Organisational readiness and Lean Thinking implementation: findings from three emergency department case studies in New Zealand

How can the healthcare system deliver sustainable performance? A scoping review

BACKGROUND

Increasing health costs, demand and patient multimorbidity challenge the sustainability of healthcare systems. These challenges persist and have been amplified by the global pandemic.

OBJECTIVES

We aimed to develop an understanding of how the sustainable performance of healthcare systems (SPHS) has been conceptualised, defined and measured.

DESIGN

Scoping review of peer-reviewed articles and editorials published from database inception to February 2021.

DATA SOURCES

PubMed and Ovid Medline, and snowballing techniques.

ELIGIBILITY CRITERIA

We included articles that discussed key focus concepts of SPHS: (1) definitions, (2) measurement, (3) identified challenges, (4) identified solutions for improvement and (5) scaling successful solutions to maintain SPHS.

DATA EXTRACTION AND SYNTHESIS

After title/abstract screening, full-text articles were reviewed, and relevant information extracted and synthesised under the five focus concepts.

RESULTS

Of 142 included articles, 38 (27%) provided a definition of SPHS. Definitions were based mainly on financial sustainability, however, SPHS was also more broadly conceptualised and included acceptability to patients and workforce, resilience through adaptation, and rapid absorption of evidence and innovations. Measures of SPHS were also predominantly financial, but recent articles proposed composite measures that accounted for financial, social and health outcomes. Challenges to achieving SPHS included the increasingly complex patient populations, limited integration because of entrenched fragmented systems and siloed professional groups, and the ongoing translational gaps in evidence-to-practice and policy-to-practice. Improvement strategies for SPHS included developing appropriate workplace cultures, direct community and consumer involvement, and adoption of evidence-based practice and technologies. There was also a strong identified need for long-term monitoring and evaluations to support adaptation of healthcare systems and to anticipate changing needs where possible.

CONCLUSIONS

To implement lasting change and to respond to new challenges, we need context-relevant definitions and frameworks, and robust, flexible, and feasible measures to support the long-term sustainability and performance of healthcare systems.

Conceptualising contexts, mechanisms and outcomes for implementing large-scale, multisite hospital improvement initiatives: a realist synthesis

DESIGN

Realist synthesis.

STUDY BACKGROUND

Large-scale hospital improvement initiatives can standardise healthcare across multiple sites but results are contingent on the implementation strategies that complement them. The benefits of these implemented interventions are rarely able to be replicated in different contexts. Realist studies explore this phenomenon in depth by identifying underlying context-mechanism-outcome interactions.

OBJECTIVES

To review implementation strategies used in large-scale hospital initiatives and hypothesise initial programme theories for how they worked across different contexts.

METHODS

An iterative, four-step process was applied. Step 1 explored the concepts inherent in large-scale interventions using database searches and snowballing. Step 2 identified strategies used in their implementation. Step 3 identified potential initial programme theories that may explain strategies' mechanisms. Step 4 focused on one strategy-theory pairing to develop and test context-mechanism-outcome hypotheses. Data was drawn from searches (March-May 2020) of MEDLINE, Embase, PubMed and CINAHL, snowballed from key papers, implementation support websites and the expertise of the research team and experts.

INCLUSION CRITERIA

reported implementation of a large-scale, multisite hospital intervention. RAMESES reporting standards were followed.

RESULTS

Concepts were identified from 51 of 381 articles. Large-scale hospital interventions were characterised by a top-down approach, external and internal support and use of evidence-based interventions. We found 302 reports of 28 different implementation strategies from 31 reviews (from a total of 585). Formal theories proposed for the implementation strategies included Diffusion of Innovation, and Organisational Readiness Theory. Twenty-three context-mechanism-outcome statements for implementation strategies associated with planning and assessment activities were proposed. Evidence from the published literature supported the hypothesised programme theories and were consistent with Organisational Readiness Theory's tenets.

CONCLUSION

This paper adds to the literature exploring why large-scale hospital interventions are not always successfully implemented and suggests 24 causative mechanisms and contextual factors that may drive outcomes in the planning and assessment stage.

Nursing staff confidence and knowledge when caring for people with self-harm injuries: a service improvement study

The knowledge and confidence of nursing staff can impact re-harming rates of patients with self-harm injury. This service improvement study sought to address the knowledge, confidence and practice issues for staff nurses and healthcare assistants (HCAs) caring for patients who had presented to the emergency department (ED) with self-harm injury. The knowledge and confidence of nursing staff was reported using Likert-style questionnaires in a longitudinal study, framed within one Plan, Do, Study, Act (PDSA) cycle. Attitudes and challenges to patient care were also sought to inform future practice. The findings, based on the responses of 10 nurses and 5 HCAs, showed an increase in knowledge and confidence among both staff groups following the education session. Of the 15 who participated, 5 provided feedback to a reflective questionnaire to assess their views 30 days after the intervention. Quantitative data revealed a perception in an increase in the standard of care. The study found that both knowledge and confidence in supporting individuals presenting with self-harm in the ED improved at 30 days post-educational intervention. The numbers in the study were small and challenge transferability, however, service improvement theory is concerned with identifying measures of success rather than statistical reliability.

A framework to guide the implementation of lean management in emergency department

PURPOSE

The paper aims at enriching the knowledge of the application of lean management (LM) in emergency department (ED), structuring the methodology for implementing LM projects and summarizing the relevant dimensions of LM adoption in ED.

DESIGN/METHODOLOGY/APPROACH

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a systematic literature review has been performed, extracting a database of 34 papers. To answer the research purpose, a descriptive and content analyses have been carried out.

FINDINGS

The descriptive analysis demonstrates that the dealt topic is worldwide emerging and multidisciplinary as it arouses interest by medical and engineering communities. Despite the heterogeneity in the adopted methodology, a framework can be grasped from the literature review. It points out the phases and activities, the tools and techniques and the enablers to be considered for guiding the developing of LM project in ED.

ORIGINALITY/VALUE

This paper provides a comprehensive overview on how to adopt LM in ED, contributing to fill in the gap emerged in the literature. From a practical perspective, this paper provides healthcare managers with a synthesis of the best managerial practices and guidelines in developing a LM project in ED.

Process improvement approaches in emergency departments: a review of the current knowledge

Purpose

The healthcare system has been under pressure to provide timely and quality healthcare. The influx of patients in the emergency departments (EDs) is testing the capacity of the system to its limit. In order to increase EDs' capacity and performance, healthcare managers and practitioners are adopting process improvement (PI) approaches in their operations. Thus, this study aims to identify the main PI approaches implemented in EDs, as well as the benefits and barriers to implement these approaches.

Design/methodology/approach

The study is based on a rigorous systematic literature review of 115 papers. Furthermore, under the lens of thematic analysis, the authors present the descriptive and prescriptive findings.

Findings

The descriptive analysis found copious information related to PI approaches implemented in EDs, such as main PIs used in EDs, type of methodological procedures applied, as well as a set of barriers and benefits. Aiming to provide an in-depth analysis and prescriptive results, the authors carried out a thematic analysis that found underlying barriers (e.g. organisational, technical and behavioural) and benefits (e.g. for patients, the organisation and processes) of PI implementation in EDs.

Originality/value

The authors contribute to knowledge by providing a comprehensive review of the main PI methodologies applied in EDs, underscoring the most prominent ones. This study goes beyond descriptive studies that identify lists of barriers and benefits, and instead the authors categorize prescriptive elements that influence these barriers and benefits. Finally, this study raises discussions about the behavioural influence of patients and medical staff on the implementation of PI approaches.

The impact of lean management on frontline healthcare professionals: a scoping review of the literature

Background

Lean management practices are increasingly used in hospitals. However, their impacts on staff have not been systematically synthesised. This scoping review aims to synthesise the evidence on the effects of Lean Management practices on frontline healthcare professionals.

Methods

A search was conducted in February 2020 on multiple databases to identify relevant sources. Studies had to satisfy the following inclusion criteria to be considered: published in English or French, peer-reviewed, empirical, studied the use of Lean in a healthcare setting and focused on its impacts on frontline workers. The studies included were heterogeneous in terms of participants. Findings were coded and classified using a thematic analysis. The quality and methodological rigour of the reviewed articles were assessed to establish a level of confidence in their findings.

Results

Of 998 identified articles, 17 were included in the review. The findings were coded into four themes: (1) Morale, motivation and job satisfaction (n = 9, 2) work intensification, job strain, anxiety, stress and dehumanisation (n = 7, 3) teamwork, communication and coordination (n = 6); and (4) learning, innovation and personal development (n = 3). Overall, the articles reported positive (n = 11), negative (n = 3) and mixed (n = 3) impacts of Lean on frontline healthcare professionals.

Conclusion

This review is the first to synthesise and highlight the gaps in the existing literature examining the impacts of Lean on frontline health professionals. The review revealed a range of both positive, negative and mixed effects, and points to the need for more empirical research to identify the underlying reasons leading to these outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06344-0.

Benchmarking outcomes on multiple contextual levels in lean healthcare: a systematic review, development of a conceptual framework, and a research agenda

Background

Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists.

Methods

We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare.

Results

We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality.

Conclusions

When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.

Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review

The most commonly used techniques for addressing each Emergency Department (ED) problem (overcrowding, prolonged waiting time, extended length of stay, excessive patient flow time, and high left-without-being-seen (LWBS) rates) were specified to provide healthcare managers and researchers with a useful framework for effectively solving these operational deficiencies. Finally, we identified the existing research tendencies and highlighted opportunities for future work. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to undertake a review including scholarly articles published between April 1993 and October 2019. The selected papers were categorized considering the leading ED problems and publication year. Two hundred and three (203) papers distributed in 120 journals were found to meet the inclusion criteria. Furthermore, computer simulation and lean manufacturing were concluded to be the most prominent approaches for addressing the leading operational problems in EDs. In future interventions, ED administrators and researchers are widely advised to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for upgrading the performance of EDs. On a different tack, more interventions are required for tackling overcrowding and high left-without-being-seen rates.

Features and Results of Conducted Studies Using a Lean Management Approach in Emergency Department in Hospital: A Systematic Review

Objective:

To perform a systematic review of the properties and results of the studies that their approaches are lean management in emergency departments and the factors which influence on their performance.

Method:

The necessary information in the first stage was collected by searching these keywords: "Lean principles" “Lean Six Sigma", "Lean Process", “Lean thinking”, “Lean Methodology”, “Toyota Production System lean processing”, "lean techniques", "emergency department”, “emergency medicine”, “emergency room” and “emergency care ” . And in the next stage the keywords such as “lean management” and “emergency” was collected from SID, Medlib, IranDoc, Google Scholar, MagIran, IranMedex data bases. For extracting the data data-extracting forms was prepared. The information we got from the forms was organized in information-extracting forms and was analyzed manually. The diagrams were drawn in Excel: 2010.

Results:

Finally, 26 essays have been included. Most of the studies were accomplished in Canada and U.S.A. only in one of the cases, the authors used the control group. Each of these terms, “lean techniques” and “lean principals”, with five times repetitions had the highest frequency. The most important team of implementation of lean management included: hospital management team or the manager of Emergency department, physicians, nurses, staffs and external counselors. Generally, 51 indicators were studied which among them the length of stay and the timing had the most frequency. After implementation of lean management, almost all studied indicators have significantly improved. 14 barriers, 14 facilitators and 10 effective factors were recognized in implementing the lean management.

Conclusion:

According to the studies, responsibility of organization’s senior management and his/her supports; increasing the knowledge of the characteristics and dimension of lean among the providers of health service; and decreasing the resistance and consulting with external counselors can have great effect on the success of lean management.

Easier and Faster Is Not Always Better: Grounded Theory of the Impact of Large-Scale System Transformation on the Clinical Work of Emergency Medicine Nurses and Physicians

Background

The effectiveness of Lean Thinking as a quality improvement method for health care has been contested due, in part, to our limited contextual understanding of how it affects the working conditions and clinical workflow of nurses and physicians. Although there are some initial indications, arising from prevalence surveys and interviews, that Lean may intensify work performed within medical environments, the evidence base still requires detailed descriptions of the changes that were actually introduced to individuals’ clinical workflow and how these changes impacted health care professionals.

Objective

The aim of this study was to explore ways in which a Lean intervention may impact the clinical work of emergency medicine nurses and physicians.

Methods

We used a realist grounded theory approach to explore the clinical work of nurses and physicians practicing in 2 emergency medicine departments from a single teaching hospital in Canada. The hospital has 1000 beds with 128,000 emergency department (ED) visits annually. In 2013, both sites began a large-scale, Lean-driven system transformation of their practice environments. In-person interviews were iteratively conducted with health care professionals from July to December 2017. Information from transcripts was coded into categories and compared with existing codes. With repeated review of transcripts and evolving coding, we organized categories into themes. Data collection continued to theoretical sufficiency.

Results

A total of 15 emergency medicine nurses and 5 physicians were interviewed. Of these, 18 individuals had practiced for at least 10 years. Our grounded theory involved 3 themes: (1) organization of our clinical work, (2) pushed pace in the front cell, and (3) the toll this all takes on us. Although the intervention was supposed to make the EDs work easier, faster, and better, the participants in our study indicated that the changes made had the opposite impact. Nurses and physicians described ways in which the reconfigured EDs disrupted their established practice routines and resulted in the intensification of their work. Participants also identified indications of deskilling of nurses’ work and how the new push-forward model of patient care had detrimental impacts on their physical, cognitive, and emotional well-being.

Conclusions

To our knowledge, this is the first study to describe the impact of Lean health care on the working conditions and actual work of emergency medicine nurses and physicians. We theorize that rather than support health care professionals in their management of the complexities that characterize emergency medicine, the physical and process-based changes introduced by the Lean intervention acted to further complicate their working environment. We have illuminated some unintended consequences associated with accelerating patient flow on the clinical workflow and perceived well-being of health care professionals. We identify some areas for reconsideration by the departments and put forward ideas for future research.

New Zealand's emergency department target - did it reduce ED length of stay, and if so, how and when?

Background

In 2009, the New Zealand government introduced a hospital emergency department (ED) target – 95% of patients seen, treated or discharged within 6 h - in order to alleviate crowding in public hospital EDs. While these targets were largely met by 2012, research suggests that such targets can be met without corresponding overall reductions in ED length-of-stay (LOS). Our research explores whether the NZ ED time target actually reduced ED LOS, and if so, how and when.

Methods

We adopted a mixed-methods approach with integration of data sources. After selecting four hospitals as case study sites, we collected all ED utilisation data for the period 2006 to 2012. ED LOS data was derived in two forms-reported ED LOS, and total ED LOS - which included time spent in short-stay units. This data was used to identify changes in the length of ED stay, and describe the timing of these changes to these indicators. Sixty-eight semi-structured interviews and two surveys of hospital clinicians and managers were conducted between 2011 and 2013. This data was then explored to identify factors that could account for ED LOS changes and their timing.

Results

Reported ED LOS reduced in all sites after the introduction of the target, and continued to reduce in 2011 and 2012. However, total ED LOS only decreased from 2008 to 2010, and did not reduce further in any hospital. Increased use of short-stay units largely accounted for these differences. Interview and survey data showed changes to improve patient flow were introduced in the early implementation period, whereas increased ED resources, better information systems to monitor target performance, and leadership and social marketing strategies mainly took throughout 2011 and 2012 when total ED LOS was not reducing.

Conclusions

While the ED target clearly stimulated improvements in patient flow, our analysis also questions the value of ED targets as a long term approach. Increased use of short-stay units suggests that the target became less effective in ‘standing for’ improved timeliness of hospital care in response to increasing acute demand. As such, the overall challenges in managing demand for acute and urgent care in New Zealand hospitals remain.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2617-1) contains supplementary material, which is available to authorized users.

Exploring "patient-centered" hospitals: a systematic review to understand change

Background

The healthcare scenario in developed countries is changing deeply: patients, who are frequently affected by multi-pathological chronic conditions, have risen their expectations. Simultaneously, there exist dramatic financial pressures which require healthcare organizations to provide more and better services with equal (or decreasing) resources. In response to these challenges, hospitals are facing radical transformations by bridging, redesigning and engaging their organization and staff.

Methods

This study has the ambitious aim to shed light and clearly label the trends of change hospitals are enhancing in developed economies, in order to fully understand the presence of common trends and which organizational models and features are inspiring the most innovative organizations. The purpose is to make stock of what is known in the field of hospital organization about how hospitals are changing, as well as of how such change may be implemented effectively through managerial tools. To do so the methodology adopted integrates a systematic literature review to a wider engaged research approach.

Results

Evidence suggests that the three main pillars of change of the system are given by the progressive patient care model, the patient-centered approach and the lean approach. However, there emerge a number of gaps in what is known about how to exploit drivers of change and their effects.

Conclusions

This study confirms that efforts in literature are concentrated in analyzing circumscribed experiences in the implementation of new models and approaches, failing therefore to extend the analysis at the organizational and inter-organizational level in order to legitimately draw consequences to be generalized. There seem to be a number of “gaps” in what is known about how to exploit drivers of change and their effects, suggesting that the research approach privileged till now fails in providing a clear guidance to policy makers and to organizations’ management on how to concretely and effectively implement new organizational models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2306-0) contains supplementary material, which is available to authorized users.

Can lean contribute to work intensification in healthcare?

Purpose

The purpose of this paper is to review and discuss the effects of the introduction of lean into healthcare workplaces, phenomena that have not been widely investigated.

Design/methodology/approach

The paper draws on discussions and findings from the literature. It seeks to bring the few geographically dispersed experiences and case studies together to draw some conclusions regarding lean’s negative effects.

Findings

Two recurring themes emerge. The first is there is little evidence of Lean’s impact on work and the people who perform it. The literature therefore suggests that we understand very little about how work conditions are changed and how Lean’s negative effects arise and may be managed in healthcare workplaces. A second observation is that Lean’s effects are ambiguous. For some Lean seems to intensify work, while for others it leads to improved job satisfaction and productivity. Given this variety, the paper suggests a research emphasis on Lean’s socio-cultural side and to derive more data on how work and its processes change, particularly in the context of healthcare team-working.

Originality/value

The paper concludes that without improved understanding of social contexts of Lean interventions its value for healthcare improvement may be limited. Future research should also include a focus on how the work is changed and whether high-performance work system practices may be used to offset Lean’s negative effects.