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For peer review only

Kaizen practice in healthcare: A qualitative analysis of hospital employees’ suggestions for improvement

Journal: BMJ Open

Manuscript ID bmjopen-2016-012256

Article Type: Research

Date Submitted by the Author: 12-Apr-2016

Complete List of Authors: Mazzocato, Pamela; Karolinska Institutet, Learning, Informatics, Management, and Ethics Stenfors-Hayes, Terese; Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Evaluation Unit von Thiele Schwarz, Ulrica; Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Centre Hasson, Henna ; Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Centre;

Stockholms Lans Landsting, Center for Epidemiology and Community Medicine Nyström, Monica; Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Medical Management Centre; Umea Universitet Nationalekonomi, Department of Public health and Clinical medicine, Epidemiology and Global health

<b>Primary Subject Heading</b>:

Medical management

Secondary Subject Heading: Qualitative research

Keywords: QUALITATIVE RESEARCH, Kaizen, Employee suggestion programme, Quality improvement, lean thinking

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TITLE PAGE

Title

Kaizen practice in healthcare: A qualitative analysis of hospital employees’

suggestions for improvement

Corresponding Author

Mazzocato Pamela, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Tomtebodavägen 18A, 17177, Stockholm, Sweden. E-mail: [email protected]; Telephone number: 0046 852483696

Co-Authors

Stenfors-Hayes Terese, Department of Learning, Informatics, Management and Ethics, Evaluation Unit, Karolinska Institutet, Stockholm, Sweden. von Thiele Schwarz Ulrica, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden Hasson, Henna, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden and Center for Epidemiology and Community Medicine, Stockholm County Council, Stockholm, Sweden

Nyström, Monica Elisabeth, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, and Department of Public health and Clinical medicine, Epidemiology and Global health, Umeå University, Umeå, Sweden

Keywords

Quality improvement, lean thinking, employee suggestion programme, qualitative research, kaizen

Word count

3221

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ABSTRACT

Objectives Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through

practices that enable employees to propose ideas for improvement and solve problems. Still,

there is limited understanding of how kaizen practices work in hospital organizations. This study

aims to explore the content of improvement efforts that hospital employees feel empowered to

address through kaizen practices.

Methods

We analysed 186 structured kaizen documents containing improvement suggestions that were

produced by employees at a Swedish hospital. Directed content analysis was used to categorise

the suggestions into: type of situation (proactive or reactive) triggering an improvement action;

type of process addressed (technical/administrative, support, and clinical); complexity level

(simple or complex); and type of outcomes aimed for (operational or socio-technical).

Compliance to the kaizen template was calculated.

Results

Seventy-two percent of the improvement suggestions were reactions to a perceived problem.

Support, technical and administrative, and primary clinical processes were involved in 47, 38,

and 16 % of the suggestions respectively. The majority of the kaizen documents addressed

simple situations and focused on operational outcomes. The degree of compliance to the kaizen

template was high for several items concerning the identification of problems and the proposed

solutions, and low for items related to the test and implementation of solutions.

Conclusions

Kaizen empowers staff to improve operational performance in support and technical

administrative processes. However, there is only a partial connection between kaizen practices

and the overall goals of healthcare organizations, such as improving the clinical care processes

across organizational boundaries.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

• The content of employee’s improvement suggestions captured in kaizen templates that

were filled in during one year at eight units in a hospital setting was analysed.

• The directed content analysis was guided by a conceptual model that builds on previous

research on lean and kaizen.

• Data was classified independently by two researchers to ensure reliability and validity in

the analysis.

• The focus of this study is constrained to the content of ideas developed through an

employee suggestion system; while the system was part of a wider kaizen approach, the

findings should be prudently generalized to kaizen practices in general.

INTRODUCTION

The management practice lean has become one of the most commonly used improvement

approaches in healthcare.[1] Lean is based on the continuous improvement of processes achieved

either by increasing customer value or reducing non-value adding activities, and by reducing

process variation and poor work conditions.[2] There is promising evidence that lean helps to

improve efficiency and quality in the short-term.[3 4] However, sustainability of results after the

initial period of short-term gains has been proven difficult to achieve,[5 6] and there is only

limited understanding of factors influencing variation in results across organizational settings.[5

7] Plausible explanations for some of the observed limitations can be found in the scope of the

lean improvement efforts. The types of outcomes addressed have mainly focused on operational

aspects of performance, while little attention has been paid to socio-technical aspects, such as

employees’ health, well-being, and creativity.[8-10] Studies on the types of organizational

processes involved have shown that lean has mainly concerned manufacturing-like processes,

such as laboratory processes,[11] and processes within one unit and not across organizational

boundaries.[8] It has also been suggested that lean practices may be more successful when

applied to services characterized by a low degree of complexity.[5] The incremental approach to

lean improvement has furthermore been perceived as an inhibitor to an organizations’ ability to

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innovate, as the focus is on improving existing products, services, and processes, rather than on

finding new ways of doing things.[12] Limited compliance to a scientific approach on

improvement may also explain the challenges to continuously improve.[8 13]

Thus, there is a need to deepen our understanding on how lean works in healthcare. Continuous

improvement (CI) lies at the core of lean, and is referred to as kaizen.[14] Kaizen is implemented

through practices that enable employees to incrementally propose ideas for improvement, solve

problems, and sustain results over time.[15] Examples of practices are kaizen blitz, continuous

process improvement (CPI) teams, and employee suggestion programmes.[16] Kaizen blitz,

sometimes referred to as “kaizen events” or rapid improvement events, are generally short-term

projects, often conducted in the format of a three to five day work session focused on a specific

process or set of activities.[17] The scope of the changes sought is focused on all or part of a

specific process, rather than broad organization practices, policies or technology changes, and

requires little investment.[18] CPI teams and employee suggestion programmes are, compared to

kaizen blitz, long-term initiatives where staff meets regularly over time.[19] While kaizen lies at

the core of lean, there is only limited understanding of how the kaizen principle is put into

practice in healthcare.

Building on previous research on lean and kaizen, we developed a conceptual model of the key

characteristics of a kaizen process (Figure 1). The input or trigger of a kaizen process, for

example an employee’s suggestion, can represent a situation that may provoke either a reactive

or a proactive activity. The former situation is tied to a problem that needs to be solved, whereas

the latter represents an opportunity to test new ideas not clearly stemming from a problem. The

improvement suggestion can involve one of three main types of organizational processes, i.e.

technical and administrative support, and primary clinical processes, or a mixture of them.[20]

The complexity level involved in the situation addressed and the suggested solution can vary,

from simple to more complex.[21] The type of outcomes addressed and expected may be

operational or socio-technical.[10] Information about the results achieved or the lack of these is

then fed back to the employees for potential learning and/or further actions.

< Insert Figure 1 here>

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This study aims to explore the content of improvement efforts that hospital employees feel

empowered to address through kaizen practices. We specifically focused on the improvement

ideas captured through an employee suggestion system at a hospital adopting multiple kaizen

practices to support continual improvement. Five specific research questions were posed:

I. To what extent do employees choose improvement suggestions that represent a reactive

or proactive activity?

II. What types of organizational processes do the improvement suggestions address?

III. What level of complexity do the improvement suggestions have?

IV. What types of outcomes are addressed in the improvement suggestions?

V. What is the degree of compliance to the kaizen template (i.e. completion of template

categories)?

METHODS

Case characteristics: the hospital and its history of working with kaizen

The study was conducted in a regional hospital in Sweden with approximately 500 employees.

At the hospital a kaizen programme for continuous improvement is ongoing since 2009. The

hospital units have the autonomy to organize their kaizen practises as they see fit, but the general

work process described below is the same for all units.

At each unit employees are encouraged to propose improvement suggestions. The improvement

process, that builds on the Plan-Do-Study-Act (PDSA) cycle,[13] is documented in specifically

designed kaizen templates (Figure 2) that are displayed on a wall, visible for all staff members.

The paper template consists of 18 items that address the problem area (service level, quality and

safety, work environment, and economics), a description of the problem and the suggestions

proposed, the decision on the solution to test and to implement, as well as expected and achieved

results. We will use the term kaizen documents for the filled in kaizen templates.


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Regular, short meetings are organized with all employees in each unit from one up to four times

a month, where initial proposals are discussed and decisions made on whether they should be

implemented or further explored. In the latter case, a small team is put together to carry out the

improvement cycle, resembling the kaizen event practice, until the next meeting. When needed,

improvement ideas are brought up to higher organizational levels.

Up to three employees at each unit serves as kaizen representatives and one member of staff

serves as a kaizen coordinator for the hospital. The coordinator brings all representatives together

a few times a year and keeps track of which and how many improvement suggestions each

hospital units produces. The number of implemented suggestions is linked to a financial reward

that can be used for staff activities. The implementation of kaizen in the hospital was supported

by an external consultant that still provides support and extra assistance to units struggling with

their kaizen work.

Eight units delivering geriatric care, medicine, gynaecology, intensive care, surgery, palliative

care, rehabilitation, and radiology were included in the current study. The excluded units were a

part of an intervention study in which the employee health promotion activities were integrated

with the kaizen work.[22] These units were excluded because this study focuses on

understanding how kaizen work.

Data collection and analysis

The kaizen documents filled in by employees in 2013 were collected in January 2014, resulting

in 186 documents that were used for analysis. All the written text from the kaizen documents

(figure 2) was transcribed into an Excel file based on the template’s questions, here after called

items. The filled parts of the Plan-Do-Study-Act (PDSA) cycle was an item also noted.

Directed content analysis [23] was used to analyse the content of the kaizen documents in order

to answer the first four research questions. The analysis was guided by the framework in Figure

1. Detailed definitions of the categories and sub-categories that guided the directed content

analysis, as well as the items included are presented in Table 1.

< Insert Table 1 here>

Research Items in Categories Sub categories Definition

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question kaizen template included in the analysis

I 5, 6 A situation that triggers an improvement suggestion

Proactive Idea for improvement, not clearly stemming from a problem Reactive A reaction to a problem encountered that is clearly described

II 5, 6, 9, 12, 15, 16

Organisational process involved [20]

Primary clinical process

Set of activities to diagnose, treat and care for patients and address specific health problems

Support processes

Set of activities that support the primary clinical process but do not (alone) improve patient health (e.g. diagnostic processes, medication management)

Technical/ Adm. processes

Set of activities that deal with the structures and infrastructures needed for the general functioning of the hospital that not directly involve patients or healthcare professionals (e.g. payment of staff or the supply of goods or services, physical environment )

III 5-6, 9, 12, 15, 16

Complexity level involved [21]

Simple One or very few components, interventions, outcomes, actors and/or units are involved

Complex Many components, interventions, outcomes, actors and/or units involved

IV 9, 12, 15, 16

Outcomes addressed or expected [10]

Operational Reduces non-value created activities, leads to increased effectiveness, efficiency and productivity (e.g. increased service quality and patient safety, better use of resources)

Socio technical

Improves aspects related to staff and work environment (e.g. job satisfaction, stress, worker health, safety and well-being, work performance, innovation and creativity, organizational involvement, and organizational citizenship)

Table 1. Definition of the categories and sub-categories used in analyses and their relation to the

research questions

The analysis was performed in several steps by the first and last authors. First, the entire material

was read through to get a sense of the whole. Secondly, categories based on the framework

(Figure 1) were pilot tested on parts of the data and definitions were agreed on. In a third step,

the two researchers independently categorised the entire data. Inter-rater reliabilities (Cohen’s

Kappa) of 0.92, 0.97, 0.97, and 0.96 were calculated for the research questions I-IV respectively.

In the few cases where there was disagreement on the categorisation, the classifications made by

the first author were used to represent the results. Frequencies and proportions of classified items

in each sub category were calculated for the total data set and also separately for the eight units.

To assess the degree of compliance to the kaizen template items (i.e. to which degree the staff

had filled in text for the items in the template, including marked anything in the PDSA-cycle’s

phases) the frequencies and proportions of information in the kaizen template items were

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calculated for all the kaizen documents. The study has been granted ethical approval by the

Regional Ethics Committee in Stockholm (ref no. 2011/1420-31/5).

RESULTS

Overview of the content in the kaizen documents

Figure 3 provides an overview of the percentage of the kaizen documents in the four categories

and sub categories (research questions I-IV).


In Table 2 these results are presented together with frequencies at unit level.


Table 2. Type of unit, number of staff working in each unit, and the percentage of the

improvement suggestions per unit assigned to subcategories within each category.

Unit Type of unit

Staff 2013

Kaizen documents

Situation Organizational process Complexity Type of outcome

Out/in-

patient

Proactive Reactive Tech-

nical

Sup-

port

Pri-

mary

Simple Complex Operative Socio-

technical n n n / % n / % n / % n / % n / % n / % n / % n / % n / %

1 out 35 63 14/22 49/78 24/38 34/54 5/8 59/94 4/6 34/54 29/46 2 out 6 17 5/29 12/71 10/59 6/35 1/6 16/94 1/6 13/76 4/24 3 in 36 22 7/32 15/68 7/32 8/36 7/32 20/91 2/9 15/68 7/32 4 out 10 30 12/40 18/60 8/27 21/70 1/3 28/93 2/7 27/90 3/10 5 in 15 19 9/47 10/53 5/26 9/47 5/26 15/79 4/21 16/84 3/16 6 out 19 11 2/18 9/82 6/55 3/27 2/18 9/82 2/18 10/91 1/9 7 out 21 5 1/ 20 4/80 4/80 0/0 1/20 4/80 1/20 3/60 2/40 8 in 23 19 2/11 17/89 6/32 6/32 7/37 15/79 4/21 16/84 3/16

Situations that triggered improvement suggestions

A majority (72%,) of the kaizen documents were related to a problem identified and thus

categorized as reactive. At unit level the proportion of reactive kaizen documents varied from 53

to 89 percent (Table 2). Examples of reactive activities included an identified problem and need

to improve documentation related to the process of discharging patients or substitute broken

equipment. An example of a proactive activity was a suggestion to buy oil color and canvas to

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enable patients in palliative care to draw paintings for decorating the wards. This example was

considered as proactive as it originated from a willingness to create a warm and pleasant

environment for patients, rather than stemming from an identified problem.

Type of organizational processes addressed

In 47 percent of the cases (n=87), the kaizen documents addressed support processes, in 38

percent (n=70) technical administrative processes, and in 16 percent (n=29) primary clinical

processes (Figure 3). In four of the units, the majority of the kaizen documents addressed support

processes, while in three units, the majority of the documents addressed technical-administrative

processes. Only in one inpatient unit did most kaizen documents address the primary clinical

care process. Examples of problems in support processes were: unclear information provided to

patients during preparation for routine examinations, or the identification of non-value adding

administrative activities in the physician workflow. In both examples the processes addressed

involved activities needed to support the patient care process, but that did not alone contribute to

improvement of patients’ health. Examples of problems related to technical-administrative

processes dealt with infrastructures needed for the general functioning of the hospital, for

example the lack of available post-it notes for new improvement suggestions, or that the

computers were not switched off during evening shifts. Examples of primary clinical processes

addressed were poor pain relief treatment for older patients and lack of standardized routines for

central line placement in emergency care.

Complexity in issues addressed and in improvements proposed

A majority (89%) of the documents addressed problems and/or proposed suggestions that were

categorised as simple (Table 2). Simple issues and related proposed solutions were often small

changes needed to the physical layout, for example changing the placement of medications to

improve the ergonomic work environment for staff or fixing the lack of aprons and gloves in the

storage area. By simply refilling the storage the risk for transmission of infections could be

reduced. Complex issues included for example when staff members were feeling uncomfortable

to collaborate across organizational boundaries or when staff at an inpatient unit complained

about patients arriving from the emergency department that needed a quick transfer to the

radiology unit.

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Types of outcomes addressed

In a majority of the cases (72%) operative outcomes were addressed in the kaizen documents. In

many cases, staff proposed changes to work processes, physical layout, or equipment that could

yield both improved quality of care for patients and a more efficient use of resources. Socio-

technical outcomes mentioned were staff well-being, suggested to be improved by for example

increasing the indoor temperature in a perceived cold work place.

Degree of compliance to the Kaizen templates

There was a large variation in the degree to which the different parts of the kaizen template items

had been filled in or not. The percentage of compliance (i.e. text filled in under each item in the

template or marked in the PDSA-phases) varied from 12 to 100 percent (Figure 4). The first nine

items concerned problem identification and planning proposed solutions. Items 3-6 and 9 were

characterized by a high degree of compliance, ranging from 75% to 98%. Items 4 (area

addressed), 7 (date of suggested solution), and 8 (person making the suggestion), were

characterized by a lower degree of compliance, ranging from 32% to 44%.


Compliance was low for several items that concerned the test and further refinement of the

improvement idea and these items were number 10 (12%), 11 (16%), and 12 (25%). Compliance

varied for items 13-18 that concerned the actual implementation of the solution and the follow-

up afterwards. Information on the date for implementation (item 13) and the person responsible

for the implementation (item 14) was provided in 63% and 35% of the kaizen documents,

respectively. The final solution approved (item 15) was described in 87% of the documents,

whereas the actual results achieved were described in 28% of the cases. The solution was signed

by and thereby approved by the managers (item 18) in 17% of the documents, but this was not a

requirement for all types of suggestions. All the four phases of the PDSA cycle (item 17) were

reported on in 25% of the documents and in 49% at least one of the PDSA cycle’s phases was

mentioned.

DISCUSSION

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Of the 186 improvement suggestions captured in the Kaizen documents during 2013 the majority

were reactions to an experienced problem in support or technical/ administrative processes. The

problems addressed and the solutions proposed were characterized by a low level of complexity

and involved mainly operational aspects of performance. The degree of compliance with

different parts of the kaizen template varied substantially. Whereas it was generally high for

items that concerned problem and solution identification, the low degree of compliance with the

parts of the template corresponding to test and implementation of the solution indicate that the

scientific application of continuous improvement cycles was less than optimal. These key

findings will be discussed in relation to the literature on employee suggestion programmes, as

well as the broader concepts of kaizen and the lean strategies that were embraced by the studied

organization.

That the majority of the kaizen documents captured simple improvement ideas that involved one

organizational unit is consistent with how employee suggestion systems are used at Toyota to

encourage employees to incrementally test and implement ideas that are within their immediate

control. At Toyota these systems do, however, not replace managers responsibility to solve more

complex system-related problems.[24] The improvement of clinical care processes that cross

organizational boundaries lies at the core of healthcare, therefore it is pivotal that kaizen

practices are developed at the management level.

The incremental nature of kaizen may also explain why the majority of the improvement ideas

were a reaction to an experienced problem. Thus, this study seems to reinforce the argument that

kaizen is helpful to improve current practices, but may offer less opportunities for innovation.[12

25] Nevertheless, further studies are needed to unravel the complex relationship between

innovation and improvement in healthcare. Current research evidence points to the fact that

innovation and quality management can be handled in parallel[12 25] and finding ways to deal

with minor every-day problems is nevertheless important.

For the type of outcomes addressed, most cases focused on the operational aspects of

performance. This finding reinforces the need for lean improvement efforts to embrace an

employees’ perspective to a larger extent.[8-10] As lean transforms work structures and

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processes, its application in healthcare can be expected to affect the employees responsible for

carrying out the work.[9] As showed by previous studies of the same hospital, efforts to integrate

operational and socio-technical improvement efforts with the kaizen system may lead to a better

understanding of the relationship between work and health and a higher engagement in health

promotion, as well as more engagement in using kaizen for improvement work in general.[26]

To achieve coherence among an organization’s improvement processes and its social, technical

and structural systems is important when attempting to improve quality in healthcare

organizations.[27]

Previous studies have shown that when implemented in practice, PDSA cycles or similar

iterative improvement methods are seldom performed as planned.[13] The test and evaluation of

the suggested solutions are particularly challenging. The fact that this study took place four years

after kaizen was introduced indicates that it is not merely a matter of time and experience with

using kaizen. Without these components in place it can be difficult for organizations to monitor

the results of improvement efforts and thus to motivate staff that their efforts actually yield the

desired results. Nevertheless, in this setting, kaizen was still used despite this short-coming,

perhaps indicating that the system, even though mostly focusing on identification and

suggestions for solutions, was perceived as valuable for staff.

Methodological considerations

The calculated frequencies and percentages are constructed from qualitative information in the

kaizen forms in order to provide an overarching pattern and actual numbers shall be interpreted

with caution. To ensure reliability and validity in the analysis data was classified independently

by two judges. Some kaizen forms contained less information and this may have introduced

some bias as they were more difficult to categorize. Nevertheless, using documents allowed us to

track the paper trails of improvements, thus providing information that are not limited by

subjective experience or memory biases.

Some variation in the use of the kaizen templates was identified but not explored in this study.

Contextual factors such as staff composition, type of processes, and the organization ability to

implement the suggested ideas may influence staff participation in kaizen activities. A design

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that includes other sources of data (e.g. interviews and observations) would have provided more

insights into how kaizen works in practice. In this study there were some indications that staff

produce more improvement suggestions in small units. Close interaction among employees can

help staff to do their work while also working constantly at improving it, and this in turn can aid

the organization to institutionalize improvement practices.[5]

CONCLUSIONS

Kaizen practices enable hospital staff to identify problems, provide, and test suggestions to

improve operational performance, mainly in support and technical administrative processes.

However, this use of kaizen suggests that there is only a partial connection between the kaizen

process and the overall organizational goals, such as improvement of clinical care processes

across organizational boundaries. This limited connection can explain some of the challenges

observed in lean efforts in healthcare, specifically concerning sustainability. Thus, there is a need

to combine kaizen practices with improvement practices that help staff and managers to address

more complex issues. Moreover, the partial compliance to the use of the various items in the

kaizen template, especially regarding test and implementation, may represent a challenge to

communicate a deeper understanding of the entire kaizen process in relation to the organization’s

goals, structure and different kinds of processes, and ultimately also risk the sustainability of

kaizen practices themselves and of their results. It may also indicate that the simplicity of

iterative approaches following the PDSA cycle is alluring, and that more efforts are needed in

organizations to be able to continually improve.

CONTRIBUTORSHIP STATEMENT

PM, TSH, UvTS, HH, and MN designed the study. TSH collected the data, PM and MN

conducted the analysis and drafted the manuscript. TSH, UvTS, and HH read and critically

revised the manuscript. All authors approved the final manuscript and are accountable for all

parts of the work.

COMPETING INTERESTS

The authors declare that they have no competing interests.

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FUNDING

This work was financially supported by AFA Insurance [grant no 110094]. Dr von Thiele

Schwarz held a fellowship in improvement science funded by Vinnvård.

DATA SHARING STATEMENT

No additional data available.

ACKNOWLEDGEMENTS

The authors would like to thank the hospital for sharing their work on kaizen and Sandra Astnell

for invaluable help in data transcription.

REFERENCES

1. Walshe K. Pseudoinnovation: The development and spread of healthcare quality improvement methodologies. Int J Qual Health Care 2009;21(3):153-59 doi: 10.1093/intqhc/mzp012[published Online First: Epub Date]. 2. Radnor ZJ, Holweg M, Waring J. Lean in healthcare: The unfilled promise? Soc Sci Med 2012;74(3):364-71 3. Dickson EW, Singh S, Cheung DS, Wyatt CC, Nugent AS. Application of lean manufacturing techniques in the Emergency Department. J Emerg Med 2009;37(2):177-82 4. Jacobson GH, McCoin NS, Lescallette R, Russ S, Slovis CM. Kaizen: a method of process improvement in the emergency department. Acad Emerg Med 2009;16(12):1341-49 5. Mazzocato P, Thor J, Backman U, et al. Complexity complicates lean: lessons from seven emergency services. J Health Organ Manag 2014;28(2):266-88 6. Andersen H, Røvik KA, Ingebrigtsen T. Lean thinking in hospitals: is there a cure for the absence of evidence? A systematic review of reviews. BMJ open 2014;4(1) doi: 10.1136/bmjopen-2013-003873[published Online First: Epub Date]. 7. Andersen H. How to design Lean interventions to enable impact, sustainability and effectiveness. A mixed-method study. J Hosp Adm 2015;4(5):p18 8. Mazzocato P, Savage C, Brommels M, Aronsson Hk, Thor J. Lean thinking in healthcare: a realist review of the literature. BMJ Qual Saf 2010;19(5):376-82 doi: 10.1136/qshc.2009.037986[published Online First: Epub Date]. 9. Holden RJ. Lean Thinking in emergency departments: a critical review. Ann Emerg Med 2011;57(3):265-78 10. Joosten T, Bongers I, Janssen R. Application of lean thinking to health care: issues and observations. Int J Qual Health Care 2009;21(5):341-47 11. Brandao de Souza L. Trends and approaches in lean healthcare. Leadersh Health Serv 2009;22(2):121-39 12. Palm K, Lilja J, Wiklund H. The challenge of integrating innovation and quality management practice. Total Quality Management & Business Excellence 2014:1-14 doi: 10.1080/14783363.2014.939841[published Online First: Epub Date].

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13. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf 2014;23(4):290-98 doi: 10.1136/bmjqs-2013-001862[published Online First: Epub Date]|. 14. LLC i. Six Sigma quality resources for achieving Six Sigma results dictionary. Secondary Six Sigma quality resources for achieving Six Sigma results dictionary. http://www.isixsigma.com/dictionary/kaizen/ 15. Imai M. The key to Japan’s competitive success. McGrow-Hill/Irwin 1986 16. Suárez-Barraza MF, Miguel-Dávila JÁ. Assessing the design, management and improvement of Kaizen projects in local governments. Business Process Management Journal 2014;20(3):392-411 doi: doi:10.1108/BPMJ-03-2013-0040[published Online First: Epub Date]. 17. Melnyk SA, Calantone RJ, Montabon FL, Smith RT. Short-term action in pursuit of long-term improvements: introducing Kaizen events. Production and Inventory Management Journal 1998;39(4):69 18. Laraia AC, Moody PE, Hall RW. The kaizen blitz: accelerating breakthroughs in productivity and performance: John Wiley & Sons, 1999. 19. Farris JA. An Empirical Investigation of Kaizen Event Effectiveness: Outcomes and Critical Success Factors. Virginia Polytechnic Institute and State University, 2006. 20. Villa S. L’operations management a supporto del sistema di operazioni aziendali. Modelli di analisi e soluzioni progettuali per il settore sanitario [Healthcare operations management. Models of analysis and planning solutions for the healthcare sector] CEDAM, 2012. 21. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud 2013;50(5):587-92 22. Stenfors-Hayes T, Hasson H, Augustsson H, Hvitfeldt Forsberg H, von Thiele Schwarz U. Merging occupational health, safety and health promotion with Lean: An integrated systems approach (the LeanHealth project). Creating Healthy Workplaces: Stress Reduction, Improved Well-Being and Organizational Effectiveness: Gower Applied Business Research, 2014:281-99. 23. Hsieh H-F, Shannon SE. Three Approaches to Qualitative Content Analysis. Qual Health Res 2005;15(9):1277-88 doi: 10.1177/1049732305276687[published Online First: Epub Date]. 24. Marksberry P, Church J, Schmidt M. The Employee Suggestion System: A New Approach Using Latent Semantic Analysis. Human Factors and Ergonomics in Manufacturing & Service Industries 2014;24(1):29-39 doi: 10.1002/hfm.20351[published Online First: Epub Date]. 25. Paul Brunet A, New S. Kaizen in Japan: an empirical study. IJOPM 2003;23(12):1426-46 26. von Thiele Schwarz U, Augustsson H, Hasson H, Stenfors-Hayes T. Promoting Employee Health by Integrating Health Protection, Health Promotion, and Continuous Improvement: A Longitudinal Quasi-Experimental Intervention Study. J Occup Environ Med 2015;57(2):217-25 doi: 10.1097/jom.0000000000000344[published Online First: Epub Date]. 27. McAlearney AS, Terris D, Hardacre J, et al. Organizational Coherence in Health Care Organizations: Conceptual Guidance to Facilitate Quality Improvement and Organizational Change. QMHC 2013;22(2):86-99 doi: 10.1097/QMH.0b013e31828bc37d[published Online First: Epub Date].

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Figure 1. The conceptual model of the key characteristics of a kaizen process used in the study.

254x190mm (96 x 96 DPI)

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Figure 2. The kaizen template used to document the improvement process at the hospital. The note has been translated from Swedish to English (amended and published with permission from KAIZEN support).

267x180mm (150 x 150 DPI)

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Figure 3. Percentage of improvement suggestions assigned to subcategories within each category (type of situation; type of process addressed; complexity level; type of outcomes).

254x190mm (96 x 96 DPI)

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98.4%

43.5%

98.4% 94.6% 100.0%

75.3%

31.2%

38.2%

92.5%

12.4% 15.6%

25.3%

63.4%

34.9%

86.6%

28.0% 26.3%

16.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

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Items in the kaizen documents

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Journal: BMJ Open

Manuscript ID bmjopen-2016-012256.R1


Date Submitted by the Author: 13-Jun-2016




Medical management




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1

TITLE PAGE

Title





Co-Authors



Keywords


Word count

3722

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Abstract Objectives Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through

practices that enable employees to propose ideas for improvement and solve problems. The aim

of this study is to describe the types of issues and improvement suggestions that hospital

employees feel empowered to address through kaizen practices in order to understand when and

how kaizen is used in health care.

Methods


produced by 165 employees at a Swedish hospital. Directed content analysis was used to

categorise the suggestions into: type of situation (proactive or reactive) triggering an action; type

of process addressed (technical/administrative, support, and clinical); complexity level (simple or

complex); and type of outcomes aimed for (operational or socio-technical). Compliance to the

kaizen template was calculated.

Results



and 16 % of the suggestions, respectively. The majority of the kaizen documents addressed




Conclusions

There is a need to combine kaizen practices with improvement and innovation practices that help

staff and managers to address complex issues, such as the improvement of clinical care

processes. The limited focus on socio-technical aspects and the partial compliance to kaizen

templates may indicate a limited understanding of the entire kaizen process and of how it relates

to the overall organizational goals. This in turn can hamper the sustainability of kaizen practices

and results.

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• Employee’s improvement suggestions captured in kaizen templates that were filled in

during one year at eight units in a hospital setting were analysed.

• A directed content analysis was carried out that was guided by categories and sub

categories that were clearly defined.

• Data was classified independently by two researchers to foster dependability and

credibility in the analysis, and disagreements checked by a third researcher.

• A design that includes other sources of data (e.g. interviews and observations) would

have provided more insights into how kaizen works in practice, such as on the influence

of contextual factors.

• The focus of this study is constrained to the content of ideas developed through an

employee suggestion system; however, the system was part of a wider kaizen approach

and therefore the findings should be prudently transferred to kaizen practices in general.

INTRODUCTION


approaches in health care.[1] Lean is based on the continuous improvement of processes

achieved either by increasing customer value or reducing non-value adding activities, and by

reducing process variation and poor work conditions.[2] There is promising evidence that lean

helps to improve efficiency and quality in the short-term.[3, 4] However, sustainability of results

after the initial period of short-term gains has been proven difficult to achieve,[5, 6] and there is

only limited understanding of factors influencing variation in results across organizational

settings.[5, 7] Plausible explanations for some of the observed limitations can be found in the

scope of the lean improvement efforts. The types of outcomes addressed have mainly focused on

operational aspects of performance, while little attention has been paid to socio-technical aspects,

such as employees’ health, well-being, and creativity.[8-10] Studies on the types of

organizational processes involved have shown that lean has mainly concerned manufacturing-

like processes, such as laboratory processes,[11] and processes within one unit and not across

organizational boundaries.[8] It has also been suggested that lean practices may be more

successful when applied to services characterized by a low degree of complexity.[5] The

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incremental approach to lean improvement has furthermore been perceived as an inhibitor to an

organizations’ ability to innovate, as the focus is on improving existing products, services, and

processes, rather than on finding new ways of doing things.[12] Limited compliance to a

scientific approach on improvement may also explain the challenges to continuously improve.[8,

13]

Thus, there is a need to deepen our understanding on how lean works in health care. Continuous

improvement lies at the core of lean, and is referred to as kaizen, a Japanese word that means

“good change.”[14] The kaizen principle is about striving for perfection through the ongoing

involvement of employees in practices that enable them to incrementally propose ideas for

improvement, solve problems, and sustain results over time.[15, 16] Examples of practices are

kaizen blitz, continuous process improvement teams, and employee suggestion programmes.[17]

Kaizen blitz, sometimes referred to as “kaizen events” or rapid improvement events, are

generally short-term projects, often conducted in the format of a three to five day work session

focused on a specific process or set of activities.[18] These projects typically involve the analysis

of current processes, the development of ideal processes, and initial implementation of the

changes needed to eliminate waste.[19] The scope of the changes sought is focused on all or part

of a specific process, rather than broad organization practices, policies or technology changes,

and requires little investment.[20] Continuous process improvement teams and employee

suggestion programmes are, compared to kaizen blitz, long-term initiatives where staff meets

regularly over time.[21] While kaizen lies at the core of lean, most studies focus on evaluating

the effects of continual improvement efforts and there is only limited understanding of how the

kaizen principle is put into practice in health care.[22]

Therefore, the aim of this study is to describe the types of issues and improvement suggestions

that hospital employees feel empowered to address through kaizen practices in order to

understand when and how kaizen is used in health care. We specifically focused on the

improvement ideas captured through an employee suggestion system at a hospital adopting

multiple kaizen practices to support continual improvement.

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METHODS



At the hospital a kaizen programme, which includes the use of an employee suggestion system,

for continuous improvement is ongoing since 2009. The initial implementation of kaizen was

supported by an external consultant that still provides support and assistance, when needed, to

the hospital units working with kaizen, which include units providing clinical services as well

administrative and support services. The units have the autonomy to organize their kaizen

practises as they see fit, but the general work process described below is the same for all units.

At each unit, employees are encouraged to propose improvement suggestions. The improvement




safety, work environment, and economics), a description of the problem and the suggestions




Individual employees can decide to what extent to fill in the kaizen template individually. The

minimum requirement is to fill in information about the identified problem but they can also

provide ideas for how to address the problem. The rest of the information in the kaizen template

is compiled as the improvement efforts move along.

Regular short meetings are organized with all employees in each unit from one up to four times a

month, where initial proposals are discussed and decisions made on whether they should be

implemented or further explored. Typically, no ideas are rejected, but not all improvement ideas

lead to a change in practice because of economic constraints, the complexity of the issue, or

disagreement among staff. The duration of the meetings vary depending on the complexity of the

issue discussed. When decisions could be made on the stop, the meetings can be very short and

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last about five minutes. For more complex issues the meetings can be longer and a small team is

put together to carry out the improvement cycle, resembling the kaizen event practice, until the

next meeting. When needed, improvement ideas are brought up to higher organizational levels.

One to three employees at each unit serve as kaizen representatives and one member of staff

serves as a kaizen coordinator for the hospital level. The coordinator brings all representatives

from the units together a few times a year and keeps track of which and how many improvement

suggestions each hospital units produces. The number of implemented suggestions is linked to a

financial reward that can be used for staff activities.

Eight units delivering geriatric care, internal medicine, gynaecology, intensive care, surgery,

palliative care, rehabilitation, and radiology were included in the current study. Eight other units

were excluded as they were a part of an intervention study in which the employee health

promotion activities were integrated with the kaizen work.[23] These units were excluded

because this health promotion intervention was deemed to influence the original kaizen practices,

and thus making it harder to understand when and how kaizen practices were used.


The kaizen documents filled in by the 165 employees working at the included units in 2013 were

collected in January 2014, resulting in 186 documents that were used for analysis. The fact this

study was conducted about four years after the initial implementation of kaizen practices enabled

to study such practices when they were in full operation rather than in an initial implementation

phase, which is beneficial to understand how kaizen works in practice. All the written text from

the kaizen documents (Figure 1) was transcribed into an Excel file based on the template’s

questions, here after called items. The filled parts of the Plan-Do-Study-Act (PDSA) cycle was

an item also noted.

Directed content analysis [24] was used to analyse the text written in the kaizen documents. The

analysis we explored four main dimensions. First, the situation that triggered the use of the

kaizen document, which may be a reaction to a perceived problem to be solved or a proactive

initiative to test new ideas not clearly stemming from a problem. Second, the type or

organizational process targeted, which can involve one of three main types of organizational

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processes, i.e. technical and administrative support, and primary clinical processes, or a mixture

of them.[25] Third, the complexity level involved in the situation addressed that can vary from

simple to more complex.[26] Fourth, the type of outcomes addressed and expected, which may

be operational or socio-technical.[10] Figure 2 provides an overview of the four perspectives

included in analysis and how they relate to each other.


Detailed definitions of the categories and sub-categories that guided the directed content analysis

as well as the items included, are presented in Table 1. The development of clear definitions

based on the literature strengthened the trustworthiness of the research process. In addition to

four dimensions in Table 1, we also assessed the degree of compliance to the kaizen template

items.


Categories

Sub categories Items in the kaizen template included in the analysis

Definition

Situation trigger-ing an improve-ment suggestion

Proactive 5, 6 Idea for improvement, not clearly stemming from a problem Reactive A reaction to a problem encountered that is clearly described

Organisational processes adressed [25]

Primary clini-cal process

5, 6, 9, 12, 15, 16


Support processes



Set of activities that deal with the structures and infrastructures needed for the general functioning of the hospital that not directly involve patients or health care professionals (e.g. payment of staff or the supply of goods or services, physical environment )

Complexity level in the issues addressed and improvement actions proposed [26]

Simple 5-6, 9, 12, 15, 16

One or very few components, interventions, outcomes, actors and/or units are involved

Complex Many components, interventions, outcomes, actors and/or units involved

Outcomes addressed/ expected [10]

Operational 9, 12, 15, 16 Reduces non-value created activities, leads to increased effectiveness, efficiency and productivity (e.g. increased service quality and patient safety, better use of resources)

Socio technical


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Table 1. Definition of the categories and sub-categories used in analyses and their relation to the

research questions




the two researchers independently categorised the entire data. The independent classification by

two judges was done to ensure dependability and credibility. Inter-rater reliabilities (Cohen’s

Kappa) of 0.92, 0.97, 0.97, and 0.96 were calculated for the four main categories respectively. In

the few cases where there was disagreement on the categorisation, a third judge’s opinion was

sought (the second author) for a majority decision. Frequencies and proportions of classified

items in each sub category were calculated for the total data set and also separately for the eight

units.






RESULTS



and sub categories. In Table 2 these results are presented at unit level.



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Unit Staff 2013

Kaizen documents

Situation triggering the suggestion

Type of organizational process

Complexity Type of outcome

Proactive Reactie Tech-

nical

Sup-

port

Pri-

mary

Simple Complex Operative Socio-

technical n n n / % n / % n / % n / % n / % n / % n / % n / % n / %

1 35 63 14/22 49/78 24/38 34/54 5/8 59/94 4/6 34/54 29/46 2 6 17 5/29 12/71 10/59 6/35 1/6 16/94 1/6 13/76 4/24 3 36 22 7/32 15/68 7/32 8/36 7/32 20/91 2/9 15/68 7/32 4 10 30 12/40 18/60 8/27 21/70 1/3 28/93 2/7 27/90 3/10 5 15 19 9/47 10/53 5/26 9/47 5/26 15/79 4/21 16/84 3/16 6 19 11 2/18 9/82 6/55 3/27 2/18 9/82 2/18 10/91 1/9 7 21 5 1/ 20 4/80 4/80 0/0 1/20 4/80 1/20 3/60 2/40 8 23 19 2/11 17/89 6/32 6/32 7/37 15/79 4/21 16/84 3/16

Table 2. Number of staff and kaizen documents, and the percentage of the improvement

suggestions in each subcategory per unit


A majority (72%) of the kaizen documents were related to a problem identified and thus

categorised as reactive. At unit level the proportion of reactive kaizen documents varied from 53












processes. Only in one unit most kaizen documents address the primary clinical care process.

Examples of problems in support processes were: unclear information provided to patients

during preparation for routine examinations, or the identification of non-value adding




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Complexity in issues addressed and in improvement actions proposed


categorised as simple (Table 2). These were often small changes needed to the physical layout,

for example changing the placement of medications to improve the ergonomic work environment

for staff or fixing the lack of aprons and gloves in the storage area. By simply refilling the

storage the risk for transmission of infections could be reduced. Complex issues included for

example when staff members were feeling uncomfortable to collaborate across organizational

boundaries or when staff at a unit complained about patients arriving from the emergency

department that needed a quick transfer to the radiology unit.

Types of outcomes addressed and expected

In a majority of the cases (72%) operative outcomes were addressed. Staff proposed changes to

work processes, physical layout, or equipment that could yield both improved quality of care for

patients and a more efficient use of resources. Socio-technical outcomes mentioned were staff

well-being, suggested to be improved by for example increasing the indoor temperature in a

perceived cold work place.

Degree of compliance to the Kaizen documents

There was a large variation to what extend the different parts of the kaizen documents had been

filled in. The percentage of compliance (i.e. text filled in under each item in the template or

marked in the PDSA-phases) varied from 12 to 100 percent between the items (Figure 4).


The parts of the template that concerned problem identification and planning proposed solutions

(items 2-9) had items with varied level of compliance. Items 3-6 and 9 were characterized by a

high degree of compliance, ranging from 75% to 98%. Items 2 (area addressed), 7 (date of

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suggested solution), and 8 (person making the suggestion), were characterized by a lower degree

of compliance, ranging from 32% to 44%.

Compliance was also low for items that concerned the test and further refinement of the

improvement idea and these items were number 10 (12%), 11 (16%), and 12 (25%). Compliance

varied for items 13-18% that concerned the actual implementation of the solution and the

monitoring of the results achieved. Information on the date for implementation (item 13) and the

person responsible for the implementation (item 14) was provided in 63% and 35% of the kaizen

documents, respectively. The final solution approved (item 15) was described in 87% of the

documents, whereas the actual results achieved were described in 28% of the cases. The solution

was signed by and thereby approved by the managers (item 18) in 17% of the documents, which

was however not a requirement for all types of suggestions. All the four phases of the PDSA

cycle (item 17) were reported on in 25% of the documents and in 49% at least one of the PDSA

cycle’s phases was mentioned.

DISCUSSION

This study adds to the current knowledge on kaizen practices in health care by providing

empirical evidence of when and how employees propose improvement ideas through an

employee suggestion programme. The evidence was generated based on the analysis of a wide

range of initiatives carried out at one hospital for a period of one year, rather than on single

improvement initiatives as often reported in the literature. Kaizen templates were most often

filled in when staff perceived a problem in support or technical/administrative processes. The

problems addressed and the solutions proposed were often characterized by a low level of

complexity and involved mainly operational aspects of performance. The degree of compliance

with different parts of the kaizen template was generally high for items that concerned problem

and solution identification and low for items corresponding to test and implementation of the

solution. The findings will be discussed in relation to the literature on employee suggestion

programmes, as well as the broader lean and kaizen literature.

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The majority of the improvement ideas suggested by the employees in the kaizen templates were

a reaction to an experienced problem. This can be related to the incremental approach to

improvement that is inherent in kaizen practices which focus on the improvement of current

practices. In other sectors, the incremental approach has been associated with reduced

opportunities for innovation.[12, 27] Current research evidence however points to the fact that

innovation and quality improvement can be handled in parallel.[12, 27] Further studies are

needed to unravel the complex relationship between innovation and incremental improvement in

health care and the practices needed to support this relationship.

The kaizen documents captured mainly simple improvement ideas that involved one

organizational unit. The focus on single units may explain the scarcity of documents that

addressed clinical care processes that often cross organizational boundaries. These findings

suggest that, like at Toyota where lean and kaizen practices were developed, employee

suggestion systems can be used to encourage employees to incrementally test and implement

ideas that are within their immediate control. At Toyota, these systems do however not replace

managers responsibility to solve more complex system-related problems.[28] In health care,

there are few examples of kaizen practices as the management level. An example is the creation

ad-hoc management structures that cross organizational boundaries, which have proven to be

effective to open up communication channels between hospital management team and

improvement teams.[5] However, for health care organizations to achieve long-term results and

to conduct improvement efforts that embrace a patient rather than a unit perspective, there is a

need to develop kaizen practices at the management level that go beyond establishing

communication channels.


performance. Thus, there is a need for lean improvement efforts to embrace an employees’

perspective to a larger extent.[8-10] As lean transforms work structures and processes, its

application in healthcare can be expected to affect the employees responsible for carrying out the

work.[9] As showed by previous studies of the same hospital, efforts to integrate operational and

socio-technical improvement efforts with the kaizen system may lead to a better understanding

of the relationship between work and health and a higher engagement in health promotion, as

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well as more engagement in using kaizen for improvement work in general.[29] To achieve

coherence among an organization’s improvement processes and its social, technical and

structural systems is important when attempting to improve quality in health care

organizations.[30]

The low degree of use of items in the kaizen documents that corresponded to test and evaluation

of new ideas indicate that the scientific application of continuous improvement cycles was not

optimal. Methods, such as PDSA cycles, that build on a iterative and scientific approach to

improvement are seldom performed as planned in health care.[13] The fact that this study was

conducted four years after kaizen was introduced indicates that it is not merely a matter of time

and experience with using kaizen. Without these components in place it can be difficult for

organizations to monitor the results of improvement efforts and thus to motivate staff that their

efforts actually yield the desired results. Nevertheless, in this setting, kaizen was still used

despite this short-coming, perhaps indicating that the system, even though mostly focusing on

identification and suggestions for solutions, was perceived as valuable for staff.

Some variation in how the units used the kaizen templates was identified although not explicitly

explored in this study because of the limited number of documents collected from each unit. We

observed for instance that more improvement suggestions were produced in small units. Close

interaction among employees can help staff to do their work while also working constantly at

improving it.[5] Future studies, can explore more in depth how contextual factors such as staff

composition, turnover rates, stress level among staff, and the organization ability to implement

the suggested ideas may influence staff participation in kaizen activities.

Strengths and limitations


kaizen documents in order to provide an overarching pattern and actual numbers shall be

interpreted with caution. Some kaizen forms contained less information and this may have

introduced some bias as they were more difficult to categorise. Nevertheless, using documents

allowed us to track the written trails of improvements, thus providing information that are not

limited by subjective experience or memory biases.

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In the analysis, the information from multiple items was used to code the documents according to

predefined categories and sub categories. This methodological choice enabled us to overcome

the constraint of missing data in some of the items. However, if more documents were available,

the separate analysis of some key items could have provided a more in depth understanding of

how kaizen works. The complexity aspect, for instance, could have been analyzed separately for

the issues addressed and the solutions proposed. Nevertheless, the choice to combine items can

provide a holistic understanding of how kaizen documents are used.

Several measures were taken to strengthen the trustworthiness of the research process, such as

having multiple researchers conducting the analysis based on clearly defined categories and sub

categories. Nevertheless, a design that includes other sources of data (e.g. interviews and

observations) would have provided more insights. This data could include information on the

actual implementation or lack thereof of changes suggested in kaizen documents and on possible

contextual factors influencing kaizen practices.

The transferability of the findings is influenced by how kaizen practices were adopted at the

studied hospital, which we thought to balance by providing a thorough description of the care.

CONCLUSIONS

Kaizen practises are mainly used by hospital staff in a reactive manner to address simple

challenges rather than in a proactive manner or in relation to complex issues. Thus, there is a

need to combine kaizen practices with improvement and innovation practices that help staff and

managers to address more complex issues, such as the improvement of clinical care processes

that cross organizational and institutional boundaries. Moreover, the limited focus on socio-

technical aspects and the partial compliance to the kaizen template, especially regarding test and

implementation items, may indicate a limited understanding of the entire kaizen process and of

how it relates to the overall organizational goals. This limited understanding can ultimately

hamper the sustainability of kaizen practices themselves and of their results. It may also indicate

that the simplicity of iterative approaches following the PDSA cycle is alluring, and that more

efforts are needed in organizations to be able to continually improve.

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.

ACKNOWLEDGEMENTS


for invaluable help in data transcription. This work was financially supported by AFA Insurance

[grant no 110094]. Dr von Thiele Schwarz held a fellowship in improvement science funded by

Vinnvård.

AUTHORS’ CONTRIBUTION

All authors designed the study, TSH collected the data, PM and MN conducted the analyses and

drafted the manuscript. All authors read, contributed to, and approved the final manuscript.

COMPETING INTERESTS


DATA SHARING

The Excel file with the qualitative directed content analysis is available by emailing [email protected].

REFERENCES

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8. Mazzocato P, Savage C, Brommels M, Aronsson Hk, Thor J. Lean thinking in healthcare: a realist review of the literature. BMJ Qual Saf 2010;19(5):376-82 doi: 10.1136/qshc.2009.037986[published Online First: Epub Date] 9. Holden RJ. Lean Thinking in emergency departments: a critical review. Ann Emerg Med 2011;57(3):265-78 10. Joosten T, Bongers I, Janssen R. Application of lean thinking to health care: issues and observations. Int J Qual Health Care 2009;21(5):341-47 11. Brandao de Souza L. Trends and approaches in lean healthcare. Leadersh Health Serv 2009;22(2):121-39 12. Palm K, Lilja J, Wiklund H. The challenge of integrating innovation and quality management practice. Total Quality Management & Business Excellence 2014:1-14 doi: 10.1080/14783363.2014.939841[published Online First: Epub Date]. 13. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf 2014;23(4):290-98 doi: 10.1136/bmjqs-2013-001862[published Online First: Epub Date] 14. LLC i. Six Sigma quality resources for achieving Six Sigma results dictionary. Secondary Six Sigma quality resources for achieving Six Sigma results dictionary. http://www.isixsigma.com/dictionary/kaizen/ 15. Imai M. The key to Japan’s competitive success. McGrow-Hill/Irwin 1986 16. Åhlström P. Lean service operations: Translating lean production principles to service operations. IJSTM 2004;5(5/6):545-64 17. Suárez-Barraza MF, Miguel-Dávila JÁ. Assessing the design, management and improvement of Kaizen projects in local governments. Business Process Management Journal 2014;20(3):392-411 doi: doi:10.1108/BPMJ-03-2013-0040[published Online First: Epub Date] 18. Melnyk SA, Calantone RJ, Montabon FL, Smith RT. Short-term action in pursuit of long-term improvements: introducing Kaizen events. Production and Inventory Management Journal 1998;39(4):69 19. Liker JK. The Toyota way: 14 management principles from the world's greatest

manufacturer. New York: McGraw-Hill, 2004 20. Laraia AC, Moody PE, Hall RW. The kaizen blitz: accelerating breakthroughs in productivity and performance: John Wiley & Sons, 1999 21. Farris JA. An Empirical Investigation of Kaizen Event Effectiveness: Outcomes and Critical Success Factors. Virginia Polytechnic Institute and State University, 2006 22. Deblois S, Lepanto L. Lean and Six Sigma in acute care: a systematic review of reviews. JHCQA 2016;29(2):192-208 doi: 10.1108/IJHCQA-05-2014-0058[published Online First: Epub Date] 23. Stenfors-Hayes T, Hasson H, Augustsson H, Hvitfeldt Forsberg H, von Thiele Schwarz U. Merging occupational health, safety and health promotion with Lean: An integrated systems approach (the LeanHealth project). Creating Healthy Workplaces: Stress Reduction, Improved Well-Being and Organizational Effectiveness: Gower Applied Business Research, 2014:281-99 24. Hsieh H-F, Shannon SE. Three Approaches to Qualitative Content Analysis. Qual Health

Res 2005;15(9):1277-88 doi: 10.1177/1049732305276687[published Online First: Epub Date]

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25. Villa S. L’operations management a supporto del sistema di operazioni aziendali. Modelli di analisi e soluzioni progettuali per il settore sanitario [Healthcare operations management. Models of analysis and planning solutions for the healthcare sector] CEDAM, 2012 26. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and

evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud 2013;50(5):587-92 27. Paul Brunet A, New S. Kaizen in Japan: an empirical study. IJOPM 2003;23(12):1426-46 28. Marksberry P, Church J, Schmidt M. The Employee Suggestion System: A New Approach Using Latent Semantic Analysis. Human Factors and Ergonomics in Manufacturing & Service Industries 2014;24(1):29-39 doi: 10.1002/hfm.20351[published Online First: Epub Date] 29. von Thiele Schwarz U, Augustsson H, Hasson H, Stenfors-Hayes T. Promoting Employee Health by Integrating Health Protection, Health Promotion, and Continuous Improvement: A Longitudinal Quasi-Experimental Intervention Study. J Occup Environ Med 2015;57(2):217-25 doi: 10.1097/jom.0000000000000344[published Online First: Epub Date] 30. McAlearney AS, Terris D, Hardacre J, et al. Organizational Coherence in Health Care Organizations: Conceptual Guidance to Facilitate Quality Improvement and Organizational Change. QMHC 2013;22(2):86-99 doi: 10.1097/QMH.0b013e31828bc37d[published Online First: Epub Date]

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279x209mm (300 x 300 DPI)

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Figure 2. Overview of the four perspectives that guided the analysis and how they relate to each other.

254x190mm (300 x 300 DPI)

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Figure 4. Degree of compliance for each item in the kaizen documents (i.e. percentage of the kaizen document that had text or markings in each one of the items).

338x190mm (300 x 300 DPI)

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Journal: BMJ Open

Manuscript ID bmjopen-2016-012256.R2


Date Submitted by the Author: 05-Jul-2016




Medical management




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TITLE PAGE

Title





Co-Authors



Keywords


Word count

3707

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Abstract Objectives Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through

practices that enable employees to propose ideas for improvement and solve problems. The aim

of this study is to describe the types of issues and improvement suggestions that hospital

employees feel empowered to address through kaizen practices in order to understand when and

how kaizen is used in health care.

Methods


produced by 165 employees at a Swedish hospital. Directed content analysis was used to

categorise the suggestions into: type of situation (proactive or reactive) triggering an action; type

of process addressed (technical/administrative, support, and clinical); complexity level (simple or

complex); and type of outcomes aimed for (operational or socio-technical). Compliance to the

kaizen template was calculated.

Results



and 16 % of the suggestions, respectively. The majority of the kaizen documents addressed




Conclusions

There is a need to combine kaizen practices with improvement and innovation practices that help

staff and managers to address complex issues, such as the improvement of clinical care

processes. The limited focus on socio-technical aspects and the partial compliance to kaizen

templates may indicate a limited understanding of the entire kaizen process and of how it relates

to the overall organizational goals. This in turn can hamper the sustainability of kaizen practices

and results.

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• Employees’ improvement suggestions captured in kaizen templates that were filled in

during one year at eight units in a hospital setting were analysed.

• A directed content analysis was carried out that was guided by categories and

subcategories that were clearly defined.

• Data was classified independently by two researchers to foster dependability and

credibility in the analysis, and disagreements checked by a third researcher.

• A design that includes other sources of data (e.g. interviews and observations) would

have provided more insights into how kaizen works in practice, such as on the influence

of contextual factors.

• The focus of this study was constrained to the content of ideas developed through an

employee suggestion system; however, the system was part of a wider kaizen approach

and therefore the findings should be prudently transferred to kaizen practices in general.

INTRODUCTION


approaches in health care.[1] Lean is based on the continuous improvement of processes

achieved either by increasing customer value or reducing non-value adding activities, and by

reducing process variation and poor work conditions.[2] There is promising evidence that lean

helps to improve efficiency and quality in the short-term.[3, 4] However, sustainability of results

after the initial period of short-term gains has been proven difficult to achieve,[5, 6] and there is

only limited understanding of factors influencing variation in results across organizational

settings.[5, 7] Plausible explanations for some of the observed limitations can be found in the

scope of the lean improvement efforts. The types of outcomes addressed have mainly focused on

operational aspects of performance, while little attention has been paid to socio-technical aspects,

such as employees’ health, well-being, and creativity.[8-10] Studies on the types of

organizational processes involved have shown that lean has mainly concerned manufacturing-

like processes, such as laboratory processes,[11] and processes within one unit and not across

organizational boundaries.[8] It has also been suggested that lean practices may be more

successful when applied to services characterized by a low degree of complexity.[5] The

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incremental approach to lean improvement has furthermore been perceived as an inhibitor to an

organizations’ ability to innovate, as the focus is on improving existing products, services, and

processes, rather than on finding new ways of doing things.[12] Limited compliance to a

scientific approach on improvement may also explain the challenges to continuously improve.[8,

13]

Thus, there is a need to deepen our understanding on how lean works in health care. Continuous

improvement lies at the core of lean, and is referred to as kaizen, a Japanese word that means

“good change.”[14] The kaizen principle is about striving for perfection through the ongoing

involvement of employees in practices that enable them to incrementally propose ideas for

improvement, solve problems, and sustain results over time.[15, 16] Examples of practices are

kaizen blitz, continuous process improvement teams, and employee suggestion programmes.[17]

Kaizen blitz, sometimes referred to as “kaizen events” or rapid improvement events, are

generally short-term projects, often conducted in the format of a three to five day work session

focused on a specific process or set of activities.[18] These projects typically involve the analysis

of current processes, the development of ideal processes, and initial implementation of the

changes needed to eliminate non-value adding steps.[19] The scope of the changes is on all or

part of a specific process, rather than on broad organization practices, policies or technology

changes, and requires little investment.[20, 21] Continuous process improvement teams and

employee suggestion programmes are, compared to kaizen blitz, long-term initiatives where staff

meets regularly over time.[22] While kaizen lies at the core of lean, most studies focus on

evaluating the effects of continual improvement efforts and there is only limited understanding

of how the kaizen principle is put into practice in health care.[23]

Therefore, the aim of this study is to describe the types of issues and improvement suggestions

that hospital employees feel empowered to address through kaizen practices in order to

understand when and how kaizen is used in health care. We specifically focused on the

improvement ideas captured through an employee suggestion system at a hospital adopting

multiple kaizen practices to support continual improvement.

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METHODS



At the hospital a kaizen programme, which includes the use of an employee suggestion system,

for continuous improvement is ongoing since 2009. The initial implementation of kaizen was

supported by an external consultant that still provides support and assistance, when needed, to

the hospital units working with kaizen. The units provide clinical services as well administrative

and support services. The units have the autonomy to organize their kaizen practises as they see

fit, but the general work process described below is the same for all units.

At each unit, employees are encouraged to propose improvement suggestions. The improvement




safety, work environment, and economics), the description of the problem and the suggestions




Individual employees can decide to what extent to fill in the kaizen template individually. The

minimum requirement is to fill in information about the identified problem but they can also

provide ideas for how to address the problem. The rest of the information in the kaizen template

is compiled as the improvement efforts move along.

Regular short meetings are organized with all employees in each unit from one up to four times a

month, where initial proposals are discussed and decisions made on whether they should be

implemented or further explored. Typically, no ideas are rejected, but not all improvement ideas

lead to a change in practice because of economic constraints, the complexity of the issue, or

disagreement among staff. The duration of the meetings vary depending on the complexity of the

issue discussed. When decisions can be made on the stop, the meetings can be very short and last

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about five minutes. For more complex issues the meetings can be longer and a small team is put

together to carry out the improvement cycle, resembling the kaizen event practice, until the next

meeting. When needed, improvement ideas are brought up to higher organizational levels.

One to three employees at each unit serve as kaizen representatives and one member of staff

serves as a kaizen coordinator for the hospital level. The coordinator brings all representatives

from the units together a few times a year and keeps track of which and how many improvement

suggestions each hospital units produces. The number of implemented suggestions is linked to a

financial reward that can be used for staff activities.

Eight units delivering geriatric care, internal medicine, gynaecology, intensive care, surgery,

palliative care, rehabilitation, and radiology were included in the current study. Eight other units

were excluded as they were a part of an intervention study in which the employee health

promotion activities were integrated with the kaizen work.[24] These units were excluded

because this health promotion intervention was deemed to influence the original kaizen practices,

and thus making it harder to understand when and how kaizen practices were used.


The kaizen documents filled in by the 165 employees working at the included units in 2013 were

collected in January 2014, resulting in 186 documents that were used for analysis. This study

was conducted about four years after the initial implementation of kaizen practices, which

enabled us to study them when they were in full operation. All the written text from the kaizen

documents (Figure 1) was transcribed into an Excel file based on the template’s questions, here

after called items. The filled parts of the Plan-Do-Study-Act (PDSA) cycle was an item also

noted.

Directed content analysis [25] was used to analyse the text written in the kaizen documents. In

the analysis we explored four main dimensions. First, the situation that triggered the use of the

kaizen document, which could be a reaction to a perceived problem to be solved or a proactive

initiative to test new ideas not clearly stemming from a problem. Second, the type or

organizational process targeted, which could involve one of three main types of organizational

processes, i.e. technical and administrative support, and primary clinical processes, or a mixture

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of them.[26] Third, the complexity level involved in the situation addressed that could vary from

simple to more complex.[27] Fourth, the type of outcomes addressed and expected, which could

be operational or socio-technical.[10] Figure 2 provides an overview of the four perspectives

included in analysis and how they relate to each other.


Detailed definitions of the categories and subcategories that guided the directed content analysis

as well as the items included, are presented in Table 1. The development of clear definitions

based on the literature strengthened the trustworthiness of the research process. In addition to the

four dimensions in Table 1, we also assessed the degree of compliance to the kaizen template

items.


Categories

Sub-categories

Definition

Items in the kaizen template included in the

analysis

Situation triggering an improvement suggestion

Proactive Idea for improvement, not clearly stemming from a problem

5, 6 Reactive

A reaction to a problem encountered that is clearly described

Organisational processes addressed [26]

Primary clini-cal process


5, 6, 9, 12, 15, 16

Support processes



Set of activities that deal with the structures and infrastructures needed for the general functioning of the hospital that not directly involve patients or health care professionals (e.g. payment of staff or the supply of goods or services, physical environment )

Complexity level in the issues addressed and improvement actions proposed [27]

Simple One or very few components, interventions, outcomes, actors and/or units are involved 5-6, 9, 12, 15,

16 Complex

Many components, interventions, outcomes, actors and/or units involved

Outcomes addressed/ expected [10]

Operational Reduces non-value created activities, leads to increased effectiveness, efficiency and productivity (e.g. increased service quality and patient safety, better use of resources)

9, 12, 15, 16 Socio technical


Table 1. Definition of the categories and subcategories used in analyses and their relation to the

research questions

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the two researchers independently categorised the entire data. The independent classification by

two judges was done to ensure dependability and credibility. Inter-rater reliabilities (Cohen’s

Kappa) of 0.92, 0.97, 0.97, and 0.96 were calculated for the four main categories respectively. In

the few cases where there was disagreement on the categorisation, a third judge’s opinion was

sought (the second author) for a majority decision. Frequencies and proportions of classified

items in each subcategory were calculated for the total data set and also separately for the eight

units.






RESULTS



and subcategories. In Table 2 these results are presented at unit level.



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Unit Staff 2013

Kaizen documents

Situation triggering the suggestion

Type of organizational process

Complexity Type of outcome

Proactive Reactive Tech-

nical

Sup-

port

Pri-

mary Simple Complex Operative

Socio-

technical

n n n / % n / % n / % n / % n / % n / % n / % n / % n / %

1 35 63 14/22 49/78 24/38 34/54 5/8 59/94 4/6 34/54 29/46 2 6 17 5/29 12/71 10/59 6/35 1/6 16/94 1/6 13/76 4/24 3 36 22 7/32 15/68 7/32 8/36 7/32 20/91 2/9 15/68 7/32 4 10 30 12/40 18/60 8/27 21/70 1/3 28/93 2/7 27/90 3/10 5 15 19 9/47 10/53 5/26 9/47 5/26 15/79 4/21 16/84 3/16 6 19 11 2/18 9/82 6/55 3/27 2/18 9/82 2/18 10/91 1/9 7 21 5 1/ 20 4/80 4/80 0/0 1/20 4/80 1/20 3/60 2/40 8 23 19 2/11 17/89 6/32 6/32 7/37 15/79 4/21 16/84 3/16

Table 2. Number of staff and kaizen documents, and the percentage of the improvement

suggestions in each subcategory per unit


A majority (72%) of the kaizen documents were related to a problem identified and thus

categorised as reactive. At unit level the proportion of reactive kaizen documents varied from 53












processes. Only in one unit most kaizen documents addressed the primary clinical care process.

Examples of problems in support processes were: unclear information provided to patients

during preparation for routine examinations, or the identification of non-value adding

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Complexity in issues addressed and in improvement actions proposed


categorised as simple (Table 2). These were often small changes needed to the physical layout,

for example changing the placement of medications to improve the ergonomic work environment

for staff or fixing the lack of aprons and gloves in the storage area. By simply refilling the

storage the risk for transmission of infections could be reduced. Complex issues included for

example when staff members were feeling uncomfortable to collaborate across organizational

boundaries or when staff at a unit complained about patients arriving from the emergency

department that needed a quick transfer to the radiology unit.

Types of outcomes addressed and expected

In a majority of the cases (72%) operative outcomes were addressed. Staff proposed changes to

work processes, physical layout, or equipment that could yield both improved quality of care for

patients and a more efficient use of resources. Socio-technical outcomes mentioned were staff

well-being, suggested to be improved by for example increasing the indoor temperature in a

perceived cold work place.

Degree of compliance to the Kaizen documents

There was a large variation to what extend the different parts of the kaizen documents had been

filled in. The percentage of compliance (i.e. text filled in under each item in the template or

marked in the PDSA-phases) varied from 12 to 100 percent between the items (Figure 4).


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The parts of the template that concerned problem identification and planning proposed solutions

(items 2-9) had items with varied level of compliance. Items 3-6 (date, person who identified the

problem, description of the improvement idea, and expected result) and 9 (improvement

suggestion) were characterized by a high degree of compliance, ranging from 75% to 98%. Items

2 (area addressed), 7 (date of suggested improvement), and 8 (person making the suggestion),

were characterized by a lower degree of compliance, ranging from 32% to 44%.

Compliance was also low (12-25%) for items that concerned the test and further refinement of

the improvement idea and these items were number 10 (date for testing the suggestion), 11

(person responsible for testing the suggestion), and 12 (suggestion implemented). Compliance

varied for items 13-18 that concerned the actual implementation of the solution and the

monitoring of the results achieved. Information on the date for implementation (item 13) and the

person responsible for the implementation (item 14) was provided in 63% and 35% of the kaizen

documents, respectively. The final solution approved (item 15) was described in 87% of the

documents, whereas the actual results achieved (item 16) were described in 28% of the cases.

The solution was signed by and thereby approved by the managers (item 18) in 17% of the

documents, which was however not a requirement for all types of suggestions. All the four

phases of the PDSA cycle (item 17) were reported on in 25% of the documents and in 49% at

least one of the PDSA cycle’s phases was mentioned.

DISCUSSION

This study adds to the current knowledge on kaizen practices in health care by providing

empirical evidence of when and how employees propose improvement ideas through an

employee suggestion programme. The evidence was generated based on the analysis of a wide

range of initiatives carried out at one hospital for a period of one year, rather than on single

improvement initiatives as often reported in the literature. Kaizen templates were most often

filled in when staff perceived a problem in support or technical/administrative processes. The

problems addressed and the solutions proposed were often characterized by a low level of

complexity and involved mainly operational aspects of performance. The degree of compliance

with different parts of the kaizen template was generally high for items that concerned problem

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and solution identification and low for items corresponding to test and implementation of the

solution. These findings will be discussed in relation to the literature on employee suggestion

programmes, as well as the broader lean and kaizen literature.

The majority of the improvement ideas suggested by the employees in the kaizen templates were

a reaction to an experienced problem. This can be related to the incremental approach to

improvement that is inherent in kaizen practices. In other sectors, this incremental approach has

been associated with reduced opportunities for innovation.[12, 28] Current research evidence

however points to the fact that innovation and quality improvement can be handled in

parallel.[12, 28] Further studies are needed to unravel the complex relationship between

innovation and incremental improvement in health care and the practices needed to support this

relationship.

The kaizen documents captured mainly simple improvement ideas that involved one

organizational unit. The focus on single units may explain the scarcity of documents that

addressed clinical care processes that often cross organizational boundaries. These findings

suggest that, like at Toyota where lean and kaizen practices were developed, employee

suggestion systems can be used to encourage employees to test and implement ideas that are

within their immediate control. At Toyota, these systems do however not replace managers

responsibility to solve more complex system-related problems.[29] In health care, there are few

examples of kaizen practices at the management level. An example is the creation ad-hoc

management structures that cross organizational boundaries, which have proven to be effective

to open up communication channels between hospital management and improvement teams.[5]

However, for health care organizations to achieve long-term results and to conduct improvement

efforts that embrace a patient rather than a unit perspective, there is a need to develop kaizen

practices at the management level that go beyond establishing communication channels.


performance. Thus, there is a need for lean improvement efforts to embrace an employees’

perspective to a larger extent.[8-10] As lean transforms work structures and processes, its

application in healthcare can be expected to affect the employees responsible for carrying out the

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work.[9] As showed by previous studies of the same hospital, efforts to integrate operational and

socio-technical improvement activities with the kaizen system may lead to a better understanding

of the relationship between work and health and a higher engagement in health promotion, as

well as more engagement in using kaizen for improvement work in general.[30] To achieve

coherence among an organization’s improvement processes and its social, technical and

structural systems is important when attempting to improve quality in health care

organizations.[31]

The low degree of use of items in the kaizen documents that corresponded to test and evaluation

of new ideas indicate that the scientific application of continuous improvement cycles was not

optimal. Methods, such as PDSA cycles, that build on a iterative and scientific approach to

improvement are seldom performed as planned in health care.[13] The fact that this study was

conducted four years after kaizen was introduced indicates that it is not merely a matter of time

and experience with using kaizen. Without these components in place it can be difficult for

organizations to monitor the results of improvement efforts and thus to motivate staff that their

efforts actually yield the desired results. Nevertheless, in this setting, kaizen was still used

despite this short-coming, perhaps indicating that the system, even though mostly focusing on

identification and suggestions for solutions, was perceived as valuable for staff.

Some variation in how the units used the kaizen templates was identified although not explicitly

explored in this study because of the limited number of documents collected from each unit. We

observed for instance that more improvement suggestions were produced in small units. Close

interaction among employees can help staff to do their work while also working constantly at

improving it.[5] Future studies can explore more in depth how contextual factors such as staff

composition, turnover rates, stress level among staff, and the organization ability to implement

the suggested ideas may influence staff participation in kaizen activities.

Strengths and limitations


kaizen documents in order to provide an overarching pattern and actual numbers shall be

interpreted with caution. Some kaizen forms contained less information and this may have

introduced some bias as they were more difficult to categorise. Nevertheless, using documents

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allowed us to track the written trails of improvements, thus providing information that are not

limited by subjective experience or memory biases.

In the analysis, the information from multiple items was used to code the documents according to

predefined categories and subcategories. This methodological choice enabled us to overcome the

constraint of missing data in some of the items. However, if more documents were available, the

separate analysis of some key items could have provided a more in depth understanding of how

kaizen works. The complexity aspect, for instance, could have been analyzed separately for the

issues addressed and the solutions proposed. Nevertheless, the choice to combine items can

provide a holistic understanding of how kaizen documents are used.

Several measures were taken to strengthen the trustworthiness of the research process, such as

having multiple researchers conducting the analysis based on clearly defined categories and

subcategories. Nevertheless, a design that includes other sources of data (e.g. interviews and

observations) would have provided more insights. This data could include information on the

actual implementation or lack thereof of changes suggested in kaizen documents and on possible

contextual factors influencing kaizen practices.

The transferability of the findings is influenced by how kaizen practices were adopted at the

studied hospital, which we thought to balance by providing a thorough description of the case.

CONCLUSIONS

Kaizen practises are mainly used by hospital staff in a reactive manner to address simple

challenges rather than in a proactive manner or in relation to complex issues. Thus, there is a

need to combine kaizen practices with improvement and innovation practices that help staff and

managers to address more complex issues, such as the improvement of clinical care processes

that cross organizational and institutional boundaries. Moreover, the limited focus on socio-

technical aspects and the partial compliance to the kaizen template, especially regarding test and

implementation items, may indicate a limited understanding of the entire kaizen process and of

how it relates to the overall organizational goals. This limited understanding can ultimately

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hamper the sustainability of kaizen practices themselves and of their results. It may also indicate

that the simplicity of iterative approaches following the PDSA cycle is alluring, and that more

efforts are needed in organizations to be able to continually improve.

ACKNOWLEDGEMENTS


for invaluable help in data transcription. This work was financially supported by AFA Insurance

[grant no 110094]. Dr von Thiele Schwarz held a fellowship in improvement science funded by

Vinnvård.

AUTHORS’ CONTRIBUTION

All authors designed the study, TSH collected the data, PM and MN conducted the analyses and

drafted the manuscript. All authors read, contributed to, and approved the final manuscript.

COMPETING INTERESTS


DATA SHARING

The Excel file with the qualitative directed content analysis is available by emailing [email protected].

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31. McAlearney AS, Terris D, Hardacre J, et al. Organizational Coherence in Health Care Organizations: Conceptual Guidance to Facilitate Quality Improvement and Organizational Change. QMHC 2013;22(2):86-99 doi: 10.1097/QMH.0b013e31828bc37d[published Online First: Epub Date].

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279x209mm (300 x 300 DPI)

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Figure 2. Overview of the four perspectives that guided the analysis and how they relate to each other.

254x190mm (300 x 300 DPI)

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254x190mm (300 x 300 DPI)

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Figure 4. Degree of compliance for each item in the kaizen documents (i.e. percentage of the kaizen document that had text or markings in each one of the items)

338x190mm (300 x 300 DPI)

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Standards for Reporting Qualitative Research (SRQR)

Section Topic Item Where in the article

the item is addressed

Title abstract

Title

Concise description of the nature and topic of

the study Identifying the study as qualitative or

indicating the approach (e.g., ethnography,

grounded theory) or data collection methods

(e.g., interview, focus group) is recommended

The title meets these

criteria

Abstract

Summary of key elements of the study using the

abstract format of the intended publication;

typically includes background, purpose,

methods, results, and conclusions

Done

Introduction

Problem

formulation

Description and significance of the

problem/phenomenon studied;

review of relevant theory and empirical work;

problem statement

Addressed in the last

three sentences in the

introduction

Purpose or

research question

Purpose of the study and specific objectives or

questions

Last paragraph in the

intro

Methods

Qualitative

approach and

research

paradigm

Qualitative approach (e.g., ethnography,

grounded theory, case study, phenomenology,

narrative research) and guiding theory if

appropriate; identifying the research paradigm

(e.g., postpositivist, constructivist/interpretivist)

is also recommended;

Directed content

analysis was explained

and motivated

Researcher

characteristics

and reflexivity

Researchers’ characteristics that may influence

the research, including personal attributes,

qualifications/experience, relationship with

participants, assumptions, and/or

presuppositions; potential or actual interaction

between researchers’ characteristics and the

research questions, approach, methods, results,

and/or transferability

No specifically

characteristics

addressed, but we

explained how we used

our previous research

conducted in the same

setting. .

Context Setting/site and salient contextual factors;

See “case

characteristics” section

in the methods

Sampling

strategy

How and why research participants, documents,

or events were selected; criteria for deciding

when no further sampling was necessary (e.g.,

sampling saturation);

First paragraph in the

“data collection and

analysis” section

Ethical issues

pertaining to

human subjects

Documentation of approval by an appropriate

ethics review board

and participant consent, or explanation for lack

thereof; other

confidentiality and data security issues

Last sentence in the

methods section

Data collection

methods

Types of data collected; details of data collection

procedures including

(as appropriate) start and stop dates of data

collection and analysis,

iterative process, triangulation of

sources/methods, and modification

of procedures in response to evolving study

See “data collection and

analysis” section

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findings; rationaleb

Data collection

instruments and

technologies

Description of instruments (e.g., interview

guides, questionnaires)

and devices (e.g., audio recorders) used for data

collection; if/how the

instrument(s) changed over the course of the

study

Second paragraph in the


analysis” section

Units of study

Number and relevant characteristics of

participants, documents, or

events included in the study; level of

participation (could be reported

in results)

First paragraph in the


analysis” section

Data processing

Methods for processing data prior to and during

analysis, including

transcription, data entry, data management and

security, verification

of data integrity, data coding, and

anonymization/deidentification of

excerpts

Last sentence in the first

paragraph of “data

collection and analysis”

Data analysis

Process by which inferences, themes, etc., were

identified and

developed, including the researchers involved in

data analysis; usually

references a specific paradigm or approach;

rationale b

Second-fifth paragraphs

in the “data collection

and analysis”

Techniques to

enhance

trustworthiness

Techniques to enhance trustworthiness and

credibility of data analysis

(e.g., member checking, audit trail,

triangulation); rationaleb

Fourth paragraph in the


analysis”

Results/findings

Synthesis and

interpretation

Main findings (e.g., interpretations, inferences,

and themes); might

include development of a theory or model, or

integration with prior

research or theory

Yes.

Links to

empirical data

Evidence (e.g., quotes, field notes, text excerpts,

photographs) to

substantiate analytic findings

Examples of from the

data analyzed are

reported throughout the

findings section.

Discussion

Integration with

prior work,

implications,

transferability,

and

contribution(s) to

the field

Short summary of main findings; explanation of

how findings

and conclusions connect to, support, elaborate

on, or challenge

conclusions of earlier scholarship; discussion of

scope of application/

generalizability; identification of unique

contribution(s) to scholarship

in a discipline or field

Yes, throughout the

discussion

Limitations Trustworthiness and limitations of findings Yes; see “strengths and

limitations” section

Other

Conflicts of

interest

Potential sources of influence or perceived

influence on study conduct

and conclusions; how these were managed

Conflicts of interest

statement included in

the article

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Funding

Sources of funding and other support; role of

funders in data

collection, interpretation, and reporting

Funding sources have

been mentioned

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