International Journal of Health Care Quality Assurance

Has Lean improved organizational decision making?

Pascale Simons Jos Benders Jochen Bergs Wim Marneffe Dominique Vandijck
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Pascale Simons Jos Benders Jochen Bergs Wim Marneffe Dominique Vandijck , (2016),"Has Lean
improved organizational decision making?", International Journal of Health Care Quality Assurance,
Vol. 29 Iss 5 pp. 536 - 549
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IJHCQA
29,5
536
Received 29 September 2015
Revised 12 February 2016
29 February 2016
Accepted 28 March 2016
Downloaded by Universiti Putra Malaysia At 20:00 02 September 2016 (PT)
International Journal of Health
Care Quality Assurance
Vol. 29 No. 5, 2016
pp. 536-549
© Emerald Group Publishing Limited
0952-6862
DOI 10.1108/IJHCQA-09-2015-0118
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/0952-6862.htm
Has Lean improved
organizational decision making?
Pascale Simons
Department of Radiotherapy, MAASTRO Clinic, Maastricht, The Netherlands
Jos Benders
Centre for Sociological Research (CESO), KU Leuven, Leuven, Belgium
Jochen Bergs and Wim Marneffe
Faculty of Business Economics, Hasselt University, Hasselt, Belgium, and
Dominique Vandijck
Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
Abstract
Purpose – Sustainable improvement is likely to be hampered by ambiguous objectives and uncertain
cause-effect relations in care processes (the organization’s decision-making context). Lean management
can improve implementation results because it decreases ambiguity and uncertainties. But does it
succeed? Many quality improvement (QI) initiatives are appropriate improvement strategies in
organizational contexts characterized by low ambiguity and uncertainty. However, most care settings do
not fit this context. The purpose of this paper is to investigate whether a Lean-inspired change program
changed the organization’s decision-making context, making it more amenable for QI initiatives.
Design/methodology/approach – In 2014, 12 professionals from a Dutch radiotherapy institute
were interviewed regarding their perceptions of a Lean program in their organization and the
perceived ambiguous objectives and uncertain cause-effect relations in their clinical processes.
A survey (25 questions), addressing the same concepts, was conducted among the interviewees in 2011
and 2014. The structured interviews were analyzed using a deductive approach. Quantitative data
were analyzed using appropriate statistics.
Findings – Interviewees experienced improved shared visions and the number of uncertain cause-effect
relations decreased. Overall, more positive (99) than negative Lean effects (18) were expressed. The
surveys revealed enhanced process predictability and standardization, and improved shared visions.
Practical implications – Lean implementation has shown to lead to greater transparency and
increased shared visions.
Originality/value – Lean management decreased ambiguous objectives and reduced uncertainties in
clinical process cause-effect relations. Therefore, decision making benefitted from Lean increasing QI’s
sustainability.
Keywords Lean management, Quality improvement, Ambiguity, Management decision making
Paper type Research paper
Introduction
Quality and safety are highly valued in healthcare. To improve service quality and safety,
many change initiatives started, although many failed to create sustained improvement
(Beer and Nohria, 2000; Brackett et al., 2013; Dixon-Woods et al., 2014; Glasgow et al., 2010;
Kaplan et al., 2014). The causes for this high failure rate are unclear. Without doubt, the
implementation process plays an important role in a change strategy’s success.
Adapting the improvement strategy to the organization’s decision-making context might
be important to successfully implement sustainable improvements. One quality
The authors thank the MAASTRO clinic managers and staff who participated in the interviews
and completed the questionnaires.
 improvement (QI) strategy is Lean management – a multifaceted approach that aims to Lean improved
improve quality, safety and efficiency. It was developed in the Toyota Motor Company organizational
and has also been adopted in healthcare (Endsley et al., 2006; Mazzocato et al., 2010;
McCarthy, 2006; Rutledge et al., 2010). The philosophy incorporates a long-term vision
decision
aiming for continuous improvement and engaging all employees. Within the Lean making?
philosophy, several tools are used improve services. Some healthcare managers
implement Lean, guided by eliminating waste based on what is defined as being valuable, 537
rather than as a total system governing the whole organization. When Lean is
implemented solely as an approach to providing process standards, creating flow,
reducing interruptions and potential errors without being part of a comprehensive
management system and adapted to the organization’s decision-making context,
improvements will be made, but these may not be sustainable (Al-Balushi et al., 2014;
Dixon-Woods et al., 2014; Kaplan et al., 2014; McIntosh et al., 2014). Even though Lean
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seems promising, no final conclusions can be drawn on its positive effects in healthcare or
on implementation challenges (D’Andreamatteo et al., 2015; Mazzocato et al., 2010;
Brandao de Souza, 2009; Waring and Bishop, 2010). Paradoxically, this is to some extent
due to its attraction: being multifaceted and multi-interpretable, it can be used in many
different ways (Benders and Van Bijsterveld, 2000; Langstrand and Drotz, 2015).

Theory
As organizational decision making helps create sustainable QI, this decision making
should be measured and considered when implementing QI programs. Organizational
decision making is a product of individual decision making and the context in which
these individuals make decisions, which are highly constrained by the task they are
doing, their position in the organization and their socio-historical-cultural position (Carley
and Frantz, 2009). This context also influences QI strategies like Lean management
(Holden et al., 2015). Thompson and Tuden (1959) characterize organizational decision
making as two conditions: first, ambiguous objectives or absent shared vision among
employees; and second, uncertain cause-effect relationships. These two conditions
combined, classify four decision-making contexts (Figure 1) for which different decision

Ambiguity of objectives
Low High
Uncertainty of cause-effects

Decision by Decision by
Low

Computation Compromise

Figure 1.
Thompson and
Decision by
High

Decision by Tuden’s (1959)

Judgment Imagination
framework for
organizational
decision making
Healthcare
 IJHCQA making and improvement approaches should be used. This classic model’s insights are
29,5 reaffirmed in Thompson’s (2003) work. Empirical results suggest that when the model’s
prescriptions are followed, the chance that organizational decision making is successful
increases (Nutt, 2010). An organization with ambiguous objectives combined with
uncertain outcomes is difficult to manage (Thompson, 2003; Thompson and Tuden, 1959).
Decision making and therefore creating change in this context is largely based on
538 inspiration (i.e. decision by imagination).
In contrast, if ambiguity and uncertainty are low, then it becomes clear why things
should be done or need changing (i.e. decision by computation). In this context, decision
making can be facilitated by formulating standard operating procedures (SOPs),
complemented with indicators to measure and monitor outcomes (Abernethy et al.,
2007). However, most healthcare settings do not fit this context because different
objectives are present, owing to complex relations between relevant stakeholders
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(e.g. patients, healthcare insurers, politicians, etc.). Additionally, professional groups and
departmental staff often experience conflicting goals and objectives (Abernethy et al.,
2007). Improvement projects often emphasize these conflicts, stretching managements’
importance. Hence, to increase QI success, the degree that objectives are ambiguous
should be decreased and consensus should be reached (Thompson and Tuden, 1959).
Healthcare professionals are primarily focussed on processes affecting their work,
which often limits their individual knowledge to specific patient processes resulting in
information asymmetry, which in turn jeopardizes mutual understanding and respect
(Vergauwen et al., 2010). Healthcare cause-effect relations are not always clear. It is
often difficult to predict with certainty the outcomes following actions, which may
result in an excuse culture where professionals are unwilling to take responsibility for
their actions (Vergauwen et al., 2010). Although staff in many care organizations have
to deal with conflicting objectives and unclear cause-effect relationships, most
improvements strategies do not consider these complex issues, which might explain
why healthcare improvement initiatives fail.
The Lean philosophy has been widely disseminated in healthcare to improve care
quality and efficiency in several care settings. Lean primarily focusses on improving
the process to its ideal state as defined by the customer (i.e. patient) (Liker, 2004).
However, Lean also defines some basic requirements to realize improvement, like
standardizing processes and increasingly visualizing information and performance.
These fundamental Toyota Production System concepts are expected to decrease
uncertainty by making processes more transparent and stable. Common goals and
shared decision making are central elements in the system, which address ambiguous
objectives. They aim to increase employee commitment to common goals, decrease
information asymmetry and increase mutual understanding between colleagues. Lean
management is an approach that strives to clarify goal ambiguity and increase insight
into cause-effect relationships. This might result in improved organizational decision
making (Figure 1) increasing the chance for sustainable QI. But does Lean succeed in
this endeavor? We evaluated Lean-inspired change program effects in a radiotherapy
institute; notably its effects on goal ambiguity and process uncertainty levels.

Setting
This study was performed at the MAASTRO clinic, a Dutch radiotherapy institute.
On average, 200 oncology outpatients are treated each day. Despite the organization’s
small scale (250 employees in February 2014), its goals for clinical performance and
research are ambitious. Since 2003, staff have been engaged in improving patient safety.
 Since 2007, several Lean based projects were initiated; e.g., treatment process (irradiation) Lean improved
was redesigned to improve compliance to safety tasks and increase efficiency (Simons organizational
et al., 2014). In 2011, the Lean philosophy was formally adopted as the long-term strategy
to realize individualized high-quality care for all patients. Employees throughout the
decision
organization followed Lean management courses. The management structure was making?
reorganized from functional to process oriented (value streams) to facilitate and improve
process innovation. Multidisciplinary teams were initiated for different care paths (e.g. 539
breast, head and neck), led by a clinician. To increase employee commitment and create a
shared vision, board members discussed the long-term vision with all employees in
multiple small group meetings during 2012. To improve clinical information, reduce
information asymmetry and optimize visual management techniques, the patient process
from initial consultation to the final irradiation and follow-up consultations was digitized.
Further standardization was unnecessary for this action. Improvements were mostly
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expected on information availability and an increasingly transparent clinical process.

To improve clinical processes, 15 projects were initiated to increase flow and decrease
waiting times in 2013. A large multidisciplinary professional group was involved in these
projects. These projects encompassed, for example, clinical administrative processes
redesign, thereby minimizing waste, increasing process transparency through designing
and implementing work flow management system, reducing waiting time and combining
patient appointments resulting in reduced patient travel time. In addition to these Lean
management projects, all treatment equipment (accelerators) and planning software were
replaced by a new integrated system between 2011 and 2012. This transition also
resulted in improved processes owing to fewer disruptions (Simons et al., 2016), which
complemented the Lean initiatives.

Methods
A quantitative questionnaire was combined with structured interviews to evaluate
organizational decision making regarding goal ambiguity and clarity about causal
relationships during a Lean transition. In 2011 and 2014, twelve employees completed
the questionnaire. In 2014, these professionals were interviewed regarding their
perceptions. All interviewees received a questionnaire before the interview to prepare
the interviewee for possibly unfamiliar concepts addressed in the interview. Both
research methods were complementary: the surveys allowed us to draw a longitudinal
picture, which the interviews help to interpret.

Questionnaires
In all, 12 interviewees completed a questionnaire in January 2011, before they were
interviewed in 2014. The questionnaire contained 25 items addressing: goal ambiguity,
information asymmetry and uncertain (clinical) process outcomes. Additionally,
6 questions (2, 4 and 22-25, Table I) addressed Lean initiative effects. A Likert scale
from one to seven (one most negative perception and seven most positive) was used.
The scores on question eight were recoded, because this item addressed negative not
positive experiences. To statistically test differences between the longitudinal results
(2011 and 2014), paired t-tests were used. Because respondents were a small group,
questionnaire results should be interpreted with care.

Interviews
In all, 12 professionals were interviewed in January 2014, including four managers
(one as practicing clinical physicist), three oncologists, two radiation technologists
 IJHCQA Mean scores
29,5 2011 2014
Questions (n ¼ 12) (n ¼ 11) p-value

1 To what extent do you perceive difficulties regarding the

knowledge/information transfer? 3.73 4.55 0.108
2 To what extent has the implementation of Lean principles affected
540 the knowledge/information transfer? 4.55 4.45 0.676
3 To what extent does the person with the substantive knowledge
about a process have the control over this process? 4.00 4.78 0.211
4 To what extent has the implementation of Lean principles affected
the process experts’ control over his processes? 4.60 4.30 0.434
5 To what extent is information in general transparent in the
organization? 4.27 4.91 0.190
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6 To what extent do the organization’s indicators fit what you think is

important for your work? 4.55 5.18 0.240
7 To what extent do the organization’s objectives fit your own
objectives? 5.20 5.50 0.394
8 To what extent do you experience conflicts between things you and
the organization find important? (recoded) 4.90 4.70 0.678
9.1 To what extent are innovative projects evaluated before the project
start? 3.00 4.00 0.067
9.2 To what extent are innovative projects evaluated during a project? 3.45 4.00 0.237
9.3 To what extent are innovative projects evaluated after project
completion? 3.18 4.18 0.111
10 To what extent are you aware of your colleagues’ practice within the
organization? 4.00 4.55 0.192
11 To what extent do you have insight in the performance of other
units? 4.36 4.82 0.320
12 To what extent do processes follow the planned trajectory? 3.60 4.50 0.004
13 To what extent is the outcome/result of your action unsure/unclear? 4.91 4.82 0.756
14 To what extent are processes standardized? 4.55 5.27 0.024
15 To what extent are procedures complied to? 4.18 4.64 0.176
16 To what extent is compliance to procedures evaluated? 3.27 4.00 0.087
17 To what extent do you know your professional responsibilities? 5.82 6.00 0.588
18 To what extent are professional responsibilities documented? 4.60 5.30 0.257
19 To what extent do you receive feedback on your responsibilities? 3.64 4.09 0.424
20 To what extent do your close colleagues share the same vision and
objectives? 5.45 5.36 0.724
21 To what extent do the different professions/disciplines in your unit
share the same vision? 4.00 4.82 0.031
22 To what extent do you think the introduction of Lean management
have been clearly communicated? 4.18 4.36 0.690
23 To what extent do you believe in benefits from Lean management
for your organization? 5.09 5.27 0.588
24 To what extent do you think has the Lean implementation positively
affected the clarity of your work? 4.45 3.64 0.181
Table I. 25 To what extent do you think that the level of quality care that is
Survey results for provided has become more clear for the organization, owing to the
2011 and just before Lean implementation? 4.82 4.73 0.796
the interviews Notes: Scores are means on a seven-point Likert scale: 1, for all questions implies most negative and 7,
in 2014 most positive. p-values are based on a paired t-test
 (oncology nurses), one clinical physicist, one administrator and one employee Lean improved
responsible for equipment. The interviews took on average 60 minutes to complete. organizational
The interviewer (main author) had ten years work experience as clinical professional in
the same organization and three years as patient safety officer. The interviews were
decision
structured using 16 questions: ambiguous objectives were addressed by four questions; making?
information asymmetry by three; uncertain cause-effect relations in care processes by
two; Lean’s perceived effects by four and expectations by three questions. Interviews 541
were audio recorded and transcribed verbatim. Following a deductive approach, each
transcript was analyzed and coded, starting from predefined categories (based on
Thompson and Tuden’s framework), using specialized software (NVIVO). During
the coding process, the predefined categories: ambiguous objectives, shared vision,
standardization, information asymmetry, attitude toward Lean and its perceived effects
were further detailed and complemented by additional categories like employee
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commitment and conflicting objectives.

Results
Surveys
In all, 11 from 12 interviewees completed the questionnaire in 2011 and 2014. The overall
average scores did not differ between measures (4.3 in 2011 vs 4.6 in 2014; p ¼ 0.11).
Processes were perceived as increasingly predictable (Table I: question 12), increasingly
standardized (question 14) and the shared vision among different professions/disciplines
had improved (question 21). Project evaluation (question 9.1) and the perceived compliance
to procedures (question 16) improved, but with less statistical certainty ( po0.1).

Interviews
To put the interview results and thus the interviewee’s perceptions into perspective,
Table II presents times the related concepts were categorized within the interviews.
Almost all interviewees expressed up front that Lean management was no longer
practiced. They all expressed several positive and negative changes that more or less
could be ascribed to Lean management. At the end of the interviews, they all concluded
that they were practicing more Lean than they had thought:
I actually think a success is that even though we cannot use the term Lean any more, we
perform things Lean. It just happens. I’m talking about continuous improvement, training
skills. There is a huge difference compared to a few years ago: the methods to train, the
involvement of employees, the development of SOPs, the people themselves. When we
implemented the new equipment, employees would not treat patients if they had no SOPs.
Five years ago, employees would have glared at you if you had just mentioned SOPs.
Most interviewees associated negative feelings to the word Lean, which were mostly
associated with efficiency in a negative sense (i.e. cost reduction). Clinical professionals
appear to interpret efficiency negatively. They are focussed on the patient and service
quality, making them less willing to reduce costs and increase efficiency in the
organization:
Colleagues of mine have many different incorrect thoughts about Lean, which do not position
Lean positively. This is particular related to […] efficiency. Efficiency is obviously quickly
interpreted as doing this fast.
Although clinical professionals appeared to perceive efficiency negatively, they did not
express a negative association to Lean management’s content. Some clinical professionals
 IJHCQA Ambiguous Uncertain cause-effect
29,5 Categorized concepts Quotations objectives relations

Attitude toward Lean

Positive 14
Negative 24
542 Perceived effects of Lean
Positive 99
Negative 18
Neutral 1
Ambiguous objectives reduced 21 |
Shared vision among colleagues increased 24 |
Lack of shared vision among colleagues 29 |
|
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Conflicts perceived in organization 67

Conflicting objectives: research and
clinical practice 18 |
Standardization 55 |
Positively perceived 37 |
Negatively perceived 10 |
Neutral 8 |
Information asymmetry in clinical process
Decreased 53 |
Sustained 21 |
Organizational information asymmetry 6 |
Decreased |
Sustained 19 |
Table II. Uncertain cause-effect relations decreased 20 |
How often concepts Employee commitment 58
were mentioned Improved commitment 32

questioned whether Lean improves their work. Managers’ beliefs regarding Lean’s
benefits were not unanimous. They expressed more negative attitudes toward Lean
than clinical professionals. The clinical professionals appeared to understand Lean better
than managers. Lean’s cultural aspects were increasingly understood by clinical
professionals, like creating a shared vision and increasing employee involvement.
Managers noticed a negative attitude against Lean in the organization. They decided to
replace Lean with flow to prevent unnecessary discussions about its terminology and
focus on Lean initiation:
If you look at the content of Lean, I think everyone can become enthusiastic about this.
Because that is about how can I do my own work better tomorrow. But if we all keep calling
these actions by name, then all professionals feel obliged to have an opinion about Lean.
Then you have a discussion about the theory, which is no good.

Effects ascribed to Lean management

Together, the 12 interviewees mentioned 118 times an effect explicitly ascribed to Lean.
Most quotations (99/118) were positive, the remaining yielded negative associations
(18/118) or referred to a neutral effect (1/118). Most positive effects were referred to
decreased information asymmetry. Furthermore, processes had become increasingly
transparent, owing to visual management and the increased opportunity to discuss
 issues and information in a multidisciplinary setting. As a result, information and Lean improved
knowledge had become increasingly clear: organizational
In every project, a technologist, a doctor and an administrative employee are represented. decision
One of the professionals is in the lead and also responsible for communicating the discussed making?
items to all relevant colleagues.
Most comments were about creating a continuous improvement culture, increased 543
efficiency, employee commitment and process standardization. Interviewees also
expressed improved teamwork and increased process performance. Employee
satisfaction improved and uncertain cause-effect relations decreased resulting from
increased clinical process transparency, improved agreement about outcomes and more
clearly defined responsibilities:
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They start to feel ownership, to feel that they realized the improvements and to have fun in
sustaining their improvements. These are the first signs of sustainable change.
Process improvement requires discussions between professionals, which is time
consuming and increases their workload, which was mentioned as a negative effect.
Poor visibility resulting from the Lean intervention was negatively perceived. The most
important negative effect was that beneficial results from Lean redesigns were not
returned to the employees in question:
You have to consider that the time gained, is returned to the people as unscheduled time.
The time gains should not again be used to schedule more patients in less time.

Ambiguous objectives
The degree that objectives were ambiguous decreased but remained a major
organizational issue. Although eight of 12 interviewees experienced reduced ambiguity
(21 quotations) and improved shared vision among colleagues (24 quotations), six
interviewees expressed issues (29 quotations) related to lacking a shared vision. Several
ambiguities were addressed: actions being invisible, conflicting goals between research
and clinical practice, no actual professional participation in management decision
making and unrealistic objectives:
I think it’s very important that we provide good patient care. I think it’s less important that we
perform research on the highest level and I actually think that’s not realistic either. Of course
we can contribute to science, but we cannot compare ourselves with Stanford or Paris. These
are institutions where 1,000 people work in a radiotherapy centre. That doesn’t seem realistic.
Interviewees were asked about possible conflicts experienced in their organization.
Although nearly all interviewees perceived the word conflict as too negative, they
frequently (67 quotations) mentioned a perceived tension. Most quotations were
associated with conflicting objectives between research and clinical practice (18). Since
the organization was not an academic institution, and therefore did not receive research
funding, most research had to be financed by clinical practice. This frustrated
employees, in particular professionals that did not participate in research activities:
The extensive focus on research demands sacrifices from the clinic, because finances are
withdrawn from the clinic to invest in research.
Our financial resources are according to a peripheral clinic. In addition, we want research and
they do believe that’s what we all want. Well, I’m not one of them all. I do not necessarily have
to perform research.
 IJHCQA The tension between process standardization, respect for individuals and
29,5 acknowledging exceptions was a concern:
The pressure to standardize everything is automatically present in our organization.
If standards are met, everyone is happy and satisfied. That brings about the risk of not
stopping the process if needed. That’s something you should watch. Standard procedures
should not be blindly followed.
544
Although ambiguous objectives were still present in the organization, improvements
were experienced among interviewees (21 quotations), which were mainly associated
with increased involvement in management decision making owing to improved
transparency, which resulted in improved understanding and trust in managers.
Interviewees also perceived improved multidisciplinary communication, because
multidisciplinary teams were created rather than focussing on individual professional
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actions, the focus shifted to the overall clinical process:

People increasingly understand the defined policies, because they increasingly see the
contexts of these policies.
The multidisciplinary care path teams resulted in working together with colleagues who
share goals. I think this is a success.
Employees not involved in research (seven of 12 interviewees) perceived conflicting
goals between research and the clinic more often, compared to employees who
participated in research activities. They also expressed a less positive perception
regarding a shared vision (Figure 2) and were less satisfied about communicating
organizational information (organizational information asymmetry sustained
and transparency even worsened). On the contrary, they perceived improved

10 Involved in research (n = 5)
Not involved in research (n = 7)
Number of references per interviewee

0
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 employee commitment and better clinical data flow. Employees who expressed an Lean improved
improved shared vision also perceived decreased clinical information asymmetry, organizational
improved clinical data flow, increased improvement culture, more problem solving,
enhanced team performance and clearer responsibilities.
decision
making?
Uncertain cause-effect relations
Uncertainty in oncology increases because treatment possibilities have been augmented 545
and complex technology is used progressively. However, nine interviewees expressed
that uncertain cause-effect relations in their work had decreased (20 quotations) in
recent years:
I think that an administrative employee, responsible for the patients’ entire schedule, will
work with more pleasure. Things are increasingly clear, because the scheduling process is
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visualized on a board. Previously, I had no overview and was always in doubt if I had done
things right. And now I can judge this up front.
Since we use specialized software to manage our standard procedures, constraints of a
treatment planning have been increasingly documented. We used to discuss and approve all
treatment plans in a doctors’ meeting. Because constraints have become increasingly clear,
only treatment plans are discussed for which constraints could not be met.
Perceived uncertainties decreased, which could have resulted from increased
standardization. Standardization was mentioned 55 times during the interviews,
37 perceived positively and ten negatively; e.g., interviewees experienced a pressure
to comply to standard procedures and a psychological barrier to stop the process if
needed. Standardization details are difficult to determine. If processes are
standardized too much, then innovation could be jeopardized, since the
organization might become bureaucratic. Standardization was experienced more
negatively by clinicians than managers:
Sometimes it’s just too procedural. I think standardization is good, but you should not
overdo it.
Although the interviewees expressed some concerns about the standardization level
that should be aimed for, they were all positive about the standardization achieved,
which decreased clinical information asymmetry. Professional knowledge became more
transparent for other disciplines and processes were more stable:
If I want to know how we should treat patients with prostate cancer over here, I can see this
very quickly. This was completely different four years ago.
What is expected from me has been increasingly standardized. This also decreases the risk of
making mistakes.
Clinical information asymmetry decreased (53 quotations). Improvements to patient
process digitalization were addressed, improved (multidisciplinary) meetings and
specialized software to manage standard clinical procedures and knowledge were
implemented. Consequently, transparency strongly increased and communication
between different disciplines improved:
We have never worked more professional than we are doing right now. We make medical,
technical and logistical judgments. We are very satisfied about our performance right now.
I think all those Lean projects have resulted in an increased documentation […] flow. This
brings clarity for everyone.
 IJHCQA Although improvements have been expressed, information asymmetry remained a
29,5 concern (21 quotations). Communication between professionals remained unclear at
certain points and although knowledge was increasingly available, employees had to
read and adhere to many procedures:
Some people are afraid that they are no longer in control if implicit knowledge is made
explicit.
546
So actually, our software to manage our procedures has brought about improvement.
Accessibility has increased, but now the problem has shifted towards […] the users. They
have to adhere to the procedures, which is just as important. We have to give each other
feedback on this issue.
The interviewees who mentioned that clinical information asymmetry had decreased,
also mentioned improvements regarding ambiguous cause-effect relations, improvement
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culture and team performance. Information asymmetry, at organizational information

level, remained high (19 quotations on sustained vs six on improved asymmetry).
Managers perceived organizational information as increasingly transparent, while
clinical professionals did not share this perception. Although most interviewees felt that
managers increasingly aimed to improve transparency, they were still unsatisfied with
the organizational communication:
The stimulus to share information in this organization is huge. Transparency is aimed for.
However, it is not as transparent as one thinks. Some things […] I just don’t understand at all.
Clinical process flow also improved, mainly owing to digitization, process
improvements brought about by multidisciplinary teams and the administrative and
treatment preparation processes becoming more transparent through management
techniques. Clinical project and clinical practice evaluation also improved, but still
remained an area for improvement. Although interviewees expressed increasingly
structured evaluation, it was still largely dependent on the employees. The increased
attention to evaluating processes resulted in a higher demand for process data.
The organization focussed more on innovation than sustainability. Project follow-up
was perceived as problematic. However, an overall positive trend toward improved
evaluation was expressed:
I think that last year, we aimed to evaluate implementations more structurally to see whether
the desired results had been achieved. Then again, you sometimes miss a baseline
measurement.
I think we do not evaluate enough. When a project reaches an end, we think we are finished.
Following up and evaluating the projects’ benefits is rarely done.

Discussion
Following the Lean management initiative, the perceived degree that objectives were
ambiguous and uncertain cause-effect relations decreased in the organization we
studied. The 12 interviewees’ perceptions were affirmed by survey results. Ambiguous
objectives remained present in the organization, although improvements were
experienced, mainly associated with increased involvement in management decision
making, improved transparency, multidisciplinary communication and an increased
focus on the overall clinical process rather than on professional actions. Commitment
improved and employees felt increasingly responsible and more involved in process
improvements. Shared visions became especially apparent in the conflicting clinical
 and research activities. Poor transparency concerning financial distribution between Lean improved
clinic and research activities could be a major cause in this conflict. Additionally, if organizational
Lean’s benefits in clinical practice are not returned to the clinic, but instead are invested
in research activities, then the conflict between clinical work and research might be
decision
reinforced. Uncertain cause-effect relations in clinical work processes had decreased making?
dramatically. Clinical activities became more transparent and responsibilities were
defined more clearly owing to increased clinical process examination by 547
multidisciplinary teams, followed by standardizing activities (deploying SOPs) to
sustain improvements (Simons et al., 2014). Clinical information asymmetry decreased,
because the operational processes improved and became clearer. Although improved
processes are obviously part of the organization, much more needs improving.
Specifically, clinicians remained dissatisfied regarding communication transparency.
Organizational information asymmetry did not improve, although interviewees
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recognized managers’ efforts to improve transparency.

Since process control improved, variable clinical process decreased resulting in less
clinical ambiguity and uncertainty. Consequently, employee discontent and perceived
problems have been transferred to a higher organizational level, namely, twofold
organizational goals: first, deliver high quality radiotherapy treatment; and second,
perform academic research. Increased transparency might have revealed an absent
shared vision among organizational goals. This improvement subsequently demands
that organizational goals and vision to be further tightened or to increase its acceptance
among employees.
As the ambiguous objectives and uncertain cause-effect relations had improved in
the organization, we concluded that organizational decision making conforms to
Thompson and Tuden’s (1959) framework and shifted from imagination in a
computation context (Figure 1). This trend could enhance QI initiatives, for instance by
implementing standard procedures and using predefined indicators for evaluation.
These results have to be appreciated given certain limitations. First, our results
cannot entirely be ascribed to the Lean transition. The organizational restructure, to
facilitate and improve process innovation, undoubtedly affected the outcomes.
Second, since our results were based on 12 individuals’ perceptions, generalizing
these results to the entire organization should be done with care. This might
limit their value, as these might not be as objective as quantitative data. However,
we present differing perceptions throughout the organization. Since an individual’s
behavior is dependent on subjective perceptions (Merton, 1995), insights play an
important role in QI. Therefore, to make high-quality care a reality, healthcare
managers should fully understand employee perceptions. In conclusion, the
Lean transition positively affected the perceived degree that objectives
are ambiguous and reduced the perceived uncertain cause-effect relations in the
clinical processes. Decision making benefitted from the Lean transition and
the chance to realize sustainable QI increased. Our conclusions hold for our
case only; however, it is reasonable to expect similar results elsewhere; i.e., as key
Lean method foci, such as value-stream mapping and continuous improvement is to
map in detail clinical operational processes, which generates insight into causal
relationships and process objectives. As our case shows, however, the latter may
have the paradoxical effect that tensions about distributing the benefits from this
enhanced process control manifest. If the Lean change program is to be sustainable,
then these tensions need to be dealt with. Thus, sustaining Lean’s gains goes beyond
an operational focus.
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Corresponding author
Pascale Simons can be contacted at: pascale.simons@maastro.nl

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