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Change agents and use of visual management tools in care process redesign: Implications on working conditions for operative managers and healthcare professionals
KTH, School of Engineering Sciences in Chemistry, Biotechnology and Health (CBH), Biomedical Engineering and Health Systems, Ergonomics.ORCID iD: 0000-0001-5879-2280
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Swedish healthcare has been subject to change efforts to increase efficiency in care processes. In the 2000-2010’s lean production has influenced healthcare with change approaches such as visual management tools to increase patient flows and efficiency. Most previous research on lean healthcare has focused single hospitals or departments as case studies focusing lean production as successful for efficiency, or “mean” production affecting the work environment. Focus in this thesis though is instead on what strategies and approaches hospitals use in their care process redesign and their associations with working conditions and systems performance. This thesis’ overall aim was to assess change strategies and change approaches at strategic and operative levels during care process redesign at hospitals, focusing organization of change agents and use of visual management tools, and its implica-tions for alignment, working conditions and systems performance. Four studies were conducted at five Swedish hospitals, whereof three had lean-inspired change strategies. One qualitative cross-sectional study, one quantitative longitudinal study and two mixed method longitudinal studies are included in the thesis. Data was collected over three years with semi-structured interviews, structured interviews, staff questionnaires, manager questionnaires and photo document-ation. Qualitative data were analyzed by content analysis. Quantitative data were analyzed with Wilcoxon tests, mixed models of repeated measurements, ANOVA, and linear regression models. Results showed strategies involve operative manag-ers as change drivers, supported by change agent functions. Change agents’ contribution to change depends on e.g. closeness to operative managers due to the change agents place in the healthcare hierarchy, and also clarity regarding roles and responsibilities in change. Change agents with a close collaboration with operative managers, have better preconditions to contribute to alignment between change strategies and change approaches. Hospital care units in the 2010’s tend to use lean-inspired operative change approaches also without working with change strategies based on lean. Operative lean approaches show associations with positive working conditions for healthcare professionals. Visual management tools as change strategy has potential to support collaboration and communication within and between organizational levels and is considered to contribute to systems performance and alignment. Visual management tools as a cognitive job resource for operative managers show associations with e.g. lower burnout and more functioning collaboration as well as daily use among nurses show associations with cognitive, social and emotional benefits, perceived systems performance and buffering mental stress. Change agents and use of visual management tools are considered as contributors for operative managers’ and healthcare professionals’ sustainable work during care process redesign.

Abstract [sv]

Svensk sjukvård har länge varit föremål för omorganisationer för att öka effektiv-iteten i vården. Under 2000-2010-talen har sjukvården tagit intryck av lean produktion och prövat olika lean-metoder för att förbättra effektiviteten i patient-flöden. Forskning har studerat fram- eller motgångar vid enskilda vårdverksam-heters införande av lean, och hur införandet påverkat effektivitet och arbetsmiljö. Det kvarstår ett forskningsbehov avseende förändringsstrategier och tillvägagångs-sätt som används i sjukvården, och hur sambanden mellan strategi, tillvägagångs-sätt och arbetsförhållanden ser ut över tid. Syftet med denna avhandling var att undersöka strategier och tillvägagångssätt, som används vid vårdprocessutveckling på sjukhus. Syftet fokuserade organisering av förändringsledare och användningen av visualiseringsverktyg, och undersökte vilken innebörd det har för arbetsförhål-landen och upplevd effektivitet i arbetet för operativa chefer och sjukvårdsprofess-ionella, samt undersökte vilken innebörd det har för samsyn inom sjukhus gällande processutveckling. Fyra delstudier genomfördes vid fem svenska sjukhus, varav tre sjukhus hade lean som huvudinspiration vid vårdprocessutveckling. En kvalitativ tvärsnittsstudie, en kvantitativ longitudinell studie och två blandat kvalitativa och kvantitativa longitudinella studier har gjorts. Datainsamling genomfördes under tre år och bestod av; delvis strukturerade intervjuer, strukturerade intervjuer, med-arbetar- och chefsenkäter och observationer. Kvalitativa data analyserades med innehållsanalys, och kvantitativa data analyserades genom jämförelser inom och mellan grupper med Wilcoxon-tester, mixed models of repeated measurements, ANOVA, och linjär regressionsanalys. Resultaten visade att förändringsstrategier ofta innebär att ansvar för att driva vårdprocessutveckling läggs på operativa chef-er. Dessa kan ha stöd från förändringsledare vars möjligheter att stötta beror bland annat på den organisatoriska närheten till de operativa cheferna och på hur tydlig roll- och ansvarsfördelning man har i processutvecklingen. Förändringsledare i nära samarbete med operativa chefer, har bättre förutsättningar att bidra till sam-verkan mellan strategier och operativa tillvägagångssätt inom och mellan organisa-toriska nivåer på ett sjukhus. Vårdenheter på 2010-talet använder lean-inspirerade tillvägagångssätt i sitt praktiska processutvecklingsarbete, även utan en sjukhus-övergripande strategi att införa lean. Lean-inspirerade tillvägagångssätt visar sig ha samband med positiva arbetsförhållanden för sjukvårdsprofessionella. Visualiser-ing har potential att stötta samverkan mellan strategier och operativa tillväga-gångssätt, och därmed även kunna bidra till systemprestanda inom sjukhus. Vis-ualisering kan tolkas fungera som arbetsresurs för operativa chefer, då de med stöd av visualisering i sitt dagliga arbete generellt har lägre utmattning och bättre fungerande samarbeten. Under- och sjuksköterskors dagliga användning av visual-iseringsverktyg hade samband med upplevda kognitiva, sociala och emotionella fördelar samt något bättre upplevd systemprestanda. Visualisering visade även en tendens till att skydda mot mental stress. Förändringsledare och användning av visualiseringsverktyg tolkas som bidragande till operativa chefers och sjukvårds-professionellas hållbara arbete vid vårdprocessutveckling på sjukhus.

Place, publisher, year, edition, pages
Stockholm: KTH Royal Institute of Technology, 2018. , p. 108
Series
TRITA-CBH-FOU ; 2018:53
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Production Engineering, Human Work Science and Ergonomics Work Sciences
Research subject
Technology and Health
Identifiers
URN: urn:nbn:se:kth:diva-238660ISBN: 978-91-7729-995-0 (print)OAI: oai:DiVA.org:kth-238660DiVA, id: diva2:1261420
Public defence
2018-12-07, T1 Emmy Rappe-salen, Hälsovägen 11, HUDDINGE, 13:00 (Swedish)
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2010‐ 0376AFA Insurance, 120321
Note

QC 20181107

Available from: 2018-11-07 Created: 2018-11-07 Last updated: 2018-11-07Bibliographically approved
List of papers
1. Lean implementation at different levels in Swedish hospitals: the importance for working conditions and stress
Open this publication in new window or tab >>Lean implementation at different levels in Swedish hospitals: the importance for working conditions and stress
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2015 (English)In: International Journal of Human Factors and Ergonomics, ISSN 2045-7812, Vol. 3, no 3-4, p. 235-253Article in journal (Refereed) Published
Abstract [en]

Healthcare organisations in Sweden are reorienting toward horizontal organisation around care processes. This paper's aim was to investigate how implementation approaches for improvements of care processes in line with lean production (LP), at hospital strategic and operative levels, are associated with working conditions and stress-related health among the employees. Five hospitals working with improvements to care processes were studied using questionnaires to employees (n = 1,303) and interviews at strategic and operative levels at baseline and follow-up. The process redesign implementation strategies varied between the strategic and operative levels. There were associations between a higher degree of LP at operative level and increased work resources and decreased work demands. Physical, cognitive and mental stress-related symptoms were only weakly associated with strategic or operative LP initiatives. There was evidence of more beneficial or improved working conditions in relation to higher degree of LP at operative levels.

Place, publisher, year, edition, pages
InderScience Publishers, 2015
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:kth:diva-179304 (URN)10.1504/IJHFE.2015.073001 (DOI)
Note

QC 20160118

Available from: 2015-12-15 Created: 2015-12-15 Last updated: 2018-11-07Bibliographically approved
2. Nurses’ use of visual management in hospitals - a longitudinal, quantitative study on its implications on systems performance and working conditions
Open this publication in new window or tab >>Nurses’ use of visual management in hospitals - a longitudinal, quantitative study on its implications on systems performance and working conditions
2018 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648Article in journal (Refereed) Published
Abstract [en]

Aim: The aim of this study was to examine potential benefits provided by dailyvisual management tool use and explore its association with systems performanceand working conditions among hospital nurses.Background: Visual management tools used in everyday work and improvementwork in health care theoretically contribute to shared understanding of complexwork systems and provide certain user benefits. Cognitive load, miscommunicationwithin and between professional groups, and pressure to engage in care processredesign add to nurses’ strained working conditions.Design: Quantitative longitudinal.Methods: Questionnaires were distributed at T0, (N = 948, 66% response rate), T1(N = 900, 70% response rate), and T2 (N = 621, 72% response rate) to nurses atfive hospitals. Three groups of users (daily users, start users, and non‐daily users)were compared by means T1–T2 (significance tested with Wilcoxon signed ranktest) and by mixed model repeated measures T0, T1, T2.Results: Daily use associated to better overview of work, collaboration, social capital,and clinical engagement. Job resources were rated higher by daily users. Mentalstress increased and development opportunities decreased over time among nondailyusers. There were associations between use and perceptions of systems performance,though the differences between groups were small.Conclusion: This study specifically explores visual management tool use in the hospitalsetting, which contributes to research by broadening the understanding of cognitive,social, and emotional benefits provided by visual management tool use. Dailyuse was associated to positive working conditions, small but positive differences insystems performance, and indicated a buffering effect on nurses’ mental stress.

Keywords
care process redesign, cognitive load, longitudinal, nurses, quantitative, visual management tools, working conditions
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Technology and Health
Identifiers
urn:nbn:se:kth:diva-238657 (URN)10.1111/jan.13855 (DOI)
Funder
AFA Insurance, 120321Forte, Swedish Research Council for Health, Working Life and Welfare, 2010‐ 0376
Note

QC 20181107

Available from: 2018-11-06 Created: 2018-11-06 Last updated: 2018-11-07Bibliographically approved
3. Organization of change agents during care process redesign in Swedish health care
Open this publication in new window or tab >>Organization of change agents during care process redesign in Swedish health care
2016 (English)In: Journal of Hospital Administration, ISSN 1927-6990, E-ISSN 1927-7008, Vol. 5, no 3, p. 20-32Article in journal (Refereed) Epub ahead of print
Abstract [en]

Background: Swedish health care organizations (HCOs) are changing using management concepts such as Lean, in attempts of improving efficiency, quality of care and work environment. Since there are pre-conditional challenges for operative managers to engage in change, HCOs tend to assign supportive functions such as change agents (CAs) to facilitate change. Research on the use of CAs in HCOs is sparse, thus the aim of this study explores role assignments and conditions of formally appointed CAs contributing to care process redesign.

Methods: A purposive sample of three Swedish hospitals initiating Lean-inspired care process redesign during 2010–2011 was done. In-depth interviews were held with fifty-one key functions during change. Focus group interviews were conducted with thirty-eight health care professionals. Data were analysed by content analysis.

Results: Top managers’ goal was to have operative management responsible for change during care process redesign, with support from assigned CAs. Organizing of CAs varied concerning, e.g. their hierarchical positions, job descriptions and practices, and conditions to act as driving forces towards change. Being granted formal power, having earned legitimacy and credibility, clarity regarding roles and responsibilities in change; a good sense of timing and ability to build relationships and trust, were identified as beneficial for CAs to support change.

Conclusions: Role assignment and organizing of CAs varies. A position closer to the operative levels, formalized and clarified responsibilities, earned legitimacy and timing support adaptation and alignment of planned change, such as Lean-inspired care process redesign.

Place, publisher, year, edition, pages
Sciedu Press, 2016
Keywords
Change agent, Lean health care, Hybrid management, Change leadership, Change management
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:kth:diva-182481 (URN)10.5430/jha.v5n3p20 (DOI)
Funder
AFA InsuranceForte, Swedish Research Council for Health, Working Life and Welfare
Note

QC 20160413

Available from: 2016-02-19 Created: 2016-02-19 Last updated: 2018-11-07Bibliographically approved
4. Operative managers' job-demands-resources when redesigning care processes
Open this publication in new window or tab >>Operative managers' job-demands-resources when redesigning care processes
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Purpose

The aim was to describe hospitals’ approaches to use change agents and visualmanagement tools, and examine change agents and visual management tools as job resourcesfor operative managers, during care process redesign.

Design

A longitudinal three year (T0, T1, T2) mixed method design was used. Qualitativedata from semi-structured interviews was collected at five hospitals (T0, T2). Quantitativedata from questionnaires (T1, T2) was collected to examine the use and support from changeagents and visual management tools among operative managers at the hospitals. Operativemanagers’ support and associations with their working conditions were further examined inrelation to the Job Demands and Resources model. Analyses of differences between groups ofoperative managers were performed with Wilcoxon tests.

Findings

Change agents as emotional job resources supported operative managers whenintroducing care process redesign. Higher change agent support was associated to positiveresults regarding burnout and organizational outcomes. Visual management tools as cognitivejob resources supported operative managers when used daily, and were associated to positiveresults regarding burnout, and organizational outcomes. Combined support from both changeagents and visual management tools was associated to beneficial organizational outcomes(collaboration between operative managers as well as between operative managers andhealthcare professionals during care process redesign, and possibilities to fulfill managerialduties) and thus were considered as important job resources for operative managers to drivechange.

Keywords
change agents, visual management, job demands and resources, operative manager, working conditions, care process redesign
National Category
Production Engineering, Human Work Science and Ergonomics Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Technology and Health
Identifiers
urn:nbn:se:kth:diva-238677 (URN)
Funder
AFA Insurance, 120321Forte, Swedish Research Council for Health, Working Life and Welfare, 2010-0376
Note

QC 20181107

Available from: 2018-11-07 Created: 2018-11-07 Last updated: 2018-11-07Bibliographically approved

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