Administrativ nydannelse i et sterkt strukturert system : en studie av fylkeskommunal tiltaksorganisering i Troms fra 1974 til 1981

Hovedfagsoppgave i samfunnsvitenskap, ISV, Universitetet i Tromsø, våren 1982Valg av tema for denne oppgaven; organisasjonsendring i et distriktspolitiskoran, avspeiler mine to faglige hovedorienteringer i studietiden. For det første en opptatthet av regionalpolitiske problemstillinger med spesiell vekt på tiltaksarbeid/tiltaksorganisering som ny distriktspolitiskstrategi. For det andre en teoretisk orientering mot det som er blitt kalt et organisasjonsteoretisk perspektiv på offentlig politikk. Hva var da mer naturlig når tema og emne skulle velges — enn å forsøke å la disse mine faglige hovedinteresser “smelte sammen’

Lost in Translation: a case-study of the travel of lean thinking in a hospital.

Background: Lean thinking as a quality improvement approach is introduced in hospitals worldwide, although evidence for its impact is scarce. Lean initiatives are social, complex and context-dependent. This calls for a shift from cause–effect to conditional attributions to understand how lean works. In this study, we bring attention to the transformative power of local translation, which creates different versions of lean in different contexts, and thereby affect the evidence for lean as well as the success of lean initiatives within and among hospitals. Methods: We explored the travel of lean within a hospital in Norway by identifying local actors’ perceptions of lean through their images of enablers for successful interventions. These attributions describe the characteristics of lean in use, i.e. the prevailing version of lean. Local actors’ perceptions of enablers for lean interventions were collected through focus group interviews with three groups of stakeholders: managers, internal consultants and staff. A questionnaire was used to reveal the enablers relative importance. Results: The enablers known from the literature were retrieved at the case hospital. The only exception was that external expert change agents were not believed to promote lean. In addition, the stakeholders added a number of new and supplementary enablers. Two-thirds of the most important enablers for success were novel, local ones. Among these were a problem, not method focus, a bottom-up approach, the need of internal consultants, credibility, realism and patience. The local actors told different stories about local enablers and had different images of lean depending on their hierarchical level. Discussion: By comparing and analyzing the findings from the literature review, the focus groups and the survey, we deduced that the travel of lean within the hospital was affected by three principles of translation: the practical, the pragmatic, and the sceptical. Further, three logics of translation were in play: translation as a funnel, a conscious sell-in, and a wash-out. This resulted in various local versions of lean. Conclusions: We conclude that lean, introduced by the management, communicated by the internal consultants, and used by the staff, is transformed more than once within the hospital. Translation is part of the explanation for the lack of evidence for lean, and translation can be decisive for outcomes

Lean thinking in hospitals: is there a cure for the absence of evidence? A systematic review of reviews

Objective: Lean interventions aim to improve quality of healthcare by reducing waste and facilitate flow in work processes. There is conflicting evidence on the outcomes of lean thinking, with quantitative and qualitative studies often contradicting each other. We suggest that reviewing the literature within the approach of a new contextual framework can deepen our understanding of lean as a quality-improvement method. This article theorises the concept of context by establishing a two-dimensional conceptual framework acknowledging lean as complex social interventions, deployed in different organisational dimensions and domains. The specific aim of the study was to identify factors facilitating intended outcomes from lean interventions, and to understand when and how different facilitators contribute. Design: A two-dimensional conceptual framework was developed by combining Shortell's Dimensions of capability with Walshes’ Domains of an intervention. We then conducted a systematic review of lean review articles concerning hospitals, published in the period 2000–2012. The identified lean facilitators were categorised according to the intervention domains and dimensions of capability provided by the framework. Results: We provide a framework emphasising context by relating facilitators to domains and dimensions of capability. 23 factors enabling a successful lean intervention in hospitals were identified in the systematic review, where management and a supportive culture, training, accurate data, physicians and team involvement were most frequent. Conclusions: In the absence of evidence, the two-dimensional framework, incorporating the context, may prove useful for future research on variation in outcomes from lean interventions. Findings from the review suggest that characteristics and local application of lean, in addition to strategic and cultural capability, should be given further attention in healthcare quality improvement