Recurring Themes

In exploring the phenomena of Lean in this chapter a number of recurring themes are identified:

2.10.1 What is Lean?

Part one was dedicated to exploring the phenomena of Lean in pursuit of a definition that would guide the thesis. In doing so, rather than concluding with an absolute definition it was found that Lean was rich in nuance (Taylor and Taylor 2008) and thus any definition of Lean would at best serve as a guide. Womack and Jones (1996) offer five principles of Lean to guide implementation whilst Spear and Bowen (1999) confer four rules; alternatively Osono et al (2008) refer to the interaction of hard and soft dimensions whilst Ohno himself declares “Improvement is never-ending – and by

writing it down, the process would become crystallized”. Thus, an absolute definition is perhaps not appropriate and a conceptualisation of the philosophy of Lean consisting of interdependent parts is more fitting. Aligned to this, the research conceptualises Lean as consisting of three essential interdependent parts: a set of principles, a system perspective, and quality tools and approaches (Ohno, 1988; Womack and Jones, 1996; 2003; Spear and Bowen, 1999 Emilliani, 2008; Näslund, 2008; Dahlgaard and Dahlgaard-Park, 2006; Towil, 2009). Part one also highlights the importance of education and training in Lean methodology as an important enabler of Lean implementation.

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2.10.1.1 Lean in healthcare

There is evidence to suggest that Lean implementation is widespread in healthcare (Radnor, 2010a; Young and McClean, 2008). However, Lean implementation is often portrayed in the literature at a local level leading a number of authors to conclude that Lean implementation in healthcare tends to be patchy and fragmented, focusing on an application of improvement tools rather than a system wide approach underpinned by Lean principles (Waldman and Schargel, 2006; Young and McClean, 2008; Proudlove et al, 2008). However, three examples of system wide implementation of Lean are identified in the literature and discussed in section 2.9 suggesting that Lean can indeed work in healthcare.

Chapter two finds a deficiency in the literature regarding how Lean is implemented in hospitals aside from the description of small isolated projects (with the exception of the three cases discussed in section 2.9), thus supporting the contention that hospitals are primarily using Lean methods and tools in a discrete and pragmatic fashion, rather than taking a systemic organisational approach advocated by many authors and recommended in Balle and Regnier (2007).

The extant literature therefore highlights variance in the approach to Lean implementation between organizations who implement a few discrete isolated projects and a small number of organizations that appear to be successfully implementing Lean across their whole organization. Pettersen (2009) also picks up on this given his endeavour to distinguish between four discernible approaches to Lean implementation, although he provides no empirical justification for his assertion. Broadly, chapter two identifies a research gap relating to the characterisation of how

Lean is implemented by English hospitals, thus leading to the following research question:

Can different approaches to Lean implementation be characterised in English hospitals?

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2.10.2 Lean and performance

Early exploration of the TPS was borne out of a quest to understand the superior performance of Toyota as discussed in Part one. The critical question then is whether hospitals that are implementing Lean are actually outperforming or improving at a greater rate than those who are not. There appears to be a significant research gap in the literature relating to the impact of Lean on organisational performance, a contention supported by Holden (2011). Healthcare specific literature reveals a number of quantitative measures at a local level in terms of a reduction in waste such as a reduction in process steps, journey times, set-up times etc but there appears to be no evaluation of the impact of Lean on overall hospital performance. The second research question endeavours to evaluate quantitatively the existence of a relationship between hospital performance and Lean implementation by drawing upon the national performance scores of English hospitals to ascertain:

Is there any quantitative support for the impact of Lean implementation upon improved hospital performance at an organisational reporting level?

2.10.3 Lean and context

Unique challenges of Lean implementation in the public sector are described in part two, specifically, the relatively high velocity of the macro context in terms of changes to regulatory control and recurrent reform coupled with the existence of multiple stakeholders and multiple lines of governance alongside transitory leadership at a local level.

The importance of context in terms of Lean implementation emerges throughout the literature review and is discussed in part one and part two of this chapter. Part one focuses primarily on the complexities of Lean implementation, in particular the counter intuitiveness of particular Lean practices such as just in time (JIT) (Oliver, 2008). Denison (1997) was incisive in his early acknowledgement of the challenge faced by organisations in terms of the requirement to change mindsets from the traditional principles of functional organising that had been adhered to for more than fifty years, to a process perspective. The limitation of a traditional functional perspective is made clear in section 2.1 in discussion of early attempts to implement

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Lean outside of Japan (Schonberger, 2007). In section 2.8.3 the same consequence of functional mindsets is described as a culture of ‘work-around’ in relation to a hospital setting (Spear, 2005).

Näslund (2008) argues that in order to create a readiness for change an organisation must adopt a systems view, and to do so, education and training is necessary. In presenting examples of a successful implementation of Lean section 2.9 highlights similarities of internal context between VMMC, Flinders and Royal Bolton, in particular a ‘crisis’ coupled with leadership commitment to organisational change. Education and training was also found to be prominent across all three case studies. As already noted, the influence of context upon Lean implementation has been a consistent theme throughout chapter 2. The influence of context can be summarised at three levels:

i. External environmental context: Economic and political influences.

The TPS is considered to have developed in response to a difficult economic environment in Japan (Holweg, 2007; Cusumano, 1988). In the public sector, we see a similar foundation where a rise in Lean implementation is attributed to the call for efficiency gains in the public sector in reports such as the Gershon Review (Radnor and Walley, 2008). The current government asserts that the NHS is to operate in the context of ‘severe constraint on spending’ coupled with the requirement of the NHS to deliver £10bn of savings by 2012/13 (NHS Operating Framework, 2010/11:1).

ii. Internal environmental context: Organisational crisis and leadership

commitment.

Analysis and comparison of Lean implementation in hospitals using the frequently cited case studies of Virginia Mason in America, Flinders Medical Centre in Australia and Royal Bolton Hospitals in the UK (see section 2.9) finds an organisational crisis coupled with leadership committed to change (via Lean implementation) as a common denominator between Lean implementation in these three exemplary case studies.

iii. Individual context: Resistance to change by management and medical

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The extant literature frequently identifies the importance of management engagement and buy-in yet analysis and comparison of Lean implementation in hospitals using the frequently cited case studies of Virginia Mason in America, Flinders Medical Centre in Australia and Royal Bolton Hospitals in the UK (see section 2.9) finds resistance to change a key limitation of Lean implementation. All three organisations reflect this problem, and the notion that change is counter cultural for the NHS.

The third research question therefore reflects the importance of context in terms of evaluating Lean implementation in healthcare:

Is there a relationship between the context of the hospital Trust and (the approach to) Lean implementation?