“What about us?”: A case study on the impact of the adoption and implementation of ‘Lean-Led Hospital Design’ on hospital staff.

This dissertation presents a 14-year longitudinal case study on the practical application of Lean principles in hospital settings, focusing on Lean-Led Hospital Design (LLHD). Launched in 2010, the research is grounded in the author’s dual role as program manager and embedded researcher at a Dutch general hospital. LLHD is defined as a participative approach that integrates Lean management into hospital facility planning, emphasizing collaboration between design teams and healthcare professionals to create efficient, patient-centered environments. The central research question explores what the adoption and implementation of ‘Lean-Led Hospital Design’ as described by Grunden and Hagood (2012) looks like when practically executed in a hospital, what is its impact on hospital staff in terms of employee experiences and waste reduction (efficiency) and how can this effectively and affordably be mapped out. Chapter 2 investigates the construction of a new hospital facility using LLHD. It identifies three mechanisms facilitating staff participation: (1) flexibility to adapt LLHD to local contexts; (2) guiding principles anchoring the design process amidst organizational change; and (3) co-creation, which promotes staff engagement in decision-making. These mechanisms improve collaboration and commitment, which are crucial for successful management implementation. Chapter 3 analyzes staff perceptions of LLHD via free-text questionnaire responses, categorizing them as dismissive (Lean-related or unrelated) and supportive (Lean-related). The majority of responses were dismissive and not directly linked to Lean, highlighting the importance of capturing the “undercurrent” of staff sentiment that often influences organizational change outcomes. Free-text responses provided a valuable, cost-effective way to gain nuanced insights into employee attitudes. Chapter 4 assesses mobile tracking devices as a tool to measure nurses’ time spent in patient rooms, used as a proxy for value-adding activities. Although no significant difference in value-adding time was found between old and new facilities, the method offered reliable, objective data with minimal interference. Still, the accuracy and fit of this approach in nursing practice require further validation. The chapter underscores the value of combining quantitative data with qualitative insights for meaningful interpretation. Chapter 5 reflects on the dual role of the author, leveraging Schön’s (1983) concept of the reflective practitioner. Three key insights emerged: (1) frequent leadership changes can compromise LLHD’s sustainability due to fluctuating top management support; (2) relocating to a new facility has emotional impacts for staff, such as nostalgia, which must be managed; and (3) long-term projects must address both internal and external contextual influences. These reflections stress the need for a coherent narrative linking strategic intent with practical action and lived experience. Chapter 6 synthesizes theoretical and methodological contributions. It reinforces the importance of co-creation to promote collaboration and alignment with Lean principles. The chapter also highlights guiding principles as a means of preventing inconsistent application of LLHD and maintaining conceptual fidelity. Furthermore, it addresses the disruptive effects of LLHD implementation on workflows and culture. The research critiques vague claims about Lean and LLHD, like waste elimination and value creation, arguing for clearer definitions and causal links to support outcomes. In summary, LLHD and Lean aim to improve efficiency and patient care, but their impact on hospital staff is complex. The study found mostly dismissive staff responses and inconclusive effects on waste reduction in nursing workflows. Two cost-effective evaluation methods (free-text analysis and mobile tracking) were used, each with strengths and limitations. The embedded research approach provided unique insight into the realities of implementing management concepts in healthcare and shaped the author’s evolving role as program manager. This dissertation offers both theoretical and practical contributions, emphasizing the human dynamics of management concept implementation and suggesting adaptable strategies for evaluating and sustaining such concepts in healthcare environments.