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Lean implementation in healthcare offsettingPhysiciansrsquo resistance to change

Pierre-Luc Fournier Marie-Heacutelegravene Jobin Liette Lapointe amp Lionel Bahl

To cite this article Pierre-Luc Fournier Marie-Heacutelegravene Jobin Liette Lapointe amp Lionel Bahl(2021) Lean implementation in healthcare offsetting Physiciansrsquo resistance to change ProductionPlanning amp Control DOI 1010800953728720211938730

To link to this article httpsdoiorg1010800953728720211938730

Published online 18 Jun 2021

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Lean implementation in healthcare offsetting Physiciansrsquo resistance to change

Pierre-Luc Fourniera Marie-Helene Jobinb Liette Lapointec and Lionel Bahld

aDepartment of Information Systems and Quantitative Methods for Management Business School Universite de Sherbrooke SherbrookeCanada bDepartment of Logistics and Operations Management HEC Montreal Montreal Canada cDepartment of Information SystemsDesautels Faculty of Management McGill University Montreal Canada dDepartment of Accounting Science Business School Universite deSherbrooke Sherbrooke Canada

ABSTRACTPhysiciansrsquo resistance towards Lean is often viewed as an important barrier to its successful implemen-tation in healthcare organisations However there exists a dearth of knowledge regarding what influ-ences reactions from physicians towards Lean and what organisations can do about it This studyadopts a behavioural perspective and focuses on the triggers of physiciansrsquo resistance towards LeanUsing longitudinal qualitative data from multiple case studies of Canadian hospitals 15 behaviouraltriggers are identified A cross-case analysis reveals that core-technical and efficiency-driven changesclash with medical professionalism and generate active resistance from physicians while leadershipand familiarity with Lean are linked to championing behaviours that mitigate it This study provides adeeper understanding of physiciansrsquo behaviours during Lean transformations and the factors that driveresistance It also provides insight into how organisations can better engage their medical staff in theirLean efforts by focussing on the process of change to offset resistance

ARTICLE HISTORYReceived 7 October 2020Accepted 13 May 2021

KEYWORDSLean production Leanhealthcare physiciansresistance to change

1 Introduction

Lean Management keeps gaining traction as a way of facingthe challenges of modern cost-effective care provision (Tlapaet al 2020 Henrique and Godinho Filho 2020) According toSouza (2009) the first documented use of Lean in healthcarefrom the scientific literature dates back to the early 2000s incountries such as the United States and the United KingdomSince then it has made its way into other healthcare systemsaround the world (Moraros Lemstra and Nwankwo 2016Costa and Godinho Filho 2016) Naturally this phenomenonhas led to increased attention from the operations manage-ment (OM) community (Bamford et al 2015 Matthias andBrown 2016 De Regge Gemmel and Meijboom 2019 LeiteBateman and Radnor 2020 Lindsay Kumar and Juleff 2020)Over the last ten years the pace of empirical research onLean in healthcare has increased steeply (Henrique andGodinho Filho 2020) At its core Lean is a holistic manage-ment system based on a culture of continuous improvement(Womack and Jones 2015) While some authors have chal-lenged its sustainability and benefits for healthcare organisa-tions (Moraros Lemstra and Nwankwo 2016 McCann et al2015) others have concluded that Lean can have positiveimpacts for hospital performance notably in terms of qualityof care (Shortell et al 2018) patient flow (Tlapa et al 2020)and staff support (Costa and Godinho Filho 2016) Howeverits sustained implementation remains difficult (Fournier andJobin 2018 Po et al 2019) There also remains gaps in ourunderstanding of the underlying mechanisms that create

barriers to its implementation (Henrique and GodinhoFilho 2020)

To that extent the resistance of physicians towards Leanchange has come to the forefront of this discussion (Akmalet al 2020 Lindsay Kumar and Juleff 2020) Practitionershave argued that physician engagement is critical to the suc-cess of Lean (Toussaint Billi and Graban 2017) while otherscholars consider physicians a barrier to its implementation(Lorden et al 2014) This has led the scientific community tocall upon researchers to study this phenomenon (Shortellet al 2018 Henrique and Godinho Filho 2020 LeiteBateman and Radnor 2020)

Recent studies have identified physiciansrsquo lack of engage-ment and resistance as a barrier to Lean implementation(Leite Bateman and Radnor 2020 Fournier Chenevert andJobin 2021 Lindsay Kumar and Juleff 2020 Akmal et al2020) While these studies discuss the importance of phys-ician engagement for the successful implementation of Leanin healthcare they also highlight the dearth of knowledgeregarding our understanding of what influences their behav-iours towards it and more specifically what organisationscan do about it Considering that evidence of Leanrsquos positiveimpact on organisational performance has recently surfacedin the literature (Shortell et al 2018 Tlapa et al 2020) andthat hospitals are likely to keep investing time and resourcesinto Lean initiatives further study of this phenomenon couldprove significant for scholars healthcare managers and pol-icy-makers

CONTACT Pierre-Luc Fournier pierre-lucfournier2usherbrookeca Department of Information Systems and Quantitative Methods for ManagementBusiness School Universite de Sherbrooke Sherbrooke Canada 2021 Informa UK Limited trading as Taylor amp Francis Group

PRODUCTION PLANNING amp CONTROLhttpsdoiorg1010800953728720211938730

2 Literature review

21 Physicians as organizational actors

The literature on organisational theory in healthcare high-lights two synergistic characteristics that define physicians ascentral organisational actors their status and power Thesecharacteristics have historically allowed the medical profes-sion to defend itself from managerial influence (Dent 2003)Sociology has also provided us with a better understandingof physiciansrsquo behaviours in healthcare organisations throughthe theory of professionalism (Freidson 1999) While health-care remains a multidisciplinary field the medical profes-sional logic remains the dominant one (Currie et al 2012)The clinician status atop healthcarersquos professional hierarchy defines the identity of physicians (Kellogg 2009) conferringconsiderable autonomy over the organisation of work anddecision-making The monopoly of expertise they exert overcare provision further contributes to their power as stake-holders (McNulty and Ferlie 2002) In the end physicians arethe de facto central lsquodecision makersrsquo of both the clinical andadministrative domains (Battilana and Casciaro 2012)

Physiciansrsquo status and power can have consequenceswhich can impact managerial decisions Physician-hospitalalignment can prove challenging because it requires botheconomic and non-economic integration meaning that itrequires both contractual and collaborative mechanisms(Trybou Gemmel and Annemans 2011) Research has shownthat physicians tend not to be influenced by traditionalrewards or incentives (Callister and Wall 2001) and that theirprofessional judgement can lead them to forgo organisa-tional rules (Dent 2003) Physicians often have the power toveto managerial decisions creating a leadership paradox inwhich one group of stakeholders possesses disproportionateinfluence over others within the collaborative governancemechanisms that determine the success of healthcare organi-sations (Fournier and Jobin 2018)

22 Physicians and organizational change

The challenge of engaging physicians in organisationalchange is well documented (Nilsen et al 2019) This is par-ticularly true with managerial innovations (Cabana et al1999) which often clash with the dominant medical profes-sional logic (Bartram et al 2020 Currie et al 2012 Suddabyand Viale 2011) During such change physicians tend totightly negotiate their participation and use their influence inorder to better control outcomes (McNulty and Ferlie 2002Bartram et al 2020) If they believe it might negativelyimpact the quality of care they provide (Cabana et al 1999Mathie 1997) the organisation of their work (RogersSilvester and Copeland 2004) or their economic well-being(Greco and Eisenberg 1993) they are more likely to resistFurthermore if a change is perceived to threaten their pro-fessional status (Light 2000) decision-making authority orprofessional judgement (Greco and Eisenberg 1993) physi-cians also tend to strongly resist Scholars have even statedthat innovations that could improve quality can be blockedby physicians because they wish to protect their professional

autonomy (Denis et al 2002) It must be emphasised how-ever that physicians can also be powerful change agents(Mathie 1997) as long as they share ownership and areinvolved in decision-making regarding the change (Bartramet al 2020)

23 Physicians and lean change

Scholars studying Lean implementation in healthcare havehighlighted physiciansrsquo resistance as a significant barrier toits successful implementation (Waring and Bishop 2010Lorden et al 2014 Lindsay Kumar and Juleff 2020 Henriqueand Godinho Filho 2020 Leite Bateman and Radnor 2020)Notably Leite Bateman and Radnor (2020) identified physi-ciansrsquo resistance as an ostensible barrier to Lean implementa-tion resulting from their influence within the co-productionprocess of healthcare According to Lindsay Kumar andJuleff (2020) the professionalism of the healthcare environ-ment offers a promising path of explanation Indeed Akmalet al (2020) identified various areas of incompatibilitybetween the medical professionalism and Lean logics Forexample medical professionalism tends to focus on the qual-ity of care whereas Lean usually targets quality of processesThis gap creates resistance from physicians who tend toview Lean as a manufacturing approach not applicable tohealthcare The authors also identify various cultural incom-patibilities where Lean challenges key notions of the medicalprofessional logic For example Lean focuses on the elimin-ation of wastes (such as mistakes) through root-cause ana-lysis and problem solving (Kaplan et al 2014) whichchallenges the assumption of medical professionalism thatmistakes are inevitable

The literature on New Public Management (NPM) also pro-vides a rich perspective (Osborne 2006) into this phenom-enon of resistance to change At the end of the twentiethcentury the emergence of NPM as the new paradigm assert-ing the superiority of private-sector managerial approachesresonated deeply within public healthcare systems aroundthe world It notably brought about major reforms built onresults-based frameworks (Bovaird 2005) which resulted in alsquotyranny of efficiencyrsquo that exacerbated resistance towardsmanagerial innovations from professionals (Fournier andJobin 2018) Thus it is not inherently surprising that Leanhas been met with much scepticism from physicians Afterall Leanrsquos move into healthcare originated from the successit showed in private manufacturing companies and did so toa certain extent under the NPM umbrella

However while the extant literature converges upon theclash between medical professionalism and Lean as anexplanation for this resistance there exists a dearth of know-ledge as to what organisations can do about it More pre-cisely there remains a gap in our understanding of howchange management can reduce or exacerbate the resist-ance that stems from the incompatibility of these two com-peting logics In this research we aim to provide a betterunderstanding of how change antecedents trigger resistanceor engagement behaviours from physicians and how overtime these triggers might help reduce the inherent gap

2 P-L FOURNIER ET AL

between medical professionalism and Lean To do so weperformed a qualitative study based on analytic induction(Gilgun 1995 Patton 2002) using longitudinal case studies ofthree separate Canadian healthcare organisations We anch-ored our study in two conceptual frameworks (Herscovitchand Meyer 2002 Oreg Vakola and Armenakis 2011) focus-sing on individualsrsquo behavioural reactions to organisationalchange Through this work we contribute to the ongoingdevelopment of knowledge regarding the underlying mecha-nisms of clinical involvement in Lean transformations

24 Conceptual framework

As a type of organisational change Lean can be met withvarious reactions from change recipients According to OregVakola and Armenakis (2011) individualsrsquo explicit reactionsto organisational change can be classified three-way affect-ive cognitive and behavioural Of interest for this research arebehavioural reactions which Herscovitch and Meyer (2002)classify as follows active resistance passive resistance compli-ance cooperation and championing (refer to Table 1 for fur-ther details)

These reactions can be influenced by various elements(Oreg Vakola and Armenakis 2011) Structural elements areaspects related to the context in which the change takesplace meaning they are not related to the change itselfThey are either individual characteristics or aspects of theinternal organisational context already existing prior to thechange taking place (Oreg Vakola and Armenakis 2011)Functional elements have to do with the change itself Theyare aspects that relate to the content of the change the pro-cess of change or the perceived benefits of the change fromthe recipientrsquos point of view (Oreg Vakola and Armenakis2011) To perform this research we combined Herscovitchand Meyer (2002) classification of change-related behaviourswith Oreg Vakola and Armenakis (2011) framework of ante-cedents of organisational change to focus on the elementsthat trigger physiciansrsquo behavioural reactions to Lean changeand how over time certain triggers can help offset resist-ance towards Lean anchored in medical professionalism

3 Methods

This qualitative research is based on three longitudinal casestudies (Yin 2017) of Canadian hospitals involved in large-scale Lean transformations Inductive research lends itselfwell to studying a phenomenon with potential for newinsight (Siggelkow 2007) In recent years qualitative researchhas proven effective in studying the fuzziness surroundingLean in healthcare in the OM community (Bamford et al2015 De Regge Gemmel and Meijboom 2019 Matthias and

Brown 2016 Akmal et al 2020 Lindsay Kumar andJuleff 2020)

Our methodology is based on the recommendations ofCaniato et al (2018) regarding case study research in OMThe multiple case study design was chosen to strengthenthe external validity of our research which is further comple-mented by a longitudinal perspective Using our conceptualframework we performed a two-stage analysis using analyticinduction (Gilgun 1995 Patton 2002) to study the factorsinfluencing physiciansrsquo reactions to Lean change over time

In analytic induction researchers develop hypotheses sometimesrough and general approximations prior to entry into the fieldor in cases where data already are collected prior to dataanalysis These hypotheses can be based on hunchesassumptions careful examination of theory or combinations(Gilgun 1995)

31 Cases

The cases used for this research were three large Canadianpublic hospitals in the province of Quebec who eachattempted to implement Lean over a three-year periodthrough the realisation of 10 large-scale Lean improvementprojects with the objective of improving organisational per-formance in terms of accessibility quality and efficiency ofcare The implementation approach was dictated through agovernmental program that provided funding to the organi-sations This funding was in part used to hire external con-sultants from an internationally recognised firm whoprovided external support technical knowledge and knowhow The organisations also benefitted from quality manage-ment teams made-up of Lean-trained managers with exten-sive healthcare experience under the purview of a Directorof the Lean Program who reported directly to the CEO Eachhospital had to conduct between 3 and 4 improvement proj-ects per year over three years These projects were con-ducted in various settings the main ones being operatingrooms medical imaging emergency departments and hospi-talisation Specific performance metrics were contextuallyattributed to each project Hospitals A and B were commu-nity-based hospitals situated within large metropolitan areasserving a combined population of roughly 400000 individu-als focussing on front-line services as well as specialisedservices such as cancer-related illnesses and elderly careHospital C was part of a large university-affiliated systemfocussed on high-volume emergency care on second-lineservices as well as specialised tertiary services For each hos-pital we performed interviews with stakeholders after yearone (T1 3ndash4 completed projects) year two (T2 6ndash7 com-pleted projects) and year three (T3 10 completed projects)of their implementation process Table A1 of the appendix

Table 1 Types of behavioural reactions to organisational change according to Herscovitch and Meyer (2002)

Behariouval reactions to organisational change Definition

Active resistance Opposition to a change through overt behaviours aimed at its failurePassive resistance Opposition to a change through covert behaviours aimed at its failureCompliance Showing minimum support by going along with a changeCooperation Showing support for a change by making efforts and modest sacrifices favouring its successChampioning Showing extreme enthusiasm for a change by going above and beyond what is required

PRODUCTION PLANNING amp CONTROL 3

provides more general information regarding the three hos-pitals under study as well as the list of improvement proj-ects undertaken over three years

32 Data collection

This research is based on the qualitative analysis of data col-lected within a larger study which focussed on the widerstory of Lean implementation in the three aforementionedhospitals in which the authors were involved This largerinquiry consisted of 99 interviews conducted with variousstakeholders using open-ended questions related to theimplementation their organisation was going through Weused 72 of the original 99 interviews to perform our studyfocussing on physicians These transcripts were selected fortwo reasons (1) physicians were discussed by respondentseither through their own volition or following questions and(2) they allowed for triangulation between respondents overtime In total eight participants from each organisation wereselected (24 total) who had been interviewed three timeseach (once a year for three years at the end of each year)The respondents for all three organisations were the ChiefExcutive Officer (CEO) the Chief Human Resources Officer(CHRO) the Chief Medical Officer (CMO) the Director of theLean program a middle manager and three front-line physi-cians who had participated in Lean change initiatives Thetwo-stage analysis based on analytic induction (Patton 2002Gilgun 1995) used a combination of structural (GuestMacQueen and Namey 2012) and descriptive (MilesHuberman and Saldana 2014) coding of the data anchoredin our conceptual framework (Oreg Vakola and Armenakis2011 Herscovitch and Meyer 2002)

33 Coding and analysis

The first stage within-case analysis was performed byreviewing the transcripts from each hospital and theirrespondents We used a combination of structural (GuestMacQueen and Namey 2012) and descriptive (MilesHuberman and Saldana 2014) coding to identify physiciansrsquo

reactions to Lean change and the elements or triggers thatappeared to influence them We then used a synthetic ana-lysis strategy (Langley 1999 Eisenhardt 1989) by pairingeach trigger identified by respondents to the correspondingreaction from physicians We then attributed a label to eachtrigger and categorised them according to our concep-tual framework

A structural code was used to identify when respondentshad discussed physiciansrsquo reactions to Lean change Withineach structural code the type of reaction was identifiedbased on Herscovitch and Meyerrsquos (Herscovitch and Meyer2002) five types of behavioural reactions to organisationalchange For each reaction its trigger was identified and thencategorised either as a structural (pre-existing conditions) ora functional trigger (related to the implementation processitself) Structural triggers were then placed within one of twosubcategories individual characteristics or organisational con-text Functional triggers were assigned to one of three subca-tegories content of the change process of the change orperceived benefits Finally each trigger was given a specificlabel allowing for triangulation within and between cases(Figure 1 summarises our coding methodology) While ourinitial labelling scheme of triggers followed the framework ofOreg et al (Oreg Vakola and Armenakis 2011) we progres-sively refined it following each iteration to ensure uniformityacross cases Thus triggers were defined refined added orremoved when sufficient data permitted so The appendicescontain an example of a coded transcript excerpt

After coding the data each case was analysed by organis-ing triggers and their related reactions into clustered matri-ces used to build a chain of evidence following each phaseof data collection We then classified how the preoccupationsof respondents regarding those triggers evolved over thethree measurement phases by highlighting when the trig-gers were discussed (T1 T2 or T3) and if a trend could beobserved over time

The second stage cross-case analysis was performed bycomparing the three cases using tables to illustrate the simi-larities and differences over time By overlapping the chainsof evidence we detected patterns related to the prevalence

DataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataData

Physician reacon to

Lean Change

Code

Code

Code

Code

Acve resistance

Cooperaon

Code

Trigger

Structural code Descripve code level 1 REACTION TO CHANGE

Descripve code level 2TRIGGER

Code

Descripve code level 3CATEGORY OF TRIGGER

Structural

Funconal

Descripve code level 5LABELLING OF TRIGGER

Labelling of triggers

Descripve code level 4SUB-CATEGORY OF

TRIGGER

Individual characteriscs

Organizaonal context

Content of the change

Process of the change

Perceived benefit(s)

Passive resistance

Compliance

Championing

Figure 1 Coding methodology

4 P-L FOURNIER ET AL

of certain triggers of physiciansrsquo reactions to Lean change Inthe following section we will summarise the findings of eachcase and then focus on the results of the cross-case analysis

4 Findings

In total we identified 15 triggers of physiciansrsquo behaviouralreactions to Lean change through our within-case analysesfour structural triggers and 11 functional triggers Of those12 were common to all three cases while the other threewere common to at least two cases Structural triggersincluded individual characteristics such as work experienceand previous experience with Lean thinking and also triggersrelated to the internal organisational context such as the his-tory of change and the history of support physicians perceivedfrom their organisation Functional triggers included threesubcategories Three triggers were categorised into the con-tent of the change work organisation complexity of thechange and core-technical change These had to do withwhat physicians according to respondents believed the pro-posed Lean change was about Four triggers were categor-ised into the process of change communicationcompensation involvement and leadership Finally four trig-gers were categorised as perceived benefits cost reductionquality improvement patient satisfaction and work lifeimprovement (Table A2 of the appendix summarisesthese findings)

41 Cross-case analysis

The second stage cross-case analysis for which the resultsare presented in Figure 2 was performed in two phases(Table A3 of the appendix also presents a summary ofresults) First we focussed on triangulating the behaviouralreactions initiated by each trigger which we then classifiedaccording to our conceptual framework The chain of evi-dence created through this process allowed us to refine ourunderstanding of each triggerrsquos effect on the behaviours ofphysicians by associating them with their induced behav-ioural reactions This part of the analysis is represented bythe Y axis in Figure 2

Phase 2 of the cross-case analysis focussed on the evolu-tion of the relationship between the triggers and theirinduced behaviours over the course of the Lean implemen-tation process Again through triangulation between thethree cases we were able to assess if the relationshipbetween a trigger and the corresponding reaction changedfrom T1 to T2 and from T2 to T3 We evaluated how fre-quently these relationships were discussed by participantsby counting the occurrences and how often they repeatedfrom respondent to respondent between cases We thenconsidered compared these results between the three meas-urement phases By assessing these relationships we couldevaluate if said relationships remained constant over timeeventually disappeared or appeared later during the imple-mentation process This part of the analysis is represented bythe X axis of Figure 2

42 Triggers of resistance behaviours

During the first year of implementation (T1) active and pas-sive resistance were triggered by various perceptions andpre-existing conditions Older more experienced physicianspassively opposed Lean through such actions as questioningthe merits of the approach and retreating into paradigmaticviews of Lean as a manufacturing-based solution not applic-able to healthcare Physiciansrsquo negative perceptions of theinternal organisational context also triggered passive resist-ance in the early stages of implementation specifically withregards to the organisationsrsquo history of change and its his-tory of providing individualised support during change Thefollowing quote provides support for this assertion

In most of our projects I had physicians come up to me and saythose things didnrsquot work the last twenty times you tried Whywould it be any different now Director of the Lean program ndashHospital B ndash T1

These findings associated to T1 are not inherently sur-prising for two reasons First clinical staff have historicallybeen resistant towards managerial innovations (McCannet al 2015) in part because they have seldom shown theability to provide meaningful improvements to care-provisionsystems The second reason has to do with the historicalcontext of healthcare organisations in Quebec where health-care workers are increasingly faced with change fatigue Inrecent years Quebecrsquos healthcare system has gone throughmultiple systemic structural changes which have exacerbatedworking conditions and done little to improve organisationalperformance (Pineault et al 2016) Interestingly as theorganisations became more familiar with Lean experienceand the internal organisational context no longer triggeredresistance from physicians These effects dwindled and even-tually disappeared in T3

As implementation progressed resistance behaviourswere generated by functional triggers related to the imple-mentation process itself When physicians believed the pro-posed change targeted the organisation of their work or ifthey saw it as highly complex instances of active and pas-sive resistance were reported in T1 and T2

Yes we did [look at the organization of work] In that instancewe asked physicians to come into work 20 minutes earlier thanwhat they were currently doing Most did not partake in thisrequest Some were quite vocal about it while others just didnrsquotdo it CHRO ndash Hospital A ndash T1

However two triggers created active resistance through-out the implementation process First physicians tended toexhibit overt opposition behaviours when under the impres-sion that the Lean initiativersquos main benefit would be costreduction This is in line with other researchersrsquo conclusionsregarding the aversion of healthcare staff regarding Lean asan efficiency-driven approach (Akmal et al 2020 RadnorHolweg and Waring 2012) One respondent was quotedas saying

We came in and for some reason [the physicians] thought thiswas about cutting costs increasing productivity It wasnrsquot reallybut it definitely came across that way Both physicians who wereinvolved in the project went back to their colleagues and pretty

PRODUCTION PLANNING amp CONTROL 5

much killed it in the egg They would not go along with itbecause they thought it was about [cost reduction] CEO ndashHospital B ndash T2

Secondly the thought of seeing the core aspects oftheir work medical practices being targeted by Leanchange created strong resistance In fact when analysingthe data it became apparent that the perception of core-technical change was the biggest initiator of activeresistance from physicians as the following statementarticulates

Thatrsquos a no go We went there a few times and it alwaysbackfired If you touch [medical practices] this is where they will

fight you tooth and nail Wersquove had success with otherprofessionals but our clinicians (physicians) well it is a differentstory Director of the Lean program ndash Hospital A ndash T3

Overall behaviours such as not attending important meet-ings related to an improvement project openly opposing thechange in discussions with colleagues and going so far as tomake data collection more difficult for consultants were trig-gered by the belief of Lean being used for reducing costs orfor changing medical practices In fine these two triggers arepossibly those who create the most friction with the domin-ant medical professional logic which in turn results in thestrongest resistance behaviours

LeadershipF-P

T2T1 T3

Work organizaonF-C

CommunicaonF-P

InvolvementF-P

Cost reduconF-B

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

Cooperaon

Acve resistance

Compliance

Passive resistance

Championing

Complexity of changeF-C

Core-technical changeF-C

CommunicaonF-P

InvolvementF-P

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

LeadershipF-P

Lean ExperienceS-I

Lean ExperienceS-I

History of changeS-O

History of supportS-O

ExperienceS-I

Work organizaonF-C

Complexity of changeF-C

Cost reduconF-B

CompensaonF-P

Implementaon Process

Beha

viou

ral R

eac

ons t

o Le

an

LegendS = Structural antecedent -gt I = Individual characteriscs O = Organizaonal contextF = Funconal antecedent -gt C = Content of the change P = Process of change B = Percived benefits

Figure 2 Triggers of behavioural reactions to Lean change over time

6 P-L FOURNIER ET AL

43 Triggers of change supporting behaviours

Positive change supporting behaviours were triggered by dif-ferent elements related to the change First perceived bene-fits related to patient satisfaction and the quality of work lifetriggered compliance and cooperation behaviours in T1though by T3 these triggers did not create any change-related behaviours Considering the core Lean tenants oflsquocreating value for the customerrsquo and of lsquorespect for peoplersquothis finding brings into question some of the basic principlesof Lean and how it positions itself in the eyes of physicians

Perceived benefits to quality improvement appeared moreconductive to positive supporting behaviours over time butin T3 cooperation behaviours were no longer enacted by itand only compliance behaviours were triggered It is import-ant to note that this research did not delve into the variousdimensions of quality in healthcare Since 30 improvementprojects were undertaken within the three hospitals qualityimprovement may have taken on different meanings andmetrics depending on the clinical or managerial circumstan-ces such as the reduction of medication errors or infectionsWe therefore focussed our attention to quality improvementin general and how respondents discussed the issue

If they can see that itrsquos about improving our quality of care itrsquoseasier to get them to somewhat engage in it (Lean change)Thatrsquos what we got in our long-term care centres They(physicians) didnrsquot really help us but they didnrsquot resist or opposeit CHRO ndash Hospital A ndash T2

Functional triggers linked to the process of change weredeemed to significantly influence positive reactions fromphysicians with the exception of compensation While payingphysicians specifically for their participation in a Lean projectdid generate compliance in T1 and T2 its effects did notreach beyond that In fact recent research by FournierChenevert and Jobin (2021) has found that compensatingphysicians for specifically taking part in Lean initiatives mightbe counterproductive Change management practices con-tributed positively to change supporting behaviours Goodcommunication triggered compliance behaviours in all threeimplementation phases while cooperation was observed inT1 and T2 Furthermore from T1 to T3 involving physiciansin the decision-making process regarding the change provedconductive to both compliance and cooperation

We donrsquot start a project without a good communication plan Welearned that from our first projects When we did that project(outpatient clinics) we made sure to communicate from start tofinish It definitely helped a lot [to get physiciansrsquo cooperation]CEO ndash Hospital A ndash T3

Itrsquos not just about keeping them informed They want to have asay and be a part of the decisions When we do that we get alot less resistance

Director of the Lean program ndash Hospital Cndash T3

The contribution of these triggers to the change-relatedbehaviours of physicians in our cases corroborates those ofAkmal et al (2020) who posit that communication while fre-quently used by managers as a tool to engage stakeholdersin change is not sufficient to offset the more potent resist-ance behaviours

Championing behaviours were not frequently observedthrough our analysis When they were however theyappeared to be linked to two specific triggers First was pre-vious experience with Lean thinking When physicians under-going Lean change had previously positively experimentedwith the approaches and techniques of Lean or if they hadhad formal training in the approach positive reactions wereobserved From T1 to T3 Lean experience triggered cooper-ation from clinicians while starting in T2 it went as far as totrigger championing behaviours The following statementfrom hospital Brsquos CMO is eloquent

We had one (physician) who did his Green Belt (Lean training) afew years ago He really acted as a catalyst to get his colleagueson board To convince them this was a good idea Heunderstood the motivations behind Lean

Chief Medical Officerndash Hospital B ndash T3

Cooperation and championing behaviours were also trig-gered by leadership Curiously this appeared much later inthe implementation process In fact while cooperation wastriggered by leadership in T2 it wasnrsquot until all three hospi-tals were further along in T3 that leadership generatedchampioning behaviours Even more so leadership appearedas a trigger able to counterbalance and even overwriteactive resistance triggered by core-technical changes and per-ceived benefits of cost reduction As one CEO points out

Really I think itrsquos all about our change agent our leader Whenour project manager acts accordingly it helps us not only getthem (physicians) on board it turns them into change agentthemselves Thatrsquos what happened in our geriatric unit Themanager was a seasoned leader and she managed to create thiscohesion this alignment CEO ndash Hospital C ndash T3

Overall our cross-case analysis allowed us to develop adetailed chain of evidence of three years of Lean implemen-tation in each hospital Through triangulation we managedto identify how each trigger appeared to generate reactionsfrom physicians over time As we will discuss most structuraltriggers disappeared from consideration within the hospitalsas some functional triggers took on a more prominent role

5 Discussion

Considering the increasing prevalence of Lean implementa-tion in healthcare organisations and systems our findingsoffer an interesting contribution to its ongoing challengesSince physicians are central actors of its implementation pro-cess their negative reactions towards it can create importantbarriers (Fournier and Jobin 2018 Leite Bateman andRadnor 2020 Akmal et al 2020) Arguably without physi-cianrsquos engagement Lean in healthcare cannot reach its fullpotential (Lorden et al 2014) It then becomes essential tounderstand what drives their reactions so that organisationscan act accordingly Our research builds upon recent worksof the operations management literature (FournierChenevert and Jobin 2021 Lindsay Kumar and Juleff 2020Akmal et al 2020) by focussing on the behavioural dimen-sion of medical resistance to Lean

PRODUCTION PLANNING amp CONTROL 7

51 The underlying resistance of physicianstowards Lean

As discussed previously Lean clashes with the dominantmedical professional logic found in healthcare organisationswhich creates an underlying resistance that is present fromthe onset of any change initiative and not easy to offsetWhile the use of Lean in healthcare is varied and touchesupon various dimensions of the care system such as ancillaryservices and procurement resistance is typically muchgreater when used in clinical settings (Lindsay Kumar andJuleff 2020 Fournier and Jobin 2018)

In our study the most negative resistance behaviourswere triggered when physicians perceived that a proposedLean change would target their medical practices As arguedby Dent (2003) resistance from physicians tends to be trig-gered by any type of change questioning their status asmedical professionals or their decision-making autonomyDuring our interviews a few respondents even mentionedthat they shied away from trying to improve processes heav-ily involving physiciansrsquo clinical practices because they couldpredict that resistance would be high However they alsoconcluded that this was futile Since Lean aims at improvingprocesses and flow it will inevitably come into contact withphysiciansrsquo clinical work

Active resistance behaviours were also triggered by per-ceptions of efficiency-driven Lean implementation This ech-oes research on NPM presented earlier and its deleteriouseffects created over the last thirty years combined with theapprehension of Lean as a manufacturing approachHowever the resistance triggered by perceptions of costreduction can also further be explained through a behav-ioural lens Physicians usually associate available resources totheir own self-efficacy (Amiot et al 2006) If they believe thatLeanrsquos main objective is to reduce such resources the per-ceived threat is even greater which triggers more resistanceThis effect may also have been exacerbated in the organisa-tions under study because most Canadian physicians areindependent fee-for-service providers (Contandriopoulos andBrousselle 2018) which might create an even bigger gapbetween physiciansrsquo perceived self-efficacy and organisa-tional interests and ultimately compound resistance behav-iours Our findings help draw a clearer picture regarding theunderlying resistance of physicians towards Lean and thetriggers that exacerbate it However the question remainswhat can organisation do about it

52 Offsetting medical resistance to Lean

The underlying resistance of physicians towards Lean changeis unlikely to go away at least for the foreseeable future Asexplained earlier the clash between the Lean and medicalprofessional institutional logics results in an inherent appre-hension towards Lean To face this issue organisations haveused traditional change management practices such as com-munication and training to try to engage stakeholders inchange efforts While these practices have been linked tohealthcare professionals supporting change (Nilsen et al

2019) our results show that in the case of physicians andLean these approaches are not sufficient This echoes thefindings of Akmal et al (2020) When triggered by threats tomedical professionalism resistance towards Lean is toostrong to be overcome by simple change management strat-egies However our results also show that it is possible tooffset active resistance by triggering championing behavioursthat support change through leadership and familiaritywith Lean

The emergence of leadership in the later phases of ourstudy was surprising not because it triggered positive changesupporting behaviours but because it did it strongly In theearly stages of implementation leadership was not a priorityfor the organisations under study But as they progressedthe organisations realised that high levels of leadership couldcreate championing behaviours In general the literature onLean advocates transformational leadership as a blueprint formanagerial behaviour (van Rossum et al 2016) Akmal et al(2020) focus on leading by example which is but one of thevarious dimensions of transformational leadership (PodsakoffMacKenzie and Bommer 1996) However in the case ofhealthcare and physicians the introduction of shared leader-ship in combination with the former could prove even moreconductive For example Bartram et al (2020) discuss co-ownership as a way of engaging physicians in workplaceinnovation As our findings show mere participation is notenough to trigger strong change supporting behaviours InT3 Lean leaders of the organisations invested efforts to cre-ate environments in which physicians shared leadership indriving improvement efforts forward by being present onunits and departments where projects were underway andbecome part of the team They also focussed on sensemak-ing and collaboration with physicians as opposed to simplycommunicating generic messages from top managementThis salience of leadership unearthed by our findings alsohighlights the importance for organisations to wisely choosetheir change agents It also brings our attention to theimplementation strategies used by healthcare organisationswhich influence the acceptance and adoption of Lean (Hunget al 2015) In our study the implementation of Leanstemmed from a governmental program In other words itused a top-down approach While physicians and staff wereconsulted in the early stages and participated in discussionsabout the implementation process the implementationteams realised how detrimental this top-down strategy hadbeen to the overall resistance of physicians Thus the emer-gence of transformational and shared leadership was alsodue to the need to catch up with resistance that emergedfrom the get-go and that could not be overcome throughtraditional change management practices

Uncertainty and unfamiliarity regarding a change is typic-ally linked with resistance (Holt et al 2007) In the case ofLean this is sometimes compounded by the jargon it usesthat is not endogenous to the medical professionFurthermore Lean relies on system thinking which can becounterintuitive with regards to medical professionals whotend to focus on the care they provide to individual patientsFor some physicians this incompatibility might result in an

8 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

between medical professionalism and Lean To do so weperformed a qualitative study based on analytic induction(Gilgun 1995 Patton 2002) using longitudinal case studies ofthree separate Canadian healthcare organisations We anch-ored our study in two conceptual frameworks (Herscovitchand Meyer 2002 Oreg Vakola and Armenakis 2011) focus-sing on individualsrsquo behavioural reactions to organisationalchange Through this work we contribute to the ongoingdevelopment of knowledge regarding the underlying mecha-nisms of clinical involvement in Lean transformations

24 Conceptual framework

As a type of organisational change Lean can be met withvarious reactions from change recipients According to OregVakola and Armenakis (2011) individualsrsquo explicit reactionsto organisational change can be classified three-way affect-ive cognitive and behavioural Of interest for this research arebehavioural reactions which Herscovitch and Meyer (2002)classify as follows active resistance passive resistance compli-ance cooperation and championing (refer to Table 1 for fur-ther details)

These reactions can be influenced by various elements(Oreg Vakola and Armenakis 2011) Structural elements areaspects related to the context in which the change takesplace meaning they are not related to the change itselfThey are either individual characteristics or aspects of theinternal organisational context already existing prior to thechange taking place (Oreg Vakola and Armenakis 2011)Functional elements have to do with the change itself Theyare aspects that relate to the content of the change the pro-cess of change or the perceived benefits of the change fromthe recipientrsquos point of view (Oreg Vakola and Armenakis2011) To perform this research we combined Herscovitchand Meyer (2002) classification of change-related behaviourswith Oreg Vakola and Armenakis (2011) framework of ante-cedents of organisational change to focus on the elementsthat trigger physiciansrsquo behavioural reactions to Lean changeand how over time certain triggers can help offset resist-ance towards Lean anchored in medical professionalism

3 Methods

This qualitative research is based on three longitudinal casestudies (Yin 2017) of Canadian hospitals involved in large-scale Lean transformations Inductive research lends itselfwell to studying a phenomenon with potential for newinsight (Siggelkow 2007) In recent years qualitative researchhas proven effective in studying the fuzziness surroundingLean in healthcare in the OM community (Bamford et al2015 De Regge Gemmel and Meijboom 2019 Matthias and

Brown 2016 Akmal et al 2020 Lindsay Kumar andJuleff 2020)

Our methodology is based on the recommendations ofCaniato et al (2018) regarding case study research in OMThe multiple case study design was chosen to strengthenthe external validity of our research which is further comple-mented by a longitudinal perspective Using our conceptualframework we performed a two-stage analysis using analyticinduction (Gilgun 1995 Patton 2002) to study the factorsinfluencing physiciansrsquo reactions to Lean change over time

In analytic induction researchers develop hypotheses sometimesrough and general approximations prior to entry into the fieldor in cases where data already are collected prior to dataanalysis These hypotheses can be based on hunchesassumptions careful examination of theory or combinations(Gilgun 1995)

31 Cases

The cases used for this research were three large Canadianpublic hospitals in the province of Quebec who eachattempted to implement Lean over a three-year periodthrough the realisation of 10 large-scale Lean improvementprojects with the objective of improving organisational per-formance in terms of accessibility quality and efficiency ofcare The implementation approach was dictated through agovernmental program that provided funding to the organi-sations This funding was in part used to hire external con-sultants from an internationally recognised firm whoprovided external support technical knowledge and knowhow The organisations also benefitted from quality manage-ment teams made-up of Lean-trained managers with exten-sive healthcare experience under the purview of a Directorof the Lean Program who reported directly to the CEO Eachhospital had to conduct between 3 and 4 improvement proj-ects per year over three years These projects were con-ducted in various settings the main ones being operatingrooms medical imaging emergency departments and hospi-talisation Specific performance metrics were contextuallyattributed to each project Hospitals A and B were commu-nity-based hospitals situated within large metropolitan areasserving a combined population of roughly 400000 individu-als focussing on front-line services as well as specialisedservices such as cancer-related illnesses and elderly careHospital C was part of a large university-affiliated systemfocussed on high-volume emergency care on second-lineservices as well as specialised tertiary services For each hos-pital we performed interviews with stakeholders after yearone (T1 3ndash4 completed projects) year two (T2 6ndash7 com-pleted projects) and year three (T3 10 completed projects)of their implementation process Table A1 of the appendix

Table 1 Types of behavioural reactions to organisational change according to Herscovitch and Meyer (2002)

Behariouval reactions to organisational change Definition

Active resistance Opposition to a change through overt behaviours aimed at its failurePassive resistance Opposition to a change through covert behaviours aimed at its failureCompliance Showing minimum support by going along with a changeCooperation Showing support for a change by making efforts and modest sacrifices favouring its successChampioning Showing extreme enthusiasm for a change by going above and beyond what is required

PRODUCTION PLANNING amp CONTROL 3

provides more general information regarding the three hos-pitals under study as well as the list of improvement proj-ects undertaken over three years

32 Data collection

This research is based on the qualitative analysis of data col-lected within a larger study which focussed on the widerstory of Lean implementation in the three aforementionedhospitals in which the authors were involved This largerinquiry consisted of 99 interviews conducted with variousstakeholders using open-ended questions related to theimplementation their organisation was going through Weused 72 of the original 99 interviews to perform our studyfocussing on physicians These transcripts were selected fortwo reasons (1) physicians were discussed by respondentseither through their own volition or following questions and(2) they allowed for triangulation between respondents overtime In total eight participants from each organisation wereselected (24 total) who had been interviewed three timeseach (once a year for three years at the end of each year)The respondents for all three organisations were the ChiefExcutive Officer (CEO) the Chief Human Resources Officer(CHRO) the Chief Medical Officer (CMO) the Director of theLean program a middle manager and three front-line physi-cians who had participated in Lean change initiatives Thetwo-stage analysis based on analytic induction (Patton 2002Gilgun 1995) used a combination of structural (GuestMacQueen and Namey 2012) and descriptive (MilesHuberman and Saldana 2014) coding of the data anchoredin our conceptual framework (Oreg Vakola and Armenakis2011 Herscovitch and Meyer 2002)

33 Coding and analysis

The first stage within-case analysis was performed byreviewing the transcripts from each hospital and theirrespondents We used a combination of structural (GuestMacQueen and Namey 2012) and descriptive (MilesHuberman and Saldana 2014) coding to identify physiciansrsquo

reactions to Lean change and the elements or triggers thatappeared to influence them We then used a synthetic ana-lysis strategy (Langley 1999 Eisenhardt 1989) by pairingeach trigger identified by respondents to the correspondingreaction from physicians We then attributed a label to eachtrigger and categorised them according to our concep-tual framework

A structural code was used to identify when respondentshad discussed physiciansrsquo reactions to Lean change Withineach structural code the type of reaction was identifiedbased on Herscovitch and Meyerrsquos (Herscovitch and Meyer2002) five types of behavioural reactions to organisationalchange For each reaction its trigger was identified and thencategorised either as a structural (pre-existing conditions) ora functional trigger (related to the implementation processitself) Structural triggers were then placed within one of twosubcategories individual characteristics or organisational con-text Functional triggers were assigned to one of three subca-tegories content of the change process of the change orperceived benefits Finally each trigger was given a specificlabel allowing for triangulation within and between cases(Figure 1 summarises our coding methodology) While ourinitial labelling scheme of triggers followed the framework ofOreg et al (Oreg Vakola and Armenakis 2011) we progres-sively refined it following each iteration to ensure uniformityacross cases Thus triggers were defined refined added orremoved when sufficient data permitted so The appendicescontain an example of a coded transcript excerpt

After coding the data each case was analysed by organis-ing triggers and their related reactions into clustered matri-ces used to build a chain of evidence following each phaseof data collection We then classified how the preoccupationsof respondents regarding those triggers evolved over thethree measurement phases by highlighting when the trig-gers were discussed (T1 T2 or T3) and if a trend could beobserved over time

The second stage cross-case analysis was performed bycomparing the three cases using tables to illustrate the simi-larities and differences over time By overlapping the chainsof evidence we detected patterns related to the prevalence

DataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataData

Physician reacon to

Lean Change

Code

Code

Code

Code

Acve resistance

Cooperaon

Code

Trigger

Structural code Descripve code level 1 REACTION TO CHANGE

Descripve code level 2TRIGGER

Code

Descripve code level 3CATEGORY OF TRIGGER

Structural

Funconal

Descripve code level 5LABELLING OF TRIGGER

Labelling of triggers

Descripve code level 4SUB-CATEGORY OF

TRIGGER

Individual characteriscs

Organizaonal context

Content of the change

Process of the change

Perceived benefit(s)

Passive resistance

Compliance

Championing

Figure 1 Coding methodology

4 P-L FOURNIER ET AL

of certain triggers of physiciansrsquo reactions to Lean change Inthe following section we will summarise the findings of eachcase and then focus on the results of the cross-case analysis

4 Findings

In total we identified 15 triggers of physiciansrsquo behaviouralreactions to Lean change through our within-case analysesfour structural triggers and 11 functional triggers Of those12 were common to all three cases while the other threewere common to at least two cases Structural triggersincluded individual characteristics such as work experienceand previous experience with Lean thinking and also triggersrelated to the internal organisational context such as the his-tory of change and the history of support physicians perceivedfrom their organisation Functional triggers included threesubcategories Three triggers were categorised into the con-tent of the change work organisation complexity of thechange and core-technical change These had to do withwhat physicians according to respondents believed the pro-posed Lean change was about Four triggers were categor-ised into the process of change communicationcompensation involvement and leadership Finally four trig-gers were categorised as perceived benefits cost reductionquality improvement patient satisfaction and work lifeimprovement (Table A2 of the appendix summarisesthese findings)

41 Cross-case analysis

The second stage cross-case analysis for which the resultsare presented in Figure 2 was performed in two phases(Table A3 of the appendix also presents a summary ofresults) First we focussed on triangulating the behaviouralreactions initiated by each trigger which we then classifiedaccording to our conceptual framework The chain of evi-dence created through this process allowed us to refine ourunderstanding of each triggerrsquos effect on the behaviours ofphysicians by associating them with their induced behav-ioural reactions This part of the analysis is represented bythe Y axis in Figure 2

Phase 2 of the cross-case analysis focussed on the evolu-tion of the relationship between the triggers and theirinduced behaviours over the course of the Lean implemen-tation process Again through triangulation between thethree cases we were able to assess if the relationshipbetween a trigger and the corresponding reaction changedfrom T1 to T2 and from T2 to T3 We evaluated how fre-quently these relationships were discussed by participantsby counting the occurrences and how often they repeatedfrom respondent to respondent between cases We thenconsidered compared these results between the three meas-urement phases By assessing these relationships we couldevaluate if said relationships remained constant over timeeventually disappeared or appeared later during the imple-mentation process This part of the analysis is represented bythe X axis of Figure 2

42 Triggers of resistance behaviours

During the first year of implementation (T1) active and pas-sive resistance were triggered by various perceptions andpre-existing conditions Older more experienced physicianspassively opposed Lean through such actions as questioningthe merits of the approach and retreating into paradigmaticviews of Lean as a manufacturing-based solution not applic-able to healthcare Physiciansrsquo negative perceptions of theinternal organisational context also triggered passive resist-ance in the early stages of implementation specifically withregards to the organisationsrsquo history of change and its his-tory of providing individualised support during change Thefollowing quote provides support for this assertion

In most of our projects I had physicians come up to me and saythose things didnrsquot work the last twenty times you tried Whywould it be any different now Director of the Lean program ndashHospital B ndash T1

These findings associated to T1 are not inherently sur-prising for two reasons First clinical staff have historicallybeen resistant towards managerial innovations (McCannet al 2015) in part because they have seldom shown theability to provide meaningful improvements to care-provisionsystems The second reason has to do with the historicalcontext of healthcare organisations in Quebec where health-care workers are increasingly faced with change fatigue Inrecent years Quebecrsquos healthcare system has gone throughmultiple systemic structural changes which have exacerbatedworking conditions and done little to improve organisationalperformance (Pineault et al 2016) Interestingly as theorganisations became more familiar with Lean experienceand the internal organisational context no longer triggeredresistance from physicians These effects dwindled and even-tually disappeared in T3

As implementation progressed resistance behaviourswere generated by functional triggers related to the imple-mentation process itself When physicians believed the pro-posed change targeted the organisation of their work or ifthey saw it as highly complex instances of active and pas-sive resistance were reported in T1 and T2

Yes we did [look at the organization of work] In that instancewe asked physicians to come into work 20 minutes earlier thanwhat they were currently doing Most did not partake in thisrequest Some were quite vocal about it while others just didnrsquotdo it CHRO ndash Hospital A ndash T1

However two triggers created active resistance through-out the implementation process First physicians tended toexhibit overt opposition behaviours when under the impres-sion that the Lean initiativersquos main benefit would be costreduction This is in line with other researchersrsquo conclusionsregarding the aversion of healthcare staff regarding Lean asan efficiency-driven approach (Akmal et al 2020 RadnorHolweg and Waring 2012) One respondent was quotedas saying

We came in and for some reason [the physicians] thought thiswas about cutting costs increasing productivity It wasnrsquot reallybut it definitely came across that way Both physicians who wereinvolved in the project went back to their colleagues and pretty

PRODUCTION PLANNING amp CONTROL 5

much killed it in the egg They would not go along with itbecause they thought it was about [cost reduction] CEO ndashHospital B ndash T2

Secondly the thought of seeing the core aspects oftheir work medical practices being targeted by Leanchange created strong resistance In fact when analysingthe data it became apparent that the perception of core-technical change was the biggest initiator of activeresistance from physicians as the following statementarticulates

Thatrsquos a no go We went there a few times and it alwaysbackfired If you touch [medical practices] this is where they will

fight you tooth and nail Wersquove had success with otherprofessionals but our clinicians (physicians) well it is a differentstory Director of the Lean program ndash Hospital A ndash T3

Overall behaviours such as not attending important meet-ings related to an improvement project openly opposing thechange in discussions with colleagues and going so far as tomake data collection more difficult for consultants were trig-gered by the belief of Lean being used for reducing costs orfor changing medical practices In fine these two triggers arepossibly those who create the most friction with the domin-ant medical professional logic which in turn results in thestrongest resistance behaviours

LeadershipF-P

T2T1 T3

Work organizaonF-C

CommunicaonF-P

InvolvementF-P

Cost reduconF-B

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

Cooperaon

Acve resistance

Compliance

Passive resistance

Championing

Complexity of changeF-C

Core-technical changeF-C

CommunicaonF-P

InvolvementF-P

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

LeadershipF-P

Lean ExperienceS-I

Lean ExperienceS-I

History of changeS-O

History of supportS-O

ExperienceS-I

Work organizaonF-C

Complexity of changeF-C

Cost reduconF-B

CompensaonF-P

Implementaon Process

Beha

viou

ral R

eac

ons t

o Le

an

LegendS = Structural antecedent -gt I = Individual characteriscs O = Organizaonal contextF = Funconal antecedent -gt C = Content of the change P = Process of change B = Percived benefits

Figure 2 Triggers of behavioural reactions to Lean change over time

6 P-L FOURNIER ET AL

43 Triggers of change supporting behaviours

Positive change supporting behaviours were triggered by dif-ferent elements related to the change First perceived bene-fits related to patient satisfaction and the quality of work lifetriggered compliance and cooperation behaviours in T1though by T3 these triggers did not create any change-related behaviours Considering the core Lean tenants oflsquocreating value for the customerrsquo and of lsquorespect for peoplersquothis finding brings into question some of the basic principlesof Lean and how it positions itself in the eyes of physicians

Perceived benefits to quality improvement appeared moreconductive to positive supporting behaviours over time butin T3 cooperation behaviours were no longer enacted by itand only compliance behaviours were triggered It is import-ant to note that this research did not delve into the variousdimensions of quality in healthcare Since 30 improvementprojects were undertaken within the three hospitals qualityimprovement may have taken on different meanings andmetrics depending on the clinical or managerial circumstan-ces such as the reduction of medication errors or infectionsWe therefore focussed our attention to quality improvementin general and how respondents discussed the issue

If they can see that itrsquos about improving our quality of care itrsquoseasier to get them to somewhat engage in it (Lean change)Thatrsquos what we got in our long-term care centres They(physicians) didnrsquot really help us but they didnrsquot resist or opposeit CHRO ndash Hospital A ndash T2

Functional triggers linked to the process of change weredeemed to significantly influence positive reactions fromphysicians with the exception of compensation While payingphysicians specifically for their participation in a Lean projectdid generate compliance in T1 and T2 its effects did notreach beyond that In fact recent research by FournierChenevert and Jobin (2021) has found that compensatingphysicians for specifically taking part in Lean initiatives mightbe counterproductive Change management practices con-tributed positively to change supporting behaviours Goodcommunication triggered compliance behaviours in all threeimplementation phases while cooperation was observed inT1 and T2 Furthermore from T1 to T3 involving physiciansin the decision-making process regarding the change provedconductive to both compliance and cooperation

We donrsquot start a project without a good communication plan Welearned that from our first projects When we did that project(outpatient clinics) we made sure to communicate from start tofinish It definitely helped a lot [to get physiciansrsquo cooperation]CEO ndash Hospital A ndash T3

Itrsquos not just about keeping them informed They want to have asay and be a part of the decisions When we do that we get alot less resistance

Director of the Lean program ndash Hospital Cndash T3

The contribution of these triggers to the change-relatedbehaviours of physicians in our cases corroborates those ofAkmal et al (2020) who posit that communication while fre-quently used by managers as a tool to engage stakeholdersin change is not sufficient to offset the more potent resist-ance behaviours

Championing behaviours were not frequently observedthrough our analysis When they were however theyappeared to be linked to two specific triggers First was pre-vious experience with Lean thinking When physicians under-going Lean change had previously positively experimentedwith the approaches and techniques of Lean or if they hadhad formal training in the approach positive reactions wereobserved From T1 to T3 Lean experience triggered cooper-ation from clinicians while starting in T2 it went as far as totrigger championing behaviours The following statementfrom hospital Brsquos CMO is eloquent

We had one (physician) who did his Green Belt (Lean training) afew years ago He really acted as a catalyst to get his colleagueson board To convince them this was a good idea Heunderstood the motivations behind Lean

Chief Medical Officerndash Hospital B ndash T3

Cooperation and championing behaviours were also trig-gered by leadership Curiously this appeared much later inthe implementation process In fact while cooperation wastriggered by leadership in T2 it wasnrsquot until all three hospi-tals were further along in T3 that leadership generatedchampioning behaviours Even more so leadership appearedas a trigger able to counterbalance and even overwriteactive resistance triggered by core-technical changes and per-ceived benefits of cost reduction As one CEO points out

Really I think itrsquos all about our change agent our leader Whenour project manager acts accordingly it helps us not only getthem (physicians) on board it turns them into change agentthemselves Thatrsquos what happened in our geriatric unit Themanager was a seasoned leader and she managed to create thiscohesion this alignment CEO ndash Hospital C ndash T3

Overall our cross-case analysis allowed us to develop adetailed chain of evidence of three years of Lean implemen-tation in each hospital Through triangulation we managedto identify how each trigger appeared to generate reactionsfrom physicians over time As we will discuss most structuraltriggers disappeared from consideration within the hospitalsas some functional triggers took on a more prominent role

5 Discussion

Considering the increasing prevalence of Lean implementa-tion in healthcare organisations and systems our findingsoffer an interesting contribution to its ongoing challengesSince physicians are central actors of its implementation pro-cess their negative reactions towards it can create importantbarriers (Fournier and Jobin 2018 Leite Bateman andRadnor 2020 Akmal et al 2020) Arguably without physi-cianrsquos engagement Lean in healthcare cannot reach its fullpotential (Lorden et al 2014) It then becomes essential tounderstand what drives their reactions so that organisationscan act accordingly Our research builds upon recent worksof the operations management literature (FournierChenevert and Jobin 2021 Lindsay Kumar and Juleff 2020Akmal et al 2020) by focussing on the behavioural dimen-sion of medical resistance to Lean

PRODUCTION PLANNING amp CONTROL 7

51 The underlying resistance of physicianstowards Lean

As discussed previously Lean clashes with the dominantmedical professional logic found in healthcare organisationswhich creates an underlying resistance that is present fromthe onset of any change initiative and not easy to offsetWhile the use of Lean in healthcare is varied and touchesupon various dimensions of the care system such as ancillaryservices and procurement resistance is typically muchgreater when used in clinical settings (Lindsay Kumar andJuleff 2020 Fournier and Jobin 2018)

In our study the most negative resistance behaviourswere triggered when physicians perceived that a proposedLean change would target their medical practices As arguedby Dent (2003) resistance from physicians tends to be trig-gered by any type of change questioning their status asmedical professionals or their decision-making autonomyDuring our interviews a few respondents even mentionedthat they shied away from trying to improve processes heav-ily involving physiciansrsquo clinical practices because they couldpredict that resistance would be high However they alsoconcluded that this was futile Since Lean aims at improvingprocesses and flow it will inevitably come into contact withphysiciansrsquo clinical work

Active resistance behaviours were also triggered by per-ceptions of efficiency-driven Lean implementation This ech-oes research on NPM presented earlier and its deleteriouseffects created over the last thirty years combined with theapprehension of Lean as a manufacturing approachHowever the resistance triggered by perceptions of costreduction can also further be explained through a behav-ioural lens Physicians usually associate available resources totheir own self-efficacy (Amiot et al 2006) If they believe thatLeanrsquos main objective is to reduce such resources the per-ceived threat is even greater which triggers more resistanceThis effect may also have been exacerbated in the organisa-tions under study because most Canadian physicians areindependent fee-for-service providers (Contandriopoulos andBrousselle 2018) which might create an even bigger gapbetween physiciansrsquo perceived self-efficacy and organisa-tional interests and ultimately compound resistance behav-iours Our findings help draw a clearer picture regarding theunderlying resistance of physicians towards Lean and thetriggers that exacerbate it However the question remainswhat can organisation do about it

52 Offsetting medical resistance to Lean

The underlying resistance of physicians towards Lean changeis unlikely to go away at least for the foreseeable future Asexplained earlier the clash between the Lean and medicalprofessional institutional logics results in an inherent appre-hension towards Lean To face this issue organisations haveused traditional change management practices such as com-munication and training to try to engage stakeholders inchange efforts While these practices have been linked tohealthcare professionals supporting change (Nilsen et al

2019) our results show that in the case of physicians andLean these approaches are not sufficient This echoes thefindings of Akmal et al (2020) When triggered by threats tomedical professionalism resistance towards Lean is toostrong to be overcome by simple change management strat-egies However our results also show that it is possible tooffset active resistance by triggering championing behavioursthat support change through leadership and familiaritywith Lean

The emergence of leadership in the later phases of ourstudy was surprising not because it triggered positive changesupporting behaviours but because it did it strongly In theearly stages of implementation leadership was not a priorityfor the organisations under study But as they progressedthe organisations realised that high levels of leadership couldcreate championing behaviours In general the literature onLean advocates transformational leadership as a blueprint formanagerial behaviour (van Rossum et al 2016) Akmal et al(2020) focus on leading by example which is but one of thevarious dimensions of transformational leadership (PodsakoffMacKenzie and Bommer 1996) However in the case ofhealthcare and physicians the introduction of shared leader-ship in combination with the former could prove even moreconductive For example Bartram et al (2020) discuss co-ownership as a way of engaging physicians in workplaceinnovation As our findings show mere participation is notenough to trigger strong change supporting behaviours InT3 Lean leaders of the organisations invested efforts to cre-ate environments in which physicians shared leadership indriving improvement efforts forward by being present onunits and departments where projects were underway andbecome part of the team They also focussed on sensemak-ing and collaboration with physicians as opposed to simplycommunicating generic messages from top managementThis salience of leadership unearthed by our findings alsohighlights the importance for organisations to wisely choosetheir change agents It also brings our attention to theimplementation strategies used by healthcare organisationswhich influence the acceptance and adoption of Lean (Hunget al 2015) In our study the implementation of Leanstemmed from a governmental program In other words itused a top-down approach While physicians and staff wereconsulted in the early stages and participated in discussionsabout the implementation process the implementationteams realised how detrimental this top-down strategy hadbeen to the overall resistance of physicians Thus the emer-gence of transformational and shared leadership was alsodue to the need to catch up with resistance that emergedfrom the get-go and that could not be overcome throughtraditional change management practices

Uncertainty and unfamiliarity regarding a change is typic-ally linked with resistance (Holt et al 2007) In the case ofLean this is sometimes compounded by the jargon it usesthat is not endogenous to the medical professionFurthermore Lean relies on system thinking which can becounterintuitive with regards to medical professionals whotend to focus on the care they provide to individual patientsFor some physicians this incompatibility might result in an

8 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

provides more general information regarding the three hos-pitals under study as well as the list of improvement proj-ects undertaken over three years

32 Data collection

This research is based on the qualitative analysis of data col-lected within a larger study which focussed on the widerstory of Lean implementation in the three aforementionedhospitals in which the authors were involved This largerinquiry consisted of 99 interviews conducted with variousstakeholders using open-ended questions related to theimplementation their organisation was going through Weused 72 of the original 99 interviews to perform our studyfocussing on physicians These transcripts were selected fortwo reasons (1) physicians were discussed by respondentseither through their own volition or following questions and(2) they allowed for triangulation between respondents overtime In total eight participants from each organisation wereselected (24 total) who had been interviewed three timeseach (once a year for three years at the end of each year)The respondents for all three organisations were the ChiefExcutive Officer (CEO) the Chief Human Resources Officer(CHRO) the Chief Medical Officer (CMO) the Director of theLean program a middle manager and three front-line physi-cians who had participated in Lean change initiatives Thetwo-stage analysis based on analytic induction (Patton 2002Gilgun 1995) used a combination of structural (GuestMacQueen and Namey 2012) and descriptive (MilesHuberman and Saldana 2014) coding of the data anchoredin our conceptual framework (Oreg Vakola and Armenakis2011 Herscovitch and Meyer 2002)

33 Coding and analysis

The first stage within-case analysis was performed byreviewing the transcripts from each hospital and theirrespondents We used a combination of structural (GuestMacQueen and Namey 2012) and descriptive (MilesHuberman and Saldana 2014) coding to identify physiciansrsquo

reactions to Lean change and the elements or triggers thatappeared to influence them We then used a synthetic ana-lysis strategy (Langley 1999 Eisenhardt 1989) by pairingeach trigger identified by respondents to the correspondingreaction from physicians We then attributed a label to eachtrigger and categorised them according to our concep-tual framework

A structural code was used to identify when respondentshad discussed physiciansrsquo reactions to Lean change Withineach structural code the type of reaction was identifiedbased on Herscovitch and Meyerrsquos (Herscovitch and Meyer2002) five types of behavioural reactions to organisationalchange For each reaction its trigger was identified and thencategorised either as a structural (pre-existing conditions) ora functional trigger (related to the implementation processitself) Structural triggers were then placed within one of twosubcategories individual characteristics or organisational con-text Functional triggers were assigned to one of three subca-tegories content of the change process of the change orperceived benefits Finally each trigger was given a specificlabel allowing for triangulation within and between cases(Figure 1 summarises our coding methodology) While ourinitial labelling scheme of triggers followed the framework ofOreg et al (Oreg Vakola and Armenakis 2011) we progres-sively refined it following each iteration to ensure uniformityacross cases Thus triggers were defined refined added orremoved when sufficient data permitted so The appendicescontain an example of a coded transcript excerpt

After coding the data each case was analysed by organis-ing triggers and their related reactions into clustered matri-ces used to build a chain of evidence following each phaseof data collection We then classified how the preoccupationsof respondents regarding those triggers evolved over thethree measurement phases by highlighting when the trig-gers were discussed (T1 T2 or T3) and if a trend could beobserved over time

The second stage cross-case analysis was performed bycomparing the three cases using tables to illustrate the simi-larities and differences over time By overlapping the chainsof evidence we detected patterns related to the prevalence

DataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataDataData

Physician reacon to

Lean Change

Code

Code

Code

Code

Acve resistance

Cooperaon

Code

Trigger

Structural code Descripve code level 1 REACTION TO CHANGE

Descripve code level 2TRIGGER

Code

Descripve code level 3CATEGORY OF TRIGGER

Structural

Funconal

Descripve code level 5LABELLING OF TRIGGER

Labelling of triggers

Descripve code level 4SUB-CATEGORY OF

TRIGGER

Individual characteriscs

Organizaonal context

Content of the change

Process of the change

Perceived benefit(s)

Passive resistance

Compliance

Championing

Figure 1 Coding methodology

4 P-L FOURNIER ET AL

of certain triggers of physiciansrsquo reactions to Lean change Inthe following section we will summarise the findings of eachcase and then focus on the results of the cross-case analysis

4 Findings

In total we identified 15 triggers of physiciansrsquo behaviouralreactions to Lean change through our within-case analysesfour structural triggers and 11 functional triggers Of those12 were common to all three cases while the other threewere common to at least two cases Structural triggersincluded individual characteristics such as work experienceand previous experience with Lean thinking and also triggersrelated to the internal organisational context such as the his-tory of change and the history of support physicians perceivedfrom their organisation Functional triggers included threesubcategories Three triggers were categorised into the con-tent of the change work organisation complexity of thechange and core-technical change These had to do withwhat physicians according to respondents believed the pro-posed Lean change was about Four triggers were categor-ised into the process of change communicationcompensation involvement and leadership Finally four trig-gers were categorised as perceived benefits cost reductionquality improvement patient satisfaction and work lifeimprovement (Table A2 of the appendix summarisesthese findings)

41 Cross-case analysis

The second stage cross-case analysis for which the resultsare presented in Figure 2 was performed in two phases(Table A3 of the appendix also presents a summary ofresults) First we focussed on triangulating the behaviouralreactions initiated by each trigger which we then classifiedaccording to our conceptual framework The chain of evi-dence created through this process allowed us to refine ourunderstanding of each triggerrsquos effect on the behaviours ofphysicians by associating them with their induced behav-ioural reactions This part of the analysis is represented bythe Y axis in Figure 2

Phase 2 of the cross-case analysis focussed on the evolu-tion of the relationship between the triggers and theirinduced behaviours over the course of the Lean implemen-tation process Again through triangulation between thethree cases we were able to assess if the relationshipbetween a trigger and the corresponding reaction changedfrom T1 to T2 and from T2 to T3 We evaluated how fre-quently these relationships were discussed by participantsby counting the occurrences and how often they repeatedfrom respondent to respondent between cases We thenconsidered compared these results between the three meas-urement phases By assessing these relationships we couldevaluate if said relationships remained constant over timeeventually disappeared or appeared later during the imple-mentation process This part of the analysis is represented bythe X axis of Figure 2

42 Triggers of resistance behaviours

During the first year of implementation (T1) active and pas-sive resistance were triggered by various perceptions andpre-existing conditions Older more experienced physicianspassively opposed Lean through such actions as questioningthe merits of the approach and retreating into paradigmaticviews of Lean as a manufacturing-based solution not applic-able to healthcare Physiciansrsquo negative perceptions of theinternal organisational context also triggered passive resist-ance in the early stages of implementation specifically withregards to the organisationsrsquo history of change and its his-tory of providing individualised support during change Thefollowing quote provides support for this assertion

In most of our projects I had physicians come up to me and saythose things didnrsquot work the last twenty times you tried Whywould it be any different now Director of the Lean program ndashHospital B ndash T1

These findings associated to T1 are not inherently sur-prising for two reasons First clinical staff have historicallybeen resistant towards managerial innovations (McCannet al 2015) in part because they have seldom shown theability to provide meaningful improvements to care-provisionsystems The second reason has to do with the historicalcontext of healthcare organisations in Quebec where health-care workers are increasingly faced with change fatigue Inrecent years Quebecrsquos healthcare system has gone throughmultiple systemic structural changes which have exacerbatedworking conditions and done little to improve organisationalperformance (Pineault et al 2016) Interestingly as theorganisations became more familiar with Lean experienceand the internal organisational context no longer triggeredresistance from physicians These effects dwindled and even-tually disappeared in T3

As implementation progressed resistance behaviourswere generated by functional triggers related to the imple-mentation process itself When physicians believed the pro-posed change targeted the organisation of their work or ifthey saw it as highly complex instances of active and pas-sive resistance were reported in T1 and T2

Yes we did [look at the organization of work] In that instancewe asked physicians to come into work 20 minutes earlier thanwhat they were currently doing Most did not partake in thisrequest Some were quite vocal about it while others just didnrsquotdo it CHRO ndash Hospital A ndash T1

However two triggers created active resistance through-out the implementation process First physicians tended toexhibit overt opposition behaviours when under the impres-sion that the Lean initiativersquos main benefit would be costreduction This is in line with other researchersrsquo conclusionsregarding the aversion of healthcare staff regarding Lean asan efficiency-driven approach (Akmal et al 2020 RadnorHolweg and Waring 2012) One respondent was quotedas saying

We came in and for some reason [the physicians] thought thiswas about cutting costs increasing productivity It wasnrsquot reallybut it definitely came across that way Both physicians who wereinvolved in the project went back to their colleagues and pretty

PRODUCTION PLANNING amp CONTROL 5

much killed it in the egg They would not go along with itbecause they thought it was about [cost reduction] CEO ndashHospital B ndash T2

Secondly the thought of seeing the core aspects oftheir work medical practices being targeted by Leanchange created strong resistance In fact when analysingthe data it became apparent that the perception of core-technical change was the biggest initiator of activeresistance from physicians as the following statementarticulates

Thatrsquos a no go We went there a few times and it alwaysbackfired If you touch [medical practices] this is where they will

fight you tooth and nail Wersquove had success with otherprofessionals but our clinicians (physicians) well it is a differentstory Director of the Lean program ndash Hospital A ndash T3

Overall behaviours such as not attending important meet-ings related to an improvement project openly opposing thechange in discussions with colleagues and going so far as tomake data collection more difficult for consultants were trig-gered by the belief of Lean being used for reducing costs orfor changing medical practices In fine these two triggers arepossibly those who create the most friction with the domin-ant medical professional logic which in turn results in thestrongest resistance behaviours

LeadershipF-P

T2T1 T3

Work organizaonF-C

CommunicaonF-P

InvolvementF-P

Cost reduconF-B

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

Cooperaon

Acve resistance

Compliance

Passive resistance

Championing

Complexity of changeF-C

Core-technical changeF-C

CommunicaonF-P

InvolvementF-P

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

LeadershipF-P

Lean ExperienceS-I

Lean ExperienceS-I

History of changeS-O

History of supportS-O

ExperienceS-I

Work organizaonF-C

Complexity of changeF-C

Cost reduconF-B

CompensaonF-P

Implementaon Process

Beha

viou

ral R

eac

ons t

o Le

an

LegendS = Structural antecedent -gt I = Individual characteriscs O = Organizaonal contextF = Funconal antecedent -gt C = Content of the change P = Process of change B = Percived benefits

Figure 2 Triggers of behavioural reactions to Lean change over time

6 P-L FOURNIER ET AL

43 Triggers of change supporting behaviours

Positive change supporting behaviours were triggered by dif-ferent elements related to the change First perceived bene-fits related to patient satisfaction and the quality of work lifetriggered compliance and cooperation behaviours in T1though by T3 these triggers did not create any change-related behaviours Considering the core Lean tenants oflsquocreating value for the customerrsquo and of lsquorespect for peoplersquothis finding brings into question some of the basic principlesof Lean and how it positions itself in the eyes of physicians

Perceived benefits to quality improvement appeared moreconductive to positive supporting behaviours over time butin T3 cooperation behaviours were no longer enacted by itand only compliance behaviours were triggered It is import-ant to note that this research did not delve into the variousdimensions of quality in healthcare Since 30 improvementprojects were undertaken within the three hospitals qualityimprovement may have taken on different meanings andmetrics depending on the clinical or managerial circumstan-ces such as the reduction of medication errors or infectionsWe therefore focussed our attention to quality improvementin general and how respondents discussed the issue

If they can see that itrsquos about improving our quality of care itrsquoseasier to get them to somewhat engage in it (Lean change)Thatrsquos what we got in our long-term care centres They(physicians) didnrsquot really help us but they didnrsquot resist or opposeit CHRO ndash Hospital A ndash T2

Functional triggers linked to the process of change weredeemed to significantly influence positive reactions fromphysicians with the exception of compensation While payingphysicians specifically for their participation in a Lean projectdid generate compliance in T1 and T2 its effects did notreach beyond that In fact recent research by FournierChenevert and Jobin (2021) has found that compensatingphysicians for specifically taking part in Lean initiatives mightbe counterproductive Change management practices con-tributed positively to change supporting behaviours Goodcommunication triggered compliance behaviours in all threeimplementation phases while cooperation was observed inT1 and T2 Furthermore from T1 to T3 involving physiciansin the decision-making process regarding the change provedconductive to both compliance and cooperation

We donrsquot start a project without a good communication plan Welearned that from our first projects When we did that project(outpatient clinics) we made sure to communicate from start tofinish It definitely helped a lot [to get physiciansrsquo cooperation]CEO ndash Hospital A ndash T3

Itrsquos not just about keeping them informed They want to have asay and be a part of the decisions When we do that we get alot less resistance

Director of the Lean program ndash Hospital Cndash T3

The contribution of these triggers to the change-relatedbehaviours of physicians in our cases corroborates those ofAkmal et al (2020) who posit that communication while fre-quently used by managers as a tool to engage stakeholdersin change is not sufficient to offset the more potent resist-ance behaviours

Championing behaviours were not frequently observedthrough our analysis When they were however theyappeared to be linked to two specific triggers First was pre-vious experience with Lean thinking When physicians under-going Lean change had previously positively experimentedwith the approaches and techniques of Lean or if they hadhad formal training in the approach positive reactions wereobserved From T1 to T3 Lean experience triggered cooper-ation from clinicians while starting in T2 it went as far as totrigger championing behaviours The following statementfrom hospital Brsquos CMO is eloquent

We had one (physician) who did his Green Belt (Lean training) afew years ago He really acted as a catalyst to get his colleagueson board To convince them this was a good idea Heunderstood the motivations behind Lean

Chief Medical Officerndash Hospital B ndash T3

Cooperation and championing behaviours were also trig-gered by leadership Curiously this appeared much later inthe implementation process In fact while cooperation wastriggered by leadership in T2 it wasnrsquot until all three hospi-tals were further along in T3 that leadership generatedchampioning behaviours Even more so leadership appearedas a trigger able to counterbalance and even overwriteactive resistance triggered by core-technical changes and per-ceived benefits of cost reduction As one CEO points out

Really I think itrsquos all about our change agent our leader Whenour project manager acts accordingly it helps us not only getthem (physicians) on board it turns them into change agentthemselves Thatrsquos what happened in our geriatric unit Themanager was a seasoned leader and she managed to create thiscohesion this alignment CEO ndash Hospital C ndash T3

Overall our cross-case analysis allowed us to develop adetailed chain of evidence of three years of Lean implemen-tation in each hospital Through triangulation we managedto identify how each trigger appeared to generate reactionsfrom physicians over time As we will discuss most structuraltriggers disappeared from consideration within the hospitalsas some functional triggers took on a more prominent role

5 Discussion

Considering the increasing prevalence of Lean implementa-tion in healthcare organisations and systems our findingsoffer an interesting contribution to its ongoing challengesSince physicians are central actors of its implementation pro-cess their negative reactions towards it can create importantbarriers (Fournier and Jobin 2018 Leite Bateman andRadnor 2020 Akmal et al 2020) Arguably without physi-cianrsquos engagement Lean in healthcare cannot reach its fullpotential (Lorden et al 2014) It then becomes essential tounderstand what drives their reactions so that organisationscan act accordingly Our research builds upon recent worksof the operations management literature (FournierChenevert and Jobin 2021 Lindsay Kumar and Juleff 2020Akmal et al 2020) by focussing on the behavioural dimen-sion of medical resistance to Lean

PRODUCTION PLANNING amp CONTROL 7

51 The underlying resistance of physicianstowards Lean

As discussed previously Lean clashes with the dominantmedical professional logic found in healthcare organisationswhich creates an underlying resistance that is present fromthe onset of any change initiative and not easy to offsetWhile the use of Lean in healthcare is varied and touchesupon various dimensions of the care system such as ancillaryservices and procurement resistance is typically muchgreater when used in clinical settings (Lindsay Kumar andJuleff 2020 Fournier and Jobin 2018)

In our study the most negative resistance behaviourswere triggered when physicians perceived that a proposedLean change would target their medical practices As arguedby Dent (2003) resistance from physicians tends to be trig-gered by any type of change questioning their status asmedical professionals or their decision-making autonomyDuring our interviews a few respondents even mentionedthat they shied away from trying to improve processes heav-ily involving physiciansrsquo clinical practices because they couldpredict that resistance would be high However they alsoconcluded that this was futile Since Lean aims at improvingprocesses and flow it will inevitably come into contact withphysiciansrsquo clinical work

Active resistance behaviours were also triggered by per-ceptions of efficiency-driven Lean implementation This ech-oes research on NPM presented earlier and its deleteriouseffects created over the last thirty years combined with theapprehension of Lean as a manufacturing approachHowever the resistance triggered by perceptions of costreduction can also further be explained through a behav-ioural lens Physicians usually associate available resources totheir own self-efficacy (Amiot et al 2006) If they believe thatLeanrsquos main objective is to reduce such resources the per-ceived threat is even greater which triggers more resistanceThis effect may also have been exacerbated in the organisa-tions under study because most Canadian physicians areindependent fee-for-service providers (Contandriopoulos andBrousselle 2018) which might create an even bigger gapbetween physiciansrsquo perceived self-efficacy and organisa-tional interests and ultimately compound resistance behav-iours Our findings help draw a clearer picture regarding theunderlying resistance of physicians towards Lean and thetriggers that exacerbate it However the question remainswhat can organisation do about it

52 Offsetting medical resistance to Lean

The underlying resistance of physicians towards Lean changeis unlikely to go away at least for the foreseeable future Asexplained earlier the clash between the Lean and medicalprofessional institutional logics results in an inherent appre-hension towards Lean To face this issue organisations haveused traditional change management practices such as com-munication and training to try to engage stakeholders inchange efforts While these practices have been linked tohealthcare professionals supporting change (Nilsen et al

2019) our results show that in the case of physicians andLean these approaches are not sufficient This echoes thefindings of Akmal et al (2020) When triggered by threats tomedical professionalism resistance towards Lean is toostrong to be overcome by simple change management strat-egies However our results also show that it is possible tooffset active resistance by triggering championing behavioursthat support change through leadership and familiaritywith Lean

The emergence of leadership in the later phases of ourstudy was surprising not because it triggered positive changesupporting behaviours but because it did it strongly In theearly stages of implementation leadership was not a priorityfor the organisations under study But as they progressedthe organisations realised that high levels of leadership couldcreate championing behaviours In general the literature onLean advocates transformational leadership as a blueprint formanagerial behaviour (van Rossum et al 2016) Akmal et al(2020) focus on leading by example which is but one of thevarious dimensions of transformational leadership (PodsakoffMacKenzie and Bommer 1996) However in the case ofhealthcare and physicians the introduction of shared leader-ship in combination with the former could prove even moreconductive For example Bartram et al (2020) discuss co-ownership as a way of engaging physicians in workplaceinnovation As our findings show mere participation is notenough to trigger strong change supporting behaviours InT3 Lean leaders of the organisations invested efforts to cre-ate environments in which physicians shared leadership indriving improvement efforts forward by being present onunits and departments where projects were underway andbecome part of the team They also focussed on sensemak-ing and collaboration with physicians as opposed to simplycommunicating generic messages from top managementThis salience of leadership unearthed by our findings alsohighlights the importance for organisations to wisely choosetheir change agents It also brings our attention to theimplementation strategies used by healthcare organisationswhich influence the acceptance and adoption of Lean (Hunget al 2015) In our study the implementation of Leanstemmed from a governmental program In other words itused a top-down approach While physicians and staff wereconsulted in the early stages and participated in discussionsabout the implementation process the implementationteams realised how detrimental this top-down strategy hadbeen to the overall resistance of physicians Thus the emer-gence of transformational and shared leadership was alsodue to the need to catch up with resistance that emergedfrom the get-go and that could not be overcome throughtraditional change management practices

Uncertainty and unfamiliarity regarding a change is typic-ally linked with resistance (Holt et al 2007) In the case ofLean this is sometimes compounded by the jargon it usesthat is not endogenous to the medical professionFurthermore Lean relies on system thinking which can becounterintuitive with regards to medical professionals whotend to focus on the care they provide to individual patientsFor some physicians this incompatibility might result in an

8 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

of certain triggers of physiciansrsquo reactions to Lean change Inthe following section we will summarise the findings of eachcase and then focus on the results of the cross-case analysis

4 Findings

In total we identified 15 triggers of physiciansrsquo behaviouralreactions to Lean change through our within-case analysesfour structural triggers and 11 functional triggers Of those12 were common to all three cases while the other threewere common to at least two cases Structural triggersincluded individual characteristics such as work experienceand previous experience with Lean thinking and also triggersrelated to the internal organisational context such as the his-tory of change and the history of support physicians perceivedfrom their organisation Functional triggers included threesubcategories Three triggers were categorised into the con-tent of the change work organisation complexity of thechange and core-technical change These had to do withwhat physicians according to respondents believed the pro-posed Lean change was about Four triggers were categor-ised into the process of change communicationcompensation involvement and leadership Finally four trig-gers were categorised as perceived benefits cost reductionquality improvement patient satisfaction and work lifeimprovement (Table A2 of the appendix summarisesthese findings)

41 Cross-case analysis

The second stage cross-case analysis for which the resultsare presented in Figure 2 was performed in two phases(Table A3 of the appendix also presents a summary ofresults) First we focussed on triangulating the behaviouralreactions initiated by each trigger which we then classifiedaccording to our conceptual framework The chain of evi-dence created through this process allowed us to refine ourunderstanding of each triggerrsquos effect on the behaviours ofphysicians by associating them with their induced behav-ioural reactions This part of the analysis is represented bythe Y axis in Figure 2

Phase 2 of the cross-case analysis focussed on the evolu-tion of the relationship between the triggers and theirinduced behaviours over the course of the Lean implemen-tation process Again through triangulation between thethree cases we were able to assess if the relationshipbetween a trigger and the corresponding reaction changedfrom T1 to T2 and from T2 to T3 We evaluated how fre-quently these relationships were discussed by participantsby counting the occurrences and how often they repeatedfrom respondent to respondent between cases We thenconsidered compared these results between the three meas-urement phases By assessing these relationships we couldevaluate if said relationships remained constant over timeeventually disappeared or appeared later during the imple-mentation process This part of the analysis is represented bythe X axis of Figure 2

42 Triggers of resistance behaviours

During the first year of implementation (T1) active and pas-sive resistance were triggered by various perceptions andpre-existing conditions Older more experienced physicianspassively opposed Lean through such actions as questioningthe merits of the approach and retreating into paradigmaticviews of Lean as a manufacturing-based solution not applic-able to healthcare Physiciansrsquo negative perceptions of theinternal organisational context also triggered passive resist-ance in the early stages of implementation specifically withregards to the organisationsrsquo history of change and its his-tory of providing individualised support during change Thefollowing quote provides support for this assertion

In most of our projects I had physicians come up to me and saythose things didnrsquot work the last twenty times you tried Whywould it be any different now Director of the Lean program ndashHospital B ndash T1

These findings associated to T1 are not inherently sur-prising for two reasons First clinical staff have historicallybeen resistant towards managerial innovations (McCannet al 2015) in part because they have seldom shown theability to provide meaningful improvements to care-provisionsystems The second reason has to do with the historicalcontext of healthcare organisations in Quebec where health-care workers are increasingly faced with change fatigue Inrecent years Quebecrsquos healthcare system has gone throughmultiple systemic structural changes which have exacerbatedworking conditions and done little to improve organisationalperformance (Pineault et al 2016) Interestingly as theorganisations became more familiar with Lean experienceand the internal organisational context no longer triggeredresistance from physicians These effects dwindled and even-tually disappeared in T3

As implementation progressed resistance behaviourswere generated by functional triggers related to the imple-mentation process itself When physicians believed the pro-posed change targeted the organisation of their work or ifthey saw it as highly complex instances of active and pas-sive resistance were reported in T1 and T2

Yes we did [look at the organization of work] In that instancewe asked physicians to come into work 20 minutes earlier thanwhat they were currently doing Most did not partake in thisrequest Some were quite vocal about it while others just didnrsquotdo it CHRO ndash Hospital A ndash T1

However two triggers created active resistance through-out the implementation process First physicians tended toexhibit overt opposition behaviours when under the impres-sion that the Lean initiativersquos main benefit would be costreduction This is in line with other researchersrsquo conclusionsregarding the aversion of healthcare staff regarding Lean asan efficiency-driven approach (Akmal et al 2020 RadnorHolweg and Waring 2012) One respondent was quotedas saying

We came in and for some reason [the physicians] thought thiswas about cutting costs increasing productivity It wasnrsquot reallybut it definitely came across that way Both physicians who wereinvolved in the project went back to their colleagues and pretty

PRODUCTION PLANNING amp CONTROL 5

much killed it in the egg They would not go along with itbecause they thought it was about [cost reduction] CEO ndashHospital B ndash T2

Secondly the thought of seeing the core aspects oftheir work medical practices being targeted by Leanchange created strong resistance In fact when analysingthe data it became apparent that the perception of core-technical change was the biggest initiator of activeresistance from physicians as the following statementarticulates

Thatrsquos a no go We went there a few times and it alwaysbackfired If you touch [medical practices] this is where they will

fight you tooth and nail Wersquove had success with otherprofessionals but our clinicians (physicians) well it is a differentstory Director of the Lean program ndash Hospital A ndash T3

Overall behaviours such as not attending important meet-ings related to an improvement project openly opposing thechange in discussions with colleagues and going so far as tomake data collection more difficult for consultants were trig-gered by the belief of Lean being used for reducing costs orfor changing medical practices In fine these two triggers arepossibly those who create the most friction with the domin-ant medical professional logic which in turn results in thestrongest resistance behaviours

LeadershipF-P

T2T1 T3

Work organizaonF-C

CommunicaonF-P

InvolvementF-P

Cost reduconF-B

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

Cooperaon

Acve resistance

Compliance

Passive resistance

Championing

Complexity of changeF-C

Core-technical changeF-C

CommunicaonF-P

InvolvementF-P

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

LeadershipF-P

Lean ExperienceS-I

Lean ExperienceS-I

History of changeS-O

History of supportS-O

ExperienceS-I

Work organizaonF-C

Complexity of changeF-C

Cost reduconF-B

CompensaonF-P

Implementaon Process

Beha

viou

ral R

eac

ons t

o Le

an

LegendS = Structural antecedent -gt I = Individual characteriscs O = Organizaonal contextF = Funconal antecedent -gt C = Content of the change P = Process of change B = Percived benefits

Figure 2 Triggers of behavioural reactions to Lean change over time

6 P-L FOURNIER ET AL

43 Triggers of change supporting behaviours

Positive change supporting behaviours were triggered by dif-ferent elements related to the change First perceived bene-fits related to patient satisfaction and the quality of work lifetriggered compliance and cooperation behaviours in T1though by T3 these triggers did not create any change-related behaviours Considering the core Lean tenants oflsquocreating value for the customerrsquo and of lsquorespect for peoplersquothis finding brings into question some of the basic principlesof Lean and how it positions itself in the eyes of physicians

Perceived benefits to quality improvement appeared moreconductive to positive supporting behaviours over time butin T3 cooperation behaviours were no longer enacted by itand only compliance behaviours were triggered It is import-ant to note that this research did not delve into the variousdimensions of quality in healthcare Since 30 improvementprojects were undertaken within the three hospitals qualityimprovement may have taken on different meanings andmetrics depending on the clinical or managerial circumstan-ces such as the reduction of medication errors or infectionsWe therefore focussed our attention to quality improvementin general and how respondents discussed the issue

If they can see that itrsquos about improving our quality of care itrsquoseasier to get them to somewhat engage in it (Lean change)Thatrsquos what we got in our long-term care centres They(physicians) didnrsquot really help us but they didnrsquot resist or opposeit CHRO ndash Hospital A ndash T2

Functional triggers linked to the process of change weredeemed to significantly influence positive reactions fromphysicians with the exception of compensation While payingphysicians specifically for their participation in a Lean projectdid generate compliance in T1 and T2 its effects did notreach beyond that In fact recent research by FournierChenevert and Jobin (2021) has found that compensatingphysicians for specifically taking part in Lean initiatives mightbe counterproductive Change management practices con-tributed positively to change supporting behaviours Goodcommunication triggered compliance behaviours in all threeimplementation phases while cooperation was observed inT1 and T2 Furthermore from T1 to T3 involving physiciansin the decision-making process regarding the change provedconductive to both compliance and cooperation

We donrsquot start a project without a good communication plan Welearned that from our first projects When we did that project(outpatient clinics) we made sure to communicate from start tofinish It definitely helped a lot [to get physiciansrsquo cooperation]CEO ndash Hospital A ndash T3

Itrsquos not just about keeping them informed They want to have asay and be a part of the decisions When we do that we get alot less resistance

Director of the Lean program ndash Hospital Cndash T3

The contribution of these triggers to the change-relatedbehaviours of physicians in our cases corroborates those ofAkmal et al (2020) who posit that communication while fre-quently used by managers as a tool to engage stakeholdersin change is not sufficient to offset the more potent resist-ance behaviours

Championing behaviours were not frequently observedthrough our analysis When they were however theyappeared to be linked to two specific triggers First was pre-vious experience with Lean thinking When physicians under-going Lean change had previously positively experimentedwith the approaches and techniques of Lean or if they hadhad formal training in the approach positive reactions wereobserved From T1 to T3 Lean experience triggered cooper-ation from clinicians while starting in T2 it went as far as totrigger championing behaviours The following statementfrom hospital Brsquos CMO is eloquent

We had one (physician) who did his Green Belt (Lean training) afew years ago He really acted as a catalyst to get his colleagueson board To convince them this was a good idea Heunderstood the motivations behind Lean

Chief Medical Officerndash Hospital B ndash T3

Cooperation and championing behaviours were also trig-gered by leadership Curiously this appeared much later inthe implementation process In fact while cooperation wastriggered by leadership in T2 it wasnrsquot until all three hospi-tals were further along in T3 that leadership generatedchampioning behaviours Even more so leadership appearedas a trigger able to counterbalance and even overwriteactive resistance triggered by core-technical changes and per-ceived benefits of cost reduction As one CEO points out

Really I think itrsquos all about our change agent our leader Whenour project manager acts accordingly it helps us not only getthem (physicians) on board it turns them into change agentthemselves Thatrsquos what happened in our geriatric unit Themanager was a seasoned leader and she managed to create thiscohesion this alignment CEO ndash Hospital C ndash T3

Overall our cross-case analysis allowed us to develop adetailed chain of evidence of three years of Lean implemen-tation in each hospital Through triangulation we managedto identify how each trigger appeared to generate reactionsfrom physicians over time As we will discuss most structuraltriggers disappeared from consideration within the hospitalsas some functional triggers took on a more prominent role

5 Discussion

Considering the increasing prevalence of Lean implementa-tion in healthcare organisations and systems our findingsoffer an interesting contribution to its ongoing challengesSince physicians are central actors of its implementation pro-cess their negative reactions towards it can create importantbarriers (Fournier and Jobin 2018 Leite Bateman andRadnor 2020 Akmal et al 2020) Arguably without physi-cianrsquos engagement Lean in healthcare cannot reach its fullpotential (Lorden et al 2014) It then becomes essential tounderstand what drives their reactions so that organisationscan act accordingly Our research builds upon recent worksof the operations management literature (FournierChenevert and Jobin 2021 Lindsay Kumar and Juleff 2020Akmal et al 2020) by focussing on the behavioural dimen-sion of medical resistance to Lean

PRODUCTION PLANNING amp CONTROL 7

51 The underlying resistance of physicianstowards Lean

As discussed previously Lean clashes with the dominantmedical professional logic found in healthcare organisationswhich creates an underlying resistance that is present fromthe onset of any change initiative and not easy to offsetWhile the use of Lean in healthcare is varied and touchesupon various dimensions of the care system such as ancillaryservices and procurement resistance is typically muchgreater when used in clinical settings (Lindsay Kumar andJuleff 2020 Fournier and Jobin 2018)

In our study the most negative resistance behaviourswere triggered when physicians perceived that a proposedLean change would target their medical practices As arguedby Dent (2003) resistance from physicians tends to be trig-gered by any type of change questioning their status asmedical professionals or their decision-making autonomyDuring our interviews a few respondents even mentionedthat they shied away from trying to improve processes heav-ily involving physiciansrsquo clinical practices because they couldpredict that resistance would be high However they alsoconcluded that this was futile Since Lean aims at improvingprocesses and flow it will inevitably come into contact withphysiciansrsquo clinical work

Active resistance behaviours were also triggered by per-ceptions of efficiency-driven Lean implementation This ech-oes research on NPM presented earlier and its deleteriouseffects created over the last thirty years combined with theapprehension of Lean as a manufacturing approachHowever the resistance triggered by perceptions of costreduction can also further be explained through a behav-ioural lens Physicians usually associate available resources totheir own self-efficacy (Amiot et al 2006) If they believe thatLeanrsquos main objective is to reduce such resources the per-ceived threat is even greater which triggers more resistanceThis effect may also have been exacerbated in the organisa-tions under study because most Canadian physicians areindependent fee-for-service providers (Contandriopoulos andBrousselle 2018) which might create an even bigger gapbetween physiciansrsquo perceived self-efficacy and organisa-tional interests and ultimately compound resistance behav-iours Our findings help draw a clearer picture regarding theunderlying resistance of physicians towards Lean and thetriggers that exacerbate it However the question remainswhat can organisation do about it

52 Offsetting medical resistance to Lean

The underlying resistance of physicians towards Lean changeis unlikely to go away at least for the foreseeable future Asexplained earlier the clash between the Lean and medicalprofessional institutional logics results in an inherent appre-hension towards Lean To face this issue organisations haveused traditional change management practices such as com-munication and training to try to engage stakeholders inchange efforts While these practices have been linked tohealthcare professionals supporting change (Nilsen et al

2019) our results show that in the case of physicians andLean these approaches are not sufficient This echoes thefindings of Akmal et al (2020) When triggered by threats tomedical professionalism resistance towards Lean is toostrong to be overcome by simple change management strat-egies However our results also show that it is possible tooffset active resistance by triggering championing behavioursthat support change through leadership and familiaritywith Lean

The emergence of leadership in the later phases of ourstudy was surprising not because it triggered positive changesupporting behaviours but because it did it strongly In theearly stages of implementation leadership was not a priorityfor the organisations under study But as they progressedthe organisations realised that high levels of leadership couldcreate championing behaviours In general the literature onLean advocates transformational leadership as a blueprint formanagerial behaviour (van Rossum et al 2016) Akmal et al(2020) focus on leading by example which is but one of thevarious dimensions of transformational leadership (PodsakoffMacKenzie and Bommer 1996) However in the case ofhealthcare and physicians the introduction of shared leader-ship in combination with the former could prove even moreconductive For example Bartram et al (2020) discuss co-ownership as a way of engaging physicians in workplaceinnovation As our findings show mere participation is notenough to trigger strong change supporting behaviours InT3 Lean leaders of the organisations invested efforts to cre-ate environments in which physicians shared leadership indriving improvement efforts forward by being present onunits and departments where projects were underway andbecome part of the team They also focussed on sensemak-ing and collaboration with physicians as opposed to simplycommunicating generic messages from top managementThis salience of leadership unearthed by our findings alsohighlights the importance for organisations to wisely choosetheir change agents It also brings our attention to theimplementation strategies used by healthcare organisationswhich influence the acceptance and adoption of Lean (Hunget al 2015) In our study the implementation of Leanstemmed from a governmental program In other words itused a top-down approach While physicians and staff wereconsulted in the early stages and participated in discussionsabout the implementation process the implementationteams realised how detrimental this top-down strategy hadbeen to the overall resistance of physicians Thus the emer-gence of transformational and shared leadership was alsodue to the need to catch up with resistance that emergedfrom the get-go and that could not be overcome throughtraditional change management practices

Uncertainty and unfamiliarity regarding a change is typic-ally linked with resistance (Holt et al 2007) In the case ofLean this is sometimes compounded by the jargon it usesthat is not endogenous to the medical professionFurthermore Lean relies on system thinking which can becounterintuitive with regards to medical professionals whotend to focus on the care they provide to individual patientsFor some physicians this incompatibility might result in an

8 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

much killed it in the egg They would not go along with itbecause they thought it was about [cost reduction] CEO ndashHospital B ndash T2

Secondly the thought of seeing the core aspects oftheir work medical practices being targeted by Leanchange created strong resistance In fact when analysingthe data it became apparent that the perception of core-technical change was the biggest initiator of activeresistance from physicians as the following statementarticulates

Thatrsquos a no go We went there a few times and it alwaysbackfired If you touch [medical practices] this is where they will

fight you tooth and nail Wersquove had success with otherprofessionals but our clinicians (physicians) well it is a differentstory Director of the Lean program ndash Hospital A ndash T3

Overall behaviours such as not attending important meet-ings related to an improvement project openly opposing thechange in discussions with colleagues and going so far as tomake data collection more difficult for consultants were trig-gered by the belief of Lean being used for reducing costs orfor changing medical practices In fine these two triggers arepossibly those who create the most friction with the domin-ant medical professional logic which in turn results in thestrongest resistance behaviours

LeadershipF-P

T2T1 T3

Work organizaonF-C

CommunicaonF-P

InvolvementF-P

Cost reduconF-B

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

Cooperaon

Acve resistance

Compliance

Passive resistance

Championing

Complexity of changeF-C

Core-technical changeF-C

CommunicaonF-P

InvolvementF-P

Quality improvementF-B

Paent sasfaconF-B

Work life improvementF-B

LeadershipF-P

Lean ExperienceS-I

Lean ExperienceS-I

History of changeS-O

History of supportS-O

ExperienceS-I

Work organizaonF-C

Complexity of changeF-C

Cost reduconF-B

CompensaonF-P

Implementaon Process

Beha

viou

ral R

eac

ons t

o Le

an

LegendS = Structural antecedent -gt I = Individual characteriscs O = Organizaonal contextF = Funconal antecedent -gt C = Content of the change P = Process of change B = Percived benefits

Figure 2 Triggers of behavioural reactions to Lean change over time

6 P-L FOURNIER ET AL

43 Triggers of change supporting behaviours

Positive change supporting behaviours were triggered by dif-ferent elements related to the change First perceived bene-fits related to patient satisfaction and the quality of work lifetriggered compliance and cooperation behaviours in T1though by T3 these triggers did not create any change-related behaviours Considering the core Lean tenants oflsquocreating value for the customerrsquo and of lsquorespect for peoplersquothis finding brings into question some of the basic principlesof Lean and how it positions itself in the eyes of physicians

Perceived benefits to quality improvement appeared moreconductive to positive supporting behaviours over time butin T3 cooperation behaviours were no longer enacted by itand only compliance behaviours were triggered It is import-ant to note that this research did not delve into the variousdimensions of quality in healthcare Since 30 improvementprojects were undertaken within the three hospitals qualityimprovement may have taken on different meanings andmetrics depending on the clinical or managerial circumstan-ces such as the reduction of medication errors or infectionsWe therefore focussed our attention to quality improvementin general and how respondents discussed the issue

If they can see that itrsquos about improving our quality of care itrsquoseasier to get them to somewhat engage in it (Lean change)Thatrsquos what we got in our long-term care centres They(physicians) didnrsquot really help us but they didnrsquot resist or opposeit CHRO ndash Hospital A ndash T2

Functional triggers linked to the process of change weredeemed to significantly influence positive reactions fromphysicians with the exception of compensation While payingphysicians specifically for their participation in a Lean projectdid generate compliance in T1 and T2 its effects did notreach beyond that In fact recent research by FournierChenevert and Jobin (2021) has found that compensatingphysicians for specifically taking part in Lean initiatives mightbe counterproductive Change management practices con-tributed positively to change supporting behaviours Goodcommunication triggered compliance behaviours in all threeimplementation phases while cooperation was observed inT1 and T2 Furthermore from T1 to T3 involving physiciansin the decision-making process regarding the change provedconductive to both compliance and cooperation

We donrsquot start a project without a good communication plan Welearned that from our first projects When we did that project(outpatient clinics) we made sure to communicate from start tofinish It definitely helped a lot [to get physiciansrsquo cooperation]CEO ndash Hospital A ndash T3

Itrsquos not just about keeping them informed They want to have asay and be a part of the decisions When we do that we get alot less resistance

Director of the Lean program ndash Hospital Cndash T3

The contribution of these triggers to the change-relatedbehaviours of physicians in our cases corroborates those ofAkmal et al (2020) who posit that communication while fre-quently used by managers as a tool to engage stakeholdersin change is not sufficient to offset the more potent resist-ance behaviours

Championing behaviours were not frequently observedthrough our analysis When they were however theyappeared to be linked to two specific triggers First was pre-vious experience with Lean thinking When physicians under-going Lean change had previously positively experimentedwith the approaches and techniques of Lean or if they hadhad formal training in the approach positive reactions wereobserved From T1 to T3 Lean experience triggered cooper-ation from clinicians while starting in T2 it went as far as totrigger championing behaviours The following statementfrom hospital Brsquos CMO is eloquent

We had one (physician) who did his Green Belt (Lean training) afew years ago He really acted as a catalyst to get his colleagueson board To convince them this was a good idea Heunderstood the motivations behind Lean

Chief Medical Officerndash Hospital B ndash T3

Cooperation and championing behaviours were also trig-gered by leadership Curiously this appeared much later inthe implementation process In fact while cooperation wastriggered by leadership in T2 it wasnrsquot until all three hospi-tals were further along in T3 that leadership generatedchampioning behaviours Even more so leadership appearedas a trigger able to counterbalance and even overwriteactive resistance triggered by core-technical changes and per-ceived benefits of cost reduction As one CEO points out

Really I think itrsquos all about our change agent our leader Whenour project manager acts accordingly it helps us not only getthem (physicians) on board it turns them into change agentthemselves Thatrsquos what happened in our geriatric unit Themanager was a seasoned leader and she managed to create thiscohesion this alignment CEO ndash Hospital C ndash T3

Overall our cross-case analysis allowed us to develop adetailed chain of evidence of three years of Lean implemen-tation in each hospital Through triangulation we managedto identify how each trigger appeared to generate reactionsfrom physicians over time As we will discuss most structuraltriggers disappeared from consideration within the hospitalsas some functional triggers took on a more prominent role

5 Discussion

Considering the increasing prevalence of Lean implementa-tion in healthcare organisations and systems our findingsoffer an interesting contribution to its ongoing challengesSince physicians are central actors of its implementation pro-cess their negative reactions towards it can create importantbarriers (Fournier and Jobin 2018 Leite Bateman andRadnor 2020 Akmal et al 2020) Arguably without physi-cianrsquos engagement Lean in healthcare cannot reach its fullpotential (Lorden et al 2014) It then becomes essential tounderstand what drives their reactions so that organisationscan act accordingly Our research builds upon recent worksof the operations management literature (FournierChenevert and Jobin 2021 Lindsay Kumar and Juleff 2020Akmal et al 2020) by focussing on the behavioural dimen-sion of medical resistance to Lean

PRODUCTION PLANNING amp CONTROL 7

51 The underlying resistance of physicianstowards Lean

As discussed previously Lean clashes with the dominantmedical professional logic found in healthcare organisationswhich creates an underlying resistance that is present fromthe onset of any change initiative and not easy to offsetWhile the use of Lean in healthcare is varied and touchesupon various dimensions of the care system such as ancillaryservices and procurement resistance is typically muchgreater when used in clinical settings (Lindsay Kumar andJuleff 2020 Fournier and Jobin 2018)

In our study the most negative resistance behaviourswere triggered when physicians perceived that a proposedLean change would target their medical practices As arguedby Dent (2003) resistance from physicians tends to be trig-gered by any type of change questioning their status asmedical professionals or their decision-making autonomyDuring our interviews a few respondents even mentionedthat they shied away from trying to improve processes heav-ily involving physiciansrsquo clinical practices because they couldpredict that resistance would be high However they alsoconcluded that this was futile Since Lean aims at improvingprocesses and flow it will inevitably come into contact withphysiciansrsquo clinical work

Active resistance behaviours were also triggered by per-ceptions of efficiency-driven Lean implementation This ech-oes research on NPM presented earlier and its deleteriouseffects created over the last thirty years combined with theapprehension of Lean as a manufacturing approachHowever the resistance triggered by perceptions of costreduction can also further be explained through a behav-ioural lens Physicians usually associate available resources totheir own self-efficacy (Amiot et al 2006) If they believe thatLeanrsquos main objective is to reduce such resources the per-ceived threat is even greater which triggers more resistanceThis effect may also have been exacerbated in the organisa-tions under study because most Canadian physicians areindependent fee-for-service providers (Contandriopoulos andBrousselle 2018) which might create an even bigger gapbetween physiciansrsquo perceived self-efficacy and organisa-tional interests and ultimately compound resistance behav-iours Our findings help draw a clearer picture regarding theunderlying resistance of physicians towards Lean and thetriggers that exacerbate it However the question remainswhat can organisation do about it

52 Offsetting medical resistance to Lean

The underlying resistance of physicians towards Lean changeis unlikely to go away at least for the foreseeable future Asexplained earlier the clash between the Lean and medicalprofessional institutional logics results in an inherent appre-hension towards Lean To face this issue organisations haveused traditional change management practices such as com-munication and training to try to engage stakeholders inchange efforts While these practices have been linked tohealthcare professionals supporting change (Nilsen et al

2019) our results show that in the case of physicians andLean these approaches are not sufficient This echoes thefindings of Akmal et al (2020) When triggered by threats tomedical professionalism resistance towards Lean is toostrong to be overcome by simple change management strat-egies However our results also show that it is possible tooffset active resistance by triggering championing behavioursthat support change through leadership and familiaritywith Lean

The emergence of leadership in the later phases of ourstudy was surprising not because it triggered positive changesupporting behaviours but because it did it strongly In theearly stages of implementation leadership was not a priorityfor the organisations under study But as they progressedthe organisations realised that high levels of leadership couldcreate championing behaviours In general the literature onLean advocates transformational leadership as a blueprint formanagerial behaviour (van Rossum et al 2016) Akmal et al(2020) focus on leading by example which is but one of thevarious dimensions of transformational leadership (PodsakoffMacKenzie and Bommer 1996) However in the case ofhealthcare and physicians the introduction of shared leader-ship in combination with the former could prove even moreconductive For example Bartram et al (2020) discuss co-ownership as a way of engaging physicians in workplaceinnovation As our findings show mere participation is notenough to trigger strong change supporting behaviours InT3 Lean leaders of the organisations invested efforts to cre-ate environments in which physicians shared leadership indriving improvement efforts forward by being present onunits and departments where projects were underway andbecome part of the team They also focussed on sensemak-ing and collaboration with physicians as opposed to simplycommunicating generic messages from top managementThis salience of leadership unearthed by our findings alsohighlights the importance for organisations to wisely choosetheir change agents It also brings our attention to theimplementation strategies used by healthcare organisationswhich influence the acceptance and adoption of Lean (Hunget al 2015) In our study the implementation of Leanstemmed from a governmental program In other words itused a top-down approach While physicians and staff wereconsulted in the early stages and participated in discussionsabout the implementation process the implementationteams realised how detrimental this top-down strategy hadbeen to the overall resistance of physicians Thus the emer-gence of transformational and shared leadership was alsodue to the need to catch up with resistance that emergedfrom the get-go and that could not be overcome throughtraditional change management practices

Uncertainty and unfamiliarity regarding a change is typic-ally linked with resistance (Holt et al 2007) In the case ofLean this is sometimes compounded by the jargon it usesthat is not endogenous to the medical professionFurthermore Lean relies on system thinking which can becounterintuitive with regards to medical professionals whotend to focus on the care they provide to individual patientsFor some physicians this incompatibility might result in an

8 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

43 Triggers of change supporting behaviours

Positive change supporting behaviours were triggered by dif-ferent elements related to the change First perceived bene-fits related to patient satisfaction and the quality of work lifetriggered compliance and cooperation behaviours in T1though by T3 these triggers did not create any change-related behaviours Considering the core Lean tenants oflsquocreating value for the customerrsquo and of lsquorespect for peoplersquothis finding brings into question some of the basic principlesof Lean and how it positions itself in the eyes of physicians

Perceived benefits to quality improvement appeared moreconductive to positive supporting behaviours over time butin T3 cooperation behaviours were no longer enacted by itand only compliance behaviours were triggered It is import-ant to note that this research did not delve into the variousdimensions of quality in healthcare Since 30 improvementprojects were undertaken within the three hospitals qualityimprovement may have taken on different meanings andmetrics depending on the clinical or managerial circumstan-ces such as the reduction of medication errors or infectionsWe therefore focussed our attention to quality improvementin general and how respondents discussed the issue

If they can see that itrsquos about improving our quality of care itrsquoseasier to get them to somewhat engage in it (Lean change)Thatrsquos what we got in our long-term care centres They(physicians) didnrsquot really help us but they didnrsquot resist or opposeit CHRO ndash Hospital A ndash T2

Functional triggers linked to the process of change weredeemed to significantly influence positive reactions fromphysicians with the exception of compensation While payingphysicians specifically for their participation in a Lean projectdid generate compliance in T1 and T2 its effects did notreach beyond that In fact recent research by FournierChenevert and Jobin (2021) has found that compensatingphysicians for specifically taking part in Lean initiatives mightbe counterproductive Change management practices con-tributed positively to change supporting behaviours Goodcommunication triggered compliance behaviours in all threeimplementation phases while cooperation was observed inT1 and T2 Furthermore from T1 to T3 involving physiciansin the decision-making process regarding the change provedconductive to both compliance and cooperation

We donrsquot start a project without a good communication plan Welearned that from our first projects When we did that project(outpatient clinics) we made sure to communicate from start tofinish It definitely helped a lot [to get physiciansrsquo cooperation]CEO ndash Hospital A ndash T3

Itrsquos not just about keeping them informed They want to have asay and be a part of the decisions When we do that we get alot less resistance

Director of the Lean program ndash Hospital Cndash T3

The contribution of these triggers to the change-relatedbehaviours of physicians in our cases corroborates those ofAkmal et al (2020) who posit that communication while fre-quently used by managers as a tool to engage stakeholdersin change is not sufficient to offset the more potent resist-ance behaviours

Championing behaviours were not frequently observedthrough our analysis When they were however theyappeared to be linked to two specific triggers First was pre-vious experience with Lean thinking When physicians under-going Lean change had previously positively experimentedwith the approaches and techniques of Lean or if they hadhad formal training in the approach positive reactions wereobserved From T1 to T3 Lean experience triggered cooper-ation from clinicians while starting in T2 it went as far as totrigger championing behaviours The following statementfrom hospital Brsquos CMO is eloquent

We had one (physician) who did his Green Belt (Lean training) afew years ago He really acted as a catalyst to get his colleagueson board To convince them this was a good idea Heunderstood the motivations behind Lean

Chief Medical Officerndash Hospital B ndash T3

Cooperation and championing behaviours were also trig-gered by leadership Curiously this appeared much later inthe implementation process In fact while cooperation wastriggered by leadership in T2 it wasnrsquot until all three hospi-tals were further along in T3 that leadership generatedchampioning behaviours Even more so leadership appearedas a trigger able to counterbalance and even overwriteactive resistance triggered by core-technical changes and per-ceived benefits of cost reduction As one CEO points out

Really I think itrsquos all about our change agent our leader Whenour project manager acts accordingly it helps us not only getthem (physicians) on board it turns them into change agentthemselves Thatrsquos what happened in our geriatric unit Themanager was a seasoned leader and she managed to create thiscohesion this alignment CEO ndash Hospital C ndash T3

Overall our cross-case analysis allowed us to develop adetailed chain of evidence of three years of Lean implemen-tation in each hospital Through triangulation we managedto identify how each trigger appeared to generate reactionsfrom physicians over time As we will discuss most structuraltriggers disappeared from consideration within the hospitalsas some functional triggers took on a more prominent role

5 Discussion

Considering the increasing prevalence of Lean implementa-tion in healthcare organisations and systems our findingsoffer an interesting contribution to its ongoing challengesSince physicians are central actors of its implementation pro-cess their negative reactions towards it can create importantbarriers (Fournier and Jobin 2018 Leite Bateman andRadnor 2020 Akmal et al 2020) Arguably without physi-cianrsquos engagement Lean in healthcare cannot reach its fullpotential (Lorden et al 2014) It then becomes essential tounderstand what drives their reactions so that organisationscan act accordingly Our research builds upon recent worksof the operations management literature (FournierChenevert and Jobin 2021 Lindsay Kumar and Juleff 2020Akmal et al 2020) by focussing on the behavioural dimen-sion of medical resistance to Lean

PRODUCTION PLANNING amp CONTROL 7

51 The underlying resistance of physicianstowards Lean

As discussed previously Lean clashes with the dominantmedical professional logic found in healthcare organisationswhich creates an underlying resistance that is present fromthe onset of any change initiative and not easy to offsetWhile the use of Lean in healthcare is varied and touchesupon various dimensions of the care system such as ancillaryservices and procurement resistance is typically muchgreater when used in clinical settings (Lindsay Kumar andJuleff 2020 Fournier and Jobin 2018)

In our study the most negative resistance behaviourswere triggered when physicians perceived that a proposedLean change would target their medical practices As arguedby Dent (2003) resistance from physicians tends to be trig-gered by any type of change questioning their status asmedical professionals or their decision-making autonomyDuring our interviews a few respondents even mentionedthat they shied away from trying to improve processes heav-ily involving physiciansrsquo clinical practices because they couldpredict that resistance would be high However they alsoconcluded that this was futile Since Lean aims at improvingprocesses and flow it will inevitably come into contact withphysiciansrsquo clinical work

Active resistance behaviours were also triggered by per-ceptions of efficiency-driven Lean implementation This ech-oes research on NPM presented earlier and its deleteriouseffects created over the last thirty years combined with theapprehension of Lean as a manufacturing approachHowever the resistance triggered by perceptions of costreduction can also further be explained through a behav-ioural lens Physicians usually associate available resources totheir own self-efficacy (Amiot et al 2006) If they believe thatLeanrsquos main objective is to reduce such resources the per-ceived threat is even greater which triggers more resistanceThis effect may also have been exacerbated in the organisa-tions under study because most Canadian physicians areindependent fee-for-service providers (Contandriopoulos andBrousselle 2018) which might create an even bigger gapbetween physiciansrsquo perceived self-efficacy and organisa-tional interests and ultimately compound resistance behav-iours Our findings help draw a clearer picture regarding theunderlying resistance of physicians towards Lean and thetriggers that exacerbate it However the question remainswhat can organisation do about it

52 Offsetting medical resistance to Lean

The underlying resistance of physicians towards Lean changeis unlikely to go away at least for the foreseeable future Asexplained earlier the clash between the Lean and medicalprofessional institutional logics results in an inherent appre-hension towards Lean To face this issue organisations haveused traditional change management practices such as com-munication and training to try to engage stakeholders inchange efforts While these practices have been linked tohealthcare professionals supporting change (Nilsen et al

2019) our results show that in the case of physicians andLean these approaches are not sufficient This echoes thefindings of Akmal et al (2020) When triggered by threats tomedical professionalism resistance towards Lean is toostrong to be overcome by simple change management strat-egies However our results also show that it is possible tooffset active resistance by triggering championing behavioursthat support change through leadership and familiaritywith Lean

The emergence of leadership in the later phases of ourstudy was surprising not because it triggered positive changesupporting behaviours but because it did it strongly In theearly stages of implementation leadership was not a priorityfor the organisations under study But as they progressedthe organisations realised that high levels of leadership couldcreate championing behaviours In general the literature onLean advocates transformational leadership as a blueprint formanagerial behaviour (van Rossum et al 2016) Akmal et al(2020) focus on leading by example which is but one of thevarious dimensions of transformational leadership (PodsakoffMacKenzie and Bommer 1996) However in the case ofhealthcare and physicians the introduction of shared leader-ship in combination with the former could prove even moreconductive For example Bartram et al (2020) discuss co-ownership as a way of engaging physicians in workplaceinnovation As our findings show mere participation is notenough to trigger strong change supporting behaviours InT3 Lean leaders of the organisations invested efforts to cre-ate environments in which physicians shared leadership indriving improvement efforts forward by being present onunits and departments where projects were underway andbecome part of the team They also focussed on sensemak-ing and collaboration with physicians as opposed to simplycommunicating generic messages from top managementThis salience of leadership unearthed by our findings alsohighlights the importance for organisations to wisely choosetheir change agents It also brings our attention to theimplementation strategies used by healthcare organisationswhich influence the acceptance and adoption of Lean (Hunget al 2015) In our study the implementation of Leanstemmed from a governmental program In other words itused a top-down approach While physicians and staff wereconsulted in the early stages and participated in discussionsabout the implementation process the implementationteams realised how detrimental this top-down strategy hadbeen to the overall resistance of physicians Thus the emer-gence of transformational and shared leadership was alsodue to the need to catch up with resistance that emergedfrom the get-go and that could not be overcome throughtraditional change management practices

Uncertainty and unfamiliarity regarding a change is typic-ally linked with resistance (Holt et al 2007) In the case ofLean this is sometimes compounded by the jargon it usesthat is not endogenous to the medical professionFurthermore Lean relies on system thinking which can becounterintuitive with regards to medical professionals whotend to focus on the care they provide to individual patientsFor some physicians this incompatibility might result in an

8 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

51 The underlying resistance of physicianstowards Lean

As discussed previously Lean clashes with the dominantmedical professional logic found in healthcare organisationswhich creates an underlying resistance that is present fromthe onset of any change initiative and not easy to offsetWhile the use of Lean in healthcare is varied and touchesupon various dimensions of the care system such as ancillaryservices and procurement resistance is typically muchgreater when used in clinical settings (Lindsay Kumar andJuleff 2020 Fournier and Jobin 2018)

In our study the most negative resistance behaviourswere triggered when physicians perceived that a proposedLean change would target their medical practices As arguedby Dent (2003) resistance from physicians tends to be trig-gered by any type of change questioning their status asmedical professionals or their decision-making autonomyDuring our interviews a few respondents even mentionedthat they shied away from trying to improve processes heav-ily involving physiciansrsquo clinical practices because they couldpredict that resistance would be high However they alsoconcluded that this was futile Since Lean aims at improvingprocesses and flow it will inevitably come into contact withphysiciansrsquo clinical work

Active resistance behaviours were also triggered by per-ceptions of efficiency-driven Lean implementation This ech-oes research on NPM presented earlier and its deleteriouseffects created over the last thirty years combined with theapprehension of Lean as a manufacturing approachHowever the resistance triggered by perceptions of costreduction can also further be explained through a behav-ioural lens Physicians usually associate available resources totheir own self-efficacy (Amiot et al 2006) If they believe thatLeanrsquos main objective is to reduce such resources the per-ceived threat is even greater which triggers more resistanceThis effect may also have been exacerbated in the organisa-tions under study because most Canadian physicians areindependent fee-for-service providers (Contandriopoulos andBrousselle 2018) which might create an even bigger gapbetween physiciansrsquo perceived self-efficacy and organisa-tional interests and ultimately compound resistance behav-iours Our findings help draw a clearer picture regarding theunderlying resistance of physicians towards Lean and thetriggers that exacerbate it However the question remainswhat can organisation do about it

52 Offsetting medical resistance to Lean

The underlying resistance of physicians towards Lean changeis unlikely to go away at least for the foreseeable future Asexplained earlier the clash between the Lean and medicalprofessional institutional logics results in an inherent appre-hension towards Lean To face this issue organisations haveused traditional change management practices such as com-munication and training to try to engage stakeholders inchange efforts While these practices have been linked tohealthcare professionals supporting change (Nilsen et al

2019) our results show that in the case of physicians andLean these approaches are not sufficient This echoes thefindings of Akmal et al (2020) When triggered by threats tomedical professionalism resistance towards Lean is toostrong to be overcome by simple change management strat-egies However our results also show that it is possible tooffset active resistance by triggering championing behavioursthat support change through leadership and familiaritywith Lean

The emergence of leadership in the later phases of ourstudy was surprising not because it triggered positive changesupporting behaviours but because it did it strongly In theearly stages of implementation leadership was not a priorityfor the organisations under study But as they progressedthe organisations realised that high levels of leadership couldcreate championing behaviours In general the literature onLean advocates transformational leadership as a blueprint formanagerial behaviour (van Rossum et al 2016) Akmal et al(2020) focus on leading by example which is but one of thevarious dimensions of transformational leadership (PodsakoffMacKenzie and Bommer 1996) However in the case ofhealthcare and physicians the introduction of shared leader-ship in combination with the former could prove even moreconductive For example Bartram et al (2020) discuss co-ownership as a way of engaging physicians in workplaceinnovation As our findings show mere participation is notenough to trigger strong change supporting behaviours InT3 Lean leaders of the organisations invested efforts to cre-ate environments in which physicians shared leadership indriving improvement efforts forward by being present onunits and departments where projects were underway andbecome part of the team They also focussed on sensemak-ing and collaboration with physicians as opposed to simplycommunicating generic messages from top managementThis salience of leadership unearthed by our findings alsohighlights the importance for organisations to wisely choosetheir change agents It also brings our attention to theimplementation strategies used by healthcare organisationswhich influence the acceptance and adoption of Lean (Hunget al 2015) In our study the implementation of Leanstemmed from a governmental program In other words itused a top-down approach While physicians and staff wereconsulted in the early stages and participated in discussionsabout the implementation process the implementationteams realised how detrimental this top-down strategy hadbeen to the overall resistance of physicians Thus the emer-gence of transformational and shared leadership was alsodue to the need to catch up with resistance that emergedfrom the get-go and that could not be overcome throughtraditional change management practices

Uncertainty and unfamiliarity regarding a change is typic-ally linked with resistance (Holt et al 2007) In the case ofLean this is sometimes compounded by the jargon it usesthat is not endogenous to the medical professionFurthermore Lean relies on system thinking which can becounterintuitive with regards to medical professionals whotend to focus on the care they provide to individual patientsFor some physicians this incompatibility might result in an

8 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

inherent misunderstanding of Lean To this end our findingsregarding the championing behaviours triggered by experi-ence and familiarity with Lean in the second wave ofimprovement projects are interesting In some instancesphysicians already experienced in Lean thinking wereinvolved in projects at the start but elsewhere projects wereundertaken where physicians had not previously experi-mented with Lean Knowing how strong an effect it trig-gered when dealing with resistance members of theimprovement teams deployed efforts and activities that werenot simply aimed at informing physicians about Lean in gen-eral and its jargon but rather by combining lsquoon the jobrsquocoaching and training Notably daily improvement andcoaching routines were used to reduce the gap between theprofessional and Lean logics where change agents and man-agers would spend structured time every day going throughproblem solving activities with clinicians This approach fav-oured a deeper understanding of Lean which progressivelymerged process thinking with quality of care Today thispractice is known as Toyota Kata (Rother 2019) and is gain-ing popularity among Lean practitioners and organisationsIn the end it proved effective at combing leadership andexperience with Lean which we identified as triggers ofchampioning behaviours able to offset active resistancefrom physicians

6 Conclusion

This study contributes to the developing research regardingLean implementation in healthcare Recent research explor-ing medical resistance towards Lean has mostly consideredresistance as a monolithic construct (Akmal et al 2020Lindsay Kumar and Juleff 2020 Leite Bateman and Radnor2020) Our research enhances that perspective by delvinginto the behavioural dimensions of resistance which helpsoffer insight into what triggers specific change-relatedbehaviours and how organisations can offset resistance

61 Implications for research

Our analysis allowed us to triangulate data from three quali-tative case studies and identify triggers of physiciansrsquo resist-ance towards Lean The use of multiple cases in addition toa longitudinal approach and a balanced pool of respondentshalf of which were physicians enhances the validity of ourfindings (Caniato et al 2018) The analysis also allowed us touncover the effects of those triggers over time We foundthat triggers which conflicted the most with medical profes-sionalism core-technical change and perception of cost reduc-tion created the strongest resistance behaviours We alsocorroborated findings from other researchers concludingthat traditional change management strategies for examplecommunication are not sufficient to countervail active resist-ance Our findings show however that there are triggersleadership and higher familiarity with Lean that can generatechampioning behaviours and offset such resistance Thisresearch builds upon the recent works of other OM scholars(Leite Bateman and Radnor 2020 Akmal et al 2020 Lindsay

Kumar and Juleff 2020) expanding it through a behaviourallens that considers the multifaceted nature of resistance toorganisational change (Oreg Vakola and Armenakis 2011Meyer et al 2002) This approach contributes a deeperunderstanding of the mechanisms through which medicalresistance towards Lean manifests

62 Implications for practice

This research also has meaningful implications for healthcareorganisations Managers and practitioners attempting to intro-duce Lean in the healthcare setting are often confronted withhigh levels of resistance from physicians Our findings showthat organisations should not merely rely on traditional changemanagement strategies unlikely to be productive Rather theyshould leverage the leadership of both their change agentsand physicians in order to create a setting through whichleadership is shared and a common understanding createdUltimately the underlying resistance created by the clashbetween managerialism and medical professionalism nurturedover the last thirty years by the deleterious effects of NPM willremain present But organisations can counteract this by inves-ting time and efforts into the triggers of strong change-sup-porting behaviours early into the implementation processthrough sensemaking and coaching routines that will increasethe chances of progressively overcoming strong resistance

The results of this research should also make policy-makersquestion how and why they adopt and deploy Lean-relatedpolicies Unfortunately system-wide Lean transformations arestill too often promoted via top-down policy deploymentmechanisms that tend to create resistance and do little topromote shared leadership between managers and cliniciansInstead of promoting Lean as a simple driver of performanceimprovement policy-makers should consider it as a frame-work that promotes the integration of managerial and med-ical priorities that centre on patientsrsquo needs and well-being

63 Limitations and future research

This studyrsquos results should be interpreted within its limita-tions First there might be other elements that trigger physi-ciansrsquo reactions towards Lean that fall outside the scope ofthis research Contextual elements not accounted for mightalso exist that have to do with the varied settings of careprovision For example physicians in an oncology wardmight react differently to certain triggers than orthopaedicsurgeons Triggers might also induce different reactions fromspecialists than they would general practitionersFurthermore the timespan of this study might not fullyaccount for how Lean evolves over time considering Leantransformations can take place over much longer periods oftime (Radnor Holweg and Waring 2012 Shortell et al 2018)The three-year period might also limit our ability to concludeon sustained behavioural changes which might take placeover a longer period

Nonetheless this study paves the way for future researchWhile we focussed strictly on physicians healthcare is not aunidisciplinary field The interactions of Lean with other

PRODUCTION PLANNING amp CONTROL 9

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

professionals should also be studied to understand howeachrsquos reactions towards Lean can differ or convergeAdditionally while our study focussed on the behaviouraldimensions of individualsrsquo reactions to organisational changethe triggers identified in this research could be studied inrelation to the affective and cognitive dimensions of change-related reactions as these are not necessarily independentfrom one another (Oreg Vakola and Armenakis 2011)Moreover our study revealed the emergence of Katas as apractice that can favour shared leadership and an increasedadaptability of Lean to the healthcare context While thepractitioner literature on this subject is quickly developing(Rother 2019) the scientific literature is extremely thinFurther research into this phenomenon would prove insight-ful moving forward Also further generalisability could beprovided through the comparison of different jurisdictions toaccount for our studyrsquos limited scope of Canadian hospitalsas well as through quantitative inquiry

Ultimately this study helps to provide a deeper under-standing of the underlying mechanisms related to physiciansrsquoreactions to Lean change and in turn contribute meaningfulknowledge regarding the implementation of Lean in health-care while helping to guide organisations undergoing suchtransformations

Disclosure statement

No potential conflict of interest was reported by the author(s)

Notes on contributors

Pierre-Luc Fournier is an Assistant Professor of opera-tions management at the Universite de SherbrookeBusiness School He holds a PhD in operations man-agement from HEC Montreal His research focuseson operations management and behavioural issuesrelated to performance management and improve-ment in healthcare organisations

Marie-Helene Jobin is a Professor of operations man-agement and logistics and the Director of inter-national relations at HEC Montreal She holds a PhDin operations and decision systems from UniversiteLaval She researches innovation and performancemanagement in healthcare organisations She is theAssociate Director of HEC Montrealrsquos HealthcareManagement Hub

Liette Lapointe is an Associate Professor of informa-tion systems and the Vice-Dean of programs atMcGill Universityrsquos Desautels Faculty of ManagementShe holds a PhD in information systems from HECMontreal Her main research integrates informationsystems management and behavioural issues as wellas issues related to the adoption of change inhealthcare settings

Lionel Bahl is an Assistant Professor of accountingscience at the Universite de Sherbrooke BusinessSchool He holds a DBA from the Universite deSherbrooke His research focuses on sustainabledevelopment and non-financial information

ORCID

Pierre-Luc Fournier httporcidorg0000-0002-0395-2176Liette Lapointe httporcidorg0000-0001-5647-0886

References

Akmal Adeel Jeff Foote Nataliya Podgorodnichenko RichardGreatbanks and Robin Gauld 2020 ldquoUnderstanding Resistance inLean Implementation in Healthcare Environments An InstitutionalLogics Perspectiverdquo Production Planning amp Control 1ndash15doi1010800953728720201823510

Amiot Catherine E Deborah J Terry Nerina L Jimmieson and Victor JCallan 2006 ldquoA Longitudinal Investigation of Coping ProcessesDuring a Merger Implications for Job Satisfaction and OrganizationalIdentificationrdquo Journal of Management 32 (4) 552ndash574 doi1011770149206306287542

Bamford David Paul Forrester Benjamin Dehe and Rebecca GeorginaLeese 2015 ldquoPartial and Iterative Lean Implementation Two CaseStudiesrdquo International Journal of Operations amp Production Management35 (5) 702ndash727 doi101108IJOPM-07-2013-0329

Bartram Timothy Pauline Stanton Greg J Bamber Sandra G LeggatRuth Ballardie and Richard Gough 2020 ldquoEngaging Professionals inSustainable Workplace Innovation Medical Doctors and InstitutionalWorkrdquo British Journal of Management 31 (1) 42ndash55 doi1011111467-855112335

Battilana Julie and Tiziana Casciaro 2012 ldquoChange Agents Networksand Institutions A Contingency Theory of Organizational ChangerdquoAcademy of Management Journal 55 (2) 381ndash398 doi105465amj20090891

Bovaird Tony 2005 ldquoPublic Governance Balancing Stakeholder Power ina Network Societyrdquo International Review of Administrative Sciences 71(2) 217ndash228 doi1011770020852305053881

Cabana M D C S Rand N R Powe A W Wu M H Wilson P AAbboud and H R Rubin 1999 ldquoWhy Donrsquot Physicians Follow ClinicalPractice Guidelines A Framework for Improvementrdquo JAMA 282 (15)1458ndash1465 doi101001jama282151458

Callister Ronda Roberts and James A Wall Jr 2001 ldquoConflict AcrossOrganizational Boundaries Managed Care Organizations VersusHealth Care Providersrdquo Journal of Applied Psychology 86 (4) 754 doi1010370021-9010864754

Caniato Federico Des Doran Rui Sousa and Harry Boer 2018ldquoDesigning and Developing OM Researchndashfrom Concept toPublicationrdquo International Journal of Operations amp ProductionManagement 38 (9) 1836ndash1856 doi101108IJOPM-01-2017-00[101108IJOPM-01-2017-0038]

Contandriopoulos Damien and Astrid Brousselle 2018 Analyse DesImpacts de la Remuneration Des Medecins Sur Leur Pratique et laPerformance du Systeme de Sante au Quebec Quebec Canada Fondsde recherche Societe et culture Quebec

Costa Luana Bonome Message and Moacir Godinho Filho 2016 ldquoLeanHealthcare Review Classification and Analysis of LiteraturerdquoProduction Planning amp Control 27 (10) 823ndash836 doi1010800953728720161143131

Currie Graeme Andy Lockett Rachael Finn Graham Martin and JustinWaring 2012 ldquoInstitutional Work to Maintain Professional PowerRecreating the Model of Medical Professionalismrdquo OrganizationStudies 33 (7) 937ndash962 doi1011770170840612445116

10 P-L FOURNIER ET AL

De Regge Melissa Paul Gemmel and Bert Meijboom 2019 ldquoHowOperations Matters in Healthcare Standardizationrdquo InternationalJournal of Operations amp Production Management 39 (910) 1144ndash1165doi101108IJOPM-03-2019-0227

Denis Jean-Louis Yann Hebert Ann Langley Daniel Lozeau and Louise-Helene Trottier 2002 ldquoExplaining Diffusion Patterns for ComplexHealth Care Innovationsrdquo Healthcare Management Review 27 (3)60ndash73 doi10109700004010-200207000-00007

Dent Mike 2003 ldquoManaging Doctors and Saving a Hospital IronyRhetoric and Actor Networksrdquo Organization 10 (1) 107ndash127 doi1011771350508403010001379

Eisenhardt Kathleen M 1989 ldquoBuilding Theories from Case StudyResearchrdquo Academy of Management Review 14 (4) 532ndash550 doi105465amr19894308385

Fournier Pierre-Luc Denis Chenevert and Marie-Helene Jobin 2021ldquoThe Antecedents of Physiciansrsquo Behavioral Support for Lean inHealthcare The Mediating Role of Commitment to OrganizationalChangerdquo International Journal of Production Economics 232 107961doi101016jijpe2020107961

Fournier Pierre-Luc and Marie-Helene Jobin 2018 ldquoUnderstandingbefore Implementing The Context of Lean in Public HealthcareOrganizationsrdquo Public Money amp Management 38 (1) 37ndash44 doi1010800954096220181389505

Freidson Eliot 1999 ldquoTheory of Professionalism Method andSubstancerdquo International Review of Sociology 9 (1) 117ndash129 doi1010800390670119999971301

Gilgun Jane F 1995 ldquoWe Shared Something Special The MoralDiscourse of Incest Perpetratorsrdquo Journal of Marriage and the Family57 (2) 265ndash281 doi102307353682

Greco Peter J M D and John M M D Eisenberg 1993 ldquoChangingPhysiciansrsquo Practicesrdquo The New England Journal of Medicine 329 (17)1271ndash1274 doi101056NEJM199310213291714

Guest Greg Kathleen M MacQueen and Emily E Namey 2012 AppliedThematic Analysis Thousand Oaks CA SAGE

Henrique Daniel Barberato and Moacir Godinho Filho 2020 ldquoASystematic Literature Review of Empirical Research in Lean and SixSigma in Healthcarerdquo Total Quality Management amp Business Excellence31 (3ndash4) 429ndash449 doi1010801478336320181429259

Herscovitch Lynne and John P Meyer 2002 ldquoCommitment toOrganizational Change extension of a Three-Component ModelrdquoJournal of Applied Psychology 87 (3) 474 doi1010370021-9010873474

Holt Daniel T Achilles A Armenakis Hubert S Feild and Stanley GHarris 2007 ldquoReadiness for Organizational Change The SystematicDevelopment of a Scalerdquo The Journal of Applied Behavioral Science 43(2) 232ndash255 doi1011770021886306295295

Hung Dorothy Caroline Gray Meghan Martinez and Michael Harrison2015 ldquoAcceptance and Adoption of Lean Redesigns in Primary CareA Contextual Analysis of Implementation Among Frontline ProvidersrdquoPaper presented at the Implementation Science Rockville MD doi1011861748-5908-10-S1-A65

Kaplan Gary S Sarah H Patterson Joan M Ching and C CraigBlackmore 2014 ldquoWhy Lean Doesnrsquot Work for Everyonerdquo BMJ Qualityamp Safety 23 (12) 970ndash973

Kellogg Katherine C 2009 ldquoOperating Room Relational Spaces andMicroinstitutional Change in Surgeryrdquo American Journal of Sociology115 (3) 657ndash711 doi101086603535

Langley Ann 1999 ldquoStrategies for Theorizing from Process DatardquoAcademy of Management Review 24 (4) 691ndash710 doi105465amr19992553248

Leite Higor Nicola Bateman and Zoe Radnor 2020 ldquoBeyond theOstensible An Exploration of Barriers to Lean Implementation andSustainability in Healthcarerdquo Production Planning amp Control 31 (1)1ndash18 doi1010800953728720191623426

Light Donald 2000 ldquoThe Medical Profession and OrganizationalChangerdquo The Handbook of Medical Sociology 5 201ndash216 doi101186s13012-019-0902-6

Lindsay Claire F Maneesh Kumar and Linda Juleff 2020ldquoOperationalising Lean in Healthcare The Impact of Professionalismrdquo

Production Planning amp Control 31 (8) 629ndash643 doi1010800953728720191668577

Lorden Andrea L Yichen Zhang Szu-Hsuan Lin and Murray J Cote2014 ldquoMeasures of Success The Role of Human Factors in LeanImplementation in Healthcarerdquo The Quality Management Journal 21(3) 26ndash37 doi10108010686967201411918394

Mathie Antonina 1997 ldquoDoctors and Changerdquo Journal of Managementin Medicine 11 (6) 342ndash356 doi10110802689239710195233

Matthias Olga and Steve Brown 2016 ldquoImplementing OperationsStrategy Through Lean Processes Within Health Carerdquo InternationalJournal of Operations amp Production Management 36 (11) 1435ndash1457doi101108IJOPM-04-2015-0194

McCann Leo John S Hassard Edward Granter and Paula J Hyde 2015ldquoCasting the Lean Spell The Promotion Dilution and Erosion of LeanManagement in the NHSrdquo Human Relations 68 (10) 1557ndash1577 doi1011770018726714561697

McNulty Terry and Ewan Ferlie 2002 Reengineering Health Care TheComplexities of Organizational Transformation Oxford New York OUPOxford

Meyer John P David J Stanley Lynne Herscovitch and LaryssaTopolnytsky 2002 ldquoAffective Continuance and NormativeCommitment to the Organization A Meta-Analysis of AntecedentsCorrelates and Consequencesrdquo Journal of Vocational Behavior 61 (1)20ndash52 doi101006jvbe20011842

Miles Matthew B A Michael Huberman and Johnny Saldana 2014Qualitative Data Analysis Thousand Oaks CA SAGE

Moraros John Mark Lemstra and Chijioke Nwankwo 2016 ldquoLeanInterventions in Healthcare do They Actually Work A SystematicLiterature Reviewrdquo International Journal for Quality in Health Care 28(2) 150ndash165 doi101093intqhcmzv123

Nilsen Per Kristina Schildmeijer Carin Ericsson Ida Seing and SarahBirken 2019 ldquoImplementation of Change in Health Care in Sweden AQualitative Study of Professionalsrsquo Change ResponsesrdquoImplementation Science 14 (1) 51 doi101186s13012-019-0902-6

Oreg Shaul Maria Vakola and Achilles Armenakis 2011 ldquoChangeRecipientsrsquo Reactions to Organizational Change A 60-Year Review ofQuantitative Studiesrdquo The Journal of Applied Behavioral Science 47 (4)461ndash524 doi1011770021886310396550

Osborne Stephen P 2006 ldquoThe New Public Governancerdquo PublicManagement Review 8 (3) 377ndash387 doi10108014719030600853022

Patton Michael Quinn 2002 Qualitative Evaluation and ResearchMethods 3rd ed Thousand Oaks CA SAGE Publications Inc

Pineault Raynald Roxane Borges Da Silva Sylvie Provost MylaineBreton Pierre Tousignant Michel Fournier Alexandre Prudrsquohommeand Jean-Frederic Levesque 2016 ldquoImpacts of Quebec PrimaryHealthcare Reforms on Patientsrsquo Experience of Care Unmet Needsand Use of Servicesrdquo International Journal of Family Medicine 20168938420 doi10115520168938420

Po Justine Thomas G Rundall Stephen M Shortell and Janet CBlodgett 2019 ldquoLean Management and US Public HospitalPerformance Results from a National Surveyrdquo Journal of HealthcareManagement 64 (6) 363ndash379 doi101097JHM-D-18-00163

Podsakoff Philip M Scott B MacKenzie and William H Bommer 1996ldquoTransformational Leader Behaviors and Substitutes for Leadership asDeterminants of Employee Satisfaction Commitment Trust andOrganizational Citizenship Behaviorsrdquo Journal of Management 22 (2)259ndash298 doi101146annurev-psych-120710-100452

Radnor Zoe J Matthias Holweg and Justin Waring 2012 ldquoLean inHealthcare The Unfilled Promiserdquo Social Science amp Medicine 74 (3)364ndash371 doi101016jsocscimed201102011

Rogers Hugh Kate Silvester and Jill Copeland 2004 ldquoNHSModernisation Agencyrsquos Way to Improve Health Carerdquo BMJ BritishMedical Journal 328 (7437) 463 doi101136bmj3287437463

Rother Mike 2019 Toyota Kata Managing People for ImprovementAdaptiveness and Superior Results New York MGH

Shortell Stephen M Janet C Blodgett Thomas G Rundall and PeterKralovec 2018 ldquoUse of Lean and Related TransformationalPerformance Improvement Systems in Hospitals in the United StatesResults from a National Surveyrdquo The Joint Commission Journal on

PRODUCTION PLANNING amp CONTROL 11

Quality and Patient Safety 44 (10) 574ndash582 doi101016jjcjq201803002

Siggelkow Nicolaj 2007 ldquoPersuasion with Case Studiesrdquo Academy ofManagement Journal 50 (1) 20ndash24 doi105465amj200724160882

Souza Luciano Brand~ao de 2009 ldquoTrends and Approaches in LeanHealthcarerdquo Leadership in Health Services 22 (2) 121ndash139 doi10110817511870910953788

Suddaby Roy and Thierry Viale 2011 ldquoProfessionals and Field-LevelChange Institutional Work and the Professional Projectrdquo CurrentSociology 59 (4) 423ndash442 doi1011770011392111402586

Tlapa Diego Carlos A Zepeda-Lugo Guilherme L Tortorella Yolanda ABaez-Lopez Jorge Limon-Romero Alejandro Alvarado-Iniesta andManuel I Rodriguez-Borbon 2020 ldquoEffects of Lean Healthcare onPatient Flow A Systematic Reviewrdquo Value in Health 23 (2) 260ndash273doi101016jjval201911002

Toussaint John John E Billi and Mark Graban 2017 Lean for Doctors

Appleton WI CatalysisTrybou Jeroen Paul Gemmel and Lieven Annemans 2011 ldquoThe Ties

That Bind An Integrative Framework of Physician-Hospital AlignmentrdquoBMC Health Services Research 11 (1) 1ndash5 doi1011861472-6963-11-36

van Rossum L K H Aij F E Simons N van der Eng and W D TenHave 2016 ldquoLean Healthcare from a Change ManagementPerspectiverdquo Journal of Health Organization and Management 30 (3)475ndash493 doi101108jhom-06-2014-0090

Waring Justin J and Simon Bishop 2010 ldquoLean Healthcare RhetoricRitual and Resistancerdquo Social Science amp Medicine 71 (7) 1332ndash1340doi101016jsocscimed201006028

Womack James P and Daniel T Jones 2015 Lean Solutions HowCompanies and Customers Can Create Value and Wealth Together NewYork Simon and Schuster

Yin Robert K 2017 Case Study Research and Applications Design andMethods Los Angeles Sage Publications

Appendix

Table A1 Characteristics of the three studied hospitals

Hospital A Hospital B Hospital C

Type of hospital Community hospital Community hospital University-affiliated hospitalNumber of employees 3900 2500 14000Number of physicians 250 200 1700Size of serviced population 180000 220000 700000Improvement projects (sectors or

processes where projectstook place)Year 1 Medical imaging

Surgical operating rooms Food services

Emergency department Procurement Surgical operating rooms Pre-admission and pre-operation

Surgical operating rooms Child and youth care Emergency department

Year 2 Long-term care centres Test centre Wheelchair rental services Human resources (call list)

Medical imaging Home care Geriatric medicine unit

Family medicine unit Geriatrics Central surgical planning Disposal of medical waste

(sterilization)Year 3 Outpatient clinics

Archives Hospitalisation planning

Human resources (call list) Hospitalisation Test centre

Geriatric medicine unit Orthopaedics (hip and knee

replacement) Post-partum and nursery

Table A2 Within-case analysis triggers of physiciansrsquo reactions to Lean change

Category Sub-category Trigger Cases where identified

Structural Individual characteristics Experience Hospitals A B and CLean experience Hospitals A B and C

Internal organisational context History of change Hospitals A B and CHistory of support Hospitals A B and C

Functional Content of the change Work organisation Hospitals A B and CComplexity of change Hospitals A and BCore-technical change Hospitals A B and C

Process of change Communication Hospitals A B and CCompensation Hospitals A B and CInvolvement Hospitals A B and CLeadership Hospitals A B and C

Perceived benefit(s) of the change Cost reduction Hospitals A B and CQuality improvement Hospitals A B and CPatient satisfaction Hospitals A and BWork life improvement Hospitals A and C

12 P-L FOURNIER ET AL

Table A3 Behavioural reactions to Lean change

Category Sub-category Trigger Reaction of physicians Evolution from T1 to T3

Structural Individual characteristics Experience Passive resistance DecreaseLean experience Cooperation and Championing Constant

Internal organisational context History of change Passive resistance DecreasedHistory of support Passive resistance Decreased

Functional Content of the change Work organisation Active and passive resistance DecreasedComplexity of change Active and passive resistance DecreasedCore-technical change Active resistance Constant

Process of change Communication Compliance and cooperation ConstantCompensation Compliance DecreasedInvolvement Compliance and cooperation ConstantLeadership Cooperation and championing Increased (strong)

Perceived benefit(s) of the change Cost reduction Active and passive resistance ConstantQuality improvement Compliance and cooperation ConstantPatient satisfaction Compliance and cooperation DecreaseWork life improvement Compliance and cooperation Decrease

Example of a coded transcript excerpt

In this example an active resistance reaction (R1) was triggered by a perceived lack of involvement of physicians in the undergoing Lean changeThis trigger (TR10) was classified in the process subcategory of functional triggers (Table A4)

Table A4 Example of coded transcript

Structural code PHYSICIAN REACTION TO LEAN CHANGE

I So can you tell me more about the improvementproject you did in the operating room

P Yes of course I was present from start to finish soI can offer some input

I Okay great Can you tell me about physicians andhow they were involved in all of it

P Oh yes sure Letrsquos just say itrsquos something westruggled with

I Okay and why do you say thatP R1Well most of them resisted a lot They werenrsquot

happy about the change Some of them werereally vocal about it and others just prettymuch ignored us and kept doing their thing

R1Reaction ndash Active resistance

I Do you have any idea why that happenedP Well I think there are a few reasons for that You

know how doctors are TR10-R1 They donrsquot likebeing told what to do and I think they felt theKaizen was imposed on them and they felt theywerenrsquot really consulted before doing it I thinkwe shouldrsquove probably done a better job oftalking to them and getting a better feel for it

TR10-R1Trigger ndash functional ndash process ndash involvement

I Interviewer P Participant

PRODUCTION PLANNING amp CONTROL 13

• Abstract
• • Introduction
  • Literature review
  • • Physicians as organizational actors
    • Physicians and organizational change
    • Physicians and lean change
    • Conceptual framework
    • • Methods
      • • Cases
        • Data collection
        • Coding and analysis
        • • Findings
          • • Cross-case analysis
            • Triggers of resistance behaviours
            • Triggers of change supporting behaviours
            • • Discussion
              • • The underlying resistance of physicians towards Lean
                • Offsetting medical resistance to Lean
                • • Conclusion
                  • • Implications for research
                    • Implications for practice
                    • Limitations and future research
                    • • Disclosure statement
                      • Orcid
                      • References
                      • • mkchapTPPC__sec
                        • Example of a coded transcript excerpt