Lean, Team and Psychosocial Factors a Longitudinal Investigation at a Swedish Hospital

Background: As health care struggles to meet increasing demands with limited resources, Lean Management is becoming a popular management approach. More is known about operational aspects of Lean application than about the socio-technical aspects such as how Lean interacts with teamwork and the psychosocial work environment. It is also unclear why and how organizations adopt Lean. Aim: This project, including four sub-studies, aimed to identify the antecedents and characteristics of Lean implementation at a Swedish Hospital. The research for this thesis also examined longitudinal changes in certain socio-technical aspects of Lean (i.e., teamwork and the psychosocial work environment). Methods: The thesis used a case study design (with data from interviews, observations and documents) to examine information about the Lean implementation at two cardiac inpatient wards and at an emergency care department at a Swedish hospital (Studies I & IV). Using employee questionnaires during the Lean implementation, teamwork and the psychosocial work environment were measured in two time periods (T1 & T2), a year and a half apart. To avoid post-hoc explanations, qualitative data about the intervention and the context was used to predict expected change patterns in teamwork and the psychosocial work environment from T1 to T2. These predictions were compared with the questionnaire data using linear regression analysis (Studies II & III). Findings: A previous history of quality improvement was an antecedent for the hospital’s adoption of Lean. Contextual factors seemed to influence both Lean implementation and its sustainability. For example, adoption of Lean varied with the degree to which staff saw a need for change. Continuous improvement, supported by visual management, when adopted successfully, kept the staff engaged and committed. Employee involvement in the Lean implementation may minimize the intervention’s harmful effects on psychosocial work factors. Lean may influence teamwork, particularly in relation to structural and productivity issues. Conclusions: The success of Lean implementation depends on its adaptation to contextual factors. In addition to the traditional focus of Lean on operational performance, the employee perspective is also important in designing, implementing and sustaining Lean. Engaging the employees in the Lean change process not only helps to sustain initial Lean success but also helps avoid harmful effects of Lean on the work environment. An initial Lean success may be sustained by engaging the staff in the change process using continuous improvement supported by visual management. Practitioners should note that, with groups struggling at initial stages of group functioning, the introduction of Lean may pose a significant challenge. To my father, Maqsood Ulhassan (late) LIST OF PUBLICATIONS I. Ulhassan W, Sandahl C, Westerlund H, Henriksson P, Bennermo M, Schwarz U, Thor J. Antecedents and characteristics of Lean thinking implementation in a Swedish hospital: a case study. Qual Manag Health Care. 2013;22(1):48-61. II. Ulhassan W, Westerlund H,Thor J, Sandahl C, Schwarz U. Does Lean Implementation interact with group functioning? Accepted for publication in Journal of Health Organization and Management. III. Ulhassan W, Schwarz U, Thor J, Westerlund H. Interactions between Lean Management and the Psychosocial Work Environment in a Hospital Setting – A Multi-Method Study. Submitted. IV. Ulhassan W, Schwarz U, Westerlund H, Sandahl C, Thor J. How Visual Management for Continuous Improvement Might Guide and Affect Hospital Staff – A Case Study. Submitted. The studies are referenced in the thesis by their Roman numerals