An Investigation into Lean Thinking Application in Medical

An Investigation into Lean Thinking Application

in Medical Design and Construction Industry in

Gaza Strip and Its Effect on Healthcare

Organizations Performance

البحث في تطبيق فلسفة التفكير الموجه في صناعة التصميم و تشييد

المنشآت الطبية في قطاع غزة وتأثير هذا التطبيق على أداء المؤسسات الصحية

By

Samah Hani Attallah

Supervised by

Dr. Khalid AbdelRaouf Al-Hallaq

Assistant Professor of Civil Engineering/ Construction Management

A thesis submitted in partial fulfillment

of the requirements for the degree of

Master of construction Project Management

February/2018

زةــغب ةــلاميــــــة الإســـــــــامعـالج

عمادة البحث العلمي والدراسات العليا

ة الهندســـــــــــــــــــةــــــــــــليـــــك

ماجستير ادارة مشروعات هندسيــة

The Islamic University of Gaza

Deanship of Research and Graduate Studies

Faculty of Engineering

Master of construction Project Management

I

Declaration

تحمل العنوان:أنا الموقع أدناه مقدم الرسالة التي

An Investigation into Lean Thinking Application in

Medical Design and Construction Industry in Gaza

Strip and Its Effect On Healthcare Organizations

Performance

البحث في تطبيق فلسفة التفكير الموجه في صناعة التصميم و تشييد

قطاع غزة وتأثير هذا التطبيق على أداء المؤسسات المنشآت الطبية في

الصحية

أقر بأن ما اشتملت عليه هذه الرسالة إنما هو نتاج جهدي الخاص، باستثناء ما تمت الإشارة إليه حيثما ورد،

لنيل درجة أو لقب علمي أو بحثي لدى أي الاخرين وأن هذه الرسالة ككل أو أي جزء منها لم يقدم من قبل

عليمية أو بحثية أخرى.مؤسسة ت

I understand the nature of plagiarism, and I am aware of the University’s policy on

this.

The work provided in this thesis, unless otherwise referenced, is the researcher's own

work, and has not been submitted by others elsewhere for any other degree or

qualification.

:Student's name سماح هاني عطالله اسم الطالب:

:Signature التوقيع:

01/20/2018 التاريخ: Date:

II

نتيجة الحكم

III

Abstract

Purpose: The aim of this research was to contribute in developing healthcare

operation through lean thinking in the Medical Design Contraction (MDC) industry in

Gaza strip. This aim has been obtained by achieving six primary objectives which are

assessing the readiness factors level for lean implementation by professionals in MDC

industry in Gaza strip, identifying the lean benefits that would convince professionals

for adopting lean thinking in MDC industry in Gaza strip, identifying and rank Critical

Success Factors (CSF’s) among healthcare organizations, investigating and ranking

the top Lean thinking challenges and barriers which face the adoption of Lean thinking

in MDC industry in Gaza strip, exploring the impact of Lean thinking implementation

on healthcare performance in order to make recommendations for adopting Lean

thinking in MDC industry in Gaza strip, and studying some hypotheses that might help

to find solutions to adopting Lean thinking in the medical sector in Gaza strip.

Design/methodology/approach: A quantitative survey was used in the research.

Three main steps were used to reach to the final amendment of the questionnaire: (1)

Face validity by presenting the questionnaire to 12 experts in the MDC industry as

well as experts in statistics, (2 ) pre-testing the questionnaire was conducted and tested

with 6 people, and (3) a pilot study was conducted by distributing 8 copies of the

questionnaire to respondents from the target group and analyzing them for testing

statistical validity and reliability were three main steps that were used to reach to the

final amendment of the questionnaire. 85 Copies of the questionnaire were distributed,

and 80 copies of the questionnaire were received from the respondents with a response

rate = 94.1%. To draw meaningful results, the collected data have been analyzed by

using the quantitative data analysis techniques (which include the Relative important

index, Pearson correlation analysis, and others) through the Statistical Package for

Social Science (SPSS) IBM version 24.

Findings: Pearson correlation analysis was used in the study which showed that

there were significant correlation between Healthcare Organizations performance and

each of the readiness factors level for lean implementation, Lean benefits, Lean CSF’s,

Lean challenges and barriers. There was a significant relationship between the Lean

benefits and Lean challenges and barriers; the Lean critical success factors and Lean

IV

challenges and barriers; the readiness level for lean implementation and the value of

Lean benefits; and between the readiness level for lean implementation and the Lean

critical success factors the Lean benefits and the Lean critical success factors. But there

was no significant relationship between the readiness level for lean implementation

and Lean challenges and barriers. Finally, recommendations were made for Healthcare

organizations and individuals respectively in order to develop healthcare operation

through lean thinking in the MDC industry Gaza strip. This aims to adopt lean thinking

and its effect on optimizing the performance in Healthcare organizations.

Keywords: Medical design and Construction (MDC) industry, Lean thinking,

Healthcare Organizations performance, Lean readiness level, Lean benefits, Lean

challenges, CSFs of Lean, Gaza strip.

V

الملخص

من هذه الرسالة في المساهمة في تطوير عمليات الرعاية الصحية من خلال تطبيق يتلخص الغرض :الغرض

طبيق على أداء الموجه في صناعة التصميم و تشييد المنشآت الطبية في قطاع غزة وتأثير هذا الت فلسفة التفكير

تقييم مستوى (1في قطاع غزة ولتحقيق هذا الغرض وضع الباحث ست أهداف وهي كالتالي: )المنظمات الصحية

شييد المنشآت الطبية في قطاع صناعة التصميم و تفي من قبل المهنيين التفكير الموجهلتنفيذ الجاهزيةعوامل

ها من شأنها إقناع المهنيين لاعتمادالتي ذات القيمة العائدة من تطبيق التفكير الموجه و تحديد الفوائد( 2)، غزة

عوامل نجاح التفكير الموجهتحديد وترتيب (3) ،طبية في قطاع غزةشييد المنشآت الفي صناعة التصميم و ت

في الموجهتواجه اعتماد التفكير تحديد وتصنيف التحديات والمعيقات التي (4)الرعاية الصحية، منظماتبين

نظمات معلى أداء الموجهتأثير تنفيذ التفكير ( دراسة5)، شييد المنشآت الطبية في قطاع غزةصناعة التصميم و ت

شييد المنشآت الطبية في صناعة التصميم و ت الموجهالرعاية الصحية من أجل تقديم توصيات لاعتماد التفكير

الموجهدراسة بعض الفرضيات التي قد يساعد على إيجاد حلول لاعتماد التفكير أخيراً و( 6)، في قطاع غزة

.في القطاع الطبي في قطاع غزة

3حيث تم استخدام : تم تطبيق الأساليب الكمية في تحليل البيانات وذلك باستخدام الاستبانة منهجية البحث

( اختبار الصلاحية من خلال تقديم 1للوصول إلى النسخة النهائية من الاستبانة وهي كالتالي: ) خطوات رئيسية

ن خبراء في مجال التحليل فضلًا عشييد المنشآت الطبية صناعة التصميم و تخبير في 12الاستبانة إلى

( الدراسة التجريبية عن 3أشخاص ممن يمثلون الفئة المستهدفة. ) 6( اختبار الاستبانة من قبل 2الاحصائي. )

نسخ من الاستبانة للفئة المستهدفة لاجراء كلًا من اختبار الصلاحية والثبات وبعد ذلك تم 8طريق توزيع وتحليل

( نسخة منها لتكون نسبة 80( نسخة منها على الفئة المستهدفة وجمع )85) اعتماد الاستبانة ومن ثم توزيع

لاستنباط النتائج 24اصدار SPSS% وأخيراً تم تحليل هذه البيانات كمياً باستخدام برنامج 94.1الاستجابة =

ودراستها بعد ذلك.

بين أداء وثيق د ارتباطستخدام تحليل ارتباط بيرسون وجو أظهرت نتائج التحليل الاحصائي با النتائج:

ذات القيمة العائدة من الفوائد، فلسفة التفكير الموجهلتنفيذ عوامل الجاهزية مستوى والرعاية الصحية منظمات

VI

. الموجهتواجه اعتماد التفكير و التحديات والمعيقات التي ، عوامل نجاح التفكير الموجه، تطبيق التفكير الموجه

التحديات والمعيقات التي و الفوائد ذات القيمة العائدة من تطبيق التفكير الموجهبين عكسيةوكانت هناك علاقة

التحديات والمعيقات التي تواجه اعتماد و عوامل نجاح التفكير الموجه وكذلك بين ؛ تواجه اعتماد التفكير الموجه

و التفكير الموجهلتنفيذ الجاهزيةمل مستوى عواقة طردية بين كما وأظهرت النتائج أن هناك علا الموجه؛التفكير

و التفكير الموجهلتنفيذ الجاهزيةمستوى عوامل ؛ وبين ذات القيمة العائدة من تطبيق التفكير الموجه الفوائد

الفوائد العجاف وعوامل النجاح الحرجة العجاف. ولكن لم تكن هناك علاقة كبيرة بين عوامل نجاح التفكير الموجه

الدراسة . وأخيرا قدمتالتحديات والمعيقات التي تواجه اعتماد التفكير الموجه التفكير الموجهلتنفيذ الجاهزيةعوامل

تطبيق خلال الرعاية الصحية والأفراد على التوالي من أجل تطوير عملية الرعاية الصحية من منظماتتوصيات ل

تحسين وهذا التطبيق يهدف إلى في قطاع غزةالطبية وتشييد المنشآتالموجه في صناعة التصميم فلسفة التفكير

.الرعاية الصحية منظماتالأداء في

الموجه، أداء منظمات الرعاية الطبية، التفكيرشييد المنشآت صناعة التصميم و تالكلمات المفتاحية:

الموجه، عوامل نجاح الصحية، مستوى الجاهزية لتطبيق التفكير الموجه، فوائد التفكير الموجه، تحديات التفكير

التفكير الموجه، قطاع غزة.

VII

Dedication

There are a number of people without whom this thesis might not have been

written, and to whom I am greatly indebted.

Firstly, this research is lovingly dedicated to my beloved Father Engineer/ Hani

Rajab Attallah and my beloved Mother Mrs. Somaya Mohammed Attallah, who

continues to learn, grow and develop and who have been a source of encouragement

and inspiration to me throughout my life, a very special thank you for providing a

writing space and for nurturing me through the months of writing. And also for the

myriad of ways in which, throughout my life, you have actively supported me in my

determination to find and realize my potential, and to make this contribution to our

world.

To my dear husband, Mr. Abdullah Faisal Mizaini who has been a constant source

of support and encouragement during the challenges of graduate and life. A very

special thank you for your practical and emotional support as I added the roles of wife,

to the competing demands of business, work, study and personal development. I am

truly thankful for having you in my life.

And without a doubt, I dedicate this thesis to my beloved sisters Ghadeer and

Ghada, and brothers Abdullah, AbdulRahman and Abdulkareem, also to me best real

friend Aya Hassan Al Khuraibi, as well the entire special people who have supported

me throughout the process of carrying out this work. Their love and encouragement

have had a significant impact on giving me the power to complete this work.

Samah Hani Attallah

VIII

Acknowledgment

Firstly, I am grateful to ALLAH the Almighty for all blessings in this life and for

giving me power and ability that were necessary to achieve this study. All thanks and

praise are due to ALLAH.

Secondly, I would like to express my deepest gratitude to my supervisor, Dr.

Khalid AbdelRaouf Al-Hallaq, Assistant Professor of Civil Engineering/ Construction

Management at The Islamic University of Gaza for his generous advice, kind

assistance and patiently guidance. Special thanks for Dr. Nadeen Abu Shaban, I am

extremely thankful and indebted to her for sharing expertise, and valuable guidance as

well as for encouraging me.

Then, I want to appreciate all the construction professionals’ respondents from the

healthcare organizations, who generously spent their precious time to participate in the

questionnaire survey of this study. In addition, I would like to thank all my friends and

colleagues at Public Aid Society. I also want to thank my entire friends who directly

or indirectly assisted me in this research study.

Last but not least, sincere gratitude and appreciation is forwarded to my family for

care, moral support and understanding during my research work.

Samah Hani Attallah

IX

Table of Contents

Declaration ............................................................................................................ I

Abstract ............................................................................................................... II

V ..................................................................................................................... الملخص

Dedication .......................................................................................................... VII

Acknowledgment ............................................................................................. VIII

Table of Contents ............................................................................................... IX

List of Tables ................................................................................................... XIV

List of Figures ................................................................................................ XVII

List of Abbreviations ................................................................................... XVIII

Introduction ........................................................................................ 2

1.1 Background of the Study .............................................................................. 2

1.2 Problem Statement ........................................................................................ 4

1.3 Scope of study ............................................................................................... 6

1.4 Significance of the research .......................................................................... 6

1.5 Research aim and objectives ......................................................................... 7

1.6 Research Question ........................................................................................ 7

1.7 Research hypotheses ..................................................................................... 8

1.8 Delimitations of the study ........................................................................... 10

1.9 Research design .......................................................................................... 11

1.10 Structure of the thesis ............................................................................... 12

Literature Review ............................................................................. 15

2.1 Background of Lean ................................................................................... 15

2.1.1 Lean History ....................................................................................... 15

2.1.2 The Five Lean Principles .................................................................... 17

2.1.3 Specify Value from the Standpoint of the End Customer: ................. 17

2.1.4 Identify the Entire Value Stream for Each Service Family ................ 17

2.1.5 Make the Product or Service Flows .................................................... 18

X

2.1.6 Respond to the Customer Pull ............................................................ 18

2.1.7 Improve Continuously in Pursuit of Perfection .................................. 18

2.2 Lean in Service Sector ................................................................................ 19

2.2.1 The Seven Types of Wastes in Service Sector.................................... 19

2.3 Lean Implementation .................................................................................. 23

2.3.1 Critical Success Factors of Lean Implementation .............................. 24

2.3.2 Challenges of Lean Implementation ................................................... 28

2.3.3 Lean Tools and Techniques ................................................................ 32

2.3.4 Benefits of Lean Implementation ....................................................... 39

2.3.5 Lean Criticisms ................................................................................... 42

2.4 Traditional versus ‘Lean-Led’ Operational Process Improvement based

Hospital Design ...................................................................................................... 43

2.4.1 Traditional Design .............................................................................. 43

2.4.2 Lean Led Design ................................................................................. 47

2.5 Healthcare Performance in Medical and Design Construction Industry .... 57

2.5.1 Financial and quality performance...................................................... 57

2.5.2 Patient Satisfaction.............................................................................. 60

2.5.3 Employee Performance ....................................................................... 62

Research Methodology ..................................................................... 67

3.1 Research strategy ........................................................................................ 67

3.2 Research period .......................................................................................... 67

3.3 Framework of the research methodology ................................................... 67

3.3.1 Stage one – development of theme ..................................................... 67

3.3.2 Stage two – literature review .............................................................. 68

3.3.3 Stage three – pilot study ...................................................................... 68

3.3.4 Stage four – the main survey .............................................................. 68

3.3.5 Stage five – statistical analysis and results ......................................... 68

3.3.6 Stage six – conclusion and recommendations .................................... 68

3.4 Research location ........................................................................................ 69

3.5 Research Population ................................................................................... 69

3.6 Sample size and characteristics .................................................................. 69

XI

3.7 Questionnaire design .................................................................................. 70

3.7.1 Part one: which is related to the respondent ‘s demographic data and

the way of work performance. ........................................................................... 71

3.7.2 Part two: to assess the readiness factors for lean implementation in

service oriented architecture by the engineers in the healthcare organizations in

Gaza Strip. ......................................................................................................... 71

3.7.3 Part three: to investigate the value of Lean benefits in the healthcare

organizations in Gaza Strip. ............................................................................... 71

3.7.4 Part four: to investigate the critical success factors in the healthcare

organizations in Gaza Strip. ............................................................................... 71

3.7.5 Part five: to investigate the Lean challenges and barriers in the

healthcare organizations in Gaza Strip. ............................................................. 71

3.7.6 Part six: to investigate the healthcare organization’s performance in

lean implementation in service oriented architecture ........................................ 71

3.8 Pilot study ................................................................................................... 71

3.9 Data analysis method .................................................................................. 85

3.10 Quantitative data analysis using SPSS ..................................................... 85

3.11 Data measurement .................................................................................... 86

3.12 The relative importance index .................................................................. 86

3.13 Non-parametric test .................................................................................. 87

3.13.1 Sign test ............................................................................................. 87

3.13.2 Mann-Whitney test ........................................................................... 87

3.13.3 Kruskal-Wallis test ........................................................................... 87

3.14 Validity of questionnaire .......................................................................... 88

3.15 Criterion related validity ........................................................................... 88

3.16 Structure validity of the questionnaire ...................................................... 88

3.17 Reliability analysis .................................................................................... 89

3.18 Summary ................................................................................................... 91

Results and Discussion ................................................................... 103

4.1 Respondents' profile ................................................................................. 103

XII

4.2 Readiness factors integral for lean implementation in service oriented

architecture. .......................................................................................................... 104

4.3 The benefits of Lean thinking ................................................................... 107

4.4 RII of Lean benefits .................................................................................. 107

4.5 Critical success factors for lean implementation ...................................... 112

4.5.1 RII of Lean CSFs .............................................................................. 112

4.6 Lean challenges and barriers .................................................................... 115

4.6.1 RII of Lean challenges and barriers .................................................. 116

4.7 Healthcare organization’s performance .................................................... 119

4.7.1 RII of Healthcare organization’s performance ................................. 120

4.8 Test of research hypotheses ...................................................................... 127

4.8.1 The correlation between the readiness level for lean implementation

and healthcare organization’s performance ..................................................... 127

4.8.2 The correlation between the benefits of lean implementation and

healthcare organization’s performance. ........................................................... 129

4.8.3 The correlation between the critical success factors and healthcare

organization’s performance. ............................................................................ 130

4.8.4 The correlation between the challenges and barriers of lean

implementation and healthcare organization’s performance. .......................... 131


and Lean challenges and barriers. .................................................................... 132

4.8.6 The correlation between Lean benefits and Lean challenges and

barriers. ............................................................................................................ 133

4.8.7 The correlation between the Lean critical success factors and Lean

challenges and barriers. .................................................................................... 134


and the Lean benefits. ...................................................................................... 135


and the Lean critical success factors. ............................................................... 136

4.8.10 The correlation between the Lean benefits and the Lean critical

success factors. ................................................................................................. 137

XIII

4.8.11 Hypothesis related to respondents’ profiles (respondent’s analysis)

......................................................................................................................... 138

Conclusion and recommendations ................................................ 147

5.1 Summary of the research .......................................................................... 147

5.2 Conclusions of the research objectives, questions, and hypotheses ......... 147

5.2.1 Outcomes related to objective one .................................................... 147

5.2.2 Outcomes related to objective Two .................................................. 148

5.2.3 Outcomes related to objective Three ................................................ 149

5.2.4 Outcomes related to objective four ................................................... 150

5.2.5 Outcomes related to objective five ................................................... 150

5.2.6 Outcomes related to objective six ..................................................... 151

5.3 Recommendations: ................................................................................... 153

5.3.1 Be Lean not LAME ........................................................................... 154

5.3.2 Develop a sense of necessity ............................................................ 155

5.3.3 Develop Lean thinking process ........................................................ 155

5.3.4 Standardize space .............................................................................. 155

5.3.5 Increase employees’ motivation ....................................................... 155

5.3.6 Increase patient's loyalty ................................................................... 155

5.4 Limitations and future research ................................................................ 156

The Reference List ............................................................................................ 159

Appendix A: Questionnaire ............................................................................. 181

Appendix B: Patient Flowchart at ED in Al-Shifaa Medical Complex ....... 202

Appendix C: Correlation coefficient ............................................................... 203

Appendix D: Glossary ...................................................................................... 211

XIV

List of Tables

Table ( 2.1):Types of Waste in Healthcare (Source : Virtue and Chaussalet, 2013) 20

Table (2.2) : The summery for CSFs of lean practice implementation ..................... 25

Table (2.3):Application and usefulness of process mapping in Hospital (Source :

Staccini et al. (2005)) ................................................................................................. 30

Table 2.4) : Application and usefulness of process mapping in Hospital (Source :

Staccini et al. (2005)) ................................................................................................. 36

Table (2.5) : Benefits of Lean practice in Healthcare industry ................................. 41

Table (2.6) : Traditional versus Lean-Led Architectural Design Philosophies (Source

: Verderbers and Fine (2012)) ................................................................................... 52

Table (2.7) : Summary of Lean Led Design Factors ................................................. 53

Table (2.8) : Summary of factors that affected financial and quality performance .. 60

Table (2.9) : Summary of factors that affected patient satisfaction .......................... 62

Table (2.10) : Summary of factors that affect employee Performance ..................... 65

Table (3.1): List of selected factors and questions for final questionnaire ............... 73

Table (3.2): Correlation coefficient of each field and the whole of questionnaire (

Source : Researcher) .................................................................................................. 89

Table (3.3) : Cronbach’s Alpha for each filed of the questionnaire and the entire

questionnaire ( Source : Researcher). ........................................................................ 90

Table (3.4) : The summary of the methodology( Source : Researcher) .................... 92

Table (4.1) : The respondent’s profile ( Source : Researcher) ................................ 104

Table (4.2) : Means and Test values for the readiness level of Lean implementation by

the professionals in the MDC industry ( Source : Researcher). ............................... 105

Table (4.3) : Means and Test values for Lean benefits( Source : Researcher) ....... 108

Table (4.4) : Means and Test values for Critical success factors for lean

implementation in service oriented architecture in MDC industry ( Source :

Researcher). ............................................................................................................. 113

Table (4.5) :Means and Test values for Lean challenges and barriers ( Source :

Researcher) .............................................................................................................. 116

Table (4.6): Means and Test values for factors affecting healthcare organization’s

performance in lean implementation in service oriented architecture in MDC industry

( Source : Researcher). ............................................................................................. 123

XV

Table (4.8):Correlation coefficient between the readiness level for lean

implementation by engineers and healthcare organization’s performance in the MDC

industry in Gaza Strip ( Source : Researcher). ......................................................... 128

Table (4.9):Correlation coefficient between the benefits of lean implementation and

healthcare organization’s performance in the MDC industry in Gaza Strip ( Source :

Researcher). ............................................................................................................. 130

Table (4.10):Correlation coefficient between the critical success factors for lean

implementation and healthcare organization’s performance in the MDC industry in

Gaza Strip ( Source : Researcher). ........................................................................... 131

Table (4.11):Correlation coefficient between the challenges and barriers of lean


Gaza Strip ( Source : Researcher). ........................................................................... 132


implementation and Lean challenges and barriers in the MDC industry in Gaza Strip (

Source : Researcher). ............................................................................................... 133

Table (4.13):Correlation coefficient between the Lean benefits and Lean challenges

and barriers in the MDC industry in Gaza Strip ( Source : Researcher). ................ 134

Table (4.14):Correlation coefficient between the Lean critical success factors and

Lean challenges and barriers in the MDC industry in Gaza Strip ( Source : Researcher).

................................................................................................................................. 135


implementation and the value of Lean benefits in the MDC industry in Gaza Strip (

Source : Researcher). ............................................................................................... 136


implementation and the Lean critical success factors in the MDC industry in Gaza Strip

( Source : Researcher). ............................................................................................. 137

Table (4.17):Correlation coefficient between the Lean benefits and the Lean critical

success factors in the MDC industry in Gaza Strip ( Source : Researcher). ............ 138

Table (4.18):Mann-Whitney test of the fields and their p-values for gender ( Source :

Researcher). ............................................................................................................. 139

Table (4.19):Kruskal-Wallis Test of the fields and their p-values for Educational

Background ( Source : Researcher). ........................................................................ 140

XVI

Table (4.20):Mann-Whitney test of the fields and their p-values for educational

qualification ( Source : Researcher). ........................................................................ 141

Table (4.21):Kruskal-Wallis Test of the fields and their p-values for Person's years of

experience ( Source : Researcher). .......................................................................... 142

Table (4.22):Kruskal-Wallis Test of the fields and their p-values for nature of the

workplace ( Source : Researcher). ........................................................................... 143

Table (4.23):Mann-Whitney test of the fields and their p-values for location of

workplace ( Source : Researcher). ........................................................................... 144

Table (4.24):Kruskal-Wallis Test of the fields and their p-values for Organization's

Establishment ( Source : Researcher). ..................................................................... 145

Table (C. 1):Correlation coefficient of each item of “Beneficial Factors for lean

implementation in service oriented architecture” and the total of this field.203

Table (C. 2) :Correlation coefficient of each item of “Critical success factors for lean

implementation in service oriented architecture” and the total of this field. 205

Table (C. 3):Correlation coefficient of each item of “Challenges and barriers factors

for lean implementation in service oriented architecture” and the total of this field207

Table (C. 4):Correlation coefficient of each item of “Factors affecting healthcare

organization’s performance in lean implementation in service oriented architecture”

and the total of this field 208

XVII

List of Figures

Figure (1.1):Hypotheses Model ( source : Researcher) ............................................ 10

Figure (1.2):Hypotheses Model (Source : Researcher) ............................................. 10

Figure (2.1): Lean activities (Source : Pascal, 2002) ................................................ 16

Figure (2.2): The most widely used of lean tools and techniques in healthcare

organizations (source : (Poksinska, 2010)) ................................................................ 32

Figure (2.3):The 5S process to organize the workplace (source : (Gapp, Fisher, &

Kobayashi, 2008)) ...................................................................................................... 33

Figure (2.4): The value stream mapping examples from Wirral Hospital ( Source :

Jones and Mitchell, 2006) .......................................................................................... 38

Figure (4.1) : RII (%) of Beneficial Factors for lean implementation in service

oriented architecture ( Source : Researcher) ............................................................ 110

Figure (4.2) : RII (%) of Critical success factors for lean implementation in service

oriented architecture (Source :Researcher). ............................................................. 114

Figure (4.3) : RII (%) of Challenges and barriers factors for lean implementation in

service oriented architecture (Source :Researcher). ................................................ 118

Figure (4.4) : RII (%) of Financial and Quality Performance (Source :Researcher).

................................................................................................................................. 125

Figure (4.5) : RII (%) of Employee Performance (Source :Researcher). ............... 126

Figure (4.6) : RII (%) of Patient Satisfaction (Source :Researcher). ...................... 126

XVIII

List of Abbreviations

3P Production, Preparation, Process.

5S Five S's (Sort, Set, Shine, Standardize And Sustain).

AED Accident And Emergency Department.

BIM Building Information Model.

CSFs Critical Success Factors.

ED Emergency Department.

GDP Gross Domestic Product.

GIS Geographic Information System.

GP General Practitioner.

HVAC Heating Ventilation And Air Conditioning.

IFD Integrated Facility Design.

IPD Integrated Project Delivery.

IT Information Technology.

JIT Just-In-Time.

KMO Kaiser-Meyer-Olkin.

MDC Medical Design Contraction.

MOH Ministry Of Health.

NGO Non-Governmental Organizations.

NHS National Health Service .

OJT On the Job Training.

PAS Public Aid Society.

r Pearson Product-Moment Correlation Coefficient.

RII Relative Importance Index.

SD Standard Deviations.

SMC Al-Shifaa Medical Complex.

SPSS Statistical Package For The Social Sciences.

TNA Training Needs Assessment.

TPS Toyota Production System.

UNRWA United Nations Relief And Works Agency.

1

Chapter 1

Introduction

2

Introduction

This chapter provides an introductory overview of the research study. It starts with

a background of the study, which provides a clear understanding of the lean thinking

philosophy. It is followed by a problem statement. Furthermore, aim and objectives of

this study are identified, followed by the research questions and research hypotheses.

After that, the research delimitations are represented to distinguish the scope of this

research study. A structure of the thesis is developed with the intention of organize the

literature review procedure.

1.1 Background of the Study

The main problems of construction are well-known: poor safety, low productivity,

bad working conditions, and lacking of quality, increase project delivery time and

waste. Several solutions and visions have been highlighted to solve these problems in

construction. Industrialization (i.e. modularization and prefabrication) is a process that

has been considered as one direction of improvement (BenTovim et al., 2007).

(Shingo, 1988) said that manufacturing has been a source of innovations and a

reference point in construction industry for many years. As, the idea of

industrialization appears directly from manufacturing. Computer automation and

integration similarly have their groundwork in manufacturing, where their adoption

and implementation is well going more than construction (Plossl, 1991).

Presently, another development direction in manufacturing arises, the influence of

which looks to be much better than that of automation and information technology.

This direction, which is stand on Lean production thinking, instead of on new

technology, stresses the importance of basic values and principles connected to

production procedures (Schonberger, 1992).

In construction, there was little interest to the new production philosophy. The goal

of this research study is to assess whether or not Lean production thinking has effects

on construction field in healthcare organizations. Lean is one of the most worth

initiatives that organizations apply to enhance its performance (Galsworth, 2010). It

3

is efficient in specifying waste and reducing costs from the operations (Hasle et al.,

2012)

Lean is important to develop design process by managing the changes in all design

phases (Chambers D. , 2011). In general, Lean is transforming the thinking way of

engineers and other building professionals work in the industry (Tousaint et al., 2013).

The key benefit of Lean to healthcare architectural design that Lean focuses on

developing safe, efficient, and waste free operational process to make the optimal

supportive patient focused physical environment possible (Graben, 2013). The use of

Lean can increase the value of the building, improve the financial position and process,

also standardize process as well as increase quality, and shorten the project duration

(Thomposon et al., 2012).

On the other hand, it is claimed that organizations can advantage by successful

implementation of Lean (Maleyeff, 2006). Previous studies indicated that one of the

most reason that Lean has not been applied in service oriented architecture is because

there is organizational traditional thinking that it is linked with production, as it was

established firstly for manufacturing intents (George, 2003). Appiotti and Bertels

(2010) also stated that in spite of the growing awareness of the need for Lean

implementation in service oriented architecture, scarce studies have examined its

efficiency to strengthen their financial position. Consequently, many books and

journals about best practices on Lean in service industry are not excited, where

healthcare organizations can learn before applying this tool (Sarkar, 2009) .

(DeSouza, 2009) also agreed that even though there are some studies for Lean

implementation in the hospital design, these studies do not have a clear base, and they

significantly lack the analysis on implementation process of Lean tools and

techniques .

To fill that gap, this study aims to contribute to develop healthcare operation

through lean thinking in the MDC industry Gaza Strip. In this thesis, the researcher

will contribute to recognize Lean tools and techniques, in addition to benefits, CSFs

and barriers that are challenged while implementing Lean.

4

1.2 Problem Statement

In Gaza Strip healthcare landscape is changing. As the nation faces increasing

fiscal pressure, there is less tolerance for limitless financing of healthcare system the

world’s most expensive system is responsible for the deaths of about 90,000 people

annually due to medical error and another 99,000 due to hospital-acquired infections.

Other nations do far better with far less (World Health Organization, 2016).

Historically healthcare organizations have built beautiful new hospitals with the

latest style and technology, but often fall short of expectations if the processes don’t

allow caregivers to provide safe, timely and affordable care a patient may be waiting

in a gorgeous waiting room with flat screen TVs and two story windows, but they are

still waiting.

A nurse may be using the newest version of an automated medication dispenser,

but that nurse can still be at risk for error and delay if the layout doesn’t support point

of use storage and safety regulations. Examples of opportunities for improvements

that can affect care delivery and the design of the physical space are endless (May,

2006).

Graban (2004) referred that Healthcare facility architects and designers have

worked diligently to understand the work of the end users and queried staff for input

and suggestions. However, staff has not always been prepared to look at their work

with an eye for improving the processes to best inform the design. Consequently,

hospitals and other patient treatment facilities have been designed with good

intentions, but the physical space does not exactly meet the needs of patients, visitors,

staff, or providers.

Ultimately, the space may not support the systems of work or patient flows

economically, safely or efficiently. The results are either resource consuming

workarounds created by staff or expensive remodels of new spaces.

Traditionally, staff input to the designers is based on “the way we’ve always done

it” opportunities for improving the work and creating a space to support the improved

work can be missed. The challenge for healthcare administrators and staff is to think

differently about how we deliver care and how we do our work. This allows clinical

5

collaboration with the architects to incorporate an improved vision for care into the

design (Liker & Hoseus, 2008).

The ultimate challenge of both healthcare professionals and design teams is NOT

to design a bigger, prettier, more expensive hospital with the same broken processes.

Rather it is to create long lasting, flexible facilities that will support the improved

vision for care delivery.

Due to the Israel violence and the continuing tight closures in (2007 – 2017) on

Gaza Strip, there are several effects on all aspects of life especially on health

infrastructure. According to the Palestinian Authority 24 healthcare organizations

were partially damaged during the conflict. The construction field was known as one

of the most encouraging fields (ILO, 2010), representative 21% of national GDP and

including 30 % of private workers prior to the crisis. Today, the construction industry

employs only 14.2 % of the total labor force in Gaza (Palestinian Central Bureau of

Statistics, 2016). Through the above mentioned context and because the continued

closures, the construction industry in Gaza Strip cannot deal with the reconstruction

barriers. Therefore, there is a request to know how to overcome these challenges.

Despite that, Lean thinking has not been considered by healthcare organizations in

Gaza Strip just like many other regions of the world. This stimulates the need for

research to determine how healthcare organizations in Gaza Strip can adopt and

implement Lean thinking into the services and projects to have the ability to resolve

all the challenging problems in medical design and construction industry. This can be

achieved by a better understanding of Lean thinking from the literature review. In

addition to field survey which can be obtained by assessing the readiness factors by

professionals for lean implementation in MDC industry in Gaza Strip and identifying

Lean benefits that could convince professionals for adopting Lean in MDC industry in

Gaza Strip. Also this study is significant to investigate Lean challenges and barriers

that face Lean adoption in the MDC industry in Gaza Strip.

Additionally, there is a growing area of research on lean implementation in

services and projects in medical design and construction industry. In particular, the

review of literature presents that no studies have examined the applicability of Lean

6

implementation in services and projects in medical design and construction industry

in Gaza Strip.

1.3 Scope of study

To achieve the aim and objectives of this research study, the scope of study mainly

focused on the medical design and construction industry in Gaza Strip. The scope of

collecting the data in this study limited to the followings:

▪ The healthcare organizations such as engineers who involved in medical design

and construction.

▪ The selected healthcare organizations must have their own managerial staffs such

as project or site manager as well as their engineers.

▪ The selected healthcare organizations are located in Gaza Strip due to the

availability of experience in construction and design medical projects.

Moreover, the systematic literature review of this study focused on the background

and important of Lean, understanding of CSFs and challenges from the implementation

of Lean, Lean tools and techniques, traditional versus Lean led healthcare

organizations design, benefits and criticism from the implementation of Lean within

MDC industry, As well as the effects of lean implementation on healthcare

organizations performance.

1.4 Significance of the research

This research study is contributing significantly to consider Lean thinking in Gaza

Strip in Palestine and investigates into Lean application in the MDC industry. Through

this research study, healthcare organizations can acquire clear understanding on the

way things are currently done and how they could be done better more safely and more

efficiently this can be achieved by better understanding of the process and architectural

design hence improve efficiency and performance of healthcare organizations or the

industry as a whole.

In addition to this study can be used as the guideline for future development to

recognize Lean thinking and try to remove physical barriers in the work flow in order

to create a creative working environment. Although there is still much work to be done

in order to understand fully the management philosophy, benefits, challenge and

7

barriers of Lean thinking, this study will contribute significantly towards the

achievement of this target.

1.5 Research aim and objectives

This research study aims to contribute to develop healthcare operation through lean

thinking in the MDC industry Gaza Strip. To achieve this aim, the study was conducted

by qualitative and quantitative methods, including literature review, pilot study, and

questionnaire surveys. This might be maintained by finding the principles of the lean

implementation and determining their effect on healthcare organizations performance,

to achieve that aim six main objectives have been determined as follows:

▪ Objective 1: To assess the level of lean implementation by professionals in MDC

industry in Gaza Strip.

▪ Objective 2: To identify the lean benefits that would convince professionals for

adopting lean thinking in MDC industry in Gaza Strip.

▪ Objective 3: To identify and rank CSF’s among healthcare organizations.

▪ Objective 4: To investigate and rank the top Lean thinking challenges and barriers

which face the adoption of Lean thinking in MDC industry in Gaza Strip.

▪ Objective 5: To explore the impact of Lean thinking implementation on healthcare

performance in order to make recommendations for adopting Lean thinking in

MDC industry in Gaza Strip.

▪ Objective 6: To study some hypotheses that might help to find solutions to

adopting Lean thinking in the medical sector in Gaza Strip.

1.6 Research Question

Lean thinking way focused mainly in production field and its effect on company's

performance and process Improvement; while, minimal attention was given to Lean

implementation in service oriented architecture sector in MDC industry. Therefore,

research questions were formulated as follows below

▪ RQ 1: What is the level of the readiness of Lean thinking implementation by the

professionals in the MDC industry in Gaza Strip?

8

▪ RQ 2: Are the benefits of Lean thinking valuable from the point view of the

professionals (According to the need for these functions) in the MDC industry in

Gaza Strip?

▪ RQ 3: Are the CSFs of Lean thinking important from the viewpoint of the

professionals (According to the need for these functions) In the MDC industry in

Gaza Strip?

▪ RQ 4: Are Lean challenges and barriers affecting the adoption of Lean thinking in

the MDC industry in Gaza Strip?

▪ RQ 5: Are Lean thinking way affecting healthcare performance in the MDC

industry in Gaza Strip?

▪ RQ 6: What is the effect of benefits of lean implementation and healthcare

organization’s on increasing the performance in the MDC industry in Gaza Strip?

1.7 Research hypotheses

According to Figure (1.1) and Figure (1.2), the study contains (11) hypotheses:

▪ H1: There is a positive relationship, statistically significant at α ≤ 0.05, between

the readiness level for lean implementation by professionals and healthcare

organization’s performance in the MDC industry in Gaza Strip.

▪ H2: There is a positive relationship ship, statistically significant at α ≤ 0.05,

between the benefits of lean implementation and healthcare organization’s

performance in the MDC industry in Gaza Strip.


the critical success factors for lean implementation and healthcare organization’s


▪ H4: There is an inverse relationship, statistically significant at α ≤ 0.05, between

the challenges and barriers of lean implementation and healthcare organization’s



the readiness level for lean implementation and Lean challenges and barriers in the


9


the Lean benefits and Lean challenges and barriers in the MDC industry in Gaza

Strip.


the Lean critical success factors and Lean challenges and barriers in the MDC



the readiness level for lean implementation and the value of Lean benefits in the



the readiness level for lean implementation and the Lean critical success factors in

the MDC industry in Gaza Strip.


the Lean benefits and the Lean critical success factors in the MDC industry in Gaza

Strip.

▪ H11: There is statistical significant differences at α ≤ 0.05 in the responses of the

research sample due to demographic data, this hypothesis can be divided into the

following sub-hypotheses:

✓ H11.1: There is statistical significant differences at α ≤ 0.05 in the

responses of the research sample due to gender.


responses of the research sample due to educational background.


responses of the research sample due to educational qualification.


responses of the research sample due to person's years of experience.


responses of the research sample due to nature of the workplace.


responses of the research sample due to location of workplace.


responses of the research sample due to organization's establishment.

10

Figure (1.1):Hypotheses Model ( source : Researcher)

Figure (1.2):Hypotheses Model (Source : Researcher)

1.8 Delimitations of the study

The study research covers the following aspects:

11

▪ Geographical: the study covers the MDC industry in Gaza Strip in Palestine. Gaza

Strip consists of five governorates: The Northern Governorate, Gaza Governorate,

the Middle Governorate, KhanYounis Governorate and Rafah Governorate.

▪ Population and Sample: research population includes 22 Healthcare organization

distributed among Gaza Strip. 80 out of 85 copies of the questionnaire had been

returned from the respondents. The sample size was chosen to provide adequate

information on reliability and a certain degree of validity.

▪ Knowledge: the study research focuses on Lean thinking adoption in the MDC

industry in Gaza Strip. It aimed to contribute to develop healthcare operation

through lean thinking in the MDC industry Gaza Strip for identifying fundamental

factors (the readiness level of Lean implementation, the CSFs of Lean, the value

of Lean thinking benefits, the Lean challenges and barriers, and this effect on

healthcare performance) which help to consider adopting Lean thinking in process

and projects by professionals in the MDC industry. According to that, a systematic

extensive literature review was conducted to review the previous related studies

that made in this field and dealt with these factors.

▪ Approach and instrument: the study research approach was a quantitative survey

research to measure the desired objectives (descriptive survey and analytical

survey). The study research technique was formed as a questionnaire. The

overriding purpose of the questionnaire was first to meet the research objectives,

then to answer the questions of the study, last to collect the data that can support

the results and discussion, as well as help in writing out the recommendations.

▪ Time: The questionnaire survey (distribution and collection) was conducted in

May, 2017, it was terminated in a period not exceeding three weeks.

1.9 Research design

To achieve the research study objectives, the following stages were done:

▪ The problem was specified by developing the research theme that contained the

established aim, objectives, hypothesis and key research questions as well as

research plan/strategy was developed by deciding on the research approach and

technique.

12

▪ Concentrated literature review was prepared to review the previous studies

conducted in this field. As a result, groups of main factors were well defined to

support the initial questioner building. A conceptual framework was planned in

this stage.

▪ Based on the extensive literature reviews, a questionnaire surveys were designed.

▪ Face validity was conducted by experts in the MDC field as well as experts in

statistics to see whether the questionnaire in this study appears to be valid or not.

▪ Pre-testing the questionnaire was done to ensure the quality of the collected data.

The pre-testing has been tested with six professionals in the MDC industry in Gaza

Strip.

▪ A pilot study was conducted in order to explore the strength and weakness sides in

the questionnaire, to edit necessary changes, and to make valuable feedback.

▪ The main survey was conducted by distributing the refined questionnaire. Field

investigation was conducted at healthcare organizations in Gaza Strip.

▪ Quantitative and qualitative data analysis methods, including statistical analysis:

factor analysis, reliability test, and Pearson correlation analyses will be conducted

using (SPSS v.24).

▪ Findings were concluded and recommendations were suggested.

1.10 Structure of the thesis

The dissertation is divided into five chapters to create a good flow for the

information. The outline of the thesis is as the following:

Chapter 1: Introduction

This chapter explains the background of the research. It provides the introduction

to guide the reader into the research topic. The problem statement and justification of

the study, research aim, objectives, questions, hypotheses, research delimitations,

research design, research limitations, and research contribution to knowledge as well

as the outline of the thesis are included in this chapter.

Chapter 2: Literature review

This chapter provides a review of the literature relevant to the research problem in

this research study. The first section describes the main contributes of lean concept by

giving a background and explaining its principle. The second areas for literature

13

review are: Lean in service sector, Lean implementation, Traditional design versus

Lean led design, and finally Healthcare organizations performance in MDC industry.

Chapter 3: Research methodology

This chapter presents the detailed research design and the method. The chapter also

explains the used technique in the analysis and issues related to data collection.

Chapter 4: Results and discussions

The findings are shown and discussed in chapter four. After results were analyzed,

they are presented, discussed and linked with the previous studies in this chapter.

Chapter 5: Conclusion and recommendations

According to the final results, recommendations and conclusion of the research are

discussed in chapter five.

References

Appendices

14

Chapter 2

Literature Review

15

Literature Review

This chapter provides a review of the literature relevant to the research problem in

this research study. The first section describes the main contributes of lean concept by

giving a background and explaining its principle. The second areas for literature

review are: Lean in service sector, Lean implementation, Traditional design versus

Lean led design, and finally Healthcare organizations performance in MDC industry.

2.1 Background of Lean

2.1.1 Lean History

Lean is a management philosophy based on two tenets: continuous process

improvement, and respect for people it was introduced firstly by (Krafcik, 1988) article

"Triumph of the Lean Production System” in order to raise the concept of using less of

everything to increase the efficiency and productivity in organizations. This means

using less human resources, inventory, space, investment in tools and time spend to

develop products (Womack and Jones, 1996).

Lean concept is regarded as a systematic approach to identifying and eliminating

non added value activities in products and services with a view to create value to

customers. (Lewis, 2000) stated that Lean is considered a set of management principles

for production with the aim of reducing waste (muda called by Japanese).

Lean includes various techniques of design, such as leadership to direct the

process that involves multi-skilled employees; teamwork to appoint workers from

different functions in groups; communication to fix critical design trade-offs and

prioritize resources; and in the same time development that includes a process with

less tools, inventory and human resources (Womack and Jones, 1996).

The technique we call Toyota Production System has been created form actual

practices from the Toyota factories, the founder of Toyota Motors, “Kiichiro Toyoda”

was deeply influenced by Henry Ford approach on the mass production strategy.

Toyoda could not adapt mass production approach from Ford Company because

the economic situation in Japan after the World War II, where the demand for mass

16

produced vehicle was low (Dale et al., 2007), This condition led up to the development

of Toyota Production System (TPS), which focused on process to construct different

models of both cars and trucks in small volume with low investment, as well as

minimizing the cost with Just-in-Time (JIT) and even shortening the lead time.

This approach helped Toyota to emphasis on the notions of minimizing cost,

maintaining the quality and providing different models to satisfy different customer

requirements (Slack et al., 2007; Melton, 2005; Dale & Lwaarden, 2007; Petersson I

2010).

TPS was the beginning of Lean practices in manufacturing, which was developed

moreover to reduce and eliminate waste in the processes within the organization

(Melton, 2005). Figure (2.1) displays the TPS House as an icon of Lean (Balle and

Regnier, 2007), which was created by “Taiichi Ohno and Eiji Toyoda” (Pascal, 2002).

Figure (2.1): Lean activities (Source : Pascal, 2002)

The roof represents the goal of Lean to eliminate waste in process by offering

quality products and services to customers. In the center of the house is the culture of

continual improvement that involves all employees of the organization.

17

In both sides of the house are two elements of TPS, such as JIT with the aim to

eliminate waste by planning and controlling operation to meet customers’ demand, as

well as Jidoka (built in quality) to detect the problems immediately in order to fix them

easier (Slack et al., 2007). Finally, the foundation is the standardization of the process.

The House of Toyota was helpful to visually explain TPS to employees (Pascal, 2002).

2.1.2 The Five Lean Principles

Womack and Jones (2003) stated that improve the sociotechnical aspect of lean

production through providing five principles within which the customer value and

waste elimination are the cores of the lean approach, Lean principles are promoted as

a universal guide to its implementation (Womack and Jones, 1996; Porter and Barker,

2005) there are five principles in lean thinking:

2.1.3 Specify Value from the Standpoint of the End Customer:

Identifying the value from the customer’s stand point provides a crucial starting

point for the implementation of lean, furthermore, it is considered the most important

element is specifying and identifying value. As Womack and Jones (1996) state that

failure to specify value correctly before applying Lean techniques can easily result in

providing the wrong product or service in a highly efficient way.

In healthcare, while, value is conceived as multilateral and indeterminate.

Interpretations and perspectives vary widely. Young and McCLean (2008) define

value from a patient pathway point view, the path patients take from the entrance of

the hospital until patient leaves; this is mean that designing pathways around creating

value to patients at each step rather than considering patient-centered activities.

2.1.4 Identify the Entire Value Stream for Each Service Family

Which is mean the end- to end collection of activities that make and provide value

for the customer or patient, by mapping all process included in creating service all

wasted activities will be provided and eliminated so that, start and end points of each

process in construction phases need to be approved previously to keep the development

and improvement focused and manageable. In practice, the mapping activity is

directed by professionals who are familiar with the patient pathways at different points

(Call handler, paramedic, nurse, matron, specialist doctor, departmental manager,

18

etc.), later coming together to map the process. The result should be enhanced the

understanding of process phases to eliminate the steps that not added value to the

customer or patient.

The value stream can include people, tools, equipment, and technologies, as well

as physical facilities, communication channels, policies and procedures.

2.1.5 Make the Product or Service Flows

Toussaint & Gerard, 2010 stated if value has been obviously defined, the value

stream identified, and clear wasteful steps eliminated, the next step is to make the

service flow continuously organize and standardize processes around optimal practice.

In a healthcare organization like a hospital, the goal should be to design to attain

continuous smooth flow through whole hospital processes so patients can obtain the

optimal level of care timely, and of the maximum quality. Its significant to implement

flow by starting from the end of patient journey and the analyze pathway and working

backwards. This is because all waiting lists of work are finished, they can easily track

the next stage in the process.

2.1.6 Respond to the Customer Pull

Pull refers to the actual customer demand that drives a business process, it is a

system based on a cascading process from downstream to upstream activities in which

nothing is produced by the upstream supplier till the downstream customer or patient

signals a need.

Recognizing that process, it might not be possible to reduce all non-value adding

steps instantly, this principle aims to eliminate waste as far as possible by “pulling”

the customer or patient to the next process step.

2.1.7 Improve Continuously in Pursuit of Perfection

Toussaint & Gerard (2010) defined perfection as the way for eliminating waste to

achieve an ideal process where value is produced at every single step should come to

be part of organization culture, where Lean becomes “the way we do things around

here”, so that non-value adding activity is continuously removed and the steps, time

and information necessary to serve the customer or patient continually falls (Daniel T.

Jones, 2016).

19

In order to implement lean principles, the top managers of the organization should

have the commitment to make lean thinking culture (Miller, 2005). Have in mind that

Lean has to be locally led and be part of the organizational strategy (Mitchell, 2006).

From operational side, there is a need to integrate more than one approach to meet the

requirements for lean thinking. The set of approaches may differ from one process to

another. In addition, many approaches may need adaptation in order to be integrated

with other approaches.

2.2 Lean in Service Sector

Lean in service sector is connected directly to architecture design and very

essential to add value to patient or customer by providing health services with higher

quality and speed the process by using fewer, but optimal resources (Pronovost &

Goeschel, 2010).

So that engineers in a need to analyze the non-value activities to reduce time, cost

and complexity through the whole phases of construction projects (Gawande, 2009)

Reiling (2007) stated that health care organizations should focus on value added

activities from customer or patient point view. In this way, they will understand better

their needs.

2.2.1 The Seven Types of Wastes in Service Sector

The Lean approach aims to reduce and eliminate each type of waste, which is a

recurrent problem for hospitals in order to achieve both real and potential value

(Murphy, 2003). Waste is defined as any element of a process that adds time, effort or

cost but not add value to customer and organization.

For them, waste is accosting that they not willing to pay. The eight wastes of Lean

translated into healthcare include: waiting (patients being patient), motion (looking for

missing patient information, sharing medical equipment/tools) and inventory (clinical

and non-clinical supplies). Processing (duplication of forms and redundant capture of

information), defects /correction (prescription errors, incorrect information, incorrect

diagnosis), transportation (moving patient, equipment, etc. unnecessarily) and, Over-

production of diagnosis tests (so-called “defensive medicine”), and work in progress

(tests waiting distribution).

20

These wastes can be identified and eliminated by using lean tools and techniques,

as defined in Table ( 2.1) (Virtue and Chaussalet, 2013). Concerning that, many

successful stories can be found on lean thinking initiatives in MDC industry which

show positive influence on productivity quality, cost, and well-timed delivery of

services as a result of applying lean principles through the healthcare organization

(McCulloch et al., 2010),

Attempts to get a clear understanding of wastes in any healthcare organization, the

eight types of wastes can be explained in terms of MDC industry. Author developed

Table ( 2.1) by combining different author's points of view.

Firstly, the seven types of wastes are well defined and described to understand the

meaning in terms of MDC perspective. Then it supports with some examples from

reviewed studies in healthcare sector. Finally, ways to address each type of waste is

illustrated. After the explanation of seven types of wastes, another new waste in health

care service is defined and supported with examples.

Table ( 2.1):Types of Waste in Healthcare (Source : Virtue and Chaussalet,

2013)

Types of Waste

Definition Healthcare

Examples from

reviewed studies Ways to address

Waiting Time It includes a delay in

one activity that can

lead up to a delay in

the following

activities. Healthcare

organization can

investigate the

waiting time by

checkup each activity

involved in the

process to identify

delays (George,

2003).

Waiting for patients,

surgical operation

staff, results,

prescriptions,

medical reports and

medicines.

Waiting for doctors

to discharge

patients.

Waiting in the

meeting for people

who show up late,

which lead to

irritation and loss of

time in which work

should be

performed.

Remove

unnecessary

steps from work

Pathway.

Motion Wasteful patient

movement or

Pointed people and

placed equipment

Look at time,

distance traveled,

21


2013)

Types of Waste


Examples from


misaligned to the

service demand: too

fast or too slow,

people or equipment

moving or walking

more than is required

to perform the

processing.

which are sited

within long distance

that causes

Unnecessary staff

movement

(Petersson et al.,

2010

Lack of basic

equipment in every

single examination

room.

and how much

time it takes to

complete a

milestone task

(cycle time).

Inventory It means using excess

inventory instead of

what is actually

required to provide

service to customers.

This should be

avoided because it

does not add value to

customers and

involves higher cost

of waiting. This kind

of waste is usually a

result of

overproduction

(George, 2003).

Using beds to hold

patients that could

be discharged or

over ordering

material to

compensate for

erratic supply.

Providing substitute

of products or

services, not what

was asked by

customers (Bicheno,

2004).

Decrease excess

inventory

)kanban or

similar “pull”

system that

replenishes only

as necessary)

Over

processing

It involves increases

costs with attempt to

add more value to

service than is needed

to satisfy customers.

(George, 2003)

Reprocessing of

exams because of

reading errors,

fulfilment of similar

forms in different

departments for the

same patient,

reschedule of

missed

appointments.

Eliminate

redundancies;

standardize

procedures,

roles,

communication;

focus on actual

needs of patients

Defect It occurs when

services are not

achieved within

specification of

customers due to

Errors in the service

Complaints about

the assistance and

products provided

that don’t attend the

customer’s

expectations (lack

Goal of zero

sentinel events;

find root causes

of common

“glitches” before

they become

22


2013)

Types of Waste


Examples from


transaction. Some of

the services are not

costly to correct

mistakes, but

organizations should

consider that they

might also lose

customers (George,

2003).

of value for the

consumer).

Readmission due to

failed discharge or

adverse drug

reactions

Repeating tests

because correct

information was not

provided.

sentinel events;

institute

checklists

Transportation It means the

movement of staff,

materials and

information, which

should be reduced for

activities that do not

add value, or are

related to occurrence

of waiting time and

queues that dissatisfy

customers (George,

2003).

It can be the

distance of transport

of test samples

because of the

centralized

resources in

organizations.

Staff walking to the

other end of a ward

to pick up notes.

Central equipment

stores for commonly

used items instead

of items located

where they are used.

Look at distance,

Number of trips

for access to

people

information

supplies reduce

handoffs.

Overproduction It refers to the excess

construction of

service outputs

(George, 2003). This

happens because

healthcare

organization produces

more services than

customers demand.

Unnecessary

referrals, tests,

hospitalizations,

materials

acquisition in

excess, Blood draws

done early before

the decision to

complete blood tests

has been made.

Patients are

admitted to the

hospital and they

wait because there is

no time to give them

service till later

Increase

communication

between

customers and

suppliers; install

on-demand

“pull” systems

23


2013)

Types of Waste


Examples from


(Petersson et al.,

2010, p. 91).

Untapped

competence

It occurs when health

care organization do

not use the

competence of

workforce and their

creativity (Petersson

et al., 2010).

The loss of skilled

employees that

could contribute for

organizational

improvement

(Petersson et al.,

2010).

Not using the

creativity of people;

not paying attention

to ideas of

employees, but only

managers (Bicheno,

2004).

Simplify IT

interactions

standardize

rooms and

equipment

standardize

definitions of

common terms

2.3 Lean Implementation

Implementing lean thinking to health care organization design in a structured way

can lead to an environment where continuous improvement, safety, efficiency, better

flow of process information, supplies and services to customer or patient.

(Thompson, 2003) stated that Lean process improvement will lead to successful

Lean architectural design: that focuses on identifying, developing and integration

efficient, safe, waste free operational process to make the most efficient and supportive

patient focused physical environment possible.

Lean as a frontline strategy and a management philosophy is always deployed in

health care organizations, even if in the early phases (Toussaint et al, 2010).

Lean lead design can start as way to focus on CSFs and remove physical challenges

and barriers, the following points are worth considering before implementing lean

thinking in facility design.

24

2.3.1 Critical Success Factors of Lean Implementation

There are several crucial factors that affecting the success of lean implementation.

Identifying (CSFs) is essential for achieving an efficient lean practice implementation.

Hence, avoiding any unnecessary loss associated with enterprise cost, time and effort.

This should be applied to all sectors including healthcare organizations. Table (2.2)

illustrates the key CSFs influencing the implementation of lean practices.

25

Literature reviews

Table (2.2) : The summery for CSFs of lean practice implementation

CSFs

(Mar

odin

, S

auri

n, &

A., 2

013)

(Kundu &

Man

ohar

, 201

2)

(Naj

em, D

hak

al, &

Ben

net

t,

2012)

(Ste

ed, 2012)

(Foli

nas

& F

aruna,

2011)

(Pap

adopoula

s, 2

011)

(Ham

id, 2011)

(Kum

ar, A

nto

ny, &

Dou

gla

s,

2009)

(Ver

maa

k, 2008)

(Kou, S

hen

, &

Chen

, 2008)

(Doss

& O

rr, 2007)

(Ach

ang

a, e

t al

., 2

006)

(Har

mon, et

al.

, 2003)

Management commitment and involvement * * * * * * * * *

Training and education * * *

Employee participation and empowerment * * * * *

Alignment to business strategy and long-term plan * * *

Managing cultural change for continuous improvement * * * * * *

Cross-functional integration *

Performance measurement * *

Sustain continuous improvement * * *

Communication with employees * * *

Rewards and recognition *

Job security and social responsibility * * *

Focusing on the need of customer * * *

Strong leadership to continuous improvement process

demonstrated by mangers at all levels. * *

26

… continued

Literature reviews

Table (2.2) : The summery for CSFs of lean practice implementation

CSFs

(Mar

odin

, S

auri

n, &

A., 2

013)

(Kundu &

Man

ohar

, 201

2)

(Naj

em, D

hak

al, &

Ben

net

t,

2012)

(Ste

ed, 2012)

(Foli

nas

& F

aruna,

2011)

(Pap

adopoula

s, 2

011)

(Ham

id, 2011)

(Kum

ar, A

nto

ny, &

Dou

gla

s,

2009)

(Ver

maa

k, 2008)

(Kou, S

hen

, &

Chen

, 2008)

(Doss

& O

rr, 2007)

(Ach

ang

a, e

t al

., 2

006)

(Har

mon, et

al.

, 2003)

Establishing measurement and feedback system. * *

Appointing a project facilitator. *

Focusing on critical process. *

Organization infrastructure. * * * *

Understanding methods, tools, and techniques. *

Willingness to take risks. * *

27

According to Womack. (1990) management support is one of the most CSFs and

lean implementation is not possible without it. Whereas, Top management have to give

more effort in encouraging all healthcare organizations staff for change by presenting

the importance of lean philosophy (Atkinson, 2004).

Top management commitment is an important factor considerably affecting both

lower level employee's attitudes and the lean practice outcome. As, the earlier

mentioned is responsible for providing consistent information about lean practices.

Besides that, increased in staff involvement were impact of improved job commitment,

job satisfaction, patient satisfaction and patient outcome (Olivo, 2007).

Abdullah et al. (2008) stated that employee involvement is akey role to drive the

possitive impact onquality improvement, this is according to the employee behavior

that affect patient's perception of service quality. Furthermore, educate, train and

empower staff is one of the process development in healthcare sector by concerning

all employee and other stakeholders in the process.

Another CSFs is communication between employees also the communication

through the top management and employees, which will affect lean thinking

implementation, active communication is a successful tool for Lean thinking

implementation in MDC industry is helpful by sharing the successful stories of Lean

implementation or with constant feedback from employees to top management for

process improvement (Doss and Orr, 2007).

Marodin et al. (2013) give emphasis on the importance of having these four CSFs

for lean implementation which are trust in organization that lean implementation well

be successful; Alignment lean to strategy and long-term plan in order to accurately

utilize lean resources; Managing cultural change for improvement; and application of

lean for all function.

Managing organizational culture is identified as a critical part of healthcare

development and implementation of lean and other quality systems (Scott at el., 2003).

According to Shahzad et al. (2012) possitive and strong culture can impact on

employees job performance. Thus, can improve in the productivity and enhance the

organizational performance.

28

The aim of every lean initiative is to emphasis on customer needs to the highest

level by determining and eliminating all types of wastes. The healthcare organization

recognized the patient as a key customer and as a critical factor to be taken into

consideration when designing process and delivering care. Furthermore, healthcare

organization should deliver greater quality health care services and provide higher

attention to patients by concentrating always on their desires when implementing lean

in healthcare organizations.

Appiotti and Bertels (2010) also have a planned contribution to the literature of

CSF’s for implementing Lean thinking, specifically for the financial healthcare

organizations through recognizing these factors: (1) Focus on designing a well-planned

strategy, (2) Specify customers’ needs and values, (3) Measure the valued factors in

order to recognize the success of Lean implementation, (4) Track the process and

understand the system before making any changes.

Atkinson (2004) emphasized that in financial service, organizations should apply

lean in the field where it has a strategic importance. This way, organizations can

enhance the focal competences to increase the competitive advantage by enhancing

the process, which will lead to save money and build customer or patient trust.

By deep understanding of latter mentioned factors before Lean implementation, it

will help to materialize the benefits as well as to make Lean culture.

2.3.2 Challenges of Lean Implementation

Even though Lean has shown great success in service field, there are challenges

they face while starting the journey of service Lean implementation. Service Lean is

filled with trials and tribulations that need an open mind that is ready to experiment.

2.3.2.1 Processes are not visible, large and complex

In a manufacturing industry, process identification is relatively easy because it is

evident. All that one needs to do is observation. Unlike manufacturing, processes are

often not visible. Sakar (2009) points out that it is more difficult to identify process

with in the service context because they are not as visible as in manufacturing. Many

times processes that are not visible result in wastes that are not visible.

29

As a result, it needs a high degree of skill, wherein one needs to search for things

such as work-around, complexity-manifestation, and voice-of-customer. In both

manufacturing and service industry abnormality identification gets enhanced by tools

such as value stream maps.

Also, due to size and complexity, managing a large process for improvements is

not easy because it not only requires integrating a large number of improvements

across all the sub-processes but also engaging teams in various functional silos.

2.3.2.2 Processes Are People Intensive

George (2003) highlighted that managing all individuals directly or indirectly

associated with the process are important, because Lean implementation for service

process would have improvement goals that could have both tangible and intangible

components.

The intangible elements of Lean implementation in service processes are

dependent on moods of people and how they are feeling it at different points of time;

consequently, they need to avoid their mistakes in process.

Aherne (2007) emphasized that generally in healthcare organizations the challenge

was to get support from the government as well as program from the management.

Beside these, in service processes, the communication of people has more significance,

consequently, they should not be treated such as machines.

2.3.2.3 Processes Are Technology Dependent

(Sarkar, 2009) states that many process in the service context are technology

enabled. Sometimes, Information Technology (IT) systems do not communicate with

each other. There could be issues pertaining to slow moving business intelligence,

flexible infrastructure, data integrity, modular processes. Therefore, it is imperative

that these IT issues are specified simultaneously to ensure Lean implementation has

the highest influence on the outcomes.

4. Very Little Books of Knowledge for Service Lean

Unlike in manufacturing field, general practitioners of service Lean do not have

success stories that they could refer to. We still have yet to come across the Toyota of

30

Literature reviews

services that we could emulate. There are very few books of knowledge available that

people could buy.

5. Concept of Pull and Flow

Implementing the concept of pull and flow as a principle of Lean is difficult to

service processes. Sometimes, people have to search about intelligent hybrid

resolutions that imitative the concept of pull as seen in manufacturing companies.

Worley and Doolen (2006) declares that it is hard to persuade workers in the

organization to change their thinking way to focus on customer or patient value and

waste elimination, as they might be resistant to new tools, such as Lean. Moreover,

delivering smaller amount of parts will be difficult for suppliers to apply Just in Time

concept.

Womack and Jones (2009) cited that customer order forecast might not be the

quantity of products they need, which cause an excess of inventory for organizations.

Wickramasinghe et al. (2014) stated that having complex patient pathways in

healthcare services is a factor that may contribute to the importance of applying lean

thinking rather than the opposite.

Table (2.3):Application and usefulness of process mapping in Hospital

(Source : Staccini et al. (2005))

Identified challenges

(Wic

kra

mas

inghe,

Al-

Hak

im,

Gonza

lez,

& T

an, 2014)

(Geo

rge,

2003)

(A

her

ne,

2007)

(Gro

ve,

et

al., 2

010)

(Sar

kar

, 2009

)

(W

orl

ey &

Doole

n, 2006

)

Lack of awareness of lean led design by

stakeholders. * * *

Lack of knowledge how to apply lean led design

to enhance service which oriented architecture. * *

31

Literature reviews

Table (2.3):Application and usefulness of process mapping in Hospital

(Source : Staccini et al. (2005))

Identified challenges

(Wic

kra

mas

inghe,

Al-

Hak

im,

Gonza

lez,

& T

an, 2014)

(Geo

rge,

2003)

(A

her

ne,

2007)

(Gro

ve,

et

al., 2

010)

(Sar

kar

, 2009

)

(W

orl

ey &

Doole

n, 2006

)

Lack of awareness of the benefits that lean led

design can bring to engineering offices and

hospitals design.

* * *

Lack of engineers skilled in the use of lean led

design concepts. * *

Process are people intensive because intangible

elements of lean implementation are depend on

moods of people and how they are feeling it.

*

Difficulty of identifying process with in the

service context because process are not visible,

large and complex.

*

Process in the service context which oriented

architecture are technology enabled which is led

to slow moving business intelligence, flexible

infrastructure, data integrity, modular processes.

*

There are very few books of knowledge available

about lean led design that people could buy. * *

Hard to persuade workers in the organization to

change their thinking way to focus on customer

or patient value and waste elimination

* *

Resistance by organization to adopt new tools

and refuse any change can focus on customer

patient value and waste elimination.

*

Un willingness of engineers to learn about lean

led design concept because the lack of success

stories and the educational culture.

*

Lack of empowering, education and providing

the relevant training to the engineers on how to

implement lean thinking on hospitals design. * *

Lack of governmental regulations to fully

support implementation of lean concept. * *

32

2.3.3 Lean Tools and Techniques

Applying lean in service sector is important to add value to customers or patients

by delivering medical services with higher quality and speed with in available

resources.

It is also focus on identifying the core of the problem so that it will not reoccurred

again. Lean services represent the concept of eliminating waste from service processes

in an attempt to increase the efficiency. However, the waste in services can be tangible

and intangible. Thus, the main challenge is to manage the intangibility of the waste, as

it is hard to identify it.

An observation study, conducted in 2010 by B. Poksinska, shows, which lean tools

and techniques are most usually used in Healthcare. The investigation was structured

by the frequency of appearance this tools in a number of papers, which discussed the

specific Lean principle, method or tool in the context of healthcare (Poksinska,

2010).Figure (2.2) presenting results and summery of that papers, those tools are

described in a more detailed way below.

Figure (2.2): The most widely used of lean tools and

techniques in healthcare organizations (source : (Poksinska,

2010))

33

2.3.3.1 The five S's (Sort, Set, Shine, Standardize and Sustain):

According to Gapp et al. (2008) 5S originally based on the Japanese acronyms of

seiri (organization), seiton (neatness), seiso (cleaning), seiketsu (standardization) and

shitsuke (discipline) As shown in Figure (2.3), 5S is used as a platform for developing

an integrated management system by creating better work place (Bamber et al., 2000).

Takashi Osada defined 5S as “housekeeping”; A framework of applying 5S within

a business was initially formalized in the early 1980s (Ho et al., 1995). The practice of

5S aims to enhance the values of organization, neatness to create healthier atmosphere,

cleaning, standardization and discipline into the workplace (Osada, 1991).

Morrow and Main (2017); and Bicheno (2004) agree that 5S is simple and helpful

tool to create lean culture through organization. Sort which is the first stage of 5S

emphasizes on keeping only essential activities and throw those that are not required.

Figure (2.3):The 5S process to organize the workplace

(source : (Gapp, Fisher, & Kobayashi, 2008))

34

Bicheno (2004) suggests that healthcare organization should prioritize things per

requirements and put them in right order.

Sort also should be performed in a regular basis, every six months depending on

the healthcare organizations; When sorting is well implemented, communication

between workers is enhanced and service quality are increased (Aherne, 2007). Set is

the second stage of 5S which is contains the orderly arrangement of desired items so

they are easy to use and accessible for anyone to find (Atkinson, 2004).

Every work, workers, equipment, parts, and instructions should be arranged in its

place and it is easier to find from the standardized locations (Bicheno, 2004). Shine is

the third stage of 5S and it is about keeping the workplace clean and swept (Morrow

and Main, 2017), this stage maintains a safer work area and problem areas are quickly

identified. In some organizations, cleaning is adopted every day for five minutes, so in

the end of the week, everything is restored to its place and looked tidy (Bicheno, 2004).

This step ensures that the workplace is prepare and ready for the next user and that

order is sustained.

The fourth stage of 5S is Standardize which is involves setting up a consistent

approach for implementing process through the organization so that employee will be

enabled to follow that process while working. Ensure standard procedures and setups

throughout the process to promote inter changeability (Morrow and Main, 2017).

Sustain is the last stage of 5S is the discipline and commitment of all other stages and

updating on continuous basis. Without sustaining the workplace can easily revert back

to being dirty and chaotic Sustain involves everyone in healthcare organizations with

the aim to make future involvements (Bicheno, 2004).

Manos et al. (2006) explained an example of 5S pathology department, which

showed great improvements of reduction of floor space usage by 40% and increase of

storage space by 17% which led to improvement in satisfaction of employees and

patients; Also 5S and workplace organization can be cooperated in layout design to

reduce walking, excess motion, delays and potential errors in any work environment.

35

2.3.3.2 Kanban

Kanban is asystem to cotrol the release of materials in an operation by using

simple, visual signals this signals can help organizations to have products according

to customers' need. In this way healthcare organizations determined the optimal time

to aquire more materials from suppliers (Slack et al., 2007).

Morrow and Main (2017) illustrated an example of kanban in sevice sector is when

employees are facing problems wih customers, immediately give a sign to the

supervisor for help. In hospitals, this tool can be used in medicine stocks to carry lower

inventory.

Kanban tool aims to reduce costs by eliminating waste activity, design work sites

that can response to change quickly according to human dignity, mutual trust and

support, and allowing workers to reach their maximum potential. the most important

advantege of placing kanban system is to find the required equipment, medicines, or

supplies within less time.

In hospital settings, Kanban is also helpful tool to notify the completion of the

process to send another patient or even medicine supply (Poole et al., 2010).

2.3.3.3 Fishbone diagram (Ishikawa diagram)

This also called cause and effect tree diagram,which is helpful to specify the main

cause of problem. Organizations face various kind of problems, and when decisions

are making without understanding the main caues of the problem, then the problem

will reoccur which will cost additional money and time for the organization. Thus, it

is helpful to use the fishbone diagram to resolve problem by determining the root cause

(Morrow and Main, 2017).

2.3.3.4 Process mapping

Process mapping showing each activity of the process flow starting from the input

to all data that will lead to outputs. Road map considered as asimplest example of the

process map it provides all information about the critical steps and it helps to specify

the bottleneck to improve the flow of process. This is the best tool for the continuous

improvement wih any workplace (Anjard, 1998).

36

Table (2.4) presented some of the applicability in hospital setting stated by

Staccini et al. (2005). Waiting time is the most recurrent problem from patients’

standpoints in any given hospital. Process mapping helps to identify activities which

are non value added or produce a bottleneck. With correct use of process mapping,

hospitals can minimize the waiting time for the patients and increase the performance

(Staccini et al., 2005).

Table (2.4) : Application and usefulness of process mapping in Hospital (Source

: Staccini et al. (2005))

Application of process mapping Typical analysis questions

Waiting - time reduction Which steps are most time-consuming? Why?

Which steps add value and which do not?

Which steps are redundant, bottlenecks, or add

complexity?

Which steps result in delays, storage, or

unnecessary movement?

Quality Improvement

(Adverse events reduction, safety

requirements)

Is variation due to common or special causes?

What are the causes of defects?

Which variables need to be managed to have the

desired effect on the relevant quality or safety

characteristics?

How should the process be changed to reduce or

eliminate variation?

Which actions can be performed to prevent new

adverse or unexpected events?

Patient satisfaction measurement How do process performance data compare to

patient expectation and perceptions data?

Cost reduction What does it cost to operate the process?

Which steps cost most? Why?

Which steps add value and which do not?

What are the causes of cost in the process?

2.3.3.5 Red tag technique:

This tool is used to coordinate between the team on the objects that are not essential

or do not work. It is necessary to decide which one to classify in red tag, where to store

37

these unnecessary items and how long to hold them (Morrow and Main, 2017). This is

one of the actual methods to category the unnecessary items within the workplace.

2.3.3.6 Value stream mapping:

Kollberg et al. (2006) states that value stream mapping is acritical tool that assists

to map all the activities in process by analyzing the flow so as to identify and eliminate

non value added one. Also, This tool is used in pre design as a useful methoed to

analyze and redesign the flow and activities within the whole health care organization

organization work that will occur in the space (Manos et al., 2006).

By value stream mapping tool to improve final service, information and material

will be required. Understating the flow of process in detail, it will help to identify the

waste that occurs within that process . Consequently, To gain the best outcomes and

accurate value stream map, healthcare organizations should develop it by involving all

stakeholders who are responsible for those activities (Morrow and Main, 2017).

Value stream mapping is significant tool, which includes frontline staff in the

process of problem identification and coming up with results (Fillingham, 2007). For

xample, in hospital, it includes mapping all activities by analyzing the whole process

from the moment patient comes until the treatment is finished (Kollberg et al., 2006).

According to Fillingham (2007), in trauma section service in Boston hospital, they

formed a team of physicians, nurses, therapists, managers and patients, who were

responsible to map patients’ journey in detail. They understood that they are delivering

poor service, because of identification of many non value added activities, errors and

duplication. It took nine months to make all improvements through different projects,

by ensuring senior leadership support, standardizing the work, setting equipments and

information in their place, reducing the length of patients’ stay by 33% and reducing

paperwork by 42% (Fillingham, 2007).

38

Figure (2.4): The value stream mapping examples from Wirral Hospital

( Source : Jones and Mitchell, 2006)

In Figure (2.4) is an example of Wirral hospital, which illustrated to understand

better the value stream mapping in the hospital setting. With this value stream

mapping, hospital was able to see that for 100 minutes of treatment, patients spend 610

minutes of their time and hospital spend 330 minutes of time.

This example clearly illustrates the amount of waste generated within the hospital

due to complex processes (Jones and Mitchell, 2006). Thus, in hospital setting, value

stream is helpful tool tostreamline the processes that are not value added.

2.3.3.7 Visual Management:

Is considered as a power tool in manufacturing, even service sector started to

implement it (Parry and Turner, 2006), visual management can apply during 5S

activity but can easily stand alone. Also, this tool is effective to improve the

communication and to provide the useful information through lights and signs to

customer or patient.

There are two kinds of visual management tool which are visual control and visual

display; visual controls that helps customer is know how long they have to wait for

39

their turn, Whereas, visual display includes charts and diagrams which are used to get

the message to employees or customers (Morrow and Main, 2017).

There are more lean tools that have application to facility design. However, by

applying just the later mentioned principles to the evaluation of process in

consideration of new space, teams will be able to reduce waste. Lean principles is not

to apply in pockets lean thinking should be involved throughout the entire design

process to maximize opportunity.

2.3.4 Benefits of Lean Implementation

Melton (2005) has highlighted the main improvements to be gained from adoption

of lean philosophy; these included the following: (a) lead time reduction for customers;

(b) less usage of inventory; (c) more efficient use of processes; (d) knowledge

management improvement; (e) cost savings and reduction in rework. With Lean

competitive advantages are achieving, financial position and process are improving,

also process standardization as well as quality are increasing (Sohal and Egglestone,

1994).

Sohal and Egglestone (1994), in a study amongst manufacturing companies in

Australia discussed that 74% of them experienced structural changes by levelling their

structure because of the implementation of Lean. Furthermore, other changes that

brought benefits were reducing the workforce, employing multi tasks employees, as

well as employee empowerment, which increased their autonomy.

Regarding the effects of using Lean, Petersson et al., (2010) reported appositive

impact on employees' competence, work completion, customer satisfaction and on the

financial benefits on the organization. Furthermore, Hanna (2017) explained that the

use of Lean can help organization to develop their way of problem resolving

capabilities and standardization. Also, it encourages empowerment of employees, and

enables organizations to achieve competitive advantage with high quality, faster

delivery time and delivery reliability (Petersson et al. , 2010).

Atkinson (2004) through his study indicates that Lean can aid in the financial

services and gives an example of financial services that benefited from Lean. Their

aim was to make the credit approval process easier so as to improve customers' service.

40

The problem was the multifaceted process that included several steps. The time to

complete the process was reduced by 60% through eliminating fourteen steps.

Lean tools benefited Healthcare services, such as mapping techniques and waste

reduction. These tools were useful to identify activities through processes that did not

add value (Piercy and Rich, 2009). Westwood et al. (2007) highlighted the benefits

that hospitals gained from Lean implementation which are Patients treated faster,

Patient flow improved, Best use of capacity, Waste reduced, Cost savings, Shorter

waiting times, Increased productivity, Reduced length of stay, more patients treated,

Safer and more reliable services, Improved staff morale and Standardized procedures

and equipment.

All these benefits aided the hospital to deliver the quality services more efficiently.

These Lean improvements should be done on continuous basis to sustain in the long

term. In similar context, Massey and Williams (2006) conducted an intensive

managerial training program for senior managers to make Lean transition in NHS UK.

This brought benefit to the company because it was about managing and performance

change, business techniques. Also, this training enhanced senior managers’

commitment and their readiness to initiate change in organizations.

Table (2.5) summarizes these benefits in service sector in various industries with

Lean implementation.

41

Table (2.5) : Benefits of Lean practice in Healthcare industry

Number of authors agreed in two benefits from Lean implementation, where one

is related to people that Lean will enhance the morale and increase competence of the

staff and another benefit is linked with process that standardized process and

(D.

Fo

lin

as &

Far

un

a, 2

011

)

(Pet

erss

on

, Jo

han

sso

n,

Bro

man

,

Blu

cher

, &

Als

term

an,

20

10)

(Pap

ado

po

ula

s, 2

01

1)

(Rex

hep

i &

P.

Sh

rest

ha,

20

11

)

(Mas

sey

& W

illi

ams,

20

06

)

(Wes

two

od

, Ja

mes

-Mo

ore

, &

Co

ok

e, 2

01

7)

(Pie

rcy

& R

ich

, 2

00

9)

(Han

na,

20

17)

Lean Benefits

* * * *

Increased employees

‘competence, improved staff

morale and reduced stress for

employees.

* Reduced time of work

completion.

* * * Improved customer satisfaction.

* * * Improved financial benefits to

the organization.

* Enhanced Problem solving

capabilities.

* * Standardized procedures and

equipment.

* * Striving to perfection by

identifying activities that did not

add value.

* Improved Patient flow.

* * Patients treated faster, safer and

more reliable.

* Best use of capacity, cost

savings, and waste.

* * * Reduced waiting times.

* * Reduced length of stay.

* Increased productivity.

* Increased senior managers’

commitment and readiness to

initiate change.

Literature reviews

42

procedures which will increase the efficiency (Melton, 2005; Sohal and Egglestone,

1994; Petersson et al., 2010; Hanna, 2007; Westwood et al. 2007).

2.3.5 Lean Criticisms

Lean manufacturing reduces costs, lead times, and inventory requirements, ensures

greater productivity, and brings about overall efficiency. Lean manufacturing also

comes in for much criticism, many organizations started to examine and improve their

transformation process.

Usually, some were successful, but there were also many failures. It was claimed

by Garrahan and Stewart (1992) and Williams et al. (1992) that Lean does not give

enough considerations to people.

Therefore, to have successful implementation of Lean for any industry, it is crucial

to motivate and empower employees, including shop floor workers, who play

significant role in identifying waste, a general view of sound studies revealing that

only one third of the hospitals trying to implement lean production achieved the results

expected. May hospitals failed to adequately implement the lean tools and techniques

According to Hayes et al. (2005).

One critique argues that the focus of organizations in short term benefits disregards

the advantages in the long run This is because they are uncertain to spent time and

make investment in innovation as the return is difficult to quantify in financial terms;

therefore, those ideas might be seen as waste (non- value added).

Worley and Doolen (2006) agree that if management does not uphold investment

in Lean implementation, it can minimize the efforts of employees toward innovative

ideas for improvements.

Also, according to Womack et al. (2007); (Chen et al. 2010) the time was fateful

for generating ideas between team to make improvements. Companies do not

implement Lean properly, because they try to minimize cost by cutting off the

workforce, and giving multiple tasks to the remaining employees.

By implementing lean concept organizations hold the best employees, who feel

motivated to work harder as they are the most respected people in the organization,

43

but employees may lose expertise in their special areas also innovation may decrease

due to the stresses in the work environment so that employees lose the feeling of job

security as organizations need more achievements with fewer employees (Chen et al.,

2010).

Another pitfall of Lean discussed by Chen et al. (2010) is the elimination of all

wastes because organizations may lose eliminate the creative times that are necessary

to innovations and focus on short-term value-adding activities and lose long-term

competitive capability through radical innovations.

Moreover, when companies try to change technologies to produce products and

services that customers want, they can end up with disruptive technology and

innovation, which is valued by customers only in short terms. Indeed, reducing only

the costs does not mean that the companies can be sustainable in long run.

Therefore, when implementing Lean, they should focus also on market demands

and technology trends in order to be competitive and innovative continuously (Chen

and Lindeke, 2010). Hines et al. (2004) highlighted these Key aspects of lean criticism

are the lack of contingency and ability to cope with variability, the lack of

consideration of human aspects, and the narrow operational focus on the shop-floor.

2.4 Traditional versus ‘Lean-Led’ Operational Process Improvement

based Hospital Design

Every single phase of the typical design – bid – build method is support with

chances to reduce cost and minimize timelines with improving the quality of the

building. This comparison presents the difference between the traditional and lean led

design. IT also display that lean led design can Improve operational process and

maximize efficiency.

2.4.1 Traditional Design

In traditional design the architects lead the design phases, drawing up some general

options based on experiences of health care organizations managers, then they prepare

design development drawings, and then construction drawings once it finished the

project is announced for bids If the price of contractor’s bid is acceptable, the owner

44

will sign a contract with the contractor and construction can then start. Traditional

design includes the following phases:

2.4.1.1 Master Planning

Chambers D. (2010) defined master planning stage as how healthcare

organizations will continue to renew themselves through the next 20 years. Over time,

whole departments of the healthcare organizations need to be remodeled, removed, or

replaced. Master planning emphasis on understanding the whole sequence in which

the whole work will be done in coming years (Graban, 2011).

Reiling (2007) has investegated that in traditional master planning, the concentrate

is on architecture, rather than on process and operations. Architects understand the life

expectation of current building and where the next expansion is most suitable, they

prepare and forecast drawings, diagrams and renderings of what the building could

appear in the future (Chambers D. , 2011). Graban (2011) has highlited that traditional

master plans don’t investigate into what could do to maximize the current operations.

For example, does the Emergency Department (ED) really need to be extended, or

could internal process improvements make capacity by improving flow? Those

opportunities and questions are left on the table in traditional design.

2.4.1.2 Predesign

The architectural staff is in the lead, guiding healthcare managers through the

basics, like where to establish the building, how high it may be, and so on (Atkinson,

2004). At this stage, main blocks of functional areas, along with a rough budget and

time frame (Verderbers and Fine, 2012). Aherne (2007) stated that the project team,

led by strategic and medical operations consultants, guides facility staff through a

design process. Reiling (2012) Presented that programming starts during this stage,

and it consists of two components as follows:

▪ Functional program: -

This narrative document defines the basic assumptions for example, the number of

patient visits the new ED will accommodate and whether it includes a fast track option,

for how many hours per day.

45

▪ Space program: -

This document inclines all the spaces that will be required. The proposed ED, for

example, may need a waiting room of 1,000 square meter to accommodate 40 people,

the restrooms, the registration area, and all of the spaces needed to complete the

project.

Based on operation models, data forms from historical and project volumes and

formulas made over time by experience on other projects planners can determine the

size and volume of rooms and medical departments (Chambers D. , 2010). Space

calculation are sometimes directed toward the way in which the last few projects are

implemented, rather than toward the actual need of the customer (Lee, 2011).

Anjard (1998) Stated that after traditional programming is accomplished, the

architect starts bubble diagrams and stacking and blocking departments; this is the

point at which the project starts to be cast in stone so, changes after this are potential,

but expensive.

Angueloy et al. (2009) furthermore, appointed out that the results of programming,

the architectural staff usually offerings two or three options for the design; those

options are shared with user group that usually contains department managers and,

sometimes, some frontline workers.

The end of programming determine milestone in the project: healthcare executives

have to sign off on the selected model before schematic design starts because main

changes after this will be hard to make (Bell and Orzen , 2011). In this traditional

model, healthcare managers are asked for this commitment before they have extremely

examined how their processes will work in the new space (Verderbers and Fine, 2012).

2.4.1.3 Schematic Design

Thompson (2006) Said that Schematic design starts after the architects return back

with a more differentiated floor plan. In this stage the major structural piece's columns,

stair wells, elevators, are finalized as well as the public areas are differentiated from

service and staff areas.

46

Angueloy et al. (2009) furthermore, explained that the health care organization

identifies its goals and budget and determines which patient floors will be affected.

Department managers and selected staff members form user groups are review the

plans to give feedback (Verderbers and Fine, 2012). According to that Chambers D.

(2010) proposed that with the end of schematic design stage, departments are

established and no longer movable, and the design is frozen; Due to so many big

decisions have been taken quickly, traditional schematic design can be a time of

conflict and confusion between staff, managers, and architects, Finishing this stage of

work can take months.

2.4.1.4 Design Development

Thompson (2003) stated that throughout design development stage, refinements

become precise. Only now, after crucial building elements are cast in stone, user

groups start to discuss whether the new space meets their operational needs.

At this stage, the architect designs a floor plan, elevation and section details and

takes into consideration things like internet technology, telecommunications,

mechanical and electrical systems. Interior space is considered, creating that balance

of beauty, function, and cost. The general contractor is probably involved and is

investigating the work for feasibility and cost (Grunden, 2007).

2.4.1.5 Bidding, Documents and Construction

Lichtig (2005) pointed that stakeholder of the user groups is complete in this stage

regardless whether traditional or Lean led design has been used to this stage. In this

stage architects prepare the construction documents for presentation to the

construction manager; the construction documents interpret the final decisions into

detailed drawings that will decide what kind of facility the general contractor and

subcontractors will construct (Wanger , 2010).

The project manager, engineers, architect, and perhaps even the sub-contractors

may have individual contracts with the healthcare facility, Managing the work through

these groups while maintaining the schedule is difficult and can become a source of

friction, cost overruns, change orders, and delay; Communication through all parties

must be maintained (Wellman et al., 2011).

47

2.4.1.6 Move in/Post occupancy

Verderbers and Fine (2012) Pointed out that in this stage the new building, with its

new technology and spaces technology, is ready for occupancy; Engineers and

architects take key healthcare organizations staff through the exercise of building

commissioning, showing them how the new facility operates, HVAC systems work,

how physical plant, how the alarm system operates, and so forth.

Moving into a new healthcare facility requires careful planning that begin well

before construction trimmings (Reiling J. , 2012). After about a year, the construction

and architect team will check back to determine whether the facility is being used as

designed, what works well, and what more can be taught (Lee, 2011).

2.4.2 Lean Led Design

Lean led design starts with Lean process design. The more Lean thinking considers

the work environment and culture, the more involved the frontline staff are, the more

committed the leaders are, and the better the facility design will be. Managers must

seek to understand, use systems thinking, and involve others. Lean led design way

includes nine stages as follows:

2.4.2.1 Master Planning

Achanga et al. (2006) highlighted that the objective of master planning is to remain

the development of a long vision of how construction projects in MDC industry will

fit together to make a continuously renewing healthcare organizations. Healthcare

organizations learning Lean thinking tend eliminate departmental barriers and patient

handoffs, also how healthcare will be delivered in the future (Lee, 2011).

Atkinson (2004) defined master planning as the stage in which data have been

collected about different service areas, observing each area and mapping at a general

level the flow in which process is currently done. Using data from these current state

value stream maps, healthcare organizations managers can make decisions about how

service lines could integrate together better in the future (Chambers D. , 2011).

In this stage the decision to standardize the healthcare organization's rooms have

been taken to make the design much easier for architects to accommodate (Reiling J. ,

48

2012). Toyota’s model for efficient development of designs and items is named 3P for

product (service to patients or customers), process, and preparation (Liker J. , 2004).

3P can be used through facility design, from the general strokes of master planning to

the deep details of move in, 3P is essential for operationalizing the staff’s great ideas

about the technique in which processes should happen; The master 3P done through

master planning examines possible changes to the service lines that will be affected by

the project in MDC industry (Larson and Greenwood, 2004).

2.4.2.2 Predesign

Healthcare organizations leaders began predesign by looking at the way in which

current processes are done at the front line and planning how they could best be done

in the future (Lee, 2011). Atkinson (2004) Stated that while architects are valued team

members at this point, the healthcare organization is still in the lead. Actually, the

architect could be seen as the customer at this stage willing to receive the process

information that will inform and update design (Aherne, 2007).

Nobody interconnects to a nurse like another nurse, Architects are very thoughtful

and caring people, but they live in a different world; Nurse leaders with knowledge of

architecture assist them press beyond the architectural question to the operational

question that affects design (Ahamd & Din, 2010). Baldwin M. (2012) Reported that

architects are better when they can accurately understand clinicians’ desires.

2.4.2.3 Value Stream Mapping

Peter & Nich (2005) Indicated that first step in value stream mapping is firsthand

observation which is provide a flow chart that shows a process from start to finish. In

this stage a multifunctional team of employees have been taken on a waste walk to

observe the process from the perspective of the patient to isolate value added activities

those for which the patient would be willing to pay from non-value added activities,

But a process map does not essentially reflect the point of view of the patient (Seth &

Panigrahi, 2015). The team will soon need more details, which are best provided over

value stream mapping.

A.Abdulmalek and Rajgopal (2007) said that the observation provided sufficient

data to convince decision makers to upgrade the area, significantly, the value stream

49

mapping exercise itself is a way to build consensus among team members. Luyster et

al. (2003) agreed that to complete conceptual and predesign in a Lean thinking it way

will take longer up front, but the patience pays off not only is additional information

exposed early, but it is also extremely important and valuable process information that

is unobtainable any other way.

(Reiling & Knutzen, 2004) Also, explained that by Lean led design programming

changes too, Traditional design allocate spaces right away and fit functions into them

as time goes by. With Lean led design, understanding process is the considerable issue,

the architect will not determine the number of rooms, for example, but rather wait to

let the process expose the appropriate number (McIvor, 2001).

2.4.2.4 Schematic Design

The advantage of understand the whole process with the creativity of architect and

staff starts to pay off with a more efficient and much quicker schematic design

(Verderbers and Fine, 2012). Peter and Nich (2005) stated that with this stage, the

team will have moved beyond value stream mapping and into even more detail,

completing its master 3P a disciplined, quick method to start trialing with designs that

will support the future state. The purpose is to try several ways to simulate designs

quickly, using the humblest of materials such as paper clips, Legos, masking tape,

chairs, etc. While these 3P simulates may not be full size, they let staff to conduct

quick process simulations (Baldwin et al., 2010).

2.4.2.5 Design Development

(Reiling & Knutzen, 2004) pointed out that by traditional design, contributors meet

discretely or in one long, exhausting meeting with the interior designer,

telecommunications, the lighting, plumbing, mechanical and medical equipment

experts, and so forth. Through Lean design, these specialists come in at strategic points

in several 3Ps which mean that space has been made in the size and configurations

needed to hear front worries and offer targeted resolutions, in context, Also, by this

stage drawings are already many layers deep (Freire and Alarcón, 2002) .

50

2.4.2.6 Bidding and Construction

Poor problem seeking was the beginning of waste in the project delivery process

and it doesn’t stop there queues, handoffs, and rework are rampant in project delivery;

In a hopeful development, new thinking and new tools have initiated to address the

eight wastes as they happen in project delivery (Ahamd & Din, 2010). Powerful

building information model (BIM) new software has begun to transform facility

planning and to link the lines between engineer, architect, designer, technician, and

construction manager (Azhar, 2011). In addition to the potential of cross-discipline

interaction among integrated project delivery (IPD) picked up steam as well, both

developments promise better efficiency in large building projects (Appiotti et al.,

2010).

2.4.2.7 Building Information Model

Joannides et al. (2012) Stated that BIM software is the most widespread and

advanced design technology currently available, The BIM image is a realistic, three

dimensional model that can layer in every detail and track proposed building changes

in real time.

BIM makes these detailed images using parametric modeling, which means that it

can control and manipulate large parameters among all the fields of a building project;

Parameters include shapes and sizes of spaces and their orientations, relationships,

natural lighting, whereabouts, changes in building components, quantities, and cost.

Parametric modeling tracks all phases concurrently (Azhar, 2011).

Baldwin M. (2012) Furthermore, pointed out that with BIM the potential grows to

build increasingly sophisticated functional systems for designing, modeling and

fabricating buildings. BIM can deal with greater levels of detail and complexity than

has ever been possible before; the software is designed to remedy detailed knowledge

as well as the type of information that Lean-led design assists to make (Elmualim and

Glider, 2013).

2.4.2.8 Integrated Project Delivery

Integrated project delivery (IPD) also called integrated facility design (IFD), IPD

give a single contract for all of the major stakeholders in a project engineer, architect,

51

construction trades, etc.; Meeting project deadlines and closing dates becomes a group

effort, and all responsibilities are shared (Aherne, 2007) .

Appiotti et al. (2010) Investigated that IPD requires major changes in the

traditional typical of design bid build, which depends on individual contracts for each

field and makes coordination a problem. Instead, IPD relies on close coordination and

collaboration through all project stakeholders’ owner, engineers, architects,

subcontractors, builders, building inspectors, and more from concept among

completion, because bidding and negotiation are attached into this process all along,

they need no extra time at this point in the project (Lee, 2011).

2.4.2.9 Move-in or post occupancy

Verderbers and Fine (2012) stated that commissioning of the building continues as

it does with the traditional design; when in-house facilities worker understands the

infrastructure of the new building. The customers for this stage are the patients who

will be benefiting from the new space. Table (2.7) summarized the Lean Led Design

Factors according to items that have been presented above.

The previous discussion describes the steps in the architectural design process,

examining the differences between traditional architectural design and lean led design

which is summarized in the following Table (2.6).

52

Table (2.6) : Traditional versus Lean-Led Architectural Design Philosophies

(Source : Verderbers and Fine (2012))

Traditional architectural design Lean-led design

Focus on design Focus on adding value for customer

patient

Starts with a functional and space

program

Starts with observation at the point of

work User groups (staff leaders within a

department or service)

Value-stream-focused teams (key

stakeholders involved across the whole

process of delivering the service to the

patient) used to analyze processes

Each user group provides feedback to

designers without benefit of

understanding.

Multidisciplinary consensus-based, future-

state processes drive the development of

the floor plan

Floor plan diagrams are adjusted to

accommodate the way the hospital

currently works; anticipated process

improvements remain unclear, undefined

Floor plan diagrams are used to validate

the value stream, optimize future

improvements.

53

Table (2.7) : Summary of Lean Led Design Factors

Literature reviews

Lean Led Design Factors

(Lee

, 2

01

1)

Ach

ang

a, E

. S

heh

ab, &

Nel

der

,

(20

06

)

Ch

amb

ers

D.

, 2

01

1

(Rei

lin

g,

20

12

)

Lik

er J

. ,

20

04

Lar

son

& G

reen

wo

od

, 2

00

4

(Ah

ern

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007

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(Ah

amd

& D

in,

201

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Bal

dw

in ,

20

12

Atk

inso

n,

(20

04)

Pet

er &

Nic

h,

(20

05

(Set

h &

Pan

igra

hi,

201

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A.A

bd

ulm

alek

& R

ajg

op

al,

(20

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)

app

ing

, L

uy

ster

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Sh

ulz

er, 20

03

G.R

eili

ng

& L

.Kn

utz

en, (2

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(McI

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der

ber

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012

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in,

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stin

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assa

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ho

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larc

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pio

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Ber

tels

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T.,

201

0

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ar,

201

1

Joan

nid

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Olb

ina,

& I

ssa,

(20

12

)

Elm

ual

im &

Gli

der

, 2

013

(Gru

nd

en,

20

07).

Standardize the spaces at master

planning stage. * * * * * * *

Improve the understanding of

workflow at master planning

stage.

* * * * * * *

Enhance the conversation with

engineer’s leaders. * * * * * * *

Lean lead design can make sound

decisions early. * * * * * * *

Examines potential changes to the

service line that will be affected

by the project during master

planning stage.

* * * * * * *

Improve the process of

information at pre design stage

that will inform design.

* * * * *

54


Literature reviews

… continued.


(Lee

, 2

01

1)

Ach

ang

a, E

. S

heh

ab, &

Nel

der

,

(20

06

)

Ch

amb

ers

D.

, 2

01

1

(Rei

lin

g,

20

12

)

Lik

er J

. ,

20

04

Lar

son

& G

reen

wo

od

, 2

00

4

(Ah

ern

e, 2

007

)

(Ah

amd

& D

in,

201

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Bal

dw

in ,

20

12

Atk

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n,

(20

04)

Pet

er &

Nic

h,

(20

05

(Set

h &

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igra

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201

5)

A.A

bd

ulm

alek

& R

ajg

op

al,

(20

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)

app

ing

, L

uy

ster

, &

Sh

ulz

er, 20

03

G.R

eili

ng

& L

.Kn

utz

en, (2

00

4)

(McI

vo

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der

ber

s &

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012

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dw

in,

Au

stin

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assa

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& T

ho

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20

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T.,

201

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201

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nid

es ,

Olb

ina,

& I

ssa,

(20

12

)

Elm

ual

im &

Gli

der

, 2

013

(Gru

nd

en,

20

07).

Understanding the way in which

current process are done at the

first line and planning how they

could be done in the future.

* * * * * *

Support design decision making

by the observation that provided

enough data to persuade them.

* * * * * *

Improve consensus among design

team members at value stream

mapping stage (visual analysis of

the flow of information and

material during each process).

* * * * * *

Try different ways to mock-up

designs quickly using the

humblest materials at schematic

design.

* * *

55


Literature reviews

… continued.


(Lee

, 2

01

1)

Ach

ang

a, E

. S

heh

ab, &

Nel

der

,

(20

06

)

Ch

amb

ers

D.

, 2

01

1

(Rei

lin

g,

20

12

)

Lik

er J

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20

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Lar

son

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od

, 2

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ern

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(Ah

amd

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20

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n,

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Pet

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h,

(20

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201

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A.A

bd

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& R

ajg

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(20

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app

ing

, L

uy

ster

, &

Sh

ulz

er, 20

03

G.R

eili

ng

& L

.Kn

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en, (2

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(McI

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der

ber

s &

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dw

in,

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, H

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ho

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10

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pio

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Ber

tels

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T.,

201

0

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ar,

201

1

Joan

nid

es ,

Olb

ina,

& I

ssa,

(20

12

)

Elm

ual

im &

Gli

der

, 2

013

(Gru

nd

en,

20

07).

Allow engineers to conduct quick

process simulation. * * *

Allow experts come in at strategic

points in various 3Ps (that helps

teams conceptualize, design and

refine work as the project

unfolds) to hear frontline

concerns and offer targeted

solutions.

* *

Start to use powerful new

building information model or

(BIM) software where all design

and construction decisions can be

recorded to blur the lines between

architect, engineer and designer

and construction manager.

* * *

56


Literature reviews

… continued.


(Lee

, 2

01

1)

Ach

ang

a, E

. S

heh

ab, &

Nel

der

,

(20

06

)

Ch

amb

ers

D.

, 2

01

1

(Rei

lin

g,

20

12

)

Lik

er J

. ,

20

04

Lar

son

& G

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wo

od

, 2

00

4

(Ah

ern

e, 2

007

)

(Ah

amd

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in,

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dw

in ,

20

12

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n,

(20

04)

Pet

er &

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h,

(20

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(Set

h &

Pan

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hi,

201

5)

A.A

bd

ulm

alek

& R

ajg

op

al,

(20

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)

app

ing

, L

uy

ster

, &

Sh

ulz

er, 20

03

G.R

eili

ng

& L

.Kn

utz

en, (2

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(McI

vo

r, 2

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1).

Ver

der

ber

s &

Fin

e, 2

012

Bal

dw

in,

Au

stin

, H

assa

n,

& T

ho

rpe,

20

10

Fre

ire

& A

larc

ón

, 2

002

Ap

pio

tti,

Ber

tels

, &

T.,

201

0

Azh

ar,

201

1

Joan

nid

es ,

Olb

ina,

& I

ssa,

(20

12

)

Elm

ual

im &

Gli

der

, 2

013

(Gru

nd

en,

20

07).

Create detailed image of one floor

or one department images using

parametric molding

* * * *

Manipulate large parameters

across all the disciplines of a

building project.

* * * *

Entrance coordination among

disciplines of building project and

clash detection.

* * * *

BIM can handle greater levels of

detail and complexity than have

over been possible before.

* * * *

Promise to improve design

results. *

Save waste from entering the new

physical environment. *

57

2.5 Healthcare Performance in Medical and Design Construction Industry

Healthcare organizations are faced with barriers and opportunities from a rapidly

changing operating environment, including increasing expectations on the quality of

healthcare. Lean concept originally developed in the automotive industry to deliver

high quality product and services while improving organizational performance and

satisfying customers.

2.5.1 Financial and quality performance

Number of healthcare organizations aim to decrease cost while improving quality,

patient satisfaction and outcome when applying lean in healthcare organizations.

Koning et al. (2006) investigated in their study that applying lean in healthcare

organizations can control healthcare cost increased. Papadopoulas (2011); Rexhepi

and Shrestha (2011); D. Folinas (2011) agreed with Koning et al. (2006) and said that

successful in applying lean in healthcare organizations can increase higher quality as

well as income and lower cost for organization. Hence, financial performance is

one significant performance measurement in healthcare organizations.

2.5.1.1 Actual project costs compared with planned budget.

Cost performance is significant indicator of project success which is used by all

stakeholders (Li, Arditi and Wang, 2012). It is always use to measure and evaluate

project performance against the estimated objective and it present organizations

profitability and productivity (Meeampol and Ogunlana, 2006). Time and cost are

measured in pre-construction and construction phases in lean led design way because

for design projects, price and time actually are important to success (Chan et al., 2002).

Construction time usually relates to the actual cost because increasing construction time

always results in extra cost to the entire project (Meeampol and Ogunlana, 2006; Ahsan

and Gunawan, 2010).

58

2.5.1.2 Work integration from different stakeholders to agree on detail construction

methods and specifications

P. C. Smith (2008) stated that coordination between stakeholders were constructed

on the roles and responsibilities of main parties. Integration from different stakeholders

required uniting the expertise, knowledge and information of many parties that support

project completion, well-developed relations between vital implementation parties

sharing vision among the operators and service benefactors for project deployment

activities, testing and verifying performance after every process completion, trust and

confidence amid organizations, and meetings to exchange concepts, designs and

dealing with conflicts (Balle and Regnier, 2007).

Poksinska (2010) Said that in construction projects, due to coordination

consideration project parties, a significant performance improvement has been

obtained. The coordination issue in the human resources of the projects has been

addressed directly (Fulford and Standing, 2014).

2.5.1.3 Offsite fabrication manage and deliver them to the onsite work as; design

modifications and change orders

N G and Price (2010) identified Off-site fabrication in construction as the process

of planning, designing, fabricating, transporting and assembling construction building

elements for rapid site assembly to a greater degree of finish than in traditional

piecemeal on-site construction.

2.5.1.4 Gathering information on deficiencies/ambiguities, in drawings and

specifications, and resolved them.

Kim and Jr., (2003) stated that gathering information on deficiencies and

ambiguities, in drawings and specifications, sharing experience in implementation

approaches and concerning work methods, reporting on the progress status and

developments, and written notes, such as letters, Offsite fabrication manage and deliver

them to the onsite work as; design modifications and change orders , including written

contract clarifications the previous mentioned factors considered as the most important

factors that affect construction project performance.

59

2.5.1.5 Providing accommodation assisted project according to requirements as;

storage space, scaffolding, plant, power, water, etc.

Site coordination is vital to improve construction projects performance. In Hong

Kong building projects, sixteen coordination factors were classified into three groups:

staffing, technical and management system (NG and Price, 2010). The most effective

factor reported is providing accommodation assisted project according to requirements

as; storage space, scaffolding, plant, power, water, etc.

2.5.1.6 All relevant stakeholders should be warn to protect the completed parts

Iyer and Jha (2006) pointed out that healthcare construction projects performance

status is affected by a large number of elements which can relate to different

diminution such as top management support, project managers' competence,

monitoring and feedback by the stakeholders and decision making process who can

protect completed parts.

2.5.1.7 Compliance to directives from the relevant engineer and revising working

programs accordingly.

It is important to realize that compliance to directives from the relevant engineer

and revising working programs accordingly improve the project progress with high

satisfaction status (Malone and Crowston, 1994).

2.5.1.8 Quantity and costs of variation orders.

Variation orders considered as basic problem in Palestinian construction industry.

The recurrent and continuous closure of borders crossing leads to create severe shortage

of construction resources; Number of projects are either on hold or subjected to major

variations due to shortage of construction resources (Enshassi et al, 2007). Table (2.8)

summarized factors that affect financial and quality performance according to items that

have been presented above.

60

Table (2.8) : Summary of factors that affected financial and quality performance

Financial and quality

performance factors

(Ensh

assi

et

al, 2007)

(Mal

one

& C

row

ston,

19

94)

Iyer

& J

ha,

(2006

)

(NG

& P

rice

, 2010)

Kim

& J

r., (2

003)

P. C

. S

mit

h, (2

008)

(Bal

le &

Reg

nie

r, 2

007)

(Poksi

nsk

a, 2

010)

(Fulf

ord

& S

tandin

g, 2014)

(Li,

Ard

iti,

& W

ang, 201

2)

(Mee

ampol

& O

gunla

na,

2006)

(Chan

, S

cott

, &

Lam

, 2002)

(Ahsa

n a

nd G

un

awan

, 20

10)

Actual project costs compared with

planned budget. * * * *

Work integration from different

stakeholders to agree on detail

construction methods and specifications

* * * *

Offsite fabrication manage and deliver

them to the onsite work as; design


*

Gathering information on

deficiencies/ambiguities, in drawings

and specifications, and resolved them

*

Providing accommodation assisted

project according to requirements as;

storage space, scaffolding, plant, power,

water, etc.

*

All relevant stakeholders should be

warn to protect the completed parts *

Compliance to directives from the

relevant engineer and revising working

programs accordingly

*

Quantity and costs of variation orders. *

2.5.2 Patient Satisfaction

Patient satisfaction is significant factor for evaluating and improvement of service

in health care organizations. Patient satisfaction is providing the basis for measuring

patient, departments and organizational outcomes (Cowinget al., 2009). As stated by

some researchers, there are some certain factors individually and collectively effect on

patient satisfaction in a positive or negative way, including:

Literature reviews

61

2.5.2.1 Healthcare service satisfaction and loyalty.

Satisfaction with different services such as meals, fees and comfortable

architectural spaces which is provided by healthcare organization were found to

positively affect loyalty (Boshoff and Gray, 2004). Dick and Basu (2004) stated that

ccustomer loyalty is both an attitude and a shopping behavior; assurance and tangibles

affected loyalty.

2.5.2.2 Physician role and patient behavior.

Ross et al. (1982) pointed that customers or patients in large multi speciality

healthcare organizations were more satisfied with physicians. Also ahigher contact

between role expectation and physician behaviour indicate more satisfied respondents

(Ditto et al., 2005).

Lovdal and Peerson (1989) highlited that physicians and other healthcare

organization personeels behaviour were central determinates of patient, attitudes about

healthcare organization as whole.

2.5.2.3 Trust in the context of healthcare.

Hall (2005) pointed that those who trust has an expectation that the trusted person

will act and behave with kindness and good manner towards them and with

competence in the field in which he or she is trusted.

2.5.2.4 Distance and hospital use.

Goodman et al. (1997) stated that certain service provide is increased by

availability. Naidu (2009) examined the relationships between distance from home,

primary care physician and hospitalization rates hand he found an inverse relationship.

2.5.2.5 Understanding hospital staff perceptions of patient priorities and perceptions.

Silvestro (2005) argues it is useful for healthcare organizations managers to

understand staff perceptions concerning patient expectations and perceptions. In the

same context Naidu (2009) through his study found that differences in staff

understanding patient priorities and perceptions did indeed emerge the study include

staff from different medical departments. Table (2.9) summarized factors that affect

patient satisfaction according to items that have been presented above.

62

Table (2.9) : Summary of factors that affected patient satisfaction

Patient Satisfaction

(Bosh

off

& G

ray, 2004

)

Dic

k &

Bas

u, (2

004)

Ross

, M

irow

sky, &

Duff

, (1

982)

(Dit

to, M

oore

, H

ilto

n, &

Kal

ish, 2005)

Lovdal

& P

eers

on,(

1989)

Hal

l (2

005)

Goodm

an e

t al

. (1

997)

Sil

ves

tro (

2005)

Nai

du, (2

009)

Satisfaction and loyalty. * *

Physician role and patient behavior. * * *

Trust in service oriented architecture in the

context of healthcare. *

Distance and hospital use. * *

Understanding hospital staff perceptions of

patient priorities and perceptions. * *

2.5.3 Employee Performance

Adopting Lean thinking in healthcare organizations had effect on employee and

work environment. Hence, employee could increase attention to eliminate non added

value activity through design process and more creative attitude to problem resolving

(Poksinska, 2010). Besides that, patient’s demands will be more respective by

engineers through implementing Lean thinking (Balle and Regnier, 2007).

Poksinska (2010) and Rexhepi and Shrestha (2011) furthermore, agreed that

employee can reduce stress and increased their morale by implementing lean in

healthcare.

As stated by some researchers, there are some certain factors individually and

collectively effect on the performance of employees in a positive or negative way,

including:

Literature reviews

63

2.5.3.1 Leadership style of the engineers

Leadership style of the engineers is a process whereby an engineer in a certain

field can influence a group of engineers to achieve the aimed goals (Doss & Orr, 2007).

Balle and Regnier (2007) said that leadership style is a group of attitude and behavior

of an engineer, which leads to a certain patterns of design that followers can deal with.

The leadership style within a healthcare organization has an influence on enhancing

employee’s performance (Armstrong and Murlis, 2004).

2.5.3.2 Coaching

Coaching considered an important tool to improve engineer’s performance

(Champathes, 2006). It is not a one-way communication and proves to be a two way

communications where engineer’s coaches determine what can be enhanced and how

it can be enhanced. Further coaching addresses the behaviors that impedes

performance (Toit, 2007).It can be further seen that coaching is all about assisting

someone new to improve performance (Starr, 2004).

2.5.3.3 Empowerment

Bartram and Casimir (2007) Stated that empowerment had significant effect on

both and satisfaction and performance, and definitely empowerment was more

powerfully correlated with the in-role performance of followers than with satisfaction

with the managers.

2.5.3.4 Participation management

In Chen and Tjosvold research (2006), they investigated that participation

management is about connecting engineers in the decision making process so they can

feel that they have the opportunity to discuss difficulties and problems as well as

influence healthcare organizational decisions.

Participation management considered engineers as partners in contributing to

organizational success so they will be motivated and so will avoid involving into

counterproductive behaviors henceforth improved performance over timely

achievement of organizational goals and objectives (Carrell et al., 1989).

64

2.5.3.5 Organizational Culture

Organizational Culture is values and behaviors of the people that considered as a

tool leads to the effective achievement of organization goals (Schein, 1990).

Organizational culture is the mindset of persons that differentiates them from each

other, within the organization of outside the organization. This take account of beliefs,

behaviors, and values of the employee’s variance from the other organization

(Hofstede, 1991).

A strong organizational culture supports adaptation and develops organization’s

employee performance by motivating employees to a shared goal and objective; and

finally modelling and directing employees’ behavior to that specific direction must be

at the top of functional and operational strategies (Daft and Weick, 1984) .

2.5.3.6 Motivate and train engineering staff

Motivation is a main determinant of job performance and unwell motivated force

will be costly in terms of extreme staff turnover, higher expenses, negative morale and

increased use of managements’ time (Jobber, 2004). Therefore, management must

know what exactly stimulates their staff so resources are dissatisfaction develops

through engineers (Jobber, 2004) .

Managers provide training to their engineers for three purposes (Belcourt et al.,

2012), which are (1) to increase productivity or the performance of employees; (2) to

achieve organizational goals; and (3) to invest in engineers to succeed in the

unpredictable and unstable engineering environment. There are three significant types

of training: training needs assessment (TNA), training contents and delivery

approaches, on the job training (OJT).

Table (2.10) summarized factors that affect employee Performance according to

items that have been presented above.

65

Literature reviews

Table (2.10) : Summary of factors that affect employee Performance

Employee Performance (J

obber

, 2004)

(Bel

court

, W

right,

& S

aks,

2012)

(Sch

ein, 1990)

(Hofs

tede,

1991

)

(Daf

t &

Wei

ck, 1984)

.

(Doss

& O

rr, 2007)

Bal

le &

Reg

nie

r, (

2007)

(Arm

stro

ng &

Murl

is, 2004).

(Cham

pat

hes

, 2006)

(Toit

, 2007)

(Sta

rr, 2004).

(Bar

tram

& C

asim

ir, 2007)

(Chen

&T

josv

old

, 2006)

(Car

rell

, K

uzm

its,

& E

lber

t, 1

989).

Leadership style of the engineers

(the combination of attitude and

behavior of a leader, which leads

to certain patterns in dealing with

the followers).

* * *

Coaching (what can be improved

and how it can be improved). * * *

Empowerment. *

Participation management

(involving employees in the

decision making process).

* *

Organizational culture. * * *

Motivate and train engineering

staff * *

Chapter 3

Research Methodology

67

Research Methodology

This chapter included information about the research design, population, sample

size, data collection, questionnaire design, questionnaire content, instrument validity,

pilot study, used processing, and analyzing methods of data. The approach undertaken

for this research comprised three components, a literature review, discussed in the

previous chapter, a questionnaire survey, and personal interviews.

3.1 Research strategy

The research strategy presented a general plan for what and how data must be

collected and how the results would be analyzed. The selected research plan will affect

the type and the quality of collected data (Ghauri and Grønhaug, 2010). To investigate

the research questions and hypotheses about adopting Lean thinking by engineers in

the MDC industry in Gaza Strip, a quantitative survey approach has been accepted.

3.2 Research period

The study started on May 2016 after the proposal was approved. The literature

review was completed at the end of February 2017. The validity testing, piloting and

questionnaire distribution and collection completed on the beginning of May 2017.

The analysis, discussion, conclusion and recommendation were completed at the

middle of August 2017.

3.3 Framework of the research methodology

A comprehensive methodology with development of questionnaires, validation of

survey instruments, collection of data, and verification of empirical findings has been

designed for this study, and can be broadly broken down into six major stages, as

described below. The detailed methodology of this study was illustrated in Table (3.1).

3.3.1 Stage one – development of theme

The first stage included definition of the problem, objectives development,

hypothesis development, and framework development.

68

3.3.2 Stage two – literature review

Selected literature on applying Lean thinking in MDC industry among healthcare

organizations provided the theoretical basis to develop the research framework for this

study. A set of factors related to every part extracted from the literature review to be

modified by a pilot study.

3.3.3 Stage three – pilot study

A pilot study was undertaken by participating 8 expert construction professionals

to pre- test the survey and subsequently modified before a final version was produced.

Clarity of questionnaire questions and their contribution to achieve the objectives were

checked before using it in the main survey. The questionnaire was modified based on

the results of the pilot study and the final list of variables was adopted to be used for

the study.

3.3.4 Stage four – the main survey

In this stage of the survey, a quantitative approach was used as the key statistical

component in the study, to get qualitative data over a self-administered questionnaire

by Gaza Strip construction professionals. In order to obtain reliable and representative

quantitative data, the questionnaires were distributed to construction engineers in

MDC industry.

3.3.5 Stage five – statistical analysis and results

Data collected was analyzed using both descriptive and inferential tools of

statistical software Statistical Package for Social Science (SPSS v24). The descriptive

tools used were percentages, Tables, mean, and standard deviations. In this study,

principle factor extraction with varimax rotation was performed through factor

analysis. To assess the suitability of the data for factor analysis, the Kaiser-Meyer-

Olkin (KMO) measure of sampling adequacy, and Bartlett‟s test of sphericity were

conducted. Spearman correlation coefficient was used for validity, Cronbach’s alpha

for reliability statistics, nonparametric tests (Sign test), etc.

3.3.6 Stage six – conclusion and recommendations

The final stage of the research included the conclusions and recommendations.

69

3.4 Research location

The research was carried out in Gaza Strip in Palestine, which consists of five

governorates: The Northern Governorate, Gaza Governorate, the Middle Governorate,

KhanYounis Governorate, and Rafah Governorate.

3.5 Research Population

In this research, the target group to be investigated was the healthcare

organizations. The total healthcare centers that were under study are 7 health care

organizations (5) of them are governmental healthcare organizations which are

(Rumah Sakit Indonesia- Northern Governorate, Al-Shifaa Medical Complex (SMC)

- Gaza Governorate, Al-Aqsa Martyrs Hospital- the Middle Governorate, Nasser

Medical Complex- KhanYounis Governorate and Abu Yousef Al Najjar Hospital-

Rafah Governorate) and the two others are one non-governmental which are

(UNRWA) and Public Aid Society (PAS). Healthcare organizations was the

population target group of this research.

3.6 Sample size and characteristics

To determine the sample size a comprehensive inventory method will be applied,

it’s the best way to collect data because it provides complete data on all parties of the

target study community. The respondents were selected according to the total number

of engineers who are working in the healthcare organizations on each governorate.

Eighty questionnaires were received back from the healthcare organizations in

different governorates.

The following summary showed the procedures done to collect the data:

▪ Number of healthcare organizations which is the target group of the research due

to March 2017 were (7) organizations.

▪ Number of questionnaires distributed was (85) questionnaires.

▪ According to the comprehensive inventory method used to determine the sample

size of the target group (85) questionnaires distributed.

▪ The total number of respondents was (80).

70

3.7 Questionnaire design

The questionnaire was initially planned based on the extensive literature review

of previous studies. Fifty-five studies were reviewed and studied in depth and

most of the previous studies used traditional by hand questionnaire, others used

Web-based questionnaire; others validated results of questionnaire using personal

interviews, three major stages were taken for constructing the questionnaire:

▪ Identifying and categorizing the first thought questions.

▪ Formulating the final questionnaire.

▪ The wording of questions.

Identification of items for the study and categorizing of the initial questionnaire

was a crucial step for the success of the research. A significant amount of work has

already been done on items of Lean CSFs, benefits, and challenges and barriers and

how it can affect the healthcare organization’s performance.

According to the review of literature belongs Lean thinking in the MDC industry,

a well-designed questionnaire was developed for the study. The questionnaire

consisted of close-ended (multiple choice) questions. Close-ended questions are more

difficult to design than open-ended questions, but they come with much more efficient

data collection, processing and analysis (Bourque & Fielder, 2003).The questionnaire

divided into five parts as follows (refer to Table (3.1)

71

3.7.1 Part one: which is related to the respondent ‘s demographic data and the way

of work performance.

3.7.2 Part two: to assess the readiness factors for lean implementation in service

oriented architecture by the engineers in the healthcare organizations in Gaza Strip.

3.7.3 Part three: to investigate the value of Lean benefits in the healthcare

organizations in Gaza Strip.

3.7.4 Part four: to investigate the critical success factors in the healthcare


3.7.5 Part five: to investigate the Lean challenges and barriers in the healthcare


3.7.6 Part six: to investigate the healthcare organization’s performance in lean

implementation in service oriented architecture

The initial questionnaire draft was designed to be reviewed by pilot study and

based on the results, the questionnaire framework was modified and refined (refer to

Table (3.1) for the refinement of questionnaire and to Appendix II for the final

questionnaire design), the questionnaire was provided with a covering letter explaining

the aim of the research, the target group, the security of the information to encourage

a high response, and the way of responding. The variety of the questions aimed first to

meet the research objectives, to cover the main questions of the study, and to collect

all the necessary data that can support the results and discussion, as well as the

recommendations in the research.

After answering the first part that related to the respondent ‘s demographic data

and the way of work performance, respondents were asked to rate each item in each of

the second, third, fourth, and fifth fields on a rating scale (five-point Likert scale) that

required a ranking (1–5), where 1 represented “the lowest scale” and 5 represented

“the highest scale”, as the case might be.

3.8 Pilot study

In order to test the appropriateness, reliability and validity of the scales before

committing to the complete sample population, a pilot study was undertaken by

inviting 12 professionals to review the questionnaire. These professionals were

72

selected with more than 10 years’ experience in construction work. Some of them

work in academic institutions and others in practical field. Pilot study was conducted

to adapt the instrument before using it in the main survey. Responses were then invited

to feedback on any comments in the design questionnaires and suggestions for refining

the survey instruments.

Pilot study was an effective way of improving question wording and avoiding

mistakes in the questionnaires. They allowed to identify potential problems and errors,

including improvement of wording for a better understanding of the questions. The

pilot study showed that some attributes were repeated, irrelevant, weak, or vague and

should be omitted. Other attributes were modified to suit Gaza Strip construction

professionals work nature and some attributes were added by pilot study. In addition,

the pilot study corrected some grammatical and spilling mistakes.

73

Table (3.1): List of selected factors and questions for final questionnaire

Factor Questions from literature Source Comments Selected Questions for this

study

Part 3: Beneficial Factors for lean implementation in service oriented architecture

Ben

efic

ial

Fact

ors


planning stage to make the

design much easier for architects

to accommodate.

(Lee, 2011), (Achanga, E.Shehab &

Nelder, (2006),(Chambers D. ,2011),

(Reiling, 2012), (Liker J.,

2004),(Larson & Greenwood,2004),

(Atkinson,2004)

Modified Standardize the spaces at master

planning stage.



stage to the detail of the future

state.

(Lee,2011),(Achanga, E.

Shehab&Nelder, 2006),(Chambers D. ,

2011), (Reiling, 2012), (Liker J. ,

2004),(Larson & Greenwood, 2004),

(Atkinson,2004)

Modified



stage.


hospital leaders by mapping at

value streams drilling down with

3p.

(Lee,2011),(Achanga, E.

Shehab&Nelder, 2006),(Chambers D. ,

2011),(Reiling, 2012),(Liker

J.,2004),(Larson & Greenwood, 2004),

(Atkinson, (2004)

Modified Enhance the conversation with

engineer’s leaders.

Lean lead design can make

sound decisions early which is

difficult to change them after

that.

(Lee,2011),Achanga, E. Shehab, &

Nelder, (2006),Chambers D. ,

2011,(Reiling, 2012),Liker J. ,

2004,Larson & Greenwood,

2004,Atkinson, (2004)

Modified Lean lead design can make sound

decisions early.

Examines potential changes to

the service line that will be

(Lee,2011),Achanga, E. Shehab, &

Nelder, (2006),Chambers D. ,

2011,(Reiling, 2012),Liker J. ,

Selected Examines potential changes to the

service line that will be affected

74


Factor Questions from literature Source Comments

Selected Questions for this

study

affected by the project during

master planning stage.

2004,Larson & Greenwood,

2004,Atkinson, (2004)

by the project during master

planning stage.




(Lee, 2011), (Aherne, 2007),(Ahamd

& Din, 2010),Baldwin ,

2012,Atkinson, (2004),,

Selected




Ben

efic

ial

Fact

ors





Peter & Nich, (2005,(Seth &

Panigrahi, 2015),A.Abdulmalek &

Rajgopal, (2007),apping, Luyster, &

Shulzer, 2003,G.Reiling & L.Knutzen,

(2004),(McIvor, 2001).,

Selected












(2004),(McIvor, 2001).,

Selected




Improve consensus among team

members at value stream

mapping stage.





(2004),(McIvor, 2001).,

Modified









design.

Peter & Nich, (2005,Verderbers &

Fine, 2012,Baldwin, Austin, Hassan,

& Thorpe, 2010,,,,

Selected




design.

Allow staff to conduct quick

process simulation.

Peter & Nich, (2005,Verderbers &

Fine, 2012,Baldwin, Austin, Hassan,

& Thorpe, 2010

Modified Allow engineers to conduct quick

process simulation.

75




study

Allow experts come in at

strategic points in various 3Ps to

hear frontline concerns and offer

targeted solutions.

G.Reiling & L.Knutzen, (2004),Freire

& Alarcón, 2002 Modified




refine work as the project unfolds)

to hear frontline concerns and

offer targeted solutions.

Ben

efic

ial

Fact

ors

Powerful new building

information model or (BIM)

software has started to transform

facility planning and to blur the

lines between architect, engineer

and designer and construction

manager.

(Ahamd & Din, 2010),Appiotti,

Bertels, & T., 2010,Azhar, 2011 Modified

Start to use powerful new

building information model or

(BIM) software where all design

and construction decisions can be


architect, engineer and designer

and construction manager.

Create detailed image of one

floor or one department images

using parametric molding

(Baldwin,2012),(Azhar,

2011),(Joannides,

Olbina&Issa,2012),(Elmualim &

Glider 2013)

Selected



parametric molding



building project.

Baldwin , 2012,Azhar, 2011,Joannides

, Olbina, & Issa, (2012),Elmualim &

Glider, 2013,,,

Selected



building project.


disciplines and clash detection.



Glider, 2013,,,

Modified



clash detection.






Glider, 2013

Selected




76




study

Promise to improve results. (Grunden, 2007) Modified Promise to improve design

results.

Save waste from entering the

new physical environment. (Grunden, 2007) Selected


physical environment.

Increased employees

‘competence, improved staff

morale and reduced stress for

employees.

(Westwood, James-Moore, & Cooke,

2017)-(Rexhepi & P. Shrestha, 2011)-

(Papadopoulas, 2011)-(Petersson,

Johansson, Broman, Blucher, &

Alsterman, 2010)

Modified

Increased engineers’ competence,

improved staff morale and

reduced stress for engineers.

Reduced time of work

completion.

(Petersson, Johansson, Broman,

Blucher, & Alsterman, 2010). Selected

Reduced time of work

completion.

Ben

efic

ial

Fact

ors

Improved customer satisfaction.

(Rexhepi & P. Shrestha, 2011)-


Blucher, & Alsterman, 2010)-(D.

Folinas & Faruna, 2011).

Modified Improved customer or patient

satisfaction.

Improved financial benefits to

the organization.




Blucher, & Alsterman, 2010).

Selected Improved financial benefits to the

organization.

Enhanced Problem solving

capabilities. (Hanna, 2017) Deleted

Standardized procedures and

equipment.

(Hanna, 2017)-(Westwood, James-

Moore, & Cooke, 2017) Selected


equipment.

Striving to perfection by


add value.

(Piercy & Rich, 2009)-(D. Folinas &

Faruna, 2011). Selected



add value.

77




study

Improved Patient flow. (Westwood, James-Moore, & Cooke,

2017) Modified

Improved Patient flow through

architectural spaces.

Patients treated faster, safer and

more reliable.


2017). Selected


more reliable.

Best use of capacity, cost

savings, and waste. (Papadopoulas,2011). Deleted

Reduced waiting times.



(D. Folinas & Faruna, 2011).

Deleted

Reduced length of stay. (Westwood, James-Moore, & Cooke,

2017)-(D. Folinas & Faruna, 2011). Deleted

Increased productivity. (Westwood, James-Moore, & Cooke,

2017). Selected Increased productivity.

Increased senior managers’

commitment and readiness to

initiate change.

(Massey & Williams, 2006). Modified

Increase senior engineering

manager’s commitment and

readiness to initiate change.

Part 4: Critical success factors for lean implementation in service oriented architecture

Cri

tica

l su

cces

s

fact

ors

Top management commitment

and involvement.

(Achanga, et al., 2006)-(Doss & Orr,

2007)-(Vermaak, 2008)-(Kumar,

Antony, & Douglas, 2009)-(Hamid,

2011)-(Steed, 2012)-(M. AL Najem,

2012)-(Kundu & Manohar, 2012)-

(Marodin, Saurin, & A., 2013)

Selected Top management commitment

and involvement.

Training and education all

stakeholders .

(Achanga, et al., 2006)-(Doss & Orr,

2007)-(Marodin, Saurin, & A., 2013) Selected


stakeholders .

78




study

Employee participation and

empowerment

(Harmon, et al., 2003)-(Kou, Shen, &

Chen, 2008)-(Vermaak, 2008)-

(Hamid, 2011)-(Marodin, Saurin, &

A., 2013)

Modified Engineers participation and

empowerment

Alignment to business strategy

and long-term plan

(Kou, Shen, & Chen, 2008)-(Vermaak,

2008)-(Marodin, Saurin, & A., 2013) Selected


and long-term plan

Managing cultural change for

continuous improvement

(Achanga, et al., 2006)-(Kumar,


2011)-(M. AL Najem, 2012)-(Kundu

& Manohar, 2012)-(Marodin, Saurin,

& A., 2013)

Selected Managing cultural change for


Cross-functional integration (Marodin, Saurin, & A., 2013) Modified Cross-functional integration

between engineering disciplines.

Cri

tica

l su

cces

s fa

cto

rs

Performance measurement (Achanga, et al., 2006)-(Marodin,

Saurin, & A., 2013) Selected Performance measurement

Sustain continuous improvement

(Papadopoulas, 2011)-(Folinas &

Faruna, 2011)-(Marodin, Saurin, & A.,

2013)

Selected Sustain continuous improvement

Communication with employees

(Doss & Orr, 2007)-(Kou, Shen, &

Chen, 2008)-(Marodin, Saurin, & A.,

2013)

Modified Communication with engineers

Rewards and recognition (Marodin, Saurin, & A., 2013) Selected Rewards and recognition

Job security and social

responsibility

(Hamid, 2011)-(Papadopoulas, 2011)-

(Marodin, Saurin, & A., 2013) Selected


responsibility

Focusing on the need of

customer

(Kou, Shen, & Chen, 2008)-(Kumar,


2011)

Selected Focusing on the need of customer

79




study

Strong leadership to continuous

improvement process

demonstrated by mangers at all

levels.

(Achanga, et al., 2006)-(M. AL Najem,

2012) Selected


improvement process


levels.

Establishing measurement and

feedback system. (Vermaak, 2008)-(Steed, 2012) Selected


feedback system.

Appointing a project facilitator. (Doss & Orr, 2007) Selected Appointing a project facilitator.

Focusing on critical process. (M. AL Najem, 2012) Selected Focusing on critical process.

Organization infrastructure.

(Doss & Orr, 2007)-(Vermaak, 2008)-

(Hamid, 2011)-(Folinas & Faruna,

2011)

Selected Organization infrastructure.

Understanding methods, tools,

and techniques. (Vermaak, 2008) Selected

Understanding methods, tools,

and techniques.

Willingness to take risks. (Doss & Orr, 2007)-(Steed, 2012) Selected Willingness to take risks.

Part 5: Challenges and barriers factors for lean implementation in service oriented architecture

Lack of awareness to lean led

design by stakeholders.

(Sarkar, 2009)-(Grove, et al., 2010)-

(George, 2003). Selected Lack of awareness to lean led

design by stakeholders.

Ch

all

enges

an

d

barr

iers

fa

ctors

Lack of knowledge how to apply

lean led design to enhance

service oriented architecture.

(Sarkar, 2009)-(Grove, et al., 2010). Modified Lack of knowledge how to apply

lean led design.

Lack of awareness to the

benefits that lean led design can

bring to engineering offices and

hospitals design.

(Worley & Doolen, 2006)-(Aherne,

2007)-(George, 2003). Modified

Lack of awareness to the benefits

that lean led design can bring to

engineering offices.

80




study

Lack of skilled engineers in the

use of lean led design concepts. (Aherne, 2007)-(George, 2003). Selected Lack of skilled engineers in the

use of lean led design concepts.

Process is people intensive

because intangible elements of

lean implementation are depend

on moods of people and how

they are feeling it.

(Sarkar, 2009) Modified

Process in the service oriented

architecture context is people

intensive so it depends on moods

of people and how they are

feeling it.

Difficulty of identifying process

within the service oriented

architecture context because

process are not visible, large and

complex.

(George, 2003). Modified Difficulty of identifying process


architecture context.


architecture context is

technology enabled which is led

to slow moving business

intelligence, flexible

infrastructure, data integrity,

modular processes.

(Sarkar, 2009) Modified Process in the service oriented

architecture context is technology

enabled.

Inadequate references about lean

led design that people could

obtain.

. Modified

Inadequate references that people

could obtain as well as real cases

in Gaza Strip or other nearby

areas in the region that have been

implemented lean led design .

Ch

a

llen

ges

an

d

barr

ier

s

fact

ors

Hard to persuade workers in the

organization to change their way

of thinking to focus on customer

(Grove, et al., 2010)-(Aherne, 2007). Deleted

81




study

or patient value and waste

elimination

Resistance by organization to

adopt new tools, and refuse any

change can focus on customer

patient value and waste

elimination.

(Wickramasinghe, Al-Hakim,

Gonzalez, & Tan, 2014). Selected



change can focus on customer or


elimination.

Unwillingness of engineers to

learn about lean led design

concept because of the lack of

success stories and the

educational culture.

(Wickramasinghe, Al-Hakim,

Gonzalez, & Tan, 2014). Modified




success stories and the

educational culture.

Lack of empowering, education

and providing the relevant

training to the engineers on how

to apply lean thinking on

hospitals design.

. Merged ..---

Lack of governmental

regulations to fully support

application of lean concept.

. Selected

Lack of governmental regulations

to fully support application of

lean concept.

82




study

Part 6: Factors affecting healthcare organization’s performance in lean implementation in service oriented architecture

Actual project costs compared

with planned budget.

(Li, Arditi, & Wang, 2012)-

(Meeampol & Ogunlana, 2006)-(Chan,

Scott, & Lam, 2002)-(Meeampol and

Ogunlana, 2006)-(Ahsan and

Gunawan, 2010)

Selected Actual project costs compared

with planned budget.

Fin

an

cial

an

d Q

uali

ty P

erfo

rman

ce



construction methods and

specifications

P. C. Smith, (2008) -(Balle & Regnier,

2007). -(Poksinska, 2010)-(Fulford &

Standing, 2014).

Selected




specifications

Offsite fabrication manage and

deliver them to the onsite work

as; design modifications and

change orders

. Selected

Offsite fabrication manage and

deliver them to the onsite work

as; design modifications and

change orders


deficiencies/ambiguities, in

drawings and specifications, and

resolved them

Kim & Jr., (2003) Selected


deficiencies/ambiguities, in

drawings and specifications, and

resolved them

Providing accommodation

assisted project according to

requirements as; storage space,

scaffolding, plant, power, water,

etc.

(NG & Price, 2010) Selected

Providing accommodation

assisted project according to

requirements as; storage space,

scaffolding, plant, power, water,

etc.

83




study

All relevant stakeholders should

be warn to protect the completed

parts

Iyer & Jha, (2006) Selected

All relevant stakeholders should

be warn to protect the completed

parts

Compliance to directives from

the relevant engineer and

revising working programs

accordingly

satisfaction status (Malone &

Crowston, 1994) Selected


relevant engineer and revising

working programs accordingly

Quantity and costs of variation

orders.

(Enshassi et al, 2007). Selected Quantity and costs of variation

orders.

Em

plo

yee

Per

form

an

ce




to certain patterns in dealing

with the followers).

(Doss & Orr, 2007). Balle & Regnier,

(2007)(Armstrong & Murlis, 2004). Selected




to certain patterns in dealing with

the followers).


and how it can be improved).

(Champathes, 2006)(Toit, 2007)(Starr,

2004). Selected


and how it can be improved).

Empowerment. (Bartram & Casimir, 2007) Selected Empowerment.




(Chen&Tjosvold, 2006)(Carrell,

Kuzmits, & Elbert, 1989). Selected




Organizational culture. (Schein, 1990)(Hofstede, 1991).(Daft

& Weick, 1984) . Selected Organizational culture.


staff

(Jobber, 2004).(Belcourt, Wright, &

Saks, 2012) Selected


staff

Training engineering staff. Merged ..---

84




study P

ati

ent

Sati

sfact

ion

Healthcare service satisfaction

and loyalty.

(Boshoff & Gray, 2004)-Dick & Basu,

(2004) Modified Satisfaction and loyalty.

Physician role and patient

behavior.

Ross, Mirowsky, & Duff, (1982) -

(Ditto, Moore, Hilton, & Kalish,

2005).-Lovdal & Peerson,(1989)

Selected Physician role and patient

behavior.

Trust in the context of

healthcare. Hall (2005) Modified

Trust in service oriented

architecture in the context of

healthcare.

Distance and hospital use. Goodman et al. (1997)-Naidu, (2009) Selected Distance and hospital use.

Understanding hospital staff

perceptions of patient priorities

and perceptions.

Silvestro (2005) -Naidu, (2009) Selected


perceptions of patient priorities

and perceptions.

As a summary, one hundred attributes were identified from literature review and researcher within five parts. Through pilot study,

26 of them were modified and 2 were merged. Another five attributes were added by pilot study to cover some missing aspects. The

final questionnaire consisted of eighty-five items.

85

3.9 Data analysis method

To improve the external validity, perceived reliability, and optimize a balance

between the depth and breadth of the research, a combination of numerous

qualitative and quantitative methods was adopted in the current research (Muskat,

2012). Actually, qualitative and quantitative research methods considered as a two

main types of data collection and analysis methods accepted in behavior and

management research studies. Qualitative methods intended to seek how and why

things happen, which was appropriate for in-depth study like group and personal

interviews, while quantitative methods attempt accurate measurement of variables,

which was appropriate for questionnaire survey data analysis. Henceforward,

a triangulation method, joining both qualitative and quantitative studies, was adopted

in the current study.

Quantitative and qualitative research methods were taken out by questionnaire

surveys and personal interviews in the further stage of study simultaneously.

Therefore, in view of the characteristics of both methods, a quantitative research

method was chosen for this first stage of study to describe and predict the causal

relationships between various factors that affecting the applicability of Lean thinking

in MDC industry.

3.10 Quantitative data analysis using SPSS

SPSS v.24 (Statistical Package for the Social Sciences) for Windows contains a

broad range of capabilities for the entire analytical process. The decision-making

information can quickly be generated by using powerful statistics, to understand and

present the results with tabular and graphical output, and share the results using a

variety of reporting methods. By using this software, five techniques were utilized and

adopted in this study:

1. Relative Importance Index (RII).

2. Nonparametric Tests (Sign test, Mann-Whitney test, Kruskal-Wallis test).

3. Spearman correlation coefficient for Validity.

4. Cronbach’s Alpha for Reliability Statistic.

5. Frequency and Descriptive analysis.

86

3.11 Data measurement

To be able to select the suitable method of analysis, the level of measurement must

be understood. For each type of measurement, there was/were an appropriate method/s

that can be applied and not others. In this research, ordinal scales were used. Ordinal

scale is a ranking or a rating data that normally uses integers in ascending or

descending order. The numbers assigned to the important (1, 2, 3, 4, 5) do not indicate

that the interval between scales are equal, nor do they indicate absolute quantities.

They are merely numerical labels (Naoum, 2007). Likert scales (originally devised by

R. Likert in 1932) which were used in this questionnaire, are devices to discover

strength of feeling or attitude towards a given statement or series of statements and the

implication here is that the higher the category chosen, the greater the strength of

agreement, but care has to be taken not to read too much in these ranked scales. They

are usually a three, five or seven-point range and ask respondents to indicate rank order

of agreement or disagreement by circling the appropriate number (Bell J., 2005). For

this study, the five-point scale was chosen. (Refer to Appendix A for used scales)

3.12 The relative importance index

The relative importance index method (RII) was used to determine the ranks of all

factors. The relative importance index was computed as (Sambasivan and Soon, 2007)

where:

RII = ∑ W

A ∗ N

(3.1)

W is the weighting given to each factor by the respondents (ranging from 1 to 5).

A = the highest weight (i.e. 5 in this case).

N = the total number of respondents

The RII value had a range from 0 to 1 (0 not inclusive), the higher the value of RII,

the more impact of the attribute. However, RII does not reflect the relationship

between the various attributes.

87

3.13 Non-parametric test

Non-parametric methods were widely used for studying populations that take on a

ranked order. The use of non-parametric methods may be essential when data have a

ranking but no clear numeric interpretation, or for data on ordinal scale non-parametric

methods make fewer assumptions; their applicability is much wider than the

corresponding parametric methods. In particular, they may be practical in situations

where little is known about the application in question. Also, due to the dependence

on fewer assumptions, non-parametric methods are more successful.

Another justification for the use of non-parametric methods is simplicity. In certain

cases, even when the use of parametric methods was justified, non-parametric

approaches may be easier to usage. Due both to this simplicity and to their greater

robustness, non-parametric methods were seen by some statisticians as leaving less

room for improper use and misunderstanding.

3.13.1 Sign test

was used to determine if the mean of a paragraph was significantly different from

a hypothesized value 3 (Middle value of Likert scale). If the P-value (Sig.) is smaller

than or equal to the level of significance, α = 0.05 then the mean of a paragraph was

significantly different from a hypothesized value 3. The sign of the Test value indicates

whether the mean is significantly greater or smaller than hypothesized value 3. On the

other hand, if the P-value (Sig.) is greater than the level of significance, α = 0.05, then

the mean a paragraph is insignificantly different from a hypothesized value 3.

3.13.2 Mann-Whitney test

Was used to examine if there was a statistical significant difference between two

means among the respondents toward the applicability of Lean among professionals

in MDC industry in Gaza Strip due to (Age, gender, educational level, etc. (.

3.13.3 Kruskal-Wallis test

Was used to examine if there was a statistical significant difference between

several means among the respondents toward applicability of Lean among

professionals in MDC industry in Gaza Strip due to (Educational background and

88

qualification, Organization's establishment, experience in the organization, experience

in construction industry, project nature, and location).

3.14 Validity of questionnaire

Statistical Validity of the Questionnaire indicates to the degree to which an

instrument measures what it is supposed to be measuring (Poilt, 1985). Validity has a

number of different aspects and assessment approaches.

To assure the validity of the questionnaire, two statistical tests should be applied.

The first test is Criterion-related validity test (Spearman test) which measured the

correlation coefficient between each paragraph in one field and the whole field. The

second test was structure validity test (Spearman test) that used to test the validity of

the questionnaire structure by testing the validity of each field and the validity of the

whole questionnaire. It measures the correlation coefficient between one filed and all

the fields of the questionnaire that have the same level.

3.15 Criterion related validity

Internal consistency of the questionnaire was measured by a scouting sample,

which consisted of 30 questionnaires through measuring the correlation coefficients

between each paragraph in one field and the whole filed.

Tables in Appendix I clarified the correlation coefficient for each paragraph of

each filed and the total of the field. The p-values (Sig.) are less than 0.05, so the

correlation coefficients of this field were significant at α = 0.05, so it can be said that

the paragraphs of each field were consistent and valid to measure what it was set for.

3.16 Structure validity of the questionnaire

Structure validity was the second statistical test that used to test the validity of the

questionnaire structure by testing the validity of each field and the validity of the whole

questionnaire. It measures the correlation coefficient between one filed and all the

fields of the questionnaire that have the same level of liker scale.

Table (3.2) clarifies the correlation coefficient for each filed and the whole

questionnaire. The p-values (Sig.) were less than 0.05, so the correlation coefficients

89

of all the fields were significant at α = 0.05, so it can be said that the fields were valid

to measure what it was set for to achieve the main aim of the study.

Table (3.2): Correlation coefficient of each field and the whole of questionnaire

( Source : Researcher)

No. Field Correlation

Coefficient

P-

Value

1 Readiness factors integral for lean

implementation in service oriented architecture 0.626 (*) <0.001

2 Beneficial Factors for lean implementation in

service oriented architecture 0.928(*) <0.001

3 Critical success factors for lean implementation

in service oriented architecture 0.846(*) <0.001

4 Challenges and barriers factors for lean

implementation in service oriented architecture 0.587(*) <0.001

5

Factors affecting healthcare organization’s

performance in lean implementation in service

oriented architecture

0.825(*) <0.001

6 Financial and Quality Performance 0.780(*) <0.001

7 Employee Performance 0.818(*) <0.001

8 Patient Satisfaction 0.802(*) <0.001

* Correlation is significant at the 0.05 level

3.17 Reliability analysis

Reliability aimed to examine the quality of measurement. It was the "consistency"

or "repeatability" of the analysis. The primary goal was the accuracy of the measures

of the dependent variable (in a correlation study both the independent and dependent

variable should be examined). Reducing sources of measurement error was the key to

enhance the reliability of the data. Reliability was typically assessed by one of the two

ways: (1) Internal consistency - Precision and consistency of test scores on one

administration of a test and (2) Stability - Precision and consistency of test scores over

time (test-retest). One of the most commonly used indicators of reliability analysis was

Cronbach’s alpha coefficient. Its scale should be above 0.6 as stated by Hair et al. and

Pallant (2008).

The reliability of an instrument was the degree of consistency which measures

the attribute it was supposed to be measuring (Poilt, 1985). The less variation an

instrument produces in repeated measurements of an attribute, the higher its reliability.

Reliability can be equated with the stability, consistency, or dependability of a

90

measuring tool. The test was repeated to the same sample of people on two occasions

and then compared the scores obtained by computing a reliability coefficient (Poilt,

1985).

This method was used to measure the reliability of the questionnaire between each

field and the mean of the whole fields of the questionnaire. The normal range of

Cronbach’s coefficient alpha value between 0.0 and + 1.0 (Richard and Anita, 2008),

and the higher values reflects a higher degree of internal consistency. The Cronbach’s

coefficient alpha was calculated for each field of the questionnaire.

Table (3.3) showed the values of Cronbach’s Alpha for each filed of the

questionnaire and the entire questionnaire. For the fields, values of Cronbach’s Alpha

were in the range from 0.677 and 0.943. This range was considered high; the result

ensured the reliability of each field of the questionnaire. Cronbach’s Alpha equals

0.967 for the entire questionnaire which indicated an excellent reliability of the entire

questionnaire.

Table (3.3) : Cronbach’s Alpha for each filed of the questionnaire and the entire

questionnaire ( Source : Researcher).

No. Field Cronbach's

Alpha

1 Readiness factors integral for lean implementation in service

oriented architecture 0.677

2 Beneficial Factors for lean implementation in service


3 Critical success factors for lean implementation in service


4 Challenges and barriers factors for lean implementation in

service oriented architecture 0.886

5

Factors affecting healthcare organization’s performance in

lean implementation in service oriented architecture 0.888

All items of the questionnaire 0.967

Thereby, it can be said that the researcher proved that the questionnaire was valid,

reliable, and ready for distribution for the population sample.

91

3.18 Summary

This chapter described the detailed adopted methodology of the research. It included

the primary design of framework for the study, details of research location, population,

and sample size. The questionnaire design was detailed including initial draft that was

modified and refined through pilot study, question format, the sequence of questions, and

the covering letter. Face validity, pre-testing the questionnaire, and a pilot study were

three main steps that were used to reach to the final amendment of the questionnaire. They

all have been illustrated through this chapter. Quantitative data analysis techniques, which

include the Relative important index, Pearson correlation analysis, and others, were

adopted to be applied by the instruments of SPSS v.24. For testing the research validity,

reliability, and adequacy of methods used in analysis, different statistical tests were used

and explained in details. The following Table (3.4) summarized the method chart.

92

Table (3.4) : The summary of the methodology( Source : Researcher)

Methodology Purpose Outcome

Stage One:

Proposal

❖ Problem definition

❖ Identify the problem

❖ Development of theme

❖ Develop aim, objectives, hypothesis, and

key research questions

❖ Develop research plan/ strategy (outline

methodology)

• Deciding on the research

approach.

• Deciding on the research

technique.

❖ Research problem

How does the implementation of lean thinking affect the

performance of service that oriented architecture in

healthcare organizations in Gaza Strip?

❖ Research Aim

To develop a clear understanding about lean thinking for

identifying the different factors which provide useful

information to consider adopting lean thinking in projects by

professionals in the MDC in Gaza Strip.

❖ Research Objectives

1. To assess the readiness factors level for lean

implementation by engineers in MDC industry in Gaza

Strip.

93



2. To identify the Lean benefits that would convince

engineers for adopting lean thinking in MDC industry in

Gaza Strip.

3. To identify and rank Lean CSF’s among healthcare

organizations.

4. To investigate and rank the top Lean thinking challenges

and barriers which face the adoption of Lean thinking in


5. To explore the impact of Lean thinking implementation

on healthcare performance in order to make

recommendations for adopting Lean thinking in MDC


6. To study some hypotheses that might help to find

solutions to adopting Lean thinking in the medical sector

in Gaza Strip.

❖ Research plan/ strategy

94



• The research approach was quantitative survey research

and qualitative data analysis to measure objectives

(descriptive survey and analytical survey).

• The research technique was a questionnaire.

Stage Two:

Literature Review

❖ Collecting existing knowledge on the

subject, reading and note-taking from

different sources such as: -

• Refereed academic research journals.

• Refereed Conferences.

• Dissertations/ Theses.

• Reports/ occasional papers/ white

papers

• Government publications.

• Books.

• Web sites.

❖ The following factors have been compiled and summarized

from the previous studies: 30 factors of Lean benefits, 19

factors of Lean critical success factors and 11 factors of Lean

challenges and barriers.

❖ They factor were reviewed in Chapter (2) in three Tables

(2.2), (2.3), (2.7), (2.8), (2.9), and (2.10). Some of those

items have been modified; other items have been merged; or

have been deleted through the process of questionnaire

development as well as some items have been added.

Questionnaire

design

❖ Questionnaires have been widely used for

descriptive and analytical surveys to find

out facts, opinions and views on what is

❖ Types of questions

Closed-ended (multiple choice) questions and ranking the

importance of factors

95



happening, who, where, how many or

how much (Naoum, 2007).

❖ Identify:

• Types of questions.

• Question format.

• The sequence of questions.

• The covering letter.

❖ Question format

Rating scale (five-point Likert scale). The rating scale (five-

point Likert scale) was chosen to format the questions of the

questionnaire with some common sets of response categories

called quantifiers (they reflect the intensity of the particular

judgment involved).

❖ The sequence of questions

The content of the questionnaire verified the objectives in

this research as follows:

• Part one: which is related to the respondent’s

demographic data and the way of work performance.

• Part two: to assess the readiness factors for lean

implementation in service oriented architecture by

the professionals in MDC industry in Gaza Strip.

• Gaza Strip.

96



• Part three: to investigate the value of Lean benefits

in MDC industry in Gaza Strip.

• Part four: to investigate the critical success factors in

in MDC industry in Gaza Strip.

• Part five: to investigate the Lean challenges and

barriers in in MDC industry in Gaza Strip.

• Part six: to investigate the healthcare organization’s

performance through lean implementation in service

oriented architecture in MDC industry in Gaza Strip.

❖ The covering letter

The questionnaire was provided with a covering letter

explaining the aim of the research, the security of the

information to encourage a high response, and the way of

responding.

❖ Face validity ❖ See whether the measurement procedure

(the questionnaire) in the study appears

to be valid or not. It is a "common-sense"

• The questionnaire was presented to twelve experts

(from Gaza and outside Palestine) by hand and by

email at different periods.

97



assessment by the experts in the MDC

field as well as the experts in Statistics.

• Many useful and important modifications have been

made for the questionnaire. Those modifications

have been explained in Table (3.1).

❖ Pre-testing the

questionnaire

❖ To make sure that the questionnaire is

going to deliver the right data and to

ensure the quality of the collected data.

❖ To find out if the survey has any logic

problems, if the questions are too hard to

understand, if the wording of the

questions is ambiguous, or if it has any

response bias, etc.

• The pre-testing was conducted and tested with six

people.

• The first phase of the pre-testing resulted with some

amendments to the wording of some words in the

questions, also, to add further explanation to some

factors to facilitate the understanding of the

questionnaire.

• The second phase was sufficient to ensure the

success of the questionnaire, where there were not

any queries, and everything was clear.

❖ Pilot study ❖ A trial run on the questionnaire before

circulating it to the whole sample to get

valuable responses and to detect areas of

possible shortcomings.

• 8 copies of the questionnaire were distributed to

respondents from the target group (The professionals

in the MDC industry in Gaza Strip).

98



❖ Often a sample of 5-10 responses is

obtained, coded, and analyzed.

❖ Questions that are not providing useful

data are discarded, and the final revisions

of the questionnaire are made.

• All the copies were collected and analyzed through

Statistical Package for the Social Sciences IBM

(SPSSv.24).

• The tests that have conducted were as follows:

1. The statistical validity of the questionnaire

2. criterion-related validity (the internal and the

structure validity).

3. The reliability of the questionnaire by Half

Split method and the Cronbach’s Coefficient

Alpha method.

• The results showed the success of the tests, and thus

the success of the questionnaire.

• The questionnaire was adopted and was distributed

to the whole sample.

• The 8 successful copies were included in the whole

sample.

99



❖ Sampling the

questionnaire and

data collection

❖ Identify the population from which the

sample is to be drawn, where the term

"sample" means a specimen or part of a

whole (population) which is drawn to

show what the rest is like.

❖ The type of the sample

❖ A convenience sample was chosen as the type of the sample,

where convenience sampling is a non-probability sampling

technique.

❖ The population:

The population involved a certain healthcare organization

where the professionals Architects, Civil Engineers,

Mechanical Engineers, Electrical Engineers, and any other

professional with a related specialization) included in the

MDC industry.

❖ Size sample

85 copies of the questionnaire were distributed, and 80

copies of the questionnaire were received from the

respondents. Thus, the whole sample was 80 (the successful

sample of the pilot study was included, which equals 12).

100



❖ Analysis and

Presentation of

the Results

❖ Analyze the results of the collected data

to determine the direction of the study.

❖ Choose the analysis instrument.

❖ Identify the method of the analysis.

❖ Present the results.

❖ Analysis instrument

IBM (SPSS v.24)

❖ Method of analysis.

Quantitative analysis of data by converting the ordinal data

to scale data.

❖ The quantitative measures/ analysis.

A. Descriptive Statistics:

1. Relative Importance Index (RII).

2. Nonparametric Tests (Sign test, Mann-Whitney test,

Kruskal-Wallis test).

3. Spearman correlation coefficient for Validity.

4. Cronbach’s Alpha for Reliability Statistic .

5. Frequency and Descriptive analysis.

B. The inferential statistics (bivariate)/ test of

hypotheses:

101



1. Cross-tabulation analysis

2. Pearson product-moment correlation coefficient/

Pearson's correlation coefficient (a parametric test)

3. Independent samples t-test to find out whether there is

a significant difference in the Mean between two

groups (a parametric test)

4. One-way Analysis of Variance (One-way ANOVA)/

(F-test) (a parametric test)

5. Scheffé's method for multiple comparisons.

❖ The tabulation, pie chart, and graph are the tools which have

been used to present the results.

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Chapter 4

Results and Discussion

103

Results and Discussion

This chapter included analysis and discussion of the results that have been

collected from field surveys. Data was analyzed using SPSS v.24 including descriptive

and inferential statistical tools. Eighty questionnaires respondents from healthcare

organizations had been considered representing a valid response rate 94.1%. This

chapter included respondents' profile, quantitative analysis of questionnaire field

survey, and finally test the research hypothesis.

4.1 Respondents' profile

The target respondents of the questionnaire survey were construction professionals

in Gaza Strip. Eighty-five questionnaires of survey were distributed on the

construction professionals in healthcare sector. This section analyzed the personal

characteristics of (80) respondents who returned valid questionnaire for study.

Among the respondents, a large majority had "from 5 to less than 10 years" of

working experience in the MDC industry, with 42.5%. The experience for the rest of

the respondents was "less than 5 years ", and "10 years and more" with 17.5% and

40.0%, respectively. With respect to the respondents' specialization, there were 12

Architects (15.0%), 32 Civil Engineers (40.0%), 22 Electrical Engineers (27.5%), 6

Mechanical Engineers (7.5%) and 8 from other specializations (10.0%) including:

Electromechanical Engineer, Environmental Engineer, and Geographic Information

System (GIS) Engineer.

Respondents for this study had a good understanding of consulting and

construction works in the MDC industry, and could thus provide reliable answers to

the questionnaire. In terms of the nature of their workplace, a majority of the

respondents were working in the Ministry of Health (MOH) with 65.0%, 20.0% were

working as contractors, 2.5% of them were working in the Non-Governmental

Organizations (NGOs), and 12.5% were working in other places such as the Engineers

Association. Table (4.1) presents the characteristics of the respondents as follows:

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Table (4.1) : The respondent’s profile ( Source : Researcher)

Demographic data Frequency Percent

Gender Male 74 92.5

Female 6 7.5

Educational Background

Architect 12 15.0

Civil 32 40.0

Electrical 22 27.5

Mechanical 6 7.5

Management - -

Other 8 10.0

Educational qualification

Bachelor's 64 80.0

Master's 16 20.0

Ph.D. - -

Person's years of

experience

Less than 5 years 14 17.5

From 5 to less than 10

years 34 42.5

10 Years and more 32 40.0

Nature of the workplace

MOH 52 65.0

NGOs 2 2.5

Contractor 16 20.0

Other 10 12.5

Location of workplace

North 2 2.5

Gaza 52 65.0

Middle 2 2.5

Khan Yuns 24 30.0

Rafah - -

Organization's

Establishment

Less than 5 years 12 15.0

From 5 to less than 10

years 22 27.5

10 Years and more 46 57.5

4.2 Readiness factors integral for lean implementation in service oriented

architecture.

There was a field contains five statements to assess the readiness level for lean

implementation in service oriented architecture by the professionals in the MDC

industry in Gaza Strip. These statements were subjected to the views of the

respondents, and the outcomes of the analysis were shown in Table (4.2). The

descriptive statistics, i.e. Means, Standard Deviations (SD), t-value (two tailed),

105

probabilities (P-value), Relative Importance Indices (RII), and finally ranks were

established and presented in Table (4.2) as follows:

Table (4.2) : Means and Test values for the readiness level of Lean implementation

by the professionals in the MDC industry ( Source : Researcher).

Item Mean S.D RII

(%)

Test

value

P-

value Rank

Lean principles and methods

need special training and

involvement

3.69 0.7 73.85 5.91 <0.001 1

Lean thinking concept should

include motivational system to be

adopted

3.64 0.8 72.82 4.94 <0.001 2

Lean concepts should cover the

overall process from start to end 3.38 1 67.69 2.36 0.012 3

Lean thinking concept in design

is considered 3.03 0.9 60.5 0.18 0.43 4

Lean thinking is widely adopted

in healthcare sector in Gaza Strip 2.93 0.8 58.5 -0.6 0.278 5

All items of the field 3.32 0.5 66.46 3.89 <0.001

The numerical scores got from the questionnaire responses providing an indication

of the readiness level of Lean implementation by the professionals in the MDC

industry Gaza Strip. To further study of the collected data, RII is used to rank the used

statements (1 to 6) to assess readiness level of Lean implementation by the

professionals according to the scores by the respondents. Table (4.2) provides RIIs

and ranks of the statements, respectively. It worth mentioning that ranking of the

statements was based on the highest Mean, RII, and the lowest SD.

The findings indicated that “Lean principles and methods need special training and

involvement” (Item No. 4) is the most important factor that would measure the

readiness level for of Lean implementation by professionals in the MDC industry. It

has been ranked as the first position with (RII =73.85%) and (P-value = 0.001)

according to the overall respondents. This result is in line with the studies of Bateman,

2012; Steiber, 2014). Also, it is consistent with which has been talked about by (

(Armenakis, 2004); Cinite et al. 2013).

106

Fillingham (2007) conducted a field study and relative to the training and the

findings indicated that training should be designed to allow for an introduction to lean

principles and methods through all the parties as well as the collaborative working in

the MDC industry to make use of the lean tools while still having support available

and this training will be the most important and necessary thing when thinking about

the adoption of Lean thinking philosophy.

“Lean thinking is widely adopted in healthcare sector in Gaza Strip” (Item No.1)

was ranked in the 5th position as the least statement of the field of “the readiness level

of Lean implementation by the professionals in the MDC industry Gaza Strip” with

(RII = 58.50%; P-value = 0.278) according to the all respondents. It is a meaningful

and realistic result about the current situation in the MDC industry in Gaza Strip.

According to the respondents, Lean thinking way is a recent philosophy, and it

hadn’t implemented on health organizations level yet. In addition to that, Lean thinking

does not be applied professionally, and thus the professionals do not get the full

benefits of Lean, where they are only using some advantages of Lean implementation.

The overall results for the field of “Readiness factors integral for lean

implementation in service oriented architecture” show that the Mean for all statements

equals 3.32 The total RII equals (66.46) %, Test-value = 3.89, and P-value less than

0.05. The sign of the test is positive, so the mean of this field is significantly greater

than the hypothesized value (3) . We conclude that the respondents agreed to field of

“Readiness factors integral for lean implementation in service oriented architecture".

Based on the previous results, the readiness level of Lean implementation by the

professionals in the MDC industry Gaza Strip is too high. These results also agree with

the results obtained by (Al-Balushi, et al., 2014) through a comprehensive review of

literature focusing on lean and lean healthcare, where they confirmed that involvement

and encouragement of professionals in lean process in construction is best succeeded

through training.

Moreover, sustainability of the lean thinking has been initiate to be linked to the

training and engagement of professionals and retraining in the fundamentals of lean

tools and techniques is considered essential when professionals' turnover is an issue.

107

(Al-Balushi, et al., 2014) stated that healthcare sector show that sustainability of lean

thinking could be at stake if these readiness factors are not addressed correctly.

4.3 The benefits of Lean thinking

There was a field contains (29) items of Lean benefits, and this list of the (29) items

was taken from the literature review and adapted by modifying or merging according

to the results of the face validity and the pretesting of the questionnaire as shown in

Chapter (3) .

These items were subjected to the views of the respondents and were analyzed.

The descriptive statistics, i.e. Means, Standard Deviations (SD), t-value (two-tailed),


established and presented in Table (4.3).

4.4 RII of Lean benefits

RII was calculated to weight each benefits of Lean (from item no. 1 to 29)

according to the numerical scores obtained from the questionnaire responses by the

professionals in the MDC industry in Gaza Strip and the results have been ranked from

the highest degree (the most important Lean benefits) to the least degree (the lowest

important Lean benefits).

Table (4.3) provides RIIs and ranks of the items of Lean benefits, respectively.

The numbers in the "rank" column represent the sequential ranking. It worth

mentioning that ranking of Lean benefits was based on the highest Mean, RII, and the

lowest SD. If some items have similar Means and RIIs, as in the case of (Item no.2 and

8); and (5 and 6), the ranking will depend on the lowest SD. More precisely, although

(item no. 2) and (item no. 8) have the same Mean and RIIs, item no. 8 is ranked higher

than the item no. 2 because it has a lower SD. The same thing was done for (item no.

5) and (item no. 6), where (item no. 6) has taken the higher rank than (item no. 5)

items were categorized with ratings from 60.50% to 71.5 % Figure (4.1).

108

Table (4.3) : Means and Test values for Lean benefits( Source : Researcher)

Item Mean S.D RII

(%)

Test

value

P-

value Rank






3.58 0.8 71.5 4.31 <0.001 1




3.58 0.9 71.5 4.16 <0.001 2

Increased engineers 'competence,

improved staff morale and reduced

stress for engineers.

3.58 1.1 71.5 3.29 0.001 3

Reduced time of work completion 3.53 1 70.5 3.28 0.001 4


engineer’s leaders. 3.5 1 70 3.12 0.002 5

Improved customer or patient

satisfaction 3.5 1 70 3.2 0.001 5

Lean lead design can make sound

decisions early. 3.46 0.9 69.23 3.26 0.001 7

Increased productivity. 3.45 0.8 69 3.64 <0.001 8


more reliable. 3.45 1 69 2.81 0.004 9

Start to use powerful new building


software where all design and

construction decisions can be


architect, engineer and designer and

construction manager.

3.43 0.9 68.5 3.08 0.002 10


workflow at master planning stage. 3.4 0.9 68 2.73 0.005 11

Support design decision making by

the observation that provided

enough data to persuade them

3.4 0.8 68 3.12 0.002 11

Improved financial benefits to the

organization 3.4 1 68 2.45 0.009 11

Promise to improve design results 3.38 1 67.5 2.3 0.013 14


service line that will be affected by

the project during master planning

stage.

3.33 0.9 66.5 2.18 0.018 15

Improve the process of information

at pre design stage that will inform

design

3.33 0.8 66.5 2.48 0.009 15

109

Table (4.3) : Means and Test values for Lean benefits( Source : Researcher)

Item Mean S.D RII

(%)

Test

value

P-

value Rank


current process are done at the first

line and planning how they could

be done in the future

3.3 1.1 66 1.78 0.042 17




3.28 1 65.5 1.76 0.043 18


points in various 3Ps(that helps


refine work as the project unfolds)

to hear frontline concerns and offer

targeted solutions

3.25 1.2 65 1.28 0.104 19

Improved Patient flow through

architectural spaces. 3.23 1 64.5 1.46 0.076 20

Allow engineers to conduct quick

process simulation 3.21 1 64.1 1.24 0.111 21


designs quickly using the humblest

materials at schematic design.

3.2 1 64 1.31 0.099 22


physical environment. 3.18 0.9 63.5 1.23 0.114 23

Manipulate large parameters across

all the disciplines of a building

project

3.15 1 63 0.92 0.181 24



clash detection.

3.13 1.1 62.5 0.72 0.236 25


equipment. 3.13 1 62.5 0.78 0.221 25


planning stage 3.1 1 62 0.63 0.267 27



parametric molding

3.03 1.1 60.5 0.15 0.442 28



add value.

3 0.9 60 0 0.5 29

All items of the field 3.33 0.6 66.52 3.47 0.001

110

Figure (4.1) : RII (%) of Beneficial Factors for lean implementation in service

oriented architecture ( Source : Researcher)

The findings indicated that “Improve consensus among design team members at

value stream mapping stage (visual analysis of the flow of information and material

during each process)” (item no. 9) is the most important benefit that would convince

non-users of Lean for adopting Lean in the MDC industry in Gaza Strip. It has been

ranked as the first position with (RII =71.5%) and (P-value = 0.05) according to the

overall respondents. The sign of the test is positive, so the mean of this item is

significantly greater than the hypothesized value (3) .

We conclude that the respondents agreed to this item, this result is in line with the

studies of (Abdulmalek & Rajgopal, 2007) and Azhar (2011). Also, it is consistent

with which has been talked about by (Fillingham, 2007). They said that improve

consensus between all design parties members at value stream mapping stage (visual

analysis of the flow of information and material during each process) is the most

important thing and necessary when keep looking for waste, checking up on the value

that healthcare organizations deliver to patients or customer, Also, keep controlling

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BF4

BF5

BF6

BF7

BF8

BF9

BF10

BF11

BF12

BF13BF14

BF15BF16BF17

BF18

BF19

BF20

BF21

BF22

BF23

BF24

BF25

BF26

BF27

BF28BF29

111

the flow of information and material through process make it a part of healthcare

organization culture.

“Striving to perfection by identifying activities that did not add value” was ranked

as the lowest valuable Lean benefit in the 29th position with (RII = 60.00%; P-value

= 0.500) according to the all respondents, which is greater than the level of significance

0.05 = . Then the mean of this item is insignificantly different from the hypothesized

value 3. We conclude that the respondents neutral to this item. On the contrary of the

result of the analysis, (Apping, Luyster, & Shulzer, 2003); Anjard (1998) and Seth &

Panigrahi, (2015) said that Lean has considered as a very effective tool, if the

organization achieve a certain steps the organization will have already prevented a

large amount of waste (no added value) from appearing within organizations

processes. However; with the support of all of organizations employees organization

need to strive towards perfection; delivering accurately what the patient or customer

needs, when they want it at an acceptable cost (Minimum cost) and within zero waste.

The top three benefits of Lean, which were rated by the target respondents, are

logical and acceptable to be the most valued benefits of Lean that would persuade the

professionals for adopting it in the MDC industry in Gaza Strip. Regarding results for

all items of the part of Lean benefits, they show that the Mean for all those items equals

3.33, and the total RII equals 66.52%, which is greater than 60% the neutral value of

RII and P-value less than 0.05., so the mean of this field is significantly greater than

the hypothesized value (3) . The sign of the test is positive and we conclude that the

respondents agreed to field of “Beneficial Factors for lean implementation in service

oriented architecture” According to all preceding results, Lean benefits are

significantly appreciated for the professionals in the MDC industry in Gaza Strip.

Don’t go out and benchmark your competitors and try to match them or beat them

by a little; the aim is zero waste and the ability to deliver your customers value. Involve

every employee within your company in implementing lean tools such as Kaizen to

drive continuous improvement of each and every aspect of your company. Lean is not

just about improving a production cell; it also about improving every other process

from order processing to invoicing and customer service.

112

4.5 Critical success factors for lean implementation

There was a field contains (19) items of Lean CSFs, and this list of the 19 items

was taken from the literature review and adapted by modifying or merging according

to the results of the face validity and the pretesting of the questionnaire as shown in

Chapter (3). These items were subjected to the views of respondents and were

analyzed. The descriptive statistics, i.e. Means, Standard Deviations (SD), t-value

(two-tailed), probabilities (P-value), Relative Importance Indices (RII), and finally

ranks were established and presented in Table (4.4).

4.5.1 RII of Lean CSFs

RII was calculated to weight each CSFs of Lean (from item no. 1 to no. 19)

according to the numerical scores got from the questionnaire responses by the


the highest degree (The strongest Lean CSFs) to the least degree (The most vulnerable

Lean CSFs).

Table (4.4) provides RIIs and ranks of Lean CSFs, respectively. The numbers in

the "rank" column represent the sequential ranking. It worth mentioning that ranking

of Lean CSFs was based on the highest Mean, RII, and the lowest SD. If some items/

variables have similar Means and RIIs, as in the case of (item no. 2 and 17); (item no.

7 and 12); and (item no. 8 and 11), the ranking will depend on the lowest SD., item no.

(17) is ranked higher than item no. (2); because it has a lower SD. The same thing was

done for (item no. 7 and 12), where item no. (7) has taken the higher rank than item

no. (12) , and for (item no. 8 and 11), where item no. (8) has taken the higher rank than

item no. (11) , items/ variables were categorized with ratings from 65.00 % to 75.5 %.

Figure (4.2).

113

Table (4.4) : Means and Test values for Critical success factors for lean

implementation in service oriented architecture in MDC industry ( Source :

Researcher).

Item Mean S.D RII

(%)

Test

value

P-

value Rank


improvement process


levels.

3.88 1 77.5 5.31 <0.001 1

Top management commitment and

involvement. 3.78 1 75.5 4.78 <0.001 2

Rewards and recognition 3.75 1.2 75 4.05 <0.001 3


and long-term plan 3.7 1 74 4.58 <0.001 4

Cross-functional integration

between engineering disciplines. 3.69 1 73.85 4.2 <0.001 5

Communication with engineers 3.63 1.1 72.5 3.75 <0.001 6

Understanding methods, tools, and

techniques. 3.63 1 72.5 4.15 <0.001 6

Engineers participation and

empowerment 3.6 1 72 3.86 <0.001 8

Performance measurement 3.58 1 71.5 3.51 0.001 9

Focusing on the need of customer 3.58 1.1 71.5 3.22 0.001 9

Sustain continuous improvement 3.55 1 71 3.53 0.001 11


responsibility 3.55 1.2 71 2.96 0.003 11


feedback system. 3.53 1 70.5 3.28 0.001 13

Focusing on critical process. 3.5 1.2 70 2.74 0.005 14


stakeholders. 3.48 1.1 69.5 2.65 0.006 15

Organization infrastructure 3.48 1.1 69.5 2.83 0.004 15

Managing cultural change for

continuous improvement 3.35 0.8 67 2.76 0.004 17

Willingness to take risks. 3.33 0.7 66.5 2.82 0.004 18

Appointing a project facilitator. 3.25 0.9 65 1.71 0.048 19

All items of the field 3.57 0.7 71.34 5 <0.001

114

Figure (4.2) : RII (%) of Critical success factors for lean implementation in

service oriented architecture (Source :Researcher).

The findings indicated that “Strong leadership to continuous improvement process

demonstrated by mangers at all levels” (Item No. 13) is the most important Lean CSFs

that would persuade the professionals for adopting Lean in the MDC industry in Gaza

Strip. It has been ranked as the first position with (RII = 77.50 %) and (P-value less

than 0.05) according to the overall respondents.

This result is consistent with which has been talked about by (Trkman, 2010) and

(Aspelund & Netland, 2014).They said that active leadership is considered more

important and to succeed with the implementation of lean, managers should commit

to, lead and take an active part in the lean program and provide and attend training and

education as well as strong leadership to improve the flow of process which has been

controlled by mangers at all stages of building construction.

“Appointing a project facilitator” (Item No. 15) was ranked as the lowest

important Lean CSFs in the 19th position with (RII = 65.00%; P-value less than 0.05)

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68

70

72

74

76

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CSF1

CSF2

CSF3

CSF4

CSF5

CSF6

CSF7

CSF8

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CSF10CSF11

CSF12

CSF13

CSF14

CSF15

CSF16

CSF17

CSF18

CSF19

115

according to the all respondents, which is greater than the level of significance

0.05 = . Then the mean of this item is insignificantly different from the hypothesized

value (3) .

We conclude that the respondents agreed to this item. On the contrary of the result

of the analysis, Abdullah et al. (2008) and (Achanga S. R., 2006) have provided in

studies the importance of the function of lean construction project facilitator that

advises the construction management team on an appropriate lean roadmap for the

organization also mentors colleagues, project team leaders and team members in lean

behavior, and lean tools; sponsors lean projects, without necessarily taking part in the

improvement activity himself.

The top three CSFs of Lean, which were rated by the respondents, are logical and

acceptable to be the most important CSFs of Lean that would persuade the

professionals for adopting it in the MDC industry in Gaza Strip. Regarding results for

all items of the part of Lean CSFs, they show that the Mean for all those items equals

3.57, and the total RII equals 71.34%, which is greater than 60% (the neutral value of

RII (3/5)*100 = 60%). The value of t-test equals 5.00; the total P-value of all the items

equals 0.001 and it is less than the significance level of 0.05. Based on all previous

results, Lean CSFs are significantly important for the professionals in the MDC


4.6 Lean challenges and barriers

There was a field contains 11 items of Lean challenges and barriers, and this list

of the 11 items was taken from the literature review and adapted by modifying or

merging according to the results of the face validity and the pretesting of the

questionnaire as shown in Chapter (3).

These items were subjected to the views of respondents and were analyzed. The

descriptive statistics, i.e. Means, Standard Deviations (SD), t-value (two-tailed),


established and presented in Table (4.5).

116

4.6.1 RII of Lean challenges and barriers

RII was calculated to weight each challenges and barriers of Lean (from item no.

1 to 11) according to the numerical scores got from the questionnaire responses by the


the highest degree (The strongest Lean challenges and barriers) to the least degree (The

most vulnerable Lean challenges and barriers).

Table (4.5) provides RIIs and ranks of Lean challenges and barriers, respectively.

The numbers in the "rank" column represent the sequential ranking. It worth

mentioning that ranking of Lean challenges and barriers was based on the highest

Mean, RII, and the lowest SD Figure (4.3).


Researcher)

Item Mea

n

S.

D

RII

(%)

Test

value

P-

value

Ran

k

Lack of knowledge how to apply

lean led design. 3.65 1 73 4.11

<0.00

1 1



enabled.

3.58 1.0

3 71.5 3.51 0.001 2

Lack of governmental regulations

to fully support application of lean

concept.

3.55 1.2

6 71 2.76 0.004 3

Lack of skilled engineers in the

use of lean led design concepts. 3.53

1.0

6 70.5 3.13 0.002 4


could obtains well as real cases in

Gaza Strip or other nearby areas

in the region that have been

implemented lean led design .

3.5 0.9

1 70 3.49 0.001 5



change can focus on customer or


elimination.

3.5 0.9

6 70 3.29 0.001 6

Lack of awareness to lean led

design by stakeholders 3.5

1.0

6 70 2.98 0.002 7

117


Researcher)

Item Mea

n

S.

D

RII

(%)

Test

value

P-

value

Ran

k




success stories and the educational

culture.

3.43 1.0

8 68.5 2.48 0.009 8



engineering offices

3.4 1.0

8 68 2.34 0.012 9




3.38 0.9 67.5 2.64 0.006 10



intensive so it depends on moods

of people and how they are feeling

it.

3.38 0.9

3 67.5 2.56 0.007 11


1

118

Figure (4.3) : RII (%) of Challenges and barriers factors for lean implementation

in service oriented architecture (Source :Researcher).

The findings indicated that “Lack of knowledge how to apply lean led design” (item

no. 2) is the strongest Lean challenges and barriers adopting in the MDC industry in

Gaza Strip. It has been ranked as the first position with (RII = 73.00%) and (P-value

less than 0.05) according to the overall respondents.

The sign of the test is positive, so the mean of this item equals (3.65) is significantly

greater than the hypothesized value (3) . We conclude that the respondents agreed to

this item. This finding is consistent with the result which has been found by Hines et

al. (2014) according to their studies, lack of knowledge and experience in addition to

cost and time constraints were the two most obstacles to Lean implementation.

The knowledge health care organizations have in thier systems and more

importantly thier engineers, is fundamental to the implementation of Lean thinking.

The success of lean in some healthcare organizations has been in part due to the

reorganization of the engineers at both design and management level. Additionally,

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CH2

CH3

CH4

CH5

CH6CH7

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CH9

CH10

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formally getting knowledge of processes is necessary especially within a construction

work environment.

“Process in the service oriented architecture context is people intensive so it

depends on moods of people and how they are feeling it” (Item No. 5) was ranked as

the lowest important Lean challenges and barriers in the 11st position with (RII =

67.50%; P-value less than 0.05) according to the all respondents, which is greater than

the level of significance. 0.05 = Then the mean of this item is insignificantly different

from the hypothesized value (3) .

We conclude that the respondents agreed to this item. In construction process has

been aligned all individuals directly or indirectly associated with the process on the

improvement organization goals.

The top three challenges and barriers to Lean adoption, which were rated by the

respondents, are logical and acceptable to be the strongest challenges and barriers to

Lean adoption in the MDC industry in Gaza Strip. Regarding results for all items of

the part of Lean challenges and barriers, they show that the Mean for all those items

equals 3.49 and the total RII equals 69.77 %, The value of t-test equals 4.39, As well

as, the total P-value of all the items are less than the significance level of 0.05. Based

on all the previous results, Lean challenges and barriers are substantially affecting the

adoption of Lean in the MDC industry in Gaza Strip.

4.7 Healthcare organization’s performance

There was a field contains 19 items under three sub factors which are Financial

and quality Performance, Employee Performance, and Patient Satisfaction of

Healthcare organization’s performance, and this list of the 19 items was taken from

the literature review and adapted by modifying or merging according to the results of

the face validity and the pretesting of the questionnaire as shown in Chapter (3).

These items were subjected to the views of respondents and were analyzed. The

descriptive statistics, i.e. Means, Standard Deviations (SD), t-value (two-tailed),


established and presented Table (4.6).

120

4.7.1 RII of Healthcare organization’s performance

The numerical scores got from the questionnaire responses providing an indication

of the Healthcare organization’s performance that affecting with Lean implementation

by the professionals in the MDC industry Gaza Strip. To further study of the collected

data, RII is used to rank the used statements (1 to 19) to study the influence of

implementing Lean on the Healthcare organization’s performance by the professionals

according to the scores by the respondents. Table (4.6) provides RIIs and ranks of the

statements, respectively. It worth mentioning that ranking of the statements was based

on the highest Mean, RII, and the lowest SD.

The mean of the field “Financial and Quality Performance” equals 3.43 (68.63%),

Test-value = 4.84, and P-value less than 0.05. The sign of the test is positive, so the

mean of this field is significantly greater than the hypothesized value (3) . We conclude

that the respondents agreed to field of "Financial and Quality Performance".

Construction projects performance needs improvement to fulfil the difficulty of the

stakeholders’ expectations and needs. Also, Construction projects are a balance

between cost, time and quality. It is likely to have high quality and low cost, but at the

expense of time, and conversely to have high quality and a fast project, but at a certain

cost.

The findings indicated that “Actual project costs compared with planned budget”

(Item No. 1) the highest important indicator under field "Financial and Quality

Performance". It has been ranked as the first position with mean equals to 3.88, RII=

(77.50%), Test-value = 5.58, and P-value less than 0.05 according to overall

respondents. The sign of the test is positive, so the mean of this field is significantly

greater than the hypothesized value (3) . We conclude that the respondents agreed to

this item. These results also agree with the results obtained by (Al-Balushi, et al., 2014)

which said that cost management is the process of estimating, allocating, and

controlling the costs in a project, it allows project manager to forecast coming expenses

to decrease the chances of it going ahead of a certain budget (Fulford & Standing,

2014). Cost is an important factor in construction project especially in MDC industry

in Gaza Strip due to the limited budget of projects, even more most of construction

projects are funded by donors those donors require special construction criteria for

https://www.designingbuildings.co.uk/wiki/Quality



https://alpha.wrke.io/project-management-guide/glossary/#allocation

121

certain costs. This study result is in line with the study of (Chan I. , 2008) which ranked

cost as an important key performance indicator.

While the item "Offsite fabrication manage and deliver them to the onsite work as;

design modifications and change orders" (Item No. 3) obtained the lowest degree of

approval that was 63.50%. Neither alternative approaches of construction nor

substitution of materials for those specified will be allowable unless accepted by the

Architect in advance and in writing for that reason it’s very difficult for other engineers

to manage fabrication off site easily (Rochester Institute of Technology, 2015).

The mean of the field "Employee Performance" equals 3.63 (72.62%), Test-value

= 5.64, and P-value less than 0.05. The sign of the test is positive, so the mean of this

field is significantly greater than the hypothesized value (3) . We conclude that the

respondents agreed to field of "Employee Performance ". Lean thinking encourage

creativity among goals and performance evaluation techniques. Engineers are more

likely to engage in concept and idea generation and risk taking from initial design stage

to completion when these are explicit performance responsibilities. Liao & Chuang,

(2004) Said that engineers who expect fair performance evaluations in construction

design stages are more positively motivated to actively offer new ideas.

This factor “Motivate and train engineering staff” (Item No. 14) obtained the

highest degree of approval that is 76.50%. These result agree with the results obtained

by Graben (2013) through an investigation study which is conducted in United State

of America where he confirmed that improving engineer's motivation is one of the

most effective issue that affecting organizations performance, also he mentioned that

non-monetary recognition is the best solution for improving engineer's motivation.

Training and development works motivate engineer because its proof the organization

is investing the necessary time and resources for engineers to obtain new skills (Folinas

and Faruna, 2011). Lianying and Fan (2013) Stated that every engineer who has been

believed his manager is sincerely concerned about his responsibility development is

likely to exhibit an increased level of job satisfaction and, ultimately, better

performance as a team player in whole construction phase

While the item “Empowerment” (Item No. 11) obtained the lowest degree of

approval that was 69.74%. On the contrary of the result of the analysis, Fulford &

122

Standing (2014) said that Empowerment can be defined as capacity making in

employees for playing their assigned responsibilities effectively, optimally and

effectively. Lahijani et al. (2012) examined through his study in Iran several factors

that affect empowering human resources, unfortunately he found that factors had led

to lack of a specific mechanism defined for qualifying human resources or even

overlooking such mechanism in development projects.

The mean of the field “Patient Satisfaction” equals 3.42 (68.48%), Test-value =

3.36, and P-value less than 0.05. The sign of the test is positive, so the mean of this

field is significantly greater than the hypothesized value 3. We conclude that the

respondents agreed to field of “Patient Satisfaction”. Patient satisfaction is a main key

of performance measurement in healthcare organizations (Cowing, Ramay, Ramaya,

& Szmerekovsky, 2009). Also, patient’s satisfaction from healthcare organization

decides the healthcare delivery structure and henceforward needs to be intermittently

measured to improve and enhance the quality of service (Ahamd and Din, 2010).

The findings indicated that “Healthcare service satisfaction and loyalty” ((Item

No. 15) is the strongest patient satisfaction that affecting healthcare organization’s

performance. It has been ranked as the first position with (RII = 71.00%) and (P-value

less than 0.05) according to the overall respondents, which is greater than the level of

significance. 0.05 = Then the mean of this item is insignificantly different from the

hypothesized value (3) . Gronholdt et al. (2010) stated that customer satisfaction ia

amain issue for every healthcare organization wishing to increase patient loyalety and

thereby create abetter organization performance.

“Distance and hospital use” (Item No. 18) was ranked as the lowest patient

satisfaction that affecting healthcare organization’s performance in the 5th position

with (RII = 66.50%; P-value less than 0.05) according to the all respondents, which is

greater than the level of significance. 0.05 = Then the mean of this item is

insignificantly different from the hypothesized value (3) . Sanz-Barbero B (2014)

stated that distances to Health care facilities with emergency room capacity vary

greatly between individual residents. Distance is a barrier to accessing hospital

emergency services.

123

The mean of the field “Factors affecting healthcare organization’s performance

in lean implementation in service oriented architecture” equals 3.49 (69.86%), Test-

value = 5.91, and P-value less than 0.05. The sign of the test is positive, so the mean

of this field is significantly greater than the hypothesized value (3) . We conclude that

the respondents agreed to field of “Factors affecting healthcare organization’s

performance in lean implementation in service oriented architecture ". There are a

number of studies have been proven that implementation lean in healthcare

organizations showed positively result for healthcare performance. This results are in

line with the study by Koning et al. (2006) which found that lean can able to control

healthcare cost increase, as well as improve quality and provide better in healthcare.

According to study conducted by Erfan (2010) concluded that applied the Lean

thinking in the healthcare sector in Libya had achieved tangible and significant

improvement in the whole performance that allowed be more flexible, productive,

smooth and with high quality service. Figure (4.4) ,Figure (4.5), Figure (4.6).

Table (4.6): Means and Test values for factors affecting healthcare

organization’s performance in lean implementation in service oriented

architecture in MDC industry ( Source : Researcher).

Item Mean S.D RII

(%)

Test

valu

e

P-value Rank

All items of Financial

and Quality

Performance

3.43 0.56 68.63 4.84 <0.001

Actual project costs

compared with planned

budget.

3.88 0.99 77.5 5.58 <0.001 1

Compliance to directives

from the relevant

engineer and revising

working programs

accordingly

3.53 0.82 70.5 4.07 <0.001 2

Work integration from

different stakeholders to

agree on detail


specifications

3.45 0.78 69 3.64 <0.001 3

124




Item Mean S.D RII

(%)

Test

valu

e

P-value Rank

Quantity and costs of

variation orders 3.45 0.9 69 3.15 0.002 3


deficiencies/ambiguities,

in drawings and

specifications, and

resolved them

3.43 0.78 68.5 3.44 <0.001 5

Providing

accommodation assisted

project according to

requirements as; storage

space, scaffolding, plant,

power, water, etc.

3.33 0.8 66.5 2.58 0.007 6

All relevant stakeholders

should be warn to protect

the completed parts

3.23 0.97 64.5 1.46 0.076 7

Offsite fabrication

manage and deliver them

to the onsite work as;

design modifications and

change orders

3.18 0.9 63.5 1.23 0.114 8

All items of Employee

Performance 3.63 0.71 72.62 5.64 <0.001

Motivate and train

engineering staff 3.83 0.98 76.5 5.3 <0.001 1

Leadership style of the

engineers (the

combination of attitude

and behavior of a leader,

which leads to certain

patterns in dealing with

the followers).

3.75 0.78 75 6.11 <0.001 2

Coaching (what can be

improved and how it can

be improved).

3.63 0.9 72.5 4.41 <0.001 3

Participation

management (involving

employees in the decision

making process).

3.55 0.88 71 3.97 <0.001 4

Organizational culture. 3.55 0.9 71 3.85 <0.001 5

125




Item Mean S.D RII

(%)

Test

valu

e

P-value Rank

Empowerment. 3.49 0.94 69.74 3.23 0.001 6

All items of Patient

Satisfaction 3.42 0.8 68.48 3.36 0.001

Satisfaction and loyalty 3.55 0.93 71 3.73 <0.001 1

Understanding hospital

staff perceptions of

patient priorities and

perceptions.

3.45 0.96 69 2.97 0.003 2

Physician role and patient

behavior 3.4 1.08 68 2.34 0.012 3

Trust in service oriented

architecture in the context

of healthcare

3.39 1.03 67.89 2.37 0.012 4

Distance and hospital

use. 3.33 1 66.5 2.06 0.023 5


Figure (4.4) : RII (%) of Financial and Quality Performance

(Source :Researcher).

0

10

20

30

40

50

60

70

80PE1

PE2

PE3

PE4

PE5

PE6

PE7

PE8

126

Figure (4.5) : RII (%) of Employee Performance (Source :Researcher).

Figure (4.6) : RII (%) of Patient Satisfaction (Source :Researcher).

66

68

70

72

74

76

78PE9

PE10

PE11

PE12

PE13

PE14

64

65

66

67

68

69

70

71PE15

PE16

PE17PE18

PE19

127

4.8 Test of research hypotheses

Hypotheses have been put to study relations between variables to support Lean

thinking Application in the MDC industry in Gaza Strip. According to Figure (1.1)

and Figure (1.2) ,eleven hypotheses were tested through applying the Pearson product-

moment correlation coefficient (Pearson's correlation coefficient). The Pearson's

correlation coefficient was used to measure the strength and direction of the

relationship (linear association/correlation) between two quantitative variables, where

the value (r = 1) means a perfect positive correlation and the value (r = -1) means a

perfect negative correlation. Each hypothesis was tested separately. The six variables

in Figure (1.1) and Figure (1.2) represent parts of the questionnaire, where the

questionnaire was built from the following six parts:

▪ Part one: which is related to the respondent’s demographic data and the way of

work performance.

▪ Part two: to assess the readiness factors for lean implementation in service

oriented architecture by the professionals in MDC industry in Gaza Strip.

▪ Gaza Strip.

▪ Part three: to investigate the value of Lean benefits in MDC industry in Gaza

Strip.

▪ Part four: to investigate the critical success factors in in MDC industry in Gaza

Strip.

▪ Part five: to investigate the Lean challenges and barriers in in MDC industry in

Gaza Strip.

▪ Part six: to investigate the healthcare organization’s performance through lean

implementation in service oriented architecture in MDC industry in Gaza Strip.

4.8.1 The correlation between the readiness level for lean implementation and

healthcare organization’s performance

H1: There is a positive relationship, statistically significant at α ≤ 0.05, between

the readiness level for lean implementation by engineers and healthcare


128

To test the hypothesis, the Pearson's correlation coefficient was used to measure

the strength and the direction of the relationship (linear association/ correlation)

between “readiness level for lean implementation by engineers” and “healthcare

organization’s performance in the MDC industry in Gaza Strip.” According to the

results of the test that shown in

Table (4.7), The "readiness level for lean implementation by engineers" is

positively related to "healthcare organization’s performance in the MDC industry in

Gaza Strip", with a Pearson correlation coefficient of (r= 0.533) and the significance

value is less than 0.05 (P-value < 0.05), and thus the relationship is statistically

significant at α ≤ 0.05 (as indicated by the double asterisk after the coefficient).

Consequently, the hypothesis H1 is accepted.

The closer (r) is to +1, the stronger the positive correlation, while the closer (r) is

to -1, the stronger the negative correlation. According to that, it can be said that the

relationship between the "readiness level for lean implementation by engineers" and

“healthcare organization’s performance in the MDC industry in Gaza Strip.” is an

intermediate positive relationship because (r= 0.533). This result means, when one

variable increases in the value, the second variable also increase in the value. In other

words, increasing the readiness level for lean implementation by engineers will

increase healthcare organization’s performance in the MDC industry in Gaza Strip.


implementation by engineers and healthcare organization’s performance in the MDC

industry in Gaza Strip ( Source : Researcher).

Field Correlation

Coefficient

P-

Value

Relationship between the readiness level for lean

implementation by engineers and Financial and Quality

Performance

0.478 0.001


implementation by engineers and Employee

Performance

0.313 0.025


implementation by engineers and Patient Satisfaction 0.461 0.001


implementation by engineers and healthcare 0.533 <0.001

129

organization’s performance in the MDC industry in

Gaza Strip.

4.8.2 The correlation between the benefits of lean implementation and healthcare

organization’s performance.

H2: There is a positive relationship ship, statistically significant at α ≤ 0.05,

between the benefits of lean implementation and healthcare organization’s




between “the benefits of lean implementation” and “healthcare organization’s

performance in the MDC industry in Gaza Strip” .According to the results of the test

that shown in Table (4.8), The "the benefits of lean implementation" is positively

related to “healthcare organization’s performance in the MDC industry in Gaza

Strip”, with a Pearson correlation coefficient of (r= 0.713) and the significance value

is less than 0.05 (P-value < 0.05), and thus the relationship is statistically significant

at α ≤ 0.05 (as indicated by the double asterisk after the coefficient). Consequently, the

hypothesis H2 is accepted.



relationship between the “benefits of lean implementation” and “healthcare

organization’s performance in the MDC industry in Gaza Strip” is a strongly positive

relationship because (r= 0.713). This result means, when one variable increases in the

value, the second variable also increase in the value. In other words, increasing the

benefits of lean implementation will increase the healthcare organization’s


130

Table (4.8):Correlation coefficient between the benefits of lean implementation

and healthcare organization’s performance in the MDC industry in Gaza Strip ( Source

: Researcher).

Field Correlation

Coefficient

P-

Value

Relationship between the benefits of lean

implementation and Financial and Quality Performance 0.660 <0.001


implementation and Employee Performance 0.544 <0.001


implementation and Patient Satisfaction 0.441 0.002


implementation and healthcare organization’s

performance in the MDC industry in Gaza Strip

0.713 <0.001

4.8.3 The correlation between the critical success factors and healthcare

organization’s performance.


the critical success factors for lean implementation and healthcare organization’s




between “critical success factors for lean implementation” and “healthcare


results of the test that shown in Table (4.9), The “critical success factors for lean

implementation" is positively related to “healthcare organization’s performance in the

MDC industry in Gaza Strip.”, with a Pearson correlation coefficient of (r= 0.618) and

the significance value is less than 0.05 (P-value < 0.05), and thus the relationship is

statistically significant at α ≤ 0.05 (as indicated by the double asterisk after the

coefficient). Consequently, the hypothesis H3 is accepted.



relationship between the “critical success factors for lean implementation” and

“healthcare organization’s performance in the MDC industry in Gaza Strip.” is a

131

positive relationship because (r= 0.618). This result means, when one variable

increases in the value, the second variable also increase in the value. In other words,

increasing critical success factors for lean implementation will increase healthcare


Table (4.9):Correlation coefficient between the critical success factors for lean


Gaza Strip ( Source : Researcher).

Field Correlation

Coefficient

P-

Value

Relationship between the critical success factors for

lean implementation and Financial and Quality

Performance

0.537 <0.001


lean implementation and Employee Performance 0.516 <0.001


lean implementation and Patient Satisfaction 0.421 0.003


lean implementation and healthcare organization’s


0.618 <0.001

4.8.4 The correlation between the challenges and barriers of lean implementation and

healthcare organization’s performance.

H4: There is an inverse relationship, statistically significant at α ≤ 0.05, between

the challenges and barriers of lean implementation and healthcare organization’s




between “challenges and barriers of lean implementation” and “healthcare


results of the test that shown in Table (4.10), The challenges and barriers of lean

implementation is related negatively to healthcare organization’s performance in the

MDC industry in Gaza Strip, with a Pearson correlation coefficient of (r= - 0.528) and

132

the significance value is less than 0.05 (P-value < 0.05), and thus the relationship is





relationship between the “challenges and barriers of lean implementation” and

“healthcare organization’s performance in the MDC industry in Gaza Strip.” is a

negative relationship because (r= - 0.528). This result means, when one variable

increases in the value, the second variable decrease in the value. In other words,

increasing the challenges and barriers of lean implementation will decrease the

healthcare organization’s performance in the MDC industry in Gaza Strip.

Table (4.10):Correlation coefficient between the challenges and barriers of lean


Gaza Strip ( Source : Researcher).

Field Correlation

Coefficient

P-

Value

Relationship between the challenges and barriers of lean

implementation and Financial and Quality Performance -.493 0.001


implementation and Employee Performance -.488 0.001


implementation and Patient Satisfaction -0.370 0.009


implementation and healthcare organization’s


-0.528 <0.001

4.8.5 The correlation between the readiness level for lean implementation and Lean

challenges and barriers.


the readiness level for lean implementation and Lean challenges and barriers in the


133



between the “readiness level for lean implementation” and “Lean challenges and

barriers in the MDC industry in Gaza Strip.” According to the results of the test that

shown in Table (4.11), we conclude there exists an insignificant relationship between

the “readiness level for lean implementation” and “Lean challenges and barriers in

the MDC industry in Gaza Strip”, with a Pearson correlation coefficient of (r= - 0.249)

and the significance value is more than 0.05. (As indicated by the double asterisk after

the coefficient). Consequently, the hypothesis H5 is rejected.


implementation and Lean challenges and barriers in the MDC industry in Gaza Strip (

Source : Researcher).

Field Correlation

Coefficient

P-

Value

There is an inverse relationship, statistically significant at

α ≤ 0.05, between the readiness level for lean

implementation and Lean challenges and barriers in the

MDC industry in Gaza Strip

-0.249 0.061

4.8.6 The correlation between Lean benefits and Lean challenges and barriers.


the Lean benefits and Lean challenges and barriers in the MDC industry in Gaza

Strip.



between “Lean benefits "and" Lean challenges and barriers in the MDC industry in

Gaza Strip.” According to the results of the test that shown in Table (4.12), “Lean

benefits is negatively related to “Lean challenges and barriers in the MDC industry in

Gaza Strip”, with a Pearson correlation coefficient of (r= - 0.470) and the significance

value is less than 0.05 (P-value < 0.05), and thus the relationship is statistically

134

significant at α ≤ 0.05 (as indicated by the double asterisk after the coefficient).

Consequently, the hypothesis H6 is accepted.



relationship between the “Lean benefits” and “Lean challenges and barriers in the

MDC industry in Gaza Strip” is a negative relationship because (r= - 0.470). This

result means, when one variable increases in the value, the second variable decrease

in the value. In other words, increasing the Lean benefits will decrease the Lean

challenges and barriers in the MDC industry in Gaza Strip.

Table (4.12):Correlation coefficient between the Lean benefits and Lean

challenges and barriers in the MDC industry in Gaza Strip ( Source : Researcher).

Field Correlation

Coefficient

P-

Value

There is an inverse relationship, statistically significant

at α ≤ 0.05, between the Lean benefits and Lean

challenges and barriers in the MDC industry in Gaza

Strip

-0.470 0.001

4.8.7 The correlation between the Lean critical success factors and Lean challenges

and barriers.


the Lean critical success factors and Lean challenges and barriers in the MDC




between “Lean critical success factors” and “Lean challenges and barriers in the

MDC industry in Gaza Strip.” According to the results of the test that shown in Table

(4.13), The Lean critical success factors is negatively related to Lean challenges and

barriers in the MDC industry in Gaza Strip., with a Pearson correlation coefficient of

135

(r= - 0.323) and the significance value is less than 0.05 (P-value < 0.05), and thus the

relationship is statistically significant at α ≤ 0.05 (as indicated by the double asterisk

after the coefficient). Consequently, the hypothesis H1 is accepted.



relationship between the “Lean critical success factors" and "Lean challenges and

barriers in the MDC industry in Gaza Strip” is a negative relationship because (r= -

0.323). This result means, when one variable increases in the value, the second variable

decrease in the value. In other words, increasing the Lean critical success factors will

decrease Lean challenges and barriers in the MDC industry in Gaza Strip.

Table (4.13):Correlation coefficient between the Lean critical success factors and

Lean challenges and barriers in the MDC industry in Gaza Strip ( Source : Researcher).

Field Correlation

Coefficient

P-

Value

There is an inverse relationship, statistically significant

at α ≤ 0.05, between the Lean critical success factors and

Lean challenges and barriers in the MDC industry in

Gaza Strip

-0.323 0.021

4.8.8 The correlation between the readiness level for lean implementation and the

Lean benefits.


the readiness level for lean implementation and the value of Lean benefits in the




between “readiness level for lean implementation” and “the value of Lean benefits in

the MDC industry in Gaza Strip." According to the results of the test that shown in

Table (4.14), “readiness level for lean implementation” is positively related to "the

136

value of Lean benefits in the MDC industry in Gaza Strip"., with a Pearson correlation

coefficient of (r= 0.526) and the significance value is less than 0.05 (P-value < 0.05),

and thus the relationship is statistically significant at α ≤ 0.05 (as indicated by the

double asterisk after the coefficient). Consequently, the hypothesis H8 is accepted.



relationship between the “readiness level for lean implementation” and “the value of

Lean benefits in the MDC industry in Gaza Strip” is an intermediate positive

relationship because (r= 0.526). This result means, when one variable increases in the

value, the second variable also increase in the value. In other words, increasing the

readiness level for lean implementation will increase the value of Lean benefits in the



implementation and the value of Lean benefits in the MDC industry in Gaza Strip (


Field Correlation

Coefficient

P-

Value

There is a positive relationship, statistically significant at


implementation and the value of Lean benefits in the

MDC industry in Gaza Strip

0.526 0.021

4.8.9 The correlation between the readiness level for lean implementation and the Lean

critical success factors.


the readiness level for lean implementation and the Lean critical success factors in

the MDC industry in Gaza Strip.



between “readiness levels for lean implementation” and “Lean critical success factors

in the MDC industry in Gaza Strip". According to the results of the test that shown in

137

Table (4.15), “readiness level for lean implementation” is positively related to "the

value of Lean benefits in the MDC industry in Gaza Strip"., with a Pearson correlation

coefficient of (r= 0.553) and the significance value is less than 0.05 (P-value < 0.05),

and thus the relationship is statistically significant at α ≤ 0.05 (as indicated by the

double asterisk after the coefficient). Consequently, the hypothesis H9 is accepted.



relationship between the “readiness level for lean implementation” and “Lean critical

success factors in the MDC industry in Gaza Strip.” is a positive relationship because

(r= 0.553). This result means, when one variable increases in the value, the second

variable also increase in the value. In other words, increasing the readiness level for

lean implementation will increase the Lean critical success factors in the MDC



implementation and the Lean critical success factors in the MDC industry in Gaza Strip

( Source : Researcher).

Field Correlation

Coefficient

P-

Value

There is a positive relationship, statistically significant at


implementation and the Lean critical success factors in

the MDC industry in Gaza Strip

0.553 <0.001

4.8.10 The correlation between the Lean benefits and the Lean critical success factors.


the Lean benefits and the Lean critical success factors in the MDC industry in Gaza

Strip.



between “Lean benefits” and “Lean critical success factors in the MDC industry in

Gaza Strip." According to the results of the test that shown in Table (4.16), "Lean

benefits " is positively related to “Lean critical success factors in the MDC industry

138

in Gaza Strip”, with a Pearson correlation coefficient of (r= 0.741) and the

significance value is less than 0.05 (P-value < 0.05), and thus the relationship is





relationship between the “Lean benefits” and “Lean critical success factors in the

MDC industry in Gaza Strip.” Is a strong positive relationship because (r= 0.741)?

This result means, when one variable increases in the value, the second variable also

increase in the value. In other words, increasing Lean benefits will increase the Lean

critical success factors in the MDC industry in Gaza Strip.

Table (4.16):Correlation coefficient between the Lean benefits and the Lean

critical success factors in the MDC industry in Gaza Strip ( Source : Researcher).

Field Correlation

Coefficient

P-

Value

There is a positive relationship, statistically significant

at α ≤ 0.05, between the Lean benefits and the Lean

critical success factors in the MDC industry in Gaza

Strip

0.741 <0.001

4.8.11 Hypothesis related to respondents’ profiles (respondent’s analysis)

H11: There is statistical significant differences at α ≤ 0.05 in the responses of

the research sample due to demographic data.

This hypothesis was to analyze the differences in the opinions of the respondents

toward the applying of Lean thinking in the MDC industry in Gaza Strip

due to many things. These things are seven sections (1) the gender, (2) the

educational background, (3) the educational qualification, (4) the person's years of

experience, (5) nature of the workplace, (6) location of workplace and (7)

organization's Establishment).The Mann-Whitney test and the Kruskal-Wallis test are

nonparametric methods used to detect whether two or more samples come from the

139

same distribution or to test whether medians between comparison groups are different,

under the assumption that the shapes of the underlying distributions are the same.

4.8.11.1 An analysis taking into account the gender.

H 11.1: There is statistical significant differences at α ≤ 0.05 in the responses of

the research sample due to gender.

Table (4.17) shows that the p-value (Sig.) is smaller than the level of significance

= 0.05 for the fields “Readiness factors integral for lean implementation in service

oriented architecture and Factors affecting healthcare organization’s performance in

lean implementation in service oriented architecture”, then there is significant

difference among the respondents toward this fields due to gender. We conclude that

the gender has an effect on this fields.

For the other fields, the p-value (Sig.) is greater than the level of significance =

0.05, then there is insignificant difference among the respondents toward these fields

due to gender. We conclude that the gender has no effect on the other fields.

Table (4.17):Mann-Whitney test of the fields and their p-values for gender (


Field Means

Test Value Sig. Male Female

Readiness factors integral for lean

implementation in service oriented

architecture

3.27 4.00 -2.313 0.021

Beneficial Factors for lean implementation

in service oriented architecture 3.28 3.86 -1.130 0.258

Critical success factors for lean


architecture

3.53 4.00 -1.105 0.269

Challenges and barriers factors for lean


architecture

3.43 4.24 -1.748 0.080

Factors affecting healthcare organization’s

performance in lean implementation in

service oriented architecture

3.43 4.21 -2.236 0.025

All items of the questionnaire 3.39 4.03 -1.823 0.068

140

4.8.11.2 An analysis taking into account the educational background.


the research sample due to educational background.

Table (4.18) shows that the p-value (Sig.) is greater than the level of significance

= 0.05 for each field, then there is in significant difference among the respondents

toward each field due to educational background. We conclude that the educational

background has no effect on each field.

Table (4.18):Kruskal-Wallis Test of the fields and their p-values for Educational

Background ( Source : Researcher).

Field Means Test Value Sig. Architect Civil Electrical Mechanical Other

Readiness factors

integral for lean

implementation in

service oriented

architecture.

3.83 3.16 3.24 3.67 3.20 8.530 0.074

Beneficial Factors

for lean

implementation in

service oriented

architecture.

3.74 3.26 3.23 3.44 3.17 4.174 0.383

Critical success

factors for lean

implementation in

service oriented

architecture.

3.70 3.46 3.57 3.67 3.70 1.235 0.872

Challenges and

barriers factors for

lean

implementation in

service oriented

architecture.

3.79 3.45 3.53 3.64 2.95 3.341 0.502

Factors affecting

healthcare

organization’s

performance in

lean

implementation in

3.94 3.38 3.62 3.18 3.16 8.256 0.083

141

service oriented

architecture.

All items of the

questionnaire 3.79 3.35 3.44 3.47 3.26 3.843 0.428

4.8.11.3 An analysis taking into account the educational qualification.


the research sample due to educational qualification.


= 0.05 for the field “Challenges and barriers factors for lean implementation in

service oriented architecture”, then there is significant difference among the

respondents toward their field due to educational qualification. We conclude that the

educational qualification has an effect on their field.



due to educational qualification. We conclude that the educational qualification has no

effect on the other fields.

Table (4.19):Mann-Whitney test of the fields and their p-values for educational

qualification ( Source : Researcher).

Field Means

Test Value Sig. Bachelor's Master's



architecture

3.31 3.38 -0.103 0.918

Beneficial Factors for lean


architecture

3.24 3.67 -1.522 0.128



architecture

3.51 3.78 -0.947 0.343

Challenges and barriers factors for

lean implementation in service


3.38 3.92 -1.980 0.048

Factors affecting healthcare

organization’s performance in lean 3.43 3.74 -1.320 0.187

142


architecture


4.8.11.4 An analysis taking into account the person's years of experience.


the research sample due to person's years of experience.


= 0.05 for the field “Factors affecting healthcare organization’s performance in lean

implementation in service oriented architecture”, then there is significant difference

among the respondents toward their field due to person's years of experience. We

conclude that the person's years of experience has an effect on their field.



due to person's years of experience. We conclude that the person's years of experience

has no effect on the other fields.

Table (4.20):Kruskal-Wallis Test of the fields and their p-values for Person's years

of experience ( Source : Researcher).

Field

Means

Test

Value Sig.

Less

than 5

years

From 5 to

less than

10 years

10 Years

and

more

Readiness factors integral for

lean implementation in


3.54 3.06 3.50 5.459 0.065


implementation in service


3.31 3.21 3.46 0.830 0.660

Critical success factors for



3.80 3.40 3.64 1.508 0.471

Challenges and barriers

factors for lean



3.52 3.35 3.63 1.097 0.578

143


organization’s performance in



3.82 3.24 3.62 7.313 0.026

All items of the questionnaire 3.58 3.27 3.56 2.334 0.311

4.8.11.5 An analysis taking into account the nature of the workplace.

H 11.5 There is statistical significant differences at α ≤ 0.05 in the responses of

the research sample due to nature of the workplace.



toward each field due to nature of the workplace. We conclude that the nature of the

workplace has no effect on each field.

Table (4.21):Kruskal-Wallis Test of the fields and their p-values for nature of the

workplace ( Source : Researcher).

Field Means Test Value Sig.

MOH Contractor Other




3.23 3.43 3.60 2.520 0.284




3.23 3.41 3.61 2.608 0.271




3.51 3.79 3.54 0.806 0.668

Challenges and barriers factors

for lean implementation in


3.50 3.50 3.44 0.076 0.963





3.46 3.42 3.73 1.427 0.490


144

4.8.11.6 An analysis taking into account the location of workplace.


the research sample due to location of workplace.



toward each field due to location of workplace. We conclude that the location of

workplace has no effect on each field.

Table (4.22):Mann-Whitney test of the fields and their p-values for location of

workplace ( Source : Researcher).

Field Means Test

Value Sig. North/

Gaza

Middle/

Khan Yuns



architecture

3.38 3.20 -1.081 0.280



architecture

3.38 3.21 -1.184 0.236



architecture

3.61 3.48 -0.795 0.427

Challenges and barriers factors for



3.56 3.35 -0.896 0.370


organization’s performance in lean


architecture

3.60 3.28 -1.951 0.051


4.8.11.7 An analysis taking into account the organization's establishment.


the research sample due to organization's establishment.



145

toward each field due to organization's establishment. We conclude that the

organization's establishment has no effect on each field.

Table (4.23):Kruskal-Wallis Test of the fields and their p-values for Organization's

Establishment ( Source : Researcher).

Field

Means

Test

Value Sig.

Less

than 5

years

From 5 to

less than

10 years

10 Years

and

more




3.13 3.30 3.38 0.941 0.625



oriented architecture.

3.11 3.23 3.43 1.484 0.476

Critical success factors for



3.14 3.41 3.75 2.846 0.241

Challenges and barriers

factors for lean


oriented architecture.

3.67 3.50 3.43 0.652 0.722





3.52 3.52 3.47 0.062 0.970


Based on the previous findings of the eleventh hypothesis (which has been broken

down into seven sections), it has appeared that the hypothesis has been rejected in

respect of seven sections (the gender, the educational background, person's years of

experience, nature of the workplace, location of workplace and organization's

Establishment).

146

Chapter 5

Conclusion and

Recommendations

147

Conclusion and recommendations

The main objective of this study was to develop healthcare operation through lean

thinking in the in the Medical and Design Construction (MDC) industry Gaza Strip.

The study also aimed to examine the influence of applying lean thinking on healthcare

organizations’ performance. This chapter included the conclusions and several

recommendations suggested for the adoption of Lean thinking in the MDC industry in

Gaza Strip, in order to optimize the performance for healthcare organizations, also this

chapter includes an overview discussed to assess the extent to which the research

objectives were met. The limitations of the study were also examined in this chapter.

5.1 Summary of the research

An investigation into the CSFs, benefits and challenges to successful Lean thinking

adoption in the MDC industry in Gaza Strip was conducted. An extensive review of

the literature was carried out to achieve the aim of the study. The purpose of the

research was to develop a clear understanding about Lean thinking for identifying the

different factors which provide useful information to consider adopting Lean thinking

by the professionals in the MDC industry in Gaza Strip. The results of 80 collected

questionnaires were analyzed quantitatively and then presented by using an

interpretive and descriptive method for qualitative data analysis, which contains

tabulation, pie chart, and graph to present the results.

5.2 Conclusions of the research objectives, questions, and hypotheses

In achieving the purpose of the study, six main objectives have been identified and

made through the findings of the analyzed collected questionnaires. These objectives

are linked to the study questions that were developed to growth one ‘s knowledge and

familiarity with the subject. The outcomes were initiate as following:

5.2.1 Outcomes related to objective one

▪ The objective was: To assess the readiness factors level for lean implementation

by professionals in MDC industry in Gaza Strip. This objective is related to the

following research question:

148

▪ The first research question: What is the level of the readiness for lean

implementation by professionals in MDC industry in Gaza Strip?

Results obtained from questionnaire survey indicated that the readiness level for

Lean implementation by the professionals in the MDC industry in Gaza Strip is high.

According to the respondents, the complicated nature of healthcare settings in Gaza

Strip, end to end process and activities view is very important beside the involvement

and encouragement of engineer’s staff in Lean activity through training.

The current study further showed that healthcare organizations First, having a poor

satisfactory system and hence a poor measurement system to progress monitoring that

consider an essential issue aligned to adopt Lean thinking in healthcare sector in Gaza

Strip. Second, Ministry of Health (MOH) imposed policies and rules that didn’t allow

construction professionals to apply Lean thinking with its tool and techniques despite

their willingness to apply Lean.

Third, lean implementation must be linked to healthcare setting professional as

long term policy with healthcare organization strategy where professionals showed

their ability to link them as well as to provide support for that work. So, concept of

design will be considered. The study findings of RII test indicated that Lean thinking

are significantly required and necessary for the professionals in the MDC industry in

Gaza Strip.

5.2.2 Outcomes related to objective Two

▪ The objective was: To identify the lean benefits that would convince professionals

for adopting lean thinking in MDC industry in Gaza Strip. This objective is related

to the following research question:

▪ The second research question: Are the benefits of Lean valuable from the

Standpoint of the professionals (according to the need for these functions) In the

MDC industry in Gaza Strip?

The study findings of RII test indicated that Lean benefits are significantly valuable

for the professionals in the MDC industry in Gaza Strip. Some benefits of Lean were

149

more valuable than others for the engineers. Lean benefits that got top ranking

according to the overall respondents are as follow: -

1. Improve consensus among design team members at value stream mapping

stage (visual analysis of the flow of information and material during each

process).

2. Increased engineers 'competence, improved staff morale and reduced stress for

engineers.

3. Increase senior engineering manager’s commitment and readiness to initiate

change

4. Reduced time of work completion

5. Improved customer or patient satisfaction

The current study further showed that professionals will intent to implement lean

construction practices in an attempt to improve performance in MDC construction.

Most professionals said that they are in a need to provide more extensive analysis of

the empirical evidence available to assess the impact of the implementation of Lean

construction.

5.2.3 Outcomes related to objective Three

▪ The objective was: To identify and rank CSF’s among healthcare organizations.

This objective is related to the following research question:

▪ The third research question: Are the CSFs of Lean thinking important from the

viewpoint of the professionals (According to the need for these functions) in the


The study findings of RII test indicated that CSFs of Lean thinking are significantly

important to identify the main factors that health care organizations should focus on to

implement Lean thinking successfully. Some CSFs of Lean thinking were more

important than others for the professionals. CSFs of Lean thinking that got top ranking

according to the overall respondents are as follow: -

1. Top management commitment and involvement;

2. Alignment to business strategy and long-term plan;

3. Cross-functional integration between engineering disciplines;

150

4. Rewards and recognition;

5. Strong leadership to continuous improvement process demonstrated by

mangers at all levels.

5.2.4 Outcomes related to objective four

▪ The objective was: To investigate and rank the top Lean thinking challenges and

barriers which face the adoption of Lean thinking in MDC industry in Gaza Strip.

This objective is related to the following research question:

▪ The forth research question: Are Lean challenges and barriers affecting the

adoption of Lean thinking in the MDC industry in Gaza Strip?

The study findings of RII test indicated that CSFs of Lean thinking are significantly

important to determine the main challenges that affecting the adoption of Lean

thinking in health care organizations. Some CSFs of Lean thinking had more affects

than others for the professionals. CSFs of Lean thinking that got top ranking according

to the overall respondents are as follow: (1) Lack of knowledge how to apply lean led

design; (2) Lack of skilled engineers in the use of lean led design concepts; (3) Process

in the service oriented architecture context is technology enabled; (4) Lack of

governmental regulations to fully support application of lean concept; (5) Inadequate

references that people could obtains well as real cases in Gaza Strip or other nearby

areas in the region that have been implemented lean led design.

5.2.5 Outcomes related to objective five

▪ The objective was: To explore the impact of Lean thinking implementation on

healthcare performance in order to make recommendations for adopting Lean

thinking in MDC industry in Gaza Strip. This objective is related to the following

research question:

▪ The fifth research question: Are Lean thinking way affecting healthcare


There are various studies proven that implementation lean in healthcare

organizations given positively result for healthcare performance. Theses objective

were discussed with details in previous chapter.

151

5.2.6 Outcomes related to objective six

▪ The objective was: To study some hypotheses that might help to find solutions to

adopting Lean thinking in the medical sector in Gaza Strip.

▪ The sixth research question: What is the effect of the readiness level for lean

implementation by engineers and healthcare organization’s on increasing the

performance in the MDC industry in Gaza Strip?

▪ The seventh research question: What is the effect of benefits of lean

implementation and healthcare organization’s on increasing the performance in the


▪ The eighth research question: What is the effect of the critical success factors for

lean implementation and healthcare organization’s on increasing the performance

in the MDC industry in Gaza Strip?

▪ The ninth research question: What is the effect of the challenges and barriers of

lean implementation and healthcare organizations on decreasing performance in

the MDC industry in Gaza Strip?

▪ The tenth research question: What is the effect of the readiness level for lean

implementation on decreasing the Lean challenges and barriers in the MDC


▪ The eleventh research question: What is the effect of the Lean benefits on

decreasing the Lean challenges and barriers in the MDC industry in Gaza Strip?

▪ The twelfth research question: What is the effect of the Lean critical success

factors on decreasing the Lean challenges and barriers in the MDC industry in

Gaza Strip?

▪ The thirteenth research question: What is the effect of the readiness level for

lean implementation on increasing the value of Lean benefits in the MDC industry

in Gaza Strip?

▪ The fourteenth research question: What is the effect of the readiness level for

lean implementation on increasing the Lean critical success factors in the MDC


▪ The fifteenth research question: What is the effect of the Lean benefits on

increasing the Lean critical success factors in the MDC industry in Gaza Strip?

152

To achieve this objective, ten hypotheses were tested through applying the Pearson

product-moment correlation coefficient (Pearson's correlation coefficient). They all

have been accepted except (H5) has been rejected.

At first (for H1, H2), Pearson correlation analysis asserted that there is a positive

relationship between The “readiness level for lean implementation by engineers” and

“healthcare organization’s performance in the MDC industry in Gaza Strip” Also, the

same relationship between “benefits of lean implementation” and “healthcare

organization’s performance in the MDC industry in Gaza Strip.” And between the

“critical success factors for lean implementation” and “healthcare organization’s

performance in the MDC industry in Gaza Strip.” Accordingly, increasing the

readiness level for lean implementation by engineers will increase healthcare

organization’s performance in the MDC industry in Gaza Strip. The same thing will

happen when increasing the value of Lean benefits and CSFs.

Also (for H4), Pearson correlation analysis proved that there is an intermediate

negative relationship between "challenges and barriers of lean implementation" and

"healthcare organization’s performance in the MDC industry in Gaza Strip." Thus,

increasing the challenges and barriers of lean implementation will decrease the

healthcare organization’s performance in the MDC industry in Gaza Strip.

For (H5) Pearson correlation analysis confirmed that there are no statistically

significant relation "readiness level for lean implementation" and "Lean challenges

and barriers in the MDC industry in Gaza Strip." at the level of α ≤ 0.05. According

to that, the hypothesis has been rejected.

Then (for H6 and H7), Pearson correlation analysis substantiated that there is an

intermediate negative relationship between "Lean benefits "and" Lean challenges and

barriers in the MDC industry in Gaza Strip". Also, the same relationship is between

"Lean critical success factors" and "Lean challenges and barriers in the MDC industry

in Gaza Strip.” Accordingly, increasing the value of Lean benefits will decrease the

challenges and barriers of lean implementation in the MDC industry in Gaza Strip. The

same thing will happen when increasing the Lean CSFs.

153

Then (for H8 and H9), Pearson correlation analysis substantiated that there is an

intermediate negative relationship between "readiness level for lean implementation"

and "the value of Lean benefits in the MDC industry in Gaza Strip." Also, the same

relationship is between "readiness level for lean implementation" and "Lean critical

success factors in the MDC industry in Gaza Strip." Accordingly, increasing the value

of Lean benefits will increase the readiness level for lean implementation in the MDC

industry in Gaza Strip. The same thing will happen when increasing the Lean CSFs.

(For H10) Pearson correlation analysis proved that there is an intermediate

negative relationship between Lean benefits” and “Lean critical success factors in the

MDC industry in Gaza Strip." Thus, increasing Lean benefits will increase the Lean

critical success factors in the MDC industry in Gaza Strip.

Finally, (H6) was about the differences in the opinions of the respondents toward

the applying Lean thinking in the MDC industry in Gaza Strip due to the (1) the gender,

(2) the educational background, (3) the educational qualification, (4) the person's years

of experience, (5) nature of the workplace, (6) location of workplace and (7)

organization's Establishment). The outcomes were as follow:

The Independent Mann-Whitney test stated that there are no statistically significant

differences recognized to the gender and educational qualification of the respondents

at the level of α ≤ 0.05 between the Means of their views on the subject of the applying

Lean in the MDC industry in Gaza Strip. In the same context, and the Kruskal-Wallis

test confirmed that there are no statistically significant differences associated to each

of the educational background, the person's years of experience, nature of the

workplace, location of workplace and organization's Establishment of the respondents

at the level of α ≤ 0.05 between the Means of their views on the same subject.

According to that, the hypothesis has been rejected regarding these seven parts.

5.3 Recommendations:

According to the achieved objectives of this research as mentioned earlier, the

recommendations below were stated as a result of the research findings. The

recommendations are as follow:

154

▪ Implementing lean thinking will change in almost every aspect of project stages as

well as healthcare organizations performance. No guide can be used because

alteration at the mental thinking level is a developmental process. Each principle

driven process will reveal new opportunities unseen because people simply could

not think in ways that made the change possible. Thinking causes action, action

causes deep learning, and learning causes new thinking.

▪ Take care to develop systems thinking, understand the difficulty of changing

mental thinking, expect deep resistance in yourself and others to decentralized

decision making, and learn about lean thinking benefits in MDC industry

▪ Healthcare organizations need to manage Lean cultures that promote the search for

waste in design and construct of healthcare organizations. So construction

managers can help their teams to apply the Lean economic concepts of efficiency

and effectiveness to redirect resources to the site as well as eliminate the budget

that prevent savings from one area being used to address the needs of other areas.

▪ Healthcare managers should use Lean both to rise above the challenges and barriers

and to meet the new imperatives in MDC industry such as lack of skilled engineers

in the use of lean led design concepts.

5.3.1 Be Lean not LAME

Join Lean early in the planning, design and construction process to provide a clear

Lean vision. So we can gain the following benefits:

▪ Reducing lead time of schematic design and design development phases.

▪ Decreasing modifications and change orders; engineers become more confident in

the design decisions over all stages.

▪ The optimal response to the unpredictable changes and contingences.

▪ Reducing project cost.

It is difficult when adopting Lean late in the design phases. Because challenges

may arise with the schedule and it becomes impossible to have all the key players

available to participate. If schematic design is underway before Lean is integrated

there may be too many constraints and decisions in place to reengineer flow and

process.

155

5.3.2 Develop a sense of necessity

Top management of healthcare organizations must look hard at the behavior and

attitudes of engineers by developing training, education and increase the sense of

necessity all stakeholders for Lean implementation. Also this might be achieved by

sharing obviously the problems in process flow, as well as emphasizing the benefits of

this process by focusing on value added activities and elimination of wastes at all

stages of the construction project.

5.3.3 Develop Lean thinking process

This can be done by establishing a workshops for engineer's staff to present Lean

tools and techniques, and choose which one would support to create future Lean

strategy in healthcare organizations in MDC industry. This may be lead to involve all

engineers' staff from the beginning of Lean thinking process.

5.3.4 Standardize space

Processes in healthcare organizations related to architectural spaces which should

be standardized, so they are understandable for employees and patients. There is a need

to list of unnecessary equipment that is not need and can be returned also to streamline

processes in this spaces.

5.3.5 Increase employees’ motivation

Lean thinking implementation requires motivated engineers staff since this will

lead to higher work performance and creativity within the healthcare organizations.

Generally, all employees can be motivated by providing incentives.

5.3.6 Increase patient's loyalty

Healthcare organizations have to provide higher quality services and give more

attention to patients by meeting always their needs. To satisfy that, staff should also

be well committed. In this way, healthcare organizations can establish the culture of

the patient's loyalty.

Healthcare organizations have to improve work environment that is patient

centered flexible efficient and affordable. Also, Healthcare organizations have to

Optimizing patient and work flow to make operational efficiencies.

156

5.4 Limitations and future research

This study has a number of limitations including:

▪ According to literature review, a number of variables were identified and used in

the questionnaire design. Too many items in a questionnaire survey may affect the

response rate and validity of the results.

▪ For the quantitative study, the data collected from the questionnaire scales may

result in uncertain reliability and common method variance. However, it should be

noted that all of the survey respondents were construction professionals who were

working in a certain Healthcare organization. Small sample size could result in

reduced accuracy of parameter estimates and reduced power for testing.

▪ The CSFs identified are based on a review of the published literature. The external

validity of the findings could be enhanced if tested using an empirical study to

collect data repetitively over an extended period, like repetitive interviews and

surveying over month’s interval.

▪ The questionnaire survey provides a generalizable study of the relationship

between Lean variables and healthcare organizations performance by professionals

in Gaza Strip for the study. To carry out an in-depth study of this topic, qualitative

research methods are suggested. Interviews or case studies on some definite cases

are recommended for cross-validating the results found in this study and

uncovering the reasons behind the results.

▪ The current study targeted the construction professionals who are working in

healthcare organizations. Hence, it is highly recommended that further study

within construction professionals who are working within another NGO healthcare

organization.

▪ The lack of studies which is related to adopting Lean thinking in Palestine and the

surrounding region had limited in somehow the results this research.

▪ To explore the strength of causal relationships in adopting Lean thinking, computer

model is recommended as further research such as BIM system. (See Appendix B

illustrate an initial model for the Accident and Emergency Department (AED) of

Al-Shifaa Medical Complex (SMC) in Gaza, Palestine)

157

Numerous limitations that have been mentioned above will create

opportunities for future research. One of the future research areas could be on

actually conducting Lean thinking with the appropriate tools and techniques in MDC

industry and study the impacts. All Lean tools and techniques may not be applied

at the same approach and some may be adjusted, but the schedule time to implement

will be reduced and the actual outcomes and results will be visualized. Also future

research areas could be on conducting accurate comparative study of healthcare

organizations after and before adopting Lean thinking in MDC industry in Gaza Strip

then between healthcare organizations over Palestine.

Furthermore, the researcher distinguish that this study is based on questionnaire,

and there might be limitations of the findings. However, researcher encourage further

research for implementation of Lean tools and techniques in service oriented

architecture to increase the knowledge within this area.

158

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159

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180

Appendixes

181

Appendix A: Questionnaire

The Islamic university of Gaza

Higher studies deanery

Faculty of Engineers – master program

Engineering project management

Dear participant's greetings,

Thank you in advance for your valuable time and contribution to this research

work, which submitted in partial fulfilment of requirements for Science Degree of

master in civil engineering/ Construction Project Management, this research is titled

as "An investigation into Lean Thinking application in Medical Design and

Construction industry in Gaza Strip", the research aim is to contribute to develop

healthcare operation through lean thinking in Gaza Strip.

The questionnaire target Group is engineers who work in the medical field of

healthcare sector (Architects, Civil engineers, Mechanical engineers, electrical

engineers, and any other professional with related specification).

The questionnaire consists of six parts, filling in the questionnaire does not require

a prior knowledge about Lean. But what is required is the answer and evaluation of

certain points with precision and objectively according to your point of view and

expertise in the field of medical construction and design in the light of the actual reality

in Gaza Strip. The validity of the questionnaire results is completely depending on

your answer accuracy.

For more accurate answers the following items needed to be clarified, please read

it carefully and answer the questions below:

Lean Thinking: is about working more efficiently and faster by causing minimal

wastes. It is created when organizations operate in thinking and listening culture,

where process design is developed by workers who deliver products or services.

182

Flow: Processing one unit of work through a series of steps in a continuous

manner, at the rate of customer demand, in a standardized way. Ideally, only value-

added tasks are linked together.

Leadership: The activities used to create and organize and evolve the organization

through an ever evolving set of business changes

Building Information Modeling (BIM): advanced real-time architectural

software that tracks the model in 3D, and includes every detail across every discipline.

Lean 3P (Production Preparation Process): this model adapted from the way

Toyota designs new equipment quickly, helps teams conceptualize, design and refine

work as the project unfolds.

Schematic design: after pre design, a way to create a more differentiated floor

plan.

Pre design: early design involving the location of the building site, as well as

major blocks of functional areas and adjacencies.

Researcher: Samah Hani Attallah.

Supervisor: Dr. Khaled Al Hallaq.

May, 2017

183

▪ Part 1: Respondents demographic data and way of work performance

❖ To which degree you consistent with the following items? Please tick (√) in the

front of the number that reflects your point of view

Name (Optional):

…………………………………………………………………….

1 Gender Male Female

2

Educational

Background

Engineering

Man

agem

ent

O

ther (…

.)

Arch

itect

C

ivil

Electrical

Mech

anic

al

3 Educational

qualification

Bachelor's

Master's Ph.D.

4

Person's years

of experience

Less

than 5

years

From 5

to less

than 10

years

10 Years and more

5 Nature of the

workplace MOH NGOs

Contactor

Other (…)

6 Location of

workplace North Gaza

Middle

Khan

Yuns Rafah

7

Organization's

Establishment

Less

than 5

years

From 5

to less

than 10

years

10 Years and more

184

▪ Part 2: Readiness factors integral for lean implementation in service oriented architecture

عوامل الجاهزية لتطبيق فلسفة التفكير الموجه في سياق الخدمة الموجهة للعمارة

❖ To which degree you consistent with the following items? Please tick (√) in the

front of the number that reflects your point of view

No. Items

1. N

ever

2. L

ittl

e 3.S

om

ewhat

4.M

uch

5.V

ery m

uch

1 Lean thinking is widely adopted in

healthcare sector in Gaza Strip.

تبَني فلسفة التفكير الموجه داخل القطاع الصحي

في قطاع غزة.

2 Lean thinking concept in design is

considered.

الأخذ بعين الاعتبار مفاهيم التفكير الموجه في

عملية التصميم.

3 Lean concepts should cover the

overall process from start to end.

مفاهيم التفكير الموجه تشمل عمليات الانشاء من

إلى النهاية.البداية

4 Lean principles and methods need

special training and involvement.

مبادئ التفكير الموجه وطرقها تحتاج إلى تدريب

ومشاركة من نوع خاص.

5

Lean thinking concept should

include motivational system to be

adopted.

185

No. Items

1. N

ever

2. L

ittl

e 3.S

om

ewhat

4.M

uch

5.V

ery m

uch

فلسفة التفكير الموجه يجب أن يحتوي على تبَني

نظام التحفيز.

▪ Part 3: Beneficial Factors for lean implementation in service oriented architecture

المنافع العائدة من خلال تطبيق فلسفة التفكير الموجه في سياق الخدمة الموجه للعمارة ▪

❖ How would you rate the following items in terms of their benefit in lean

implementation in service oriented architecture at hospital design in Gaza Strip?

Please tick (√) in front of the number that reflects your point of view.

No. Items

1.E

xtr

emel

y l

ow

Ben

efic

ial

2.L

ow

ben

efic

ial

3.M

oder

atel

y

ben

efic

ial

4.H

ighly

ben

efic

ial

5.E

xtr

emel

y H

igh

Ben

efic

ial

1 Standardize the spaces at master

planning stage.

.الرئيسي التخطيط مرحلة في المساحات توحيد

2 Improve the understanding of

workflow at master planning stage.

التخطيط مرحلة في العمل سير فهم تحسين

.الرئيسي

3 Enhance the conversation with

hospital leaders.

.المستشفى قادة مع لغة الحوار تعزيز

4 Lean lead design can make sound

decisions early.

186

No. Items

1.E

xtr

emel

y l

ow

Ben

efic

ial

2.L

ow

ben

efic

ial

3.M

oder

atel

y

ben

efic

ial

4.H

ighly

ben

efic

ial

5.E

xtr

emel

y H

igh

Ben

efic

ial

قرارات اتخاذ يمُكن من فلسفة التفكير الموجه

.مبكر وقت في سليمة

5


service line that will be affected by

the project during master planning

stage.

التي الخدمة خط على المحتملة التغييرات فحص

التخطيط مرحلة خلال بالمشروع ستتأثر

.الرئيسي

6

Improve the process of information

at pre design stage that will inform

design.

قبل ما مرحلة في المعلومات عملية تحسين

.التصميم تبلغ سوف التي التصميم

7


current process are done at the first

line and planning how they could be

done in the future.

التي الحالية العملية بها تتم التي الطريقة فهم

القيام لكيفية والتخطيط الأول السطر تحدث في

.المستقبل في بها

8

Support design decision making by

the observation that provided enough

data to persuade them.

187

No. Items

1.E

xtr

emel

y l

ow

Ben

efic

ial

2.L

ow

ben

efic

ial

3.M

oder

atel

y

ben

efic

ial

4.H

ighly

ben

efic

ial

5.E

xtr

emel

y H

igh

Ben

efic

ial

الملاحظة خلال من التصميم قرارات اتخاذ دعم

لإقناعهم. البيانات من يكفي ما توفر التي

9



mapping stage (visual analysis of the

flow of information and material

during each process).

فريق أعضاء بين في الآراء التوافق تحسين

التدفق )التحليل خرائط رسم مرحلة في التصميم

كل خلال والمواد المعلومات لتدفق البصري

.عملية(

10


designs quickly using the humblest

materials at schematic design.

لنمذجة التصميم المتابعة مختلفة طرق محاولة

مرحلة في مواد متواضعة باستخدام بسرعة

.التصميم التخطيطي

11 Allow engineers to conduct quick

process simulation.

سريعة. عملية محاكاة بإجراء للمهندسين السماح

12




refine work as the project unfolds) to

188

No. Items

1.E

xtr

emel

y l

ow

Ben

efic

ial

2.L

ow

ben

efic

ial

3.M

oder

atel

y

ben

efic

ial

4.H

ighly

ben

efic

ial

5.E

xtr

emel

y H

igh

Ben

efic

ial

hear frontline concerns and offer

targeted solutions.

استراتيجية بالوقوف على نقاط للخبراء السماح

لمساعدة فريق المهندسين لانشاء الأفكار الأولية

وتقديم للمخاوف الاستماع ذلك للتصميم وك

.الحلول الناجعة

13

Start to use powerful new building


software where all design and

construction decisions can be


architect, engineer and designer and


حيث للمعلومات جديد نموذج بناء البدء باستخدام

يسجل فيها كافة قرارات التصميم والانشاء

المعماري المهندس بين وازالة العقبات

.البناء ومدير ومصمم والمهندس

14

Create detailed image of one floor or

one department images using

parametric melding

مجموعة أو لطابق واحد مفصلة صورة إنشاء

بارامتري نموذج باستخدام بأكلمه صور لقسم

)متعدد الأبعاد(.

189

No. Items

1.E

xtr

emel

y l

ow

Ben

efic

ial

2.L

ow

ben

efic

ial

3.M

oder

atel

y

ben

efic

ial

4.H

ighly

ben

efic

ial

5.E

xtr

emel

y H

igh

Ben

efic

ial

15

Manipulate large parameters across

all the disciplines of a building

project.

معالجة العوامل الكبيرة و المتعددة عبر

تخصصات بناء المشروع المختلفة.

16



clash detection.

المختلفة في بناء التخصصات بين التداخل تنسيق

الخلاف. عن المشروع والكشف

17


detail and complexity than have over

been possible before.

مع من التعامل نمذجة معلومات البناء يمكن

من أفضل والتعقيد التفاصيل من أكبر مستويات

.قبل الذي كان مسموحا به من

18 Promise to improve design results.

التصميم. نتائج بتحسين الوعد

19 Save waste from entering the new

physical environment.

حفظ الموارد للدخول ببيئة فيزيائية جديدة.

190

No. Items

1.E

xtr

emel

y l

ow

Ben

efic

ial

2.L

ow

ben

efic

ial

3.M

oder

atel

y

ben

efic

ial

4.H

ighly

ben

efic

ial

5.E

xtr

emel

y H

igh

Ben

efic

ial

20

Increased engineers’ competence,

improved staff morale and reduced

stress for engineers.

معنوياتهم وتحسين المهندسين, كفاءة زيادة

عليهم. الضغط وخفض

21 Reduced time of work completion.

تخفيض الوقت اللازم لانهاء العمل بشكل كامل.

22 Improved customer or patient

satisfaction.

.المرضى أو العملاء رضا تحسين

23 Improved financial benefits to the

organization.

تحسين الفوائد المالية للمنظمة.

24 Standardized procedures and

equipment.

.توحيد الاجراءات وكذلك المعدات

25 Striving to perfection by identifying

activities that did not add value.

التي الأنشطة تحديد خلال من الكمال إلى السعي

.قيمة تضف أي لم

26 Improved Patient flow through

architectural spaces.

191

No. Items

1.E

xtr

emel

y l

ow

Ben

efic

ial

2.L

ow

ben

efic

ial

3.M

oder

atel

y

ben

efic

ial

4.H

ighly

ben

efic

ial

5.E

xtr

emel

y H

igh

Ben

efic

ial

.خلال الفراغات المعمارية المرض تدفق تحسين

27 Patients treated faster, safer and

more reliable.

وأكثر أسرع بشكل معالجة المرضى يعالجون

موثوقية. وأكثر أمانا

28




زيادة التزام المهندسين المدراء وكذلك زيادة

استعدادهم للبدء في التغيير.

29 Increased productivity.

زيادة الانتاجية.

▪ Part 4: Critical success factors for lean implementation in service oriented architecture

عوامل نجاح تطبيق فلسفة التفكير الموجه في سياق الخدمة الموجه للعمارة ▪

▪

❖ How would you rate the following CSFs in terms of their importance in lean

implementation in service oriented architecture at hospital design in Gaza Strip?

Please tick (√) in front of the number that reflects your point of view.

192

No. Items

1.U

nim

port

ant

2. O

f li

ttle

import

ance

3.M

oder

atel

y

import

ant

4.i

mport

ant

5. V

ery

import

ant

1 Top management commitment and

involvement.

.ومشاركتها العليا الإدارة التزام

2 Training and education all

stakeholders .

.المصلحة أصحاب جميع وتثقيف تدريب

3 Engineers participation and

empowerment

وتمكينهم المهندسين مشاركة

4 Alignment to business strategy and

long-term plan

طويلة العمل والخطة استراتيجية مع المواءمة

.الأجل

5 Managing cultural change for


ثقافة البيئة المحيطةالادارة السليمة للتغير في

المستمر التحسين أجل من

6 Cross-functional integration

between engineering disciplines.

التخصصات الهندسية المختلفة. بين التكامل

7 Performance measurement

القياس الدوري للأداء

8 Sustain continuous improvement

193

No. Items

1.U

nim

port

ant

2. O

f li

ttle

import

ance

3.M

oder

atel

y

import

ant

4.i

mport

ant

5. V

ery

import

ant

المحافظة على مواصلة التحسين المستمر

9 Communication with engineers

المهندسين. مع التواصل

10 Rewards and recognition

والتقدير. المكافآت

11 Job security and social responsibility

الاجتماعية. والمسؤولية الوظيفي الأمن

12 Focusing on the need of customer

.العملاء حاجة على التركيز

13


improvement process demonstrated

by mangers at all levels.

على للمدراء المستمر التحسين لعملية قوية قيادة

المستويات جميع .

14 Establishing measurement and

feedback system.

الراجعة والتغذية القياس نظام إنشاء .

15 Appointing a project facilitator.

.للمشروع ميسر تعيين

16 Focusing on critical process.

.الحرجة العملية على التركيز

17 Organization infrastructure.

194

No. Items

1.U

nim

port

ant

2. O

f li

ttle

import

ance

3.M

oder

atel

y

import

ant

4.i

mport

ant

5. V

ery

import

ant

.للمنظمة التحتية البنية

18 Understanding methods, tools, and

techniques.

فهم الطرق, الأدوات والتقنيات

19 Willingness to take risks.

الرغبة في تحمل المخاطر

▪ Part 5: Challenges and barriers factors for lean implementation in service oriented architecture

التحديات والمعيقات التي تواجه فلفة التفكير الموجه في سياق الخدمة الموجه للعمارة ▪

▪

❖ How would you rate the following barriers in front of in lean implementation in

service oriented architecture at hospital design in Gaza Strip? Please tick (√) in

front of the number that reflects your point of view.

No. Items

1.V

ery w

eak

2. W

eak

3.A

ver

age

stre

ngth

4.S

trong

5.V

ery s

trong

1 Lack of awareness to lean led design

by stakeholders.

قلة الوعي بمفهوم التفكير الموجه الذي يقود

.المهندسين ذوي العلاقة قبل من عملية التصميم

2 Lack of knowledge how to apply

lean led design.

195

No. Items

1.V

ery w

eak

2. W

eak

3.A

ver

age

stre

ngth

4.S

trong

5.V

ery s

trong

فلسفة التفكير الموجه تطبيق بكيفية قلة المعرفة

.الذي يقود عملية التصميم

3



engineering offices.

التي بفوائد فلسفة التفكير الموجه المعرفة عدم

و على الهندسية يمكن أن تعود على المكاتب

.وجه الخصوص المعنيين بتصميم المستشفيات

4 Lack of skilled engineers in the use

of lean led design concepts.

استخدام في المهرة المهندسين إلى الافتقار

.الموجه التفكير فلسفة مفاهيم

5



intensive so it depends on moods of

people and how they are feeling it.

هي للعمارة الموجهة الخدمة سياق في العملية

وبذلك تعتمد بشكل كبير على الأشخاص عملية

. يشعرون وكيف الناس مزاج على تعتمد هي

6




العمارة سياق ضمن العملية تحديد صعوبة

.للخدمات الموجهة

196

No. Items

1.V

ery w

eak

2. W

eak

3.A

ver

age

stre

ngth

4.S

trong

5.V

ery s

trong

7



enabled.

تعتمد للعمارة الموجهة الخدمة سياق في العملية

.بشكل كبير على التكنولوجيا

8


could obtain as well as real cases in

Gaza Strip or other nearby areas in

the region that have been

implemented lean led design.

فلسفة التفكير حول كافية عدم وجود مراجع

عليها وكذلك الحصول للناس يمكن التي الموجه

أو في عدم وجود بناء حقيقي في قطاع غزة

أماكن مجاورة للمنطقة تم تنفيذه بواسطة استخدام

فلسفة التفكير الموجه.

9

Resistance by organization to adopt

new tools, and refuse any change can

focus on customer or patient value

and waste elimination.

جديدة, أدوات لتبني منظمة قبل من المقاومة

قيمة على يركز أن يمكن تغيير أي ورفض

.وكذلك تقليص هدر الموارد العملاء او المريض

197

No. Items

1.V

ery w

eak

2. W

eak

3.A

ver

age

stre

ngth

4.S

trong

5.V

ery s

trong

10

Unwillingness of engineers to learn

about lean led design concept

because of the lack of success stories

and the educational culture.

فلسفة على التعرف في المهندسين رغبة عدم

النجاح قصص نقص بسبب الموجه التفكير

.التعليمية والثقافة

11

Lack of governmental regulations to

fully support application of lean

concept.

فلسفة تطبيق لدعم حكومية أنظمة وجود عدم

كامل بشكل الموجه التفكير

▪ Part 6: Factors affecting healthcare organization’s performance in lean implementation in service


العوامل المؤثرة على أداء المؤسسات الصحية في سياق الخدمة الموجه للعمارة ▪

▪

❖ How would you rate the following items in front of its influence in lean

implementation in service oriented architecture at hospital design in Gaza Strip? Please

tick (√) in front of the number that reflects your point of view.

198

No. Items

1. N

ever

2. L

ittl

e 3.S

om

ewhat

4.M

uch

5.V

ery m

uch

Financial and Quality Performance

والجودة المالي الأداء

1 Actual project costs compared with

planned budget.

.المقررة بالميزانية مقارنة للمشروع الفعلية التكاليف

2



construction methods and specifications

للاتفاق المصلحة أصحاب مختلف بين العمل تكامل

والمواصفات التفصيلية البناء أساليب على

3

Offsite fabrication manage and deliver

them to the onsite work as; design


موقع العمل إلى وتسليمها الموقع خارج التصنيع

التغيير وأوامر التصميم التعديلات بناءا على

4


deficiencies/ambiguities, in drawings

and specifications, and resolved them

في الغموض,/ القصور أوجه عن المعلومات جمع

وحلها. والمواصفات, الرسومات

5

Providing accommodation assisted

project according to requirements as;

storage space, scaffolding, plant, power,

water, etc.

199

No. Items

1. N

ever

2. L

ittl

e 3.S

om

ewhat

4.M

uch

5.V

ery m

uch

لمتطلبات؛ وفقا للمشروع المساعدة المساكن توفير

المياه, الطاقة, النباتات, السقالات, التخزين, مساحة

الخ

6 All relevant stakeholders should be

warn to protect the completed parts

لحماية المعنيين المصلحة أصحاب جميع توعية

المكتملة. الأجزاء

7


relevant engineer and revising working

programs accordingly

ومراجعة الصلة ذات المهندس لتوجيهات الامتثال

لذلك. وفقا العمل برامج

8 Quantity and costs of variation orders.

التغيير. أوامر وتكاليف كمية

Employee Performance

أداء الموظفين

9

Leadership style of the engineers (the

combination of attitude and behaviour

of a leader, which leads to certain

patterns in dealing with the followers).

موقف وسلوك القائد,) المهندسين لدى القيادة أسلوب

مع التعامل في معينة أنماط إلى يؤدي الذي الأمر

.تباعه(أ

.

200

No. Items

1. N

ever

2. L

ittl

e 3.S

om

ewhat

4.M

uch

5.V

ery m

uch

10 Coaching (what can be improved and

how it can be improved).

التدريب )ما يمكن تحسينه وكيف سيتم تحسينه(

11 Empowerment.

التمكين.

12

Participation management (involving

employees in the decision making

process).

المشاركة الادارية شمل الموظفين في عمليات صنع

القرار.

13 Organizational culture.

ثقافة المنظمة.

14 Motivate and train engineering staff

طاقم المهندسين. وتدريب تحفيز


15 Satisfaction and loyalty.

الرضا و الولاء.

16 Physician role and patient behaviour.

قواعد الأطباء وسلوك المرضى.

17 Trust in service oriented architecture in

the context of healthcare.

201

No. Items

1. N

ever

2. L

ittl

e 3.S

om

ewhat

4.M

uch

5.V

ery m

uch

الرعاية سياق في للعمارة الموجهة الخدمة في الثقة

.الصحية

18 Distance and hospital use.

المسافة واستخدام المستشفى.

19


perceptions of patient priorities and

perceptions.

أولويات حول المستشفى موظفي تصورات فهم

.وتصوراته المريض

Thank You for Your Participation,

شاكرين لكم وقتكم الثمن في تعبئة هذا الاستبيان

202

Appendix B: Patient Flowchart at ED in Al-Shifaa Medical Complex

203

Appendix C: Correlation coefficient

Table (C. 1) clarifies the correlation coefficient for each item of the “Beneficial

Factors for lean implementation in service oriented architecture” and the total of the

field. The p-values (Sig.) are less than 0.05, so the correlation coefficients of this field

are significant at α = 0.05, so it can be said that the items of this field are consistent

and valid to be measure what it was set for.


implementation in service oriented architecture” and the total of this field.

No. Item Correlation

Coefficient

P-

Value

1. Standardize the spaces at master planning stage .610 <0.001

2. Improve the understanding of workflow at master

planning stage. .684 <0.001

3. Enhance the conversation with engineer’s leaders. .515 <0.001

4. Lean lead design can make sound decisions early. .316 0.025

5.

Examines potential changes to the service line that

will be affected by the project during master

planning stage.

.681 <0.001

6. Improve the process of information at pre design

stage that will inform design .549 <0.001

7.

Understanding the way in which current process

are done at the first line and planning how they

could be done in the future

.666 <0.001

8.

Support design decision making by the

observation that provided enough data to persuade

them

.600 <0.001

9.

Improve consensus among design team members

at value stream mapping stage (visual analysis of

the flow of information and material during each

process).

.534 <0.001

204




Coefficient

P-

Value

10. Try different ways to mock-up designs quickly

using the humblest materials at schematic design. .487 0.001

11. Allow engineers to conduct quick process

simulation .663 <0.001

12.

Allow experts come in at strategic points in

various 3Ps(that helps teams conceptualize, design

and refine work as the project unfolds) to hear

frontline concerns and offer targeted solutions

.659 <0.001

13.

Start to use powerful new building information

model or (BIM) software where all design and

construction decisions can be recorded to blur the

lines between architect, engineer and designer and


.473 0.001

14. Create detailed image of one floor or one

department images using parametric molding .636 <0.001

15. Manipulate large parameters across all the

disciplines of a building project .638 <0.001

16. Entrance coordination among disciplines of

building project and clash detection. .606 <0.001

17. BIM can handle greater levels of detail and

complexity than have over been possible before. .665 <0.001

18. Promise to improve design results .485 0.001

19. Save waste from entering the new physical

environment. .769 <0.001

20. Increased engineers ‘competence, improved staff

morale and reduced stress for engineers. .739 <0.001

21. Reduced time of work completion .578 <0.001

205




Coefficient

P-

Value

22. Improved customer or patient satisfaction .596 <0.001

23. Improved financial benefits to the organization .788 <0.001

24. Standardized procedures and equipment. .602 <0.001

25. Striving to perfection by identifying activities that

did not add value. .679 <0.001

26. Improved Patient flow through architectural

spaces. .444 0.002

27. Patients treated faster, safer and more reliable. .577 <0.001

28. Increase senior engineering manager’s

commitment and readiness to initiate change. .367 0.010

29. Increased productivity. .485 0.001

Table (C. 2) clarifies the correlation coefficient for each item of the “Critical

success factors for lean implementation in service oriented architecture” and the total

of the field. The p-values (Sig.) are less than 0.05, so the correlation coefficients of

this field are significant at α = 0.05, so it can be said that the items of this field are

consistent and valid to be measure what it was set for.

Table (C. 2) :Correlation coefficient of each item of “Critical success factors for

lean implementation in service oriented architecture” and the total of this field.


Coefficient

P-

Value

1. Top management commitment and

involvement. .695 <0.001

2. Training and education all stakeholders. .796 <0.001

3. Engineers participation and empowerment .691 <0.001

206

Table (C. 2) :Correlation coefficient of each item of “Critical success factors for

lean implementation in service oriented architecture” and the total of this field.


Coefficient

P-

Value

4. Alignment to business strategy and long-term

plan .660 <0.001

5. Managing cultural change for continuous

improvement .687 <0.001

6. Cross-functional integration between

engineering disciplines. .690 <0.001

7. Performance measurement .660 <0.001

8. Sustain continuous improvement .768 <0.001

9. Communication with engineers .743 <0.001

10. Rewards and recognition .604 <0.001

11. Job security and social responsibility .662 <0.001

12. Focusing on the need of customer .694 <0.001

13. Strong leadership to continuous improvement

process demonstrated by mangers at all levels. .734 <0.001

14. Establishing measurement and feedback

system. .831 <0.001

15. Appointing a project facilitator. .495 0.001

16. Focusing on critical process. .649 <0.001

17. Organization infrastructure .615 <0.001

18. Understanding methods, tools, and techniques. .757 <0.001

19. Willingness to take risks. .285 0.037

207

Table (C. 3) clarifies the correlation coefficient for each item of the “Challenges

and barriers factors for lean implementation in service oriented architecture” and the

total of the field. The p-values (Sig.) are less than 0.05, so the correlation coefficients

of this field are significant at α = 0.05, so it can be said that the items of this field are

consistent and valid to be measure what it was set for.


for lean implementation in service oriented architecture” and the total of this field


Coefficient

P-

Value

1. Lack of awareness to lean led design by

stakeholders 0.762 <0.001

2. Lack of knowledge how to apply lean led design. 0.784 <0.001

3. Lack of awareness to the benefits that lean led

design can bring to engineering offices 0.795 <0.001

4. Lack of skilled engineers in the use of lean led

design concepts. 0.802 <0.001

5.

Process in the service oriented architecture

context is people intensive so it depends on

moods of people and how they are feeling it.

.609 <0.001

6. Difficulty of identifying process within the

service oriented architecture context. .719 <0.001

7. Process in the service oriented architecture

context is technology enabled. .650 <0.001

8.

Inadequate references that people could obtains

well as real cases in Gaza Strip other nearby

areas in the region that have been implemented

lean led design .

.702 <0.001

9.

Resistance by organization to adopt new tools,

and refuse any change can focus on customer or

patient value and waste elimination.

.582 <0.001

208


for lean implementation in service oriented architecture” and the total of this field


Coefficient

P-

Value

10.

Unwillingness of engineers to learn about lean

led design concept because of the lack of success

stories and the educational culture.

.518 <0.001

11. Lack of governmental regulations to fully support

application of lean concept. .638 <0.001

Table (C. 4) clarifies the correlation coefficient for each item of the “Factors

affecting healthcare organization’s performance in lean implementation in service

oriented architecture” and the total of the field. The p-values (Sig.) are less than 0.05,

so the correlation coefficients of this field are significant at α = 0.05, so it can be said

that the items of this field are consistent and valid to be measure what it was set for.



architecture” and the total of this field


Coefficient

P-

Value

Financial and Quality Performance

1. Actual project costs compared with planned

budget. .522 <0.001

2. Work integration from different stakeholders to

agree on detail construction methods and

specifications

.786 <0.001

3. Offsite fabrication manage and deliver them to the

onsite work as; design modifications and change

orders

.707 <0.001

209





Coefficient

P-

Value

4. Gathering information on

deficiencies/ambiguities, in drawings and

specifications, and resolved them

.530 <0.001

5. Providing accommodation assisted project

according to requirements as; storage space,

scaffolding, plant, power, water, etc.

.526 <0.001

6. All relevant stakeholders should be warn to protect

the completed parts .697 <0.001

7. Compliance to directives from the relevant

engineer and revising working programs

accordingly

.648 <0.001

8. Quantity and costs of variation orders .624 <0.001

Employee Performance

9. Leadership style of the engineers (the combination

of attitude and behavior of a leader, which leads to

certain patterns in dealing with the followers).

.792 <0.001

10. Coaching (what can be improved and how it can be

improved). .759 <0.001

11. Empowerment. .829 <0.001

12. Participation management (involving employees in

the decision making process). .863 <0.001

13. Organizational culture. .677 <0.001

14. Motivate and train engineering staff .762 <0.001


210





Coefficient

P-

Value

15. Satisfaction and loyalty .858 <0.001

16. Physician role and patient behavior .884 <0.001

17. Trust in service oriented architecture in the context

of healthcare .749 <0.001

18. Distance and hospital use. .851 <0.001

19. Understanding hospital staff perceptions of patient

priorities and perceptions. .586 <0.001

211

Appendix D: Glossary

3P: Product, Process, Preparation. This model, adapted from the way Toyota designs

new equipment quickly, helps teams conceptualize, design and refine work as the

project unfolds.

5S: Toyota-based discipline involves Sort; Set in order; Shine; Standardize; Sustain.

Workers decide how the building will function and where things will go, in a

disciplined and standardized way. (See Workplace Organization.)

BIM: Building Information Model, advanced real-time architectural software that

tracks the model in 3D, and includes every detail across every discipline.

CT scanners: computed tomography X-ray system

CV: cardiovascular

Current state value stream map: a map describing the flow of: a) information

contained in the request for service, and b) a step-by-step chart showing how the

request is carried out. The current state map, based on actual frontline observations,

provides graphic evidence of where the process works, and where it breaks down. It

points the way to waste that needs to be eliminated.

Design development: Architectural stage where refinements are made, room by room.

The plan is already fixed.

ED: emergency department

Evaluation Criteria (in 3P, things participants must consider):

Key assumptions—things that cannot be changed

Design criteria to examine work flows and pathways

Organizational criteria, which include the mission, vision and values and make sure

that what is being planned aligns with them.

IFD or IPD: Integrated Facility Design or Integrated Project Delivery grants a single

contract for all of the major players in a project: architect, engineer, construction

trades, etc. Everyone is jointly responsible for the outcome.

212

Kaizen (rapid improvement event): generally translated as “change for the good.” A

way to look closely at processes or problems, analyzing how they arose and using the

wisdom of the team to quickly devise experiments and improve. Kaizen is done within

the existing walls with as little resource as possible.

Kanban: This word translates from Japanese as “signboard.” Hospitals think of “par

levels,” or amounts of things to be kept on hand. Kanban is a way to ensure that the

right amounts of the right items are on hand at all times. Kanban can be simple cards,

or barcodes, but they signal to the supplier when something is running low and allow

items to be replenished “just in time,” so inventory does not accumulate. (See

Workplace Organization.)

Move-In/Post-occupancy: At this stage of a lean project, it’s time for Workplace

Organization, which includes 5S, visual workplace and kanban tracking.

Observation: teams go to the point where work is done (“gemba”) to respectfully

watch processes in action.

Programming (architectural term):

Functional program (narrative document)

Space program (line-by-line spreadsheet of all spaces that will be needed)

“Pull” system: a system that replenishes itself as necessary, rather than stockpiling

inventory on-site. The “Pull” system can be used to move equipment from shelves,

people through waiting rooms. It is one of the 14 principles of The Toyota Way as

outlined by Jeffrey Liker.

Schematic design: after pre-design, a way to create a more differentiated floor plan.

Value: Value is created when a good or service delivered to the patient is something

the patient and/or customer (i.e., insurance company) would be willing to pay for.

Value stream map: visual analysis of the flow of information and material during

each process.