the possibility to do it without intervention of the leader. Also, it is mentioned that the nurses may not yet be aware of their capabilities to actually engage in second-order problem solving. An important task of Lean leaders in this respect is explained by the leader of team N: “I think they are still often insecure about having the solution
themselves. They can do more than they think. I would really like to bring that up, that will make them grow and strengthen the team”.
Finally, within the high second-order problem solving teams A1 and A2, both Lean leaders are recognized as coaches, whereas this coaching role is only acknowledged in one of the four teams of group 6. This implies that, as the teams mature in PW, the Lean leaders increasingly use a coaching leadership style to support the nurses in problem solving. In team A1, this coaching role in relation to problem solving is expressed as follows: “It’s not like this
anymore: Here is my problem, solve this for me. Now she asks: what do you think is a good solution? Or she says: go and investigate how you could make that happen” (A1-03). In this
way, a coaching role of Lean leaders may positively influence the relationship between Lean maturity and second-order problem solving.
4.3.2 Comparison of groups 5 and 6 (LM*LL)
24 of second-order problem solving. The Lean leader of team K has an important role in stimulating nurses to engage in second-order problem solving. Both the leader and the nurses mention that the nurses are continuously motivated to look at current problems through the lens of PW. One of the main parts of PW is the standardized improvement cycle that is used for analysing and solving problems. This is the so-called ‘Hairdryer model’, which can be seen as a tool to engage in second-order problem solving, since it follows steps such as group discussions about current problems, mapping the current situation, collecting data, implementing changes and doing audits to see the effects. The Lean leader within this team continuously motivates and stimulates nurses to follow these steps and to go beyond ad hoc problem solving, as the following quote illustrates: “I have to say continuously: Do not try to
solve this in an ad hoc way, but try to do this according to the steps of the program” (K-01).
Moreover, the tasks of this leader are mostly focused on empowering and stimulating nurses to let them be in the lead. As one interviewee put it: “The leader creates the conditions for us
to take the initiative in improving things” (K-02). Finally, the leader of team K makes clear to
the team that PW is a group effort and that everyone should be involved in problem solving. This is successfully transferred to the nurses, as the following comment of the nurse outside of the PW core team illustrates: “PW is addressed very collectively here” (K-03).
In contrast, the Lean leaders within group 6 were found to have a more controlling function regarding problem solving. Although some nurses within these teams acknowledge that PW is about evolving the nurses and teams to become self-steering in problem solving, the leaders still invest a lot of time in being involved in this process. For instance, the leader of team N is still focused on trying to make the nurses approach problems in a different way: “I try to
direct them and to show them different sides of problems, so that they will look at problems in another way” (N-01). Furthermore, the specific role of the leader to motivate all nurses to
look at problems through the PW lens, is only recognized in one of the four cases of group 6. This is supported by the following quote: “Since I am no member of the core team, the leader
does not motivate me use the Hairdryer model” (I-03). Thus, one of the main reasons that
second-order problem solving abilities are less developed in these teams, could be that the Lean leaders seem to invest less energy on stimulating nurses to use the Hairdryer model. As a result, problems are often still approached in unstructured ways, as the following comment illustrates: “I think that it is still often done in an instinctive way” (L-02).
4.3.3 Comparison of groups 1 and 2 (HH*HM)
25 First of all, in all teams within both groups, the Lean leader is seen as a coach, who only assists the nurses in problem-solving when needed. Furthermore, in all teams, it is repeatedly mentioned that problems are solved by the nurses themselves, since they are very capable of doing this according to the steps of the Hairdryer model. Therefore, the team leader has become less involved in this process, which is supported by the following comment: “It may
sound weird, but since Productive Ward, we all know how to deal with problems, and we don’t necessarily need the leader for it.” (H-02). In a previous section, it has already been
discussed that teams A1 and A2 also have a relatively low involvement of the team leader in problem solving, since these are highly self-steering teams. Thus, there are clear similarities between groups 1 and 2. However, the individual interviews revealed that the independent role of nurses is more diffused throughout the entire team in both A1 and A2. The following comments of nurses within teams B and H illustrate a slightly more dependent role of some nurses, as well as a higher involvement of the team leader in problem solving: “The leader
helps, thinks along and is involved” (B-02) and: “We need collaboration, tips and feedback on how to solve problems” (H-03). Thus, the leaders within these teams employ the same
Lean leadership practices and behaviours, such as stimulating nurses to be in the lead and developing self-steering teams, but not to the same extent. Another difference pertains to the fact that the leaders within teams A1 and A2 are seen as role models, who are very enthusiastic towards PW. The analysis reveals that this is not the case in team B. Because of the earlier described negative situation within team B, the leader is not enthusiastic and is not seen as the driving force behind the PW. This absence of a role model could have negative effects on the degree of second-order problem solving.
In order to find support for the findings of the comparison between groups 1 and 2 (HH*HM), groups 3 and 4 (MM*ML) have also been compared. This cross-case comparison also suggests that the presence of a role model is important. For instance, in team D, where there is a low degree of second-order problem solving (group 4), the leader is less enthusiastic and can barely be described as the driving force of PW. As one of the nurses in team D said: “We
are not enthusiastic, we don’t know what we are doing. And I see that the team leader feels the same way” (D-03). This is in contrast with team E, where there is a higher degree of
second-order problem solving: “Our leader is very enthusiastic and fanatic” (E-02). Also, the importance of stimulating nurses to come up with their own solutions by promoting independency is supported. This independent role of nurses was not well-developed in teams C and D, whereas some leaders within the other teams pointed out that it is increasingly stimulated. For instance, leader of team J said: “My role is to stimulate nurses to take
responsibility and to take the wheel” (J-01). From the viewpoint of the nurses, this is
perceived as encouraging and stimulating: “The team really has the feeling that they have
their own responsibilities and that they have a say” (J-03). This implies that a shift takes
place from an active supervising role to a coaching leadership style as PW matures in the teams.
4.3.4 Comparison of teams A1 and A2 (HH*HH)
26 other departments of hospital B, whereas almost all nursing departments of hospital A have also already made a start with the program. Nevertheless, the analysis of both teams has revealed high similarities regarding the moderating role of Lean leadership, as both leaders stimulate second-order problem solving by having a coaching role and by letting the nurses be in the lead. Also, the leaders in both teams focus on keeping everyone involved in problem solving. This is mostly done through visualizing of the results of improvement projects throughout the ward, and by providing insights about the reasons for doing certain modules or projects.
There are also differences regarding the role of Lean leadership between these teams. In team A1, which has started with PW about one year earlier than A2, the Lean leader has made some unique decisions in order to stimulate everyone to engage in second-order problem solving. First of all, all nurses within the team are encouraged to organize and be the chair of PW meetings, so that this is not only done by members of the core team. The following comment illustrates this: “I try to let everyone lead a PW meeting once in a while, so that is it
not always done by the same people” (A1-01). Furthermore, the Lean leader of A1 has also
made the decision to regularly switch the members of the PW core team, in order to let all nurses experience what it is like to be involved in improvement projects. The following quote explains this: “We had a large group that was enthusiastic about PW and a group that was
not. The latter was not present at PW meetings and training sessions, so they did not get informed. That does not motivate, it results in resistance” (A1-01). These leadership activities
have helped nurses to feel more ownership of PW, and therefore, they feel more responsible to engage in improvement projects, as the following quote reflects: “It really helps if you feel
responsible for something, because then you will really take care of it” (A1-03). As a result of
these leadership decisions, all nurses in team A1 are actively involved in PW, and have thereby all gained experience in tackling problems with the Hairdryer model. Although both teams revealed a high degree of second-order problem solving, these leadership practices were unique for team A1, and were generally perceived as an extra motivation for the nurses. 4.3.5 Overview of the cross-case findings
The cross-case analysis has revealed several Lean leadership roles, practices and behaviours that may influence the relationship between Lean maturity and second-order problem solving. These findings have been linked to the aggregate dimensions, which were elaborated in the within-case analysis. Table 13 provides an overview of what has emerged from this section.
Table 13 – Moderating roles, practices and behaviours of Lean leaders
Moderating roles, practices & behaviours of Lean leaders
Cross-case comparison Cases within the comparison where the item was mentioned
Leader has a coaching role HH*HM, HH*LL, MM*ML A1, A2, B, C, E, G, H, J, N
Leader is a role model HH*HM, MM*ML A1, A2, E, G, H
Encouraging nurses to be in the lead HH*HH, HH*HM, HH*LL, MM*ML, LM*LL
A1, A2, B, C, E, H, I, J Evolving the team to become self-steering HH*HM, HH*LL A1, A2, H
