Parallel session at European Lean Educator Conference 2017

1. faculty of economics
and business
innovation management &
strategy
Continuous improvement in HC:
towards a mature approach
ELEC 2017, 8-9 Nov
Session: Learning Lean / Lean Learning in Healthcare
dr. O.P. (Oskar) Roemeling
University of Groningen
o.p.roemeling@rug.nl
Authors: Bianca van Elp, Oskar Roemeling & Nick Ziengs

2. |
faculty of economics
and business
innovation management &
strategy
An opportunity for improvement…

3. |
faculty of economics
and business
innovation management &
strategy
Some background….
Msc. thesis project focused on Leadership and CI.
Successful project at a case organization with several years of
experience with Lean.
The limited attention to soft-aspects made us decide to build a paper.
We plan to submit our final-paper to Production Planning and Control.
Today: highlights and main insights.

4. |
faculty of economics
and business
innovation management &
strategy
Study background
Lean aims to improve process flow through the reduction of waste and
variation and is one of the most popular approaches in HC.
(D’Andreamatteoa, Iannia, Legab, & Sargiacomoa, 2015; Roemeling, Land, Ahaus, Slomp, & Bijllaardt, 2017; Shah & Ward,
2007)
Main pillar of Lean is continuous process improvement or CI, and CI can be
seen as a dynamic capacity to achieve a sustained competitive advantage.
(Teece, Pisano, & Shuen, 1997)
CI initiatives in healthcare environments rarely get past the initial stages of
maturity.
(Roemeling, Land, & Ahaus, 2017)
Soft aspects, such as leadership, of CI receive little attention, yet these are
becoming more and more relevant in the discussion of Lean.
(Radnor, 2010; Poksinska, 2010; Matthias and Brown, 2016; Losonci, Kása, Demeter, Heidrich, and Jenei, 2017)

5. |
faculty of economics
and business
innovation management &
strategy
Study background
Our research underlines the importance of soft aspects when working
according to Lean principles.
We focus on the role of leadership style and explore the relationship between
leadership and maturity of the Lean approach.
Central RQ:
How do transactional and transformational leadership styles
facilitate the development of continuous improvement activities?

6. |
faculty of economics
and business
innovation management &
strategy
Some theory…
We think of continuous improvement as:
An organization its attempts to continuously analyze work
processes, and introduce both incremental and large scale
improvements.
We can distinguish between five stages of CI development
(maturity). (Bessant et al. 1992 )
1. Pre-interest --- 5. embedded in organizational routines.

7. |
faculty of economics
and business
innovation management &
strategy
Some theory…
Transformational: characterized by a focus on- and care about
followers and their personal needs and development.
Transactional: relationship focused on extrinsic rewards, give
and take.
Maturity CI Behavior Goals Focus Suggested
Leadership Style
1 Pre-CI interest “Natural” or background
improvement
Short-term General Transactional
2 Structured CI Formal attempts to create
and sustain CI
Short-term General Transactional
3 Goal-oriented CI CI is directed at company
goals and objectives
Long-term Specific Transformational
4 Proactive CI CI is largely self-driven by
individuals and groups
Long-term Specific Transformational
5 Full CI capability CI is the dominant way
of life
Long-term Specific Transformational

8. |
faculty of economics
and business
innovation management &
strategy
Approach
To investigate the role of Leadership styles in CI maturity we conducted an
embedded single case study.
EldCare: healthcare provider in the Netherlands, employs over 6.000
people. In 2010 EldCare adopted Lean as their preferred CI approach.
EldCare won the first national Lean award in 2014.
The organization focuses primarily on providing nursing care, either at
home or at one of the eight EldCare facilities.

9. |
faculty of economics
and business
innovation management &
strategy
Approach
Data collection:
• Interviews: 17 in total with team leaders and members.
• Site visits: during orientation and research phase.
• Observations: during team meetings.
• Documents: e.g. internal reports.
Analysis:
• Coding of transcripts using inductive and deductive codes.
First within teams, then across teams.

10. |
faculty of economics
and business
innovation management &
strategy
Findings
Based on interviews and observations we determine leadership style.
Manager Leadership Style Explanation
MAN01 Transactional Direct, open, confronting, say what you see, asks many
questions, customer-oriented, impose conditions,
contingent reward, action-oriented, overseeing
MAN02 Transactional
(transformational)
Direct, action-oriented, asks many questions, taking
decisions, apodictic, involvement, contingent reward,
overseeing, connector
MAN03 Transactional
(transformational)
Action-oriented, listens, asks questions, contingent
reward, passive management-by-exception, being
proud, self-confidence
MAN04 Transformational
(transactional)
Focus on feeling good, asks an open attitude, listens,
learn from mistakes, facilitates, cooperation at the work
floor, action-oriented, contingent reward
MAN05 Transformational Use of metaphors, involvement, enthusiastic, future-
oriented, good atmosphere, being a role model,
personal attention, customer and care-oriented

11. |
faculty of economics
and business
innovation management &
strategy
Team
Lean
since ...
Level
Maturity
1 2 3 4 5
TM01
2012 3 Goal-oriented CI
Explanation: Pilot location, structure of “Improve” is not fully implemented,
label “Improve” is unknown but the tools are known, structural problem-solving
Quotes
MAN04: “We have an open culture at this location”
MEM06: “The manager is very involved, he listens to me and tries to
understand me”
TM02
2012 2 Structured CI
Explanation: Pilot location, different managers in short time frame, barely
familiar with every tool, not everyone at the location is informed, structural
problem-solving
Quotes
MAN03: “I hope that the Lean consultants stay at our organization”
MEM05: “He always has his door open, he is really approachable”
TM03 2012 4 Proactive CI
Explanation: Pilot location, CI is integrated, familiarity with “Improve” and
every tool, progressiveness, structural problem-solving
Quotes
MAN02: “I see at other locations that the Lean consultant is more on the
foreground, but I do everything by myself at this location”
MEM09: “I think it is a pity that the manager is barely apparent at the work
floor”

12. |
faculty of economics
and business
innovation management &
strategy

13. |
faculty of economics
and business
innovation management &
strategy

14. |
faculty of economics
and business
innovation management &
strategy
Discussion
Based on previous studies (e.g. Bessant et al., 1992; Crosby, 1979; Cupello, 1994), we
expected that the longer team members work with continuous
improvement principles, the more mature the approach becomes.
Our studied case did not support this assumption.
We identify differences in maturity in teams, this difference does
not appear to be linearly related to the time of introduction of the
continuous improvement principles.

15. |
faculty of economics
and business
innovation management &
strategy
Discussion
In order to move to a more mature approach a mix of both
transactional and transformational styles is more effective than a
single style.
This is in contradiction with most established ideas where the
transformational style is the preferred style. Especially when
thinking of Lean applications.

16. |
faculty of economics
and business
innovation management &
strategy
Proposition 1: Adopting a single leadership style will limit CI
maturity and prevent the achievement of full CI maturity.
Proposition 2: A transactional leadership style should be
emphasized at lower levels of CI maturity, whereas a
transformational leadership style should be emphasized at
higher levels of maturity.
Proposition 3: A mix of leadership styles is more effective in
reaching higher levels of CI maturity than applying a single
leadership style.
Discussion

17. |
faculty of economics
and business
innovation management &
strategy
Contact?
o.p.roemeling@rug.nl