This paper explores discourses around Lean by examining the perceptions of new users of Lean in the public sector. The paper draws on actor-network theory as the basis for exploring what these new users think about Lean and uses data analysis tools to extrude concepts of significance. The data suggests that Lean continues to retain diverse, parallel and competing perspectives. The responses also signal that key concepts of Lean are missing from the discourses, and that this highlights a need to discuss Lean as a mindset-not just as a set of tools. The paper suggests future directions for research to further explore the issues emphasised by respondents. IMPACT This paper provides three major lessons for public managers and policy-makers who are in the process of introducing Lean to reduce costs and improve the quality of services. The first is the presence of diverse, parallel and competing discourses around Lean. Second, there is a missing awareness of central Lean concepts like quality, strategy and flow for managers and key personnel in public services for whom Lean is new. Finally, there is the need to emphasise Lean as a mindset in order to support a viable and coherent platform in public services. These lessons have implications for the objectives, perspectives and ways of organizing work associated with Lean initiatives. In particular, when communicating with new users of Lean, the mindset perspective of Lean must be emphasised, and the key concepts behind this mindset, such as quality, strategy and flow need to be developed and conveyed to new users. Clarity in communication of Lean concepts will increase the chances of setting realistic expectations for new users of Lean.

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Introduction: Care transitions between specialist and primary healthcare services for people with concurrent substance abuse and mental health problems are characterised by vulnerability and arbitrariness.Objectives: By studying factors that influence integration in a Norwegian context, this study aims to investigate, from a municipal perspective, why care transitions are still tricky after the introduction of the key Coordination Reform.Methods: This study has an explorative approach based on interviews with managers and front-line professionals in primary care. We applied the conceptual framework of functional and normative integration of the Rainbow Model. Results:The municipal actors emphasise that integration is hampered by limited cooperation with general practitioners in referrals to hospital, challenges of communication and loss of meeting points. They experienced close cooperation with sociomedical polyclinics for substance abuse, while challenges in cooperation with district psychiatric centres indicated an interdependence of functional and normative integration. Questioning hospital discharge of patients to primary care was a recurring theme for the municipal actors. Thus, the governing framework of the Coordination Reform has coexisted with fragmentation in organisational structures and divided professional cultures. Conclusions:The coexistence of the new and the old regimes seems to hamper functional and normative integration in care transitions.

Kapitlet diskuterer hvilke organisatoriske utfordringer som bør håndteres for at prosessorienterte modeller kan bidra til bedre samordning. Behandlingslinjer er et illustrerende eksempel på en slik prosessorientert tilnærming, og det empiriske materialet er hentet fra en studie om innføring av to ulike behandlingslinjer for ADHD. Gjennom å belyse hvordan selve standardiseringsarbeidet ble gjennomført, trekkes det frem tre organisatoriske utfordringer. Den første er anvendelsesområdet for behandlingslinjen. En avgrensing kan bidra til at standardiseringsarbeidet blir utført tett på de som har informasjon om hvilke samordningsutfordringer som må løses. Den andre utfordringen er å anvende hensiktsmessige verktøy og teknikker i standardiseringsarbeidet med henblikk på å finne egnede tiltak for å bedre samordningen. Og den tredje er forberedelse for god implementering, og at det iverksettes kompetansehevende tiltak i samarbeid med de som skal anvende det nye verktøyet. Disse tre utfordringene er alle sentrale i standardiseringsarbeidet, og bør håndteres for at prosessorienterte modeller kan bidra til bedre samordning.

By studying how primary care providers organize their services for people with concurrent substance abuse and mental health problems (dual diagnosis), this study aims to investigate formal and informal integration mechanisms. The study has an explorative approach based on interviews with people with dual diagnosis, managers, and front-line professionals in a Norwegian municipality of medium size. We found poor formal structures for internal coordination between services for mental health care and services for substance abuse, although they were organised in the same unit. Further, there were challenges in cooperation between this unit and the other healthcare units. Front-line professionals seemed to compensate for poor formal organisational structures with individual, informal coordination arrangements. Drawing on organisational theory, in particular the dilemmas of street-level bureaucrats and the role they play in policy implementation, this chapter discusses the importance and limitations of informal coordination measures for people with dual diagnosis.