‘Lean Dancing’: How Involvement in Continuous Improvement and Lean Techniques Relate to Hospital Performance and Workers’ Wellbeing through Autonomy
Round 1
Reviewer 1 Report
The authors contribute to the evolving literature on employee outcomes of CI / lean by presenting additional empirical data from a cross-sectional employee survey in one hospital. For empirical reasons alone, this is relevant and I’d like to encourage them to revise this paper. For that, I have a number of suggestions.
The introduction should be sharpened, or preferably completely re-written from scratch. I suggest the editor clarifies to what extent the paper needs to be embedded in the literature on ‘Strategic HRM’. As I read it, the paper is on employee outcomes of an lean-inspired change process. That is relevant in its own right, and as far as I am concerned, references to Strategic HRM distract from this essence. A complication here is that ‘lean’ / CI are probably mostly introduced by operational managers aiming to improve work processes rather than by HRM staff with improved employee outcomes in mind. That leaves unaffected that both have employee outcomes.
It is essential to distinguish upfront between the generic concept of lean and CI as one particular manifestation of that. Preferably, the discussion goes to CI as fast as possible. This is important as ‘lean’ in general may have quite different employee outcomes than CI. An issue, and in my eyes a mistake, is that both are easily conflated in the literature which obscures our view on their employee outcomes rather than sharpens that.
However, if ‘lean’ is maintained, a much more sophisticated treatment of its origins is needed (see f.i. publications by Takahiro Fujimoto on Toyota, and Holweg, M. (2007). The genealogy of lean production. Journal of Operations Management, 25(2), 420-437.). For one thing, sociotechnical ideas played no role at all. Standardization does not stem from Scientific Management; the latter only reinforced an existing (and long) tradition. Regarding ‘human aspects’, the following paper should be used as it makes clear that ‘Respect for people’ is conflated with the actual meaning ‘Respect for craftmanship’:
Ljungblom, M., & Lennerfors, T. T. (2021). The Lean principle respect for people as respect for craftsmanship. International Journal of Lean Six Sigma. 12(6) 1209-1230.
Another issue is that it is asserted twice that lean is increasingly applied in hospitals. One would expect a reference to an empirical paper with longitudinal data. That is not the case and instead, there is a reference to Boxall, P., & Huo, M. L. Fostering the high-involvement model of human resource management: what have we learnt and what 745 challenges do we face? Asia Pacific Journal of Human Resources 2022, 60, 41-61. This paper does not even mention hospital(s) or the healthcare sector.
The key distinction between first order and second order autonomy, to use Dutch sociotechnical terms, is classic in Dutch sociotechnical design and was already highlighted by De Sitter. Internationally and in the context if the research question treated here, the paper by De Treville & Antonakis (reference 28) who use ‘choice autonomy’ and ‘reponsible autonomy’ is more appropriate than the (later) publication use here (reference 25). These international terms may allow to link your results more closely other existing literature.
The items in Appendix I should be placed in the methodology section of the main text, and their pros and cons discussed there, especially regarding their psychometric qualities. The itmes for engagement and burnout are probably derived from existing instruments, but does that also hold for other outcome variables?
The hospital’s approach to lean also needs to be discussed. What exactly was introduced using what labels, why was it introduced and by whom (operational and/or line; support of top?)?
Analytically, it may make sense to distinguish between lean technique 2 = PDCA-use, and the other ones, or perhaps better, each technique separately. The issue is that these are rather different, and that PDCA is closely linked to CI and thus the CI-measures. Furthermore, visualizing performance is a rather general technique which may be used without any connection to a lean program.
Line 200, ref. [37]: note that these authors very explicitly distinguish between lean as generic concept and CI as the concrete manifestation studied in their paper.
Discussion: make sure to distinguish sharply between the findings for your case, and ‘lean’ in general. A subsection title like ‘Lean relates to’ already suggests that this holds for lean in general, where ‘CI related to…’ is case-specific.
Line 571ff: the discussion between optimists and pessimists on ‘lean’s employee outcomes has already advanced to realizing the critical importance of how ‘lean’ is applied (what content in what context), and that differences in that are decisive for ‘positive’ or ‘negative’ outcomes. Key is specifying characteristics of the content (f.i. CI, preferably with details about the CI-program) and the contexts (f.i. a well-structured vs. a fairly chaotic work environment, as you mention using ref. 37). I think you can be more specific about your contribution by acknowledging that the black-white contrast has been surpassed by a contingency view, and spell out what you have to add to that. That bears on the discussion (line 593ff) how typical your findings are and thus can be expected to be found elsewhere.
Line 638: here you state the obvious by using the word ‘can’. Of course this is possible. You have more to say namely that in your study this possibility materialized.
Line 678-683 ad common method bias: it should be stated in particular that it is worthwhile to measure performance independently, to allow employee perceptions to be linked to ‘actual’ performance data. On the other hand (cf. line 647ff) you may want to mention that employee perceptions, rather than ‘hard data’, drive employee behavior, and that these perceptions are thus vitally important.
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Reviewer 2 Report
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Reviewer 3 Report
The study explores Lean as it relates to improvement practices with the potential to generate value in hospitals, to the extent that hospital workers' perceptions of Lean are related to their perceptions of performance and well-being.
The abstract of the work is sufficiently well structured, but perhaps at the first meeting in the text all abbreviations should be explained, including HRM.
In keywords, I suggest not to use abbreviations such as HRM and the differentiated wording of Continuous Improvement.
The introduction transposes the reader into the theme of the work and finally formulates the objective of the research.
The research model and the 6 hypotheses derived from the study of the specialized literature are presented.
The statistical research methodology is clearly described, and the results are presented in a structured manner. The limitation comes from the collection of data from a single hospital and does not provide at least a national picture of the study conducted.
In the discussion paragraph, the results of the study are interpreted in relation to other researches, but not consistently enough.
The results obtained can be related to other achievements in which Lean methods are integrated into reference frameworks for the sustainable evaluation of hospitals, such as: Moldovan F., Blaga P., Moldovan L., Bațaga T. An Innovative Framework for Sustainable Development in Healthcare: The Human Rights Assessment. Int. J. Environ. Res. Public Health 2022, 19, 2222. DOI: 10.3390/ijerph19042222.
The work does not contain drafting errors and the bibliography is comprehensive, but can be expanded with the indicated references.
I congratulate the team of authors for this study.
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Round 2
Reviewer 1 Report
My compliments for your revision.
Please find a few optional notes attached.
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