Kees Ahaus

Implementation of Lean Six Sigma in small- and medium- sized manufacturing enterprises in the Netherlands

In this paper we provide an exploration and analysis of Lean Six Sigma (LSS) implementation in Dutch manufacturing/engineering small- and medium-sized enterprises (SMEs). Critical success factors (CSFs) and impeding factors are identified and analysed. Exploratory empirical evidence about LSS implementation in Dutch SMEs was collected from a survey study on Dutch SMEs. Statistical testing was applied to validate the ranking of the CSFs. To deepen insight in how organizations translate CSFs into practice and cope with impeding factors, additional in-depth qualitative information was gathered from six case studies. Linking to customer, vision and plan statement, communication and management involvement and participation are the highest ranked CSFs. Internal resistance, the availability of resources, changing business focus and lack of leadership are the strongest impeding factors. The case studies confirmed the importance of the CSFs and revealed three new CSFs: personal LSS-experience of Top management, development of the project leaders soft skills and supply chain focus. SMEs in the Netherlands make no distinct separation between lean manufacturing and Six Sigma, but rather apply both approaches intertwined.

A four phase development model for integrated care services in the Netherlands

BackgroundMultidisciplinary and interorganizational arrangements for the delivery of coherent integrated care are being developed in a large number of countries. Although there are many integrated care programs worldwide, the process of developing these programs and interorganizational collaboration is described in the literature only to a limited extent. The purpose of this study is to explore how local integrated care services are developed in the Netherlands, and to conceptualize and operationalize a development model of integrated care.MethodsThe research is based on an expert panel study followed by a two-part questionnaire, designed to identify the development process of integrated care. Essential elements of integrated care, which were developed in a previous Delphi and Concept Mapping Study, were analyzed in relation to development process of integrated care.ResultsIntegrated care development can be characterized by four developmental phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase; and the consolidation and transformation phase. Different elements of integrated care have been identified in the various developmental phases.ConclusionThe findings provide a descriptive model of the development process that integrated care services can undergo in the Netherlands. The findings have important implications for integrated care services, which can use the model as an instrument to reflect on their current practices. The model can be used to help to identify improvement areas in practice. The model provides a framework for developing evaluation designs for integrated care arrangements. Further research is recommended to test the developed model in practice and to add international experiences.

The implementation of integrated care: the empirical validation of the Development Model for Integrated care.

BackgroundIntegrated care is considered as a strategy to improve the delivery, efficiency, client outcomes and satisfaction rates of health care. To integrate the care from multiple providers into a coherent client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and patient transfers. The Development Model for Integrated care (DMIC) describes nine clusters containing in total 89 elements that contribute to the integration of care. We have empirically validated this model in practice by assessing the relevance, implementation and plans of the elements in three integrated care service settings in The Netherlands: stroke, acute myocardial infarct (AMI), and dementia.MethodsBased on the DMIC, a survey was developed for integrated care coordinators. We invited all Dutch stroke and AMI-services, as well as the dementia care networks to participate, of which 84 did (response rate 83%). Data were collected on relevance, presence, and year of implementation of the 89 elements. The data analysis was done by means of descriptive statistics, Chi Square, ANOVA and Kruskal-Wallis H tests.ResultsThe results indicate that the integrated care practice organizations in all three care settings rated the nine clusters and 89 elements of the DMIC as highly relevant. The average number of elements implemented was 50 ± 18, 42 ± 13, and 45 ± 22 for stroke, acute myocardial infarction, and dementia care services, respectively. Although the dementia networks were significantly younger, their numbers of implemented elements were comparable to those of the other services. The analyses of the implementation timelines showed that the older integrated care services had fewer plans for further implementation than the younger ones. Integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding their integrated care activities.ConclusionsAlthough the patient composites and the characteristics of the 84 participating integrated care services differed considerably, the results confirm that the clusters and the vast majority of DMIC elements are relevant to all three groups. Therefore, the DMIC can serve as a general quality management tool for integrated care. Applying the model in practice can help in steering further implementations as well as the development of new integrated care practices.

The usefulness of lean six sigma to the development of a clinical pathway for hip fractures

AIMS AND OBJECTIVES The objective of this study was to show the usefulness of lean six sigma (LSS) for the development of a multidisciplinary clinical pathway. METHODS A single centre, both retrospective and prospective, non-randomized controlled study design was used to identify the variables of a prolonged length of stay (LOS) for hip fractures in the elderly and to measure the effect of the process improvements--with the aim of improving efficiency of care and reducing the LOS. RESULTS The project identified several variables influencing LOS, and interventions were designed to improve the process of care. Significant results were achieved by reducing both the average LOS by 4.2 days (-31%) and the average duration of surgery by 57 minutes (-36%). The average LOS of patients discharged to a nursing home reduced by 4.4 days. CONCLUSION The findings of this study show a successful application of LSS methodology within the development of a clinical pathway. Further research is needed to explore the effect of the use of LSS methodology at clinical outcome and quality of life.

Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety

BackgroundPracticing safe behavior regarding patients is an intrinsic part of a physician’s ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians’ risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians’ behaviors.MethodsWe carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach.ResultsWe identified four factors that could affect the relationship between malpractice litigation risk and physicians’ behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals’ response to physicians following incidents.ConclusionIn complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

Implementation of continuous improvement based on Lean Six Sigma in small- and medium-sized enterprises

Research has highlighted a need for a specific and practical implementation framework for deploying Lean Six Sigma (LSS) in small- and medium-sized enterprises (SMEs). The success of LSS implementation in SMEs is highly dependent on the extent to which an LSS deployment programme addresses the specific properties of SMEs. In this study we have evaluated an existing framework for Six Sigma implementation for SMEs [Kumar, M., Antony, J., & Tiwari, M. K. (2011). Six Sigma implementation framework for SMEs – a roadmap to manage and sustain the change. International Journal of Production Research, 49(18), 5449–5467] using a multi-method triangulation approach. The objectives of this study were firstly to strengthen the foundations of the existing framework by uncovering evidence for some of its elements and, secondly, to identify the proposed revisions to the framework, especially focussed on its application in manufacturing SMEs. The results of our study are a collection of confirmations and revision proposals for the framework, leading to a revised conceptual framework.

The moderating role of leadership in the relationship between management control and business excellence

This study deals with the moderating role of leadership in the relationship between management control as part of total quality management (TQM) and business excellence in terms of purposive change. Data were collected via a survey filled out by managers working at 44 locations in the Correctional Services sector of the Correctional Institutions Agency (DJI) in the Netherlands. A total of 618 responses (83%) were obtained. Our hypothesis was derived from a conceptual model and tested using Pearsons r as an effect size index. The results show strong relations between the dimensions of management control and the styles of active leadership, on the one hand, and between the management control dimensions and business excellence in terms of purposive change, on the other hand. The results also indicate that transformational leadership is the most influential factor in the relationship between the management control construct and purposive change. It is concluded that organisations are strengthened by a management control system which is applied in combination with an intensive management communication approach in a context of transformational leadership. These findings have important implications for the further research on interventions in management control as part of TQM.

Service decomposition: a conceptual analysis of modularizing services

Purpose – Applying “modularity” principles in services is gaining in popularity. The purpose of this paper is to enrich existing service modularity theory and practice by exploring how services are being decomposed and how the modularization aim and the routineness of the service(s) involved may link to different decomposition logics. The authors argue that these are fundamental questions that have barely been addressed. Design/methodology/approach – The authors first built a theoretical framework of decomposition steps and the design choices involved that distinguished six decomposition logics. The authors conducted a systematic literature search that generated 18 empirical articles describing 16 service modularity cases. The authors analysed these cases in terms of decomposition logic and two main contingencies: modularization aim and service routineness. Findings – Only three of the 18 articles explicitly addressed the service decomposition by reflecting on the underlying design choices. By unravelling...

A survey study to validate a four phases development model for integrated care in the Netherlands

BackgroundThe development of integrated care is a complex and long term process. Previous research shows that this development process can be characterised by four phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase and the consolidation and transformation phase. In this article these four phases of the Development Model for Integrated Care (DMIC) are validated in practice for stroke services, acute myocardial infarct (AMI) services and dementia services in the Netherlands.MethodsBased on the pre-study about the DMIC, a survey was developed for integrated care coordinators. In total 32 stroke, 9 AMI and 43 dementia services in the Netherlands participated (response 83%). Data were collected on integrated care characteristics, planned and implemented integrated care elements, recognition of the DMIC phases and factors that influence development. Data analysis was done by descriptive statistics, Kappa tests and Pearson’s correlation tests.ResultsAll services positioned their practice in one of the four phases and confirmed the phase descriptions. Of them 93% confirmed to have completed the previous phase. The percentage of implemented elements increased for every further development phase; the percentage of planned elements decreased for every further development phase. Pearson’s correlation was .394 between implemented relevant elements and self-assessed phase, and up to .923 with the calculated phases (p < .001). Elements corresponding to the earlier phases of the model were on average older. Although the integrated care services differed on multiple characteristics, the DMIC phases were confirmed.ConclusionsIntegrated care development is characterised by a changing focus over time, often starting with a large amount of plans which decrease over time when progress on implementation has been made. More awareness of this phase-wise development of integrated care, could facilitate integrated care coordinators and others to evaluate their integrated care practices and guide further development. The four phases model has the potential to serve as a generic quality management tool for multiple integrated care practices.

An implementation framework for public service charters: Results of a concept mapping study

Abstract Many organizations have introduced service charters to improve service quality and user satisfaction. However, this goal is not always achieved, with the literature showing both implementation successes and failures. In this article, we analyse the organizational enablers for the implementation of service charters using a concept mapping methodology with an integrated Delphi study. Our empirical investigation, with the support of forty-five experts who had worked with public service charters in the Netherlands, has resulted in a framework involving forty-four organizational enablers. It shows that implementing a service charter requires a change management process that addresses both structures/systems and cultural aspects.