Creating a Force of Development in Swedish Healthcare : A Contribution from the First-Line Managers’ Perspective When Driving Improvement Work Based on Lean


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Publication Details

Author list: Kahm, Therese

Publisher: Mid Sweden University

Place: Sundsvall

Publication year: 2019

ISBN: 978-91-88947-18-5


This thesis is about the healthcare managers, working at operational levels, defined as the first-line managers. These managers often are given the role and responsibility to integrate improvements into daily work. A stronger development ability of Swedish healthcare requires first-line managers with a developed ability to lead change. Thereby efforts must be made to provide these managers with supportive work conditions when leading and developing organizations. One approach to organizational development is Lean, which refers to a strong improvement culture based upon a supportive and highly engaged leadership as well as a strong customer focus. The purpose of this thesis is to contribute to knowledge about and an understanding of the conditions that influence first-line healthcare managers’ abilities to drive improvement work based on Lean. Some of the conditions investigated are; time, receiving support from the own manager, feeling joy in improvement work and being assured about the effects of Lean.

The thesis is based on three separate analyses of a web-based survey, which relate to the two research questions. The study was conducted in a Swedish healthcare organization two years after the initiation of Lean. The analyses are presented in three separate papers. The first research question considers; How can an instrument be developed that investigates first-line managers’ views on their role, conditions and ability to drive improvement work based on Lean? The second question is; What can be learned from using the instrument that investigates first-line managers’ views on their role, conditions and ability to drive improvement work based on Lean? A qualitative study based on a hermeneutic, inductive, qualitative research approach was conducted in order to meet the research purpose and answer the research questions.

The thesis is mainly based on three papers. In paper 1 it is stated that the assuredness about the effects of Lean was quite high among the managers when the survey was conducted, such as that Lean contributes to a greater patient focus and to the development of an improvement culture. In paper 2 it is noted that the first-line managers view their role as crucial in improvement work based on Lean. Time, support from coworkers, and a clear vision and clear goals were the three conditions they considered to be most important for their ability. The results presented in paper 3 show that to initiate improvement work based on Lean, they ask for own managers who are assured about Lean and include them in discussions. They view their role and responsibility in relation to their coworkers as extensive, for instance increating a culture where problems and mistakes are viewed as possibilities to improve and for encouraging that new work procedures are tested. The findings indicate a need for a deeper understanding of Lean. It is concluded that a thorough understanding of Lean is a main condition for the first-line managers´ ability to drive improvement work based on the approach. Developing a common view of Lean takes time, which is important to emphasize in the practical setting to motivate for a long-term perspective. This development takes highly motivated, assured and persistent leaders with a continuous improvement attitude and a mission to improve healthcare together.

There is also an applied research question; How can the use of the instrument contribute to developing first-line managers’ role, conditions, and ability to drive improvement work based on Lean? In its essence, Lean is concerned with improving a system and since the instrument raises questions about relationships between organizational members, it sets focus on the system and calls on a system view. The responsibility for one management level must continuously be set I relation to another, when putting the pieces together in the “improvement puzzle”. Change depends on adjustments in human behavior and the instrument establishes a focus on the people in the processes necessary for development and results. The instrument also provides opportunity and structure to investigate and talk about the soft conditions important for the ability, such as receiving support from the own manager, and feeling inspiration and being assured. The practice of Lean requires changes in attitudes, new habits, new skills in the whole system, meaning in each individual from the executive management to the front-line workers. Thereby self-reflection becomes important, which requires forums for dialogue. It is concluded that such forums can influence first-line healthcare managers’ abilities to drive improvement work based on Lean. In dialogue forums improvement work can be reflected upon and learned from together.


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