A case-based methodology for lean implementation in hospital operations

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.

Diagnosing patient flow issues in the emergency department: an Australasian hospital case study

PURPOSE

This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector.

DESIGN/METHODOLOGY/APPROACH

An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors.

FINDINGS

High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management's commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident.

RESEARCH LIMITATIONS/IMPLICATIONS

This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays.

PRACTICAL IMPLICATIONS

This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow.

ORIGINALITY/VALUE

This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department's value stream maturity.

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.

Process control: simply a matter of efficiency or of survival and costs? A single-centre quality improvement project in living donor renal transplant

BACKGROUND

Rising incidence and prevalence of end-stage renal disease is a worldwide concern for sustainability of healthcare systems and societies. Living donor renal transplant [LDRT] provides highest health achievements and cost containment than any alternative form of renal replacement therapy. Nonetheless, about 25% of potential LDRTs are missed for causes directly related with inadequate timing in donor assessment. Our quality improvement (QI) project implement process control tools and strategy aiming at reducing total evaluation time for donor candidates and minimizing dialysis exposure for intended recipients, which are the two main determinants of clinical outcomes and costs.

METHODS

The study includes patients who underwent donor nephrectomy between January 1, 2017 and December 31, 2021. Six Sigma DMAIC approach was adopted to assess Base Case performance (Jan2017-Jun2019) and to design and implement our QI project. Study of current state analysis focused on distribution of time intervals within the assessment process, analysis of roles and impacts of involved healthcare providers and identification of targets of improvement. Improved Scenario (Jul2019-Dec2021) was assessed in terms of total lead time reduction, total pre-transplantation dialysis exposure and costs reduction, and increase in pre-emptive transplantations. The study was reported following SQUIRE 2.0 Guidelines for QI projects.

RESULTS

Study population includes 63 patients, 37 in Base Case and 26 in Improved Scenario. Total lead time reduced from a median of 293 to 166 days and this in turn reduced pre-transplantation dialysis exposure and costs by 45%. Rate of potential pre-emptive donors' loss changes from 44% to 27%.

CONCLUSIONS

Lean methodology is an effective tool to improve quality and efficiency of healthcare processes, in the interest of patients, healthcare professionals and payers.

Lean healthcare applied systematically in a medium-sized medical clinic hospitalization

PURPOSE

The objective of this paper is to propose a systematic application of Lean Healthcare in the hospitalization activity in the medical clinic entry process.

DESIGN/METHODOLOGY/APPROACH

The methodology used is established in three stages: the first aims to map the process in which the focus activity is inserted, using lean tools, as well as integrating the employees involved in the application. The second is the proposal to apply the systematic, together with the employees, using the A3 tool step by step. Finally, the third stage confirms the applied systematic, collecting the results and analyzing the initial situation with those reached.

FINDINGS

As a result, improvements were made in the medical clinic entry process, such as reduced waiting time for patients, at approximately 53.8%, with a decrease in the standard deviation of the times - of approximately 79.14%, and displacement of those involved, of 72%, in addition to eliminating unnecessary activities for the process. Furthermore, the empirical results on the efficiency of this systemic application in medical clinic enable the replication of this proposal, generating a systematic.

RESEARCH LIMITATIONS/IMPLICATIONS

Despite establishing a systematic proposal with real results, it is focused on only one application, due to time limitations, may generate a subjective evaluation of the systematic. Thus, for future research, it is recommended to expand this systemic application in other activities of different processes.

PRACTICAL IMPLICATIONS

The practical implications of this paper are precisely related to the data obtained with the application made, developing a Lean Healthcare systematic not previously seen, which is strategic, systemic and has a roadmap to assist in its application and, in addition, brings with it practical results that prove their efficiency.

SOCIAL IMPLICATIONS

The social implications of this paper are presented in its empirical results, considering that the study hospital serves, in addition to its host city, 28 other smaller municipalities around it, improving the flow of processes, ensuring better management of the clinic doctor. In addition, the results can assist the processes flow of other medical clinics in hospitals around the world, especially at critical moments, such as pandemics or epidemics.

ORIGINALITY/VALUE

Due to the positive results obtained in the systematic application, this paper fills a gap identified in the literature, proposing a systematic application of Lean Healthcare that is systemic and strategic, in addition to including a roadmap and analysis of data applied in a medium-sized Brazilian hospital, presenting positive practical results exposed in the paper.

The first evidence about conceptual vs analytical lean healthcare research studies

PURPOSE

Several authors have examined the lean healthcare literature, but besides all efforts made, articles comparing conceptual and analytical studies were not found. Thus, a systematic review is conducted aiming to understand the state of the art of lean healthcare by investigating and comparing how conceptual and analytical articles address tools/methods, application fields, implementation barriers and facilitators and positive and negative impacts.

DESIGN/METHODOLOGY/APPROACH

Articles in English about lean healthcare, published in journals in the last ten years (2009-2018) and indexed in Web of Science (WoS) or Scopus were examined and assessed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) protocol. A qualitative content analysis on the eligible articles was conducted, and results from the conceptual and analytical studies were compared.

FINDINGS

There is a literature gap regarding tools/methods in both conceptual and analytical approaches once they prioritize for different items. Barriers, facilitators and negative impacts are perceived differently within both categories and might require more extensive analysis. The same items prevail in both conceptual and analytical categories when analyzing healthcare fields and positive impacts.

ORIGINALITY/VALUE

There is a lack of articles comparing conceptual and analytical studies concerning lean healthcare. So, this study's relevance is in identifying theoretical and applied research gaps to strengthen the lean healthcare state of the art and to integrate theoretical-applied knowledge. For healthcare professionals, it might provide an overview of the key factors that can promote lean implementation.

Development of supply chain value stream map for government-supported drug distribution system

Purpose

The requirement of high-quality government-supported healthcare services has necessitated the significance of recognizing new management practices to enhance patient satisfaction. Hence, the purpose of this study is to address the patient's enhanced custom needs through the implementation of supply chain value stream mapping (SCVSM) in government-supported drug distribution system (DDS) for enhanced patient's satisfaction.

Design/methodology/approach

This study elucidates the role of one popular emerging management technique (i.e. SCVSM) in the healthcare sector by an investigative case study. The DDS in Rajasthan (India) was selected for this study. The data for this analysis were gathered in three ways (i.e. direct observation, documentary analysis and semi-structured interviews).

Findings

The outcome of this current study reveals that it is possible to apply the tool (SCVSM) to investigate the wastes in DDS to deliver the medicines at right time, right quantity and right quality. The application of SCVSM concluded that the various Kaizens (areas needed to improve) in lead time; transportation and routing should be adopted. The study further implemented kaizen on the current SCVSM and developed future SCVSM.

Research limitations/implications

Although various stages and functions exist in the healthcare supply chain, the current study is focused on the distribution system of drugs. The proposed approach provides a platform for both researchers and academicians to understand the existing DDS and to implement the SCVSM approach in the healthcare environment. The results show that the proposed SCVSM model is able to identify some operational bottlenecks and wastes which interfere in DDS.

Originality/value

It was observed that limited literature related to lean implementation on DDS and implementation of SCVSM on the healthcare environment in general and government-supported or public in specific are available. The current study on the application of SCVSM in DDS is unique in nature and will definitely add value to the existing literature of the application of value stream mapping (VSM) on the healthcare supply chain management field.