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The Intricate Relationship of Employee Engagement and Lean Approach

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 Hospital Topics

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/vhos20

The Intricate Relationship of Employee

Engagement and Lean Approach toward Quality
Improvement of the Public Hospitals

Shatha Hawarna, Selim Ahmed, Ibrahim Alqasmi, Dewan Mehrab Ashrafi,

Muhammad Khalilur Rahman & Pradeep Paraman

To cite this article: Shatha Hawarna, Selim Ahmed, Ibrahim Alqasmi, Dewan Mehrab Ashrafi,
Muhammad Khalilur Rahman & Pradeep Paraman (2023): The Intricate Relationship of
Employee Engagement and Lean Approach toward Quality Improvement of the Public
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Hospital Topics
https://doi.org/10.1080/00185868.2023.2192995

The Intricate Relationship of Employee Engagement and Lean Approach

toward Quality Improvement of the Public Hospitals
Shatha Hawarnaa, Selim Ahmedb , Ibrahim Alqasmic , Dewan Mehrab Ashrafid, Muhammad
Khalilur Rahmane and Pradeep Paramanf
a
School of Business and Quality Management, Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates; bWorld School
of Business, World University of Bangladesh, Dhaka, Bangladesh; cPublic Health School of Health Sciences, Saudi Electronic University,
Riyadh, Saudi Arabia; dULAB School of Business, University of Liberal Arts Bangladesh, Dhaka, Bangladesh; eFaculty of
Entrepreneurship and Business, Universiti Malaysia Kelantan, Kelantan, Malaysia; fFaculty of Business and Accounting, Segi University,
Petaling Jaya, Malaysia

ABSTRACT KEYWORDS
The lean approach is a value-added system that reduces cost and waste to continuously Lean approach; employee
improve the quality performance of the healthcare organization. The present study investigates engagement; top
the relationships of the lean approach with top management team and employee engagement management team; quality
toward quality improvement of the public hospitals in Malaysia. This study used stratified improvement; public hospital
random sampling to collect data from the public hospitals’ staff who were directly involved
with patient services. In this study, PLS-SEM 3.3.4 was applied to measure the research
constructs and hypotheses. The research findings indicate that the lean approach has a
significant relationship with the top management team and employee engagement to
positively impact the quality improvement of the public hospital. However, research findings
also indicate that the top management team has no significant influence on quality
improvement in public hospitals, but it has an indirect effect through the lean approach
and employee engagement. The findings of the study will provide guidelines on how the
lean approach contributes to the body of knowledge and practical implications to continuously
improve the quality performance of public healthcare system.

Introduction quality performance in hospitals (Leite 2022).

Healthcare services are seeking ways to reduce
expenses and waste while simultaneously enhanc-
ing patient safety in an attempt to uphold the
quality of their services (Muharam and Firman
2022). To improve efficiency and service quality
in hospitals, lean concepts have been increasingly
popular in recent years and have thus emerged
as a powerful tool for ensuring quality perfor-
mance in the healthcare sector and employee
engagement (Bossone et  al. 2022). Lean is a busi-
ness strategy that aims to maximize value for
customers by decreasing process waste and imple-
menting new ideas on a continual basis (Chan
et  al. 2014). There is a growing body of literature
that recognizes the importance of the lean
approach, which is a value-added system and
aims to reduce cost and waste by heightening
Thus, this lean approach concept has received
much scholarly attention (Muharam and Firman
2022). An investigation completed in 2007 found
that lean methods can be successfully used in
the healthcare industry (Muharam and Firman
2022). The application of this approach to health-
care is known as “lean healthcare” (Bossone et  al.
2022). Several studies have indicated that lean
techniques can reduce waiting times, improve
patient flow times, boost the quality of services
delivered, improve quality of care, and even
decrease mortality (Muharam and Firman 2022).
The lean approach is both flexible and adaptable,
and hence, it can be used in a variety of health-
care environments (Muharam and Firman 2022).
Additionally, patients in healthcare organizations
have the opportunity to engage in the healthcare

CONTACT Selim Ahmed selim.ahmed@business.wub.edu.bd World School of Business, World University of Bangladesh, Dhaka, Bangladesh.
© 2023 Taylor & Francis Group, LLC
2 S. HAWARNA ET AL.
process and interact with a wide range of health-
care professionals, and such interaction provides
the primary mechanism for the correct diagnosis,
treatment, and prevention of disease (Janati et  al.
2017). Management strategies such as the Lean
approach can be used to enhance healthcare orga-
nizations’ quality enhancement since they are
based on complicated processes that often result
in high prices, poor quality services, and cus-
tomer dissatisfaction. The ultimate goal of the
lean approach is to improve the quality of the
process by cutting out processes that don’t add
value (waste), which typically cause delays, neces-
sitate additional resources, and thus raise the
overall cost (Gandhi et  al. 2000). However, the
application of Lean thinking to healthcare is rel-
atively a new notion, but there is already general
consensus indicating its potential with regard to
cost, waiting, and patient safety improvements
(Burgess and Radnor 2013; Bossone et  al. 2022).
However, for the operationalization of the lean
approach, employees’ engagement is considered
a major challenge in the healthcare industry
(Weerasooriyan and Alwis 2017). Employee
engagement is the positive attitude that an
employee has toward their organizations along
with organizational values (Men 2015). To gain
benefits from lean thinking, management must
prioritize and focus on generating a higher level
of employee engagement since employee engage-
ment is vital to organizational performance and
successful change implementation (Mann 2005).
Additionally, this acts as a precursor to the min-
imization of mistakes and human errors while
they are performing their duties and responsibil-
ities (Sendawula et  al. 2018). Existing literature
has focused on the impact of lean approach on
employee engagement in the healthcare industry
(Mahmoud et  al. 2021). However, studies that
have focused on predicting the effectiveness of
lean approach through employee engagement are
limited and scant. Henceforth, there is a crucial
need to develop insights on how employee
engagement fosters the implementation of lean
approach in healthcare organizations, more spe-
cifically, in public hospitals. Additionally, the lean
approach implementation necessitates the support
of the top management team for making strategic
decisions (Ahmed, Abd Manaf, and Islam 2018a)
and for generating higher employee engagement,
which results in quality improvement (Shafer and
Moeller 2012). Earlier studies have shed light on
the existing relationships among the top manage-
ment team, work performance, lean approach,
and quality improvement in the healthcare setting
(Graban and Toussaint 2018; Shortell et  al. 2021;
Bakar et  al. 2022; Narayanan et  al. 2022).
Although prior studies explicitly outlined the
underlying mechanism of those relationships in
the case of Malaysian private hospitals (Ahmed,
Manaf, and Islam 2021), studies that focused
solely on Malaysian public hospitals are limited
(Tajudin and Habidin 2020), indicating a research
gap that needs to be bridged. Healthcare in
Malaysia is governed by the Ministry of Health
and it is reported that providing quality care to
patients in public hospitals is a challenge since
public hospitals are overburdened (Ren 2007;
Ahmed, Abd Manaf, and Islam 2018a). According
to Pillay et  al. (2011), waiting times for 15-minute
consultations with medical staff can be as long
as two hours because of severe workloads, delays
in work processes, poor work-related attitudes,
inadequate facilities, and management and super-
vision issues in Malaysian public hospitals. Thus,
there is a critical need to investigate what factors
are essential in delivering and improving the ser-
vice quality of Malaysian public hospitals.
Besides, the importance of the top manage-
ment team in the implementation of the lean
approach into organizations is worth mentioning
since they take the decisions which are strategic
in nature for the purpose of integrating lean
practices into organizational infrastructure, lead-
ing to quality improvements. Prior studies have
indicated that the top management team showed
a positive influence on employee engagement,
lean six sigma, and quality performance in hos-
pitals (Ahmed, Abd Manaf, and Islam 2018b;
Bhat et  al. 2019). However, very little is known
about how the top management team directly
and indirectly affects employee engagement, lean
approach, and quality improvement in Malaysian
hospitals, particularly in public hospitals.
Henceforth, based on the above discussion, this
study aims to address the identified research gap
by examining the effects of the top management
team on employee engagement, lean approach,

and quality improvement in Malaysian public
hospitals. This study also reveals how employee
engagement directly impacts the lean approach
and how it indirectly impacts quality improve-
ments through the lean approach. Additionally,
this study examines how both the lean approach
and employee engagement influence quality
improvements in Malaysian public hospitals.
Moreover, the study also investigates the indirect
influence of the top management team on quality
improvement of public hospitals through a lean
approach and employee engagement.
The study contributes to the existing literature
in various ways. First, earlier studies have
focused on how workforce management and lean
six sigma influenced quality improvement in
Malaysian hospitals (Ahmed, Abd Manaf, and
Islam 2018b). However, very little is known
about the significance of the lean approach in
enhancing quality improvement in Malaysian
public hospitals. Therefore, this study empha-
sizes solely on the lean approach and contributes
by enhancing the theoretical depth and deep-
ening understanding of the significance of the
lean approach in enhancing the quality of ser-
vices in Malaysian public hospitals. Secondly,
previous studies have investigated the impact of
top management and workforce management on
service quality improvement in the Malaysian
healthcare setting (Ahmed, Manaf, and Islam
2021). However, not much is known with regard
to the impact of workforce management and top
management in enhancing the quality improve-
ment in public hospitals in Malaysia.
Nevertheless, there are existing studies that have
examined the direct relationships between top
management teams and employee engagement
with quality improvement in both public and
private hospitals. (Ahmed, Abd Manaf, and
Islam 2018b; Ahmed, Manaf, and Islam 2021;
Pfaff et  al. 2021). However, studies that have
examined the mediating effect of the top man-
agement team and employee engagement in fos-
tering the quality of services in Malaysian public
hospitals are scant. Henceforth, this study adds
to the current body of literature and contributes
by exhibiting the mediating impacts of top man-
agement team and employee engagement in
ensuring how to deliver superior quality,
Hospital Topics 3
explicitly in Malaysian public hospitals, through
the lean approach.
Literature Review
Top Management Team
The top management team refers to the involve-
ment of a small group of the most influential
executives in the business organization (Cano,
Murray, and Kourouklis 2022). The top manage-
ment team, lean approach, and employee engage-
ment (Amin, Zailani, and Rahman 2021) are
crucial for the successful quality improvement of
the public hospital (Ahmed, Manaf, and Islam
2021). Krause, Roh, and Whitler (2022) and Su
et  al. (2022) argued that the concept of a top
management team is poorly explained in empir-
ical research. Hence, the top management team
explores the literature to better understand how
it reflects the lean approach and influences
employee engagement to develop the quality per-
formance of the healthcare sector. The top man-
agement team provides effective resources and
positive direction to the employees of the orga-
nization for improving quality performance
(Hameed et  al. 2022; Cano, Murray, and
Kourouklis 2022; Chang et  al. 2022). According
to Haldorai, Kim, and Garcia (2022), a top man-
agement team can create an opportunity for
employees to gain knowledge of the work envi-
ronment, which will assist business organizations
to implement the quality performance of the
management system. To put into effect the best
management systems, the top management team
can take the initiative to undertake a unique
management of lean approach to enhance the
performance of healthcare organizations.
Maintaining the higher quality practices of the
top management team increases the possibility
of organizational performance development
(Krause, Roh, and Whitler 2022). The lack of
support of the top management team on the lean
approach and ensuring employees’ engagement
in their work can lead to a failure to enhance
the quality performance of the organization
(Tortorella et  al. 2022; Trakulsunti et  al. 2022).
Cano, Murray, and Kourouklis (2022) posited that
top management serves as a motivating force for
4 S. HAWARNA ET AL.
the development of quality improvement in orga-
nizations. The strong support of the top man-
agement team can assist in implementing quality
management practices in an organization.
Casteleiro and Mendes (2022) stated that top
management commitment can increase employees’
engagement in a work environment and help to
build quality management systems for achieving
quality performance in organizations. To achieve
the quality of the organization, the top manage-
ment team is required to set quality standards,
develop the lean approach, evaluate employee
engagement, and awareness of the quality per-
formance of the organization (Beraldin, Danese,
and Romano 2019).
The quality performance is an interrelated set
of policies that decorate workforce control to
achieve the goal of the organization (Chow et  al.
2021; Wong, Olanrewaju, and Lim 2021). Ahmed,
Abd Manaf, and Islam (2018b) stated that quality
execution is a framework that makes the vision
of the organization comprehended and helps
every worker of the agency perceive their com-
mitment to improving quality performance to
adjust to client needs and wants. To develop
quality implementation in the healthcare industry,
managers need to characterize the outcomes of
medical services and evaluate the quality improve-
ment (Rahman, Bhuiyan, and Zailani 2021a;
Kirkegaard et  al. 2022; Mamun et  al. 2022). The
top management team can target to improve the
system of healthcare quality management to meet
the long-term goal of the healthcare sector (Ai
et  al. 2022). For the effective execution of quality
management (Rahman et  al. 2021b), the top man-
agement team can focus on engaging the employ-
ees for improving the quality performance of the
organization. If the top management team
empowers employee engagement, the employees
will be accountable for their work, which will
enhance the achievement of the goal of organi-
zational performance (Hassan, Zailani, and
Rahman 2021). Ahmed, Manaf, and Islam (2021)
examined the importance of top management
commitment and workforce management for the
quality performance of hospitals, and the findings
indicated that the top management team can play
a crucial role in the quality improvement of the
hospital. Parkhi (2019) indicated that the top
management team makes the strategic decision
for the adoption of a lean approach for the devel-
opment of quality performance. Ahmed, Abd
Manaf, and Islam (2018b) suggested that the top
management team reflects a lean approach and
employee engagement toward improving the qual-
ity performance of the healthcare sector. In line
with the discourse, this study explores the fol-
lowing hypothesis:
Hypothesis 1: Top management team has a positive
impact on lean approach
Hypothesis 2: Top management team positively influ-
ences employee engagement
Hypothesis 3: Top management team has a direct rela-
tionship with quality improvement of the public
hospital
Employee Engagement
Employee engagement is the extent to which
employees feel passionate about the work and
are intellectually committed to the organization.
Employee engagement is an important factor in
any organization’s effective execution of any unique
changes (Benkarim and Imbeau 2021). Giauque
et  al. (2022) stated that employee engagement
refers to a situation where workers are persuaded
to deliver quality service with a commitment to
the goals of the organization. Employees’ efforts
and abilities can make a success for the organi-
zation because employee engagement in job per-
formance is the process that sincerely advances
work insight (Tomašević et  al. 2021). Employee
engagement can play a crucial role in developing
the quality service performance of the health-
care sector. To improve quality performance, the
healthcare industry can reform human resource
strategy to expand the value and fairness of
healthcare management (Mazzocato et  al. 2010;
Rahman et  al. 2021c). Employees’ engagement in
healthcare management requires enhancements in
abilities at all levels of healthcare-related services,
for example, doctors’ care, nurse care, patient
care, and patient enrollment accuracy, among
others (Ai et  al. 2022; Jankelová, Joniaková, and
Romanová 2022). Employees’ active engagement
can assist healthcare organizations to improve
quality performance.

Many employees are engaged in the
decision-making strategy of different companies,
and managers of the company use the lean
approach to improve the quality performance of
the organization (Klein et  al. 2023). Trubetskaya,
Manto, and McDermott (2022) indicated that
employee engagement improves organizational
culture for problem-solving and a lean approach
reduces the cycle time of the business process
and enhances the quality performance of orga-
nizations. Employee engagement can support the
lean approach to improve the quality performance
of the organization. Al Fannah et  al. (2022) used
the lean approach and agile teams in a tertiary
care hospital and stated that employee engage-
ment supports the lean method to improve the
quality performance of the organization. Employee
engagement can lead to adopting a lean approach,
which increases employee interest and commit-
ment to the quality improvement of organizations
(Marsilio et  al. 2022). In the setting of this
review, it is believed that employee engagement
reflects a lean approach toward quality improve-
ment in hospitals. Thus, this study postulated that:
Hypothesis 4: Employee engagement has a direct influ-
ence on lean approach
Hypothesis 5: Employee engagement has a positive
impact on quality of the public hospital
Lean Approach
The lean approach can improve the quality per-
formance of healthcare organizations. It empha-
sizes the patient’s perception of reasonable
medical service costs and increases the efficiency
of service delivery (Hihnala et  al. 2018). It can
be described with many factors to measure the
quality improvement of the healthcare industry.
Typically, the lean method leads to assistance in
the continuous enhancement of quality execution
in the medical service industry. Leite, Bateman,
and Radnor (2020) explained patient safety and
highlighted the issues in healthcare services, and
suggested that hospitals can adopt a lean approach
to improve quality performance. The lean method
assists the healthcare sector to eliminate waste
and work balance in the quality service process
(Bhat et  al. 2022; Martins Drei and Sergio de
Hospital Topics 5
Arruda Ignacio 2022). Demirli et  al. (2021) pos-
tulated that lean approach increases the process
speed by decreasing costs and long waiting times
of patients for healthcare services and improving
the quality performance of hospitals. The lean
approach is required to improve the business
process because it increases productivity and
enables the reduction of the cost of complexity
(Bharsakade et  al. 2021). The healthcare organi-
zation can consider adopting a lean approach for
the development of quality performance (Akmal
et  al. 2022), including leadership, management
practices, funding, work culture, strategy, com-
petency, efficiency, and performance-based proj-
ects. In the context of this study, the lean
approach may lead to improving the quality per-
formance of hospitals. Thus, we postulated that:
Hypothesis 6: Lean approach has a positive effect on
quality improvement of the public hospital.
Quality Improvement
Quality improvement refers to the framework used
to improve the process and system (Kirkegaard
et  al. 2022) of the particular products and ser-
vices under the organization. In the context of
this study, quality improvement is the framework
used to develop healthcare services in hospitals.
Healthcare quality improvement in hospitals
seeks to standardize the processes, procedures,
and structure to reduce variation, attain expect-
able results, and evolve outcomes for patient
safety, security, and healthcare systems in hospi-
tals (Cox et  al. 2022). Hospitals need to reform
their human resource policies, particularly top
management support, employee engagement, and
the adoption of a lean approach to improve the
quality performance of hospitals (Ahmed, Manaf,
and Islam 2021). The lean approach can play a
mediating role in the relationship between the
top management team and the quality improve-
ment of the organization. The adoption of lean
approach is crucial in healthcare organizations, as
it reduces waste time, increases the efficiency of
workforce management, and improves the qual-
ity performance of the hospital (Marsilio et  al.
2022; Vanichchinchai 2022). Previous studies
focused on the direct impact of top management
6 S. HAWARNA ET AL.
Figure 1.  Research framework with hypotheses.
commitment on lean six sigma, workforce man-
agement, and quality performance of hospitals
(Ahmed, Abd Manaf, and Islam 2018b; Alkhaldi
and Abdallah 2020; Ahmed, Manaf, and Islam
2021) examined the direct. There is a lack of lit-
erature on the mediating role of the lean approach
and employee engagement in the support of qual-
ity performance in healthcare organizations. This
study investigates the mediating role of the lean
approach and employee engagement in the rela-
tionship between the top management team and
the quality improvement of public hospitals in
Malaysia. In line with the discourse, this study
examines the proposed hypothesis (Figure 1):
Hypothesis 7a: Top management team indirectly influ-
ences the quality improvement of the public hospital
through the mediating effect of lean approach
Hypothesis 7b: Top management team has a positive
and indirect impact on quality improvement of the
public hospital through the mediating effect of employee
engagement
Hypothesis 7c: Employee engagement has an indirect
influence on quality improvement of the public hospital
through the mediating effect of lean approach
Methodology
The present study applied a quantitative research
method to investigate the impact of the top man-
agement team on quality improvement of public
hospitals through the mediating effects of lean
approach and employee engagement. In this study,
we used stratified random sampling to collect
data from eight Malaysian public hospitals’ staff
who were directly involved with patient services,
such as medical physicians, nurses, pharmacists,
patient care officers, and medical laboratory tech-
nologists. The hospitals were selected based on
their number of beds (minimum 100 beds) and
accredited by the Malaysian Society for Quality
in Health (MSQH) for ensuring healthcare quality
services. On the other hand, respondents were
selected based on their working experience (min-
imum one year) in the same hospital.
This study used a self-administered survey
questionnaire to obtain responses from the hospi-
tals’ staff. The survey questionnaire was developed
based on four research variables: top management
team, employee engagement, lean approach, and
quality improvement. The first research variable
was the top management team, which consisted of
4 items: (1) the top management team has objec-
tives for quality performance; (2) the hospital’s
top management team appreciates individual staff
contributions to improving healthcare service; (3)
the top management team works closely with
employees to improve the quality performance
of our hospital (4) top management decides what
to do when a patient complains about the ser-
vice received. These items were adapted from
Harmancioglu, Grinstein, and Goldman (2010),
Guesalaga (2014), and Ahmed, Abd Manaf,
and Islam (2018b). The second research vari-
able was employee engagement, which consists
of four items: (1) employees are committed to
participating in quality improvement processes;
(2) employees are responsible for improving the
hospital’s performance; (3) employees feel happy
to work with the team; and (4) employees under-
stand the ultimate objectives of the hospital.
These four items are adapted from Kennedy and
Daim (2010) and Ahmed, Abd Manaf, and Islam
(2018b). The third research variable was lean
approach that pertains to four items: (1) hospi-
tal implements “5S” practices to create a more
efficient work environment (2) hospital uses root
cause analysis to identify causes of quality prob-
lems in the healthcare services (3) hospital uses
kaizen methods to continuous improvement in
processes (4) hospital uses value stream mapping
(VSM) to identify the non-value added activities.
These items are adapted from Gowen, McFadden,
and Settaluri (2012) and Ahmed, Abd Manaf, and
Islam (2018b). The final research variable was
quality improvement, which consists of six items:
 Hospital Topics 7

(1) the hospital’s quality management process has
been improved; (2) the cost of medical services
has been reduced; (3) the severity of errors in
medical services has been reduced; (4) patient
waiting time (meet with medical personnel) has
been reduced; (5) waste in processes has been
reduced (6) the number of patient complaints
has been decreased. These six items were adapted
from Gowen, McFadden, and Settaluri (2012)
and Antony and Kumar (2012). All four research
variables’ items were measured by a five-point
Likert scale (1 = strongly disagree, 3 = neutral,
5 = strongly agree).
This research was initially approved by the
Institute for Health Management (IHM) and the
Medical Research & Ethical Committee (MREC),
under the guidance of the National Institute of
Health (NIH) and the Ministry of Health (MOH)
of Malaysia. After receiving approval from the
relevant healthcare authorities, 8 public hospitals
were contacted to solicit responses from their
staff. The ethical approval form was submitted to
the top management of the hospitals before the
data was collected from the respondents. During
the data collection process, the respondents were
assured of their anonymity and the confidentiality
of their responses. Participation in the survey was
voluntary, and respondents were free to decline
their participation at any stage.
In this study, we distributed 300 survey ques-
tionnaires to the respondents and received 226
usable responses (75.33% response rate). Of these
226 respondents, 16 (7.08%) responses were from
small hospitals (100–200 beds), 117 (51.77%)
responses were from medium hospitals (201–300
beds), and 93 (41.15%) responses were from large
hospitals (above 300 beds). For analyzing the
data, SmartPLS 3.3.4 software was employed to
measure the reliability and validity of the con-
structs. This software was also used to test the
hypotheses via partial least squares structural
equation modeling (PLS-SEM).
Results
Construct Validity of Measurement Model
The construct validity of the measurement model
was examined before testing the hypotheses of
the study. The measurement model was examined
based on internal consistency, reliability, and
validity of the constructs. To confirm the reli-
ability and internal consistency, Cronbach’s alpha,
rho_A and composite reliability (CR) values must
be 0.70 or above (Hair, Howard, and Nitzl 2020).
The results of the measurement model indicate
that all four research variables’ (top management
team, employee engagement, lean approach, and
quality improvement) Cronbach’s alpha, CR, and
rho_A values were above the minimum required
value of 0.70 (see Table 1). Thus, it can be
ensured that all research variables are reliable
with internal consistency (Hair et  al. 2017).
Besides the results of reliability and internal
consistency, the present study evaluated the valid-
ity of the constructs based on three distinguished
tests, such as construct validity, convergent valid-
ity, and discriminant validity. The first construct
and convergent validity were determined by outer

Table 1. Construct validity of the measurement model.

Variable Item Outer Loading Cronbach Alpha rho_A Composite Reliability AVE
Top management team TM1 0.918 0.927 0.931 0.948 0.821
TM2 0.895
TM3 0.922
TM4 0.889
Employee engagement EE1 0.895 0.891 0.895 0.924 0.753
EE2 0.838
EE3 0.842
EE3 0.895
Lean approach LA1 0.710 0.870 0.879 0.913 0.726
LA2 0.897
LA3 0.923
LA4 0.863
Quality improvement QI1 0.801 0.926 0.931 0.942 0.732
QI2 0.818
QI3 0.815
QI4 0.880
QI5 0.907
QI6 0.906
8 S. HAWARNA ET AL.
loadings and average variance extracted (AVE)
values. To meet the requirements of both con-
struct and convergent validity, the outer loading
must be 0.70 or greater, and the AVE value
should be 0.50 or greater (Hair, Howard, and
Nitzl 2020). The results of construct validity illus-
trate that both outer loadings and AVE values
were greater than 0.7 and 0.5, which met the
requirements for construct and convergent valid-
ity (see Table 1).
In addition, discriminant validity was mea-
sured to ensure the reflective of the con-
struct and its most robust relationships with
its indicators. The discriminant validity was
examined according to the two different tests,
such as the Fornell-Larcker criterion and the
Heterotrait-Monotrait Ratio (HTMT). To confirm
the discriminant validity of the research variables,
the construct indicators must have the highest
loading compared to other constructs within
the underlying latent construct involved in the
PLS-SEM (Hair, Howard, and Nitzl 2020). Based
on the results, both the Fornell-Larcker crite-
rion and Heterotrait-Monotrait Ratio (HTMT)
tests indicated that the values of the constructs
had more significant loadings compared to other
constructs within their respective underlying
constructs (see Tables 2 and 3). Thus, it can be
confirmed that the discriminant validity of the
measurement model was acceptable.
Evaluation of Structural Model
The present study tested the hypothesized rela-
tionships using the PLS-SEM method after con-
firming the reliability and validity of the
constructs. To measure the hypothesized
Table 2.  Results of Fornell-Larcker criterion.
Variable Employee engagement
Employee engagement 0.868
Lean approach 0.667
Quality improvement 0.778
Top management team 0.753
Table 3.  Results of Heterotrait-Monotrait Ratio (HTMT).
Variable Employee engagement
Employee engagement  
Lean approach 0.753
Quality improvement 0.845
Top management team 0.828
relationships, we used the bootstrapping approach
to determine the significance of path coefficients
(Henseler 2018). The findings of the SEM tests
are illustrated in Figure 2 and Tables 3–5.
The results of PLS-SEM analysis illustrate that
top management team has positive and signifi-
cant relationship with lean approach (β = 0.321,
t = 2.930, p-value = 0.004) and employee engage-
ment (β = 0.753, t = 12.616, p-value = 0.000). The
PLS-SEM results also indicate that employee
engagement has direct significant relationship
with lean approach (β = 0.425, t = 4.456, p-value
= 0.000) and quality improvement (β = 0.524,
t = 4.601, p-value = 0.000). In addition, the results
indicate that the lean approach has a positive and
significant relationship with quality improvement
(β = 0.317, t = 2.826, p-value = 0.006). However,
top management team does not have direct and
significant influence on quality improvement of
the public hospital (β = 0.057, t = 0.606, p-value =
0.546). Based on the above coefficient results, it
can be remarked hypothesis 1, 2, 4, 5 and 6 (H1,
H2, H4, H5 & H6) are supported at a 5% (p < 0.05)
significant level. On the other hand, hypothesis 3
(H3) was not supported at a 5% (p < 0.05) signif-
icant level (see Table 4 and Figure 2).
As above, Table 4 illustrates that the top
management team has no direct and significant
influence on quality improvement of public hos-
pitals, but it has an indirect and significant influ-
ence on quality improvement of public hospitals
through the full mediating effects of the lean
approach (β = 0.152, t = 2.723, p-value = 0.007)
and employee engagement (β = 0.152, t = 2.723,
p-value = 0.007). Interestingly, the results also
indicate that employee engagement indirectly
influence the quality improvement of the public
Lean approach Quality improvement Top management team
0.852
0.703 0.856
0.641 0.655 0.906
Lean approach Quality improvement Top management team
     
0.780
0.712 0.693
 Hospital Topics 9

Figure 2. Output of PLS-SEM.

Table 4.  Hypothesized path coefficients.

Hypothesized Path Coefficient Relationships Coefficient (β) t-value p-value Remarks
H1 Top management team → Lean approach 0.321 2.930 0.004 Supported
H2 Top management team → Employee engagement 0.753 12.616 0.000 Supported
H3 Top management team → Quality improvement 0.057 0.606 0.546 Not Supported
H4 Employee engagement → Lean approach 0.425 4.456 0.000 Supported
H5 Lean approach → Quality improvement 0.317 2.826 0.006 Supported
H6 Employee engagement → Quality improvement 0.524 4.601 0.000 Supported

Table 5.  Results of specific indirect effects.

Hypothesis Specific Indirect Effects Coefficient (β) Std. Dev. t-value p-value Support
H7a TMT → LA → QI 0.102 0.048 2.108 0.038 Full
H7b TMT → EE → QI 0.395 0.100 3.952 0.000 Full
H7c EE → LA → QI 0.135 0.061 2.217 0.029 Partial
Notes: TMT = Top management team, LA = Lean approach, EE = Employee engagement, QI = Quality
improvement.

hospitals via a partial mediating effect of lean Table 6.  Values of R square and predictive relevance.
approach (β = 0.152, t = 2.723, p-value = 0.007). Predictive
Variable R2 Adjusted R2 relevance (Q2)
Thus, it can be concluded that hypotheses 87a, Quality improvement 0.668 0.658 0.465
7b, and 7c (H7a, H7b & H7c) are supported at Lean approach 0.489 0.479 0.345
Employee engagement 0.567 0.562 0.409
a 5% (p < 0.05) significant level (see Table 5).
The analysis of the PLS-SEM results also
indicates that the path coefficients are com- predictive relevance of endogenous variables (qual-
patible with the study’s data. PLS-SEM results ity improvement, lean approach, and employee
reveal that quality improvement is explained by engagement) using Stone–Geisser’s value. The
the top management team, lean approach, and bootstrapping results illustrate the predictive
employee engagement at 66.8%. On the other relevance (value) of three endogenous variables
hand, the lean approach is explained by both top are 0.465, 0.345 and 0.409 for quality improve-
management team and employee engagement at ment, lean approach, and employee engagement,
48.9%, and employee engagement is explained respectively. Based on the above results, it can be
by top management team at 56.7% (see Figure confirmed that the present research model has
2 and Table 6). This study also determined the predictive relevance (see Table 6).
10 S. HAWARNA ET AL.
Discussion and Implications
This study was set out with the aim of assessing
the relationship of lean approach with top man-
agement team and employee engagement toward
quality improvement in public hospitals in
Malaysia. The research findings indicated that
the lean approach has a significant relationship
with the top management team, quality improve-
ment, and employee engagement, which is con-
sistent with prior literature (Graban and Toussaint
2018; Vanichchinchai 2022). Additionally, the
study has shown that while the lean approach
and employee engagement both significantly and
directly influenced the quality improvement of
hospitals, contrary to our expectations, this study
did not detect any evidence of the direct and
significant effect of the top management team on
quality improvement. It is somewhat surprising
that no direct effect of the top management team
was observed in the research setting. This finding
has raised intriguing insights on the nature of
the top management team in generating quality
improvement with regard to the service delivery
improvement process in Malaysian public hospi-
tals. However, this finding also accords with the
earlier observation of Ahmed, Abd Manaf, and
Islam (2018b) in the field of private healthcare
settings in Malaysia. One of the issues that
emerged from these findings is that the top man-
agement team indirectly influenced the quality
improvement of public hospitals through the
mediating effect of the lean approach. In previous
studies, it has been shown how lean six sigma
affects quality performance in the healthcare set-
ting (Ahmed, Abd Manaf, and Islam 2018b).
However, this result about how the lean approach
affected quality improvement in the public health-
care setting has not been reported before. Thus,
these findings have important implications for
policy-makers in the implementation of lean
thinking within public hospitals. It also adds to
the existing literature and enhances the theoret-
ical depth by delving deeper into how the lean
philosophy influences the relationship between
the top management team and the service quality
provided by Malaysian public hospitals (Table 6).
Nevertheless, employee engagement revealed
an indirect influence on quality improvement of
the public hospital through the mediating effect
of the lean approach, indicating that engaged
and committed individuals are more prone to
adopt Lean thinking that drives the quality of the
service in Malaysian public hospitals. It implies
that when employees have a higher degree of
commitment and engagement, they are more
focused, dedicated, and psychologically present
in carrying out the tasks that are associated with
the lean approach, such as reducing costs and
waste, reducing delays for patients, resulting in
improved service quality in the healthcare setting
(Sendawula et  al. 2018; Atapattu and Huybers
2022). This finding is also consistent with the
study of Fournier, Chênevert, and Jobin (2021),
where it was found that employees’ commitment
toward adopting lean is fostered and ensured by
good management practices. Furthermore, our
findings also suggest that although the lean
approach, which is known as a value-added
system, may directly impact quality improve-
ment, the top management team alone cannot
positively influence the quality improvement in
Malaysian public hospitals without the integra-
tion of lean thinking. Therefore, these findings
augment the theoretical depth and contribute
to the current body of literature with regard to
the lean approach implementation in the public
healthcare setting and significantly highlight the
crucial impact of lean thinking in enhancing ser-
vice quality through the top management team.
Consequently, the lean champions (top manage-
ment team) may develop a unique infrastructure
within an organization and take extensive steps
to stress the importance of the lean approach
and make optimal use of personnel, assets, and
technology to serve the patients in the healthcare
industry so that waste is minimized (Ilangakoon
et  al. 2022; Oudrhiri et  al. 2022). Besides, results
also showed that without the engagement of
employees, the top management team is unable
to assure superior service quality in Malaysian
public hospitals. Furthermore, the top manage-
ment team is required to keep the employees
engaged through various mechanisms like ade-
quate planning, recognition, effective communi-
cation and training programs, rewards, employee
surveys, and feedback for the purpose of achiev-
ing improved service quality in the Malaysian

public healthcare setting (Hayes 2010; de Bruin,
Roberts-Lombard, and de Meyer-Heydenrych
2021). Additionally, taking employees’ reviews
and feedback into consideration, supporting man-
agement and fostering employee engagement and
relations can be adopted as some of the internal
strategies that public hospitals in Malaysia may
follow to strengthen the association between their
top management team and quality performance
through employee engagement (Ahmed, Abd
Manaf, and Islam 2018b; Griffith 2009). In addi-
tion, public hospitals in Malaysia may evaluate
and develop their strategic planning processes for
the purpose of augmenting their productivity and
service quality. The top management team may
also identify relevant information from various
sources within the organization to create value
and meet its performance objectives and, accord-
ingly, set targets for employees that are aligned
to the hospital’s strategies and goals. In a nut-
shell, the combination of findings provides some
support for the conceptual premise that the top
management team of Malaysian public hospitals
should focus on lean approach implementation by
keeping their employees committed and engaged
with the aim of enhancing, generating and pro-
viding superior quality services to patients.
Conclusions
The findings of the study indicate that the lean
approach and employee engagement significantly
influence the quality improvement of public hos-
pitals in Malaysia. However, the research findings
also indicate that the top management team does
not significantly influence (directly) the quality
improvement of public hospitals. Though the top
management team has no direct and significant
relationship with quality improvement, but it has
an indirect significant relationship with quality
improvement of the public hospitals through the
mediating effects of lean approach and employee
engagement. These findings provide insightful
guidelines for the practitioners of healthcare orga-
nizations to focus more on employee engage-
ment and lean approach to create a strong bridge
between the top management team and quality
improvement of public hospitals to ensure the
best healthcare services to patients.
Hospital Topics 11
Despite the novel insights offered by this
study, it has some limitations. Firstly, this study
has employed a quantitative approach through
PLS-SEM to generate the results. Since there are
a few existing case studies available on the lean
approach, future studies may focus on using the
triangulation method or mixed-method for the
purpose of ensuring higher accuracy and robust-
ness of the findings. Secondly, our study has explic-
itly concentrated on the Malaysian public hospitals.
Therefore, it would be interesting to see in further
studies whether the proposed variables impact the
service quality in public and private hospitals dif-
ferently in the Malaysian healthcare sector. Thirdly,
this study has drawn samples from respondents
who were directly related to patient services, such
as medical physicians, nurses, pharmacists, patient
care officers, and medical laboratory technologists.
Thus, it would also be interesting if researchers
included the members of top management and
policy-makers in future studies. Moreover, this
study investigated the responses of the internal
employees, and future studies may explicitly con-
centrate on the perception of patients in identi-
fying how top management, lean approach, and
employee engagement influence quality improve-
ment so that the perceptions of patients and inter-
nal employees can be compared. Lastly, our study
has incorporated mediating variables such as lean
approach and employee engagement in showing
the indirect impacts of the top management team
and employee engagement in ensuring improved
quality of service in the Malaysian healthcare
sector. Future studies may attempt to incorporate
moderating variables such as hospital size and type
to see if they strengthen or weaken the effects of
the proposed exogenous and endogenous variables.
Funding
The author(s) reported there is no funding associated with
the work featured in this article.
ORCID
Selim Ahmed http://orcid.org/0000-0002-0361-6797
Ibrahim Alqasmi http://orcid.org/0000-0001-9258-9630
Muhammad Khalilur Rahman http://orcid.
org/0000-0001-9057-9121
Pradeep Paraman http://orcid.org/0000-0001-8668-9336
12 S. HAWARNA ET AL.
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