Systematic Reviews (Outcomes)

Systematic reviews of published articles assessing health, process, satisfaction, and cost outcomes of Lean in healthcare organizations

Glasgow, J.M., Scott-Caziewell, J.R.; Kaboli, P.J. (2010). ‘Guiding Inpatient Quality Improvement: A Systematic Review of Lean and Six Sigma’, 36 (12), pp. 533-540.

A systematic literature review was conducted to determine whether Lean, Six Sigma, or Lean Sigma have been effectively used to create and sustain improvements in the acute care setting. Databases were searched for articles published in the healthcare, business, and engineering literatures. Study inclusion criteria required identification of a Six Sigma, Lean, or Lean Sigma project; quality improvement efforts focused on hospitalized patients; descriptions of project improvements; and reported results. 47 out of 539 potential articles met inclusion criteria. The authors concluded that Lean, Six Sigma, and Lean Sigma all can address a wide variety of acute care problems, but that the true impact of these methodologies is difficult to judge given the lack of rigorous evaluation or evidence of clearly sustained improvements. More research is needed to provide greater understanding of these approaches and how to achieve sustainable improvement.

Holden, R.J. (2011). ‘Lean Thinking in Emergency Departments: A Critical Review’, Annals of Emergency Medicine, 57 (3), pp. 265-278.

This article critically reviewed 18 articles describing the implementation of Lean in 15 Emergency Departments (EDs) in the United States, Australia, and Canada. The author used an analytical framework from occupational research to generate 6 core questions regarding Lean’s effect on ED work structures and processes, patient care, and employees, as well as Lean’s success factors. Identified Lean process changes often involved the creation of separate patient streams along with structural changes including new technologies, communication systems, staffing modifications, and reorganization of physical space. Patient care was usually found to improve, as many EDs reported decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative effects were reported, with explored patient effects typically limited to patient satisfaction. The effect on employees was rarely measured, but there were some indicators of positive effects. Factors for Lean success included employee involvement, management support, and preparedness for change. The author concluded that Lean appears to offer significant improvement opportunities in spite of methodological concerns, and that more research is needed on Lean’s effects on patient health and employees and how Lean can be best implemented in healthcare.

Moraros, J., Lemstra, M., and Nwankwo, C. (2016). ‘Lean interventions in healthcare: do they actually work? A systematic literature review’, International Journal for Quality in Health Care, 28 (2), pp. 150-165.

A systematic literature review was conducted to assess the effect of Lean on worker and patient satisfaction, health and process outcomes, and financial costs. 9 different databases (including PubMed and Medline) were searched for peer-reviewed articles that examined a Lean intervention and included quantitative data, resulting in 22 articles inspected. Data on design, methods, interventions and key outcomes were extracted and collated. They found that there was 1) no statistically significant association with patient satisfaction and health outcomes, 2) a negative association with financial costs and worker satisfaction, and 3) a potential but inconsistent benefit to process outcomes like patient flow and safety. The authors concluded that evidence to date does not support the belief that Lean leads to healthcare quality improvements. They called for more rigorous, higher quality and better conducted scientific research to definitively ascertain the impact and effectiveness of Lean in healthcare.

Shazali, N.A., Habidin, N.F., Ali, N. et al. (2013). ‘Lean Healthcare Practice and Healthcare Performance in Malaysian Healthcare Industry’, International Journal of Scientific and Research Publication, 3 (1).

The authors conducted a literature review of Lean healthcare practices. They aimed to analyze the relationship between Lean healthcare and healthcare performance as defined by 3 elements: financial performance, customer satisfaction, and employee performance. The researchers found that while previous studies have identified critical success factors for Lean implementation, limited empirical studies have investigated the relationship between Lean and healthcare performance. They also proposed future research in designing a structured questionnaire to obtain pilot study data for healthcare practices in Malaysia.

Vest, J.R. and Gamm, L.D. (2009). ‘A critical review of the research literature on Six Sigma, Lean and StuderGroup’s Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare’, Implementation Science, 4, pp. 35-43.

Vest and Gamm conducted a systematic literature review of 3 current popular change strategies, including Lean, and examined peer-reviewed evidence of their effectiveness. The authors found that studies universally concluded the strategies’ success and applicability to a wide variety of settings and problems. However, the vast majority of these studies contained methodological limitations including weak study designs, inappropriate analyses, and failure to rule out alternate hypotheses. Additionally, many studies did not provide substantial evidence for lasting effects or changes in organizational culture. The paper concluded that improved design and analysis of these change theories would provide more effective guidance to healthcare managers; more rigorous evaluation of project consultants and partnerships with academic healthcare researchers were suggested as ways to accomplish this.