Group 8 presentation – Service Operations Management

1. Anca Milea - Student ID: 1826060/1

2. Vladimir Dubinji – Student ID: 1319727
3. Adriano Badita – Student ID: 1933927
4. Andreea Graure – Student ID: 1933921/1
5. Daniela-Gianina Avasiloaie – Student ID: 1938122
6. Taushanna Pinnock – Student ID: 1564745
ISSUE 1 Student ID: 1826060/1

Q1: PEOPLE WERE PLACED AT UNDUE RISK OF HARM.

PEOPLE WERE UNABLE TO EASILY CALL STAFF FOR

ASSISTANCE WHEN THEY NEEDED IT. RISK
MANAGEMENT PLANS WERE NO ALWAYS FOLLOWED
CORRECTLY TO MITIGATE THE RISK OF HARM.
PEOPLE’S MEDICINES WERE NOT MANAGED SAFELY.
THE SERVICE DID NOT ALWAYS FOLLOW GOOD
INFECTION CONTROL PROCEDURES.
 Student ID: 1826060/1

QUALITY MANAGEMENT

According to Dodwad (2013),“Quality in healthcare is defined as everything the healthcare

organization undertakes to fulfill the needs of its customer, be it the patient, the payer, the admitting

doctor, the employer, or an internal customer within the organization”

• Quality Planning and Assurance

• Quality Control

• Quality Improvement
 • Student ID: 1826060/1

DONABEDIAN APPROACH TO STANDARD

QUALITY

• Structure- factors which affect the context how the care is deliver

• Process- organisational system and process

• Outcome- the impact on the people using the services

 • Student ID: 1826060/1

FACTORS AFFECTING THE QUALITY OF

HEALTHCARE
Lack of
Poor trainings
management

Staff relating to
record the
Pacien Safety incidents

Policy and
procedures no
followed
To safe guard
residents for the
risk or abuse
 • Student ID: 1826060/1

RECOMENDATIONS

• Recruitment and training process

• Safe use of medication

• In-place framework to shield people from the risk of neglect

• Manage safety of infection control

 • Student ID: 1826060/1
THE IMPROVEMENT JOURNEY
Securing Wider
Assesing Readiness Securing Board Support Organizational buy-in
and Creating a Vision
d

Recruitment and Long-term

continous programme of
improvement improvement
skils Financial
resources for
Audit staff and
trainings
Risk Infrastructure
Management development
needed
 • Student ID: 1826060/1
THE IMPROVEMENT JOURNEY

Sustaining an
Aligning Activity Organization-Wide
Approach

●
Analyze and ●
Updated ●
Ensuring that staff remain
feedback data on the management board engaged and supportive of
effects of ●
Identifying and the programme
improvement activity unlocking operational
●
Ability to manage the
Supervising and delivery expectations
barriers to improvement
●

spot checking on
●
Have systems and
●
Ensuring that resources
medication and procedures to manage
are allocated risks
infection control intelligently ●
Regularly review the
●
Appropriately ●
Quality improvement strategic management
induction and training feedback process
 • Student ID: 1826060/1

REFERENCES
Dodwad, S., 2013. Quality management in healthcare. Indian Journal of
Public Health, 57(3), p.138.

Dodwad, S., 2020. Quality Management In Healthcare. [ebook] Maharashtra,

p.140. Available at: <http://file:///C:/Users/1/Desktop/New%20folder
%20(3)/Quality_management_in_healthcare.pdf> [Accessed 27 October
2020].

Mosadeghrad, A., 2012. A Conceptual Framework for Quality of

Care. Materia Socio Medica, [online] 24(4), p.251. Available at:
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3732361/> [Accessed 27
October 2020].
 • Student ID: 1319727
ISSUE 2

INTRODUCTION
• Garside House Nursing Home residents are at
risk of malnutrition and dehydration (CQC,
2019).

• Malnutrition is a severe condition where

there is no enough nutrient in the diet (NHS).

• Dehydration means the body is losing more

fluid than it is consuming. If left untreated,
the condition can worsen and become a
serious problem (NHS).
 • Student ID: 1319727
CONSEQUENCES OF MALNUTRITION AND DEHYDRATION

Four main malnutrition FOUR MAIN DEHYDRATION

EFFECTS ON THE BODY:
effects on the body:

Increased risk of falls  WEAK IMMUNE

SYSTEM

Loss of muscle and

hypoxic responses  NEGATIVE IMPACT ON
HEART HEALTH

Depression & Apathy  INCREASED RISK OF

OBESITY

Decreased cardiac
output  PREMATURE AGING
“Good hydration is important for all age groups …” (NHS).
 • Student ID: 1319727
WHY THE CARE PLAN WENT
WRONG?

The Donabedian model (1966) can evaluate factors affecting quality assurance.

Shortage of permanent staff  Meal plan is not filled or filled incorrectly

Agency staff not trained properly  No regular intervals between reviews

 Staff relies on service users common sense

Care is not person-centred

RECOMMENDATIONS:
dehydration issues
 Increase awareness about
dehydration within staff and
service users.
 Find out residents’ preferences for
drinks and increase availability
and variety (feedback).
 Staff should encourage service
users to consume adequate
amounts of drinks.
 Drinking aid (cups, mugs, bottles).
• Student ID: 1319727
malnutrition issues
Increase awareness about
malnutrition with staff and service
users.
Create the environment that
prevents malnutrition (feedback -
menu, choice, preferences, modified
texture foods)
Minimize interruptions or
unnecessary distractions during
mealtime
Offer assistance to service users
who might need help
 • Student ID: 1319727
IMPROVEMENT PLAN
1 Audit and Feedback - collection of data whether the organization
has a capacity to make the change and feedback from service
users/staff/service users family members.
2 A clear commitment from the board and senior

managers is required.
3 A clear vision of the change should be presented
to all employees at once.
4 Appointing of the executive leader of the change
process.
5 Attention to progress and to barriers.
6 Focus on outcomes - change is difficult process and
The Health Foundation
path might be rough.
(Beauchamp, Heidari-Robinson, Heywood 2016)
 • Student ID: 1319727
CONCLUSION
• Quality assurance is defined as all
activities undertaken to predate &
prevent poor quality (Neetvert, nd).

• Balanced diet and drinking plenty of

water leads to a better quality of life
(Prestige Nursing+Care, 2015).

• A safe living environment and 24/7

care keep seniors happy
(Nursing Home Abuse Center, 2019).
 • Student ID: 1319727
References

https://www.completecareshop.co.uk/drinking-aids/

https://www.chriscolotti.us/everything-else/miscellaneous/properly-deal-poorly-handled-warranty-claims/

https://healthcaremarketreview.com/avedis-donabedian-and-the-birth-of-healthcare-quality-assurance/

https://www.health.org.uk/publications/reports/the-improvement-journey

https://www.malnutritionpathway.co.uk/tipsheets/tipsheet_carehomes.pdf

https://www. mcentr-zdorove.mozello.ru/interesting/params/post/1720915/

https://www.mckinsey.com/business-functions/organization/our-insights/reorganization-without-tears#

https://www.nursinghomeabusecenter.com/blog/senior-happiness-nursing-homes/

https://q.health.org.uk/blog-post/uk-wide-q-community-event-2019-live-blog/

https://www.reactto.co.uk/resources/malnutrition-and-dehydration/

https://share.baptisthealth.com/dehydration-effects-the-human-body/

https://www.staffordshire.gov.uk/Advice-support-and-care-for-adults/Help-and-support-with-daily-living/Eating-and-drinking/Dehydration-and-
older-people-detailed-factsheet.aspx

https://www.thebalancecareers.com/executive-support-and-leadership-in-change-management-1917803
 • Student ID: 1933927
• ISSUE 3
• SERVICE OPERATIONS MANAGEMENT
• Board Room Case Study - Garside House Nursing Home

I’m Adrian Badita and the CQC Issue which I will discuss is about the
fact, people were not supported to have maximum choice and control of
their lives and staff did not support them in the least restrictive way
possible and in their best interests; the policies and systems in the
service did not support this practice.
 • Student ID: 1933927

Technical quality - effectiveness of care in producing achievable

health gain

Interpersonal quality - extent of accommodation of the patient needs and

preferences

Amenities - comfort of physical surroundings

attributes of the organisation of service provision ( Donabedian A, 1980)
 • Student ID: 1933927
MAXWELL’S DIMENSIONS OF SERVICE QUALITY
IN HEALTHCARE (MAXWELL RJ. 1984)

EFFECTIVE EFFICIENT ACCESSIBLE

RESPONSIVE EQUITABLE APPROPIATE

 • Student ID: 1933927
Dimensions of service quality Berry’s 10 dimensions
• Reliability involves consistency of performance and dependability
• Responsiveness concerns the willingness or readiness of employees to provide service
• Competence means possession of the required skills and knowledge to perform the service
• Access involves approachability and ease to contact
• Courtesy involves politeness, respect, consideration and friendliness of contact personnel
• Communication means keeping costumers informed in language they can understand and
listening to them
• Credibility involves trustworthiness, believability, honesty
• Security is the freedom from danger, risk or doubt
• Understanding/knowing customer involves making the effort to understand the costumer’s
needs
• Tangibles include the physical evidence of the service. (Parasuraman, A Parsu & Zeithaml,
Valarie & Berry, Leonard,1985).
 • Student ID: 1933927
• According to Cqc.org.uk (2015)–Effectiveness in health and social
care organisations is focused on your care, treatment and support, it
achieves good outcomes, helps you to maintain quality of life and is
based on the best available evidence (Cqc.org.uk, 2015).
• “The Health and Social Care Act 2008 recognises that there is a
relationship between quality of care and the efficient and effective use
of resources. The legislation requires the CQC to have regard to
providers’ use of resources within our overall purpose as a quality
regulator” (Cqc.org.uk, 2015).
 RECOMMENDATIONS • Student ID: 1933927

When Cqc are inspecting care homes,

there are five questions they are looking
answers from (Cqc.org.uk, 2015)
•Is it safe?
•Is it effective?
•Is it caring?
•Is it responsive to people’s needs?
•Is it well-led?
 • Student ID: 1933927
People in care homes receive accommodation and nursing or personal care as a single package
under one contractual agreement.
A registered manager is a person who is legally responsible for how the service is run and for the
quality and safety of the care provided.

Is it safe?
this means to look for evidence that people were protected from abuse and avoidable harm
Managers should empower their teams to identify and make improvements in their areas of work
and introduced improvement huddles to give all staff a voice in identifying opportunities for change
•  People should feel safe and protected by the staff, but they also have as much freedom as
possible to do the things they want to do, regardless of their disability or other needs.
• Staff should receive more information about how to raise safeguarding and being trained in
safeguarding awareness.
• Staff should be well informed to any risks to people who is using the service. Staff should be able to
talk through what actions they should take based on people's individual risk assessments.
• Where incidents or accidents had occurred, these should be analysed to ensure learning took place
to prevent a re-occurrence and minimise risks.
 • Student ID: 1933927
Is it effective? this means to looked for evidence that people's care, treatment and support
achieved good outcomes and promoted a good quality of life, based on best available evidence.
• Staff should have the right knowledge, qualifications and skills to carry out their role so that
people have a good quality of life.
• Staff should speak with health and social care professionals, such as GPs, and take the right
action at the right time to keep people in good health.

Is it caring? this means to look for evidence that the service involved people and treated
them with compassion, kindness, dignity and respect.
• Staff should know about people’s background, likes, hopes and needs. This includes any needs
they have because of age, disability, sex (gender), gender identity, race, religion or belief.
• Staff should offer people choices routinely and would consider their reaction when the person
was unable to say what they thought.
• Staff shoul treat them with dignity and respect. They should spend time with them, develop
trusting relationships and are concerned for their wellbeing.
 • Student ID: 1933927
Is it responsive to people’s needs? this means to look for evidence that the service met
people's needs.
• Supporting people to develop and maintain relationships to avoid social isolation; support to follow
interests and to take part in activities that are socially and culturally relevant to them
• People should have the opportunity to participate in a broad range of social activities. They should be
supported to live life to the full despite many people having complex needs and sometimes life limiting
medical conditions. The service provided should support people needed to fulfil their aspirations even
when they were very unwell.

Is it well-led? this means to look for evidence that service leadership, management and governance
assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair
culture.
• Should be promoted a positive culture that is person-centred, open, inclusive and empowering, which
achieves good outcomes for people.
• The registered manager should be visible to people and clearly know them well and being approachable
and listening to them.
• Staff should have the confidence to report concerns about the care that colleagues, carers and other
professionals give. When this happens they should be supported and their concerns to be thoroughly
 REFERENCES ADRIAN BADITA
• Student ID: 1933927
• Cqc.org.uk. (2015). [online] Available at:
https://www.cqc.org.uk/sites/default/files/20151028_delivering_cost_effective_care_in_the_NHS.pdf [Accessed
on 24th Oct, 2020].
• Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor: Michigan Health
Administration Press; 1980. Available at: Google Books <https://books.google.co.uk/books> [Accessed on 24th
Oct, 2020]
• Health.uk, [online] Available at:
https://www.health.org.uk/sites/default/files/QualityImprovementMadeSimple.pdf [Accessed on 24th Oct, 2020]
• Johnston, Robert, Clark, Graham and Shulver, Michael (2012). Service Operations Management: Improving
Service Delivery.4th ed. Harlow: Pearson Education Ltd. Available at: Google Books <
https://books.google.co.uk/books> [Accessed on 22th Oct, 2020]
• Maxwell RJ. ”Respects in NHS management: quality assessments in health” British Medical Journal. 1984;
288:148–72. Available at: Google Books <https://books.google.co.uk/books> [Accessed on 23th Oct, 2020]
• Schwartz, M., 2017. Business ethics: An ethical decision-making approach. [ebook] London: Wiley. Available at:
Google Books < https://books.google.co.uk/books> [Accessed on 22th Oct, 2020]
• Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? The
Milbank Quarterly. 1998; 76(4):517–564. Available at: Google Books <https://books.google.co.uk/books>
[Accessed on 24th Oct, 2020]
 STUDENT ID 1933921/1

ISSUE 4.
PEOPLE TOLD US THEIR REGULAR
STAFF WERE KIND AND CARING AND
TREATED THEM WELL. THE
FREQUENT USE OF AGENCY STAFF
IMPACTED ON PEOPLE’S EXPERIENCE
OF CARE.

SOME PRACTICES IN THE SERVICE

COMPROMISED PEOPLE’S DIGNITY.
 STUDENT ID 1933921/1

• Quality healthcare is a human right

and it means “doing the right things
right and making continuous
improvements, obtaining the best
WHAT IS possible clinical outcome, satisfying
QUALITY? all customers, retaining talented
staff and maintaining sound financial
performance” (Leebov and Scott,
2003)
 STUDENT ID 1933921/1

TQM

• The TQM strategy focuses on :

• Fulfilling consumer needs
• Detecting issues
• Developing commitment
• And one of its core principles is
customer focus
(Total Quality Management (TQM), Six Sigma, and Lean Production - Bus141 Wiki,
2020) STUDENT ID 1933921/1
 STUDENT ID 1933921/1
Insufficient induction Overuse of agency
and training staff

FACTORS Staffing levels didn't balance

the dependence tool data
AFFECTING
THE QUALITY
OF CARE
 STUDENT ID 1933921/1

RECOMANDATIONS
FOLLOWING THE HEALTH IMPROVEMENT JOURNEY THE FOLLOWING STEPS ARE
REQUIRED TO PERFORM :

• Assessing rediness
A readiness assessment will need to be performed in order to identify how prepared the
organization is for change.
• Securing board support
• Board support needs to be secured as quality improvement needs to become central to
the work of the organization.

• The board will also need to provide financial support as an increasing number of
employees will need to receive improvement training and get the chance to use their skills
to better care and support for the residents.
STUDENT ID 1933921/1
 STUDENT ID 1933921/1
RECOMANDATIONS
• Developing improvement skills and infracstructure
1. Improvement skills need to be developed, staffing needs to reach a safe level and
this can be achieved by over-staffing by 20% to allow for sickness, training, and
other unplanned absences.
2. Improvement skills need to be developed staffing needs to reach a safe level and
this can be achieved by over-staffing by 20% to allow for sickness, training, and
other unplanned absences.
3. The management should consider having a team of bank staff who can cover gaps in
the rota. Agency staff should be used only for emergencies and it should be ensured
that they know about the service, policies, and procedures and that they get a full
induction.
 STUDENT ID 1933921/1

RECOMANDATIONS

4. And last but not least, as there are a lot of things that can impact short-term
staffing levels and affect the safety of the service, contingency plans need to
be put in place, to respond to these and ensure that responsible staff knows
what these are.

STUDENT ID 1933921/1
 STUDENT ID 1933921/1

SUMMARY
 The three major factors that lead to the Garside House poor CQC rating were :
•Insufficient induction and trainings
•Excessive use of agency staff
•Staff shortages
In order to improve the service the management should :
•Provide regular trainings for staff
•staffing needs to reach a safe level
•The management should consider having a team of bank staff who can cover gaps in the rota
•Agency staff should be used only for emergencies and it should be ensured that they know about
the service, policies, and procedures and that they get a full induction
•STUDENT ID 1933921/1
• STUDENT ID 1933921/1

• STUDENT ID 1933921/1
 STUDENT ID 1933921/1

REFERENCES
• Sites.google.com. 2020. Total Quality Management (TQM), Six Sigma, And Lean
Production - Bus141 Wiki. [online] Available at:
<https://sites.google.com/site/bus141hmackinnon/ch-2-business-procwss-
management/total-quality-management-tqm> [Accessed 19 October 2020].
• Sites.google.com. 2020. Total Quality Management (TQM), Six Sigma, And Lean
Production - Bus141 Wiki. [online] Available at:
<https://sites.google.com/site/bus141hmackinnon/ch-2-business-procwss-
management/total-quality-management-tqm> [Accessed 15 October 2020].
• The Health Foundation. 2020. The Q Community | The Health Foundation. [online]
Available at: <https://www.health.org.uk/what-we-do/supporting-health-care-
improvement/partnerships-to-support-quality-improvement/the-q-community>
[Accessed 13 October 2020].
 Student ID1938122

SERVICE OPERATIONS MANAGEMENT

Quality management in healthcare:

Garside House Nursing Home

ISSUE 5
Daniela-Gianina Avasiloaie

Student Number: 1938122

 Student ID: 1938122

INTRODUCTION
•This presentation analyzes the main causes of poor quality within the
Garside House Nursing Home in regards to service responsiveness.
•The main issues identified are:
• Lack of patient’s and relatives involvement in care planning
• Service is not patient-centered and thus does not meet individual
patient’s needs.
• Lack of end-of-life plans
• (Care Quality Commission, 2019).
 Student ID: 1938122
DIMENSIONS OF SERVICE QUALITY

•Quality- the “degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with current
professional knowledge.” (The Health Foundation, 2019).
•Maxwell identified six dimensions of service quality that constitute good quality
management in healthcare. (Maxwell, 1992).

• Effectiveness • Access
• Acceptability • Equity
• Efficiency • Relevance
 Student ID: 1938122

CAUSES OF POOR QUALITY AT THE

GARSIDE HOUSE NURSING HOME

•Lack of patient’s and Relatives Involvement in

Care Planning
•Service is not patient-centered
•Poor Risk Mitigation Plans
•Lack of End-of-Life Plans

(Care Quality Commission, 2019).

 Student ID: 1938122

RECOMMENDATIONS FOR IMPROVEMENT

1. Assessing Readiness
2. Secure Board’s Support
3. Secure Wider Organizational Buy-in and Creating a Vision
4. Develop Improvement Skills and Infrastructure
5. Align Activity
6. Sustaining an Organization-wide Approach

(Care Quality Commission, 2019; Jones et al., 2019).

 Student ID: 1938122
SUMMARY
•Garside House Nursing Home does not provide an opportunity for patients
and their relatives to take part in care planning.
•Thus, care services are not individualized to meet individual needs
•The care home does not provide opportunities for patients to develop
relationships that leads to higher risks of social isolation.
•Garside’s directors have not implemented effective risk mitigation and end-
of-life plans.
•Thus, to address the issues the care home is facing, the directors should
follow the six steps of the improvement journey recommended by the Health
Foundation.
 Student ID: 1938122
REFERENCES
•Care Quality Commission. 2019. Garside House Nursing Home Inspection
Report. [Online]. Available at
https://api.cqc.org.uk/public/v1/reports/16e0608a-6454-4b20-8ac5-
4f8ef10d5693?20200101130000 [Accessed 20th October 2020].
•Jones, B., Horton, T., and Warburton, W. 2019. The Improvement Journey:
Why organization-wide improvement in healthcare matters, and how to get
started. [Online]. Available at
https://www.health.org.uk/sites/default/files/2019-05/2019-
THF_Improvement_journey_visual.pdf [Accessed 20th October 2020].
 Student ID: 1938122

REFERENCES

• Maxwell, R.J. 1992. Dimensions of quality revisited: From thought to

action. Quality in Healthcare, Vol. 1, pp. 171-177.

• The Health Foundation. 2019. Quality Improvement made simple: What

every board should know about healthcare quality improvement. [Pdf].
 Student ID: 1564745
ISSUE 6
TAUSHANNA PINNOCK

•I will be answering issue 6

•The service did not engage in a meaningful way with the
people receiving care and their relatives. Systems were in
place to monitor the quality of the service however they
had not identified all the concerns raised in this inspection.
 Student ID: 1564745

WHAT CONSTITUTE TO GOOD QUALITY MANAGEMENT

IN HEALTHCARE

• According to Donabedian Approach to standard (2005) there are three

component of quality of care that measure the improvement in care
they are Structure, Process, and outcome.
• www.improvement.nhs.uk
 Student ID: 1564745
• Garside nursing home was inspected by CQC . Garside home was
rated to be inadequate. Care plans did not reflected that people
\\health and social care needs under the act of health and social
care act 2008.
• Relative were not given the options of contributing or reviewing
care plans relatives did not have any option or preferences.
• Relative felt family member were left in bed and isolated and
engaging with other resident.
• Failure to improve the quality and safety of the effectively
breaching regulation 17 in health and social care act. 2008 .
• Annual Survey with relative rating unsatisfactory , this is not render
in any improvement with engagement.
 Student ID: 1564745

MANAGERS
• Managers did not invited relatives, or clinical staff in to participated in the
reviewing of care. No keyworkers or champions were assigned to residents in
order to provide effective care.
• Lack of documentation that resolved in poor quality of leadership.
• End of Life care plan and support showed lack of planning for service users with
terminal illnesses.
• Lack of knowledge and training was a contributing factor into spiral downwards
Garside House. Quality framework was not applied in this organisation such as
Donabedian Approach to standard. No structure was been applied to working
environment lack quality and effectiveness to deliver care.
Outcome by applying effective care this will result in better healthcare
organisation.
 Student ID: 1564745

SUMMARY
• In order for Garside Nursing home to be improve all board member
has to buy-in quality training in order to have governance to improve
the quality of care is been delivery.
• Be transparent and open to changes with culture.
• Treat each resident as individual and identified to their needs.
• Keeping families updated about their relatives.
• Follow company vision
• Provide training for staff.
• Provide staff incentives
 Student ID: 1564745

THE IMPROVEMENT JOURNEY

• Assessing readiness by understanding and knowing your organisation needs improvement, with
the quality of care provided. New Governance new infrastructure and leadership is needed to
improve Garside Home. Implemented help externally to achieve set goals.
• Securing Board Support In order for improvement the quality of care new staragaties need to be
adapt implemented training although resources are limited. This can be adapted through internal
intervention.
• Securing Wider Organisation Buy-in, researching find what structure your organisation can adapt.
Creating visions and feedback, team building development activity.
• Developing Improvement Skills and infrastructure by using systematic framework such as
Dondiandan in the organisation structure input and output to improve the skills that are required.
• Aligning and Coordinating activity it is pretendant all board member and staff are going in the
same direction and not pulling apart.
 Student ID: 1564745

THE IMPROVEMENT JOURNEY

By applying sustaining an organisation –wide approach. All board members
should aligned with the approach that Garside House needs to be improved:
Short term plan for improvement within the next 6 months
Long term plan expanding over the next 12 months
Staff training, follow up. Keeping staff updated with each step of the journey
for improvement.
( Kurt Lewin) applying Unfreezing, change, Refreeze model.
To identified each step for improvement.
Develop partnership with Local hospice, local authority.
 Student ID: 1564745

REFERENCES - TAUSHANNA PINNOCK

Health and Social care Act 2008

Donabedian(2005)
Health and Social Care Act 2008 regulation 17
Kurt Lewin