The aim of this thesis is to investigate, whether my physician colleagues are correct, when they state that in reality Lean is New Public Management. The first part of the thesis investigated the roots of Lean, in order to define what authentic Lean is. This literary analysis included establishing a time line for the evolvement of Lean, determining that Lean was coined as a term describing the Toyota Production System (TPS). The article (Krafcik 1988) coining the term Lean concluded, that Lean was a specific Toyota attribute, not a generic Japanese effect. However, as TPS was introduced in USA, small changes were added, due to a number of books on the Japanese miracle, based on a different methods used by Japanese manufacturers. The quintessential book on Lean: Lean thinking (Womack and Jones 2003) is a collection of case studies on implementing Lean, and these cases included a number of techniques related to American management techniques. Since then the terms Fake TPS and Fake Lean have been coined. This thesis proposes, that the leadership model of Lean can described as Curling Leadership. The next part of the thesis was a comparison of Lean to the big models of reform in the Western World: New Public Management (NPM), New Public Governance (NPG) and New Weberian state (NWS), the modernized form of the classic Weberian state as described by Pollitt & Bouckaert (Pollitt and Bouckaert 2011). The comparison found some shared values and tools between Lean and all three models, and no more similarity between NPM and Lean than with the other two models. A further analysis found fundamental and not reconcilable differences between NPM and Lean, such as focus on long-term relationships with employees as well as suppliers in Lean versus contracts in NPM; and trust versus control. Empiric data from the health care system in Zeeland, Denmark included the budget agreements from Region Zeeland from 2010-2017, The Key Performance Indicators of a Lean Board in a medical department, and interviews with three elite informants placed in central positions in the healthcare system. The analysis used Pollitt & Bouckart’s model for comparative analysis of public reform, viewing the big models as menus with different dishes. Tools may be used by more than one model, but in different ways, as a main dish or side dish, thus determining whether the menu is one or another. Furthermore, the analysis used Patton’s model for Developmental Evaluation to determine attributes of evaluation on the Lean boards. The analysis found a mix of different tools and menus in the Health care system, except for NPG. In the budget agreements the biggest clash seemed to be between NPM and NWS, leading to management by incentives being stopped in 2016, as it had not been possible to slow down the effect of this type of management. The NPM tool of incentives had been too effective. Lean was in the early years a part of the region’s management philosophy and in recent years has been mentioned less and less. The current management philosophy is value-based management. The interviews showed a clear adherence to the Lean model presented by Womack & Jones (Womack and Jones 2003). The aim of implementing Lean was as much to increase the well-being of the workers, increase satisfaction from the patient by assuring less waiting time, as getting more health for the money. An important tool in the Lean model was Management by Objectives (MBO), and the analysis elucidated that MBO in principle are contradictory to TPS, as MBO has a defined goal, and when this is achieved, you have reached your goal, whereas TPS has a focus of constant improvement, and you can always do better. It also highlighted a possible confusion, when introducing MBO and measuring in a NWS organization such as a Public Danish hospital setting, where an objective a priori will be seen as an order. An objective can also be seen as an ideal end stage or as a method to monitor progress to motivate to keep going or as visual management of processes to pinpoint changes in processes. In addition, an important feature are the usage of the measuring: is the aim to punish/push or is it to identify problems in order to help solve them. An important feature of Lean is seeing problems as a source of learning, so far as to say that an organization, that believes it has no problem, has a problem indeed. Thus, it is an obligation of workers to notice and tell of problems. The final part of the empirical analysis investigated the KPI on the Lean board, and found that ‘a problem is a problem’, the goal of the KPI being either achieved (green) or failed (red). Using Patton’s distinction between traditional evaluation and developmental evaluation, the evaluation happening at the Lean board were a Traditional Evaluation with Fear of Failure, rather than a Developmental Evaluation with a focus on Hunger for Learning. As Hunger for Learning is fully compatible with Lean, and Fear of Failure is in opposition to lean, reaching the full potential of Lean is precluded. To conclude, the analysis showed a mix of different tools and menus with NPM being somewhat eclipsed by NWS and further that the full potential of Lean was eclipsed by NPM methods. The Trust necessary for Lean was eclipsed by the control part of NPM, and fear of failure overcame hunger for learning. The co-creation aspect of Lean was not achieved. In order to gain the full benefits of Lean it is therefore necessary to be careful to use the two types of menus separately. Lean appears to be the ideal management system in the healthcare system with the focus on the patient-customer, on quality and of trust and respect for workers driven by public service motivation.
|Master of Public Governance, (Executive Master Programme) Final Thesis
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