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The purpose of this paper is to uncover the mechanisms influencing the sustainability of behavior changes following the implementation of teamwork.

Realistic evaluation was combined with a framework (DCOM®) based on applied behavior analysis to study the sustainability of behavior changes two and a half years after the initial implementation of teamwork at an emergency department. The DCOM® framework was used to categorize the mechanisms of behavior change interventions (BCIs) into the four categories of direction, competence, opportunity, and motivation. Non-participant observation and interview data were used.

The teamwork behaviors were not sustained. A substantial fallback in managerial activities in combination with a complex context contributed to reduced direction, opportunity, and motivation. Reduced direction made staff members unclear about how and why they should work in teams. Deterioration of opportunity was evident from the lack of problem-solving resources resulting in accumulated barriers to teamwork. Motivation in terms of management support and feedback was reduced.

The implementation of complex organizational changes in complex healthcare contexts requires continuous adaption and managerial activities well beyond the initial implementation period.

By integrating the DCOM® framework with realistic evaluation, this study responds to the call for theoretically based research on behavioral mechanisms that can explain how BCIs interact with context and how this interaction influences sustainability.

The purpose of this paper is to explain how different emergency services adopt and adapt the same hospital-wide lean-inspired intervention and how this is reflected in hospital process performance data.

A multiple case study based on a realistic evaluation approach to identify mechanisms for how lean impacts process performance and services’ capability to learn and continually improve. Four years of process performance data were collected from seven emergency services at a Swedish University Hospital: ear, nose and throat (ENT) (two), pediatrics (two), gynecology, internal medicine, and surgery. Performance patterns were linked with qualitative data collected through realist interviews.

The complexity of the care process influenced how improvement in access to care was achieved. For less complex care processes (ENT and gynecology), large and sustained improvement was mainly the result of a better match between capacity and demand. For medicine, surgery, and pediatrics, which exhibit greater care process complexity, sustainable, or continual improvement were constrained because the changes implemented were insufficient in addressing the higher degree of complexity.

The variation in process performance and sustainability of results indicate that lean efforts should be carefully adapted to the complexity of the care process and to the educational commitment of healthcare organizations. Ultimately, the ability to adapt lean to a particular context of application depends on the development of routines that effectively support learning from daily practices.

The purpose of this paper is to compare the implementation of 12 different organisation and management innovations (OMIs) in Swedish healthcare, to discover the generic and specific factors important for successful healthcare improvement change in a public health system.

Longitudinal cross‐case comparison of 12 case studies was employed, where each case study used a common framework for collecting data about the process of change, the content of the change, the context, and the intermediate and final outcomes.

Clinical leaders played a more important part in the development of these successful service innovations than managers. Strategies for and patterns of change implementation were found to differ according to the type of innovation. Internal organisational context factors played a significant role in the development of nearly all, but external factors did not. “Developmental evolution” better described the change process than “implementation”.

The 12 cases were all of relatively successful change processes: some unsuccessful examples would have provided additional testing of the hypotheses about what would predict successful innovation which were used in the case comparison. The cross‐case comparative hypothesis testing method allows systematic comparison if the case data are collected using similar frameworks, but this approach to management research requires considerable resources and coordination.

Management innovations that improve patient care can be carried out successfully by senior clinicians, under certain circumstances. A systematic approach is important both for developing and adapting an innovation to a changing situation. A significant amount of time was required for all involved, which could be reduced by “fast‐tracking” approval for some types of change.

This is the first empirical report comparing longitudinal and contextualised findings from a number of case studies of different organisational and management healthcare innovations. The findings made possible explanations for success factors and useful practical recommendations for conditions needed to nurture such innovation in public healthcare.

The purpose of this paper is to identify the most influential determinants of healthcare employees’ problem-solving capabilities and attitudes towards kaizen initiatives, and clarify how these determinants are related to social outcomes.

Drawing on the input-process-outcome framework, applied to kaizen initiatives, the determinants of the input and process factors are embodied in hypotheses concerning the direct effects of input and process factors on social outcomes and the indirect effects of input factors on social outcomes resulting from process factors. The hypotheses are tested through multiple regressions using data from 105 kaizen initiatives drawn from two hospitals.

Of the 14 determinants investigated, goal clarity, team autonomy, management support, goal difficulty and affective commitment to change (ACC) are the most influential determinants of kaizen capabilities and/or employees’ attitude. Goal clarity, goal difficulty, team autonomy and management support are also found to influence social outcomes directly and/or indirectly through ACC, internal processes and/or an action orientation.

The results support healthcare practitioners to understand how to establish “focused kaizen” actions to leverage specific determinants that positively influence social outcomes.

This study provides an original contribution to the literature concerning effective kaizen initiatives in healthcare operations by empirically testing a comprehensive model of the relationship between kaizen initiative determinants and social outcomes. Unlike previous studies, which are mostly anecdotal or focused on one or few determinants, this research adopts a holistic view, and investigates a pluralist set of determinants on social outcomes through a systematic and quantitative approach.