Empirical Studies (Components: Cardiology, CHC, ED, Pharmacy, Primary Care)

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.