Empirical Studies (Outcomes: Primary Care, Radiology, Surgery, Non-Dept Specific, Other)

Primary research articles assessing health, process, satisfaction, and cost outcomes of Lean in healthcare organizations

Primary & Preventive Care

Blackmore C.C., Edwards J.W., Searles C. et al. (2013). ‘Nurse practitioner-staffed clinic at Virginia Mason improves care and lowers costs for women with benign breast conditions’, Health Affairs, 32, pp. 20-26.

A breast clinic was implemented at Virginia Mason Medical Center in Seattle, Washington using Lean methods. The clinic was found to substantially improve care timeliness and efficiency for women with symptomatic benign breast conditions. Women received their final benign diagnosis in an average of four rather than 16 days, with fewer imaging studies and physician visits, when compared to a control group. Savings to the employer were estimated at $316/patient, primarily from increased work productivity. Direct care costs decreased an estimated 19%, to $213/patient. The authors stated that by decreasing both direct medical costs and indirect costs such as work absenteeism and presenteeism, the Virginia Mason Breast Clinic created substantial savings for providers and employers while delivering care that patients rated highly.

Hung, D., Harrison, M., Martinez, M. et al (2016). “Scaling Lean in Primary Care and Impacts on Organizational Performance”, Journal of Patient-Centered Research and Reviews, 3 (3), pp. 206.

The authors conducted an observational study of phased Lean implementation among 328 physicians in 46 primary care departments housed within 17 geographically distinct clinic locations. Performance metrics included: workflow efficiency, productivity, operating expenses, clinical quality and patient, physician and staff satisfaction. Interrupted time series analysis using generalized linear mixed models was used to examine lean impacts on organizational performance over time. They found that Lean implementation resulted in system-wide improvements in workflow efficiencies, physician productivity and clinical quality metrics (P < 0.05). Patient satisfaction with access to care, handling of personal issues and overall experience of care also increased, but decreased with respect to interactions with care providers (P < 0.05). Departmental operating costs decreased, though this was not statistically significant. Finally, annual staff and physician satisfaction scores increased in key domains, ranging from employee engagement and connection to purpose to relationships with staff and physician time spent working. The authors concluded that Lean system redesigns resulted in improvements on a variety of metrics ranging from provider workflow efficiencies to satisfaction among patients and staff.

Radiology

Karstoft, J., & Tarp, L. (2011). ‘Is Lean Management implementable in a department of radiology?’ Insights into Imaging, 2 (3), pp. 267–273.

Lean principles were applied in a radiology department at a very large non-profit hospital, Odense University Hospital (OUH) in Denmark. The radiology department received support from a private consultant who assessed the “hows” and “whys” of the department’s work. A multidisciplinary Lean team was formed and a clinically respected radiographer appointed as its leader. Kaizen, value stream mapping (VSM), 5S, and single minute exchange of die (SMED) were all used to increase efficiency in the department’s CT section. The tools resulted in the radiology department’s ability to examine 6 more patients during the day (900 more patients/year). Consequently, waiting lists fell dramatically across all department sections after the introduction of Lean. The authors noted that the response from the staff was positive—they had an easier overview of the day’s program, a better workflow/environment, and became focused on continuing improvement.

Lodge, A. and Bamford, D. (2008). ‘New Development: Using Lean Techniques to Reduce Radiology Waiting Times’, Public Money & Management, 28 (1), pp. 49-52.

This article reported on how systems were enhanced through the application of Lean principles within a UK hospital division of diagnostics and clinical support. The NHS Improvement Plan required that by 2008 the maximum wait from a general practitioner referring a patient, to that patient commencing definitive treatment should be 18 weeks. Early estimates in the division indicated that in order to meet this 18-week target, access to services must be in a zero- to four-week window. Lean was proposed as a mode to accomplish this. Working groups, comprising a cross-section of professional disciplines and grades, were set up with membership from across the department, division and the wider organization to understand the current performance of radiology services. The views of service users (patients and referrers) were sought, along with those of staff working in the departments in order to generate a picture of the current service provision from which to model the required changes. The working groups decided to implement an internet-based waiting list for radiology services. All radiology departments began using the internet-based waiting list module in September 2006, which since then contributed to a significant reduction in waiting times across the different imaging modalities. The longest waiting time was decreased by over 30% in all areas due to more efficient waiting list management.

Martin A.J., Hogg P., and Mackay S. (2013). ‘A mixed model study evaluating Lean in the transformation of an orthopaedic radiology service’, Radiography, 19 (1), pp. 2–6.

In this mixed model approach, researchers evaluated Lean’s effectiveness as a method to improve an orthopaedic healthcare service with long waiting times and poor satisfaction among patients and staff. Data were collected before and after Lean implementation from staff and patient questionnaires, as well as from the Radiology Information System. The authors used proportionate stratified random sampling for patient data collection and a theoretical sample for staff data collection. Pre-implementation data were collected during the team’s value stream mapping process, and used to plan and implement changes. Data before and after implementation were compared using Levine’s test for equality of variance and a 2-sample t-test; results demonstrated that Lean resulted in better patient experiences, higher staff satisfaction, and an increase in productivity. The authors concluded that these findings supported the proposition that Lean is an effective way to improve healthcare service.

Surgery

Burkitt K.H., Mor M.K., Jain R et al. (2009). ‘Toyota Production system quality improvement initiative improves perioperative antibiotic therapy’, American Journal of Managed Care, (15), pp. 633-642.

A pre-post quasi-experimental study was conducted to assess the role of a Lean intervention on appropriateness of perioperative antibiotic therapy and in length of hospital stay (LOS) among surgical patients. Local and national retrospective cohorts were used. The authors used Lean methods to implement a multifaceted intervention to reduce nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections on a Veterans Affairs surgical unit, which led to a QI intervention targeting appropriate perioperative antibiotic prophylaxis. Appropriate perioperative antibiotic therapy was defined as selection of the recommended antibiotic agents for a duration not exceeding 24 hours from the time of the operation. The local electronic medical record system was used to identify patients undergoing the 25 most common surgical procedures and to examine changes in appropriate antibiotic therapy and LOS over time. Overall, 2550 surgical admissions were identified from the local computerized medical records. The proportion of surgical admissions receiving appropriate perioperative antibiotics was significantly higher (P <.01) in 2004 after initiation of Lean (44.0%) compared with the previous 4 years (range, 23.4%-29.8%) primarily because of improvements in compliance with antibiotic therapy duration rather than appropriate antibiotic selection. There was no statistically significant decrease in LOS over time.

Collar R.M., Shuman A.G., Feiner S. et al. (2012). ‘Lean management in academic surgery’, Journal of American College Surgeons, 214 (6), pp. 928–936.

Surgical practice was identified as a specialty providing many opportunities to improve efficiency. To this end, this study evaluated Lean thinking in an academic otolaryngology operating room (OR) as a method to improve efficiency and profits, while preserving team morale and educational opportunities. An 18-month prospective ‘quasi-experimental’ study was used, with a multidisciplinary team systematically implementing Lean thinking. The team recorded OR turnover and turnaround time during an observer-effect period as well as after Lean implementation, and measured Lean’s impact on teamwork, morale, and surgical resident education through validated surveys. During the Lean intervention period, significant decreases in turnover and turnaround time were noted (29 v. 38 minutes; p < 0.001 and 69 v. 89 minutes; p < 0.001, respectively). Composite morale scores also found improved morale after implementation (p = 0.011), with no effect on resident education. Lastly, financial implications of Lean found an annual opportunity revenue of $330,000 for one OR used twice weekly. The authors noted that Lean requires cultural change through empowerment of workers to engage in continuous quality improvement, thus contradicting traditional hierarchical management. They also emphasized the importance of sustaining Lean improvements; regular meetings among key stakeholders (including management and OR employees) to review data and refine plans were used toward this end, and continued on a quarterly basis after the study.

McCulloch P., Kreckler S., New S. et al. (2010). ‘Effect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unit’, The BMJ, 341 (7781), pp. 1043–1046.

The authors investigated the effect of Lean quality improvement methods on service reliability and efficiency in an emergency general surgery ward of a university hospital in the UK. It used an interrupted time series study design and determined outcomes by measuring 7 safety relevant care processes. This was based on 969 patients admitted during the 4-month study period before Lean intervention, and 1114 patients admitted during the 4-month study period after Lean intervention was completed. The researchers found that for the 5 process measures targeted for Lean intervention, there were significant relative improvements in compliance, ranging from 28% to 149% with a p-value < 0.007. 2 processes measures were not targeted for Lean intervention and did not improve significantly. There was also a significant reduction in new safety events after transfer to other wards (p < 0.028), though most adverse events were attributed to delays in investigations and treatment from factors outside of the emergency ward’s control. In conclusion, the authors found that Lean can substantially improve compliance across multiple safety-related processes at the same time. They noted that given hospital care’s interrelated nature, this may not translate into improvements in safety outcomes unless system-wide approaches are adopted.

Muder R.R., Cunningham C., McCray E., et al. (2008). ‘Implementation of an industrial systems-engineering approach to reduce the incidence of methicillin-resistant Staphylococcus aureus infection’, Infection Control Hosp Epidemiol, 29, pp. 702-708.

A before-after intervention study was conducted to measure the effectiveness of a Lean approach to implementing a methicillin-resistant Staphylococcus aureus (MRSA) prevention program. The study took place in an ICU and a surgical unit in the Pittsburgh Veterans Administration hospital and included all patients admitted to these units. The MRSA prevention program was comprised of 4 elements: 1) the use of standard precautions for all patient contact, with emphasis on hand hygiene; 2) the use of contact precautions for interactions with patients known to be infected or colonized with MRSA; 3) the use of active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and 4) use of Lean to facilitate consistent and reliable adherence to the infection control program. The rate of healthcare-associated MRSA infection in the surgical unit decreased from 1.56 infections per 1,000 patient-days in the 2 years before the intervention to 0.63 infections per 1,000 patient-days in the 4 years after the intervention (a 60% reduction; P = .003). The rate of healthcare-associated MRSA infection in the ICU decreased from 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to 1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction; P = .001). The combined estimate for reduction in the incidence of infection after the intervention in the 2 units was 68% (95% confidence interval, 50%-79%; P < .001).

Simons, F., Aij, K., Widdershoven, G. and Visse, M. (2014). ‘Patient safety in the operating theatre: how A3 thinking can help reduce door movement’, International Journal for Quality in Health Care, 26 (4), pp. 366–371.

Previous research stressed the importance of reducing door movement during surgery to prevent surgical site infections. The authors used Lean A3 thinking to reduce door movement in one operating room for orthopedic surgery, executing an A3 report that promoted structured problem-solving based on Plan-Do-Check-Act (PDCA) cycles. A multidisciplinary team was assembled for the A3 intervention, which first defined the problem, and then investigated the current situation. They found current average door movements/hour and variations in average door movement/hour between surgeons. From these findings, the team determined a target condition for door movement, deemed as zero door movements between incision and closing of wound (except for specific clinical reasons; e.g. X-rays, unexpected materials, employee breaks, emergencies). The gap between current and target condition was then analyzed using a fish-bone diagram to identify 13 root causes of door movement in 4 categories (people, machines, methods, and materials). Actions for improvement were directed toward these 13 root causes and the effects of changes were monitored over 12 months. The intervention led to a sustained 78% decrease in door movements, bringing down the mean number of door movements/hour from 24 to 4 in the OR.

van Vliet E.J., Sermeus W., van Gaalen C.M. et al. (2010). ‘Efficacy and efficiency of a Lean cataract pathway: a comparative study’, Quality and Safety in Health Care, 19 (6), pp. 13.

A prospective cohort of 616 cataract patients receiving Lean care was compared to both a historical cohort of 591 patients that received traditional care and to patients waiting for Lean care in the prospective cohort. To determine efficacy, the authors analyzed how many patients received care that adhered to Lean cataract pathway specifications. To evaluate efficiency, they analyzed how often patients visited the hospital and how many additional patients were able to access the pathway. The authors found that patient visits decreased by 23% and access to the cataract pathway increased by 42%; they noted that these percentages would have been nearly twice as large if healthcare staff had adhered to Lean pathway specifications. Based on these findings, the authors emphasized the importance of ensuring buy-in from healthcare providers to adhere consistently to Lean pathway specifications.

Hospital (Non-Department Specific)

Drotz, E. and Poksinska, B. (2014). ‘Lean in healthcare from employees’ perspectives’, Journal of Organization and Management, 28 (2), pp. 177-195.

This paper aimed to contribute toward a deeper understanding of the new roles, responsibilities, and job characteristics of employees in Lean healthcare organizations. The paper was based on 3 cases studies of healthcare organizations that were regarded as successful examples of Lean healthcare applications. Data were collected by methods including interviews, observations, and document studies. The authors found that Lean caused organizational focus to shift from healthcare professionals, where clinical autonomy and professional skills were the guiding principles, to process improvement and teamwork. They noted that different job characteristics may make it difficult to implement certain Lean practices in healthcare. Teamwork and decentralization of authority were given as examples of Lean practices that could be considered counter-cultural because of healthcare’s strong professional culture and uneven power distribution, with doctors as dominant decision makers.

Goodridge, D., Westhorp, G., Rotter, T. et al. (2015). ‘Lean and leadership practices: development of an initial realist program theory’, BMC Health Services Research, 15 (0), pp. 362.

The authors attempted to address the questions: “What changes in leadership practices are associated with the implementation of Lean?” and “When leadership practices change, how do the changed practices contribute to subsequent outcomes?” using a qualitative, multi-step approach. They collected data through a key informant consultation, a stakeholder workshop, documentary review, 26 audiotaped and transcribed interviews with health region personnel, and team discussions. These data yielded seven initial hypotheses, finding that Lean: 1) aligns the aims and objectives of health regions; 2) permits attention and resources to quality improvement and change management; 3) provides an integrated set of tools for particular tasks; 4) changes leaders’ attitudes or beliefs about appropriate leadership and management behaviors; 5) demands increased levels of expertise, accountability, and commitment from leaders; 6) measures and uses data effectively to identify actual and relevant local problems and root causes of those problems; and 7) creates/supports a ‘learning organization’ culture.

Holden, R.J., Eriksson, A., Andreasson, J. et al. (2015). ‘Healthcare workers’ perceptions of lean: A context-sensitive, mixed-methods study in three Swedish hospitals’, Applied Ergonomics, pp. 181-192.

This article looked into two key areas for further Lean research: 1) the effect of contextual factors on Lean, and 2) healthcare workers’ perceptions of Lean. The authors specifically addressed how hospital workers’ perceptions of Lean implementation varied across contexts. Standardized surveys were completed by RNs and physicians across hospital units (N=236, 57% response rate). The study found that employees’ perceptions varied by hospital, and that employees in higher-acuity units reported more favorable perceptions of Lean. The study also found that nurses reported more favorable perceptions than physicians.

Jimmerson, C., Weber, D., and Sobek, D.K. (2005). ‘Reducing Waste and Errors: Piloting Lean Principles at Intermountain Healthcare’, The Joint Commission Journal on Quality and Patient Safety, 31 (5), pp. 249-257.

Lean tools, specifically value stream maps (VSMs) and A3 reports were used in a pilot project at Intermountain Healthcare to improve efficiencies. Participants made many improvements, ranging from simple changes implemented immediately (for example, heart monitor paper not available when a patient presented with a dysrhythmia) to larger projects involving patient or information flow issues across multiple departments. Most of the improvements required little or no investment and reduced significant amounts of wasted time for front-line workers. In one unit, turnaround time for pathologist reports from an anatomical pathology lab was reduced from 5 to 2 days.

Sampalli, T., Desy, M., Dhir, M. et al. (2015). ‘Improving wait times to care for individuals with multi-morbidities and complex conditions using value stream mapping’, International Journal of Health Policy and Management, 4 (7), pp. 459–466.

Over an 18-month time period, healthcare staff applied a patient-centric approach that included Lean methodology of Value Stream Mapping (VSM) to improve wait times to care. The evaluation framework was grounded in the needs and perspectives of patients and individuals waiting to receive care. Patient-centric views were obtained through surveys such as Patient Assessment of Chronic Illness Care (PACIC) and process engineering-based questions. In addition, Lean VSM was added to identify non-value added processes contributing to wait times. From this process, the care team successfully reduced wait times to 2 months in 2014 with no wait times for care anticipated in 2015. Increased patient engagement and satisfaction were also noted. In addition, successful transformations and implementation resulted in resource efficiencies without cost increases. The authors stated that patients showed significant improvements in functional health after intervention.

Portioli-Staudacher, A. (2008). ‘Lean Healthcare: An Experience in Italy’, Lean Business Systems and Beyond, 257, pp. 485-492.

The results of a Lean implementation at an Italian hospital were presented, stemming from a need to cut cost and reduce inventory. A large reduction in inventory was achieved, and broken processes leading to excessive inventories were identified to remove the problem’s root causes. Finally, hospital staff was taught to think differently about materials management activities: rather than by batching (e.g. ordering 3 weeks’ worth of a medicine at once), better and faster results were achieved by standardizing activities and managing orders and activities throughout the week (e.g. ordering medicines every day to replace those consumed).

White M., Wells J.S., and Butterworth T. (2014). ‘The impact of a large-scale quality improvement programme on work engagement: Preliminary results from a national cross-sectional-survey of the ‘Productive Ward’’, International Journal of Nursing Studies, 51 (12), pp. 1634-1643.

This paper examined the impact of a large-scale Lean Quality Improvement program, the ‘Productive Ward’, on work engagement of involved nurses and ward teams in the UK. Using the Utrecht Work Engagement Scale (UWES), the authors surveyed, measured, and analyzed work engagement in a representative test group of hospital-based ward teams who had recently commenced the latest phase of the national ‘Productive Ward’ initiative in Ireland and compared them to a control group of similar size and matched (as far as is possible) on variables such as ward size, employment grade and clinical specialty area. 338 individual datasets were recorded, n = 180 (53.6%) from the Productive Ward group, and n = 158 (46.4%) from the control group; the overall response rate was 67%, and did not differ significantly between the Productive Ward and control groups. The work engagement mean score (±standard deviation) in the Productive group was 4.33(±0.88), and 4.07(±1.06) in the control group, representing a modest but statistically significant between-group difference (p = 0.013, independent samples t-test). Similarly modest differences were observed in all three dimensions of the work engagement construct. Employment grade and the clinical specialty area were also significantly related to the work engagement score (p < 0.001, general linear model) and (for the most part), to its components, with both clerical and nurse manager grades, and the elderly specialist areas, exhibiting substantially higher scores. The authors concluded that their findings demonstrate how Lean QI activities appear to positively impact work engagement of ward-based teams.

Other

Kimsey, D.B. (2010). ‘Lean methodology in health care’, AORN, 92 (1), pp. 53-60.

A rapid improvement team at Lehigh Valley Health Network, Allentown, Pennsylvania, implemented a plan, do, check, act cycle to determine problems in the central sterile processing department, test solutions, and document improved processes. By using A3 thinking, a consensus building process that graphically depicts the current state, the target state, and the gaps between the two, the team worked to improve efficiency and safety, and to decrease costs. Gap analysis was conducted to examine the initial and future state of the staff’s tool sterilization cycle. By eliminating jack jams and increasing drying temperature to the expected level, staff increased capacity by 30%. Additionally, after repairing and calibrating tools, staff members were able to eliminate the flash cycle portion of the sterilization cycle, saving 10 hours of work per day. The sterile processing team and senior leaders found that non-preventive maintenance calls decreased from 6 per month to 2. The cost of non-preventive maintenance decreased from $12,000 per month to $3,600 per month. The average use of the equipment increased from 60% to 90%, and the use of a responsibility plan for routine inspection and maintenance of equipment increased from 0% to 90%. The end result was cancellation of a unit upgrade because it was no longer needed.