Lean in healthcare: A comprehensive review

Contextual Conditions and Performance Improvement in Primary Care

BACKGROUND

Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns.

METHODS

We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes.

RESULTS

Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support.

CONCLUSIONS

Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change.

Delivering direct patient care in the haemodialysis unit: a focused ethnographic study of care delivery

Background

Direct patient care is a term used within nursing and healthcare to help quantify and qualify care delivery. Direct patient care time is considered as a valuable measure by healthcare providers to indicate efficiency and to quantify nursing work, however little is understood of the patient experience and care delivery in haemodialysis settings.

Aim

The aim of this study was to gain an understanding of patients' and nursing staff perceptions and experiences of 'direct patient care' within one haemodialysis unit.

Methods

A focused ethnographic approach utilised participant observations, informal questioning, photographs and 27 semi-structured interviews of registered nurses, clinical support workers and patients. Observation notes and interviews were transcribed and thematically analysed.

Results

The key finding was the construction and reconceptualisation of care delivery in this setting. Care was identified to be delivered in two distinct ways, both of which allowed patients to feel cared for. 'Active care' where patients feel cared for when they are being dealt with directly by staff and 'Passive care' where patients feel cared for through staff availability and visibility.

Conclusion

Developing this understanding of patient care delivery in this specialism has highlighted some important aspects to the way care can be delivered which challenges current traditional understandings of direct patient care. Time spent with a patient is not the only important consideration to patient experience in haemodialysis. This understanding of passive care could improve care experiences in this setting.

Quality improvement in hospitals' surgery-related processes: A systematic review

Background: There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The fundamentals of QI begin with an understanding of the underlying theoretical framework. This study aims to provide an overview of the existing QI models and frameworks for general surgery. Methods: In this systematic review, published literature from January 2007 until September 2018 were retrieved from PubMed, Scopus, Web of Science and Embase databases, and Google Scholar using the MeSH terms related to QI and surgery. In total, 25 fulltext articles were finally included, and data extraction was based on research objectives. Results: Nine models were identified for QI in general surgery. These models were categorized into two main groups: (i) conceptual models or frameworks designed for QI in industry and applied in surgery, and (ii) those designed specifically for QI in surgery. Identified QI models were more used for improving postoperative processes and pre-hospital trauma care, identifying causes of prolonged periods of stay and lowering LOS index, improving surgical antimicrobial prophylaxis and antibiotics administrating during surgery process, reducing and controlling infections, reducing complications, reducing mortality and morbidity, reducing waiting times and start time delays, reducing variability and improving surgical clinic experience, reducing costs, improving operating room efficiency by removing processes that add no value, and lowering per-capita costs. Conclusion: According to the findings of this study, there are different models and frameworks with different aspects and dimensions for QI in surgery, which is recommended to use either of these models alone or with each other for specific circumstances. The use of these models in surgery is increasing, and it is recommended that these models could be used according to their functions in cases such as reducing the unnecessary use of resources, increasing the satisfaction of patients and their families with health care and improving the efficiency, safety and quality of healthcare in the surgical departments.

Exploring Care Attributes of Nephrologists Ranking Favorably on Measures of Value

BACKGROUND

Despite growth in value-based payment, attributes of nephrology care associated with payer-defined value remains unexplored.

METHODS

Using national health insurance claims data from private preferred provider organization plans, we ranked nephrology practices using total cost of care and a composite of common quality metrics. Blinded to practice rankings, we conducted site visits at four highly ranked and three average ranked practices to identify care attributes more frequently present in highly ranked practices. A panel of nephrologists used a modified Delphi method to score each distinguishing attribute on its potential to affect quality and cost of care and ease of transfer to other nephrology practices.

RESULTS

Compared with average-value peers, high-value practices were located in areas with a relatively higher proportion of black and Hispanic patients and a lower proportion of patients aged >65 years. Mean risk-adjusted per capita monthly total spending was 24% lower for high-value practices. Twelve attributes comprising five general themes were observed more frequently in high-value nephrology practices: preventing near-term costly health crises, supporting patient self-care, maximizing effectiveness of office visits, selecting cost-effective diagnostic and treatment options, and developing infrastructure to support high-value care. The Delphi panel rated four attributes highly on effect and transferability: rapidly adjustable office visit frequency for unstable patients, close monitoring and management to preserve kidney function, early planning for vascular access, and education to support self-management at every contact.

CONCLUSIONS

Findings from this small-scale exploratory study may serve as a starting point for nephrologists seeking to improve on payer-specified value measures.

Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects

Background

The Plan-Do-Study-Act (PDSA) method is widely used in quality improvement (QI) strategies. However, previous studies have indicated that methodological problems are frequent in PDSA-based QI projects. Furthermore, it has been difficult to establish an association between the use of PDSA and improvements in clinical practices and patient outcomes. The aim of this systematic review was to examine whether recently published PDSA-based QI projects show self-reported effects and are conducted according to key features of the method.

Methods

A systematic literature search was performed in the PubMed, Embase and CINAHL databases. QI projects using PDSA published in peer-reviewed journals in 2015 and 2016 were included. Projects were assessed to determine the reported effects and the use of the following key methodological features; iterative cyclic method, continuous data collection, small-scale testing and use of a theoretical rationale.

Results

Of the 120 QI projects included, almost all reported improvement (98%). However, only 32 (27%) described a specific, quantitative aim and reached it. A total of 72 projects (60%) documented PDSA cycles sufficiently for inclusion in a full analysis of key features. Of these only three (4%) adhered to all four key methodological features.

Conclusion

Even though a majority of the QI projects reported improvements, the widespread challenges with low adherence to key methodological features in the individual projects pose a challenge for the legitimacy of PDSA-based QI. This review indicates that there is a continued need for improvement in quality improvement methodology.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4482-6) contains supplementary material, which is available to authorized users.

Assessing the state of lean and six sigma practices in healthcare in Mexico

PURPOSE

The purpose of this study is to assess the state at which lean and six sigma (LSS) are used as a management system to improve the national health system national health system of Mexico.

DESIGN/METHODOLOGY/APPROACH

Cross-sectional survey-research. The survey was administered at 30 different hospitals across six states in Mexico. These were selected using convenience sampling and participants (N = 258) were selected through random/snowball sampling procedures, including from top managers down to front-line staff.

FINDINGS

Only 16 per cent of respondents reported participation in LSS projects. Still, these implementations are limited to using isolated tools, mainly 5s, failure mode and effects analysis (FMEA) and Fishbone diagram, with the lack of training/knowledge and financial resources as the top disabling factors. Overall, LSS has not become systematic in daily management and operations.

RESEARCH LIMITATIONS/IMPLICATIONS

The sampling procedure was by convenience; however, every attempt was made to ensure a lack of bias in the individual responses. If still there was a bias, it is conjectured that this would likely be in overestimating the penetration of LSS.

PRACTICAL IMPLICATIONS

The penetration of LSS management practices into the Mexican health system is in its infancy, and the sustainability of current projects is jeopardized given the lack of systematic integration. Hence, LSS should be better spread and communicated across healthcare organizations in Mexico.

ORIGINALITY/VALUE

This is the first research work that evaluates the use of LSS management practices in a Latin American country, and the first journal paper that focuses on LSS in healthcare in Mexico.

Staff perception of Lean, care-giving, thriving and exhaustion: a longitudinal study in primary care

Background

Lean is commonly adopted in healthcare to increase quality of care and efficiency. Few studies of Lean involve staff-related outcomes, and few have a longitudinal design. Thus, the aim was to examine the extent to which changes over time in Lean maturity are associated with changes over time in care-giving, thriving and exhaustion, as perceived by staff, with a particular emphasis on the extent to which job demands and job resources, as perceived by staff, have a moderated mediation effect.

Method

A longitudinal study with a correlational design was used. In total, 260 staff at 46 primary care units responded to a web survey in 2015 and 2016. All variables in the study were measured using staff ratings. Ratings of Lean maturity reflect participants’ judgements regarding the entire unit; ratings of care-giving, thriving, exhaustion and job demands and resources reflect participants’ judgements regarding their own situation.

Results

First, over time, increased Lean maturity was associated with increased staff satisfaction with their care-giving and increased thriving, mediated by increased job resources. Second, over time, increased Lean maturity was associated with decreased staff exhaustion, mediated by decreased job demands. No evidence was found showing that job demands and job resources had a moderated mediation effect.

Conclusion

The results indicate that primary care staff may benefit from working in organizations characterized by high levels of Lean maturity and that caregiving may also be improved as perceived by staff.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4502-6) contains supplementary material, which is available to authorized users.

A systematic review of Lean in healthcare: a global prospective

Purpose

Fostered by a rapid spread beyond the manufacturing sector, Lean philosophy for continuous improvement has been widely used in service organizations, primarily in the healthcare sector. However, there is a limited research on the motivating factors, challenges and benefits of implementing Lean in healthcare. Taking this as a valuable opportunity, the purpose of this paper is to present the key motivating factors, limitations or challenges of Lean deployment, benefits of Lean in healthcare and key gaps in the literature as an agenda for future research.

Design/methodology/approach

The authors used the secondary data from the literature (peer-reviewed journal articles) published between 2000 and 2016 to understand the state of the art. The systematic review identified 101 articles across 88 journals recognized by the Association of Business Schools ranking guide 2015.

Findings

The systematic review helped the authors to identify the evolution, current trends, research gaps and an agenda for future research for Lean in healthcare. A bouquet of motivating factors, challenges/limitations and benefits of Lean in healthcare are presented.

Practical implications

The implications of this work include directions for managers and healthcare professionals in healthcare organizations to embark on a focused Lean journey aligned with the strategic objectives. This work could serve as a valuable resource to both practitioners and researchers for learning, investigating and rightly adapting the Lean in the healthcare sector.

Originality/value

This study is perhaps one of the comprehensive systematic literature reviews covering an important agenda of Lean in Healthcare. All the text, figures and tables featured here are original work carried by five authors in collaboration (from three countries, namely, India, the USA and the UK).

What Is Lean Management in Health Care? Development of an Operational Definition for a Cochrane Systematic Review

Industrial improvement approaches such as Lean management are increasingly being adopted in health care. Synthesis is necessary to ensure these approaches are evidence based and requires operationalization of concepts to ensure all relevant studies are included. This article outlines the process utilized to develop an operational definition of Lean in health care. The literature search, screening, data extraction, and data synthesis processes followed the recommendations outlined by the Cochrane Collaboration. Development of the operational definition utilized the methods prescribed by Kinsman et al. and Wieland et al. This involved extracting characteristics of Lean, synthesizing similar components to establish an operational definition, applying this definition, and updating the definition to address shortcomings. We identified two defining characteristics of Lean health-care management: (1) Lean philosophy, consisting of Lean principles and continuous improvement, and (2) Lean activities, which include Lean assessment activities and Lean improvement activities. The resulting operational definition requires that an organization or subunit of an organization had integrated Lean philosophy into the organization's mandate, guidelines, or policies and utilized at least one Lean assessment activity or Lean improvement activity. This operational definition of Lean management in health care will act as an objective screening criterion for our systematic review. To our knowledge, this is the first evidence-based operational definition of Lean management in health care.

The influence of policy makers over Lean implementations in healthcare

Purpose

It is often argued that Lean enables the challenges of contemporary healthcare delivery to be tackled in relation to consistently high-quality care, while utilizing the full potential of available resources. Nevertheless, system-wide implementations of Lean are notoriously difficult and the desired results are often not achieved. Policy makers play a pivotal role in enabling healthcare organizations to enact more precise strategies and frameworks through steering professionals toward both adopting guidelines and becoming more comfortable with Lean as an improvement technique. However, the difficulties in achieving system-wide implementations of Lean indicate their shortcomings in this respect. The purpose of this paper is to outline how these shortcomings may be manifested empirically.

Design/methodology/approach

A qualitative content analysis of Swedish counties’ annual reports with regard to how the implementation of Lean is presented and promoted.

Findings

The study shows that policy makers have vague and divergent perceptions of what Lean is, and that they often reduce Lean to a means of achieving cost reductions and savings, while relying on the education of managers as the primary factor to ensure implementation.

Originality/value

In order for policy makers to facilitate system-wide implementations of Lean, this study indicates that they need to rectify their simplistic perception of Lean while elaborating on why and how Lean should be implemented in healthcare.

Applying lean management to reduce radiology turnaround times for emergency department

Given the high impact of emergency department (ED) on the quality of care delivered by an hospital, and the many challenges it is facing (eg, overcrowding, excessive waiting time, cost containment, and increasing demand from patients), innovative managerial approaches should be adopted in order to develop safer and more efficient healthcare in this setting. The current study focuses on an application of lean thinking to reduce radiology turnaround times for ED, with the final aim to highlight the key factors enabling the adoption of lean thinking in this context. A research framework has been developed in the literature to analyse lean projects in healthcare and it has been adapted to study the case selected in an Italian hospital. In particular, organizational aspects, phases, and activities of the applied methodology, tools and procedures, and the achieved outcomes have been analysed. The study reports how radiology turnaround times for ED can be significantly reduced applying lean management principles and techniques. The achieved results contribute not only to comply with the regulation, but also to enhance the quality of care delivered to the patient; moreover, staff communication, involvement, and process awareness are favoured by the realization of similar projects promoting the diffusion of a lean culture.

Reduced isolation room turnover time using Lean methodology

OBJECTIVE

To prevent environmental transmission of pathogens, hospital rooms housing patients on transmission-based precautions are cleaned extensively and disinfected with ultraviolet (UV) light. To do so consistently requires time and coordination, and these procedures must avoid patient flow delays and associated safety risks. We sought to improve room turnover efficiency to allow for UV disinfection.

DESIGN

A 60-day quality improvement and implementation project.

SETTING

A quaternary academic pediatric referral facility.

INTERVENTIONS

A multidisciplinary healthcare team participated in a 60-day before-and-after trial that followed the Toyota Production System Lean methodology. We used value-stream mapping and manual time studies to identify areas for improvement. Areas addressed included room breakdown, room cleaning, and wait time between cleaning and disinfection. Room turnover was measured as the time in minutes from a discharged patient exiting an isolation room to UV disinfection completion. Impact was measured using postintervention manual time studies.

RESULTS

Median room turnover decreased from 130 minutes (range, 93-294 minutes) to 65 minutes (range, 48-95 minutes; P < .0001). Other outcomes included decreased median time between room breakdown to cleaning start time (from 10 to 3 minutes; P = .004), room cleaning complete to UV disinfection start (from 36 to 8 minutes; P < .0001), and the duration of room cleaning and curtain changing (from 57 to 37 minutes; P < .0001).

CONCLUSION

We decreased room turnover time by half in 60 days by decreasing times between and during routine tasks. Utilizing Lean methodology and manual time study can help teams understand and improve hospital processes and systems.

Using Lean Six Sigma to Improve Delayed Intracranial Hemorrhage Screening in a Geriatric Trauma Population

PURPOSE

Geriatric trauma patients taking preinjury anticoagulant or antiplatelet (ACAP) medications are at greater risk for delayed intracranial hemorrhage (DICH), a rare but potentially life-threatening condition. Routine repeat head computed tomography (RRHCT) scans can identify DICH. Our objective was to decrease the rate of missed RRHCT in a level 1 Midwest trauma center geriatric minor trauma population on preinjury ACAP medications.

OBJECTIVE

The objective of the quality improvement project was to identify the root cause of the missed RRHCTs and to implement a comprehensive solution to reduce rates of missed RRHCTs.

METHODS

Medical records from before and after the intervention were evaluated. Frequencies and percentages were calculated. In addition, χ and logistic regression were utilized. The Lean Six Sigma (LSS) DMAIC (Define, Measure, Analyze, Improve, and Control) process was used to drive process improvement.

RESULTS

At baseline, 15% (41 of 267) of RRHCTs were missed. After solution implementation, missed RRHCTs dropped to 4% (2 of 50). Of the 2 that were missed, zero were clinically inappropriate misses, making the postimplementation rate effectively 0%.

CONCLUSION

The LSS DMAIC process helped health care professional to facilitate improved adherence to the department's practice guideline with respect to RRHCT. Adherence with this guideline can help providers identify patients with DICH, a potentially life-threatening condition.

Sustainment of Lean Redesigns for Primary Care Teams

BACKGROUND

Quality improvements are notoriously followed by "backsliding" or relapse to the status quo. This mixed-methods study examined the sustainment of Lean workflow redesigns for primary care teams several years after being implemented in a large, ambulatory care delivery system.

METHODS

We conducted qualitative interviews of 57 leaders and frontline providers, and fielded post-Lean implementation surveys to 1164 physicians and staff in 17 primary care clinics across the system. We analyzed interviews and conducted independent sample t tests to identify key factors that facilitated the sustainment of new workflows among primary care teams. All analyses were conducted after Lean redesigns were implemented and scaled across the system in 3 consecutive phases.

RESULTS

Adherence to Lean redesigns was highest in the pilot clinic, despite having the longest postdesign measurement period. Members of the pilot clinic reported greatest participation in designing workflows, were most highly engaged in quality improvement efforts, and held most favorable beliefs about Lean changes. Adherence to redesigns was lowest among clinic members in the second phase of implementation; these members also reported highest levels of burnout.

CONCLUSIONS

Staff participation in Lean redesign is a key to facilitating buy-in and adherence to changes. Change ownership and continued availability of time for improvement activities are also critical to the long-term success of Lean implementation in primary care.

Getting New Test Results to Patients

: New diagnostic results are constantly arriving to outpatient practices. It is imperative to effectively communicate these results and their implications to patients.

METHODS

We surveyed 100 patients and our clinic personnel to assess opinions regarding methods of communication in common scenarios.

RESULTS

Response rate was 79% from patients and 75% from clinic personnel. Most patients thought letters were an appropriate way to receive normal test results (83%). They also felt medical-technician calls were appropriate for normal results (88%), medication dose changes (75%), or need for additional studies (71%). Respondents considered nurse calls acceptable in most scenarios except for new diagnoses of cancer or need for surgery; the consensus was that physicians should directly communicate to patients in these situations.

CONCLUSIONS

Providers should take the time to discuss results with patients that lead to significant interventions, but employ support staff to disseminate information about normal results, medication dose changes, and need for additional diagnostic testing.

Lean culture: a comprehensive systematic literature review

Purpose

The purpose of this paper is to assess the level of pragmatic ambiguity (PA) lean culture has currently in the manufacturing and service literature.

Design/methodology/approach

A comprehensive systematic review of academic (journals, books and theses) and commercial literature was undertaken drawn from a six databases search of two keywords (“lean” and “culture”) and related citations.

Findings

A total sample of 1,066 references (678 academic papers, 121 books, 103 theses and 164 commercial documents) were analyzed. The authors found contributions from 67 countries but oddly, only two came from Japan. In total, 89 percent of citations were directly about lean culture. However, for 86 percent of them, lean culture was only discussed superficially. All four literature segments show an over 85 percent agreement on lean culture being an organizational aim. The authors encountered 103 definitions of organizational culture and found 13 definitions of lean culture. Issues of culture gap, leadership, human resource management, sustainability and innovation are found to amplify lean culture’s already high PA level.

Research limitations/implications

Further research and development are needed to decrease lean culture’s PA level and improve understanding of lean from a cultural perspective.

Practical implications

Current lean culture’s high PA level has positive and negative effects on lean implementation. Taking lean implementation from a cultural perspective may facilitate an organization’s lean transformation journey.

Originality/value

This is the first systematic literature review on lean culture using a broad and inductive approach. An original evidence-based definition of organizational culture is proposed.

Critical success factors for Lean implementation in IT outsourcing relationships

Purpose

Following positive results of Lean implementation in manufacturing environments, Lean has become an emerging philosophy for clients and suppliers of information technology (IT) services. However, how to implement Lean in IT outsourcing relationships has been addressed sparsely in academic literature. The purpose of this paper is to investigate critical success factors (CSFs) for implementing Lean in IT outsourcing relationships. Key findings, implications and avenues for future research are discussed.

Design/methodology/approach

Six IT outsourcing relationships were qualitatively investigated by means of 36 semi-structured interviews. CSFs were identified based on interview transcription analyses, selection techniques and expert reviews.

Findings

In total, 16 CSFs for Lean implementation in IT outsourcing relationships are identified and described.

Practical implications

The CSFs presented in this paper indicate key areas that deserve managerial attention to steer Lean implementation efforts in IT outsourcing relationships in a favorable direction.

Originality/value

This study is the first to describe the phenomenon of “Lean IT outsourcing” and provides researchers and practitioners with a foundation to further examine Lean implementation in IT outsourcing relationships.

Disrupting activities in quality improvement initiatives: a qualitative case study of the QuICR Door-To-Needle initiative

BACKGROUND

Healthcare quality improvement (QI) efforts are ongoing but often create modest improvement. While knowledge about factors, tools and processes that encourage QI is growing, research has not attended to the need to disrupt established ways of working to facilitate QI efforts.

OBJECTIVE

To examine how a QI initiative can disrupt professionals' established way of working through a study of the Alberta Stroke Quality Improvement and Clinical Research (QuICR) Door-to-Needle Initiative.

DESIGN

A multisite, qualitative case study, with data collected through semistructured interviews and focus groups. Inductive data analysis allowed findings to emerge from the data and supported the generation of new insights.

FINDINGS

In stroke centres where improvements were realised, professionals' established understanding of the clinical problem and their belief in the adequacy of existing treatment approaches shifted-they no longer believed that their established understanding and treating the clinical problem were appropriate. This shift occurred as participants engaged in specific activities to improve quality. We identify these activities as ones that create urgency, draw professionals away from regular work and encourage questioning about established processes. These activities constituted disrupting action in which both clinical and non-clinical persons were engaged.

CONCLUSIONS

Disrupting action is an important yet understudied element of QI. Disrupting action can be used to create gaps in established ways of working and may help encourage professionals' involvement and support of QI efforts. While non-clinical professionals can be involved in disrupting action, it needs to engage clinical professionals on their own terms.

Improving Nurses’ Hand-off Process on Oncology Setting Using Lean Management Principles

Background: Patients in oncology setting are struggling with the complexed disease, and long and intensive treatment options. This increase the need of patients for more coordination and effective hand-off between health providers including nurses. Aims: The main aim of this project is to improve the effectiveness of hand-off between nurses in the oncology setting using lean management principles. Methods: One group pretest-posttest quasi-experimental design was conducted at King Hussain Cancer Center during quarter two to quarter four in 2017. The project was conducted using the lean tools including root cause analysis, redesigning the hand-off process; using structured tools, and standardization of the hand-off process. Results: The finding of this project showed a significant decreasing in the hand-off duration and the incidence of events related to nursing practice deviation in post-intervention. Moreover, the results showed that the nurse satisfaction score was improved. However, there is a little difference in patient satisfaction results between two quarters for overall satisfaction and per each domain. Conclusion: The project approved that the use of structured tools, safety briefing, and standardized hand-off process play important role in improving the effectiveness of the hand-off process.

Lean implementation in healthcare supply chain: a scoping review

PURPOSE

The purpose of this paper is to identify the lean production (LP) practices applied in healthcare supply chain and the existing barriers related to their implementation.

DESIGN/METHODOLOGY/APPROACH

To achieve that, a scoping review was carried out in order to consolidate the main practices and barriers, and also to evidence research gaps and directions according to different theoretical lenses.

FINDINGS

The findings show that there is a consensus on the potential of LP practices implementation in healthcare supply chain, but most studies still report such implementation restricted to specific unit or value stream within a hospital.

ORIGINALITY/VALUE

Healthcare organizations are under constant pressure to reduce costs and wastes, while improving services and patient safety. Further, its supply chain usually presents great opportunities for improvement, both in terms of cost reduction and quality of care increase. In this sense, the adaptation of LP practices and principles has been widely accepted in healthcare. However, studies show that most implementations fall far short from their goals because they are done in a fragmented way, and not from a system-wide perspective.

Lean Methods Applied to CAD/CAM Pedagogy in the Dental Simulation Laboratory

Dental education is incorporating computer-assisted design/computer-assisted manufacturing (CAD/CAM) into patient care delivery. The aim of this study was to determine if lean production methods applied to the preclinical phase of dental education would reduce the students' time (efficiency) to complete CAD/CAM indirect restorations (CAD/CAM IR) without compromising the desired quality of the CAD/CAM tooth preparations (effectiveness). In 2016, all third-year students at one U.S. dental school were randomly assigned to control and research groups (approximately 33 per group). The control group was taught using existing methods, while the course was redesigned to incorporate lean methods for the research group. Cycle times of the CAD/CAM IR process for both groups were collected and statistically analyzed to compare the effectiveness of the redesign. Standardized grading forms and tools were used to assess the quality of the CAD/CAM tooth preparations. The research group demonstrated significantly faster preparation times with both crowns and onlays (p<0.05) than the control group. The research group also produced CAD/CAM crown and onlay designs at a significantly faster pace than the control group (p<0.05). There was no significant difference between the control and research groups associated with the scanning process times (p>0.05) nor in the quality of the CAD/CAM tooth preparations (p>0.05). This study demonstrated that lean methods applied to pedagogy significantly decreased preparation and design times in a CAD/CAM restorative dentistry course without compromising the quality of the CAD/CAM tooth preparations.

Implementation of Lean and Six Sigma principles in ophthalmology for improving quality of care and patient flow

Lean management is a set of principles aimed at improving processes by identifying and eliminating steps that do not add value to the consumer. Such steps lead to wasted time, resources, and expenses and result in customer and employee dissatisfaction. Although initially invented and perfected for factory assembly lines in the automobile industry, it has since disseminated extensively and has repeatedly proven a powerful "engine" for improving quality and quantity in the health-care setting. Lean implementation benefits include improved safety, reduced waiting times, increased patient satisfaction, and cost reduction. Nevertheless, it appears to be less familiar and appreciated in ophthalmology and more specifically as a tool for managing an efficient eye care clinic. In this review, we explain what "Lean" and Six Sigma are and highlight their implementation in settings such as cataract surgery, laser capsulotomy, an ophthalmic emergency room and its role as a powerful tool for improving clinic patient flow. We discuss basic principles of Lean management, review examples of implementing these principles in an ophthalmology practice, and finally, offer physicians practical tools for identifying "wasteful" processes and ways to eliminate them.

Effect of Lean Six Sigma on quality performance in Malaysian hospitals

PURPOSE

The purpose of this paper is to investigate the effects of Lean Six Sigma (LSS) and workforce management on the quality performance of Malaysian hospitals. This paper also investigates the direct and indirect relationships between top management commitment and quality performance of the healthcare organisations in Malaysia.

DESIGN/METHODOLOGY/APPROACH

This study applied stratified random sampling to collect data from 15 different hospitals in Peninsular Malaysia. The self-administered survey questionnaires were distributed among 673 hospital staff (i.e. doctors, nurses, pharmacists, and medical laboratory technologists) to obtain 335 useful responses with a 49.47 per cent valid response rate. The research data were analysed based on confirmatory factor analysis and structural equation modelling by using AMOS version 23 software.

FINDINGS

The research findings indicated that LSS and workforce management have a significant impact on quality performance of the Malaysian hospitals, whereas senior management commitment was found to have an insignificant relationship with quality performance. The research findings indicate that senior management commitment has no direct significant relationship with quality performance, but it has an indirect significant relationship with quality performance through the mediating effects of LSS and workforce management.

RESEARCH LIMITATIONS/IMPLICATIONS

This research focussed solely on healthcare organisations in Malaysia and thus the results might not be applicable for other countries as well as other service organisations.

ORIGINALITY/VALUE

This research provides theoretical, methodological, and practical contributions for the LSS approach and the research findings are expected to provide guidelines to enhance the level of quality performance in healthcare organisations in Malaysia as well as other countries.

Lean and Six Sigma practices in the public sector: a review

Purpose

The purpose of this paper is to provide a critical analysis of publications relating to the use of continuous improvement (CI) methodologies, such as Lean, Six Sigma and Lean Six Sigma over a 17-year period, to identify the themes and gaps, while informing the development of a future research agenda.

Design/methodology/approach

The systematic literature review identified 121 papers published between 2000 and 2017 from searches of over 1,400 peer-reviewed academic journals and also identified the application of Lean, Six Sigma and Lean Six Sigma across the public sector.

Findings

This research compares the scale and breadth of the public sector with the application of CI methodologies and finds that such application is unstructured and, in some areas, sporadic. The research identifies common themes and research gaps including areas such as lack of shared understanding of Lean, gaps in strategy development and leadership and an overfocus on tools alone.

Research limitations/implications

The methodology is focussed on the journals rated in the ABS Journal Guide 2015, which allowed manual searches for accuracy and relevance to the area of investigation. It is recognised that this may exclude some articles which have been published in other journals but allowed for a structured and detailed investigation. The research identifies some very clear gaps which can inform future research agendas.

Practical implications

The paper details the implications and challenges to the public sector, generally, and to executive leadership, specifically, and, in particular, covers the common issues and concerns, which in turn will assist public sector organisations in implementing, reviewing or refreshing their CI initiatives.

Originality/value

No similar work has been conducted and while some individual areas such as health and education have been the subject of more focus, this research explores the public sector as a whole and considers the patterns of research in that context.

An integrative approach to improving patient care pathways

PURPOSE

Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help.

DESIGN/METHODOLOGY/APPROACH

Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches.

FINDINGS

A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors provide a conceptual framework that requires empirically testing.

PRACTICAL IMPLICATIONS

This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery.

ORIGINALITY/VALUE

For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.

Why So Glum? Understanding the Challenges in Meeting User's Needs on Trauma Surgical Rounds

BACKGROUND

Trauma patient rounds are complex, with a high volume of complicated patients in a dynamic environment with competing priorities and workflows. This presents challenges to quality improvement as single-method research approaches fail to comprehensively understand these complex systems. We used a mixed-methods approach to understand factors contributing to system inefficiency and user dissatisfaction on daily patient rounds at a safety-net teaching hospital and level 1 trauma center.

MATERIALS AND METHODS

A human-centered design uses ethnographic observations and in-depth interviews to understand the challenges and needs facing users of a system. We performed in-context observations and 22 in-depth interviews with a cross-section of care team members, patients, and families. Using the lean methodology, we performed time observations of 15 rounds, tracking activities related to flow, and classified them as 'value added' and 'non-value added.'

RESULTS

Lean time observations revealed that 34.2% of time was spent on 'non-value-added' activities. Qualitative interviews revealed that all users reported perceived inefficiency as their greatest challenge on rounds. Among these users, there were three distinct user groups: connectors, learners, and doers, and each group had a different set of needs and priorities for rounds which were not being met.

CONCLUSIONS

To adequately address complex environments, we need to understand the strains on both the system and its users so that we can create sustainable quality-improvement programs. By mixing methods using lean and human-centered design processes, we were able to gain a more comprehensive understanding of the system- and human-centered factors affecting rounds on a trauma surgical service.

Organizational issues for the lean success in China: exploring a change strategy for lean success

BACKGROUND

The purpose of this paper is to explore a change strategy for lean success in hospitals based on a comprehensive review of the Chinese literature.

METHODS

The methodology is a systematic review of the Chinese literature which identified 212 case study papers about lean implementation. We did a thematic content analysis of the 212 papers.

RESULTS

Lean applications in Chinese hospitals show significant increases and are mainly used in the fields of outpatient services, operating rooms, pharmacy and logistics. Most hospitals applied lean as a single project but some were beginning to use lean as a systemic path for improvement with an emphasis on lean and strategy. The main goals were to increase the operating efficiency and reduce operating costs. Patients were not central to lean applications. Chinese hospitals appear to lack a full understanding of lean. Four factors appear to be critical for lean success - organizational leadership, adequate technology, stakeholder involvement and individual and organizational benefits. The relationship of these factors changes over time.

CONCLUSIONS

This is the first paper to provide a comprehensive view of lean application in Chinese hospitals. The findings presented in this paper provide a systemic evidence to the application of lean in healthcare.

Is Lean sustainable in today's NHS hospitals? A systematic literature review using the meta-narrative and integrative methods

Purpose

Methodological variance and quality, heterogeneity of value and divergent approaches are reasons for the varied results of Lean interventions in healthcare despite ongoing global popularity. However, there is piecemeal evidence addressing the sustainability of initiatives-the aim of this review is to use an integrative approach to consider Lean's sustainability and the quality of available evidence in today's National Health Service (NHS).

Data sources

A literature review of AMED, CINAHL, Cochrane, JBI, SCOPUS, DelphiS, MEDLINE, EMBASE, MIDIRS, Web of Science and PsycINFO electronic databases was conducted.

Study selection

Peer-reviewed studies in NHS hospitals/trusts that concerned undiluted, service-wide Lean adoption and contained quantitative data were included. Reference lists were consulted for evidence via a snowball approach. Methodological quality was assessed using an adapted critical appraisal tool.

Data extraction

Research design, method of intervention, outcome measures and sustainability were extracted.

Results of data synthesis

Electronic searches identified 12 studies eligible for inclusion. This comprised of five quasi-experimental designs (one mixed-method), three multi-site analyses, one action research, one failure mode and effects analysis, one content analysis of annual reports and one systematic review. Six articles considered sustainability with two of these providing measured successes. Despite diverse and positive outcomes studies lacked scientific rigour, failed to consider confounding issues, were at risk of positive bias and did not demonstrate sustainability with any statistical significance.

Conclusion

Lean has ostensible value but it is difficult to draw a conclusion on efficacy or sustainability. Higher quality scientific research into Lean and the effect of staffing cultures on initiatives are needed to ascertain the extent that Lean can affect healthcare quality and subsequently be sustained.

Improving the Workflow Efficiency of An Outpatient Pain Clinic at A Specialized Oncology Center by Implementing Lean Principles

Objective

Adult outpatient oncology pain clinics face many challenges due to the increased number of patients, the restriction of electronic appointment systems, overcrowding, waiting time, and patient dissatisfaction. This project aimed to improve clinic time efficiency, decrease clinic waiting time, and improve patient satisfaction.

Methods

Lean thinking concepts and their tools, for example, value-stream mapping and value added (VA)/non-VA (NVA) analysis were used. Electronic appointment system slots were stratified based on patient visit type. A total of 187 patients were included in a time-motion survey at three different occasions: preintervention (n = 67) and two consecutive quarter postintervention time points (n = 64, n = 56). Simultaneously, patient satisfaction was reported quarterly by a quality management office.

Results

The pain clinic workflow became more efficient; the mean clinic waiting time decreased from 72.5 min at preintervention to 19.5 and 21 min at the two postintervention quarters, respectively. Moreover, patient satisfaction improved from 75% at the preintervention to 100% and 96.7% at the two postintervention quarters.

Conclusions

Redesigning the process of an electronic appointment system using lean thinking considerably decreases patients' waiting time, improves patient satisfaction, improves resource utilization, allows proper scheduling based on patient visit types, eliminates unnecessary waste processes, and reallocates health-care providers' time toward direct, individualized patient care.

Going home with baby: innovative and comprehensive support for new mothers

Shorter length of stay for postpartum mothers and their newborns necessitates careful community follow-up after hospital discharge. The vast amount of information given during the initial postpartum period can be overwhelming. New parents often need considerable support to understand the nuances of newborn care including newborn feeding. Primary health care and community services need to ensure there is a seamless continuum of care to support, empower, and educate new mothers and their families to prevent unnecessary hospital readmission and other negative health outcomes. The Healthy & Home postpartum community nursing program provides clinical communication and supports to bridge the gap between acute hospital and community follow-up care through home visits, a primary health care clinic, a breastfeeding center, a breastfeeding café, a postpartum anxiety and depression support group, bereavement support, and involvement in a Baby-Friendly Initiative™ coalition. Nurses working in the program have the acute care skills and resources to complete required health care assessments and screening tests. They are also international board-certified lactation consultants able to provide expert breastfeeding and lactation care. This paper describes how the Healthy & Home program has evolved over the past 25 years and offers suggestions to other organizations wanting to develop a postpartum program to meet the physical and mental health needs of postpartum families to promote maternal and infant wellbeing.

Qualifications and Skills Required for Performance Improvement: A Content Analysis of Job Postings

EXECUTIVE SUMMARY

Healthcare reform and the implementation of a national quality strategy in the United States have increased emphasis on quality improvement. Additionally, as healthcare organizations focus on value, they are paying more attention to quality in the context of cost and seeking to address these concerns through various performance improvement initiatives. Given the importance of these initiatives, this study analyzed the improvement job positions posted by U.S. healthcare organizations, specifically with respect to the qualifications and skills required. The author conducted a content analysis of improvement job postings using an inductive approach to capture and categorize core information about each posting and a deductive approach to evaluate skills required for selected job areas. The results show that healthcare organizations have invested in a breadth of improvement positions across all levels of the organization. Many positions are tied to strategic initiatives. The greatest number of positions posted were in the performance improvement area, followed by quality improvement, process improvement, Lean, Six Sigma, and Lean Six Sigma. These research results may be useful to healthcare organizations for strategic resource planning purposes and to educators and professional associations to target programs that offer students and members the opportunity to gain needed qualifications and skills.

A reason to renovate: The association between hospital age of plant and value-based purchasing performance

BACKGROUND/PURPOSE

Value-based purchasing (VBP) is increasing in influence in the health care industry; however, questions remain regarding the structural factors associated with improved performance. This study evaluates the association between age of hospital infrastructure and VBP outcomes.

METHODOLOGY

Data on 1,911 hospitals from three sources (the American Hospital Association Annual Survey Database, the American Hospital Association DataViewer Financial Module, and the Centers for Medicare & Medicaid Services Hospital VBP Total Performance Scores data set) were evaluated. Age of health care facilities was represented by the "average age of plant" financial ratio. VBP performance was measured by an aggregate Total Performance Score composed of four equally weighted domains, including Efficiency and Cost Reduction, Clinical Care, Patient- and Caregiver-Centered Experience, and Patient Safety. We hypothesize that average age of plant is negatively correlated with each of these measures.

RESULTS

Hospitals within the lowest quartile of average age of plant (0-8.13 years) were found to have a total Performance Score of 2.35 points higher than hospitals with a an average age of plant in the fourth quartile (14.63 years and above; R = 21.5%; p < .001) while controlling for hospital ownership, size, teaching status, geographic location, service mix, case mix, length of stay, community served, and labor force relative cost. Comparable results were found within the VBP domains, specifically for Clinical Care (β = 4.09, p < .001) and Patient Experience (β = 3.41, p < .001). Findings for the Patient Safety and Efficiency domains were not significant. A secondary and more granular examination of capitalized assets indicates organizations with higher building asset accumulated depreciation per bed in service were associated with lower total performance (β = -.25, p < .001), Clinical Care (β = -.31, p < .05), and Patient Experience scores (β = -.45, p < .001).

CONCLUSIONS

The results of this study provide evidence of an inverse association between a hospital's age of plant and specific elements of VBP performance.

PRACTICE IMPLICATIONS

To date, no studies have investigated the relationship between hospital age of plant and value-based care. The results of our study may serve as supportive foundational evidence for health care leaders to target future capital investments to improve VBP outcomes.

Using the Collective System Design Methodology to Improve a Medical Center Emergency Room Performance

Emergency Room (ER) crowding is one of the more complex issues in the healthcare system worldwide. Crowding gives rise to long ER waiting times, patient dissatisfaction, and negative effects on a healthcare systems' performance. This paper focuses on the utilization of the Collective System Design (CSD) methodology to optimize the performance of an ER, which is of principal importance both from a life-threatening and an economic standpoint. The CSD technique is applied to detect areas of deficiency and to identify the functional requirements of the system to address those issues. The ER and system engineering specialists' team gathered data from the electronic medical center log and their system observation. The team determined the functional requirements and effective solutions, and implemented a continuous improvement plan to enhance ER performance. From a statistical standpoint, a significant decrease in the median of the door-to-doctor time measure (27 min vs 13 min) and a substantial improvement in the patients' level of satisfaction with the quality of health care (20th percentile vs 41th percentile) were observed after the implementation of the CSD methodology. The CSD methodology augments the implementation of lean tools by providing a language for defining the requirements and corresponding solutions for a system design. Using the CSD methodology, results in a significant increase in the ER's capacity to treat patients efficiently.

Throughput efficiency and service quality after process redesign at a cancer day care unit: Two sides of the coin?

This study was designed to focus on the patient perspective in a reorganisation of care processes at a cancer day care unit (CDU). The effects of dose banding and of taking blood samples one day (or more) before the day care treatment (on Day -1) are investigated in terms of throughput efficiency and perceived service quality. Data were collected by mapping patient processes in detail and surveying patients in two CDUs at a university hospital (n = 308). A univariate model was used to investigate the effect of these factors on patient throughput time, and perceived service quality was examined with multiple linear regression. Taking blood samples on Day -1 decreases patient throughput time and increases the perceived service quality by improving the patient's perception of technical expertise and the outcome. This has a globally positive effect on patients' perceived service quality. Dose banding affected neither patient throughput time nor perceived service quality. Taking the pretreatment blood sample on Day -1 can be considered an important process design characteristic, as it increases both efficiency and service quality.

The joint use of resilience engineering and lean production for work system design: A study in healthcare

Although lean production (LP) has been increasingly adopted in healthcare systems, its benefits often fall short of expectations. This might be partially due to the failure of lean to account for the complexity of healthcare. This paper discusses the joint use of principles of LP and resilience engineering (RE), which is an approach for system design inspired by complexity science. Thus, a framework for supporting the design of socio-technical systems, which combines insights from LP and RE, was developed and tested in a system involving a patient flow from an emergency department to an intensive care unit. Based on this empirical study, as well as on extant theory, eight design propositions that support the framework application were developed. Both the framework and its corresponding propositions can contribute to the design of socio-technical systems that are at the same time safe and efficient.

Lean healthcare: scale, scope and sustainability

Purpose

Lean healthcare is highlighted in the literature as an approach to quality improvement and operational efficiency. The purpose of this paper is to study how Lean healthcare has been implemented by analyzing empirical outcomes.

Design/methodology/approach

The authors used a literature review as the primary research method, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses process. Peer-reviewed journals were analyzed – searching for Lean healthcare implementation, tools used, wastes addressed, outcomes and sustainability.

Findings

Evidence suggests that Lean can improve healthcare operational effectiveness. However, empirical studies show implementation is still highly localized with small successes. Most transformations are focused on implementing one or two Lean tools that primarily target patient waiting times and there is minimal evidence about sustainability. Establishing clear definitions for healthcare-related Lean terminology may improve practice, especially episodic care and service quality.

Originality/value

This work provides a Lean healthcare case review. The research makes a significant contribution to Lean healthcare by increasing understanding (scale, scope and sustainability). From a theory building perspective, the authors suggest that barriers to adoption include a common healthcare-specific Lean terminology, and a need to expand implementation beyond small successes. This understanding will help identify key areas for further research in Lean healthcare management.

Analysis of the preparation and administration of medications in the hospital context based on Lean thinking

Abstract Objectives: To analyze the current way medications are prepared and administered in the hospital setting and to apply a method to establish priorities for problems detected. Method: This is an exploratory-descriptive case study. The data were collected through observation and focus groups with 13 participants who were part of a health team in a surgical inpatient unit of a public university hospital. The analysis was based on a lean production framework. Results: A value stream map was constructed of the current way drugs are prepared and administered, identifying the clients in the process and their requirements. Forty-five current problems were identified, based on requirements that were not met with eight being prioritized to improve planning. Conclusion: Having prioritized the problems, the planning and implementation of continuous improvements in the medication process were started in order to reduce errors and improve the quality of services.

Redefining and reinvigorating the role of physics in clinical medicine: A Report from the AAPM Medical Physics 3.0 Ad Hoc Committee

Derived from 2 yr of deliberations and community engagement, Medical Physics 3.0 (MP3.0) is an effort commissioned by the American Association of Physicists in Medicine (AAPM) to devise a framework of strategies by which medical physicists can maintain and improve their integral roles in, and contributions to, health care and its innovation under conditions of rapid change and uncertainty. Toward that goal, MP3.0 advocates a broadened and refreshed model of sustainable excellence by which medical physicists can and should contribute to health care. The overarching conviction of MP3.0 is that every healthcare facility can benefit from medical physics and every patient's care can be improved by a medical physicist. This large and expansive challenge necessitates a range of strategies specific to each area of medical physics: clinical practice, research, product development, and education. The present paper offers a summary of the Phase 1 deliberations of the MP3.0 initiative pertaining to strategic directions of the discipline primarily but not exclusively oriented toward the clinical practice of medical physics in the United States.

Can continuous improvement lead to satisfied customers? Evidence from the services industry

Purpose

To achieve higher customer satisfaction (CS), companies implement continuous improvement (CI) programs, regardless of the growing evidence of their failure to achieve declared goals. The purpose of this paper is twofold: first, to identify whether companies are able to improve CS through the application of CI; and, second, to identify what organizational practices are able to facilitate the impact of CI on CS.

Design/methodology/approach

To test the developed assumptions, the study uses the structural equation modeling technique. The data for analysis were collected from 304 service companies via a custom web-survey.

Findings

The research confirms the direct positive impact of CI on CS. Further, the study demonstrates that management commitment and rewards system that encourages employees to participate in CI play the major facilitating role in improving CS through CI. These practices accompanied by quality-oriented culture and employee training in the improvement tools provide necessary infrastructure to sustain CI in the companies over time. Additionally, regardless of the vital role of goal setting for CI established in previous research, the proposed study finds a limited ability of goal setting, as compared to other organizational practices, to facilitate CI–CS relationship.

Originality/value

The study contributes to the scarce field of research on CI implementation in the services environment. Further, the research assesses CS as a variable of interest, as opposite to the previous studies, considering CS as a part of the composite variable. The research assesses the impact of the training in CI methodology on the CI–CS relationship, while previous research focuses on the general, work-related training. The findings provide an important basis for further academic work in the area of quality management. The identified practices can serve as guidance for managers, implementing CI in their companies due to the high fit of the proposed model.

Process value of care safety: women's willingness to pay for perinatal services

Objective

To evaluate the process value of care safety from the patient's view in perinatal services.

Design

Cross-sectional survey.

Settings

Fifty two sites of mandated public neonatal health checkup in 6 urban cities in West Japan.

Participants

Mothers who attended neonatal health checkups for their babies in 2011 (n = 1316, response rate = 27.4%).

Main Outcome Measure

Willingness to pay (WTP) for physician-attended care compared with midwife care as the process-related value of care safety. WTP was estimated using conjoint analysis based on the participants' choice over possible alternatives that were randomly assigned from among eight scenarios considering attributes such as professional attendance, amenities, painless delivery, caesarean section rate, travel time and price.

Results

The WTP for physician-attended care over midwife care was estimated 1283 USD. Women who had experienced complications in prior deliveries had a 1.5 times larger WTP.

Conclusions

We empirically evaluated the process value for safety practice in perinatal care that was larger than a previously reported accounting-based value. Our results indicate that measurement of process value from the patient's view is informative for the evaluation of safety care, and that it is sensitive to individual risk perception for the care process.

A value-based taxonomy of improvement approaches in healthcare

Purpose The concept of value is becoming increasingly fashionable in healthcare and various improvement approaches (IAs) have been introduced with the aim of increasing value. The purpose of this paper is to construct a taxonomy that supports the management of parallel IAs in healthcare. Design/methodology/approach Based on previous research, this paper proposes a taxonomy that includes the dimensions of view on value and organizational focus; three contemporary IAs - lean, value-based healthcare, and patient-centered care - are related to the taxonomy. An illustrative qualitative case study in the context of psychiatric (psychosis) care is then presented that contains data from 23 interviews and focuses on the value concept, IAs, and the proposed taxonomy. Findings Respondents recognized the dimensions of the proposed taxonomy and indicated its usefulness as support for choosing and combining different IAs into a coherent management model, and for facilitating dialog about IAs. The findings also suggested that the view of value as "health outcomes" is widespread, but healthcare professionals are less likely than managers to also view value as a process. Originality/value The conceptual contribution of this paper is to delineate some important characteristics of IAs in relation to the emerging "value era". It also highlights the coexistence of different IAs in healthcare management practice. A taxonomy is proposed that can help managers choose, adapt, and combine IAs in local management models.

System-wide lean implementation in health care: A multiple case study

Background Lean practices have been widely used by health care organizations to meet efficiency, performance and quality improvement needs. The lean health care literature shows that the effective implementation of lean requires a holistic system-wide approach. However, there is still limited evidence on what drives effective system-wide lean implementation in health care. The existing literature suggests that a deeper understanding of how lean interventions interact with the organizational context is necessary to identify the critical variables to successfully sustain system-wide lean strategies. Purpose and methodology: A multiple case study of three Italian hospitals is conducted with the aim to explore the organizational conditions that are relevant for an effective system-wide lean implementation. A conceptual framework, built on socio-technical system schemas, is used to guide data collection and analysis.

FINDINGS

The analysis points out the importance to support lean implementation with an integrated and coordinated strategy involving the social, technical, and external components of the overall hospital system.

SUCCESSFUL IMPLEMENTATION OF LEAN AS A MANAGERIAL PRINCIPLE IN HEALTH CARE: A CONCEPTUAL ANALYSIS FROM SYSTEMATIC LITERATURE REVIEW

PURPOSE

The aim of this study was to identify and analyze the characteristics of leadership and management associated with a successful Lean thinking adaptation in healthcare.

DESIGN

A systematic literature review was undertaken using electronic databases: PubMed, PubMed Systematic Review, ABI/INFORM, Business Source Complete, Emerald, JBI, and Cinahl. Inclusion criteria were: (i) a description of Lean management or leadership in health care, (ii) a reference to Lean thinking, (iii) a peer-reviewed original research article or a literature review, and (iv) a full text article available in English. Among the 1,754 peer-reviewed articles identified, nine original articles and three systematic reviews met the inclusion criteria. Data on informants, methods, and settings were extracted and collated. Content analysis was used to conduct a review of the nine original studies describing and analyzing the success factors of Lean adaptation. The characteristics of leadership and management were analyzed by using the concept of a managerial windshield that divides leadership and management into four ontological dimensions: activities, style, focus, and purpose, each with typical developmental stages of skills and capabilities. The current study has some limitations: some papers from the journals not indexed in the searched databases may have been overlooked and the literature searches were carried out only for a 5-year period.

FINDINGS

Considering the results using the windshield concept emphasizes the philosophy, principles, and tools of Lean thinking. Lean leadership and management factors in health care were mainly conceptualized as skills and capabilities such as problem solving, making changes occur, empowering, communicating, coaching, supporting, facilitating, being democratic, organizational learning, and organizational success, all of which represented middle-stage or advanced managerial skills and capabilities.

PRACTICAL IMPLICATIONS

A conceptual analysis of systematically reviewed studies of Lean leadership and management point to certain traits as being typical when adapting Lean thinking to health care. The concept of a managerial windshield is useful when categorizing and analyzing essential managerial skills and capabilities for Lean implementation. Findings are beneficial when learning and educating the skills required for Lean transformation in healthcare organizations.