Do All Staff Members Need to Share the Same Purpose?: The Case of Kaizen in a Japanese Hospital

: It is said that when an organization embarks on a new activity, the entire organization needs to be on board with the organizational purpose of that activity. However, in the case of Hospital X, which implemented kaizen, even though the purposes of kaizen differed across workers, the usefulness of these new activities was communicated as being shared purposes (a) among workers in the same division where superiors and subordinates work closely together and (b) among workers performing the same jobs but in different divisions. Thus, the new activities were adopted by the entire organization without having a common organizational purpose.

Abstract: It is said that when an organization embarks on a new activity, the entire organization needs to be on board with the organizational purpose of that activity. However, in the case of Hospital X, which implemented kaizen, even though the purposes of kaizen differed across workers, the usefulness of these new activities was communicated as being shared purposes (a) among workers in the same division where superiors and subordinates work closely together and (b) among workers performing the same jobs but in different divisions. Thus, the new activities were adopted by the entire organization without having a common organizational purpose.

Introduction
When an organization adopts new ideas or activities, it may encounter resistance from stakeholders inside and outside the organization. Because of this, studies have noted that several patterns are common to make changes in the behavior of stakeholders affected by the new activities (Yamaguchi, 2015), and an increase in the ratio of people supporting these activities is effective in gaining legitimacy for them (Kikuchi, 2018).
On the other hand, Van de Ven (1986) held that it is necessary for an organization to have shared purposes in order to mobilize stakeholders for new activities, while Takeishi, Aoshima, and Karube (2012) asserted the importance that an organization's members have shared purposes from the top of the organization or down. Shein (1980) and, in the more distant past, Barnard (1938) also asserted the importance of members from the top to the bottom of an organization having a shared purpose for their activities so as to continue the organization's activities.
In an organization with many divisions and positions, however, it is not a simple matter for members of the organization to continue sharing purposes. Members in different divisions within an organization usually have different orientations (Lawrence & Lorsch, 1967), and even members of the same division may have different roles and purposes depending on their position (Kanai, 1991). Also, Takeishi et al. (2012) recognized that, when members have diverse purposes, it is not easy to generalize reasons for doing something.
In fact, at Hospital X, which is the subject of this case study, nurses did not have shared purposes when the new activities began, and thus, there was no overarching reason requiring these new activities. Yet nurses in several wards and at several positions went along with the new activities.

Case Study
Hospital X is a large general hospital in Tokyo that provides acute care to patients in emergency or critical conditions. In 2013, Hospital X was confronted with the risk of having its nursing staff cut down due to medical policies if by 2018 it was unable to produce data showing that the nurses in its wards were specialized in acute care. At the time, the hospital was experiencing high levels of job turnover and overtime among nurses, and it thus needed to quickly review its nursing practice. Ms. A, the Deputy Director of Nursing and an Executive in the Nursing Service Department, visualized the work of the nurses and wanted kaizen to be implemented in the nursing structure within the hospital's wards. From personal experience, medical industry literature, and academic conferences that she had attended, Ms. A was concerned that the usefulness of the kaizen activities and tools may not be recognized by all the nurses even after she explained it to them. This is because, as shown below, even nurses have different purposes, concerns, and background knowledge, depending on their positions and their wards.

Differences of purpose among positions
Ranked in order of hierarchy, the positions of the nurses in the hospital are executive nurse, head nurse, assistant head nurse, leader nurse, and floor nurse.

Executive nurses
Executive nurses oversee the hospital's nurses and prevent interference by management that could hinder nursing work and support the head nurses so that they can provide high-quality care in each ward.

Head nurses (and assistant head nurses)
Head nurses create an environment for the facilitation of high-quality care in each ward. They find out about the trends of the hospital's management from the executive nurses and share the status of ward operations with each other at a monthly meeting of head nurses. The head nurses then decide whether to adopt better ways to run the wards from what they learned about at these meetings. They also mentor the leader nurses and leader nurse candidates under them as they gain leadership skills. When appropriate, a head nurse may be assisted by an assistant head nurse.

Leader nurses
Leader nurses act as go-betweens with the head nurses so that the floor nurses can focus on providing high-quality care. Floor nurses who have developed a sufficient ability to respond to patient needs are promoted to the leader nurse position, but leadership skills alone are not enough. New leader nurses and leader nurse candidates participate in year-round training for that role and improve their leadership abilities through classroom learning, hands-on experience in their wards, and reporting to their class about their experiences.

Floor nurses
Floor nurses are involved in direct operations by visiting patients,

Diffusion of kaizen into other wards
The kaizen process in the first hospital ward and feedback from the workers were made known to the other wards at the head nurse meeting, leader nurse training sessions, and internal nursing research presentations.
In the head nurse meeting, the ward's head nurse, who was involved in the visualization, spoke for about ten minutes on their efforts, at the behest of Ms. A. She then reported on results and impressions. Other head nurses, hearing such feelings as "It was not as difficult as I expected," and "Kaizen on our own would take years, but now we can get the help of the FIer," began expressing interest without even being asked by Ms. A.
In addition, as was the case for the first ward, some wards were able to work on practical issues in training leader nurses. At training sessions, leader nurses from other wards heard about the role that leader nurses played in kaizen and how it helped develop their leadership capabilities. These leader nurses then thought of kaizen as a good opportunity to sharpen their leadership skills. Leader nurses thus learned about kaizen ahead of time, so that when they were told by their head nurses that they would be implementing kaizen, they readily accepted the idea of acting as intermediaries between the head nurse and the floor nurses.  As can be seen in Table 1, kaizen purposes, active implementors, and programs differed across wards. However, as has been noted, kaizen was implemented in six other wards by using the existing meeting structure and training sessions as forums for conveying information on kaizen and its impact.

Nephrology Ward
Kaizen was implemented here to reduce the amount of overtime. The head nurse, with the cooperation of the assistant head nurse, explained to the leader nurses and floor nurses about the necessity of kaizen and made them visualize it. The results were that overtime was being caused by the large amount of work related to medications. With the help of the leader nurses, the floor nurses thus became involved in coming up with kaizen measures, and medication-related work was redistributed between the day and night shifts to reduce the amount of this work done during the day shift. At the same time, the distribution of labor with pharmacists for medication-related work was altered. As a result, total overtime in the ward was reduced by 160 hours per month.

Cardiology Ward
The head nurse of this ward was concerned about the lengthy

Hematology Ward
This ward faced problems like low level of job satisfaction and high turnover rate. When performing the visualization, they added the following two points: (1) blood disease-related tasks were added to the survey items and (2) because the floor nurses were concerned that the amount of time spent at visualization would reduce the time they could devote to their usual tasks, Ms. B, who had supported kaizen in several wards, got the floor nurses to agree after conveying to them the importance of preparation and practice in visualization. As a result of the visualization, the nurses found out that they were spending large amounts of time on medication-related tasks and especially on clinical trials, so the head nurse and assistant head nurse, in consultation with the physicians, decided to have the physicians help nurses take blood samples. This allowed for better relations between physicians and nurses.

Respiratory Ward
The head nurse of this ward expected large amounts of overtime, so medication related to pulmonary medicine was added to the survey items during visualization. However, the results differed from the head nurse's expectations, as the ward had little overtime and the nurses were performing well. Accordingly, there was no need for kaizen, but the atmosphere in the ward became more relaxed after the efforts being made by the floor nurses were visualized.

Palliative Care Ward
At the time, this ward worked on a three-shift schedule, while all the other wards used a two-shift schedule. The ward was planning to change to a two-shift schedule, and the head nurse wanted to visualize the current work flow to get raw data for a new workflow. However, when kaizen was explained to the floor nurses, some expressed concern that the kaizen process would not give them

Discussion and Conclusion
This paper analyzes the process of diffusion of new "kaizen" activities over three years based on visualization among nurses in seven wards at Hospital X. At this hospital, the purposes of workers that participated in the visualization differed by position and ward. Unlike the assertion of Van de Ven (1986), 2 a shared purpose was not all that mattered. In addition, there was no creation of a common reason to convey the usefulness of kaizen (Takeishi et al., 2012).
In this hospital's wards, however, the usefulness of kaizen was conveyed as being all nurses, regardless of their position or division, working toward a shared purpose. As shown in Figure  2 In addition, Ferlie, Fitzgerald, Wood, and Hawkins (2005) and Freidson (1970) focused on differences in action goals and interests by type of professional when examining factors that promote or impede new initiatives in professional organizations. In the case discussed in this paper, members involved in implementing the new activities were aware of kaizen's usefulness, although Kosuge (2017) made it clear that, although a high market orientation and high kaizen awareness among members are correlated, kaizen awareness may be high even when market orientation is low.