Microsoft Word - 543318_KMulders_MasterThesis_118pages.docxO rganization Studies
Embracing Lean Leadership: An empirical study on the interaction between Lean leadership principles and a successful Lean implementation at the team-level of analysis
Name Karin Mulders BSc. ANR 543318 Date December 2016
Master thesis
Extended Master Circle 4
Title of Master’s thesis
Embracing Lean leadership: an empirical study on the interaction between Lean
leadership principles and a successful Lean implementation at the team-level of analysis
Background information
Educational institution
Second supervisor A.C. Smit MSc
3
Preface
Hereby, I proudly present my Master’s thesis. This thesis was executed at the request of the
Elisabeth-TweeSteden Hospital (ETZ) and was written under the supervision of the Tilburg
University. It is the finalization of the Extended Master Organization Studies and marks the
end of my junior traineeship at ETZ.
During my traineeship in the ETZ, I mainly focused on projects related to the Lean-
philosophy. Since the hospital is currently engaged in the development of a leadership
program, I wanted to contribute by investigating which type of leadership is necessary on
team leader-level.
This research could not have succeeded without the help of some people, whom I really like
to thank. First of all, throughout the whole process, I received much guidance from my first
supervisor, Hans van Dijk, who was always available to provide valuable insights.
Furthermore, I would like to thank my second supervisor, Sander Smit, for his comments
which truly helped me to improve my research.
In special, I would like to give thanks to my professional supervisor, Marcel Boonen, as he
was always available to discuss my progress and to provide me with valuable feedback. His
passion towards the Lean-philosophy was contagious and really encouraged me during my
research.
Finally, I would like to thank my family and friends for their unconditional support and to
motivate me during the finalization of this Master’s thesis.
I am very grateful to have had this opportunity and I hope you will enjoy reading my
research!
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Abstract
Embracing Lean leadership: an empirical study on the interaction between Lean leadership
principles and a successful Lean implementation at the team-level of analysis
Research objective – An increasing amount of healthcare organizations are engaged in the
implementation of the Lean philosophy (Poksinska, 2010). The concept of Lean leadership
should provide guidance during the implementation process (Mann, 2009). The objective of
this research was to examine to what extent the five Lean leadership principles of
Dombrowski and Mielke (2014) can be applied to the healthcare industry and to explore if
there were any additional principles that might affect Lean implementation success. In
addition, this research presents explanations why these Lean leadership principles are
considered to be important to enhance Lean implementation success. The Lean leadership
principles consist of the improvement culture, self-development, qualification, Gemba and
Hoshin Kanri.
Methods – This research contains an empirical study consisting of two phases in which both
quantitative as qualitative research is applied. First, questionnaires were conducted in order to
test the relationships between the Lean leadership principles and Lean implementation
success. Second, interviews were conducted in order to get a more in-depth understanding of
these relationships. It is executed on the inpatient clinics of a multi-site hospital, thereby
questioning both team leaders as nurses.
Results – Following the quantitative research, it was found that self-development and Gemba
had a significant effect on Lean implementation success. The improvement culture,
qualification and Hoshin Kanri did not have a significant effect on Lean implementation
success. However, the qualitative results showed that all five Lean leadership principles could
be important to enhance Lean implementation success.
Conclusion – This research shows that the Lean leadership principles of Dombrowski and
Mielke (2014) are only partially applicable within the healthcare industry.
Keywords – Gemba, Hoshin Kanri, Implementation success, Improvement culture, Lean,
Lean leadership, Qualification, Self-development
1.1 Research objective and research question ........................................................................................... 10
1.2 Relevance ........................................................................................................................................... 10
2.3 Lean leadership ................................................................................................................................... 19
2.3.1 Improvement Culture ................................................................................................................... 20
4.1 Phase 1: Data collection and sample strategy ..................................................................................... 27
4.2 Phase 1: Data measurement and operationalization ............................................................................ 28
4.3 Phase 1: Data analysis ......................................................................................................................... 30
5. Results: Phase 1 ..................................................................................................................... 33
6. Discussion: Phase 1 ............................................................................................................... 46
7. Methods: Phase 2 .................................................................................................................. 49
7.1 Phase 2: Data collection and sample strategy ..................................................................................... 50
7.2 Phase 2: Data analysis ......................................................................................................................... 50
8. Results: Phase 2 ..................................................................................................................... 51
9. Discussion: Phase 2 ............................................................................................................... 62
10. General Discussion .............................................................................................................. 67
13. Appendices list ..................................................................................................................... 79
Appendix A | Fifteen rules to give practical assistance in Lean leadership ........................................... 80
Appendix B | Phase 1 | Codebook first questionnaire ........................................................................... 81
Appendix C | Phase 1 | First questionnaire (Lean implementation success) ......................................... 82
Appendix D | Phase 1 | First questionnaire (Lean leadership principles: team leader) ......................... 83
Appendix E | Phase 1 | Results first questionnaire (Lean implementation success) ETZ Elisabeth ..... 88
Appendix F | Phase 1 | Results first questionnaire (Lean implementation success) ETZ TweeSteden 89
Appendix G | Phase 1 | Results first questionnaire (Lean leadership principles) ETZ Elisabeth .......... 90
Appendix H | Phase 1 | Results first questionnaire (Lean leadership principles) ETZ TweeSteden ..... 91
Appendix I | Phase 1 | SPSS-output first questionnaire ....................................................................... 92
Appendix J | Phase 1 | Codebook second questionnaire ....................................................................... 94
Appendix K | Phase 1 | Second questionnaire (Lean leadership principles: nurses) ............................. 95
Appendix L | Phase 1 | Results second questionnaire (Lean leadership principles) ............................. 96
Appendix M | Phase 1 | SPSS-output second questionnaire ................................................................... 98
Appendix N | Phase 2 | Interview guide .............................................................................................. 100
Appendix O | Phase 2 | Coding scheme ............................................................................................... 101
Appendix P | Phase 2 | Transcript Respondent A ............................................................................... 102
Appendix Q | Phase 2 | Transcript Respondent B ................................................................................ 107
Appendix R | Phase 2 | Transcript Respondent C ................................................................................ 112
Appendix S | Phase 2 | Transcript Respondent D ............................................................................... 115
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List of figures Figure 1 Seven types of waste (Rouppe van der Voort et al., 2013)……………….. 14
Figure 2 The five core principles of Lean (Womack & Jones, 1996)……………… 15
Figure 3 Seven types of waste in the service industry (Bicheno & Holweg, 2009)... 18
Figure 4 Lean leadership model (Dombrowski & Mielke, 2013).............................. 20
Figure 5 Conceptual model………………………………………………………… 23
Figure 6 Research timeline…………………………………………………………. 25
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List of tables Table 1 First questionnaire: Cronbach’s alpha……………………………………. 31
Table 2 Second questionnaire: Cronbach’s alpha…………………………………. 33
Table 3 First questionnaire: Lean implementation success……………………….. 35
Table 4 First questionnaire: Descriptives and correlations………………………... 37
Table 5 First questionnaire: Application of Lean Leadership principles………….. 39
Table 6 Standard multiple regression analysis…………………………………….. 41
Table 7 Comparison Lean implementation success and application of Lean leadership principles………………………………………………………………….. 42
Table 8 Second questionnaire: Application of Lean leadership principles………... 44
Table 9 Second questionnaire: Descriptives and correlations…………………….. 45
Table 10 Results interviews………………………………………………………… 52
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Almost all healthcare organizations face the same challenge: improving the quality of patient
care, increasing the number of patients served and reducing wait times, while keeping costs in
check (Fine et al., 2009). Simultaneously, they face problems with crowding, delays and
patient safety (Holden, 2010). To address these problems, they increasingly implement the
management philosophy Lean (Holden, 2010). The essence of Lean is doing more with less
through the elimination of non-value-adding steps, which are called muda in Japanese and
waste in English (Fine et al., 2009).
While Lean was originally developed in the automotive industry, it has spread across the
manufacturing and the service-based industries (Fine et al., 2009). More recently, the
healthcare industry has demonstrated successes using the Lean-principles in the United States,
the United Kingdom, Australia and Canada (Fine et al., 2009; Melton, 2005). However, due to
the fundamental different working processes in the healthcare industry compared to
manufacturing enterprises, the Lean philosophy might not be as suitable to this industry
(Lahaye, 2014)
In general, Lean-initiatives often evoke resistance and acceptance proceeds arduously,
resulting in a decline of the gradient of improvement of time (Melton, 2005; Wiegel & Maes,
2013). Lean is often presented as a mystical process and too often, unless one is working with
teaching-oriented consultants and trainers, the benefits of Lean disappear shortly after the
consultant or trainer leaves (Fine et al., 2009). Several authors emphasize that a sustainable
implementation of the Lean-philosophy requires a change in the culture of the organization
(Mann, 2005; Liker, 2004; Swartling & Drotz, 2013). Therefore, during the implementation
process, Lean should be determined as a change process in which waste is eliminated through
a structured process that trains and empowers front-line workers (Fine et al., 2009; Wiegel &
Maes, 2013).
Alhuraish et al. (2014) and Swartling and Drotz (2013) identified leadership as the most
critical key factor during such a change process. This stresses the need to identify and support
a Lean change leader who possesses those qualities found in other successful ‘change agents’.
Currently, many leaders are engaged in non-Lean daily routines and habits that are very
difficult to break with (Emiliani & Emiliani, 2013). In addition, Lean contains many
important nuances and details that are impossible to grasp without daily practice (Emiliani &
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Emiliani, 2013). This clarifies why it has been difficult for leaders to fully understand and
correctly practicing the Lean-philosophy and are therefore unable to lead an organization-
wide Lean transformation (Emiliani & Emiliani, 2013; Mann, 2014).
The few enterprises with a successful and sustainable Lean implementation seem to have a
different leadership approach (Dombrowski & Mielke, 2014). Many studies confirm that a
different way of leadership is necessary but few give practical advice (Achanga et al., 2006;
Dombrowski & Mielke, 2014; Liker & Convis, 2012; Mann, 2009). Therefore, differences
remain between departments within an organization concerning their level of Lean
implementation success. To help executives in realizing Lean leadership, Dombrowski and
Mielke (2014) developed five fundamental principles of Lean leadership that describe the
practices of these leaders and should enhance the probability of a successful Lean
implementation. These five principles consist of the improvement culture, self-development,
qualification, Gemba and Hoshin Kanri, which I will explain further below.
1.1 Research objective and research question
Up till now, these principles have only been studies in manufacturing enterprises, leaving
their applicability to the healthcare industry unknown. The objective of this research was to
examine to what extent the Lean leadership principles of Dombrowski and Mielke (2014) can
be applied to the healthcare industry and to explore if there were any additional Lean
leadership principles that might affect Lean implementation success. In addition, it presents
explanations why the Lean leadership principles are considered to be important to enhance
Lean implementation success.
The research question is derived from the research objective and is formulated as follows:
“To what extent do the Lean leadership principles of Dombrowski and Mielke (2014) affect
Lean implementation success in the healthcare industry and why are they considered to be
important?”
1.2.1 Theoretical Relevance
Due to the youth of the Lean healthcare literature, there remain gaps in the current collection
of knowledge (Aij, 2015). In the existing literature, there is a considerable amount of
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scientific interest for the general concepts of Lean and Lean leadership (Achanga et al., 2006;
Dun, 2015; Emiliani & Emiliani, 2013; Jimmerson, Weber & Sobek, 2005; Holden, 2011;
Liker & Convis, 2012; Melton, 2005; Scherrer-Rathje et al., 2009; Wiegel & Maes, 2013).
There is stated that different levels of leaders (executive, network and, line) and types of
culture (operator, engineering and executive) are required to interact and collaborate to
successfully bring about change (Aij, 2015). However, only limited empirical research is
executed regarding Lean leadership at the team-level, especially in the healthcare industry
(Poksinska, Swartling & Drotz, 2013). In many studies, the role of the Board of Directors and
the managers is explored, thereby disregarding the role of team leaders (Achanga et al., 2006;
Worley & Doolen, 2006). This is remarkable, as team leaders are the people who are located
at the work floor and have day-to-day contact with the executives of Lean, namely the nurses.
There is little agreement about what leadership styles and competencies are important to
implement Lean transformation and there is a need for research that provides a deeper
understanding of Lean leadership practices, certainly in the healthcare industry (Aij, 2015). In
addition, this research will comply with the suggested line of research provided by Emiliani
and Emiliani (2013), in which they emphasize the value in determining specific practice
routines that enable successful implementation outcomes. As such, previous information
legitimizes additional research into factors that influence implementation success on team-
level in the healthcare industry. This research aims to elaborate on these matters to expand the
knowledge concerning the characteristics required for effective Lean leadership in order to
achieve Lean implementation success in the healthcare industry.
1.2.2 Practical Relevance
Research on the application of Lean in healthcare has been limited and as a result many
questions remain on how Lean can be best implemented in this industry (Holden, 2010).
There is a need for research-based studies that provide a deeper understanding of Lean
leadership and Lean management practices (Poksinska et al., 2013). There are very few
studies of Lean leadership in the healthcare industry that relate findings to a leadership model,
thereby not specifying which qualities and characteristics Lean leaders should require to be
successful (Aij, 2015). The five fundamental principles of Lean leadership of Dombrowski
and Mielke (2014) become more and more spread and applied outside the healthcare industry.
However, executives often struggle to put the theoretical approaches of Lean leadership into
practice (Dombrowski & Mielke, 2014). Therefore, Dombrowski and Mielke (2014) designed
fifteen rules to give practical assistance in everyday Lean leadership. These rules emerging
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from the Lean leadership principles, are presented in Appendix A. This research aims to
identify whether these principles of Dombrowski and Mielke (2014), including the associated
rules, are applicable in the healthcare industry. In this way, healthcare institutions can train
their team leaders more specifically following these principles, in order to obtain more
successful implementation results.
2. Theoretical Framework
Nowadays, many organizations are interested in adopting the Lean-philosophy. The fact that
the Lean-philosophy includes numerous insights and techniques that are developed at
different times and places makes it hard to indicate the moment of commencement (Wiegel &
Maes, 2013). If we link the emergence of Lean to the Toyota Motor Corporation in Japan,
where the core of Lean thinking has been developed as an alternative for the traditional mass
production, the beginning of the twentieth century should be marked as its starting point
(Lahaye, 2014; Wiegel & Maes, 2013).
It was in those years that entrepreneur Sakichi Toyoda, founder of the Toyoda Group in 1902,
first developed the Jidoka-concept which turned out to be start of Lean-thinking (Becker,
1902). As founder of a spinning- and weaving business, he invented an automatic loom
capable of detecting a snapped thread that automatically stopped the loom, thereby preventing
production of poor quality (Becker, 1998; Holweg, 2007). The automatic loom made it
possible for an employee to operate on six machines at a time, compared to operating on only
a single machine which was usual back then (Holweg, 2007).
A few years later, his son Kiichiro Toyoda took over the company and started manufacturing
automobiles by transforming the organization into Toyoda Automotive Works (Becker, 1998;
Holweg, 2007). Until then, the Japanese automotive market was dominated by the local
“…half the human effort in the factory, half the manufacturing scope, half the
investment in tools, half the engineering hours to develop a new product in half the time.
Also it requires keeping far less than half the needed inventory on site, results in many
fewer defects, and produces a greater and ever growing variety of products.”
(Womack et al. 1990)
subsidiaries of Ford and General Motors (Becker, 1998). Kiichiro started designing the Model
AA by making considerable use of Ford and General Motors Components (Holweg, 2007).
From that moment on, the truck and car production started and in 1936 the Toyota Motor
Company was formally formed (Holweg, 2007).
Unfortunately, the company ended up in serious financial troubles during World War II, as
the production facilities were destroyed which resulted in growing inventories of unsold cars
(Holweg, 2007). Then, the new director of the manufacturing arm, got inspired by the power
of standardization as implemented at Ford Motor and was determined to implement these
mass production techniques at Toyota (Holweg, 2007). However, back then, Japan was caught
up in a financial crisis causing them to have less resources available which made mass
production no longer profitable (Lahaye, 2014). Therefore, it was essential that more efficient
production methods were developed, ultimately leading to the development of Lean’s
predecessor: the Toyota Production System (Burgess & Radnor, 2013).
Taiichi Ohno, who is considered to be the creator of the Toyota Production System, made a
significant contribution by the development of a system referred to as Just-In-Time, meaning
the production of only the exact amount of already ordered items containing a minimum
amount of waste; a principle that is still central to the current philosophy of Lean (Becker,
1998). Ohno did not have any experience in manufacturing automobiles, and it has been
argued that his ‘common-sense approach’ without any preconceptions has been instrumental
in developing the fundamentally different Just-In-Time philosophy (Holweg, 2007).
Western countries became intrigued by the Toyota Production System with which Toyota was
able to keep producing high-quality products even during the oil crisis in 1973 (Holweg,
2007). This eventually brought the American and Japanese car production together, as Toyota
and General Motors decide to engage themselves in a joint venture (Holweg, 2007). In the
eighties, the Toyota Production System was renamed into Lean, after which it was eventually
introduced as the Lean Production System by Jim Womack in 1990 (Wiegel & Maes, 2013).
Hence, the first Lean concepts and techniques were developed to solve problems people were
facing at that time (Wiegel & Maes, 2013). This is important to realize as it indicates that
Lean is not a static framework, but operates as a basis to start analyzing present problems and
solving them (Wiegel & Maes, 2013). Lean aims to improve quality by focusing on the
identification and elimination of waste throughout a product’s entire value stream (Alhuraish,
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Robledo & Kobi, 2014; Rouppe van der Voort et al., 2013; Scherrer-Rathje, Boyle &
Deflorin, 2009). In Figure 1, seven forms of waste are provided that are considered activities
that add no value from the perspective of the customer (Rouppe van der Voort et al., 2013).
The Just-In-Time principle illustrates the concept of the first type of waste expressed in the
prevention of overproduction. The growing inventories at Toyota, resulting from the inflicted
damage by World War II, should be categorized under the fourth type of waste expressed in
inventory.
Figure 1. Seven types of waste (Rouppe van der Voort et al., 2013)
In many organizations, the application of Lean concerns a transformation of the
organizational culture from the inside out. Womack and Jones (1996) have appointed this
transformation with the term Lean thinking, meaning:
When keeping the cultural changes in mind, the sole focus on waste reduction will not create
a true Lean thinking organization (Dombrowski & Mielke, 2014). Hence, Lean is not only
about the use of certain techniques and quality improvement tools, but in many organizations,
it concerns a whole-systems approach that creates a culture in which everyone is continuously
improving processes and production (Liker, 1997; Toussaint & Berry, 2013). Thus, besides
defining Lean as a toolbox, it is often described is as a management philosophy and a
Waste
6. Movement
7. Defects
“… Lean thinking is Lean, because it provides a way to do more and more with less and
less – less human effort, less equipment, less time, and less space - while coming closer
and closer to providing customer with exactly what they want.”
(Womack & Jones, 1996)
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leadership style (Wiegel & Maes, 2013). In order to provide a guideline while implementing
Lean, Womack and Jones (1996) developed ‘five core principles’ as shown in Figure 2. The
first core principle concerns the identification of value, meaning the idea that products or
services should be designed for and with customers, should suit the purpose, and need to be
set at the right price (Young et al., 2014). The second core principle is about the belief that
each step in production must produce value for the customer, thereby eliminating all sources
of waste (Young et al., 2014). The third core principle concerns the creating of flow, in which
the system must flow efficiently, ideally without intermediate storage (Young et al., 2014).
The fourth core principle implies that the process must be flexible and be geared to individual
demands, producing exactly what the customers need (Young et al., 2014). The fifth and last
principle is about the ideology that one must act and strive for perfection (Young et al., 2014).
Figure 2. The five core principles of Lean (Womack & Jones, 1996)
2.2 Lean in the healthcare industry
In the nineties, Womack and Jones (1994) argued that Lean can be applied in any sector, both
within the manufacturing industry as well as the service sector (Lahaye, 2014). It was a few
2. Map the Value
5. Seek Perfection
1. Identify value
“Lean utilizes a continuous learning cycle that is driven by the ‘true’ experts in the
processes of healthcare, consisting of the patients and its family, the medical staff and
the support staff.”
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years later that Lean was first applied in the healthcare industry (Wiegel & Maes, 2013).
Healthcare is a risky business; doctors, nurses and other healthcare professionals deal with a
group of customers who are often frail, vulnerable and frightened (Fillingham, 2007).
Healthcare managers, Boards and clinical leaders are faced with a significant challenge as the
degree of organizational complexity is high and many procedures have a significant level of
risk (Fillingham, 2007). They desperately need to implement a system that can simultaneously
improve quality, morale and productivity (Fillingham, 2007). As the healthcare industry
struggles to meet increasing demands with limited resources, Lean has become a popular
management approach in this field (Liker, 1997; Toussaint & Berry, 2013; Ulhassan, Schwarz
& Tor, 2014). When applying the Lean-philosophy to new industries such as the healthcare
industry, the general techniques and concepts will be interpreted differently (de Souza, 2009).
The Lean-practitioner should give its own interpretation to the Lean concepts and techniques
in a way that is will become applicable to his current circumstances (de Souza, 2009; Lahaye,
2014). Since its first application in the healthcare industry many articles, originating from
different countries, are published in which the application of Lean in this industry was clearly
showed (Lahaye, 2014). This suggests that Lean has the potential to be a valuable
management philosophy in healthcare (Lahaye, 2014).
However, that Lean can dramatically improve a sector as significant as healthcare is still a
matter of belief, rather than proof, and there are some obvious reasons why the healthcare
industry may differ crucially from other sectors (Young & McClean, 2008). There are several
researchers who suggest that, because Lean initially was developed to serve the
manufacturing industry, Lean will never know similar tremendous successes in the healthcare
industry (Lahaye, 2014).
First, the scale and complexity of healthcare organizations set them apart from manufacturing
and many other service sectors (Young & McClean, 2008). This complexity is derived from,
among other thing, the influence of professions (e.g., physicians, nurses, pharmacists and
administrators) and other stakeholders (e.g. patients and government), often with seemingly
incompatible interests, perspectives and time horizons (Golden, 2006). During the
implementation process of Lean in hospitals, many tend to disregard these differences
between the private sector and the public sector (Lahaye, 2014). Being part of the public-
sector entails being influenced by a regulatory system and government agencies (Lahaye,
2014).
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Second, many hospitals are characterized by deeply established and institutionalized
practices, which often hampers a successful introduction of Lean (Lahaye, 2014). The
literature also suggests considerable variability in the implementation of Lean with
differences in approach and scope (Aij, 2015). Most healthcare providers tend towards small
enclosed projects that create ‘pockets of best practice’ rather than adopting an organization or
system-wide approach (Aij, 2015).
Third, when trying to apply the original core principles of Womack and Jones (1996) to this
industry, the determination of value and waste are disputable concepts (Lahaye, 2014).
Originally, the concept of value refers to the products and services for which customers are
willing to pay for and wastes are the products and services for which customers are not
willing to pay for (Lahaye, 2014). However, these definitions are not that straightforward in
hospitals as different actors have their own point of view from which they define the concept
of value (Lahaye, 2014). This often results in value-appreciation for one party, but
simultaneously this can mean a value-depreciation for others involved (Lahaye, 2014; Young
& McClean, 2008). In the healthcare industry, it should be a matter of course that the patient
holds the decisive vote in shaping the concept of value in its own treatment (Lahaye, 2014).
However, due to the absence of a single customer with a compelling view of value, the
definition of value is often decided based on what items add operational value to the system
instead of living up to the patient perspective (Lahaye, 2014; Young & McClean, 2008).
Finally, many healthcare professionals argue that every patient is different, unlike every
manufactured product in a manufacturing company (de Souza & Pidd, 2011). This is a
misunderstanding of Lean in healthcare, since patients are not considered identical, but
offered similar treatments if they fall into similar categories (de Souza & Pidd, 2011). Such
patient pathways are a sequence of care operations shared by a group of patients that are
sufficiently similar to one another. Therefore, a hospital can be viewed as a set of parallel
patient pathways in which patients still receive individual treatment by clinicians and are not
forced into clusters, but they often fall naturally into one (de Souza & Pidd, 2011).
Thus, as the original core Lean principles from Toyota are finely tuned to the specific
environment of manufacturing, it is unlikely that the specific practices could transfer to the
healthcare industry with equal successes (Jimmerson et al., 2005). Jimmerson et al. (2005)
therefore decided to redefine the existing core Lean principles, thereby developing six
principles of Lean in the healthcare industry:
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3. On demand
5. No waste
6. Overall safety for patient, staff and clinicians
In Figure 4, the ‘original seven wastes’ have also been redefined to better fit the service
industry, which include healthcare organizations (Bicheno & Holweg, 2009). In healthcare,
wastes are processes that do not add value for the patient, creates delays and increase the
patient journey time unnecessarily (Hobson, 2005). In practice, the key is to ensure that by
removing the waste, the root cause of a problem is eliminated, not just the symptom (Melton,
2005).
Figure 3. Seven types of waste in the service industry (Bicheno & Holweg, 2009)
Waste
2.3 Lean leadership
Based on the previous paragraph, it has become clear that when healthcare organizations try
to implement the Lean philosophy, there must be given sufficient attention to the selection of
specific and appropriate ways to translate the Lean principles to a hospital environment
(Lahaye, 2014). Only when Lean methods are implemented effectively, the real benefits of
Lean can be realized and can it change the way of thinking, looking, acting and reacting
within an organization (Lahaye, 2014; Powell, Alfnes & Semini, 2009). Creating sustainable
cultural change in any organization is challenging because organization inertia resists change
(Keiser, 2012). Therefore, during the implementation process of Lean, operational practices
need to change but people, both managers and employees, must also go through a process of
change (Aij, 2015). Effective leadership is a critical element of creating lasting change in an
organization and is particularly important during a Lean transformation (Keiser, 2012). As
effective leadership in the complex environment of healthcare organizations is critical, the
concept of ‘Lean leadership’ should enable patients and healthcare organizations to enjoy the
benefits of Lean practices experienced by organizations in other industries (Aij, 2015).
As mentioned before, Lean is often equated with the tools that are used to create efficiencies
and standardize processes (Mann, 2009). However, the largest part of the Lean transformation
is expended on changing leader’ practices and behaviors and ultimately their mindset (Mann,
2009). If Lean is a sentiment that is not strongly held by leaders within an organization, a
successful Lean implementation has no chance (Wiegel & Maes, 2013).
De Souza and Pidd (2011) argues that healthcare leaders are generally chosen for their
problem-solving skills, particularly ‘firefighting’, in which quick, temporary solutions are
provided. The leader’s role has changed radically with the implementation of Lean, involving
a shift from managing processes to developing and coaching people (Poksinska et al., 2013).
Dombrowski and Mielke (2013) provided a more precise description of Lean leadership,
“A methodical system for the sustainable implementation and continuous improvement
of Lean production systems. It describes the cooperation of employees and leaders in
their mutual striving for perfection. This includes the customer focus of all processes as
well as the long-term development of employees and leaders.”
(Dombrowski & Mielke, 2013)
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consisting of five fundamental principles as shown in Figure 5. These fundamental principles
are further elaborated on in the following paragraphs, after which Figure 6 shows the
conceptual model including the five hypotheses of this research.
Figure 4. Lean leadership model (Dombrowski & Mielke, 2013)
2.3.1 Improvement Culture
The improvement culture comprises all attitudes and behaviors of both Lean leaders and their
followers that result in a continuous striving to perfection (Dombrowski & Mielke, 2014).
Lean leaders are expected to teach their followers the values and cultural norms of the
organization, which means they must understand and live the culture (Poksinska et al., 2006).
The culture must support the followers and be characterized by trust, shared responsibility and
openness to experimentation without fear of failure (Poksinska et al., 2006). When leaders
engage their followers in the process of continuous improvement, followers will be more
willing to accept initiatives and develop a sense of ownership of them (Walley, Stephens &
Bucci, 2006). In a no-blame culture, the root cause of any problem is sought to prevent
recurrence (Aij, 2015). Creating such culture requires support, provision of necessary
resources and encouragement of employees to contribute ideas, since it are the employees that
most thoroughly understand the vulnerabilities of business processes (Aij, 2015). Whenever
the improvement culture is missing, Lean-initiatives will often fail as Lean is an isolated
initiative at that moment, a momentary improvement activity (Wiegel & Maes, 2013).
Hypothesis 1: By creating an improvement culture, Lean leadership will enhance Lean
implementation success
Q ua
lif ic
at io
2.3.2 Self-development
This second principle implies that Lean leaders need to have a strong commitment to self-
development and must develop themselves first before they can take responsibility for
teaching others the Lean-philosophy (Poksinska et al., 2006). As leaders act as role models
for their employees, the self-development of a leader is an important principle since some
attributes depend on the leader’s personality but others have to be learned and developed (Aij,
2015; Dombrowski & Mielke, 2014). During the implementation of Lean, it is important that
leaders are trained in Lean as they need to express their support in both words and action
(Wiegel & Maes, 2013). Leaders should keep themselves updated concerning the processes,
quality control and training sessions in Lean in order to successfully implement Lean and to
be able to guide their followers (Dombrowski & Mielke, 2014; Walley et al., 2006).
Hypothesis 2: By leaders focusing on self-development, Lean leadership will enhance Lean
implementation success
2.3.3 Qualification
Qualification is about coaching and developing others (Poksinska et al., 2006). A Lean leader
is not the person who adds value to the product, but functions as a coach by creating, building
the team and developing their skills (Dombrowski & Mielke, 2014). The continuous
development of processes must go along with a continuous development of the leader’s
followers (Dombrowski & Mielke, 2014). Lean leaders do not solve problems themselves, but
challenge, encourage and empower their followers to encourage them to think problems
through for themselves (Aij, 2014; Poksinska et al., 2006). Leaders need to educate their
followers on a daily basis during their daily activities, allowing the follower to be constantly
challenged and learn by solving actual problems (Dombrowski & Mielke, 2014). A follower
who has engaged him-/herself in the implementation of Lean, must own sufficient resources
and time available (Wiegel & Maes, 2013).
Hypothesis 3: By providing training, resulting in qualified followers, Lean leadership will
enhance Lean implementation success
2.3.4 Gemba
A Lean leadership system differs from a hierarchical system in which leaders tell their
followers what to do and how to do it (Toussaint & Berry, 2013). Lean, in a sense, turns
22
leadership upside down, with followers doing much of the innovating and leaders trusting
them to do it and supporting them (Toussaint & Berry, 2013). The term Gemba refers to the
place of value-adding, which in a healthcare setting may refer to an outpatient clinic or
inpatient clinic (Dombrowski & Mielke, 2014; Fine et al., 2009). Leaders often spend a lot of
time in their offices and conference rooms, but these locations are not where value is created
(Toussaint, 2013). In this perspective, the value comprises the measureable results that really
matter to patients, covering issues such as death and pain (Toussaint, 2013). Just as their
followers that add value each day, a Lean leader must add value too and not just by meeting
community leaders, monitoring insurance reimbursement rates and considering mergers but
by actually helping their followers improve value for the patient (Toussaint, 2013). The
followers are the first ones who notice deviations from the standard and they know best about
common defects and disturbances (Dombrowski & Mielke, 2013). According to this principle,
Lean leaders should go to the work floor frequently in order to truly understand the processes
and to get a first-hand impression of the problem (Dombrowski & Mielke, 2014). It
emphasizes the Lean principle in which value is created on the front lines, not in boardrooms
(Fine et al., 2009). Leaders need to support their followers by regularly visiting the work floor
to learn firsthand about problems and barriers to improvement, by becoming teachers and role
models of quality improvement (Toussaint & Berry, 2013).
Hypothesis 4: By working and being part of the Gemba, Lean leadership will enhance Lean
implementation success
2.3.5 Hoshin Kanri
The principle of Hoshin is also knows as target management or policy deployment
(Dombrowski & Mielke, 2014). As Lean is aimed at more decentralized improvement
activities, it is important to define a general policy to ensure there is alignment between
individual team activities and the long-term goals of the organization (Aij, 2015; Dombrowski
& Mielke, 2014). A Lean leader should ensure that every follower is aware of its contribution
to the bigger picture (Dombrowski & Mielke, 2014). This principle encourages followers to
reach the root cause of problems before searching for solutions, creating sustainable plans for
implementation and taking appropriate action for implementation (Dombrowski & Mielke,
2014).
23
Hypothesis 5: By emphasizing the importance of a follower’s individual contribution, Lean
leadership will enhance Lean implementation success
2.4 Conceptual model
The following conceptual model applies to this research, see Figure 6. The dependent variable
in the model concerns the variable ‘Lean implementation success’ wherein it is assumed that
this variable is affected by at least five independent competencies. These are the
‘improvement culture’, ‘self-development’, ‘qualification’, ‘Gemba’ and ‘Hoshin Kanri’. The
sixth box, that concerns the ‘?’, indicates that during the data collection additional meaningful
variables that define Lean leadership may emerge and thus can be added to the model.
Figure 5. Conceptual model
This research was executed at the request of Elisabeth-TweeSteden Hospital (ETZ). In the
past, the region of Tilburg was incorporated with several hospitals and outpatient clinics
known as the Elisabeth Hospital and the TweeSteden Hospital located at venues in Tilburg,
Waalwijk and Oisterwijk. In order to continue to provide care in this area and its
surroundings, a merger between these establishments was initiated. Since January 2016, the
merger between these hospitals was finalized from a legal point of view and a new company
name was introduced: Elisabeth-TweeSteden Hospital (ETZ). Currently, the organization
24
counts around six thousand employees causing them to be classified as one of the largest top
clinical hospitals in the Netherlands. For the past ten years, ETZ is engaged in implementing
elements of Lean which also provides assistance during the challenges they are facing caused
by the merger. Their main challenge is to strike a balance between standardizing working
processes but simultaneously providing customized care that suits the individual patient.
3.1 Research design
The goal of this Master’s Thesis was to conduct further research into the relationship between
Lean leadership principles and Lean implementation success in the healthcare industry. This
research is executed at the inpatient clinics within two locations of the ETZ, namely ETZ
Elisabeth (Ez) and ETZ TweeSteden (TSz). In this Master’s Thesis, I will apply both a
quantitative as well as a qualitative design as several writers suggest that there can be value in
bringing the two types of data together (Bernard, 2011; Sale, Lohfeld & Brazil, 2002; Ritchie
& Lewis, 2003).
First, quantitative research enabled me to quantify attitudes, opinions and behaviors and to
compare results form a larger sample population (Sale, Lohfeld & Brazil, 2002). Additional
qualitative research enabled me to explore complex relationships between variables within
their natural environment as it can be difficult to fully grasp the interactions between humans
on the one hand and several variables on the other hand (Worley & Doolen, 2006).
Within both phases of this research, the unit of observation is at the individual level as both
team leaders and nurses are being investigated. The unit of analysis is at the team-level, as
conclusions on team level are drawn from data collected from these individuals. Within this
research, a cross-sectional design is applied, as it allows me to compare different variables at
the same time.
25
The empirical study described in this Master’s Thesis consists of two phases, as shown in
Figure 6. The first phase of the empirical study concerns quantitative research in which two
questionnaires were distributed. The first questionnaire was directed at the team leader of
each inpatient clinic and measured both Lean implementation success at their inpatient clinic
and their application of Lean leadership principles. The second questionnaire was directed at
the nurses and measured the application of Lean leadership principles as executed by their
team leader. Since this phase concerns both the measurement of Lean implementation success
per inpatient clinics and the measurement of the application of Lean leadership principles as
executed by team leaders, an answer is provided concerning the five hypotheses elaborated on
within this research.
Lean implementation success was measured by a self-constructed questionnaire filled in by
the team leader of each inpatient clinic (first questionnaire). The results of this questionnaire
also determined the sample applied in the second questionnaire and the second phase of this
research, as the two inpatient clinics with the highest level of Lean implementation success
and the two inpatient clinics with the lowest level of Lean implementation success were
selected.
The application of the Lean leadership principles was also measured by self-constructed
questionnaires, evaluated by both the team leader (first questionnaire) as the nurses of an
inpatient clinic (second questionnaire). The items within the questionnaires are based on the
Lean leadership principles of Dombrowski and Mielke (2014). Since the evaluation of the
application of Lean leadership principles by the team leaders themselves concerns a quite
subjective measure, the perspectives of their nurses were also included within this phase.
The data derived from the two questionnaires will analyze to what extent team leader comply
with the Lean leadership principles of Dombrowski and Mielke (2014) working at an
inpatient clinic with a high level of Lean implementation success compared to an inpatient
clinic with a low level of Lean implementation success. The results of the first phase provided
input for the questions asked during the interviews conducted within the second phase of this
research.
The second phase in this Master’s Thesis concerns qualitative research, in which semi-
structured face-to-face interviews were conducted by questioning team leaders working at the
inpatient clinics. In this thesis, the semi-structured interviews were conducted in order to gain
26
an in-depth understanding of the relationship between Lean leadership and a successful Lean
implementation and to explore if there were any additional principles that might be a valuable
contribution to the Lean leadership model of Dombrowski and Mielke (2014). More
specifically, it tried to investigate why these Lean leadership principles are considered to be
important to enhance Lean implementation success.
4. Methods: Phase 1
First questionnaire
The first questionnaire is directed at the team leaders and measures both Lean implementation
success at an inpatient clinic as their application of the Lean leadership principles. The items
that measured Lean implementation success were developed by the former trainee working at
this hospital and are shown in Appendix C. This questionnaire is applied as it is the current
measurement that is applied within the ETZ in order the measure the Lean implementation at
departments. The items that measured the application of Lean leadership principles were
added to fit this research and contains self-constructed questions based on the fifteen rules to
give practical assistance in everyday Lean leadership, shown in Appendix A, and can be
aggregated to the five Lean leadership principles of Dombrowski and Mielke (2014). The
complete questionnaire is concerned with descriptive research, as it provides information
about the current state of affairs concerning the level of Lean implementation success and the
current Lean leadership-approach of the team leaders.
Second questionnaire
The second questionnaire is directed at the nurses and measures the application of the Lean
leadership principles as executed by their team leader. By also exploring the perspective of
the nurses, the current practices of a team leader are examined from both his or her own
perspective as elaborated on in the first questionnaire and from an external point of view as
elaborated on in this second questionnaire. By analyzing both the perspective of a team leader
as the perspectives of multiple nurses, a conclusion can be drawn on multiple perspectives.
This questionnaire is concerned with descriptive research, as it provides information about
the current judgments of the nurses concerning the behavior of the team leader working at
their inpatient clinic.
27
To ensure and enhance the reliability of the two questionnaires and make replication possible,
I applied two structured questionnaires that increased the consistency of measurement. Also
before the questionnaires were disseminated, a pilot test was conducted by sending the
questionnaires out to two respondents. By distributing questionnaires, each team leader and
each nurse was exposed to the same closed-ended questions (Bernard, 2011). This is applied
in order to control the input that triggers people’s responses so that their output can be reliably
compared (Bernard, 2011). In addition, as the questionnaires included items referring to
people’s behavior, the anonymity provided a sense of security causing some people to be
more willing to report socially undesirable behaviors and traits (Bernard, 2011).
4.1 Phase 1: Data collection and sample strategy
First questionnaire
The quantitative data derived from the first questionnaire was gathered by distributing the
questionnaire to the team leader of each inpatient clinic within the ETZ. The selection of
respondents was based on the strategy of purposive sampling in which its goal was to focus
on certain characteristics of the population of interest (Singleton et al., 1993). In this
questionnaire, this refers to the team leader of an inpatient clinic as he or she is expected to
possess an overall view of the activities at their department. It was required that a team leader
was working at the specific inpatient clinic for at least one year. If this was not the case, the
Head of Department would be approached. In order to reach the appropriate respondents, a
list of current team leaders was collected followed by sending them an e-mail in which a short
description of the research was provided. Both team leaders of ETZ Elisabeth Hospital
(N=26) and ETZ TweeSteden Hospital (N=16) were contacted, resulting in the distribution of
42 questionnaires.
The respondents were given the opportunity to schedule an appointment, whereby I would be
present during the moment that team leaders filled in the questionnaires. In case it was not
possible to arrange an appointment with the respondent, the questionnaire was distributed
electronically or a paper version was provided. In case that two team leaders derived from the
same inpatient clinic filled in the questionnaire, the data derived from both respondents was
further analyzed within this research. Eventually, several team leaders responded by stating
that they did not have enough time to complete the questionnaire, one department was
recently closed due to relocation as a result of the merger and another department is rented by
28
an external company. This eventually resulted in a response rate of 66.7%. The data collection
took place from July until November.
Second questionnaire
The quantitative data derived from the second questionnaire was gathered by electronically
distributing the questionnaire to nurses (N=X) of four inpatient clinics. These consist of the
two inpatient clinics with the highest level of Lean implementation success and the two
inpatient clinics with the lowest level of Lean implementation success, as established by the
first questionnaire, and shown in Appendix E and F. The selection of respondents was based
on the strategy of purposive sampling, as only nurses were being questioned that were
working at the selected inpatient clinics (Singleton, 1993). In order to reach the appropriate
respondents, the team leaders were sent an e-mail which included a request to provide an
overview of the nurses working at their inpatient clinic (Bernard, 2011). Due to the fact that
this questionnaire could involve sensitive information about their judgment of their team
leader’s behavior, I made clear that their team leader would not get insight in the answers they
provided in order to stimulate them to be as honest as possible.
4.2 Phase 1: Data measurement and operationalization
First questionnaire
implementation success and the application of Lean leadership principles. Lean
implementation success was assessed by a self-constructed measure of 34 items. The items
are based on four concepts, which are problem solving ability, culture and behavior, Lean
progress and the use of Lean methodologies. Problem solving ability was measured by 8
items, in which team leaders had to assess on what percentage of their team, the statement
applied to (e.g. What percentage of your team sees and recognizes a problem when one
occurs?). Culture and behavior was measured by 10 items, in which team leaders had to
assess on what percentage of their team, the statement applied to (e.g. What percentage of
your team is focusing on improvement activities on a daily basis?) Lean progress was
measured by 10 items, in which team leaders had to assess on whether their team used a
specific Lean methodology (e.g. Daystart) and by 10 items in which team leaders had to
assess on how frequently their team used a specific Lean methodology (e.g. Often).
29
The application of Lean leadership principles was assessed by a self-constructed measure
consisting of 15 items, based on the fifteen rules to give practical assistance to Lean leaders,
as shown in Appendix A. the fifteen closed-end questions are based on the five Lean
leadership principles of Dombrowski and Mielke (2014), in which each principle was
measured by 3 items. Concerning these items, team leaders had to reflect on their own
behavior and needed to assess to what extent they agreed with the statement. The five Lean
leadership principles consist of the improvement culture (Cronbach’s α = .738; e.g. I have a
lot of experience and/or knowledge of the current work processes at the department), self-
development (Cronbach’s α = -.575; e.g. I have sufficient knowledge to perform my
leadership duties), qualification (Cronbach’s α = .587; e.g. I believe I have good problem
solving skills), Gemba (Cronbach’s α = 0.446; e.g. I can devote enough time to each employee
to support them well in their daily work) and Hoshin Kanri (Cronbach’s α = .799; e.g. I strive
to establish a perfectly organized department by setting small intermediate goals). A 5-point
Likert scale was applied ranging from 1 (i.e. totally disagree) to 5 (i.e. totally agree).
Second questionnaire
The second questionnaire contains closed-end questions that embody the definition of Lean
leadership, as shown in Appendix K. Lean leadership was assessed by a self-constructed
measure consisting of 15 items, based on the fifteen rules to give practical assistance to Lean
leaders, as shown in Appendix A. These rules were based on the five Lean leadership
principles of Dombrowski and Mielke (2014) and consisted of the improvement culture
(Cronbach’s α = .602; e.g. My team leader is very accessibly in case problem arise at the
department), self-development (Cronbach’s α = .714; e.g. I believe my team leader has
sufficient knowledge to perform his job), qualification (Cronbach’s α =.787; e.g. My team
leader tries to intervene into the team as much as possible, causing a low level of hierarchical
distribution), Gemba (Cronbach’s α = .883; e.g. My learning moments are mostly integrated
into my daily work) and Hoshin Kanri (Cronbach’s α = .486; e.g. By setting small goals, our
team leader keeps us focused on a perfectly organized department). Each principle was
measured by 3 items, in which nurses had to asses to what extent they agreed with the
statement. A 5-point Likert scale was applied ranging from 1 (i.e. totally disagree) to 5 (i.e.
totally agree).
First questionnaire
The data analysis concerning the quantitative data derived from the first questionnaire builds
on the developed codebook, as shown in Appendix B. The codebook spells out how the
collected data was transformed into numbers that were manipulated statistically and in which
an attempt was made to discover certain patterns (Bernard, 2011). The content of this
codebook consists of an overview of what variables I have studied, how I have called these
variables and how I have stored information about them (Bernard, 2011).
The statistical calculations concerning the establishment of Lean implementation success per
inpatient clinic were calculated by means of Microsoft Excel. As each question had its own
rating, meaning that not every question was equally important, specific calculations needed to
be made before eventually formulating an average score per inpatient clinic. The average
scores of the inpatient clinics were compared to each other, after which the two inpatient
clinics with the highest level of Lean implementation success and the two inpatient clinics
with the lowest level of Lean implementation success were selected for the second
questionnaire and phase two of this research. However, as the inpatient clinic with the highest
level of Lean implementation success was not able to cooperate, the next inpatient clinic with
the highest level of Lean implementation success was approached.
The statistical calculations concerning the application of Lean leadership principles were
executed by using Microsoft Excel and the IBM SPSS Software. First, in order to calculate
the internal consistency of the items that measure the same construct, I have calculated the
Cronbach’s α per construct, as shown in Appendix I. In this research, only the Lean
leadership principles that meet the required Cronbach’s α of at least 0.7 were included in the
analysis. In case the Cronbach’s α included a score below 0.7, only the item that was most
representative for that specific Lean leadership principle was included for further analysis.
The Cronbach’s α concerning the improvement culture and Hoshin Kanri did meet the
required score of at least 0.7, as shown in Table 1. The Cronbach’s α of self-development,
qualification and Gemba did not the meet the required score of at least 0.7, as shown in Table
1. Due to the poor correlation between the items of these three constructs, two items per
construct were discarded. As a result, the analysis concerning self-development will only
cover item 50, thereby disregarding items 48 and 49. Qualification will only cover item 53,
31
thereby disregarding items 51 and 52. Gemba will only cover item 54, thereby disregarding
items 55 and 56.
Table 1 First questionnaire: Cronbach’s alpha N Cronbach’s alpha Improvement culture 3 .738 Self-development 3 -.575 Qualification 3 .587 Gemba 3 .446 Hoshin Kanri 3 .799
In addition, in order to test if a factor analysis was possible to confirm the existence of the
five principles of Lean leadership of Dombrowski and Mielke (2014), bot the sample size and
the strength of the relationship among the variables are important (Pallant, 2013). Following
the absolute minimum sample size of 100 by MacCallum et al., (1999), this criterion has not
been met. In order to establish the strength of the intercorrelations among the items, the
Bartlett’s test (P < 0.05) and Kaiser-Meyer-Olkin (> .6) measure were calculated. Within this
research, the Bartlett’s test is .533 and the Kaiser-Meyer-Olkin is significant (p = 0.002),
thereby not complying with the requirements. As only two correlation coefficients exceed a
value of .3, the strength of the relationships among the variables is too low, thereby excluding
a factor analysis from this study.
Eventually, in order to determine the extent that team leader believed they applied the Lean
leadership principles, an average score per construct was calculated resulting in an overview
of the application of the five Lean leadership principles of Dombrowski and Mielke (2014)
per inpatient clinic.
The statistical calculations concerning the relationship between Lean implementation success
and the application of Lean leadership principles were executed by means of IBM SPSS
Software. By this, a standard multiple regression analysis was executed in order to test the
five hypotheses based on the correlation between the multiple independent variables and a
continuous dependent variable, including both strength and direction of the relationship.
Applied to this research, it was conducted to provide an initial understanding concerning the
relationship between the five Lean leadership principles of Dombrowski and Mielke (2014) as
independent variables and Lean implementation success as dependent variable. More
specifically, it was executed to address how well the Lean leadership principles are capable of
predicting Lean implementation success.
32
In order to test if a multiple regression analysis was possible, the data had to comply with
several assumptions. The first assumption concerns generalizability, which in this research
indicates a required sample of 90 respondents, following N > 50 +8 m in which m is the
number of independent variables (Pallant, 2013). Due to the fact that the ETZ only consists of
42 inpatient clinics, the first assumption cannot be complied with. This implies a restriction
concerning the generalizability of the results derived from this analysis. The second
assumption concerns establishing the absence of multicollinearity by analyzing the bivariate
correlations between the independent variables (<.7) (Pallant, 2013). No multicollinearity has
been found between the independent variables improvement culture, self-development,
qualification, Gemba and Hoshin Kanri. In addition, with regards to the absence of
multicollinearity, the Tolerance-value (<.0.10) and the VIF-value (>10) were not exceeded
(Pallant, 2013). The third assumption concerns linearity and homoscedasticity, thereby
indicating the absence of outliers within the data, which was confirmed by means of a
generated Normal P-P Plot and a Scatterplot (Pallant, 2013). Concerning the Normal P-P Plot,
the residuals show a linear relationship through a diagonal line from bottom left to top right.
The residuals within the Scatterplot are roughly rectangularly distributed, thereby also
confirming homoscedasticity (Pallant, 2013).
Second questionnaire
The data analysis concerning the quantitative data derived from the second questionnaire
build on the developed codebook, as shown in Appendix J. The codebook spells out how to
transform the collected data into numbers that can be manipulated statistically and how is
searched for patterns (Bernard, 2011). The content of this codebook consists of an overview
of what variables I have studied, how I have called these variables, and how I have stored
information about them (Bernard, 2011).
The statistical calculations concerning the application of Lean leadership principles, as
viewed from the perspective of nurses, were calculated by means of Microsoft Excel and IBM
SPSS Software. In order to calculate the internal consistency of the items that measure the
same construct, I have calculated the Cronbach’s α per construct. In case the Cronbach’s α
included a score below 0.7, only the item that was most representative for that specific Lean
leadership principle was included for further analysis. The Cronbach’s α concerning the self-
development, qualification and Gemba did meet the required score of at least 0.7, as shown in
Table 2. The Cronbach’s α of the improvement culture and Hoshin Kanri did not the meet the
33
required score of at least 0.7, as shown in Table 2. Due to the poor correlation between the
items of these three constructs, two items per construct were discarded. As a result, the
analysis concerning the improvement culture will only cover item 1, thereby disregarding
items 2 and 3. Hoshin Kanri will only cover item 13, thereby disregarding items 14 and 15.
Table 2 Second questionnaire: Cronbach’s alpha N Cronbach’s alpha Improvement culture 3 .602 Self-development 3 .714 Qualification 3 .787 Gemba 3 .883 Hoshin Kanri 3 .486
The data derived from this second questionnaire was used to substantiate the answers that
team leaders provided concerning their application of the Lean leadership principles.
Therefore, as this concerns a qualitative analysis, the execution of a regression analysis is not
necessary. In order to determine the extent that nurses believed their team leader applied the
Lean leadership principles, an average score per construct was calculated. This resulted in an
overview of the application of the specific Lean leadership principles of Dombrowski and
Mielke (2014) per inpatient clinic as viewed from the perspective of nurses.
5. Results: Phase 1
This chapter is structured by first presenting the results derived from the first questionnaire,
consisting of the measurements of both Lean implementation success and the application of
Lean leadership principles, followed by a first analysis concerning the five hypotheses.
Subsequently, it will present the results derived from the second questionnaire which will
provide an additional check concerning the application of Lean leadership principles.
First questionnaire
The objectives of the first questionnaire was to present the scores on the level of Lean
implementation success and the scores on the application of Lean leadership principles per
inpatient clinic throughout the ETZ.
Concerning the first objective to measure the level of Lean implementation success, Table 3
shows the average scores on problem solving ability, culture and behavior, Lean progress and
the use of Lean instrument per inpatient clinic. In the sixth column, an average score of these
34
variables is provided which represents the level of Lean implementation success per inpatient
clinic, which refers to the dependent variable in the conceptual model. The inpatient clinics
with the highest level of Lean implementation success are J (ETZ Elisabeth) and BB (ETZ
TweeSteden), as highlighted in green. The inpatient clinics with the lowest level of Lean
implementation success are DD (ETZ TweeSteden) and FF (ETZ TweeSteden), which are
highlighted in red. The cross-signs within the remaining inpatient clinics indicated missing
values within the data collection, meaning that the respondent skipped the question or an
electronic error took place during the moments respondents filled in the questionnaire.
In addition, within Table 3, the average scores of the level of Lean implementation success of
both ETZ Elisabeth as ETZ TweeSteden are provided. ETZ Elisabeth shows an average score
of 2.9, whereas ETZ TweeSteden shows an average score of 3.0. By observing that both
hospitals score around average, the possibility of a location-effect can be excluded during the
analysis.
35
Average Score problem solving ability
Average score culture and behavior
Average score Lean Progress
Lean implementa- tion success
ETZ Elisabeth (2.9) A 2.8 2.9 3.2 2.3 2.8 B 2.1 2.6 2.5 2.6 2.5 C - - - - - D 2.8 2.9 2.8 2.3 2.7 E 1.6 2.0 3.0 3.0 2.4 F - - - - - G 3.5 3.4 2.8 3.0 3.2 H x x x x x I 2.3 3.7 3.2 3.1 3.0 J 4.5 4.1 3.5 3.7 4.0 K 2.8 3.3 x x 3.1 L - - - - - M - - - - - N - - - - - O - - - - - P 3.4 2.3 2.3 2.1 2.5 Q 2.1 1.9 2.8 3.8 2.7 R 3.6 3.0 3.2 2.5 3.1 S 2.3 2.7 3.0 3.7 2.9 T x x x x x U 3.0 3.7 2.8 3.0 3.1 V - - - - - W 2.8 3.0 2.8 3.3 3.2 X 3.0 2.8 3.0 3.2 3.0 Y 2.3 2.4 2.2 3.2 2.5
ETZ TweeSteden (average score = 3.0) Z 3.4 3.9 3.0 3.1 3.3 AA 2.3 2.4 3.0 2.8 2.6 BB 3.5 4.1 3.5 3.4 3.6 CC - - - - - DD 2.8 2.6 2.2 1.2 2.2 EE - - - - - FF 1.1 1.8 2.3 2.1 1.8 GG x x x x x HH - - - - - II 3.1 3.6 3.2 2.2 3.0 JJ 2.4 3.0 3.0 2.5 2.7 KK 2.5 2.3 - - 2.4 LL 2.8 2.1 2.7 1.7 2.3 MM 2.3 2.3 2.7 2.2 2.4 NN 4.0 3.6 2.4 2.6 3.1 OO 3.8 3.7 3.3 2.9 3.4
36
Table 4 presents the means and correlations among variables that can be aggregated to the
dependent variable Lean implementation success. In addition, the means and correlations of
the Lean leadership principles of Dombrowski and Mielke (2014) are presented. As shown in
the second column of Table 4, some respondents did not answer all the items related to the
level of Lean and the use of Lean instruments at an inpatient clinic. Due to multicollinearity,
the correlation between problem solving ability and culture and behavior (.726) as well as the
correlation between qualification and Gemba (.844) should possibly be disregarded, as the
correlation exceed the value of .7 (Pallant, 2007).
37
Table 4 First questionnaire; Descriptives and correlations
N Minimum Maximum Mean S.D. 1. 2. 3. 4. 5. 6. 7. 8. 9.
1. Problem Solving Ability 25 1.13 4.50 2.7500 .75949 1
2. Culture and Behavior 25 1.70 4.10 2.8640 .70112 .726** 1
3. Lean level 23 2.17 4.00 2.8725 .45156 .349 .514* 1
4. Use of Lean instruments 23 1.20 3.75 2.7311 .68582 .045 .280 .497* 1
5. Improvement Culture 23 2.00 5.00 4.0145 .73497 .029 .107 .418* .271 1
6. Self-development 23 2.00 5.00 4.1739 .57621 .220 .039 -.053 .099 .483* 1
7. Qualification 23 2.00 5.00 4.1087 .65830 .085 .203 .121 .151 .628** .467* 1
8. Gemba 23 1.50 5.00 3.7029 .69260 .283 .347 .265 .258 .604** .604** .844** 1
9. Hoshin Kanri 23 2.00 5.00 3.2464 .82399 .257 .380 -.027 -.082 .386 .533** .614** .692** 1 **. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).
38
Concerning the second objective to measure the application of the Lean leadership principles
of Dombrowski and Mielke (2014), Table 5 shows the average scores concerning the
improvement culture, self-development, qualification, Gemba and Hoshin Kanri, as viewed
from the perspective of a team leader. In the seventh column, the average score concerning
these Lean leadership principles is provided. The two inpatient clinics that show the highest
average score on the application of the Lean leadership principles are II (ETZ TweeSteden)
and OO (ETZ TweeSteden), which are highlighted in green. The two inpatient clinics that
show the lowest average score on the application of the Lean leadership principles are A
(ETZ Elisabeth) and W (ETZ Elisabeth), which are highlighted in red.
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Table 5 First questionnaire: Application of Lean Leadership principles Inpatient
Clinic Improvement
Culture Self-
score ETZ Elisabeth (average score = 3.9)
A 2.0 2.0 2.0 - 1.0 1.8 B 4.3 4.0 4.0 3.0 3.3 3.7 C - - - - - - D 4.3 5.0 4.0 4.0 2.3 3.9 E 4.6 4.0 4.0 4.0 2.3 3.8 F - - - - - - G 4.3 4.3 5.0 4.3 4.0 4.4 H x x x x x x I 4.3 4.0 4.0 4.0 4.0 4.1 J 4.7 4.0 4.0 5.0 4.0 4.4 K - - - - - - L - - - - - - M - - - - - - N - - - - - - O - - - - - - P 3.7 5.0 4.0 3.0 3.3 3.8 Q 4.0 5.0 4.0 4.0 3.0 4.0 R 4.3 4.0 4.0 4.0 3.7 4.0 S 4.7 5.0 4.0 4.0 3.7 4.3 T - - - - - - U 4.0 4.0 4.0 4.0 4.0 4.0 V - - - - - - W 3.7 4.0 4.0 3.0 2.7 3.5 X 4.0 5.0 4.0 4.0 2.7 3.9 Y 2.7 4.0 4.0 5.0 3.3 3.8
ETZ TweeSteden (average score = 4.0) Z 3.7 4.0 4.0 4.0 3.0 3.7 AA 4.7 5.0 4.0 4.0 2.3 4.0 BB 5.0 4.0 5.0 4.0 4.0 4.4 CC - - - - - - DD 3.0 4.0 4.0 3.0 4.0 3.6 EE - - - - - - FF 3.7 4.0 4.0 4.0 3.7 3.9 GG x x x x x x HH - - - - - - II 4.7 5.0 5.0 5.0 5.0 4.9 JJ 4.7 5.0 5.0 5.0 2.3 4.4 KK x x x x x x LL 4.3 4.0 4.0 3.0 3.0 3.7 MM 3.7 3.7 3.0 3.0 2.7 3.2 NN 3.3 50 4.0 4.0 3.0 3.9 OO 5.0 5.0 5.0 5.0 4.0 4.8
40
Hypotheses
This section presents the statistical calculations concerning the five hypotheses elaborated on
in this research by means of a multiple regression analysis. The hypotheses are based on the
independent variables the improvement culture, self-development, qualification, Gemba and
Hoshin Kanri.
First, the improvement culture (! = .165, t = 1.22, p = .243; Table 6) turned out not to have a
significant effect on Lean implementation success, thereby not supporting hypothesis 1. This
implicates that when a leader creates an improvement culture, it will not enhance Lean
implementation success.
Second, self-development (! = .677, t = 2.94, p = .010; Table 6) showed a significant effect
on Lean implementation success, thereby supporting hypothesis 2. This implicates that when
a leader focuses on self-development, it will enhance Lean implementation success.
Third, qualification (! = .-0.089, t = -.872, p = .397; Table 6) turned out not to have a
significant effect on Lean implementation success, thereby not supporting hypothesis 3. This
implicates that when a leader provides training, resulting in qualified followers, it will not
enhance Lean implementation success.
Fourth, Gemba (! = .278, t = 2.062, p = .048; Table 6) showed a significant effect on Lean
implementation success, thereby supporting hypothesis 4. This implicates that when a leader
is working and present at the Gemba, it will enhance Lean implementation success.
Fifth, Hoshin Kanri (! = -.112, t = 2.06, p = .388; Table 6) turned out not to have a significant
effect on Lean implementation success, thereby not supporting hypothesis 5. This implicates
that when a Leader emphasizes the importance of follower’s individual contribution, it will
not enhance Lean implementation success.
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Qualification -.089 Gemba .278**
Adjusted $² F
Note: values are standardized (%′')
Table 7 presents a comparison table, which presents the inpatient clinics with the highest and
lowest level of Lean implementation success and their score concerning the application of
Lean leadership principles. Furthermore, it provides the data on the inpatient clinics with the
highest and lowest score concerning the application of Lean leadership principles and their
level of Lean implementation success. Following these results, several findings are important
to consider.
First, the inpatient clinics with the highest level of Lean implementation success did not have
the highest score on the application of the Lean leadership principles. The same applies to the
inpatient clinics with the lowest level of Lean implementation success, as they did not have
the lowest score on the application of the Lean leadership principles. This implies that the
application of Lean leadership principles will not necessarily result in a high level of
implementation success in the healthcare industry.
Second, concerning seven of eight inpatient clinics, the score on the application of Lean
leadership principles turned out to be higher compared to their level of Lean implementation
success.
Third, with regards to inpatient clinics FF and II, the differences between the average scores
of the Level of Lean implementation success and the application of Lean leadership principles
42
are exceptionally large. These are important findings, as they show that even though the team
leaders are committed to the application of Lean leadership principles, it does not always lead
to a high level of Lean implementation success.
Table 7 Comparison Lean implementation success and application of Lean leadership principles Inpatient clinic
Location Lean implementation success
Application Lean leadership principles
DD TSz 2.2 3.6 FF Tsz 1.8 3.9 J Ez 4.0 4.4 BB Tsz 3.6 4.4 A Ez 2.8 1.8 W Ez 3.2 3.5 II TSz 3.0 4.9 OO Tsz 3.4 4.8
Previous section provided the results regarding the measurements of Lean implementation
success and the application of Lean leadership principles per inpatient clinic, viewed from the
perspective of the team leader. In the following section, the perspectives of the nurses are
presented.
Second questionnaire
The objective of the second questionnaire was to present the scores on the application of the
Lean leadership principles, as viewed from the perspectives of the nurses. The goal of this
questionnaire was to provide an additional check concerning the responses that team leaders
provided concerning their application of Lean leadership principles, elaborated on in the first
questionnaire. Within Table 8, the average scores concerning the application of the Lean
leadership principles are presented, as viewed from the perspective of the nurses. This chapter
will compare the results concerning the perspectives of both the team leader and his or her
nurses concerning the application of the Lean leadership principles. In addition, it will
compare these results with the level of Lean implementation success at the inpatient clinic in
order to analyze whether the application of Lean leadership principles also results in a higher
level of Lean implementation success.
As shown in Table 8, the nurses working at inpatient clinic B indicated a much lower score on
the application of the Lean leadership principles compared the own judgment of the team
43
leader. In addition, the team leader provided a higher score on the application of the Lean
leadership principles compared to the level of Lean implementation success, whereas the
nurses provided a lower score on the application of the Lean leadership principles compared
to the level of Lean implementation success. This is notable as it turned out that the team
leader and the nurses are not in agreement concerning the application of the Lean leadership
principles, but are indeed successful in the implementation of Lean. This could imply that the
nurses attach less value at the application of Lean leadership principles in order to implement
Lean at the inpatient clinic
The nurses working at inpatient clinic D indicated a lower score on the application of the
Lean leadership principles compared to the own judgment of the team leader. However, as it
concerns an average score of 4.3 opposed to an average score of 4.4, the difference is very
small. Both the team leader as the nurses indicated an average score on the application of the
Lean leadership principles that exceeds the average score on the level of Lean implementation
success. Knowing that inpatient clinic D has a high level of Lean implementation success, and
both the team leader and the nurses indicated an average score on the application of Lean
leadership principles, this would imply that Lean leadership could be valuable in order to
implement Lean.
The nurses working at inpatient clinic A indicated a lower score on the application of the Lean
leadership principles compared to the own judgment of the team leader. Still, both the
perspectives of the team leader and the nurses turned out to be higher compared to their level
of Lean implementation success. As it concerns an inpatient clinic with a low level of Lean
implementation success, it would imply that the application of Lean leadership principles will
not necessarily be valuable in order to implement Lean.
Concerning the response received from the nurses working at inpatient clinic C, only one
nurses provided feedback. As it concerns the inpatient clinic with the lowest level of Lean
implementation success, this is a typical finding. It suggests that very low priority is set on the
Lean-philosophy.
44
Table 9 presents the means and correlations among the five Lean leadership principles of
Dombrowski and Mielke (2014). Due to multicollinearity, the correlations between Gemba
and the improvement culture (.777), Gemba and self-development (.817), Gemba and
qualification (.840), Hoshin Kanri and the improvement culture (.733) and Hoshin Kanri and
Gemba (.793) should possibly be disregarded, as the correlation exceed the value of .7
(Pallant, 2007).
High Lean implementation success Low implementation success Inpatient Clinic B Inpatient Clinic D Inpatient Clinic A Inpatient Clinic C
2.8 4.5 3.9 3.4 2.9 4.5 3.5 3.1 4.6 4.5 3.7 3.8 4.7 3.6 4.5 3.3 3.6 4.3 3.4
3.7 3.8 3.9 3.8 3.9 3.8
3.9 Average score perspective nurses
3.3 4.3 3.6 3.4 Average score perspective team leader
4.4 4.4 3.5 3.9 Level of Lean implementation success
4.0 3.5 2.7 1.8
N Minimum Maximum Mean S.D. 1. 2. 3. 4. 5.
1. Improvement Culture 21 2,67 4,67 3,8254 .56391 1
2. Self-development 21 2,67 5,00 3,9683 .54676 .687** 1
3. Qualification 21 2,67 5,00 3,8571 .69579 .641** .698** 1
4. Gemba 21 2,67 5,00 3,8413 .83413 .777** .817** .840** 1
5. Hoshin Kanri 21 2,67 4,33 3,6667 .53748 .733** .624** .654** .793** 1 **. Correlation is significant at the 0.01 level (2-tailed).
46
6. Discussion: Phase 1
Within this chapter, the results derived from the first phase of this research are discussed. In
addition, it will provide certain limitations that are important to consider.
6.1 Main findings
Within the first questionnaire, team leaders had to assess on the level of Lean implementation
success and the application of Lean leadership principles at their inpatient clinic. With these
results, an answer was provided concerning the extent that the five Lean leadership principles
of Dombrowski and Mielke (2014) have on Lean implementation success. Within this
research, it was hypothesized that the improvement culture, self-development, qualification,
Gemba and Hoshin Kanri would enhance Lean implementation success. Following the results,
the relationships of both self-development and Gemba on Lean implementation success,
showed statistically significant results. The results regarding the improvement culture,
qualification and Hoshin Kanri on Lean implementation success showed no statistically
significant results. Therefore, following the quantitative results, it can be concluded that the
Lean leadership principles of Dombrowski and Mielke (2014) are only partially applicable for
the healthcare industry.
The relationship between Lean leadership and Lean implementation success has been the
focus of research by many scholars. Therefore, it is valuable to compare current findings with
the existing literature in order to explain the potential different outcomes. The supported
relationships between self-development and Gemba on the level of Lean implementation
success are in lin