Enablers for change. A mixed-methods study of Lean-based quality improvement in hospitals

Abstract

17 quality improvement interventions based on Lean thinking constituted the point of departure for this thesis. How can we understand, and explain, that some Lean interventions succeed while others do not, within one hospital? New insight can reduce the quality chasm in health care, by shedding light on enablers for quality improvement. Enablers for Lean interventions were identified through a systematic umbrella review. The most frequent enablers were leadership support, ownership, commitment and a supportive culture. Characteristics of Lean and the local application should be given more attention in change management, in addition to the organizations' cultural and strategic capability. Local actors’ perceptions of enablers for successful interventions were collected through focus group interviews and a survey. All the enablers, with the exception of the need for external experts, were retrieved locally. In addition, we identified more than 20 local enablers, two-thirds of which were assessed most important for success. Among these were a problem, not a method focus, a bottom-up approach, credibility, realism and patience. The management, the consultants and the staff emphasized different enablers. Three principles and three interrelated logics of translation were deduced. We found that translation processes brought about diverging work-floor versions of Lean, which partly explain the lack of evidence for Lean, and are decisive for interventions outcomes. The 17 interventions’ success was ranked by an experienced Lean panel. 30 percent were assessed as highly successful, 60 percent as moderately successful and 10 percent as minimally successful. A linear mixed model regression analysis showed that a comprehensive project organization, multidisciplinary teams, improvement for patients, employee- and safety staff engagement, and a reach across organizational silos were related to success. Policymakers are guided to tailor quality interventions to fit the context, which eventually will affect the outcome of care.