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Lean healthcare from a change management


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Article May 2016


DOI: 10.1108/JHOM-06-2014-0090

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Evaluation & the Health Professions

The role of leadership and workforce flexibility when


implementing lean healthcare

Journal: Evaluation & the Health Professions


Fo
Manuscript ID: EHP-13-0169

Manuscript Type: Original Manuscript


r
Lean Healthcare, Transformational Leadership, Team Leadership,
Keywords:
Workforce Flexibility, Change Capacity, The Elemental Change Model
Pe

Healthcare organizations are subject to a tremendously changing


environment which leads organizations to focus on cost reduction and
performance improvement. Lean healthcare is used in a growing number of
hospitals to increase the efficiency and quality of care. However, healthcare
er

organizations encounter problems with the implementation of change due


to the implementation gap: the gap between strategy and execution. This
research aims to increase scientific knowledge regarding factors that
diminish the implementation gap and make the transition from the toolbox
lean towards an actual transformation to lean healthcare.
Re

We expected transformational leadership, team leadership and workforce


flexibility to be sociotechnical factors that positively influence a lean
healthcare implementation. Transformational leadership will ensure the
vi

Abstract: required top-down commitment and team leadership, on the other hand,
creates the required active, bottom-up behaviour of employees.
Furthermore, healthcare organizations are characterized by professional
ew

and functional silos and a hierarchical structure which impedes the


workforce flexibility that is required to adapt organizational elements and
optimize the entire process flow. A survey was conducted among
employees of an operating theatre (OT) in a Dutch university medical
centre. The results showed positive correlations between both leadership
styles and the implementation of lean healthcare. Moreover, the results
indicated a strong correlation between workforce flexibility and the
implementation of lean healthcare. With the use of a change management
model, The Elemental Change Model, we suggest leadership and workforce
flexibility to be part of an organizations change capacity and crucial
success factors for a lean healthcare implementation.

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Page 1 of 26 Evaluation & the Health Professions

1
2
3 THE ROLE OF LEADERSHIP AND WORKFORCE FLEXIBILITY WHEN
4
5 IMPLEMENTING LEAN HEALTHCARE
6
7 Abstract
8
9 Healthcare organizations are subject to a tremendously changing environment which leads
10
11 organizations to focus on cost reduction and performance improvement. Lean healthcare is
12
13
used in a growing number of hospitals to increase the efficiency and quality of care. However,
14 healthcare organizations encounter problems with the implementation of change due to the
15
16 implementation gap: the gap between strategy and execution. This research aims to increase
17
18
scientific knowledge regarding factors that diminish the implementation gap and make the
Fo
19 transition from the toolbox lean towards an actual transformation to lean healthcare.
20
21
22 We expected transformational leadership, team leadership and workforce flexibility to be
r
23 sociotechnical factors that positively influence a lean healthcare implementation.
24
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25 Transformational leadership will ensure the required top-down commitment and team
26
27 leadership, on the other hand, creates the required active, bottom-up behaviour of employees.
28 Furthermore, healthcare organizations are characterized by professional and functional silos
er

29
30 and a hierarchical structure which impedes the workforce flexibility that is required to adapt
31
32 organizational elements and optimize the entire process flow. A survey was conducted among
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33 employees of an operating theatre (OT) in a Dutch university medical centre. The results
34
35 showed positive correlations between both leadership styles and the implementation of lean
36
healthcare. Moreover, the results indicated a strong correlation between workforce flexibility
vi

37
38 and the implementation of lean healthcare. With the use of a change management model, The
39
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40 Elemental Change Model, we suggest leadership and workforce flexibility to be part of an


41
42 organizations change capacity and crucial success factors for a lean healthcare
43 implementation.
44
45
46
47
48 Keywords: Lean Healthcare, Transformational Leadership, Team Leadership, Workforce
49
50 Flexibility, Change Capacity, The Elemental Change Model
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52
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55
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Evaluation & the Health Professions Page 2 of 26

1
2
3 THE ROLE OF LEADERSHIP AND WORKFORCE FLEXIBILITY WHEN
4
5 IMPLEMENTING LEAN HEALTHCARE
6
7 Introduction
8
9 Healthcare organizations are increasingly forced to adapt to developments regarding medical
10
11 information, technologies, and relationships with other (healthcare) systems (Brandao de
12
13
Souza & Pidd, 2011). As a consequence, the healthcare sector is subject to continuous change
14 (Lapointe, Lamothe & Fortin, 2002; Adler et al., 2003; Lnsisalmi, Kivimki, Aalto &
15
16 Ruoranen, 2006; Dahlgaard, Pettersen & Dahlgaard-Park, 2011). Simultaneously to these
17
18
changes, healthcare organizations are forced to maintain and improve performance, quality of
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19 care and patient satisfaction (Brandao de Souza & Pidd; Dahlgaard et al.). Also patient safety
20
21 is a focal point, as it is clear from one of the most influential reports in healthcare of the last
22
two decades: "To err is Human: Building a Safer Health System (Kohn, Corrigan &
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23
24 Donaldson, 2000). This report by the Institute of Medicine ensured that patient safety has
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26 become a primary concern in the healthcare sector (Brennan, Gawanda & Studdert, 2005).
27
28 Healthcare organization can improve patient safety, quality of care, efficiency, patient
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30 satisfaction and performance by the use of lean principles (Womack & Jones, 2003; Young,
31
32 Brailsford, Connell et al., 2004; Jimmerson, Weber & Sobek, 2005.; King, Ben-Tovim &
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33 Bassham, 2006; Kollberg et al., 2006; Brandao de Souza, 2009; Dickson, Anguelov, Vetterick
34
35 et al., 2009; Brandao de Souza & Pidd, 2011; Holden, 2011). Lean principles stem from the
36
Japanese manufacturing industry and are centred to create value with less work by the
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37
38 enhancement of existing organizational processes and structures (Womack & Jones; Kim,
39
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40 Spahlinger, Kin & Billi, 2006, Brandao de Souza). Traditionally, business management
41
42 techniques such as lean were seen as a distinct discipline from healthcare management. This
43 has changed in the past decade where the value of integrating business management
44
45 techniques into healthcare management has been recognized as a means of delivering higher
46
47 quality and more efficient care (Trisolini, 2002). In this context, Ben-Tovim et al. stress that
48 the basics of process improvement, and therefore the lean principles (value, stream, flow, pull
49
50 and perfection) are as appropriate for healthcare as they are for other service and
51
52 manufacturing industries.
53
54 Lean can be described as an integrated system of principles, practices, tools, and techniques
55
56 focused on reducing waste, synchronizing work flows, and managing variability in production
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flows (De Koning, Verver, van den Heuvel, Bisgaard & Does, 2006: p.5). The salient
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1
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3 characteristic of lean is the emphasis on the reduction of waste. In the lean philosophy, the
4
5 patient should be considered as the primary customer, and the obvious application of lean in
6 healthcare seems to lie in eliminating delays, repeated encounters, errors, and inappropriate
7
8 procedures (Young et al., 2004).
9
10 However, numerous studies showed that improvement programs such as lean have often not
11
12 met expectations, resulting in large variations in clinical and economic outcomes (Adler et al.,
13
14 2003). It is argued that healthcare organizations in general have difficulties to implement
15 change initiatives (Adler et al.; Doss & Orr, 2007; Joosten, Bongers, & Janssen 2009;
16
17 Dahlgaard et al., 2011). This difficulty to successfully implement a change initiative can be
18
explained by the strategy-to-performance gap or implementation gap as an implementation
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20 gap refers to the discrepancy between a firms change strategy and the actual implementation
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22 (Floyd & Woodridge, 1992; Mankins & Steele, 2005).
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Research shows that the implementation gap can occur when managers are mainly concerned
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26 with input and output, but give little attention to the throughput of change initiatives (e.g. Ten
27
28 Have, Ten Have & Van der Eng, 2011). It seems that when implementing lean in a healthcare
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30
environment (in this paper defined as lean healthcare), the implementation gap occurs when
31 a primary focus is on the specific lean tools (input) and short-term outcomes (output) rather
32
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33 than on developing an in-depth understanding of the sociotechnical factors that enhance the
34
35
complete change process (throughput) (Joosten et al., 2009). We expect leadership and
36 workforce flexibility to be variables that will diminish the implementation gap and thus
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38 strengthen a successful transition to lean healthcare. The following sections will elaborate on
39
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40 the variables leadership and workforce flexibility and the expected relationships with the
41 implementation of lean healthcare.
42
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44 Transformational Leadership
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46 Several academic papers mention leadership as an enabler or inhibitor for the success of lean
47
48 (Young et al., 2004; Jimmerson et al., 2005; Womack et al., 2005; Doss & Orr, 2007; Bodek,
49
50
2008; Holden, 2011; Brandao de Souza & Pidd, 2011). Doss & Orr even suggest that
51 leadership is the missing link between an academic approach to lean systems and an
52
53 organizations actual transformation toward lean practices.
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55 In fact, leadership is needed at the top level of every changing organization (e.g. Bass, 1985;
56
57 Den Hartog, Van Muijen & Koopman, 1997; Johnson, 1998; Dulewicz & Higgs, 2003). The
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Evaluation & the Health Professions Page 4 of 26

1
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3 top can create a vision that is widely understood which inspires the companys employees,
4
5 encourage desirable behaviour and strengthens the organizations capacity for change
6 (Oxtoby, McGuiness & Morgan, 2002; Klarner, Porbst & Soparnot, 2008). Klarner et al. call
7
8 this transformational leadership. Existing literature shows a contrast between transactional
9
10 leadership and transformational leadership (Bass, 1985). A transactional leader motivates his
11 or her followers to perform exactly as expected, whereas a transformational leader inspires his
12
13 or her followers to do more than what was formerly expected (Hater & Bass, 1988). In fact,
14
15 transactional leadership consists of an exchange between a leader and a follower. This
16 relationship between leader and follower is characterized by the clarification of performance
17
18 criteria, stated expectations and what they will receive in return. A transformational leader, on
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19
20 the other hand, is able to facilitate and affect transformation in changing situations with great
21 impact such as the implementation of lean healthcare. By defining a specific need for change,
22
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23 creating new visions and mobilizing commitment to those visions, a transformational leader
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should be able to transform an organization (Den Hartog et al., 1997).
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25
26
27 Empirical findings stress the need for transformational leadership at the top level during a
28
lean healthcare implementation. A study conducted by Jimmerson et al. (2005) at
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Intermountain Health Care (IHC; Salt Lake City) showed that the drive and commitment of
31
32 senior management reassured workers that the implementation of the lean system was not just
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34 another management trend, and it appeared as key issue for securing sustainability and
35
success of the hospital. The effect of senior management commitment on change processes
36
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37 and outcomes was also emphasized in the study of Dickson et al. (2009) where they studied
38
39 the transformation to lean healthcare in the emergency departments of four hospitals.
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40
41 Team leadership
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44 The concept of transformational leadership seems to create the top-down commitment that is
45 required for a successful transformation to lean healthcare (Jimmerson et al., 2005; Dickson et
46
47 al., 2009). Yet, besides top-down commitment, a bottom-up approach for the implementation
48
49 is needed (Zidel & Hacker, 2006; Carson, Tesluk & Marrone, 2007). In terms of lean
50 healthcare, all employees need to be aware of the daily generation of waste as they need to
51
52 identify areas for improvement. To reinforce their enthusiasm to identify waste and propose
53
54 improvements, they must engage in all of an organizations processes (Kim et al., 2006).
55 Senior managers should thus be strongly committed but simultaneously understand the fact
56
57 that employees time that is spent on the shop floor often provides better insight into areas
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1
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3 that need improvement. Therefore, units should be authorized to self-manage toward an ideal
4
5 level of functioning (Jimmerson et al., 2005).
6
7 Literature regarding self-management shows that if multifunctional teams have the
8
9 responsibility to improve their own tasks, there is a need for team leadership (Pearce &
10 Conger, 2003; Carson et al., 2007). Team leadership, or shared leadership, is cited by Pearce
11
12 and Conger (2003):
13
14
15
a dynamic, interactive influence process among individuals in groups for which the
16 objective is to lead one another to the achievement of group or organizational goals or
17
18 both. This influence process often involves peer, or lateral, and at other times involves
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20
upward or downward hierarchical influence (p. 1).
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22 Team leadership increases the power of all employees and is dispersed among the
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24 organizations members rather than focused on a single appointed formal leader (Pearce &
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25 Conger, 2003; Carson et al., 2007). The authorization of key (team)players throughout the
26
27 organization as effective leaders will increase the level of involvement and strengthens the
28
organizations bottom-up dynamics. Team leadership therefore seems to realize active
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30 participation by, and the utilization of, the capabilities of all organizations employees, which
31
32 is a necessity for the bottom-up implementation when applying lean healthcare (Kim et al.,
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34 2006).
35
36 Workforce Flexibility
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39 Besides the impact of different leadership styles during the change process, healthcare
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40 organizations deal with functional and professional silos - structures of fragmented care and
41
42 professional practice that can create barriers for the optimization of work processes and
43
44 structures (Brandao de Souza & Pidd, 2011). Lean teaches that optimizing the performance of
45 an individual unit or silo is insufficient; the entire process flow must be improved, which
46
47 requires cooperation of all operating units to achieve meaningful and sustained performance
48
49 improvement (Kim et al., 2006). Subsequently, the hierarchical structure of healthcare
50 organizations can form a barrier for the implementation of lean healthcare as it constraints
51
52 bottom-up behaviour (Brandao de Souza & Pidd). These characteristics of different silos and
53
54 a hierarchical structure in healthcare organizations may hinder the flexibility in adapting
55 procedures, processes, behaviour and skills when implementing lean healthcare (Drucker,
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57 1994; Lapointe et al., 2002; Thakur, Hsu & Fontenot, 2011). It may reinforce institutionalism
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Evaluation & the Health Professions Page 6 of 26

1
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3 and impede the workforce flexibility to change to an efficient organizational framework that
4
5 enables optimization of the entire process flow. Workforce flexibility is defined as the
6 dynamic capability of the firm in the sense that it is focused on adapting employee attributes -
7
8 such as knowledge, skills, and behaviours - to changing environmental conditions
9
10 (Bhattacharya, Gibson & Doty, 2005: p.1). For the implementation of lean healthcare, the
11 optimization of work processes and structures is required and the right degree of workforce
12
13 flexibility can thus increase the required adaption to the changing processes and structures.
14
15 Dickson et al. (2009) strengthen this assumption as they found empirical evidence that the
16 workforce flexibility reinforces the implementation of lean healthcare.
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18
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19 Aim of Research
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21 Recently, researchers have shown an increased interest in lean healthcare, yet statistical
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23 evidence regarding success factors of lean healthcare remains absent in the current literature
24
(Holden, 2011). This research aims to increase knowledge of the success factors the
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26 throughput of lean implementation, in order to diminish the implementation gap of lean
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28 healthcare. This study reports on a quantitative case study executed in an operating theatre
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(OT) of a Dutch university medical centre. The OT presents a unique and high-risk
31 environment that makes the implementation of lean relatively complex in comparison to other
32
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33 units in a healthcare organization (Healey, Undre & Vincent, 2004; Undre, Sevdalis, Healey,
34
35
Darzi & Vincent, 2006). Statistical evidence for the successful implementation of lean
36 principles will help this complex environment closing the implementation gap which, in turn,
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37
38 can accelerate clinical and economic outcomes (Adler et al., 2003).
39
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40 This research will focus on transformational leadership and team leadership as leadership
41
42 styles that positively influence the lean healthcare implementation process. Moreover,
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44 workforce flexibility is also expected to positively influence the lean healthcare
45 implementation process, as it enables healthcare organizations to adapt organizational
46
47 elements in order to optimize the entire process flow. This leads to the following hypotheses:
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50
Hypothesis 1 (H1): Transformational leadership is positively related to the implementation of
51 lean healthcare.
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54 Hypothesis 2 (H2): Team leadership is positively related to the implementation of lean
55 healthcare.
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3 Hypothesis 3 (H3): Workforce flexibility is positively related to the implementation of lean
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5 healthcare.
6
7 Study Design And Methods
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9
10 Case description and participants
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12 A survey-based methodology was used for the case of an operating theatre (OT). The OT of
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14 the surveyed teaching hospital started with the implementation of lean healthcare in 2010. A
15 process improvement team started efforts throughout the entire OT to address issues by
16
17 defining and targeting on performance and metrics for improvement. The implementation of
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lean healthcare was strengthened by a cross-functional process improvement team consisting
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20 of OT employees and aided by an external consultant.
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24 With a total of 380 employees, the OT is the largest department of the teaching hospital and
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25 consists of multiple sub-divisions. The respondents were asked to complete a 69-item survey,
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27 which was distributed by e-mail to all of the employees of the operating theatre (n=380).
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After two weeks, a reminder e-mail was sent to those who had not yet responded or who had
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30 responded incompletely. All respondents were informed about confidentiality and anonymity
31
32 of the survey.
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35 Out of the 380 potential respondents, 115 employees participated in the study providing us
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37 with an overall response rate of 30.26%. Generally, a response rate of 20% to 40% is regarded
38
39 as accurate and representative of a target group (Badger & Werrett, 2005). The average age of
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40 the respondents was 40.55 years, with a standard deviation of 10.64 years. The majority of the
41
42 participants were women (62.60%), and their tenure with the organization was somewhat
43
44 dispersed (M = 8.10 years, SD = 7.39 years).
45
46 As theory suggests that transformational leadership is of particular importance at the senior
47
48 management level when implementing lean healthcare (Jimmerson et al., 2005; Dickson et al.,
49
50
2009), questions assessing transformational leadership referred to my direct supervisor.
51 Furthermore, a distinction was made between respondents in order to test differences in
52
53 transformational leadership between two senior management levels which are a) head of the
54
55
operating theatre and b) unit leaders. As the unit leaders as well as the administrative staff
56 directly report to the head of operating theatre, they were coded as hierarchical level 1 which
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58 assessed the degree of transformational leadership of the head of operating theatre.
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3 Consequently, the remaining medical employees that report directly to one of the unit leaders
4
5 were coded as hierarchical level 2. The results of the latter assessed the degree of
6 transformational leadership regarding the unit leaders.
7
8
9 In contrast to transformational leadership, team leadership was focused on all employees and
10 was assessed by questions that referred to the my team members.
11
12
13 Survey validity
14
15 The cross-sectional survey was developed to test the three hypotheses measuring relationships
16
17 between transformational leadership, team leadership, workforce flexibility with the
18
implementation of lean healthcare. All of the measures were collected with a 7-point Likert
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20 scale with the following response possibilities: 1 (fully disagree), 2 (disagree), 3 (slightly
21
22 disagree), 4 (neither disagree nor degree), 5 (slightly agree), 6 (agree), 7 (fully agree). To
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24 assess the internal consistency of each scale, the Cronbachs alpha procedure was used
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25 (Cronbach, 1951).
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28 To ensure internal validity, the multi-item scale for each construct in the questionnaire was
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29
developed in three stages. First, a preliminary set of existing scales and its items was collected
30
31 based on an extensive literature review. Second, as the items had to be translated into Dutch,
32
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33 the back-translation-back technique was applied as it reinforces internal validity (Saunders et


34
al., 2009). Hence, all of the items were translated from English (source questionnaire) into
35
36 Dutch (target questionnaire) by a professional translating agency. Subsequently, the target
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38 questionnaire was translated into the source questionnaire again by a bilingual translator in
39
English and Dutch. Comparing the two source questionnaires, a final translated version of the
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41 questionnaire could be created. During the third stage, all of the 69 translated items were
42
43 discussed with a lean healthcare consultant from the operating theatre and researcher.
44
Modifications were made to assimilate their submission, and face validity was assessed based
45
46 on these responses. To ensure construct validity, all of the items were formulated to focus the
47
48 respondent on the target of interest.
49
50 Statistical analyses
51
52
53 The association between the implementation of lean healthcare and the covariates as well as
54
the inter-correlations among all of the covariates were assessed with the use of Pearson
55
56 correlation in SPSS 20.
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3
4
5
Dependent Variables
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7 implementation of lean healthcare.
8
9 To collect the data regarding the implementation of lean healthcare, a system of Dahlgaard et
10
11 al. (2011) was used called A System for Assessing and Improving Healthcare Organizations.
12 Dahlgaard et al. designed and tested a questionnaire for assessing the health level of hospital
13
14 departments using lean healthcare indicators. Questions regarding lean processes and lean
15
16 results were incorporated in the current questionnaire to assess the implementation of lean
17 healthcare. To ensure clarity among all of the respondents, some of the items were adjusted to
18
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19 the specific context, and lean-specific concepts were introduced. For example, the concept of
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21 flow and pull was briefly explained prior to the related item. All questions referred to the
22 respondents perception of the extent that lean healthcare processes and results were present
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24 and implemented in the operating theatre. Sample items included The operating theatre is
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26 continuously striving to reduce waiting time for patients or projects and Patients
27 satisfaction has been improved during the last 3 years. The overall reliability of the construct
28
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29 implementation of lean healthcare was .96, with M = 3.68 and SD = 1.42.


30
31
Independent Variables
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33 transformational leadership.
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35 The occurrence of the independent variable transformational leadership was assessed using
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the leader behaviour questionnaire (LBQ) that was developed by Cox (1994), followed by
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38 Cox and Sims (1996), and further analysed by Pearce, Perry and Sims (2001). As this study
39
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40 considered the transformational leadership style, only questions from transformational


41
behaviour of the LBQ were used. Subsequently, to strengthen the examination of
42
43 transformational leadership, two dimensions were added based on Pearce and Sims (2002):
44
45 (a) having high performance expectations and (b) using inspirational communication. Items
46
were modified to reflect the unique aspect of the research site. For example, the term my
47
48 team leader was changed to my direct supervisor in all items in order to assess
49
50 transformational leadership regarding all formal leaders who included 1) head of operating
51
theatre and 2) unit leaders. An example item is My direct supervisor expects me to give
52
53 100% all of the time. The reliability scale in the present study was .96, with M = 4.66 and
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55 SD = 1.36.
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3 team leadership.
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5 The perceived existence of team leadership was assessed by the shared leadership perception
6 survey (Wood, 2005). Wood derived questions from the theory of Porter-OGrady and Wilson
7
8 (1995) as well as from Hillers (2002) leadership questionnaire. The scale showed good
9
10 psychometric validity in the study that was conducted by Wood, and four dimensions were
11 identified: (1) Joint completion of tasks; (2) Mutual skill development; (3) Decentralized
12
13 interaction among personnel; (4) Emotional support. The four dimensions consisted of 19
14
15 items that were used in the present study, sample item: Team members encourage one other
16 during challenging times at work. Next, three items were reversed-scored because the
17
18 questions sought to determine a mere directive nature of leadership, in contrast to team
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20 leadership (Wood, 2005). The Cronbachs alpha for this scale was .88 with M = 4.47 and SD
21 = 0.87.
22
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24 workforce flexibility.
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25 The data from the workforce flexibility construct was used for measuring the dynamic
26
27 capability of a firm to adapt its employee attributes. Bhattacharya, Gibson and Doty (2005)
28
developed a questionnaire that resulted in 22 items, including three dimensions: (1) Skill
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flexibility; (2) Behaviour flexibility; and (3) HR practice flexibility. With respect to the
31
32 current study, the dimension HR practice flexibility was excluded from the study as HR
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34 practice is not part of healthcare-specific employee characteristics. Therefore, 15 items
35
remained for the final analysis. Subsequently, items were modified to reflect the unique
36
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37 aspect of the healthcare context as well as the perceptions of the respondents. For example,
38
39 terms such as our firm were changed to the operating theatre and customer
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40
requirements were changed to patient needs. Sample item: employees of the operating
41
42 theatre are capable of putting new skills to use within a short time. The Cronbachs Alpha
43
44 for this scale was .94 with M = 4.09 and SD = 1.28.
45
46 Control variables and Scale Reliability
47
48
49 The study controlled for two demographic variables (age and gender), two job-situation
50 variables (job function, job tenure) and the respondents awareness of the implementation of
51
52 lean healthcare within the operating theatre (lean awareness) to address alternate explanations
53
54 for the formulated hypotheses. The mean tenure score for each respondent was computed after
55 offering a non-limited option. Furthermore, questions were coded 0 and 1 to identify
56
57 significant differences between male (0) or female (1) and awareness of lean implementation
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3 Yes (0) or No (1). The job function control variable offered 22 potential functions within the
4
5 operating theatre. At last, an age assessment offered a non-limited option to complete.
6
7 Table 1 (see Appendix A) gives means, standard deviations, correlations and Cronbachs
8
9 Alphas for all of the variables that are included in this study. Each construct showed a scale
10 reliability of .88 or greater, allowing all of the items to be preserved. The reliability rates can
11
12 be seen on the diagonal of table 1 (Appendix A).
13
14
15 Results
16
17 Test of Hypotheses
18
A linear regression analysis was conducted in order to test hypotheses 1 and 2. In both
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20 analyses, the implementation of lean healthcare was used as the dependent variable. The
21
22 assessment of hypothesis 1 showed a significant result in predicting the implementation of
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24 lean healthcare, = .30, t(115) = 3.35, p < .001, R2 = .09. This finding proposed that the
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25 implementation of lean healthcare is positively related to the level of transformational


26
27 leadership of supervisors. The analysis for team leadership predicting the implementation of
28
lean healthcare, hypothesis 2, also showed a significant relationship, = .38, t(115) = 4.35, p
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30 < .001, R2 = .14. This result indicated that the level of team leadership had a positive
31
32 correlation with the implementation of lean healthcare.
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34
35 Hypothesis 3 investigated the relationship between workforce flexibility and the
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39 workforce flexibility and the implementation of lean healthcare (R = .72, p < .01). In more
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40 detail, workforce flexibility explained a unique variance of 46% when compared to


41
42 transformational leadership in predicting the implementation of lean healthcare, R2 = .46,
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44 F(1, 112), p < .001. Workforce flexibility also explained the unique variance of 40% when
45 compared to team leadership predicting the implementation of lean healthcare, R2 = .40, F(1,
46
47 112), p < .001. This indicated that workforce flexibility had relatively 46% and 40% greater
48
49 contributions than transformational leadership and team leadership in predicting the
50 implementation of lean healthcare. In addition, workforce flexibility correlated with a score of
51
52 R=.77 with lean process and R=.59 with lean results. This showed that within the construct of
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54 the implementation of lean healthcare, the degree of workforce flexibility had a greater
55 influence on the lean process compared to the effect on lean results.
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3 All control variables were included in the analyses, but no correlation with the
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5 implementation of lean healthcare was found.
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7
8 Additional analyses
9
10 In addition to the hypotheses, some additional analyses were carried out. An independent t-
11 test (2-sided) was conducted to investigate differences in transformational leadership within
12
13 the senior management levels. A significant difference was found between hierarchical level 1
14
15 (M = 5.72, SD = .97) and hierarchical level 2 (M = 4.52, SD = 1.36), t(111) = 3.42, p < .01.
16 This result implied that the head of operating theatre was perceived to be a more
17
18 transformational leader than the unit leaders. In case of team leadership, the independent t-test
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20 (2-sided) again showed a significant difference between hierarchical level 1 (M = 5.05, SD =
21 .55) and hierarchical level 2 (M = 4.40, SD = .87), t(111) = 3.20, p < .01. This implied that the
22
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23 degree of team leadership was higher among unit leaders and administrative staff in
24
comparison to the other medical employees. However, the difference between the hierarchical
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26 levels did not show a significant effect on the relationship between leadership and the
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28 implementation of lean healthcare.
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32
Discussion
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34 Research showed that healthcare organizations have difficulties to successfully implement
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36 change initiatives and achieve sustainable results (Adler et al., 2003; Doss & Orr, 2007;
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37 Joosten et al., 2009; Dahlgaard et al., 2011). In order to create an organization that supports
38
39 and realizes a successful implementation of lean healthcare, specific attention should be given
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41 to sociotechnical aspects that can diminish the implementation gap (Joosten et al.) This
42 research aims to increase statistical knowledge concerning success factors the throughput
43
44 of lean implementation, in order to support the transition from merely implementing lean
45
46 tools to actually improving the quality of care.
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48 This research hypothesized that transformational leadership, team leadership and workforce
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50 flexibility, as independent variables, could contribute to the implementation of lean healthcare
51
52
and diminish the implementation gap. The results indicated a positive relationship between a
53 transformational leadership style and the implementation of lean healthcare, which indicate
54
55 that increasing the level of transformational leadership in a healthcare organization can
56
57
benefit the implementation of lean. Yet the effect of differences in transformational leadership
58 between senior management levels on lean healthcare implementation remain unclear. In
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3 addition, team leadership also showed a positive correlation with the implementation of lean
4
5 healthcare, indicating that team leadership positively relates to the implementation of lean
6 healthcare. Our results, however, did not indicate a significant difference in this relationship
7
8 between employees who possess formal leading positions and employees in general.
9
10 The analysis showed that the workforce flexibility has a strong relationship with the
11
12 implementation of lean healthcare. This direct effect had a unique variance of respectively
13
14 46% and 40% compared to the relationship between leadership and the implementation of
15 lean healthcare. This finding demonstrates the importance of the flexibility of a healthcare
16
17 specific workforce when implementation lean healthcare.
18
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20 The Elemental Change Model
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22 Models can be used to better understand research findings (e.g. Shafer, Smith & Linder,
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24 2005). We use the recently developed Elemental Change Model (Ten Have et al., 2011) as a
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25 change management model to add extra meaning to our findings. The Elemental Change
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27 Model identifies five meta factors that hinder or facilitate change: Rationale, Effect, Focus,
28
Energy and Connection (see figure 1. The Elemental Change Model). It is crucial that all
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30 factors are developed to the required level. In fact, to attain successful change, an organization
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32 should align or balance its necessities for survival (change vision) with its possibilities for
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34 organizational change (change capacity) (Ten Have, Ten Have, Huijsmans, & Van der Eng,
35 2013).
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50
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Figure 1. The Elemental Change Model. Adopted from Ten Have et al. (2011).
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53
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56 The Rationale stands for the reason behind the change. It must be understood on a cognitive
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58 level (for example an understandable strategy) but must also resonate on a more affective
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3 level to bring up the necessary sense of urgency (Kotter, 1995). Effect includes the tangible
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5 change results for the organization and its employees. It also incorporates factors that anchor
6 the results in the organization such as monitoring and feedback (Ten Have et al., 2013). The
7
8 meta factor Connection refers specifically to the management of the change initiative, such as
9
10 the appropriate change strategy and approach, the unity between multiple and coexisting
11 change initiatives and related interventions, but also its pacing and sequence.
12
13
14 The variables and associated relationships examined in this study appear to relate to the
15 factors Energy and Focus, who in combination define an organizations change capacity (see
16
17 figure 1. The Elemental Change Model). The factor Energy refers to the preparedness and
18
readiness for change among the organizations members. The organizations preparedness and
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20 readiness can be strengthened by appropriate and supportive leadership and the accurate
21
22 allocation of resources (Ten Have et al., 2013). The current research considers
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24 transformational leadership at the senior management level and team leadership throughout
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25 the entire organization as leadership styles that stimulate the implementation and success of
26
27 lean healthcare, as the results demonstrated a positive relationship between both leadership
28
styles and the implementation of lean healthcare. It appears that appropriate leadership,
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according to Ten Have et al., as part of the Energy construct contributes to the change
31
32 capacity of an organization and the consequent success of lean healthcare.
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34
35
The workforce flexibility of caregivers in this research is considered to be a sociotechnical
36 aspect (or success element) within the Focus factor, as it can be argued that a certain degree of
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38 flexibility within the workforce is crucial to arrive at an adequate organizational framework
39
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40 that stimulates successful change results. The Focus factor is regarded as the adequate
41 organizational framework or, in other words, the alignment of specific organizational
42
43 elements with the change goals of the organization (Ten Have et al., 2013). The rigidity of
44
45 these elements determine the flexibility or changeability of an organization. Among others
46 these elements include, rules and procedures, rituals, mindsets, structures and systems (Ten
47
48 Have et al., 2013). The results showed that the workforce flexibility has a strong positive
49
50 relationship with the implementation of lean healthcare. Workforce flexibility, as part of the
51 Focus construct, seems to enable the organization in adapting its organizational elements and
52
53 employee attributes, such as procedures, behaviour, knowledge, skills, rituals, mindsets,
54
55 structure and systems in order to optimize the entire process flow and make the transition to
56 lean healthcare. Therefore, workforce flexibility can be seen as an important Focus aspect that
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3 strongly contributes to the change capacity of an organization and consequently stimulates a
4
5 successful implementation of lean healthcare.
6
7 Practical implications
8
9
10
We suggest that the use of transformational leadership and team leadership styles together
11 with a flexible workforce make a strong contribution to the change capacity of a healthcare
12
13 organization that is implementing lean. As the change capacity increases, it is more likely that
14
15
an organization can achieve sustainable economic and clinical outcomes (Adler et al., 2003).
16 Healthcare managers can use these findings to analyse the organizations change capacity and
17
18 improve the outcome on existing (OT) care processes when applying lean healthcare. It alerts
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19
20
managers to the importance of the sociotechnical factors that give insight in the throughput
21 and diminish the implementation gap, allowing the healthcare organization to make the
22
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23 transition from the toolbox lean to the actual improvement of the quality of care.
24
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26 With regards to leadership, healthcare managers should assure that at the senior management
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28 level, leaders possess a transformational leadership style. In addition, team leadership needs
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30
to be stimulated at every level in the organisation. The latter implies that key (team)players
31 throughout the organization should be authorized to be effective leaders and identify areas of
32
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33 waste. Combining these two leadership styles will increase the Energy which, in turn,
34
35
strengthens the organizations capacity to change (Ten Have et al., 2013). Moreover,
36 managers need to establish an adequate organizational framework that enables the
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38 organization to adjust its organizational elements in a way that the implementation of lean
39
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40 healthcare can be successful and desired outcomes can be achieved. To create this appropriate
41 framework, or Focus, the workforce flexibility has shown to be a crucial factor. Flexibility of
42
43 the workforce will enable the organization to enforce multidisciplinary work across silos,
44
45 minimize sub-optimization, and adapt behaviour, skills and processes such that lean
46 healthcare can be implemented successfully.
47
48
49
50 Limitations and future research
51
52 A limitation of our study is the absence of a baseline measurement of the OT, before the
53
54 implementation of lean healthcare. The comparison of a baseline measurement with a follow-
55 up measurement could give useful insight in the process of lean healthcare during
56
57 implementation and identify latent factors that influence the organization and the
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3 implementation of lean. Further research is therefore useful, where a longitudinal study is
4
5 recommended in order to enable researchers to follow respondents and processes for an
6 extended period of time.
7
8
9 Another limitation applies to our observation that lean healthcare is not a clear-cut construct.
10 This study operationalized the construct through survey questions, yet the construct remains
11
12 ambiguous since the possibility exists that not every possible aspect of lean healthcare was
13
14 incorporated. In addition, the questionnaire was based on perceptions and did not make use of
15 numbers, such as key performance indicators. This could have made the examination of the
16
17 lean implementation in the surveyed OT subjective.
18
Fo
19
20
Future research should investigate the effect of transformational leadership on lean healthcare
21 implementation in different levels of management seniority. This study showed that the head
22
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23 of the operating theatre was perceived as a more transformational leader in comparison to the
24
unit leaders. However, no effect was found between these two senior management levels
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26 within the positive relation between transformational leadership and the implementation of
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28 lean healthcare. Future research could focus on the different positions of formal leaders and
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their impact on the success of lean healthcare.
31
32 Furthermore, future research could further investigate the Elemental Change Model which we
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34 used in this research. We suggested that the current findings are linked to an organizations
35 change capacity, which will stimulate the success of a transition to lean healthcare. However,
36
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37 more research is needed into the causal effect of the variables on the organizations change
38
39 capacity and the consequent effect on a lean healthcare implementation.
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41 Conclusions
42
43
44 In summary, leadership and workforce flexibility are success factors that enable healthcare
45 organizations to make the transition from a mere theoretical approach to the actual
46
47 transformation to lean healthcare. An appropriate leadership style increases the energy to
48
49 change. Moreover, the workforce flexibility will determine to what extent the organizational
50 elements such as behavior, procedures, systems and structures can be adjusted in a way that
51
52 the lean principles can be implemented and processes can be optimized. In particular,
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54 healthcare organizations need to focus on the structure of different professional and functional
55 silos and the hierarchical structure which can impede the optimization of the entire process
56
57 flow. Taken altogether, the appropriate use of leadership and sufficient flexibility within a
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3 caregivers workforce will strengthen the organizations change capacity and therefore
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5 diminish the implementation gap that impedes a successful lean healthcare implementation.
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5 Appendix A. Tables
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7 Table 1. Means, Standard Deviations and inter-correlations
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10 Mean SD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

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12 1 Implementation of lean healthcare 3.86 1.42 (.96)
13 2 Process 3.74 1.50 .94** (.94)

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14 3 Results 3.61 1.51 .94** .77** (.94)
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16 4 Transformational Leadership 4.66 1.36 .30** .32** .24** (.96)
17

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5 Performance Expectations 5.10 1.43 .23* .26** .18 .78** (.86)
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6 Challenge to status quo 4.26 1.64 .30** .31** .25** .84** .58** (.88)
19

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20 7 Vision 4.46 1.66 .23* .26** .19* .90** .61** .66** (.93)
21 8 Idealism 4.64 1.52 .29** .30** .25** .88** .57** .66** .77** (.92)
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9 Inspirational Communication 4.83 1.66 .24* .26** .18* .91** .62** .68** .82** .75** (.92)
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10 Team Leadership
11 Joint completion of tasks
4.47
4.25
0.87
1.27
.38**
.40**
.39**
.41**
.32**
.33**
.47**
.54**
.33**
.41**
.41**
.48** ev
.42**
.48**
.42**
.46**
.45**
.48**
(.88)
.93** (.93)

iew
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27 12 Mutual Skill Development 5.45 0.88 .05 .11 -.02 .11 .06 .16 .08 .06 .11 .42** .28** (.74)
28 13 Interaction among personnel 4.37 1.12 .20* .15 .23* .01 -.11 -.05 .06 .04 .07 .47** .20* .01 (.58)
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14 Emotional Support 4.68 0.99 .10 .15 .03 .26** .18 .22* .18 .27** .29** .65** .44** .55** .28** (.53)
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31 15 Workforce Flexibility 4.09 1.28 .72** .77** .59** .17 .17 .17 .15 .13 .11 .32** .29** .21** .13 .23* (.94)
32 16 Skill Flexibility 3.99 1.43 .67** .72** .53** .25** .26** .25** .22* .16 .18 .30** .28** .20* .08 .20* .91** (.91)
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17 Behaviour Flexibility 4.18 1.36 .65** .68** .54** .07 .06 .08 .05 .08 .03 .29** .25** .18 .15 .22* .92** .68** (.93)
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Page 25 of 26 Evaluation & the Health Professions

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17 Figure 1. The Elemental Change Model. Adopted from Ten Have et al. (2011).
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Evaluation & the Health Professions Page 26 of 26

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5 Appendix A. Tables
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7 Table 1. Means, Standard Deviations and inter-correlations
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10 Mean SD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Fo
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12 1 Implementation of lean healthcare 3.86 1.42 (.96)
13 2 Process 3.74 1.50 .94** (.94)

rP
14 3 Results 3.61 1.51 .94** .77** (.94)
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16 4 Transformational Leadership 4.66 1.36 .30** .32** .24** (.96)
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5 Performance Expectations 5.10 1.43 .23* .26** .18 .78** (.86)
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6 Challenge to status quo 4.26 1.64 .30** .31** .25** .84** .58** (.88)
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rR
20 7 Vision 4.46 1.66 .23* .26** .19* .90** .61** .66** (.93)
21 8 Idealism 4.64 1.52 .29** .30** .25** .88** .57** .66** .77** (.92)
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9 Inspirational Communication 4.83 1.66 .24* .26** .18* .91** .62** .68** .82** .75** (.92)
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10 Team Leadership
11 Joint completion of tasks
4.47
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.40**
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.41**
.32**
.33**
.47**
.54**
.33**
.41**
.41**
.48** ev
.42**
.48**
.42**
.46**
.45**
.48**
(.88)
.93** (.93)

iew
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27 12 Mutual Skill Development 5.45 0.88 .05 .11 -.02 .11 .06 .16 .08 .06 .11 .42** .28** (.74)
28 13 Interaction among personnel 4.37 1.12 .20* .15 .23* .01 -.11 -.05 .06 .04 .07 .47** .20* .01 (.58)
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14 Emotional Support 4.68 0.99 .10 .15 .03 .26** .18 .22* .18 .27** .29** .65** .44** .55** .28** (.53)
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31 15 Workforce Flexibility 4.09 1.28 .72** .77** .59** .17 .17 .17 .15 .13 .11 .32** .29** .21** .13 .23* (.94)
32 16 Skill Flexibility 3.99 1.43 .67** .72** .53** .25** .26** .25** .22* .16 .18 .30** .28** .20* .08 .20* .91** (.91)
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17 Behaviour Flexibility 4.18 1.36 .65** .68** .54** .07 .06 .08 .05 .08 .03 .29** .25** .18 .15 .22* .92** .68** (.93)
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