The first evidence about conceptual vs analytical lean healthcare research studies

Economic Impact of Lean Healthcare Implementation on the Surgical Process

OBJECTIVES

The objective of this study was to analyse and detail surgical process improvement activities that achieve the highest economic impact.

METHODS

Over 4 years, a team of technicians and healthcare professionals implemented a set of Lean surgical process improvement projects at Vall d'Hebron University Hospital (VHUH), Barcelona, Spain. Methods employed in the study are common in manufacturing environments and include reducing waiting and changeover time (SMED), reducing first time through, pull, and continuous flow. Projects based on these methods now form part of the daily routine in the surgical process. The economic impact on the hospital's surgical activity budget was analysed.

RESULTS

Process improvements have led to annual operational savings of over EUR 8.5 million. These improvements include better patient flow, better management of information between healthcare professionals, and improved logistic circuits.

CONCLUSIONS

The current cultural shift towards process management in large hospitals implies shifting towards results-based healthcare, patient-perceived value (VBHC), and value-added payment. A Lean project implementation process requires long-term stability. The reason a considerable number of projects fail to complete process improvement projects is the difficulty involved in establishing the project and improving management routines. Few studies in the literature have investigated the economic impact of implementing Lean management a posteriori, and even fewer have examined actual cases. In this real case study, changes to surgical block management were initiated from stage zero. After being carefully thought through and designed, changes were carried out and subsequently analysed.

Unveiling the Impact of Lean Leadership on Continuous Improvement Maturity: A Scoping Review

Purpose

Lean Management (LM) is a process improvement approach with growing interest from healthcare organizations. Obtaining a culture of continuous improvement is a primary objective of LM, and a culture of continuous improvement indicates a mature LM approach, and here leadership plays a central role. However, a comprehensive overview of leadership activities influencing LM maturity is lacking. This study aims to identify leadership activities associated with continuous improvement and, thus, LM, maturity.

Methods

Following the PRISMA guidelines, a scoping literature review of peer-reviewed articles was conducted in twenty healthcare management journals. The search provided 466 articles published up until 2023. During the selection process, 23 studies were included in the review. The leadership activities related to continuous improvement maturity were identified using the grounded theory approach and data coding.

Results

The analysis highlighted a total of 58 leadership activities distributed across nine themes of LM leadership. Next, analysing leadership activities concerning the different maturity levels revealed three maturity stages: beginner, intermediate, and expert. Based on the findings, we propose a framework that guides suitable leadership activities at the various stages of LM maturity. The framework provides leaders in healthcare with a practical overview of actions to facilitate the growth of the LM approach, and the related propositions offer academics a theoretical basis for future studies.

Conclusion

This review presents the first comprehensive overview of LM leadership activities in relation to continuous improvement and LM maturity. To enhance LM maturity, leaders are encouraged to consider their leadership style, (clinical) stakeholder involvement, alignment with the organizational strategy, and their role in promoting employee autonomy.

What are barriers and facilitators in sustaining lean management in healthcare? A qualitative literature review

BACKGROUND

Lean management (LM) is a continuous improvement methodology originating from manufacturing and is widely adopted in healthcare to improve processes. LM shows promising results in healthcare and research on the topic is increasing. However, it can be difficult to sustain LM over time, and an overview of facilitators or barriers that influence the sustainment of LM in a healthcare context is unavailable.

METHODS

Prior to search, five inclusion and exclusion criteria were defined to establish suitability of identified articles for our research question. This study was based on 24 selected peer-reviewed studies that reported on the sustainment of LM in healthcare organisations, published in the last five years. Following the Preferred Reporting Items for Systemtic Reviews and Meta-Analyses (PRISMA) guidelines, all articles were scanned, retrieved for full-text and analysed thematically.

RESULTS

Following thematic analysis, we identified four overarching themes: Mobilising Employees, Guiding Change Efforts, Methods, and Local Context. Key facilitators for supporting LM are fostering an improvement culture and learning culture, providing professional development opportunities, assigning more responsibilities to employees in decision making processes and appointing change agents to act as local LM leaders. Key barriers for sustaining LM include overburdening employees with responsibilities, omitting staff involvement during LM implementation, lack of patient engagement, lack of resources to engage with LM, a lack of leadership commitment and follow-up on projects, and a lack of knowledge of LM among leaders.

CONCLUSION

Overall, studies emphasise the importance of actively involving and engaging the workforce to embed LM into organisational culture. Reflecting on the origins of LM, healthcare organisations can find inspiration in the virtue of respecting people in their journey to sustain and cultivate an improvement culture. LM provides potential to change healthcare for the better and could help healthcare organisations to cope with increasing external pressures.

Measuring the current state-of-the-art in lean healthcare literature from the lenses of bibliometric indicators

Purpose

Lean healthcare (LHC) applies lean philosophy in the healthcare sector to promote a culture of continuous improvement through the elimination of non-value-added activities. Studies on the subject can be classified as conceptual (theoretical) or analytical (applied). Therefore, this research compares bibliometric indicators between conceptual and analytical articles on LHC.

Design/methodology/approach

For data collection, the PRISMA Protocol was employed, and 488 articles published from 2009 to 2021, indexed in the Scopus and WoS databases, were retrieved.

Findings

This study reveals how conceptual and analytical LHC studies are organized in terms of the most relevant journals, articles, institutions, countries, the total number of citations, collaboration networks (co-authorship, international collaboration network and institutional collaboration network) and main co-words.

Originality/value

Only four papers conducting bibliometric analysis on LHC studies were identified in the Scopus and Web of Science databases. In addition, none of these papers compared conceptual and analytical bibliometric indicators to reveal the evolution, organization and trends of each category. Therefore, this work is not only the first to make this comparison but also the first to analyze the collaboration between authors, institutions and countries in relation to studies on LHC. The analyses performed in this work allow one new possible understanding, by researchers and health professionals, of the literature behavior in this field of study.

A Lean Manufacturing Progress Model and Implementation for SMEs in the Metal Products Industry

The manufacturing industry faces the challenge of small and diversified customer orders. To meet this challenge, strong internal production capabilities are required. A lean manufacturing process that uses fewer resources and offers greater process improvement will help SMEs to continue to contribute to the global economy. Though SMEs provide most employment opportunities, previous studies have focused on large companies in auto-manufacturing-related industries. With the commitment and support of the management, and the application of a value stream map (VSM) and related improvement tools, we produced a practical process improvement model for a lean manufacturing system in an SME. With the commitment and support of the management and the joint efforts of the project improvement staff, the 10 improvement projects over a six-month period all achieved their goals: reduction in lead time from 26 days to 19.5 days, improvement of welding per people per hour (PPH) efficiency by 28.3%, improvement of packaging PPH efficiency by 64.1%, improvement of working in process (WIP) efficiency at the production site by 83.84%, and improvement of raw material storage by 83.84%. The efficiency of the raw material warehouse inventory was improved by 58.63%, and the efficiency of the shipment completion rate was improved by 14.5%.

Application of Value Stream Mapping in E-Commerce: A Case Study on an Amazon Retailer

In recent years, the e-commerce market has grown significantly, and the online retail market has become very competitive. Online retailers strive to improve their supply chain operations to reduce costs and to improve customer satisfaction. Value stream mapping (VSM), a tool created by the lean production movement to identify and reduce errors, losses, and lead time and to improve value-added activities, has been proven to be effective in many manufacturing processes. In this study, we investigate the application of value stream mapping (VSM) in the supply chain of an e-commerce retailer on Amazon. By visualizing the entire supply chain with VSM, the waste that is produced during the delivery process from the retailer to the customer was identified. The five whys method was then applied to find the root cause of the waste. Furthermore, a scoring method was developed to evaluate and compare two different supply chain logistic models to identify a strategy for improvement. This study provides a systematic methodology to understand, evaluate, and improve the entire e-commerce supply chain process utilizing VSM. It was demonstrated that the methodology could improve supply chain management efficiency, customer satisfaction, and cost reduction.

A practical framework for achieving value creation and capture in healthcare through process improvement

PURPOSE

The purpose of this study was to examine the concept of value in healthcare through a practical appraisal of the applicability of a conceptual framework, which is aimed at supporting the measurement and realisation of financial benefits from process improvement (PI) activities in a hospital setting.

DESIGN/METHODOLOGY/APPROACH

A single case study of a hospital system in Melbourne, Victoria, Australia, was used to assess the applicability of the framework. The study sought to verify the framework's intention, that PI methods could be used to address known wastes that contribute to the cost of providing healthcare. The case study examines the current approach taken by the hospital to measure and realise financial benefits from PI activities and compares these to the components of the Strategy to Balance Cost and Quality in Health Care framework to assess its applicability in practice.

FINDINGS

The case study revealed that the steps described in the framework were fundamentally in place albeit with some variation. Importantly, the case study identified an additional step that could be added into the framework to support hospitals to better define their portfolio of initiatives to deliver value. The case study also clarified three types of contributory elements that should be in place for the application of the framework to be successful.

PRACTICAL IMPLICATIONS

The Framework to Achieve Value in Healthcare is offered to hospitals as a model by which they can look to reduce expenditure through the removal of non-value adding activities. The modification to the conceptual framework has arisen from a single case study and would benefit from further testing by other hospitals in other policy settings (i.e. other countries).

ORIGINALITY/VALUE

This is the first paper to examine and enhance an existing framework to assist hospitals balance cost and quality through PI.

Externalities of Lean Implementation in Medical Laboratories. Process Optimization vs. Adaptation and Flexibility for the Future

Important in testing services in medical laboratories is the creation of a flexible balance between quality-response time and minimizing the cost of the service. Beyond the different Lean methods implemented so far in the medical sector, each company can adapt the model according to its needs, each company has its own specifics and organizational culture, and Lean implementation will have a unique approach. Therefore, this paper aims to identify the concerns of specialists and laboratory medical services sector initiatives in optimizing medical services by implementing the Lean Six Sigma method in its various variants: a comparative analysis of the implemented models, with emphasis on measuring externalities and delimiting trends in reforming/modernizing the method, a comprehensive approach to the impact of this method implementation, and an analysis of available databases in order to underline the deficit and information asymmetry. The results highlighted that in the case of clinical laboratories, the Lean Six Sigma method is conducive to a reduction of cases of diagnostic errors and saves time but also faces challenges and employees' resistance in implementation.

A conceptual framework for a systemic understanding of barriers during lean implementation

Purpose

Multiple organisations which have attempted to implement lean production/manufacturing/thinking have failed to achieve significant benefits. Practitioners and researchers have identified the barriers that hinder successful implementation. This study first consolidates such lean implementation barriers that are common across all industry sectors. Further, a systemic understanding of lean barriers is attempted by determining causal relationships between barriers and their relative causal strength.

Design/methodology/approach

Barriers to lean implementation were first identified from extant literature and categorised into broad barrier groups. These barrier groups were classified into four categories as specified by Liker's 4P model of lean–philosophy, people and partnership, processes and problem-solving. Additionally, interrelations between barriers, both within and among these four categories were determined.

Findings

The barriers classified under philosophy were the most critical as it affects the barriers in other groups. Similarly, barriers such as lack of leadership and top management commitment, lack of resources, shortage of lean consultants and trainers, lack of systemic understanding of lean and the need for its implementation, lack of lean expertise and training were found to be the most critical causal barriers.

Research limitations/implications

Highly critical barriers in terms of causality should be addressed with high priority, as effective measures against them may eliminate or reduce the impact of other barriers.

Originality/value

This study addresses the confusion regarding the high number of lean barriers in extant literature by providing a systemic understanding of the same. By exploring the interrelations among barriers, the most important causal barriers and barrier types (4Ps) are identified, the knowledge of which could improve lean implementation success. This is a novel attempt in the domain of lean.

From Lean Production to Lean 4.0: A Systematic Literature Review with a Historical Perspective

Over recent decades, the increasing competitiveness of markets has propagated the term “lean” to describe the management concept for improving productivity, quality, and lead time in industrial as well as services operations. Its overuse and linkage to different specifiers (surnames) have created confusion and misunderstanding as the term approximates pragmatic ambiguity. Through a systematic literature review, this study takes a historical perspective to analyze 4962 papers and 20 seminal books in order to clarify the origin, evolution, and diversification of the lean concept. Our main contribution lies in identifying 17 specifiers for the term “lean” and proposing four mechanisms to explain this diversification. Our research results are useful to both academics and practitioners to return to the Lean origins in order to create new research areas and conduct organizational transformations based on solid concepts. We conclude that the use of “lean” as a systemic thinking is likely to be further extended to new research fields.

Gamification in E-Learning and Sustainability: A Theoretical Framework

Progress in communication technologies and social isolation caused by the COVID-19 pandemic have supported the acceptance of e-learning. In the e-learning context, gamification has been identified as one of the most promising trends. Many researchers believe in the game elements’ capacity to drive learning, skills acquisition, and changes for more sustainable behavior. However, the literature on the subject is dispersed, addressing behavioral attitudes and elements in an isolated and fragmented way. This study aims to present a framework relating game elements to behavioral attitudes to promote sustainability and ensure quality of learning. The methodology is based on a systematic literature review using the PRISMA protocol, covering the content analysis of 130 articles indexed in the Web of Science database. For the framework construction, the following were identified: behavioral attitudes stimulated by gamification; main game elements and how they relate to each other. Based on this, a framework called 7GOALS (Gamification-Oriented Active Learning Steps) associated with the PDCA (Plan, Do, Check, Act) was established. The proposed structure is multidisciplinary and can be used in any knowledge field that uses gamification. With this, themes such as sustainability can be widely disseminated and leverage changes towards more sustainable behaviors that adhere to the real world.

Application of Lean Six Sigma in conservative dentistry: an action research at an Indian dental college

Purpose

The article evaluates the obstacles, lessons learned and managerial implications of deploying Lean Six Sigma (LSS) in a dental college hospital in India.

Design/methodology/approach

The work adopts the action research (AR) methodology to establish a case study, which is carried out using the LSS define–measure–analyze–improve–control (DAMIC) approach in a dental college. It uses LSS tools to enhance the productivity and performance of the Conservative Dentistry Department of a dental college and to unravel the obstacles and success factors in applying it to the education and healthcare sector together.

Findings

The root cause for high turn-around time (TAT) is ascertained using LSS tools and techniques. The effective deployment of the solutions to the root causes of variation assists the dental college to reduce the TAT of the Conservative Dentistry process from an average of 63.9 min–36.5 min (i.e. 42.9% improvement), and the process Standard Deviation (SD) was reduced from 2.63 to 2 min. This, in turn, raises the sigma level from 0.48 to 3.23, a noteworthy successful story for this dental college.

Research limitations/implications

While the results and recommendations of this research are focused on a single case study, it is to be noted that the case study is carried out with new users of LSS tools and techniques, especially with the assistance of interns. This indicates the applicability of LSS in dental colleges; thus, the adopted modality can be further refined to fit India's education and hospital sector together.

Originality/value

This article explains the implementation of LSS from an aspiring user viewpoint to assist dental colleges and policymakers in improving competitiveness. In addition, the medical education sector can introduce an LSS course in the existing programme to leverage the potential of this methodology to bring synergy and collaborative research between data-based thinking and the medical field based on the findings of this study. The most important contribution of this article is the illustration of the design of experiments (DOE) in the dental college process.

Lessons from a Surgical Center Satellite Warehouse in a Large Brazilian Public Hospital

Brazilian public hospitals face several operational problems not only related to poor public management practices and their complex nature, but also the economic, and social contexts. Considering this scenario and the fact that efforts in supply management might affect a hospital organization’s excellence, this research aims to identify improvements in the logistic operations at the surgical center satellite warehouse of a Public Hospital located in Brazil. A case study based on an exploratory and qualitative approach was conducted by employing document analysis, semi-structured interviews, and on-site observations. Seven major problems concerning lack of surgical material, the non-definition of crucial logistic parameters, low information flow, surgical supply control, and management problems were pointed and addressed by seven independent but complementary actions that considered the Brazilian healthcare system’s particularities. Given the nature of exploratory research, the results are not exhaustive and cannot be generalized to different contexts. However, they help understand that reducing the waste of the logistics processes makes it possible to improve the attention to the local population that uses public health services.

Applying Industry 4.0 technologies in the COVID–19 sustainable chains

Purpose

The purpose of this paper is 1) to investigate the effects on the crucial Industry 4.0 technological innovations that interact between the real and virtual worlds and that are applied in the sustainable supply chain process; 2) to contribute to the identification of the opportunities, the challenges and the gaps that will support the new research study developments and 3) to analyze the impact of the Industry 4.0 technologies as facilitators of the sustainable supply chain performance in the midst of the Coronavirus (COVID-19).

Design/methodology/approach

This research is performed through a bibliographic review in the electronic databases of the Emerald Insight, the Scopus and the Web of Science, considering the main scientific publications on the subject.

Findings

The bibliographic search results in 526 articles, followed by two sequential filters for deleting the duplicate articles (resulting in 487 articles) and for selecting the most relevant articles (resulting in 150 articles).

Practical implications

This article identifies the opportunities and the challenges focused on the emerging Industry 4.0 theme. The opportunities can contribute to the sustainable performance of the supply chains and their territories. The Industry 4.0 can also generate challenges like the social inequalities related to the position of the man in the labor market by replacing the human workforce with the machines. Therefore, the man-machine relationship in the Industry 4.0 era is analyzed as a gap in the literature. Therefore, as a way to fill this gap, the authors of this article suggest the exploration of the research focused on the Society 5.0. Also known as “super-smart society,” this recent theme appeared in Japan in April 2016. According to Fukuda (2020), in addition to the focus on the technological development, the Society 5.0 also aims at the quality of life and the social challenge resolutions.

Originality/value

This article contributes to the analysis of the Industry 4.0 technologies as facilitators in the sustainable supply chain performance. It addresses the impacts of the Industry 4.0 technologies applied to the supply chains in the midst of the COVID-19 pandemic, and it analyzes the research gaps and limitations found in the literature. The result of this study can add value and stimulate new research studies related to the application of the Industry 4.0 technologies as facilitators in the supply chain sustainable performance. It can encourage the studies related to the COVID-19 impacts on the sustainable supply chains, and it can promote the research development on the relationship among the man, the machine and the labor in the Fourth Industrial Revolution.

The Role of Value Stream Mapping in Healthcare Services: A Scoping Review

Lean healthcare aims to manage and improve the processes in the healthcare sector by eliminating everything that adds no value by improving quality of services, ensuring patient safety and facilitating health professionals’ work to achieve a flexible and reliable organization. Value Stream Mapping (VSM) is considered the starting point of any lean implementation. Some papers report applications of VSM in healthcare services, but there has been less attention paid to their contribution on sustainability indicators. The purpose of this work is to analyze the role of VSM in this context. To do so, a scoping review of works from recent years (2015 to 2019) was done. The results show that most applications of VSM reported are in the tertiary level of care, and the United States of America (USA) is the country which leads most of the applications published. In relation with the development of VSM, a heterogeneity in the maps and the sustainability indicators is remarkable. Moreover, only operational and social sustainability indicators are commonly included. We can conclude that more standardization is required in the development of the VSM in the healthcare sector, also including the environmental indicators.