Empirical Studies (Components: Non-Department Specific)

Primary research articles identifying components, methods, barriers and facilitators for implementing Lean in healthcare organizations

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.