sustaining lean: lessons from a large medical care provider

Sustaining Lean: lessons from a large medical care

provider

Jessica van Toorn

S3813088

[email protected]

+31646461189

MSc Business Administration- Change Management

Faculty of Economics and Business

University of Groningen

Supervisor: Dr. O.P. Roemeling

Co-assessor: Prof. Dr. J.D.R. Oehmichen

February 1st, 2021

Number of words: 14.459

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ABSTRACT

Background: Lean Management (LM) has been shown to positively influence healthcare process

performance. Consequently, there is a considerable research base that shows the implementation and

performance implications of LM. However, the sustainability of LM efforts over time, especially in the

healthcare context, has been overlooked. Therefore, this study was designed to identify how a healthcare

provider with a successful LM program was able to sustain LM over prolonged periods of time.

Method: This study is conducted within a large Dutch medical care provider. In this qualitative case-

study, four departments were studied and analysed. All departments were able to sustain LM over

prolonged periods of time. Data for the study consisted of primary data in the form of interviews and

secondary archival data.

Findings: The results indicated four categories facilitating the sustainability of LM. These categories

include: (1) The role of leadership, (2) Repetition of the Lean message, (3) Education, and (4) Employee

commitment. This study provides a deeper understanding on how each of these identified categories

contributes to the sustainability. In addition, the results indicated barriers that hinder the sustainability

of LM. These barriers include: lack of time and space, employees resistance, and fear. Based on these

results, a theoretical framework has been developed that guides healthcare organizations in sustainability

thinking.

Conclusion: This study provides healthcare organizations with insights into how they can sustain LM.

It provides them with a comprehensive understanding of the four categories of facilitators that contribute

to the sustainability of LM. In addition to these facilitators, this study also gave insights into the various

barriers that hamper the road to sustain LM. This study adds to the literature by providing a framework

that assists healthcare organizations to sustain LM.

Keywords: Lean Management, Continuous Improvement, Healthcare, Sustainability

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1. INTRODUCTION

Healthcare organizations are facing multiple challenges which include an aging population, increasing

complexity of care, and the demand for more long-term care for chronic diseases (Aij & Teunissen,

2017). These challenges require healthcare organizations to improve their service performance in terms

of efficiency, cost-effectiveness, affordability, and safety (Poksinska, 2010). To achieve higher

performance, healthcare organizations are adopting Lean Management (Aij & Rapsaniotis, 2017).

Lean Management (LM) in healthcare is defined as: “a management philosophy to develop a

hospital culture characterised by increased patient and other stakeholder satisfaction through continuous

improvements, in which all employees (managers, physicians, nurses, laboratory people, technicians,

office people etc.) actively participate in identifying and reducing non-value-adding activities (waste)”

(Dahlgaard, Pettersen & Dahlgaard-Park, 2011, p. 677). In essence, LM is focused on enhancing value

for the patient by eliminating activities that would be considered wasteful from a LM perspective (de

Souza, 2009; Poksinska, 2010).

LM delivers a comprehensive set of tools in order to achieve a successful continuous

improvement (CI). However, there is no unified method to implement LM (Daaleman et al., 2018).

According to Mazzocato, Stenfors-Hayes, von Thiele Schwarz, Hasson and Nyström (2016), LM is one

of the most widely used approaches to quality improvement in the context of healthcare to improve the

effectiveness and efficiency of care delivery.

Prior research focuses mainly on the implementation and performance implications of LM

within organizations (Smith, Poteat-Godwin, Harrison & Randolph, 2012; Moraros, Lemstra &

Nwankwo, 2016; Morales-Contreras, Chana-Valero, Suárez-Barraza, Saldaña Díaz & García García,

2020; Mazzocato et al., 2012). The implementation of LM has been shown to improve healthcare process

performance in terms of cost savings, reduction in medical errors, reduced patient waiting times,

increased productivity, and improved working conditions (Costa & Godinho Filho, 2016; Mazzocato,

Savage, Brommels, Aronsson & Thor, 2010; Smith et al., 2012; Suárez-Barraza, Smith & Dahlgaard-

Park, 2012). However, these positive outcomes of LM do not necessarily imply that related CI activities

are sustained (Poksinska, 2010; Henrique & Godinho Filho, 2018). Indeed, many healthcare

organizations are experiencing difficulties in sustaining LM (Aij & Rapsaniotis, 2017; Hallam &

Contreras, 2018; Poksinska, 2010; Leite, Bateman & Radnor, 2019; Liberatore, 2013).

The sustainment of LM often comes with a culture of CI (Poksinska, Swartling & Drotz, 2013;

Poksinska, 2010; Dahlgaard et al., 2011). However, healthcare organizations often lack such a culture

since they simply focus on the application of LM tools (Poksinska, 2010). Culture is therefore a

component that can contribute to the sustainment of LM, but that does not necessarily have to be the

case. In other words, it is plausible that a cultural change is not always required to sustain LM. Especially

since cultural change is both complex and time intensive (Dahlgaard et al., 2011). If an organization is

still able to sustain LM, even if they do not experience it as part of their culture, that is also sufficient

for their sustainability.

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In this study, we argue that the sustainment of LM does not depend solely on whether or not it

is embedded in the culture, also other unknown factors might be of importance. For example, according

to Aij and Rapsaniotis (2017), leadership is also a component that can contribute to the sustainment of

LM. However, the question is whether these components are the only ones or whether there are also

other unknown components that can contribute to the sustainability of LM.

Whilst research on the first part of LM journey (i.e., implementation and performance

implications) is abundantly present, little research is devoted to the sustainability of LM over the long

term, especially in the healthcare context (Poksinska, 2010; Mazzocato et al., 2012; Costa & Godinho

Filho, 2016; Hallam & Contreras, 2018). This is rather remarkable given the fact that LM sustainability

is typically acknowledged as a key aspect of LM implementation (D’Andreamatteo, Ianni, Lega &

Sargiacomo, 2015; Lindsay, Kumar & Juleff, 2019). Therefore, more rigorous research is required on

how LM is sustained in healthcare over prolonged periods of time. It is important to investigate this,

because healthcare organizations do not want LM to fade away after the implementation (Poksinska,

2010; D’Andreamatteo et al., 2015). Hence, this study focuses on obtaining a better insight into what

does and what does not contribute to the sustainability of LM.

This study aims to fill this gap by identifying how a healthcare provider with a successful LM

program was able to sustain LM over prolonged periods of time. This results in the following research

question: “How are Lean management improvement activities sustained within a healthcare context?”.

Through a qualitative study, based on unique case data, we are able to identify multiple barriers and

facilitators towards LM sustainability.

This research will be conducted at a large medical care provider from the Netherlands. It adds

to the literature on LM, and especially the sustainability of LM, through the development of a framework

to guide sustainability thinking. Moreover, this research is valuable to healthcare providers as it provides

a better understanding on how LM initiatives could be sustained.

This study is structured as follows: first, we reviewed past research on the concepts LM, LM in

healthcare, and the sustainability of LM. Subsequently, we described the methodology of this study. In

the next section, the findings that emerge from this study are presented, followed by a discussion section.

Finally, this study is summarized with an overall conclusion.

2. LITERATURE REVIEW

The aim of this study is to investigate how LM improvement initiatives are sustained within a healthcare

provider that possesses a successful LM program. The literature review is structured as follows, first,

the background and meaning of the LM concept are discussed. Subsequently, the meaning and

application of LM in the healthcare sector are explained. Finally, literature with regard to the

sustainability of LM is reviewed.

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2.1 Introduction to Lean

The concept of LM originated from the Toyota Production System (TPS) and was developed by the

Japanese Toyota Motor Corporation in the 1940s (Melton, 2005). While the roots of LM can be found

within the automotive and manufacturing industries, it has extended to service industries, including

healthcare sectors (Moraros et al., 2016). The TPS served as the basis for the five principles of LM,

which is a methodology focused on quality improvement within organizations (Womack, Jones & Roos,

1990; Mazzocato et al., 2010; Pepper & Spedding, 2010; Moraros et al., 2016). These five principles

are described by Moraros et al. (2016) as follows: (1) define value from the customer’s perspective, (2)

identify all stages in the value stream and remove those that are considered wasteful, (3) create a flow

of seamless stages to the customer, (4) allow the customer to extract value from the producer, and (5)

pursue perfection through a CI of processes. In the pursuit of companies to understand and implement

LM, these principles lend themselves as a guideline.

Previous research has emphasized the difficulty of conceptualizing LM, here the absence of a

universal definition is one of the major issues (Radnor, Holweg & Waring, 2012; Shah & Ward, 2007;

Hopp & Spearman, 2004; Pettersen, 2009). This can lead to a lack of clarity as to what exactly is meant

by the term. In this study LM is defined as: “a managerial approach for improving processes based on a

complex system of interrelated socio-technical practices” (Bortolotti, Boscari & Danese, 2015, p. 182).

In other words, LM is about continually improving quality by focusing on creating and delivering value

to the customer and eliminating non-value added activities, also called waste or muda (Womack &

Jones, 2003; Soliman & Saurin, 2017; Costa & Godinho Filho, 2016). The goal is to enhance customer

value in order to generate high-value service delivery.

Since 2002, the quality improvement approach LM has been widely adopted within healthcare

organizations as Lean Healthcare Management System to improve healthcare services (Poksinska, 2010;

de Souza, 2009). According to de Souza (2009), the application of LM seems to be effective in

improving healthcare organizations and their associated processes. In the following paragraph, LM and

its application in the healthcare sector is discussed based on previous research.

2.2 Lean in healthcare

This study focuses on the sustainability of LM over time, which will be discussed in more detail after

this paragraph. First, however, we provide a broader overview of the application of LM in healthcare.

Healthcare organizations have different organizational settings compared to the automotive and

manufacturing industries (Poksinska, 2010). They are complex systems in which the technical and social

systems are intertwined. In this complex service environment, patients are part of the system (Hicks,

McGovern, Prior & Smith, 2015; Soliman & Saurin, 2017). In recent years, healthcare organizations are

facing multiple challenges, which include an increasing demand for healthcare services and the

associated growing costs (de Souza, 2009). As a result, they are confronted with greater challenges in

improving the quality and efficiency of their healthcare systems. This resulted in an increased interest

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in implementing LM in healthcare to improve their service performance towards a more efficient and

high quality care for patients (Poksinska, Fialkowska-Filipek & Engström, 2016; Smith, Hicks &

McGovern, 2020). Yet because of their complexity, healthcare organizations should not blindly adopt

LM from manufacturing. It requires adaptations to suit their needs (Radnor & Walley, 2008; Poksinska,

2010).

LM in healthcare is often described as a CI approach that consists of identifying and eliminating

non-value-adding activities (waste) in the healthcare delivery to create maximum value for patients

(Poksinska et al., 2016; Radnor et al., 2012; Dahlgaard et al., 2011). Some examples of activities that

would be considered wasteful from a LM perspective include: long waiting times, medical errors, and

lack of resources. In essence, this approach helps to improve the flow of patients, resulting in shorter

waiting times and hospital stays, and lower costs.

LM is based on five principles. In recent years, the use of these principles in the healthcare

sector has increased as a means to improve care processes and eliminate waste (Aij, Visse &

Widdershoven, 2015). However, LM and its application in the healthcare sector is characterized by three

core principles, which are the first three steps from Womack and Jones (2003): value identification,

waste elimination, and generation of customer value (Poksinska, 2010). Although the principles are

guiding principles to improve the effectiveness and efficiency of care delivery, there is no unified way

to implement LM (Daaleman et al., 2018). There are significant variations with regard to the

implementation of LM in the healthcare sector (Radnor et al., 2012).

According to Hasle, Nielsen and Edwards (2016), the implementation of LM in healthcare has

not reached its level of maturity. LM in healthcare is often seen as a project and/or as an ancillary activity

that is not incorporated in the day-to-day activities of employees (Hasle et al., 2016). Healthcare

organizations tend to implement LM as a one-sided approach with the focus on applying LM tools to

processes, rather than a system-wide approach where a CI culture needs to be developed (Poksinska,

2010; de Souza, 2009; Radnor et al., 2012). The limited adoption might be one of the reasons that LM

is rarely sustained within healthcare organizations.

There is a considerable research base on LM in healthcare, especially with regard to its

implementation, and to the performance implications (D’Andreamatteo et al., 2015). Literature has been

shown that the implementation of LM provides good results, which include improved quality and

performance of healthcare processes (Costa & Godinho Filho, 2016; Mazzocato et al., 2010; Smith et

al., 2012; Suárez-Barraza et al., 2012). However, there is much to learn about some issues that have

been overlooked and remain under investigated. One of these issues concerns the sustainability of LM

over time (D’Andreamatteo et al., 2015; Liberatore, 2013; Mazzocato et al., 2012; Moraros et al., 2016;

Poksinska, 2010; Hallam & Contreras, 2018). How do we make sure that we continue to work with LM

and that it does not fade away after a few projects? Therefore, it is important to investigate this issue.

The sustainability of LM is discussed in the next paragraph.

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2.3 The sustainability of Lean

The scarce evidence available on LM sustainability emphasized the difficulty of this topic, especially in

the healthcare context (Aij & Rapsaniotis, 2017; Hallam & Contreras, 2018; Leite et al., 2019;

Poksinska, 2010; D’Andreamatteo et al., 2015; Liberatore, 2013). The sustainability of LM is one of the

least understood issues and therefore there are still unanswered questions (Proctor et al., 2015). The

application of improvement tools is meaningless without efforts to sustain LM over time, because

sustainability is an important implementation result (Flynn et al., 2018). There is also a risk that the

improvement will fade away after the implementation. That is why it is important to ensure that LM

improvement activities are sustained within organizations. In this way, LM becomes an inherent part of

the organization and its employees and will therefore deliver more value to the patient (Radnor, 2011).

According to existing literature, there is a lack of a uniform definition about the concept

sustainability (Moore, Mascarenhas, Bain & Straus, 2017; Proctor et al., 2015; Flynn et al., 2018). In

this study, sustainability is defined as: “the continuation or the integration of new practice within an

organization whereby it has become a routine part of care delivery and continues to deliver desired

outcomes” (Doyle et al., 2013, p. 2). However, it does not require LM to be seen as a cultural element

in order to be considered sustainable. It is reasonable to assume that a cultural change is not always

required to sustain LM.

Little research is devoted to the sustainability of LM in the context of healthcare

(D’Andreamatteo et al., 2015; Costa & Godinho Filho, 2016; Lindsay et al., 2019; Mazzocato et al.,

2012; Poksinska, 2010). However, the scarce evidence that is available (Leite et al., 2019; Liberatore,

2013) shows that the success rate of sustaining LM is low. This has to do, among other things, with the

difficulty to deal with the barriers to sustain LM over time (Moore et al., 2017; Leite et al., 2019).

Literature shows that there are ideas about the barriers that could hamper the sustainability of

LM in healthcare. One of the barriers is the complexity of healthcare environments. The challenging

technical, social and institutional context makes it difficult to reproduce and adapt LM. This leads to

low success rates in terms of LM sustainability (Leite et al., 2019; Bateman, Hines & Davidson, 2014;

Radnor & Walley, 2008). In addition, healthcare organizations tend to implement LM as a project-based

approach (one-sided approach) rather than a system-wide approach.

A system-wide approach that includes a long-term strategy and a culture for CI is helpful for

the sustainability of LM (Poksinska, 2010; de Souza, 2009; Radnor, 2011; Radnor et al., 2012). Other

problems are: poor communication, lack of commitment of employees with regard to LM, lack of

resources, and leadership failure (de Souza & Pidd, 2011; Leite et al., 2019; Grove, Meredith, MacIntyre,

Angelis & Neailey, 2010). Addressing these barriers could support the sustainment of LM over the long

term.

Besides the barriers, there are also facilitators that might contribute to the sustainment of LM.

Although there is not much evidence on how to sustain LM in the context of healthcare, there are studies

that show their ideas that might contribute to this. First of all, developing a strong leadership might play

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an important role when it comes to sustaining LM (Radnor, 2011; Aij & Teunissen, 2017; Aij et al.,

2015; Flynn et al., 2018). Without continuous commitment and effort from leaders, the sustainment of

LM could not be realized (Poksinska et al., 2013). Moreover, whether the organization brings in LM

through external consultants or whether it is much more something that takes place in the organization

itself might be important. However, according to Poksinska (2010), it is difficult to sustain LM when

the consultants leave the organization. In addition, appropriate communication might contribute to the

sustainment of LM. According to Radnor (2011), there is a need to keep employees focused on CI until

they have become accustomed to the new way of working. Furthermore, the sustainability of LM might

depend on the training of employees within an organization. Such training can provide participants with

skills and knowledge in the field of LM that can benefit LM sustainability (Radnor, 2011; Al-Balushi et

al., 2014).

Based on previous studies, we present the underlying framework (Figure 1) of this study. For

the continuation of this study, we are particularly interested in how and why the barriers and facilitators

contribute and what other barriers or facilitators might play a role when it comes to LM sustainability.

Therefore, the aim of this study is to investigate how a healthcare provider with a successful LM program

was able to sustain LM over prolonged periods of time. The next chapter discussed the methodology of

this study.

Figure 1: Currently identified components of LM sustainability

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3. METHODOLOGY

In this section, the methodology used in this study is discussed. The methodology is structured as

follows, first, the type of research is explained. Subsequently, the case setting is discussed. Furthermore,

the approaches to data collection have been outlined. Finally, this section ends with a description of how

the data were analysed, followed by a figure of the coding process.

3.1 Type of research

According to Edmondson and McManus (2007), prior research could be nascent, intermediate or mature.

The nascent theory is most appropriate in this study, because little is known about the sustainability of

LM over the long term, especially in the healthcare context. Therefore, the following research question

has been formulated: “How are Lean management improvement activities sustained within a healthcare

context?”. This research question is open-ended in which data have been interpreted for meaning that

contributed to the identification of patterns.

Because little prior research has been done on the phenomenon of interest, the sustainability of LM

in healthcare, deep and rich information has been used to better understand this phenomenon

(Edmondson & McManus, 2007). More detailed information supports a better understanding of the

deeper stories and mechanisms involved, which are key when it comes to answering ‘how’ questions

(Edmondson & McManus, 2007). That is why a qualitative case study was most suitable and therefore

has been applied in this study.

Qualitative research is explanatory in nature and focuses on identifying and explaining relationships

regarding the phenomenon of interest. Moreover, qualitative data were appropriate in this study, because

these kind of data were beneficial for theory generation (Edmondson & McManus, 2007; Lee, Mitchell

& Sablynski, 1999). Therefore, in-depth interviews have been applied in order to establish new theory.

3.2 Case setting

To select an appropriate case organization, a number of criteria were considered. First, the case

organization must operate in the context of this study (i.e., healthcare) where LM improvement efforts

are used. Second, interviewees need to have experience with working on LM projects. Third, the

organization must have different departments with a successful LM program that have been able to

sustain LM over prolonged periods of time. Based on these criteria, a major Dutch medical care provider

was selected.

The organization distinguishes itself with a wide range of excellent specialists in medical care

and a number of areas of expertise. In total, there are 35 different specialisms, 3.000 employees, 211

medical specialists, and 300 volunteers. The organization cooperates closely with general practitioners

and other care providers in order to strive for the best care.

The organization is also a learning organization that focuses on CI. They were one of the first

organizations who adopted LM in their healthcare services. The organization has been actively

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improving its healthcare processes for almost 10 years. The LM approach has been used to organize the

healthcare delivery faster, more pleasant or smarter for the patient. This resulted in a long history of LM

improvement activities, such as reducing the length of stay and patient waiting times. That is why this

organization is appropriate to examine the aforementioned research question.

The organizations offers various in-house training programs to train employees in the domain

of LM. Within the organization a coding system is used, in which the different training programs are

expressed in terms of colours: yellow belt (beginner), orange belt (intermediate), and green belt

(advanced). These programs vary in terms of duration, complexity, and content. The yellow belt program

is characterized by a four-hour training in which employees are introduced to the basic principles of

LM. The orange belt program involves a more comprehensive training (20 hours), where employees are

provided with more in-depth knowledge of LM and they need to work on their own improvement project

alongside the training. The green belt program entails a more advanced training (64 hours), in which

extensive knowledge in LM including static process analysis is offered to employees. Besides the

training, employees need to work independently on an improvement project. By participating in these

training programs, the organization aims to foster a learning improvement culture that allows each

employee to contribute to improve value for patients. In the meantime, a large number of successful

projects have been completed. By conducting research at this organization, we have gained insights into

which aspects drive projects to a success and which aspects hinder this. In this way, we have discovered

more about the sustainability of LM over time within the organization.

In this qualitative case study, four different departments have been examined: Pathology (Case

A), Finance and Administration (Case B), Facility Management (Case C), and Neurosurgery (Case D).

This is a mix of different types of departments, which are departments that focus on providing care (Case

A & Case D) and departments that focus on supporting or enabling the provision of care (Case B & Case

C). In other words, there is a distinction between direct care departments and support departments. All

departments are aware of healthcare-related issues and are active in this context. However, in terms of

content, they have different tasks. The four departments were provided by the organization and were

considered successful when it comes to the sustainability of LM. By looking at the overlapping

components between the departments, we have been able to discover the categories and their underlying

reasons that explain how and why these departments are successful in LM sustainability. In this way, we

were able to explore how LM improvement activities are sustained within a healthcare context.

3.3 Data collection

Interviews

To study the sustainability of LM, qualitative data were collected by means of semi-structured in-depth

interviews. The semi-structured interview is a type of interview in which predetermined questions are

retained and thus ensure that all relevant subjects are covered. This type of interview also allows for

follow-up questions if needed. By using this data collection method, respondents were encouraged to

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bring their personal experiences and perceptions into their responses. This ultimately led to deeper and

richer answers. Since little is known about the sustainability of LM over time, deep and rich information

was needed to better understand the phenomenon. Therefore, this type of interview was consistent with

this study, as it provided the opportunity to elaborate deeply on a particular subject.

In total, 15 interviews were conducted with an average duration of 55 minutes. In this study, we

applied purposive sampling and only respondents who possessed the right knowledge, skills, and

expertise of working with LM in a healthcare environment have been interviewed. Therefore, two

professionals per department have been selected: (1) unit head or coordinator of the department, and (2)

a professional who has completed an educational LM program. Since these professionals have

experience working with LM, they were expected to provide the most valuable insights.

As a consequence of Covid-19, the interviews were conducted digitally via StarLeaf. Recording

equipment has been used during the interviews to allow transcriptions to be made at a later stage. The

interview questions were structured in the following categories: (1) introduction, (2) LM improvement

activities, and (3) the sustainability of LM. All questions were open-ended in order to guarantee deep

and rich information. Examples of questions are: ‘What ensures that LM is embedded in your daily

activities?’, ‘Which stimulating factors play a role in sustaining continuous improvement through LM?’,

and ‘To what extent has your department been able to sustain LM over time?’. The entire interview

protocol including all interview questions can be found in Appendix I. The protocol is checked by the

case contact to guarantee that the questions and the environment are aligned. This protocol is the latest

version, as it has been updated in the meantime in order to provide the best possible insights. Moreover,

an overview of all interviews that have been conducted is presented in Table 1.

Table 1: Overview of the conducted interviews

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Informal conversations

In addition to interviews, informal conversations with the case contact have occurred on a regular basis.

These served mainly to familiarize oneself with the organization, to develop a sense of direction for this

study, and to clarify ambiguities.

Secondary data

For the purpose of context- and topic familiarization, secondary archival data have been used in this

study. A more specific overview of these type of data are presented in Table 2.

Table 2: Overview secondary data

3.4 Data analysis

After data collection, the data were analysed by means of a coding process in which the data were

classified into codes and categories in order to find patterns (Saldana, 2012). The analysis of data

extracted from interviews included transcribing, reading and encoding the transcriptions. The coding

process was conducted by means of the Atlas.ti software. This program has served as a tool to structure

the data in order to discover patterns.

The coding process began with the provision of codes to the transcriptions. Both inductive codes

that emerge from data and deductive codes that emerge from literature have been used for this purpose.

Examples of inductive codes are: ‘delegate’, ‘recurring agenda item’, and ‘take initiative’. Moreover,

some examples of deductive codes that have been used in this study are: ‘leader behaviors’, and

‘employee resistance’. This first part of the coding process in which the data collected were summarized

by means of codes is also known as first-order coding (Wolfswinkel, Furtmueller & Wilderom, 2013).

After the first-order coding, the codes were organized into different categories and sub-

categories. The main categories in this study included: the role of leadership, repetition of the Lean

message, education, employee commitment, and barriers to sustain LM. Subsequently, the

interrelationships between the categories and their sub-categories have been identified. Finally, the

process of finding patterns and relationships took place until a conceptual theory emerged from the data.

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This process of refining the identified codes and categories is also known as second-order coding

(Wolfswinkel et al., 2013). The coding process is shown in Figure 2. Moreover, an overview of the most

important codes and categories for this study is represented in a codebook, which can be found in

Appendix II.

Figure 2: Structure of the coding process

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4. FINDINGS

This chapter provides insights into which facilitators and barriers play a role in the sustainment of a LM

approach within a healthcare provider. First, each individual department is subjected to a within-case

analysis to identify the most important insights of each case. Second, we present the cross-case analysis

highlighting the main insights obtained from the within-case analysis. The within-case analysis is

structured as follows, per case we focus on: (1) The role of leadership, (2) Repetition of the Lean

message, (3) Education, (4) Employee commitment, and (5) Barriers to sustain LM.

4.1 Case A: Pathology

4.1.1 The role of leadership

To explore the role of leadership we distinguish between leadership behaviors and leadership attitudes.

Leadership behaviors

To explore leadership behaviors, we identified two main tasks. Leaders need to stimulate and motivate,

and coach and facilitate their employees.

Stimulating and motivating is expressed in the following behaviors demonstrated by leaders in

Case A. Leaders need to delegate LM tasks, show results, inform, show personal interest, monitor LM

activities, interact with team members, compliment, and visit the work floor. An overview of all

identified stimulating and motivating behaviors is shown in Figure 3.

When leaders wish to stimulate and motivate their employees, they need to involve the

employees in the process of CI through regular improvement meetings, and by delegating LM tasks

providing responsibility and autonomy. Moreover, leaders need to show the results of projects, and

highlight progress that has been made. In essence, leaders need to provide feedback and make gains

visible. When employees are shown the results of their efforts and when they are involved in CI, this

builds enthusiasm and raises awareness of the benefits of LM.

‘I like to put the responsibility with the people themselves. People are the owners. We are all

professionals, we all work in medical care, so I also expect something from these people. I am not

going to say: “You have to do this and you have to do that and then it all has to be done”. I am not

going to do that. The responsibility rests with the people themselves’. (Jaap)

‘That is the only way in which we can take the employees with us and where they can also give

feedback. And then things are discussed, people can ask questions or submit ideas. That also has a

stimulating effect’. (Melany)

‘Try to make them enthusiastic by showing them how something becomes easier or better for the

patient or clearer or less error-prone. And then they all look in the same direction, that you just want

to work flawlessly for the patient’. (Melany)

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Figure 3: Identified stimulating and motivating leadership behaviors in quotations

Next to stimulating and motivating, coaching and facilitating employees to keep doing LM is of

importance. Leaders must provide support, time, and space for employees which enables them to work

with LM on an ongoing basis. In addition, leaders need to act as a role model for their employees. Their

exemplary behavior provides employees with the necessary support and guidance that enables them to

keep working with LM.

‘That you are supported and given resources and time. So of course you need the unit head for that as

well. You need a manager who supports you. My unit head always does that. So you need time, space

and resources to be able to carry out things’. (Melany)

‘You have to act on it yourself, of course. If you are not committed, then it is not going to work. So you

have to convey it [...]. You have to act on it and you have to explain what it is. You have to stimulate

and motivate people to do that’. (Jaap)

Leadership attitudes

In Case A, the results show the most evidence for acknowledging the importance and usefulness of LM.

In essence, leaders need to take LM seriously, since by acknowledging the importance of LM and its

usefulness, they can successfully convey it to their employees. As a result, employees also take LM

seriously.

‘As a manager, you also have to take it seriously. If you take it seriously, then employees can take it

seriously too’. (Pieter)

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4.1.2 Repetition of the Lean message

In order to sustain LM over a longer period of time, it is important to keep repeating the Lean message.

Repetition ensures that all employees are on board and stay involved. In Case A, message repetition

took several forms which include through newsletters and during meetings. However, the newsletter

(sent through e-mail) was considered a lesser effective medium as most employees do not access

computers during their work. Instead, ensuring that LM is discussed during meetings was considered

more effective, especially when it is a recurring agenda item.

‘You just have to keep explaining and naming it. That is really important! [...]. Otherwise, it only

becomes something for the management which is not the intention. You have to keep communicating it

to the whole department to get everyone on board’. (Jaap)

‘We had a newsletter, but we considered it to be ineffective because it was not read since many people

do not sit behind their PCs. They all work in the lab. So we do not do that anymore. Now we use work

meetings’. (Melany)

‘It is a fixed item on the agenda and that is why we can keep it’. (Melany)

4.1.3 Education

Education in the domain of LM is a facilitator to sustain LM over time. In Case A, the green belt training

was considered to be effective. Training creates awareness and a different mindset in LM, and provides

a structure to work with. This enables employees to look at their environment in a different way.

Moreover, in Case A, offering training to the majority of the department was considered to be effective

as this ensures that all employees possess the same knowledge about LM. This keeps them on the same

page when it comes to this topic.

‘The more people understand this, the more people look at things from a different point of view. You

look at problems and alerts in a different way when you have completed an education [...]. So you get

awareness of working with Lean’. (Melany)

‘Well, like I said, you give them a certain baggage. You need training to be able to keep working

according to that system [...]. You need to have 60/70 percent of the employees in your department

who can do that and who understands that. Then the majority knows the theory and understand what it

means and why a certain project is being tackled according to that system. And yes, then it works’.

(Jaap)

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4.1.4 Employee commitment

To explore employee commitment we distinguish between employee behaviors and employee attitudes.

Employee behaviors

Employees in Case A exhibit initiative behavior in order to sustain LM. Employees need to take

initiative by reporting problems, providing ideas for improvement, and by making improvements

themselves. This raises their involvement in LM.

‘Well, by creating alerts in their work. We have a system in which we can create alerts in our daily

work […]. So employees at all units create alerts and they are monitored on a monthly basis to see

how often something has happened […]. There are also people who come up with their own

suggestions, like: “Well, I think we need to improve that. Because that is too messy, it needs to be

improved”’. (Melany)

‘It is about applying what you have learned […]. Just do it, make improvements!’. (Pieter)

Employee attitudes

In Case A, the results show the most evidence for intrinsic motivation as the most important employee

attitude to sustain LM. Employees need to have intrinsic motivation in LM. When employees have this

intrinsic motivation to improve, this builds enthusiasm to keep improving. In this way, employees

remain involved and focused on LM.

‘Yes, employees really need to have the intrinsic motivation to improve. Only then we will continue to

do so’. (Melany)

4.1.5 LM barriers

Looking at the elements that hamper the road to sustain LM approaches, the lack of time and space as

well as employee resistance were considered to be the main barriers in Case A. The cause of lack of

time and space can be expressed by the fact that employees sometimes experience a certain work

pressure, because of the peak moments in their work. Moreover, employees give priority to their own

work, leaving less time for LM. The cause of employees’ resistance has to do with the generation gap

and the preservation of existing routines. In Case A, a generation is gap is present, which translates into

the older generation not being enthusiastic about LM and not understanding its usefulness and necessity.

They prefer to maintain the existing routines and therefore have a hard time moving away from it.

‘Time. Of course, we just have our work here. Sometimes there are also some peaks [...]. So time is an

issue’. (Melany)

‘Of course, we also have a generation gap in the department. Well, those people do not see this in the

same way as the younger people who are very enthusiastic about it. They all see bears on the road to

18

something that is becoming more difficult. Like: “In the past it did not have to be that way, so why

should it be that way now?”. So that is indeed something you run into’. (Melany)

4.2 Case B: Finance & Administration




To examine leadership behaviors, we determined two main tasks. Leaders need to stimulate and

motivate, and coach and facilitate their employees.

Stimulating and motivating is manifested in the following behaviors demonstrated by leaders in

Case B. Leaders need to delegate LM tasks, show results, celebrate successes, compliment, show

personal interest, visit the work floor, and monitor LM activities. An overview of all identified

stimulating and motivating behaviors is shown in Figure 4.

In cases where leaders aim to stimulate and motivate their employees, they should involve

employees in the CI process. In Case B, having regular improvement meetings, and delegating LM tasks

are seen as important behaviors to achieve this. When employees have the autonomy and responsibility

in LM activities, this results in increased motivation and job satisfaction and they are more inclined to

improve again. Moreover, leaders need to demonstrate the results of projects, and highlight the

improvements made. In other words, leaders need to provide feedback and make gains visible. When

employees are shown the obtained results, this builds enthusiasm and raises awareness of the benefits

of LM. Furthermore, leaders need to pay attention to celebrating successes as this gives employees a

positive incentive to keep working with LM.

‘Involving people. So also say: “What do you think?”. Then you keep them involved in making

improvements. You also have to give them the opportunity to help improve’. (Jan)

‘If they are responsible themselves and eventually implement an improvement themselves, then I think

it has a positive effect on their motivation. Then he thinks: “Oh gosh I have improved that, well that

has now been resolved. I did that myself”. So then he is more inclined to do that again’. (Eva)

‘People only participate in continuous improvement when you make them enthusiastic and when they

see the results, so that they can work faster and more efficiently. Next time they will think: “Hey, that

is nice! We would like to do that again, because it might even get better”. So if you do that and you

bring it across enthusiastically, then people will join’. (Jan)

‘The most important thing is to celebrate successes […]. Small things and big things need to be

celebrated as well, attention should be paid to that’. (Robert)

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Figure 4: Identified stimulating and motivating behaviors in quotations

Besides stimulating and motivating, coaching and facilitating employees in LM is important with regard

to its sustainability. Leaders need to guide employees, provide support, and act as a role model. In

addition, leaders need to facilitate their employees by giving them time and space for CI. These aspects

encourage employees to keep doing LM over the long term.

‘Yes, but do not supervise them by solving it yourself, but guide them by saying: "Let's find out

together how we can do it better" [...]. But leave the searching to the employees’. (Robert)

‘You have to show exemplary behavior yourself’. (Robert)

‘You have to give employees some time for that. The space and time to actually investigate: “Hey,

what am I doing and how can I improve?”’. (Isabel)


Leaders in Case B hold multiple attitudes in order to sustain LM. First, leaders need to acknowledge the

importance and usefulness of LM. More specifically, they need to believe in LM and the benefits it

provides. Second, they need to be enthusiastic about LM. Both attitudes ensure that the positivity with

regard to LM is conveyed to the employees.

‘My unit head is always very focused on Lean [...]. So I think if you have someone who is enthusiastic

about it from the top, then it is more likely to trickle down to the underlying departments. To the unit

heads underneath and then back to the teams'. (Isabel)

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Keep repeating the Lean message is deemed to be important when it comes to its sustainability.

Repetition ensures that LM is eventually embedded in the department. In Case B, the repetition of the

message occurred in a variety of ways, including through e-mail, feedback, during meetings and

dialogues. However, e-mail was perceived as a rather less effective medium since employees receive a

relatively large number of e-mails per day. Nevertheless, it is unclear which dissemination channel is

most effective when it comes to message repetition. Yet, we do know it is important that LM is a

recurring item on the agenda.

‘Just bring it up on a regular basis, repeatedly. This can be done by means of feedback or by means of

a meeting or just a dialogue each time about: “Hey, do you see any improvements?”. And then it will

be embedded at some point’. (Isabel)

‘No, that does not work. Mails do not work [...]. Mailing is very easy. You get a lot of e-mails a day.

Sometimes I also get 50 a day’. (Jan)

‘Every week we have a work meeting. So every week we talk a lot about it in our department: “How

can we improve this?”’. (Jan)

‘He also made this a fixed item on the agenda, that is really important’. (Jan)

4.2.3 Education

In order to sustain LM, education in this domain is important. In Case B, both the green and orange belt

were deemed to be effective. In this case, training generates awareness surrounding the concept of LM

and its benefits. In essence, training gives employees a different mindset that makes them better able to

improve continuously. This permits employees to behold their surroundings in a completely new

manner. Moreover, training provides employees with a structure through the tools that are necessary to

improve. Finally, a group training in LM for the entire department was considered to be effective in

Case B. When the entire department is educated in LM, this raises their involvement around LM and

ensures that everyone is on the same page and follows the same system.

‘It is more the mindset I got from the training and therefore I know how to approach certain

improvement processes […]. And also the tools to tackle it. What are the right steps? What is the right

order?’. (Eva)

‘Training makes you more familiar with the concept of Lean and what you can achieve with it. And

you learn how to use it [...]. It also teaches you how to start an improvement idea. How can I improve

my work? [...]. So I think training in Lean will give you the tools to implement it in your daily work’.

(Isabel)

‘The more people you involve in continuous improvement, the more you improve. Then a kind of group

training for the entire team or department would be a great idea’. (Eva)

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Employee behaviors

Two behaviors are characterized as helpful in Case B with regard to the sustainment of LM. Employees

need to take initiative, and communicate with peers.

When employees want to take initiative, they need to identify and report problems, suggest

improvement ideas, and implement improvements themselves. This builds enthusiasm and raises

involvement in LM. Alongside taking initiative, employees need to communicate with colleagues about

LM in order to increase employee involvement. In other words, when employees interact with each other

about LM, it keeps everyone focused on the topic.

‘I think it has more to do with simply being able to report problems and if something goes wrong that

it is identified and mentioned […]. So yes, what they are doing is reporting that something is going

wrong. Because if that does not show up, you cannot improve anything’. (Eva)

‘And that is why we are always improving, because we are constantly talking to each other about it:

“Hey, how can we get it better?”’. (Jan)

Employee attitudes

In terms of employee attitudes, intrinsic motivation is cited as an important contributor in the

sustainment of LM. This implies that employees should be intrinsically motivated to work with LM.

Whenever employees possess this intrinsic motivation, enthusiasm for CI is developed. As a result,

employees stay focused on LM and thus on improving their processes.

‘I think it is also due to the mentality of the people. We are very enthusiastic about improving [...]. So

you need to like it. If you do not like it, then it will not work out’. (Jan)

‘Just like I said, I think there must already be a foundation in your own intrinsic motivation to

improve’. (Eva)

‘If you have the intrinsic value in improving, “I want to do my job faster, easier and better”, that is

very important. And I always find it interesting to see where the accelerations are, or improvements in

processes [...]. But what I am saying, it has to be intrinsic’. (Isabel)

4.2.5 LM barriers

In Case B, the elements hindering the sustainability of LM include the lack of time and space, employee

resistance, and fear. In terms of lack of time and space, employees often do not have time for LM,

because they have other priorities in their work. Without giving employees time and space, they

experience CI as an additional workload, which results in a negative feeling towards LM. Regarding

employee resistance, Case B experiences a generation gap within the department. The older generation

is not very enthusiastic about LM. Instead, they are more positive about the existing routines and

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therefore prefer to maintain them. Finally, the fear of improving or making mistakes results in a negative

feeling towards LM among employees. This in turn affects the sustainment.

‘You very often hear in practice: “I do not have time for this, I am so busy” or “I have to fix all the

mistakes” [...]. You have to give them time and space to do so. Otherwise you will notice that people

may experience extra pressure […], which can make them feel negatively about implementing Lean or

continuous improvement projects’. (Isabel)

‘Yes, I also have a couple of colleagues who are a bit older and say: “Yes, but it is going well, right?

It works well how things are going now” […]. They are not very enthusiastic and they are not eager’.

(Jan)

‘I believe that the greatest barrier is intertwined in people themselves. So the fear of change is often a

barrier. Fear of making mistakes. So I think it is more about culture’. (Eva)

4.3 Case C: Facility Management




In the examination of leadership behaviors, two main tasks can be separated. Leaders need to stimulate

and motivate, and coach and facilitate their employees.

Leaders in Case C exhibited the following behaviors as part of stimulating and motivating.

Leaders need to delegate LM tasks, show results, interact with team members, inform, monitor LM

activities, celebrate successes, visit the work floor, show personal interest, and compliment. An

overview of all identified stimulating and motivating behaviors is shown in Figure 5.

Leaders need to involve employees in the process of CI in order to stimulate and motivate them.

This is expressed by frequent improvement meetings where they can discuss LM. Delegating LM tasks

(i.e., providing responsibility and autonomy in LM) is also considered useful for the purpose of

stimulating and motivating employees. Both generate input to continue to improve, as most

improvement ideas come from the work floor. In addition, leaders are supposed to present the results of

projects, and emphasize the advancements that have been made. Specifically, leaders have to provide

feedback and showcase the gains. This raises awareness of the benefits of LM and encourages employees

to improve.

‘Most ideas come from the teams themselves. The work floor is where the ideas for improvement

projects are generated. So that is where most of the profit is. And that is where you have to stimulate

people to participate. So you have to involve them […]. Discussing that together is important’. (Petra)

‘Give others the responsibility and space to make improvements’. (Henk)

‘When people see that things are getting better, they also become more aware that they can contribute.

That they can change something themselves, which leads to an improvement. That works’. (Maarten)

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Beyond stimulating and motivating, coaching and facilitating employees to keep working with LM is of

importance. Leaders need to provide their employees with support in CI and act as a role model. This

allows employees to eventually do it themselves and enables them to keep doing it. Moreover, leaders

must accommodate their employees by granting them time and space for CI.

‘You need to guide the employees in continuous improvement, so that they can do it themselves in the

long run […]. So you need to be sharp and hold up a mirror to people all the time. And not come up

with solutions yourself, but let people think for themselves’. (Maarten)

‘You may really want to improve, but if you do not have time in your work or if your manager does not

give you time, you will not get anywhere’. (Jolanda)

‘You also need to act on it and convey it to the employees’. (Peter)


Leaders in Case C highlight one important attitude to sustain LM. Leaders themselves need to be

enthusiastic about LM. When employees experience this enthusiasm, this also builds enthusiasm among

them. In this way, LM and its benefits is conveyed to the employees. As a result, LM remains at the

centre of attention.

‘I think our leader is also enthusiastic about it and this is also passed on to the managers and the

teams. So it just depends on who you have above you as a leader'. (Petra)

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With regard to the sustainability of LM, the results of Case C highlight that continuous repetition of the

Lean message is beneficial. This allows LM to eventually be sustained in the department. In Case C,

message repetition adopted different forms, including different kinds of meetings. Message repetition

was considered effective, especially when it is a recurring agenda item.

‘You just have to communicate it to your employees. Communication is important all the time, so keep

communicating about it. And actively express and disseminate it among employees’. (Peter)

‘It is about communication and continuing to communicate: "This is the way we do it" [...]. Yes, and

then it is perseverance. That is the sustainability’. (Henk)

‘We have our weekly meetings and we have monthly performance board meetings, so then we discuss

the KPIs. And we also have quarterly meetings with the unit heads’. (Henk)

‘Yes, that is a bit the same. Just the week start. That tells you what you have to do and that makes it

very easy to sustain Lean. It is also important to make it an agenda item, because then it will come

back again and again’. (Petra)

4.3.3 Education

The provision of education in LM is an important component that contributes to its sustainability. In

Case C, both the green and orange belt were seen as effective. When employees participate in LM

training, it increases their awareness in terms of LM principles and its benefits. In fact, training reshapes

employees' mindset, making them more capable of CI. Moreover, training stimulates the intrinsic

motivation of employees to improve and to keep improving. Finally, it provides employees with a

structure as it allows them to work according to the same system.

‘Yes I think it is a good thing that the hospital educates their people. Then they know how to improve.

And if everyone uses the same standard, that is a good thing. And you do not have to have a green belt

for that, but orange belt is also good. Then, at least, you can improve continuously’. (Jolanda)

‘This is just to make people aware of what waste is, so the basic principles. I think it is important that

everyone realizes that’. (Maarten)

‘The moment you do have to pass such a training, then you have the success of it and you are proud of

it. But you also had to leave something behind or do something for it. I think that helps to stimulate the

intrinsic motivation, so that the people really go for it and keep improving’. (Henk)

‘Yes, I think so! Because everyone will work according to the same system. If you know and

understand the systematics, then it is also quite easy to start a new process of improvement’. (Peter)

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Employee behaviors

Multiple behaviors are manifested by employees in Case C in order to sustain LM, including: taking

initiative, communicating with peers, and listening to the client.

In terms of taking initiative employees should signal and report issues, propose ideas for

improvement, and initiate improvements on their own. This implies that employees need to be proactive

by taking initiative in LM. Moreover, employees need to communicate with peers about LM and the

associated improvement projects. This increases awareness and keeps them involved in LM. Finally,

employees should listen to clients to receive feedback. Using their feedback allows employees to

optimize and keep optimizing their services accordingly.

‘Well, like I said, employees themselves come up with: "Hey, but that can be done differently. Can we

not do it better this way?"’. (Peter)

‘So when employees run into something, they report it’. (Peter)

‘Everyone is asking each other about: "What is the current situation? What else do you need?". So we

are constantly communicating with each other. What are we doing? How do we do that? That is really

important’. (Petra)

‘Yes, in the end I think you have to listen to the customer. It is crucial that the customer says: “Hey,

how satisfied are we with the service and where do we see opportunities for improvement?”. So I think

you have to be very receptive to that. So you also have to discover that and listen to them’. (Henk)

Employee attitudes

Employees in Case C specify two important attitudes in order to sustain LM. First, employees need to

be intrinsically motivated in LM, and they must be interested in working with it and continuing to do

so. In fact, CI by using the LM approach should be embedded in employees’ DNA. Through this intrinsic

motivation, they remain focused on CI. This keeps LM at the centre of attention. Second, employees

need to believe in LM and its benefits. In other words, they need to recognize its importance and

usefulness.

‘The employees also like it a lot. That is the intrinsic motivation again […]. They do have that intrinsic

motivation to improve’. (Peter)

‘Because it is also in my DNA to improve continuously. I am always looking for ways to do things

differently, better, smarter, faster, easier’. (Maarten)

‘So in the end, the employee must have faith in it, in continuous improvement’. (Henk)

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4.3.5 LM barriers

In Case C, the lack of time and space, and employee resistance were considered as the main barriers to

LM sustainability. With respect to the lack of time and space, this barrier derives from the fact that

employees are too busy with their own work. Essentially, employees have other priorities, resulting in

little to no time to think about LM and improving their operations. Moreover, employees perceive the

fact that they must do this alongside their own work as difficult. As a result, they experience an increased

workload, which negatively affects employees’ feelings regarding LM. In terms of employee resistance,

this barrier relates to the generation gap and the maintenance of existing routines. Case C is facing a

generational gap. The older generation is more reluctant to CI, because they are accustomed to a certain

way of working and want to preserve this way.

‘Yes time. Just time. I do find that difficult. Just that you have to do it next to your own work, that

makes it difficult […]. Everybody is busy being busy. And I can see that. And that also has a bit of an

impact on people's commitment. Because we are so busy, we do not have much time to think about

improving’. (Jolanda)

‘If you do not have the time and space to do projects, then nothing will be improved’. (Petra)

‘And, of course, people who work here for a long time and who are used to a certain way of working

are more reluctant to change’. (Henk)

4.4 Case D: Neurosurgery




Two primary tasks were identified in the examination of leadership behaviors. Leaders need to stimulate

and motivate, and coach and facilitate their employees.

In Case D, leaders displayed the following behaviors when it comes to stimulating and

motivating. Leaders need to delegate LM tasks, show results, celebrate successes, inform, monitor LM

activities, interact with team members, visit the work floor, show personal interest, and compliment. An

overview of all identified stimulating and motivating behaviors is shown in Figure 6.

In terms of stimulating and motivating employees, involving them in the CI process by

leveraging periodic improvement meetings, and by delegating LM tasks are deemed to be effective. This

triggers employees’ intrinsic motivation and builds enthusiasm. Moreover, leaders need to provide

examples of projects, and highlight the progress that has been made. By doing so, this raises awareness

of LM and its benefits, builds enthusiasm, and encourages employees to improve. Furthermore, leaders

need to celebrate successes with their employees. When employees have celebrated successes, this

increases awareness of their efforts and encourages them to improve continuously.

27

‘I think that you give autonomy to the employee. Organize it yourself. That is really the most important

thing: ownership, autonomy […]. Because then your intrinsic motivation is triggered. If you have

control and think: “What is best for the department?”, yes then people become happy and then you get

less resistance. But you also see that it sticks quickly’. (Esther)

‘I also give examples of my previous improvements or things that have changed and then people think:

“Oh that is how it works, so good!”. And that it does not necessarily require a lot of time, but it

produces a lot of good results. Well if you can explain and show that, then you will notice that people

are starting to improve and continue to do so’. (Esther)

‘Celebrating successes, so that people really become aware of it: “Oh yes, this is what we do it for”. I

think that is very important to be able to sustain it for a long time’. (Sophie)


Next to stimulating and motivating, coaching and facilitating employees in LM is important. Leaders

need to provide employees with the necessary support in LM and show exemplary behavior. By doing

so, employees are taken along in the process of CI. This in order to raise awareness of the benefits of

LM and to build enthusiasm for working with LM and continuing to do so.

‘I think we have to coach them above all. Not to come up with solutions ourselves, but to take them

along. So coaching them in the process to come up with their own solutions’. (Sophie)

‘I think if the leader and the coordinators among them do not convey that to the team, then I think it is

doomed to fail […]. So if you, as a leader, do not believe in it and do not act on it, that you do not take

an exemplary role in it, then you just know that the rest will not either’. (Nienke)

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The main attitude that leaders in Case D cite as important to the sustainment of LM is to acknowledge

its importance and usefulness. This means that they must be convinced about LM and the benefits it

yields to them. Subsequently, radiating this to the employees ensures that LM does not become bogged

down.

‘So you also need to believe in it as a leader, otherwise it will get bogged down and then nothing

happens […]. So to sustain, you need to show that you believe in it. That you have a convincing role’.

(Miranda)


Keep repeating the Lean message is important to sustain LM over time. Repetition ensures that all

employees are and remain involved in LM. The more often repetition take place, the more the employees

are exposed to LM and the more positive they become about it. When employees remain involved

through message repetition, LM is perceived as an integral part of the department. In Case D, message

repetition includes through an improvement board and during meetings. However, it is not clear which

dissemination channel is most effective. Nevertheless, it is evident that it is important for the

sustainability of LM to let it come back by making it a recurring item on the agenda.

‘The power resides in repetition, that you repeat it all the time. For example, that you have a constant

improvement board or work meetings, or that you always let it come back in team meetings. As a

result, improving quality, safety, becomes normal in the department’. (Esther)

‘If you regularly come into contact with something and if something is told to you on a regular basis,

you will believe it more and more and you are more likely to do something with it. And then it also

becomes easier to sustain it in the department’. (Anna)

‘Continuous improvement must be on the agenda of team meetings. And in any case, I always have a

heading “quality and safety”, which includes continuous improvement [...]. So because it is

continuous, you also have to have a moment to give it a place and to let it come back again and

again’. (Esther)

4.4.3 Education

Education in LM is important to its sustainability. In Case D, the yellow belt training was considered to

be effective as it provides employees with the fundamentals of LM. Training in LM raises awareness

and creates a different mindset among employees. As a result, employees are able to look at their

everyday surroundings from a different perspective, identifying opportunities for improvement.

Essentially, the different mindset that is created through training enables employees to work with LM

and improve accordingly. Moreover, when employees are educated in LM, it builds a structure to work

with and it makes sure everyone comprehends LM in the same manner. In other words, this allows

29

employees to work according to the same system, which means they are all on the same wavelength as

far as LM is concerned.

‘So we are all yellow belt educated. All nurses, all employees had to do the training. This was

facilitated in a team day, which actually puts you all in a different mindset: “We work with processes

and we have to see where the waste is”. And I think that is a very good basis to look further from

there: "Okay, but how can we shape this in the department?"’. (Sophie)

‘Yes, I think so. Because then you understand what the goal is and why you do something. In my entire

department you have to understand the basics, so that everyone knows why you are going to do

something’. (Anna)



Employee behaviors

To sustain LM over time, two behaviors are designated as being important in Case D: employees need

to take initiative, and communicate with peers.

Initiative behavior is expressed by pointing out problems, offering possibilities for

improvement, and by bringing about improvements themselves. By doing so, employees’ enthusiasm

and commitment to LM will be increased. Besides taking initiative, employees need to communicate

with colleagues about LM. More specifically, they must encourage and support each other in LM

throughout the mutual interactions they have. This keeps everyone involved in LM and ensures that the

topic remains at the centre of attention.

‘That the employees themselves put things on the improvement board [...]. So especially indicating

problems’. (Sophie)

‘They just make improvements [...]. And bring things up during work meetings, like: "What problems

do I encounter?" [...]. And at some point, people are constantly thinking about improving: "How did I

work today? And how can things be different tomorrow?"’. (Esther)

‘Yes, that is actually the same thing I have been saying the whole time, that is just that we all keep

talking about it with each other’. (Sophie)

Employee attitudes

Regarding Case D, the data highlight two attitudes that contribute to the sustainability of LM. First of

all, intrinsic motivation in LM and thus in improving the work processes is of importance. This creates

interest and enthusiasm to continuously improve. Secondly, employees need to acknowledge the

importance and usefulness of CI. These two attitudes keep LM at the centre of attention.

30

‘If you are intrinsically motivated in the work process of the nurses or whoever, then it affects them.

And only then they enter the action mode and start to change’. (Esther)

‘I think I have colleagues who are actively engaged in thinking along and who recognize the

importance of improving. They also pass this on to other colleagues’. (Anna)

‘So you have to recognize the benefits of improvement projects. Yes, if you do not see any advantage in

that, then it is not going to work’. (Anna)

4.4.5 LM barriers

In Case D, the data pinpoint both lack of time and space, and employee resistance as aspects that impede

the sustainability of LM. Here, employees are often too busy with their own work, which increases their

workload when they also focus on LM. As a result, they do not have the time or the inclination to make

improvements. Due to the lack of time and space, employees give priority to their own work, leaving

less time for CI. Moreover, there are employees who are not very enthusiastic about CI as this rearranges

their way of working. Therefore, they are more likely to resist changes.

‘It is often very busy in care. So you are very glad that you have finished your work, so to speak. And

then I can also imagine that a lot of people have something like: “If I have to think about that too, well

I do not have time for that at all”. So that is a barrier, yes’. (Anna)

‘Some people say: “No, I have been doing this for years, I am going to do what I have always done”.

And then they almost get into a fight. So that is rather difficult’. (Sophie)

4.5 Cross-case analysis

In this paragraph, the previously found insights from the within-case analysis are juxtaposed and

compared. All identified insights can be found in Table 3.


According to the results, two overarching tasks have been identified as desirable to exhibit as a leader

in order to sustain LM: (1) stimulating and motivating, and (2) coaching and facilitating. Several

concrete behaviors can be distinguished in each of these tasks, all of which are presented in Table 3.

With regard to the former, both delegating LM tasks, and demonstrating results by making gains visible

are designated as most important towards LM sustainability in this study. With respect to the latter,

providing support in LM, acting as a role model, and giving employees time and space to work with LM

are considered to be conducive to sustain LM. In contrast to the abovementioned behaviors, the results

related to the desired leader attitudes appeared to be less pronounced. Yet, their importance should not

be overlooked, as both are important in the sustainment of LM.

31


Based on the results, on the one hand, it is acknowledged that the repetition of the Lean message is very

important. However, no unambiguous conclusion can be drawn regarding the most effective way to do

this. From the cases, different ways of dissemination emerge, of which the use of e-mail is generally

considered less effective. The use of meetings probably works, especially when it is a fixed item on the

agenda. The fact that all cases are successful in sustaining LM does not exclude the other ways (e.g.,

improvement board or dialogues) in which dissemination is possible. Nevertheless, the power rests in

repeating and continuously bringing the Lean message to the attention when it comes to the

sustainability of LM.

4.5.3 Education

Drawing on the results, all different cases were unequivocal with regard to the importance of education

in the sustainment of LM. For example, it was repeatedly indicated that training serves as a suitable

instrument to raise employees’ awareness of LM. Moreover, training provides employees with the

necessary mindset and structure, enabling them to look at their environment in a different way. However,

there is no consensus on which type of training (yellow, orange, or green belt) is considered most

effective, since the provided trainings varied from case to case. Yet, this did not hinder the sustainability

of LM as all departments were successful in this.


All the cases were unanimous that taking initiative by employees increases commitment to LM and

hence contributes to its sustainability. Important ways that were suggested from the cases to achieve this

include identifying problems, suggesting ideas, and making improvements themselves. In addition, it

can be concluded that if healthcare organizations want to sustain LM, it is important that employees are

intrinsically motivated and interested in improving their operations. These important components of

employee commitment ensure that LM remains at the centre of attention in the operational parts of the

organization.

4.5.5 LM barriers

From all cases, three aspects stand out as barriers hindering the sustainability of LM: (1) lack of time

and space, (2) resistance from employees, and (3) fear. With regard to the former, employees are often

too busy with their own work, leaving little or no time to improve their processes. With reference to

employee resistance, primarily older employees prefer to maintain the existing routines and are more

reluctant to improve as this often involves rearrangements in their work. With respect to the latter, the

fear of improving or making mistakes causes negative feelings towards LM.

32

Table 3: Cross-case analysis

5. DISCUSSION

Within this study, the aim was to investigate how a healthcare provider with a successful LM program

was able to sustain LM over prolonged periods of time. For this purpose, we developed the following

research question: “How are Lean management improvement activities sustained within a healthcare

context?”. Through this study we were able to identify multiple facilitators and barriers towards LM

sustainability and therefore we have managed to answer the research question. In this section, the main

findings of this study are discussed in relation to existing literature. Moreover, theoretical contributions

and managerial implications are described. Finally, the limitations and suggestions for future research

are presented.

5.1 Main findings in relation to existing literature

First, this study highlights the role of leadership as a facilitator when it comes to the sustainability of

LM. This is also well recognized by existing literature (Radnor, 2011; Aij & Teunissen, 2017; Aij et al.,

2015; Flynn et al., 2018). The study by van Dun, Hicks and Wilderom (2017) examined the behaviors

leaders should exhibit to be an effective LM leader. Yet, none of the above studies provides clarity as

to which specific behaviors are appropriate for sustainability purposes. We add to these earlier findings

by showing which behaviors support LM sustainability in the healthcare context. We presented two

overarching tasks in terms of leadership behaviors that lend themselves as beneficial contributors to LM

sustainability: (1) stimulating and motivating, and (2) coaching and facilitating. Stimulating and

motivating is manifested in several ways as this study reveals. However, two concrete behaviors are

considered most important in this study, which are delegating LM tasks, and demonstrating results by

making gains visible. These identified behaviors related to LM sustainability are an addition to the

abovementioned studies. With respect to coaching and facilitating, providing support and acting as a

role model are helpful to sustain LM. Acting as a role model is in line with the findings of Aij, Simons,

Widdershoven and Visse (2013) who state that exemplifying behavior and thus acting as a role model

is an important facilitator. Furthermore, this study indicates that leaders need to assist employees by

giving them time and space to work with LM, which supports earlier findings by Dombrowski and

Mielke (2014).

Second, repetition of the Lean message is identified as a facilitator contributing to LM

sustainability. The power rests in repeating the message continuously. This contradicts the findings of

Radnor (2011), Hallam and Contreras (2018), and Naik et al. (2012), as they suggest that communication

is an important category that contributes to the sustainability of LM. It is assumed that this difference

has to do with the scope of the studies. This study focuses entirely on the sustainability of LM and takes

a more practical scope, whereas the abovementioned studies do not fully focus on this topic. Instead,

they describe the sustainability in a rather global and abstract way.

Third, education in the domain of LM is revealed as a facilitator to LM sustainability in this

study. Clearly, the findings of Radnor (2011) and Al-Balushi et al. (2014) also consider this as an

34

enabler. Based on this study, training raises awareness of LM, which guides sustainability thinking. The

researchers Souza and Alves (2018) are consistent with this finding. Moreover, this study identified that

training provides employees with a different mindset and structure that enables them to look at their

environment in a different way. This can be linked to the study by Poksinska (2010), which found that

when employees are educated in LM, they gradually understand that there is a large amount of waste in

their work processes and that the basic principles of LM could help them. This study also indicates that

all specific types of training used in this study (i.e., yellow, orange, and green belt), contribute to LM

sustainability, regardless of the differences in complexity. As a result, no unified answer can be given

as to which type of training is most effective when it comes to the sustainability. To our knowledge, no

existing literature has been found confirming or denying this.

Fourth, this study identified employee commitment as a facilitator contributing to LM

sustainability. This is in line with the study by Anand, Chhajed and Deflin (2012). However, based on

this study, we added the distinction between employee behaviors and attitudes to sustain LM. With

reference to the behaviors, taking initiative, communicating with peers about LM, and listening to the

client were identified as components contributing to the sustainability of LM. To our knowledge, no

existing literature has been discovered confirming or denying the relevance of these employee behaviors

regarding LM sustainability. With regard to employee attitudes, employees who are intrinsically

motivated in LM and in improving their processes are beneficial with regard to the sustainability.

Intrinsic motivation was also considered important by Taylor, McSherry, Cook and Giles (2020).

Fifth, three main barriers are identified that hamper the road to sustain LM. These barriers

include: lack of time and space (i.e., workload or other priorities), employee resistance (i.e., generation

gap or maintaining existing routines), and fear (i.e., fear to improve or fear to make mistakes). According

to Aij et al. (2015), employees perceive performing LM tasks as an additional pressure since they need

their time to execute and finish their normal work. This is consistent with the identified barrier of this

study: lack of time and space. In addition, studies by Aij et al. (2015), and Morrow, Robert, Maben and

Griffiths (2012) indicated that existing routines hinder organizations to sustain changes. This is

congruent with the identified barrier: employee resistance. In contrast to the two barriers above, the last

identified barrier in this study (i.e., fear) is not mentioned in the studies by Aij et al. (2015), and Morrow

et al. (2012). To our knowledge, this barrier is also not reported in other existing literature as a barrier

to sustain LM in the healthcare context.

5.2 Theoretical contributions and managerial implications

5.2.1 Theoretical contributions

This study contributes to existing literature (e.g., Radnor, 2011; Aij et al., 2015; Flynn et al., 2018) by

confirming the role of leadership as a facilitator contributing to the sustainability of LM. As indicated

earlier, these findings are inconclusive as to which hands-on behaviors are appropriate for sustainability

purposes. Hence, we complement the role of leadership by adding two overarching leadership tasks

35

containing several concrete behaviors that contribute to the sustainability of LM. Besides the leadership

behaviors, we add to the literature important leadership attitudes that are helpful to sustain LM.

Based on the results, this study adds an additional insight to the studies by Radnor (2011),

Hallam and Contreras (2018), and Naik et al. (2012). These studies suggest that communication is a

facilitator contributing to LM sustainability. However, we believe that communication as a category is

not a proper term to use as a facilitator. It is not a straightforward concept, but it is rather vague. We do

understand this focus, however based on our results, we suggest to take the repetition of the Lean

message as the main category, of which communication is a subset. We think this better captures what

healthcare organizations need to do in a more practical way to sustain LM, which is to keep repeating

the message.

In addition, the fact that education in LM is designated as an important facilitator in its

sustainability is congruent with earlier findings of Radnor (2011) and Al-Balushi et al. (2014). Yet, by

distinguishing between different types of training, this study approaches education from a more practical

perspective. This teaches us that regardless of the different types of training offered in terms of

complexity, they all contribute to the sustainability of LM. More specifically, there is not one which is

seen as most effective when it comes to LM sustainability. That is why this study complements existing

literature as it provides a more detailed understanding of the education component as a facilitator in LM

sustainability.

Moreover, this study identifies employee commitment as a facilitator to LM sustainability,

which corresponds to the findings of Anand, Chhajed and Deflin (2012). However, these researchers

did not elaborate further on the specific behaviors and attitudes that are appropriate for sustainability

purposes. We contribute to their work by breaking down employee commitment into employee

behaviors and attitudes that are useful for LM sustainability. The results regarding employee behaviors

(i.e., taking initiative, communicate with peers, and listen to client) contribute to existing literature,

whereas the results regarding employee attitudes (i.e., intrinsic motivation) confirm the study by Taylor

et al. (2020).

Furthermore, this study shows different barriers hindering the sustainability of LM. One new

barrier has been identified which adds to existing literature (e.g., Aij et al., 2015; Morrow et al., 2012).

Based on the results and contributions, we developed a theoretical framework to further evolve

LM sustainability thinking. The updated theoretical framework is presented in Figure 7. This framework

contributes to the literature on LM, especially on its sustainability, as it guides healthcare organizations

to sustainability thinking. This framework assists healthcare organizations to sustain LM as it provides

more specific information on how LM improvement activities could be sustained. By giving a deeper

understanding on how each of the main categories contributes to the sustainability of LM, we were able

to expand the literature on this topic.

Figure 7: Updated theoretical framework

Based on this study, the following propositions have been formulated:

Proposition 1: Stimulating and motivating, and coaching and facilitating are important leadership tasks,

each with its own behaviors, to sustain LM approaches.

Proposition 2: When the Lean message is repeated continuously through different channels, this

contributes to the sustainability of LM.

Proposition 3: Any kind of training in LM contributes to its sustainability.

Proposition 4: In terms of employee behaviors: taking initiative, communicating with peers about LM,

and listening to the client contribute to the sustainability of LM.

Proposition 5: The lack of time and space, employee resistance, and fear hamper the road to sustain LM

approaches.

5.2.2 Managerial implications

This study provides a number of implications for managers and therefore offers insights into how they

can sustain LM over time.

This study provides managers with fairly self-explanatory, hands-on behaviors that leaders can

act upon in their daily work to successfully sustain LM. In turn, these behaviors, supplemented by the

identified attitudes, provide a guideline for managers to take into account in recruitment and selection

in case a new leader needs to be appointed. A way to assess whether potential leaders possess the desired

behaviors to sustain LM is through role-playing. During a role-play they must, for example, demonstrate

their ability to delegate. This is valuable information to determine the extent to which a candidate is

capable to sustain LM.

In addition, this study shows that repetition of the Lean message is important when it comes to

its sustainability. Interestingly, the way in which the message is spread is less important than repeating

the message itself. This gives flexibility for managers when it comes to the dissemination channel. Based

on the results, the use of meetings seems to be suitable, especially when it is a fixed agenda item.

Therefore, the advice to managers is to schedule a monthly department-wide LM meeting that explicitly

addresses this topic. Moreover, we recommend them to delegate this to weekly team meetings in which

LM becomes a fixed item on their agenda. To bring LM to the attention at different moments, for

example through meetings, is suitable to foster sustainability.

Moreover, in terms of education, all specific types of training (i.e., yellow, orange, and green

belt) offered in this study contribute to the sustainability of LM, regardless of the differences in

complexity. Hence, it does not matter what kind of training you need to offer. This gives flexibility for

managers when it comes to offering training in LM. Based on the results, we would advise managers to

provide all employees with a framework of Lean thinking, including the various wastages, to give

employees the basic knowledge in LM. An efficient way to accomplish this is through a group training

in LM, which ensures that everyone has the same knowledge. As a result, all employees are able to look

at their environment in that specific way, which enables them to improve their work continuously.

38

Furthermore, this study identifies that intrinsic motivation with regard to LM, and thus

improving, is important among employees. In practice, this provides guidelines for managers to consider

in recruitment and selection. In the case of no or little intrinsic motivation among employees, this

provides opportunities for managers to exert extra influence on this. For example, this could be realized

by enforcement through extrinsic motivations (e.g., rewards).

Finally, lack of time and space is identified as a barrier to sustain LM. Managers can

accommodate this by giving employees half a day a week the time to work with LM and to think about

improving their processes. By pausing their normal work activities, employees are given all the time to

focus on LM and on improving their work. However, it is important that this is coordinated within the

teams so that it does not interfere with their daily activities. In this way, LM remains at the centre of

attention.

5.3 Limitations and future research

A number of limitations can be identified in this study. First, the number of people interviewed varied

across the different disciplines. This is a limitation with regard to the quality of this research. However,

we have made sure that we were always as well informed as possible within the disciplines.

Nevertheless, if the study would be replicated, future research could better focus on four cases with the

same number of interviewees and with the same type of functions across the different cases. This in

order to strengthen the quality of the research.

Second, there were three employees who were no longer working in the department for which

they were being interviewed, but they did try to reflect on that situation. However, this was difficult

because it was often some time ago that they worked there. So if this study would be replicated, it would

be better to focus on employees who are working in the specific department for which they are being

interviewed. This will enable them to provide better answers to the questions.

Third, the interviews could not take place face-to-face due to Covid-19. That is why the

interviews were conducted via the video conferencing software StarLeaf. Despite the fact that it was a

good solution to still conduct interviews, this also entailed difficulties. For example, the internet

connection sometimes dropped down during interviews. Because of this, valuable time was lost.

Moreover, the screen sometimes jammed, making it difficult to hear parts of the conversation properly.

As a result, it was a hard time to transcribe the interviews. Finally, the digital way of conducting

interviews made it more difficult to interpret non-verbal communication. To avoid these problems,

future research could therefore better focus on conducting face-to-face interviews, if possible.

Fourth, the fact that this study only considered multiple cases within one specific setting

(healthcare context) to arrive at the established results, makes it difficult to provide any assertions with

respect to its generalizability. Future research that considers a variety of settings (e.g., construction) may

reveal whether the conclusions replicate in other fields.

39

6. CONCLUSION

This study provides insights into the facilitators and barriers that contribute to the sustainability of LM

in the healthcare context. In this study, we were particularly interested in how and why these facilitators

and barriers play a role. This study revealed four categories of facilitators contributing to the sustainment

of LM: (1) The role of leadership, (2) Repetition of the Lean message, (3) Education, and (4) Employee

commitment. Underlying these categories, a more comprehensive understanding on how each of these

identified categories contributes to the sustainability of LM is given. Besides these facilitators, this study

revealed some barriers hindering the sustainability including lack of time and space, employee

resistance, and fear. This study adds to the literature on LM, especially on its sustainability, through the

development of a framework. This framework is relevant for healthcare organizations as it guides

sustainability thinking. It provides a better understanding on how LM improvement initiatives could be

sustained in healthcare organizations.

40

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APPENDICES

Appendix I: Interview protocol

Allereerst zou ik u graag willen bedanken voor uw deelname aan dit onderzoek. Ik zal mijzelf even kort

voorstellen. Mijn naam is Jessica van Toorn. Momenteel zit ik in de laatste fase van de master opleiding

Change Management aan de Rijksuniversiteit Groningen. Dat is de reden dat ik een onderzoek naar de

succesfactoren voor het behoud van continu verbeteren uitvoer. Om de zorg steeds op het hoogste niveau

te houden, is het noodzakelijk om continu te verbeteren. De Lean-methode wordt gebruikt om de zorg

sneller, prettiger of slimmer te organiseren voor de patiënt. Inmiddels zijn er een flink aantal

medewerkers opgeleid en Lean projecten afgerond. Door beter te begrijpen hoe deze projecten tot een

succes leiden, kunnen we het ondersteuningsaanbod verbeteren. Daarnaast krijgt de afdeling zelf zicht

op de invloed factoren voor het behoud van het continu verbeteren.

In dit interview zal ik vragen stellen over de Lean projecten waar u onderdeel van bent geweest en wat

deze projecten volgens u tot een succes hebben gemaakt. Daarnaast ben ik vooral geïnteresseerd in het

vasthouden van continu verbeteren door middel van Lean. Ik ben benieuwd naar uw ervaringen en

inzichten, dit betekent dat er geen foute antwoorden zijn. Het interview zal ongeveer 30 tot 45 minuten

duren. Daarnaast zal het interview geheel vertrouwelijk en anoniem verwerkt worden. Om de uitkomsten

van het interview zo volledig en nauwkeurig mogelijk uit te kunnen werken, wil ik u vragen of ik het

interview mag opnemen? (Formulier laten ondertekenen)

Heeft u misschien vooraf al vragen?

Dan start ik nu de opname en dan kunnen we beginnen.

45

A. Interview protocol leidinggevende

Algemeen + introductie Lean Management

1. Kunt u zichzelf kort voorstellen? (wat is uw achtergrond?)

o Kunt u een uitleg geven over uw functie binnen de gehele organisatie?

o Wat is de rol van uw afdeling binnen de gehele organisatie?

o Wat is uw rol binnen uw afdeling/team?

o Hoe lang bent u werkzaam in deze functie?

o Wat heeft u hiervoor gedaan?

2. Wat is uw ervaring met Lean?

o Heeft u ook een Lean opleiding gehad? Zo ja, welke was dat dan?

3. Wat verstaat u onder het Lean werken?

4. Welke werkzaamheden voert u als unithoofd uit om uw afdeling te ondersteunen in het

werken met Lean?

Lean management verbeterprojecten

5. Kunt u wat meer vertellen over de meest recente verbeterprojecten op uw afdeling?

o Wat was het doel van de verbeterprojecten?

o Wat was het resultaat van de verbeterprojecten?

o Wat was het tijdsbestek waarin deze projecten werden uitgevoerd?

6. Wat was volgens u het belangrijkste resultaat van de verbeterprojecten?

o Hoe succesvol was het resultaat?

o Kunt u een voorbeeld van een verbeterproject benoemen die waarde heeft toegevoegd

voor de patiënt?

o Monitoren jullie de resultaten van de verbeterprojecten?

7. Het gaat bij het continu verbeteren niet alleen om het doen van een project. Een belangrijk

onderdeel van veel van de projecten is het volgen van een p-d-c-a cyclus. In hoeverre is uw

afdeling succesvol met het inbedden van de p-d-c-a cyclus in uw afdeling?

o Hoe komt het dat jullie wel/niet in staat zijn geweest om de p-d-c-a cyclus in te

bedden?

o Waar blijkt dat uit?

Leiderschap

8. Op welke manier draagt u als leidinggevende bij aan het vasthouden van de Lean uitkomsten?

o Wat doet u dan op uw afdeling om een Lean aanpak vast te houden?

o Hoe gaat dat dan?

9. Wat zijn volgens u als leidinggevende de kenmerken van een team die erin slaagt om het

continu verbeteren vast te houden?

o Waarom zijn deze kenmerken succesvol in het vasthouden van continu verbeteren?

10. Wat zijn volgens u de karaktereigenschappen die mensen volgens u moeten hebben om het

continu verbeteren te behouden?

o Hoe kan je ervoor zorgen dat het continu verbeteren in het DNA van de mensen komt?

11. In hoeverre is training op het gebied van Lean een meerwaarde voor het behoud ervan? o Hoe komt dat denkt u?

o Waarom is dat dan zo?

12. Heeft u ook het idee dat de medewerkers die een green of orange belt opleiding hebben

gevolgd een bijdrage leveren aan het behoud van een Lean aanpak?

o Hoe komt dat denkt u?


o Op wat voor manier draagt de opleiding bij aan het behoud?

o Waarom denkt u dat juist die elementen bijdragen aan het behoud van een Lean

aanpak?

13. In welke mate speelt leiderschap een rol bij het vasthouden van een Lean aanpak over tijd?

46


o Kunt u een voorbeeld noemen waarom leiderschap wel/geen rol speelt bij het

vasthouden van Lean over tijd?

o Wat moet een leider volgens u dan doen om het vasthouden van een Lean aanpak te

laten slagen?

Het vasthouden van een Lean aanpak (sustainability)

14. Wat verstaat u onder een leer- en verbetercultuur?

o In hoeverre vindt u dat dit een onderdeel is van Lean?

15. In hoeverre is er volgens u sprake van een leer- en verbetercultuur binnen uw afdeling?



o Waarom denkt u dat?

o Kunt u een voorbeeld geven waaruit blijkt dat er wel/niet sprake is van een leer- en

verbetercultuur binnen uw afdeling?

16. In hoeverre is uw afdeling in staat geweest om het continu verbeteren door middel van Lean

vast te houden over tijd?

o Hoe kan het dat jullie wel/niet in staat zijn om de Lean aanpak vast te houden? (indien

ze niet succesvol zijn: wat zou er dan moeten veranderen om het continueren van de

projecten en daarmee de Lean aanpak mogelijk te maken?)


o Op welke manier hebben jullie Lean weten vast te houden op de afdeling?

o Wat doen de mensen op uw afdeling om het continu verbeteren vast te houden?

o Waren er misschien mensen in uw team die een rol hebben gespeeld bij het

vasthouden van een Lean aanpak en daarmee het continu verbeteren?

o Zijn er bepaalde werkzaamheden op uw afdeling die maken dat jullie heel goed met

Lean kunnen werken en daarmee ook kunnen vasthouden?

o Zijn er team of afdeling gerelateerde aspecten die een rol spelen bij het behoud van

het continu verbeteren?

o Kunt u een voorbeeld noemen waaruit blijkt dat uw afdeling nog steeds actief is met

continu verbeteren?

17. Wat voor stimulerende factoren spelen een rol bij het vasthouden van continu verbeteren door

middel van Lean? (bijvoorbeeld.: heeft dit te maken met leiderschap, training, ervaring, etc.?)

o Waarom denkt u dat deze factoren tot een succes leiden bij het vasthouden van het

continu verbeteren door middel van Lean over tijd?

o Wat is het mechanismen daarachter dat leidt tot het vasthouden van het continu

verbeteren?

18. Welke belemmeringen heeft u ervaren in uw afdeling met het vasthouden van een Lean

aanpak?

o Indien er belemmeringen waren: waarom denkt u dat deze belemmeringen zich

hebben voorgedaan?

o Hoe heeft u de belemmeringen opgelost?

o Indien er geen belemmeringen waren: waarom denkt u dat er geen belemmeringen

waren?

19. Wie ziet u als de Lean leider binnen uw afdeling?

20. Op welke manier draagt de Lean leider, volgens u, bij aan het vasthouden van het Lean

werken binnen de afdeling?

o Wat doet de Lean leider dan om het Lean werken vast te houden?

o Hoe gaat dat dan?

47

Slot

21. Is er iets dat u zou willen toevoegen, iets dat ik had moeten vragen?

22. Kent u daarnaast nog andere collega’s die de green of orange belt opleiding heeft gevolgd

en/of betrokken is geweest bij de implementatie van één van deze projecten die ik zou kunnen

interviewen?

Dan zijn we nu aan het eind gekomen van dit interview. Ik wil u dan ook graag bedanken voor uw

deelname en uw waardevolle informatie aan dit onderzoek! Ik stop vanaf nu de opname.

B. Interview protocol geschoolde Lean medewerker (yellow, orange of green belt)

Algemeen + introductie Lean Management

1. Kunt u zichzelf kort voorstellen? (wat is uw achtergrond?)

o Kunt u een uitleg geven over uw functie binnen de gehele organisatie?

o Wat is de rol van uw afdeling binnen de gehele organisatie?

o Wat is uw rol binnen uw afdeling/team?

o Hoe lang bent u werkzaam in deze functie?

o Wat heeft u hiervoor gedaan?

2. Wat is uw ervaring met Lean?

o Heeft u ook een Lean opleiding gehad? Zo ja, welke was dat dan?

3. Wat verstaat u onder het Lean werken?

4. Welke werkzaamheden voert u uit om uw afdeling te ondersteunen in het werken met Lean?

Lean management verbeterprojecten

5. Kunt u wat meer vertellen over de meest recente verbeterprojecten op uw afdeling?

o Wat was het doel van de verbeterprojecten?

o Wat was het resultaat van de verbeterprojecten?

o Wat was het tijdsbestek waarin deze projecten werden uitgevoerd?

6. Wat was volgens u het belangrijkste resultaat van de verbeterprojecten?

o Hoe succesvol was het resultaat?

o Kunt u een voorbeeld van een verbeterproject benoemen die waarde heeft toegevoegd

voor de patiënt?

o Monitoren jullie de resultaten van de verbeterprojecten?

7. Het gaat bij het continu verbeteren niet alleen om het doen van een project. Een belangrijk

onderdeel van veel van de projecten is het volgen van een p-d-c-a cyclus. In hoeverre is uw

afdeling succesvol met het inbedden van de p-d-c-a cyclus in uw afdeling?

o Hoe komt het dat jullie wel/niet in staat zijn geweest om de p-d-c-a cyclus in te

bedden?


Opleiding

8. Welke opleiding heeft u gevolgd met betrekking tot Lean?

9. Hoe zag uw opleidingstraject eruit?

o Hoe zagen de trainingen inhoudelijk eruit?

o Wat heeft u geleerd van de opleiding?

o Zijn er elementen die u heeft gemist en dus graag had willen zien tijdens de opleiding?

Zo ja, wat had u graag behandeld willen hebben tijdens de opleiding?

10. Denkt u dat training of educatie een meerwaarde heeft voor het behoud van continu verbeteren?



11. In hoeverre draagt die opleiding, volgens u, bij aan het behoud van een Lean aanpak?

o Op wat voor manier draagt de opleiding bij aan het behoud van een Lean aanpak?

48

o Waarom denkt u dat juist die elementen eraan bijdragen?

12. Op wat voor manier zorgt u ervoor dat er nieuwe projecten worden gestart? Dus dat je blijft

continu verbeteren?

13. Krijgen jullie ook binnen de opleiding uitgelegd hoe je continu verbeteren door middel van

Lean kan vasthouden over tijd?

o Hoe worden jullie daarin gestimuleerd en gemotiveerd?

14. Wat zijn volgens u de karaktereigenschappen die mensen volgens u moeten hebben om het

continu verbeteren te behouden?

o Hoe kan je ervoor zorgen dat het continu verbeteren in het DNA van de mensen komt?

Het vasthouden van een Lean aanpak (sustainability)

15. Wat verstaat u onder een leer- en verbetercultuur?

o In hoeverre vindt u dat dit een onderdeel is van Lean?

16. In hoeverre is er volgens u sprake van een leer- en verbetercultuur binnen uw afdeling?



o Waarom denkt u dat?

o Kunt u een voorbeeld geven waaruit blijkt dat er wel/niet sprake is van een leer- en

verbetercultuur binnen uw afdeling?

17. In hoeverre is uw afdeling in staat geweest om het continu verbeteren door middel van Lean

vast te houden over tijd?

o Hoe kan het dat jullie wel/niet in staat zijn om de Lean aanpak vast te houden? (indien

ze niet succesvol zijn: wat zou er dan moeten veranderen om het continueren van de

projecten en daarmee de Lean aanpak mogelijk te maken?)


o Op welke manier hebben jullie Lean weten vast te houden op de afdeling?

o Wat doen de mensen op uw afdeling om het continu verbeteren vast te houden?

o Waren er misschien mensen in uw team die een rol hebben gespeeld bij het

vasthouden van een Lean aanpak en daarmee het continu verbeteren?

o Zijn er bepaalde werkzaamheden op uw afdeling die maken dat jullie heel goed met

Lean kunnen werken en daarmee ook kunnen vasthouden?

o Zijn er team of afdeling gerelateerde aspecten die een rol spelen bij het behoud van

het continu verbeteren?

o Kunt u een voorbeeld noemen waaruit blijkt dat uw afdeling nog steeds actief is met

continu verbeteren?

18. Wat voor stimulerende factoren spelen een rol bij het vasthouden van continu verbeteren door

middel van Lean? (bijvoorbeeld.: heeft dit te maken met leiderschap, training, ervaring, etc.?)

o Waarom denkt u dat deze factoren tot een succes leiden bij het vasthouden van het

continu verbeteren door middel van Lean over tijd?

o Wat is het mechanismen daarachter dat leidt tot het vasthouden van het continu

verbeteren?

19. Welke belemmeringen heeft u ervaren in uw afdeling met het vasthouden van een Lean

aanpak?

o Indien er belemmeringen waren: waarom denkt u dat deze belemmeringen zich

hebben voorgedaan?

o Hoe heeft u de belemmeringen opgelost?

o Indien er geen belemmeringen waren: waarom denkt u dat er geen belemmeringen

waren?

20. In welke mate speelt leiderschap een rol bij het vasthouden van een Lean aanpak over tijd?


o Kunt u een voorbeeld noemen waarom leiderschap wel/geen rol speelt bij het

vasthouden van Lean over tijd?

49

o Wat moet een leider volgens u dan doen om het vasthouden van een Lean aanpak te

laten slagen?

21. Op welke manier draagt uw leidinggevende bij aan het vasthouden van de Lean uitkomsten?

o Wat doet de leidinggevende dan op uw afdeling om een Lean aanpak vast te houden?

o Hoe gaat dat dan?

22. Wie ziet u als de Lean leider binnen uw afdeling?

23. Op welke manier draagt de Lean leider, volgens u, bij aan het vasthouden van het Lean

werken binnen de afdeling?

o Wat doet de Lean leider dan om het Lean werken vast te houden?

o Hoe gaat dat dan?

Slot

24 Is er iets dat u zou willen toevoegen, iets dat ik had moeten vragen?

25. Kent u daarnaast nog andere collega’s die de green of orange belt opleiding heeft gevolgd

en/of betrokken is geweest bij de implementatie van één van deze projecten die ik zou kunnen

interviewen?

Dan zijn we nu aan het eind gekomen van dit interview. Ik wil u dan ook graag bedanken voor uw

deelname en uw waardevolle informatie aan dit onderzoek! Ik stop vanaf nu de opname.

C. Toestemmingsformulier

Titel onderzoek: Het vasthouden van Lean Management over een langere periode

Verantwoordelijke onderzoeker: Jessica van Toorn

In te vullen door de deelnemer

Ik verklaar op een voor mij duidelijke wijze te zijn ingelicht over de aard, methode, doel en belasting

van het onderzoek. Ik weet dat de gegevens en resultaten van het onderzoek alleen anoniem aan

derden bekend gemaakt zullen worden. Mijn vragen zijn naar tevredenheid beantwoord.

Ik begrijp dat audiomateriaal of bewerking daarvan uitsluitend voor analyse en/of wetenschappelijke

presentaties zal worden gebruikt.

Ik stem geheel vrijwillig in met deelname aan dit onderzoek. Ik behoud me daarbij het recht voor om

op elk moment zonder opgaaf van redenen mijn deelname aan dit onderzoek te beëindigen.

Naam deelnemer: …………………………………………………………………………..

Datum: …XX/XX/20XX… Handtekening deelnemer: …...………………………………….

In te vullen door de uitvoerende onderzoeker

Ik heb een mondelinge en schriftelijke toelichting gegeven op het onderzoek. Ik zal resterende vragen

over het onderzoek naar vermogen beantwoorden. De deelnemer zal van een eventuele voortijdige

beëindiging van deelname aan dit onderzoek geen nadelige gevolgen ondervinden.

Naam onderzoeker: Jessica van Toorn

Datum: XX /XX/XXXX Handtekening onderzoeker:

Appendix II: Codebook

Category Second-order code Definition First-order code Quotation

Role of leadership Leader behaviors A set of actions made by a

leader in interaction with

his/her employees in an

organizational setting that

contribute to the sustainability

of LM (Szabo, Reber, Weibler,

Brodbeck & Wunderer, 2001).

Stimulating and

motivating employees

‘So we are constantly stimulating people to look at it to

see if they cannot get it better? Yes, that is something

you have to do continuously’. (Jaap)

‘We definitely have a leader who stimulates you to take

up projects, to improve’. (Petra)

‘You are the leader [...]. So you have to keep stimulating

people to keep improving’. (Jan)

Delegate ‘I like to put the responsibility with the people

themselves. People are the owners. We are all

professionals, we all work in medical care, so I also

expect something from these people. I am not going to

say: “You have to do this and you have to do that and

then it all has to be done”. I am not going to do that.

The responsibility rests with the people themselves’.

(Jaap)

‘Because if they are responsible themselves and

eventually implement an improvement themselves, then I

think it has a positive effect on their motivation. Then he

thinks: “Oh gosh I have improved that, well that has

now been resolved. I did that myself”. So then he is more

inclined to do that again’. (Eva)

‘I think that you give autonomy to the employee.

Organize yourself. That is really the most important

thing: ownership, autonomy […]. Because then your

intrinsic motivation is triggered. If you have control and

think: “What is best for the department?”, yes then

people become happy and then you get less resistance.

But you also see that it sticks quickly’. (Esther)

51

Show results ‘Try to make them enthusiastic by showing them how

something becomes easier or better for the patient or

clearer or less error-prone. And then they all look in the

same direction, that you just want to work flawlessly for

the patient’. (Melany)

‘People only participate in continuous improvement

when you make them enthusiastic and when they see the

results, so they can work faster and more efficiently.

Next time they will think: “Hey, that is nice, we would

like to do that again, because it might even get better”.

So if you do that and you bring it across

enthusiastically, then people will join’. (Jan)

‘When people see that things are getting better, they also

become more aware that they can contribute. That they

can change something themselves, which leads to an

improvement. That works’. (Maarten)

Celebrate successes ‘The most important thing is to celebrate successes […].

Small things and big things need to be celebrated as

well, attention should be paid to that’. (Robert)

‘Celebrating successes, so that people really become

aware of it: “Oh yes this is what we do it for”. I think

that is very important to be able to sustain it for a long

time’. (Sophie)

Show personal interest ‘You have to show interest, of course’. (Jaap)

‘Yes! And also entering people's offices to ask: “How

are you doing?”’. (Jan)

Interact with

employees

‘But also just the interaction with employees, where I

really hope they will see it as a low threshold’. (Henk)

52

‘But just keep talking and asking questions to the

employees and being curious. And do not fill in the

blanks’. (Pieter)

Compliment

employees

‘I always try to tell the staff what they do well. And

giving compliments [...]. I think that is important too’.

(Pieter)

‘Yes, and giving compliments is always important too.

Like, “Oh, you solved that well. Great job'. Yes, then you

also see that people have the feeling of growing’.

(Sophie)

Inform employees ‘Yes, what I like about our unit head is that she keeps us

well informed. So I think that is an important condition

for getting involved in new things’. (Anna)

‘And keep everyone informed about the projects. Why

are we doing this? And what will it look like later on?

And do you have any ideas for that? Because I do notice

that people like to be informed […]. And we do that very

well’. (Melany)

Visit the work floor ‘What I always did, every day I went over the whole lab

from the beginning to the end. Also on the one hand to

say hello but also to be present. That is one of the Lean

aspects: “Back to the basics”. Go and look at the work

place itself. Talk to people. I think that is also one of the

strengths of leadership, just really go to the work floor.

Go to the place where it all happens’. (Pieter)

‘I walk around the hospital every Friday afternoon, both

hospital-wide and on the departments. On the one hand,

I try to have contact with the staff so they also notice

that you are approachable. But also vice versa, I think it

is important to hear and see them. So in the end, you

also build up your comments. And I think it is just

53

important to see and to observe: “Hey, what is going

on?”’. (Henk)

Monitor LM ‘The unit head pays attention to it to check if it still

works as agreed’. (Jolanda)

‘The head of the department must also ensure that

improvements are made in the departments. That we

continue to work efficiently. That she also monitors

that’. (Jan)

‘Also monitor whether everyone continues to do so, that

it does not fade away. That is important’. (Henk)

Coaching and

facilitating

‘That you are supported and given resources and time.

So of course you need the unit head for that as well. You

need a manager who supports you. My unit head always

does that. So you need time, space and resources to be

able to carry out things’. (Melany)

Give employees time

and space

‘You may really want to improve, but if you do not have

time in your work or if your manager does not give you

time, you will not get anywhere’. (Jolanda)

‘You have to give employees some time for that. The

space and time to actually investigate: “Hey, what am I

doing and how can I improve?”’. (Isabel)

‘Yes, I think you should mainly facilitate and ensure that

there is space and time for this in order for someone to

take it up’. (Eva)

Provide support ‘You need to guide the employees in continuous

improvement, so that they can do it themselves in the

long run […]. So you need to be sharp and hold up a

mirror to people all the time. And not come up with

solutions yourself, but let people think for themselves’.

(Maarten)

54

‘I think we have to coach them above all. Not to come up

with solutions ourselves, but to take them along. So

coaching them in the process to come up with their own

solutions’. (Sophie)

Role model ‘You have to show exemplary behavior yourself’.

(Robert)

‘I think if the leader and the coordinators among them, if

they do not convey that to the team, then I think it is

doomed to fail […]. So if you, as a leader, do not believe

in it and do not act on it, that you do not take an

exemplary role in it, then you just know that the rest will

not either’. (Nienke)

‘Well, anyway, a leader must always set a good example

himself’. (Maarten)

Leader attitudes Certain ways of thinking and

feeling that leaders possess

that contribute to the


Enthusiastic about LM ‘My unit head is always very focused on Lean [...]. So I

think if you have someone who is enthusiastic about it

from the top, then it is more likely to trickle down to the

underlying departments. To the unit heads underneath,

and then back to teams'. (Isabel)

‘I think our leader is also enthusiastic about this and this

is also passed on to the managers and the teams. So it just

depends on who you have above you as a leader'. (Petra)

Acknowledge the

importance and

usefulness of LM

‘So you also need to believe in it as a leader, otherwise

it will get bogged down and then nothing happens […].

So to sustain, you need to show that you believe in it.

That you have a convincing role’. (Miranda)

Repetition of the

Lean message

Communication Exchanging information about

LM among people.

Recurring agenda item ‘It is a fixed item on the agenda and that is why we can

keep it’. (Melany)

‘Continuous improvement must be on the agenda of

team meetings. And in any case, I always have a heading

“quality and safety”, which includes continuous

55

improvement [...]. So because it is continuous, you also

have to have a moment to give it a place and to let it

come back again and again’. (Esther)

Keep talking about

LM

’You just have to keep explaining and naming it. That is

really important! [...]. Otherwise, it only becomes

something for the management which is not the

intention. You have to keep communicating it to the

whole department to get everyone on board’. (Jaap)

‘The power resides in repetition, that you repeat it all

the time. For example, that you have a constant

improvement board or work meetings, or that you

always let it come back in team meetings. As a result,

improving quality, safety, becomes normal in the

department’. (Esther)

Medium ‘We had a newsletter, but we considered it to be

ineffective because it was not read since many people do

not sit behind their PCs. They all work in the lab. So we

did not do that anymore. Now we use work meetings’.

(Melany)

‘And every week we have a work meeting. So every week

we talk a lot about it in our department: “How can we

improve this?”.’ (Jan)

‘We have our weekly meetings and we have monthly

performance board meetings, so then we discuss the

KPIs. And we also have quarterly meetings with the unit

heads’. (Henk)

Education Training in LM Training in LM means that

employees acquire some

knowledge, skills, and

competence in LM.

Raises awareness ‘This is just to make people aware of what waste is, so

the basic principles. I think it is important that everyone

realizes that’. (Maarten)

‘The more people understand this, the more people look

at things from a different point of view. You look at

56

problems and alerts in a different way when you have

completed an education [...]. So you get awareness of

working with Lean’. (Melany)

Provides mindset ‘It is more the mindset I got from the training and

therefore I know how to approach certain improvement

processes […]. And also the tools to tackle it. What are

the right steps? What is the right order?’(Eva)

‘So we are all yellow belt educated. All nurses, all

employees had to do the training. So that was facilitated

in a team day, which actually puts you all in a different

mindset: “We work with processes and we have to see

where the waste is”. And I think that is a very good

basis to look further from there: "Okay, but how can we

shape this in the department?"’. (Sophie)

Provides structure ‘Training makes you more familiar with the concept of

Lean and what you can achieve with it. And you learn

how to use it [...]. It also teaches you how to start an

improvement idea. How can I improve my work? [...]. So

I think training in Lean will give you the tools to

implement it in your daily work’. (Isabel)

‘Yes, I think so! Because everyone will work according

to the same system. If you know and understand the

systematics, then it is also quite easy to start a new

process of improvement’. (Peter)

‘Well, like I said, you give them a certain baggage. You

need training to be able to keep working according to

that system [...]. You need to have 60/70 percent of the

employees in your department who can do that and who

understand that. Then the majority knows the theory and

understand what it means and why a certain project is

being tackled according to that system. And yes, then it

works’.(Jaap)

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Employee

commitment

Employee behaviors A set of actions made by an

employee in an organizational

setting that contribute to the


Take initiative ‘Well, like I said, employees themselves come up with:

"Hey, but that can be done differently. Can we not do it

better this way?"’. (Peter)

‘They just make improvements [...]. And bring things up

during work meetings, like: "What problems do I

encounter?" [...]. And at some point, people are

constantly thinking about improving: "How did I work

today? And how can things be different tomorrow?"’.

(Esther)

Communicate with

peers about LM

Everyone is asking each other about: "What is the

current situation? What else do you need?". So we are

constantly communicating with each other. What are we

doing? How do we do that? That is really important’.

(Petra)

‘And that is why we are always improving, because we

are constantly talking to each other about it: “Hey how

can we get it better?”’. (Jan)

Listen to the client ‘Yes, in the end I think you have to listen to the

customer. It is crucial that the customer says: “Hey, how

satisfied are we with the service and where do we see

opportunities for improvement?”. So I think you have to

be very receptive to that. So you also have to discover

that and listen to them’. (Henk)

Employee attitudes Certain ways of thinking and

feeling that employees possess

that contribute to the


Intrinsic motivation ‘Just like I said, I think there must already be a

foundation in your own intrinsic motivation to improve’.

(Eva)

‘If you have the intrinsic value in improving, “I want to

do my job faster, easier and better”, that is very

important. And I always find it interesting to see where

the accelerations are, or improvements in processes

[...]. But what I am saying, it has to be intrinsic’.

(Isabel)

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‘Yes, employees really need to have the intrinsic

motivation to improve. Only then we will continue to do

so’. (Melany)

Acknowledge the

importance and

usefulness of LM

‘So in the end, the employee must have faith in it, in

continuous improvement’. (Henk)

‘I think I have colleagues who are actively engaged in

thinking along and who recognize the importance of

improving. They also pass this on to other colleagues’.

(Anna)

‘So you have to recognize the benefits of improvement

projects. Yes, if you do not see any advantage in that,

then it is not going to work’. (Anna)

Barriers to sustain

LM

Lack of time and space Having little or no time and

space to do improvements.

Workload ‘It is often very busy in care. So you are very glad that

you have finished your work, so to speak. And then I can

also imagine that a lot of people have something like:

“If I have to think about that too, well I do not have time

for that at all”. So that is a barrier, yes’. (Anna)

‘Because you very often hear in practice: “I do not have

time for this, I am so busy” or “I have to fix all the

mistakes” [...]. You have to give them time and space to

do so. Otherwise you will notice that people may

experience extra pressure […], which can make them

feel negatively about implementing Lean or continuous

improvement projects’. (Isabel)

Other priorities ‘Yes time. Just time. I do find that difficult. Just that you

have to do it next to your own work, that makes it

difficult […]. Everybody is busy being busy. And I can

see that. And that also has a bit of an impact on people's

commitment. Because we are so busy, we do not have

much time to think about improving’. (Jolanda)

Employee resistance When an employee exhibits

any form of behavior or

Generation gap ‘Of course, we also have a generation gap in the

department. Well, those people do not see this in the

59

reaction when confronted with

changes. This behavior or

reaction slows down the

process of change and has a

negative impact on LM.

(Nakhoda & Tajik, 2017)

same way as the younger people who are very

enthusiastic about it. They all see bears on the road to

something that is becoming more difficult. Like: “In the

past it did not have to be that way, so why should it be

that way now?”. So that is indeed something you run

into’. (Melany)

‘Yes, I also have a couple of colleagues who are a bit

older and say: “Yes, but it is going well, right? It works

well how things are going now” […]. They are not very

enthusiastic and they are not eager’. (Jan)

Existing routines ‘Some people say: “No, I have been doing this for years,

I am going to do what I have always done”. And then

they almost get into a fight. So that is rather difficult’.

(Sophie)

‘And, of course, people who work here for a long time

and who are used to a certain way of working, are more

reluctant to change’. (Henk)

Fear When employees are afraid to

engage with LM and to

improve their processes.

Fear to improve ‘I believe that the greatest barrier is intertwined in

people themselves. So the fear of change is often a

barrier. Fear of making mistakes. So I think it is more

about culture’. (Eva)

Fear to make mistakes ‘People are sometimes afraid of change because they do

not know what the consequences will be. And they are

afraid to make mistakes’. (Maarten)

sustaining lean: lessons from a large medical care provider

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