name: dr. karin wuertz-kozak degree: mba … · lean management, often also called lean...

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NAME: Dr. Karin WUERTZ-KOZAK

DEGREE: MBA

SUPERVISOR: Prof. Dr. Roy Damary

TITLE: Implementation of Lean Management in Swiss Hospitals

A Multi-Case Study on the Effects of Staff Information and

Training on Adoption and Utilization of Lean

DATE: September 2015

STUDENT NO: 1314228

Project submitted in partial fulfilment

of the requirements of the

Master of Business Administration

in Leadership and Sustainability

of the University of Cumbria

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Abstract

In this study the implementation of Lean Hospital Management (LHM) is

analyzed in five Swiss hospitals.

Different implementation approaches were used in the investigated hospitals:

Successive or progressive implementation, with or without unit-specific Lean

Administrators (line management) to support the Lean Manager(s). The importance

of information flow to ensure successful implementation is brought out, as is

ongoing training, with special emphasis on experiential training (e.g. through Huddle

Boards or Gemba Walks). The logic behind LHM is explained, with Diagnosis

Related Group (DRG) reimbursement systems identified as a major driving force.

Concerns remain about assessing all aspects of the success of LHM as well as

about its sustainability.

Finally the results of the study lead to a recommended approach to LHM

implementation, focusing on the aspects communication, information and training.

Keywords

Lean Hospital Management; Switzerland; Change Management; Employee

Information; Employee Training; Adoption; Utilization; Recommendations;

Interviews; Questionnaire; Multiple Case Study.

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Acknowledgement

I owe my deepest gratitude to my supervisor Prof. Dr. Roy Damary, who was

always available for discussion and gave excellent scientific input during the

planning, evaluation and writing phase. I could have not asked for a better mentor

and thoroughly enjoyed the interaction!

I thank Mr. Wahbi from “Mehr als Durchschnitt” for excellent statistic counseling

during this project.

I am specifically grateful to those who volunteered for the test run of my

questionnaire: Prof. Dr. Melloh, Prof. Dr. Blattert, Dr. Rothenfluh, Dr. Liebscher and

Mr. Janes. Thank you for the excellent feedback.

I would also like to thank H+ Bildung for organizing the Swiss Network Meeting on

Lean Health Care in April 2015, during which I was able to convince five Swiss

hospitals to participate in this study. Of course, this dissertation would not have

been possible without the commitment of the Lean Managers of these participating

hospitals, who allocated time for interviews and questionnaire distribution.

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Declaration of Authenticity

I declare that the material contained in this project is the end result of my own work

and that due acknowledgement has been given in the bibliography and references

to ALL sources be they printed, electronic or personal.

The Word Count of this Project is 16’456

(excluding title page, abstract, key words, acknowledgement, declaration of authenticity, table of contents, figures, figure legends, tables, table headings, bibliography, appendix)

SIGNED:

………………………….………

DATE

08.09.2015 ………………………….……..

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Table of Contents

Abstract ............................................................................................................................. 2

Acknowledgement ............................................................................................................. 3

Declaration of Authenticity ............................................................................................... 4

Table of Contents .............................................................................................................. 5

1. From Lean Manufacturing to Hospital Management .......................................... 7

2. Aims, Research Questions and Hypotheses .................................................... 10

2.1. Aims ..................................................................................................................... 10

2.2. Research Questions ............................................................................................. 10

2.3. Hypotheses .......................................................................................................... 11

3. Literature Review ................................................................................................ 11

3.1. The Principles of Lean Management .................................................................... 12

3.1.1. Definition and History ........................................................................................... 12

3.1.2. Demarcation of LM to Just-in-Time (JIT), 5S and Six Sigma ................................. 14

3.1.3. Relevance ............................................................................................................ 15

3.2. Lean Hospital Management .................................................................................. 16

3.2.1. Developments Necessitating Strategic Changes in Hospitals ............................... 16

3.2.2. Applicability of Lean Management in Hospitals ..................................................... 19

3.2.3. Outcome of Lean Hospital Management ............................................................... 19

3.2.4. Lean Principles and the Role of Information and Training ..................................... 21

3.2.5. Implementation Tools as Forms of Continuous Training ....................................... 23

3.3. Change Management ........................................................................................... 28

3.3.1. The Principles of Change Management ................................................................ 28

3.3.2. The Role of Information & Communication in Organizational Change ................... 30

3.3.3. The Role of Training in Organizational Change .................................................... 31

4. Methods .............................................................................................................. 34

4.1. Research Design .................................................................................................. 34

4.1.1. Type of Research ................................................................................................. 34

4.1.2. Research Cases (Hospitals) ................................................................................. 35

4.1.3. Interviews ............................................................................................................. 36

4.1.4. Questionnaire ....................................................................................................... 36

4.2. Data Analysis ....................................................................................................... 39

4.2.1. Interviews ............................................................................................................. 39

4.2.2. Questionnaires ..................................................................................................... 39

4.2.3. Recommendations for LHM Implementation ......................................................... 41

4.2.4. Statistics ............................................................................................................... 41

5. Results ................................................................................................................ 42

5.1. Interviews ............................................................................................................. 42

5.1.1. Interview Logistics ................................................................................................ 42

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5.1.2. Interview Results .................................................................................................. 42

5.2. Questionnaires ..................................................................................................... 44

5.2.1. Distribution of Returned Questionnaires ............................................................... 44

5.2.2. Descriptive and Comparative Depiction of Questionnaire Results ........................ 47

5.2.3. Correlation between Information, Training, Utilization & Adoption ......................... 63

5.2.4 Relations between Information, Training, Utilization & Adoption ........................... 68

5.2.4. Effects of Employee Demographics on Lean Utilization & Adoption ...................... 69

6. Conclusion .......................................................................................................... 70

6.1. Summary of Main Findings ................................................................................... 70

6.2. Interpretation and Significance of the Data Obtained ............................................ 72

6.3. Study Limitations .................................................................................................. 79

6.4. Answers to the Research Questions ..................................................................... 81

6.5. Recommendations (Suggestions on LHM Implementation) .................................. 83

7. Bibliography ....................................................................................................... 86

Appendix .......................................................................................................................... 97

A1. Demarcation of LM to Just-in-Time (JIT), 5S and Six Sigma ..................................... 97

A2. Structure of the Interviews and Questionnaire ........................................................... 99

A3. Informed Consent Form........................................................................................... 103

A4. Questionnaire .......................................................................................................... 105

A5. Sample Size Calculation.......................................................................................... 118

A6. Statistical Analysis ................................................................................................... 119

A7. Interview Summary Hospital 1 ................................................................................. 122





A12. Results of Hospital 1 ............................................................................................... 138





A17. Correlation Analysis (Pearson Correlation Coefficient, p value) ............................... 178

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1. From Lean Manufacturing to Hospital Management

Lean Management (LM), which was first employed by Toyota, the Japanese car

company, is a customer-centered strategy that tries to maximize the value for the

customer while simultaneously minimizing the costs. Cost reduction is reached by

continuously optimizing process efficiency and by eradicating of all forms of waste,

such as overproduction, long waiting times and excessive inventory. Inefficient

transportation, work flows and staff movements and as well avoidable defects and

errors are also targeted (Liker, 2004, Womack et al., 1990). LM is hence a strategy

that is thought to ensure competitiveness, profitability and sustainability.

Although typically found in the industrial sector, LM can be successfully applied

to service sectors, albeit with the need to specifically adapt certain methods. As LM

has evolved at production lines and has thus originally focused on “items”, its

applicability to “people” (i.e. the service industry) may initially be counterintuitive.

However, the usefulness of LM for the service industry, whose utmost goal is to

reach high customer satisfaction at simultaneous cost control, becomes evident

when considering that LM is in fact a customer-centered strategy (Bowen and

Youngdahl, 1998).

Similar to other service branches, LM is hence also a suitable strategy for

hospitals (so-called Lean Hospital Management LHM), as it allows to focus

rigorously on the patients’ needs through improvement of medical services. LHM

seeks to improve patient flow, eliminate forms of waste that do not help, or may

even harm the patient (such as inefficient information transfer between

departments), and therefore increase patient satisfaction and safety (Graban,

2011). LHM hence aims to ensure competitiveness through outstanding patient care

and financial profitability through effective and “waste-free” treatments and services.

As soon as the potential of LHM became evident, a boost for LHM could - and still

can - be observed word-wide, resulting in increasing numbers of hospitals that

employ this strategy with the goal of ensuring their economic survival. This hype

around LHM is multifactorial and different primary stimuli may exist in different

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countries, even though the causes below mentioned often apply (Horisberger et al.,

2014, Pöhls, 2012a, Graban, 2011).

One of the main underlying causes for financial turmoil of hospitals has been the

switch from “cost-based” compensation to “Diagnosis Related Groups (DRG)-

based” reimbursement of medical treatments in many countries, e.g. the US (1983),

Germany (2003) and Switzerland (2012), to name just a few (Mayes, 2007). In

DRG-based reimbursement, each sick person is categorized into a group of patients

with similar conditions, according to which the hospital receives financial

compensation from the patient’s health insurance. As the duration of the hospital

stay and the types of service and treatment provided are not taken into account,

hospitals are required to provide cost-effective and efficient care to their patients in

order to maintain their economic equilibrium (Sloan et al., 1988).

Another major change affecting hospitals is the widespread liberalization of

healthcare that allows patients to freely select their health service providers in the

case of elective surgeries, hence increasing the competition amongst hospitals (von

Reinersdorff, 2002). Specifically information and ratings provided through the

internet (types/quality of services, reputation/quality of the medical staff) are thought

to strongly enhance competition of hospitals in the years to come (Emmert et al.,

2013, Moser et al., 2010).

Implementation of LHM, like implementation of any new corporative strategy,

requires application and execution of appropriate change management. As strategic

changes strongly affect the people in an organization, communication is crucial.

Research has demonstrated that the majority of people demonstrate a natural

resistance to change that is often grounded on insecurities and fear. Therefore, the

needs and benefits of the forthcoming change have to be communicated in order to

imbed people in the change process rather than imposing change (Burnes, 2004,

Coghlan, 1993, Waring and Bishop, 2010).

Because of the negative associations that many people have with the word

“lean”, such as layoffs and belt-tightening measures, careful information of

employees is even more crucial in case of LHM implementation (Hoeft and Pryor,

2016). In this context, the acceptance and positive evaluation of the strategic

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change by so-called opinion leaders amongst the workforce at an early stage is

vital, as it will support effective and successful adoption throughout the company as

explained by the Diffusion of Innovations Theory. Everett M. Rogers, the founder of

the Diffusion of Innovations Theory, defines adoption as the deliberate decision of

“full use of an innovation as the best course of action available” (Rogers, 1983),

indicating that adoption also entails aspects of commitment and engagement. In this

work, the term “adoption” will be used according to Rogers.

While staff involvement is essential with any organizational change, ensuring

acceptance, adoption and engagement by the workforce is specifically relevant in

the context of introducing LHM in hospitals. As the workforce of the hospital

(physicians, nurses, administration with patient contact) directly interacts with

patients, they play an indispensable role for patient satisfaction and hence for

reaching the utmost goal of LHM. As a result, some authors encourage hospital

executives to put a strong emphasis on early staff involvement, enhanced

management-staff communication, sufficient information transfer and suitable

training offerings (Whitfield and Poole, 1997, Cassell et al., 2006, Glossmann et al.,

2000).

Although the positive impact of staff information and training on the adoption and

utilization of lean processes in hospitals has been suggested by some authors, very

few experimental data exist that support this hypothesis. Furthermore, it is not clear

which methods of information and training result in a superior outcome and whether

the outcome is influenced by staff characteristics such as profession or years of

professional experience. Importantly, no studies exist to date that have analyzed the

effects of staff information and training on the adoption and utilization of Lean in

Swiss hospitals, where LHM has been increasingly adopted due to the exacerbating

financial pressure and competition.

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2. Aims, Research Questions and Hypotheses

2.1. Aims

Based on the identified lack in the literature, the following aims were defined:

Aim 1: To determine how Swiss hospitals informed and trained their staff in Lean

Hospital Management and how employees perceived the quality and

quantity of the information and training provided

Aim 2: To determine whether and to which degree staff information and training

influenced staff adoption and utilization of lean processes in Swiss hospitals

Aim 3: To determine whether staff characteristics (such as age, profession, years

of professional experience) have an influence on lean adoption and

utilization

Aim 4: To define recommendations for staff information and training for Lean

Hospital Management that are likely to result in superior staff adoption and

utilization

2.2. Research Questions

The associated research questions (RQ) can be formulated as follows:

RQ 1: Which methods are/were used by the Swiss hospital to provide lean

information and lean training to their staff and which employees are/were

informed/trained?

RQ 2: Is there a correlation between the quality of the information and training

provided and the lean adoption and utilization by employees?

RQ 3: Which information and training methods are/were successful in creating

lean adoption and lean utilization by employees?

RQ 4: Which employee characteristics (age, profession, years of professional

experience) lead to the highest degree of lean adoption and lean utilization?

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2.3. Hypotheses

Taking evidence from the published literature on Lean (Hospital) Management

as well as Organizational Change Management into account, it is hypothesized that

hospitals that offer suitable information and training are able to increase the

perceived benefit of LHM and instigate employees to adopt and utilize lean

principles, including enhanced intention for future utilization.

Lean adoption and utilization is however likely to be affected by specific staff

characteristics, such as age, profession or years of professional experience.

3. Literature Review

Although this project focusses on the effects of staff information and training

during the implementation of Lean Management specifically in hospitals, a thorough

understanding of the general concepts, problems and relevance of Lean

Management is necessary to understand the reasoning behind and the importance

of the research questions described on .

Therefore, the literature review will commence with an introduction to the

general theory of Lean Management before clarifying the continuously increasing

interest of hospitals in Lean Management and highlighting the most common

approaches to successfully do so.

As introduction of Lean Management in hospitals typically induces far-reaching

changes in organizational structure, hierarchy and employee tasks, important

aspects of change management will be illustrated in the last section of the literature

review (with a focus on communication, information and training).

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3.1. The Principles of Lean Management

3.1.1. Definition and History

Lean Management, often also called Lean Manufacturing (LM), is a strategy

originally described by Toyota that has been extensively adopted by the

manufacturing sector after convincing evidence of its advantages was provided

(Womack et al., 1990).

LM aims to focus all activities towards providing increased customer satisfaction

by reducing or eliminating efforts that create no or little impact customer value (=

waste = muda). As illustrated in Figure 3.1, seven types of waste are distinguished

in LM, although their relevance may largely vary between organizations. Continuous

elimination of all forms of waste and hence continuous improvement (kaizen) are

crucial in LM.

Figure 3.1:

Types of Waste

Seven types of waste (= muda)

that are typically identified in LM.

Through continuous improvement

(= kaizen), work standardization is

possible and progress can be

reached.

[Adapted from (Trilogiq, 2015)]

In LM, each key process in an organization’s work is expected to be valuable,

capable, available, adequate and flexible and create a lean value stream. The main

underlying principles or LM, apart from waste elimination and continuous

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improvement are: just-in-time (JIT) production, focus on quality during the entire

process (= jidoka), standardization and production smoothing (= heijunka), all of

which are based on stability (e.g. team stability, strategic stability, etc.) (Biazzo and

Panizzolo, 2000, Womack et al., 1990). The principles of LM and the harmony that

needs to exist between the foundations and pillars in order to support the roof, i.e.

the ultimate goals, are often illustrated in the form of a Lean House (Figure 3.2).

Figure 3.2: The Lean House

The Lean House, illustrating the foundations and pillars that are ultimately thought to ensure enhanced

customer value through reduced production costs, improved quality level and optimized delivery times.

[Adapted from: (Trilogiq, 2015)].

LM can improve the efficiency of work processes by applying a set of 5 steps:

Initially, the value of a product/service (as seen by the customer) has to be

identified. All processes in the value stream are then analyzed for their impact on

value creation. Steps that are not resulting in value are eliminated and a new,

frictionless process is created thereafter, which also allows for flexibility in case of

changing customer needs. By implementing continuous improvement processes,

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sustainability can be reached if employees provide management with feedback on

room for perfection (Liker, 2004).

In the early 1990s, after the publication of the book “The Machine that Changed

the World (Womack et al., 1990), LM was predominantly applied to the

manufacturing sector and was still strongly influenced by typical implementation

aspects of the automobile sector. Only in the years thereafter, the application of LM

underwent progressive broadening and experienced a shift in focus from product

perfection and waste removal towards enhanced customer value (Hines et al.,

2004). With its broadened applicability, LM has become increasingly popular as

confirmed by the extensive list of lean companies and is today applied in a large

variety of sectors, ranging from construction, through financial services and

software development, to the public sector and the service industry including

healthcare, to only mention a few selected ones (Aziz and Hafez, 2013, De Koning

et al., 2008, Hanna, 2007, Radnor et al., 2006, Poppendieck and Poppendieck,

2003, Kim et al., 2006).

3.1.2. Demarcation of LM to Just-in-Time (JIT), 5S and Six Sigma

Just-in-Time (JIT) is a well-established strategy that aims at increasing efficiency

by reducing inventory, whereas 5S is a Japanese work approach to keep a

workplace clean and in order and therefore reduce waste (Sort, Set in Order, Shine,

Standardize, Sustain). Six Sigma is a management and quality control concept that

seeks improved products or services by identifying defects and minimizing their

occurrence.

All three approaches are often used as stand-alone strategies, but are also

relevant in the context of LM. JIT and 5S are in fact important segments of LM,

whereas Six Sigma is often combined with LM to form a strategy that is commonly

known as Lean Six Sigma (Shah and Ward, 2007, Biazzo and Panizzolo, 2000,

Hutchins, 1999, Hirano et al., 2006, Ohno and Mito, 1988, Brandao de Souza, 2009,

Liker, 2004, Casey et al., 2009, Kwak and Anbari, 2006, Anbari, 2002, Antony and

Banuelas, 2002, Black and Revere, 2006, Deming, 1986, The W. Edwards Deming

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Institute, 2015, George et al., 2006, Ahmed et al., 2013). This demarcation is

graphically shown in Figure 3.3 and more details are given in Appendix A1.

Figure 3.3: Connection between LM, JIT, 5S and Six Sigma

Although 5S, JIT and Six Sigma are stand-alone strategies, they are also connected to LM. While 5S

and JIT constitute essential parts of LM, Six Sigma is a complementary strategy that is often applied in

conjunction with LM as Lean Six Sigma.

3.1.3. Relevance

In case-studies and simulation studies, the financial, cultural and organizational

benefits of LM were shown, e.g. by release of working capital, increase of supply

chain speed, product/service quality, customer satisfaction and flexibility as well as

reduction in manufacturing time, product/service costs and inventory (Melton, 2005,

Abdulmalek and Rajgopal, 2007, Ahls, 2001, Alavi, 2003, Emiliani, 2001, Womack

et al., 1990).

However, LM strategies have not triumphed universally due to two main issues:

On the one hand, communication and management support have a significant

influence on the outcome, especially as the word Lean tends to evoke fear of layoffs

and other radical measures for cost saving (Cassell et al., 2006, Graban, 2011).

This underlines that successful LM creation does not only require the

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implementation of technical tools, but also demands appropriate communication, i.e.

transfer of information from management to staff. Furthermore, LM implementation

often requires a fundamental - and importantly a sustainable - change of

organizational culture (Stübner, 1995, Amaro, 2007, Bhasin and Burcher, 2006).

Moreover, LM is commonly criticized for its low ability to cope with variability and

negligence of the value of human capital. However, the latter aspect is slowly being

diminished as newer versions of LM start to specifically appreciate the

organization’s human capital (Hines et al., 2004).

3.2. Lean Hospital Management

3.2.1. Developments Necessitating Strategic Changes in Hospitals

In many countries worldwide, hospitals have been, are and/or will be

experiencing increasing cost pressure and competition, caused predominantly by

extensive demographic changes, alterations in medical reimbursement mechanisms

(with a switch from “cost-based” reimbursement to Diagnosis Related Group/DRG-

based reimbursement) and social changes, including increased relevance of social

networks and public relations in shaping opinions and determining decisions. These

extensive changes in the healthcare environment are at least partially responsible

for the recent focus on LHM (Horisberger et al., 2014).

Demographic changes

Over the past century, our societies have continually aged, leading to increasing

percentage of people over the age of 60 and a decreasing percentage of young

people below the age of 15 years. In fact, according to estimates, 50% or the

population in 2030 will be 50 years or older and the life expectancy will be around

90 years. 15% of the population will be 75 years or older, an age corresponding to

the average life expectancy in developed nations in the 1990s (GBD 2013 Mortality

and Causes of Death Collaborators, 2015, Harper, 2014).

Early research in the 1990s indicated that ageing of the society will cause a

major acceleration in the rise of healthcare costs (Mendelson and Schwartz, 1993).

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However, these sensitivity analyses were based on models that did not account for

improved health of the elderly, hence overestimating the effect of demographic

changes on healthcare expenditures (Felder, 2013). Newer, more realistic models

however estimate the annual increase of healthcare cost in Switzerland, the focus

region of this study, to be as high as 0.5% to 0.7% between 2000 and 2030

(Steinmann et al., 2007). Healthcare costs are furthermore thought to accelerate

due to the prevalence of sedentary lifestyle and the aggravating phenomenon of

obesity (Finkelstein et al., 2009, Manson et al., 2004). As a consequence, health

care systems will have to be progressively cost-cautious and hospitals consequently

more efficient to ensure financial sustainability.

DRG-based reimbursement

One of the main reasons for increased financial pressure in hospitals that made

strategic changes necessary is the switch from “cost-based” reimbursement to

“DRG-based” reimbursement of medical treatments. DRG-based reimbursement

means that patient cases are assigned to a specific Diagnosis Related Group

(DRG), i.e. to a group of patients with similar diagnosis, age and performed

procedure. Hospitals are reimbursed for the treatment of the patient by a lump-sum,

so that that the actual duration of the patient’s hospital stay or the effectively

provided services are not taken into account. If patients are provided with

disproportionate services or have above-average lengths of stay, the hospital needs

to use proprietorial financing to cover unduly costs. In Switzerland, DRG-based

reimbursement of medical treatments was introduced in 2012 and hence later than

in its neighboring countries Austria (1997) and Germany (2003) and much later than

in the pioneer USA (1983) (BMG Deutschland, 2014, BMG Österreich, 2010, BAG

Schweiz, 2013, Mayes, 2007).

DRG-based compensation is thought to countervail medical inflation and

enhance healthcare transparency while simultaneously inducing healthcare

competition and forcing hospitals to work more efficiently (Kongstvedt, 2001,

Albrecht and Töpfer, 2006). In order to be profitable, hospitals in DRG-based

reimbursement countries need to provide cost-effective and efficient care to their

patients (Sloan et al., 1988). While the DRG system has certainly helped to

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eliminate unnecessary services and procedures as well as excessively long hospital

stays, quality of care has to be carefully monitored as hospitals may tend to restrict

services and discharge patients too early to ensure cost-effectiveness (Fassler et

al., 2015).

Competition

With increasing liberalization of healthcare, more and more patients are able to

freely select their health service providers (von Reinersdorff, 2002). Patient

satisfaction is hence an increasingly relevant characteristic of hospitals that may

determine a sick person’s hospitals choice in case of elective surgeries.

While information regarding hospital quality and patient satisfaction used to be

gained predominantly from the general practitioner, family and friends as well as

one’s previous experiences years ago, social networks and public relations are

becoming increasingly relevant in information collection and opinion formation today

(Moser et al., 2010, Emmert et al., 2013). Online patient forums, online support

groups, as well as online rating sites register rising visitor numbers (Emmert et al.,

2013), illustrating that patients nowadays play a more active role in decision-making

and seek to be better informed about their treatment options (= patient

empowerment). While more than 80% (in the US) use the web to gather health-

related information (Kadry et al., 2011), approximately half of these internet users

state that the collected information is ultimately influencing their selection of a

specific hospital or physician (PwC, 2012). However, although patients may feel

more capable judging a healthcare provider’s qualification after consulting

healthcare forums, strongly voiced satisfaction or dissatisfaction of users can cause

significant bias on online platforms (Kadry et al., 2011, Moyer, 2010).

High patient satisfaction can hence be a major competitive advantage of

hospitals. Satisfaction is not only determined by the treatment outcome itself, but

also by other factors such as the quality and quantity of services provided, the

physical appearance of the hospital and waiting times (Andaleeb, 2001, Saad

Andaleeb, 1998, Reidenbach and Sandifer-Smallwood, 1990). With patient voices

being increasingly heard through social media, hospitals need to enhance and

better control patient satisfaction - not only to ensure good online ratings and high

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patient loyalty, but also long-term sustainability in a more and more competitive

environment (Houle and Fleece, 2011, Hribek and Schmalen, 2000). The increasing

level of competition amongst hospitals is becoming more obvious through recent

extrapolations, with estimates that 25% to 30% of hospitals in industrialized

Western countries are likely to be closed by 2020 (Houle and Fleece, 2011,

Albrecht and Töpfer, 2006).

3.2.2. Applicability of Lean Management in Hospitals

The severe changes in the healthcare environment stated above, which put

hospitals under increasing competition and financial pressure and necessitate

improved efficiency in patient care with concomitantly improved patient satisfaction,

explains why many hospitals started to consider changing their strategy. As LM

seeks to improve the efficiency of work processes (e.g. through elimination of

waste) and consequently customer satisfaction, it is seen as having potential to

prepare hospitals for their challenging future (Brandao de Souza, 2009). However,

the originally described methods had to be adapted and developed to fit the hospital

setting, e.g. by redefining types of waste. Overproduction in manufacturing settings

have their equivalent in unnecessary testing in hospital settings, while product

defects correspond to medical errors and complications (Fillingham, 2007).

3.2.3. Outcome of Lean Hospital Management

The literature on LHM provides conflicting outcome results, illustrating both

successful and failed examples (Andersen et al., 2014). The various reasons

contributing to the observed lack of evidence are described in more detail below:

Methodological weaknesses that limit the validity of published studies have been

identified. Flaws are mostly related to study design (e.g. single case studies), bias

and lack of alternative hypotheses (Andersen et al., 2014, Mazzocato et al., 2010,

Young and McClean, 2008).

Evaluating the outcome of LHM is complex and challenging as hospitals, and

thus the performed measures, are highly setting-dependent and strongly influenced

by the hospital’s social component. Furthermore, correlation of changes in

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benchmark parameters (such as patient satisfaction) with the introduction of LHM is

often hampered by simultaneous application of other strategies/tools as well as the

dynamic nature of the healthcare landscape, with e.g. incessant legislative and

technical adaptations (Andersen et al., 2014, 2011, Ovretveit and Gustafson, 2002).

Furthermore, the outcome of LHM depends on the applied conceptual

framework, which in many articles is not specified in detail. Lean facilitators are

context-specific and suitable communication and information, experiential training,

thoughtful engagement of stakeholders (specifically of staff) and the creation of an

appropriate organizational culture that supports exposure of waste and errors are

often described as crucial (Andersen et al., 2014, Fillingham, 2007, Wood, 2014).

Despite these difficulties, studies have shown that LHM is capable of improving

patient care and patient satisfaction through more efficient work process flow, which

not only results in reduced lead time and throughput time, but also in increased

patient throughput. By eliminating wasteful operational procedures, costs are

reduced and the workload of employees can be eased.

A typical example is the use of tablets to directly enter patient information online,

where the status of each patient appears in real-time. This simple method not only

avoids electronic post-processing of handwritten paperwork, but also prevents

patients from being asked the same questions by multiple staff. As a consequence,

the time for quality patient-staff interaction can be increased. By creating efficient

work processes of employees, interaction is however not only increased and

improved with patients, but also with other employees, which allows for better

information transfer between the workforce and avoids mistakes through

miscommunication.

In the best of cases, LHM can in fact reduce the number of complications as well

as the mortality rate, shorten the recovery time and length of stay and thus improve

the quality of care while concurrently reducing costs (Joint Commission, 2006,

Glossmann et al., 2000, Pöhls, 2011, Wood, 2014, Fillingham, 2007, Casey et al.,

2009, Mazzocato et al., 2010, Graban, 2011).

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3.2.4. Lean Principles and the Role of Information and Training

For the implementation of LHM, the LM principles originally defined by Toyota

are often considered most appropriate (Graban, 2011): Total elimination of waste

and respect for people. In order to ensure fulfillment of these two core principles,

proper information and communication as well as suitable training are necessary as

explained below.

Principle “Respect”

The emphasis on respect for staff can be observed in lean hospitals and is

based on their high importance for the hospital’s success. For patients, nurses and

physicians are the main representatives - the face - of a hospital and hence have an

immediate influence on patient satisfaction (Pöhls, 2011, Hribek and Schmalen,

2000, Wieseke, 2004). Respectful interaction with staff is described to increase job

satisfaction and attractiveness of a workplace, leading to a reduction in employee

turnover - an aspect that is specifically relevant in the medical field in which well-

educated and well-trained personnel are of shortage. Therefore, a competitive

advantage can be created by warranting respect for staff (Geiser, 2012, Johnson

and McIntye, 1998, Gaertner, 2000).

LHM seeks to protect employees from work overload through elimination of

waste (see below) and increased efficiency of work processes. Ensuring that every

employee is assigned an appropriate amount of work, which importantly is in line

with his/her expertise and skills, clearly highlights the existence of staff respect in

LHM. Studies illustrate that another aspect that makes employees feel treated

respectfully is empowerment (Laschinger, 2004). Empowerment and self-

actualization can be created through active inclusion of employees in problem

solving and work process improvement. In fact, LHM seeks to inform and train

employees in such a way that they become problem-solvers who commit to

continuous improvement (kaizen).

22

Principle “Waste Elimination”

As 30-40% of expenditures in hospitals are thought to be waste (Graban, 2011),

the relevance of waste elimination (e.g. through LHM) becomes obvious - especially

in light of the increasing cost pressure and competition. Elimination of waste not

only saves costs, but also reduces the workload of employees, thus preventing

overtime and ensuring that work time is spent on valuable tasks that are in

accordance with the employees’ skills (see principle “respect”).

To initiate and continuously maintain the process of waste elimination in

hospitals according to the Kaizen principle, LHM offers a number of powerful

technical tools, such as Kaizen Events, Gemba Walks and Huddle Boards. All of

these tools are part of continuous, experiential learning performed on-the-job. By

partaking, employees experience a high level of involvement, develop skills relevant

to their daily work and attain the capability to become problem-solvers that fix

waste-related issues rather than working around the obstacles (Benson and Dundis,

2003, Deppe, 1993, Ballé and Régnier, 2007, Spear, 2005, Kabst et al., 1996,

Mazzocato et al., 2010, Nelson et al., 2007, Alkalay et al., 2015, Kaplan and

Patterson, 2008, Young and McClean, 2008, Zidel, 2006)

Information and Training

In order to put LHM – and specifically the principles “respect” and “waste” – into

practice, information and training of employees is required as mentioned above.

Most hospital management boards follow the recommendation of Mark Graban and

other LHM specialists to form a dedicated process improvement team (one of more

Lean Managers) that is responsible for LHM implementation and staff information

and training (Graban, 2011). The Lean Managers are trained in lean principles and

methods over an extended period of time, often by external lean consultants and

through visits of other lean hospitals, and are hence able to understand and apply

the most relevant lean tools. In the subsequent steps of implementation, Lean

Managers are then also responsible for information and training of the workforce.

Informing employees is an important aspect during LHM implementation. While

details regarding the relevance of communication and information during

23

organizational change will be illustrated under 3.3.2., it is important to highlight at

this stage that LHM can only be successful if employees commit to lean thinking

and adopt lean principles, as they are ultimately the ones responsible to drive

continuous improvement on a daily basis. Information events, such as assemblies,

not only provide an opportunity to transfer knowledge about lean (principle, tools,

timeline, benefit, etc.), but also to demonstrate commitment of the entire leadership

and to emphasize the hospital’s lean vision (Alkalay et al., 2015, Andersen et al.,

2014, Biazzo and Panizzolo, 2000, Brandao de Souza, 2009, Poksinska, 2010).

Organization and management of employee training is also the responsibility of

the Lean Managers (together with consultants if involved), although it is common to

delegate this task to one or more selected employees on each unit. These

employees, often called Lean Administrators, form the line management level and

function as a link between Lean Managers and the unit’s workforce (Graban, 2011,

Zidel, 2006, Pöhls, 2011, Sager, 1993, Knyphausen, 1991, Reiss, 1993). Lean

training is typically imbedded in its practice, mostly in the form of experiential

training on-the-job (see 3.3.3.). Importantly, training is not only conducted at the

beginning of the implementation as a means for initial skill transfer, but also

thereafter for continuous competence improvement. Training on-the-job (at any time

point) allows direct involvement of employees in lean restructuring and effective

implementation of the kaizen principle. As training encourages employees to

participate in the optimization process, employees experience heightened

empowerment, self-actualization and ideally job satisfaction (Benson and Dundis,

2003, Deppe, 1993, Ballé and Régnier, 2007, Spear, 2005, Kabst et al., 1996,

Mazzocato et al., 2010, Nelson et al., 2007, Alkalay et al., 2015, Kaplan and

Patterson, 2008, Young and McClean, 2008, Zidel, 2006).

3.2.5. Implementation Tools as Forms of Continuous Training

With waste elimination being the main goal in LHM, a variety of tools exists to

identify typical places or situations that are characterized by frequent interruptions,

miscommunication, unnecessary motion or cumbersome workarounds. The Lean

Managers, together with Lean Administrators and the unit’s workforce, can identify

24

waste in work processes by resorting to a variety of well-established techniques and

tools.

Importantly, all of these tools constitute training possibilities for employees,

underlining the fact that LHM is characterized by extensive on-the-job training. As

effecting LHM is (in ideal cases) characterized by unremitting development of

processes and employees, implementation and training are typically coalesced in

lean hospitals. The lean tools described below are hence not only used in the

introduction phase to transfer initial skills and knowledge, but are mostly employed

as regular practice afterwards (Andersen et al., 2014, Kabst et al., 1996).

Kaizen Events

Kaizen events normally span approximately one week (plus the respective

planning phase) and aim to analyze and optimize complex work processes or entire

units. Participants in the Kaizen Event are cross-functional and cross-hierarchical.

Some participants have no daily direct contact or major interaction with the

unit/department that is analyzed to ensure impartiality. The team, which is led

through the event by the Lean Managers, starts with an orientation phase on-site as

to observe processes and understand work flows (Figure 3.4). Orientation is

followed by an analysis phase, during which the data collected are reviewed, the

current status evaluated, wasteful processes identified and possible improvements

developed and prioritized. One or more high priority themes are selected and action

plans developed that will allow the envisioned, improved state to be reached. The

findings of the analysis as well as the selected approaches are then communicated

to the unit’s team, which is trained if necessary. During the actual implementation of

the improvements, previously determined milestones are checked and results are

summarized and reported at the end of the realization (Graban, 2011, Cyger, 2015,

Kenney and Berwick, 2010).

25

Figure 3.4: Kaizen Event

Process of Kaizen Events, in which a team analyzes the current process in a specific unit to make

improvements to the value stream [Adapted from: (Dager, 2015)].

Gemba Walks

The Japanese word Gemba refers to “the place where the work is done”. Gemba

Walks are extended visits of the Lean Managers and senior leaders on-site, i.e. at a

specific hospital unit, where they observe processes firsthand and talk directly to the

involved staff. A typical example of a Gemba Walk is the participation of the LHM

Team in ward rounds. Being trained in the identification of waste and able to think

across departmental borders allows identifying the root cause of problems or

workarounds that have become daily practice. In Gemba Walks, the PDCA principle

(Plan – Do – Check – Act) is applied as the managers get on-site (Do), analyze the

work processes (Check) and develop and thereafter implement (Act) the optimized

process. The efficiency of Gemba Walks can be increased by repeatedly asking a

series of questions illustrated in Figure 3.5, in combination with persistent enquiring

into the reasons underlying specific work flows. Especially in the initial phase of

LHM implementation, when Gemba Walks are not yet common practice, it is

important to communicate that their goal is to identify process issues, but not to

blame anyone for the faulty process.

26

If conducted correctly, Gemba Walks are an excellent possibility to better

understand the flawed nature of processes and to subsequently optimize the work

flow and hence value stream. Furthermore, Gemba Walks constitute a possibility to

acquaint employees with the lean philosophy and to enhance their critical thinking.

This lean training will ultimately allow them to identify problems and suggest

improvements themselves, which is an essential mainstay of Huddle Boards (see

below) (Graban, 2011, Cyger, 2015, Kenney and Berwick, 2010, Bremer, 2014).

Figure 3.5:

Gemba Walk

The most relevant

10 questions

during Gemba

Walks.

[From (Leask, 2015)]

Huddle Boards

In many hospitals, Huddle Boards are installed in each unit and are an excellent

tool to visualize the lean progress (Figure 3.6). The set-up of a huddle board can

differ from hospital to hospital, but usually includes a possibility for employees to

point out problems (i.e. wasteful processes) that they have noted. Post-its are

commonly used to collect ideas for improvement, as they can be easily moved

across the board depending on their processing status.

27

Figure 3.6: Huddle Board

Typical set-up of a huddle board as described by Swiss researchers (Alkalay et al., 2015) that

incorporates the Kaizen philosophy of continuous improvement. Suggestions for improvement by the

team are written on post-its and added onto the board, where they are moved according to their

progress. Relevant patient information (such as allergies) are often included on huddle boards to

improve patient safety.

During scheduled gatherings around the huddle board, so called Huddles (e.g.

incorporated into team meetings), problems and suggestions are discussed within

the team. Changes that can be easily made and do not require substantial

resources are moved to the “Just-do-it” part of the board and someone will be

assigned to the realization. Once the improvement is accomplished, the post-it gets

moved to the “Success” area. Suggestions that require more planning or resources

are moved to the respective area of the board and will enter an official PDCA cycle

through the LHM Team. Typically, the board also contains a section dedicated to

any essential patient information that is crucial for everyone to know, such as

allergies, other specific needs of patients or discharge plans.

28

Huddle Boards are considered to be an excellent tool to ensure continuous

improvement (Kaizen) through direct involvement of employees. With successes

being visually highlighted, the benefits of LHM become evident, hence increasing

engagement and motivation of the team. Furthermore, Huddles ensure efficient

transfer of information in an official manner, which allows development of

standardized work processes and improves patient safety. Huddles at the unit’s

board as well as visit of other huddle boards furthermore are an efficient and

economic training tool that can be easily incorporated into the daily hospital routine

(Graban, 2011, Cyger, 2015, Kenney and Berwick, 2010).

3.3. Change Management

3.3.1. The Principles of Change Management

At certain times, organizations may have to adapt their strategy due to

significant internal or external stimuli to ensure future financial profitability and

sustainability. Such stimuli can either threaten the success of an organization or

open new possibilities for business (Todnem By, 2005). Demographic, technical or

legislative changes, as well as competition-related alterations, are typical examples

(Graetz, 2000). As strategic changes are anticipated to have significant impact on

an organization’s success, they will likewise also have an impact on its processes,

systems, structures and/or job roles (Creasey, 2014). Implementation of a new

strategy causes significant changes for the organization’s employees. Appropriate

change management, i.e. suitable processes, tools and techniques, are needed to

help employees in the transition phase, enhance their engagement in the change

process and thus ensure achievement of the desired business outcome (Todnem

By, 2005). Change management is accordingly more than project management

(with its focus on the execution of the change, e.g. using time tables, setting goals

and applying control mechanisms), as it has a major people focus (Creasey, 2014).

Employees that do not understand the need for change and are comfortable with

not changing may demonstrate indifference, pessimism and/or cynicism or even

resistance to change (Coghlan, 1993, Kotter, 1995, Kotter and Schlesinger, 1979,

29

Watson, 1971). In fact, employee resistance has been shown to be a major cause

of failed change programs (up to 70% failure)(Kotter, 1995). If change management

tools are inappropriate or non-existent and if no attention is paid to effectively

changing the organizational culture, employees are at high risk of feeling insecure,

incompetent and fearing loss of control, purpose and sense of identification. As a

consequence, employees will actively resist the change with the goal to conjure up

the old, “safe” environment (Coghlan, 1993, Watson, 1971, Balogun and Hailey,

2008, Burnes, 2004).

As mentioned above, change management should put major emphasis on

assisting the organizations human assets, an approach that is often called people-

centred implementation (Prager and Overholt, 1994). In fact, it has been

demonstrated that early involvement of employees enhances the chances for

successful outcome (Chawla and Kevin Kelloway, 2004, Prosci, 2014).

Furthermore, prompt identification and persuasion of so-called opinion leaders, i.e.

employees whose behavior is closely watched and often imitated by others,

increases the chances to convince a sufficient number of employees in this critical

initial phase (Kim, 2015). Similar to successful spreading of innovations through the

societies as explained by the Diffusion of Innovation Theory (Rogers, 1983),

efficient spreading of change through an organization depends on ample early

adopters to subsequently enhance peer-peer-communication and infect other staff

to follow (Kim, 2015, Robinson, 2009, Pöhls, 2011, Rogers, 1983, Katz and

Lazarsfeld, 1970).

While the typical mechanisms of change adoption and diffusion were depicted

above (Whitfield and Poole, 1997, Cassell et al., 2006, Kotter, 1995, Luecke, 2003,

Todnem By, 2005), the role of information and communication as well as the role of

training, which is specifically relevant to ensure sustained success of strategic

changes will be discussed in detail in the following two chapters (Cappelli et al.,

1997, Strebel, 1996, Rothwell, 1999, Knowles, 1973).

30

3.3.2. The Role of Information & Communication in Organizational Change

Communication with stakeholders, specifically with employees, has been shown

to be a major outcome determinant during strategic change and is hence one of the

main mainstays of change management. Through good communication, information

related to e.g. goals and benefits can be distributed, which will allow employees to

understand and accept the change. Communication and thus provision of

information is considered crucial for change adoption and engagement and is one of

the most powerful tools to counteract pessimism and resistance. (Antony et al.,

2003, De Cerio, 2003, Hamid, 2011, Hines et al., 2004). Importantly, evidence from

the literature suggests providing information early on and for all levels of the

organization as rumors of changes will cause ambiguity and subsequently anxiety

and refusal. Aiming for open communication and mutual trust is thus crucial in

organizational development (Jick and Peiperl, 2010, Beckhard, 1969, Allen et al.,

2007). The implementation of LHM shares the same communication and

information requirements as any other strategic change, albeit possibly with higher

criticality due to the negative notion of the word “lean” (which can cause immediate

reluctance) and the importance of medical staff in shaping the face of a hospital as

explained in the preceding chapters.

The effectiveness of change communication is enhanced by following simple rules:

Communication should occur repeatedly and ideally through different channels

(with a preference to face-to-face communication) to increase information

retention.

Information provided by personnel in high hierarchical positions is believed to

reinforce the importance of a message, but should be combined with additional

communication via direct supervisors so that employees feel personally

addressed and affected.

To further enhance retention of the information, examples with direct relevance

to the employees should be presented.

Furthermore, active contribution should be endorsed to ensure a sense of

ownership and to enhance engagement.

31

By following these rules and by providing quality change communication,

employees are more likely to embrace the change as illustrated by experimental

studies (Klein, 1996, Dansereau and Markham, 1987, Daft and Lengel, 1983, Gioia

and Sims, 1986, Jablin, 1979, Beckhard, 1969, Allen et al., 2007).

At the beginning of the change, the rationale for the change has to be made

clear, e.g. by illustrating the discrepancy between ideal and actual outcome or by

explaining disturbing alterations in the organization’s environment (e.g. legislative

changes affecting the profitability). The underlying urgency should be demonstrated

and the benefits of the change for both, the organization and the employee, need to

be highlighted. Ultimately, a new vision should be developed and communicated,

allowing employees to understand in which direction the organization – and hence

everyone on the team – will move in the time to come. While delivering information

during the initial phase is essential, sharing outcome and progress during the

changing stage is also important. This not only entails successes, but also the

discussion of difficulties and – if applicable - how these have been solved. In both

phases, the behavior of the strategic leaders has to be in accordance with the

verbalized information and attention needs to be paid to not only provide

information, but truly change attitudes and organizational culture (Kanter, 2003,

Kotter, 1995, Luecke, 2003, Todnem By, 2005, Day and Antonakis, 2012, Klein,

1996, Young and Post, 1993).

3.3.3. The Role of Training in Organizational Change

Strategic changes in organizations often require the workforce to apply new

techniques, to take over other tasks and to perform daily processes in a new and

not habitual manner. These changes can reduce the confidence of employees and

can threaten their perceived level of control. In order to counteract these

developments and ensure change acceptance, adoption and compliance in the

workforce, training possibilities need to be provided to convey the newly required

skills to the organizations employees. Importantly, humans have a natural desire to

learn, driven by the urge to successfully deal with problems or tasks in their daily

(work) life (Knowles, 1973, Rothwell, 1999). The current literature provides evidence

32

that training - and correspondingly learning if seen from the employee perspective –

facilitates implementation of change and increases the rate of success. Underlying

mechanisms are however not only acquisition of knowledge and thus increased

capability to perform new tasks, but also satisfaction of employee-specific needs,

resulting in heightened motivation and engagement. In reference to Maslow’s

Hierarchy of Needs, training ensures above-mentioned job capability and therefore

wages (first level), safety (second level), social belonging through group interaction

(third level), self-esteem through improved performance (fourth level) and self-

actualization through empowerment via direct participation in optimizing work

processes (fifth level) (Benson and Dundis, 2003, Deppe, 1993, Ballé and Régnier,

2007, Spear, 2005, Strebel, 1996, Cappelli et al., 1997, Schneider and Goldwasser,

1998, Vithessonthi and Thoumrungroje, 2011).

The relevance of training for job performance and employee satisfaction, which

eventually will affect job performance too, is thus eminent. Companies can facilitate

organizational learning by providing suitable training and learning opportunities,

which can range from conventional learning (i.e. class-room style learning) to

experiential learning and/or action learning. Experiential learning, which focusses on

direct involvement of learners in the learning process (i.e. hands-on learning), is

thought to better address the individual’s strengths, needs and potential and thus to

induce confidence and an individual sense of purpose. The experiential learning

theory (ELT) developed by David A. Kolb (Kolb et al., 2001) describes a four-stage

training cycle (Figure 3.7) that learners commonly undergo:

1) Immediate and concrete experiences

2) Observations and reflections

3) Creation of abstract concepts

4) Active testing and experimentation, which then create new experiences

33

Figure 3.7:

Experiential Learning Cycle

Four-stage experiential learning

cycle as described by David A.

Kolb.

A continuation of experiential learning is action learning, in which real problems

are being solved in the training setting. After encountering the problem in a team,

possible solving strategies are discussed and an action plan formulated (Revans,

1982, Rothwell, 1999).

Experiential learning and action learning have been described to be of value in

LHM implementation and continuation (Smeds, 1994, Zan et al., 2015, Seddon and

Caulkin, 2007, Kabst et al., 1996). During simulation games or Gemba walks, which

are commonly applied, employees are able to experience work processes and can

identify possibilities for improvement through elimination of waste. Once new

structures and processes are developed, they can be actively tested, hence

generating ownership and dedication. Consequently, continuous improvement

through employee-based initiative is stimulated (Elgood, 1996, Wyton and Payne,

2014, Seddon and Caulkin, 2007, Kabst et al., 1996).

34

4. Methods

4.1. Research Design

4.1.1. Type of Research

In this study, descriptive and explanatory research approaches were combined.

The descriptive research approach was used to investigate and thereafter describe

how lean information and training was provided to employees in Swiss Hospitals

from the view of Lean Managers and their employees. Comparisons between

investigated hospitals were conducted. The explanatory research part aimed at

analyzing to which extent lean information and training determined the level of lean

adaption and utilization (correlative research with regression analyses).

Due to the limited time frame of the dissertation, a cross-sectional study design,

i.e. data collection at only one point of time, was chosen. In order to enhance the

research significance, five Swiss hospitals were investigated (case series/ multiple-

case study). This approach not only increased the number of survey participants,

hence ensuring sufficient power for correlation analyses, but also allowed

comparative evaluations and hence identification of similarities and differences

within and between the hospitals. In order to ultimately create recommendations for

employee information and training during LHM, the increased level of evidence and

wider relevance created by a multiple-case study was considered crucial (Yin, 1981,

Baxter and Jack, 2008, Saunders et al., 2011).

Only primary data were used for analysis, i.e. those collected through semi-

structured interviews with the Lean Manager(s) of each participating hospital, as

well as through an employee survey. In both cases, a combination of quantitative

and qualitative data was gathered. Anonymization of hospitals, Lean Managers and

employees was ensured throughout the study (Saunders et al., 2011)

For further details on subjects, sampling and data collection (interviews, surveys)

see sections below.

35

4.1.2. Research Cases (Hospitals)

Candidate hospitals for this study were identified at the Swiss Network Meeting

on Lean Health Care in April 2015 through personal interaction. The following

inclusion and exclusion criteria were applied:

Hospital inclusion criteria: Implementation of lean in at least one unit already;

the Lean Manager or a member of the Lean Management Team had to be willing to

give an interview on the techniques and processes employed during lean

implementation; the directorate/management of the hospital had to permit the

employee survey and the interview; interviews and surveys had to be conductible in

German.

Exclusion Criteria: Implementation of lean merely planned or most recently

started; denial of interview and/or employee survey.

A total of five Swiss hospitals could be identified that fulfilled the above

mentioned criteria and were willing to participate in the study. The group consisted

of four public hospitals and one private hospital, which are from herein labelled with

Hospital 1-5 to ensure anonymization. The geographical location of the participating

hospitals is indicated in Figure 4.1.

Figure 4.1: Geographical location of participating hospitals

Map of Switzerland, showing the location of the five participation hospitals.

36

4.1.3. Interviews

Goal of the Interviews

Semi-structured face-to-face interviews with the Lean Manager or a member of

the Lean Management Team of each participating hospital were conducted with the

goal to better understand the processes of lean implementation, the status of lean

implementation as well as the level and type of lean information and training offered

to employees. Furthermore, problems during LHM implementation were identified

whenever possible.

Structure of the Interviews

While the exact course of the interview was kept open to allow case-specific

issues to be discussed, a base structure of the interviews was maintained (details

see Appendix 2). Briefly, interviewees were first asked for hospital-specific

concepts of LHM and chosen implementation approaches, followed by a series of

questions related to information and training of employees. The last section of the

interview focused on any additional aspects that the interviewee wanted to discuss

as well as on survey details (unit, distribution of questionnaires etc.).

All interviewees were given the choice of anonymization of the hospital and/or

their own identity and signed an informed consent form (Appendix 3). As most

interviewees requested anonymization of both identities, all data are presented

anonymously. Interviews were not tape recorded in order to put interviewees at

ease and to enhance their openness, but hand-written notes were taken throughout

the conversation and transcribed within 48 hours (Rubin and Rubin, 1995).

4.1.4. Questionnaire

Goal of the Questionnaire

A questionnaire was developed with the goal to identify the employees’

perception of the information and training with regard to type, quality and quantity.

Furthermore, clarification was sought about the employees’ level of interest and

participation in lean information and training as well as about the learning outcome.

37

Finally, the questionnaire aimed at in-depth analysis of the employees’ adoption and

utilization of lean, hence allowing correlation analyses between information/training

and adoption/utilization (for details see Appendix 2).

Questionnaire Respondents

Hospital units participating in the survey were selected together with the

interviewed Lean Manager, taking into account the specific structure and process of

lean implementation of each hospital. In Hospital 1, questionnaires were distributed

in the only fully lean unit/clinic existing at the time of the survey. In Hospital 2, the

newest fully lean unit was selected for the survey. In Hospital 3, which had already

been turned completely lean, three units were selected which – based on previous

surveys – were known to show an average lean adoption and utilization. While a

mixture of low and high adoption units would have been scientifically more

compelling, the units with below-average adoption had already been questioned

frequently in the past and were hence predicted to show low response rates and

high resistance. In Hospital 4, a fully lean small clinic, the questionnaires were

distributed to all units. In Hospital 5, all three lean units were involved.

After an initial pre-notification of the units through the Lean Manger and/or the

investigator, which has been described to enhance participation specifically of

medical staff (Flanigan et al., 2008), print-outs of the questionnaires were

distributed to the members of the units by the Lean Manager. In Hospital 3, the

identical questionnaire was provided as an online survey (surveymonkey.com) as

requested by the hospital management. Physicians, nurses as well as

administrative staff (with or without patient contact) were encouraged to participate.

The importance of the survey, the time frame (2 weeks; exact date indicated on the

cover page of the questionnaire) and the collection mode were announced by the

Lean Manager or a representative, following recommendations from the literature

(Flanigan et al., 2008). After approximately one week, employees were given a

reminder.

Questionnaires were collected through a collection box (placed at a convenient

location, e.g. nearby an information desk) in Hospital 1, 2 and 4. In Hospital 5,

questionnaires could be sent to the Lean Manager by internal mail or alternatively

38

by email (as scan) either to the Lean Manager or to the investigator. In Hospital 3,

no collection was required due to the online nature of the survey.

Structure of the Questionnaire

The questionnaire was composed of six main parts: (1) cover page, (2)

questions related to lean information, (3) questions related to lean training, (4)

questions related to lean adoption and utilization, (5) questions related to

demographic data and (6) closing statement. For details see Appendix 2

(description of structure) and Appendix 4 (questionnaire).

For all parts, recommendations and standards described in the literature were

taken into account. Whenever possible, questions were adopted (and if needed

adapted) from previously published surveys to ensure validity, reliability and

discrimination. In order to increase the response rate, the questionnaire contained a

cover letter emphasizing the importance of participation, was composed of close-

ended questions and took a maximum of 10 minutes to answer (Saunders et al.,

2011, Litwin, 1995, Flanigan et al., 2008, Korb, 2012, Ruck, 2013, Hargie and

Tourish, 2009, Goldhaber and Krivonos, 1977, Graban, 2011, Brandao de Souza,

2009, Wood, 2014, Pöhls, 2011, Ajzen and Madden, 1986, Beck and Ajzen, 1991,

Ajzen, 2002).

Types of Question

To investigate how lean information and training had been provided in the

hospital, closed-ended questions were formulated which included the most

commonly applied modes of information and training as described in the literature

(Graban, 2011, Brandao de Souza, 2009, Wood, 2014). The option “other” with an

open text field was given to gather all possible answers.

Determination of the ratio of informed participants was conducted through

dichotomous contingency questions (yes/no – if not, why) for written information,

assembly/meeting-based information and training. For the contingency subpart, a

closed-ended format was chosen, i.e. responders were able to select from a

selection of given choices. The option “other” was included as well (see above).

39

The perceived quality and quantity of the information and training provided was

identified by 3 point (too little, adequate, too much) and 5 point scales (very poor,

poor, ok, good, very good) respectively as described by Sorrel Brown from the Iowa

State University (Brown, 2010).

For the measurement of latent variables such as attitudes or opinions, Likert-

type scale questions were used. Each question was introduced by the sentence

“How do you rate the following statement?”. The participant could choose from 7

answers that were organized vertically: strongly agree, mostly agree, agree

somewhat, neutral, disagree somewhat, mostly disagree, strongly disagree. The 7

point Likert Scale was preferred over the 5 point Likert Scale to increase

differentiation and hence refinement of the responses, to minimize neutral answers

and to raise metricality of the data (Millsap, 2014, Krosnick and Presser, 2010).

Sample Size Calculation

In order to ensure sufficient power for statistical analyses (survey data), the

required number of questionnaires - i.e. the number of participants - was calculated

at the beginning of the study, yielding n ≥ 15 for each hospital. Details on the

calculation are presented in Appendix 5.

4.2. Data Analysis

4.2.1. Interviews

A descriptive analysis of the interview notes was performed. For each hospital, a

summary describing the most relevant aspects of LHM implementation (with a focus

on information and training) was created (Appendix 7-11). In addition, a

comparative table, highlighting selected aspects, was generated (Table 5.2).

4.2.2. Questionnaires

Data gathered through employee questionnaires were analyzed in three different

ways, as described in more detail below: A descriptive analysis (data from each

40

hospital), a comparative analysis (between hospitals) as well as explanatory

analysis (correlation and regression between questionnaire items).

Descriptive Analysis

In the descriptive part, the number of collected questionnaires as well as their

distribution according to age, years of professional experience and profession was

identified for each hospital, as well as comprehensively for all hospitals. In addition,

the answers to all survey questions were summarized separately for each hospital

to identify hospital-specific outcomes with regard to the employees’ perception of

information and training and the employees’ lean adoption and utilization

(Appendix 12-16). In addition, these results were incorporated in the comparative

analysis as described on the following page.

For all analyses, questions with either Likert-Scale format or dichotomous format

underwent numerical coding, followed by calculation of Means and Standard

Deviations (StDev), which are uses for statistical analysis. In addition, the

Frequency Distributions, i.e. the percentage of a specific answer in the entire

sample, was calculated and illustrated in a graphical manner (Thomas, 2004,

Hartung et al., 2009).

Comparative Analysis

In this part, Means and Frequency Distributions for specific questionnaire items

were compared between hospitals. Whenever possible, hospitals with significantly

higher or lower scores than others were identified.

Correlative (Explanatory) Analysis

For the correlative analysis, numerical data collected for all hospitals were

pooled. Selected items of the questionnaire were tested for correlation. Selected

variables where furthermore tested for regression. An example is correlation and

regression testing between perceived quality of the information and the degree of

lean utilization. In addition, analyses were preformed to determine whether specific

employee characteristics (age, years of professional experience, profession)

correlate with the degree of lean adoption and utilization.

41

4.2.3. Recommendations for LHM Implementation

Recommendations for employee information and training during LHM

implementation were developed based on the combined results of interviews and

questionnaires (descriptive, comparative, and correlative). Initially, hospitals that

reached above- or below average results in lean adoption and utilization were

identified (marginalized groups). In a next step, those aspects of information and

training that showed (positive or negative) correlation with lean adoption and

utilization were highlighted. Questionnaire- and interview-based data were utilized

to detect specific LHM implementation aspects that were characteristic of the

marginalized hospitals (best/worst) or could explain any other apparent result

patterns. Based on this combined evidence, ten recommendations were formulated

that are believed to enhance the outcome of LHM (see Discussion).

4.2.4. Statistics

All survey results (except demographics of participants) were treated as metric

data and tested (if appropriate) for normal distribution, homogeneity of variances,

autocorrelation and multicollinearity. Results are shown as Mean StDev or

Frequency Distribution.

A detailed description of the statistical tools applied can be found in Appendix 6.

Briefly, (Welch’s) ANOVA with Bonferroni Posthoc Testing, One Sample T test,

Pearson Correlation test, Spearman rank correlation, Freeman-Halton test and

Regression test were used. All tests were performed in SPSS, with a significance

level (p) < 0.05, as described in the literature (Hartung et al., 2009, Harrell et al.,

1996, Backhaus et al., 2013, Brosius, 1998).

42

5. Results

5.1. Interviews

5.1.1. Interview Logistics

Semi-structured face-to-face interview with Lean Managers were performed

between May 2015 and July 2015. Details on the interviews (date, location,

anonymization request) are given in Table 5.1. All interviews took between 45 min

and 70 min and one interview was followed by a lean unit visit.

Table 5:1: Information about the conducted interviews

Date and location of the interview as well as requested type of anonymization (I = Interviewee,

H = Hospital)

Number Date Location Requested Anonymization

Hospital 1 12.05.2015 On site -

Hospital 2 01.07.2015 On site I, H




5.1.2. Interview Results

In Table 5.2, the most relevant aspects of LHM are compared between all five

hospitals. Comparative aspects include implementation history (start, mode, current

status), personnel responsible for LHM implementation (hospital-level, unit-level,

consultants) as well as details on the information and training provided (for current

employees and new employees). A detailed description of the interviews with all

results can be found in Appendix 7 to Appendix 11.

43

Table 5:2: Overview of LHM Implementation in the participating five Swiss hospitals

Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5

Start of Implementation Mid-2014 Mid-2013 Early 2012 Mid-2013 Mid-2012

Mode of Implementation Successive Successive Highly Progressive

In one go In one go Successive

Status of Implementation 1 clinic (6 units) 6 units Fully Fully 3 units

Lean Managers (LM) Hospital-Level

3 LM (20/30/80%)

2 LM part-time now:1 LM full-time

1 LM full-time 4 managers in

support part-time 1 LM full-time 1 LM full-time

Lean Administrators (LA) Unit-Level

1 LA (10%) 1 Moderator

3-5 LA (= Core Team)

None 14 LA in total for

all units (10% each)

None

Lean Consultancy Initially Mid-/Long-term Mid-term

(task-based re-involvement)

Initially (task-based re-involvement)

Mid-term (task-based re-involvement)

Employee Information Very high High Low Very high Low-Medium

Employee Training High High Medium Very high Medium

Refresher Training No No No Yes No

New Employee Information High Medium Low High Low

New Employee Training On-the-job On-the-job On-the-job Regular and/or

Refresher Training On-the-job

On-the-job

44

5.2. Questionnaires

5.2.1. Distribution of Returned Questionnaires

A total of 98 questionnaires were returned, of which 85% were answered

completely. In the remaining questionnaires, one or more answers were not

provided by the participants. In three cases, participants restrained from providing

all of the requested demographic information, likely in fear of being identifiable. In

Hospital 3, three employees indicated that they did not know the meaning of LHM

(despite working in a lean unit) and could hence not provide answers to all

questions. One additional employee did not specifically write this comment, but

showed a similar response pattern (with same blanks) as these three participants.

In order to include this important finding numerically, unanswered questions related

to the quantity or quality of lean information received the lowest rank within the

given scale. In contrast, unanswered questions related to the quality/quantity of lean

training were left empty as training may not necessarily be offered to all employees.

As complete unawareness about lean (as observed in the above mentioned cases)

will hinder lean adoption, unanswered questions related to this aspect were also

assigned the lowest score.

Figure 5.1 illustrates the quantity of collected questionnaires per hospital

(number, percentage). The number of questionnaires required to ensure sufficient

power in case of statistically challenging results (Appendix A5: n=12, n=15) was

reached in all hospitals except Hospital 5, which may be slightly underpowered in

comparative analyses, at least in cases with high variation between the

respondents.

45

Figure 5.1:

Questionnaire distribution amongst

hospitals

Number of questionnaires collected

per hospital (small boxes) as well as

percentage (size of pie segments).

Questionnaires were further analyzed for demographic distribution (profession,

age, years of professional experience). Overall highest participation of nurses

(63.3%) can be noted, followed by administrative employees (20.4%) and

physicians (11.2%). Others and unknown cases account for merely 5.1%.

Questionnaires collected in Hospital 3 and 5 were only answered by nurses (1x

unknown profession in Hospital 3), whereas the most diverse distribution (with

regard to profession) was present in Hospital 4 (Figure 5.2)

Figure 5.2: Questionnaire distribution by profession

Number/Percentage of physicians, nurses and administrative employees returning questionnaires.

Data are shown for each hospital (left) as well as comprehensively over all hospitals (right).

46

Participation of different age groups was found to be relatively uniform in the first

four age ranges (< 30 years up to 59 years: 21.4%, 21.4%, 27.6% and 23.5%

respectively), but lower participation was noted amongst older employees (≥ 60

years: 5.1%). Differences between hospitals were less pronounced for age

distribution than for profession distribution, although a high percentage of young

respondents (< 30 years: 43.8%) can be seen in Hospital 2 (Figure 5.3). Moderate

and long professional experience of respondents (in the respective area) were most

common (10-19 years: 23.5%; ≥ 20 years: 43.9%), with equal distribution amongst

the two less experienced groups (16.3% versus 15.3%). Details regarding the

distribution of years of professional experience are illustrated in Figure 5.4.

Figure 5.3: Questionnaire distribution by age

Number/Percentage of different age groups returning questionnaires. Data are shown for each

hospital (left) as well as comprehensively over all hospitals (right).

47

Figure 5.4: Questionnaire distribution by professional experience

Number/Percentage of groups with different length of professional experience (in the current work

area) returning questionnaires. Data are shown for each hospital (left) as well as comprehensively

over all hospitals (right).

5.2.2. Descriptive and Comparative Depiction of Questionnaire Results

In this chapter, all questionnaire results are summarized, graphically illustrated

and comparisons amongst participating hospitals are conducted. Hospital-specific

results are shown in the Appendix 12-16.

From the employees’ perspective, information about LHM was predominantly

transferred during assemblies, with selection rates ranging from 53.8% (Hospital 5)

to 96.8% (Hospital 4). Different from all other hospitals, the initial LHM assembly

was a mandatory event in Hospital 4, hence explaining its strikingly high rate.

Information transfer through personal meetings (Lean Managers, Lean

Administrators) was frequently selected in all hospitals except Hospital 3 (20%),

which had opted for a highly progressive implementation. This approach - in

combination with the large size of the hospital – possibly explains the low level of

personal communication during LHM implementation. Information was furthermore

distributed in written forms (email, leaflets) in all hospitals. Under the option “other”,

participants recurrently named team meetings, morning meetings during shift

changes and eLearning (Table 5.3).

48

Table 5:3: Types of lean information offered in the participating hospitals

Types of lean information offered in the five hospitals as known by the participants of the survey.

Results are presented as % of participants selecting each option. The most frequently named

information type in each hospital is highlighted in bold.


Assembly 66.7 75.0 60.0 96.8 53.8

Personal Meeting 50.0 56.3 20.0 67.7 38.5

Leaflet 37.5 43.8 6.7 32.3 15.4

Email 16.7 18.8 20.0 64.5 15.4

Other 12.5 - 33.3 32.3 23.1

When considering all information modes, 100% of participants in Hospitals 1, 2,

4 and 5 stated that they had received information about LHM. In Hospital 3, 27% of

participants stated that they had not received any information concerning lean and

three respondents explicitly stated that they did not know the meaning of LHM,

despite working in a lean unit. The level of information was significantly different in

Hospital 3 compared to all other hospitals (Figure 5.5).

Figure 5.5:

Level of Lean Information

Percentage of informed versus

uninformed employees in all

hospitals.

if p < 0.05 between indicated

hospitals.

In most hospitals, the majority of employees judged the amount of information as

appropriate (74% - 94%). However, in accordance to the level of information

transfer, a substantial proportion of employees in Hospital 3 (40%) felt that too little

49

information had been provided. Differences between hospitals did not reach

statistical significance (Figure 5.6).

Figure 5.6:

Quantity of Lean Information

Rating of information quantity,

indicated as % of employees

selecting each of the possible

answers (appropriate, too much,

too little).

The information quality was rated (in average) as “good” in Hospitals 1, 2, 4 and

5. In Hospital 3, the information quality was perceived as “ok” and was found to be

significantly inferior to Hospitals 2 and 4 (Figure 5.7).

Figure 5.7:

Quality of Lean Information

Rating of information quality,

indicated as Mean and StDev,

based on the following coding:

1 = very poor; 2= poor; 3 = ok;

4 = good; 5 = very good


hospitals; () if p = 0.05 between

indicated hospitals.

In all hospitals, implementation of LHM was supported by Lean Consultants.

Importantly, some of the hospitals had hired the same consultancy companies,

hence explaining certain similarities concerning applied training tools. As shown in

Table 5.4, talks by consultants were frequently named by survey participants, with

50

an exceptionally high percentage in Hospital 4 (90.3%). Huddles are commonly

applied training tools in Hospitals 1, 2 and 5, whereas Huddles seems less

established in Hospitals 3 and 4. The overall results indicate that Hospital 4 was

highly engaged in lean training, followed by Hospital 1 and 2. In Hospital 3 and 5,

employees were less aware of training offered during LHM implementation and

sustainment, which also corresponds to the statements of the interviewed Lean

Managers (see 5.1.5 and 5.1.7). Detailed graphical illustrations of hospital-specific

training offerings can be found in Appendix 12-16. Although survey participants in

all hospitals new about a variety of training options, only Hospital 4 reached a

training level of 100%. Similarly, all but one participant (who indicated time

constraints) had received training in Hospital 2. In all other hospitals, the percentage

of untrained employees was however considerably higher as shown in Figure 5.8.

The training level was overall lowest in Hospital 5, with an alarming 73% of

participants indicating that they had not received any form of training.

Table 5:4: Types of lean training offered in the participating hospitals

Types of lean training offered in the investigated hospitals as known by the participants of the survey.

Results are presented as % of participants selecting each option. The most frequently named training

type in each hospital is highlighted in bold.


Talk by Consultants 62.5 62.5 40.0 90.3 33.3

Talk by Colleagues 45.8 43.8 20.0 48.4 41.7

Workshop 62.5 37.5 33.3 64.5 16.7

Gemba 58.3 62.5 53.3 38.7 50.0

Huddle 70.8 68.8 13.3 32.3 50.0

Simulation 33.3 50 40.0 19.4 -

Case Study 12.5 18.8 13.3 45.2 -

Visit (other hospitals) 8.3 - 6.7 9.7 8.3

51

Figure 5.8:

Level of Lean Training

Percentage of trained versus

untrained employees in all

hospitals.


hospitals.

In accordance to findings about the training level, only employees in Hospital 2

(100%) and Hospital 4 (90%) perceived the amount of training provided to be

(mostly) appropriate. In all other hospitals, training deficiencies were criticized

(Figure 5.9). However, those employees that had received training rated the quality

(in average) as good and no statistically significant differences were observed

between hospitals (Figure 5.10).

Figure 5.9:

Quantity of Lean Training

Rating of training quantity,


selecting each of the possible

answers (appropriate, too much,

too little).


hospitals.

52

Figure 5.10:

Quality of Lean Training

Rating of training quality,

indicated as Mean and StDev,

based on the following coding:

1 = very poor; 2= poor; 3 = ok;

4 = good; 5 = very good

Participants were furthermore asked whether (according to their knowledge)

training for new employees existed in their hospital. Responses were inconsistent in

all hospitals except Hospital 4, which showed a 90% agreement rate (Figure 5.11).

Inconsistency as well as frequent selection of the option “Don’t know” can be based

on two aspects: Employees might in fact not know whether new employee training

exists. Taking the high turnover rates in hospitals into account, which necessitate

recurrent integration of new staff into existing teams (and concomitantly transfer of

knowledge), it seems critical that the workforce is aware of new employee training.

As the question did not specify whether on-the-job training was implicated, the

second possibility is that participants were unsure about the question’s precise

intent.

Figure 5.11:

New Employee Training

Existence of training for new

employees as perceived by the

survey participants. Results are


selecting each answer (N.A. =

not answered).

53

As previously described in Table 5.2, the implementation of LHM has

progressed differently in the five hospitals, ranging from creation of some lean units

(Hospitals 1, 2 and 5) to fully lean hospitals (Hospitals 3 and 4).The implementation

status was (on average) estimated correctly by employees of Hospital 1, but was

underestimated by the employees of all other hospitals as illustrated in Table 5.5.

Interestingly, a large number of employees of Hospital 3 (33%) was not able to

answer the question (Don’t know / No Answer).

Table 5:5: Status of LHM Implementation

Status of LHM implementation as perceived by the survey participants (Mean StDev). Coding:

1 = just started; 2= one unit/department, 3 =few units/departments; 4 = entire hospital. n.s.= not

significant


Perceived Status 2.980.63 2.380.72 2.300.82 3.100.84 2.500.67

Real Status 3 3 4 4 3

Statistical Significance n.s. p=0.0034 p=0.0001 p=0.0001 p=0.0261

Percentage No Answer - - 13% - -

Percentage Don’t know - 20% 3% -

In order to better understand whether critical information content had been

transferred successfully to the employees, participants were asked (on 7-Point

Likert Scales) whether a lean vision, the urgency underlying LHM implementation

and the anticipated benefits of LHM implementation were communicated effectively.

Figure 5.12 illustrates that the majority of participants corroborated communication

of a lean vision (Mean = 5.60 to 6.16 / Maximum = 7 if 100% fully agree), but results

were less convincing for Hospital 3 (Mean = 4.07). The substandard outcome of

Hospital 3, which reached statistical significance in comparison to the other

hospitals, results from those employees not having received any information (and

training) about LHM. Note that this pattern recurs in all of the preceding results

(Figures 5.13 to 5.22).

54

Figure 5.12: Communication of the Lean Vision

Level of agreement to the statement “With the information provided, the hospital has communicated a

clear and understandable Lean Vision.” Results are shown as Frequency Distribution (# = 3%) and

Mean StDev. For the calculation of a numerical Mean, the 7-Point Likert Scale was coded (1 = fully

disagree; 7 = fully agree). if p < 0.05 between indicated hospitals.

Figure 5.13 and Figure 5.14 illustrate that employees (in general) had received

information on the urgency of LHM implementation as well as on the anticipated

benefits of LHM, the latter with overall slightly higher rating. For both aspects,

Hospitals 4 and 5 received the best scores, which were significantly higher than for

Hospital 3, but not statistically different from Hospital 1 and Hospital 2.

55

Figure 5.13: Communication of the Urgency for LHM

Level of agreement to the statement “With the information provided, the hospital has made clear why a

change towards a Lean Hospital is required now.” Results are shown as Frequency Distribution (# =

3%) and Mean StDev. For the calculation of a numerical Mean, the 7-Point Likert Scale was coded

(1 = fully disagree; 7 = fully agree). if p < 0.05 between indicated hospitals.

Figure 5.14: Communication of Lean Benefits

Level of agreement to the statement “With the information provided, the hospital has clearly

demonstrated the benefits of moving towards a Lean Hospital.” Results are shown as Frequency

Distribution (# = 3%) and Mean StDev. For the calculation of a numerical Mean, the 7-Point Likert

Scale was coded (1 = fully disagree; 7 = fully agree). if p < 0.05 between indicated hospitals.

56

When asked whether they felt prepared to use LHM as a result of the training

(and information) provided, the vast majority of employees in Hospitals 1, 2 and 4

agreed (83%, 93% and 90%, respectively). In Hospitals 3 and 5, only 43% and 55%

confirmed this statement, and none of the participants selected complete

agreement. The observed differences were underlined by statistical evidence as

shown in Figure 5.15. Employees of Hospital 4 were – according to the results

depicted in Figure 5.16 - particularly encouraged to proactively employ lean

management in their unit/department (Mean = 6.16). Very good results were

furthermore detected in Hospital 2 (Mean = 5.75), whereas active and autonomous

use of Lean was least encouraged in Hospital 3 (Mean 4.36, significantly lower than

Hospital 4).

Figure 5.15: Current Capability of Employees to use LHM

Level of agreement to the statement “Through the training provided, I feel fully prepared to use Lean in

my daily work.” Results are shown as Frequency Distribution (# = 3%) and Mean StDev. For the

calculation of a numerical Mean, the 7-Point Likert Scale was coded (1 = fully disagree; 7 = fully

agree). if p < 0.05 between indicated hospitals.

57

Figure 5.16: Encouragement for proactive use of LHM

Level of agreement to the statement “During the training, it was encouraged to actively and

autonomously improve Lean in my unit/department”. Results are shown as Frequency Distribution (# =

3%) and Mean StDev. For the calculation of a numerical Mean, the 7-Point Likert Scale was coded

(1 = fully disagree; 7 = fully agree). if p < 0.05 between indicated hospitals.

As adoption and utilization of LHM can be influenced by how well its benefit (for

the hospital and specifically for the own work) are understood by employees, these

two aspects were also investigated. In general, employees comparably recognize

the benefits for the hospital and for their own work as depicted in Figure 5.17 and

Figure 5.18. For both types of benefits, highest values were obtained in Hospital 5

and lowest in Hospital 3.

58

Figure 5.17: Perceived Benefits of LHM for the Hospital

Level of agreement to the statement “I can clearly see the benefits of a change towards Lean for this

hospital.” Results are shown as Frequency Distribution (# = 3%) and Mean StDev. For the



Figure 5.18: Perceived Benefits of LHM for the Own Work

Level of agreement to the statement “I can clearly see the benefits of a change towards Lean for my

own work in the hospital.” Results are shown as Frequency Distribution (# = 3%) and Mean StDev.

For the calculation of a numerical Mean, the 7-Point Likert Scale was coded (1 = fully disagree; 7 =

fully agree). if p < 0.05 between indicated hospitals.

59

The following results clarify the level of lean adoption and utilization. Sound

adoption exists if implementation of LHM is seen as a good development and if

employees recommend the use of LHM to other colleagues (working in non-lean

units or non-lean hospitals). In addition, personnel that firmly adopted lean also

intend to use lean in the future (see Figure 5.22). As shown in Figure 5.19, the

statement that implementation of LHM is a positive change received excellent

agreement levels in Hospital 4 and Hospital 6 (Mean > 6) and also quite high

agreement in Hospital 1 (Mean = 5.63). The level of agreement in Hospital 3 (Mean

= 4.0) was significantly inferior to all three hospitals (but not to Hospital 2). A

basically identical pattern (with similar differences between hospitals) was detected

when investigating the willingness to recommend LHM to colleagues not using lean

principles yet (Figure 5.20). However, slightly fewer employees agreed to

recommendation of LHM than to approval of LHM as a positive change. Presuming

that recommendation constitutes a relatively high level of adoption, results indicate

that lean adoption is in progress and still has room for improvement.

Figure 5.19: LHM Adoption, measured by the rating of LHM as a positive change

Level of agreement to the statement “I consider the implementation of Lean in this hospital to be a

positive change.” Results are shown as Frequency Distribution (# = 3%) and Mean StDev. For the



60

Figure 5.20: LHM Adoption, measured by LHM recommendation

Level of agreement to the statement “I highly recommend usage of Lean Principles to my colleagues

that work in non-lean departments or other non-lean hospitals.” Results are shown as Frequency

Distribution (# = 3%) and Mean StDev. For the calculation of a numerical Mean, the 7-Point Likert

Scale was coded (1 = fully disagree; 7 = fully agree). if p < 0.05 between indicated hospitals.

While Hospital 2 was not amongst the best hospitals for the analyzed

parameters thus far, results indicate that it possesses the highest rate of lean

utilization. In fact, 75% of employees fully agree to using lean principles during their

daily work (Figure 5.21). As other adoption and utilization makers are merely

average (or by trend below average) in Hospital 2, this result indicates that LHM is

partially imposed and not fully adopted. Whether this negatively impacts the work

outcome in Hospital 2 cannot be answered with the applied study design. It can

furthermore be noted that employees in Hospital 3 apply lean principles to a

significantly lower degree than the workforce of any other hospital.

61

Figure 5.21: Current LHM Utilization

Level of agreement to the statement “I already use Lean Principles during my daily work.” Results are

shown as Frequency Distribution (# = 3%) and Mean StDev. For the calculation of a numerical

Mean, the 7-Point Likert Scale was coded (1 = fully disagree; 7 = fully agree). if p < 0.05 between

indicated hospitals.

The proportion of employees anticipating to use LHM in the future plays an

essential role in change sustainability and can be seen as a marker of both

utilization and adoption. Future application of lean principles was rated highest in

Hospital 4, with 45% fully and 29% of employees strongly stating that they will

enhance utilization of LHM in the time to come. In contrast, Hospital 3 showed the

lowest scores and may hence encounter the highest sustainability problems.

Hospital 2, which was characterized by very high current utilization, showed a trend

for below-average scores for future application, with 50% giving a neutral or

negative response (Figure 5.22).

62

Figure 5.22: Anticipated LHM Utilization

Level of agreement to the statement “In the future, I want to further enhance utilization of Lean

Principles in this hospital.” Results are shown as Frequency Distribution (# = 3%) and Mean StDev.

For the calculation of a numerical Mean, the 7-Point Likert Scale was coded (1 = fully disagree; 7 =

fully agree). if p < 0.05 between indicated hospitals.

63

5.2.3. Correlation between Information, Training, Utilization & Adoption

In order to test whether a dependency exists between lean information, training,

utilization and adoption, correlation analyses were performed. Following commonly

applied guidelines for correlation interpretation (Brosius, 1998), a Pearson

Correlation Coefficient (R) > 0.4, indicative of a moderate or higher correlation, was

set as a minimum baseline. Correlations with R > 0.6 (= strong correlation) or R >

0.8 (= very strong correlation) will be emphasized explicitly. Exact Pearson

Correlation Coefficients and p-values are listed in Appendix A17 for completeness.

In addition to the variables that can be directly taken from the questionnaire (i.e.

single questions), an information score and an adoption score were calculated. The

information score was calculated as the Average of Questions 6, 7 and 8, which (in

conjunction) aimed at identifying to what degree critical content (lean vision,

urgency, and benefits) had been conveyed during information transfer. The same

technique was applied to generate an adoption score for each participant, based on

Questions 19, 20 and 22. These questions rate the employees’ agreement to lean

being a positive change for the hospital (19), the employees’ willingness to

recommend lean to colleagues (20) and the intention to use lean principles in the

future (22).

Table 5.6 illustrates that the quality of the information provided significantly

correlates with all of the investigated variables. As one might expect, enhancement

of the information quality influences how convincing a hospital can communicate its

lean vision, the urgency of change and the anticipated lean benefits and to what

degree it can encourage employees to use lean proactively. Importantly, there is a

correlation between the information quality and the perceived benefits for the

hospital (moderate) and for the own work (strong). All other variables related to

adoption and utilization of lean (including the Adoption Score) show a moderate, but

significant dependency of the information quality. The quality of lean training

correlates with the perceived benefits of lean (hospital, own work), the intention to

(proactively) use lean principles in the future and the overall lean adoption.

64

Table 5:6: Results of Correlation Analysis, with Information Quality and Training Quality as Test Variables

Results show the Pearson Correlation Coefficient to illustrate the level of dependence between

reference points (top row) and variables (left column). Statistical significance was reached whenever

≥ weak correlations were detected. N.A. if test for correlation was not applicable.

Information Quality Training Quality

Vision (communicated) moderate N.A.

Urgency (communicated) moderate N.A.

Benefits (communicated) moderate N.A.

Proactivity encouraged moderate moderate

Benefits for hospital (recognized) moderate moderate

Benefits for own work (recognized) strong moderate

Lean = positive change moderate moderate

Recommendation of lean moderate weak

Utilization (daily work) moderate weak

Future utilization moderate moderate

Information Score moderate N.A.

Adoption Score moderate moderate

The information content (i.e. vision, urgency, benefits) considerably affects the

extent to which employees perceive lean to be an overall positive change (with

benefits for the hospital and themselves) and furthermore shows (in almost all

cases) a strong correlation with the remaining aspects of lean adoption

(recommendation of lean to others, Adoption Score). The intention to use lean

principles in the future is also strongly associated with the information content,

whereas the current utilization shows less interconnection. Naturally, all three

65

variables show very strong dependency to the Information Score (= average of

vision, urgency and benefits), emphasizing the validity of the score (Table 5.7).

Table 5:7: Results of Correlation Analysis, with Information Content (Vision, Urgency, Benefits) as Test Variables




Vision Urgency Benefits

Urgency (communicated) strong N.A. N.A.

Benefits (communicated) strong very strong N.A.

Proactivity encouraged strong strong strong

Benefits for hospital (recognized) strong strong strong

Benefits for own work (recognized) strong strong strong

Lean = positive change strong strong strong

Recommendation of lean strong strong moderate

Utilization (daily work) moderate moderate moderate

Future utilization strong strong strong

Information Score very strong very strong very strong

Adoption Score strong strong strong

Encouragement of active and autonomous application of lean principles during

the daily work positively affects the recognized benefits of lean and contributes to

employees considering implementation of LHM as a positive change (Table 5.8). In

accordance, testing demonstrated a strong association between encouragement of

proactivity and lean adoption as well as future use of lean, whereas current practice

of lean is only moderately correlated. Results furthermore indicate that employees

66

acknowledging the beneficial nature of LHM for the hospital are more likely to

realize the benefits of lean for their own work (very strong correlation), but no

cause-effect statements can be made from the correlation data. A high perception

of lean benefits (for the hospital or for the own work) strongly correlates with lean

adoption (lean seen as positive change, recommendation of lean to others,

Adoption Score) and the intention for future utilization. Concerning the current use

of lean, a previously observed pattern (for the variables training quality and

information content) reoccurs: Although a significant correlation between perceived

benefits and the current use of lean exists, the correlation coefficient is lower than

for future utilization (benefits for the hospital: 0.549 versus 0.702; benefits for the

own work: 0.538 versus 0.780).

Table 5:8: Results of Correlation Analysis, with Proactivity, Perceived Benefits for the Hospitals and Perceived Benefits for the Own Work as Test Variables




Proactivity

encouraged

Benefits for

hospital

Benefits for

own work

Benefits for hospital (recognized) strong N.A. N.A.

Benefits for own work (recognized) strong very strong N.A.

Lean = positive change strong strong strong

Recommendation of lean strong strong strong

Utilization (daily work) moderate moderate moderate

Future utilization strong strong strong

Information Score strong strong strong

Adoption Score strong strong very strong

67

Table 5.9 illustrates to what degree lean adoption variables (lean seen as a

positive change, lean recommended to others) and lean utilization correlate with the

other test parameters. As one might expect, consideration of LHM as a positive

change and recommendation of LHM to colleagues are very strongly correlated.

Both variables are also very strongly associated with the intention to use lean in the

future, but only moderately correlated to the de facto current use of lean principles.

Utilization of lean during the daily work correlates moderately with all depicted

variables. As the aspects concerning positive change and recommendation are both

included on the lean Adoption Score, the very strong dependency amongst these

variables is obvious and only confirms the validity of the score. Furthermore, the

adoption score shows a very strong correlation with the intention for future utilization

of lean (not shown).

Table 5:9: Results of Correlation Analysis, with Level of Adoption (Lean = Positive Change, Recommendation of Lean) and Current Utilization of Lean as Test Variables


reference points (top row) and variables (left column). Statistical significance was reached whenever ≥

weak correlations were detected. N.A. if test for correlation was not applicable.

Positive Change Recommend. Utilization

(daily work)

Recommendation of lean very strong N.A N.A.

Utilization (daily work) moderate moderate N.A.

Future utilization very strong very strong moderate

Information Score strong strong moderate

Adoption Score very strong very strong moderate

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5.2.4 Relations between Information, Training, Utilization & Adoption

In the next step, it was determined whether a (positive or negative) relation

exists between lean information, training, utilization and adoption. To do this,

specific dependent and independent variables were chosen and subjected to a

regression analysis. Different from the correlation analysis, this approach allows

determination of whether the independent variables influence the outcome of the

dependent variables. More specifically, the algebraic sign of the Standardized

Regression Coefficient β indicates whether a positive or negative connection exists.

Table 5.10 summarizes the dependent and independent variables used in the

regression analysis.

Table 5:10: Dependent and Independent Variables.

Dependent and independent variables used in the Regression Analysis, which tests whether independent variables (e.g. quality of information) impact the outcome of the dependent variables (e.g. current utilization of lean principles).

Dependent Variables Independent Variables/Predictors

Current utilization of lean principles (Q21) Quality of Information (Q5)

Intended future utilization of lean principles (Q22) Quality of Training (Q13)

Adoption Score (Average of Q19, Q20, Q22) Information Score (Average of Q6, Q7, Q8)

Benefits of the Hospital (recognized) (Q17)

Benefits of the Own Work (recognized) (Q18)

Improvement of the quality of information leads to higher recognition of lean

benefits for the own work (β = 0.269, p =0.046), but has no direct effect on the

adoption of lean, the current/future utilization of lean or the recognition of lean

benefits for the hospital, although a correlation exists to all of these aspects.

Good training marginally increases the perceived benefits for the hospital (β =

0.229, p =0.060) and own work (β = 0.206, p =0.085), but has no direct effect on

adoption or utilization although a correlation exists.

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Appropriate communication of a lean vision, lean urgency and lean benefits

during information directly and strongly induces the level of perceived benefits for

the hospital and the own work (β = 0.467, p =0.000 and β = 0.351, p =0.002) as well

as lean adoption (β = 0.444, p =0.000) and the intention for future utilization of lean

(β = 0.403, p =0.001).

Importantly, none of the variables has any effect on the current utilization of lean

principles, hence illustrating the mandatory nature of de facto utilization.

5.2.4. Effects of Employee Demographics on Lean Utilization & Adoption

In the survey, participants were asked to indicate their age (from a set of given

ranges), years of professional experience (from a set of given ranges) and

profession. These demographic characteristics were correlated with the agreement

of participants to lean being a positive change, to the current as well as future

utilization of lean as well as to the lean Adoption Score.

Age was shown to significantly correlate with the perception of LHM

implementation as a positive change ( = 0.309, p =0.002), the level of overall

adoption ( = 0.287, p =0.005) and the intention to use lean principles in the future

( = 0.261, p =0.012). As illustrated by the correlation coefficient , all of these

aspects increase with increasing employee age. As expected, age also strongly

correlates with the professional experience ( = 0.776, p =0.000).

Similarly, the level of professional experience (measured in years) correlates

with the approval of LHM (LHM = positive change; = 0.281, p =0.006) and the

adoption score ( = 0.223, p =0.029) while the association with intended future use

did not reach significance.

The type of profession (physician, nurse, administration) does not affect the

perception of LHM implementation as a positive change, the current use of lean, the

intended future use of lean or the adoption score. Importantly, none of the variables

(age, professional experience, profession adoption score) correlates with the actual

utilization of lean principles.

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6. Conclusion

6.1. Summary of Main Findings

Implementation of LHM

The information gathered during personal interviews clearly identified

consistencies (but also dissimilarities) related to LHM implementation amongst the

participating hospitals. Implementation of LHM was comprehensively seen as a

suitable means to ensure sustainability after the launch of DRG-based

reimbursement in Switzerland. Cost reduction through elimination of waste (in

combination with the development of standardized and efficient work processes), as

well as increased patient satisfaction, safety and interaction, were named as

desired outcomes by all hospitals, albeit with slightly different emphases.

Stimulation of employee satisfaction through increased interaction time with the

patients, reduced time for administrative tasks (through increased efficiency), less

overtime accumulation and enhanced individual responsibility and a consequent

decline in staff fluctuation was also often identified as a prime goal of LHM. The

herein collected data therefore confirm published literature describing LHM as a

route to competitive advantage by cost reduction and enhancement of customer

satisfaction, thus combining the strategies of “cost leadership” and “differentiation”,

despite their being described as mutually exclusive by Michael Porter in the 1980s

(Porter, 1980, Porter, 1985, Kabst et al., 1996, Poksinska, 2010).

In order to improve the outcome of LHM implementation, all hospitals sought

assistance from lean consultants, who helped to train the Lean Management Team,

provided documents (information and training material, forms, etc.) and in some

cases took over certain aspects of staff information and training. The consultancy

time frame however differed between hospitals (from initial involvement to long-term

appointment), mostly depending on the available manpower attributable to the

internal Lean Management Team. However, lean knowledge was always

transferred from consultants to the Lean Management team to ensure in-house

skills to drive continuous improvement as recommended in multiple publications

(Ballé and Régnier, 2007, Kaplan and Patterson, 2008, Aherne, 2007).

71

Apart from the consultancy timeframe, differences were furthermore noted

concerning the existence of line managers. As lean organizations are typically

characterized by lower hierarchies and increased delegation of responsibilities to

single units, which then follow the principle of self-organization, the relevance of line

management has been emphasized in the literature (Sager, 1993, Knyphausen,

1991, Reiss, 1993). In some of the hospitals investigated (Hospitals 1, 2 and 4), line

management was created through nomination of Lean Administrators on each lean

unit. In contrast, no such structure was present in Hospital 3 and Hospital 5 at the

time of data collection.

All interviewees confirmed that implementation of LHM induced positive

changes, but most changes stemmed from “soft” areas, such as enhanced

interdisciplinary collaboration. Effective measurability of the outcome of LHM was

lacking in all hospitals, causing Lean Managers uniformly to request suitable tools to

objectively measure specific key performance indicators. Lean Managers also

repeatedly raised concerns about achieving cultural changes and sustainability of

LHM.

Lean Information

Questionnaire results illustrate that a 100% information rate was reached in four

of five Swiss hospitals, identical to the Virginia Mason, the vanguard of LHM

(Womack et al., 2005). Only in Hospital 3 did not all participants feel informed. The

majority of employees rated the amount of information, which was provided though

assemblies, personal meetings and in written form, as appropriate.

The quality of information was rated as good in all hospitals but Hospital 3,

whose score was downgraded by those employees that felt completely uninformed.

Importantly, effective communication of specific information content (vision,

urgency, benefits) was shown to enhance the perceived benefits of LHM (for

hospital and for own work), lean adoption and future lean utilization. Information

quality per se is also important, but only has direct effects on the perceived benefits

for the own work.

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Lean Training

In the cases investigated, lean training was achieved at varying degrees. In

Hospital 2 and 4, (almost) 100% of interviewed employees received training. In

contrast, all other hospitals showed training shortcomings, resulting in criticism from

the workforce. The applied training tools, as well as the quality of the training (as

perceived by the employees that had received training), were fairly similar, probably

because creation and establishment of employee training was supported/conducted

by lean consultants in all five hospitals. In all hospitals, training incorporated theory-

based approaches (talks by consultants and colleagues) to explain and illustrate

lean tools to be applied in subsequent experiential (practical) training sessions with

a high relevance for the daily work, e.g. workshops, Gemba walks, Huddle Boards

or simulations.

Results of this study not only underline that training quality correlates with

adoption and future utilization of lean principles, but also demonstrate that good

training directly enhances the perceived benefits for the hospital and the own work.

Furthermore, the importance of emphasizing proactivity to further enhances

adoption, commitment, engagement and hence sustainability became evident.

6.2. Interpretation and Significance of the Data Obtained

Lean Management

Lean organizations commonly appoint one of more Lean Managers to oversee

the overall implementation of LM. Previously published literature however also

emphasizes the relevance of additional line managers (e.g. Lean Administrators) in

lean organizations to ensure efficient delegation of responsibilities throughout all

levels. Results obtained in this study support this notion.

In Hospital 3 (without unit-based Lean Administrators), several of the survey

participants indicated that they had not received any information and training, and

were even not familiar with the term LHM, resulting in low adoption and

(current/future) utilization of lean principles. Due to the absence of unit-based Lean

Administrators, all communication related to LHM had to be undertaken by the Lean

Manager (i.e. the highest level of Lean Management), which is unrealistic in a large

73

hospital, especially if a progressive implementation (in one fell-swoop) is chosen

rather than a successive implementation approach, as was the case.

In Hospital 5 (also without unit-based Lean Administrators), implementation of

LHM in was neither swift nor efficient (2 units, < 2 years) due to a lack of lean

manpower - especially on the units themselves. Furthermore, the number of

questionnaires collected in Hospital 5 was exceptionally low, which may indicate

that only a certain ratio of employees in the analyzed units are committed (with

above-average scores), whereas remaining (non-responding) employees have very

little interest in LHM. Absence of unit-specific Lean Administrators that also function

as role models, motivators and leaders, can negatively affect engagement and

commitment amongst the team (Sager, 1993, Knyphausen, 1991, Reiss, 1993).

However, additional data are necessary to confirm this hypothesis.

The number of appointable Lean Managers and Administrators - together with

the size of the hospital - should also determine which implementation approach

(successive versus progressive) is selected. Progressive implementation of LHM is

an excellent method to streamline progress in an entire hospital, but requires

sufficient manpower to inform (and train) all employees. Although progressive

implementation can yield excellent results as demonstrated by the small Hospital 4,

opting for successive implementation with in-depth introduction of LHM in selected

units may be expected to be safer and ultimately more successful in most cases (as

shown by the negative results of progressive Hospital 3). Successive

implementation requires however that lean units do not form separate islands which

are excluded from the hospital entity. With an increasing incidence of cross-

divisional work, especially in case of patients with complex diseases or multiple

comorbidities, protection of strenuously developed cultural changes towards lean

(which is in stark contrast to normal hospital culture) needs to be emphasized (Kim

et al., 2007, Alkalay et al., 2015, Ballé and Régnier, 2007, Laursen et al., 2003).

Transfer of Lean Information

It has previously been described that lean organizations are generally

characterized by higher information transfer (as measured by the frequency of team

briefings) as their non-lean counterparts because employees have to resume higher

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681949/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1681949/

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levels of autonomy and individual responsibility. In fact, very high rates of

information amongst employees could also be confirmed in this study. Interestingly,

some Lean Managers (especially in Hospital 1 and 4) stated that the amount of

information felt rather excessive, but only very few employees confirmed this

perception. It was however more common for employees to criticize a lack of

information, indicating that assessments of information quantity can ultimately differ

between employees and Lean Managers.

Apart from the amount of information provided, results of this study indicate that

the timing is also essential. Published works suggest including high-level

management in the strategic planning and informing middle management and (at

least) workers directly involved in a timely manner (i.e. before the start of pilot

projects). This enhances a positive outcome of organizational changes. Little

evidence however exists that factually supports this statement (Wittek et al., 2014,

Quirke, 1995).

Findings from Hospital 5 (collected during the interview) confirm this

recommendation. While employees working in the pilot units (to which the survey

was distributed) were informed through lean consultants before the project start and

later repeatedly by the Lean Manager, managerial staff received the first official

information approximately 6 months after the start of the pilot projects. At that time,

details about problems in one of the pilot projects had already spread through the

middle management squad, causing challenging and provocative debates during

the event and subsequent resistance amongst the leadership personnel. Major

efforts were needed to reverse attitudes towards LHM in the following months and it

is unclear to what degree Lean Management has ultimately succeeded.

Information quality and information content (specifically with regard to lean

vision, urgency and benefit) were identified as enablers of successful LHM

implementation by positively affecting lean adoption and utilization, specifically

future intended use (see also “Sustainability of LHM”).

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Training in Lean Hospitals

Recent studies demonstrate that training and development of employees is

typically higher in lean than in non-lean organization and that the outcome of lean

can in fact be enhanced through appropriate education. In this study, training rates

were found to be different among the five hospitals, but it is unclear how these rates

compared to “normal” hospitals. However, it was noted that training was provided at

all hierarchical levels as commonly observed in lean organizations.

An important finding also is that the quality of training correlates with adoption

and utilization scores. Greater success with training may be explained by the fact

that educated employees can become problem-solvers that fix waste-related issues

rather than working around the obstacles. As training in lean organizations is

commonly used to gain first-hand experience of lean benefits and hence induce

adoption and commitment, training it is often on-the-job or experiential. Experiential

training, e.g. in the form of kaizen events in which employees become involved in

characterization of current processes and subsequent development and

implementation of changes, ensures permanent skill improvement with direct

relevance to the daily work, consolidation of lean thinking and self-actualization

through empowerment (Benson and Dundis, 2003, Deppe, 1993, Ballé and Régnier,

2007, Spear, 2005, Kabst et al., 1996, Mazzocato et al., 2010, Nelson et al., 2007,

Alkalay et al., 2015, Kaplan and Patterson, 2008, Young and McClean, 2008, Zidel,

2006).

Measuring the Success of LHM

Data collected during interviews with Lean Managers highlight the problem of

how to best measure the success of LHM implementation – a topic that has gained

increasing interest in the most recent publications on lean healthcare. The efficiency

of the patient care chain and thus lead times in lean hospitals can be objectively

quantified by the flow model, a system that measures the temporary occurrence of

eight typical stations in patient care (e.g. demand for care, booking, first visit, etc.).

However, measurement systems that can reliably and reproducibly detect other

important aspects, such as patient satisfaction, are also urgently needed.

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Lean Managers should emphasize the establishment of such tools not only to

prove the success of LHM (e.g. related to productivity, costs, through-put, quality,

inventory or patient satisfaction and safety) to the hospital management, but also to

assure employees of the positive effects of their efforts (Womack et al., 2005, Lawal

et al., 2014, Mazzocato et al., 2012, Kollberg et al., 2006, Mazzocato et al., 2010,

Philips Healthcare, 2011).

Sustainability of LHM

A common concern in the investigated Swiss hospitals is the sustainability of

LHM. Sustainability can only be reached if engagement, adoption and commitment

of employees are achieved, e.g. through active, creative and self-dependent

involvement as well as training and knowledge. Furthermore, comprehensive

changes in the organizational culture - with an emphasis on continuous questioning

and improvement that is free of blame - are necessary (Ballé and Régnier, 2007,

Chalice, 2007, Spear, 2005, Kim et al., 2007, Mann, 2010, Aherne, 2007, Kaplan

and Patterson, 2008, Poksinska, 2010).

In this study, adoption and utilization were measured as indicators of LHM

outcome and sustainability as previously described in the literature (Womack et al.,

2005, Pöhls, 2011). Overall, good adoption and utilization scores were detected and

these were found to be affected by numerous factors.

Lean adoption, utilization and sustainability are determined by the information

quality, specifically by how well the hospital was able to convey a lean vision. In

fact, communication of a lean vision, ideally by inspirational leaders that

demonstrate strong executive support, is thought to induce excitement,

engagements and inspiration amongst employees.

Demonstration of the urgency underlying LHM implementation and the

anticipated beneficial outcome of LHM were also identified as crucial aspects. For

LHM, the sense of urgency is – at least in Switzerland – rooted in changing

reimbursement formats, which lead to increasing financial pressure and endangered

sustainability of hospitals. While it is important to emphasize that the well-being of

the hospital (and with that job security) is under threat, it is also crucial to highlight

the benefits of LHM and thus identify LHM as a suitable countermeasure.

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Results of this study furthermore identify a certain importance of training quality

for the level of adoption and (future) utilization. Hospital 3 for example not only

received the lowest training quality score, but also achieved significantly lower

adoption and utilization than the other hospitals.

Apart from training quality, the encouragement of proactivity during training (or

information) strongly correlates with adoption and utilization – a finding that has also

been confirmed by others. An excellent example for the relevance of proactivity

encouragement is Hospital 4, which was not only the most efficient in promoting

proactive use of lean, but also the reached highest scores for recommendation of

lean and intention for future use of lean amongst all five hospitals.

Results of this study also point out that high levels of current implementation of

LHM are not necessarily a predictor of future utilization and hence sustainability. In

Hospital 2, current utilization was ranked exceptionally high, whereas intended

future use received significantly lower scores. In cases of mandatory organizational

change, current utilization may simply constitute imposed use (with little adoption

and commitment), with a high risk of decreasing job satisfaction and loyalty,

potentially with sabotage-like behavior. In contrast, the intention to utilize LHM in the

future is a tool to detect adoption and commitment and hence to distinguish

voluntary from forced use and sustainable from non-sustainable implementation. In

fact, extensive research has demonstrated that intended behavior is translated into

actual behavior in the majority of case, illustrating that future use intention

constitutes a good behavior predictor with adequate correlative power.

Importantly, these findings, interpretations and conclusions depicted in the

preceding paragraphs are supported by numerous other publications (Ajzen, 1991,

Pöhls, 2012b, Rogers, 1983, Brown et al., 2002, Caudron, 1995, Macy et al., 1995,

Martin, 1994, Kabst et al., 1996, Mazzocato et al., 2010, Kotter, 1995, Kotter, 2008,

Andersen et al., 2014, Womack et al., 2005, Teich and Faddoul, 2013, Feng and

Manuel, 2008, Philips Healthcare, 2011, Cummings and Worley, 2015, Rutledge,

2009).

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The Effect of Employee Demographics

Interestingly, all Lean Managers stated in the interviews that it felt more difficult

to involve and convince physicians than nurses or administrative personnel. The

results of our study however do not show any profession-specific differences in lean

adoption or utilization and this finding was confirmed by unpublished data from

other Swiss researchers. However, it was noted that the number of physicians

participating in the survey was relatively low in most hospitals (11% across all

hospitals). This may not only distort the statistical analysis (large differences in

profession-specific group sizes), but might also indicate that only a small proportion

of physicians was sufficiently committed to lean to fill out the questionnaire. Without

additional interviews with physicians working on the respective units, this statement

is however purely speculative. Nevertheless, it is important to remember that

involvement of physicians, who often function as opinion leaders and role models in

hospitals, is crucial for the success of LHM implementation.

Another finding worth pointing out is the correlation between employee age (and

professional experience) and lean adoption and utilization, with older employees

showing higher adoption and utilization scores. This is contrary to common

stereotyping which assigns higher change resistance and lower adaptability to new

techniques to older employees. However, several change management studies

confirm und underline the finding herein described, with age being inversely

correlated with resistance to change. When critically evaluating lean adoption, Lean

Managers and Administrators should not solely focus on older employees, but

should also – and with special emphasis – investigate younger employees. The

lower scores of young employees, which may have joined the hospital recently, may

also be related to the lack of training designed for new employees.

Similar effects of employee demographics during organizational (lean) change

were also reported by some other authors (Angerer, 2015, Kunze et al., 2013, Chiu

et al., 2001, Heinrich, 2004, Andersen et al., 2014).

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6.3. Study Limitations

One of the limitations of this study is the bias that Lean Managers may have

brought to the data gathering process. Lean Managers not only provided

information on the process of LHM implementation, but also selected participating

lean units and initiated distribution of questionnaires to employees. Although special

care was taken to elucidate issues and problems in LHM implementation during the

interviews, Lean Managers may have (consciously or unconsciously) described the

process in an unrealistic positive manner to enhance self-presentation and conjure

a favorable image of the hospital. In addition, selection of participating units and

survey participants within these units may have been less objective and systematic

than purported, possibly resulting in non-representative samples and bias of the

data (Poria, 2004).

Data obtained in this study may furthermore be affected by response bias. As

the total number of possible participants in the different units is unknown, the

response rate cannot be estimated. However, analysis of the number of returned

surveys indicates that the response rates in some hospitals (e.g. Hospital 5) must

have been relatively low, despite repeated reminders. Non-responders may reflect

lower organizational commitment, job satisfaction and job identification, leading to

an overestimation of results as described in the literature. Specifically approaching

absentees to identify their reasoning for not participating would shed light on the

degree of bias. Bias may nonetheless occur from the group of respondents. It is

also possible that an overly high percentage of extremely dissatisfied employees

(e.g. Hospital 3) participated in the survey, who were finally given the chance to

express their displeasure with the processes of LHM implementation anonymously

(Rogelberg et al., 2000, Tomaskovic-Devey et al., 1994, Groves, 2006, Baruch and

Holtom, 2008).

Despite a test run with healthcare professionals, it was noted that specific

questions posed problems, either for the respondents or for data evaluation.

Questions related to the quantity of information and training provided (Q4/Q12 with

scores too little = -1, appropriate = 0, too much = 1) would have better been

80

structured for score linearity (similar to quality ratings), hence permitting suitable

correlation and regression analysis.

Q16, which enquired on the encouragement of proactive use of lean principles,

was included under training. However, questionnaires returned indicated that

employees were also urged to use lean autonomously and actively during

information events (or in the written information material). It is unclear whether all

employees scored proactivity promotion by taking information and training into

account, or whether some employees only focused on training while ignoring

encouragement of proactivity during information transfer.

Another weakness of the survey is related to the basic assumption that all

employees working in lean units are familiar with the concept of lean (not true for

Hospital 3). As questions did not include an option for lean ignorance, several

employees of Hospital 3 left numerous questions unanswered. In order to include

this important finding in the results, unanswered questions were assigned the

respective lowest score ex post for appropriate topics (quantity/quality of

information, information content, lean adoption and utilization). This may however

have distorted the overall results. In future surveys, the possibility that employees

lack any lean knowledge despite working in lean units should be taken into account

and appropriate answer options should be provided.

In this study, hospitals from a confined regional area (German-speaking part of

Switzerland) were included. Therefore, transferability of the results to other regions

or countries is not certain. In future experiments, data should also be gathered from

hospitals in other areas of Switzerland and other European countries with similar

healthcare systems (e.g. Germany, Austria) to confirm transferability and thus

enhance the study impact.

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6.4. Answers to the Research Questions

In Table 6.1, the research questions posed on Page 11 will be succinctly

answered. Detailed information related to each point can be found in preceding

chapters 6.1 to 6.3.

Table 6.1: Research Questions and Answers

Question Answer

1. Which methods

are/were used by the

Swiss hospital to

provide lean information

and lean training to their

staff and which

employees are/ were

informed/ trained?

Information for employees was mostly delivered

via assemblies and personal meetings. Written

information was additionally provided in all

hospitals. In only one hospital, the information

event was mandatory. Four hospitals managed

to inform 100% of employees (working in lean

units). New employees are typically informed

during orientation events.

Various types of lean training (described in the

lean literature) were offered in all hospitals.

Although theory-based training (talks) was

conducted, experiential training was specifically

emphasized. Lean training was offered to

employees of all hierarchical levels and

professions, but the percentage of trained

employees differs strongly between hospitals. In

only one hospital, new employees are offered

specific training options, whereas all other

hospitals give on-the-job training.

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2. Is there a correlation

between the quality of

the information and

training provided and

the lean adoption and

utilization by em-

ployees?

Information and training quality were correlated

with lean adoption and future utilization, but did

not directly lead to higher adoption and

utilization. However, information content, i.e.

effective communication of vision, urgency and

benefits, directly induced lean adoption and the

intention for future utilization of lean (but not

current utilization).

3. Which information and

training methods are/

were successful in

creating lean adoption

and lean utilization by

employees?

Information provided to employees was

successful when it emphasized the aspects

vision, urgency and benefits to effectively induce

lean adoption and utilization. It proved crucial

that hospitals inform all affected employees

about LHM as non-informed employees tend to

show high resistance. Experiential training that

allows employees to see the benefits of LHM

first-hand also supported lean adoption and

(future) utilization. Better outcome was achieved

when proactive use of lean principles was

emphasized during training. Ample and

continuous training possibilities to (ideally) all

employees, including new employees, provided

higher adoption.

4. Which employee cha-

racteristics (age, pro-

fession, years. of prof.

experience) lead to the

highest degree of lean

adoption and lean

utilization?

Older employees and employees with more

professional experience not only tended to value

LHM more favorably, but also showed higher

lean adoption and intended future utilization. No

differences in lean adoption and utilization were

found between professions.

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The results obtained hence confirm most of the study hypotheses: Suitable lean

information (specifically with regard to content, i.e. communication of vision,

urgency and benefits) increases the perceived benefits of LHM (for the hospital and

the own work) and leads to higher adoption and intention for future utilization.

Although training quality showed overall weaker direct effects, better training

marginally increased the perceived benefits of LHM (hospital and own work).

Contradictory to the hypothesis, information and training have no direct effect on

current utilization of lean principles. Age (as well as profession experience) affects

lean adoption and utilization (increasing scores with increasing age).

6.5. Recommendations (Suggestions on LHM Implementation)

In Table 6.2, the ten most relevant recommendations for the implementation of

LHM based on the findings of this study – are summarized.

Table 6.2: Recommendations for the implementation of LHM

Nr. Recommendation

1. Progressive vs Successive Implementation: Large hospitals should

implement LHM using a successive approach to be able to provide sufficient

information and training to employees. Small hospitals are advised to choose

progressive (one fell-swoop) implementation if (and only if) they have

adequate manpower to guarantee adequate communication with the entire

workforce as well as ample training options in the early implementation

phases.

2. Early Training and Information: Ensure early training and information of the

upper management to warrant full understanding and support of the hospital’s

lean vision.

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3. Unit Lean Administrators: Appoint line managers, e.g. unit-specific Lean

Administrators to enhance information flow and comprehensive training of all

group members. Choose Lean Administrators based on voluntarism,

engagement and good communication skills (with all professions). Provide

extensive training to Lean Administrators as these will be the main faces of

LHM in each unit.

4. Inform Widely: When opting for a successive implementation, do not only

inform employees of the affected units in a timely manner, but also provide

information to all middle management early on. Thoroughly select

communication style and content as early mistakes are difficult to reverse.

5. Mandate Basic Information: Make the employee information event

mandatory to ensure basic lean knowledge of all affected employees. If

necessary, offer two information events at different times to reach all

employees.

6. Vision, Urgency & Benefits: With the information provided, emphasize the

lean vision, the urgency underlying lean implementation as well as the

anticipated lean benefits (for hospital and employees), as this will increase

adoption and future utilization of lean. Take into account that employees tend

to perceive information at a lower level of importance than Lean Managers

and Administrators

7. Theoretical vs Experiential Training: Provide theoretical training (e.g. talks)

so that employees understand lean concepts and tools, but emphasize

experiential training. Experiential training that allows employees to experience

the benefits of lean first-hand increases lean adoption and utilization,

specifically intended future utilization. Ensure cross-functionality, involvement

of all professions and continuity of the training.

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8. Praise Progress: Increase self-esteem and self-actualization (and hence

motivation) in employees by supporting proactive use of lean principles during

information and/or training and by praising successes (e.g. on Huddle

Boards).

9. Check Progress: Regularly control lean adoption through small surveys.

Questions elucidating the intention to use lean principles in the future and the

willingness to recommend lean to colleagues are good indicators of lean

adoption and commitment.

10. No False Assumptions: Do not credulously assume that…

… Young employees show higher adoption than older employees.

….Current use of lean principles is per se by conviction and hence

sustainable.

…Employees will conduct non-mandatory eLearning because it is easy

to use.

86

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Appendix

A1. Demarcation of LM to Just-in-Time (JIT), 5S and Six Sigma

The following paragraphs provide additional information to Chapter 3.2.1.

Just-in-Time (JIT)

Just-in-Time (JIT), which also has its origin in Japan, became part of the

strategy applied in the Toyota Production System, where it formed one of the

essential pillars of LM. While JIT aims predominantly at increasing efficiency (by

reducing inventory), LM strategies aim to use increased efficiency to offer products

with increased value for the customer by reducing any waste (and that also includes

inventory). JIT can hence be a stand-alone production strategy, but is also one of

the main concepts of LM which shall reduce buffers between steps. (Shah and

Ward, 2007, Biazzo and Panizzolo, 2000).

JIT strategies try to reduce or eliminate inventory at all stages in the production

process, hence also decreasing carrying costs and therefore increasing the

company’s profit. However, in order to be able to apply JIT successfully, the raw

materials required for the work processes have to be constantly available at very

similar quality and costs. Reliability of suppliers hence becomes essential (Hutchins,

1999, Hirano et al., 2006, Ohno and Mito, 1988).

As hospitals are service companies (in contrast to production companies), JIT is

primarily related to minimizing internal queues of patients as well as a reduction in

excessive medical inventory (Brandao de Souza, 2009, Liker, 2004, Casey et al.,

2009).

5S

5S is a Japanese work approach that aims to reduce waste in the workplace,

predominantly by keeping it clean and in order. As indicated by the name, 5S is

based in five columns, which can be translated as Sort (Seiri), Set in Order (Seiton),

Shine (Seiso), Standardize (Seiketsu), and Sustain (Shitsuke). Although 5S can be

applied separately, it is also often one of the first procedures being applied when

98

implementing LM. By employing 5S, work material will for example be assigned a

useful storage space to avoid unnecessary search time (Moulding, 2010). However,

effective translation of Muda in LM also requires scrutinizing and questioning work

processes, leading to a more far-fetching structural change than 5S-based

workplace cleaning/structuring.

In the hospital setting, 5S not only eradicates the need to search for supplies

and materials, but also enhances the professional appearance of the hospital units

through reduction in waste and cluttering. By a better organization of e.g. the

medicine cupboard, mix-ups with regard to drugs or dressing material can be

avoided and patient safety increased.

Six Sigma

Six Sigma is a management approach that aims to improve products or services

by identifying defects and minimizing their occurrence. As a quality control concept,

Six Sigma aims to achieve success rates of 99.9997% by applying statistical tools

and techniques that had previously been successfully employed in Total Quality

Management (TQM). TQM was originally applied in Japan by W. Edwards Deming,

with the goal to improve the reputation of Japanese products and to ensure high

customer satisfaction. Although Japanese TQM was contemplated critically by other

nations, it was finally introduced successfully in the US in the 1980s and was

followed a decade later by Six Sigma, which puts emphasis on the fast completion

and financial measurability of quality enhancements (Kwak and Anbari, 2006,

Anbari, 2002, Antony and Banuelas, 2002, Black and Revere, 2006, Deming, 1986,

The W. Edwards Deming Institute, 2015). While Six Sigma and TQM focus on the

reduction of defects and also hence variation in the production process, LM

eliminates waste and improves process flow. Therefore, both methods aim to

ultimately increase customer satisfaction, despite having a different focus. With their

complementarity, LM and (Six) Sigma are often combined, resulting in a strategy

that is commonly known as Lean Six Sigma (George et al., 2006).

When Lean Sigma is applied in hospitals, the focus is to reduce the number of

errors and hence improve patient care by enhanced quality control. As errors can

have substantial consequences in a hospital setting, possibly even leading to

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patient death, error avoidance and patient safety are in fact central aims of LM in

hospitals. Thus, Lean hospitals mostly apply a combined approach (i.e. Lean Six

Sigma), although the strategy is often entitled LM for simplicity (Ahmed et al., 2013)

A2. Structure of the Interviews and Questionnaire

The following paragraphs provide additional information to Chapter 4.1.3 and 4.1.4.

Structure of the Interviews

All interviewees were given the choice of anonymization of the hospital and/or

their own identity and signed an informed consent form (Appendix A3). As most

interviewees requested anonymization of both identities, all data are presented

anonymously. Interviews were not tape recorded in order to put interviewees at

ease and to enhance their openness, but hand-written notes were taken throughout

the conversation and transcribed within 48 hours (Rubin and Rubin, 1995). While

the exact course of the interview was kept open to allow case-specific issues to be

discussed, a selection of questions/issues was brought up in all interviews.

For an easy opening of the interview, interviewees were asked to define LHM as

well as to indicate the main reasons for LHM implementation and the anticipated

benefits thereof. Furthermore, the hospital-specific history of LHM implementation

was elucidated (begin and current status; involvement of lean consultants;

composition of the Lean Team; etc.). In this context, the investigator inquired about

the existence of a lean vision.

In a second set of questions, information about employees during LHM

implementation was elicited. In detail, interviewees were asked to specify at what

time and how employees were informed about the upcoming change and which

employees were informed. The content of the information provided was also

analyzed and interviewees were asked the rate (in hindsight) the information

provided (quality/quantity) and to estimate/describe the workforce’s

response/reaction.

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In the next interview block, similar questions as for information were posed, but

with respect to training (what kind of training; how much training; offered when, by

whom and to whom; etc.). Inquiries were made related to the existence of training

for new employees as well as refresher options for existing staff. Any problems

related to employee training (non-participation, resistance, etc.), but also success

stories with regard to adoption and utilization, were explored.

The last phase of the interview was introduced by asking the interviewee

whether any important aspects related to LHM implementation had not been

covered thus far or whether he/she wanted to reinforce any previously mentioned

aspects. Finally, the unit(s) participating in the survey was/were defined and the

distribution and collection of questionnaires was discussed.

Structure of the Questionnaire

The questionnaire was composed of six main parts, which will be described in

more detail in the following paragraphs. For all parts, recommendations and

standards described in the literature were taken into account. Whenever possible,

questions were adopted (and if needed adapted) from previously published surveys

to ensure validity, reliability and discrimination (Saunders et al., 2011, Litwin, 1995).

In order to increase the response rate, the questionnaire contained a cover letter

emphasizing the importance of participation, was composed of close-ended

questions and took a maximum of 10 minutes to answer (Flanigan et al., 2008).

Cover page: The front page of the questionnaire was used to inform participants

about the study (investigator, goal of the study, relevance of participation,

information on how to submit the questionnaire) and to give an estimation of the

required time to complete the questionnaire (< 10 minutes). High ethical research

standards were maintained by including a confidentiality statement and stressing

the voluntary nature of participation. For the online survey in Hospital 3, it was

pointed out that participants could not be backtracked through the IP-address of the

computer/smart phone, and that several employees could use the same device for

participation. In addition, fundamental requirements for participation in the survey,

101

namely being an employee of the investigated hospital and working in a lean unit,

were clearly emphasized (Saunders et al., 2011, Korb, 2012).

Questions related to lean information: In the second part of the questionnaires,

participants were asked to indicate how (to their knowledge) the employees were

informed about the implementation of LHM and whether they consumed the

information provided. A reason had to be selected if the answer was no. In addition,

the participants were asked to rate the general quantity and quality of the

information, but also to indicate the content quality with regard to specific aspects

(vision, urgency, benefits) (Ruck, 2013, Hargie and Tourish, 2009, Goldhaber and

Krivonos, 1977). In this section, the participants were also asked to indicate

(according to the information that they had) how far LHM implementation had

progressed.

Questions related to lean training: The third part identified (from the participants’

point of view) which types of training had been provided during LHM

implementation; options to select from were based on the literature (Graban, 2011,

Brandao de Souza, 2009, Wood, 2014). Furthermore, questions investigated the

degree of partaking and the perceived overall quantity and quality. The

content/quality was evaluated in more detail by asking the participant how capable

they felt to use lean in their daily work and to what degree active and autonomous

use had been encouraged. Existence of new employee training was also probed.

Questions related to lean adoption and utilization: This part of the questionnaire

was based on a previously published survey-based study which aimed to identify

success criteria of sustainable lean implementation by using a single case approach

(one hospital in Germany) (Pöhls, 2011). Although the previously published study

did not specifically investigate the role of information and training on lean adoption

and utilization per se, it generally investigated factors influencing lean adoption,

such as the perceived cost-benefit-ratio of lean implementation, the attitude towards

lean, the degree of patient focus, the experienced benefit of lean, the existing lean

knowledge and the degree of anticipated benefits. Questions related to lean

adoption (i.e. operationalization, behavioral intention) and utilization were hence

102

adapted from K. Pöhls as well as other relevant sources (Pöhls, 2011, Ajzen and

Madden, 1986, Beck and Ajzen, 1991, Ajzen, 2002).

Questions related to demographic data: In order to test whether differences in

employee characteristics influenced answers and to determine which characteristics

lead to higher degrees of lean adoption and utilization, participants were asked to

indicate their profession, their age range and their range of years of professional

experience in the healthcare field. In all hospitals except number 3 (specific

anonymization standards), the sex of the participants was also collected.

Closing statement: At the end of the survey, employees were thanked for their

participation and details on questionnaire collection (deadline, place) were

repeated. Furthermore, full contact details of the investigator were shown.

103

A3. Informed Consent Form

Consent Form

The purpose of the study being conducted is to elucidate how Swiss Hospitals

inform and train their employees when implementing Lean. In addition to this

interview, questionnaires will be distributed to the hospital employees that are

exposed to Lean. The to-be-approached group of employees will be agreed upon

with the hospital. With the questionnaires, the employees’ perception of the offered

information and training as well as their adoption and utilization of Lean will be

investigated. The results of this study will help to identify best practice for employee

information and training when implementing Lean. There are no risks involved in

participating in this study.

Participation consists of one interview, lasting approximately 45 minutes. There may

be additional follow-ups/clarifications through email, unless otherwise requested by

the participant.

By selecting the type of anonymization, each participant can determine the desired

level of privacy.

yes no either way

Anonymization of the interviewee □ □ □

Anonymization of the hospital □ □ □

If anonymization of the interviewee is selected, the name of the interviewee will not

be mentioned in the report. Instead, the term „Representative of the Lean

Management Team” will be used. If anonymization of the hospital is selected, the

hospital will be named as „Hospital + consecutive number”. The geographical

location of all participation hospitals will be shown on a map (), but no link will be

made between the geographical location and the assigned number of each hospital.

The results will be available to participants upon request as an MBA dissertation.

Please contact the interviewer Dr. Karin Würtz with any questions or concerns.

http://www.cumbria.ac.uk/


104

Name of the Interviewee Name of the Hospital

Date & Signature of Interviewee Date & Signature of Interviewer

Contact Information

Dr. Karin Würtz

Department for Health Science and Technology, ETH Zurich

Phone: 044 633 8126; Email: [email protected]

105

A4. Questionnaire

YOUR OPINION COUNTS Questionnaire on the Implementation of Lean Hospital

Management in the «Name» Hospital This survey is being carried out by Dr. Karin Würtz in the context of a research project on

“Lean Hospital Management” in Switzerland.

The Management of the «Name» Hospital has kindly agreed to participate in this research,

which aims to elucidate possibilities to improve implementation of Lean Management in

Swiss hospitals. Your participation will help to ensure (in the future) suitable information

and training of employees when hospitals introduce Lean Management.

The information you provide will be entirely confidential. It will only be used for the

purpose of this research and no individuals will be identified within the data. The Hospital

Management will only receive the analysed data and will not have access to the

questionnaires.

Your participation in this survey is voluntary and will take only 10 minutes. Should you at a

later stage want to withdraw your questionnaire from the study, you can contact Dr. Würtz

at any time. Contact details can be found on the last page.

Please return the questionnaire to the collection box located at the information desk of the

hospital (main entrance) by «date».

Thank you very much for your time and for sharing your opinion.

Dr. Karin Wuertz



106

Please fill out this questionnaire if you work at the «Name» Hospital and if

you have been exposed to the Lean Management Strategy in this hospital.

Questions related to Lean Information of Employees

=1= To your knowledge, how were the employees informed about the Lean Management Strategy (e.g. what it is, why it is needed, etc.)?

Tick as many boxes as apply

Assemblies

Leaflets/Brochures

Emails

Personal Meetings

□ □ □ □

Others ________________________________

=2= If offered, did you participate in the personal meetings and/or assemblies?

Tick one box only

Yes □

No □ Not offered □

2.1 If not, what were the reasons?


Not enough time

Not enough interest

Not informed early enough

Not informed at all

□

□

□

□

Others_____________________

107

=3= If offered, did you read the written information, such as leaflets, brochures and/or emails?

Tick one box only

Yes □




Not enough time

Not enough interest

Not informed early enough

Not informed at all

□

□

□

□

Others _____________________

=4= How do you rate the quantity of the information provided?

Tick one box only

Too much

Appropriate

Too little

□ □ □

=5= How do you rate the quality of the information provided?

Tick one box only

Very good

Good

Ok

Poor

Very Poor

□ □ □ □ □

108

=6= How do you rate the following statement?

“With the information provided, the hospital has communicated a clear and understandable Lean Vision (= i.e. where the hospital wants to go in the future).”

Tick one box only

Strongly agree Mostly agree Agree somewhat

Neutral Disagree somewhat Mostly disagree Strongly disagree

□ □ □ □ □ □ □


“With the information provided, the hospital has made clear why a change towards a Lean Hospital is required now.”

Tick one box only



□ □ □ □ □ □ □

109


“With the information provided, the hospital has clearly demonstrated the benefits of moving towards a Lean Hospital.”

Tick one box only



□ □ □ □ □ □ □

=^9= To your knowledge, how far has the implementation of Lean Management progressed in this hospital?

Tick one box only

Implementation has just started It has been implemented in one unit/department It has been implemented in a few units/departments It has been implemented in the entire hospital

Don’t know

□ □ □ □ □

110

Questions related to Lean Training of Employees

.10. To your knowledge, how is/was training in Lean Management delivered in this hospital?


No training was offered □

Theoretical Training

Lectures/Talks by colleagues

Lectures/Talks by consultants

Simulation of work processes

Case Studies

□

□

□

□

Practical Training

On-site observation (e.g. Gemba Walks)

Workshops (e.g. identification of wasteful processes in your unit)

Regular Group Discussions (e.g. Huddle Board)

Visit of other lean hospitals

□

□

□

□

Others ___________________________________________________

=11= If offered, did you participate in the training provided?

Tick one box only

Yes □




Not enough time

Not enough interest Not invited early enough

Not invited at all

□ □ □ □

Others _____________________

111

=12= How do you rate the quantity of the training provided?

Tick one box only

Too much

Appropriate

Too little

□ □ □

=13= How do you rate the quality of the training provided?

Tick one box only

Very good

Good Ok Poor Very Poor

□ □ □ □ □

=14= To your knowledge, is Lean training offered to new employees?

Tick one box only

Yes

No Don’t know

□ □ □

112

.15. How do you rate the following statement?

“Through the training provided, I feel fully prepared to use Lean in my daily work.”

Tick one box only



□ □ □ □ □ □ □


“During the training, it was encouraged to actively and autonomously improve Lean in my unit/department.”

Tick one box only



□ □ □ □ □ □ □

113

Questions related to Lean Adoption & Utilization


“I can clearly see the benefits of a change towards Lean for this hospital.”

Tick one box only



□ □ □ □ □ □ □


“I can clearly see the benefits of a change towards Lean for my own work in the hospital.”

Tick one box only



□ □ □ □ □ □ □

114


“I consider the implementation of Lean in this hospital to be a positive change.”

Tick one box only



□ □ □ □ □ □ □


“I highly recommend usage of Lean Principles to my colleagues that work in non-lean departments or other non-lean hospitals.”

Tick one box only



□ □ □ □ □ □ □

115


“I already use Lean Principles during my daily work.”

Tick one box only



□ □ □ □ □ □ □


“In the future, I want to further enhance utilization of Lean Principles in this hospital.”

Tick one box only



□ □ □ □ □ □ □

116

Questions related to You

.23. What is your sex?

Tick one box only .24.

What is your age?

Tick one box only

Male Female

□ □

< 30 years

30- 39 years 40 - 49 years

50 - 59 years ≥ 60 years

□ □ □ □ □

.25. What is your profession?

Tick one box only

Physician

Nurse

□ □

Administration (with patient contact) □ Administration (without patient contact) □

Other ______________________________________________

.26. How many years of professional experience in this field do you have?

Tick one box only

< 5 years

5 - 9 years

10 -19 years

≥ 20 years

□ □ □ □

117

Thank you very much for completing this questionnaire. Please return it to the «place» until «date».

Should you have any questions regarding this survey, please contact: Dr. Karin Würtz

Department of Health Science and Technology

ETH Zurich

Hönggerbergring 64, HPP-O12

8093 Zurich

Phone: 044 633 8126

Email: [email protected]

mailto:[email protected]

118

A5. Sample Size Calculation

The following paragraphs provide additional information to Chapter 4.1.4

In order to ensure sufficient power for statistical analyses (survey data), the

required number of questionnaires - i.e. the number of participants - was calculated

at the beginning of the study. The study contains two general types of statistical

analysis: a) Comparative Analyses of Means (between the five hospitals); b)

Correlation and Regression Analyses.

As Correlation and Regression Analyses are performed on the sum of the

returned questionnaires from all hospitals, reaching sufficient statistical power was

not considered problematic. In contrast, the Comparative Analyses rely on the

number of participants in each hospital and are hence at a higher risk of being

underpowered. Therefore, an online tool provided by DSS Research was used to

estimate the required number of participants for each hospital. The test was

performed for 7-Point Likert Scale data and considered two different scenarios:

The calculated mean of the two hospitals shows a clear difference (average =

4.0 versus 5.5), but the standard variation in both hospitals is high (StDev = 2.5).

The calculated mean of the two hospitals is similar (average = 5.0 versus 5.5),

but the data are tight (StDev = 0.75).

The sample size estimation indicated that ≥ 15 participants per hospital would

ensure sufficient power even in challenging cases (Figure A5.1). The scenarios

“large difference/little variation” and “little difference/large variation” were not tested

as these are statistically more obvious.

119

Figure A5.1: Sample Size Estimation

Estimation of the required sample size (i.e. questionnaires per hospital) to reach statistical significance

upon comparison of two hospitals when using 7-Point Likert Scale data. Two typical survey scenarios

(large difference/high variation; little difference/little variation) were exemplarily tested. In these

scenarios, a sample size of n ≥15 and n ≥12 provides sufficient statistical power (DSS Research,

2015).

A6. Statistical Analysis

The following paragraphs provide additional information to Chapter 4.2.4.

For statistical analyses, all survey results (except demographics of participants)

were treated as metric data (Hartung et al., 2009).

Comparative statistical analyses were performed by ANOVA or Welch’s ANOVA

after testing for normal distribution and homogeneity of variances (through Q-Q

Plots and Levene’s test, example shown in Figure A6.1) due to the relatively low

samples number per hospital (Harrell et al., 1996, Backhaus et al., 2013).

120

Figure A6.1: Confirmation of Normal Distribution by Q-Q Plots

By plotting empiric versus estimated (i.e. normally distributed) quantiles, normal distribution of experimental data can be confirmed. Results from a representative example (Q 17) are depicted.

If homogeneity of variance was lacking, Welch’s ANOVA (instead of normal

ANOVA) was used to test for differences between group means. If ANOVA revealed

significance of the results, Bonferroni Posthoc Testing was applied to test for

individual differences between hospitals. To compare the perceived and the real

status of implementation (Q9), a One Sample T test was applied. All tests were

performed in SPSS, with a significance level (p) < 0.05. Results are shown as Mean

StDev or Frequency Distribution.

Correlative statistical analysis of metric data was performed by Pearson

Correlation test, using linear regression models after pooling the data of all

hospitals. To allow for linear regression, data were tested for occurrence of minimal

residuals and homoscedasticity (= homogeneity of variance). Normal distribution

was presumed due to the high sample number (Harrell et al., 1996, Backhaus et al.,

2013). Furthermore, absence of autocorrelation and multicollinearity were confirmed

(Durbin-Watson-test, VIF analysis). Normal distribution of all data used in the

regression analyses was confirmed by Normal P-P Plots of Regression

Standardized Residuals as exemplarily shown in Figure A6.2.

121

Figure A6.2:

Confirmation of Normal Distribution

by P-P Plots

By plotting empiric versus estimated (i.e.

normally distributed) quantiles, normal

distribution of experimental data can be

confirmed. The result for one

representative dependent variable (future

use) is depicted.

The resulting correlation coefficient R was interpreted as suggested in the

statistics literature (Brosius, 1998): 0 = no correlation; 0-0.2 = very weak correlation;

0.2-0.4 = weak correlation; 0.4-0.6 = moderate correlation; 0.6-0.8 = strong

correlation; 0.8-0.99 very strong correlation; 1 = perfect correlation.

Correlative statistical analysis of ordinal data was performed by Spearman rank

correlation or Freeman-Halton test. The Spearman test was used to determine

whether age or years of professional experience show a correlation with adoption

and utilization (Hartung et al., 2009). To test whether certain professions show

higher or lower adoption and utilization of lean, the Freeman-Halton test was

applied. Finally, regression analyses were performed in SPSS to examine whether

quality, quantity and content of the information provided directly affect adoption and

utilization of lean.

Professional statistics counseling was sought to ensure suitability of all statistical

approaches and validity of the results obtained.

122

A7. Interview Summary Hospital 1

Hospital 1 introduced LHM under the name “patient-centered medicine” mid-

2014 in its ophthalmic clinic (3 units: day clinic, polyclinic, one ward). To prepare for

the implementation, a selected managerial team visited the LHM pioneer, the

Virginia Mason Institute (Seattle, US), beginning of 2014 and thereafter developed a

lean strategy. In the subsequent year, three additional units/wards of the ophthalmic

clinic were changed to lean and two additional clinics are planned for the coming

year. LHM implementation is primarily being conducted by three Lean Managers

(20%, 30% and 80% work effort), who were initially supported and trained by lean

consultants. Apart from the Lean Managers, the lean team currently comprises six

Lean Administrators (10% work effort each, one for each unit) and six lean

moderators of the Huddle Boards (one for each unit).

By implementing LHM, Hospital 1 sought to accomplish the move towards

patient-centered medicine, with increased patient satisfaction and safety through

personalized treatments at the best quality possible. Due to the extended interaction

between patients and (medical) employees, a simultaneous increase in employee

satisfaction (and reduction in turnover rates) was anticipated too. The strategic

change towards LHM was predominantly necessitated by the growing economic

pressure in the Swiss healthcare system, which requires more efficient work

processes. The hospital aims at increasing patient volumes by 3% annually while

keeping resources constant. In order to reach these goals, standardization and

visualization of work processes, together with (internal/external) performance

ratings, value stream analyses, workforce task analyses and 5S were performed in

a transparent manner. Value adding processes were reinforced, waste eliminated

and inter-professional, respectful interaction and collaboration encouraged.

Management staff was pre-informed about the introduction of LHM before the

actual start. Employees at the ophthalmic clinic received information at one of two

assemblies (morning and evening to accommodate all work shifts). The estimated

attendance rate was approximately 50% (no attendance lists, not obligatory). In

addition, employees received verbal information during their Monday staff meetings

(several times, by Lean Managers) as well as written information through the

123

hospital newsletter. The concepts of LHM were furthermore introduced (and still

are) at the bimonthly resident education. With the information provided, the hospital

reinforced the goal of LHM and underlined that no layoffs related to LHM

implementation would ever occur. Furthermore, the various lean tools, such as

Gemba Walks, were explained. New employees are informed about LHM during

their orientation day.

During the implementation phase, employees received training through different

formats. A group of employees was sent to Hospital 2 for training, which had

already started with LHM implementation. Furthermore, role plays with changes of

profession were conducted to illustrate profession-specific tasks and problems and

to synchronize the work flow.

Huddles, which take place on 4 or 5 days of the week (depending on the unit)

are used for continuous training and information (5 min per day, all professions

including administration). Ideas for improvement of work flows and elimination of

waste can be added to the Huddle Board by any employee (May 2014 to December

2014: 113 implemented changes; January 2015 to May 215: 66 changes).

In order to ensure continuous improvement (kaizen), Lean Managers, Lean

Administrators and Huddle Board Moderators meet every six week to discuss

current lean issues. Short meetings (20 min) with inter-professional teams and

designated moderators are performed once per week. As physicians often refrain

from training due to time constraints, personal training at convenient times was and

still is commonly used. Furthermore, lean training will in the future count towards

physician education (credit points). New employees currently do not receive specific

training, but are trained on-the-job (e.g. Huddle Boards). Biyearly training modules

for new employees are however planned.

The main issues during LHM implementation in Hospital 1 were resistance from

single employees, a lack of interest and/or time of physicians and a low level of

standardization. While personal discussions with employees mostly solved the first

two problems, the lack of standardization (which resulted in extensive

communication and hence effort from the Lean Managers) was overcome by

increasing experience. Current problems are related to sustainability (especially

124

when taking into account staff turnover/fluctuation) as well as measurement of

success. Success criteria, namely patient satisfaction (surveys every 6 months),

employee satisfaction and turnover rates, are influenced by many factors, not only

the implementation of LHM. With regard to soft criteria that are hard to quantify, an

improvement in transdisciplinary collaboration and team building has (according to

the interviewee) taken place.

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In Hospital 2, lean was first introduced in a newly opened unit that had

undergone renovation and reconstruction (summer 2013). As the entire unit was

staffed with a new team (partially with existing employees), it was considered to be

an ideal candidate (and the right time point) for LHM implementation. In August

2013, a lean team, comprising two Lean Managers (nursing staff, not full-time) and

the unit’s nurse managers was formed and trained by lean consultants. Due to the

small size of the lean team, the consultants not only trained the lean team (e.g.

through lean simulations), but also took over large parts of the initial work (prepare

information material, plan meetings and assemblies, etc.). After a preparation phase

of 2 months, lean was effectively introduced in the pilot unit in October 2013,

followed by the next unit beginning of 2014. While the lean team in the pilot unit only

included the nurse managers (and the hospital’s Lean Managers), lean teams in the

subsequently transformed units also involved staff from different hierarchies.

Diversity of the lean team (physicians, nurses, administration) was warranted. In

mid-2015, a Lean Manager (full-time) was hired, who will - in the medium term -

replace the lean consultants and will only be partially supported by the two original

(part-time) Lean Managers. Currently, six lean units exist (two more in the

associated hospitals), one of which had been transformed most recently (early

2015). All units had been selected based on voluntariness (often in combination

with restructuring/rebuilding), which (according to the interviewee) simplified the

implementation process.

In general, implementation of LHM in Hospital 2 focused on the optimization of

work processes, with an improved skill and grade mix that is thought to ensure

larger patient flow-through with constant staff numbers. Skill and grade mix refers to

teams with an ideal mix of skills, backgrounds and competences, in which tasks are

distributed in accordance to everyone’s skills and talents. As a consequence,

employees were thought to have more time for the patient, who consequently would

move towards the center of work processes. In addition, standardization of

processes was sought, which is specifically relevant for Hospital 2 as it is part of a

hospital group (three sites in total). While no clear lean vision had been formulated

126

or communicated, the importance of LHM had been illustrated by including it as one

of the hospital’s five core goals.

With an increasing amount of LHM implementation experience, information and

training processes were altered and improved. In the first unit, the nurse managers

were informed very early as they became part of the core team and received

specific training from the lean consultants. All other employees were informed in

writing before reopening of the renovated unit. Personal meetings led by the lean

consultants took place after reopening, during which the lean principles were

explained. In meetings, consultants and Lean Managers also explained the main

goal (increased patient throughput) and reaffirmed that no layoffs were planned.

Although the unit was new, it was mostly staffed with employees that had

previously worked at Hospital 2 and were hence familiar with the old structures. As

information provision was not yet optimized, with a lack of information in certain

areas, some aspects were criticized (e.g. lack of a ward office), hence resulting in

partial resistance amongst employees.

As a result of learning from these initial problems, information today is provided

on a personal level and certain topics are specifically addressed to avoid early

resistance. Furthermore, lean core teams are larger and include – as far as possible

- representatives of all professions and hierarchical levels to enhance internal

information flow. Due to the increased size of the core teams, whose members are

all part of the unit that is being transformed, most of the information is handled

autonomously by the unit itself. Information material and tools are however provided

by the consultants/Lean Managers, targeting lean goals (improved skill grade mix,

patient satisfaction and throughput), lean principles (e.g. continuous process rather

than project with milestones and specified end), lean performance numbers (c

value) and lean instruments. One of the globally used lean instruments that

employees are explicitly informed about is the 7P system that allows employees to

improve patient interaction (employed every morning with every patient), thereby

enhancing patient satisfaction and safety: person (who am I), plan of the day,

priority (from the patient’s view), personal hygiene (help needed?), pain (rating 1-

10), position of items (can the patient reach everything) and presence (next staff

127

visit). While employees are informed at the beginning of the LHM implementation,

no refresher courses exist to date. New employees are informed through the nurse

manager(s), using established documents, but no specific format is employed.

No official lean training was offered during transformation of the first lean unit,

but training happened on-the-job (learning by doing). In the subsequently

transformed units, training was emphasized and provided by the core lean team,

with the support of lean consultants. In detail, simulations and 7P training are

commonly provided (see above) and continuous training is delivered through

meetings at the unit’s Huddle board (morning and afternoon, 5 min each). During

Huddles, employees are encouraged to suggest improvements (by using kaizen

forms or white boards), which has – especially at the beginning – resulted in a large

number of optimizations. Regular Gemba Walks are planned for the future. In

addition, employees can go to other lean units for training. New employees are

included in the normal on-the-job training (Huddle Boards), but do not receive

tailored training. Often, new employees are paired with a more experienced

member of the team, who provides insights and training.

As patients are asked every day how satisfied they were with the performance of

the last day (result recorded), it could be demonstrated that the number of patient

complaints was reduced in lean units. Furthermore, the number of calls (via the

patient’s bell) was decreased by one third. Results on overall patient satisfaction

(evaluated every two years) do not exist yet. One of the main issues during LHM

implementation was involvement of physicians, who often showed high resistance

(especially at older age) and little interest and had limited time. Due to the

hierarchical structures, the general attitude of a team of physicians was largely

influenced by the opinion of the head physician. This problem became evident at

the opening of the first lean unit, which was visited by very few physicians despite

the convenient time (5-6 PM). In the subsequently transformed units, LHM was thus

introduced to head physicians during personal meetings. Furthermore, stakeholder

involvement was broadened over time (inclusion of all professions, e.g. janitors,

cooks, pharmacists, etc.) and interaction at professional interfaces was

strengthened.

128


In Hospital 3, the idea of implementing LHM emerged in 2010/2011, before the

change towards DRG-based reimbursement in Switzerland had actually been

effected (but had been announced). During the phase of lean strategy development,

the hospital management (including the lean management team) visited two lean

hospitals, the Virginia Mason Institute (Seattle, US) as well as another lean hospital

in Kuala Lumpur (Malaysia). After strategy definition, two small pilot projects (e.g.

case management) were conducted during a test phase, followed by

implementation of LHM in several units in early/mid-2012, and soon thereafter in all

units. Implementation was conducted by one full-time Lean Manager, who was

supported by four additional members of the strategy and process management

team (all in part-time), as well as two lean consultants (one for strategy, one for

implementation). Consultants were involved predominantly in the initial/mid-term

phase to transfer knowledge and skills, but are still involved today for specific tasks

or projects, albeit for restricted periods of time only. No Lean Administrators were or

are assigned on the units directly, although it is planned that unit heads will become

lean administrators in the future.

The overall goal of implementing LHM was to focus on the well-being of the

patient through standardization and optimization of patient processes. Improved and

standardized patient processes were thought to result ultimately in enhanced

patient satisfaction through improved processes and reduced waiting times as well

as accelerated patient recovery. Expedited recovery and hence shorter stays (at

overall high patient satisfaction rates) are seen as highly important in ensuring

financial sustainability, specifically after the switch to DRG-based reimbursement

and with ever increasing personnel costs. Elimination of process-related problems

was believed not only to improve patient throughput, but also to enhance employee

satisfaction, hence reducing staff fluctuation. Due to the importance of LHM for

future sustainability and success, lean principles were formulated as a service

commitment and included in the vision of Hospital 3.

As LHM was introduced in a highly progressive manner (almost in one go, one

fell-swoop), the entire hospital was informed about the implementation after the pilot

129

projects. Information was provided through the hospital’s newsletter as well as

through an eLearning tool, composed of two comic-based short movies that explain

LHM and the Hospital’s service commitment/vision and a quiz. The eLearning tool

has been continuously accessible since the beginning of LHM implementation. As

watching the movies and doing the quiz is not mandatory, the percentage of

eLearning users is merely moderate (higher for nurses than physicians). New

employees are informed about LHM during their Welcome Day, when the two

movies are shown. Provision of any other information is the responsibility of the

respective unit, but no standardized formats exist and execution is not controlled.

Workshops were conducted to offer lean training to selected employees,

spanning different professional backgrounds and hierarchical levels. Employees

demonstrating early resistance were included on purpose to convince them of the

beneficial nature of LHM. While nurses showed high participation rates, physicians

were less interested in attending, except in cases of strong inter-professional

interfaces (e.g. emergency unit, intensive care unit). The quality of these workshops

was rated highly by the participants (internal survey data). In addition to workshops,

Gemba Walks, value stream analyses and simulations were conducted.

Furthermore (and amongst others), wasteful work processes were identified in team

exercises and action plans formulated, e.g. by creating lean spaghetti diagrams with

employees. Huddle Boards are used on the units to ensure constant training as well

as continuous improvement of work processes through employee-based

suggestions that are voted on directly by the team (except if suggestions involve

major restructuring or costs).

Measuring the success of LHM implementation is considered a main challenge

in Hospital 3. Some measurable criteria had not been precisely evaluated and

analyzed before the implementation, such as employee fluctuation. Patient flow

(waiting times, check-in, check-out) are not quantified rigorously, although a slight

improvement has in general been recognized. Furthermore, many physicians still

believe that waiting patients are a sign of popularity. Although most employees have

recognized the benefits of LHM for the patient and themselves, the lack of clearly

measurable indicators of success as well as the problematic transfer of information

130

(no Lean Administrators on the units) tends to threaten the sustainability of LHM.

Hospital 3 is hence prepared to make structural changes in the future, e.g.

assigning a Lean Administrator in each unit and providing profession-specific

information and training. In hindsight and according to the interviewee, LHM would

probably have been more successful if the implementation had been done in a more

successive manner that allowed for in-depth training and information of employees

in one (or few) units.

131


Hospital 4 was inspired to implement LHM by one of its partner hospitals, who

had experienced positive outcomes. A small pilot project was conducted

successfully and the strategic decision to implement LHM was made. A process

manager who had previously worked with the Hospital 4 (as a freelancer) and

hence new the specific structures as well as the workforce was hired in full-time

(Lean Manager and Process Manager). Lean consultancy firms were invited to

apply and the decision was made for a team of consultants with a strong focus on

cultural change and practical implementation. The consultants were involved for one

year (initialization phase plus half of the implementation phase, i.e. rapid transfer of

knowledge and skills) and are today re-hired only to perform specific tasks for which

in-house knowledge is absent. The Lean Manager is supported by 14 Lean

Administrators who spend 10% of their work effort on lean tasks.

Different from its partner hospital, LHM was introduced in one go (and not

successively) owing to the small size of the hospital and the consequential high

level of interaction between employees. It was feared that successive

implementation would cause irritation amongst the workforce, especially if

employees with high knowledge about LHM implementation were to interact with

employees that had not heard of LHM implementation.

Implementation commenced with a four months initialization phase (begin: mid-

2013), during which information (for management and employees) and training (for

management and selected employees, i.e. Lean Administrators) was provided

(detailed information: see below). On-site implementation of LHM was started end

of 2013/beginning of 2014 in all units, and was completed end of 2014, with

implementation speed varying between different units. In 2015, the hospital moved

towards a phase of consolidation and sustainment, in which the units maintain and

progress lean independently, with occasional involvement of the Lean Manager.

With sufficient experience, units can now adjust Huddle Boards and Lean

Guidelines to fit their specific needs (albeit within certain frames), hence ensuring

high applicability and benefit.

132

In Hospital 4, LHM was introduced primarily as a suitable tool to eliminate

wasteful processes and to optimize administrative tasks. Wasteful processes, along

with ever increasing administrative work load in healthcare (due to changing laws

and regulations, hence requiring more documentation), are seen as major threats to

patient-staff interaction (with respect to quantity, but also quality). The goal of LHM

implementation was hence to increase the interaction time between medical staff

and patients, an aspect that was also included in the Hospital’s vision.

Information of management and employees took place during the initialization

phase (mid-2013). Hospital management was first informed (and intensively trained)

to induce lean enthusiasm and to ensure that management would be able to answer

employee questions correctly and comfortably. Thereafter, a mandatory staff

assembly (with attendance check) was scheduled, during which the consultants

informed all employees about LHM. One of the speakers, a physician himself, was

able to build excellent rapport with the medical staff and was thus able to convince

them of the benefits of LHM. In addition, the course of action and time plan were

illustrated and the lean vision communicated (see above). Further information was

provided repeatedly throughout the year 2014 by the Lean Manager in order to

deepen the workforce’s understanding of lean. In the future, eLearning tools (e.g. a

lean movie) will be created. Currently, new employees are informed about LHM

during their hospital tour (day 1), the hospital presentation (day 2) as well as during

their personal introduction to process management and lean management (day 2,

approximately 1 hour, by the Lean/Process Manager).

Training in Hospital 4 took place in steps. First, hospital management was

intensively trained for two to three days. During 01/2014 and 03/2014, 14 Lean

Administrators were trained for several days. Lean Administrators (named Lean

Masters) were selected from those employees that voluntarily signed up for the task

(10% work effort) after the first lean information event (mostly nurses, but also

physicians and administrative staff). During the remaining months of 2014, 49% of

all employees with leadership functions, as well as 58 normal employees, were

rigorously trained during an entire day and training is being continued at the time

being. Training tools include: Gemba Walks (mostly at the initial phase, conducted

133

by consultants), role games (with fictive change of the participants’ professions) and

visit of other units. Huddle Boards (see previous hospitals) as well as direct (unit-

based) problem identification and solving are also performed as continuous on-the-

job training.

Training courses are internally evaluated (questionnaires), with overall positive

employee feedback. Refresher training is offered, either as short exercises (45 min)

during which wasteful processes are identified on-site (own or different unit) in

interdisciplinary and inter-hierarchical teams or as one-day training courses, which

are offered once per quarter. During one-day refresher training sessions, a specific

problem (e.g. overtime, tardiness of ward rounds) is treated by analyzing the current

state, suggesting a SMART goal (specific-measurable-accepted-realistic-timely) and

providing a plan of action. New employees can participate in these refresher

trainings or in regular training events, but also receive on-the-job training.

Similar to other hospitals described before, one of the main challenges in

Hospital 4 is to identify and quantify the success of LHM implementation. An

increase in interaction time between patients and staff, the prime goal of LHM

implementation, is hardly measurable. In addition, constant changes in the

administrative work-load distort observations and further impede evaluations.

Measuring patient satisfaction, which is done every three years, is demanding and

interpretation of the data obtained is difficult owing to a large number of influencers.

When comparing data gathered in 2011 and in 2014, no significant difference could

be detected with regard to patient satisfaction. Similarly, no differences were

detected in staff fluctuation. While little fluctuation exists amongst more experienced

employees, high fluctuation exists amongst young medical staff, which may be

explained by their need to gain experience at different work places.

Although many variables were not measureable or did not show significant

changes, the length of stay could be reduced. Concomitantly, a higher patient

throughput was noted, which could be handled with the same workforce size,

indicating that processes had become more efficient since LHM implementation.

134

Another large challenge identified in Hospital 4 relates to company culture. An

overall change in culture, with full incorporation of lean thinking, is expected to take

several years and is difficult to maintain.

135


Implementation of LHM in Hospital 5 was initiated in mid-2012, as a response to

the introduction of DRG-based reimbursement in Switzerland. After identifying LHM

as a possible strategy to ensure future sustainability, the hospital management

visited the Virginia Mason Institute (Seattle, US) to better understand application of

lean principles in a hospital setting. In spring 2013, five units were selected for a

pilot test and employees of the selected units were informed and trained by lean

consultants (details see below). Lean consultants were involved for a restricted

period of time to transfer skills and knowledge and are now only re-involved for

specifically challenging tasks/projects. A Lean Manager (full-time) was hired more

than a year after the start of the pilot projects when it became obvious that

dedicated personnel was needed to implement LHM successfully. No Lean

Administrators exist on the units.

Today (2 years after the start), two of the five pilot projects have been

successfully implemented and a third unit is on its way (delayed due to rebuilding of

the unit). At the time of the interview, two of the pilot projects were still in the

implementation process (external units, less involvement of the Lean Manager) and

three additional units were about to be transformed.

The main reason to implement LHM in Hospital 5 was to increase efficiency and

productivity through optimization of process, hence creating the means to withstand

the increasing financial pressure due to DRG-based reimbursement. Apart from

long-term sustainability, the anticipated benefits were an increase in patient safety

and satisfaction as well as in employee satisfaction through prolonged patient

interaction, simplification of processes and reduced overtime. In addition,

continuous identification of wasteful processes, followed by optimization of

structures and tasks, was thought to create a suitable (thus far not existing)

transparent error culture (admit errors, no cover-up, no blame).

Information of employees was conducted successively. Employees working in

the selected pilot units were informed at the beginning of the respective trial project

through the lean consultants (spring 2013). All managers and employees in

136

leadership positions were informed end of 2013 (i.e. after the start of the pilot

projects) through the hospital’s CEO, who explained the principles of lean, and

reported on the outcome of the pilot projects. However, repeatedly applied

comparisons to the automobile industry (which is characterized by production line

processes) and failure of one of the pilot projects (a partially lean project) created

strong initial resistance amongst the hospital’s leadership personnel.

In spring/mid-2014, a Lean Manager was hired, who soon started to conduct

voluntary kick-off information events, discussing elimination of wasteful processes

and thus optimization of processes. As basically almost no information had been

provided before, the principles and benefits of LHM and the fact that no lay-offs

were planned had to be explained in detail and early resistance/annoyance had to

be counteracted. In addition, employees – specifically physicians that did not

participate in kick-off events (lack of time, lack of interest) - were informed during

personal meetings (5-10 min). Today, new employees are informed at the general

Information Event for newcomers.

Lean training was started in the pilot units and was conducted through

consultant-guided Gemba Walks, followed by training on-the-job (learning by doing,

project exercises). Today, Huddle Boards (on which improvements are recorded)

are used on a regular basis and interdisciplinary lean workshops are offered

through the Lean Manager. Both training methods allow employees to directly

observe the beneficial effects of LHM. A lean workshop on ward rounds, specifically

on head physician ward rounds, is planned. These rounds were recently identified

as a sore spot, with major delays and errors that might – in the worst case -

threaten patient safety. Role games may be introduced in the future to increase

interdisciplinary and inter-hierarchical understanding and appreciation. No specific

training for new employees currently exists, but on-the-job training and participation

in aforementioned workshops is common.

A major problem identified in Hospital 5 is sustainability of LHM, caused by the

non-existence of unit-specific Lean Administrators and the relatively rare visits of

the Lean Manager on-site, at least to those units that are farther away from the

main building. In addition, mediocre involvement of physicians, especially in very

137

hierarchical units, has been recognized. Some of the problems today seem still to

be related to the mistakes made in the early phases of LHM implementation (lack of

information, faulty communication style). Nonetheless, two (almost three) stations

have now been transformed successfully, with relatively high enthusiasm amongst

the team members, who recognize the benefits of lean for their own daily work.

Measuring the benefits of LHM implementation for the hospital itself is however

considered challenging: Firstly, no definite goals were set before the

implementation; secondly, measurability of success criteria is difficult due to a lack

of useful tools and the presence of other influencing factors (e.g. patient

satisfaction, employee satisfaction, number of calls through the patient’s bell). For

certain success criteria (e.g. patient calls), the employment of suitable tools would

be possible, but has not yet taken place. One measurable value that has however

significantly improved is accumulated overtime, indicating that processes indeed

became more effective through LHM implementation.

138

A12. Results of Hospital 1

In the following chapter, the survey results of Hospital 1 are illustrated in detail.

The results are also incorporated in the comparative analysis (see 5.2.2). Aspects

related to questionnaire distribution (number of returned questionnaire, distribution

by age, years of professional experience, profession) are only shown in 5.2.1.

Figure A12.1: Types and Level of Information (Hospital 1)

Types of information, indicated as % of participants selecting each option (left) and percentage of

informed versus uninformed employees (right).

Figure A12.2: Quantity and Quality of Information (Hospital 1)

Rating of Information Quantity and Quality, indicated as % of employees selecting each answer. For

information quality, Mean and StDev are indicated on top of the right figure (coding: very poor = 1;

very good = 5).

139

Figure A12.3: Types and Level of Training (Hospital 1)

Types of training, indicated as % of participants selecting each option (left) and percentage of trained

versus untrained employees (right).

Figure A12.4: Quantity and Quality of Training (Hospital 1)

Rating of Training Quantity and Quality, indicated as % of employees selecting each answer. For

training quality, Mean and StDev are indicated on top of the right figure (coding: 1 = very poor; 5 =

very good).

140

Figure A12.5:

New Employee Training (Hospital 1)

Existence of training for new employees as

perceived by the survey participants. Results are

indicated as % of employees selecting each

answer.

Figure A12.6:

Status of LHM Implementation

(Hospital 1)

Status of LHM implementation as

perceived by the survey participants (in

blue, Mean StDev). The real

implementation status is shown for

reference in grey.

141

Figure A12.7: Information Content (Vision, Urgency, Benefits) (Hospital 1)

Level of agreement to the statements given below. Results are shown as Frequency Distribution and


disagree; 7 = fully agree).

“With the information provided, the hospital has communicated a clear and understandable Lean

Vision.” (= Vision)

“With the information provided, the hospital has made clear why a change towards a Lean Hospital is

required now.” (= Urgency)

“With the information provided, the hospital has clearly demonstrated the benefits of moving towards a

Lean Hospital.” (= Benefits)

142

Figure A12.8: Capability of Employees to Use LHM (Hospital 1)




“Through the training provided, I feel fully prepared to use Lean in my daily work.” (= Preparation)

“During the training, it was encouraged to actively and autonomously improve Lean in my

unit/department.” (= Proactivity)

143

Figure A12.9: Perceived Benefits of LHM (Hospital 1)




“I can clearly see the benefits of a change towards Lean for this hospital.” (= Benefit for Hospital)

“I can clearly see the benefits of a change towards Lean for my own work in the hospital.” (= Benefit

for Own Work)

144

Figure A12.10: LHM Adoption (Hospital 1)




“I consider the implementation of Lean in this hospital to be a positive change.” (= Positive Change)

“I highly recommend usage of Lean Principles to my colleagues that work in non-lean departments or

other non-lean hospitals.” (= Recommend to Colleagues)

145

Figure A12.11: LHM Utilization (Hospital 1)




“I already use Lean Principles during my daily work.” (= Current Use)

“In the future, I want to further enhance utilization of Lean Principles in this hospital.” (= Future Use)

146












very good = 5).

147







very good).

148

Figure A13.5:





answer.

Figure A13.6:


(Hospital 2)





reference in grey. Asterisk (*) indicates

statistically significant difference.

149











150








151







for Own Work)

152








153







154












very good = 5).

155







very good).

156

Figure A14.5:





answer.

Figure A14.6:


(Hospital 3)







157











158








159







for Own Work)

160








161







162












very good = 5).

163







very good).

164

Figure A15.5:





answer.

Figure A15.6: (Hospital 4)








165


Level of agreement to the statements given below. Results are shown as Frequency Distribution

(# = 3%) and Mean StDev. For the calculation of a numerical Mean, the 7-Point Likert Scale was

coded (1 = fully disagree; 7 = fully agree).







166








167







for Own Work)

168








169







170












very good = 5).

171







very good).

172

Figure A16.5:





answer.

Figure A16.6:


(Hospital 5)







173











174








175







for Own Work)

176








177







178

A17. Correlation Analysis (Pearson Correlation Coefficient, p value)

The following two tables depict the Pearson Correlation Coefficients and p values

(significance values) obtained from the correlation analysis in SPSS. Different from

the main document, all values are shown (independent of how useful a correlation

determination between two variables may be). The variables are labelled according

their number in the questionnaire and the calculated scores (information score,

adoption score) are included, using appropriate abbreviations (InfoSc, AdopSc).

Q5 Q6 Q7 Q8 Q13 Q16

Q5 1

1

0.578

0.000

0.509

0.000

0.516

0.000

0.668

0.000

0.574

0.000

Q6 0.578

0.000

1

1

.737

0.000

0.785

0.000

0.342

0.004

0.616

0.000

Q7 0.509

0.000

0.737

0.000

1

1

0.823

0.000

0.364

0.002

0.647

0.000

Q8 0.516

0.000

0.785

0.000

0.823

0.000

1

1

0.409

0.000

0.646

0.000

Q13 0.668

0.000

0.342

0.004

0.364

0.002

0.409

0.000

1

1

0.458

0.000

Q16 0.574

0.000

0.616

0.000

0.647

0.000

0.646

0.000

0.458

0.000

1

1

Q17 0.555

0.000

0.696

0.000

0.733

0.000

0.732

0.000

0.484

0.000

0.660

0.000

Q18 0.649

0.000

0.660

0.000

0.706

0.000

0.646

0.000

0.522

0.000

0.715

0.000

Q19 0.508

0.000

0.696

0.000

0.672

0.000

0.686

0.000

0.417

0.000

0.578

0.000

Q20 0.513

0.000

0.635

0.000

0.638

0.000

0.586

0.000

0.304

0.009

0.683

0.000

Q21 0.421

0.000

0.548

0.000

0.414

0.000

0.523

0.000

0.301

0.010

0.569

0.000

Q22 0.572

0.000

0.664

0.000

0.678

0.000

0.628

0.000

0.463

0.000

0.674

0.000

InfoSc 0.588

0.000

0.924

0.000

0.941

0.000

0.862

0.000

0.378

0.000

0.671

0.000

AdopSc 0.573

0.000

0.712

0.000

0.711

0.000

0.677

0.000

0.424

0.000

0.697

0.000

179

Q17 Q18 Q19 Q20 Q21

Q5 0.555

0.000

0.649

0.000

0.508

0.000

0.513

0.000

0.421

0.000

Q6 0.696

0.000

0.660

0.000

0.696

0.000

0.635

0.000

0.548

0.000

Q7 0.733

0.000

0.706

0.000

0.672

0.000

0.638

0.000

0.414

0.000

Q8 0.732

0.000

0.646

0.000

0.686

0.000

0.586

0.000

0.523

0.000

Q13 0.484

0.000

0.522

0.000

0.417

0.000

0.304

0.009

0.301

0.010

Q16 0.660

0.000

0.715

0.000

0.578

0.000

0.683

0.000

0.569

0.000

Q17 1

1

0.830

0.000

0.752

0.000

0.709

0.000

0.549

0.000

Q18 0.830

0.000

1

1

0.780

0.000

0.735

0.000

0.538

0.000

Q19 0.752

0.000

0.780

0.000

1

1

0.801

0.000

0.512

0.000

Q20 0.709

0.000

0.735

0.000

0.801

0.000

1

1

0.499

0.000

Q21 0.549

0.000

0.538

0.000

0.512

0.000

0.499

0.000

1

1

Q22 0.702

0.000

0.780

0.000

0.803

0.000

0.801

0.000

0.494

0.000

InfoSc 0.765

0.000

0.731

0.000

0.732

0.000

0.683

0.000

0.513

0.000

AdopSc 0.773

0.000

0.819

0.000

0.927

0.000

0.937

0.000

0.534

0.000

name: dr. karin wuertz-kozak degree: mba … · lean management, often also called lean...

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