Primary research articles identifying components, methods, barriers and facilitators for implementing Lean in healthcare organizations
Ulhassan W., Sandahl C.P., Westerlund HP et al. (2013). ‘Antecedents and characteristics of Lean thinking implementation in a Swedish Hospital: a case study’. Quality Management in Health Care, 22 (1), pp. 48–61.
This case study investigated a cardiology department’s experience from initial adoption to adaptation of Lean thinking. It sought to determine how the department – which had a long history of quality improvement – decided to introduce Lean, and how Lean impacted employees’ work. The authors used semi-structured interviews, non-participant observations, and document studies to gather this information. They then conducted content analysis of the data, finding that the department’s previous improvement efforts may have facilitated the introduction of Lean thinking. This history was not as important in predicting the sustained usage of Lean over time. Additionally, individual differences in staff members’ perceived need for change led to varying degrees of Lean adoption. For successful Lean implementation, the authors found work re-design and teamwork beneficial to improving patient care. Similarly, problem solving was deemed helpful in maintaining staff engagement and thus sustained improvements.
Community Health Clinics (CHCs) & Rural Facilities
Carter, P.M., Desmond, J.S., Akanbobnaab, C. et al. (2012). ‘Optimizing Clinical Operations as part of a Global Emergency Medicine Initiative in Kumasi, Ghana: Application of Lean Manufacturing Principals to Low Resource Health Systems’, Academic Emergency Medicine, 19 (3), pp. 338–347.
This study aimed to describe the application of Lean to improve clinical operations at Komfo Anokye Teaching Hospital in Ghana, while identifying key lessons learned to aid future global improvement initiatives. A 3-week Lean improvement program focused on the admissions process at the hospital was completed by a 14-person team in six stages: problem definition, scope of project planning, value stream mapping, root cause analysis, future state planning, and implementation planning. Additionally, 8 lessons learned from the initiative were identified: 1) the Lean process aided in building a partnership with Ghanaian colleagues; 2) obtaining and maintaining senior institutional support was necessary and challenging; 3) addressing power differences among the team to obtain feedback from all team members was critical to successful Lean analysis; 4) choosing a manageable initial project was critical to influence long-term Lean use in a new environment; 5) data intensive Lean tools could be adapted and were effective in a less-resourced health system; 6) several Lean tools focused on team problem-solving techniques worked well in a low-resource system without modification; 7) using Lean highlighted that important changes do not require an influx of resources; 8) despite different levels of resources, root causes of system inefficiencies were often similar across healthcare systems, but require unique solutions appropriate to the clinical setting.
Emergency Department (ED)
Naik T., Duroseau Y., Zehtabchi S. et al. (2012). ‘A structured approach to transforming a large Public Hospital Emergency Department via Lean methodologies’, Journal for Healthcare Quality, 34 (2), pp. 86–97.
The authors outlined a systemic method to apply Lean principles across the entire emergency department (ED) patient experience to transform a high volume ED in 1 hospital. They then compared ED performance metrics before and after Lean implementation, finding that median and IQR results showed improvement on several metrics after implementation. The hospital partnered with a Lean consulting firm, established an executive Lean steering committee that ranked True North metrics for the hospital’s improvement vision, and then determined major value streams based on their contribution to True North metrics. The ED was identified as a key value driver and selected as 1 of 4 service lines for initial Lean intervention. At the emergency department level, an ED Lean steering committee was created and trained in a 2-day Lean introduction program. The committee consisted of departmental leadership and other key stakeholders, such as representatives from finance and hospital operations. The steering committee participated in a 3-day value stream analysis to map out implementation over the first year. Rapid Improvement Events (RIEs) were held monthly, and enlisted an 8 – 12 member team of front-line staff (e.g. MDs, RNs, support staff) with varying degrees of relationship to the process of focus, providing diverse perspectives. A facilitator experienced in Lean principles guided the team, and a member with intimate knowledge of the process (often a director/manager) was assigned as ‘process owner,’ with oversight of implementation/sustainment. A new standard workflow and responsibilities were then immediately shared with front-line staff following RIEs. Visible executive commitment at all levels was noted as critical to successful Lean transformation.
Al-Araidah, O., Momani, A., and Khasawneh, M. etal. (2009). ‘Lead-Time Reduction Utilizing Lean Tools Applied to Healthcare: The Inpatient Pharmacy at a Local Hospital’, 32 (1), pp. 59-66.
The authors applied selected principles of Lean management to reduce time associated with drug dispensing at an inpatient pharmacy at a local hospital. Thorough investigation of the drug dispensing process revealed unnecessary complexities leading to delays in medication delivery. DMAIC (Define, Measure, Analyze, Improve, Control) and 5S (Sort, Set-in-order, Shine, Standardize, Sustain) were used to identify and reduce waste that increased the lead-time in healthcare operations at the pharmacy understudy. The study’s results revealed potential savings of >45% in drug dispensing cycle time.
Primary & Preventive Care
Grove, A.L., Meredith, J.O., Macintyre, M. et al. (2010). ‘Lean implementation in primary care health visiting services in National Health Service UK’, Quality and Safety in Health Care, 19 (5).
Findings were presented on a 13-month Lean implementation in National Health Service (NHS) primary care health visiting (HV) services from May 2008 to June 2009. A Lean Thinking project team was established which included staff and management from a variety of roles related to the HV service, without formalized roles or project champions. This team took part in 8 workshops throughout the project to share ideas and learn from one another, and were assisted by Lean consultants. Stakeholder and value stream mapping (VSM) was used to determine essential tasks in health visiting services and links between relevant stakeholders. Through discussion with these stakeholders, waste processes were identified and new process maps were produced. Quantitative data were provided through a 10-day time-and-motion study of a selected number of staff. Analysis of VSM processes revealed that 67% of 67 identified processes were waste; the revised process map reduced this to 23 process steps. One notable example of improved processes was a change to methods of contacting central administration. Initially, administrative staff would wait for large quantities of documents to accumulate before dispatching them in weekly batches to central administration; this led to extended waits for patient appointments and increased stress to employees due to uneven workloads. To improve this process, the Lean Thinking team introduced more document envelopes that could be dispatched daily, thus eliminating uneven workloads from batching of documents and shortening the average wait for a new appointment from 1 week to 2 days. The study concluded that a large amount of waste could be eliminated through simplification and standardisation of day-to-day tasks, without the need for expensive or time-consuming organisational changes. The authors noted that members of the Lean team continue to make small improvements in their respective areas, but that changes in organizational culture and management practice will be required to provide a supportive environment for change. Management support across the entire organization was also cited as necessary to sustain and introduce future Lean initiatives.
Gray, C., Martinez, M., and Hung, D. (2014). ‘PS1-29: Changing the Culture of Medicine: An Exploration of Lean Healthcare in Primary Care’, Clinical Medicine & Research, 12 (1-2), pp. 98–99.
This study qualitatively evaluated a Lean implementation at a large healthcare organization. Researchers conducted observations of key implementation events and interviewed frontline leaders, as well as physicians, nurses, and medical assistants who participated in the change effort. The data produced from these qualitative methods were analyzed and coded using an inducted, grounded approach. The paper highlighted five main changes that produced cultural conflict when this healthcare organization implemented Lean. They were 1) adopting team care approaches, 2) democratization of the workplace and the erosion of hierarchies, 3) reducing variation and standardizing work, 4) surveillance of staff and employees, and 5) a perceived emphasis on profit over patient care. The authors concluded that implementing new ways of delivering care in healthcare organizations is often met with many challenges. Some of these challenges may be rooted in a conflict between new sets of cultural values and those that have historically existed in the field of medicine. Reconciling these conflicts may be one of the most difficult challenges healthcare organizations face as they try to implement wide- scale change.
Grove, A.L., Meredith, J.O., Macintyre, M. et al. (2010). ‘UK health visiting: challenges faced during lean implementation’, Leadership in Health Services, 23 (3), pp. 204-218.
The paper presented challenges identified during a lean implementation in a health visiting service within a large primary care trust in NHS UK. A triangulated approach to data collection was used to determine the root cause of challenges faced during lean implementation. The 3 methods were selected for qualitative analysis were semi‐structured interviews, document analyses, and researcher participant observation. From these methods, 6 key challenges were identified: 1) high process variability, 2) a lack of understanding of lean, 3) poor communication and leadership, 4) target focused implementation, 5) problems defining waste, and 6) difficulty in defining the customer and what the customer values.
Hung, D., Gray, C., Martinez, M. et al. (2016). ‘Acceptance of Lean redesigns in primary care: A contextual analysis’, Health Care Management Review, publication forthcoming.
This study aimed to identify contextual factors that were most critical to implementing and scaling Lean redesigns in all primary care clinics of a large ambulatory care system. The authors conducted over 100 interviews and focus groups with frontline physicians, clinical staff, and operational leaders. Data analysis was then conducted using a modified Consolidated Framework for Implementation Research, called CFIR-PR. Several domains identified through CFIR-PR were vital to acceptance of Lean redesigns. In the implementation process, acceptance was influenced by time and intensity of exposure to changes, top-down versus bottom-up implementations, and degree of employee engagement in developing new workflows. Important factors of the inner setting were the clinic’s culture and style of leadership, and availability of information on Lean’s effectiveness. Lastly, individual and team characteristics regarding changed work roles, and related issues of professional identity, authority, and autonomy were important.
Hospital (Non-Department Specific)
Aij, K.H., Simons, F.E., Widdershoven, G.A.M. et al. (2013). ‘Experiences of leaders in the implementation of Lean in a teaching hospital—barriers and facilitators in clinical practices: a qualitative study’, BMJ Open, 3 (10), e003605.
This study aimed to systematically investigate the experiences of leaders in the implementation of Lean within a teaching hospital in the Netherlands. Authors conducted semi-structured, in-depth interviews of 31 medical, surgical and nursing professionals with an average of 19.2 years of supervisory experience. All professionals were appointed to a Lean Training Program and were directly involved in the implementation of Lean. Based on interview results, the researchers found that leadership management support, a continuous learning environment, and cross-departmental cooperation were seen as significant for successful Lean implementation. The results suggested that a Lean Training Program contributed to positive outcomes in personal and professional skills that were evident during the first 4 months after program completion.
Andersen, H. and Rovik, K.A. (2015). ‘Lost in translation: a case-study of the travel of lean thinking in a hospital’, BMC Health Services Research, 15, pp. 401.
The paper explore the ‘travel’ of Lean within a Norway hospital by assessing local actors’ Lean perceptions through their images of factors for successful Lean intervention. These perceptions described the characteristics of Lean in use. Perceptions were collected through focus group interviews with three groups of stakeholders: managers, internal consultants and staff. A questionnaire was used to reveal the factors’ relative importance. Identified important factors for Lean’s success matched the literature, except that external expert change agents were not perceived to promote Lean. New factors were also added. Two-thirds of the most important identified factors were novel, local ones. Among these were a ‘problem’ rather than ‘method’ focus, a bottom-up approach, internal consultants, credibility, realism, and patience. Local actors had different images of Lean depending on their hierarchical level. The authors concluded that ideas of Lean were transformed more than once within the hospital.
Ballé, M. and Régnier, A. (2007). “Lean as a learning system in a hospital ward”, Leadership in Health Services, 20 (1), pp. 33-41.
Lean was applied in a hospital ward by nursing staff, who identified a number of complex nursing issues, such as medication distribution errors, catheter infections, nosocomial infections, bedsores. 5S was implemented in storage areas in order to move supplies out of ward corridors and keep corridors clear for safety reasons. Nursing practices were also standardized, resulting in the rate of incidents per patients being reduced by 45% over 2 years. The nursing manager additionally reported that her greatest satisfaction from the Lean process was perceived noticeable improvement in nurse-patient relationships.
Brandao de Souza, L. and Pidd, M. (2011). ‘Exploring the barriers to Lean health care implementation’, Public Money & Management, 31 (1), pp. 59-66.
This work analyzed implementation barriers in the UK National Health Service’s (NHS) application of Lean healthcare principles. It concluded that with slight modifications for the healthcare industry, Lean thinking can achieve good results. The authors conducted their analysis based on interviews with directors, managers, and healthcare practitioners as well as their own experiences implementing Lean at the NHS. The first major barrier identified was provider concerns that Lean treats patients as uniform ‘parts’; clarification and evidence must be provided to show otherwise. Additional identified barriers were professional and functional silos, organizational hierarchies, and shifting managerial focus from temporary to permanent solutions. In addressing the former two issues, non-hierarchical multidisciplinary teams must be established to ensure unbiased performance improvement across departments. For the latter matter, managers may be trained to make decisions using evidence-based analysis. To prevent the undesirable side effects of using performance measures to quantify Lean’s impact, implementation teams should be involved in defining their own metrics, and Lean terminology should be standardized to prevent miscommunication. Overall, it was found that provider empowerment and clear structure should be emphasized for Lean implementation to be successful.
Burgess, N. and Radnor, Z. (2013). ‘Evaluating Lean in healthcare’, International Journal of Health Care Quality Assurance, 26 (3), pp. 220-235.
The authors presented observations on Lean implementation in UK hospitals based on content analyses of all annual reports and websites for said hospitals over two time periods. They found that Lean implementation overall tends to be isolated to a few projects within organizations, and that across hospitals there exists a spectrum of implementation levels ranging from tentative to systemic. Time-series data noted an increase in Lean usage and system-wide Lean approaches over time. The paper concludes that further analysis is needed to document the effects of organizational context on Lean approaches used and the sustainability of said approaches.
Eiro, N.Y., & Torres-Junior, A.S. (2015). ‘Comparative study: TQ and Lean Production ownership models in health services’, Revista Latino-Americana de Enfermagem, 23 (5), pp. 846–854.
Eiro and Torres-Junior compared the application of Total Quality (TQ) and Lean models in healthcare through a descriptive case study in Brazil. TQ and Lean were compared at a large medical diagnostic service and a medium-sized private hospital that had implemented Lean before. The study found that Lean was better suited for people that work systemically and generate flow, leading to increased adherence to standard work as well as continuous improvement and staff involvement in problem-solving. The TQ model was found to be more widespread, and to involve more bureaucratic procedures that were continuously audited and required more stable control.
Esain, A., Williams, S. and Massey, L. (2008). ‘Combining Planned and Emergent Change in a Healthcare Lean Transformation’, Public Money & Management, 28 (1), pp. 21-26.
A longitudinal study was employed to evaluate the implications of planned and emergent change when deploying 5S Lean at a UK NHS Trust that employed approximately 13,000 staff serving a population of around 600,000 at multiple locations. Formal interviews were conducted with 4 hospital personnel/managers who acted as Lean change agents, a questionnaire was employed that collected data on successes and problems in implementation, and observations were recorded during meetings and workshops. All of the change agents were supportive of 5S, but indicated there were limitations. They thought the tool should not be seen as a vehicle for major change but, rather, as a starting point. It was suggested that 5S is an integral part of wider strategic change management program.
Kinder, T. and Burgoyne, T. (2013). ‘Information Processing and the Challenges Facing Lean Healthcare’, Financial Accountability & Management, 29 (3), pp. 271-290.
The authors suggested that the level of information required by Lean projects was beyond the capacity of many NHS trusts, and used Galbraith’s information processing theory as a mode of explanation for why many NHS Lean healthcare projects failed. They concluded that, if generalizable, their findings challenge the premise that Lean can be used to deliver sustainable cost reduction while improving quality of care. On a micro-level, the paper cited lack of clinician support and rejection of the ‘cuts’ ideology as reasons for failed Lean implementation. The paper focused on information processing management as a mechanism to examine how the complexity and uncertainty of healthcare affected Lean implementation. It found that most Lean initiatives involved less than 20% of staff, and ‘rapid improvement events’ (RIEs) rather than long-term systemic applications. Other studies were cited stating issues with Lean implementation such as silos of Lean usage, lack of staff training and opportunities for experimentation, and overly long time to complete projects. The authors looked at two Lean implementation projects and conducted interviews with 3 project participants, 2 team leaders, and the Deputy Chief Executive using a prepared survey. They deemed that Lean and all other change projects are ‘information-hungry’. Lacking information processing systems make their sustained success difficult. Inadequate information processing, low senior clinician engagement, and absence of commitment-based HR were seen as difficulties for Lean RIEs.
Radnor, Z., Holweg, M. and Waring, J. (2012). ‘Lean in healthcare: The unfilled promise?’, Social Science & Medicine, 74 (3), pp. 364-371.
This paper reported on 4 Lean implementation case studies in the UK National Health Service (NHS). Similar to others, it found that implementation often involved Lean ‘tools’ such as rapid improvement events (RIEs) that led to localized improvements. Contextual differences between Lean healthcare and manufacturing were cited: first, patients’ status as both customers and commissioners of care in the private sector, which impacts how customer value is defined; second, the healthcare industry’s design as ‘capacity-led’, which limits the ability to influence demand and utilize freed-up resources. If not addressed, these differences could severely limit Lean’s impact on healthcare. The authors interviewed senior, middle management, and front-line NHS employees. They assessed implementation on 4 dimensions: 1) Lean’s definition, 2) activities undertaken, 3) organizational readiness, and 4) sustainability of process improvements. The study found that the definition of ‘customer’ and customer value was often variable and not clearly ascertained, leading to improvements guessing at what customers wanted that were not necessarily aligned or even compatible across care pathways. It also deemed that, similar to in manufacturing, there must be a shift from tool-based to continuous improvement approaches for widespread, sustained productivity gains to be achieved.
Ulhassan, W., Ulrica von Thiele, S., Thor, J. et al. (2014). ‘Interactions between lean management and the psychosocial work environment in a hospital setting – a multi-method study’, BMC Health Services Research, 14, pp. 480.
This work aimed to ascertain the effects of Lean on the psychosocial work environment. As such, psychosocial work environment was measured twice with the Copenhagen Psychosocial Questionnaire (COPSOQ) employee survey during Lean implementations on May-June 2010 (T1) (n = 129) and November-December 2011 (T2) (n = 131) at three hospital units (an Emergency Department (ED), Ward-I and Ward-II). Information based on qualitative data analysis of the Lean implementations and context from a previous paper was used to predict expected change patterns in the psychosocial work environment from T1 to T2 and subsequently compared with COPSOQ-data through linear regression analysis. Between T1 and T2, qualitative information showed a well-organized and steady Lean implementation on Ward-I with active employee participation, a partial Lean implementation on Ward-II with employees not seeing a clear need for such an intervention, and deterioration in already implemented Lean activities at ED, due to the declining interest of top management. Quantitative data analysis showed a significant relationship between the expected and actual results regarding changes in the psychosocial work environment. Ward-I showed major improvements especially related to job control and social support, ED showed a major decline with some exceptions while Ward-II also showed improvements similar to Ward-I. The study’s results suggested that Lean may have a positive impact on the psychosocial work environment when properly implemented, and that deterioration of Lean work may correlate with deterioration of psychosocial work environment. The authors also noted that employee involvement in Lean change processes may minimize any potential harmful psychosocial effects from Lean intervention.