What is Lean?

-A case study of how Akademiska Hospital’s departments work

with Lean

Christian Jonsson

Anna Randefelt

Företagsekonomiska institutionen

Kandidatuppsats VT 2013

Handledare: Anders Forssell

Inlämningsdatum: 2013-06-05

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ABSTRACT The main purpose of this thesis is to examine how Lean is applied at the Akademiska

hospital in Uppsala, Sweden. Lean is regarded as a solution for many issues

connected to healthcare. We consider it interesting to examine to what extent Lean is

applicable to healthcare in regard with that Lean is initially created for the production

industry. We have conducted interviews with leaders and employees at the head

division and at four different departments to see if there exists a difference in how

they work Lean. From our study we can see that Lean is manifested differently at the

departments based on which typology of technology they belong to and how the

leaders communicate Lean to its employees. We hope that this study has clarified

both difficulties and opportunities with implementing Lean at a hospital. Suggestions

for further studies would be to examine what implications there could be with

combining Lean with other management philosophies.

Keywords: Lean, Lean healthcare, Long-linked technology, Intensive technology,

Organizational change, Akademiska sjukhuset.

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Table of Contents

1. Introduction  .....................................................................................................................  6  1.1   Increased demand in healthcare  ....................................................................................  6  1.2   Lean as the solution  ..........................................................................................................  6  1.3 Lean and its flaws  .................................................................................................................  7  1.4 Akademiska Hospital  ...........................................................................................................  7  1.5 Purpose  ....................................................................................................................................  8  

2. Theory framework  .........................................................................................................  8  2.1 Organizational change  .........................................................................................................  8  

2.1.1 Organizational processes  ............................................................................................................  8  2.1.2 Translating Ideas  ...........................................................................................................................  8  2.1.3 Open communication  ...................................................................................................................  9  

2.2 Typology of Technology  ......................................................................................................  9  2.2.1 Intensive technology  ..................................................................................................................  10  2.2.2 Long-linked technology  ............................................................................................................  11  

2.3 Lean  .......................................................................................................................................  11  2.3.1 Background  ...................................................................................................................................  11  

2.4  Lean  Principles  ..................................................................................................................  12  2.4.1 Value  ...............................................................................................................................................  12  2.4.2 The value stream  ..........................................................................................................................  12  2.4.3 Flow  .................................................................................................................................................  13  2.4.4 Pull  ...................................................................................................................................................  13  2.4.5 Perfection  .......................................................................................................................................  13  

2.5  Lean  Practices  ...................................................................................................................  14  2.5.1 Jidoka  ..............................................................................................................................................  14  2.5.2 Just In Time  ...................................................................................................................................  14  2.5.3 Kaizen  .............................................................................................................................................  15  

3. Method  ...........................................................................................................................  15  3.1 Choice of study object  ........................................................................................................  15  3.2 Research design  ...................................................................................................................  16  3.3 Choice of Informants  ..........................................................................................................  16  3.4 Interviews  .............................................................................................................................  17  3.5 Interview procedures  .........................................................................................................  18  3.6 Method discussion  ...............................................................................................................  18  

3.6.1 Validity and Reliability  .............................................................................................................  18  3.6.2 Generalizability of study  ...........................................................................................................  20  

4. Lean use at Akademiska Hospital  ............................................................................  20  4.1 Introducing Lean at Akademiska Hospital  ...................................................................  20  4.2 The departments  .................................................................................................................  22  

4.2.1 Medical Informatics and Technology (MIT)  .....................................................................  22  4.2.2 Children’s Hospital Emergency (CHI)  ................................................................................  23  4.2.3 Electroconvulsive Therapy (ECT)  .........................................................................................  25  4.2.4 Medical Imaging (MI)  ...............................................................................................................  26  

5. Analysis  ..........................................................................................................................  27  5.1 Typology of Technology  ....................................................................................................  27  

5.1.1 Medical Informatics and Technology (MIT) Department  .............................................  27  5.1.2 Electro Convulsive Therapy (ECT) Department  ..............................................................  28  5.1.3 Children’s Hospital Emergency (CHI) Department  ........................................................  28  5.1.4 Medical Imaging (MI) Department  .......................................................................................  29  

5.2 Jidoka  ....................................................................................................................................  29  5.3 Just in Time  ..........................................................................................................................  30  

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5.4 Kaizen  ....................................................................................................................................  30  5.5 Organizational Processes  ..................................................................................................  31  5.6 Translating Ideas  ................................................................................................................  31  

6. Conclusion  .....................................................................................................................  32  

7. Suggestions for future research  ................................................................................  34  8. References  .....................................................................................................................  35  

Interviews:  .........................................................................................................................  38  

Interview guide (English)  ...............................................................................................  39  Appendix 1A: Department level  .............................................................................................  39  Appendix 1B: Head department  ............................................................................................  40  

Intervjuguide (Swedish)  .................................................................................................  41  Appendix 2A: Avdelningsnivå  ................................................................................................  41  Appendix 2B: Huvudkontoret  ................................................................................................  42  

     

                                           

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1. Introduction  In the introduction chapter we will outline the current healthcare situation and

Lean’s role with a focus on healthcare. Thereafter we will introduce Akademiska

hospital, the center focus of our project, which leads us to the purpose of this thesis.

1.1 Increased demand in healthcare  The demand for healthcare is increasing and this trend is estimated to continue at an

exponential pace. It is estimated that the costs for healthcare will increase 30% by

2050 (SvD, 2012). Hospitals have become more concerned with adopting efficient

methods to reduce wasteful spending since they must operate within their budget

capacity without compromising the quality of care (Radnor et al, 2011). This topic of

discussion on how hospitals should reduce spending has been in the public spotlight

internationally. Many management ideas such as Six Sigma, Total Quality

Management amongst other have become popular among organizations that seek to

reduce cost or increase legitimacy and efficiency (Burnes, 2003). Within the last

years, one popular management idea that has been widely adopted by organizations is

Lean (Radnor et al, 2011). Hospitals worldwide have implemented Lean1 into their

operation to increase cost efficiency (Bliss, 2009).

1.2 Lean as the solution  Lean is a philosophy on how to handle resources efficiently where the aim is to create

value for its customers by eliminating elements that do not create value for the

customer (Womack & Jones, 2003: 15). Though it was initially intended for the car

production industry it has been widely adopted by companies within a range of

industries, both production and service oriented (Petersson et al, 2010). In the recent

years it has been regarded as the new “it” management tool (Bliss, 2009) since it is

claimed to create opportunities for increased competitiveness and profitability no

matter what business (Womack & Jones, 2003).

                                                                                                               1 Lean has many definitions, which can make it difficult to conclude a concrete definition (Modig & Åhlström, 2012: 91). In this thesis we choose to define Lean as a philosophy, which creates flow in an operation's processes as it eliminates wasteful procedures for the customer's value.

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1.3 Lean and its flaws  Although Lean can be used to create efficiency, it has some potential flaws. Business

authors, Modig and Åhlström (2012) have criticized that Lean’s applicability and

utility are vague. Some argue that the biggest problem to make Lean efficient is

convincing the leaders and employees to accept it (Läkartidningen I, 2010). Further,

it is questioned if Lean truly is effective in businesses where there is a high degree of

uncertainty since Lean requires standardization, which cannot always be possible in

operations with a high degree of uncertainty (FALF, 2010). In terms of healthcare, it

has been debated if Lean is applicable in healthcare since people are more complex

than machines (Läkartidningen II, 2010). Some even argue that the quality of

healthcare has worsened with Lean (Zaremba, 2013).

1.4 Akademiska Hospital  Although it has been questioned for its applicability, many hospitals in Sweden have

launched Lean into their operations (Läkartidningen II, 2010). One example is

Akademiska hospital, which adopted Lean in 2009 (Källman & Carlquist, 2011).

Having laid out the complexities with applying Lean, and the fact that an

organizational change such as Lean can be used to different extents and reshaped in

many varieties within an organization (Røvik, 2000: 156ff) we find it of interest to

explore the Lean philosophy adopted by Akademiska hospital. Further, we want to

understand how Lean is manifested and used in the hospital’s departments since Lean

has its origins in the car-manufacturing industry, which is vastly different compared

to the multiple and complex processes found in the hospital environment (Miller,

2005).

The background has led us to the problem formulation: How does Akademiska

Hospital’s departments work with Lean?

The sub-questions are subsequences of the problem formulation with regard of the

subject we have chosen.

1. What factors explain why they work with Lean in this specific way?

2. Is Lean a suitable solution for every department at the hospital?

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1.5 Purpose  The outcome of an organizational change depends on how a new organizational

method is implemented in its departments (Røvik, 2000: 152ff). Therefore, we think

it is of interest to see how management ideas are being used and implemented into an

organization. Consequently, the main purpose of this project is to examine how

Akademiska hospital in Uppsala applies Lean in order to create value for its patients

and how this might differ between its medical departments. To fulfill this purpose,

the philosophy of Lean, the tools, the principles and its challenges must be described.

The following step in order to fully learn how Lean is applied in the hospital’s

activities is by the collection of data through interviews with employees at the

department level and the head department.

2. Theory framework  In the theoretical chapter the concepts of change, Thompson’s typology of technology

(1967) and Lean will be introduced. An organization’s culture determines how it will

respond to a structural change to make Lean effective. Further, we suggest through

Thompson’s organizational theory that an organization which is similar to the

production industry can easier make its processes flow, which is a key point with

Lean. Lastly, we present the Lean concept, its background and the five principles by

Womack and Jones (1996) for becoming successful with Lean.

2.1 Organizational change

2.1.1 Organizational processes  Since the world is at constant change, organizations must adapt and change

constantly in order to keep up with the competitors and satisfy the ever-changing

needs of the customers. Organizations are changing continuously in order to obtain

legitimacy and success, thus they incline to model themselves after successful

organizations in their field (Dimaggio & Powell, 1983: 152f).

2.1.2 Translating Ideas  When implementing ideas into the organization, it is first translated at a higher level

of the organization, while thereafter being translated into its departments (Røvik,

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2000: 152ff). When it reaches down to the department level it can take many

different shapes since many different actors and groups play a role in it. The

translations are usually broken down in the organizational departments where they

are made to fit with the departments’ goals and aims. Therefore it is argued that the

organizational departments are interesting groups to study, as they help to understand

how a concept is spread and to what extent it is being reshaped into department

specific variations (Røvik, 2000: 157ff). Burns (2003) explains that leaders hold a

key position when it comes to changes in an organization (p. 639). Røvik (2000)

further states that when leaders see change as foreign they tend to neglect these

organizational changes (p. 113).

2.1.3 Open communication  To enable a successful organization it is necessary that the leaders are able to create

an open culture where the co-workers feel safe and confident towards suggesting

improvements. This will create an atmosphere where workers are motivated to

identify flaws and continuously improve their operations (Larsson, 2008: 102;

Burnes, 2003). Moreover, it is important that the leaders create the right conditions

for enabling improvements and that they encourage learning. Knowledge barriers are

believed to be the cause for mistakes and bad decisions, but with a flatter structure

where the relationship between the leader and employee is close, these knowledge

barriers can be broken (Larsson, 2008: 102). To enable this, it is suggested that

feedback and improvement suggestions should come from the bottom, as well as

from the top (Tasler et al, 2008: 4ff).

2.2 Typology of Technology  Thompson brings up the importance of managing organizations no matter their

organizational nature and uncertainty. He acknowledged three types of organizations

based on their technological environment; long linked technology, mediating

technology and intensive technology. Thompson considered that technology is an

important aspect for comprehending multifaceted environments and through these

typologies of technology managers could gain help dealing with its organizational

complexities. In this theory part, we will however only focus on intensive and long-

linked technology since the mediating technology is about linking clients or

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customers that wish to be interdependent (Thompson, 2003: 16), which is not

relevant for our research.

2.2.1 Intensive technology  Some organizations may experience that it is harder to work with flows and

standardization than others on the basis of their operation. For example, emergency

wards may find it difficult to plan the patient flow in advance since they do not know

what kind of care the patient needs upon arrival. Every patient’s injuries are unique

and therefore the patient determines the order of procedure (Forssell & Westerberg,

2007: 84f). This type of organizational technology is defined by Thompson (2003) as

an intensive technology where “a variety of techniques is drawn upon in order to

achieve change in some specific object” (p. 17) Moreover, the selection, combination

and order of the techniques are determined by the object itself and therefore intensive

technology can be regarded as a custom technology. It is only successful if all of the

necessary techniques are available (Thompson, 2003: 17f). Therefore, it is more

difficult to create flow when there is a high degree of uncertainty in an operation

(FALF, 2012). However, according to Thompson (2003) technologies can co-exists

in an organization. A common problem related to this type of multiple-component

organization is the creation bottlenecks2 since one part of the production may be

more efficient than another (p. 44f).

Figure 1. Graphic presentation of Thompson’s (2003) Intensive technology.    

                                                                                                               2 A process consists of many stages and a bottleneck is the stage in the process that has the longest cycle time or the slowest flow. Consequently, this limits the flow in the entire process (Modig & Åhlström, 2012: 38)

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2.2.2 Long-linked technology  As an opposition to the intensive technology there is the long-linked technology. This

means that C can only be performed after the act of B is completed and act B can

only be activated after act A is completed. This is a technology that is commonly

found in the mass production assembly line where only one product is produced. This

production technology approaches perfection when a single object is processed on the

basis of that they only need one kind of technology. This means that they can

determine on forehand what type of tools and machines are needed in the process, as

well as what kind of workflow arrangements and personnel that are needed.

Consequently, the repetition of the production process leads to experience and with

experience follows the means of eliminating imperfections such as waste (Thompson,

2003: 15f).

Figure 2. Graphic presentation of Thompson’s (2003) Long-linked technology.

2.3 Lean

2.3.1 Background  The Lean principles originates from the Japanese car company Toyota, relating back

to the 1950’s. After the Second World War, Japan was destructed and the Japanese

companies were forced to find efficient ways to manage their operations (Modig &

Åhlström, 2012: 64). Toyota’s representatives travelled to the United States of

America in search for ideas on how to efficiently produce cars. They discovered that

the mass production approach used in the U.S.A. was very costly as stocks and

defective products were found at the end of the production line. Moreover, they

realized this approach would not be affordable in their destructed and local Japanese

market. They knew they had to focus on what the customers’ value in order to thrive

in the Japanese market. As a result they created an effective car production, which

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was later named Toyota Production System3 (Modig & Åhlström, 2012: 65). In the

late 1980’s the American James Womack found that Toyota manages its supply

chain, customer relations, product development and operations better than companies

that used the mass production approach. With this, the book “The machine that

changed the world” was published, which led to the labeling now known as Lean

(Womack & Jones, 2003: 9).

2.4  Lean  Principles4  

In 1996 Womack and Jones published the bestselling book “Lean Thinking” were

they further developed their thoughts of Lean. In this book they present five

principles that leads to a successful use of Lean. The authors withhold the assumption

that an organization consists of processes. By following the five principles in the

specific stage order, the organization can add value, eliminate waste and continuously

improve their processes.

2.4.1 Value  Value must be defined by the customer. However, as value is created by the

organization but set by the consumer, it can in many cases lead to difficulties in how

to define value (Womack & Jones, 2003: 16). Sometimes not even the customers

know what is of value to them, and what is of value to one customer may differ from

another customer. Value can also differ between different departments of an

organization. However, the value formulation should be regarded as a guide to steer

the organization towards a desired direction. This gives the employees the possibility

to make their own decision in regard with the common values, which render a softer

organization that can handle deviations in a much smoother manner (Petersson et al,

2010: 31).

2.4.2 The value stream  In order to create an efficient and predictable process in the organization one must

look into the value stream. The aim of value stream is to identify the parts in the

customer flow that adds value to the customer as well as the parts that do not add

                                                                                                               3 ”A production system which is steeped in the philosophy of ’the complete elimination of all waste’ imbuing all aspects of production in pursuit of the most efficient methods” (Toyota, 2013) 4 Lean principles takes the notion that it is possible to determine what is waste and value from the customer's point of view so the non value added products can be found and eliminated. Further, it takes the assumption that non-value added activities can be measured and defined and freeing up resources is an advantage for the organization (Radnor et al, 2011: 366).

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value (Womack & Jones, 2003: 37f). When standardizing the work, one can easily

identify non-value adding parts in the organization. These non-value parts are to be

considered as waste that must be eliminated. However, it is argued that waste may

also be found outside the organization and can therefore be difficult to locate

(Womack & Jones, 2003: 20). Moreover, a total elimination of waste is argued to be

impossible, however the strive towards waste reduction is favorable for everyone

(Petersson et al, 2010: 88).

2.4.3 Flow  Flow efficiency is defined as a measurement of how much a unit is processed from

when a need is identified to the time when the need is satisfied. Flow efficiency

focuses on the needs of the customer and resource efficiency on the needs of the

company (Modig & Åhlström, 2011: 13). The fundamentals of flow as presented by

Womack and Jones (2003) are not new to the world of production. It is easy to grasp

the fundamentals of flow in the assembly line, a procedure that Henry Ford perfected

in the early 20th century. However, in non-production businesses it is harder to

understand how a flow is created. Thus, people tend to separate activities into

different departments, unaware of the consequences connected to it. All the resources

within the department are used to its maximum and the members of the department

are kept busy; they are resource efficient (Womack & Jones, 2003: 21f). However, by

only focusing on the department specific tasks, waste is created as the products or

customers are kept waiting in the connected departments for their turn in the

progression of their need.

2.4.4 Pull  When a flow is established the organization can let the customer pull the products

from the organization instead of pushing the products into the company. If a company

lets the customer pull the products, there will always be a customer for every product,

which eliminates stock (Womack & Jones, 2003: 24f).

2.4.5 Perfection  When the antecedents of the fifth and final stage are actively worked with, it is soon

realized that the work with the processes will never reach the state of perfection.

Perfection is about constantly working with the stages. This is why Lean as a concept

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never can just be implemented and then left to live its own life within the

organization. The perfection stage is pushed towards absolute efficiency, the more

you work with it; the better you become at it (Womack & Jones, 2003: 25f).

                 

Figure 3. Graphic presentation of Womack and Jones’ (1996) Lean principles.

2.5  Lean  Practices  

In order to realize the Lean principles presented above a company may take use of

practices. These practices can be regarded both as philosophies as well as means of

realizing the five principles of Womack and Jones.

2.5.1 Jidoka  Jidoka is built around two principles that ensure products have been built properly.

The first is “Built in Quality”, which requires every employee to have high

competence and work in agreement with the organization’s goal by following

standards and requirements. The other principle “Stop the Process” is the process of

immediately stopping production when something has gone wrong. This allows

employees to quickly identify, analyze and eliminate the problem and thus creates

high quality products (Petersson et al, 2010: 57).

2.5.2 Just In Time  Just in time strives to produce and deliver a product or service at the right time. It is

based on the principles takt, continuous flow and pull. Takt is the speed of the

production flow, how much should be produced per time unit in order to provide the

requested amount. The second principle Continuous flow maintains the materials and

products in a constant movement to minimize stops in the process. The third principle

pull; is when the organization starts producing a good or service, after receiving the

customer’s order which prevents unnecessary costly buffers (Petersson et al, 2010:

51).

VALUE   VALUE  STREAM   FLOW   PULL   PERFECTION  

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2.5.3 Kaizen

Kaizen holds the principle that improvements should be made continuously by both

leaders and employees in order to reduce waste (Womack & Jones, 2003: 35). Means

of improvements could be for example meetings, education days and training. To

enable improvements the organization requires a formalized structure, where

everyone’s proposals are valued, applied and reviewed according to their alignment

to the company’s objectives (Imai, 2012).

JIDOKA JUST IN TIME KAIZEN STOP THE PROCESS BUILT IN QUALITY

TAKT CONTINUOUS FLOW PULL

IMPROVEMENTS

Figure 4. Overview of Lean practices

3. Method  In this section we present our choice of case, the structure of our research and how

the data has been collected. Lastly, the possible flaws and generalizations connected

to our method will be explained in the method discussion.

3.1 Choice of study object  The debate about Lean in healthcare has been in the media’s spotlight for the past

years, which has influenced our interest in the topic. Additionally, since Lean

originates from the production industry, we are curious about how Lean operates

within a hospital, considering the vast differences between the hospital and industry

settings. We chose to conduct our study at the Akademiska hospital located in

Uppsala, Sweden. Firstly, Akademiska hospital is a convenient study because of its

location, which provides more accessibility. Secondly, Womack & Jones (2003)

argue that it takes several years for an organization to become familiar and efficient

with Lean. Akademiska hospital adopted Lean four years ago (2009) and therefore

we consider it a relevant hospital to explore.

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3.2 Research design  For the data collection and analysis, this study has taken the form of being inductive.

According to Saunders et al (2012), an inductive approach should be adopted when

exploring a topic and developing a theoretical explanation that is derived from the

data received (p. 48). This is a suitable approach since we did not know the results of

how Akademiska hospital works prior to our interviews. Our project takes a

descripto-explanatory form. This is a combination of both descriptive and exploratory

elements, where description tends to be the precursor for explaining the material

collected (Saunders et al, 2012: 177). In order to understand and compare the

collected data, we need to first describe how Lean is being applied in the departments

of Akademiska hospital, while thereafter being able to explain why they work with

Lean in this specific way.

To gather data, a qualitative study has been made, which is suggested to be suitable

when using an inductive approach (Saunders et al, 2012: 377). In a qualitative study

the focus is put on the words rather than on the quantification of data (Bryman, 2008:

366). Further, Johannessen and Tufte (2003: 70) argue that a qualitative study is a

preferable method to gather a broad amount of information and it creates better

requisites for a discussion. This is explained by the fact that in a qualitative study

there is higher flexibility as the interviewer can easily discover new dimensions and

thoughts and thus guide the informant into specific topics. We consider a qualitative

study suitable for our thesis since we want to understand what factors determines the

success of Lean at Akademiska hospital and capture the informants’ thoughts

concerning their experience of working with the method on a daily basis.

3.3 Choice of Informants  For this study eight interviews have been conducted. Two interviews have been done

with employees working at the head department of Akademiska hospital with

strategic projects. This has provided us with a deeper understanding of how

Akademiska hospital works with Lean. Six interviews have been made with

department managers and employees at the department level. We have chosen to keep

the informants anonymous since Walsham (2006: 327) claims that the informants

will feel more comfortable and more open to answer questions. Akademiska hospital

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consists of many departments and we have chosen to conduct interviews at four

departments. These four departments are a conscious choice since they have very

different settings. By having interviews at these four departments we hope to obtain

an overall picture and a greater understanding of how Lean can be used in a hospital

to create value to its patients, while clarifying both differences and similarities.

Medical Informatics and Technology (MIT) department has the responsibility for

the maintenance of Akademiska hospital’s medical devices. The department is not

directly involved with patients; instead it has more of a production structure.

Children’s Hospital Emergency (CHI) department takes care of children with

critical conditions. In this department the patients’ situation is unknown upon arrival

and it is difficult to plan ahead.

Electroconvulsive Therapy (ECT) department is a small and specific department,

which provides electrical shocks for depressed patients to make them feel better.

These procedures are short, simple and booked in advance.

Medical Imaging (MI) department is a central area for the whole Akademiska

Hospital’s patients since many patients in different departments end up at the MI to

get diagnosis of their organs. At this department you schedule a time in advance,

however emergency patients are prioritized.

3.4 Interviews  For enabling flexibility and to allow our informants to express themselves in their

own words, our interviews have been semi-structured. In semi-structured interviews

there are a set of questions that list themes and emphasize key questions; however

they can vary between each interview and follow-up questions can be added if

necessary (Saunders et al, 2012: 374). This approach has enabled us a deeper

understanding as we have formulated a set of key questions and have asked

additional questions if there were misunderstandings or if a condition could be

described more in detail. To create a natural sequence of questions the order of the

questions may have varied between each interview. More specifically, we performed

the interviews in two blocks where the department informants received the interview

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questions from block one, which focused on how the specific department works. The

head of department informants received the second interview block, which focused

more on the overall aim of Lean at Akademiska Hospital and its future plans.

3.5 Interview procedures  The interviews were performed at the hospital. Saunders et al (2012) suggest that you

should choose a place where the participants can feel comfortable and where the

interview can proceed without interruptions (p. 386). All the interviews were

performed in a quiet office that was chosen by the respondents. This is an advantage

since the participants easier can find documents that support points they are making

and provide the interviewers with the documents (Saunders et.al, 2012: 387). In two

of the interviews we received documents that explained organizational procedures

and job assignments.

There were two interviewers present at the interviews. However, in order to keep the

interview structured we had distinct roles where one of us took notes and the other

one asked the questions. Before the interviews started we asked for permission to

record the interview. Repstad (2007) recommends the use of recorders and says that

there are many advantages connected to it. Negative effects of recording can be that

the respondents feel inhibited (p. 93). However, based on the respondents’ relaxed

body language we felt that they were not affected negatively by the recording. One

respondent did not allow us to record the interview.

In order to compile the data and to obtain all the information received at the

interviews the interviews have been transcribed. We conducted our interviews in

Swedish as it is argued that it is preferable to do it in the local language (Walsham,

2006: 323f), which can make the respondent more comfortable with sharing

information.

3.6 Method discussion

3.6.1 Validity and Reliability

An assessment of the reliability and validity is necessary in order to carry out the

research and to increase its credentials. Validity implies to how specific and

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appropriate the data is for obtaining the aims of the research (Bryman, 2008: 376).

We have performed interviews in four departments within the hospital for ensuring a

large and rich environment. We believe that these four departments capture various

settings and structures, therefore we consider that we are able to draw general

conclusions of Akademiska hospital as a whole. A factor which may have influenced

our validity is that in some departments we were only able to interview one person,

which can have led to a narrower picture than if we could have interviewed another

person in the department. However, since some departments only had one manager,

we had no control of the circumstances. To ensure high validity, it is suggested that

questions should be asked clearly and sensibly (Saunders et al, 2012: 382ff). To

achieve this, we have asked our respondents various questions and clarified by

providing examples where there may have been confusion. Further, in order to

prepare the informants, we sent the interview questions a few days in advance. We

consider that this has provided the informants time to think about the questions and

how they should respond. On the other hand this may have narrowed down their

insight for the question and possibly lead to a more restricted answer. However, in

one department they did not receive the interview questions in advance, but they were

given the opportunity to read and reflect the questions before the interview started.

One factor that may have influenced the data is that most of our informants have

leading positions in the organization. This may have created a bias, considering that

the informant could have possibly wanted to influence and present their department

in a positive way.

Reliability implies to what extent a study can be repeated at a later stage and obtain

the same data (Bryman, 2008: 376). There is always a concern that another researcher

may not get the same data, as there are many variables that influence the conditions

(Saunders et al, 2012). For example, not all of the departments have multiple leaders,

but the fact that some informants we interviewed were chosen by the head of the

division may affect the study’s reliability – on what criteria did the head of the

division proceed from when he chose the informants? Would we get the same results

and information if we interviewed another manager at a later point? Repstad (2007)

says that researchers are in many cases dependent on leaders in order to find suitable

informants, and that this may cause concerns since it may not be known on what

criteria the choice of informants is based on when a third person is making the

  20  

choice. However, the most important criteria when choosing and interviewing an

informant is that you believe that the informant has relevant information about the

question formulation (p. 89). We consider that a repeated study with people within

the same position would not vary too significantly, considering that a person with the

same position would have similar work knowledge. Further, to increase reliability we

have carefully chosen the interview questions and also taken use of a third person, in

order to gain an additional perspective on how to formulate questions so the

questions were relevant for achieving the goal of our research.

3.6.2 Generalizability of study  Since this study has been carried out at Akademiska hospital, most of the analysis is

aimed at getting an understanding of how Akademiska hospital works with Lean.

Nevertheless, as this study has been carried out in Sweden, we consider that it may be

applicable for other hospitals in Sweden that are using Lean since they may face

similar circumstances. Although it can be discussed for its generalization, we

consider that many involving thoughts and explanations provided in this thesis can be

of an advantage to explain other hospital’s Lean work.

4. Lean use at Akademiska Hospital  In this chapter we will present our results of our empirical research that will

underline the analysis in the following chapter. Firstly, the overall aim of Lean at

Akademiska hospital and how they work with it will be presented. Thereafter the four

departments will be presented and it will be specified how they work with Lean and

how they create flow in their operations.

4.1 Introducing Lean at Akademiska Hospital  In 2008, Akademiska hospital’s Vice-President was looking for a new way to work

with improvements. They had difficulties with long queues and were facing

challenges concerning increased hospital expenses and there was a demand for a

better education of the employees in how to improve their internal operations. They

noticed that many Swedish hospitals had started to implement Lean in their

organization in an attempt to seek remedy for its future difficulties. In February 2009

  21  

Akademiska hospital commenced with a top-down implementation of Lean, where

they educated the hospital staff during one and a half years (Informant 8).

To this day, Lean at Akademiska hospital’s main objective is to create an effective

flow at a department level and this has created effective departments. However, less

attention has been given to the larger patient processes that stretches across several

departments. Informant 8 says that more attention will be given to these larger

processes in the future since they have received new directives this January. These

directives aim to detect large interdepartmental processes and how to improve these

(Informant 7). Every department have their own way of working with processes and

informant 7 calls for common guidelines that can be broken down to the specific

departments. However, they are working with creating general guidelines so that the

hospital can maintain a smooth interdepartmental patient flow. Informant 8 calls this

the stage two of the implementation of Lean at Akademiska hospital.

In an attempt to make Lean more familiar for the employees the hospital has given

the department leaders the opportunity to name the Japanese tools of Lean on their

own. When Lean was introduced they were determined to use the Japanese words,

but now many departments are using the Swedish equivalent vocabulary in the daily

business (Informants 7 & Informant 8).

Combined with Lean, Akademiska hospital is also working with balanced scorecards

in order to control and monitor operations. It is based upon five different perspectives

ranging from economy to patients. The balanced scorecards are broken down from

the hospital top-level down to individual employees. Informant 7 asserts that the

process of balanced scorecards has not yet found its true shape and improvements are

still needed.

  22  

4.2 The departments

4.2.1 Medical Informatics and Technology (MIT)  The MIT department gives assistance in the procurement of medical devices that is

used by Akademiska hospital’s departments. They perform maintenance and

investigate accidents of medical devices. Further, they educate medical staff in how

to handle medical devices (Informant 1).

At the MIT department there is a clear and visible flow structure, which can be

explained by the resemblance of the production industry according to Informant 1.

Medical devices arrive to a designated arrival table and then the devices are logged

into the system. The devices are then divided and distributed to the medical device

technicians and engineers. The devices have a clear and visible path through the

maintenance system and when a part completes a stage it is logged into the system

and continues to the next stage. In the last stage, a technician performs a final check-

up to ensure that the devices are functioning correctly before they are re-transferred

to the hospital’s medical departments (Informant 1). The devices arrive and depart

twice a day and this procedure is maintained by a specially assigned staff member.

To ensure an even and continuous flow they have yearly contracts with the medical

departments on which devices must be taken in for maintenance. In this way they can

allocate the maintenance of the devices over a time and in that manner create a “takt”

to work with and visualize their work. Takt enables them to make goals that they

must achieve within a certain time, where the team’s achievements are demonstrated

on a map with the use of colorful buttons (Informant 1).

The introduction of Lean, which led to the use of takt, has created a higher feeling of

responsibility among the employees and has allowed tasks to be completed more

efficiently than before. In terms of improvement they do not use Kaizen tags5 to its

full extent, as it is too time consuming (Informant 1). However they take use of

Kaizen for major improvements involving the whole department. They have meetings

with their team once per week and twice a month they have a forum for improvement

suggestions on a lower department level and they continuously educate their

employees both on- and off location to ensure and maintain a high level of

                                                                                                               5 Kaizen tag is a note on which improvement suggestions are written down.

  23  

knowledge (Informant 2). Except from working actively with the tools of Lean, the

MIT department is ISO 9001 certified which ensures high quality by following a set

of principles (Informant 2). Moreover, they have adopted balanced scorecards in

order to maintain an efficient and reliable follow-up procedure of the goals that

determines what must be done during the year (Informant 1).

4.2.2 Children’s Hospital Emergency (CHI)  Children under the age of 15 years with life threatening injuries or other urgent

conditions are received at the children's emergency ward. They work according to a

system of prioritization where the patient that has the most critical condition receives

medical treatment first (Akademiska sjukhuset I, 2013).

The CHI-department consists of many processes, which vary depending on the

condition of the incoming patient. Some parts are highly standardized and others are

yet to be standardized. Informant 3 maintains the notion that the first meeting with

the patients is the most important one and therefore they have standardized the

procedure of the incoming patients. When the patients arrive at the emergency ward

they are divided according to a triage-system, in which the patient is coded by a set of

colors depending on how critical the situation is. This system enables the doctor to

quickly see which patient needs to be prioritized. Another standardized process is

when the patient is transferred to another department. The doctor creates a patient

treatment plan, which must be followed so that everybody at the new department

knows exactly what to do. This eliminates waste connected to not knowing the

treatment plan for the patient (Informant 3).

The outcome of a Lean value stream analysis was a flow nurse, who handles the

communication between the emergency ward and other departments on the matters of

patient transfers. The job of the flow nurse is to have an overall picture of the current

situation and have the responsibility of making this transfer function efficiently

(Informant 4). This has enabled the doctors to only focus on taking care of the

patients, as before, the doctors had to waste time communicating with other

departments when transferring a patient. Further, they have standardized the patient

discharge process to ensure that the patient gets all the information needed in order to

  24  

fully understand the care that has been given as well as future implications the patient

may encounter (Informant 3).

After the patient has been coded in the triage-system a doctor arrives and makes his

judgment of the situation. This process as a whole is for many reasons hard to

standardize since it is not known in advance what the patient needs. The examination

process consists of many small handling alternatives depending on the patient’s

condition. Thus, there is a form of standardization within these handling alternatives

since there exists predetermined procedures connected to specific types of injuries or

illnesses. Another challenge with creating a constant flow is that they are working in

shifts, which means that the work is handed over to other personnel during the day.

However, they aim to get a smooth shift transition by having no more than two

untreated patients by the shift transition (Informant 3).

As a way of ensuring that the goals of the departments are reached, they work in

accordance with balanced scorecards, which are derived from the national directives

“God Vård”. These scorecards are broken down from division level down to

individual staff members. Within the department they also have their own time goals.

For instance, one goal is to treat each patient within 4 hours upon arrival (Informant 4

& Informant 3).

For improving the CHI-department they have education days and forums of meetings

where the staff can discuss issues they have detected as well as suggest solutions for

these. These improvements are done without Japanese terminologies as these are

considered to alienate and create a foreign work environment. Instead, the

fundamental ideas of Lean, such as using Kaizen board6 is maintained through

meetings and working towards goals. Once every sixth months they have a larger

meeting, which is planned a long time in advance so that every staff member is able

to attend this meeting. It is further described by Informant 3 that it is important that

every employee feels that it is their department, which they create together, and that it

is not the department managers (Informant 3).

                                                                                                               6 This is a board on which improvement suggestions are placed.

  25  

4.2.3 Electroconvulsive Therapy (ECT)  The ECT-department is a part of the emergency and consulting psychiatry

(Akademiska sjukhuset II, 2013). They assist the psychiatry by giving electric shocks

to the brain, which extricates certain hormones that can normalize the hormone

levels in the brain. This helps severely depressed people to overcome depression

(Informant 5).

Since the ECT-department recently has changed premises they had the opportunity to

form the building structure to uniquely fit their operation. There are four manned

stations in which nurses and doctors are working. All the patients are booked in

advance and they arrive 15 minutes apart from each other. Approximately 50% of the

patients are hospital admitted and the rest have a medical letter of referral. The first

two stages of the treatment each take about ten minutes to perform. It is these two

stages that determine the time between the patients. The third stage is the

department’s bottleneck since the patients need 30-45 minutes to wake-up from the

anesthesia. However, the recovery room is large enough to ensure a continuous flow

without any interruptions. The fourth stage is a post-recovery room where the

patients rest and recover from the treatment. When the hospital admitted patients are

ready to return to their departments the ECT-staff calls the hospital admitted patients’

department to handle the patient transfer.

In order to maintain a secure and reliable treatment all of the steps and stations in the

ECT-department are standardized. However, some stations are more open for

craftsmanship than others. The procedures of meeting and talking with the patients

are less standardized. On the other hand, the procedures of pre-medication, how to

put a needle, giving anesthesia and the surveillance system in the recovery room are

highly standardized to ensure good care. They perform treatments three days a week

and on non-treatment days they are performing administrative work, planning for the

upcoming day and educating themselves and other personnel at the hospital.

Informant 5 explains that many patients are scared of this treatment and to minimize

patient anxiety they have tried to reduce waiting time with the use of Lean value

stream analysis. However, sometimes they encounter complications in the treatment

room, which may affect the overall flow. By the end of the week, these

  26  

complications are discussed on the matter of how they can find a way to avoid them

in the future. Changes are followed up the week after to see if it is successful or if it

needs to be altered in some way. They work with continuous improvements by

weekly meetings. An idea is brought up at a meeting, discussed and then tested for

three months. When it comes to improving the skills of the staff they have both on-

location and off-location education. Colleague to colleague education is normal and

if someone has special skills in one area that may be relevant for the operations at the

ECT-department, this person will educate his colleagues. They also have formal

education days where they go to other premises for a day or two.

4.2.4 Medical Imaging (MI)  MI’s main assignment is to perform patient diagnosis by using medical equipment in

order to obtain images of the body, while some other goals of MI is to conduct

extensive research within the field (Akademiska Sjukhuset III, 2013).

In the MI department many actions have been taken to improve the passage for its

patients since the Lean implementation at Akademiska Hospital. In 2012 MI became

fully organ oriented, which means that instead of focusing on what methods and

devices was to be used on the patient, the focus has been put on the part of the body

where the diagnosis is needed. This has led to an increased flow, where the takt, from

the time that the patient receives the medical letter of referral to the time that they

receive their diagnosis has improved significantly. Moreover it has also led to better

control and coordination within the operation. When ST-doctor has made a patient

diagnosis it is followed-up by experts (doctors) who do a double check that the

diagnosis is correct. Before, when MI was method oriented, the ST-doctor’s check-up

was the final word that the patient received, while at a later stage when the patient’s

situation was double-checked it could appear to be wrong. These X-ray inspections

and MRT inspections have been standardized. However, many processes within the

operation are still to be standardized (Informant 6). MI is renowned over the whole

hospital for its efficient way of handling material equipment. They have structured

the system so that they buy their materials in smaller but more frequent amounts.

This has set an example for the whole hospital how you can reduce waste (Informant

7).

  27  

In the MI-department the work can be considered to have two ways of operating,

either it can be elective or emergent. Further, MI has created a system of ranking their

acute patients on a scale between one and ten, depending how sick the patient is.

Based on this ranking, MI delivers the inspection dates so the patients with the most

critical situation get treated first. In the emergency operation there exists a clear flow

according to Informant 6, as the procedure has been visualized and made into clear

steps on purpose to create a quicker and smoother operation. Besides following the

Akademiska Hospital’s 4-hour rule, they aim to deliver answers within two hours

(Informant 6).

When it comes to leaders and managers, since 2010 the amount has decreased by half

since there were too many leaders. The result of this has been a flatter organization

where there is an increased communication between employees and leaders. When it

comes to improvements, this is argued to come from above and from below in the

organization, where the leaders and employees are able to improve the operation

when it is considered necessary (Informant 6).

5. Analysis                                              In this chapter an analysis will be introduced, grounded on the theoretical framework

and empirical data that has been collected. First, we analyze the prerequisites for

creating flow within our four chosen departments. Thereafter, we discuss Lean-

relating themes we have found within the departments and lastly we analyze Lean as

an organizational change and to what extent it has been adopted.

5.1 Typology of Technology

5.1.1 Medical Informatics and Technology (MIT) Department  From the empirical data it can be seen that the departments where the operation can

to a high extent be standardized and planned in advance are the departments where it

is the easiest to detect flows. In accordance with Thompson (2003), in long-linked

technology, it is easier to plan ahead and create flow when there is only one kind of

product that is processed repeatedly. At the MIT-department they are processing

many kinds of apparatus, however the procedures of the maintenance can be

standardized since a device is processed many times during its lifecycle (Informant

  28  

1). The tools, machines and knowledge that are needed are known in advance since

they plan the maintenance of the devices on a yearly basis. This implies that they can

perfect their operations by standardization and thus eliminate wasteful activities.

Hence, the MIT-department can be fundamentally defined according to Thompson

(2003) as long-linked technology.

5.1.2 Electro Convulsive Therapy (ECT) Department  In the ECT-department they are giving electric shocks to the brain in order to cure

depressed patients. All the patients have a letter of referral, which means that the

evaluation of the need of this type of treatment is done at another department. This

procedure of giving shocks is standardized and every patient is receiving the same

care as others (Informant 5). As earlier stated, Thomson’s (2003) theory of long-

linked technology requires that only one type of product is being processed. In this

case the product is the extrication of hormones in the patient’s brain. All stages of the

patient process are standardized in order to secure that the patients are receiving a

high standard of care (Informant 5), which in turn enables the elimination of wasteful

activities. Since every stage of the treatment is standardized they can easily detect

deviations and correct them in order to perfect their operations. At the ECT-

department they are in accordance with the long-linked technology. Moreover, when

they planned the flow and the structure of the building they used a value stream

analysis. This value stream analysis focused on minimizing waiting-time for the

patients (Informant 5). Therefore, it can be argued that Womack and Jones (2003)

Lean principles can be used for creating flow at the ECT-department.

5.1.3 Children’s Hospital Emergency (CHI) Department  The condition of a patient upon arrival at the emergency department is in many cases

unknown to the medical staff and the illness or injury is often unique. In order to

handle such situation according to Thompson (2003) the hospital must provide the

emergency ward with adequate resources that can determine how to care for the

patient. However, the triage-system is one standardized process which grade the

incoming patients based on the urgency of their injuries, so that the doctor knows

which patient needs treatment first. Another standardized process is the transfer of

the patients to other departments, with the help of a flow nurse. It was discovered

through a value stream mapping that a nurse who would operate as a link between the

  29  

emergency and intermediary department in the children’s’ hospital could create a

clearer and quicker process for the transfer of the patient. Therefore, we can draw the

assumption that Womack and Jones (2003) principles of value stream analysis are

effective for detecting waste areas.

These two processes are standardized and similar to all patients but the whole patient

process cannot be planned ahead since the condition of the patient is unknown prior

to arrival. This uncertainty requires a variety of specialized doctors in order to be able

to give the best possible care for the patient. Moreover, the patient’s path through the

system is also unique in that manner since the order of the care is dependent on the

injury or illness of the patient. With the uncertainty factor in mind, the intensive

technology as described by Thompson (2003) can be found in the CHI-department.

5.1.4 Medical Imaging (MI) Department  The MI-department can be considered as both elective and emergent. In the emergent

care the patients are ranked on the basis of their condition whereas in the elective

care, the patients that need the same kind of diagnosis devices are concentrated to one

day. The emergent care demands many specialized doctors in stand-by to secure good

care since they do not know in advance what the patient needs and in what order the

procedures should be done. The elective care on the other hand is thoroughly planned

in advance and all the patients are experiencing the same kind of procedures. The

stages are standardized and the procedure is regularly repeated. This makes the MI-

department dual-technological since they are simultaneously operating with the

intensive and long-linked technology. Therefore it can be argued that Thompson’s

(2003) idea that an organization can hold two different typology technologies at the

same time is confirmed.

5.2 Jidoka  The main objective for all the departments is to provide good quality and value for

their patients, thus Jidoka can be found within their operations since they want to

ensure that the patient gets the best possible treatment. As mentioned by Informant 8,

one of the main objectives with Lean was to further educate their employees, which

can be related with the Jidoka principle, Built in Quality, where they aim to educate

their employees so they have the right knowledge and can provide better service for

  30  

their customers. To further ensure high quality all the departments take use of

different goal directions and requirements. In the MIT department they take use of

ISO standards for ensuring high quality for the devices (Informant 2), while for

instance at CHI department they take use of the national directives “God Vård”

through balanced scorecards (Informant 3). These measurements are standardized and

required thus ensuring high quality. ECT department on the other hand argue that

they are able to guarantee good care through the standardization of all stages in the

patient process (Informant 5). To further increase quality and decrease the possibility

of an incorrect outcome the MI department assure the patient diagnosis with a re-

check-up (informant 6) while at the MIT-department they also double check the

devices before sending them back (Informant 1).

5.3 Just in Time  It is claimed (Informant 1; Informant 2; Informant 5 & Informant 6) that working

with a certain speed, named takt enables better planning and structure. At the MIT-

department, Informant 1 said that since Lean was adopted they have worked in

accordance to a takt; which has led to a clearer responsibility of what must be done

within a certain time, leading to quicker results for sending back the devices to their

original departments. At the ECT-department they plan everything accordingly with

the patient process, which creates flow and reduces bottlenecks (Informant 5).

Further, in the MI department it was found that they could reduce material waste by

having a constant and smaller material acquisitions (Informant 7). This approach can

be argued to hold a “Just in Time” approach as it aims to produce the right amount in

order to reduce waste. However, in CHI-department the creating of takt can be more

complex as it is difficult to plan ahead how many patients you will receive on a

certain day. Further, there exist two shifts within the CHI department, which may

complicate the planning. However, by making goals that they aim to have handled

within a certain time frame they can create a takt to work with (Informant 3).

5.4 Kaizen  All the departments consider that communication with the employees is important

for success. Thus, they all have meetings and other communication forums

(Informant 1; Informant 3; Informant 5 & Informant 6), which is concurrent with

Burnes (2003) who argues that communication is the basis for improvements.

  31  

Therefore, Kaizen, the action of continuously improving can be found within every

department and Womack and Jones (2003) Lean principle, perfection could be

argued to exist within the departments. As described by Tasler et al (2008) it is

important that feedback and improvements are welcomed by everybody, which can

be linked to Akademiska Hospital. It is explained by Informant 3 that it is important

that all the employees feel as a part of the organization. Moreover, Informant 6

explains that all employees are encouraged to suggest improvements. Further,

Informant 6 explains that they have halved the amount of managers within the last

two years due to inefficiencies. Therefore it could be argued that knowledge barriers

can be a big reason for inefficiencies, which can be broken down with the use of

Lean (Larsson, 2008).

5.5 Organizational Processes  Powell and Dimaggio (1983) argue that organizations tend to follow similar

organizations within their surroundings. This can be related to the Akademiska

hospital who decided to launch Lean after seeing that it had led to improvements in

other Swedish hospitals (Informant 8). Therefore, we may draw the assumption that

following similar organizations gives the belief that they will obtain legitimacy and

success, which is confirmed by Informant 7.

5.6 Translating Ideas  Just as Røvik (2000) claims that an idea is first commenced at the top of the

organization, Akademiska hospital adopted Lean through a top-down approach

(Informant 8). When it comes to working with Lean it is described that there are no

general rules applied, instead they have department guidelines that suit their

operation (Informant 7 & Informant 8), which is further explained at the department

levels. As a result, Røvik’s (2000) idea of translating an organizational change to fit

their operation can be found. When it comes to improvements, ECT and CHI

department do not have Kaizen boards for improvements, whereas MIT and MI

department take use these. It could be questioned what determines this usage,

however as explained by ECT and CHI department, they consider to be better

without it (Informant 4 & Informant 2).

  32  

When it comes to the usage of Japanese terminologies, it can be seen that some

departments have not applied these into their operations. At first, when Lean was

introduced at Akademiska hospital they were committed to use these terminologies

(Informant 7 & Informant 8). However, they shortly realized that it was unpopular

among the employees, which led to the removal of Japanese words (Informant 7).

This can be explained by Røvik’s (2000) viewpoint, which claims that if something

seems foreign, it can be rejected. In the CHI-department, which can be considered to

be an intensive technology, Informant 3 explains that these terminologies would have

been too alien for the employees, thus they do not use these. Inclined by Burnes

(2003) that the department leader has a big role when it comes to accepting changes,

it can be discussed whether this assumption is true. However in the long-linked

technology department MIT, we found that they used these terminologies to a higher

extent. Therefore it could be discussed if a technology typology that is closer to the

long-linked technology adopts easier these terminologies, which corresponds with

Røvik’s (2000) thoughts of rejection.

6. Conclusion  

In  this  chapter  we  will  first  explain  what  we  have  discovered  based  on  our  analysis,  

while  thereafter  answering  our  research  questions  and  draw  some  final  remarks.  

 We have discovered that the departments where they work most with Lean, are the

departments that have a strong connection to the long-linked technology presented

by Thompson. Since Lean is fundamentally based upon a long-linked technology,

e.g. serial production, we have come to the conclusion that it is not possible for the

Akademiska hospital to implement Lean in all of their departments without altering it

to fit the specific departments’ structure. This is explained by the fact that hospital

operations are complex and they have numerous fields of medicine. In our case,

some of the departments are working with emergency care, others with elective care

or the maintenance of the medical devices.

It can be questioned to what extent a department is following the principles of Lean

since the patient flow and processes cannot always be determined in advance. As

mentioned earlier, in a long-linked technology it is easier to create flow and to

  33  

standardize. However, even in the departments that can be fundamentally described

as intensive technological, improvement areas have been found through Lean, and

they have been able to standardize parts of their operations. Thus, we have found that

Lean thinking is present at all of the examined departments, but how they actively

work with it differs between them.

The use of Lean tools, as well with the usage of Lean vocabulary are not mandatory

to the departments and the leaders can alter it to fit their own structure and operation.

At some departments they are only using Swedish words to describe the tools of

Lean and they do not work with the Kaizen-tools, as it is not considered to fit their

departments. Other departments on the other hand are actively using both Lean

terminologies and the Kaizen tool of improvements. Even though the departments

work in unique ways, Lean can be found at all the departments as they all work with

continuous improvements and flow efficiency. Thus, Lean is custom-made to the

department specific context, which correspond with Røvik’s thoughts that an

organizational idea is transformed to suit a specific department.

To answer the research questions; we have detected two factors that can explain why

they work with Lean in a specific way. Firstly, the fundamental technology of the

department affect to what extent Lean is applicable to their operations since Lean in

many cases requires predetermination. Secondly, the leaders of the organization can

decide how they want to work with Lean, which affects the shape of Lean at the

department. Therefore, it is important that the leaders of the organization

communicate the benefits of Lean, so it is effective and not considered to be foreign

which countervails its successfulness.

To sum up, we have discovered that it is not possible for all departments to

incorporate Lean completely since the uncertainty factor in certain departments plays

a major role. However, we have come to the conclusion that Lean can be a suitable

solution for all the departments, since the tools of Lean has enabled improvements at

all the departments, even where the patient process is unique to every patient. We

believe that this study may be useful to other hospitals that would like to implement

Lean since it explains both difficulties and opportunities with the Lean philosophy.

  34  

7. Suggestions for future research  During the research we encountered that the Akademiska hospital is using balanced

scorecards combined with Lean in order to create goals for the departments and the

employees. We did not further elaborate this use of balanced scorecards since we

were specifically looking at Lean. A suggestion for future research would be to

investigate what implications this combination may have on the organization.

Another dimension that our research could have taken would have been to study the

line of decisions at the hospital. The Akademiska hospital is a vertical organization

but the departments are working horizontally with Lean. What kind of issues can one

find connected to this? Why have they decided to do this? And is this why they have

had troubles with interdepartmental flows?

                                                 

  35  

8. References

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centrum-rontgen/Om-oss/ [Accessed on 03.05.2013].

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26 (1), p. 39-42.

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Bryman, A. (2008) Social research methods. 3rd edition. Oxford: Oxford University

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Dimaggio, P. T & Powell, W. W. (1983) The Iron Cage Revisited: Institutional

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Sociological Review, 48(2), p. 147-160.

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nytt-under-solen [Accessed on 2013.04.14].

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flödeseffektivitet. Stockholm: Stockholm School of Economics Institute for Research.

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turn deviations into success! Bromma : Part Media.

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Røvik, K.A (2000) Moderna organisationer-trender inom organisationstänkandet vid

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dodade-herr-b [Accessed on 2013.04.25]

 

  38  

Interviews:  Informant 1. Medical informatics and Technology, 2013-04-12

Informant 2. Medical informatics and Technology, 2013-04-12

Informant 3. Children’s Hospital Emergency, 2013-04-16

Informant 4. Children’s Hospital Emergency, 2013-04-16

Informant 5. Electro convulsive therapy, 2013-04-17

Informant 6. Medical Imaging, 2013-04-24

Informant 7. Head of department for strategic projects, 2013-05-03

Informant 8. Head of Department of Plastic- and Maxillofacial Surgery, 2013-05-03

  39  

Interview guide (English)

Below, our interview block no. 1 and no. 2 is presented. However, these questions are

only preliminary since we have formed our interviews as semi-structured, where we

might have added follow up questions and further discussions depending on the

interview progression. In the start of our interview we presented ourselves and the

aim of our research. Thereafter we have asked our informants to talk about their

background and their role at Akademiska Hospital. We have divided our interview

questions into two blocks. In block 1 (Appendix 1) we asked the informants 1-6 who

work at a department, how they work with Lean at their specific departments.

Meanwhile the questions in the second block (Appendix 2) was given to informants 7

and 8 at the head department, where we asked questions concerning the overall work

of the Lean looks at the hospital.

Appendix 1A: Department level

1. What is your role in the department?

2. How does the University Hospital overall mission affect your daily work?

3. What objectives must be achieved?

4. How is the operations planned based on its objectives?

5. What is done at the operation to achieve these objectives?

6. Is there a particular important goal?

7. Can you influence the goals?

8. Are there unique goals for your department?

9. How do you work with flow efficiency in your department?

10. Are there flows that you have had difficulties to handle? What has been done in

order to solve these?

11. Are there processes in your department which are difficult to make effective,

when looking at it from a flow perspective?

12. How do you cooperate with other department to avoid bottlenecks and waiting?

13. Can you describe a normal patient/customer process?

14. What do you do in order to eliminate waste of resources?

15. Does it differ anything in comparison with the Akademiska hospital’s common

directives?

16. How does the improvement work look like in your department and what tools do

  40  

you use?

17. How do you handle the continuing training/ education at your department?

18. Have you standardized certain job assignments, is there space for self-

determination?

19. Are all the job assignments standardized or are there exceptions?

20. How do you work with Lean, which tools are being used and does it differ from

other departments?

Appendix 1B: Head department

1. Who are you and what do you do?

2. Why was Lean introduced at the Akademiska Hospital?

3. What has improved?

4. Have you encountered any problems with the implementation of Lean?

5. Do you think anything has worsened since it was adopted?

6. In which departments do you think it has been easier and more difficult to create

flow? Why?

7.There are those who believe that flow can not be created in all businesses, what do

you think?

8. How does it look in the current situation?

9. How does the hospital break the overall goal down to its departments and to the

individuals?

10. How does it function for the hospital, which has a vertical line organization, to

work with lean?

11. How is a major change at the hospital done when it comprises several

departments?

12. How does it look like in the future?

 

   

  41  

Intervjuguide (Swedish)  Nedan presenteras vårt intervjublock 1 och intervjublock 2. Dessa frågor är endast

preliminära eftersom vi har lagt upp våra intervjuer semi-strukturellt, där vi lagt

följdfrågor och ytterligare diskussioner beroende på hur samtalet har fortskridit.

Inledningsvis presenterade vi oss själva och förklarade syftet med vår forskning.

Därefter har vi bett våra informanter att berätta om sin bakgrund och deras roll vid

Akademiska sjukhuset. Vi har delat upp intervjufrågorna i två block. I block 1 (bilaga

1) har vi ställt frågor till informanterna 1-6 om hur avdelningen jobbar med Lean.

Frågorna i andra blocket (bilaga 2) har ställts till informanterna 7 och 8 på

huvudkontoret, där har vi frågat hur det övergripande arbetet med Lean ser ut på

sjukhuset.

Appendix 2A: Avdelningsnivå

1. Vad är din roll på avdelningen?

2. Hur påverkar Universitetssjukhuset övergripande uppdrag det dagliga arbetet?

3. Vilka mål ska uppnås?

4. Hur planeras verksamheten utifrån målen?

5. Vad gör ni för att uppnå målen?

6. Finns det något särskilt viktigt mål?

7. Kan du påverka målen?

8. Finns det unika mål för din avdelning?

9. Hur arbetar ni med flödeseffektivitet på din avdelning?

10. Finns det flöden som ni har haft svårt att hantera? Vad har gjorts för att lösa

dessa?

11. Finns det processer på er avdelning som är svåra att effektivisera utifrån ett

flödesperspektiv?

12. Hur samarbetar ni med andra avdelningar för att undvika flaskhalsar och väntan?

13. Kan du beskriva en vanlig patient/kund-process?

14. Vad gör ni för att eliminera resursslöseri på er avdelning?

15. Skiljer det sig något mot Akademiska sjukhusets gemensamma direktiv?

16. Hur ser förbättringsarbetet ut på er avdelning och vilka verktyg använder ni?

17. Hur hanterar ni den interna fortbildningen på er avdelning?

  42  

18. Har ni på något sätt standardiserat arbetsuppgifterna, finns det utrymme för

självbestämmande?

19. Är alla arbetsuppgifter på avdelningen standardiserade eller finns det undantag?

20. Hur arbetar ni med Lean, vilka verktyg används och skiljer det sig från andra

avdelningar?

Appendix 2B: Huvudkontoret

1. Vem är du och vad gör du?

2. Varför introducerades lean på Akademiska sjukhuset?

3. Vad har förbättrats?

4. Har ni stött på några problem med införandet av Lean?

5. Anser ni att något har försämrats sen den antogs?

6. I vilka avdelningar anser ni att det har varit lättare och svårare att skapa flöde i?

Varför är det så?

7. Det finns de som anser att flöde inte kan skapas i alla verksamheter, vad anser ni?

8. Hur ser det ut i dagsläget?

9. Hur bryts sjukhusets övergripande mål ner till verksamheten på de enskilda

avdelningarna?

10. Hur fungerar det med att sjukhuset är en vertikal linjeorganisation, samtidigt som

ni jobbar lean?

11. Hur sker en större förändring till på Sjukhuset som omfattar flera avdelningar?

12. Hur ser det ut i framtiden?