LEAN HEALTHCARE RESEARCH...

LEAN HEALTHCARERESEARCH SYMPOSIUM

2019

LEAN AND PHYSICIANS: From Antecedents to Behavioral Support of Change

Pierre-Luc Fournier, PhDAssistant ProfessorDepartment of Information Systems and Quantitative Methods for ManagementBusiness SchoolUniversity of Sherbrooke

Introduction

Lean in Healthcare

3

THE ORIGINS OF LEAN

1930 20191940 1950 1960 1970

Taichi Ohno begins work on

TPS

Edwards Deming arrives in Japan

First written documentation on TPS

1965

“Lean” is coined by John Krafcik.

Five principles of Lean by

Womack and Jones1996

DNA of the TPS in HBR by Spear

1999

1980

“The Machine that changed the world” is

published.

1990 2000

Shigeo Shingo develops

SMED.1969

Shingo develops Poka-Yoke based on

Jidoka.

1960Ohno works on Kanban, JIT and the reduction of

wastes.

International Motor Vehicle Program at MIT

1979

1988

1947

NUMMI joint venture, GM &

Toyota1984

The Toyota Way by Liker

2004

Nightingale and Mize: lean

as a holistic management

system2002

10 dimensions of Lean by Shah and Ward

1990

2007

Toyota Kata by Rother

2010

CLEAR Research Symposium 2019 – Pierre-Luc Fournier, PhD

4

• Worldwide use (early 2000s)

• Disputed results

• Trouble sustainingimplementation

LEAN IN HEALTHCARE

From Costa and Godinho Filho (2016) and Moraros, Lemstra et al. (2016)


5

• For many, Lean in healthcare has failed to produce conclusive gains at the organizationallevel (Radnor and Osborne 2012).

• Two recent studies delved deep into the subject.

Costa and Godinho Filho (2016)

• Literature review

• Current trends in academic research

• 107 papers on Lean healthcare

Moraros, Lemstra et al. (2016)

• Literature review

• The impact of Lean interventions in healthcare

• 22 papers on Lean impact evaluation

Conclusion: no conclusive evidence of positive effects of Lean at the organizational level...

THE UNFULFILLED PROMISE…


6

FINDINGS

• Implementation is localized• Based on tools and techniques (visual elements)

• Systematization of gains is difficult

• Organizations are caught in a ‘’state of transition.’’• Project-based mindset• Maturity does not progress• Daily continuous improvement rarely takes place

• Sustaining Lean is difficult!


7

SHORTELL, RUNDALL ET AL.

Stephen M. Shortell Ph.D. Professor of Health Policy and Management,Dean Emeritus,School of Public HealthUniversity of California at Berkeley

Thomas Rundall, Ph.D.Professor of Health Policy and ManagementSchool of Public HealthUniversity of California at Berkeley

1222 American hospitals

69.3% use Lean

Positive impact of Lean on organizationalperformance

• Maturity level• Leader engagement• Daily management system• Training and coaching

Shortell, S. M., Blodgett, J. C., Rundall, T. G., & Kralovec, P. 2018. Use of Lean and Related Transformational Performance Improvement Systems in Hospitals in the United States: Results From a National Survey. Joint Commission Journal on Quality and Patient Safety.


8

WHY SUCH DIFFICULTY?

Fournier, P.-L., & Jobin, M.-H. 2018. Understanding before implementing: the context of Lean in public healthcare organizations. Public Money & Management, 38(1): 37-44.


PHYSICIANSAs Organizational Actors

10

PHYSICIANS AS ORGANIZATIONAL ACTORS

STATUS• Atop the clinical hierarchy (Kellogg 2009)• Ascendancy over all other healthcare professionals

(Giaimo 2009)

POWER• Large professional autonomy (Giaimo 2009)• Monopoly of expertise (McNulty and Ferlie 2002)

Creates a leadership paradox. Pluralism Concentratedpower

‘’Central decision-makers’’ of both the clinicaland administrative domains (Battilana and Casciaro 2012)

Traditional ‘’rewards and punishments’’ don’t work(Callister and Wall Jr, 2001)


11

PHYSICIAN CENTRALITY AND CHANGE

Inertia towards change (Cabana, Rand et al. 1999)

Resistance tends to be higher(Lapointe and Rivard 2005, Lapointe and Rivard 2007, Rivard, Lapointe et al. 2011)

Negotiate their participation (McNulty and Ferlie 2002)

• Professional dominance

• Decision-making authority

• Professional judgment

• Economic well-being

• Organization of work

• Quality of care to patients

Exacerbated if change threatens

However, physicians can also be powerful change agents (Goldstein and Ward 2004)!• They must be involved in strategic decision-making and viewed as partners.


12

PHYSICIANS AND LEAN

• Physician engagement is critical to success (Toussaint, Billi et al. 2017)

• Physicians can be barriers to implementation (Lorden, Zhang et al. 2014)

• However, no empirical studies go beyond ‘’physician engagement is important for Lean change’’.

• Before Lean, drawing on TQM and BPR…• Under-involvement (Shortell, Levin et al. 1995)

• Fail when imposed on physicians (McNulty andFerlie 2004)

• "Medical work is complex and not accessible to standardization" (Freidson, 1984)

• “Sacred view of healthcare” (Zimmerer, Zimmerer et al. 1999)


COMMITMENT TO ORGANIZATIONAL CHANGE

And What Influences It.

14

COMMITMENT TO CHANGE

Herscovitch, L., & Meyer, J. P. 2002. Commitment to organizational change: extension of a three-component model. Journal of Applied Psychology, 87(3): 474.

Continuance commitment

to cange

+

-

Normative commitment

to change +

Affective commitment

to change

Behavioral Support for change


15

ANTECEDENTS OF CHANGE

Oreg, S., Vakola, M., & Armenakis, A. 2011. Change recipients’ reactions to organizational change: A 60-year review of quantitative studies. The Journal of Applied Behavioral Science, 47(4): 461-524.

Category Definition Sub-category

Pre-changeantecedents

Pre-existing conditions in place priorto the change

Individual characteristics

Internal organizational context

Changeantecedents Aspects related to the change itself

Content of the change

Process of the change

Perceived benefits of the change

Antecedents are the ”reasons for the reactions rather than the reaction itself”.


16

Behavrioal support for

Lean change (BSUP)

+

-

Affective commitment to

Lean change (ACC)

Continuance commitment to

Lean change (CCC)

CONCEPTUAL MODEL


Perceived benefits

Reduction of costsImprovement of qualityImprovement of patient satisfactionImprovement of working life

Individual characteristics

Lean experience

Internal organizational context

History of organizational supportHistory of organizational change

Process of the change

CompensationParticipationQuality of change communicationTransformational leadership behavior

Pre-

chan

ge

Content of the change

Extent of the change

H2a, H3a

Cha

nge H5b, H6b, H7b, H8b

METHOD

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RESEARCH METHOD

SURVEY

• Survey development with validation from experts across North America

• Use of existing measures (58 items)

• Email• Two reminders

• Hosted online by QUALTRICS

Quantitative methodology


19

SAMPLE

NWNC

SW

SC

NEMW

Over 60 hospitals

N = 632 physicians

n = 176 physicians

Response ate = 27,85%


20

DEMOGRAPHIC VARIABLES

Respondants (N = 632, n = 176)

n Percentage

Gender Male 95 54.0 %Female 81 46.0 %

Medical SpecialtySpecialist 80 45.5 %General practitioner 96 54.5 %

Employment statusEmployee 114 64.8 %

Independant worker 62 35.2 %

Compensation No 151 85.8%Yes 25 14.2%

Previous Lean experience No 60 34.1%Yes 116 65.9%

Response rate = 27.85%


21

MEASUREMENT RELIABILITY AND CONSTRUCT VALIDITY

• Confirmatory Factor Analysis using MaximumLikelyhood approach.

• Average Variance Extracted (AVE) for convergent validity (0,520 to 0,835)

• AVE > Max r2 for divergent validity

• Reliability using Graham (2006)


Good Fit!

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COMMON METHOD BIAS

1. Separation strategy (Podsakoff, MacKenzie et al. 2003)• Measures were psychologically separated• Participants guaranteed anonymity

2. Harman’s single factor test (Harman 1976)• Largest explained variance by any single factor was 38.64%

3. CFA using latent factor test (Podsakoff, MacKenzie et al. 2003)• No loss of significance• No improvement of model fit


RESULTSAnd analysis

24

STRUCTURAL MODEL

• Structural Equation Modeling• Model trimming approach (Ullman

and Bentler, 2012)

• Controlling for:age, gender, medical specialty and employment status

• Mediation analysis• bootstrapping method at 5000

samples.

Good Fit!


25

Behavioral support of Lean change

Affective commitment to

Lean change

Continuancecommitment to

Lean Change

Individual CharacteristicsAgeGenderMedical specialtyLean experience

Internal Organizational ContextHistory of organizational supportHistory of organizational change

Content of the ChangeExtent of change

Process of ChangeCompensationParticipationQuality of change communicationTransformational leadership behavior

Perceived BenefitsReduction of costsImprovement of qualityImprovement of patient satisfactionImprovement of working life


DISCUSSION

27

COMMITMENT TO LEAN CHANGE

• Affective commitment is the transmission that favors the adoption of new behaviors.

• Continuance commitment has little to no effect on behavioral support for Lean change.


28

PRE-CHANGE ANTECEDENTS

Individual Characteristics

• Demographic variables(age, gender, medical specialty)

• Lean experience

• Employment status

Internal Organizational Context

• History of organizational support

• History of organizational change


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Individual Characteristics

• Demographic variables(age, gender, medical specialty)

• Lean experience

• Employment status

No significant effect!

Significant effect:• Training• Familiarity with Lean favors

affective commitment


30


Internal Organizational Context

• History of organizational support• History of organizational change

Little to no impact on behavioralsupport fo Lean change.

That is (very) good news…


31

CHANGE ANTECEDENTS

Content of the Change

Perceived BenefitsProcess of Change

• Extent of change • Participation

• Compensation

• Quality of change

communication

• Transformational

leadership behavior

• Reduction of costs

• Improvement of quality

• Improvement of patient

satisfaction

• Improvement of

working life


32

CHANGE ANTECEDENTS

Content of the Change

Surprisingly…minimal impact on behavioral support for Lean change.

• Extent of change


33

CHANGE ANTECEDENTS

Perceived benefits

Confirms what we have known for a while…

Lean for cost reduction = high risk of failure

Pay attention to the organizational discourseregarding Lean

• Reduction of costs

• Improvement of quality

• Improvement of patient

satisfaction

• Improvement of

working life


34

CHANGE ANTECEDENTS

Process of Change

• Participation

• Compensation

• Quality of change

communication

• Transformational

leadership behavior


35

CHANGE MANAGEMENT

Process of change

• Participation• Compensation• Quality of change

communication• Transformational leadership

behavior

Physicians must be involved in the decision-making process.

Not simply informed…


36

CHANGE MANAGEMENT

Process of change



behavior

Paying physicians for theirparticipation is not conclusive.

Can even be negative, because itstimulates continuancecommitment…


37

CHANGE MANAGEMENT

Process of change



behavior

Relevant and accurate information.

Communicate the reasons for the change.

Communicate continuously, throughout the change.

Avoid infobesity!


38

CHANGE MANAGEMENT

Process of change



behavior

The six dimensions of transformationalleadership behavior:1. Articulate a vision;2. Provide a role model;3. Communicating high performance

expectations;4. Provide individual support;5. Foster the acceptance of group goals;6. Provide intellectual stimulation.

Rubin, R. S., Munz, D. C., & Bommer, W. H. 2005. Leading from within: The effects of emotion recognition and personality on transformational leadership behavior. Academy of Management Journal, 48(5): 845-858.


39

CHANGE MANAGEMENT

Process of change



behavior

Liker, J. K., Convis, G. L., & Meskimen, J. 2012. The Toyota way to lean leadership: achieving and sustaining excellence through leadership development: McGraw-Hill.

TRUE NORTH VALUESChallenge

Kaizen MindGo and SeeTeamwork

Respect

1. Commit to Self-DevelopmentLearn to live the True North Values throughrepeated Learning Cycles.

3. Support Daily KaizenBuild local capability throughout for dailyManagement & Kaizen.

4. Create Vision and Align GoalsCreate True North vision and align goals vertically and horizontally.

2. Coach and Develop OthersSee and challenge true potential in othersthrough self-development learning cycles.


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CHANGE MANAGEMENT

Process of change



behavior

In the end...

Organizations must invest in the development of their changemanagement capabilities.


CONCLUSION

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CONCLUSION

Contributions:1. Notorious difficulty to study physicians as organizational actors.

• Especially with quantitative methods

2. First quantitative study on the role of physicians during Lean change.

3. Investigation of an operations management phenomena using behavioral sciences.

4. Offers insights and potential solutions to healthcare organizations undergoing Lean

change.

Objective: understand the impact of antecedents of change on physicians’ behavioral support of Lean change.

Limits:1. USA vs other jurisdictions2. Physicians as a cluster of individuals3. Use of cross-sectional data must be enhanced.


ACKNOWLEDGEMENTS

44CLEAR Research Symposium 2019 – Pierre-Luc Fournier, PhD

QUESTIONS?

46

Pierre-Luc Fournier, PhDAssistant ProfessorDepartment of Information Systems and Quantitative Methods for ManagementBusiness SchoolUniversité de Sherbrooke

819 821-8000, poste [email protected]


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