This study examines Lean—conceptualized as Involvement in Continuous Improvement and Lean Techniques—in hospitals. Specifically, we aim to determine the extent to which hospital workers’ perceptions of Lean are related to perceptions of their performance and wellbeing, and to what extent these relationships are explained by autonomy. Our data (n = 754) come from a Lean implementation study in a Dutch hospital, and are analysed using structural equation modelling. First, our results indicate that Involvement in Continuous Improvement positively relates to hospital workers’ perceptions of several dimensions of hospital performance (quality, service, efficiency, and predictability) and their own wellbeing (burnout and engagement)—a mutual benefit for both employer and employees. However, we also show that the Lean Techniques do not significantly relate to wellbeing. Second, our study reveals that it is essential to distinguish between responsible autonomy and choice autonomy, as we found differing mediating effects. Based on these findings, we recommend HR executives to move away from approaches that focus on happy few and to move away from approaches that focus on techniques.

Purpose This study aims to examine to what extent the relationships between hospital workers’ perceptions of lean leadership behaviour, their engagement and the hospital unit’s perceived performance are mediated by job demands. Design/methodology/approach The data (n = 1,624) come from a lean implementation study in a Dutch hospital and are analysed using structural equation modelling in Mplus (v8.4). Findings The results confirm that lean leadership behaviour is related to employee engagement and hospital unit performance as perceived by employees, and these relationships are partially mediated through job demands. More specifically, the authors found that the type of job demand explains the direction of mediation effects. On the one hand, so-called challenging demands positively mediate the relationships between lean leadership behaviour and its outcomes. Conversely, hindering demands negatively mediates the relationship between lean leadership behaviour and perceived unit performance. Practical implications The authors recommend hospital organisations and human resources managers start by helping hospital leaders understand the underlying mechanisms that explain the effects of leadership on employees’ perceptions and, second, support their frontline leaders by providing training, coaching and feedback on how to influence job demands in a way that creates an optimal work environment for hospital employees. Originality/value The authors contribute to the literature by building upon insights from the job demands-resources model to explain the effects of lean leadership behaviour and by investigating the relevance of lean leadership in a hospital context, given the phenomenon’s strong roots in manufacturing.