Given the large volume of data arising from these interviews, this paper focuses specifically on: a) how Lean changes leadership practices and; b) when leadership practices do change, how do those changed practices contribute to later outcomes?
As a model of an interested party's preference ranking of the motor vehicles, the subsequent uncertainty (sensitivity) analysis considered here, relates to what minimal (lean) changes would be necessary to a vehicle's emissions so that their preference ranking is improved.
Lean changes the priorities of leaders by emphasizing the importance of this type of engagement.
A set of seven initial hypotheses regarding the manner in which Lean changes leadership practices were developed from our data.
Prior to the lean changes, patients were triaged upon arrival by a nurse (or by a physician if arriving by ambulance).
Therefore, regarding this ward, there is a risk that those who were happier with the Lean changes constituted a larger share of potential respondents at T2.
The P-chart in Figure 1 shows that a systematic increase in the percentage of patients who leave the A&E within four hours coincides with the implementation of the lean changes described below (see case description).
The 'Quantitative demands' and 'Cognitive demands' scales under the domain 'Demands at work', which were among the scales most relevant to Lean, changed as expected in all three units.
Thus, although the design of this study does not allow causal inferences, the study does suggest that Lean interventions may be related to changes in the psychosocial work environment; positively when Lean is fully implemented and negatively when Lean changes deteriorate.
Since this study included one unit that successfully implemented Lean during the study period (Ward-I), one where previously implemented Lean changes deteriorated (the ED) and one which partially implemented Lean during the study period (Ward-II), we performed a comparison between the patterns for the three units (Additional file 1).
