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Kaltenbrunner, MonicaORCID iD iconorcid.org/0000-0003-2211-620x
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Kaltenbrunner, M. (2020). A staff perspective on Lean maturity, well-being, and quality in primary care. (Doctoral dissertation). Gävle: Gävle University Press
Open this publication in new window or tab >>A staff perspective on Lean maturity, well-being, and quality in primary care
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Lean is commonly implemented in healthcare but it is unclear how much of Lean is adopted and whether Lean is associated with staff’s well-being and quality of care.

Aim: To describe staff perception of Lean maturity in primary care, and to determine to what extent staff-rated Lean maturity is associated with staff rated thriving, exhaustion, and musculoskeletal complaints, as well as staff rated quality of care.

Method: Survey data were collected in 2015 (n=481 staff) and 2016 (n=351 staff) at 48 primary care units; they were analyzed using confirmatory factor analysis (Paper I), and multiple regression analysis, taking nesting within units into account when possible (Paper II-IV). Interviews (n=12 staff) and observations (n=28 staff) were analyzed deductively.

Results: The developed Lean in Healthcare Questionnaire, based on Liker’sdescription of Lean, generally showed acceptable psychometric properties (Paper I). Lean maturity varied within and between units. The highest maturity concerned staff adherence to routines, and the lowest concerned having a change agent at the unit (Paper II). Lean maturity was positively associated with staff satisfaction with care, both cross-sectionally (Paper II) and, mediated by increased resources, in a longitudinal analysis (Paper IV). The 12-month prevalence of musculoskeletal complaints in the shoulders, neck, and low back was 50-58%, and the 7-day prevalence 25-37% (PaperIII). Lean maturity was not associated with musculoskeletal complaints (PaperIII). Increased Lean maturity was, however, associated with increased thriving, mediated by increased job resources, as well as with decreased exhaustion, mediated by decreased job demands (Paper IV).

Conclusion: Lean maturity varied in primary care. It was positively associated with staff-rated quality of care and thriving, and negatively associated with exhaustion. Musculoskeletal complaints were common, but not associatedwith Lean maturity.

Abstract [sv]

Bakgrund: Lean i hälso-och sjukvården är vanligt. Det är dock oklart i vilken utsträckning Lean har implementerats och om det finns samband mellan Lean och välbefinnande.

Syfte: Att beskriva hur personal uppfattar mognaden av Lean inom primärvården, samt att påvisa i vilken utsträckning det finns ett samband mellan medarbetarnas skattning av mognad av Lean och deras skattning av thriving, utmattning och muskuloskeletala besvär, samt deras skattning av vårdkvalitet i primärvården.

Metod: Enkätdata samlades in 2015 (n=481 medarbetare) och 2016 (n=351 medarbetare) vid 48 primärvårdsenheter, som analyserades med konfirmatorisk faktoranalys (delstudie I) och multipel regressionsanalys (delstudie II-IV). Intervjuer (n=12 medarbetare) och observationer (n=28 medarbetare) analyserade deduktivt.

Resultat: Lean in Healthcare Questionnaire utvecklades, baserat på Liker’s beskrivning av Lean (delstudie I). Mognaden av Lean varierade, högst mognad rörde efterlevnad av rutiner, lägst mognad rörde att ha en person på enheten som ansvarade för Lean implementeringen (delstudie II). Positiva samband sågs mellan mognad av Lean och medarbetares tillfredställelse med den vård de givit, i tvärsnitts- (delstudie II) samt longitudinell data (medierat av ökade resurser) (delstudie IV). Muskuloskeletala besvär från skuldror, nacke och ländrygg de senaste 12 månaderna uppgavs av 50-58%, besvär de senaste 7 dagarna uppgavs av 25-37% (delstudie III). Inget samband sågs mellan mognad av Lean och muskuloskeletala besvär (delstudie III). Samband sågs mellan ökad mognad av Lean och ökad thriving medierat av ökade resurser, samt minskad utmattning, medierat av minskade krav (delstudie IV).

Slutsats: Mognaden av Lean varierade inom primärvården. Positiva samband framkom mellan mognad av Lean och medarbetarnas skattning av vårdkvalitet och thriving. Sambandet till utmattning var negativt och inga samband framkom rörande muskuloskeletala besvär. Men att ha muskuloskeletala besvär var vanligt.

Place, publisher, year, edition, pages
Gävle: Gävle University Press, 2020. p. 58
Series
Doctoral thesis ; 12
Keywords
LiHcQ, CFA, GEE, musculoskeletal, MSD, thriving, exhaustion, quality, longitudinal, mixed-methods, LiHcQ, KFA, GEE, muskuloskeletal, MSB, thriving, utmattning, vårdkvalitet, longitudinell, mixad metod
National Category
Other Medical Sciences
Research subject
Health-Promoting Work
Identifiers
urn:nbn:se:hig:diva-31086 (URN)9789188145406 (ISBN)9789188145413 (ISBN)
Public defence
2020-02-27, Stora Jadwigasalen, Kungsbäcksvägen 47, Gävle, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2020-02-04 Created: 2019-12-19 Last updated: 2020-04-02Bibliographically approved
Kaltenbrunner, M., Mathiassen, S. E., Bengtsson, L. & Engström, M. (2019). Lean maturity and quality in primary care. Journal of Health Organisation & Management, 32(2), 141-154
Open this publication in new window or tab >>Lean maturity and quality in primary care
2019 (English)In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 32, no 2, p. 141-154Article in journal (Refereed) Published
Abstract [en]

Purpose - The purpose of this paper is to 1) describe Lean maturity in primary care using a questionnaire based on Liker’s description of Lean, complemented with observations, and 2) determine the extent to which Lean maturity is associated with quality of care measured as staff-rated satisfaction with care and adherence to national guidelines. High Lean maturity indicates adoption of all Lean principles throughout the organization and by all staff.

Design/methodology/approach - Data were collected using a survey based on Liker’s four principles, divided into 16 items (n = 298 staff in 45 units). Complementary observations (n = 28 staff) were carried out at four units.

Findings - Lean maturity varied both between and within units. The highest Lean maturity was found for ‘adhering to routines’ and the lowest for ‘having a change agent at the unit’. Lean maturity was positively associated with satisfaction with care and with adherence to national guidelines to improve healthcare quality. 

Practical implications - Quality of primary care may benefit from increasing Lean maturity. When implementing Lean, managers could benefit from measuring and adopting Lean maturity repeatedly, addressing all Liker’s principles and using the results as guidance for further development.

Originality/value - This is one of the first studies to evaluate Lean maturity in primary care, addressing all Liker’s principles from the perspective of quality of care. The results suggest that repeated actions based on evaluations of Lean maturity may help to improve quality of care.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2019
Keywords
healthcare, Lean principles, Liker, observations, qualitative
National Category
Other Health Sciences
Identifiers
urn:nbn:se:hig:diva-26374 (URN)10.1108/JHOM-04-2018-0118 (DOI)000463633800002 ()30950305 (PubMedID)2-s2.0-85060950444 (Scopus ID)
Available from: 2018-03-23 Created: 2018-03-23 Last updated: 2020-01-29Bibliographically approved
Kaltenbrunner Nykvist, M., Bengtsson, L., Mathiassen, S. E., Högberg, H. & Engström, M. (2019). Staff perception of Lean, care-giving, thriving and exhaustion: a longitudinal study in primary care. BMC Health Services Research, 19(1), Article ID 652.
Open this publication in new window or tab >>Staff perception of Lean, care-giving, thriving and exhaustion: a longitudinal study in primary care
Show others...
2019 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 19, no 1, article id 652Article in journal (Other academic) Published
Abstract [en]

Background

Lean is commonly adopted in healthcare to increase quality of care and efficiency. Few studies of Lean involve staff-related outcomes, and few have a longitudinal design. Thus, the aim was to examine the extent to which changes over time in Lean maturity are associated with changes over time in care-giving, thriving and exhaustion, as perceived by staff, with a particular emphasis on the extent to which job demands and job resources, as perceived by staff, have a moderated mediation effect.

Method

A longitudinal study with a correlational design was used. In total, 260 staff at 46 primary care units responded to a web survey in 2015 and 2016. All variables in the study were measured using staff ratings. Ratings of Lean maturity reflect participants’ judgements regarding the entire unit; ratings of care-giving, thriving, exhaustion and job demands and resources reflect participants’ judgements regarding their own situation.

Results

First, over time, increased Lean maturity was associated with increased staff satisfaction with their care-giving and increased thriving, mediated by increased job resources. Second, over time, increased Lean maturity was associated with decreased staff exhaustion, mediated by decreased job demands. No evidence was found showing that job demands and job resources had a moderated mediation effect.

Conclusion

The results indicate that primary care staff may benefit from working in organizations characterized by high levels of Lean maturity and that caregiving may also be improved as perceived by staff.

Keywords
COPSOQ, JD-R theory, linear mixed model, LiHcQ Lean in healthcare questionnaire, quality of care, thriving, exhaustion
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hig:diva-29441 (URN)10.1186/s12913-019-4502-6 (DOI)000484951700004 ()31500624 (PubMedID)2-s2.0-85071970266 (Scopus ID)
Available from: 2019-04-05 Created: 2019-04-05 Last updated: 2020-01-29Bibliographically approved
Kaltenbrunner, M., Bengtsson, L., Mathiassen, S. E. & Engström, M. (2018). Lean i primärvården - en bild av hur Lean tillämpas. In: Per Lindberg (Ed.), FALF KONFERENS 2018 Arbetet – problem eller potential för en hållbar livsmiljö?   10-12 juni 2018 Gävle: Program och abstracts. Paper presented at FALF2018 - forum för arbetslivsforskning, 10-12 juni 2018, Gävle (pp. 112). Gävle: Gävle University Press
Open this publication in new window or tab >>Lean i primärvården - en bild av hur Lean tillämpas
2018 (Swedish)In: FALF KONFERENS 2018 Arbetet – problem eller potential för en hållbar livsmiljö?   10-12 juni 2018 Gävle: Program och abstracts / [ed] Per Lindberg, Gävle: Gävle University Press , 2018, p. 112-Conference paper, Oral presentation with published abstract (Other academic)
Abstract [sv]

Bakgrund

Lean har sitt ursprung i bilindustrin och har spridits till andra sektorer såsom hälso-och sjukvård. Implementering av Lean syftar vanligtvis till att öka vårdkvaliten. Vid utvärderingar av Lean saknas ofta en beskrivning av vilka principer av Lean som implementeras och i vilken utsträckning. Föreliggande studie utgår från Likers beskrivning av Lean. Liker beskriver Lean i fyra övergripande grupper kallad 4P modellen; philosophy, processes, people and partners, och problem-solving (filosofi, processer, anställda och partners, och problemlösning), som består av ett antal principer. Att implementera alla principer och involvera alla medarbetare är ovanlig, vilket Liker menar är avgörande om organisationen ska nå de mål de satt med att införa Lean.

Syfte

Syftet med studien var att illustrera hur Lean praktiseras inom primärvården. 

Metod

Studien utgår från ett större forskningsprojekt där både privata och landstingsägda primärvårdsenheter deltog. All personal vid enheterna fick 2016 besvara en enkät om Lean-principer, svarsfrekvens 35% (298 medarbetare vid 45 enheter). Höga Lean skattningar indikerade hög mognad av Lean vilket innebar att medarbetarna var kunniga rörande den efterfrågade Lean-principen; låg mognad av Lean innebar att man helt saknade principen på sin arbetsplats eller hade implementerat den i liten utsträckning av ett fåtal medarbetare. Baserat på enkätsvaren valdes fyra enheter ut för observationer, två med hög mognad av Lean och två med låg mognad. Observationerna inkluderade intervjuer och fältanteckningar som illustrerade hur 4P-modellen praktiserades på enheterna. Hälso- och sjukvårdspersonal med olika professioner deltog (n=28).

Resultat

Rörande filosofi ansåg medarbetarna vid alla fyra enheter att den närmaste chefen, återkommande men i varierande utsträckning, kommunicerade gemensamma mål. Patienternas behov styrde planeringen av vården. Processer kunde innefatta att medarbetarna baserade sin planering av vården på statistik. För vissa patientgrupper eller symtom fanns generella ordinationer, d.v.s. utan kontakt med läkare, t.ex. på vilka prover som skulle tas. Rörande anställda och partners var det vanligt att arbeta i team både inom och utanför sin enhet. Men det framkom även att medarbetarna inte arbetade tillsammans fast de borde det. Problemlösning förekom men ofta ostrukturerat med brister på uppföljning. En enhet hade påbörjat utvecklande av problemlösning genom dagliga möten och strullistor att dokumentera problemen på.

Konklusion

Tillämpning av Lean varierar i stor utsträckning mellan vårdcentralerna. Ett par enheter hade implementerat Lean i större utsträckning och dessa enheter var mer strukturerade rörande t.ex. problemlösning och teamarbete.

 

Place, publisher, year, edition, pages
Gävle: Gävle University Press, 2018
Keywords
Lean, hälso- och sjukvård, observationer, kvalitativ, ständiga förbättringar
National Category
Other Health Sciences
Identifiers
urn:nbn:se:hig:diva-27039 (URN)978-91-88145-28-4 (ISBN)
Conference
FALF2018 - forum för arbetslivsforskning, 10-12 juni 2018, Gävle
Available from: 2018-06-15 Created: 2018-06-15 Last updated: 2020-01-29Bibliographically approved
Kaltenbrunner, M., Bengtsson, L., Mathiassen, S. E. & Engström, M. (2017). A questionnaire measuring staff perceptions of Lean adoption in healthcare: development and psychometric testing. BMC Health Services Research, 17(1), Article ID 235.
Open this publication in new window or tab >>A questionnaire measuring staff perceptions of Lean adoption in healthcare: development and psychometric testing
2017 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 17, no 1, article id 235Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

During the past decade, the concept of Lean has spread rapidly within the healthcare sector, but there is a lack of instruments that can measure staff's perceptions of Lean adoption. Thus, the aim of the present study was to develop a questionnaire measuring Lean in healthcare, based on Liker's description of Lean, by adapting an existing instrument developed for the service sector.

METHODS:

A mixed-method design was used. Initially, items from the service sector instrument were categorized according to Liker's 14 principles describing Lean within four domains: philosophy, processes, people and partners and problem-solving. Items were lacking for three of Liker's principles and were therefore developed de novo. Think-aloud interviews were conducted with 12 healthcare staff from different professions to contextualize and examine the face validity of the questionnaire prototype. Thereafter, the adjusted questionnaire's psychometric properties were assessed on the basis of a cross-sectional survey among 386 staff working in primary care.

RESULTS:

The think-aloud interviews led to adjustments in the questionnaire to better suit a healthcare context, and the number of items was reduced. Confirmatory factor analysis of the adjusted questionnaire showed a generally acceptable correspondence with Liker's description of Lean. Internal consistency, measured using Cronbach's alpha, for the factors in Liker's description of Lean was 0.60 for the factor people and partners, and over 0.70 for the three other factors. Test-retest reliability measured by the intra-class correlation coefficient ranged from 0.77 to 0.88 for the four factors.

CONCLUSIONS:

We designed a questionnaire capturing staff's perceptions of Lean adoption in healthcare on the basis of Liker's description. This Lean in Healthcare Questionnaire (LiHcQ) showed generally acceptable psychometric properties, which supports its usability for measuring Lean adoption in healthcare. We suggest that further research focus on verifying the usability of LiHcQ in other healthcare settings, and on adjusting the instrument if needed.

Keywords
service sector, health care sector, Lean maturity, instrument development, survey
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hig:diva-22027 (URN)10.1186/s12913-017-2163-x (DOI)000397166800002 ()28340573 (PubMedID)2-s2.0-85016132981 (Scopus ID)
Projects
Lean
Available from: 2016-06-30 Created: 2016-06-30 Last updated: 2019-12-19Bibliographically approved
Kaltenbrunner Nykvist, M., Bengtsson, L., Mathiassen, S. E. & Engström, M. (2014). Towards a Questionnaire to Measure Lean in Health Care. In: Kasper Edwards och Jørgen Winkel (Ed.), 8th NOVO Symposium, Sustainable health care production systems - Abstract book: . Paper presented at 8th NOVO symposium, Sustainable Health Care Production Systems, Copenhagen, Denmark, 6-7 november 2014 (pp. 19-20). Lyngby: Danmarks Tekniske Universitet, DTU
Open this publication in new window or tab >>Towards a Questionnaire to Measure Lean in Health Care
2014 (English)In: 8th NOVO Symposium, Sustainable health care production systems - Abstract book / [ed] Kasper Edwards och Jørgen Winkel, Lyngby: Danmarks Tekniske Universitet, DTU, 2014, p. 19-20Conference paper, Oral presentation with published abstract (Refereed)
Abstract [en]

The rapid spread of Lean implementation within the health care sector has made it urgent to evaluate the effects of Lean on productivity, working conditions and health. Therefor an instrument is needed to measure Lean in primary care. The aim with this research is to find an instrument that captures the character of Lean. A literature search was conducted in Academic Search Elite, WileyOnlineLibrary, PubMed, Cinahl, PsycInfo, JSTOR, ScienceDirect, Emerald and Scopus. Keywords used were reflecting Lean and measurement and the search resulted in 7933 hits. Included were articles that presented an instrument that had the possibilities to distinguish between high or low Lean adoption. Malmbrandt and Åhlstöm´s (2014) instrument fulfilled criteria and was chosen. The original instrument was firstly translated to Swedish. A back translation was made by a bilingual authorized translator. The prototype will be tested among health care professions in Sweden using the think aloud method (TA) with the aim to explore how the participants perceive and interpret the Swedish version (Collins 2003). Immediately afterwards, they will be interviewed about how they interprets specific expressions in the questionnaire. After every round of 5-15 interviews the prototype will be adjusted and when saturation is reached the TA will terminate. After psychometric tests the finalized Swedish version of the instrument is to be used in a longitudinal study to describe status of Lean and how Lean correlate with the health of primary health care staff, there working conditions and productivity over time.

Place, publisher, year, edition, pages
Lyngby: Danmarks Tekniske Universitet, DTU, 2014
Keywords
Lean, instrument, measure, health care, Lean, instrument, mäta, hälso- och sjukvård
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:hig:diva-18571 (URN)10.11581/DTU:00000008 (DOI)
Conference
8th NOVO symposium, Sustainable Health Care Production Systems, Copenhagen, Denmark, 6-7 november 2014
Available from: 2014-12-19 Created: 2014-12-17 Last updated: 2018-03-13Bibliographically approved
Kaltenbrunner, M. Lean maturity and musculoskeletal complaints among primary care staff. A longitudinal study.
Open this publication in new window or tab >>Lean maturity and musculoskeletal complaints among primary care staff. A longitudinal study
(English)Manuscript (preprint) (Other academic)
National Category
Other Medical Sciences
Identifiers
urn:nbn:se:hig:diva-31232 (URN)
Available from: 2019-12-18 Created: 2019-12-18 Last updated: 2019-12-19Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-2211-620x

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