Middle management as key to sustained Continuous Improvement

Master Thesis BA Change Management M.W. Barendregt

Middle management as key to sustained

Continuous Improvement

Marion Barendregt

S3231933

Rijksuniversiteit Groningen

Master’s Thesis BA Change Management

EBM724A20

Dr. O.P. Roemeling

Dr. C. Reezigt

20th of August 2018

Groningen, the Netherlands

18.999 words


1


2

Table of contents Table of contents 2

Abstract 4

Chapter 1: Introduction 5

Chapter 2: Literature review 7

Continuous Improvement 7

Lean within the healthcare sector 8

Sustainability of Continuous Improvement 9

Change management domain of leadership 10

Continuous improvement leadership 10

Conceptual framework 12

Chapter 3: Methodology 14

Case study 14

Data collection 15

Data analysis 17

Chapter 4: Results 18

Within case 18

Case A 19

Reflection on implementation 19

Leadership 19

Cross-departmental learning 20

Communication 21

Ownership 21

Case B 22


Leadership 22


Communication 24

Ownership 24

Case C 25


Leadership 25


Communication 26

Ownership 27

Case D 28


Leadership 28



3

Communication 29

Ownership 29

Cross-case analysis 31

Cross-case leadership 31

Prescribed leadership styles 34

Cross-case analysis of cross-departmental learning 35

Cross-case analysis of communication 35

Cross-case analysis of ownership 36

Chapter 5: Discussion 37

Chapter 6: Conclusion 39

Managerial implications 39

Limitations 40

Future research 40

References 41

Appendices 47

Appendix one: Questionnaire manager 47

Appendix two: Questionnaire team leader 50

Appendix three: Questionnaire employee 54

Appendix four: Interview guide old 59

Appendix five: Interview guide new 61

Appendix six: Results questionnaire all three professions 63

Manager 63

Team leader 69

Employee 76

Appendix seven: Codebook 81

85


4

Abstract Purpose – The purpose of this paper is to propose that leadership is one of the crucial factors in the sustainability

of continuous improvement. This article presents a case study focusing specifically on the role of leadership, but also

other additional factors which improve sustained results on expands the understanding of convenient leadership in

healthcare organizations during continuous improvement.

Design/methodology/approach – The paper presents an explorative investigation from an analysis of the

literature, documents and feedback from four units in a healthcare related organization onto the role of leadership in the

sustainability phase of continuous improvement.

Findings - The paper expressed the crucial role of leadership, and especially the role of middle management, in

the sustainability phase of continuous improvement. Whereby not one leadership style amongst leaders is found to be

convenient, multiple leadership styles on different hierarchical levels in the organization should be adopted. Interviewees

express lean leadership at managerial level and team leadership at team level as most convenient. Furthermore, additional

influential factors are found, namely cross-departmental learning, communication and ownership. Aforementioned

factors can all be characterized as leadership behaviors found as relative in this research.

Originality/value - In this case study, in the sustainability phase of continuous improvement the role of middle

management is mentioned as crucial. The additional influential factors on the sustain results are also proved to be

leadership characteristics, therefore the role of leadership is even highlighted as fundamental. The knowledge acquired

in this research is based on experiences of employees of a healthcare related organization on the level of sustainability

and dynamics with their leader. This may help the reader examining the most suitable leadership approach towards

sustained continuous improvement in a healthcare organization.

Keywords - Healthcare, Continuous Improvement, Sustainability of Continuous Improvement, Leadership,

Middle Management.

Paper type - Case study


5

Chapter 1: Introduction he public sector faces major enduring challenges in improvements, from which the healthcare sector is one of

their biggest concerns (Francis, 2010; Keogh, 2013). From the 1970’s and 1980’s on, focus in the healthcare

sector is on improvements of service performance and reduction of healthcare spending, arising from the need

to adapt as an organization to developments in areas as information and technology (Radnor, Holweg, & Waring, 2012).

Aforementioned improvements and reductions became even more important when healthcare organizations shifted

towards a patient-focused care, which resulted in an increase in quality of care, patient satisfaction, increased performance

and efficiency (Brandao de Souza, 2009). Improvement of processes are indicated as fundamental to solve issues

surrounding a patient-efficient focus (Brandao de Souza, 2009), therefore the concepts of lean and continuous

improvement will be introduced.

Two decades ago the interest in the lean philosophy increased within the healthcare, whereby lean can be seen

as a helpful tool to an improved, value-based healthcare organization (D’Andreamatteo, Ianni, & Sargiacomo, 2015). In

short, Womack and Jones (1996) holistically describe that the lean philosophy aims to redesign organizational processes

to reduce waste and enhance productivity with the creation of a continuous improvement culture. Lean has proven itself

within healthcare organizations to deliver cost-effective, high-quality care (Berwick, 1989; Berwick, Godfrey, &

Roessner, 1991; Laffel, & Blumenthal, 1989). Furthermore, a growing number of organizations who implemented Lean

showed the benefits gained from Lean (Waring, & Bishop, 2010; Radnor et al., 2012). Significantly, the necessity to

eliminate the non-value adding processes is grown. This became apparent in the research of Hagen (2011), who expressed

that 95% of healthcare operations are considered to have processes that do not add value. This leaves a substantial space

for improvement.

Last decade, reflections on lean implementation emphasized to be more successful in healthcare organization as

a system-wide and sustained improvement philosophy which embodies ongoing redesign of core processes and care

pathways (Radnor, Holweg, & Waring, 2012; Mann, 2009; Burgess, & Radnor, 2013). Therefore, it can be stated that

lean needs to be indicated as dynamic, characterized by the continuous improvement approach (D’Andreamatteo et al.,

2015). To elaborate, continuous improvement provokes employees to determine and establish solutions for process

improvements, which enhances circumstances to implement those improvement within their work environment.

However, several authors revealed that not all results of lean become sustained (Burgess, & Radnor, 2013; Stelson, Hille,

Eseonu, & Doolen, 2017). Dombrowski and Mielke (2014) state that various lean implementations fail to succeed in the

long term.

Several researchers investigated the sustainability of lean (Bessant, Caffyn, Gilbert, & Harding, 1994; Jorgensen,

Matthiessen, Nielsen, & Johansen, 2007; Fryer, Ogden, & Anthony, 2013) whereby Bessant, Caffyn and Gallagher (2001)

developed a model which highlights the five stages in the evolution process of adaptation of continuous improvement, in

order to deepen the understanding and prescribe elements to successfully manage this process (Bessant et al., 1994).

Thereby, it can be implied that along those five stages, the maturity of the continuous improvement approach grows

which nuances that along the continuum, improvements and behaviors progressively become sustained. As literature

T


6

reveals, the role of leaders is significant in steering employees’ behaviors towards the sustainability of lean. Especially

since leaders are responsible for the developed vision for change and the creation of a culture of continuous improvement

(Beer & Nohria, 2000; Boonstra, 2004). Therefore it can be implied that leaders are of importance within sustainability

of lean.

Based on the presented literature, due to limited research a gap persists on the sustainability of lean within the

healthcare sector. Although lean is a widely used concept in healthcare, limited attention has been paid to the role of

leadership within the evolutionary process of adaptation towards continuous improvement. Whilst recent research

focused on contributions of leadership (Dombrowski, & Mielke, 2014; Amer, & Shaw, 2014), these studies do not

investigated the influential role of leaders in relationship to the sustainability of lean. Therefore, the purpose of this thesis

is to explore the role of leadership within the sustainability of lean for the healthcare sector. This study adopts the

following research question:

How does leadership influence the sustainability of lean within the healthcare environment?

The aim of this paper is to assess the role of leadership in relation with employee behaviors to adapt to lean along

the evolution of continuous improvement. The findings will be an extension on the literature about sustainability of lean

related to effective leadership. Managerial interest will be triggered since the paper holds to influence employees’

responses towards continuous change by the dominant role of leaders.

The remainder of this papers is structured as follows. The second chapter will provide a theoretical framework

for the main concepts, and will present the initial conceptual framework. In the third chapter, the methodology will be

introduced whereby the data collection, analysis and cases for the case study will be elaborated. After conducting the

questionnaire and interviews, this paper analyzes the results and will represent them in a constructive manner. The

discussion will compare the findings with current literature. As last, the conclusion will answer the research question and

present additional findings.


7

Chapter 2: Literature review n this chapter, the terms from this research and therefore the remaining research question will be elaborated on. The

literature will provide descriptions and explanations of important concepts. Those concepts are continuous

improvement, lean, sustainability of continuous improvement, and several leadership styles. Last, the conceptual

framework is presented. The concepts of continuous improvement and lean are described to deepen the understanding of

approaches change management. After this broad introduction, the focus will be on multiple leadership styles clustered

in the paragraph of continuous improvement leadership.

Continuous Improvement As quality of services is critical to a firm’s success, many attempts have been made over the years to deploy

continuous improvement programs (Laureani, & Antony, 2018). Continuous improvement can be seen as an overarching

element of lean, whereby it provokes employees to determine and establish solutions for process improvements for their

own work environment (Dahlgaard, Pettersen, & Dahlgaard-Park, 2011). Furthermore, continuous improvement

encompasses an organization-wide scope. Continuous improvements is the main aim for any organization to help them

to achieve quality and operational excellence and to enhance performance (Assarlind, Gremyr, & Bäckman, 2013;

Thomas, Barton, & Chuke-Okafor, 2008). Even so, Brunet and New (2003) support that continuous improvement entails

three key elements. First of all, it is continuous, since it is an embedded nature of practice and also has a place in never-

ending journey towards quality and efficiency. Second, continuous improvement is usually incremental in nature. Last,

continuous improvement is participative by entailing involvement and intelligence of the workforce (Brunet, & New,

2003). Clustered, continuous improvement is mostly defined by researchers as a culture of sustained improvements,

targeting elimination of waste in all systems and processes of an organization, whereby it encompasses everyone working

together to make improvements without necessarily making huge capital investments. From the view of management,

continuous improvement is an integrative philosophy for continuously improving quality of products or services and

processes to achieve customer satisfaction (Singh, & Singh, 2015). This is also visible in a growing body of literature on

successful lean and continuous improvement principles and methodologies (Aij, Visse, & Widdershoven, 2015), whereby

the healthcare sector is exposed to continuous change (Adler, Riley, Kwon, Signer, Lee, & Satrasala, 2003; Dahlgaard et

al., 2011).

It is commonly believed by respective researchers that successful adoption of continuous improvement desires

significant commitment to its continuous improvement culture (Gaucher, & Coffer, 1993; Heilpern, & Nadler, 1992;

Shortell, O'Brien, Hughes, Carman, Foster, Boerstler, & O'Connor, 1994; McLaughlin, & Kaluzny, 1990; Holtskog,

2013). Accordingly, Bessant, Caffyn and Gallagher (2001) refer to challenges which arise from adopting a continuous

changing culture. The researchers therefore suggest to adapt to new routines and behaviors pursuant to the continuous

improvement philosophy. The continuous improvement philosophy emphasizes on creating an improvement-based

learning culture within the company (Augsdorfer, & Harding, 1995). In order to embed a continuous improvement

culture, support from managers at each level would be required (Pokinska, 2010).

I


8

Lean within the healthcare sector During the 1980’s, Toyota became known for its production system: Toyota production system (TPS) (Pettersen,

2009). TPS is also known in the Western world as lean production (Womack, Womack, Jones & Roos, 1990). Lean

production emphasizes the continuous improvement of processes to achieve performance goals, by reducing waste and

eliminating non-value adding steps in these processes. As supported by Brandao de Souza (2009), lean functions as an

integrated system of principles, tools and techniques. Womack and Jones (1996) define lean as ‘Reconfiguring

organizational processes to reduce waste and enhance productivity based upon application of specialist analytical tools

and techniques coupled with creating a culture of continuous improvement’. This description alluded to be

comprehensive for this research.

The healthcare sector is subject to continuous change whereby healthcare organizations are forced to maintain

and improve performance, quality of care and patient satisfaction (Adler et al., 2003; Dahlgaard et al., 2011; Brandao de

Souza, 2009; Dickson, Anguelov, Vetterick, Eller, & Singh, 2009; Jimmerson, Weber, & Sobek, 2005; Womack, &

Jones, 1996; Young, Brailsford, Connell, Davies, Harper, & Klein, 2004). As elaborated by Waring and Bishop (2010),

lean contains reorganizing and rationalizing healthcare services through translation of management practices from the

manufacturing sector. A more healthcare related description of lean is the definition of Dahlgaard et al. (2011), who refer

to Lean as “Management philosophy to develop a hospital culture characterized by increased patient and other

stakeholder satisfaction through continuous improvements, in which all employees actively participate in identifying and

reducing non-value-adding activities (waste)”. This definition underscores the focus on cultural, long-term improvements

on a broad scope, but seems to be imprudent in exclusively focusing on satisfaction. Therefore the description of Womack

and Jones (1996) remains most extensive. Ben-tovim, Bassham, Bolch, Martin, Dougherty, and Szwarcbord (2007)

stresses that basics of process improvement, and therefore used the lean principles, are as relevant for healthcare as for

other service industries. Womack and Jones (1996) indicate that lean tools and techniques bring about changes within

every day work activities, which embodies behavioral changes. The occurrence of behavioral changes is according to

change management often linked with cultural change, as the philosophy behind continuous improvement.

Nevertheless, several barriers exist which can slow down the adoption process of lean. Most important within

the healthcare sector, is the stagnation of adoption process due to organizational complexity and highly autonomous

medical specialists (Brandao de Souza, 2009). Healthcare organizations seem to indicate lean as a tool-based approach,

and lean hits a glass ceiling whereby alignment with the wider strategy is obstructed (Radnor, Holweg, & Waring, 2012).

Qualified researchers state that organisations have applied selected tools and methods from the lean philosophy, but

seldom adopted lean as a holistic management system (Stentoft Arlbjørn, Vagn Freytag, & de Haas, 2011; Chicksand,

Watson, Walker, Radnor & Johnston, 2013; Radnor, Osborne, & Nasi, 2013). Brandao da Souza (2009) and Grove (2010)

mention the hierarchical structure, which constrains bottom-up behavior as required of all employees, and functional and

professional silos as barriers to optimization of work processes and structures. These barriers are elucidated by several

authors, whereby research over the last twenty-five years highlight the role of professional groups in resisting and

weakening healthcare reform (Ackroyd, 1996; Harrison, & Pollitt, 1995; Waring & Currie, 2009). Despite the barriers,


9

growing evidence suggests that implementation of lean within the healthcare has potential impact on quality of care

(Radnor, Holweg, & Waring, 2012). Based on lean as prevalent in healthcare, many authors regard lean implementation

as delivering sustained and continuous service improvement aligned towards organizational strategy whereby lean

becomes part of the organizational culture (Davies et al., 2004).

Sustainability of Continuous Improvement As highlighted by D’Andreamatteo, Ianni, Lega, & Sargiacomo (2015), the sustainability of continuous

improvement approach is influenced by external tensions to improve care, and internal factors as staff’s willingness to

accept change. In fact, implementation accounts for only 20 percent of effort needed to achieve lean transformation. The

remaining 80 percent is effort made by change managers (Mann, 2012) who face challenges of altering the mindset of

leaders and employees (Dombrowski, & Zahn, 2011). This view is supported by Bessant et al. (2001), who state that

continuous improvement management is often poorly understood. To elaborate, since it does not refer to outcomes only,

but also process through which these outcomes can be achieved. This research highlights that continuous improvement

is an evolution and aggregation of set of key behavioural routines within the firm (Bessant et al., 2001). Some authors

argue that effective leadership is essential for lean transformation in the long term (Dombrowski, & Zahn, 2011; Mann,

2012; Keiser, 1997). Simon and Canacari (2012) state that sustainability of continuous improvement requires a

combination of commitment from senior management and prevailing culture of continuous improvement. Augsdorfer

and Harding (1995) emphasized that in order for continuous improvement to be sustainable, it has to be viewed as a long

term and companywide approach. Furthermore, respective researchers defined challenges for sustainable lean; (1) lack

of investment in team improvements, (2) lack of participation of top management during change process, (3) lack of

leadership and (4) pressure for quick results in detriment of long-term thinking and culture of continuous improvement

(Henrique, & Filho, 2018; Ruben, Vinodh, & Asokan, 2017).

As mentioned by Bessant et al. (2001), the sustainability of lean can be interpreted by the maturity of continuous

improvement evolution. The five stages of evolution can be entitled as 1) pre-CI interest in the concept has been triggered

but implementation is on ad hoc basis, 2) structured CI, 3) goal oriented CI, 4) proactive CI, and 5) full CI capability.

Figure 1 elaborates those five stages. Jorgensen et al. (2007) criticize on the model since it illustrates the gradual but

steady development of continuous improvement, through the adoption of certain behaviors that build organizational

capabilities. In parallel with these stages, the behavioral change is defined in expanding routines parallel with the

evolution of continuous improvement. Along the evolution of behavioral change towards a sustainable approach, the

maturity of continuous improvement increases likewise. The learning process embodies the settlement of new patterns

of behavior by processes of reinforcing behavior, and needs to be repeated frequently and for long enough to routinize.

Progression from one stage to next involve both maturing of particular routines and also adding new routines to the core

set (Bessant et al., 2001). During the changes of behavior, the cycle needs to be repeated frequently and for long enough

for new patterns to take root. Furthermore, the model is developed in order to create ability to find and solve problems

systematically or ability to share knowledge across boundaries. The sustainability will be achieved differently per level


10

within the organization, namely by departments’ focus on implementing Lean tools and preserving the motivation. On

higher level, the emphasis will be on maintaining a culture of continuous improvement (Aji, Visse, & Widdershoven,

2015).

Figure 1: Stages in evolution of Continuous Improvement (Bessant et al., 2001)

Change management domain of leadership As mentioned before, the implementation of lean requires behavioral change in order to sustain within the

organization. This behavioral change demands leadership qualities in order to maintain an improvement culture (Keiser,

1997; Mann, 2012; Dombrowski, & Zahn, 2011). Therefore, it can be concluded that the healthcare needs leadership

styles with high concern for people. Wikström and Dellve (2009) indicate that leadership in healthcare seems to be shaped

by certain complexities, derived from internal and external dynamics. A large and growing body of literature has

investigated the role of leadership within lean. Snee (2010) elaborates on this view by stating: “Leaders enable an

organization to move from one way of working to another way of working”. Furthermore, respective researchers conclude

that a one-best-way approach is not applicable to the healthcare sector (Delmatoff, & Lazarus, 2014; Wikström, & Dellve,

2009). Hereafter, several leadership styles will be discussed which are often related to continuous improvement.

Continuous improvement leadership Within the article of van Assen (2016), attention is paid to four styles of leadership for healthcare organizations.

The four leadership styles are also applicable towards a continuous improvement environment. Van Rossum, Aji, Simons,

van der Eng and ten Have (2016) indicated leadership as success factor in the transition from technical ‘lean tools’ to

required organizational transformation through continuous improvement. Within the article the respective researchers

expressed transformational and team leadership. The following leadership styles will be discussed below: (1)


11

transformational leadership, (2) transactional leadership, (3) empowering leadership, (4) lean leadership and (5) team

leadership.

First, transformational leadership is mentioned as approach characterized by an inspirational leadership style

whereby leaders identify the need for change, create a vision to guide indicated change, and inspirational characteristics

are used in order to create commitment amongst employees (Bass, & Yammarino, 1991). This view is echoed by Avolio,

Bass, and Jung (1999) who indicate that transformational leadership is likely to result in empowered followers.

Respective researchers indicate that transformational leadership is desired at the top in order to create culture and

objectives which must be adopted by transactional leaders in middle management ranks (Waldman, & Atwater, 1992;

Wofford, Goodwin, & Whittington, 1998; Bass, Waldman, Avolio, & Bebb, 1987).

Second, transactional leadership. Transactional leadership is characterized by mutual dependency whereby

both leader and employee contribute to exchange of valued outcomes (Burns, 1978). As highlighted by Wofford et al. is

transactional leadership most often performed by the middle management. Bremer, Daniels, Gupta, and McCarty (2005)

utilize both transactional and transformational forms of leadership in order to successfully deploy lean, since this

combination acquires leadership and commitment by incorporating organization’s culture which serve as basis for

successful quality improvement. But both approaches differ in the way they encourage employees to accomplish their

goals.

Third approach is empowering leadership. Conger (1989) views this type of leadership as influencing others

by developing and empowering followers’ self-leadership capabilities. To elaborate, this style is characterized by

delegation in which employees are given decision making authority. Transformational- and transactional leadership target

on empowerment (Pearce, & Sims, 2002). In extension, empowering leadership can therefore be considered to be more

appropriate for the lower levels in the organization.

Fourth, lean leadership is similar to transformational leadership in calling for visionary and charismatic

leadership from the top. However, lean leadership is overarching since it also targets tribute to the workforce and

operational level (Holmemo, & Ingvaldsen, 2016). Lean leadership is according to Dombrowski and Mielke (2014)

characterized by (1) describing cooperation of employees and leaders to mutual strive for perfection, (2) customer focus

of all processes, and (3) is expressed as ‘the’ style for sustainable implementation of continuous improvement and lean.

Lean leadership is compared towards transformational leadership, but should be as applicable at the level of the middle

management, and therefore is the more comparable with transactional leadership. But whereby transactional leadership

is accomplishing goals with rewards, lean leadership makes use of the inspiring approach whereby they connect with

operational level.

In order to extend literature on the contributory role of leadership on the sustainability of lean the article of van

Rossum et al. (2016) indicated leadership as success factor in the transition from technical ‘lean tools’ to required

organizational transformation through continuous improvement. The researchers highlight another leadership style,

namely team leadership. According to the researchers, transformational leadership is expected to ensure required top-

down commitment, whereas team leadership creates active, bottom-up behavior of employees (van Rossum et al., 2016).


12

Accordingly, team leadership is a dynamic, interactive influence processes amongst individuals in groups for which the

objective is to lead one another to achievement of group or organizational goals. Those leaders must attempt to increase

the level of involvement and strengthen the bottom-up dynamics to create a culture of identifying waste, proposing

improvements and implementing solutions (van Rossum et al., 2016). This in contrast to transactional leadership whereby

a mutual dependency is necessary to accomplish this culture and improvements. Furthermore, team leadership is similar

to empowering- and transformational leadership in encouraging the empowerment and delegating responsibilities, but all

three are assumed to be on another level at the hierarchical ladder.

Conceptual framework In this paragraph the conceptual framework is visualized. The concepts elaborated on before will result in a

framework which presents the potential relationship between sustainability and leadership. Literature on continuous

improvement highlighted that healthcare organizations have trouble to succeed and sustain results. Successful projects

are indicated to benefit from aspects as; (1) top management commitment, (2) staff involvement, (3) information and

knowledge sharing, (4) organizational culture, (5) communication, and (6) effective leadership (Waring, & Bisschop,

2010; Ben Ruben et al., 2017; Stelson, Hille, Eseonu, & Doolen, 2017; Rees, 2014; Pocha, 2010). Even so, respective

researchers mentioned the lack of team improvements, lack of participation of top management commitment, and lack of

leadership as challenges to sustain change (Henrique, & Filho, 2018; Ben Ruben, Vinodh, & Asokan, 2017).

Aforementioned indicate that besides leadership, also other factors influence the sustainability of continuous

improvement. Organizations sometimes fail to address the translation of leadership and commitment amongst top

management during organizational (Grove et al., 2010). To elaborate, besides a bottom-up approach, also a top-down

approach is needed to implement solutions. Which is not often taken into consideration is that besides changing the

organization, also the leadership style needs to be changed (Waring, & Bisschop, 2010). The following figure represents

the conceptual framework whereby the influential factors for sustainable results are marked. With a focus on effective

leadership with leadership styles indicated on the level of hierarchy.


13

Figure 2: Conceptual framework

Effective leadership

Staff involvement

Top management commitment

Sustained results of

continuous improvement

Team improvements

Long term thinking of continuous

improvement

Information and knowledge sharing

Top management - transformational leadership

Middle management - transactional or

lean leadership

Teams and individuals - Empowering- or

team leadership


14

Chapter 3: Methodology he research had a qualitative approach, with three different qualitative methods in order to perform

triangulation. Thereby, the research is performed as a case study which explored the relationship between the

change management perspective of leadership and the sustainability of continuous improvement approach

amongst four cases. The case study provided a major advantage, since it investigates the ‘how’ questions for developing

new theories and ideas for the academic field (Yin, 1989; Eisenhardt, 1989).

Case study Case studies are preferred when ‘how’ or ‘why’ questions are being posed (Yin, 1989). Since this research

question entails: “How does leadership influence the sustainability of continuous improvement within the healthcare

environment?”, the case study approach is appropriate. The case study embodied four cases within one psychological

care organization, which implemented lean in order to improve the performance of the organization.

The healthcare organization consist of around the 4000 employees. The organization started with lean in 2014,

whereby first contact with lean within the organization was in 2015. This organization’s scope is divided into several

business units focused on primarily psychological care. The organization embodies 42 locations amongst 21 places within

the Netherlands. Whereby it is most active within the North of the Netherlands. Lean is implemented in order to: (1) to

improve quality of the service, and (2) to work efficiently. Within the organization the lean program is introduced by the

board of directors, whereby they emphasized the necessity of the organization to keep track of future market forces.

Subsequently, external and internal environmental pressures are such a big constraint on being profitable and to deliver

customization for this healthcare organization. The Lean program was introduced top-down, whereby they designed the

project as bottom-up during the implementation and transformation. Over a period of three years, two waves of Green

Belt are educated by the Master Black Belt. In total, sixteen employees were trained as Green Belt and executed

improvement projects as part of this education. Amongst those Green Belts, staff members, team leaders and employees

were educated. Other functions got a short introduction on the Lean philosophy as so-called Yellow Belt. Based on

aforementioned, this organization was marked as ideal for this case study.

The unit of analysis chosen for the case study are four out of the seven business units. Whereby the elderly

psychiatry, adult psychiatry, general business and concern were chosen. Amongst those four business units, fourteen

attendants were collected from whom the manager, team leader or employee was trained as Green Belt. Preferably, at

least two employees in the aforementioned positions were trained in lean techniques. Those four cases were investigated

on the sustainability of continuous improvement, and the potential influential role of leadership. As first, Case A consisted

of five participants from which four are educated Green Belts. The manager is informally educated by the lean

philosophy. Second, Case B embodied four attendants whereby three were educated Green Belts, the manager was

educated Black Belt on a formal training outside the organization. Third, amongst Case C two out of three were educated

Green Belts, whereby the manager informally gained knowledge from the lean philosophy. Last, the fourth case D consist

of one educated Green Belt and one informally trained Black Belt outside of the organization. All participants indicated

T


15

to have the basic understanding of lean and the educated Green Belts proved experience gained from the improvement

project. Whereby all departments matched this preference. Since most participants have been trained Green Belt, the

dynamics between leader-follower became visible based on their experience with improvements at departmental- or team

level. To collect information for this case study the researcher used documents, questionnaires and interviews. This

combination offered a more comprehensive insight into the subject matter.

Data collection The description of the case study previously highlighted three methods to collect data, defined as triangulation.

Triangulation should be understood as means of extending our knowledge of the research issue (Flick, 2004).

Furthermore, it exists to explore and explicate ways in which concepts from different methodologies can peacefully

coexist and cooperate within a single study. This multiple methods approach was chosen to build a more unified body of

knowledge (Kakkuri-Knuuttila, Kakkuri-Knuuttila, Lukka, & Kuorikoski, 2008). The case study approach was expressed

by Eisenhardt (1989) as applicable for researches whom was to build theory. Accordingly, this research embodied theory

development whereby the role of leadership amongst the sustainability of continuous improvement has not yet been

addressed in the academic literature (van Aken, Berends, & van der Bij, 2012). The qualitative approach incorporated

documents, questionnaires and interviews. Supported that qualitative methods should be utilized in complementary

fashion to contribute to the more holistic findings of the qualitative approach (Jick, 1979).

Method Amount Role in research

Documents 14 documents (Posters, project chart, slides

and evaluation documents)

To explore the program of the organization

and to prepare for case selection and

description.

Questionnaire 10 (managers represented 30%, the team

leaders 42%, and as last the employees

with 28%)

To define the level of sustainability within

the organization and to gather more general

findings which led towards more specific

questions in the interviews.

Interviews 14 (four managers, six team leaders and

four employees).

To collect reasons behind the levels of

sustainability and answers given in the

questionnaire. Furthermore, more future

oriented questions can be asked. Most

valuable method to collect data on

dynamics and findings. The codebook

proved to be helpful to present the findings

and to see relationships and gather new

insights.

Table 1: Data collection overview

After visualizing the methods used and relevant information on the purpose of the method in table one, the data

collection starts off with the first method of the triangulation. Namely, documents were approached. Documents as the

project charter, roll-out of improvement projects, and posters of Green Belt projects were investigated. Documents were

gathered by one of the Black Belts and from the intranet. This data collection method was used to analyze explanations

on the lean program. Furthermore, those documents gave insides into which possible results the questionnaire and


16

interview would provide. Furthermore, those documents were analyzed to sense relationships between the intention of

the program and the performed outcomes. Last, the analysis provided insights for in-depth questionnaire- and interview

questions.

As second, the questionnaire gathered qualitative data amongst of employees whom are educated as Green Belts

or those supervisors. Those employees responded anonymous. Even so, it contributed to uniformity among respondents

(Mathison, 1988; Flick, 2004). Respondents were faced with five themes, meaning lean program, lean at departmental

level, sustainability of lean and several roles of leadership. During the questionnaire, respondents had the opportunity to

respond carefully without interference (Mathison, 1988; Flick, 2004). Qualtrics, system provided by the Rijksuniversiteit

of Groningen, was used to create and share a mostly structured and partly unstructured questionnaire. Especially since

this questionnaire consisted of three themes with the 5-point Likert scale from “strongly disagree” to “strongly agree”.

This 5-point Likert scale was chosen to measure respondent’s attitude towards statements presented. Two other themes

provided the opportunity to choose one of the four provided answers. Three out of the five themes had the chance for

participants to elaborate on their choices within an open question setting. Those questionnaires were sent amongst the

three levels to collect results. In total the questionnaire was sent to 30 employees. Furthermore, the qualitative data was

used as preliminary tool for more in-depth interview questions. The analysis of the questionnaire provided the researcher

the opportunity to deepen interview questions, by asking for oral explanation on answers given. Those three

questionnaires were tried upon the researcher and the supervisors. Next to that, the data generated the level of

sustainability and the amount of leadership expressed within the concerned units and departments. Since the research

embodied three levels within the organization, namely manager, team leader and employee, three questionnaires were

conducted. All three questionnaires revealed the same themes but with different perspectives to collect data about the

leader-respondent dynamics. Those questionnaires can be found in appendices one to three.

In order to finish triangulation, interviews collected data by a semi-structured approach. This approach was

chosen in order to uncover the story behind participant’s experiences (Miles, & Huberman, 1994). On beforehand the

interview guide was made based on different sub-topics to structure those interviews. Participants were required to sign

the informed consent of the Rijksuniversiteit Groningen to agree upon participation. Even so, they signed that data

collected is supposed to be used within this thesis anonymously. Furthermore, the data was recorded on a digital audio

recorder and transcribed by the interviewer. In order to analyze the data, the interviews were transcribed. All participants

had the opportunity to read and to review their transcript. The interview guide was tried amongst the first interviewee,

the interviewee guide contained 26 questions by then, and this proved to be too much, therefore some introduction and

less important questions were deleted. Appendices four and five present both interview guides.

Within this thesis, employees were referred to by their function, e.g. “Manager …, 2018”, “TL…., 2018” or

“EM …, 2018”, the number is added based on the order of interviews by function. Prior to analyzing the interview data,

the interviewees were reviewed on experience with improvement projects. Such as indirect experiences with the

implementation and transformation of improvement projects. Furthermore, their role within the sustainability of lean was

tested. The interviews were done amongst fourteen employees and all held in person. More specifically, it contained four


17

managers, six team leaders and four employees. As preferred the interviews were amongst different levels of the hierarchy

from four different units. From those units, two units were perceived as low scorers on the sustainability of continuous

improvement. Important note, also depended on their role within the sustainability. Whereby two other units were proven

to be more experienced and sustained on results of continuous improvement. To conclude, those three data collection

methods provided a diverse and broad scope of data. In the following paragraph the analysis is evoked.

Data analysis The researcher first analyzed documents, posters and factsheets available on the lean program. From those

documentation, insights were collected which brought some light on the establishment of the lean program. Which later

on was combined with the results of employees´ responses and experiences towards the program and improvement

projects themselves from the questionnaire and interviews. The collected qualitative data helped to get beyond initial

conceptions and to generate or revise conceptual frameworks (Miles & Huberman, 1994).

The questionnaire amongst employees was designed to gather a dataset with a general view on lean within the

organization. From the 30 respondents approached, 10 employees on several positions within the organization responded

towards the questionnaire. Whereby the managers represented 30%, the team leaders 42%, and as last the employees

with 28%. The results of the questionnaire evoked the researcher with a general view of the introduction of lean,

sustainability of lean and the role of leadership. Those results provided the researcher to generalize in-depth questions

for the interviews in order to dick deeper towards explanations of those answers collected. Based on the questions asked,

several figures were used to display results. For the Likert-point scale questions, the bar chart was chosen to present

answers on the statements. Furthermore, the multiple choice questions will be presented in pie charts. According to the

findings on the sustainability of lean, those results will be compared with the levels of maturity of the continuous

improvement approach conducted by Bessant et al. (1994). Last, a table of the results from the questionnaire will be

represented with the most significant findings for this research. All visualizations, figures and tables will be presented in

appendix five and six.

By analyzing the results of the semi-structured interview, the researcher made an extension on the existing

theory. Those transcripts of the interviewees were analyzed through screening, reading and summarizing. This process

happened multiple times whereby dynamics and relationships became visible. The results were visualized in the code

book, especially since coding offered the researcher a formal system to organize data obtained (Bradley, Curry & Devers,

2007). The codebook is defined into deductive and inductive codes. Whereby deductive codes led towards similarities

and differences, and inductive codes indicated relationships. This codebook can be found in appendix six. The codebook

made it possible to quickly recognize relationships or to elaborate on assumptions which could be made. The codebook

list started as too broad and is made more comprehensive in two times. The results presented are strengthened by the use

of excerpts. The results provided empirical insights in dynamics between leader-follower and the ‘how’ and ‘why’ of

leaders role within the sustainability of continuous improvement. Even so, on managerial level, organizations are induced

with findings which characterize the dynamics between leader-follower and their outcomes on improvement projects.


18

Chapter 4: Results n this section, the findings of this research are presented. The results are presented based on findings from the four

cases, and a cross-case is presented as well. First per case is introduced a short reflection on the implementation

process. The findings present amongst the units low levels of sustainability whereby the researcher choose to

elaborate on the implementation phase as well to strengthen the understanding of the limited sustained results.

Furthermore, the results of the questionnaire will be supported by findings from the interviews. The findings of four cases

present influential factors on the sustainability. Those influential factors are: leadership, cross-departmental learning,

communication, and ownership. In the cross-case analysis the influential factors, and most important the role of

leadership is reflected. Also leadership characteristics and -styles are revealed.

Within case Amongst four units, fourteen employees were interviewed. Amongst those four units, several employees are

educated Green Belts. All cases are categorized on the level of sustainability of continuous improvements during the

questionnaire and interviews. Results indicate differences in sustainability levels. Furthermore, results present that cross-

departmental learning, communication and retention, ownership and leadership influence this level of sustainability. In

table two, the levels of sustainability per case are presented.

Case Level of sustainability Characteristics

Case A Level II - Several projects performed;

- Enthusiasm increases;

- Learn by doing;

- Successes are visible.

Case B Level I - Several successes gained;

- Several performed projects;

- Enthusiasm on broader scope.

Case C Level II - Multiple projects performed;

- Enthusiasm increases;

- Project management;

- Limited influence on care departments.

Case D Level I - Multiple projects performed;

- Ad-hoc improvements;

- Limited influence on care departments. Table 2: level of sustainability indicated by case

I


19

Case A

Reflection on implementation The first experience with implementation of improvements projects was gathered by team leaders during the

education to become Green Belts. The interviewees recognized the added value of lean as eliminating waste and defining

the customer value (TL two, 2018; TL three, 2018; TL five, 2018). Another interviewee extended this view by

determining that lean contributes towards increasing quality of the service: “The first requirement in order to improve

the quality, is the recognition of what could be done differently and/or be improved” (TL three, 2018). The majority

reviewed the lean program as pilots performed at team- and departmental level. However, those interviewees expressed

that the top management should have been involved as well in order to achieve sustainable change (Manager one, 2018).

This incapacity was indicated as a lack of leadership, especially since those leaders failed to educate employees and to

motivate others (Manager one, 2018). This is supported by the results of the questionnaire, whereby the attention of

directors towards the lean program was indicated as low (Questionnaire TL two, 2018; Questionnaire Manager one,

2018). This lack of attention is supported by the following excerpt: “Most of the improvements are performed on

operational level. There was not a sufficient level of engagement amongst the board of directors. Therefore it is less

visible what the effects are on organizational level” (TL two, 2018). Another interviewee expressed that implementing

improvement projects should be based on organizational goals, instead of the chosen team- or departmental problems

(TL three, 2018). Despite the negative view on top management involvement, some improvement projects proved

sustainable results on departmental- and team level. One interviewee explicated: “The improvement project of the Green

Belt education led towards an acknowledgement that an investment in time, resources and employees definitely can lead

towards improvements or changes” (TL three, 2018).

The level of sustainability of continuous improvement can be indicated at level two in case A (Questionnaire TL

two, 2018; Questionnaire Manager one, 2018). This is supported by the fact that nearly all team leaders performed

multiple projects after education. Most improvement successes, despite the limited scope of improvements, are still

visible on team- or department level (Questionnaire TL five, 2018). Last, within the unit, enthusiasm to improve

increased, due to external pressures to improve and internal acknowledgement of successes from previous improvements.

Leadership Leadership is mentioned as one of the influential factor to sustain continuous improvement. Leadership is

expressed as important in the following way: “The organization needs to sense threats and opportunities and decide

which road to take. This needs to be a translation towards the directors, who are in the position to determine how it will

affect the care groups. The directors translate those messages towards managers, and eventually they translate it in

concrete ways what needs to be done on operational level, in collaboration with team leaders” (TL three, 2018). Team

leader three considers the role of middle management as one of a linking pin, providing a connection between top

management decisions and the consequences for employees on operational level. One interviewee agrees upon this view


20

by stating: “As team leader or manager, you are responsible for repeating ‘why’ we change our behavior and ‘how’ this

will become routine in doing it differently” (TL four, 2018).

A minority indicated top management as most important level in order to sustain changes. When the board of

directors have influence on defined improvement projects, they acquire the opportunity to generate continuous

improvements company-wide. As expressed by one of the interviewees: “Projects for the education of Green Belt were

supposed to be chosen or reflected on by the board of directors, but in reality the director did not have an impact on the

project itself and was not commitment” (TL four, 2018). The continuous top management commitment is needed in order

to express to lower levels support and attention towards their performance improvements (TL two, 2018, TL three, 2018,

TL four, 2018).

Others agreed that middle management has a significant role in the achievement of sustainability, explained by

the following quote: “The management level has to cope less with the teams, and more able to look across the

departments. Regarding change, those leaders play a more important role than team leaders” (TL three, 2018). This is

supported by other interviewees since middle management is in the position to translate abstract higher-order goals into

practical implications (TL two, 2018; TL four, 2018; TL five, 2018), and middle management is able to create a network

of communication and learning across departments (TL three, 2018). On the level of team leaders, successes were gained

through their continuous involvement and attention on lean performances which encouraged employees (TL two, 2018;

TL three, 2018; TL five, 2018).

Overall, the role of leadership and its behavior in Case A can be typified as crucial whereby both top-down and

bottom-up approaches are needed (TL two, 2018; TL three, 2018). In turn, these actions resulted in convenient leadership

styles performed on multiple levels. In Case A sustainability was mostly achieved due to middle management

involvement which established network of cross-departmental learning. Even so, also marked as successful are the

leadership characteristics performed by team leaders which encouraged ownership.

Cross-departmental learning Cross-departmental learning can be explained by the majority that not only their own experiences and knowledge

are satisfying enough for a continuous improvement culture. The underlying value of cross-departmental learning is

cross-departmental communication (TL two, 2018). On departmental level, more cross-communication is needed since

it could increase shared problem solving and cross-departmental learning. This was stated by multiple interviewees who

recognized the added value of cross-departmental learning, since it gathered insights into the patient-central process

which is assured to increase the quality and customer-value (TL three, 2018; TL four, 2018). This was highlighted by

team leader two (2018): “From the moment we started with connecting with other departments within the unit, we could

exchange information about how we work smart. This is viewed as useful within other departments as well”. It can be

considered that the role of team leaders is to desire cross-departmental learning and act upon this desire towards the

manager, who is able to facilitate this process. This view is shared by multiple interviewees who indicated that the role

of team leaders is of major importance in selecting which knowledge and experience to exchange (TL two, 2018; TL


21

three, 2018; TL four, 2018). This must be stimulated by the manager who is able to facilitate team leaders in developing

a network for cross-departmental learning (TL three, 2018; Manager one, 2018).

Overall, the role of cross-departmental learning in Case A can be typified as leadership characteristic. In Case A

sustainability was mostly due to cross-departmental learning facilitated by the manager, and performed by the team

leaders (TL three, 2018; Manager one, 2018).

Communication Communication is mostly indicated by interviewees as the need for transparent communication. Transparent

communication within a continuous improvement setting is expressed in clearly communicating the urgency, vision and

project plan to all employees within the organization (TL two, 2018; TL three, 2018). Furthermore, transparent

communication can be reached by translating abstract, higher-order goals, towards concrete improvements at lower levels

(Manager one, 2018). It can be considered that managers and team leaders both have a role in expressing transparent

communication. This view is supported by team leader two (2018): “The whispering game is known by everyone, whereby

important information is getting lost or being twisted. Along those several layers within this organization, this results

into information slips. It all depends upon transparent communication”. From top towards bottom, all levels should act

towards the same purpose, namely continuous improvement (TL four, 2018; TL five, 2018). In order to let continuous

improvements stick, retention is needed (TL three, 2018; TL four, 2018). Retention is fed by continuously evaluating

results, supported by one interviewee: “Every month I ask my colleagues if the results are right and visible for them.

Otherwise we can change some bottlenecks. By asking their opinion, satisfaction increases” (TL two, 2018).

Overall, the role of communication in Case A can be typified as leadership characteristic. In Case A sustainability

was mostly due to transparent communication expressed on every layer. From the top to the bottom, the translation of

higher-order, abstract goals towards operational achievements should be clear and transparent. It can be implied that the

sustainability requires continuous attention towards transparent communication.

Ownership Whilst the top management is important to be committed towards improvement projects, interviewees expressed

that on team level the most substantial difference are visible (Manager one, 2018, TL two, 2018). The manager referred

to the necessity of ownership in the following way: “Sometimes it needs to collapse in order to let them experience the

necessity to change. If I review myself, I solved too much for them. I had to let problems escalate into real problems”

(Manager one, 2018). Another interviewee echoed this view: “Personally, I recognize confusion amongst employees

within change, especially since we as leaders, have taken away their responsibility within the care, but by now we need

to give them the responsibility back” (TL four, 2018). It can be considered that team leaders and managers acknowledge

their role in constraining to delegate responsibilities amongst employees, but do recognize the need for responsibilities

by employees to encourage ownership. Moreover, one excerpt reflects ownership with the underlying factor of

responsibility: “It is part of the human being to desire for responsibility within your job. This exerts the feeling of


22

importance. Furthermore, this ensures you to perform better than expected” (TL four, 2018). Whilst a minority

mentioned that ownership first needs to be at the top, the majority agreed that ownership for the problem must be acquired

at team level. One interviewee expressed the importance of ownership amongst the team by: “The team is of great

importance in executing improvement projects, since they are the ones who have to feel the problem in order to express

willingness to improve” (TL five, 2018). This view is echoed by one interviewee who expressed: “When everyone is

responsible for the whole, everyone wants and feels the necessity to improve” (TL five, 2018).

Overall, the role of ownership in Case A can be typified as leadership characteristic of team leaders. In turn,

team leaders can encourage ownership amongst a team, and delegate responsibilities. It is supported that those behaviors

are required to be visible within everyday life (TL two, 2018, TL three, 2018), which implies that ownership is needed

in order to achieve sustainability.

Case B

Reflection on implementation Whilst the minority alluded the notion that lean was taught as end themselves, the majority agreed upon the idea

that lean would be more valuable as means to an end (TL six, 2018; TL one, 2018). The following fragment supports this

view: “It is an instrument, a way of thinking and that's how they have to see it. How can I use the instrument? And

recognizing the added-value” (TL one, 2018). Furthermore, lean is indicated as applicable to the organization since it is

focused on the patient (EM four, 2018). Team leader six (2018) indicated that the ambition of the program is improvement

across departments, more on the patient-central process. As side-effects, the majority mentioned that the approach of the

program was to implement lean with mostly staff departments (EM four, 2018; TL one, 2018).

As expressed in the questionnaire, the level of sustainability of continuous improvement can be indicated at level

one in Case B. The following excerpt indicated that within the organization, the enthusiasm about lean is limited; “The

majority simply has no interest in lean and does not see it as their choice” (TL one, 2018). This is supported by limited

amount of improvement projects performed, besides those for the education of Green Belt. However, limite improvement

successes are still visible on department level, it diluted over time (TL six, 2018; TL one, 2018). The findings of the

questionnaire support aforementioned which indicates the lowest level of sustainability (Questionnaire TL six, 2018;

Questionnaire TL one, 2018).

Leadership Employee four (2018) expressed that leadership is essential to change: “You always need a leader as driving

force, even when you delegate leadership towards the lowest level”. Team leader six (2018) highlighted the major

importance of leadership at multiple levels within change: “In order to change, I also need help from my supervisor and

the board of directors as well”. The lack of top management commitment resulted in less middle management

commitment towards results and limited successful employee performance. This can be supported by the following

excerpt: “It happened less often that the board of directors mentioned it and performed upon lean principles” (Manager


23

three, 2018). It can be considered that the manager recognized the lack of top management commitment, whereby it

stagnated on middle management level. The manager identified his role as translator of abstract, higher-order goals into

practical context dependent achievements (Manager three, 2018). However, the limited top management could be

considered as a bottleneck in expressing upon this desire. In order to accomplish sustained results they ought to have

congruence between the top and bottom: “What is chosen as direction at the top, should be translated towards the bottom.

At the opposite, what is signaled at the bottom should be expressed towards the top” (TL six, 2018). The middle

management is by the interviewees marked as crucial in translating (TL one, 2018, Manager three, 2018). One

interviewee partly disagreed and highlighted: “The top- and middle management has a major responsibility in searching

for contact with the lowest layer in order understand each other” (TL six, 2018). From this it can be considered that the

middle manager is in the most suitable position to start such conversations.

The role of the team leader is characterized by being involved within the operations and able to stimulate and

motivate both individuals and teams (EM four, 2018; TL six, 2018; TL one, 2018). Despite the necessity of adequate

leadership amongst team leaders, leadership can also be placed at the lowest level. Employee four (2018) expressed:

“When leadership is performed at the lowest level, those employees become empowered for process improvements.

Thereby it will become more sustained within everyday work and performances”. All interviewees agreed that leadership

needs to be authentic: “When you express to give them more responsibilities, this should be revealed from their behaviors,

just as being facilitated” (Manager three, 2018).

Overall, leadership at Case B is typified as essential to influence or moderate other influential factors for

sustained results. In turn, these actions results into leadership characteristics and styles which should be most appropriate

to sustain continuous improvement. Such as, example behavior, translating higher-order, abstract goals, and commitment.

Cross-departmental learning Cross-departmental learning is indicated by one interviewee as crossing boundaries of departments or teams

leads towards shared problem-solving. This is supported by the following excerpt: “You have to show them how things

work in each department. Whereby you indirectly ask both parties to think of shared problem-solving” (TL six, 2018).

The purpose of cross-departmental learning is to make the connection stronger whereby they are able to think about the

whole process (Manager three, 2018). It is considered that as a team leader, their role is important to focus on connecting

employees. Last, the manager recognized that cross-departmental learning should be possible, especially since some

departments are identical in their way of working or the care they provide (Manager three, 2018).

Overall, the role of cross-departmental learning in Case B can be typified as a sustainable factor. In turn, these

findings present that the role of both team leader and manager are important, but the manager is more important in

recognizing similarities and facilitating the network.


24

Communication Transparency along layers is fundamental in order to express the urgency, vision and objectives of change

(Manager three, 2018). Abstract, higher-order goals are supposed to be clear for managers and team leaders, in order to

let them perform according those goals (TL six, 2018; TL one, 2018). One interviewee expressed dissatisfaction about

transparent communication: “The communication between me and my manager is going well, but from that moment on it

stagnates. It is not transparent or visible what happens. Undoubtedly a lot is going on, but it is not visible or

communicated” (TL six, 2018). Team leader six (2018) noticed that transparent communication, directly or indirectly, is

essential. Furthermore, another interviewee expressed the added value of transparent communication: “If it is clear which

interests everyone has, it is possible to create foundation for change” (TL one, 2018). It can be considered that leaders

recognize their role in transparent communication. Last, the manager highlighted the necessity for transparent

communication: “The way the message is expressed, from an underlying mindset and plan, it will turn out to be a different

conservation with the rest of the organization, in comparison to just following the hype of lean” (Manager three, 2018).

As aforementioned excerpt indicated, the context dependency of the information is of importance: “In order to implement

projects, the workforce needs to be attracted to the project in order to succeed, since they are the essentials in converting

the project towards the context” (Manager three, 2018). This requires a major investment of time to have that

conversation (Manager three, 2018). It can be considered that the manager recognizes the importance of connecting with

the lowest levels in the organization, in order to have conversation about topics that matter.

Overall, the role of transparent communication in Case B can be indicated as important factor to sustain results.

Especially since, the manager recognize the role to connect with the lowest level, and to translate the abstract, higher-

order goals towards practical achievements. Furthermore, leadership characteristics for both managers and team leaders

become apparent.

Ownership Ownership is more visible by employees who are more mature in performing their tasks (TL six, 2018; EM four,

2018). Employees’ ability to increase ownership is reflected by interviewees as feeling the problem as their own

accomplished through give them responsibilities to experiment with improvements for the problems (TL six, 2018).

Ownership can be defined as the ability to think beyond their own work (EM four, 2018). It can be considered that team

leaders are recognizing their role in encouraging ownership by trusting employees to delegate responsibilities. Findings

present that when the employees are trusted and got space and tools to perform their tasks, results will become noticeable

(TL one, 2018). Manager three (2018) expressed that employees should get responsibilities, additional authorizations and

mandations.

The results indicate that leaders have a significant role in supporting the increase of ownership, this was

explicated by team leader one (2018): “If you do not pay attention to the necessity and project itself it does not grow into

something which employees feel as ‘theirs’”. The added value of attention is shared by another interviewee: “Ownership

will only remain with attention and focus on their responsibilities, when they feel empowered in their own tasks they will


25

be the owner of successes and failures” (Manager three, 2018). For leaders to facilitate ownership, it is important to stay

focused and attached to the results, especially since the sustainability phase acquires roles and responsibilities to be clear

to let the new routines stick (TL one, 2018). At team level, it became apparent that ownership amongst a team is

significant factor for sustainability (EM four, 2018). Team leader six (2018) expressed: “An improvement project can be

marked as successful when the results are achieved in team collaboration. Due to the fact that the problem was carried

on team level”. Whereby the manager argues that sustained results are only possible when from the top till bottom

ownership is apparent (Manager three, 2018).

Overall, the role of ownership in Case B can be typified as crucial to sustain results. In turn, the actions of

especially team leaders need to encourage ownership by delegating responsibilities and trusting the capacity of

employees.

Case C

Reflection on implementation Case C recognized the contributory role of implementing lean as eliminating the steps whom are not valuable

for the customer (EM one, 2018; Manager two, 2018). Besides, two employees recognize that lean should be used as

means to an end, instead of an end themselves (EM one, 2018; EM three, 2018). One employee argued the way the

organization introduced lean, since the organization failed to come forward with the subject: “The organization

expressed; ´we will use lean´, whereby in my opinion it would have been more valuable to introduce it as ´we will reduce

the throughput time. Whereby we will make use of methods from lean´. (EM three, 2018). The manager supported this

view by noting that they introduced an organization-wide program which has been put down over the people, instead of

with the people (Manager two, 2018). All three interviewees recognized as facilitators for change, that other care-

departments most often lacked to work towards a goal or purpose (EM one, 2018; EM three, 2018; Manager two, 2018).

It can be implied that this will not lead towards sustainable results and working situation.

As supported by the results of the questionnaire, sustainability of lean philosophy within this case can be marked

as narrow. 33% percent of the interviewees of this department indicated that the sustainability was on level two, instead

of the 66% who indicated the first level as most appropriate for the organization. Employee one (2018) recognized that

their role as facilitator leaded towards limited viable results and therefore less sustainable results than just the department

level is not be seen.

Leadership As spread by the manager, leadership has a significant role in translating higher-order, abstract goals into

practical achievements (Manager two, 2018). This is supported by the following excerpt: “Personally, I think that we as

organization can learn more to implement the mission, and can more succeed in translations” (Manager two, 2018). The

minority reflects upon the idea that team leaders are of importance in connecting those goals from the top towards the

bottom. The majority mentioned the manager to be in this position, supported by employee one (2018): “The strength of


26

combining forces between top-down and bottom-up is that managers are in the position to view which needs the units

have, and what it requires from the teams and organization itself”. The manager highlighted the contributory role of top

management to be committed towards change, whereby this is supported by: “At the top, commitment needs to be

transparent and this need to be shown in their behavior. Especially since their goals need to be accomplished at lower

levels” (Manager two, 2018). It can be considered that the role of leaders is important in translating, performing upon

transparent communication, and involvement in improvements. It is supported that: “At departments were team

commitment is higher, due to involvement of the manager, the departments are more successful” (EM one, 2018). One

interviewee mentioned the strength of commitment amongst the middle management, whereby is highlighted: “The

sustainability depends on the departments, which indirectly means the managerial level” (EM one, 2018). This is

additional to their role in establishing a network of cross-departmental learning (EM one, 2018). Aforementioned

expressed the necessity of leadership in the sustainability, whereby their role is to continuously focus on the results as

towards their employees.

Overall, the role and behaviors of leaders can be identified as essential to sustain results. For both team leaders

and managers characteristics are mentioned to be example behavior, facilitating cross-departmental learning, encouraging

ownership and translating abstract, higher-order goals into practical achievements.

Cross-departmental learning Cross-departmental learning is being referred to as a connection towards a collaboration in order to organize and

steer towards patient-centered processes (EM one, 2018). Employee three (2018) supported this view: “Nowadays

departments have a transcending stake, when the patient is helped within another department, the responsibility of your

own work in your department does not disappear”. The staff departments facilitated the organization in cross-

departmental information within the information systems, whereby the patient can be followed across departments (EM

one, 2018). This implies that cross-departmental learning is of much importance during the sustainability in order to

improve continuously, and share results to sustain them beyond boundaries of the departments. One interviewee

expressed the low threshold in order to learn cross-departmental: “The value of combining forces can already be

accomplished by asking the manager for the information or contacts needed. If they do not facilitate the information or

network, the board of directors can be approached” (EM one, 2018). Another strength of cross-departmental learning is

the shared problem solving (EM three, 2018). The organization of care departments did not participate in cross-

departmental learning (EM three, 2018). However, after combining departments in audits or reflections, the network was

developed in which they will ask help or share experiences.

Communication Continuous attention towards sending the right message is mentioned as important for the sustainability of

continuous improvements: “The perseverance in evaluations is running back after a while. However, an evaluation

continuously visualize the performance. As the performances decrease, conversations can be held on how to continuously


27

improve those” (EM one, 2018). Employee three (2018) agreed upon the continuous attention, defined as structural

attention. Furthermore, retention is accompanied by attention, expressed by the following excerpt: “While expressing

continuous attention towards the change employees become more aware of the resources and handles available to them”

(EM three, 2018). It was considered by two interviewees that leaders should perform according to this continuous

evaluation. One interviewee referred to retention that will produce sustained results; “Within a team you need to

encourage employees to look at the whole process again, whereby old results and steps will be reviewed in order to

connect this with urgencies at that specific moment in time” (EM one, 2018). Even so, the manager supported this view

by highlighting that within the department the lessons learned need to be reflected, in order to round the circle (Manager

two, 2018). Furthermore, the interviewees highlight the importance of conversations between the top and bottom,

especially since management information does not explain experiences behind generated data (EM one, 2018; EM three,

2018). As employee three (2018) further elaborated: “It is possible to support the data with observations in order to

assess whether it sinks or is still going well”. The organization did not manage to translate messages towards the bottom.

It can be considered that leaders are the ones who need to spread this message towards lower levels. Highlighted in the

following excerpt: “It most often depends on rolling out the message in one line from the board of directors on. However,

the sense of urgency needs to be felt at departmental level as well” (EM one, 2018).

Overall, communication can be identified in Case C as transparent which is communicated by leaders. In

extension, the transparent communication amongst leaders can become sustain by continuous translation, and retention.

Ownership It was mentioned by most interviewees that ownership was created, accomplished through: “What I learned from

previous projects is that walking through the result and steps to take with all employees really makes a difference, you

are able to let them be the owner of the results” (EM three, 2018). Furthermore this employee expressed: “Ownership

need to be acquired through the people who need to put it into practice since they need to see the usefulness and necessity,

but also the added value which it can bring” (EM three, 2018). It can be considered that staff employees recognize the

added value of ownership amongst employees but also in teams (Manager two, 2018). As is highlighted, a team can be

of importance for the final ownership feeling, especially the case when the same profession is more aligned and now

convey an unambiguous message (EM three, 2018). Accordingly, ownership is described as responsibilities and trust

(EM three, 2018; Manager two, 2018). Recognition of the role of leaders in delegating responsibilities and expressing

trust is found (EM one, 2018). As last, the interviewees highlight the necessity of ownership amongst all layers, especially

since the lack of ownership at one layer can lead towards limited results (EM three, 2018).

Overall, the role of ownership in Case C is expressed as essential. Whereby leaders need to encourage ownership

by expressing trust and delegating responsibilities. Also, ownership should be performed at each hierarchical level.


28

Case D

Reflection on implementation One educated Green- and one Black Belt are employee and manager of a staff department. Whereby they mention

that their experience is gathered through being part of the project team and as facilitator of improvement projects. The

employee expressed that the education has been a good basis of using lean as means, however the employee indicated

that in order to sustain the approach of lean they should have consulted aspects of lean for a longer time (EM two, 2018).

Both recognize that by now, the lean program does not contain a long breath approach. Furthermore, employee one

(2018) recognized that the role as facilitator blocked the visibility of the results, since several leadership behaviors are

needed for this. Experiences of sustainable results are limited for the same reason, therefore this unit will present short

representations of findings under the themes. Improvement projects performed went on ad-hoc basis. Furthermore by

being facilitator in improvement projects the influence was limit to enthusiasm others of other teams and departments.

Therefore it can be implied that the sustainability of those projects can be marked as narrow.

Leadership As can be highlighted from leadership amongst improvement projects, the team leader is in a position to block

or support change (EM one, 2018). By the lack of support of the team leader the department required a strong involvement

of the manager in order to let it succeed and sustain. The manager is indicated by the interviewees as sponsor (EM one,

2018; Manager four, 2018). The sponsor needs to be on the level of manager or team leader in order to make the difference

and to acquire acceptance amongst a broader spectrum. As supported by one of the interviewees: “The ones you can’t

miss within an organization are the ones who have the power to let change happen, those are the ones needed to sponsor

change” (Manager four, 2018). As can be reflected from the program, commitment amongst the top has significant

influence on sustained results of improvements. The manager reported that: “When the organization loses its focus on

continuous improvement, the board of directors needs to represent and act upon their original idea and focus on creating

a improvement culture” (Manager four, 2018). Along those projects, team leaders and managers showed different

characteristics. Those team leaders varied from constraining towards actively involved. Characteristics as; visionary,

example behavior and communicating clear and transparent helped them to create commitment for those improvements

(EM two, 2018).

Overall, leadership is identified as crucial in order to sustain results. In turn, this can be implied from the

characteristics which it requires, namely example behavior, transparent communication, and empowering employees by

being inspirational.

Cross-departmental learning Employee two performed cross-departmental improvement projects, whereby after the pilot project the right

approach was found. After successful results on the pilot, other departments became enthusiastic right away (EM two,

2018). It can be considered that successes on one department can lead towards cross-departmental learning. Besides the


29

cross-departmental learning amongst employees, both interviewees highlighted the missed opportunity of the

organization to create a network of lean specialists. Whereby expertise and knowledge gained by those pilot projects can

make it more accessible to achieve sustain results across boundaries of departments or even units (EM two, 2018;

Manager four, 2018).

Communication The sustainability of improvement projects is reviewed with communication as influential factor. Whereby

during the sustainability communication is indicated as continuous attention towards employees, and evaluations of

results. Besides the results, the manager highlighted the importance of reflecting on the project. This view is supported

by the following excerpt: “As member of the steering committee of lean, we led the Black Belt design and write the project

plan in collaboration with us. The project plan is designed to be our red thread during the creation of an improvement

culture“(Manager four, 2018). In order to ensure sustainable results on improvement projects, the organization needed

to embody drawings upon the sustainability. Nevertheless, both manager and employee reflect the sustainability drawings

were not embodied by the organization.

Ownership According to ownership, one interviewee highlighted the importance of employees to ´feel´ the problem. This is

supported by the employee whom highlighted: “You have to go back to the basics in order to let employees face the

problems ahead of them, whereby the penny need to fell in order to understand the necessity” (EM two, 2018). Whereby

both interviewees mentioned that it is important to create a feeling of ownership amongst the team (EM two, 2018;

Manager four, 2018). Team leaders are implied to be the ones whom together with their team feel the problem in order

to make the change happen. As last, the employee mentioned that the team which was result oriented, acquired as team

the most sustainable results (EM two, 2018). Therefore it can be typified in Case D that the team commitment is

contributing towards the ownership.


30

Table three expresses the lessons learned per case. Hereby the input for cross-case analysis will be presented and

a short recap on the findings of the within case will be conferred.

Sustainability factors

Case Leadership Cross-departmental learning Communication Ownership

Case A ● Managerial level in the

position to monitor and

manage improvements.

● Middle management spill

between top and operational

level

● Middle management translate

higher-order abstract goals into

operational improvements

● Top management important in

performing transformational

and continuously support the

improvement approach.

● Middle management able to

create network for cross-

departmental learning.

● Team leaders continuously

involved and monitor lean

performances.

● Share experiences and

knowledge is viewed to be

successful for multiple

departments.

● Low threshold on

exchanging information

towards other departments.

● Team leaders put the

exchange in practice.

Whereby managers facilitate

the cross-departmental

learning.

● Patient-centered process

thinking is encouraged.

Implied to increase quality

and customer-value.

● Transparent communication

expressed as clear

information from the top

towards the bottom of the

organization.

● All layers should work for

same purpose, as continuous

improvement.

● Retention leads towards

sustainable results,

continuously evaluate

results.

● Delegating responsibilities

needed. Organization took too

much care of employees.

● Importance of team

commitment.

● When responsibility is shared

amongst everyone, they wants

and feel necessity to improve

● Role of leaders to delegate

responsibilities, mostly team

leaders.

Case B ● Team leader are important

since they are involved with

those who put it into practice,

and able to stimulate and

motivate individuals as team

itself;

● Leadership at individual level

encouraged empowerment and

more sustained results in

everyday live;

● Top management commitment

required to be continuous;

● Middle management translator

of higher-order, abstract goals

into practical achievements;

● Both top-down and bottom-up

required within line of

hierarchy. Top and middle

management facilitators of

combination top-down and

bottom-up;

● Authentic leadership required

whereby leaders behave upon

the organizational or

departmental goals.

● More processes-thinking

encouraged;

● Cross-departmental learning

encouraged shared-problem

solving.

● Manager should facilitate

network for cross-

departmental learning.

● Leader is in the position to

continuously repeat

information.

● Higher-order, abstract goals

should be transparent for

managers and team leaders

to act upon them.

● Lowest levels important in

context-dependent

translation.

● Conversations between

management and lowest

level necessary to sustain.

Encouraged transparency.

● Ownership defined as thinking

beyond their own work.

● Empowered employees want

to be owners of successes, just

as failures

● Delegating responsibilities

leads towards empowered

employees.

● Leadership should facilitate

ownership by staying focused

and attached to improvement

results, so role of team leaders.

● Role of the team important in

collaboration to sustain results.

Case C ● Middle management as

facilitator and sponsor of

combination of top-down and

bottom-up;

● Sustainability depends upon

managerial level. Suggested to

be supporters of team

commitment.

● Minority indicated team

leaders as most important in

leadership.

● Low threshold in order to

learn cross-departmental.

● Organize and steer patient-

centered processes.

● Encouraged shared

problem-solving.

● Managers are in position to

facilitate network.

● Continuous evaluation of

results needed to sustain.

● Conversations between top

and bottom to get

explanation behind data

gathered from systems,

● Circle needs to be rounded,

so evaluations on lessons

learned and so on.

● Transparent communication

is rolled out from the top to

the bottom, and successful is

departments feel necessity

to change as well.

● Ownership need to be felt at

those who put it into practice.

● Team of importance in

ownership feeling.

● Both individual and team

ownership important.

● Delegating responsibilities and

trust employees important for

ownership feeling.

● Ownership need to be at all

layers in order to sustain.

● Leaders’ role to delegate

responsibilities and expressing

trust.

Case D ● Managers should characterize

example behavior, transparent

communication and be

inspirational.

● Top management in position to

continuously support change

as being inspirational.

● Successes on one

department encouraged

cross-departmental learning.

● Missed opportunity of

organization to create

network of lean specialists.

● Retention is constantly

repeating and getting back

to results.

● Organization need to

embody drawings upon

sustainability.

● Ownership amongst team

important.

● Team leaders in position to

encourage ownership at mostly

team level.

● Result oriented, or mature

teams express more

ownership.

Table 3: Lessons per case on sustainability factors from within cases


31

Cross-case analysis It can be implied that leadership is of much importance within the sustainability of continuous improvement.

Leadership is reviewed by all cases, and the cross-case analysis will introduce leadership characteristics and styles which

must be performed in order to sustain improvements. Besides leadership, also three other factors were marked by all

interviewees as important in order to sustain continuous improvements. Therefore the following paragraphs will present

cross-case findings on leadership, cross-departmental learning, communication and ownership.

Cross-case leadership Findings from the four cases present that different characteristics and approaches of leadership are used at

varying levels within the organization. There exist different views on the most important level of leadership. But

unanimity is expressed about that not one specific hierarchical level can be indicated as most important in order to sustain

continuous improvement. But, the superiority does agree that multiple hierarchical levels should be involved. In

extension, overall interviewees mention multiple leadership styles divided over multiple levels. Even so, the styles need

to be supported by leadership characteristics which fit with the hierarchical level.

Three out of four cases do highlight the exceptional role of middle management in the sustainability of

continuous improvement. The middle management is identified by Case A as most important since their position is

between the top and bottom. This requires them to translate higher-order, abstract goals into practical improvements, but

also should build the network for cross-departmental learning. The aforementioned characteristics are echoed by

interviewees of all other cases. Case C further adds another criterion on the role of middle management, namely

facilitating team commitment whereby they should inspire individuals and teams to be involved in the change. In

extension, Case D does identify example behavior and transparent communication as additional behaviors expressed by

the managers. As can be considered, the role of middle management is most important in the sustainability phase and

should be marked as driver in the change.

Besides managers, the minority supported that leadership should be located at the level of individuals. Supported

by employee four (2018) from case B, empowered individuals are able to sustain results in everyday live. This indicates

that the role of team leaders is important to facilitate the delegation of responsibilities to encounter the level of

empowerment. Case A defines the role of team leaders more as continuous commitment and monitoring improvements,

which will lead to sustained results. The majority does agree that the team leader is in the position to create ownership.

The strong role of individuals and team leaders is supported by some interviewees, but employee four (2018) expressed

why: “Change always need a champion for change, whereby leadership is important to be on the level of this champion.

Therefore I personally prefer to have strong leadership at the workforce which will result in broader responsibility for

process improvements and in order to let it stick within their daily performance”. It can be considered that the role of

team leader is most suitable. However, others indicate middle management to be the sponsor of change: “The ones you

can’t miss within an organization are the ones who have the power to let change happen, those are the ones needed to

sponsor change” (Manager four, 2018). The middle management can be favored for the position of sponsor, implied


32

from aforementioned excerpt and support of multiple interviewees. This view is not implicitly supported by the Case B,

whereby there is a minority which supports the role of team leaders in improvements, but the role of top management is

expressed by the majority as more important in propagating the continuous improvement culture. Amongst Case D the

view on top management is echoed.

Nevertheless, there exist unanimity about the significant role of middle management in the sustainability. Case

A supports more the view of team leaders whereby other cases supports the importance of top management. There exist

more congruence on which behaviors or characteristics should be performed by which level of leadership. This can be

seen in the next figure.

Figure 4: Leadership characteristics at team- and departmental level

Leadership characteristics

at team level

Example behavior

Encourage ownership

Facilitate resources

Coach employees towards

goal accomplishment

Leadership characteristics

at departmental level

Develop network for cross-

departmental learning

Inspire to improve

Translate higher-order,

abstract goals towards

concrete improvements


continuous improvement


33

Characteristics of team leaders are mentioned as; (1) facilitate resources (2) encourage ownership, (3) example behavior,

and (4) coach for goal accomplishment. The following table four represents the descriptions and findings of those

characteristics.

Leadership characteristic Description Reference(s)

Facilitate resources Resources can be indicated by interviewees as tangible or

intangible, whereby space and time is mentioned as intangible.

Tangible resources contain systems where can be worked with

in order to solve a problem. If employees are not in the position

to accomplish their task with the system, within their workday

or whatsoever, the team leader is in the position to provide

those resources needed in order to accomplish tasks and

contribute towards goal achievement.

“Within a highly mature team, my role is different. Namely,

I am responsible for giving them all the information needed,

and that they are connected in this process of information

in order to let them perform their tasks properly” (TL six,

2018).

Encourage ownership Ownership is reviewed as influential factor which should be

facilitated by leaders since it encompasses trust, empowerment

and responsibilities. Encouraging ownership can be done

within several roles, but most often the inspiring or

motivational way towards the delegation of responsibilities

and empowering others to own the problem or project.

“Ownership will only remain with attention and focus on

their responsibilities, when they feel empowered in their

own tasks they will be the owner of successes and failures”

(Manager three, 2018).

Example behavior Example behavior is described as the expression of leaders in

word and deeds that they continuously support the

improvement.

“The example behavior needed in order to change, are most

often expected to be performed by the team leader in order

to strengthen their support” (EM one, 2018).

“Employees reflect upon their team leader” (EM one, 2018)

If leaders are able to propagate the change by expressing

this in their behaviors, after a while employees will be able

to follow as well (Manager three, 2018).

Coach for goal

accomplishment

Where they were coaching employees towards performing the

improvements and whereby they learned new behavioral

routines. As team leader, this position is closest to those who

need to perform the improvements in detail, which means that

this is role is recognized as major important by all interviewees

(EM three, 2018; EM one, 2018; Manager four, 2018).

It can be considered that the role of leaders is important in

translating, performing upon transparent communication,

and involvement in improvements. It is supported that: “At

departments were team commitment is higher, due to

involvement of the manager, the departments are more

successful” (EM one, 2018).

Table 4: Leadership characteristics of team leaders

In comparison with leadership at team level, there are some additional characteristics which fit more managers

at departmental level. Furthermore, the majority mentioned that coaching of employees is less visible amongst manager

in the organization, especially since their span of control is too broad to really coach employees (TL six, 2018; TL seven,

2018; EM four, 2018). Additional characteristics of managers are mentioned as; (1) inspire to improve (2) translate

higher-order, abstract goals towards concrete improvements, and (3) build network for cross-departmental learning.

Elaborated in table five, the leadership characteristics will be mentioned.

Leadership characteristics Description Reference(s)

Inspire to improve The board of directors and managers are expressed to

inspire the rest of the organization about ‘why’ this

change is most appropriate to this organization.

Successes were gained through their continuous

involvement and attention on lean performances

which encouraged employees (TL two, 2018; TL

three, 2018; TL five, 2018).

Translate higher-order, abstract

goals towards concrete

improvements

Role of manager is to translate and communicate

information in order to let the top and workforce be at the

same level within changes (Manager three, 2018).

“It most often depends on rolling out the message in

one line from the board of directors on. However,

the sense of urgency needs to be felt at departmental

level as well” (EM one, 2018).


34

“The organization needs to sense threats and

opportunities and decide which road to take. This

needs to be a translation towards the directors, who

are in the position to determine how it will affect the

care groups. The directors translate those messages

towards managers, and eventually they translate it

in concrete ways what needs to be done on

operational level, in collaboration with team

leaders” (TL three, 2018).

Build network for cross-

departmental learning

Managers should facilitate the cross-departmental

network, whereby team leaders can find others to share

knowledge and all contribute to process-broad thinking

which cross the borders of those departments.

“After accomplishing the change on my own

department, the successes were visible and could

quite easily be facilitated to other departments” (TL

three, 2018).

The role of managers is of significant importance

since this position is both in direct contact with the

top and bottom within this organization. They are

on the position to facilitate in creating a network for

team leaders or employees in order to share

knowledge on improvements across departments

(TL seven, 2018).

Table 5: Leadership characteristics at managerial level

Prescribed leadership styles

Per hierarchical layer differences can exist in which leadership style is most appropriate. Two or more different

leadership styles on various levels are desirable in order to introduce and make the change happen. According to the

sustainability of continuous improvements a distinction can be made between leadership on the level of managers or team

leaders. In the cross-case analysis the following leadership styles came to the front: (1) Lean leadership, (2)

transformational leadership, (3) team leadership, (4) empowering leadership, and (5) situational leadership.

First, lean leadership is expressed among the units to be underdeveloped, and the knowledge on what lean

leadership embodies is not well developed. However, some excerpts do reflect the characteristics of lean leadership.

Stated by team leader six (2018): “The board of directors has a major responsibility in searching for contact with the

lowest layer in order understand each other”. Another excerpt highlighted that the context dependency of the information

is of importance: “In order to implement projects, the workforce needs to be attracted to the project in order to succeed,

since they are the essentials in converting the project towards the context” (Manager three, 2018). This requires a major

investment of time to have that conversation (Manager three, 2018). It can be considered that the manager recognizes the

importance of connecting with the lowest levels in the organization.

Second, transformational leadership. Transformational leadership is characterized by inspiring followers on

improvement projects. Besides, the ongoing character of continuous improvement is identified to be important for the

sustainability of continuous improvement. As can be reflected from the program, commitment amongst the top has

significant influence on sustained results of improvements. The manager reported that: “When the organization loses its

focus on continuous improvement, the board of directors needs to represent and act upon their original idea and focus

on creating an improvement culture” (Manager four, 2018).


35

On the level of team leaders and employees most often the production comes at first, therefore less space and

time is available to change (EM four, 2018). However, the results reveal that this is of importance in order to succeed in

improvements and sustain results. Eight interviewees mentioned the importance of delegating responsibilities and trusting

employees which makes them feel empowered (TL six, 2018). Empowerment amongst employees increases the level of

sustainability of the results. Team leadership and empowering leadership are two leadership styles that are mentioned

by empowering individuals, whereby they contrast in that team leadership also focused on empowerment of team as a

whole. One employee expressed also the contributory role of another leadership style, namely situational leadership.

Recognized as: “Situational leadership depends upon which competencies employees have and in which growth phase

the team is, every position within this company asked for another approach based on their competencies” (EM three,

2018).

Interviewees implied that the team process is of much relevance to acquire the results of improvement projects.

Therefore, the team leadership style can be highlighted as most appropriate by team leaders. As can be considered, lean

leadership should be recognized as most appropriate on managerial level This outpaced transformational leadership, since

lean leadership exclusively focuses on the whole unit beneath managers, instead of just one level.

Cross-case analysis of cross-departmental learning

Along the four units, cross-departmental learning is mentioned by the majority of interviewees. Furthermore,

two out of four cases do reflect upon the shared problem-solving, which encourage departments or teams to collectively

think in solutions on how to solve problems (Case B & C). Besides the shared problem-solving, also the patient-centered

process benefits from cross-departmental learning, supported by all cases. As stated by two team leaders of Case A:

“Patient-centered process which is assured to increase the quality and customer-value” (TL two, 2018; TL three, 2018).

According to the sustainability, half of the cases recognized that successful results amongst pilot projects let other

departments and teams realize the sustainable effect it can has on their work (Case A & D), whereby two other cases

reflect on the low threshold of cross-departmental learning (Case A & C). In accordance, the role of leadership in cross-

departmental learning is marked as managers who facilitate and develop the network of cross-departmental learning. And

team leaders who perform on the resources within the network. This view is supported by all cases.

Cross-case analysis of communication

All cases mention the need for transparent communication. The superiority supports the description of

transparent communication of team leaders of case A, namely: “Transparent communication is indicated by all

interviewees as clear information from the top towards the bottom, all working at several levels for the same purpose,

namely continuous improvement” (TL four, 2018; TL five, 2018). As is indicated by two out of four cases, the continuous

evaluation and reflection on results and performances should be done in order to sustain results. Whereby one is more

indicating to repeat changes in behaviors (Case C), while others convey on management information in order to sustain


36

(Case A & D). Subsequently, continuous evaluation is indicated by all cases to be the best way to sustain results.

However, three out of four cases expressed that only management information is not disclosing all the necessary

information on performances, therefore leaders should gather experiences behind those data. The role of managers is

indicated to hold conversations with employees at the lower levels, supported by Case B and C. Whereby Case B

elaborates that context-dependent translation of problems should be done in combination with the manager to create

congruence amongst the goals at the top and concrete improvements at the bottom. As can be alluded from all cases, the

role of leadership is of significance. Furthermore, it can be considered that transparent communication does lead to

sustained results if retention of results will be done.

Cross-case analysis of ownership

Two out of four cases mention that the organization took too much care of employees. Whereby Case A

recognized that therefore the task maturity can be indicated as low, especially since the lack of responsibilities on

individual or team level is narrow (Case A & D). Delegations of responsibilities is indicated by all cases on the level of

team leaders, whereby only Case B elaborates that this should be in the position of team leaders since they are attached

to the results and focused on the performances. However, three out of four cases do support that team leaders are able to

acquire ownership on team level. Ownership amongst teams is indicated to sustain more results (Case B, C, & D).

This study has investigated the role of leadership within the sustainability of continuous improvement. Results

have shown that additional sustainability factors exist, namely cross-departmental learning, communication and

ownership. The additional factors are proven to be leadership characteristics for sustained results as well. Therefore it

can be concluded that the additional factors can be performed by leaders, which introduces a new theoretical model.

Which expresses the significant role of leadership. Figure four visualizes the new model.

Figure 4: Improved view on influential factors for sustainability of continuous improvement.

Leadership

Cross-departmental

learning

Communication

Ownership


continuous

improvement


37

Chapter 5: Discussion he aim of this paper was to investigate the relationship between leadership and the sustainability of continuous

improvements in a healthcare organization. The sustainability of continuous improvement within the

organization proved itself as limited in scope and therefore minimum of behavioral changes are performed.

Nevertheless, the results gained are most often sustained. As expressed by respective researchers, the sustainability does

depend upon leadership, since a lack of leadership stagnated the sustainability (Henrique, & Filho, 2018; Ruben, Vinodh,

& Asokan, 2017). The research brought to the surface that the role of leadership is of significant importance. Findings

were gathered about which characteristics and styles were identified as most convenient in sustaining results of

improvements. In order to elaborate, the leadership characteristics and styles suggest distinction between departmental-

and team level. The organization should perform multiple leadership styles at the same time, depending on the level of

hierarchy.

Amongst the literature, several leadership styles are combined with a hierarchical layer. Transformational

leadership is identified for top- and middle management. Which is partly supported in the research. On top management

level the style of transformational leadership is supported, especially since their contributory role in the continuous

improvement culture, supported by respective researchers in the literature (Waldman, & Atwater, 1992; Wofford,

Goodwin, & Whittington, 1998; Bass, Waldman, Avolio, & Bebb, 1987). But transformational leadership can also be

invalidated since the knowledge on lean leadership in the organization is narrow. Besides, this research highlights the

significant role of middle management which requires a more comprehensive leadership style, namely lean leadership.

Hereby it extends transformational leadership, by connecting with the operational level in an organization and the

customer focus of processes (Dombrowski, & Mielke, 2014). All encouraged by managers through cross-departmental

learning. Leadership behaviors within the organization do confirm with the requirements of Dombrowski and Mielke on

lean leadership. The view of Bremer, Daniels, Gupta, and McCarty (2005) on transformational and transactional

leadership at top- and middle management is not supported by this research, transformational and lean leadership are

more applicable towards this healthcare organization. Managers are indicated to play a crucial role in sustained results

by encouraging and facilitating; cross-departmental learning, communication, and ownership.

As mentioned that each level of the hierarchy should perform a convenient leadership style, team leaders need

to apply team leadership. However, empowering leadership also encourages empowerment and delegates responsibilities,

the organization proved to be more compelling by team contributions for departmental goal accomplishment (van Rossum

et al., 2016), therefore the team leadership approach is more applicable. Another important characteristics is that team

leadership activates bottom-up behavior (van Rossum et al., 2016). This is also supported within this research. Partial

agreement can be gathered on the view of van Rossum et al. (2016) on the combination of transformational- and team

leadership. This research extends this view with lean leadership as well.

Besides leadership, also three other sustainability factors became apparent. The three factors of cross-

departmental learning, communication and ownership, do partly agree with those factors mentioned in the literature

review, namely top management commitment, staff involvement, information and knowledge sharing, organizational

T


38

culture, communication, and effective leadership (Waring, & Bisschop, 2010; Ben Ruben et al., 2017; Stelson, Hille,

Eseonu, & Doolen, 2017; Rees, 2014; Pocha, 2010). Not all aforementioned success factors are on the same level of this

research, therefore organizational culture cannot be compared with the results found. Top management commitment can

be indicated by the research as part of leadership. Whereby staff involvement is linked on ownership. And information

and knowledge sharing goes well with cross-departmental learning. To dick deeper, respective researchers mentioned the

lack of team improvements as challenge in the sustainability of continuous improvement (Henrique, & Filho, 2018; Ben

Ruben, Vinodh, & Asokan, 2017). This research expressed the significance of team improvements under ownership.

To elaborate, this research has extended new relationships amongst sustainability factors which are all influenced

by leadership, therefore leadership is not a sustainability factor itself, but it contains of multiple behaviors and

characteristics to focus on to encourage sustainability. Besides the organization recognized a bottom-up approach is also

necessary to sustain results, just as a top-down approach. Last, this research supports the view of Waring and Bisschop

(2010) that besides changing the organization, also the leadership style needs to be changed.


39

Chapter 6: Conclusion s can be concluded from this research, there exists no road-map towards a sustainable continuous

improvement yet. Especially within the healthcare, this subject is less investigated. The sustainability of

continuous improvement investigated in the case-organization is indicated as limited, however still some

meaningful results are found. The research question: “How does leadership influence sustainability of continuous

improvement within the healthcare environment?”, revealed that leadership is significant in the sustainability of

continuous improvement. Leadership within the sustainability phase is not a one-best-way approach, but should contain

multiple leadership styles at the same time. Therefore, each level of hierarchy is able to perform another leadership style

to achieve similar results. Results concluded that on departmental level lean leadership is most appropriate. Despite the

limited knowledge on lean leadership within the organization, most employees proved that lean leadership fits the

successes of the sustainability phase on managerial level. Thereby, lean leadership should perform three important

characteristics in order to sustain results. Besides the role to inspire others, also the development of a network for cross-

departmental learning and the transparent translation of higher-order, abstract goals towards concrete achievements is of

major importance. On team level, leaders should perform team leadership. Comprehensive characteristics for team

leadership are example behavior and encouraging ownership.

Middle management can be identified as fundamental to behave on a lean leadership style. According to the

sustainability phase, lean leadership style is more appropriate since the middle management can facilitate the connection

with the top- and operational level. Furthermore, middle management is in the position to perform on cross-departmental

learning, ownership and communication. Aforementioned factors are all influenced or moderated by leadership when it

comes to sustained results.

Managerial implications The research brought to the front some managerial implications. At first, the research organization taught the

researcher to educate all levels of the organization in order to develop a foundation for continuous improvement.

Furthermore, the managerial level should also be educated, but more on leading change and how to behave on the acquired

leadership characteristics to accomplish sustainable results of continuous improvement. In extension, managers should

be taught to behave as lean leader, whereby team leaders should manage along the team leadership style. Another

managerial implications contains the organizational culture. As could be read between the lines, the organization has

cultural problems with trust and delegation of responsibilities. Workshops should be given on role playing, whereby

managers will be in the position of employees, and the other way around. Real life cases should be chosen to act on, and

through collaboration and open conversations individuals, and the team will become open to new behaviors whereby

trust and delegation of responsibilities is normal. Even across departments employees can participate. This brings us to

the last managerial implication, the creation of a learning organization. The learning organization can be established by

improvement projects along departments, but also by bringing together the same professions and let them brainstorm on

how to improve the quality of their care delivery. A convenient network to approach will help employees to learn from

A


40

each other and seek for each other’s help. In order to establish this network, all levels need to have monthly meetings to

talk about a development of the network.

Limitations A number of limitations need to be considered. The most obvious limitation is the scope of the research.

Especially since the investigation embodied four units, including two staff departments. With just a couple employees

per case, the scope of the research can be defined as narrow. Furthermore, the organization seemed to be less developed

in the philosophy as was assumed beforehand. Therefore the results on the sustainability could be less clear evaluated.

Especially since the limited amount of employees educated in lean. Therefore the decision was made to include four units

with multiple educated Green Belts per unit, otherwise by interviewing non-educated employees results should have

shown less valid and comprehensive. Besides the scope of the four units, the scope of departmental and team level can

be referred to as limitation. The chosen levels of hierarchy were more approachable and even so, their role within the

organization was in the documentary on the lean program defined as meaningful, therefore the choice was made to focus

on those levels. Next to that, the experience and skills of the researcher who interviewed all interviewees can be marked

as a limitation. The results gathered could have had a different approach if asked by someone else. Moreover, more

profound findings could be gathered if more probing questions were asked. As last, the triangulation approach was less

used by the researcher before. The researcher experienced some difficulties with the information gathered from the

questionnaire to add in the results.

Future research As can be expressed as limitation, the narrow scope on team and departmental level, could also be seen as an

opportunity for future research. Especially since each level of hierarchy is able to perform another leadership style to

achieve similar results. The organizational and individual level of analysis could be chosen to expand the empirical data

gathered. Next to that, the research has asked a broad spectrum of questions, whereby more focused research on the role

of a particular level of hierarchy, or leadership characteristics or styles could be addressed. Furthermore, the research

focused on one particular organization in the field of healthcare, future research may reveal that the results differ among

other healthcare organization, or another field of interest.


41

References Ackroyd, S. (1996). Organization contra organizations: professions and organizational change in the United

Kingdom. Organization Studies, 17(4), 599-621.

Adler, P.S., Riley, P., Kwon, S.W., Signer, J.K., Lee, B. and Satrasala, R. (2003), “Performance improvement

capability: keys to accelerating performance improvement in hospitals”, California Management Review, Vol. 45 No. 2,

pp. 12-33.

Aij, K. H., Visse, M., & Widdershoven, G. A. (2015). Lean leadership: an ethnographic study. Leadership in

Health Services, 28(2), 119-134.

Amer, H., & Shaw, C. (2014, November). Lean Leadership Paradoxes: A Systematic Literature. In THE 2014

(5TH) INTERNATIONAL CONFERENCE ON ENGINEERING, PROJECT, AND PRODUCTION MANAGEMENT (p.

272).

Assarlind, M., Gremyr, I., & Bäckman, K. (2013). Multi-faceted views on a Lean Six Sigma application.

International Journal of Quality & Reliability Management, 30(4), 387-402.

Assen, M. F. V. (2016). Exploring the impact of higher management’s leadership styles on Lean management.

Total Quality Management & Business Excellence, 1-30.

Augsdorfer, P., & Harding, R. (1995). Changing competitive forces in Europe continuous improvement in a

sample of French, German and British companies. European Business Review, 95(4), 3-9.

Avolio, B. J., Bass, B. M., & Jung, D. I. (1999). Re‐examining the components of transformational and

transactional leadership using the Multifactor Leadership. Journal of occupational and organizational psychology, 72(4),

441-462.

Barnas, K. (2011). Theda Care’s business performance system: sustaining continuous daily improvement

through hospital management in a lean environment. The Joint Commission Journal on Quality and Patient Safety, 37(9),

387-AP8.

Bass, B. M., & Yammarino, F. J. (1991). Congruence of self and others' leadership ratings of naval officers for

understanding successful performance. Applied Psychology, 40(4), 437-454.

Bass, B. M., Waldman, D. A., Avolio, B. J., & Bebb, M. (1987). Transformational leadership and the falling

dominoes effect. Group & Organization Studies, 12(1), 73-87.

Beer, M., & Nohria, N. (2000). Cracking the code of change. HBR’s 10 must reads on change, 78(3), 133-141.

Ben Ruben, R., Vinodh, S., & Asokan, P. (2017). Implementation of Lean Six Sigma framework with

environmental considerations in an Indian automotive component manufacturing firm: a case study. Production Planning

& Control, 28(15), 1193-1211.

Ben-Tovim, D. I., Bassham, J. E., Bolch, D., Martin, M. A., Dougherty, M., & Szwarcbord, M. (2007). Lean

thinking across a hospital: redesigning care at the Flinders Medical Centre. Australian Health Review, 31(1), 10-15.

Berwick, D. M. (1989). Continuous improvement as an ideal in health care.


42

Berwick, D. M., Godfrey, B. A., & Roessner, J. (1991). Curing health care: new strategies for quality

improvement. Journal for Healthcare Quality, 13(5), 65-66.

Bessant, J., Caffyn, S., & Gallagher, M. (2001). An evolutionary model of continuous improvement behaviour.

Technovation, 21(2), 67-77.

Bessant, J., Caffyn, S., Gilbert, J., Harding, R., & Webb, S. (1994). Rediscovering continuous improvement.

Technovation, 14(1), 17-29.

Bhuiyan, N., & Baghel, A. (2005). An overview of continuous improvement: from the past to the present.

Management decision, 43(5), 761-771.

Boonstra, J. (2004). Some reflections and perspectives on organizing, changing, and learning. Dynamics of

organizational change and learning, 447-475.

Bradley, E. H., Curry, L. A., & Devers, K. J. (2007). Qualitative data analysis for health services research:

developing taxonomy, themes, and theory. Health services research, 42(4), 1758-1772.

Bradshaw, P., & Boonstra, J. J. (2004). Power dynamics in organizational change. Dynamics of organizational

change and learning. Wiley, 279-299.

Brandao de Souza, L. (2009). Trends and approaches in lean healthcare. Leadership in health services, 22(2),

121-139.

Bremer, M., Daniels, L., Gupta, P., & McCarty, T. (2005). The Six Sigma Black Belt handbook. New York, NY:

The McGraw-Hill Companies.

Brunet, A. P., & New, S. (2003). Kaizen in Japan: an empirical study. International Journal of Operations &

Production Management, 23(12), 1426-1446.

Burgess, N., & Radnor Z. (2012). Service improvement in the English National Health Service: complexities

and tensions. Journal of Management & Organization, 18(5):594–607.

Burgess, N., & Radnor, Z. (2013). Evaluating Lean in healthcare. International journal of health care quality

assurance, 26(3), 220-235.

Burns, J. M. (1978). Leadership. NY: Harper & Row.

Chicksand, D., Watson, G., Walker, H., Radnor, Z., & Johnston, R. (2012). Theoretical perspectives in

purchasing and supply chain management: an analysis of the literature. Supply Chain Management: An International

Journal, 17(4), 454-472.

Conger, J. A. (1989). Leadership: The art of empowering others. Academy of Management Perspectives, 3(1),

17-24.

Dahlgaard, J. J., Pettersen, J., & Dahlgaard-Park, S. M. (2011). Quality and lean health care: A system for

assessing and improving the health of healthcare organisations. Total Quality Management & Business Excellence, 22(6),

673-689.

D’Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review.

Health policy, 119(9), 1197-1209.


43

Delmatoff, J., & Lazarus, I. R. (2014). The most effective leadership style for the new landscape of healthcare.

Journal of Healthcare Management, 59(4), 245-249.

Dickson, E.W., Anguelov, Z., Vetterick, D., Eller, A. and Singh, S. (2009), “Use of Lean in the emergency

department: a case series of 4 hospitals”, Annals of Emergency Medicine, Vol. 54, pp. 504-510.

Dombrowski, U., & Mielke, T. (2014). Lean leadership–15 rules for a sustainable lean implementation. Procedia

CIRP, 17, 565-570.

Dombrowski, U., & Zahn, T. (2011, December). Design of a lean development framework. In Industrial

engineering and engineering management (IEEM), 2011 IEEE international conference on (pp. 1917-1921). IEEE.

Eisenhardt, K. M. (1989). Building theories from case study research. Academy of management review, 14(4),

532-550.

Flick, U. (2004). Triangulation in qualitative research. A companion to qualitative research, 3, 178-183.

Francis, R. (2010). Independent inquiry into care provided by mid Staffordshire NHS Foundation Trust January

2005 - March 2009 (Vol. 1). The Stationery Office.

Gaucher, E.J., & Coffey, R.J. (1993). Total quality in healthcare: from theory to practice. San Francisco: Jossey-

Bass, pp. 598

Grove, A.L., Meredith, J.O., Macintyre, M., Angelis, J. and Neailey, K. (2010), “UK health visiting: challenges

faced during Lean implementation”, Leadership in Health Services, Vol. 23 No. 3, pp. 204-218.

Harrison, S., & Pollitt, C. (1995). Controlling Health Professionals. Buckingham: Open University Press.

Heilpern, J., & Nadler, D. (1992). Implementing Total Quality Management: A Process of Cultural Change. In

Organizational Architecture.

Henrique, D. B., & Filho, M. G. (2018). A systematic literature review of empirical research in Lean and Six

Sigma in healthcare, Total Quality Management & Business Excellence, DOI: 10.1080/14783363.2018.1429259

Holden, R.J. (2011). Lean thinking in emergency departments: a critical review. Annals of Emergency Medicine,

57(3):265–78.

Holmemo, M. D. Q., & Ingvaldsen, J. A. (2016). Bypassing the dinosaurs?–How middle managers become the

missing link in lean implementation. Total Quality Management & Business Excellence, 27(11-12), 1332-1345.

Holtskog, H. (2013). Continuous Improvement beyond the Lean understanding. Procedia CIRP, 7, 575-579.

Huberman, A. M., & Miles, M. B. (1994). Data management and analysis methods.

Jick, T. D. (1979). Mixing qualitative and quantitative methods: Triangulation in action. Administrative science

quarterly, 24(4), 602-611.

Jimmerson, C., Weber, D. and Sobek, D.K. (2005), “Reducing waste and errors: piloting lean principles at

intermountain healthcare”, The Joint Commission of Journal on Quality and Patient Safety, Vol. 31 No. 5, pp. 249-257.

Kakkuri-Knuuttila, M. L., Lukka, K., & Kuorikoski, J. (2008). Straddling between paradigms: A naturalistic

philosophical case study on interpretive research in management accounting. Accounting, Organizations and Society,

33(2-3), 267-291.


44

Keiser, A. (1997) Rhetoric and myth in management fashion. Organization, 4(1), 49–74.

Keogh, B. (2013). Review into the quality of care and treatment provided by 14 hospital trusts in England:

overview report. 2013.

King, D. L., Ben‐Tovim, D. I., & Bassham, J. (2006). Redesigning emergency department patient flows:

application of lean thinking to health care. Emergency Medicine Australasia, 18(4), 391-397.

Laffel, G., & Blumenthal, D. (1989). The case for using industrial quality management science in health care

organizations. Jama, 262(20), 2869-2873.

Laureani, A., & Antony, J. (2018). Leadership–a critical success factor for the effective implementation of Lean

Six Sigma. Total Quality Management & Business Excellence, 29(5-6), 502-523.

Mann, D. (2009). The missing link: Lean leadership. Frontiers of Health Services Management, 26(1), 15–26.

Mann, M. (2012). The sources of social power: Volume 3, global empires and revolution, 1890-1945 (Vol. 3).

Cambridge University Press.

McLaughlin, C. P., & Kaluzny, A. D. (1990). Total quality management in health: making it work. Health Care

Management Review, 15(3), 7-14.

Mathison, S. (1988). Why triangulate?. Educational researcher, 17(2), 13-17.

Miles, M. B., Huberman, A. M., Huberman, M. A., & Huberman, M. (1994). Qualitative data analysis: An

expanded sourcebook. Sage.

Niemeijer, G. C., Trip, A., De Jong, L.J., Wendt, K.W., & Does, R. J. M. M. (2012). Impact of 5 years of Lean

Six Sigma in a University Medical Center. Quality Management in Health Care 21(4):262–8.

Osborne, S. P., Radnor, Z., & Nasi, G. (2013). A new theory for public service management? Toward a (public)

service-dominant approach. The American Review of Public Administration, 43(2), 135-158.

Pearce, C. L., & Sims Jr, H. P. (2002). Vertical versus shared leadership as predictors of the effectiveness of

change management teams: An examination of aversive, directive, transactional, transformational, and empowering

leader behaviors. Group dynamics: Theory, research, and practice, 6(2), 172.

Pettersen, J. (2009). Defining lean production: some conceptual and practical issues. The TQM journal, 21(2),

127-142.

Pocha, C. (2010). Lean Six Sigma in healthcare and the challenge of implementation of Six Sigma methodologies

at a Veterans Affairs Medical Center. Quality Management in Healthcare, 19(4), 312-318.

Poksinska, B. (2010). The current state of Lean implementation in healthcare: literature review. Quality

Management in Health Care, 19(4):319–29.

Radnor, Z. J., Holweg, M., & Waring, J. (2012). Lean in healthcare: the unfilled promise?. Social science &

medicine, 74(3), 364-371.

Rees, G. H. (2014). Organisational readiness and Lean Thinking implementation: Findings from three

emergency department case studies in New Zealand. Health services management research, 27(1-2), 1-9.


45

Simon, R. W., & Canacari, E. G. (2012). A practical guide to applying lean tools and management principles to

health care improvement projects. AORN journal, 95(1), 85-103.

Singh, J., & Singh, H. (2015). "Continuous improvement philosophy – literature review and directions",

Benchmarking: An International Journal, Vol. 22 Issue: 1, pp.75-119, https://

doi.org/10.1108/BIJ-06-2012-0038.

Shortell, S. M., O'Brien, J. L., Hughes, E. F., Carman, J. M., Foster, R. W., Boerstler, H., & O'Connor, E. J.

(1994). Assessing the progress of TQM in US hospitals: findings from two studies. The Quality letter for healthcare

leaders, 6(3), 14-17.

Snee, R. D. (2010). Lean Six Sigma–getting better all the time. International Journal of Lean Six Sigma, 1(1),

9-29.

Stelson, P., Hille, J., Eseonu, C., & Doolen, T. (2017). "What drives continuous improvement project success in

healthcare?", International Journal of Health Care Quality Assurance, Vol. 30 Issue: 1, pp.43-57,

https://doi.org/10.1108/IJHCQA-03-2016-0035

Stentoft Arlbjørn, J., Vagn Freytag, P., & de Haas, H. (2011). Service supply chain management: A survey of

lean application in the municipal sector. International Journal of Physical Distribution & Logistics Management, 41(3),

277-295.

Thomas, A., Barton, R., & Chuke-Okafor, C. (2008). Applying lean six sigma in a small engineering company–

a model for change. Journal of Manufacturing Technology Management, 20(1), 113-129.

Van Rossum, L., Aij, K. H., Simons, F. E., van der Eng, N., & ten Have, W. D. (2016). Lean healthcare from a

change management perspective: The role of leadership and workforce flexibility in an operating theatre. Journal of

health organization and management, 30(3), 475-493.

Van Aken, J. E., Berends, J. J., & van der Bij, J. D. (2012). Problem solving in organizations: A methodological

handbook for business and management students. Cambridge University Press.

Visser, J. J. (2014). Lean in the warehouse: Measuring lean maturity and performance

within a warehouse environment. Rotterdam School of Management. Erasmus

University Rotterdam.

Waldman, D.A., & Atwater, L.E. (1992). The nature of effective leadership and championing processes at

different levels in an R&D hierarchy. Journal of High Technology Management Research, 5, pp. 233-245.

Waring, J. J., & Bishop, S. (2010). Lean healthcare: rhetoric, ritual and resistance. Social science & medicine,

71(7), 1332-1340.

Waring, J., & Currie, G. (2009). Managing expert knowledge: organizational challenges and managerial futures

for the UK medical profession. Organization Studies, 30(7), 755-778.

Wikström, E., & Dellve, L. (2009). Contemporary leadership in healthcare organizations: fragmented or

concurrent leadership. Journal of health organization and management, 23(4), 411-428.


46

Wofford, J. C., Goodwin, V. L., & Whittington, J. L. (1998). A field study of a cognitive approach to

understanding transformational and transactional leadership. The Leadership Quarterly, 9(1), 55-84.

Womack, J. P., & Jones, D. T. (1996). Beyond Toyota: how to root out waste and pursue perfection. Harvard

business review, 74(5), 140-158.

Womack, J. P., Womack, J. P., Jones, D. T., & Roos, D. (1990). Machine that changed the world. Simon and

Schuster.

Young, T., Brailsford, S., Connell, C., Davies, R., Harper, P. and Klein, J.H. (2004), “Using industrial processes

to improve patient care”, British Medical Journal, Vol. 328 No. 7432, pp. 162-164.

Yin, R. K. (1989). Case study research: Design and methods, revised edition. Applied Social Research Methods

Series, 5.


47

Appendices

Appendix one: Questionnaire manager


48


49


50

Appendix two: Questionnaire team leader


51


52


53


54

Appendix three: Questionnaire employee


55


56


57


58


59

Appendix four: Interview guide old Within this appendix, the interview guide before revision will be presented.

Allereerst bedankt voor het meewerken aan mijn afstudeeronderzoek. Als master studente Change Management aan de Rijksuniversiteit

Groningen verzamel ik data binnen Lentis om mijn afstudeeronderzoek naar het behoud van een Lean aanpak te kunnen voltooien. Het doel

van het interview is om factoren naar voren te krijgen welke bijdrage aan het behoud (ofwel de sustainability) van een Lean aanpak. Daarnaast

kijk ik hoe leiderschap op verschillende niveaus binnen de organisatie invloed heeft op en bijdraagt aan het behoud van Lean.

De informatie die uit het interview komt wordt uitsluitend voor het onderzoek gebruikt en wordt vertrouwelijk behandeld. Gedurende het

interview heb je uiteraard de gelegenheid om terug te keren naar eerdere vragen en tevens kent dit interview geen goede of foute antwoorden.

Voordat wij het interview beginnen wil ik je goedkeuring vragen voor het gebruik van de inhoud van dit interview op en of je akkoord bent

met dat het interview wordt opgenomen. Hierbij het informed consent om te tekenen, om dit te bevestigen.

Allereerst zal ik enkele algemene vragen stellen over de organisatie en welke verbeterprojecten je betrokken bent of bent geweest. Daarna

zullen er vragen volgen met betrekking tot het behoud van verbeterprojecten op organisatie en afdelingsniveau. Gevolgd door vragen met

betrekking tot de interactie met je leidinggevende of je eigen rol als leidinggevende in verbeterprojecten. Tot slot zullen er vragen worden

gesteld over de rol van leidinggevende in het behoud van verbeterprojecten.

Is er voordat wij beginnen met het interview nog iets wat jij wilt vragen?

Algemeen

Allereerst zal ik een paar vragen stellen met betrekking tot jouw eigen functie, ervaring met verbeterprojecten en het doel van de

verbeterprojecten binnen de organisatie.

1. Hoelang bent u werkzaam bij de organisatie?

2. Welke functies heeft u binnen de organisatie gehad?

3. Heeft u formele training(en) gehad op het gebied van verbeteren?

4. Hoe bent u in aanraking gekomen met het SLIM programma?

5. Hoeveel ervaring heeft u met verbeterprojecten?

6. Welke rol vervult u voornamelijk in verbeterprojecten?

7. Hoe zou u het gebruik van het SLIM programma omschrijven binnen de organisatie?

8. Hoe zou u zelf kwaliteit in de zorg omschrijven?

9. Welke kwaliteitsaspecten probeert de organisatie met het SLIM programma aan te stippen?

10. In welk opzicht voegt het gebruik van het SLIM programma toe aan deze kwaliteit van de zorg?

11. Hoe heeft u de verbeterproject(en) ervaren?

12. Welke factoren hebben ervoor gezorgd dat u graag een verbeterproject en Green Belt opleiding wilde volgen?

Behoud van de Lean aanpak

De volgende vragen gaan over hoe verbeterprojecten zijn geïmplementeerd, hoe ervoor gezorgd wordt dat deze resultaten behouden blijven

en hoe de organisatie continue verbeterprojecten blijft invoeren.

1. Hoe zou u een succesvol verbetertraject omschrijven?

2. Kunt u iets vertellen over de implementatie van een verbetertraject

a. En in hoeverre is deze succesvol geweest voor de afdeling of organisatie?

3. Kunt u beschrijven hoe de organisatie de resultaten van verbetertrajecten probeert vast te houden over de lange termijn?

a. In hoeverre beschouwt u dit succesvol?

4. Wat zijn volgens u de belangrijkste factoren die invloed hebben op het succes van een verbeterproject?

a. Waarom denkt u?

b. Zit hier verschil in op team en/of afdelingsniveau?

5. Wat zijn volgens u de belangrijke factoren die ervoor zorgen dat een traject langer wordt behouden?

a. Hoe zit dit met de succesvolheid van een traject?

b. Kun je hier een voorbeeld van geven?

6. Naast dat voorgaande vragen voornamelijk over team- en afdelingsniveau gingen, heb ik nu een vraag met betrekking tot de gehele

organisatie. Welke factoren dragen bij aan het behoud van de Lean aanpak binnen de gehele organisatie?

7. In hoeverre zijn voorgenoemde factoren aanwezig?


60

De rol van de leidinggevende

1. Hoe zou u de betrokkenheid van uw leidinggevende(n) bij SLIM/verbeterprojecten omschrijven?

2. Naar jouw mening, wat doet uw leidinggevende zodat hij/zij zorgt voor een bijdrage aan het implementeren van verbeterprojecten?

3. Kunt u beschrijven hoe de leidinggevende om gaat met het behoud van Lean/verbeterprojecten op de afdeling?

4. Op welke manier zorgt hij/zij voor blijvende betrokkenheid onder medewerkers? Hoe gaat dit in zijn werk?

5. Welke manier van communiceren typeert uw leidinggevende?

6. Op basis van een streven naar succesvolle uitkomsten van verbetertrajecten, wat doet uw leidinggevende extra om hieraan bij te

dragen?

7. In hoeverre heeft uw leidinggevende zicht op dingen welke beter kunnen/dienen te worden?

8. In hoeverre is de leidinggevende in staat om een ‘cultuur’ te creëren waarin binnen het team of de afdeling veranderingen

zelfstandig tot stand komen?

9. Kunt u beschrijven hoe uw leidinggevende de patiënt centraal zet in de manier waarop jullie werken?

10. In welke mate werkt uw leidinggevende op basis van top-down en bottom-up communicatie en verbeterinitiatieven binnen de

verbeterorganisatie?

Bijdrage van een leidinggevende in het behoud van Lean aanpak

Op basis van voorgaande vragen met betrekking tot het behoud van de verbeteraanpak en succesvolle verbeterprojecten, hebben we ook de

leidinggevende eigenschappen besproken. In dit onderdeel wil ik graag door enkele vragen heen met betrekking tot hoe deze

leiderschapsaspecten eventueel kunnen bijdragen aan het behoud van een verbeteraanpak.

1. Kunt u beschrijven hoe resultaten van verbeterprojecten nog steeds merkbaar en/of succesvol zijn binnen de organisatie?

2. Welke bijdrage levert de leidinggevende hierin?

3. Naar jouw mening, op welk niveau binnen de organisatie is leiderschap gedurende verbeterprojecten het meest nodig denk je? En

waarom?

4. Kunt u beschrijven op welke manier de leidinggevende een cultuur binnen de organisatie heeft gecreëerd waarin continu verbeteren

een speerpunt is?

5. Indien leidinggevende: Welk belang geeft u uw eigen rol in het behouden van de Lean aanpak?

6. Wat doen medewerkers/collega’s om te zorgen dat aanpak behouden wordt? Indien leidinggevende: Welke gedragingen zouden

medewerkers naar uw idee moeten laten zien om bij te dragen aan het behoud van de verbeteraanpak? En hoe kan dit worden

gefaciliteerd door een leidinggevende?

7. Wat zijn naar uw mening de belangrijkste eigenschappen welke een leidinggevende moet hebben om het behoud van

verbeterprojecten binnen de organisatie te waarborgen?

8. Welke kennis omtrent succesvolle resultaten van verbeterprojecten zou je willen delen binnen de organisatie?

Tot slot..

Wil je nog iets toevoegen aan de gestelde vragen? Is er een onderwerp niet aan bod gekomen waar u toch wat over wilt vertellen of welke

relevant kan zijn? Heeft u verder iemand die ik volgens u zou moeten spreken? Graag zou ik u de transcript toesturen op volledigheid, is

dat akkoord? Is er verder nog informatie welke u wilt delen?


61

Appendix five: Interview guide new Within this appendix, the interview guide after revision is presented based on question in the categories of sustainability

of continuous improvement, leadership’s influential role and the role of leadership within the sustainability of continuous

improvement.

Allereerst bedankt voor het meewerken aan mijn afstudeeronderzoek. Als master studente Change Management aan de Rijksuniversiteit

Groningen verzamel ik data binnen Lentis om mijn afstudeeronderzoek naar het behoud van een Lean aanpak te kunnen voltooien. Het doel

van het interview is om factoren naar voren te krijgen welke bijdrage aan het behoud (ofwel de sustainability) van een Lean aanpak. Daarnaast

kijk ik hoe leiderschap op verschillende niveaus binnen de organisatie invloed heeft op en bijdraagt aan het behoud van Lean.

De informatie die uit het interview komt wordt uitsluitend voor het onderzoek gebruikt en wordt vertrouwelijk behandeld. Gedurende het

interview heb je uiteraard de gelegenheid om terug te keren naar eerdere vragen en tevens kent dit interview geen goede of foute antwoorden.

Voordat wij het interview beginnen wil ik je goedkeuring vragen voor het gebruik van de inhoud van dit interview op en of je akkoord bent

met dat het interview wordt opgenomen. Hierbij het informed consent om te tekenen, om dit te bevestigen.

Allereerst zal ik enkele algemene vragen stellen over de organisatie en welke verbeterprojecten je betrokken bent of bent geweest. Daarna

zullen er vragen volgen met betrekking tot het behoud van verbeterprojecten op organisatie en afdelingsniveau. Gevolgd door vragen met

betrekking tot de interactie met je leidinggevende of je eigen rol als leidinggevende in verbeterprojecten. Tot slot zullen er vragen worden

gesteld over de rol van leidinggevende in het behoud van verbeterprojecten.

Is er voordat wij beginnen met het interview nog iets wat jij wilt vragen?

Algemeen

Allereerst zal ik een paar vragen stellen met betrekking tot jouw eigen functie, ervaring met verbeterprojecten en het doel van de

verbeterprojecten binnen de organisatie.

1. Hoelang bent u werkzaam bij de organisatie?

2. Welke functies heeft u binnen de organisatie gehad?

3. Heeft u formele training(en) gehad op het gebied van verbeteren?

4. Hoe bent u in aanraking gekomen met het SLIM programma?

5. Hoe zou u het gebruik van het SLIM programma omschrijven binnen de organisatie?

6. Hoe zou u zelf kwaliteit in de zorg omschrijven?

7. In welk opzicht voegt het gebruik van het SLIM programma toe aan deze kwaliteit van de zorg?

8. Hoe heeft u de verbeterproject(en) ervaren?

Behoud van de Lean aanpak

De volgende vragen gaan over hoe verbeterprojecten zijn geïmplementeerd, hoe ervoor gezorgd wordt dat deze resultaten behouden blijven

en hoe de organisatie continue verbeterprojecten blijft invoeren.

1. Kunt u iets vertellen over de implementatie van een verbetertraject

a. En in hoeverre is deze succesvol geweest voor de afdeling of organisatie? En waarom?

2. Kunt u beschrijven hoe de organisatie de resultaten van verbetertrajecten probeert vast te houden over de lange termijn?

a. In hoeverre beschouwt u dit succesvol?

3. Wat zijn volgens u de belangrijke factoren die ervoor zorgen dat een traject langer wordt behouden?

a. Hoe zit dit met de succesvolheid van een traject?

b. Kun je hier een voorbeeld van geven?

4. Welke factoren dragen bij aan het behoud van de Lean aanpak binnen de gehele organisatie? En in hoeverre zijn voorgenoemde

factoren aanwezig?

De rol van de leidinggevende

1. Hoe zou u de betrokkenheid van uw leidinggevende(n) bij SLIM/verbeterprojecten omschrijven?

2. Naar jouw mening, wat doet uw leidinggevende zodat hij/zij zorgt voor een bijdrage aan het implementeren van verbeterprojecten?

3. Kunt u beschrijven hoe de leidinggevende om gaat met het behoud van Lean/verbeterprojecten op de afdeling?

4. In hoeverre heeft uw leidinggevende zicht op dingen welke beter kunnen/dienen te worden?

5. In hoeverre is de leidinggevende in staat om een ‘cultuur’ te creëren waarin binnen het team of de afdeling veranderingen

zelfstandig tot stand komen?

6. Kunt u beschrijven hoe uw leidinggevende de patiënt centraal zet in de manier waarop jullie werken?

7. In welke mate werkt uw leidinggevende op basis van top-down en bottom-up communicatie en verbeterinitiatieven binnen de

verbeterorganisatie?


62

Bijdrage van een leidinggevende in het behoud van Lean aanpak

Op basis van voorgaande vragen met betrekking tot het behoud van de verbeteraanpak en succesvolle verbeterprojecten, hebben we ook de

leidinggevende eigenschappen besproken. In dit onderdeel wil ik graag door enkele vragen heen met betrekking tot hoe deze

leiderschapsaspecten eventueel kunnen bijdragen aan het behoud van een verbeteraanpak.

1. Kunt u beschrijven hoe resultaten van verbeterprojecten nog steeds merkbaar en/of succesvol zijn binnen de organisatie?

2. Naar jouw mening, op welk niveau binnen de organisatie is leiderschap gedurende verbeterprojecten het meest nodig denk je? En

waarom?

3. Wat zijn naar uw mening de belangrijkste eigenschappen welke een leidinggevende moet hebben om het behoud van

verbeterprojecten binnen de organisatie te waarborgen?

4. Welke kennis omtrent succesvolle resultaten van verbeterprojecten zou je willen delen binnen de organisatie?

Tot slot..

Wil je nog iets toevoegen aan de gestelde vragen? Is er een onderwerp niet aan bod gekomen waar u toch wat over wilt vertellen of welke

relevant kan zijn? Heeft u verder iemand die ik volgens u zou moeten spreken? Graag zou ik u de transcript toesturen op volledigheid, is

dat akkoord? Is er verder nog informatie welke u wilt delen?


63

Appendix six: Results questionnaire all three professions

Manager


64

\


65


66


67


68


69

Team leader


70


71


72


73


74


75


76

Employees


77


78


79


80


81

Appendix seven: Codebook

Quality in Healthcare

Code Description Example one Example two Example three

Quality - in

healthcare

environment

Q/HCE

Quality can be

indicated as patient-

centralized processes

whereby in

collaboration the best

care will be

delivered.

Team leader five: “That

everybody works

according to general

guidelines but also has

attention for the client.

Furthermore, the

organization needs to keep

its worth. More a mutual

relationship”.

Employee two: “The quality of care

is for example that professionals

listen to the patient, probe about

complications of the patient, and is

able to diagnose a clear diagnosis.

Which in extends, can easily be

communicated with the patient, and

from which they work together on a

plan to deliver care”.

Employee two: I think

quality can be described as

that what you deliver to

your patient which is in

congruence with their

desires. And this within the

amount of money, time and

with resources as required.

Lean and Continuous Improvement

Code Description Example one Example two

Green Belt

G/B

Persons who is able to work

methodological and

statistically in order to

improve within an

organization.

Manager four: “If we look at the perfect

picture, the green belt need to have

some capabilities. These capabilities are

analytical skills, someone who can

distinguish main issues from side issues.

Furthermore the person needs to have

feeling to improve. Being social and

able to encourage others may also be

important”.

Employee one: “Employees are

educated to make use of lean

methods and resources from the

lean philosophy”.

Green Belt education

GB/E

Education in

methodological and

statistical learning to

understand results and to

perform techniques to

improve.

Team leader five: “I thought this

education would help me to perform

better on improvement projects. It gave

me more structure, whereby

improvement projects really became

apparent. My personal experience is this

pragmatic but strategic education. It

gave me some new insides”.

Employee one: “We worked a lot

with numbers and statistics to

understand the background of all

the numbers and information we

were gathering. We less practiced

in with practical tools”.

Lean in organization.

L/IO

Degree to which people are

trained and skilled to use the

Lean tools and mindset

within everyday tasks to

reduce waste and create

adding value for customers.

Manager four: “lean will not be

implemented as reduction method. The

focus needs to be on the outcome, than

the quality will follow. Just as the lower

costs. Lean means going for quality, and

eventually will result in cost reduction”.

Team leader five: “Lean focuses on

eliminating waste and finding the

added value for the customer”.

Purpose Lean -

implementation in

organization

PL/IO

The organization wants to

create a more process-

oriented view when thinking

about improvements.

Manager four: “Improving itself, but

also more processes thinking was nice

to organize. [...] Next to process-

thinking, I hoped we could have a

dialogue about what's next together in

the organization”.

Employee one: “The real lean

thinking approaches improvements

from the customer. Therefore this

organization needs to learn to think

more about the whole processes.


82

Sustainability of Lean and CI

Code Description Example one Example two Example three

Sustainability of

Lean

SUST/LEAN

Lean is typified in the

organization as method to

generate a process-oriented

thinking. Whereby the

patient will contribute from

this cross-departmental

approach.

Employee one: “It is successful

if you can come back to what

you´ve done as team, and are

able to hold those

improvements. [...]

Furthermore, success is visible

when the team gets

understanding of the results,

improvements, and financial

situation”.

Team leader five: “Quick,

simple and efficient working.

That's when the specials gets

space to perform its profession,

and has less to do with

administrative processes”.

Sustainability

factor - Open

culture

SUSF/OPENCUL

The organizational culture

is identified as less open,

whereby improvements can

be identified in trust, and

honest communication.

Team leader five: “We need an

open culture where men dares

to and is able to address

problems. Furthermore they

need to accept and help each

other”.

Manager three: “Our culture

can be more pronounced and to

be able to say more clearly what

we think of our values and

norms. I think we should also

speak to each other more

professionally. So not

reproachful but professional

why we did it so well and why

do some things happen. That

means you also create a culture

where you can get rid of the

sound”.

Sustainability

factor - Top

management

commitment

SUSF/TMC

The success of

organizations and the

sustainability of results does

depend on top management.

The top management should

continuously stay

committed to the change by

paying attention.

Manager three: “At the top,

clear commitment has to be

apparent and their commitment

needs to be visible in their

behaviors and expresses”.

Manager three: “It has to start at

the top, whereby they believe in

the method needs to be clear.

Someone needs to be waked in

the middle of the night and

answer ´how to improve?´ with

lean since it is most suitable.

Consistently propagating lean”.

Team leader two: “The

necessity of continuous

top management

commitment is needed in

order to express to lower

levels support and

attention towards their

performance

improvements”.

Sustainability

factor: Leadership

SUSF/LS

Sustainability depends upon

leadership whereby it is

about who is expressing

which desires and will

manage the stakes of

multiple stakeholders.

Team leader six: “But you are

not able to change by yourself,

you need support from other

supervisors and even the board

of directors”.

Team leader five: “The role of

leaders is to manage the

improvement. Furthermore,

facilitating is of importance as

well in order to perform”.

Sustainability

factor - Leadership

at top level

SUSF/LST

All level in the organization

require a different approach

in the sustainability. The

top management is

designing the vision and

need to express committed

towards their own initiative

continuously.

Team leader three: “The

organization needs to sense

threats and opportunities and

decide which road to take. This

needs to get a translation

towards the directors, who are

in the position to define how it

will affect the care groups.

Those directors translate those

messages towards managers,

and eventually they translate on

concrete ways what needs to be

Manager four: “When the

organization loses its focus on

continuous improvement, the

board of directors needs to

represent and act upon their

original idea and focus on

creating an improvement

culture”


83

done on operational level, in

collaboration with team

leaders”

Sustainability

factor - Leadership

at management

level

SUSF/LSM




middle management is most

often translating higher-

order, abstract towards

concrete achievements.

Employee two: “The

sustainability depends upon the

departments, which indirectly

means the managerial level”.

Manager three: The manager

identified his role as translator

of abstract, higher-order goals

into practical context dependent

achievements.

Sustainability

factor - Leadership

at team leader level

SUSF/LSTL




team leaders are closest to

the lowest level and more

able to show example

behavior and coach them.

Employee four: The role of the

team leader is characterized as

those who are involved within

the operations and able to

stimulate and motivate both

individuals and teams.

Team leader two: On the level

of team leaders, successes were

gained through their continuous

involvement and attention on

lean performances which

encouraged employees.

Employee one: Some team

leaders started the

conversation and

expressed the right

behavior on how to

improve.

Sustainability

factor - Leadership

at individual level

SUSF/LSI



in the sustainability.

Individuals are also able to

perform as leaders whereby

they are empowered in

decision making.

Employee four: “When

leadership is performed at the

lowest level, those employees

become empowered for process

improvements. Thereby it will

become more sustained within

everyday work and

performances”.

Sustainability

factor: Ownership

SUSF/OS

It can be defined as the

ability to think beyond their

own work.

Team leader one: “For leaders

to facilitate ownership, it is

important to stay focused and

attached to the results,

especially since the

sustainability phase acquires

roles and responsibilities to be

clear to let the new routines

stick”.

Manager three: “Ownership will

only remain with attention and

focus on their responsibilities,

when they feel empowered over

their own tasks they will be the

owner of successes, just as

failed outcomes”.

Team leader six: Task

maturity of the team is of

importance. When the

team has lots of

ownership, those

employees can be trusted

to give them space in

which they are able to

perform their tasks. [...]

Mostly information is

needed to supervise them

on daily basis.

Sustainability

factor: Role of

middle

management

SUSF/RMM

Most special role is

subscribed to the middle

management since they are

both in close contact with

top and bottom. And are

able to create multiple

networks for the rest.

Team leader four: “This is

supported since middle

management is in the position

to translate abstract higher-

order goals into practical

implications”.

Team leader five: I think that

especially the third echelon is

the most important link in terms

of changes. And it also has

surpassing qualities and it can

also do more. [...] The third

echelon is also less involved

with the teams, so it can also

look over the care groups, and if

there are changes they could

play a more important role there

than team leaders.

Team leader three: “The

management level is less

coping with the teams, and

more able to look across

the departments.

According to change,

those leaders play a more

important role than team

leaders”.

Sustainability

factor: Retention

SUSF/RET

In order to sustain, the

leaders need to repeat the

outcomes of the

improvements and need to

Team leader six: What I think is

important is that you are

constantly have results of

improvements on the agenda

Manager three: What we often

not do is keep picking up.

Rounding the circle.. It sounds

very easy to round the circle,

Employee two: I always

have the idea that you

have to repeat it regularly.

Show them the numbers,


84

keep track on them. and that you do not let yourself

run pass the acquired results.

but we must continuously

monitor this very consistently.

and confront them with it:

´we are low in this score

and this figure. Red

numbers are signaled

again, how is this

possible? Also try to

involve people who are

involved personally.

Sustainability

factor: Cross-

departmental

learning

SUSF/CDC

The organization can

increase their performance

and be more sustainable in

lean when they generate

shared-problem solving,

process-thinking and cross-

communication.

Team leader two: “From cross-

departmental learning my team

learned to work more closely

together, which improved the

performance”.

Manager three: “Personally, I

prefer to look at the whole

chain instead of only small

pieces of the process”.

Employee one: “Another

strength of cross-

departmental learning is

the shared problem

solving.

The staff departments

facilitated the organization

in cross-departmental

information within the

systems, whereby the

patient can be followed

across departments”.

Sustainability

factor - Team

commitment

SUSF/TM

Not only as individual their

task performance is

important, but most on team

level. Broader scope creates

more commitment and

better results.

Employee one: “At departments

were team commitment is

higher, due to involvement of

the manager, the departments

are more successful”

Team leader six: “An

improvement project can be

marked as successful when the

results are achieved in team

collaboration. Due to the fact

that the problem was carried on

team level”.

Team leader five: “The

team is of great

importance within

executing improvement

projects, since they are the

ones whom have to feel

the problem in order to

express willingness to

improve”. “When

everyone is responsible for

the whole, everyone wants

and feels the necessity to

improve”.

Leadership in Lean

Code Description Example one Example two

Leadership

characteristic -

Example behavior

LC/EXAMBH

Individuals mostly perform as

their supervisor asks them,

another element is their

behavior which they copy from

the supervisor.

Team leader four: The visible behavior

is mainly about a team leader who fully

supports it. He will handle the

conversation himself, explain why and

clearly convey a vision. But also

participates and gives example

behavior. These employees reflect on

the behavior of the team leader.

Manager three: “When you express

to give them more responsibilities,

this should be revealed from their

behaviors, just as being facilitated”.

Leadership

characteristic -

Employees need to be inspired

to be committed. They need to

Employee two: The second team leader

already had a vision and just did it and

Team leader two: Successes were

gained through their continuous


85

Spreading vision feel the sense of urgency. went along with it and got it done

quickly.

involvement and attention on lean

performances which encouraged

employees.

Leadership

characteristic -

Open

communication

The organization need to

communicate across teams and

departments and need to stay in

contact about threats and

opportunities.

Manager three: What has to be done?

Sounds soft or too little, but I think it

starts with being in conversation with

them and making clear why we do

things and why.

Team leader six: “The top- and

middle management has a major

responsibility in searching for

contact with the lowest layer in order

understand each other”.

Leadership in

successes - Balance

Bottom-Up and

Top-Down

Both a top-down and bottom-up

approach will contribute

towards better quality and

results which can be sustained,

therefore the combination need

to be found in order to be

successful on the long term.

Employee one: The cohesion bottom-

up and top-down is important,

especially in the communication from

the board of directors which is

abstractly translated into concrete

information at departmental level.

Team leader six: In order to

accomplish sustained results they

have congruence between the top

and bottom: “What is chosen as

direction at the top, should be

translated towards the bottom. At the

opposite, what is signaled at the

bottom should be expressed towards

the top” (TL six, 2018).

Leadership

characteristic -

Translator

Higher-order, abstract goals

need to be translated towards

more concrete improvements in

order to change, but more

important when they want to

sustain results on the long run.

Team leader two: “Those middle

managers have more influence on the

top management, but are also in the

position to translate abstract higher-

order goals into practical implications”.

Manager three: “Be able to translate

what the organization initiates at the

top need to accurately be translated

towards concrete information for the

workforce”.