Merel Visse

Experiences of leaders in the implementation of Lean in a teaching hospital—barriers and facilitators in clinical practices: a qualitative study

Objectives To date, experiences of leaders in the implementation of Lean after a Lean Training Programme have not been systematically investigated within teaching hospitals. Existing studies have identified barriers and facilitators only from an improvement programme perspective and have not considered the experiences of leaders themselves. This study aims to bridge this gap. Design Semistructured, indepth interviews. Setting One of largest teaching hospitals in the Netherlands. Participants 31 medical, surgical and nursing professionals with an average of 19.2 years of supervisory experience. All professionals were appointed to a Lean Training Programme and were directly involved in the implementation of Lean. Results The evidence obtained in this study shows that, from the perspectives of participants, leadership management support, a continuous learning environment and cross-departmental cooperation play a significant role in successful Lean implementation. The results suggest that a Lean Training Programme contributed to positive outcomes in personal and professional skills that were evident during the first 4 months after programme completion. Conclusions Implementing Lean in a teaching hospital setting is a challenge because of the ambiguous and complex environment of a highly professionalised organisation. The study found that leadership management support and a continuous learning environment are important facilitators of Lean implementation. To increase the successful outcomes of leadership actions, training should be supplemented with actions to remove perceived barriers. This requires the involvement of all professionals, the crossing of departmental boundaries and a focus on meaning-making processes rather than simply ‘implementing’ facts. Therefore, this research suggests that programme participants, such as staff members and leaders, can mutually explore the meanings of Lean thinking and working for their own contexts. By entering this shared learning process (eg, learning on the job) the ownership of Lean implementation could also increase.

Patient issues in health research and quality of care: an inventory and data synthesis.

Aim  The purpose of this review is to generate an inventory of issues that matter from a patient perspective in health research and quality of care. From these issues, criteria will be elicited to support patient(s) (groups) in their role as advisor or advocate when appraising health research, health policy and quality of health care.

Dialogue for Air, Air for Dialogue: Towards Shared Responsibilities in COPD Practice

For the past several years patients have been expected to play a key role in their recovery. Self management and disease management have reached a hype status. Considering these recent trends what does this mean for the division of responsibilities between doctors and patients? What kind of role should healthcare providers play? With findings based on a qualitative research project of an innovative practice for people with Chronic Obstructive Pulmonary Disease (COPD) we reflect on these questions. In-depth interviews conducted with people with COPD, physiotherapists and a pulmonologist show that shifting responsibilities require a supportive attitude from healthcare providers and a dialogical communication between patients and professionals. Our findings show more is needed in order to motivate people with COPD to take responsibility and become co-owners in a process of recovery. The case example illustrates that people with COPD need support from fellow patients to learn to accept their disabilities. Awareness that COPD is more than just a lack of air, that mind and body interact, is a first step to investigate other potential problems and to enhance one’s quality of life.

Lean leadership: an ethnographic study

PURPOSE The purpose of this study is to provide a critical analysis of contemporary Lean leadership in the context of a healthcare practice. The Lean leadership model supports professionals with a leading role in implementing Lean. This article presents a case study focusing specifically on leadership behaviours and issues that were experienced, observed and reported in a Dutch university medical centre. DESIGN/METHODOLOGY/APPROACH This ethnographic case study provides auto-ethnographic accounts based on experiences, participant observation, interviews and document analysis. FINDINGS Characteristics of Lean leadership were identified to establish an understanding of how to achieve successful Lean transformation. This study emphasizes the importance for Lean leaders to go to the gemba, to see the situation for ones own self, empower health-care employees and be modest. All of these are critical attributes in defining the Lean leadership mindset. ORIGINALITY/VALUE In this case study, Lean leadership is specifically related to healthcare, but certain common leadership characteristics are relevant across all fields. This article shows the value of an auto-ethnographic view on management learning for the analysis of Lean leadership. The knowledge acquired through this research is based on the first authors experiences in fulfilling his role as a health-care leader. This may help the reader examining his/her own role and reflecting on what matters most in the field of Lean leadership.

Practising Political Care Ethics: Can Responsive Evaluation Foster Democratic Care?

This paper examines if and how responsive evaluation as a deliberative approach can serve as a guide for a politically oriented care ethics. A political care ethics puts the assignment of responsibilities and the inclusion of multiple perspectives of people at the centre of care. It honours the expressive-collaborative nature of care practices. It is responsive to political positions of vulnerability, fragility and resilience of those whom it concerns. From this, the interest in deliberative approaches is growing. Deliberative approaches aim to elicit, articulate and connect the voices of people with policy. Responsive evaluation is an empirical approach helpful to fostering mutual understanding, deliberation and inclusion. It aims to carefully understand perspectives of a variety of people and facilitate a dialogue between people on their experiences with a caring practice. The paper explores how responsive evaluators pay specific attention to asymmetric power relations and the way conflicts are handled by a case example. The case example focuses on the inclusion of professionals’ perspectives and illustrates that responsive evaluators actively reflect upon, energize and guide asymmetries in practices. This occurs by articulating and including multiple voices, searching for common ground, while simultaneously respecting differences. The paper concludes by discussing how responsive evaluation can be used to inform care ethics as a political ethics and how responsive evaluation may be enriched by care ethics itself.

Patient safety in the operating theatre: how A3 thinking can help reduce door movement

ISSUE Research has often stressed the significance of reducing door movement during surgery for preventing surgical site infections. This study investigated the possible effect of a lean A3 intervention on the reduction of door movement during surgery in a university medical center in the Netherlands. INITIAL ASSESSMENT A digital counter recorded door movement during 8009 surgical procedures during 8 months. The number of door movements per surgical procedure ranged from 0 to 555, with a mean of 24 door movements per hour across 26 specialisms. CHOICE OF SOLUTION We aimed to reduce door movement in one operating room for orthopedic surgery by a lean A3 intervention. This intervention was executed by means of an A3 report that promotes structured problem solving based on a Plan-Do-Check-Act cycle. IMPLEMENTATION The steps of the A3 report was followed and completed one-by-one by a multidisciplinary team. The effect of the changes was monitored over the course of 12 months. EVALUATION The use of a lean A3 intervention resulted in a sustainable decrease of door movements by 78%, from a mean of 24 to a mean of 4 door movements per hour during orthopedic surgery at one OR. LESSONS LEARNED This paper shows the relevance of and the possibility for a reduction of door movement during surgery by lean management methods in general and an A3 intervention in particular. This intervention stimulated dialogue and encouraged knowledge-sharing and collaboration between specialized healthcare professionals and this resulted in a thorough root-cause analysis that provided synergy in the countermeasures-with, according to respondents, a sustainable result.

Moral Learning in an Integrated Social and Healthcare Service Network

The traditional organizational boundaries between healthcare, social work, police and other non-profit organizations are fading and being replaced by new relational patterns among a variety of disciplines. Professionals work from their own history, role, values and relationships. It is often unclear who is responsible for what because this new network structure requires rules and procedures to be re-interpreted and re-negotiated. A new moral climate needs to be developed, particularly in the early stages of integrated services. Who should do what, with whom and why? Departing from a relational and hermeneutic perspective, this article shows that professionals in integrated service networks embark upon a moral learning process when starting to work together for the client’s benefit. In this context, instrumental ways of thinking about responsibilities are actually counterproductive. Instead, professionals need to find out who they are in relation to other professionals, what core values they share and what responsibilities derive from these aspects. This article demonstrates moral learning by examining the case of an integrated social service network. The network’s development and implementation were supported by responsive evaluation, enriched by insights of care ethics and hermeneutic ethics.