An action research study on the adoption of a Lean Management System in a healthcare organization attempting to transform its culture
Abstract: This dissertation focuses on the adoption of an integrated performance management system (inspired by a Lean philosophy) in a Quebec healthcare institution. Several institutions in the field of healthcare have adopted Lean principles with the objective of improving the quality of care and services. Unfortunately, an emphasis on the adoption of tools and techniques has limited its potential for improvement since one of the main pillars of a lean philosophy, respect for people, has been lost in translation. The belief that people are the greatest asset of an organization, and that investment in their development is essential, is central to the dynamic learning ability that is the heart of a Lean philosophy (Holweg, 2007). Studies of organizational learning from a cultural perspective highlight that learning is the result of the interactions between people and organizational elements, and this learning is embodied in the artifacts of culture. Organizational culture is, therefore, a social, dynamic and cyclical phenomenon that is constantly redefining itself. In this study, an organization is seen as a culture (contrary to the view that an organization 'has' a culture), whereby an organization is defined as a loosely structured and incompletely shared system of symbols and meanings that emerges through dynamic interaction . This interaction leads either to a reinforcement or to a change in symbols and meanings. The objective of this study is to illustrate from a cultural perspective, how a healthcare organization implements an integrated lean management system. The research strategy is a longitudinal study, carried out as action research. It is situated in a postmodern pragmatist paradigm (rooted in the philosophical tradition of Chia (2003)) where the researcher participates directly with members of the organization, introducing reflexive practices that help guide action and generate knowledge. Two iterative cycles were completed, during which research participants supported the organization in changing 'the way things are done', with the goal of improving the safety and delivery of care through efficient processes, judicious use of resources, dedication of employees to their practice, and accessibility of care and services. In other words, to refocus actions on the 'core business' (clinical operations). Qualitative data was collected over a three-year period. The data consisted of the researcher's observation notes, sixty-two semi-structured interviews, and institutional documents. The data collected was analyzed in several stages; a descriptive account of the process was generated first; an analysis of the lean transformation over the period of the study was then conducted; and finally, the implementation process was analyzed from a cultural perspective. The descriptive narrative account of the change process begins with the CHUS in 2014 introducing their integrated performance management system (SPCHUS) and ends with the CIUSSS of Estrie-CHUS (created as a result of the reform adopted in February and implemented in April 2015) and the adoption of their system SGIP. Included in the descriptive narrative are the key learnings of the research participants following each action research cycle, and the adjustments made to the introduction of the performance management system for the next steps in implementation. Of particular note in the learnings and the subsequent adjustments was the behavioral nature of the changes, with little (if any) questioning of the notably classic beliefs of management manifested in individual actions and interactions. A lean philosophy of management inherently relies on very different beliefs, and the discrepancy between the beliefs of the current and desired system should be made explicit in order for changes in the underlying mindset to occur. As Toussaint and Berry (2013) so eloquently state "before we can change we need to understand why we act as we do" (p. 11). The analysis of the lean transformation that occurred over both action research cycles highlighted how the instrumentalism of the implementation, the bureaucratic nature of the organization, and the various understandings coexisting in the organization concerning Lean contributed to the lack of learning in the organization. The present research reinforced previous findings that organizational learning is fundamental for achieving a philosophy driven level of transformation, and that moving from a tool-driven to a system-driven level of transformation is extremely difficult in public healthcare (Mackenzie and Hall, 2015). In addition, the in-depth study of the implementation of a management system rooted in a lean philosophy answers a suggestion for research in this key area that is under investigated in the current literature (D'Andreamatteo, Ianni, Lega and Sargiacomo, 2015). The final level of analysis attempts to partially fill the gap in the scientific literature of analyzing lean implementations from a cultural perspective. This study analyzes the change process using Hatch's (1993) dynamic model of organizational culture with very specific examples allowing the researcher to illustrate that the adoption of an integrated management system, inspired by a Lean philosophy, requires a cultural change. The key to cultural change is the change in meanings that arises through interaction, and as this study has illustrated, this occurs through organizational learning. This requires an approach to implementation that demonstrates a desire to learn. It also requires a change of perspective concerning the role of the leader in culture change as the orchestrater of change, which dominates the literature. Instead, a leader's role becomes one of managing meaning, of inviting input from others, asking probing questions, encouraging multiple points of view and providing opportunities for discussion and reflection. Thus, while leaders are making enormous efforts to re-structure and re-conceptualize public healthcare institutions, this study illustrates the need to pay attention to meanings that are generated through interaction, as cultural evolution emerges precisely from these interactions (Houle and Roberts, 2016).Résumé : Cette thèse porte sur l'adoption d'un système intégré de gestion de la performance (inspiré de la philosophie de gestion Lean) dans un établissement de soins de santé québécois. Dans le but d'améliorer la qualité de leurs soins et services, plusieurs institutions dans le domaine des soins de santé ont adhéré aux principes de gestion Lean, avec des niveaux très variables de succès. L'objectif de la présente étude est d'illustrer d'un point de vue culturel, comment une organisation de soins de santé met en œuvre un système de gestion Lean. La stratégie de recherche est longitudinale et réalisée dans le cadre d'une recherche-action. Des données qualitatives ont été recueillies sur une période de trois ans. Elles sont issues des notes et observations de la chercheuse, de soixante-deux entrevues semi-structurées ainsi que de documents institutionnels secondaires. Les données recueillies ont été analysées à différents stades : une description du processus a d'abord été établie, suivie d'une analyse de la transformation Lean pendant la période de l'étude. Pour conclure, le processus de changement a été analysé dans une perspective culturelle selon le modèle dynamique de culture organisationnelle de Hatch (1993). Le chercheur, exemples très spécifiques à l'appui, illustre que l'adoption d'un système intégré de gestion, inspiré de la philosophie Lean, requiert un changement culturel. La clé du changement culturel se situe dans les interactions amenant à l'apprentissage de deuxième niveau. L'étude approfondie de la mise en place d'un système de gestion inspiré de la philosophie de gestion Lean répond à une suggestion de recherche dans ce domaine clé étudié actuellement (D'Andreamatteo et coll., 2015). Également, la recherche tente de combler des écarts, dans la littérature scientifique, identifiés par plusieurs auteurs qui indiquent qu'une analyse d'une perspective culturelle permettra une compréhension plus profonde des transformations Lean illustrant ainsi pourquoi les transformations s'avèrent une réussite ou un échec, et par le fait même, d'identifier des pistes pour gérer une telle transformation (Davies et Mannion, 2013 ; Synder et coll., 2016 ; Taher et coll., 2016).