1 Pal. Jour. V.16, I.2, 2017, Copyright 2017 by Palma Journal, All Rights Reserved Available online at: Lean Management Model Designing for Public Hospitals in Kohgiluyeh and Boyer-Ahmad and Bushehr Provinces Lida Gholizadeh, Ph.D. Candidate, Department of Health Services Administration, Science and Research Branch, Islamic Azad University, Tehran, Iran Irevan Masoudi Asl, Corresponding Author, Ph.D. of Health Services Management, Associate Professor, Majlis Research Center, Tehran, Iran, Kamran Hajinabi, Assistant Professor, Department of Health Services Administration, Science and Research Branch, Islamic AzadUniversity, Tehran, Iran Pouran Raeeisi Dehkordi Associate Professor School of Management and Medical Information Services, Iran University of Medical Sciences, Tehran, I.R. Iran Abstract Background and Objective: Lean management is an issue that recently has been formed in the field of health and clinical services. A system that only what is required by the client needed quality be produced in less time. In other words, value is defined only in the eyes of the customer and what the customer not considered as values is waste that can be removed or reduced. The aim of this study was developing a lean management model for public hospitals of Kohkiluyeh-Boyer Ahmad and Bushehr provinces. Methods: This research was and applied and comparative-descriptive study. In this study, with using researchers studies the framework of basic model provided and then use the opinions of 30 experts became to the conceptual model. with using 60 questions questionnaire, the validity of the content of the method developed by the researchers and expert judgment and Cronbach's alpha and test-retest reliability of the method was discussed, the opinions of 500 primary health care practitioners were collected. then a two-stage exploratory and confirmatory factor analysis and structural equation modeling with use of statistical software SPSS21 And AMOS20 carried out to review and modify the conceptual model. Results: Exploratory factor analysis identified six factors of human, technology, management, processes, and relational that explain 58/574 percent of the total variance. Confirmatory factor analysis also showed that among identified factors, technology factor with 0/953 coefficient have greatest impact and management factor with 0/615 coefficient have lowest impact on the pattern of lean management in public hospitals to improve the quality of services. Conclusion: The lean management with the model of this research is able to identify the appropriate infrastructure, factors affecting the deployment of lean management In public hospitals and appropriate strategy for using the lean management to improve the delivery of primary health care and reduce waste. The results, represent guidelines for using effective implementation of lean management to increase efficiency and ability to compete in the global market offers. Keywords: lean management, quality improvement, public hospitals. Introduction Health care systems in different countries including the United States received enormous pressure to improve the security, performance quality, and to increase revenue. Patients and insurance companies demanded safer, more efficient and more quality health care systems (Dickson et al., 2009). In addition, government agencies were looking for solutions to reduce health care costs and increase the quality of Palma Journal
2 12 L.Gholizadeh et.al. services at the same time (Waring & Bishop, 2010). The demand for health care services increased with increase of community life, but financial conditions of health care systems deteriorated (Poksinska, 2010). In Iran also the weak management and reduction of the hospitals efficiency, skyrocketing health care costs, lack of manpower, the budget deficit, reduction of the quality of health care services and lack of satisfaction among patients and healthcare workers are the challenges that hospitals, especially public hospitals are facing. In recent years, many private hospitals and a few of public hospitals by changing management attitudes and increasing the quality of health care have increased their tariffs and received money of patients and in this way they had a substantial profitability. But most public hospitals which are managed by government budget and managers appointed by university of medical sciences, always have losses, waste of medical resources and reduction of the services quality (Sheikhi, 2013). Hence many hospitals consider lean management as a tool that can improve their conditions of service and performance. Lean management tries to improve quality within the organizational structure and it can equip health care organizations with a different methodology to achieve better results without further investment. Moreover, lean management can have some advantages such as faster response time, higher quality and more innovation, lower costs, reduction of suffering and frustration and even more satisfied employees (Satis, 2011). Lean management is based on continuous improvement of quality and aims to increase value and reduce waste, variability, and poor working conditions (Radnor et al., 2012) and entails setting standards to reduce waste (Allen, 1995). Literature showed that lean management became very popular for showing effectiveness in manufacturing companies in Japan (Womack, Jones, & Roos, 1990). This concept was first introduced by the chief executive of Toyota, Kiichiro Toyoda and Taichi Aysnoo to identify different types of waste in the Toyota production system (Black, 2008). The Toyota production system equipped persons with some means to improve their work constantly, add value to their products or services, and stimulate employees and managers to be flexible to changes (Dickson et al., 2009). In short, lean management can be defined as a group of people who are doing the work and try to improve their working conditions through regular resolution of the problem in order to improve the organization to achieve the objectives and targets. Despite growing awareness of the need for the application of lean management in the service sector, few studies have evaluated its effectiveness for promoting the quality of services. As a result, there are not a lot of books and magazines about best practices in lean management in health care system (Sarkar, 2009). Moreover, De Souza (2009) stressed that although there are several studies on the application of lean management in the hospital, there is no strong basis for these studies. They are significantly lacking analysis about the process of applying lean tools and techniques. Thus the researcher sought to design a model for the deployment of lean management in public hospitals. In this study, in order to develop an initial and conceptual model of research, the related literature and research at home and abroad were reviewed and the success key factors of lean management and its challenges, lean management techniques and tools that can be used in the field of services, especially hospitals were identified. Research Methodology This study was an applied and descriptive research. The study population included all employees of public hospitals in Kohgiluyeh and Boyer-Ahmad and Bushehr provinces. From this population 500 persons were selected using a single-stage random cluster sampling method. This means that of all the public hospitals in Kohgiluyeh and Boyer-Ahmad and Bushehr provinces 10 health centers were selected randomly and questionnaires were delivered to the staff that was willing to cooperate in the investigation. A self-made questionnaire was used to collect data which contains 60 items and 6 sub-tests (human dimension, technology dimension, management dimension, process dimension, contact dimension, and structural dimension). Replies are scored based on the five-item Likert scale as very low (0), low (1), moderate (2), high (3), and very high (4). The questionnaire was set based on the purpose of research and its theoretical framework. After compiling questions and its sub-tests, the questionnaire was given to three experts in the field of lean management to review its validity. After review, validity of the questionnaire was approved by these three experts. After confirming the validity of the questionnaire, to determine the construct validity of questionnaire exploratory factor analysis was used. For the implementation of the exploratory factor analysis, quality of correlation matrix in questions and also the content sampling of questionnaire were
3 Lean Management Model evaluated. KMO coefficient was 0.88 which implies that the information contained in the data matrix is meaningful and sample size is satisfactory. Based on the results of exploratory factor analysis using principal components analysis and varimax rotation, 6 factors with especial value and greater than 1 were extracted that explains 57.58% of the variance of total scale. Based on the percent of the equity variance, approved factors are respectively human dimension, technology dimension, management dimension, process dimension, contact dimension, and structural dimension. These findings confirmed the construct validity of the questionnaire for management model. Moreover, to check the reliability of these tools, its reliability coefficient was obtained through Cronbach alpha as follow. Reliability coefficient for human measure is (0.751), for technology measure is (0.953), for management measure is (0.615), for process measure is (0.92), for contact measure is (0.83), and for structural measure is (0.81). Moreover, the reliability of the total of these tools was 0.95 using split half method. Findings 500 participants participated in this study of which 50.2% were female and the rest were male. 49.2% were between years old. 25.2% of the participants had graduate studies and organizational position and 37.8% of them had undergraduate studies. After the factor analysis and varimax rotation 6 factors were identified. [Table 1] shows the total amount of explained variances by these six factors. Table 1: The variance explained by the six factors of lean management model Total Variance Explained s Initial Eigenvalues Extraction Sums of Squared Loadings Rotation Sums of Squared Loadings Total % of Variance Cumulative % Total % of Variance Cumulative % Total % of Variance Cumulative % The [Table 1] shows the Eigen Values and the variance associated with the factors. Eigen Values for each factor are a proportion of the variance of total variables which is explained by that factor. Based on the [Table 2] results, research items are divided into 6 factors that the first factor explains % of variance, the sixth factor explains just 6.467% of variance and in total these 6 factors explains % of variance. Table 2: Average of lean management factors after exploratory factor analysis s At least At most Average Standard Deviation Human Technology Management Process Contact Structural As can be seen in the [Table 2], the management factor had the highest response with an average of and standard deviation of and the process factor had the lowest response with an average of and standard deviation of
4 14 L.Gholizadeh et.al. Table 3: Fitting indicators of confirmatory model for lean management model to promote quality of public hospital services Chi-square P-Value RMSEA According to the findings of [Table 3], proposed model of the study in all fitting indicators such as NFI, CFI, PCFI has a relatively good fit and fitting indicators of the experimental model suggest that the obtained data match with the conceptual (proposed) model. In other words, data and empirical models are compatible with each other and data support experimental pattern. Therefore, based on the fitting indicators of total model it can be concluded that the mentioned factors are effective factors in lean management to improve the quality of public hospitals in Kohgiluyeh and Boyer-Ahmad and Bushehr provinces. In order to assess the impact of each factor on the general model of lean management in improving the quality of services in public hospitals in Kohgiluyeh and Boyer-Ahmad and Bushehr provinces, regression relationships between factors and factors relationship with the original concept of research which is lean management in improving the quality of services in public hospitals were investigated. In fact, at this stage the convergent validity of survey variables were studied and the validity of overall operating model of study was determined Table 4: parameters and impact coefficients of confirmatory factor analysis measurement model in lean management pattern in improving the quality of public hospital services s Path Parameter Standard Standard Critical Significance estimation parameter error rate level First factor (human) ---> Lean management Seventh factor (structural) ---> Lean management Sixth factor (contact) ---> Lean management Fifth factor (process) ---> Lean management Third factor (management) ---> Lean management Second factor (technology) ---> Lean management [Table 4] reviews the parameters and impact coefficients of second-order confirmatory model in lean management to improve the quality of services in public hospitals. The results indicate that the technology factor with a coefficient of has the highest impact and the management factor with a coefficient of has the lowest impact in lean management model to improve the quality of public hospital services. Discussion and Conclusion In this study, at first literature, previous research and lean management models were reviewed in order to develop a primary model of lean management to improve the quality of public hospital services. After detection of lean management model variables, to summarize variables and to determine factors of lean management in improving the quality of services, exploratory factor analysis was conducted on the collected data and according to [Table 1], it was found that 60 variables of this study can be summarized to seven main factors. This means that 7 variables are in the first factor as human factor, 10 variables are in the second factor as technology factor, 15 variables are in the third factor as management factor, 9 variables are in the fourth factor as process factor, 7 variables are in the fifth factor as contact factor and 12 variables are in the sixth factor as structural factor. After exploratory analysis to review the fitness of conceptual model with the collected data, the confirmatory factor analysis was used. As shown in [Table 3], proposed model of research has been fitted in all aspects of fitness. This means that the data and experimental model are consistent with each other and data supports the experimental model. Finally, the results of [Table 4 show that of the seven factors identified in lean management model, the technology factor with a coefficient of has the highest impact and the management factor with a coefficient of has the lowest impact PCFI CFI NFI 0.903
5 Lean Management Model in lean management model to improve the quality of public hospital services. Therefore, it can be said that findings of this study are in line with Sheikhi (2013), Bani Asadi, Vatan Khah & Hosseini (2013), DiGioia, Greenhouse, Chermak & Hayden (2015), Andreamatteo, Lanni, Lega & Sargiacomo (2015), Farjam et al., (2010) and Globenko & Sianova (2012). All these researchers found that lean management improves service quality and in their review, they more study human and contact dimensions of lean management. About the impact of technology factor in lean management model, we can refer to Ker, Wang, Hajli, sang & Ker (2014) study. The result of their research highlighted the impact of lean technology factor in improvement of hospitals service quality and waste reduction and by selection of digital scanning technology showed a significant reduction in time processes. About the impact of management factor on the improvement of the quality of public hospital services, Abdullah, Uli & Tari (2008), Atkinson (2004) and Cotte, Farber, Merchant, Paranikas & Sirkin (2008) emphasized the importance of management factor and its impact on improving the quality. These researchers concluded that increase of relationship among employees, and the relationship between employees and management will be the benefits of lean implementation. Clear and effective relationship as one of the success factors in the application of lean management in service sector is helpful for providing staff feedback for the manager to improve the quality. Finally, the findings showed that there is a positive and significant relationship between lean process and structural factors with improvement of quality and two factors of process and structure have a direct impact on improvement of quality. In this regard, Cotte et al., (2008) also emphasized the changes in the processes and structures for easier understanding of them which will motivate employees and improve the quality. Westwood et al., (2007) emphasized the creation of smaller changes in improvement process which reduce waste and increase employee and patients satisfaction. But it should be noted that the main challenge of lean management is lack of standard processes in the service sector. Sarkar (2009) stated that identifying the processes in the service sector is very hard because they are not as obvious as processes in the manufacturing sector. Moreover, because of size and complexity, it is difficult for organizations to deal with processes to minimize waste. Therefore, processes must be registered consistently in order to keep track of performance. According to what was said above, lean management is a very important concept because it requires broad understanding, high commitment and depth analysis of the problem. In the long term many organizations used lean to improve quality, reduce costs, and provide faster service. To be successful in the application of lean management in public hospitals existence of a committed manager to support the organization and participation and commitment of all staff is necessary. Lean management focuses on identifying the root of the problems to prevent their recurrence. Its successful is the result of participation of all levels of managers and staff, organizational structures and procedures and the use of new technologies. Understanding these factors before implementing lean will help to realize its benefits and also to create a lean culture. Acknowledgments This manuscript has been extracted from research project Lean Management Model Designing for Public Hospitals in Kohgiluyeh and Boyer-Ahmad and Bushehr Provinces approved by the Department of Health Services Administration, Science and Research Branch, Islamic Azad University, Tehran, Iran. The authors would like to thank the deputy, and all of the participants and personnel of the Public Hospitals in Kohgiluyeh and Boyer-Ahmad and Bushehr Provinces. Footnotes Authors Contribution:All of the authors approved the content of the manuscript, contributed significantly to the research and were involved the writing of the manuscript.. Irevan Masoudi Asl. kamran Hajinabi. Pouran Raeeisi Dehkordi were responsible for the study conception and design, data collection and analysis, preparing the draft of manuscript and making critical revisions. revisions to the paper for important intellectual content and English editing. Funding/Support:The funding was provided by the Department of Health Services Administration, Science and Research Branch, Islamic Azad University, Tehran, Iran.
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