Lean in healthcare: A comprehensive review

Lean management in health care: a review of reviews of socio-technical components for effective impact

PURPOSE

The aims of the implementation of lean management in health care are to improve quality of care, to eliminate waste and to increase efficiency. The purpose of this study is to contribute to the advancement of knowledge by investigating which main socio-technical factors are considered to be effective for the implementation and management of lean initiatives.

DESIGN/METHODOLOGY/APPROACH

A systematic review of literature reviews on lean management in health care was conducted. The components of the socio-technical system are identified by moving from the socio-technical drivers that support organization-wide quality improvement practices and the lean implementation process in health care. The impacts of lean management are classified using the internal processes, patient, learning and financial dimensions.

FINDINGS

The 28 reviews retrieved confirm the current and increasing interest in lean management. While more than 60% of them call for a system-wide approach, system-wide implementations have rarely been observed, and, instead, adoption in isolated units or departments, or the use of single techniques and tools, prevails. The most commonly investigated socio-technical components are organizational structure, techniques and tools and organizational culture and strategic management. Significant impacts are reported for all the four dimensions. Nonetheless, the review reveals that there is still a lack of evidence on the sustainability of lean results and a need for a standardized impact measurement system.

ORIGINALITY/VALUE

This work stands out as the first review of reviews of how the socio-technical components of the lean management approach obtain positive impacts within the patient, internal processes, learning and financial dimensions.

Implementing Lean Quality Improvement in Primary Care: Impact on Efficiency in Performing Common Clinical Tasks

BACKGROUND

Many primary care practices have adopted Lean techniques to reduce the amount of time spent completing routine tasks. Few studies have evaluated both immediate and sustained impacts of Lean to improve this aspect of primary care work efficiency.

OBJECTIVE

To examine 3-year impacts of Lean implementation on the amount of time taken for physicians to complete common clinical tasks.

DESIGN

Non-randomized stepped wedge with segmented regression and interrupted time series analysis (January 2011-December 2016).

PARTICIPANTS

A total of 317 physician-led teams in 46 primary care departments in a large ambulatory care delivery system.

INTERVENTION

Lean redesign was initiated in one pilot site followed by system-wide spread across all primary care departments. Redesigns included standardization of exam room equipment and supplies, streamlining of call management processes, care team co-location, and team management of the electronic inbox.

MEASURES

Time-stamped EHR tracking of physicians' completion time for 4 common tasks: (1) office visit documentation and closure of patient charts; (2) telephone call resolution; (3) prescription refill renewal; and (4) response to electronic patient messages.

RESULTS

After Lean implementation, we found decreases in the amount of time to complete: office visit documentation (- 29.2% [95% CI: - 44.2, - 10.1]), telephone resolution (- 22.2% [95% CI: - 38.1, - 2.27]), and renewal of prescription refills (- 2.96% per month [95% CI: - 4.21, - 1.78]). These decreases were sustained over several years. Response time to electronic patient messages did not change significantly.

CONCLUSIONS

Lean redesigns led to improvements in timely completion of 3 out of 4 common clinical tasks. Our findings support the use of Lean techniques to engage teams in routine aspects of patient care. More research is warranted to understand the mechanisms by which Lean promotes quality improvement and effectiveness of care team workflows.

Implementation Strategies for Frontline Healthcare Professionals: People, Process Mapping, and Problem Solving

Implementation science is focused on developing and evaluating methods to reduce gaps between research and practice. As healthcare organizations become increasingly accountable for equity, quality, and value, attention has been directed to identifying specific implementation strategies that can accelerate the adoption of evidence-based therapies into clinical practice. In this perspective, we offer three simple, practical strategies that can be used by frontline healthcare providers who are involved in on-the-ground implementation: people (stakeholder) engagement, process mapping, and problem solving. As a use case example, we describe the iterative application of these strategies to the implementation of a new home sleep apnea testing program for patients in the Veterans Health Administration (VA) healthcare system.

Technology-dependent pedagogical process redesign: leveraging lean methods

Purpose

This research compared the efficacy of process outcomes leveraging lean methods versus traditional pedagogy applied to dental education dependent on emerging technology. The pedagogical objective was to improve system efficiency without compromising traditional outcomes of effectiveness (quality).

Design/methodology/approach

The research team tested the efficacy of a lean A3 framework to identify, remove waste and redesign a technology-dependent simulation laboratory course (CAD/CAM/IR Restorative Dentistry). Students were also sensitized to time-in-chair to introduce a stronger patient focus. Baseline data collected from a control group were statistically compared to the research group's data after the course redesign. In addition, course time allocations were measured and then compared.

Findings

The results showed the interventions significantly reduced procedure cycle times without compromising quality. Additionally, the course was more efficiently conducted as measured by course time allocations.

Practical implications

This research demonstrated that the use of the A3 framework enhanced learning through process documentation, reengineering and systems optimization resolving issues of inefficiency associated with the CAD/CAM/IR pedagogy. This work is significant because it demonstrates the practice of using lean interventions to redesign and improve a technology-based healthcare course to maximize benefits.

Originality/value

This research is the first to examine how to leverage lean methods in a healthcare simulation laboratory, dependent on innovative technology, to educate and train future practitioners. This research applied statistical rigor in a controlled experiment to maximize its applicability and generalizability.

Psychosocial factors in nursing work and occupational risks: a systematic review

OBJECTIVE

to identify, in international scientific production, the main psychosocial factors in nursing work, found through the Copenhagen Psychosocial Questionnaire (COPSOQ) application.

METHODS

a systematic review study of psychosocial factors at work among nursing professionals, who used COPSOQ in the assessment of work environments.

RESULTS

fifteen articles were identified, which highlighted as main psychosocial dimensions of nursing work demands, work organization, social relationships and leadership, work-home interface, workplace health and well-being and offensive behaviors.

CONCLUSION

the high demands for cognitive, emotional work and work pace were identified in the nursing routine. Management support had a positive impact. Physical and psychological violence and shift work interfere in family life, aggravating the fatigue of these professionals. Interventions for reducing work stress presuppose the identification of psychosocial factors involved in nursing work.

Optimising the integration of technology-enabled solutions to enhance primary mental health care: a service mapping study

Background

Despite the widely acknowledged potential for health information technologies to improve the accessibility, quality and clinical safety of mental health care, implementation of such technologies in services is frequently unsuccessful due to varying consumer, health professional, and service-level factors. The objective of this co-design study was to use process mapping (i.e. service mapping) to illustrate the current consumer journey through primary mental health services, identify barriers to and facilitators of quality mental health care, and highlight potential points at which to integrate the technology-enabled solution to optimise the provision of care based on key service performance indicators.

Methods

Interactive, discussion-based workshops of up to six hours were conducted with representative stakeholders from each participating service, including health professionals, service managers and administrators from Open Arms – Veterans & Families Counselling Service (Sydney), a counselling service for veterans and their families, and five headspace centres in the North Coast Primary Health Network, primary youth mental health services. Service maps were drafted and refined in real time during the workshops. Through both group discussion and the use of post-it notes, participants worked together to evaluate performance indicators (e.g. safety) at each point in the consumer journey (e.g. intake) to indicate points of impact for the technology-enabled solution, reviewing and evaluating differing opinions in order to reach consensus.

Results

Participants (n=84 across participating services) created service maps illustrating the current consumer journey through the respective services and highlighting barriers to and facilitators of quality mental health care. By consensus, the technology-enabled solution as facilitated by the InnoWell Platform was noted to enable the early identification of risk, reduce or eliminate lengthy intake processes, enable routine outcome monitoring to revise treatment plans in relation to consumer response, and serve as a personal data record for consumers, driving person-centred, coordinated care.

Conclusions

Service mapping was shown to be an effective methodology to understand the consumer’s journey through a service and served to highlight how the co-designed technology-enabled solution can optimise service pathways to improve the accessibility, quality and clinical safety of care relative to key service performance indicators, facilitating the delivery of the right care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06069-0.

Modeling, Assessment and Design of an Emergency Department of a Public Hospital through Discrete-Event Simulation

Emergency departments in hospitals are having many difficulties in achieving the performance levels required by health regulators and society. The waiting times as well as the total throughput time are examples of performance indicators that emergency departments need to improve in order to provide a better service to the community. To achieve improvement of performance, the present paper shows a methodology to assist the design process of an emergency department using simulation techniques. In this study, the emergency department of a hospital located in the northern region of Portugal was considered to test the proposed simulation technique. The emergency department initial state was assessed, in terms of patient flow, as well as the human resources needed at every stage of the service. In order to understand in depth the process that a patient goes through during an emergency episode, a comprehensive study was performed on the hospital database. This allowed the analytical description of an emergency episode, which was further used as an input to the simulation model. After developing the simulation model with the information obtained by the hospital’s database, a validation stage was performed. Finally, in order to achieve an optimized design for the emergency department several variant scenarios were considered and evaluated. This methodology proved to be very useful in determining an optimized operation for complex, and non-linear systems.

Value-based lean implementation in a surgical unit: the impact of the methodology

Purpose

This paper aims to present a method for strategic planning and implementation processes in health care based on lean management.

Design/methodology/approach

Within the framework of the action research methodology, the authors present the ten steps of a kaizen project, which enable lean transformation over a period of time. The study is underpinned by a literature review of enablers and barriers and an implementation case in a tertiary care hospital.

Findings

Key points and possible contingency issues are presented for each of the steps, and a successful lean tools intervention is illustrated by examples of improvement projects of the surgical process. Conclusions of the implementation establish a roadmap for improvement projects in hospital environments based on lean management, thus bridging the existing gap between the large number of theoretical projects (much of the projects described are not sustainable over time as the hospital sector is very particular) that have failed to be implemented, or been paused mid-term, and the self-sustaining projects developed by improvement teams in the hospital.

Originality/value

The study details knowledge gleaned from a three-year project entailing various stages: forming improvement teams; training health-care professionals in lean management; drawing up a process map to identify value stream mapping improvement opportunities; implanting projects and verifying the results obtained; and finally, laying the cornerstones, which would make the project self-sustaining and open to long-term continuous improvement.

Evaluation of System Modelling Techniques for Waste Identification in Lean Healthcare Applications

Purpose

Waste identification plays a vital role in lean healthcare applications. While the value stream map (VSM) is among the most commonly used tools for waste identification, it may be limited to visualize the behaviour of dynamic and complex healthcare systems. To address this limitation, system modelling techniques (SMTs) can be used to provide a comprehensive picture of various system-wide wastes. However, there is a lack of evidence in the current literature about the potential contribution of SMTs for waste identification in healthcare processes.

Methods

This study evaluates the usability and utility of six types of SMTs along with the VSM. For the evaluation, interview-based questionnaires were conducted with twelve stakeholders from the outpatient clinic at the Heart and Vascular Institute at Cleveland Clinic Abu Dhabi.

Results

VSM was found to be the most useful diagram in waste identification in general. However, some SMTs that represent the system behaviour outperformed the VSM in identifying particular waste types, e.g., communication diagram in identifying over-processing waste and flow diagram in identifying transportation waste.

Conclusion

As behavioural SMTs and VSM have unique strengths in identifying particular waste types, the use of multiple diagrams is recommended for a comprehensive waste identification in lean. However, limited resources and time, as well as limited experience of stakeholders with SMTs, may still present obstacles for their potential contribution in lean healthcare applications.

Moving from service to sustainable services: a healthcare case study

Purpose

Worldwide, healthcare systems struggle to sustain the delivery of services at a time of increasing demand, limited resources and growing expectations from users, coupled with dealing with the aftermath of the Covid-19 pandemic and the threat of other outbreaks. There has never been a more important time to sustain innovation and improvements. Using an illustrative case, the authors assess the application of two existing frameworks to identify the key propositions and dimensions required to deliver sustainable services.

Design/methodology/approach

This illustrative case study focuses on a service provided by a chronic disease, multidisciplinary community healthcare team in the UK. Experienced-based interviews were conducted with health professionals, patients and relatives to provide a rich account of a care pathway design. A high-level process map is used to visualise the key touch points.

Findings

The authors identify all seven propositions of the SERVICE framework being present along with additional dimensions relating to sustaining innovation and improvement.

Research limitations/implications

This research is limited to a chronic disease care pathway. However, the authors believe the results could be applicable to other medical conditions, which are supported by a similar multi-disciplinary service delivery model.

Practical implications

The authors provide a sustainable public service operations SERVICES framework for health professionals and managers to consider when (re)designing care pathways.

Originality/value

This research contributes to the emerging discipline of public service operations research by empirically testing for the first time the SERVICE framework within healthcare. The authors have included additional factors associated with innovation and improvement and recommended further development of the framework to include factors, such as economic sustainability, highly relevant to the context of universal healthcare systems.

Lean in Healthcare: Time for Evolution or Revolution?

ABSTRACT

Lean has gained recognition in healthcare as a quality improvement tool. The purpose of this research was to examine the extent to which quality improvement projects in healthcare adhered to Lean's eight-step process. We analyzed 605 publications identified through a systematic literature review following PRISMA guidelines. Each publication was coded using a structured coding sheet. The most frequent type of publication reported empirical research (48.6%) and most of these (80.3%) shared the results of the Lean projects. Of the 237 publications reporting Lean projects, more than half (71.3%) used an experimental, one-site, pre/postdesign. The impact of the project was most often measured using a single metric (59.1%) that was operational (e.g., waiting time). Although most Lean project publications reported the use of tools to "break down the problem" (84.4%, Step 2) and "see countermeasures through" (70.0%, Step 6), fewer than half described using tools associated with each of the other steps. Projects completed an average of 2.77 steps and none of the projects completed all steps. Although some may perceive low adherence to the tenets of Lean as a deficiency, it may be that Lean approaches are evolving to better meet the needs of healthcare.

Sustainability and Kaizen: Business Model Trends in Healthcare

Kaizen, or continuous improvement, is a management tool that allows the identification of activities that have no value in the processes examined. This identification leads to the improvement of these processes within any organization and promotes economic and social sustainability, and to a lesser extent environmental sustainability. Kaizen, already widely and successfully employed in the industrial sector, is now being applied in the health sector. However, the health sector tends to publish only the results of how processes have been improved in finely focused areas and the resulting benefits. The majority of the benefits focus on time and cost reduction. In this study, the authors carried out a bibliometric analysis using the Scimat program, which maps the thematic evolution of Kaizen in the health sector and its relationship with sustainability, in order to promote the interest of the health sector for this type of process improvement. The findings confirm that the implementation of Kaizen is recent and constantly evolves and grows, and that it can help economic and social sustainability, and to a lesser extent environmental sustainability.

Patient experiences after implementing lean primary care redesigns

OBJECTIVE

To examine the effect of Lean primary care redesigns on patient satisfaction with care and timeliness of care received.

DATA/SETTING

We used patient surveys and time-stamped electronic health record (EHR) data in a large ambulatory care system.

DESIGN

Lean-based changes to clinical spaces and care team workflows were implemented in one pilot site and then scaled to all primary care departments across the system. Redesigns included standardizing equipment and patient education materials in examination rooms, streamlining call management functions, co-locating physician and medical assistant dyads in a shared workspace, and creating new care team workflows. We used a non-randomized stepped-wedge study design and segmented regression with interrupted time series analysis to examine Lean impacts on patient outcomes.

DATA COLLECTION

We analyzed patient satisfaction ratings and wait times as documented by the EHR. These longitudinal data were collected for 317 physician-led teams in 46 primary care departments from January 2011 to December 2016.

PRINCIPAL FINDINGS

After implementation of Lean redesigns, patients reported a 44.8 percent increase in satisfaction with the adequacy of time spent with care providers during office visits (P < .05). They also reported 71.6 percent higher satisfaction with their care provider's ability to listen to their concerns, and a 55.4 percent increase in perceived staff helpfulness at the visit (P < .01). Based on monthly EHR data, the amount of time elapsed between a patient request for a routine appointment and the scheduled visit day decreased from baseline by an average 2 percent per month (P < .01). On the day of the visit, patient wait times to be seen also decreased gradually by an average 1.2 percent per month (P < .05).

CONCLUSIONS

Patient experiences of care after Lean implementations have not been widely studied in primary care settings. We found that Lean redesign yielded improvements that may strengthen clinical operations while enhancing value for patients.

Exploring the emotional experience of lean

PURPOSE

This research aims to contribute to the literature on Lean implementation in healthcare by studying the emotional experiences of the relevant actors related to a Rapid Process Improvement Workshop (RPIW) in a UK healthcare context. The purpose of this study was to go beyond what people think about Lean and towards an exploration of their subjective, emotional and "feeling" experience and whether that emotional experience influenced Lean implementation.

DESIGN/METHODOLOGY/APPROACH

A phenomenological and symbolic interactionist qualitative case study was undertaken. Data related to participants' emotional experience were collected through non-participant observation and semi-structured interviews. Data were analysed using thematic network analysis.

FINDINGS

This paper provides novel insights into the emotional experience of Lean as experienced through an RPIW. The findings reveal that participation in an RPIW is much more than a technical process. It influences how people feel about themselves, is based on relationships with others, and requires mental, physical and emotional effort. All of these factors influence engagement with, initiation of and sustainability of the RPIW.

RESEARCH LIMITATIONS/IMPLICATIONS

A new conceptual framework for the planning and implementation of RPIWs has been developed. However, because of the chosen research approach, the results may lack generalisability. Therefore, researchers are encouraged to test the framework and proposed practice implications.

ORIGINALITY/VALUE

Despite emotions being an integral part of individual and social everyday life, emotional experience has not been studied in relation to Lean. This study is the first to explore emotions in relation to Lean, with implications for practice as to how RPIWs are managed with a new framework for implementation being proposed.

Line managers and employees use of lean task boards in Norwegian municipal healthcare sector: a tool for action learning?

PURPOSE

This study aims to analyse the line managers and employees' use of lean task boards over time in Norwegian municipalities using action learning theory. The research question was the following: what kind of action learning processes do the line managers and employees' use of the lean task board promote in municipalities' healthcare units?

DESIGN/METHODOLOGY/APPROACH

This qualitative case study data from a Norwegian municipality involved analyses of 750 internal self-recorded logs from task board sessions from 6 different units and 25 semi-structured interviews of managers and employees.

FINDINGS

The task board works for line managers to make employees responsible for forwarding ideas, solutions and implementation of new actions. The use of the task boards contributes to systemising work through establishing new routines and improving orderliness at work. The line managers used the task boards as a project management system to track progress in the purchasing of diverse equipment and initiatives to improve professionalism and their units' facilities. The study explains the learning challenges for managers using the lean task board, as the method promotes finding experience-based solutions that do not involve critical reflection and use of theory.

PRACTICAL IMPLICATIONS

The lean task board is well-suited for managers to promote learning processes that counteract chaos in local healthcare organisations. However, the task board has limitations as a method for improving services amongst healthcare units and for solving difficult problems.

ORIGINALITY/VALUE

The study contributes to understanding how action learning theory can be applied to the analysis of the results of lean task board sessions.

Outcomes of managing healthcare services using the Theory of Constraints: A systematic review

Despite ever-increasing resources devoted to healthcare, lack of capacity and timeliness are still chronic problems worldwide. This systematic review aims to present an overview of the Theory of Constraints (TOC) implementations in healthcare services and their outcomes. We analysed 42 TOC implementations (15 full-text articles, 12 video proceedings, and 2 theses/disserations) from major scientific electronic databases and TOC International Certification Organization Conferences. All implementations reported positive outcomes, both tangible and intangible. The two main improvements reported by authors were in productivity (98%; n = 41) - more patients treated - and in the timeliness of care (83%; n = 35). Furthermore, the selected studies reported dramatic improvements: 50% mean reductions in patient waiting time; 38% reduction in patient length of stay; 43% mean increase in operating room productivity and 34% mean increase in throughput. TOC implementations attained positive results in all levels of the health and social care chain. Most TOC recommendations and changes showed almost immediate results and required little or no additional cost to implement. Evidence supports TOC as a promising solution for the chronic healthcare problem, improving quality and timeliness, both necessary conditions for providing effective healthcare.

Healthcare Engineering: A Lean Management Approach

This work tries to answer the following question: can healthcare be engineered using lean management tools? Lean is known to achieve successful results when implemented in the manufacturing sector. Typical results are operational cost reduction, cycle time reduction, and higher customer satisfaction. The service sector, however, has seen mixed results. For the last two decades, educators and healthcare professionals are trying to implement lean tools in healthcare. Some reported success and many did not, for variety of reasons. In this paper, we search the literature and reveal the special nature of healthcare services, success factors, and barriers facing implementation of lean in healthcare. We then conduct a survey of 18 elite Jordanian hospitals to study the case holistically. Statistical analysis of the survey results confirmed some of what the literature revealed; organizational leadership seems to be the most dominant factor, followed by knowledge of employees about lean, training, and patient satisfaction (customer focus). Another important finding, not captured by the literature, is that lean implementation success depends on educating physicians about continuous improvement and lean and ensuring they are part of the improvement team. Based on the revealed enablers and obstacles, we created a full lean implementation framework. This framework was then used along with selected engineering tools to implement lean in a major hospital successfully. Implementation results showed 60% of reduction in cycle time, 80% reduction in operational cost, and many other benefits.

Addressing Behavioral Health Concerns in Trauma: Using Lean Six Sigma to Implement a Depression Screening Protocol in a Level I Trauma Center

BACKGROUND

Patients with physical injuries or chronic conditions may be impacted by mental health conditions, which significantly affect their participation and progress in treatment. The Patient Health Questionnaire-2 (PHQ-2) depression screening can identify patients who are at greatest risk for depression to provide better whole-person care.

OBJECTIVE

The quality improvement project objective was to identify and design a process that would result in the PHQ-2 depression screening for admitted trauma patients with a minimum 75% completion rate.

METHODS

Lean Six Sigma (LSS) process design methodology, DMADV (define, measure, analyze, design, and verify), drove process improvement. Medical records from before (December 2018 through February 2019) and after (March 2019 through May 2019) the intervention were evaluated using frequencies, percentages, χ, and multivariable logistic regression to determine the effectiveness of the intervention.

RESULTS

PHQ-2 document location was imperative to successful compliance, which increased from 60.74% (78 of 128) to 80.56% (87 of 108). Specifically, weekend compliance increased from 42.9% (18 of 42) to 82.8% (24 of 29).

CONCLUSION

LSS DMADV methodology helped health care professionals design a process to facilitate compliance with the PHQ-2 depression screening protocol in trauma patients. Adherence with this screening can help increase the number of behavioral health consultations, which in turn improves the treatment of traumatic injury survivors.

Applying Lean Six Sigma to Reduce the Incidence of Unplanned Surgery Cancellation at a Large Comprehensive Tertiary Hospital in China

Unplanned surgery cancellation (USC) was an important quality management issue in the course of medical care for surgical patients, which caused inappropriate use of hospital resources and had negative impacts on quality and safety. This study used Lean Six Sigma to reduce the incidence of USC. Following the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process, the main factors influencing the USC were identified, such as the time of informing patient admission, the time of submitting operation notice, and the management of test report follow-up. A series of measures were implemented including improving the health education content of virtual bed patients, standardizing the way of communication between the Admission Management Center and the patients, improving the timing of anesthesia evaluation, optimizing the process of operation notice with an information system, and implementing the regulations of virtual bed management. The incidence of USC reduced from 10.21% in Jan. 2016 to 3.8% in Dec. 2016, and the Z-score increased from 1.25 to 1.68, which improved patient safety and demonstrated that Lean Six Sigma was an effective method to solve cross-department issues in hospital.

Implementation Science to Respond to the COVID-19 Pandemic

The COVID-19 pandemic continues to expand globally, requiring massive public health responses from national and local governments. These bodies have taken heterogeneous approaches to their responses, including when and how to introduce and enforce evidence-based interventions-such as social distancing, hand-washing, personal protective equipment (PPE), and testing. In this commentary, we reflect on opportunities for implementation science to contribute meaningfully to the COVID-19 pandemic response. We reflect backwards on missed opportunities in emergency preparedness planning, using the example of PPE stockpiling and supply management; this planning could have been strengthened through process mapping with consensus-building, microplanning with simulation, and stakeholder engagement. We propose current opportunities for action, focusing on enhancing the adoption, fidelity, and sustainment of hand washing and social distancing; we can combine qualitative data, policy analysis, and dissemination science to inform agile and rapid adjustment to social marketing strategies to enhance their penetration. We look to future opportunities to enhance the integration of new evidence in decision-making, focusing on serologic and virologic testing systems; we can leverage simulation and other systems engineering modeling to identify ideal system structures. Finally, we discuss the ways in which the COVID-19 pandemic challenges implementation science to become more rapid, rigorous, and nimble in its approach, and integrate with public health practice. In summary, we articulate the ways in which implementation science can inform, and be informed by, the COVID-19 pandemic, looking backwards, proposing actions for the moment, and approaches for the future.

Recommendations for enhancing the usability and understandability of process mining in healthcare

Healthcare organizations are confronted with challenges including the contention between tightening budgets and increased care needs. In the light of these challenges, they are becoming increasingly aware of the need to improve their processes to ensure quality of care for patients. To identify process improvement opportunities, a thorough process analysis is required, which can be based on real-life process execution data captured by health information systems. Process mining is a research field that focuses on the development of techniques to extract process-related insights from process execution data, providing valuable and previously unknown information to instigate evidence-based process improvement in healthcare. However, despite the potential of process mining, its uptake in healthcare organizations outside case studies in a research context is rather limited. This observation was the starting point for an international brainstorm seminar. Based on the seminar's outcomes and with the ambition to stimulate a more widespread use of process mining in healthcare, this paper formulates recommendations to enhance the usability and understandability of process mining in healthcare. These recommendations are mainly targeted towards process mining researchers and the community to consider when developing a new research agenda for process mining in healthcare. Moreover, a limited number of recommendations are directed towards healthcare organizations and health information systems vendors, when shaping an environment to enable the continuous use of process mining.

Lean Healthcare in the institutional, professional, and patient perspective: an integrative review

OBJECTIVE

To analyze the scientific evidences in the literature about the evaluation of Lean Healthcare after its implementation.

METHOD

An integrative review conducted in the CINAHL, Scopus, WOS, and Embase databases, and in the PubMed portal, resulting in 18 articles published in English, Spanish and Portuguese, from 2008 to 2019.

RESULTS

The findings were categorized into results for the institution, professional, and patient. The predominant category was institutional, with cost analysis and increased productivity, followed by the professional, with job satisfaction and leadership, and finally the patient, with satisfaction, attitudes, and behaviors.

CONCLUSION

This study reinforces the need to establish, for management, a systematic method of monitoring the results achieved in the Lean Healthcare implementation phase. Since the value in this method is defined by the patient, further research in this aspect may lead to new evidence.

Zwischen Traum und Trauma - Aufbau und Betrieb einer Kohortenstation für Patient_innen mit COVID-19 in einem Akutspital - Eine Fallstudie

Between dream and distress - Setting up and running a cohort ward for COVID-19 Patients at an acute hospital - A case study Abstract. Background: In the context of the pandemic, hospitals must be able to care for COVID-19 patients within a very short timeframe.

OBJECTIVE

Description of the setting up of a cohort ward for patients with COVID-19 on a surgical ward including the development of the nursing team.

METHODS

The intrinsic retrospective case study describes the situation, identifies special phenomena in a reflective manner and links them to existing knowledge. Data were anecdotal, routine data were collected in the context of nursing practice development.

RESULTS

Setting up the cohort ward in a Swiss hospital consisted of structural and technical planning, infection control measures, the establishment of interprofessional structures, and internal communication. During the four-week operation, 71 patients were treated. The use of practice development methodology initiated a cultural change. The reflection describes a field of tension between "dream and distress": As a dream, the lived experience of optimal care, with well-functioning processes, sufficient material, sufficient personnel and a very good interprofessional cooperation was evaluated. Distress in the form of high infection rates as well as psychological and physical stress did not occur. After the cohort ward was closed, there was a risk working back in normal operations based on existing economical and organizational conditions, with the knowledge that a different cooperation and organization is possible.

CONCLUSIONS

Positive experiences from the "crisis mode" should be used to further develop essential operations during normal times.

Lean thinking by integrating with discrete event simulation and design of experiments: an emergency department expansion

BACKGROUND

Many management tools, such as Discrete Event Simulation (DES) and Lean Healthcare, are efficient to support and assist health care quality. In this sense, the study aims at using Lean Thinking (LT) principles combined with DES to plan a Canadian emergency department (ED) expansion and at meeting the demand that comes from small care centers closed. The project's purpose is reducing the patients' Length of Stay (LOS) in the ED. Additionally, they must be assisted as soon as possible after the triage process. Furthermore, the study aims at determining the ideal number of beds in the Short Stay Unit (SSU). The patients must not wait more than 180 min to be transferred.

METHODS

For this purpose, the hospital decision-makers have suggested planning the expansion, and it was carried out by the simulation and modeling method. The emergency department was simulated by the software FlexSim Healthcare®, and, with the Design of Experiments (DoE), the optimal number of beds, seats, and resources for each shift was determined. Data collection and modeling were executed based on historical data (patients' arrival) and from some databases that are in use by the hospital, from April 1st, 2017 to March 31st, 2018. The experiments were carried out by running 30 replicates for each scenario.

RESULTS

The results show that the emergency department cannot meet expected demand in the initial planning scenario. Only 17.2% of the patients were completed treated, and LOS was 2213.7 (average), with a confidence interval of (2131.8-2295.6) min. However, after changing decision variables and applying LT techniques, the treated patients' number increased to 95.7% (approximately 600%). Average LOS decreased to 461.2, with a confidence interval of (453.7-468.7) min, about 79.0%. The time to be attended after the triage decrease from 404.3 min to 20.8 (19.8-21.8) min, around 95.0%, while the time to be transferred from bed to the SSU decreased by 60.0%. Moreover, the ED reduced human resources downtime, according to Lean Thinking principles.

Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review

Healthcare services are facing challenges in increasing their efficiency, quality of care, and coping with surges in demand. To this end, some hospitals have implemented lean healthcare. The aim of this systematic review is to evaluate the effects of lean healthcare (LH) interventions on inpatient care and determine whether patient flow and efficiency outcomes improve. The review was performed according to PRISMA. We used six databases to search for studies published from 2002 to 2019. Out of 5732 studies, 39 measuring one or more defined outcomes were included. Hospital length of stay (LOS) was measured in 23 studies, 16 of which reported a reduction, turnover time (TOT) decreased in six out of eight studies, while the turnaround time (TAT) and on-time starts (OTS) improved in all five and seven studies, respectively. Moreover, eight out of nine studies reported an earlier discharge time, and the boarding time decreased in all four cases. Meanwhile, the readmission rate did not increase in all nine studies. Lastly, staff and patient satisfaction improved in all eight studies. Our findings show that by focusing on reducing non-value-added activities, LH contributed to improving patient flow and efficiency within inpatient care.

From self-management to a systemized process: the implementation of lean management in a Chinese hospital's pharmacy intravenous admixture services center

PURPOSE

The purpose of this paper is to explore the importance of lean leadership in an implementation in a Chinese hospital, considering a particular focus on the attitudes of nursing professionals while identifying specific cultural or institutional factors in China that might affect the implementation.

DESIGN/METHODOLOGY/APPROACH

The authors use Harrison et al.'s (2016) framework to explore the outcomes of a nine-month action research project whereby the authors observed the process and outcomes of implementing lean in a pharmacy intravenous admixture service of a Chinese hospital.

FINDINGS

The implementation of lean had positive results, which improved the efficiency of the operation, reduced the work start time and the amount of staff, and improved clinical satisfaction. In the process of implementation, nursing professionals showed a positive attitude toward the implementation and showed no obvious resistance under the positive influence of the head nurse. The combination of Chinese cultural characteristics, nursing culture and strong leadership enabled lean success.

ORIGINALITY/VALUE

The unit moved from self-management to a systemized process of using lean concepts and methods, it is an important change for hospital managers.

COVID-19 outbreak: implications on healthcare operations

Purpose

The COVID-19 pandemic is considered a major disruptive event of this decade, raising unforeseen socio-economic implications worldwide. This novel virus has increased the influx of patients in hospitals, and healthcare organisations are facing unprecedented constraints in their operations to deal with increased demand and pressed capacity. Thus, this article evaluates the impact of the COVID-19 pandemic on healthcare systems' demand, resources and capacity and provides research directions.

Design/methodology/approach

This is a viewpoint article and uses timely information on healthcare operations from both scholars and managers, published by diverse sources during the COVID-19 outbreak.

Findings

The authors discuss the focus on “flattening the curve of infection” as a measure to protect healthcare, delay the impact of increased demand and reorientate healthcare supply chain practices. Furthermore, the authors evaluate the role of lean practices on managing demand and capacity and improving quality across healthcare operations and supply chain. Finally, the authors suggest research directions on modern operational issues that emerged during this pandemic, such as discussions around the sustainability of lean post-pandemic, “just in time” practices, inventory trade-offs and lack of organisational responsiveness during untenable events.

Originality/value

In this article, the authors provide a contemporary assessment of the implications of the COVID-19 pandemic on healthcare operations, underscoring main economic and operational elements that can be affected, such as unforeseen demand, resources and capacity shortage. Therefore, the authors assess that healthcare organisations, practitioners and governments have to anticipate operational and economic impacts and, ultimately, to reassess their plans to deal with such adverse events.

Improvisation during a crisis: hidden innovation in healthcare systems

Background

Crises, such as the COVID-19 pandemic, risk overwhelming health and social care systems. As part of their responses to a critical situation, healthcare professionals necessarily improvise. Some of these local improvisations have the potential to contribute to important innovations for health and social care systems with relevance beyond the particular service area and crisis in which they were developed.

Findings

This paper explores some key drivers of improvised innovation that may arise in response to a crisis. We highlight how services that are not considered immediate priorities may also emerge as especially fertile areas in this respect.

Conclusion

Health managers and policymakers should monitor crisis-induced improvisations to counteract the potential deterioration of non-prioritised services and to identify and share useful innovations. This will be crucial as health and social care systems around the world recover from the COVID-19 pandemic and head into another potential crisis: a global economic recession.

Improving forensic processes performance: A Lean Six Sigma approach

Quality practices in forensic science are often in tension with providing timely results. When the Costa Rican Department of Forensic Sciences ballistics unit achieved accreditation under ISO/IEC 17020:2012 in 2018, the unit started experiencing slower turnaround times. With a view to expediting the resolution of forensic examination processes, the unit undertook a Lean Six Sigma project with a five-phase problem-solving methodology. The unit began to use data and process tools to transform its current state. The completion of all phases showed that two main aspects were preventing the laboratory from fulfilling the customers’ expectations: standardization and constraints. This project took 6 months and improvements were seen through the reduction of the number of pending cases with a backlog of more than 3 months by 97% and the turnaround time from 4 months to 1 month. Through this project, leadership identified an effective methodology, creating a positive impact on customers’ expectations.

Analysis and Evaluation of Reviews on Lean and Six Sigma in Health Care

BACKGROUND AND OBJECTIVES

Health care is a complex industry in which professionals are facing the challenge of balancing lower costs with better health and quality of care. To remain competitive, health care organizations have promoted the use of Lean and Six Sigma in various settings. More than 300 refereed English-language articles about Lean and/or Six Sigma in health care are found in the literature, and many reviews have been published on this subject.

METHODS

This article characterizes the literature by evaluating and classifying 22 reviews, based on year of publication, country, taxonomy, health care setting, outcome, tools, and enabling factors, in order to identify gaps in the literature and set new directions for research.

RESULTS

Findings indicate that 90% of reviews are characterized by restrictive inclusion criteria that result in the inclusion of only 3% to 66% of the literature at the corresponding time. Furthermore, there is no full comprehensive literature review available on Lean and Six Sigma in health care. Other gaps in the literature include more studies with better research design, broader applications in various health care settings and various countries, sustainability assessment and long-term effects, and evidence of failed Lean and Six Sigma implementations.

CONCLUSION

This study provides an updated starting point for future research to researchers and practitioners in the field.

Lean Lobectomy: Streamlining Video-Assisted Lobectomy to Increase the Value of Lung Cancer Care

PURPOSE

A review of the outcomes of patients who received our video-assisted thoracic surgery (VATS) lung lobectomy in 2015 revealed long lengths of stay, inefficient care transitions, and overuse of resources. Focused process redesign offers a proven method for instituting improvement and changes in health care. We sought to use systems process improvement to streamline VATS lobectomies at our institution, and we targeted cost drivers to optimize quality of care and minimize overuse of resources.

METHODS

We performed a retrospective review of perioperative practices between January 2015 and March 2016 for patients undergoing VATS lobectomy that helped establish a value stream map, used a granular cost database, and performed real-time analysis. We used an outcomes database, which allowed us to identify cost drivers, practice variability, and rent seeking. We implemented process redesign with constant review and formal value stream reanalysis at 6-month intervals over a 2-year period.

RESULTS

We ultimately experienced an overall 187% reduction of time in the operating room (297 v 159 minutes). Our process redesign also resulted in significantly fewer chest x-rays per patient (mean, 6.7 v 2), laboratory draws (100% v 5.7%), and consultations (100% v 5.7%), which resulted in a 234% reduction in mean length of stay (4.4 v 1.88 days) and an overall cost reduction of 40%. These changes did not have a detrimental effect on patient outcomes: pulmonary complications (16.9% v 8.6%), cardiac complications (13.2% v 8.6%), and readmission rates (13.6% v 2.9%) all decreased.

CONCLUSION

By using value stream analysis and process redesign methodologies, closely paired with highly granular cost and outcomes data, we were able to achieve significant improvements in patient outcomes and use of resources.

Leanness evaluation in health-care organizations using fuzzy logic approach

Purpose

Lean practices are one of the fundamental practices adopted by health-care organizations to improve service quality and to reduce cost. In this context, the measurement of leanness in health-care organizations has become imperative. The purpose of this study is to measure the leanness of a hospital using fuzzy logic.

Design/methodology/approach

The design of the research includes two major steps. First, the identification of enablers, criteria and attributes of leanness constitutes the measures of assessment. Second, the above measures in the case hospital are assessed by using fuzzy logic approach.

Findings

This study suggests that leanness assessment is essential to identify the current lean capability of a health-care organization. This would help the health-care organizations to improve their lean performance further. The findings of the study suggest that the leanness of the case hospital is “Lean” (fuzzy range: 5.61, 7.24 and 8.91).

Practical implications

This study brings in three important implications from managerial point of view. First, it helps the management to assess the current level of leanness of the hospital. Second, it identifies the attributes that prevent the organization from being more lean. Third, it provides suggestive measures to address the weaker attributes and enables the enhancement of lean performance further.

Originality/value

The leanness assessment framework developed in the hospital operations is found to be original, and it adds value to the leanness assessment in health-care operations.

Lean: increase efficiency in stroke patient care

Purpose

Many healthcare organizations are looking for methods, such as Lean, to reduce their costs and increase the productivity of their professionals. The Lean method looks at every step in every process to assess if this step adds value for the customer or not. The aim of this study was to explore the value adding and non-value adding process steps in stroke patient admission in an integrated care stroke service in the Netherlands.

Design/methodology/approach

This study focused on discharge of stroke patients from hospital acute treatment, and they were admitted for rehabilitation. According to the Grounded Theory, value stream mapping, organized interviews and expert meetings and coded was used. A configuration analysis was used to distinguish aggregates and configurations.

Findings

The most reported issues concerned in the paper are as follows: (1) insufficient internal logistics in the hospital, (2) miscommunication about medical readiness for discharge of the patient, (3) missing or delayed medical patient information, (4) overlapping discharge interviews, (5) unsafe transfer of sensitive information and (6) waiting lists and queuing up in rehabilitation facility.

Originality/value

At least six main areas of waste were identified in this stroke service, and they form the target for waste reducing activities. The results give insight in possible wastes in healthcare organizations and are therefore beneficial for other healthcare organizations which are planning to reduce wastes.

Nurse managers implementing the lean management system: A qualitative study in Western Canada

AIM

This study explores the perceptions and experiences of nurse managers involved in implementing the Lean management system in a Western Canadian province.

BACKGROUND

The provincial government of Saskatchewan, Canada, implemented a multimillion-dollar investment in the Lean management system to transform health care delivery by reducing waste and increasing efficiency of processes and outcomes.

METHODS

This qualitative exploratory study employed semi-structured interviews with 14 nurse managers in urban and rural health regions in one Canadian province.

RESULTS

Six themes outline the difficulties nurse managers experienced in juggling role responsibilities alongside a poorly implemented change system with scarce resources.

CONCLUSION

The results showed tensions in the implementation of a Lean model adapted in the context of health care organisations. The expectations for nurse managers to be pivotal players in the implementation of transformative health care practices that promote and sustain strategies to reduce waste, improve coordination and increase patient safety require investment in leadership development.

IMPLICATIONS FOR NURSING MANAGEMENT

Lean management systems significantly impact the roles of nurse managers who require adequate resources and training to successfully adapt. The results of this study may be used for more effective support mechanisms for nurse managers.

Effects of Lean Healthcare on Patient Flow: A Systematic Review

OBJECTIVES

To assess the effects of lean healthcare (LH) on patient flow in ambulatory care and determine whether waiting time and length of stay (LOS) decrease after LH interventions.

METHODS

A systematic review was performed with close adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched for studies of healthcare organizations applying LH interventions within ambulatory care published between 2002 and 2018. Six databases and grey literature sources were used. Two reviewers independently screened and assessed each study. When consensus was difficult to reach, a third reviewer intervened. Finally, a summary of findings was generated.

RESULTS

Out of 5627 studies, 40 were included. Regarding LOS for all patients, 19 out of 22 studies reported a decrease. LOS for discharged patients decreased in 11 out of 13 studies, whereas LOS for admitted patients was reduced in 6 out of 7 studies. Waiting time for patients before seeing a healthcare professional decreased in 24 out of 26 studies. Waiting time to treatment and waiting time for appointments were minimized in 4 and 2 studies, respectively. Patients who left without being seen by a doctor decreased in 9 out of 12 studies. Finally, patient and staff satisfaction were measured in 8 and 2 studies, respectively, with each reporting improvements.

CONCLUSIONS

According to our findings, LH helped to reduce waiting time and LOS in ambulatory care, mainly owing to its focus on identifying and minimizing non-value added (NVA) activities. Nevertheless, evidence of the impact of LH on patient/staff satisfaction and the translation of the obtained benefits into savings is scarce among studies.

Construction of nursing knowledge in commodified contexts: A discussion paper

This original article outlines a theoretical path and posterior critical analysis regarding two relevant matters in modern nursing: patterns of knowing in nursing and commodification contexts in contemporary health systems. The aim of our manuscript is to examine the development of basic and contextual nursing knowledge in commodified contexts. For this purpose, we outline a discussion and reflexive dialogue based on a literature search and our clinical experience. To lay the foundation for an informed discussion, we conducted a literature search and selected relevant articles in English, Spanish, and Portuguese that included contents on patterns of knowing, commodification, and nursing published from 1978 to 2017. Globalization, commodification, and austerity measures seem to have negative effects on nursing. Work conditions are worsening, deteriorating nurse-patient relationships, and limiting reflection on practice. Nurses must develop knowledge to challenge and participate in institutional organization and public health policies. Development of nursing knowledge may be difficult to achieve in commodified environments. Consequently, therapeutic care relationships, healthcare services, and nurses' own health are compromised. However, by obtaining organizational, sociopolitical, and emancipatory knowledge, nurses can use strategies to adapt to or resist commodified contexts while constructing basic knowledge.

One Multidisciplinary Cleft and Craniofacial Team's Experience in Shifting to Family-Centered Care

Family-centered care is a high-priority focus area in health care and is associated with increased family satisfaction and quality of life, better health outcomes and family follow-up, decreased burden of care, and improved efficiency of resource utilization. Motivated by our aim to improve clinic efficiency and patient retention, our multidisciplinary cleft palate and craniofacial center has been undergoing a complex family-centered reorganization over the past 3 years. We seek to share our experience in hope the information will be a useful starting point to other teams in structuring their own family-centered improvements. We suggest the following stepwise method to achieve a more family-centered process: (1) gathering preintervention data, (2) brainstorming challenges with stakeholders, (3) brainstorming solutions with stakeholders, (4) implementation, (5) follow-up and troubleshooting, (6) further implementation, and (7) gathering postintervention data. Additionally, we found the use of institutional resources added substantial value to our efforts.

Business process improvement methods in healthcare: a comparative study

PURPOSE

According to the literature concerned with this study, less than satisfactory outcomes have been achieved through implementing business process improvements methods (BPIMs) in industries, in general, and in healthcare, in particular. The existing methods used need to be enhanced in order to create more effective outcomes. There has also been a lack of studies documenting gaps or shortfalls in implementing BPIMs, to be presented to the BPI research community. Therefore, researchers of this paper have attempted to fill gaps between theory and practice. On the contrary, there is also a need to link practical outcomes in the healthcare domain with those of the BPI research community. The purpose of this paper is to review popular BPIMs, techniques and tools applied in the healthcare domain; it seeks to examine and highlight their significant roles, clarify their pros and cons, and find opportunities to enhance their impact on the achievement of more sustainable improvements in the healthcare domain.

DESIGN/METHODOLOGY/APPROACH

This study has been carried out by using a methodology combining an in-depth literature review with a comparison framework, which is called as the "Framework for Comparing Business Process Improvement Methods." The framework is composed of seven dimensions and has been adapted from four recognized, related frameworks. In addition to the in-depth review of related literature and the adapted comparison framework, researchers have conducted several interviews with healthcare BPI practitioners in different hospitals, to attain their opinions of BPI methods and tools used in their practices.

FINDINGS

The main results have indicated that significant improvements have been achieved by implementing BPIMs in the healthcare domain according to related literature. However, there were some shortfalls in the existing methods that need to be resolved. The most important of these has been the shortfall in representing and analyzing targeted domain knowledge during improvement phases. The tool currently used for representing the domain, specifically flowcharts, is very abstract and does not present the domain in a clear form. The flowchart tool also fails to clearly present the separation of concerns between business processes and the information systems processes that support a business in a given domain.

PRACTICAL IMPLICATIONS

The findings of this study can be useful for BPI practitioners and researchers, mainly within the healthcare domain. The findings can help these groups to understand BPIMs shortfalls and encourage them to consider how BPIMs can be potentially improved.

ORIGINALITY/VALUE

This researchers of this paper have proposed a comparison framework for highlighting popular BPIMs in the healthcare domain, along with their uses and shortfalls. In addition, they have conducted a deep literature review based on the practical results obtained from different healthcare institutions implementing unique BPIMs around the world. There has also been valuable interview feedback attained from BPI leaders of specific hospitals in Saudi Arabia. This combination is expected to contribute to knowledge of BPIMs from both theoretical and practical points of view.

Bibliometric Review of the Knowledge Base on Healthcare Management for Sustainability, 1994–2018

In response to the United Nations’ (UN) Sustainable Development Goals (SDGs), health care organizations throughout the world have adopted management initiatives designed to increase their sustainability. This review of research used bibliometric methods to analyze a dataset comprised of 477 documents extracted from the Scopus database. The review sought to document research on sustainable healthcare management (SHM) that has accumulated over the past 25 years. Results indicated that the intellectual structure of this body of knowledge is comprised of three schools of thought: (1) sustainable change in health care services, (2) innovations in managing health care operations, and (3) prioritizing and allocating resources for sustainability. The review also highlighted the recent topical focus of research in this literature. Key topics were linked to organization and management of health care services, quality of patient care, and sustainability of health care delivery.

Streamlining an existing hip fracture patient pathway in an acute tertiary adult Irish hospital to improve patient experience and outcomes

OBJECTIVE

To improve access for hip fracture patients to surgery within 48 h of presentation to the Emergency Department, and to increase the number of patients receiving pre-operative orthogeriatric review, through streamlining an existing hip fracture patient pathway.

DESIGN

A pre-post design involving a multi-disciplinary team use of the Define, Measure, Analyse, Improve and Control framework integral to Lean Six Sigma (LSS) methodology, to assess and adapt the existing hip fracture pathway from presentation to Emergency Department to the initiation of surgery.

SETTING

A 600-bed teaching hospital in Ireland.

PARTICIPANTS

Nursing, medical, administrative and physiotherapy staff working across Emergency Medicine, Orthogeriatrics and Orthopaedic Specialities and Project management.

INTERVENTIONS

LSS methodology was used to redesign an existing pathway, improving patient access to ortho-geriatrician assessment, pain relief and surgery in line with the Irish Hip Fracture Data Base Key performance indicators.

MAIN OUTCOME MEASURES

Access to pain relief, access to surgery and volume of patients receiving ortho-geriatric assessment.

RESULTS

The percentage of patients undergoing surgery within 48 h of presentation to Emergency Department increased from 55% to 79% at 3 months, and to 85% at 6 months. Improvements were also achieved in the secondary performance metrics relevant to quality of patient care. All care pathway changes were cost neutral.

CONCLUSIONS

Hip fracture surgery within 48 h of presentation to hospital is a recognized standard of hip fracture care associated with decreased length of stay and decreased mortality. With respect to this performance metric, this intervention has contributed to improved patient outcomes.