MEDICAL MANAGEMENT CENTER DEPARTMENT OF LEARNING, INFORMATICS, MANAGEMENT AND ETHICS Karolinska Institutet, Stockholm, Sweden LEAN, TEAM AND PSYCHOSOCIAL FACTORS A LONGITUDINAL INVESTIGATION AT A SWEDISH HOSPITAL Waqar Ulhassan Stockholm 2014 All previously published papers are reproduced with permission from the publisher. Published by Karolinska Institutet. Printed by Åtta. Cover illustration produced using an online free service at www.
© Waqar Ulhassan, 2014 ISBN 978-91-7549-439-5 Medical Management Center, Department of Learning, Informatics, Management and Ethics Lean, Team and Psychosocial Factors A Longitudinal Investigation at a Swedish Hospital Academic dissertation For the PhD degree at Karolinska Institutet. The thesis will be defended at Inghesalen, Tomtebodavägen 18a, Campus Solna On Thursday, February 20, 2014, at 9:00 a. Main Supervisor: Opponent: Ulrica von Thiele Schwarz Professor Peter Hasle Associate Professor Center for Industrial Karolinska Institutet, Sweden Production, Department of Business and Engineering, Co-supervisors: Aalborg University, Christer Sandahl Copenhagen, Denmark Professor in Leadership Behaviors Karolinska Institutet, Sweden Examination Board: Professor Sari Ponzer Hugo Westerlund Karolinska Institutet Professor in Epidemiology, Stress Södersjukhuset, Research Institute, Stockholm Stockholm, Sweden University, Sweden Ida Gremyr Johan Thor Associate Professor Lecturer Chalmers University of Karolinska Institutet, Sweden and Technology Jönköping Academy for Gothenburg, Sweden Improvement of Health and Welfare, Jönköping University, Carl Åborg Sweden Associate Professor Uppsala University, Uppsala, Sweden Stockholm 2014 ABSTRACT Background: As health care struggles to meet increasing demands with limited resources, Lean Management is becoming a popular management approach. More is known about operational aspects of Lean application than about the socio-technical aspects such as how Lean interacts with teamwork and the psychosocial work environment.
It is also unclear why and how organizations adopt Lean. Aim: This project, including four sub-studies, aimed to identify the antecedents and characteristics of Lean implementation at a Swedish Hospital. The research for this thesis also examined longitudinal changes in certain socio-technical aspects of Lean (i., teamwork and the psychosocial work environment). Methods: The thesis used a case study design (with data from interviews, observations and documents) to examine information about the Lean implementation at two cardiac inpatient wards and at an emergency care department at a Swedish hospital (Studies I & IV).
Using employee questionnaires during the Lean implementation, teamwork and the psychosocial work environment were measured in two time periods (T1 & T2), a year and a half apart. To avoid post-hoc explanations, qualitative data about the intervention and the context was used to predict expected change patterns in teamwork and the psychosocial work environment from T1 to T2. These predictions were compared with the questionnaire data using linear regression analysis (Studies II & III). Findings: A previous history of quality improvement was an antecedent for the hospital’s adoption of Lean.
Contextual factors seemed to influence both Lean implementation and its sustainability. For example, adoption of Lean varied with the degree to which staff saw a need for change. Continuous improvement, supported by visual management, when adopted successfully, kept the staff engaged and committed. Employee involvement in the Lean implementation may minimize the intervention’s harmful effects on psychosocial work factors.
Lean may influence teamwork, particularly in relation to structural and productivity issues. Conclusions: The success of Lean implementation depends on its adaptation to contextual factors. In addition to the traditional focus of Lean on operational performance, the employee perspective is also important in designing, implementing and sustaining Lean. Engaging the employees in the Lean change process not only helps to sustain initial Lean success but also helps avoid harmful effects of Lean on the work environment.
An initial Lean success may be sustained by engaging the staff in the change process using continuous improvement supported by visual management. Practitioners should note that, with groups struggling at initial stages of group functioning, the introduction of Lean may pose a significant challenge. To my father, Maqsood Ulhassan (late) LIST OF PUBLICATIONS I. Ulhassan W, Sandahl C, Westerlund H, Henriksson P, Bennermo M, Schwarz U, Thor J.
Antecedents and characteristics of Lean thinking implementation in a Swedish hospital: a case study. Qual Manag Health Care. Ulhassan W, Westerlund H,Thor J, Sandahl C, Schwarz U. Does Lean Implementation interact with group functioning? Accepted for publication in Journal of Health Organization and Management.
Ulhassan W, Schwarz U, Thor J, Westerlund H. Interactions between Lean Management and the Psychosocial Work Environment in a Hospital Setting – A Multi-Method Study. Ulhassan W, Schwarz U, Westerlund H, Sandahl C, Thor J. How Visual Management for Continuous Improvement Might Guide and Affect Hospital Staff – A Case Study.
The studies are referenced in the thesis by their Roman numerals CONTENTS 1 Introduction.1 Challenges for Health Care .1 History of Lean .2 Defining and Measuring Lean .3 Customer Focus in Lean.4 Employee Involvement in Lean .5 The Ultimate Goal of Lean .3 Lean in Health Care .1 Adaptation of Lean in Health Care .1 Teamwork in Lean Theory.2 Teamwork in Health Care .5 Lean and Psychosocial Work Environment. 11 2 Aims and Specific Objectives .2 The Cardiology Department .3 The Emergency Department .2 Main Research Strategies .2 The Pettigrew and Whipp Model of Strategic Change .3 Study design, Data Collection and Analysis .1 Study I and Study IV .2 Study II and Study III .1 Lean Adoption at the Cardiology Department .2 Lean Efforts at Ward-I and Ward-II .3 Lean Efforts at the Cardiac ED .1 Continuous Improvement at Ward-I .2 Continuous Improvement at Ward-II.3 Study II and III .1 Situation of Settings at T1 and T2 .2 Documentation of Expected Outcome Patterns.3 Description of the Sample .4 Study II Findings .5 Study III Findings .4 Summary of Main Findings.1 Employees’ Willingness to Change.2 Adaptation of Lean in Health Care .3 Sustaining Lean in Health Care .2 Content and Process .2 Lean-inspired Teamwork .3 Continuous Improvement and 5S .2 Psychosocial Work Environment. 62 Appendix I: Interview Guide (Study I). 69 Appendix II: Interview Guide (Study IV).
70 Appendix III: COPSOQ Instrument (Study III). 71 LIST OF FIGURES Figure 1. Pettigrew and Whipp’s model with examples from the present project. A Model of Lean’s effects on employees and patient care by Holden1.
Timeline for Lean intervention and data collection at three settings. Actual changes in GDQ subscales at the three settings. COPSOQ patterns for scales most responsive to Lean at three settings. COPSOQ scale change patterns at three settings.
COPSOQ scales change patterns at three settings. 47 LIST OF TABLES Table 1. A health care team typology adapted from Andreatta95. Summary of the thesis studies’ design, data collection and analysis.
GDQ Stages, scales, and subscales with sample items used in Study II. Norms for GDQ scale scores. COPSOQ domains, scales and sample items used in Study III. An overview of Lean intervention parts implemented at the three settings.
Performance indicators with annual percentage change at the Cardiac ED. Changes expected in GDQ subscales at three settings with motivations. Changes expected in COPSOQ scales for Ward-I with motivations. Changes expected in COPSOQ scales for Ward-II with motivations.
Changes expected in COPSOQ scales for ED with motivations. Characteristics of the sample for each setting in Study II. Characteristics of the sample for each setting in Study III. GDQ actual scale scores at T1 & T2 for each setting.
Regression analysis results for GDQ and COPSOQ. COPSOQ scale scores in the three study settings at T1 and T2. 45 LIST OF TERMS AND ABBREVIATIONS BSC Balanced Scorecard is a multidimensional framework for describing, implementing and managing strategy at all levels of an enterprise.2 CI Continuous Improvement is a culture of sustained improvement targeting the elimination of waste in all systems and processes of an organization by involving all the employees.3 COPOSQ Copenhagen Psychosocial Questionnaire CQI Continuous Quality Improvement. Its purpose is to design quality in the process using statistical methods.4 ECG Electrocardiogram is a machine used to measure heart’s electrical impulses generated by the polarization and depolarization of cardiac tissues and to translate it into a wave form.
ED Emergency Department GDQ Group Development Questionnaire ICU Intensive Care Unit IMGD Integrated Model of Group Development is a life cycle model of group development, developed by integrating aspects of other available models.5 IMVP International Motor Vehicle Program Lean “Lean is an integrated sociotechnical system whose main objective is to eliminate waste by concurrently reducing or minimizing supplier, customer and internal variability”.6 MIT Massachusetts Institute of Technology Six Sigma “A quality improvement methodology focusing on reducing errors and process variability”.4 TPS Toyota Production System is the production system developed at the Toyota Motor Corporation which is now commonly known as ‘Lean’. TQM Total Quality Management is “The management philosophy to improve continuously the quality of products and processes to meet or exceed customer expectations”.4 VM Visual Management VMPS Virginia Mason Production System VSM Value Stream Mapping is “A primary Lean tools that describes the flow of material and information through a system. This is carried out by graphically portraying the current process, enabling one to see where value is added and lost”.1 CHALLENGES FOR HEALTH CARE Given the increasing tension between resources and expenditures in health care, health care providers, especially hospitals, are under great pressure to increase their efficiency in providing patient care and in ensuring patient safety.8,9 These challenges may be addressed in many ways, including reducing costs, shortening waiting times and minimizing medical errors.7 Various solutions have been identified that may meet these challenges: for example, teamwork,10,11 continuous improvement (CI)12 and increased employee engagement13 in the care process. Today health care providers use different business models, originating in the business sector, in their practice.
Such models include Total Quality Management (TQM), Continuous Quality Improvement (CQI), Six Sigma and Lean Thinking (referred to as Lean in this thesis).8,9,14,15 These management models, which emphasize process improvement strategies such as teamwork, continuous improvement and employee engagement16,17 are appealing in the health care setting. In addition, in recent years the Swedish health care sector has faced severe challenges such as reduced staffing, the increased care demands, and inadequate financing.18 To meet these challenges, in the 1990s, many Swedish health care organizations tried to adopt and adapt different industrial management methods.19-21 These actions meant there was a shift from traditional ways of controlling the public sector to a more participatory approach that included all stakeholders in the decision-making. As a result, physicians now have responsibility for medical care, and hospital managers have responsibility for administrative matters.22 The adoption of Lean, among other improvement strategies adopted by Swedish health care organizations, may be seen as a part of the ‘New Public Management’ approach.23 This shift has challenged the traditional medical hierarchy and has accentuated the power conflict between physicians and managers. Lean implementation in Swedish health care has had to deal with this challenge as well.1 History of Lean Lean management was originally developed by the Toyota Motor Corporation (Toyota) in Japan under the name Toyota Production System (TPS).17 Toyota, founded in 1933, began production of automobiles around 1950 in the financial crisis era of post-World War II Japan.6 Because of the severe shortage of even the most basic necessities of life, many Japanese manufacturers began producing inexpensive consumer goods in an attempt to survive the recession.
Toyota management, however, was convinced of the need to produce high quality automobiles despite the difficult economic circumstances. Therefore, Toyota management searched for new ways to do more with less. The result was a novel production system known as TPS.24 Henry Ford, in Highland Park, Michigan, had already developed the concept of ‘flow’ in the late 1910s.25 Ford had developed assembly lines to transport and assemble automobile parts quickly and 1 efficiently. A Toyota manager, Taiichi Ohno, with others, advanced Ford’s idea to suit Toyota’s needs and resource constraints.26,27 Several tools and techniques were developed that improved the production process using the available resources.
The first person to use the term Lean for TPS was John Krafcik, a Master’s degree student at the Massachusetts Institute of Technology (MIT) in the mid-1980s.