Readiness factors for lean implementation in healthcare settings – a literature review

A framework for lean implementation in preoperative assessment: Evidence from a high complexity hospital in Italy

Purpose: A routine preoperative assessment is considered both ineffective and inefficient. Despite the widespread application of lean thinking in healthcare, there is little evidence of successful experiences in preoperative admissions in order to reduce "No value added" activities. A conceptual framework reporting the drivers (clinic, tools, innovation, organization, and governance) and impacts (patient, efficiency, sustainability, time, learning and growth) was developed. Methodology: Drawing on the experience of an Italian high complexity hospital, this paper analyzes the case study by reporting evidence on how to implement lean in preoperative assessment and how to evaluate the positive results obtained. Results: Applying lean principles, the identification of value improved the appropriateness of care by creating 40 personalized pathways; the value stream resulted in a reduction of "No Value Added Time" from 37% to 28%, chest X-rays from 41% to 14% and cardiac visits from 49% to 37%; the pursuit of continuous flow through innovation contributed to increase the use of digitalization; the new pull organization helped to reduce the average time spent per year by 1.5 h; the continuous improvement was ensured through the governance of results. Conclusion: The proposed framework should be used to improve the quality of care in preoperative admissions by adopting the lean drivers for successful implementation and reporting the impacts.

The relationship between self-efficacy and sustainable Lean management systems within the healthcare arena

PURPOSE

The purpose of this paper is to improve the understanding of the social contexts of sustainable Lean culture in healthcare by examining self-efficacy (SE) as a fundamental construct related to the value of perceived readiness, prior education of Lean and the importance of leadership's system-level support.

DESIGN/METHODOLOGY/APPROACH

A descriptive correlational study was conducted to identify the relationships between SE and Lean readiness factors, SE and prior Lean training, SE and clinical vs administrative roles and SE and perceived system-level support in a large health system.

FINDINGS

There was a statistically significant difference in self-reported readiness to use Lean tools between individuals who had received Lean training during their academic education and those who had not; however, their level of education did not impact SE. Lastly, and perhaps most important, the learner who embodies SE also has system-level support.

RESEARCH LIMITATIONS/IMPLICATIONS

Future directions of this research, in addition to assessing team readiness as other studies suggest, would be to evaluate individual team member readiness by gauging SE and addressing deficits prior to the deployment of process improvement (PI) projects to promote success and sustainability.

PRACTICAL IMPLICATIONS

This contributes to the ongoing scholarship of Lean management systems, providing clinical and non-clinical leaders with a contextual understanding of their supportive role in the SE of teams.

ORIGINALITY/VALUE

This study demonstrates the value of understanding SE of individual team members and how it can contribute to overall improved team outcomes, directly impacting the sustainability of Lean change culture and its promotion of improved patient safety, cost efficiencies and access to care.

Toward a roadmap for sustainable lean adoption in hospitals: a Delphi study

BACKGROUND

The benefits of lean adoption in healthcare include improved process efficiency and quality of patient care. However, research indicates that lean implementation in healthcare, and specifically hospitals, is often not sustained. Furthermore, there is a need for maturity models that guide lean implementation, specifically in hospitals. This study develops a prescriptive maturity model named the Sustaining of Lean Adoption in Hospitals Roadmap (SOLAR) that acts as a practical guideline for the sustainable adoption of lean in hospitals.

METHODS

The SOLAR has three theoretical foundations, namely lean implementation success factors in hospitals, implementation science, and change management theory. A systematic literature review was conducted to determine the lean implementation success factors in hospitals as the first building block. Secondly, practices from implementation science were used to create the action items in the SOLAR. Ten change steps were elicited from change management theory as the third theoretical building block of the roadmap. We refined the roadmap through three Delphi rounds that verified its useability in hospitals.

RESULTS

The final SOLAR consists of four maturity phases (prepare, plan, experiment and learn, and sustain) and includes action items for each phase related to the hospital's strategy, resources, engaging of people, and culture. The action items and change management steps shown in the SOLAR are not intended as an exhaustive list but provide guidelines on aspects hospitals must consider when they aim to adopt lean sustainably.

CONCLUSIONS

The strong theoretical base of the SOLAR enables hospitals to safely experiment and learn which implementation methods are best suited to their unique environment. The SOLAR is, therefore, an actionable guideline that informs both academics and practitioners involved in lean adoption in hospitals. This roadmap can guide future retrospective longitudinal or action research.

A conceptual model for evaluating readiness for lean practices using a fuzzy logic approach: A case study in Bangladeshi healthcare institutes

In the realm of healthcare, an imperative necessity for all, institutions are increasingly recognizing the advantages of adopting lean strategies to enhance performance. Lean implementation in healthcare can lead to significant improvements in efficiency, patient care, and overall institutional performance. This paper aims to assess the readiness levels for implementing lean practices in healthcare institutes in Bangladesh, employing a fuzzy logic approach. The construction of a conceptual model is grounded in literature review and expert opinions, incorporating critical enablers, criteria, and attributes identified from extensive research. Factors measured include leadership commitment, workforce capability, operational processes, technological infrastructure, and organizational culture, each pivotal in determining readiness for lean implementation. The fuzzy logic approach is particularly useful in this context due to its ability to handle uncertainty and imprecision, which are common in complex environments like healthcare. This methodology not only provides a clear picture of current capabilities but also highlights specific areas that need enhancement, paving the way for more targeted and effective lean interventions. Data sourced from consultations with experts in three prominent hospitals in Bangladesh forms the basis of the analysis, enabling a detailed examination of readiness levels. The model's application of fuzzy logic facilitates a comprehensive assessment, revealing 12 critical attributes across the hospitals that require attention. Interestingly, the evaluation identifies varying levels of readiness, with two hospitals demonstrating moderate readiness and one showing a lower level. This conceptual approach has significant potential to assist top management in healthcare companies by providing a structured framework to prioritize crucial areas for improvement. By accurately assessing readiness levels and pinpointing weaker aspects before implementing lean strategies, this study aims to transform the healthcare industry. Ultimately, its implementation has the potential to enhance organizational performance and elevate standards in patient care, contributing to improved healthcare delivery in Bangladesh and beyond.

Leading well and staying psychologically healthy: the role of resources and constraints for managers in the healthcare sector

PURPOSE

Maintaining a healthy and productive workforce is a challenge for most organizations. This is even truer for health organization, facing staff shortages and work overload. The aim of this study is to identify the resources and constraints that influence managers' mental health and better understand how they are affected by them.

DESIGN/METHODOLOGY/APPROACH

A qualitative approach was chosen to document the resources, the constraints as well as their consequences on managers in their day-to-day realities. The sample included executive-, intermediate- and first-level managers from a Canadian healthcare facility. A total of 62 semi-structured interviews were conducted. The coding process was based on the IGLOO model of Nielsen et al. (2018) to which an employee-related level was added (IGELOO).

FINDINGS

Results highlight the importance of considering both resources as well as constraints in examining managers' mental health. Overarching context, organizational constraints and the management of difficult employees played important roles in the stress experienced by managers.

PRACTICAL IMPLICATIONS

The results offer a better understanding of the importance of intervening at different levels to promote better organizational health. Results also highlight the importance of setting up organizational resources and act on the various constraints to reduce them. Different individual strategies used by managers to deal with the various constraints and maintain their mental health also emerge from those results.

ORIGINALITY/VALUE

In addition to addressing the reality of healthcare managers, this study supplements a theoretical model and suggests avenues for interventions promoting more sustainable organizational health.

A cross-organizational Lean deployment in an Italian regional healthcare system

PURPOSE

This study explores how Lean was deployed in several hospitals in the Apulia region in Italy over 3.5 years.

DESIGN/METHODOLOGY/APPROACH

An exploratory qualitative design was drawn up based on semi-structured interviews.

FINDINGS

The drivers of Lean in hospitals were to increase patient satisfaction and improve workplace well-being by eliminating non-value-add waste. The participants highlighted three key elements of the pivotal implementation stages of Lean: introduction, spontaneous and informal dissemination and strategic level implementation and highlighted critical success and failure factors that emerged for each of these stages. During the introduction, training and coaching from an external consultant were among the most impactful factors in the success of pilot projects, while time constraints and the adoption of process analysis tools were the main barriers to implementation. The experiences of the Lean teams strongly influence the process of spontaneous dissemination aided by the celebration of project results and the commitment of the departmental hospital heads.

PRACTICAL IMPLICATIONS

Lean culture can spread to allow many projects be conducted spontaneously, but the Lean paradigm can struggle to be adopted strategically. Lean in healthcare can fail because of the lack of alignment of Lean with leadership in healthcare and with their strategic vision, a lack of employees' project management skills and crucially the absence of a Lean steering committee.

ORIGINALITY/VALUE

The absence of managerial expertise and a will to support Lean implementation do not allow for systemic adoption of Lean. This is one of the first and largest long-term case studies on a Lean cross-regional multi-hospital application in healthcare.

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.

Psychometric assessment of organizational readiness scale for digital innovations and antecedents of organizational readiness

BACKGROUND: This article aims to perform a psychometric assessment of the scale of organizational readiness for digital innovations in a transition economy and to examine the antecedents of organizational readiness for digital innovations. METHODOLOGY: The study employed a quantitative research method to analyze data collected from a sample of 1236 health professionals. The scale secondary confirmatory factor and linear regression analysis were employed to verify organizational readiness and test the respective hypotheses about organizational readiness for digital innovation, respectively. RESULTS/CONCLUSIONS: The research findings show that the organizational readiness scale for digital innovations is valid and reliable in transition economies. Findings show that the relationship between variables such as adaptation of human resources (AHR), cognitive readiness (COR), planning for new telehealth and e-health (PNTH), IT readiness (ITR), resource readiness (RR), partnership readiness (PR), and cultural readiness (CUR) are correlated with the innovations implementation effectiveness (IIE), and organizational readiness for digital innovation is positive statistically significant. Findings also suggest that Integration of old technologies (IoT) and organizational readiness for digital innovation is statistically significant and have negative relationship.

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.

Does organizational readiness matter in lean thinking practices? An agency perspective

Purpose

Extant research documents the importance of lean thinking for organizations, however, as prior research has largely focused on hard lean practices, but little is known about the effects or the significance of soft lean practices. This research attempts to address this issue by examining how soft lean practices enhance organizational lean readiness, and in turn increase the success of lean implementation.

Design/methodology/approach

This research adopts a single case study design in a small-medium enterprise livestock feed manufacturing organization, and investigates the period from late 2011 through the end of 2019 covering two attempts at lean implementation – an initial failed attempt followed by a successful introduction of lean within the case organization. The research analyzes interviews with 29 managers and employees from all organizational levels and departments within the case organization. Secondary data including organizational documents and performance measures and metrics were also incorporated into the research design.

Findings

Drawing on agency theory, the authors advance a principal-agent interaction perspective to conceptualize organizational lean readiness – specifically, the authors consider the “state or condition” of four agency factors (goal conflict, information asymmetry, risk aversion and length of relationship), and explore if these four agency factors can be utilized as proxies for organizational readiness for lean implementation. The authors identify the formation of a shared vision and identity within the organization as an effective mechanism through which soft lean practices enhance organizational lean readiness. Finally, the analysis offers an understanding of how the long-term success of lean implementation is improved by the introduction of soft lean practices as a prerequisite to create organizational readiness for the implementation of hard lean practices.

Originality/value

The study is unique in the sense that it empirically links agency theory and the role of soft lean practices in developing organizational lean readiness in a small-medium enterprise context by defining the ideal state of four agency factors as proxies for organizational readiness.

Uncovering Readiness Factors Influencing the Lean Six Sigma Pre-Implementation Phase in the Food Industry

The aim of this study is to identify the readiness factors of Lean Six Sigma (LSS) for the food manufacturing industry. A multi-method qualitative approach was used. Semi-structured interviews were conducted with twelve quality practitioners and three case food companies to identify and explore the LSS readiness factors in the food manufacturing industry. Twenty-eight factors were identified and classified into six LSS readiness factors (RF) in the food manufacturing industry context, namely, management support and leadership, organisational culture readiness, process management, project management, employee involvement, and external relations. This study could benefit managers in the food business as a diagnostic tool to evaluate their readiness to implement LSS prior to investing in the programme. The proposed framework identifies LSS readiness dimensions and their attributes to enable food businesses to conduct readiness level self-assessments, thereby contributing to the successful implementation of LSS in the food manufacturing industry. The determined readiness factors will potentially enable an organisational transformation to be better understood, making the implementation of LSS practices in food businesses more successful and sustainable.

Creating digital ecosystem for small and medium enterprises: the role of dynamic capability, agile leadership and change readiness

Purpose

The digitization efforts for small and medium enterprises (SMEs) as a result of advances in information technology are challenging, with one of them being the creation of digital ecosystems for SMEs. This study aims to develop a model of the relationship between SMEs’ readiness to change, agile leadership and dynamic capability to implement a digital ecosystem for SMEs in the creative industry in Semarang, Central Java, Indonesia.

Design/methodology/approach

A survey methodology was used in this study. Respondents in this study were creative industry SMEs in Semarang, Central Java, Indonesia. SMEs in the creative industry sector were chosen as samples as they require digital technology to manage their business development, production and distribution, customer relationships and to innovate in their businesses. In total, 250 creative SMEs, selected based on a purposive random sampling method, were included in this study. Data were analyzed using structural equation model-partial least square.

Findings

This study provides current insights and future needs for implementing digital ecosystems in SMEs in Indonesia’s creative industries. It also identifies three critical conditions for dealing with Industry 4.0: organizational readiness to change, agile leadership and dynamic capability.

Originality/value

In response to information technology advancements, this study proposes a new model for implementing digital ecosystems for SMEs. Furthermore, this study adds knowledge about the concept of a service-oriented technology ecosystem to help SMEs operate more efficiently. It focuses on the interaction of entities to improve the system’s utility, gain benefits and promote information exchange.

Readiness for lean-sustainability in start-ups during the COVID-19 era

Purpose

This study aims to “identify”, “analyse” and “categorise” the lean-sustainability enablers for start-ups during the COVID-19 epidemic using total interpretive structural modelling (TISM).

Design/methodology/approach

A closed-ended questionnaire was used to collect data in addition to the scheduled interview. The TISM methodology is used to determine how the variables interact, and the matrice d’Impacts croises-multiplication applique´ a classement (MICMAC) method is used to rank and categorise the lean-sustainability enablers.

Findings

This study identified ten lean-sustainability enablers for start-ups during the COVID-19 pandemic. The study says that the key factors are leadership and managerial commitment, implementation of employee skills and abilities, strategic need, personnel engagement and financial ability.

Research limitations/implications

The study focused primarily on lean-sustainability characteristics for start-ups.

Practical implications

This research will aid key stakeholders and academics in better understanding the factors that contribute to lean-sustainability in start-ups.

Originality/value

This study proposes the TISM technique for start-ups, which is a novel attempt in the subject of lean-sustainability in this industry.

The role of lean in healthcare during COVID-19 pandemic

Purpose

The impact of the COVID-19 pandemic on healthcare operations has raised questions about the applicability and capacity of the lean approach to respond to critical events. Thus, with a dearth of studies addressing this issue, this study aims to understand the role of lean in healthcare operations under the disruptive impact of the COVID-19 pandemic.

Design/methodology/approach

Drawing on a case study carried out in an emergency department in Brazil during the COVID-19 outbreak, the author presents results from semi-structured interviews and document analysis.

Findings

The results show three prominent themes that respond to this study's purpose: lean applicability during the pandemic, lean challenges during the pandemic and the pandemic impact on the lean processes. Furthermore, the study underscores that lean is not the panacea to operational problems caused by the pandemic in healthcare organisations, but it eases the impact on their operations. Finally, this study contributes to the discipline of operations management and highlights the need to rethink lean applications during disruptive events, focusing on flexibility, adaptability and patients' needs.

Research limitations/implications

The literature addressing the pandemic impact on healthcare operations is still new and emerging; therefore, it is possible that some of the studies that are under review and could contribute to this study were not considered.

Practical implications

The study provides a better understanding of the lessons learned from the real-world experiences gained during the pandemic, helping managers to make informed decisions when developing contingency plans to improve healthcare readiness and responsiveness under crisis conditions (e.g. untenable demand and constrained capacity).

Originality/value

Given the contemporary nature of this pandemic, only few emerging studies addressing the impact of the pandemic on lean healthcare operations are available and scholars are calling for more empirical studies. Furthermore, there is an increasing criticism and scepticism about the applicability of lean in healthcare during a pandemic. Thus, this research both provides original contributions by responding to scholars' calls for novel research in this area and further contributes towards filling the void in the literature.

Success factors for lean six sigma projects in healthcare

Identifying critical success factors (CSFs) of continuous improvement projects is crucial for management control and operations management domains. Despite the availability of manufacturing-related literature, studies on CSFs in more dynamic and complex healthcare-related operations are scarce. This study, based at a large public tertiary healthcare organization, identifies CSFs in implementing Lean Six Sigma (LSS). 62 LSS projects completed by Green Belts in consultation with Black Belts were analyzed for project success by a review team of practitioners (Black Belters) and academics. Using a grounded theory approach, numerous success factors were initially identified. A series of brainstorming sessions and workshops helped to narrow down and revise all the CSFs present in each of the 62 LSS projects to eight CSFs. The success of the 62 completed projects was assessed against each of the eight CSFs on a five-point Likert scale. Success was measured against whether the project met its stated aim and achieved the Key Performance Indicators that had initially been identified. Finally, the correlations of each factor rating against project success were analyzed to validate the relationship between each success factor and project success. The findings confirm that all eight CSFs identified are significantly correlated to project success. This study contributes to the management control, operations management, and healthcare literature by identifying CSFs of continuous improvement projects and introducing a relatively unique, rigorous, and practically proven evaluation method applied via an industry and academic partnership. Specified CSFs and the method used to identify these will benefit managers of continuous improvement projects.

Qualitative study exploring factors affecting the implementation of a vocational rehabilitation intervention in the UK major trauma pathway

OBJECTIVES

This study aimed to: (1) understand the context for delivering a trauma vocational rehabilitation (VR) intervention; (2) identify potential barriers and enablers to the implementation of a VR intervention post-trauma.

DESIGN

Qualitative study. Data were collected in person or via phone using different methods: 38 semistructured interviews, 11 informal 'walk-through care pathways' interviews, 5 focus groups (n=25), 5 codesign workshops (n=43). Data were thematically analysed using the framework approach, informed by the Consolidated Framework for Implementation Research.

SETTING

Stakeholders recruited across five UK major trauma networks.

PARTICIPANTS

A variety of stakeholders were recruited (n=117) including trauma survivors, rehabilitation physicians, therapists, psychologists, trauma coordinators and general practitioners. We recruited 32 service users (trauma survivors or carers) and 85 service providers.

RESULTS

There were several issues associated with implementing a trauma VR intervention including: culture within healthcare/employing organisations; extent to which healthcare systems were networked with other organisations; poor transition between different organisations; failure to recognise VR as a priority; external policies and funding. Some barriers were typical implementation issues (eg, funding, policies, openness to change). This study further highlighted the challenges associated with implementing a complex intervention like VR (eg, inadequate networking/communication, poor service provision, perceived VR priority). Our intervention was developed to overcome these barriers through adapting a therapist training package, and by providing early contact with patient/employer, a psychological component alongside occupational therapy, case coordination/central point of contact, and support crossing sector boundaries (eg, between health/employment/welfare).

CONCLUSIONS

Findings informed the implementation of our VR intervention within the complex trauma pathway. Although we understand how to embed it within this context, the success of its implementation needs to be measured as part of a process evaluation in a future trial.

Modeling critical success factors for sustainable LSS implementation in hospitals: an empirical study

Purpose

The objective of this paper is to investigate, assess and develop a hierarchical model to evaluate the interrelationship of critical success factors (CSFs) that influence the deployment of Sustainable LSS framework in hospitals. Further, developed model has been validated to investigate its applicability in hospitals towards sustainable LSS implementation.

Design/methodology/approach

“Interpretive Structural Modeling” (ISM) has been utilized to develop a convenient hierarchy and contextual relationship of key CSFs throughout the implementation pathway in Indian healthcare industry through systematic literature review and expert opinion, which is ensured by a taxonomy of CSFs using MICMAC (“Matrice d' Impacts Croisés-Multiplication Appliquée á un Classement”) and questionnaire-based survey to empirically validate the model through utilizing “Structural Equation Modelling” (SEM).

Findings

In this study, 17 keys CSFs to sustainable LSS implementation in healthcare industry have been investigated, and modeled. “Social and environmental responsibility,” “Financial return and project success stories,” “Top management involvement and leadership to implement Sustainable LSS,” “Availability of required resources, and their efficient utilization” are found to be the most essential CSFs for successful sustainable LSS implementation in healthcare industry. Further, classification of CSFs has been done for better interpretation of their nature using MICMAC approach. Moreover, the applicability of the proposed model has been empirically assessed utilizing SEM.

Research limitations/implications

The scrutiny of data reveals that the initial inputs from experts throughout the ISM pathway could trigger biased inputs into the study and generalization of the results into others, it might be viable that this propounded model might trigger distinct outcomes for contrasting types of healthcare organizations.

Practical implications

This model on sustainable LSS would support the decision-makers, practitioners and researchers to predict key CSFs through deployment and support the existing academic research on sustainable LSS. Accordingly, the focus on the CSFs of the sustainable LSS can be prioritized to diminish waste, and enhance patient satisfaction and safety.

Originality/value

This paper is an original contribution of analysis of CSFs in Indian healthcare industry utilizing an integrated ISM-MICMAC and SEM approach.

Prioritization of critical success factors for sustainable Lean Six Sigma implementation in Indian healthcare organizations using best-worst-method

Purpose

Recent years have seen an increased demand for healthcare services, presenting a need to improve service quality through the deployment of sustainable Lean Six Sigma (LSS). This study aims to identify critical success factors (CSFs) of sustainable LSS and prioritize them based on their intensity of importance for the effective implementation of sustainable LSS in the healthcare environment.

Design/methodology/approach

The present study identified 33 leading CSFs through a comprehensive literature review and expert experience and classified them into six major categories based on organizational functions. The primacy of these CSFs is established using the best-worst-method (BWM) approach. The significant advantage of this approach is that the decision-maker identifies both the best and worst criteria among alternatives prior to pairwise comparisons, leading to fewer pairwise comparisons and saving time, energy and resources. It also provides more reliable and consistent rankings.

Findings

The findings of the present study highlight the economic and managerial (E&M) CSFs as the most significant CSFs among the major category criteria of sustainable LSS-CSFs, followed by organizational (O), knowledge and learning (K&L), technological (T), social and environmental (S&E), and external factors (EF). Similarly, management involvement and leadership to implement sustainable LSS (E&M1), structured LSS deployment training and education (K&L2), and availability of required resources and their efficient utilization (O2) are ranked as the topmost CSFs among sub-category criteria of sustainable LSS-CSFs.

Practical implications

The prioritization of sustainable LSS-CSFs determined in this study can provide healthcare managers, researchers and decision-makers with a better understanding of the influence on effective deployment of sustainable LSS, resulting in improved service quality in hospitals.

Originality/value

This paper is an original contribution to the analysis of CSFs in an Indian healthcare institute, utilizing the BMW method for ranking the sustainable LSS-CSFs. The advantage of utilizing and distinguishing the performance of this approach compared to other MCDA approaches in terms of (1) least pairwise comparison and violation, (2) consistency (3) slightest deviation and (4) conformity.

Lean adoption, implementation, and outcomes in public hospitals: benchmarking the US and Italy health systems

Background

Despite the growing interest in transformational performance improvement among nearly all countries, international benchmarking has rarely been used. Cross-comparative research could allow an appreciation of the extent of Lean’s use in healthcare and a better evaluation of possible cultural influences on Lean implementation. This study provides a comparative international benchmarking of Lean adoption, implementation, and outcomes of hospitals in the US and Italy.

Methods

The National Survey of Lean, developed in 2017 in the US and adapted in Italy in 2019 was used to compare the two healthcare systems along three dimensions: the maturity of adoption, the implementation approach, identifying both strategic and operational activities and tools, and the Lean performance, investigated through patients, employed, and affiliated staff, costs, and service provision areas. Descriptive statistics including T-tests were used to examine differences between the two countries on the study variables.

Results

Lean has been adopted less by Italian public hospitals (36%) than US public hospitals (53%). Each country averages 4 years of experience with Lean. Italian hospitals reported being at a higher maturity stage while the US implemented a more system-wide approach, developing Lean in more operational units. The daily management system, leadership commitment, education and training indexes were higher or the same in the US while in Italy, hospitals had a higher self-reported performance index.

Conclusion

This exploratory work is one of the first international benchmarking studies on Lean implementation in healthcare systems using a standardized survey with a common set of definitions and questions. The study identifies different forms of Lean implementation that can be adopted, both at strategic and operational levels, with related perceived outcomes. Despite the US public hospitals being more likely to report a higher number of units using Lean, a higher daily management system index and use of Lean tools, Italian hospitals report more achievements primarily due to Lean. Further research can build on these findings by examining the relationship between Lean adoption/implementation and independent, objective performance measures.

What makes an effective Quality Improvement Manager? A qualitative study in the New Zealand Health System

PURPOSE

Quality improvement is an international priority, and health organisations invest heavily in this endeavour. Little, however, is known of the role and perspectives of Quality Improvement Managers who are responsible for quality improvement implementation. We explored the quality improvement managers' accounts of what competencies and qualities they require to achieve day-to-day and long-term quality improvement objectives.

DESIGN

Qualitative exploratory design using an interpretivist approach with semi-structured interviews analysed thematically.

SETTING AND PARTICIPANTS

Interviews were conducted with 56 quality improvement managers from 15 (out of 20) New Zealand District Health Boards. Participants were divided into two groups: traditional and clinical quality improvement managers. The former group consisted of those with formal quality improvement education-typically operations managers or process engineers. The latter group was represented by clinical staff-physicians and nurses-who received on-the-job training.

RESULTS

Three themes were identified: quality improvement expertise, leadership competencies and interpersonal competencies. Effective quality improvement managers require quality improvement experience and expertise in healthcare environments. They require leadership competencies including sense-giving, taking a long-term view and systems thinking. They also require interpersonal competencies including approachability, trustworthiness and supportiveness. Traditional and clinical quality improvement managers attributed different value to these characteristics with traditional quality improvement managers emphasising leadership competencies and interpersonal skills more than clinical quality improvement managers.

CONCLUSIONS

We differentiate between traditional and clinical quality improvement managers, and suggest how both groups can be better prepared to be effective in their roles. Both groups require a comprehensive socialisation and training process designed to meet specific learning needs.

The need for management education of healthcare management employees

Given the wide professional discussion on the dominating professional focus of healthcare managers at the expense of management knowledge, the main goal of this paper is to verify the extent, to which management education of healthcare workers affects the level of their management skills.

METHODOLOGY

The Descriptive statistics methods have been used to answer research questions regarding the differences in the perception of the managerial skills and their disposition importance between managers with a completed management education and without it. Emphasis was placed on people management skills and communication skills. The research sample consisted of 253 healthcare managers.

RESULTS

Managers with a completed specialized management study are characterized by higher values of entrepreneurial competences and communication skills. They also have exceptional skills in the area of initiator of change. Another significant difference is the higher adaptation of roles and low critique of their subordinates. They are oriented at workers and relationships with them.

CONCLUSION

Our results show that management education of healthcare managers significantly contributes to the implementation of newer approaches to people management and the use of the necessary management skills, which are a source of higher efficiency in the context of the present world of work and its challenges.

Lean adoption in hospitals: the role of contextual factors and introduction strategy

Background

In the scientific literature, many studies describe the application of lean methodology in the hospital setting. Most of the articles focus on the results rather than on the approach adopted to introduce the lean methodology. In the absence of a clear view of the context and the introduction strategy, the first steps of the implementation process can take on an empirical, trial and error profile. Such implementation is time-consuming and resource-intensive and affects the adoption of the model at the organizational level. This research aims to outline the role contextual factors and introduction strategy play in supporting the operators introducing lean methodology in a hospital setting.

Methodology

The methodology is revealed in a case study of an important hospital in Southern Italy, where lean has been successfully introduced through a pilot project in the pathway of cancer patients. The originality of the research is seen in the detailed description of the contextual elements and the introduction strategy.

Results

The results show significant process improvements and highlight the spontaneous dissemination of the culture of change in the organization and the streamlined adoption at the micro level.

Conclusion

The case study shows the importance of the lean introduction strategy and contextual factors for successful lean implementation. Furthermore, it shows how both factors influence each other, underlining the dynamism of the organizational system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06885-4.

Lean implementation within healthcare: imaging as fertile ground

PURPOSE

The purpose of this paper is to understand the barriers and enablers to lean implementation as part of an imaging quality improvement programme from a socio-cultural perspective.

DESIGN/METHODOLOGY/APPROACH

An in-depth 33 month ethnographic study, using observation and qualitative interviews, examined the process of lean implementation as part of an improvement programme.

FINDINGS

Implementation of lean was more successful compared with other reports of lean in healthcare settings. Key enablers of lean were high levels of multidisciplinary staff involvement and engagement; the professional credibility of facilitators and clinicians as early adopters, all within a wider culture of relatively strong inter-professional relationships in the imaging department. These enablers combined with the more routinised and standardised nature of imaging pathways compared to some other acute specialties suggest that imaging is fertile ground for lean, linked to the manufacturing origins of lean.

PRACTICAL IMPLICATIONS

When introducing lean within healthcare settings, special attention needs to be paid to the specific healthcare context and the existing cultures of inter-professional relationships. Fostering an improvement culture and engagement with training, together with adequate financial resource, are a key to contributing to the level of acceptability of an improvement tool such as lean.

ORIGINALITY/VALUE

This ethnographic study, bringing together rich multi-source data, has provided a detailed insight into the cultural workings of the process of lean implementation within a complex healthcare system.

Interprofessional, multitiered daily rounding management in a high-acuity hospital

PURPOSE

The purpose of this explanatory case study is to explain the implementation of interprofessional, multitiered lean daily management (LDM) and to quantitatively report its impact on hospital safety.

DESIGN/METHODOLOGY/APPROACH

This case study explained the framework for LDM implementation and changes in quality metrics associated with the interprofessional, multitiered LDM, implemented at Saint Francis Hospital and Medical Center (SFHMC) at the end of 2018. Concepts from lean, Total Quality Management (TQM) and high reliability science were applied to develop the four tiers and gemba rounding components of LDM. A two-tailed t-test analysis was utilized to determine statistical significance for serious safety events (SSEs) comparing the intervention period (January 2019-December 2019) to the baseline period (calendar years 2017 and 2018). Other quality and efficiency metrics were also tracked.

FINDINGS

LDM was associated with decreased SSEs in 2019 compared to 2017 and 2018 (p ≤ 0.01). There were no reportable central line-associated blood stream infection (CLABSI) or catheter-associated urinary tract infection (CAUTI) for first full calendar quarter in the hospital's history. Hospital-acquired pressure injuries were at 0.2 per 1,000 patient days, meeting the annual target of <0.5 per 1,000 patient days. Outcomes for falls with injury, hand hygiene and patient experience also trended toward target. These improvements occurred while also observing a lower observed to expected length of stay (O/E LOS), which is the organizational marker for hospital's efficiency.

RESEARCH LIMITATIONS/IMPLICATIONS

LDM may contribute greatly to improve safety outcomes. This observational study was performed in an urban, high-acuity, low cost hospital which may not be representative of other hospitals. Further study is warranted to determine whether this model can be applied more broadly to other settings.

PRACTICAL IMPLICATIONS

LDM can be implemented quickly to achieve an improvement in hospital safety and other health-care quality outcomes. This required a redistribution of time for hospital staff but did not require any significant capital or other investment.

SOCIAL IMPLICATIONS

As hospital systems move from a volume-based to value-based health-care delivery model, dynamic interventions using LDM can play a pivotal role in helping all patients, particularly in underserved settings where lower cost care is required for sustainability, given limited available resources.

ORIGINALITY/VALUE

While many hospital systems promote organizational rounding as a routine quality improvement process, this study shows that a dynamic, intense LDM model can dramatically improve safety within months. This was done in a challenging urban environment for a high-acuity population with limited resources.

A conceptual model of Lean culture adoption in healthcare

Purpose

This work seeks to offer a greater understanding of Lean healthcare implementation challenges conceptually taking a situated cultural organizational change perspective.

Design/methodology/approach

A descriptive model of healthcare organizations’ Lean adoption trajectories is built using ripple and bridging modelization strategies from elements of three classic organizational change theories and knowledge from Lean, organizational culture, healthcare and operations management literature.

Findings

The “contingent Lean culture adoption” (CLCA) model suggests five theoretical trajectories the healthcare organizations may experience when conducting a Lean transformation. These trajectories evolve from a new concept of Lean cultural friction (LCF) which represents cultural friction that a healthcare organization encounters toward an ultimate Lean culture proficiency state through time. From high to low initial LCF, a healthcare organization may in its Lean proficiency course end up in three states: lower, similar or higher LCF situation.

Research limitations/implications

The CLCA model demonstrates the potential to be developed into a framework and possibly a Lean cultural friction theory pending further qualitative and quantitative validation.

Practical implications

The CLCA model may help healthcare managers to use more appropriate cultural change strategies during their organization’s Lean journey.

Originality/value

This work enriches the concept of Lean cultural change which may apply not only to healthcare organizations but also to other ones. It suggests the existence of a healthcare organization Lean culture proficiency archetype and introduces the notion of Lean cultural friction.

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

PURPOSE

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

DESIGN/METHODOLOGY/APPROACH

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

FINDINGS

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

ORIGINALITY/VALUE

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

Utilizing Lean Leadership Principles to Build an Academic Primary Care Practice of the Future

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim.

Exploring the emotional experience of lean

PURPOSE

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

DESIGN/METHODOLOGY/APPROACH

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

FINDINGS

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

RESEARCH LIMITATIONS/IMPLICATIONS

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

ORIGINALITY/VALUE

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

Lean Six Sigma implementation and sustainability roadmap for reducing medication errors in hospitals

Purpose

The purpose of this study is to propose a Lean Six Sigma (LSS) roadmap to guide healthcare practitioners in the implementation of LSS along with a customized LSS tool kit for reducing medication errors.

Design/methodology/approach

The authors initially critically reviewed several frameworks/roadmaps of Lean, Six Sigma and LSS which have been proposed in healthcare sector from the existing literature. This review has led to an understanding of key characteristics, limitations and reasons behind the development of such frameworks/roadmaps. A conceptual roadmap was developed and then validated by a number of LSS experts and a healthcare practitioner. Based on the previous studies and taking LSS experts’ opinions into account, a revised roadmap for reducing medication is presented.

Findings

The roadmap for LSS in reducing medication errors is developed. This roadmap includes three phases: Phase 1 cultural readiness for LSS employment in reducing medication errors; Phase 2 preparation, initialization and implementation; and Phase 3 sustainability.

Research limitations/implications

The roadmap has been tested with only a handful of practitioners of LSS. Moreover, only two case studies have been carried out in a Thai hospital setting which followed the roadmap. In order to improve the validity of research, more case studies need to be executed and more people should be used for testing the roadmap with varied cultures.

Originality/value

This is the first attempt in the development of a LSS roadmap that healthcare practitioners can follow to reduce medication errors using LSS methodology and sustaining LSS in their organizations.

School readiness to adopt a school-based adolescent nutrition intervention in urban Indonesia

OBJECTIVE

To identify school community readiness to adopt a school-based adolescent nutrition intervention.

DESIGN

Cross-sectional study: mixed-methods design. The community readiness model was used to guide instrument development and qualitative analysis. Quantitative data are presented using descriptive statistics. Each statement was rated on a seven-point Likert scale, thereby producing scores between 1 (strongly disagree) and 7 (strongly agree).

SETTING

Ten of the twenty current public secondary schools in Bogor, Indonesia.

PARTICIPANTS

Ninety teachers and ten school principals.

RESULTS

Eating behaviour problem awareness was present among all participants; awareness of efforts to improve eating habits was also present, but these efforts were perceived as having low efficacy; support from the City Education Authority and Health Authority was present, but the support type did not match the perceived needs; nutrition education had not been implemented across the entire school community due to competing priorities; existing nutrition policies did not provide concrete scenarios and clear guidelines for nutrition-friendly schools; the availability and accessibility of healthy foods at schools were considered to be key factors in improved adolescent nutrition; positive attitudes existed among respondents towards the implementation of various nutrition programmes, and the median and mode were seven in all types of school-based intervention.

CONCLUSIONS

The school community readiness level regarding school-based adolescent nutrition interventions is currently in the action phase, implying that community leaders have begun organising efforts to address issues in adolescent nutrition and are aware of their consequences. Future support should be directed towards improving existing efforts and offering concrete ideas and clear policy guidelines for implementation.

Lean readiness assessment model – a tool for Humanitarian Organizations' social and economic sustainability

Purpose

purpose of this study is to present a Lean Readiness Assessment Model (LRAM) for assessing the readiness of Humanitarian Organizations (HO) for adopting Lean Management (LM) (Johanson et al.) practices. Literature reveals that implementation of LM itself is a cost and most organizations have failed to adopt LM techniques due to a non-readiness status and a non-supportive organizational culture. This situation indicates that the assessment of organizations' readiness before implementation of lean techniques is necessary.

Design/methodology/approach

This was an empirical quantitative study. Based on a synthesis of the literature, a conceptual model was developed by identifying seven critical success factors (CSFs). The CSFs were validated by HO professionals via a questionnaire-based survey. The data from the responses were analysed by applying partial least square structured equation modelling (PLS-SEM) using the SmartPLS3 software.

Findings

A proven LRAM was constructed that consists of CSFs (independent and mediating variables), which have reflected positive coefficients and significant t >1.96 and p < 0.05 values. The CSFs that are significant include process management, planning and control management, customer relationship management, human resource management, communication and coordination management and a positive organizational culture. The CSFs of supplier relationship and top management and leadership had insignificant t and p values and were dropped from the final LRAM.

Originality/value

This is a unique and rare study in its nature which developed LRAM for HO sector. The contribution of this model is to improve the efficiency and sustainability (economic and social aspects) of an HO under scarce resource conditions.

Leanness evaluation in health-care organizations using fuzzy logic approach

Purpose

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

Design/methodology/approach

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

Findings

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

Practical implications

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

Originality/value

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

Adapting a Lean leadership-training program within a health care organization through cocreation

Purpose

The purpose of this paper is to describe and evaluate a Lean leadership-training program within the health-care sector. A training program developed through a cocreative process with the intent of enhancing the possibilities for a context-specific adaption of Lean.

Design/methodology/approach

A cocreated leadership-training program, executed over a period of one year, is described both as a model development process and as the final training program. The program was evaluated through reflective discussions and feedback as well as a written final evaluation of the program from participants in the program.

Findings

The evaluation shows that the objectives of the training program were met, at least among the participants who attended the whole program. Using a cocreative process when developing and realizing a leadership-training program enhances the possibilities for an organization to adapt Lean to its own context. One condition for this approach to be successful is that the expectations of both the organization and the university need to be in focus through the whole process. In addition, the executive team needs to be continuously engaged and create conditions for the organization to realize the potential benefits of the training program.

Originality/value

This paper highlights the challenge when applying Lean in a health-care organization but also describes a way to address Lean training and learning in this context.

An academic perspective of participation in healthcare redesign

Healthcare redesign, based on building collaborative capacity between academic and clinical partners, should create a method to facilitate flow between the key elements of health service improvement. However, utilising the skills and resources of an organisation outside of the health facility may not always have the desired effect. Accountability and mutually respectful relationships are fundamental for collaborative, sustainable and successful completion of clinical research projects. This paper provides an academic perspective of both the benefits of academic involvement in facilitating healthcare redesign processes as well as the potential pitfalls of involving external partner institutions in internal healthcare redesign projects.

Creating a development force in Swedish healthcare

PURPOSE

The purpose of this paper is to present the results from a study that investigates first-line healthcare managers' views on their role and the conditions that influence their ability to drive improvement work based on Lean.

DESIGN/METHODOLOGY/APPROACH

A questionnaire was sent to all first-line managers in a healthcare organization to investigate their views on their role, conditions and ability to create change according to Lean. The results from four of the questions are presented, which focus on how crucial they consider their role to be for managing improvement work based on Lean, what work tasks their time is spent on, what factors they consider to be important to their ability to drive change and what factors best describe what Lean provides.

FINDINGS

The results show that first-line managers claim that their role is crucial in improvement work, but when they defined their work tasks, the time spent on improvements was not frequently described. Time, support from coworkers, and a clear vision and clear goals were the three factors that they considered to be most important to their ability to drive improvement work. Considering their leadership, Lean contributed to the structure with tools and supportive methods.

ORIGINALITY/VALUE

The questions can be used separately or as part of the entire questionnaire before and along a Lean process to obtain a better understanding of how to create a sustainable Lean approach in healthcare. Understanding the factors that first-line managers consider supporting their ability in improvement work and what they consider Lean provides is important in creating a development force in Swedish healthcare.

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).

Critical success factors for the successful initiation of Lean in public hospitals in KwaZulu-Natal: a factor analysis and structural equation modelling study

BACKGROUND

Lean thinking is one of several operations-management techniques which have yet to be fully embraced in the South African health care sector. In most health care managers' service delivery mandates, what needs to be done might be known, but it is how it should be done which might be alien to most managers. In order to recognise the "how", one needs to know the critical success factors for Lean initiation.

METHODS

The research took the form of an observational descriptive study with quantitative methods. The objectives were to identify the key variables for the successful initiation of Lean and then to conduct factor analysis and structural equation modelling (SEM) on these variables leading to the identification of critical success factors (CSFs) for Lean initiation. Simple random sampling was applied to select the participants from various categories of 500 senior managers across 73 KwaZulu-Natal (KZN) public hospitals. The sample size was 218, with a response rate of 96.8% (n = 211). For the purpose of identifying key variables for the successful initiation of Lean and then of conducting factor analysis and SEM on these variables, a self-administered, structured questionnaire was used. Data were reduced using exploratory factor analysis (EFA) to identify latent constructs. Confirmatory factor analysis (CFA) was used to determine the reliability and validity of these factors. Structural equation modelling (SEM) fit indices were then applied to assess acceptability of the measurement model.

RESULTS

Certain variables were eliminated during EFA if they cross-loaded onto more than one factor, since this caused discriminant validity problems. In addition, if variables loaded weakly onto a factor, they were not retained. Three critical success factors (CSFs) were identified in this study: strategic leadership and organisational attitude; integration of Lean elements, tools, and techniques; and basic stability in operational processes. All reliability and validity conditions have been met (RMSEA = 0.085; CFI = 0.956 and χ²/df = 2.513), consequently rendering the model reliable and valid.

CONCLUSION

None of the three CSFs can be viewed in isolation, as they all have significance at different dimensions of capability within the organisation. The use of these CSFs and the context, content, application, and outcome of Lean should be viewed in light of the organisation's strategic, technical, structural, and cultural environment. Further research in the effectiveness of these CSFs for the rollout of Lean in South African hospitals would be of benefit to the Lean body of knowledge.

Revolution or 30-year fad? A role for I-O psychology in Lean management

Lean management and related ideas have had a significant impact on organizations throughout North America and the world. Despite its popularity and impact, I-O psychologists have largely neglected Lean as a research topic and few I-O psychologists engage in applied practice in the area. In this focal article, we provide a working definition of Lean and present examples of Lean’s influence. Next, we outline possible reasons to explain I-O psychologists’ indifference to Lean. Finally, we provide some topic areas that I-O psychologists can use to contribute to the Lean literature. By using I-O psychologists’ skill in measurement and evaluation, along with our considerable organizational theory, we believe that I-O psychology can improve Lean and broaden their impact. We hope this focal article will inspire I-O psychologists to reconsider a research and practice area that they have previously ignored. In addition, we hope that this article causes I-O psychologists to reflect on their role to play in addressing popular management trends.

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.

Lean bundles in health care: a scoping review

PURPOSE

The purpose of this paper is to review original research on lean management (LM) in health care to identify potential research gaps and present recommendations for future research. The paper also discusses the current state of implementing LM practices in health care. In addition, it presents and highlights "lean bundles" imported from manufacturing, namely, total quality management (TQM), human resource management, just-in-time and total productive maintenance, as a potential implementation strategy of LM in hospitals to optimize overall health care performance.

DESIGN/METHODOLOGY/APPROACH

The scoping review was conducted based on the guidelines specified by Arksey and O'Malley (2005). Relevant included studies were retrieved by searching various electronic databases. The PRISMA guidelines were applied to identify and select eligible studies.

FINDINGS

The majority of previous studies used selected practices to measure LM in health care. In most cases, these practices reflected a narrow and biased view of LM. Lean bundles which comprehensively view LM and reflect all its aspects have rarely been discussed in the health care literature. Evidence about the contribution of lean bundles to hospital performance needs to be addressed in future studies.

PRACTICAL IMPLICATIONS

This paper demonstrates the implementation of the four lean bundles in hospitals. It argues that, instead of adopting one dimension or selected practices of LM, hospitals viewing LM as a comprehensive multi-dimensional approach through the adoption of the four lean bundles are expected to maximize their performances.

ORIGINALITY/VALUE

This is one of the first works to comprehensively review and discuss lean bundles in the context of health care. It argues that the adoption of the four lean bundles by hospitals will enable them to yield the maximum LM performance benefits. In addition, a proposed survey questionnaire based on the literature review is provided to assist researchers in conducting future empirical studies.

Lean readiness within emergency departments: a conceptual framework

Purpose

The purpose of this paper is to develop a framework to assess the lean readiness within emergency departments (EDs) and identify the key quality practices deemed essential for lean system (LS) implementation.

Design/methodology/approach

An extensive review of the lean healthcare literature was conducted, including LS implementation within the healthcare sector (both generally and in EDs), best ED quality practices, essential factors for LS implementation within healthcare and lean readiness assessment frameworks. The authors identified six main categories from a literature review (top management and leadership, human resources, patient relations, supplier relations, processes and continuous improvement (CI)), and validated these based on experts’ opinion.

Findings

Several factors were identified as crucial for EDs, including top management and leadership, human resources, patient relations, supplier relations, processes and CI.

Research limitations/implications

The framework has not yet been tested, which prevents the author from declaring it fit for EDs.

Practical implications

This framework will help ED managers determine the factors that will enable/hinder the implementation of LSs within their premises.

Originality/value

To the author’s knowledge, this is the first lean readiness assessment framework for EDs and one of the few lean readiness assessment frameworks in the literature.

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.

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.

Measuring change attitudes in health care organizations

PURPOSE

Measuring attitudes of healthcare providers and managers toward change in health care organizations (HCOs) has been of widespread interest. The purpose of this paper is to evaluate the psychometric characteristics and usability of an abbreviated German version of the Change Attitude Scale.

DESIGN/METHODOLOGY/APPROACH

The Change Attitude Scale was used in a survey of healthcare providers and managers in German hospitals after the implementation of a breast cancer center concept. Reliability analysis, confirmatory factor analysis, structural equation modeling and bivariate analysis were conducted.

FINDINGS

Data from 191 key persons in 82 hospitals were analyzed. The item-scale structure produced an acceptable model fit. Convergent validity was shown by significant correlations with measures of individuals' general opinions of the breast center concept. A non-significant correlation with a scale measuring the hospital's hierarchical structure of leadership verified discriminant validity. The interaction of key persons' change attitude and hospitals' change performance through change culture as a mediator supported the predictive validity.

RESEARCH LIMITATIONS/IMPLICATIONS

The study found general support for the validity and usability of a short version of the German Change Attitude Scale.

PRACTICAL IMPLICATIONS

Since attitudes toward change influence successful implementation, the survey may be used to tailor the design of implementation programs and to create a sustainable culture of high readiness for change.

ORIGINALITY/VALUE

This is the first study finding that a short instrument can be used to measure attitudes toward change among healthcare providers and managers in HCOs.

Interlinking Lean and sustainability: how ready are leaders?

Purpose

The purpose of this paper is to explore the evidence of interlinkages between Lean and sustainability among organisational leaders in the early stages of Lean implementation.

Design/methodology/approach

A multiple-site case study was conducted to study the connections between Lean and sustainable development during the implementation stages of a Lean practice. In-depth interviews were conducted with managers about their knowledge and understanding of the interlinkages between Lean and sustainable development. The findings were then used as an analytic frame to determine whether these interlinkages were present in the organisation.

Findings

Evidence of interlinkages between Lean and sustainable development was found; however, their presence was incomplete and inconsistent across clinics.

Research limitations/implications

Insights from the research can help organisations plan for the implementation of Lean practice, particularly when a sub-goal is to achieve sustainable development.

Originality/value

The study shows the importance of focussing on managers’ knowledge and understanding of the interlinkages between Lean and sustainable development when implementing Lean in order to utilise Lean’s full potential to achieve sustainability.