Lean and in-between : culture and discourse in a health-care system improvement Story
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Subjectethnography; health care; lean; organizational culture; organizational discourse; Saskatchewan
Background: Lean is a process improvement methodology born in automobile manufacturing and since applied to other manufacturing sectors and, more recently, the public sector. As the Government of Saskatchewan applies lean to its provincial health-care system, emerging literature debates the effectiveness, questions the financial investment, and suggests that employees may not support the changes. The purpose of this research is to explore the communicative meanings and discourses within the employee experiences of lean. Methods: This research moves from interpretive to critical analysis of institutional texts, interview data, and participant observation of one key lean ritual: the rapid process improvement workshop. Semi-structured interviews focus on phenomenological employee experiences with an appreciative inquiry lens to generate recommendations for lean implementation. Employee and manager narratives are analyzed critically to explore key characters, syllogisms, and themes, while data is categorized into themes derived from research in England’s National Health Service, and coded to produce an ethnographic account of the Saskatchewan lean experience. Results: Results revealed key institutional and organizational discourses of necessary change, eliminating waste, and improving the patient experience. Process improvement workshops are shown to generate and perpetuate a unique organizational culture, with emergence of a counterculture of non-lean-favouring networks. Narratives focus on health-care providers as key characters who either support or do not support lean, or who gain meaningful patient perspective and experience that drive improvements. Institutional and managerial sources of power are discussed as both driver of organizational discourse and factor in employee dissatisfaction. Recommendations discuss improvements to training, lean components, employee engagement, patient experience, communication, and interpersonal team building. Conclusion: Organizations implementing or considering lean must recognize communication and culture as key success factors in the employee experience of lean, with attention to the recommendations that will better represent provider voices and enable longer-term system change in the interest of health-care recipients. Keywords: lean, health care, organizational discourse, culture, ethnography, Saskatchewan
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