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Annotated Bibliography on Lean in Healthcare Organizations Prepared by Justine Po, Bozwell Bueno, and Raj Topiwala Research Assistants, CLEAR

Overview This annotated bibliography update compiles summaries and findings of systematic reviews and primary research articles focused on lean management’s application in healthcare settings, with the majority of summarized articles published within the last 3 years. All papers were published between 2000 and 2017. Primary research articles were restricted to those that focused on lean or lean-Six Sigma in healthcare. Articles are organized by whether they addressed 1) health, process, satisfaction, and cost outcomes; 2) components, methods, barriers, and facilitators of lean healthcare interventions; or 3) lean tool development, testing, and validation in healthcare. For primary articles, papers are further sub-categorized by the organizational unit (e.g. ER, surgery, laboratory) in which lean was implemented.

October 2017 Updated

Support for this work was provided by Catalysis, Lean Enterprise Institute, and Rona and Associates. For additional resources see clear.berkeley.edu.

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Table of Contents Systematic Reviews ............................................................................................................................................... 4

Systematic reviews assessing health, process, satisfaction, and cost outcomes of Lean in healthcare organizations ............ 4

Acute Care .......................................................................................................................................................................... 4

Emergency Department ...................................................................................................................................................... 5

Geriatrics ............................................................................................................................................................................ 5

General ............................................................................................................................................................................... 6

Systematic reviews identifying components, methods, barriers and facilitators for implementing Lean in healthcare

organizations ........................................................................................................................................................................... 9

General ............................................................................................................................................................................... 9

Published Primary Research Articles ............................................................................................................... 15

Primary research articles assessing health, process, satisfaction, and cost outcomes of Lean in healthcare organizations .. 15

Acute Care (Medical/Surgical) ......................................................................................................................................... 15

Community Health Clinics (CHCs) & Rural Facilities .................................................................................................... 19

Emergency Department (ED) ........................................................................................................................................... 22

Intensive Care Unit (ICU) ................................................................................................................................................ 31

Laboratory ........................................................................................................................................................................ 33

Outpatient Care ................................................................................................................................................................ 39

Pharmacy .......................................................................................................................................................................... 44

Primary & Preventive Care .............................................................................................................................................. 50

Radiology .......................................................................................................................................................................... 53

Surgery.............................................................................................................................................................................. 56

General ............................................................................................................................................................................. 73

Other ................................................................................................................................................................................. 88

Primary research articles identifying components, methods, barriers, and facilitators for implementing Lean in healthcare

organizations ......................................................................................................................................................................... 90

Cardiology ........................................................................................................................................................................ 90

Community Health Clinics (CHCs) & Rural Facilities .................................................................................................... 93

Emergency Department (ED) ........................................................................................................................................... 94

Intensive Care Unit (ICU) ................................................................................................................................................ 96

Pharmacy .......................................................................................................................................................................... 97

Primary & Preventive Care .............................................................................................................................................. 99

Surgery............................................................................................................................................................................ 103

General ........................................................................................................................................................................... 104

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Primary Research on Lean Tool Development, Testing, and Validation in Healthcare ..................................................... 115

Intensive Care Unit (ICU) .............................................................................................................................................. 115

Surgery............................................................................................................................................................................ 115

General ........................................................................................................................................................................... 116

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Systematic Reviews

Systematic reviews assessing health, process, satisfaction, and cost outcomes of

Lean in healthcare organizations

Acute Care

Deblois, S., & Lepanto, L. (2015). Lean and Six Sigma in acute care: a systematic review of reviews.

International Journal of Health Care Quality Assurance, 29(2), 192-208. doi: 10.1108/IJHCQA-05-

2014-0058

This paper was a systematic review of literature reviews summarizing lean and Six Sigma

management techniques and outcomes in acute care settings. The authors searched 8 databases and

assessed methodological quality of included reviews using AMSTAR. A narrative synthesis was then

performed, and data reported according to PRISMA standards. There were 149 articles published

between 1999 and January 2015 that were identified and reviewed, with 7 publications ultimately being

included in the systematic review. Quality of evidence ranged from poor to fair.

The most consistent finding was that lean and Six Sigma seem to be better suited for processes

involving a linear sequence of events. The review also found that tracked outcomes were most often

related to processes and quality, and acute settings most often described were operating suites, ICUs,

and EDs. Lean and Six Sigma were found to be valuable process optimization approaches in the acute

care setting. The authors stated that more studies of high methodological quality were needed to better

understand components and barriers to lean and Six Sigma implementation. Field studies comparing the

effects of lean and Six Sigma to other quality improvement initiatives were suggested as an area of

future research.

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Emergency Department

Holden, R. J. (2011). Lean Thinking in Emergency Departments: A Critical Review. Annals of Emergency

Medicine, 57(3), 265-278. doi:10.1016/j.annemergmed.2010.08.001

This article critically reviewed 18 articles describing the implementation of Lean in 15

Emergency Departments (EDs) in the United States, Australia, and Canada. The author used an

analytical framework from occupational research to generate 6 core questions regarding Lean’s effect on

ED work structures and processes, patient care, and employees, as well as Lean’s success factors.

Identified Lean process changes often involved the creation of separate patient streams along with

structural changes including new technologies, communication systems, staffing modifications, and

reorganization of physical space. Patient care was usually found to improve, as many EDs reported

decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen.

Few null or negative effects were reported, with explored patient effects typically limited to patient

satisfaction. The effect on employees was rarely measured, but there were some indicators of positive

effects. Factors for Lean success included employee involvement, management support, and

preparedness for change. The author concluded that Lean appears to offer significant improvement

opportunities in spite of methodological concerns, and that more research is needed on Lean’s effects on

patient health and employees and how Lean can be best implemented in healthcare.

Geriatrics

Butler, M. (2016). Introduction of the Productive Ward: Releasing Time to Care to Programme. Introducing the

Programme to a Care of the Older Person Unit. [MSc Thesis]. Dublin: Royal College of Surgeons in

Ireland.

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This broad literature review sought out key themes in papers on the introduction of the

Productive Ward Programme, which began in the UK National Health System and was based on lean

principles. The author states that the Productive Ward Programme was developed with the aim of

empowering staff to identify areas for improvement by providing information, time, and skills to teams

while allowing them to take ownership of the quality of care in their ward. Databases searched included

Cinahl, Pubmed, Emerald, and Google Scholar. Results were limited to articles published in English

between 2006 and 2016. Key terms used were ‘productive ward,’ ‘productive community hospital,’ and

‘releasing time to care.’ The search was then refined to review articles examining the benefits of

introduction, implementation, and adoption of the program within the healthcare setting.

Key themes found were the importance of communication with stakeholders, need for positive

leadership at multiple levels, alignment of the initiative with organizational goals, and support from

senior leadership. The literature also noted that the Productive Ward emphasized different key points of

the program depending on the audience, and that the program could bridge gaps between executive

leadership and frontline staff through a shared language helping to foster shared interests and values.

Open communication was repeatedly stated as a vital part of successful implementation.

General

Glasgow, J.M., Scott-Caziewell, J.R., & Kaboli, P.J. (2010). Guiding Inpatient Quality Improvement: A

Systematic Review of Lean and Six Sigma. The Joint Commission Journal on Quality and Patient

Safety, 36(12), 533-540.

A systematic literature review was conducted to determine whether Lean, Six Sigma, or Lean

Sigma have been effectively used to create and sustain improvements in the acute care setting.

Databases were searched for articles published in the healthcare, business, and engineering literatures.

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Study inclusion criteria required identification of a Six Sigma, Lean, or Lean Sigma project; quality

improvement efforts focused on hospitalized patients; descriptions of project improvements; and

reported results. 47 out of 539 potential articles met inclusion criteria. The authors concluded that Lean,

Six Sigma, and Lean Sigma all can address a wide variety of acute care problems, but that the true

impact of these methodologies is difficult to judge given the lack of rigorous evaluation or evidence of

clearly sustained improvements. More research is needed to provide greater understanding of these

approaches and how to achieve sustainable improvement.

Moraros, J., Lemstra, M., and Nwankwo, C. (2016). Lean interventions in healthcare: do they actually work? A

systematic literature review. International Journal for Quality in Health Care, 28(2), 150-165.

doi:10.1093/intqhc/mzv123

A systematic literature review was conducted to assess the effect of Lean on worker and patient

satisfaction, health and process outcomes, and financial costs. 9 different databases (including PubMed

and Medline) were searched for peer-reviewed articles that examined a Lean intervention and included

quantitative data, resulting in 22 articles inspected. Data on design, methods, interventions and key

outcomes were extracted and collated. They found that there was 1) no statistically significant

association with patient satisfaction and health outcomes, 2) a negative association with financial costs

and worker satisfaction, and 3) a potential but inconsistent benefit to process outcomes like patient flow

and safety. The authors concluded that evidence to date does not support the belief that Lean leads to

healthcare quality improvements. They called for more rigorous, higher quality and better conducted

scientific research to definitively ascertain the impact and effectiveness of Lean in healthcare.

Shazali, N. A., Habidin, N. F., Ali, N., Khaidir, N. A., & Jamaludin, N. H. (2013). Lean Healthcare Practice and

Healthcare Performance in Malaysian Healthcare Industry. International Journal of Scientific and

Research Publication, 3(1), 301-305.

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The authors conducted a literature review of Lean healthcare practices. They aimed to analyze

the relationship between Lean healthcare and healthcare performance as defined by 3 elements: financial

performance, customer satisfaction, and employee performance. The researchers found that while

previous studies have identified critical success factors for Lean implementation, limited empirical

studies have investigated the relationship between Lean and healthcare performance. They also proposed

future research in designing a structured questionnaire to obtain pilot study data for healthcare practices

in Malaysia.

Vest, J. R. and Gamm, L. D. (2009). A critical review of the research literature on Six Sigma, Lean and

StuderGroup's Hardwiring Excellence in the United States: the need to demonstrate and communicate

the effectiveness of transformation strategies in healthcare. Implementation Science, 4(1), 35-43.

doi:10.1186/1748-5908-4-35

Vest and Gamm conducted a systematic literature review of 3 current popular change strategies,

including Lean, and examined peer-reviewed evidence of their effectiveness. The authors found that

studies universally concluded the strategies’ success and applicability to a wide variety of settings and

problems. However, the vast majority of these studies contained methodological limitations including

weak study designs, inappropriate analyses, and failure to rule out alternate hypotheses. Additionally,

many studies did not provide substantial evidence for lasting effects or changes in organizational

culture. The paper concluded that improved design and analysis of these change theories would provide

more effective guidance to healthcare managers; more rigorous evaluation of project consultants and

partnerships with academic healthcare researchers were suggested as ways to accomplish this.

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Systematic reviews identifying components, methods, barriers and facilitators

for implementing Lean in healthcare organizations

General

Al-Balushi, S., Sohal, A. S., Singh, P. J., et al. (2014). Readiness factors for lean implementation in healthcare

settings – a literature review. Journal of Health Organization and Management, 28(2), 135-153.

This paper sought to determine readiness factors critical to the success of Lean applications in

healthcare. To this end, a comprehensive literature review focusing on lean and lean healthcare was

conducted. Commonly cited readiness factors were leadership, organizational culture, communication,

training, measurement, and reward systems. The authors also found that an organization’s ability to

implement a decentralized management style and undertake an end-to-end process view were important,

which was noted as particularly difficult for complex healthcare settings.

Andersen, H., Rovik, K. A., and Ingebrigsten, T. (2014). Lean thinking in hospitals: is there a cure for the

absence of evidence? A systematic review of reviews. BMJ Open, 4 (1). doi: 10.1136/bmjopen-2013-

003873

The authors noted that there is conflicting evidence regarding Lean outcomes, with quantitative

and qualitative studies often contradicting each other. The article aimed to identify factors facilitating

intended outcomes from lean interventions, and to understand when and how different facilitators

contribute. A 2-dimensional conceptual framework combining Shortell’s Dimensions of capability and

Walshes’ Domains of an intervention was used in conducting a systematic review of lean review articles

concerning hospitals, published in the period 2000–2012. Identified lean facilitators were then

categorized according to the intervention domains and dimensions of capability provided by the

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framework. 23 factors were identified for successful Lean intervention, with supportive management

and culture, training, accurate data, physicians and team involvement cited most frequently.

Brandao de Souza, L. (2009). Trends and approaches in Lean healthcare. Leadership in Health Services, 22(2),

121-139. doi: 10.1108/17511870910953788

In this paper, Brandao de Souza conducted a systematic search and critical literature review of

Lean healthcare articles up to 2008 in ten countries. The author employed search and metasearch

engines to identify relevant works, using key words such as “Lean healthcare”, “Lean hospital”, and

“Lean medical”. This search garnered over 90 sources, which the author then cross-referenced to find

further works. Multiple speculative U.S. studies reported positive results from use of Lean initiatives in

improving patient flow and in both clinical and non-clinical settings. However, none of these studies

provided explicit evidence of their results. The review also found that healthcare lags far behind the

manufacturing industry’s level of excellence in Lean applications, and that many case studies have been

branded as Lean while only applying one or two of Lean’s concepts. Overall, this paper concluded that

while there seems to be consensus over Lean’s potential for improving healthcare delivery, more critical

and concrete evidence is needed. Cross-organizational interaction was stated as a further avenue of

exploration.

Curatolo, N., Lamouri, S., Huet, J., & Rieutord, A. (2014). A critical analysis of Lean approach structuring in

hospitals. Business Process Management Journal, 20(3), 433-454. doi: 10.1108/BPMJ-04-2013-0051

This literature review analyzed published lean literature in the hospital setting. A methodological

maturity-level framework was used as well as 11 activities defined by the authors as characteristic of

business process improvement (BPI). The maturity-level framework defined levels from 0-6 to indicate

how much methodological support an article had to allow other practitioners to replicate its results.

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Researchers defined 0 as “Lean approach not described or poorly described” and 6 as “Lean approach

structured with a procedure model, techniques, results, role defined for each activity, and information

model.” A total of 142 articles reporting lean process improvement in hospitals were selected, all of

which sought to transform an existing process into an improved future process.

Most articles identified did not provide any description of the lean approach (level 0), preventing

other practitioners from reproducing results. The authors focused the rest of their analysis only on

articles with at least a procedure model described (≥ level 2). Only 17 out of 142 articles were found to

be at least a level 2, and none were level 5 or 6. All 17 were case studies: ten were categorized as

‘manufacturing like,’ six as ‘patient flow,’ and one as ‘organizational’.

Each of the 11 BPI activities were quoted in at least half of the 17 articles. These activities were

1) understand the environment of the organization, 2) select a process to improve, 3) establish top

management support, 4) organize a project team, 5) understand the selected process, 6) measure process

performance, 7) analyze the process, 8) improve the process, 9) manage change through communication

and training, 10) implement the new process, and 11) monitor performance indicators.

The authors recommend that hospitals introduce a lean approach starting at the micro-level by

acting on one or more operational processes using a ‘system-driven’ approach. They also suggested use

of the 11 BPI activities as a procedure model for lean approaches.

D’Andreamatteo, A. Ianni, L., Lega, F. & Sargiacomo, M. (2015). Lean in healthcare: a comprehensive review.

Health Policy, 119(9), 1197-1209. doi: 10.1016/j.healthpol.2015.02.002

A comprehensive literature review was conducted to find Lean healthcare articles published up

to 2013. Thematic analysis was then performed to extract and synthesize data for 243 articles. Lean was

mostly explored in a hospital setting, with theoretical works focusing mostly on barriers, challenges, and

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success factors. Underexplored areas of analysis included Lean sustainability, measurement frameworks,

and system-wide approaches. Authors concluded that while promising, more conclusive findings on

Lean are needed; particular investigation on the magnitude of investments required and engagement of

the whole organization were suggested. Managers and policy makers were additionally encouraged to

use research to learn how to play a pivotal role for more effective Lean implementation in different

health contexts.

Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean thinking in healthcare: a

realist review of the literature. Quality and Safety in Health Care, 19(5), 376-382.

doi:10.1136/qshc.2009.037986

The authors conducted a realist literature review to examine how Lean has been put into practice

in healthcare and how it has worked. They limited their review pool to Lean healthcare applications that

impacted patient care, and excluded hybrid approaches, resulting in 33 articles for review. A thematic

analysis was then conducted. The authors noted 4 different change mechanisms: 1) understanding

processes to generate shared understanding, 2) organizing and designing for effectiveness and

efficiency, 3) improving error detection to increase awareness and process reliability, and 4)

collaborating to systematically solve problems to enhance continual improvement. They concluded that

Lean has been successfully applied in a wide range of healthcare settings, and that most Lean healthcare

implementations have reported narrower rather than system-wide applications, contrasting with Lean’s

holistic view. Recommendations for better implementation were to directly involve senior management,

work across functional divides, pursue value creation for patients and other customers, and nurture a

long-term view of continual improvement.

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Plytuk, C.F., Gouvea da Costa, S.E., & Pinheiro de Lima, E. (2013). Lean in Healthcare: A Systematic

Literature Review and Social Network Analysis [Masters thesis]. Curitiba, Brazil: Pontifícia

Universidade Católica do Paraná.

The authors conducted a systematic review of 139 papers from the Lean Healthcare literature to

identify groupings in the Lean research field. Bibliometric citation/ co-citation and Social Network

analysis were used to investigate the articles sampled. Common paper themes involved Lean in context

of the NHS UK, pathology laboratories, reduction of variability and Six Sigma, other laboratories, and

emergency departments. Analysis of number of authors per paper found a high level of collaboration in

Lean healthcare research, with 65% of papers having between 3-12 authors. The literature review

concluded that the results revealed a still emergent field marked by poorly explored relationships and

knowledge, indicating many possibilities for future research.

Poksinska, B. (2010). The Current State of Lean Implementation in Health Care: Literature Review. Quality

Management in Health Care, 19(4), 319-329. doi:10.1097/QMH.0b013e3181fa07bb

This article sought to discuss the current state of Lean healthcare implementation through a

comprehensive literature review. It found that Lean healthcare improvement focused on 3 main areas: 1)

defining value from the patient’s perspective, 2) value stream mapping, and 3) eliminating waste in an

attempt to create continuous flow. Value stream mapping was noted as the most frequently applied Lean

healthcare tool. Typical implementation steps were to conduct Lean training, initiate pilot projects, and

utilize interdisciplinary teams. A noted barrier was lack of applied healthcare knowledge from Lean

consultants.

Young, T. P. & McClean, S. I. (2008). A critical look at Lean Thinking in healthcare. Quality and Safety in

Health Care, 17(5), 382-386. doi:10.1136/qshc.2006.020131

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This paper provided a preliminary analysis of areas where the read-across from other sectors to

Lean healthcare is relatively well understood, based on a broad review of its impact on care delivery.

The authors concluded that there was scope for methodological development in Lean healthcare by

defining three themes associated with value—the operational, the clinical and the experiential.

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Published Primary Research Articles

Primary research articles assessing health, process, satisfaction, and cost

outcomes of Lean in healthcare organizations

Acute Care (Medical/Surgical)

Calderon, A. S., Blackmore, C. C., Williams, B. L., Chawla, K. P., Nelson-Peterson, D. L., Ingraham, M. D., …

Kaplan, G. S. (2014). Transforming Ward Rounds Through Rounding-in-Flow. Journal of Graduate

Medical Education, 6(4), 750–755. doi:10.4300/JGME-D-13-00324.1

Researchers at a US, Washington state medical center implemented and evaluated lean

methodologies in clinical rounding in order to improve timely patient discharge and intern work hours.

Researchers conducted a 5 day Rapid Improvement Workshop to identify waste resulting from the

current batched rounding process, where care teams would cycle through patient beds in a series four

times for electronic health record (EHR) pre-rounds, clinical pre-rounds, attending rounds, and

discharge presentation. Identified waste from the intern workflow specifically included: 1) asking

patients for information multiple times 2) decreased recall, and 3) constant travel.

The team developed a Rounding in Flow process, where the intern stayed with the same patient

from EHR pre-rounds to discharge presentation, with the resident and attendant joining later for their

respective processes. As they were finishing final documentation of the first patient, a second intern

would begin EHR pre-rounds, allowing physicians to toggle between the two interns.

Researchers conducted a natural experiment comparing 3 different attending groups: 1)

intervention hospitalists, 2) control hospitalists who are not part of the residency program, and 3)

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surgical non-hospitalists. A total of 22,604 patients were identified as the sample between January 2011

and July 2012. Percentage of patients with a discharge order by 9AM increased significantly from 8.6%

to 26.6% (95% CI 16.1–19.9; p < .001). Resident duty hour violations, defined as a resident working in

excess of 10 hours per day, decreased from 2.96 per intern to 0.98 per intern (95% CI 1.09–2.87; p <

.001). Average daily intern work hours also decreased from 12.3 to 11.9 hours (difference, 0.4 hours;

95% CI 0.16–0.69; p < .002).

Ellingson, K., Muder, R. R., Jain, R., Kleinbaum, D., Feng, P.J., Cunningham, C., ... Jernigan, J. (2011).

Sustained Reduction in the Clinical Incidence of Methicillin-Resistant Staphylococcus aureus

Colonization or Infection Associated with a Multifaceted Infection Control Intervention. Infection

Control and Hospital Epidemiology, 32(1), 1–8. doi:10.1086/657665

Interrupted time-series analyses were used to assess the impact and sustainability of a

multifaceted intervention to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission

over 3 chronologically overlapping phases at 1 U.S. hospital. The researchers examined individuals

admitted to acute care units between October 1, 1999 and September 30, 2008. They found that after the

intervention’s initiation in 2001, clinical incidence of MRSA colonization decreased, culminating in a

total 61% decrease in the 7-year post-intervention period (p=0.02). The intervention consisted of 3

elements: 1) Lean and positive deviance change strategies to promote adherence to infection control

protocol, 2) enhanced emphasis on hand hygiene and environmental disinfection, and 3) active

surveillance testing of anterior nares and open wounds within 48 hours after admission to identify

patients asymptomatically colonized with MRSA for prompt initiation of contact precautions. The study

demonstrated a significant and sustained intervention-associated reduction in hospital-wide MRSA

transmission, as defined by clinical incidence of MRSA colonization or infection.

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McConnell, J. K., Lindrooth, R. C., Wholey, D. R., Maddox, T. M., & Bloom, N. (2015). Modern Management

Practices and Hospital Admissions. Health Economics, 25(4), 470-485. doi:10.1002/hec.3171

This study assessed whether modern management practices such as lean and publicly reported

performance measures were associated with hospital choice for acute myocardial infarction (AMI)

patients. 18 cardiac care management practices were defined and measured in a survey, with 6 out of

those 18 being lean practices. These practices were included in a national survey of US cardiac units

with a response rate of 46% (n = 581). The authors used a “method of multiple imputation” to account

for potential non-response bias; however they noted that they could not completely rule out correlation

of response with unmeasured characteristics. The American Hospital Association (AHA) Guide and

Medicare’s 2009 Hospital Cost Reporting and Information System file were used to acquire hospital

characteristics information.

The 2010 Medicare Provider Analysis and Review file was used to identify a sample of AMI

patients over 65, who were admitted to a hospital with at least 1 other competitor within 50 miles and at

least 24 annual discharges. The percentage of patients who reported “YES, they would definitely

recommend the hospital” was used as a global measure for patient satisfaction. To calculate predicted

AMI admissions compared to actual admissions and predicted Herfindahl-Hirschman Index, Medicare

Provider Analysis and Review data were also used. Additionally, management scores were calculated by

taking hospital managers’ survey scores on a 1 – 5 Likert scale and converting them into z-scores. A

more positive z-score indicated better performance in that particular practice (e.g. admitting patients,

measuring performance). An adjusted management score averaging the z-scores of all 18 practices was

then used as the primary measure of overall management practice.

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Analysis of adjusted management scores and patient admissions found that a 1 standard

deviation higher management score correlated with an 8.31% higher number of AMI admissions. The

largest change in admissions was positively correlated with the percentage of patients who would

“definitely recommend the hospital.” Higher admission rates compared to other hospitals within the

patient’s vicinity were identified as a proxy for a patient’s hospital preference. The researchers

interpreted this positive association between management scores and number of admissions as follows:

Management practices were correlated directly with admissions through reputational effects and

indirectly through improved performance on publicly reported measures. Overall, analysis found that

management scores had a statistically significant positive relationship with both AMI processes (e.g.

provision of percutaneous coronary intervention within 90 minutes of arrival) and percentage of patients

who would recommend the hospital.

Pittenger, K., Williams, B. L., Mecklenburg, R. S., & Blackmore, C. C. (2015). Improving Acute Respiratory

Infection Care Through Nurse Phone Care and Academic Detailing of Physicians. The Journal of the

American Board of Family Medicine, 28(2), 195–204. doi:10.3122/jabfm.2015.02.140197

Researchers at a US Pacific Northwest primary care clinic system implanted and evaluated a new

Acute Respiratory Infection (ARI) care pathway using lean methodologies in order to reduce

unnecessary antibiotic prescription. The research team conducted value stream mapping of the current

ARI pathway, as well as root cause analysis of inappropriate antibiotic use. Expanded physician training

and the introduction of nurse phone care were identified as potential interventions. At regularly

scheduled primary care section meetings, additional training in appropriate use of antibiotics in ARI

treatment, tracking, and local benchmarking of antibiotic prescription rates were included. Twenty-four

providers with high prescription rates or high patient volume were also selected for additional coaching

through email.

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Established patients who called to make appointments for ARI were immediately offered a

phone appointment with an onsite nurse. The nurse offered no prescriptions, but the nurse confirmed

diagnosis, offered patient education, and counseled on self-care and disease management. An in-person

provider appointment was always offered, with high risk patients always scheduled for same day

appointments. The implementation of the ARI value stream was associated with a 29.4% decrease in the

antibiotic prescribing rate per episode of ARI, after adjusting for seasonality and a general downward

trend in antibiotic prescribing (absolute decrease 16.5%, 95% CI, -.205 to -.125; p < .001). Nurse phone

consults were completed for 13.8% of ARI episodes, with 8.3% of episodes not requiring a provider

visit at all. Institutional cost savings from the intervention were estimated at $175,000.

Community Health Clinics (CHCs) & Rural Facilities

Bailey, R. (2016). Exploring the Process of Lean Training in the Healthcare Industry. [DBA thesis]. Walden

University.

This dissertation was a qualitative single case study that sought to explore how healthcare

managers successfully implemented lean training strategies to combat costs. Participants were 8

healthcare managers at a single rural care hospital in Tennessee who had implemented strategies to train

staff in lean principles. For data collection, a semi-structured interview was conducted with each

manager, and public hospital data and quality reports were reviewed. Yin’s 5-phase qualitative data

analysis process was used: Compiling the data, disassembling the data, reassembling the data,

interpreting the data, and concluding the data. Themes that emerged from the author’s analysis were

improving quality of patient care, teamwork and collaboration, hands-on learning, and training the

trainers.

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Kanamori, S., Sow, S., Castro, M. C., Matsuno, R., Tsuru, A., & Jimba, M. (2015). Implementation of 5S

management method for lean healthcare at a health center in Senegal: a qualitative study of staff

perception. Global Health Action, 8(1). doi:10.3402/gha.v8.27256

The authors attempted to assess the Lean 5S management method’s effect on the workplace,

healthcare process and outcomes, and applicability to resource-poor settings based on a pilot

intervention of the 5S program in a Senegal health facility. They conducted a qualitative study by

interviewing 21 health center staff members 1 year after the pilot intervention. Staff were asked about

their views on the changes brought on by the 5S program in their workplace, daily routines, and services

provided. Interviews were then transcribed and organized by emerging themes using thematic analysis in

the coding process. The authors concluded that the 5S management method was perceived to have

improved the quality of healthcare services and staff motivation in a resource-poor healthcare facility

with a disorderly work environment in Senegal.

Snyder, K.D. & McDermott, M. (2009). A Rural Hospital Takes on Lean. Journal for Healthcare Quality,

31(3), 23-28.

This paper discussed the journey a 99-bed rural hospital took to integrate Lean into its

organization and the outcome. The first year focused on the development of healthcare-specific Lean

training modules, honing change management skills and leadership training. The hospital CEO and

senior management invited 52 personnel (a mix of managers, nurse supervisors, line staff, and business

personnel) to be a part of the program. Team expectations included attendance at all workshops,

participation in a Lean project, and willingness to be a trainer or mentor to future Lean teams. Senior

management agreed to provide support to all team members, including time and scheduling commitment

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and assistance in reducing or eliminating barriers for success. Change management workshops were

delivered by certified university facilitators.

The hospital CEO defined 3 parameters for projects: meet the organization's strategic mission,

include a 70% clinical and 30% nonclinical project mix, and involve no large requests for new money.

The first Lean project aimed to decrease time spent obtaining supplies from a particular supply room

from entry to exit on the morning shift by 20%. Time savings of 6 minutes, 53 seconds/supply search

and annual cost savings of $9851/year were observed. A second project aimed to reduce ED waiting

times by 10% and resulted in 68 minute time savings from 230 minutes to 162 minutes after Lean. The

third and last project worked to meet a standard the clinical information be documented in e-medical

records within 30 minutes post-nursing assessment. Improvements resulted in reducing the average time

that elapsed between taking a patient's vitals and inputting data into the EMR from a high of 538

minutes after to within 30 minutes of taking the patient's vitals. The authors found that these projects

showed that similar improvements from Lean are possible within all aspects of the medical community.

Weaver, A., Greeno, C. G., Goughler, D. H., Yarzebinski, K., Zimmerman, T., & Anderson, C. (2013). The

impact of system level factors on treatment timeliness: utilizing the Toyota production system to

implement direct intake scheduling in a semi-rural community mental health clinic. Journal of

Behavioral Health Services Research, 40(3), 294–305. doi:10.1007/s11414-013-9331-5

Previous research consistently demonstrated that treatment timeliness (the amount of time

between consumers’ initial contact with mental health service providers and their first appointment) was

an important predictor of whether consumers attended their appointments. Lean was thus evaluated as a

method to change intake procedures on treatment timeliness within a semi-rural community mental

22

health clinic. A team of administrators, clinicians, and staff conducted value stream mapping of the

clinic’s intake process and identified non-value added elements, potential sources of error, and waste.

They then designed a new intake process based on Lean that focused on specifying the process in

detail, with unambiguous connections between each step, and a simple and direct pathway. The team

found it important to understand average intake/day, times of day with heaviest intake, and months with

higher intake volume in order to determine when more help was needed and how much time intake staff

would have for other duties. For data analysis, 100 randomly selected cases opened the year before the

change and 100 randomly selected cases opened the year after the change were examined using analysis

of covariance (ANCOVA). The authors found that changing intake procedures using Lean significantly

decreased the average number of days consumers waited for appointments from 11 days to 8 days (p =

.03).

Emergency Department (ED)

Burström, L., Letterstål, A., Engström, M. L., Berglund, A., & Enlund, M. (2014). The patient safety culture as

perceived by staff at two different emergency departments before and after introducing a flow-oriented

working model with team triage and lean principles: a repeated cross-sectional study. BMC Health

Services Research, 14, 296-308. doi:10.1186/1472-6963-14-296

A repeated cross-sectional study was conducted to determine the patient safety culture in a

county hospital ED and a university hospital ED. The authors used the Hospital Survey On Patient

Safety Culture questionnaire to assess this culture before and after a quality improvement project using

Lean principles and team triage at both EDs. At the county hospital, a difference between baseline and

follow-up was observed in three dimensions. For two of these dimensions, teamwork within hospital and

23

communication openness, a higher score was measured at follow-up; information and support to staff at

adverse events was rated lower at follow-up. At the university hospital, 3 dimensions were found as

lower at follow-up: staffing, information and support to patients at adverse events, and patient safety

grade. A higher score was measured at follow-up for teamwork across hospital units and teamwork

within hospital. Overall, the authors concluded that the improvement project led to changes in self-

estimated patient safety culture, with improvements in perceived teamwork and communication

openness, and declines in perceived information and support to staff during adverse events.

Chan, H., Lo, S., Lee, L., Lo, W., Yu, W., Wu, Y., ... Chan, J. (2014). Lean techniques for the improvement of

patients’ flow in emergency department, World Journal of Emergency Medicine, 5(1), 24–28.

doi:10.5847/wjem.j.1920-8642.2014.01.004

A quantitative, pre- and post-Lean design study was conducted to evaluate a series of Lean

methods implemented to improve admission and blood result waiting times at an ED. These methods

included structured re-design process, priority admission triage (PAT) program, enhanced

communication with medical department, and use of new high sensitivity troponin-T (hsTnT) blood test.

Triage waiting time, consultation waiting time, blood result time, admission waiting time, total

processing time and ED length of stay were compared before and after implementation. After Lean

implementation, the triage waiting time and end waiting time for consultation were significantly

decreased. The admission waiting time to the emergency medical ward (EMW) was also significantly

decreased from 54.76 minutes to 24.45 minutes after implementation of the PAT program (P<0.05). The

authors concluded that Lean management can improve the patient flow in ED, with adherence to lean

principles being crucial to enhance high quality emergency care and patient satisfaction.

24

Claret P. G., Bobbia X., Olive S., Demattei C., Yan J., Cohendy R., ... de la Coussaye J. E. (2016). The impact

of emergency department segmentation and nursing staffing increase on inpatient mortality and

management times. BMC Health Services Research, 16(1), 279-286. doi:10.1186/s12913-016-1544-x

This before-after study aimed to investigate the impact of a lean-based ED segmentation on

patient mortality and management delays in a French university hospital. ED segmentation consisted of

the development of a new patient care geographical layout on a pre-existing site and changing the

organization of patient flow. Data were collected through the hospital’s electronic medical record system

and compared to matching seasons from the previous year to adjust for seasonal differences in mortality.

A total of 83,322 patient visits were analyzed, with 61,118 before and 22,204 after segmentation.

Overall, there was a significant decrease in inpatient mortality after segmentation, from 1.5% during

summer 2011 to 1.3% during summer 2012 (OR = 0.85, 95% CI: 0.72,0.99).

Dickson, E. W., Anguelov, Z., Vetterick, D., Eller, A., & Singh, S. (2009). Use of Lean in the Emergency

Department: A Case Series of 4 Hospitals. Annals of Emergency Medicine, 54(4), 504-510.

doi:10.1016/j.annemergmed.2009.03.024

Participants in 2 academic and 2 community EDs that instituted Lean as their single process

improvement strategy made observations of their behavioral changes over time. They also measured the

following metrics related to patient flow, service, and growth from before and after implementation:

time from ED arrival to ED departure (length of stay), patient satisfaction, percentage of patients who

left without being seen by a physician (2 EDs), the time from ordering to reading radiographs (1 ED),

and changes in patient volume. The authors found that one year post-Lean, length of stay was reduced in

3 of the EDs despite an increase in patient volume in all 4. Each observed an increase of patient

satisfaction lagging behind by at least a year. They additionally noted that the narratives indicate that the

25

closer Lean implementation was to the original Toyota principles, the better the initial outcomes. The

immediate results were also greater in the EDs in which the frontline workers were actively participating

in the Lean-driven process changes. A factor that considerably affected the outcomes in the second and

third year post-implementation was the level of continuous leadership commitment to Lean.

El Sayed, M.J., El-Eid, G.R., Saliba, M., Jabbour, R., & Hitti E. A. (2015). Improving Emergency Department

Door to Doctor Time and Process Reliability: A Successful Implementation of Lean Methodology.

Medicine, 94 (42), e1679. doi:10.1097/MD.0000000000001679

This study aimed to determine the effectiveness of Lean management on improving emergency

department (ED) door-to-doctor times at an academic, urban tertiary care hospital. The authors

performed a before and after study at the ED after implementing a series of Lean-driven interventions

over a 20-month period. A convenience sample from the pre-intervention phase (February 2012) was

compared to another from the post-intervention phase (mid-October to mid-November 2013). Individual

control charts were used to assess process stability. Post-intervention, a statistically significant decrease

in mean door-to-doctor time (40.0 mins ± 53.44 vs 25.3 mins  ± 15.93, P < 0.001) was found. Length of

stay of both admitted and discharged patients dropped from 2.6 to 2.0  hours and 9.0 to 5.5  hours,

respectively. All other variables including emergency department visit daily volumes, hospital

occupancy, and left-without-being-seen rates were comparable.

Ford A. L., Williams J. A., Spencer M., McCammon, C., Khoury, N., Sampson, T. R., ... Lee, J. M. (2012).

Reducing door-to-needle times using Toyota’s Lean manufacturing principles and value stream analysis.

Stroke, 43(12), 3395–3398. doi:10.1161/STROKEAHA.112.670687

Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke was

previously shown to improve the efficacy of tPA, urging national efforts to reduce door-to-needle times.

26

To this end, the authors used Lean process improvement to develop a streamlined intravenous tPA

protocol. A multidisciplinary team conducted value stream analysis (VSA) of the acute ischemic stroke

patient pathway. 132 stroke patients treated with tPA before VSA and 87 patients treated with tPA after

VSA were directly compared on baseline characteristics, protocol metrics, and clinical outcomes. VSA

exposed several tPA protocol inefficiencies, which were then addressed through roll-out of a new

protocol designed to minimize delays. Average door-to-needle time dropped 21 minutes from 60 to 39

minutes post-VSA (p < 0.0001), and the % of patients treated <= 60 minutes from hospital arrival

increased from 52% to 78% post-VSA (p < 0.0001), with no change in hemorrhage rates. The paper

concluded that future studies should be implemented to determine whether this intervention is

sustainable across various hospital settings.

Greenwalt, M., Griffen, D., & Wilkerson, J. (2017). Elimination of Emergency Department Medication Errors

Due To Estimated Weights. BMJ Quality Improvement Reports, 6(1).

doi:10.1136/bmjquality.u214416.w5476

This project was created in response to 10 instances of medication dosing errors in a US urban

emergency department (ED) over an 11 month period that were that were due to incorrect documented

weight in the electronic medical record (EMR). When a patient was first admitted into the ED, nursing

staff would document an estimated weight, which was subsequently used to measure their medication

dose. After the patient was stabilized, nursing then weighed the patient on a scale to document the true

value. The authors conducted baseline measures of weight accuracy by looking at a total of 726 ED

patients seen during June 2015.

Average variance of estimated and true weights was 5.63%, and 13.8% of patients had an

estimated weight that varied more than 10%. An interdisciplinary project team utilized the lean-Six

27

Sigma DMAIC project structure, including quality trees, work process mapping, and fishbone diagrams,

to determine interventions. Implementation of interventions was done in three phases, including 1)

obtaining actual weights upon triage, 2) increased service and maintenance for scales, and 3) removal of

estimated weight from EMR. Proportion of patients with documented actual weight increased from 19%

to 91%. The authors note that 10% of patients were found to have no documented weight at all, but that

the removal of estimated weight still prevents the possibility of filling medication order with incorrect

values.

Kane, M., Chui, K., Rimicci, J., Callagy, P., Hereford, J., Shen S., Norris, R., & Pickham, D. (2015). Lean

Manufacturing Improves Emergency Department Throughput and Patient Satisfaction. Journal of

Nursing Administration, 45(9), 429-434. doi:10.1097/NNA.0000000000000228

This study involved a multidisciplinary team led by nurses and physicians who developed a plan

to meet increasing demand and improve patient experience in the ED without expanding the ED’s

resources. An assessment and planning phase consisting of 3 meetings was conducted. Meetings were

standardized and goals and objectives established to maximize effectiveness. A current state map was

created that identified wait times and left-without-being-seen (LWBS) rates as key metrics to improve

upon. The multidisciplinary team conducted value stream mapping, two 5S organization initiatives,

three rapid process improvement workshops, and active daily management (gemba) to improve these

key metrics.

The lean implementation was performed with 20 clinical staff over approximately 350 person-

hours. It resulted in a 17% reduction in median length of stay (282 minutes to 243 minutes) and a 73%

reduction in door-to-doctor time (49 minutes to 13 minutes). LWBS rates fell from 2% to 0.65%. The

results were achieved during a period of 7% growth in throughput without increasing the size of the ED,

28

at only a 1% growth in cost. Patient satisfaction metrics were also improved according to the Council of

Teaching Hospitals’ peer group percentile rankings, with “likelihood to recommend” increasing from

the 12th percentile to the 75th percentile and “waiting time to see doctor” improving from the 7th

percentile to the 75th percentile. The authors concluded that lean implementation significantly decreased

patient wait times and length of stay, while improving patient throughput and satisfaction.

Kelly, A., Bryant, M., Cox, L., & Jolley, D. (2007). Improving emergency department efficiency by patient

streaming to outcomes-based teams. Australian Health Review, 31(1), 16-21.

A pre-post study was conducted at an emergency department (ED) at a 300-bed, community

teaching hospital in Melbourne, Australia. It aimed to describe the procedure and results of a process

redesign based on task analysis and Lean thinking approaches aimed at improving ED efficiency. The

study compared 12-month periods before and after the process redesign for total episodes of ambulance

bypass, waiting times (overall and by triage category) and total ED time (overall and by triage category).

Time data were then analyzed using non-parametric methods. While the years were broadly comparable,

there was an 8.4% increase in total hours of care delivered (a marker of ED workload) in the year after

the change. Episodes of ambulance bypass reduced by 55% (120 v. 54). There were statistically

significant waiting time reductions for triage categories 3 and 5 (median reductions 5 and 11 minutes

respectively). There was an increase in total ED time for triage category 3 (median increase 7 min) and a

decrease for categories 4 and 5 (median reduction 14 and 18 min, respectively). The authors concluded

that process redesign using task analysis and Lean could improve ED efficiency.

Mazzocato, P., Holden, R. J., Brommels, M., Aronsson, H., Bäckman, U., Elg, M., & Thor, J. (2012). How does

Lean work in emergency care? A case study of a Lean-inspired intervention at the Astrid Lindgren

29

Children’s hospital, Stockholm, Sweden. BMC Health Services Research, 12(1), 28-41.

doi:10.1186/1472-6963-12-28

The authors aimed to address the gap in knowledge of how and why lean interventions succeed

or fail. They utilized a mixed methods design to evaluate an in-depth case study of a Lean-inspired

intervention in a Swedish hospital, particularly in its pediatric Accident & Emergency (A&E)

Department - the largest of 3 pediatric A&Es in Stockholm. The study aimed to compare performance

before and after lean intervention as well as explain how and why lean worked. The hospital’s weekly

average data on waiting times and patient volume were collected for 52 weeks before and 104 weeks

after Lean implementation for quantitative analysis. Additionally, qualitative data from interviews and

documents were retrospectively collected from the intervention-planning phase and prospectively

collected during the implementation phase. Analysis of variance (ANOVA) was used to assess

differences in performance pre- and post-Lean, revealing an increase in % of patients completing their

A&E visit within 4 hours from 67% to 80% [95% CI (65.5, 69.7), (78.2, 82.4)] that was maintained 2

years after the intervention. Average time to first physician consultation also decreased by 24% from 67

to 51 minutes [95% CI, (61.7, 71.5), (46.5, 56.3)] and was sustained 2 years post-Lean at 54 minutes

[95% CI, (49.4, 59.2)].

The authors explained that Lean was effective because it reduced work ambiguity, created clear

connections between caregivers who were dependent on each other, developed seamless and

uninterrupted flow, and enabled continuous improvement through worker empowerment. Barriers to

greater improvements from Lean were cited: these were job mismatch, discomfort with being monitored

or with inter-professional collaboration, and some employees’ distance from change-related decision-

making, leading to a feeling of being inadequately informed. The authors suggested further research into

30

which Lean changes contribute most to performance improvement, claims of contextual conditions

critical to further success, and the effects of Lean on employee working conditions.

Murrell, K. L., Offerman, S. R., & Kauffman, M. B. (2011). Applying Lean: Implementation of a Rapid Triage

and Treatment System. Western Journal of Emergency Medicine, 12(2), 184-191.

Lean principles were used to implement emergency department (ED) process improvements in 1

U.S. hospital, leading to the development of a Rapid Triage and Treatment (RTT) system. A

retrospective, observational study was then conducted comparing electronic medical record data 6

months before and after implementation to determine whether Lean principles had an effect on ED

metrics. The researchers found that changes in ED processes using Lean thinking and available

resources improved efficiency. Mean ED length of stay was reduced by 36 minutes and the % of patients

leaving without being seen by a doctor was reduced from 4.5% to 1.5% (95% CI). Months prior to any

changes, weekly process improvement meetings with front-line staff and department leadership were

conducted to gain staff input and plan process changes. Value stream mapping was used to analyze the

flow of patients through the ED. Non-value-adding steps were identified and then streamlined to remove

waste; weekly process meetings continued after implementation to constantly re-evaluate and modify as

needed. The researchers emphasized staff and physician involvement throughout the process.

Ng, D., Vail, G., Thomas, S., & Schmidt, N. (2010). Applying the Lean principles of the Toyota Production

System to reduce wait times in the emergency department. Canadian Journal of Emergency Medicine,

12(1), 50-57.

In recognition of patient wait times, and deteriorating patient and staff satisfaction, the authors

set out to improve these measures in the emergency department (ED) without adding any new funding or

beds. Lean techniques such as value stream mapping, just-in-time delivery techniques, workplace

31

organization, reduction of systemic wastes, use of the worker as the source of quality improvement, and

ongoing refinement of process steps formed the basis of the project. This resulted in major

improvements in departmental flow without adding any additional ED or inpatient beds. The mean

registration to physician time decreased from 111 minutes to 78 minutes. The number of patients who

left without being seen decreased from 7.1% to 4.3%. The length of stay (LOS) for discharged patients

also decreased from a mean of 3.6 to 2.8 hours. Lastly, an improvement in ED patient satisfaction scores

was noted following the implementation of Lean principles.

Vermeulen, M. J., Stukel, T. A., Guttmann, A., Rowe, B. H., Zwarenstein, M., ... Schull, M. J. (2014).

Evaluation of an Emergency Department Lean process improvement program to reduce length of stay.

Annals of Emergency Medicine, 64(5), 427–438. doi:10.1016/j.annemergmed.2014.06.007

Researchers sought to determine the effects of a Lean Emergency Department (ED) process

improvement program on ED wait times and quality of care. They directed a retrospective cohort study

of all ED visits at program and control sites during 3 waves from April 2007 to June 2011 in Ontario,

Canada. The authors then conducted time series analyses comparing pre- and post-Lean implementation

at program sites as well as difference-in-differences analyses comparing changes in program sites versus

control sites. They found that while median ED waiting times did decrease at program sites, those

benefits were diminished or disappeared when compared to control sites, which were exposed to system-

wide initiatives such as public reporting and pay-for-performance. Further research was suggested to

evaluate the effectiveness of Lean methods in the ED before warranting widespread use.

Intensive Care Unit (ICU)

32

Muder, R. R., Cunningham, C., McCray, E., Squier, C., Perreiah, P., Jain, R., ... Jernigan, J. A. (2008).

Implementation of an industrial systems-engineering approach to reduce the incidence of methicillin-

resistant Staphylococcus aureus infection. Infection Control Hosp Epidemiol, 29(8), 702-708.

doi:10.1086/589981

A before-after intervention study was conducted to measure the effectiveness of a Lean approach

to implementing a methicillin-resistant Staphylococcus aureus (MRSA) prevention program. The study

took place in an ICU and a surgical unit in the Pittsburgh Veterans Administration hospital and included

all patients admitted to these units. The MRSA prevention program was comprised of 4 elements: 1) the

use of standard precautions for all patient contact, with emphasis on hand hygiene; 2) the use of contact

precautions for interactions with patients known to be infected or colonized with MRSA; 3) the use of

active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and

4) use of Lean to facilitate consistent and reliable adherence to the infection control program. The rate of

healthcare-associated MRSA infection in the surgical unit decreased from 1.56 infections per 1,000

patient-days in the 2 years before the intervention to 0.63 infections per 1,000 patient-days in the 4 years

after the intervention (a 60% reduction; P = .003). The rate of healthcare-associated MRSA infection in

the ICU decreased from 5.45 infections per 1,000 patient-days in the 2 years before to the intervention to

1.35 infections per 1,000 patient-days in the 3 years after the intervention (a 75% reduction; P = .001).

The combined estimate for reduction in the incidence of infection after the intervention in the 2 units

was 68% (95% confidence interval, 50%-79%; P < .001).

Shannon, R. P., Frndak, D., Grunden, N., Lloyd, J. C., Herbert, C., Patel, B., … Spear, S. J. Using Real-Time

Problem Solving to Eliminate Central Line Infections. Journal on Quality and Patient Safety. 32(9):

479-487. 2006.

33

Researchers at a US academic medical center implemented lean strategies in two Intensive Care

Units (ICUs) in order to reduce central line associated bloodstream infections (CLABs). A team

consisting of directors, nurses, physicians, and administrators first trained in Perfecting Patient Care,

then worked to apply these methods in their clinical practice. The team began by first reviewing the

medical records of the 1,753 patients with CLABs between July 2002 and June 2003. They also spent 40

hours observing the placement of central lines, helping reveal issues with materials, communication,

training, and other factors that contribute to error. Between July 2003 and June 2004, the team closely

tracked and investigated any new infections to identify the root cause. After observation and

investigation, the team implemented the following changes: pre-procedure checklist, standard line

insertion kit, standard procedure documentation, and daily observation of dressing site. Incidence and

risk of infection was compared at baseline, as well as one, two, and three years post-intervention.

Between baseline and Year 3, rate of infections decreased from 10.5 infections per 1000 line days to .39

infections per 1000 line days, a 96% decrease. During the baseline year there were 19 recorded deaths

associated with CLABs; his was reduced to 0 by Year 3.

Laboratory

Cankovic, M., Varney, R. C., Whiteley, L., Brown, R., D’Angelo, R., Chitale, D., & Zarbo, R. J. (2009). The

Henry Ford Production System: LEAN Process Redesign Improves Service in the Molecular Diagnostic

Laboratory: A Paper from the 2008 William Beaumont Hospital Symposium on Molecular Pathology.

Journal of Molecular Diagnostics: JMD, 11(5), 390–399. doi:10.2353/jmoldx.2009.090002

Lean was used in a molecular diagnostic laboratory to assess inefficiencies and improve speed of

result generation. Baseline data analysis revealed that the greatest challenge to timely result generation

occurred in the pre-analytic phase of specimen collection and transport; as such, efforts focused

34

primarily on re-designing pre-analytic processes using Lean principles. The lab’s goal was to complete

greater than 90% of the molecular tests in less than 3 days. The authors stated that Lean processes

resulted in fewer steps, approaching the ideal of a one-piece flow for specimens through

collection/retrieval, transport, and different aspects of the testing process. Lean created a 44% reduction

in molecular test turnaround time for tissue specimens, from an average of 2.7 to 1.5 days. In addition,

extending Lean principles to clinician suppliers resulted in a markedly increased number of properly

collected and shipped blood specimens (from 50 to 87%). These continuous quality improvements were

accomplished by empowered workers in a blame-free environment and are now being sustained with

minimal management involvement.

Chwang, W. B., Iv, M., Smith, J., Kalnins, A., Mickelsen, J., Bammer, R., . . . Zeineh, M. (2017). Reducing

Functional MR Imaging Acquisition Times by Optimizing Workflow. RadioGraphics, 37(1), 316-322.

doi:10.1148/rg.2017160035

Researchers at a US academic medical center implemented and evaluated lean methodologies in

order to improve functional MRI acquisition times. After noting lengthy acquisition times exceeding two

hours or more, researchers initiated a project to reduce acquisition times from 76 to 60 minutes without

sacrificing quality. A multi-disciplinary team of radiology fellows, faculty, technologists, administrators,

and quality improvement managers evaluated their current state by retrospectively analyzing all

functional MRI exams between January 2013 and August 2015. The team later conducted cause and

effect analysis and identified the following key interventions: 1) eliminating intravenous contrast

medium, 2) implementing real time monitoring, 3) updating technologist and physician checklist, and 4)

updating visual slides and audio. Mean acquisition time and standard deviation reduced significantly

from 76 minutes to 53.2 and 21.5 minutes to 8.4, respectively (p < 0.01). Proportion of examinations

meeting quality standards increased from 42% to 85%.

35

Damato, C., & Rickard, D. (2015). Using Lean-Six Sigma to Reduce Hemolysis in the Emergency Care Center

in a Collaborative Quality Improvement Project with the Hospital Laboratory. Joint Commission

Journal on Quality and Patient Safety, 41(3), 99-107.

This before-after study conducted value stream mapping (VSM) in the emergency care center

(ECC) of a health care system in a large US town. The goal was to reduce hemolysis from 9.8% to 2%

in the ECC. In the VSM process, a project team of 3 laboratory managers and 2 lean-Six Sigma experts

identified hemolysis as one of seven non-value-added activities in the blood collection and pre-

analytical processes. They identified potential root causes of hemolysis and verified these against

healthcare best practices. After identification, the team then developed a system-wide protocol involving

standardized collection processes, implemented competency-based training, and improved ECC hiring

practices.

Baseline hemolysis data was collected from July 2009 to December 2009, with a mean

hemolysis percentage of 9.8%. Post-implementation data was collected from June 2010-September

2010, and showed a 64% reduction from baseline to 3.5%. This did not meet the hospital’s goal of 2%.

After the post-implementation data collection, a collaborative pilot project was launched using

PDSA cycles to confirm or negate the validity of setting a 2% goal in the ECC. A range of hemolysis

levels (from a low of 0.9% to a high of 5.8%) was shown in five non-pilot pods. The two pods with full-

time phlebotomists reduced hemolysis to 0.5%. From this data the team concluded that a 2% goal was

attainable. As it was not economically feasible to permanently hire full-time ECC phlebotomists in all

the pods, the team had phlebotomists transfer their knowledge and skills by training ECC staff (nurses

and technicians) through shadowing of the phlebotomists, teach-back, and real-time practice with

immediate feedback. New hiring practices were also integrated into the ECC, requiring that multi-skilled

36

technologists have phlebotomy training before hire and have one day of compulsory laboratory

education during their orientations. Over 4 after the changes in training and hiring practices, the mean

ECC hemolysis percentage was consistently <.50%.

Isaac-Renton, J. L., Chang, Y., Prystajecky, N., Petric, M., Mak, A., Abbott, B., ... Miller, J. D. (2012). Use of

Lean Response to Improve Pandemic Influenza Surge in Public Health Laboratories. Emerging

Infectious Diseases, 18(1), 57–62. doi:10.3201/eid1801.101485

Multidisciplinary response and rapid implementation of process changes based on Lean methods

were used at a provincial public health laboratory in British Columbia, Canada, to improve laboratory

surge capacity in the 2009 influenza H1N1 pandemic. In the face of a 10-fold increase in demand for

influenza testing without approval for additional staff, the lab needed to improve efficiency by changing

workflow processes. Before the onset of the pandemic, PHMRL staff had been trained in Lean methods,

and many had participated in activities to enhance laboratory processes. A Lean Team comprising

medical, scientific, senior, and bench-level technical staff and some administrative and support

personnel was set up to apply Lean methods to the influenza laboratory workflow. They created a

visually displayed value stream of all discrete steps in the lab workflow for influenza detection. Review

of ‘waste’ steps was conducted and a kaizen session performed by lab staff, culminating in the creation

of a scalable and standardized work process. Observed and computer simulating evaluation results from

rapid process changes showed that use of Lean tools successfully expanded surge capacity, which

enabled response to a 10-fold increase in testing demands.

Quetz J. S., Dantas I. F., Hirth C. G., Brasil C. G., & Juaçaba, S. F. (2015). Preliminary results of Lean method

implementation in a pathology lab from Northeastern Brazil. Brazilian Journal of Pathology and

Laboratory Medicine, 51(1), 33-38. doi:10.5935/1676-2444.20150007

37

This case study utilized lean tools in a Brazilian medical center to improve processes in a

pathology laboratory. Lean training was conducted by a team of facilitators comprised of 2 pathologists,

a pharmacist, an administrator, and a receptionist. Trainings sometimes included the CEO and the entire

body of employees. Value stream mapping (VSM) was then conducted, as well as spaghetti diagrams

and an A3 report. After VSM, the team implemented ‘first in, first out’, standardization, and continuous

flow to reduce lead time from 8 – 10 days to 5 days.

It was noted that the laboratory was able to easily support an increase in number of exams in

2014 under the new system; continuous flow contributed to this by evening out demand. The authors

stated that the lean implementation created a more collaborative work environment and increased

worker autonomy. They noted that lean efforts depended on the CEO’s support and the involvement of

multidisciplinary, multi-hierarchical teams. Plan-Do-Study-Act (PDSA) cycles and visual management

will be continuously used to improve processes in this laboratory.

Samuel, L., & Novak-Weekley, S. (2014). The Role of the Clinical Laboratory in the Future of Health Care:

Lean Microbiology. Journal of Clinical Microbiology, 52(6), 1812–1817. doi:10.1128/JCM.00099-14

This article aimed to provide commentary on Lean’s applications to microbiology labs, while

discussing at length the development and results of a Lean program at the HFHS Department of

Pathology and Laboratory Medicine. In 2007, the HFHS Department of Pathology and Laboratory

Medicine used a Lean management approach to consolidate 4 microbiology labs into 1 lab with a

projected 55 full-time staff conducting 700,000 tests annually. In using this approach, the department

was able to achieve consolidation and take on additional work during the integration process, without a

comparable increase in staffing. The authors concluded that Lean management practices have brought

standardization, savings, and quality to many different industries; Lean management practices within the

38

clinical microbiology laboratory could help to address the many economic, political, and medical

challenges that labs face today and in the future.

Sinnott P. L., Breckenridge J. S., Helgerson P., & Arch S. (2015). Using Lean Management to Reduce Blood

Culture Contamination. Joint Commission Journal on Quality and Patient Safety, 41(1), 26-32.

In this pre-post study, a lean quality improvement initiative was undertaken by a US Veterans

Affairs (VA) medical center to reduce its blood culture contamination (BCC) rate. A 40-hour, 1 week

rapid process improvement workshop (RPIW) was conducted by representatives from hospital medicine,

ED, nursing, phlebotomy, clinical microbiology, and others. The RPIW identified root causes of

variation in blood culture procedures and potential improvement strategies. Changes in BCC rates were

tracked over 5.25 years (2009 - 2014, including 1.5 years before the RPIW). Additionally, results from

the primary medical center were compared to data from a similar VA medical center during the same

time period.

Four root causes of BCC were identified through the RPIW and refined over a 90-day period.

The following countermeasures were then developed: Standardized training, certification, and

recertification procedures for nurses; redesigned blood culture kit; modified order templates to default to

a peripheral blood draw; wall posters with simple and clear instructions for blood draws; modified

specimen labels to include standard data elements; monthly tracking and feedback of contaminated

culture rates; and discontinued low-value speciation.

At baseline, annual average BCC rate at the medical center was 4.2%. In Year 1 post-RPIW,

BCC rate fell to 3.4%, then to 2.8% in Year 2, and 2.4% in Year 3. BCC rate increased to 3.0% in Year

4. Each year exhibited a significant BCC reduction compared to baseline, with p ≤ .0010 for all years. At

the comparison VA site, baseline BCC rate was 4.2% and BCC change was only significant in Year 2.

39

However, using a difference-in-difference estimation to find the effect of the lean intervention on BCC

rates independent of the underlying BCC rate, the underlying BCC rate was 3.6%. Only Year 3’s BCC

rate was significantly different from the baseline underlying rate (p=.004, 95% CI:-0.259,-.0051).While

the authors recognized that these results were disappointing, they noted that the project did reduce

annual BCC rates by nearly 30% during the study period.

Sunyong M. (2004). Lean Management and Six Sigma yield big gains in hospitals immediate response

laboratory: Quality improvement techniques save more than $400,000. Clinical Leadership and

Management Review, 18(5), 255-258.

This pre-post study evaluated a hospital laboratory’s efforts to implement lean with the

assistance of outside consultants. The stated goal was to reduce lab sample turn-around time with fewer

staff resources. After noting that collecting all hospital samples from patients in a two-hour period

created a daily bottleneck, the lab transitioned to three separate rounds of sampling, with phlebotomists

required to deliver each sample to the lab directly after it was drawn. This change reportedly allowed the

lab to reassign six phlebotomists, realizing savings of $160,000 per year. Addressing the layout of the

lab itself, devices were reorganized according to the measured usage by lab staff. Finally, visual

management strategies were implemented to address stock and inventory difficulties. Cabinet doors

were removed and standards for automatic supply reordering were established. A reduction of 4.5

technologists resulted in savings of $250,000 per year. In the first year of implementation overtime

spending fell from $130,000 to $52,000, a 60% decrease. Overall savings in the first year totaled more

than $400,000. Furthermore, the authors attributed an improvement in patient satisfaction scores to the

intervention (which resulted in less need to wake patients in the middle of the night).

Outpatient Care

40

Aij, K. H., Widdershoven, G., & Visse, M. (2014). Lean Process Mapping Techniques: Improving the Care

Process for Patients with Oesophageal Cancer. Global Journal of Management and Business Research,

14(2), 81-98.

This case study tested the hypothesis that Lean value-stream mapping (VSM) could help

streamline care for patients with esophageal cancer. The study took place in one of the largest tertiary

referral center for esophageal cancer in the Netherlands. The researchers began the project by evaluating

the care pathway, revealing that it was unsystematic and could lead to medical errors. Researchers then

cut the number of steps needed to begin treatment from 128 to 103 and applied standardization to reduce

variability. This implementation reduced the time it took for patients to start treatment from 13.5 to 10.5

weeks.

Baril, C., Gascon, V., Miller, J., & Côté, N. (2015). Use of a discrete-event simulation in a Kaizen event: A case

study in healthcare. European Journal of Operational Research, 249(1), 327-339.

doi:10.1016/j.ejor.2015.08.036

The authors of this paper used a business game and discrete event simulation during a Kaizen

event to simulate scenarios defined by team members in an outpatient hematology-oncology clinic. The

goal was to allow a rapid and successful implementation of solutions to reduce patient lead time from

registration to treatment preparation. The study began with the formation of a project team (including

clinicians, managers, and academics), a project launch, and employee interviews to ensure group

alignment of objectives. Process mapping of the patient pathway was then carried out for 4 different care

pathways: 1) Blood sample, meet with doctor, schedule appointment, and treatment, 2) blood sample

and treatment only, 3) treatment only, and 4) meet with doctor and schedule appointment only. After

more data was gathered about clinic processes, a study was conducted to gather data on the time it took

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for patients to reach each step in a pathway. Total lead time from registration to meeting with a doctor

could only be calculated for 2 pathways: For pathway 1 total wait time was 69.31 minutes (93% of total

lead time), and for pathway 4 total wait time was 48.50 minutes (97% of total lead time). These wait

times were both considered too high, and reducing lead time by 45% was identified as the main

objective of the Kaizen event.

Next, a business game was developed that randomly placed participants into the role of patients

with differing needs (e.g., treatment type, name of doctor to meet) and had them schedule an

appointment based on the patient’s need. A simulation model was used that modified patient arrival rates

based on the schedules generated. This allowed researchers to measure with the discrete event

simulation how scheduling impacted patient wait times. The Kaizen event lasted 3 days and resulted in

an action plan to implement changes, ideally in 20 working days.

The authors stated that because pathways 1 and 2 were divided over 2 days, it wasn’t possible to

compare results before and after testing improving propositions. Therefore only data on lead times for

pathway 3 were collected 19 weeks after implementing the changes. The researchers found that patient

delays before receiving treatment were reduced by 74% from 61 to 16 minutes, which was less than the

simulated result of 90% reduction during Kaizen. The authors hypothesized that this gap could be

explained by limits of the model not accounting for factors like patient lateness and treatments being

late. The authors concluded from their findings that participants’ involvement is crucial for the success

of an ambitious project. They noted that use of simulation and business games can encourage

participation from all members, as well as measure potential impacts of changes before implementation.

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Kamiya, Y., Ishijma, H., Hagiwara, A., Takahashi, S., Ngonyani, H. A. M., & Samky, E. (2017). Evaluating the

impact of continuous quality improvement methods at hospitals in Tanzania: a cluster-randomized trial.

International Journal for Quality in Health Care, 29(1), 32-39. doi:10.1093/intqhc/mzw128

This cluster-randomized trial evaluated the impact of lean 5S on patient satisfaction in outpatient

care units of 16 district-level hospitals in Tanzania. Eight district-level hospitals were randomly

allocated to the intervention group and 8 hospitals to the control group. Outpatient exit surveys were

conducted at all 16 hospitals at 3 time points (baseline, midpoint, and follow-up) between September

2011 and 2012: they measured cleanliness, wait times, various aspects of patient experience, and overall

patient satisfaction on a Likert scale.

At baseline, no statistical difference was found for cleanliness between the intervention and

control hospitals; at follow-up the intervention hospitals had higher scores than the controls with p<0.1

for 4 out of 5 cleanliness variables. Waiting time also decreased significantly at midpoint and follow-up

for 2 out of 4 locations (consulting room and pharmacy) within the intervention hospitals, compared to

control hospitals. Waiting time differences were not significant in the outpatient department and

laboratory, suggesting to the authors that it is easier to reduce lead-time in the consulting room and

pharmacy. Patient experience scores were significantly higher for the intervention hospitals at midpoint,

but this difference diminished at follow-up, suggesting that hospital personnel did not maintain initial

improvements. Patient satisfaction scores were significantly higher for the intervention hospitals at

midpoint but this difference was not significant at follow-up. The authors hypothesized that this could be

due to the development of patients’ higher expectations for the intervention hospitals over time, given

that the exit survey asked “if the main reason a patient came to the hospital was dealt with to their

satisfaction.” The authors concluded that 5S implementation successfully improved hospital cleanliness,

waiting time, and overall rating in the outpatient department, but that the effects on patient satisfaction

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were not strong. They suggested that this could be the result of the intervention’s ‘training of trainers’

approach, whereby the success of 5S was dependent on the motivation and ability of the ‘trainers.’

LaGanga L. R. (2011). Lean Service Operations: Reflections and New Directions for Capacity Expansion in

Outpatient Clinics. Journal of Operations Management, 29(5), 422–433. doi:10.1016/j.jom.2010.12.005

A Lean process improvement project was implemented that aimed to increase capacity to admit

new patients into a healthcare service operation system. Analysis of 1,726 appointments in outpatient

services for the year before and after the project found a 27% increase in capacity to intake new patients

and a 12% reduction in patient no-show rates as a result of changes in service processes from the

improvement project.

Wood, D. L., Brennan, M. D., Chaudhry, R., Chihak, A. A., Feyereisn, W. L., Woychick, N. L., . . . Larusso, N.

F. (2008). Standardized care processes to improve quality and safety of patient care in a large academic

practice: the Plummer Project of the Department of Medicine, Mayo Clinic. Health Services

Management Research, 21(4), 276-280. doi:10.1258/hsmr.2008.008009

The Plummer Project, conducted at a US Mayo Clinic in 2008, aimed to increase physicians’

efficiency and quality of patient care through process redesign and technology upgrades. This was done

largely through standardization of the department’s rooming process (the assigning of patients to rooms

according to diagnosis). Clinical assistants were trained to assist physicians in the collection and

documentation of key information during the onboarding of patients.

Clinical notes were reviewed by researchers before and after the rooming standardization was

implemented. Documentation of referring physician, allergies, advanced directives, and complete

medication lists increased by 31%, 18%, 81%, and 50%, respectively (p < .001). While physicians

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completed all clinical notes prior to standardization, post intervention physicians completed only 79%,

with the remaining being completed by clinical assistants. Physician satisfaction was assessed using a

survey with 12 respondents. Almost all respondents (92%) reported that received training was

“Adequate” or “More than Adequate.” When asked about overall satisfaction with the new rooming

process, 66% of respondents reported “Good” or “Very Good.”

Pharmacy

Aboumatar, H. J., Winner, L., Davis, R., Peterson, A., Hill, R., Frank, S., . . . Farmer, D. (2010). Applying Lean

Sigma Solutions to Mistake-Proof the Chemotherapy Preparation Process. The Joint Commission

Journal on Quality and Patient Safety, 36(2). doi:10.1016/s1553-7250(10)36014-4

This before-after study that took place in 2006 at a US outpatient pharmacy at a Johns Hopkins

cancer center assessed the effectiveness of the chemotherapy preparation and dispensing in the

pharmacy. On June 5–7, 2006, a lean-Six Sigma workshop was conducted to study and improve the

methods of the pharmacy to help reduce the risk of serious adverse drug events that are especially

possible among administration of chemotherapeutic agents.

To study all opportunities for error during the chemotherapy preparation process, the lean-Six

Sigma experts applied Failure Mode and Effects analysis which called for meetings with all frontline

pharmacists and technicians to brainstorm failure modes of the preexisting chemotherapy preparation

process. Fifty-six failure modes were identified, and a risk priority number (RPN) was calculated for

each by multiplying the estimated failure frequency, detectability, and severity. Many relatively

inexpensive and easily-implemented “mistake-proofing” interventions were introduced via workplace

redesign, process redesign, and development of standard operating procedures for pharmacy staff. For

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the newly designed process, the total estimated RPN across all 56 failure modes was 30% lower than the

pre-existing process.

Data was compared between five months before the workshop to the five months after it, and the

hospital’s patient safety reporting system showed a decrease in the incidence of events that reached

patients and required monitoring and an increase in the incidence of events that resulted in no harm or

did not reach patients because of early detection by staff. Although quantitative use of data from error

reporting is limited by the fact that reporting is voluntary and subjective estimates of RPNs are used,

application of lean-Six Sigma solutions enabled a reduction in the likelihood of chemotherapy

preparation errors.

Chiarini, A. (2012). Risk management and cost reduction of cancer drugs using Lean Six Sigma tools.

Leadership in Health Services, 25(4), 318-330. doi:10.1108/17511871211268982

Researchers evaluated a lean improvement project in a public Italian hospital targeted toward the

management of cancer drugs. After delivering surveys to medical staff in order to identify priorities for

the upcoming year, senior management identified cancer drug management priorities in two spheres: 1)

increased health and safety for staff that handle them, and 2) cost reduction in cancer drug management.

A team was assembled with the Head of Pharmacy as the sponsor, and value stream mapping was

conducted to map the drug process from request to administration to patient. They established baseline

risk by looking at injuries in the prior year, and found that 17.8% of nurses who managed these drugs

reported an adverse event. The team identified three major causes of these events (fall, inhalation,

prick), and calculated a Risk Priority Number (RPN) for each based on likelihood of occurrence,

severity of event, and detection or capability of detection.

The team utilized Ishikawa (“fishbone”) diagrams to determine potential root causes of these

adverse events, and the following process gaps were identified: excess centers for preparation and

46

administration of drugs, inadequate preventative measures by staff, unsuitable equipment, oversupply of

drugs, and difficulty in tracking drug orders.

To address these gaps, the team created a dedicated unit responsible for the management of

cancer drugs across the entire hospital. In addition to this unit, the teams also implemented more robust

staff training, expanded health surveillance, created specific work instructions for drug management,

and incorporated new request tracking software and barcode tracking. Six months after implementation,

success was measured by evaluating the change in RPN under each adverse event category. For falls,

inhalation, and pricks RPN was reduced by 50% (126 to 63), 78% (288 to 64), and 50% (80 to 40),

respectively. The author notes that this reduction was largely due to reductions in the occurrence

variable. Estimated cost savings from inventory reduction resulting from reduced waste and unnecessary

drug stock was $200,000.

Hintzen, B. L., Knoer, S. J., Van Dyke, C. J, & Milavitz, B. S. (2009). Effect of lean process improvement

techniques on a university hospital inpatient pharmacy. American Journal of Health System Pharmacy,

66(22), 2042-2047. doi:10.2146/ajhp080540

The effect of Lean process improvement on an inpatient university hospital pharmacy, the

University of Minnesota Medical Center (UMMC), was evaluated. Workflow in the sterile products area

(SPA) was improved through the creation of accountability, standard work, and movement toward one-

piece flow. Increasing the number of IV batches decreased pharmaceutical waste by 40%. Through SPA

environment improvements and enhanced workload sharing, two FTE technicians from the SPA were

redistributed within the department. SPA waste reduction yielded an annual saving of $275,500. Quality

and safety were also improved, as measured by reductions in missing doses, expired products, and

production errors. In the inventory area, visual control was improved through the use of a double-bin

system, the number of outdated drugs decreased by 20%, and medication inventory was reduced by

47

$50,000. Benefits of this process included an estimated annual cost saving of $289,256 due to waste

reduction, improvements in workflow, and decreased staffing requirements.

Furukawa P. O., Cunha I. C. K. O., & Pedreira M. L. G. (2016). Evaluation of environmentally sustainable

actions in the medication process. Revista Brasileira de Enfermagem, 69(1), 16-22. doi:10.1590/0034-

7167.2016690103

This pre-post study analyzed the ability of lean-Six Sigma to reduce waste in the medication

process, by following the process from reception to pharmacy to disposal. The study was conducted at a

large 446-bed hospital in Sao Paulo, Brazil from February to September 2010. An interdisciplinary team

of 6 professionals from nursing, pharmacy, and environmental management participated in all stages of

the project: definition, measurement, analysis, implementation, and control process.

The team began by conducting process mapping of the medication process. Problems were

identified related to irrational use of resources, many medications returned and discarded at the

pharmacy, and incorrect discard of waste. These problems were then ranked in terms of priority based

on a cause effect matrix and effort impact matrix to determine which issues would result in the greatest

reduction of waste using the least resources. Root causes of these problems were analyzed using the 5

Why’s. Then an action plan was developed based on root causes, including clear delegation of tasks and

explicit deadlines.

The lean-Six Sigma intervention resulted in a 74.8% reduction in chemical, infectious, and

sharps waste, a 33.3% increase in common recyclable waste, and a 20% increase in common non-

recyclable waste. Based on the results, the authors concluded that the development of environmentally

sustainable actions is possible in hospital settings, thereby reducing use of resources and volume of

waste.

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L’Hommedieu, T., & Kappeler, K. (2010). Lean methodology in I.V. medication processes in a children’s

hospital. American Journal of Health-System Pharmacy, 67(24), 2115-2118. doi:10.2146/ajhp100151

Researchers sought to implement and evaluate the impact of lean methods on the preparation

process for non-emergent IV medication in a United States pediatric hospital. The practice of using 12 to

24 hour batches often resulted in wasted medication if the therapy was changed, the dosage adjusted, or

a patient’s weight fluctuated. Researchers first conducted a retrospective analysis of all medication

orders over a 30 day period, allowing them to identify the peak times of day when orders were subject to

change or discontinuation. Value stream mapping was conducted to depict the flow of IV preparation

and identify non-value added tasks. Idle time, in particular, was identified as a large source of non-value

added time, suggesting the need to prepare batches more frequently.

Researchers used an optimization model with the independent variable as the number of IV

batches prepared per day, and other variables including number of IV doses prepared per day, number of

doses per batch, time per batch, labor cost, waste cost, and cost of delivery. This model identified 4

batches per day as the most efficient. Seven days of returned and wasted IV medications were collected

before and after the implementation of lean to assess the impact of the new process. During this period,

while total number of dispensed doses increased by 16.6% (8,054 to 9,907), total wasted doses dropped

by 8.6% (1,339 to 853; p < .05). With these reductions, annual savings were estimated at $426,244, a

2.6% reduction in overall drug expenditures (p < .05).

Raab, S. S., Andrew-Jaja C., Condel J. L., & Dabbs, D. J. (2007). Improving Papanicolaou Test Quality and

Reducing Medical Errors by Using Toyota Production System Methods. American Journal of Obstetrics

& Gynecology, 194(1), 57-64. doi:10.1016/s1077-9108(08)70253-6

49

Researchers at an American university implemented a Toyota Production System (TPS), 1-by-1

continuous workflow process in a gynecology office and laboratory to improve Papanicolaou test

quality. A process improvement team met with the gynecologist to determine how TPS strategies should

be implemented in his practice, together designing a comprehensive checklist for the ideal Papanicolaou

test. In the laboratory, the team also designed a one piece flow process for assessing the tests. TPS

implementation began in March 2004, and data was analyzed until November 2004. For comparison,

baseline data was collected retroactively for the period between March and November of 2003.

The frequency of a positive diagnosis with an absent transformation zone component (TZC)

decreased from 9.86% to 4.74% (p = .001) between pre intervention and post intervention. Between pre

and post intervention the percentage of women who had an additional Papanicolaou test or surgical

procedure decreased from 76.0% to 29.4%. The percentage of women who had a high severity diagnosis

(cervical intraepithelial neoplasia or squamous intraepithelial lesion) increased from 8.1% to 60.0% (p =

.002). A statistically significant correlation was found between the gynecologist’s impression of test

quality and the Papanicolaou test diagnosis of absent TZC (p = .01) with an r2 = .162.

Rico, R. A. & Jagwani, J. M. (2013). Application of lean methods to compounding services in hospital

pharmacy. European Journal of Hospital Pharmacy, 20(3), 168-173. doi:10.1136/ejhpharm-2012-

000221

This study was conducted in the pharmacy department of a large Spanish tertiary care hospital

between January 2010 and December 2011. The intended goal was to implement and evaluate lean

methods in a hospital pharmacy department, specifically surrounding sterile preparations. Researchers

classified sterile preparations into three categories: 1) total parenteral nutrition, 2) IV admixtures, and 3)

compounding sterile preparation (CSP). Between January and June 2010, researchers conducted kaizen

50

events and value stream mapping (VSM) to document the following: workflow for each classification,

time spent from prescription creation to patient delivery, daily variability in workload, and potential

process delays. Afterward, baseline data was collected during a 2 week period based on findings from

kaizen and VSM. Between June 2010 and December 2011, improvement projects were implemented and

sustained. Data was collected during the first two weeks of implementation. Variables measured

included first time quality, processing time, value added time, non-value added time, and lead time.

CSP production was found to have both high demand and very high seasonality. Production

process was identified as a main source of delay due to this unpredictability, so many of the value

stream improvements focused on this process. This included developing an algorithm to identify sterile

preparations appropriate for generating stocks. Overall, the process improvements were associated with

increased productivity (e.g., CSP production increased by 94%) and improved first time quality (from

56% to 95%) compared to the pre-implementation period.

Primary & Preventive Care

Blackmore C. C., Edwards J. W., Searles, C., Wechter, D., Mecklenburg, R., & Kaplan, G. S. (2013). Nurse

practitioner-staffed clinic at Virginia Mason improves care and lowers costs for women with benign

breast conditions. Health Affairs, 32(1), 20-26. doi: 10.1377/hlthaff.2012.0006

A breast clinic was implemented at Virginia Mason Medical Center in Seattle, Washington using

Lean methods. The clinic was found to substantially improve care timeliness and efficiency for women

with symptomatic benign breast conditions. Women received their final benign diagnosis in an average

of four rather than 16 days, with fewer imaging studies and physician visits, when compared to a control

group. Savings to the employer were estimated at $316/patient, primarily from increased work

productivity. Direct care costs decreased an estimated 19%, to $213/patient. The authors stated that by

51

decreasing both direct medical costs and indirect costs such as work absenteeism and presenteeism, the

Virginia Mason Breast Clinic created substantial savings for providers and employers while delivering

care that patients rated highly.

Hung, D. Y., Harrison, M. I., Martinez, M. C., & Harold, S. L. (2016). Scaling Lean in Primary Care and

Impacts on Organizational Performance. Journal of Patient-Centered Research and Reviews, 3(3), 206.

The authors conducted an observational study of phased Lean implementation among 328

physicians in 46 primary care departments housed within 17 geographically distinct clinic locations.

Performance metrics included: workflow efficiency, productivity, operating expenses, clinical quality

and patient, physician and staff satisfaction. Interrupted time series analysis using generalized linear

mixed models was used to examine lean impacts on organizational performance over time. They found

that Lean implementation resulted in system-wide improvements in workflow efficiencies, physician

productivity and clinical quality metrics (P < 0.05).

Patient satisfaction with access to care, handling of personal issues and overall experience of

care also increased, but decreased with respect to interactions with care providers (P < 0.05).

Departmental operating costs decreased, though this was not statistically significant. Finally, annual

staff and physician satisfaction scores increased in key domains, ranging from employee engagement

and connection to purpose to relationships with staff and physician time spent working. The authors

concluded that Lean system redesigns resulted in improvements on a variety of metrics ranging from

provider workflow efficiencies to satisfaction among patients and staff.

Locke, A., & Kamo, N. (2016). Utilizing clinical pharmacists to improve delivery of evidence-based care for

depression and anxiety in primary care. BMJ Quality Improvement Reports, 5(1).

doi:10.1136/bmjquality.u211816.w4748

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Researchers at a United States medical center implemented and evaluated lean methodologies in

order to develop new mental health care pathways to increase medication adherence for patients with

depression and anxiety disorders. A workgroup consisting of physician, nursing, and pharmacy leaders

was assembled to analyze current state, finding that 12-week and 6-month medication adherence among

these patients was at the regional average and that there was no direct pharmacist involvement after

medication initiation or changes. The team noted an opportunity to incorporate pharmacists into the

team based care model, prompting the care pathway redesign through a series of Plan-Do-See-Act

(PDSA) rapid cycle improvements.

In PDSA Cycle 1, patients prescribed with anti-depression or anti-anxiety medication were

scheduled for a two week follow up call with a pharmacist, followed by a six week follow up visit with a

provider. This repeats until the patient realized a 50% reduction in baseline PHQ9 (depression) and/or

GAD7 (anxiety) assessments. In PDSA Cycle II, the administration of PHQ9 and GAD7 were

eliminated due to time constraints. After implementation with all participating providers, PDSA Cycle

III was initiated which also called for an in-person visit with a pharmacist at the six week mark. Of the

165 patients with a pharmacy referral during Cycle I, 58% completed consults with an average call time

of 15 minutes. In Cycle II with 738 patients, 55% of patients starting new medication were successfully

reached by the pharmacist, and average call time was reduced to 7 minutes. Of these, 20% completed an

intervention, including management of side effects and change of dosage or medication.

Nazarali, S., Rayat, J., Salmonson, H., Moss, T., Mathura, P., & Damji, K. F. (2017). The application of a “6S

Lean” initiative to improve workflow for emergency eye examination rooms. Canadian Journal of

Ophthalmology, 52(5), 435-440. doi:10.1016/j.jcjo.2017.02.017

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Researchers at an Alberta, Canada medical center implemented Lean methodology in order to

improve workflow in emergency eye examinations. After medical residents and staff reported

disorganization in exam rooms causing work related stress, a quality improvement consultant

investigated and ultimately found that the average resident spent 45 minutes per day searching for

supplies and moving between exam rooms. A team consisting of administrators, residents, and nursing

staff utilized the 6S lean model to examine existing processes of the eye exam rooms, including

outlining problem areas and inefficiencies, mock patient interviews, spaghetti mapping, and kaizen

events. Total costs of the project including labor and supplies was $8,546.35. Six months after

implementation, the 6s audit checklist score increased from 44 to 77. To sustain improvements, the

authors recommended that the unit manager to hold occasional orientation sessions to reacquaint staff

with quality improvement processes.

Radiology

Karstoft, J., & Tarp, L. (2011). Is Lean Management implementable in a department of radiology? Insights into

Imaging, 2(3), 267–273. doi:10.1007/s13244-010-0044-5

Lean principles were applied in a radiology department at a very large non-profit hospital,

Odense University Hospital (OUH) in Denmark. The radiology department received support from a

private consultant who assessed the “hows” and “whys” of the department’s work. A multidisciplinary

Lean team was formed and a clinically respected radiographer appointed as its leader. Kaizen, value

stream mapping (VSM), 5S, and single minute exchange of die (SMED) were all used to increase

efficiency in the department’s CT section. The tools resulted in the radiology department’s ability to

examine 6 more patients during the day (900 more patients/year). Consequently, waiting lists fell

dramatically across all department sections after the introduction of Lean. The authors noted that the

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response from the staff was positive—they had an easier overview of the day’s program, a better

workflow/environment, and became focused on continuing improvement.

Kim, C. S., Hayman, J. A., Billi, J. E., Lash, K., & Lawrence, T. S. (2007). The Application of Lean Thinking

to the Care of Patients With Bone and Brain Metastasis With Radiation Therapy. Journal of Oncology

Practice, 3(4), 189-193. doi:10.1200/jop.0742002

Researchers at the University of Michigan (US) implemented lean strategies to decrease the

amount of time between evaluation and radiation treatment among patients with brain and bone

metastases. A process improvement team was formed to target the radiation department because these

patients were among the most symptomatic, the department had standardized planning and delivery

procedures, and the materials needed to administer same day treatment were almost always available.

The team, consisting of nurses, therapists, physicians, and administrators, developed current and future

state value stream maps. Dispatch and scheduling were identified as areas of improvement, and to

address this the team designed a standardized scheduling process that included the notification of

nursing, therapist, and billing staff. Six months of patient data prior to implementation was collected to

establish baseline measures. The number of steps from evaluation to radiation administration decreased

from 27 to 16. Between baseline and post intervention, the percentage of patients undergoing evaluation,

stimulation, and treatment in a single day increased from 43% to 94%.

Lodge, A. & Bamford, D. (2008). New Development: Using Lean Techniques to Reduce Radiology Waiting

Times. Public Money & Management, 28(1), 49-52. doi:10.1111/j.1467-9302.2008.00618.x

This article reported on how systems were enhanced through the application of Lean principles

within a UK hospital division of diagnostics and clinical support. The NHS Improvement Plan required

that by 2008 the maximum wait from a general practitioner referring a patient, to that patient

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commencing definitive treatment should be 18 weeks. Early estimates in the division indicated that in

order to meet this 18-week target, access to services must be in a zero- to four-week window. Lean was

proposed as a mode to accomplish this.

Working groups, comprising a cross-section of professional disciplines and grades, were set up

with membership from across the department, division and the wider organization to understand the

current performance of radiology services. The views of service users (patients and referrers) were

sought, along with those of staff working in the departments in order to generate a picture of the current

service provision from which to model the required changes. The working groups decided to implement

an internet-based waiting list for radiology services. All radiology departments began using the internet-

based waiting list module in September 2006, which since then contributed to a significant reduction in

waiting times across the different imaging modalities. The longest waiting time was decreased by over

30% in all areas due to more efficient waiting list management.

Martin A. J., Hogg P., & Mackay S. (2013). A mixed model study evaluating Lean in the transformation of an

orthopaedic radiology service. Radiography, 19(1), 2–6. doi:10.1016/j.radi.2012.09.005

In this mixed model approach, researchers evaluated Lean’s effectiveness as a method to

improve an orthopaedic healthcare service with long waiting times and poor satisfaction among patients

and staff. Data were collected before and after Lean implementation from staff and patient

questionnaires, as well as from the Radiology Information System. The authors used proportionate

stratified random sampling for patient data collection and a theoretical sample for staff data collection.

Pre-implementation data were collected during the team’s value stream mapping process, and used to

plan and implement changes. Data before and after implementation were compared using Levine’s test

for equality of variance and a 2-sample t-test; results demonstrated that Lean resulted in better patient

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experiences, higher staff satisfaction, and an increase in productivity. The authors concluded that these

findings supported the proposition that Lean is an effective way to improve healthcare service.

Simons P., Benders J., Bergs J., Marneffe W., & Vandijck D. (2016). Has Lean improved organizational

decision making? International Journal of Health Care Quality Assurance, 29(5), 536-549.

doi:10.1108/IJHCQA-09-2015-0118

This study investigated whether a lean program changed an organization’s decision-making

context and made it more amenable to quality improvement initiatives. Two 25-question surveys, one in

2011 and one in 2014, were conducted with 12 professionals from a Dutch radiotherapy institute to

assess their perceptions of lean in their organization and the perceived ambiguous objectives and

uncertain cause-effect relations in their clinical processes. Structured interviews were analyzed using a

deductive approach.

Interviewees expressed improved shared vision and decreased number of uncertain cause-effect

relations. 99 positive lean effects and 18 negative lean effects were shared. Positive effects included

reduced ambiguity of objectives and decreased information asymmetry in clinical process. Negative

effects included conflicting objectives between research and clinical practice and unrealistic objectives.

Overall, the authors found that lean implementation led to greater transparency and shared visions.

Surgery

Aij, K. H., Simons, F., Visse, M., & Widdershoven G.A.M. (2014). A Focus on Throughput: Lean Improvement

of Nurse Scheduling in the Operating Theatre. Global Journal of Management and Business Research,

14(1), 75-81. doi:10.17406/GJMBR

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Researchers at a Dutch university medical center conducted lean value stream mapping to

improve nurse scheduling processes in the hospital’s operating theatre (OT). A team consisting of OT

physicians, nurses, and administrators was assembled to map the current state of the hospital’s OT. At

the same time, the team conducted 7 observation days over a 2 month period to measure the waste and

errors resulting from the scheduling process. Error was classified into three categories: 1) employee

qualification/supply, 2) timing related issues, and 3) location based issues. The team created an ideal

state, and discussed the discrepancies between it and the current state to create a new OT schedule. After

implementation, 7 days of post intervention observation were conducted to assess any change in waste

or errors. Total number of observed errors reduced by 90%, from 35 to 2. Observed waste was reduced

by by 41%. Total number of transfers in the process also decreased by 11%, from 44 to 39.

Bradywood, A., Farrokhi, F., Williams, B., Kowalczyk, M., & Blackmore, C. C. (2017). Reduction of Inpatient

Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical

Care Pathway. Spine, 42(3), 169-176. doi:10.1097/brs.0000000000001703

Researchers at an American hospital neurosurgery department implemented lean methodologies

to reduce length of stay and medical error among lumbar spine post-operative patients. A team

consisting of nurses, surgeons, physical therapists, and physician assistants conducted value stream

mapping (VSM) as well as staff and patient surveys, to understand the current state of the post-operative

care pathway. Primary patient concerns included pain management, handoffs between clinical staff, and

discharge readiness. A targeted literature review was conducted to establish best practices for these

concerns. The team then conducted VSM once more to establish a future state that was the basis for their

interventions.

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Key elements included the implementation of electronic order sets within electronic medical

records to reduce variability, posters with clearly defined milestones for patients and families, and daily

interdisciplinary rounding with physician and nursing staff. Researchers examined length of stay (LOS)

and quality outcomes before and after implementation among 585 lumbar fusion patients who matched

diagnosis criteria between January 2012 and September 2014. Following the interventions, LOS fell

from 3.9 to 3.4 days (p < 0.001). Urinary catheter removal by day 2 increased from 77% to 87% (p =

.003). Percentage of patients discharged to home increased from 64% to 75% (p < 0.002). No

statistically significant changes were reported for changes in patient falls, pain scores, or patient

satisfaction.

Burkitt, K. H., Mor, M. K., Jain, R., Kruszewski, M. S., McCray, E. E., Moreland, M. E., ... Fine, M.J. (2009).

Toyota Production system quality improvement initiative improves perioperative antibiotic therapy.

American Journal of Managed Care, 15(9), 633-642.

A pre-post quasi-experimental study was conducted to assess the role of a Lean intervention on

appropriateness of perioperative antibiotic therapy and in length of hospital stay (LOS) among surgical

patients. Local and national retrospective cohorts were used. The authors used Lean methods to

implement a multifaceted intervention to reduce nosocomial methicillin-resistant Staphylococcus aureus

(MRSA) infections on a Veterans Affairs surgical unit, which led to a QI intervention targeting

appropriate perioperative antibiotic prophylaxis. Appropriate perioperative antibiotic therapy was

defined as selection of the recommended antibiotic agents for a duration not exceeding 24 hours from

the time of the operation. The local electronic medical record system was used to identify patients

undergoing the 25 most common surgical procedures and to examine changes in appropriate antibiotic

therapy and LOS over time.

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Overall, 2550 surgical admissions were identified from the local computerized medical records.

The proportion of surgical admissions receiving appropriate perioperative antibiotics was significantly

higher (P <.01) in 2004 after initiation of Lean (44.0%) compared with the previous 4 years (range,

23.4%-29.8%) primarily because of improvements in compliance with antibiotic therapy duration rather

than appropriate antibiotic selection. There was no statistically significant decrease in LOS over time.

Caruso, T. J., Wang, E., Schwenk, H. T., Scheinker, D., Yeverino, C., Tweedy, M., . . . Sharek, P. J. (2017). A

quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis. Pediatric

Anesthesia, 27(7), 702-710. doi:10.1111/pan.13137

Researchers at Stanford University implemented and evaluated a lean initiative in order to

improve appropriate antibiotic dosing at a US hospital. A baseline measurement of cefazolin dosing

indicated that only 40% of cases were aligned with institutional recommendations. This prompted a

multidisciplinary team of anesthesiologists, surgeons, internists, and pharmacists to develop an A3

project plan to improve cefazolin dose compliance. The A3 plan included background, current and

future state value stream mapping, gap identification, measurable goals, analysis of the problem, and

recommended countermeasures. The following countermeasures were developed from the A3: 1) the

creation of a preoperative antibiotic order set in the electronic medical records, 2) revision of operating

room (OR) antimicrobials to be concentrated and without dextrose, 3) moving antibiotic delivery to OR

at the start of the day, and 4) the delivery of badges with visual aides detailing correct dosage.

The primary outcome measure was cefazolin dosage at 30 mg/kg, and the secondary outcome

compared compliance with dosage between those ordered electronically and verbally. Researchers

analyzed cefazolin administration of 9086 patients between January 2012 and May 2016. By April 2014

mean cefazolin compliance rate was 84%. Between September 2015 and May 2016, after the badges had

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been introduced, compliance rate was 93% with significantly reduced variation. Researchers also

compared 649 administrations by electronic order with 1929 administration with verbal order between

October 2014 and May 2016. Compliance rate was significantly higher among those given with

electronic orders, at 96% versus 76% of verbal orders (p < 0.001).

Cima, R., Brown, M. J., Hebl, J. R., Moore, R., Rogers, J. C., Kollengode, A., … & Deschamps, C. (2011). Use

of Lean and Six Sigma Methodology to Improve Operating Room Efficiency in a High-Volume

Tertiary-Care Academic Medical Center. Journal of the American College of Surgeons, 213(1), 83-92.

doi: 10.1016/j.jamcollsurg.2011.02.009

A process improvement team at a US Mayo Clinic implemented lean process improvement

measures across the entire operating room (OR) suite to increase performance and reduce costs. An

interdisciplinary leadership team conducted value stream mapping (VSM) of patient flow from surgical

decision to patient discharge. Five key aims were developed from VSM: unplanned volume variation,

streamlining preoperative testing, reducing non operative time, reducing collection of redundant

information, and improved employee engagement.

Baseline data for for 3 surgical specialties (gynecologic oncology, general thoracic,

general/colorectal) were collected to assess performance pre intervention. Patient wait times longer than

10 minutes at surgical admission desk decreased from 42% to 12% (p < 0.0001). Proportion of on time

arrivals to perioperative area also improved from 52% to 81% (p < 0.0001). Across all three specialties,

non operative OR time was significantly improved.

Collar, R. M., Shuman, A. G., Feiner, S., McGonegal, A. K., Heidel, N., Duck, M., ... Bradford, C. R. (2012).

Lean management in academic surgery. Journal of American College Surgeons, 214(6), 928–936.

doi:10.1016/j.jamcollsurg.2012.03.002

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Surgical practice was identified as a specialty providing many opportunities to improve

efficiency. To this end, this study evaluated Lean thinking in an academic otolaryngology operating

room (OR) as a method to improve efficiency and profits, while preserving team morale and educational

opportunities. An 18-month prospective ‘quasi-experimental’ study was used, with a multidisciplinary

team systematically implementing Lean thinking. The team recorded OR turnover and turnaround time

during an observer-effect period as well as after Lean implementation, and measured Lean’s impact on

teamwork, morale, and surgical resident education through validated surveys.

During the Lean intervention period, significant decreases in turnover and turnaround time were

noted (29 v. 38 minutes; p < 0.001 and 69 v. 89 minutes; p < 0.001, respectively). Composite morale

scores also found improved morale after implementation (p = 0.011), with no effect on resident

education. Lastly, financial implications of Lean found an annual opportunity revenue of $330,000 for

one OR used twice weekly. The authors noted that Lean requires cultural change through empowerment

of workers to engage in continuous quality improvement, thus contradicting traditional hierarchical

management. They also emphasized the importance of sustaining Lean improvements; regular meetings

among key stakeholders (including management and OR employees) to review data and refine plans

were used toward this end, and continued on a quarterly basis after the study.

Dubey, S., Chauhan, L., Gupta, N., Singh, A., & Arora, A. (2016). Using lean Six Sigma to improve throughput

efficiency at tertiary care eye hospital. Journal of Ophthalmic Research, 3(2), 79-83.

Researchers at an Indian tertiary care eye hospital implemented and evaluated lean

methodologies intended to reduce wait times in their outpatient departments, pre-surgical area, and

operating room (OR). A team consisting of administrators and medical staff conducted value stream

mapping, and measured baseline patient lead time to use as a control. Their current state was compared

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to future state, and the following improvements were made based on the identified gaps: new

streamlined protocol for OR scheduling, expanded registration counter, and color maps for patients in

high volume areas. Median lead time in the outpatient department decreased 19%(from 118 to 95

minutes), and decreased by 60% in the pre-surgical area (from 82 to 33 minutes). The operating room

experienced a less exaggerated 6% decrease in median lead time from 245 to 230 minutes. In the same

time frame patient satisfaction also increased from 73% to 87%.

Filho, M. G., Boschi, A., Rentes, A. F., Thurer, M., & Bertani, T. M. (2015). Improving Hospital Performance

by Use of Lean Techniques: An Action Research Project in Brazil. Quality Engineering, 27(2), 196-211.

doi:10.1080/08982112.2014.942039

This action research study presented the implementation of lean methods in the surgery

department of a Brazilian hospital. The researchers first began by defining the scope of the project and

forming an internal team with the hospital’s superintendent director as the project lead. The Material and

Sterilization Center (MSC) was identified by the director as a key area of focus as it was one of the main

contributors to disrupted flow and higher cost. The project’s objective was to reduce cost, increase

sterilization capacity, and reduce surgery delays due to lack of MSC surgical supplies. Value stream

mapping was conducted and flowcharts developed for typical patient movements throughout all steps of

the surgery process, beginning when the patient leaves for the hospital.

In order to reach the MSC’s desired future state, 5S and visual management were used to

increase efficiency, simplify processes, and reduce waste. A pull system was also used to meet demand

more efficiently.

The researchers found that the lean intervention resulted in a reduction in changeover time

between MSC autoclave cycles from 34 minutes to 4 minutes (88% reduction). Autoclave cycle time

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overall was reduced from 2 hours to 1.5 hours, resulting in a 64% capacity increase. This generated a

direct cost reduction of 78%. Lastly, the pull system and increased MSC efficiency resulted in a

significant 94% reduction in surgery delays.

Karvonen, S., Nordback, I., Elo, J., Havulinna, J., & Laine, H. J. (2016). The Elimination of Transfer Distances

Is an Important Part of Hospital Design. Health Environments Research & Design Journal.

doi:10.1177/1937586716680062

This case study used a patient flow analysis with from-to charts to influence new hospital design

and layout planning at a university hospital’s musculoskeletal surgery unit. The authors began by

determining the main activities of the surgery unit, then studying the routes and physical movement of

all patients treated in the unit over 1 year. From this data, an ideal layout of the new hospital was

generated to minimize transfer distances. This was done by placing related activities near one another,

based on patient flow analysis. The hospital’s architectural design was then created based on the

developed layout. Lastly, the authors compared current transfer distances to the distances they estimated

patients would move in the new hospital.

The authors estimated that the new design would result in a 50% reduction in transfer distances

for inpatients and a 30% reduction for outpatients. They concluded that a detailed patient flow analysis

with from-to charts can substantially shorten transfer distances, thereby minimizing patient transfers (a

non-value-adding activity). This reduction supported productivity improvement, cross-functional

teamwork, and patient safety through placement of patient flow activities close to each other.

Leeuwen, K. C., & Does, R. J. (2010). Quality Quandaries: Lean Nursing. Quality Engineering,23(1), 94-99.

doi:10.1080/08982112.2010.529486

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This case study details length of stay (LOS) reductions among elective hip replacement patients

at a large Dutch teaching hospital using lean-Six Sigma interventions. A flowchart detailing a patient’s

journey from admission to discharge was created, and a cause and effect matrix was drafted to identify

factors that could impact LOS. The group identified improvements in wound care as a potential target to

reduce LOS. A baseline analysis of 56 patients was performed to further explore these factors. ANOVA

tests were run and found that there were significant differences in LOS depending on specialist, day of

admission, gender, and discharge destination.

Various interventions were implemented to address these potential factors, including clustering

surgeries during days of low theatre capacity, strict discharge guidelines, and alternative wound

treatment. One new wound care process involved the development of a new wound plaster to be used

post surgery. 102 patients underwent surgery with the original plaster, and 69 with the newly developed

alternative. The average LOS among the alternative patients was .5 days lower than that of the original

group. The group reported savings of $110,000 annually due to a reduction of personnel (.5 FTE) and

readmissions.

Lunardini, D., Arington, R., Canacari, E. G., Gamboa, K., Wagner, K., & McGuire, K. J. (2014). Lean

Principles to Optimize Instrument Utilization for Spine Surgery in an Academic Medical Center: An

Opportunity to Standardize, Cut Costs and Build a Culture of Improvement. The Spine Journal, 14(11).

doi:10.1016/j.spinee.2014.08.075

This case study details the implementation of lean practices in a Northeastern US academic

medical center in order to optimize procedures for operating room (OR) instruments among spinal

surgeries. Physician and nursing staff first noticed that many surgical instruments were not being used in

each case, prompting them to convene a leadership team comprised of a surgeon, administrator,

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technician, and nursing staff to fully define the problem and map out existing processes. Focusing on

orthopedic and neurological surgery cases, the team conducted Value stream mapping (VSM) of the

instruments from processing, to usage, and finally to reprocessing. The team audited each instrument in

a generic spine set, noting the number, weight, and usage of each instrument. The team also hosted an

“instrument fair” to give OR staff an opportunity to examine various OR instruments, and provide

feedback on vital instruments necessary for surgical sets. Using knowledge gained from VSM and the

“instrument fair”, the leadership team created a final list of instruments for a new universal spine

instrument set, removing the nonessential from circulation. Total number of instruments fell from 152 to

89, a 41% decrease. Total weight fell from 42.1 lbs to 24.6 lbs, a 42% reduction. Annual cost savings

were estimated at $41,000 based on efficiencies in labor, materials, central processing, and inventory

reduction.

Mazur, L. M., Johnson, K., Pooya, P., Chadwick, J., & McCreery, J. (2016). Integrating Lean Exploration

Loops Into Healthcare Facility Design: Programming Phase. Health Environments Research & Design

Journal, 10(3), 116-130. doi:10.1177/1937586716680063

This case study sought to explore what, when, and how lean can add value during the

programming phase of design in a large academic hospital. The study took place during the design

efforts of a surgical tower to house 19 operating rooms (ORs) as well as support spaces (e.g., pre- and

post-op, central processing and distribution, materials management). Lean exploration loops (LELs)

were conducted to generate evidence to support decision-making, primarily in comparing the benefits of

a large footprint with few floors versus a smaller footprint with more floors and support spaces not

adjacent to ORs on the same floor.

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LELs quantified key operational and design features, which created opportunities to gain buy-in

from stakeholders through active participation in many analyses. The authors concluded that lean was

most valuable during programming when it focused on high-level operational and design issues to help

establish consensus among stakeholders.

McCulloch, P., Kreckler, S., New, S., Sheena, Y., Handa, A., & Catchpole, K. (2010). Effect of a “Lean”

intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ, 341, 1043–

1046. doi:10.1136/bmj.c5469

The authors investigated the effect of Lean quality improvement methods on service reliability

and efficiency in an emergency general surgery ward of a university hospital in the UK. It used an

interrupted time series study design and determined outcomes by measuring 7 safety relevant care

processes. This was based on 969 patients admitted during the 4-month study period before Lean

intervention, and 1114 patients admitted during the 4-month study period after Lean intervention was

completed. The researchers found that for the 5 process measures targeted for Lean intervention, there

were significant relative improvements in compliance, ranging from 28% to 149% with a p-value <

0.007. 2 processes measures were not targeted for Lean intervention and did not improve significantly.

There was also a significant reduction in new safety events after transfer to other wards (p <

0.028), though most adverse events were attributed to delays in investigations and treatment from factors

outside of the emergency ward’s control. In conclusion, the authors found that Lean can substantially

improve compliance across multiple safety-related processes at the same time. They noted that given

hospital care’s interrelated nature, this may not translate into improvements in safety outcomes unless

system-wide approaches are adopted.

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Muder R. R., Cunningham, C., McCray, E., Squier, C., Perreiah, P., Jain, R., ... Jernigan, J. A. (2008).

Implementation of an industrial systems-engineering approach to reduce the incidence of methicillin-

resistant Staphylococcus aureus infection. Infection Control Hosp Epidemiol, 29(8), 702-708.

doi:10.1086/589981

A before-after intervention study was conducted to measure the effectiveness of a Lean approach

to implementing a methicillin-resistant Staphylococcus aureus (MRSA) prevention program. The study

took place in an ICU and a surgical unit in the Pittsburgh Veterans Administration hospital and included

all patients admitted to these units. The MRSA prevention program was comprised of 4 elements: 1) the

use of standard precautions for all patient contact, with emphasis on hand hygiene; 2) the use of contact

precautions for interactions with patients known to be infected or colonized with MRSA; 3) the use of

active surveillance cultures to identify patients who were asymptomatically colonized with MRSA; and

4) use of Lean to facilitate consistent and reliable adherence to the infection control program.

The rate of healthcare-associated MRSA infection in the surgical unit decreased from 1.56

infections per 1,000 patient-days in the 2 years before the intervention to 0.63 infections per 1,000

patient-days in the 4 years after the intervention (a 60% reduction; P = .003). The rate of healthcare-

associated MRSA infection in the ICU decreased from 5.45 infections per 1,000 patient-days in the 2

years before to the intervention to 1.35 infections per 1,000 patient-days in the 3 years after the

intervention (a 75% reduction; P = .001). The combined estimate for reduction in the incidence of

infection after the intervention in the 2 units was 68% (95% confidence interval, 50%-79%; P < .001).

Paim, R., Costa, A., de Carvalho, J., & Costa Lima, I. A. (2016). Lean healthcare application in a surgical

procedures appointment scheduling center in a maternity. Brazilian Journal of Operations & Production

Management, 13(4), 452-461. doi:10.14488/BJOPM.2016.v13.n4.a5

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This action research study applied lean healthcare concepts and tools in the surgical scheduling

process at a network of maternity hospitals in Rio de Janeiro, Brazil. The authors conducted

benchmarking visits of other Rio de Janeiro maternity wards to identify best practices, analyzed current

working conditions, and compared indicators before and after the intervention. Qualitative data focused

on understanding the work process was collected by observing hospital professionals and having them

describe internal procedures and documents. After lean implementation, results were analyzed to

identify strengths and considerations for future improvement. After implementation, the number of

surgeries performed increased 15-17% in two different surgical centers. The authors concluded that

better management of patient demand resulted in increased capacity utilization. Results also showed that

adherence to surgery safety protocol increased by 13%, average length of stay decreased by 52%, and

patient satisfaction with reception service increased by 32%.

Raab, S. S., Grzybicki, D. M., Sudilovsky, D., Balassanian, R., Janosky, J. E., & Vrbin, C. M. (2006).

Effectiveness of Toyota Process Redesign in Reducing Thyroid Gland Fine-Needle Aspiration Error.

American Journal of Clinical Pathology, 126(4), 585-592. doi:10.1309/njq1-l7ka-10uk-v93q

US researchers implemented and evaluated a Toyota Production System process redesign in

order to reduce diagnostic error among patients who underwent cytologic evaluation of thyroid nodules.

Researchers first performed root cause analysis on all thyroid gland fine-needle aspirations (FNAs)

performed between January 2003 and December 2004 that returned a false positive or a false negative.

The first developed intervention was the standardization of diagnostic terminology, prompted by non-

uniform terminology used by technologists from different hospitals. The second was the promotion of

technologists performing FNAs, as opposed to other staff, so that results can be immediately interpreted.

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To analyze the diagnostic terminology standardization, researchers analyzed all 1,543 thyroid

FNAs performed between January 2003 and January 2005 to establish a baseline, and analyzed those

performed between January 2005 and January 2006 for post intervention. To assess the promotion of

immediate interpretation, researchers analyzed only FNAs performed in 2005. Terminology

standardization was associated with a reduction in atypical diagnoses (p < 0.01). There were also

significantly fewer surgeries, false negatives, and repeated duplicate FNAs. Sensitivity also increased

significantly. Cases that were interpreted immediately were associated with significantly lower non-

interpretable specimens and repeated FNA rates. Immediate interpretation was not associated with a

significant change in diagnostic accuracy.

Sibia, U. S., Grover, J., Turcotte, J. J., Seanger, M. L., England, K. A., King, J. L., & King, P. J. (2016).

Decreasing Postanesthesia Care Unit to Floor Transfer Times to Facilitate Short Stay Total Joint

Replacements. Journal of PeriAnesthesia Nursing. doi:10.1016/j.jopan.2016.08.007

Researchers at the Center for Joint Replacement at a US Medical Center implemented and

evaluated lean strategies in order to reduce outpatient surgery transfer times. In August 2015 a physician

led steering committee identified the post-anaesthesia care unit (PACU) to floor throughput as a process

that would benefit from lean quality improvement initiatives. A Rapid Improvement Event (RIE) was

held, led by a team consisting of a clinical educator, charge nurse, PACU nurse, joint unit nurse, and

physical therapist. The team first pulled record of all patients who had undergone knee replacement,

knee and hip surgery, or spinal fusions between January and July 2015. Baseline transfer time was

recorded at 62 minutes, and patients that underwent surgery on Wednesday and Thursday were more

likely to have longer transfer times than those seen on Monday. The team examined reasons for patient

transfer times above 30 minutes, and found that availability of nursing staff and lack of timely room

cleaning were major factors. The following changes were made in an attempt to decrease transfer time:

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standardization of discharge criteria, increased flexibility for charge nurse to restructure staffing, and

visual access to operating boards to track patient status in real time. Researchers measured transfer times

one month after implementation, finding that average transfer time had decreased from 62 to 30 minutes,

a 52% improvement (p < .001).

Simons, F. E., Aij, K. H., Widdershoven, G. A., & Visse, M. (2014). Patient safety in the operating theatre: how

A3 thinking can help reduce door movement. International Journal for Quality in Health Care, 26(4),

366–371. doi:10.1093/intqhc/mzu033

Previous research stressed the importance of reducing door movement during surgery to prevent

surgical site infections. The authors used Lean A3 thinking to reduce door movement in one operating

room for orthopedic surgery, executing an A3 report that promoted structured problem-solving based on

Plan-Do-Check-Act (PDCA) cycles. A multidisciplinary team was assembled for the A3 intervention,

which first defined the problem, and then investigated the current situation. They found current average

door movements/hour and variations in average door movement/hour between surgeons. From these

findings, the team determined a target condition for door movement, deemed as zero door movements

between incision and closing of wound (except for specific clinical reasons; e.g. X-rays, unexpected

materials, employee breaks, emergencies). The gap between current and target condition was then

analyzed using a fish-bone diagram to identify 13 root causes of door movement in 4 categories (people,

machines, methods, and materials). Actions for improvement were directed toward these 13 root causes

and the effects of changes were monitored over 12 months. The intervention led to a sustained 78%

decrease in door movements, bringing down the mean number of door movements/hour from 24 to 4 in

the OR.

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Valsangkar, N. P., Eppstein, A. C., Lawson, A. R., & Taylor, A. N. (2017). Effect of Lean Processes on

Surgical Wait Times and in a Tertiary Care Veterans Affairs Medical Center. Journal of the American

Medical Association Surgery, 152(1), 42-47. doi:10.1001/jamasurg.2016.2808

This study examined the effect of lean processes (e.g., value stream mapping) on wait times for

surgical procedures at a tertiary care Veterans Affairs (VA) medical center. Key outcome measures were

wait time, clinic and telehealth volume, number of no-shows, and operative volume. The researchers

utilized VA databases to assess these changes in elective general surgeries before, during, and after lean

implementation. Analyses were based on paired t-tests and the total timeframe of the study was 3 fiscal

years.

Multidisciplinary teams participated in rapid process improvement (RPI) workshops to identify

systemic inefficiencies and strategies to reduce canceled consultations, diagnostic re-work, and no-

shows. High-priority triage with enhanced operating room flexibility was instituted to reduce scheduling

wait times. After rollout of RPI projects, mean patient wait times decreased from 33.4 days (SD 8.3) in

2012 to 26.0 days (SD 9.5; p = .07) in 2013. In 2014, wait times decreased further to 12 days (SD 2.1; p

= .07 compared to 2013). Operative volume increased from 931 patients in 2012 to 1,072 in 2014.

Combined clinic, telehealth, and e-consultation encounters also increased from 3,131 in 2012 to 3,517 in

2014, while no-shows decreased from 366 in 2012 to 227 in 2014 (p=.02). The authors concluded based

on these findings that multidisciplinary collaboration among systems can reduce systemic inefficiencies

and improve patient experience.

van Vliet, E. J., Sermeus, W., van Gaalen, C. M., Sol, J. C., & Vissers, J. M. (2010). Efficacy and efficiency of

a Lean cataract pathway: a comparative study. Quality and Safety in Health Care, 19(6), e13.

doi:10.1136/qshc.2008.028738

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A prospective cohort of 616 cataract patients receiving Lean care was compared to both a

historical cohort of 591 patients that received traditional care and to patients waiting for Lean care in the

prospective cohort. To determine efficacy, the authors analyzed how many patients received care that

adhered to Lean cataract pathway specifications. To evaluate efficiency, they analyzed how often

patients visited the hospital and how many additional patients were able to access the pathway. The

authors found that patient visits decreased by 23% and access to the cataract pathway increased by 42%;

they noted that these percentages would have been nearly twice as large if healthcare staff had adhered

to Lean pathway specifications. Based on these findings, the authors emphasized the importance of

ensuring buy-in from healthcare providers to adhere consistently to Lean pathway specifications.

Yousri, T., Khan, Z., Chakrabarti, D., Fernandes, R., & Wahab, K. (2011). Lean thinking: Can it improve the

outcome of fracture neck of femur patients in a district general hospital? Injury,42(11), 1234-1237.

doi:10.1016/j.injury.2010.11.024

Researchers at a Birmingham, United Kingdom hospital discuss the implementation of a lean

value stream approach in the management of hip fracture patients. Key stakeholders met to map the

patient journey from admission to discharge that detailed four distinct steps: pulling patients from ER,

preparing patients for surgery, pushing patients to surgery theatres, rehabilitation, and discharge.

309 patients were recruited to assess outcomes before the lean intervention, and another 299

were recruited to assess outcomes post intervention. Outcome measures included overall and 30-day

mortality, admission to theatre time, admission to trauma ward, and length of stay. Chi-Squared tests

were run to assess differences in outcomes between pre and post lean patients. Statistically significant

reductions were found only in overall and 30-day mortality. Overall mortality decreased from 20.7% to

11.4% (p = .002, X2= 9.8, df = 1), and 30-day mortality decreased from 11.7% to 6.7% (p = .0394, X2=

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4.5, df = 1). Changes in door to theatre time, admission to a trauma ward, and length of hospital stay

were not statistically significant.

General

Afsar-Manesh, N., Lonowski, S., & Namavar, A. A. (2017). Leveraging lean principles in creating a

comprehensive quality program: The UCLA health readmission reduction initiative. Healthcare.

doi:10.1016/j.hjdsi.2016.12.002

This study that took place in 2011 at UCLA Health assessed the effectiveness of lean

methodology implementation in reducing the health center’s 30-day readmission rates. The clinical

program targeting readmissions was the Readmission Reduction Initiative (RRI), which involved all

clinical and non-clinical departments and groups of UCLA Health and focused on three key elements of

lean methodology: leadership, culture and process. In regards to the “process” element of lean

methodology, the RRI council utilized three major tools: A3 to guide the quality improvement efforts,

Root Cause Analysis to retrospectively identify the underlying cause of a problem, and value stream

mapping to identify and optimize the value-added components of each process from a patient’s

perspective.

The Medicine, General Surgery, and Pediatrics departments were identified and prioritized as

having the greatest opportunity for improvement in readmission rates. Those three departments, along

with others ranging from Neurosurgery to Orthopedics, all initiated lean-methodologic programs, such

as after-hours centers and suggestion systems to allow patients to send images of their wounds to nurse

practitioners for immediate triage. Baseline readmission rate at UCLA from 9/2010 – 12/2011 illustrated

a mean of 12.1%. After the start of the RRI program, for the period of 1/2012 – 6/2013, the readmission

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rate decreased to 11.3% (p < 0.05). As shown in this study, a systematic clinical approach grounded in

lean methodologies is a viable solution to the complex problem of reducing readmission rates.

Al-Hyari, K., Abu Hammour, S., Abu Zaid, M. K., & Haffar, M. (2016). The impact of Lean bundles on

hospital performance: does size matter? International Journal of Health Care Quality Assurance, 29(8),

877-894. doi:10.1108/IJHCQA-07-2015-0083

This paper studied the effect of implementing lean tools (e.g., just-in-time, total quality

management) on hospital performance in private hospitals in Jordan, and evaluated how much

organization size could affect the relationship between lean tool implementation and hospital

performance. The researchers analyzed the impact of lean on quality, cost, patient and staff satisfaction,

and overall healthcare performance. Main lean tools (just-in-time, human resource management, and

total quality management) were found to be effective in large, small, and medium-sized private hospitals

without significant differences in advantages that depend on size.

Balfour, M. E., Tanner, K., Jurica, P. J., Llewellyn, D., Williamson, R. G., & Carson, C. A. (2017). Using Lean

to Rapidly and Sustainably Transform a Behavioral Health Crisis Program: Impact on Throughput and

Safety. The Joint Commission Journal on Quality and Patient Safety, 43(6), 275-283.

doi:10.1016/j.jcjq.2017.03.008

Researchers applied and evaluated lean methods in order to optimize clinical operations at a US

behavioral health crisis facility. Between April and June 2014, Connections AZ assumed management of

the behavioral health facility and began engaging with frontline staff through town halls, rounding, and

clinical observation. Through these meetings they established the following quality aims and associated

outcomes: Timeliness (door-to-door dwell times, door-to-doctor times), Safety (staff injuries), Least

Restrictive (security calls for patients), and Partnership (time on diversion).

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Two phases were implemented, Phase 1 between July and December 2014, and Phase II between

October and December 2014. During Phase I, an interdisciplinary team consisting of management,

frontline staff, and previous patients conducted value stream mapping to map the current and future state

of the patient triage process. In comparing gaps between current and future states the team identified the

following quality improvement initiatives: moving high risk patients to a more secure observation unit,

streamlining room assignment to use space more efficiently, and reducing redundancy by creating a

single, streamlined assessment tool. Phase II involved hiring an additional behavioral health medical

professional (BHMP) to address continued long wait times and frequent diversions after Phase I.

Authors compared patient encounter data pre-intervention between January and December 2014,

and post intervention between January and December 2015. In the clinic median door-to-door dwell

time decreased by 225 minutes (95% confidence interval [CI]:−224–−208; p < 0.0001), and in the

observation unit median door-to-door dwell time decreased by 2 hours (CI:−3.7 – −2.0; p < 0.0001). The

proportion of patients evaluated by a BHMP increased by 21%(CI: 19–23;p < 0.0001), and the mean

number of emergent security calls per month decreased by 9.2 (CI:−16.3–−2.0; p = 0.017). Total number

of staff injuries decreased by 2.1 (CI:−4.1–−0.02; p = 0.034).

Blackmore, C. C., Mecklenburg, R. S., & Kaplan, G. S. (2011). At Virginia Mason, Collaboration Among

Providers, Employers, And Health Plans To Transform Care Cut Costs And Improved Quality. Health

Affairs, 30(9), 1680-1687. doi:10.1377/hlthaff.2011.0291

An American medical center collaborated with local insurers and employers in order to develop

standard approaches to care for patients with common conditions, reduce unnecessary care, and decrease

costs. Collaboratives included representatives from the hospital, local employers, and participating

health plans. Each collaborative first identified major quality and cost concerns of the employer as the

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major purchaser of healthcare. These typically involved common and less complex conditions, including

headache, low back pain, and joint pain. Targeted chart review often showed large variability in care

unrelated to disease severity, presenting opportunities for savings. For each condition targeted for

improvement, a clinical value stream was created by hospital providers to determine the optimal clinical

path that a patient should follow.

Value streams were created by mapping all steps that occur in the care of a patient, and

eliminating any visits, tests, or treatments not in line with current clinical evidence. Cost and outcome

information was shared between entities, and areas where reimbursement was misaligned with value

were addressed.

Researchers discussed outcomes from the implementation of the headache value stream,

involving the movement away from often unnecessary imaging tests and towards follow up calls with

nurse practitioners. After implementation MRI rate decreased by 23.2%, lumbar MRI rate decreased by

23.4%, and sinus CT rate decreased by 26.8%. Between January and June 2010 researchers found that

same or next day appointments with the headache nurse practitioner was available in 95% of cases, with

average patient satisfaction scores of 91%.

Ching, J. M., Long, C., Williams, B. L., & Blackmore, C. (2013). Using Lean to Improve Medication

Administration Safety: In Search of the “Perfect Dose”. The Joint Commission Journal on Quality and

Safety, 39(5), 195-204. doi: http://dx.doi.org/10.1016/S1553-7250(13)39026-6

Staff at a United States medical center conducted time-motion studies to test the change in

medication errors after implementing lean practices. Lean interventions were implemented in 13 units

totaling 313 beds, including acute care (78%), ICU (10.5%), rehabilitation (5.6%), and ER (5.4%).

Kaizen Events and Rapid Process Improvement Workshops were conducted with frontline staff from

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each unit. Interventions were implemented to improve the medication room layout. Six components of

nursing standard work were implemented: comparing medication with records, consistent labeling, two

form identification, explaining medication, charting immediately, and preventing distractions.

Researchers conducted observations at baseline, throughout the lean implementation process, and

at a final follow up period. In each of the 13 identified units, trained nurse auditors observed the full

medication administration process and recorded any violations of the six nursing standard work

practices. Afterward the medication order was compared to the medication administered, and errors

were further classified as incorrect time, dose, form, route, technique, and/or time. A total of 9,244 doses

among 2,139 patients were observed in a six month period.

From baseline to follow up, the study realized a reduction from 83 violations per 100 doses to 42

violations per 100 doses. Identified errors also saw a reduction of 10.3 to 2.8 errors per 100 doses from

baseline to follow up. In the same period, the number of doses with perfect adherence increased from 37

to 68 per 100 doses.

Da Silva, I. B., Seraphim, E. C., Agostinho, O. L., Lima Jr., O. F., & Batalha, G. F. (2015). Lean office in

health organization in the Brazilian Army, International Journal of Lean Six Sigma, 6(1), 2-16. doi:

10.1108/IJLSS-09-2013-0053

This case study evaluated the effectiveness of lean in healthcare at a Brazilian military medical

center. A hired multidisciplinary management group by the name of G5 held meetings with staff,

doctors, and management to teach them lean concepts. They also conducted value stream mapping

(VSM) to identify waste within the medical center. Lean techniques were conducted to achieve the

waste reduction goal: future VSM, continuous flow, 5S, time reduction, and standardized work. For

example, it was found that communication failures in the center’s laboratory were leading to longer

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patient care. Non-value adding activities like these were then subject to root cause analysis and future

VSM.

After conducting a climate survey of employees, the researchers found that employees’ personal

satisfaction increased from 30% before lean implementation to 70% after lean implementation. The

authors also found that after lean implementation, the medical center’s rank rose to 2nd place out of 21

medical centers in Brazil.

Drotz, E. & Poksinska, B. (2014). Lean in healthcare from employees’ perspectives. Journal of Organization

and Management, 28(2), 177-195.

This paper aimed to contribute toward a deeper understanding of the new roles, responsibilities,

and job characteristics of employees in Lean healthcare organizations. The paper was based on 3 cases

studies of healthcare organizations that were regarded as successful examples of Lean healthcare

applications. Data were collected by methods including interviews, observations, and document studies.

The authors found that Lean caused organizational focus to shift from healthcare professionals, where

clinical autonomy and professional skills were the guiding principles, to process improvement and

teamwork. They noted that different job characteristics may make it difficult to implement certain Lean

practices in healthcare. Teamwork and decentralization of authority were given as examples of Lean

practices that could be considered counter-cultural because of healthcare’s strong professional culture

and uneven power distribution, with doctors as dominant decision makers.

Ferguson, A., Aaronson, B., & Anuradhika, A. (2016). Inbox Messaging: an effective tool for minimizing non-

urgent paging related interruptions in hospital medicine provider workflow. BMJ Quality Improvement

Reports, 5(1). doi:10.1136/bmjquality.u215856.w7316

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This study used lean to reduce pages for non-urgent communication, in order to minimize

workflow interruptions at Virginia Mason Hospital. To facilitate the implementation, a workgroup was

formed consisting of unit-based leaders, nurses, providers, administrators, and IT staff. A baseline

measurement of paging data was conducted over a 2-week period, facilitated by an RN project manager

and hospital leader. Inbox messaging was then identified by the workgroup as a tool that could provide

back-and-forth messaging without audible interruptive alerts. This method was chosen due to its success

as a tool in Virginia Mason's ambulatory setting. Multiple PDSA cycles were then implemented to fine

tune the messaging intervention. Immediately after implementation, inbox messages increased from 0 to

80, and non-urgent pages decreased from 103 to 38 (p<.001). The total number of communications also

increased after the intervention from 116 to 131 (p<.001). The authors concluded that the inbox

messaging tool was successful in reducing the number of non-urgent, interruptive pages from hospital

RNs to hospital medicine providers.

Goodridge, D., Westhorp, G., Rotter, T., Dobson, R., & Bath, B. (2015). Lean and leadership practices:

development of an initial realist program theory. BMC Health Services Research, 15(1), 362-377.

doi:10.1186/s12913-015-1030-x

The authors attempted to address the questions: “What changes in leadership practices are

associated with the implementation of Lean?” and “When leadership practices change, how do the

changed practices contribute to subsequent outcomes?” using a qualitative, multi-step approach. They

collected data through a key informant consultation, a stakeholder workshop, documentary review, 26

audiotaped and transcribed interviews with health region personnel, and team discussions. These data

yielded seven initial hypotheses, finding that Lean: 1) aligns the aims and objectives of health regions;

2) permits attention and resources to quality improvement and change management; 3) provides an

integrated set of tools for particular tasks; 4) changes leaders’ attitudes or beliefs about appropriate

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leadership and management behaviors; 5) demands increased levels of expertise, accountability, and

commitment from leaders; 6) measures and uses data effectively to identify actual and relevant local

problems and root causes of those problems; and 7) creates/supports a ‘learning organization’ culture.

Holden, R. J., Eriksson, A., Andreasson, J., Williamsson, A., & Dellve, L. (2015). Healthcare workers’

perceptions of lean: A context-sensitive, mixed-methods study in three Swedish hospitals. Applied

Ergonomics, 47, 181-192. doi:10.1016/j.apergo.2014.09.008

This article looked into two key areas for further Lean research: 1) the effect of contextual

factors on Lean, and 2) healthcare workers’ perceptions of Lean. The authors specifically addressed how

hospital workers’ perceptions of Lean implementation varied across contexts. Standardized surveys were

completed by RNs and physicians across hospital units (N=236, 57% response rate). The study found

that employees’ perceptions varied by hospital, and that employees in higher-acuity units reported more

favorable perceptions of Lean. The study also found that nurses reported more favorable perceptions

than physicians.

Idemoto, L., Williams, B., & Blackmore, C. (2016). Using lean methodology to improve efficiency of electronic

order set maintenance in the hospital. BMJ Quality Improvement Reports, 5(1).

doi:10.1136/bmjquality.u211725.w4724

Researchers at an American medical center implemented and evaluated lean methodologies in

order to create a comprehensive process for order set review and maintenance. Prior to the evaluation,

the average duration of the order set review process was 79.6 days (SD = 68), prompting the hospital to

standardize the process. A team consisting of staff from IT, lab, and nursing was assembled to conduct a

root cause analysis that revealed the following contributors to delay and variability: 1) priority of request

was not visible to analysts, 2) coordination was required by three separate teams to complete review, and

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3) additional clarification was often required before build could be completed. The team created a

production schedule that grouped incoming order sets by clinic department, with the goal of 15 to 25

order sets per department per month.

High priority requests were able to be made and marked as such, where they would be completed

as resources became available. Responsibilities and scope of work were outlined between the three

involved teams (primary content experts, secondary content experts, process owners). Order sets were

placed in an editable Word document with track changes enabled, and sent to all three groups at once for

simultaneous review. Bi-monthly meetings were scheduled to review final versions of these order sets.

Between March and August 2014, 142 order sets that that underwent the new review process were

analyzed. Average review process duration decreased from 79.6 days to 43.2 days (p < 0.001 CI=22.1,

50.7).

Jimmerson, C., Weber, D., & Sobek, D. K. (2005). Reducing Waste and Errors: Piloting Lean Principles at

Intermountain Healthcare. The Joint Commission Journal on Quality and Patient Safety, 31(5), 249-257.

The authors describe lean project pilots at a US rural community medical center across the

cardiology diagnostic lab, pharmacy, rehabilitation department, billing department, and facility services.

First, a seven week training course was conducted to train over 150 participants on value stream

mapping and A3 problem solving. Various improvement efforts resulted from these trainings, including

cost savings of nearly $1 million per year after transitioning from paper checks to electronic payments.

The authors present a case study describing one of these interventions: an application of lean

thinking in the anatomical pathology lab to reduce pathology report turnaround time. A team consisting

of technologists and pathologists conducted value stream mapping for the entire workflow from receipt

of specimen to delivery of the report. They identified the grossing room, where the initial process and

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documentation of samples occur, as the large source of delay. Using A3 problem solving and root cause

analysis, the team identified 4 major problems: flow of paperwork lagging behind the flow of

specimens, scheduling conflicts between specimen collecting and the grossing room, lagging

transcription reports, and inconsistent work processes leading to labeling error. New processes were

designed around these issues to map a new future state.

The authors identified three key factors to successful implementation: 1) giving participants an

opportunity to gain a fresh view of their work and identify waste, 2) staff enthusiasm towards the

improvement process, 3) the use of common templates (i.e., A3) to facilitate interdepartmental

collaboration, and 4) active engagement from senior leadership.

Kanamori, S., Castro, M. C., Sow, S., Matsuno, R., Cissokho, A., & Jimba, M. (2016). Impact of the Japanese

5S management method on patients’ and caretakers’ satisfaction: a quasi-experimental study in Senegal.

Global Health Action. 9. doi:10.3402/gha.v9.32852

This pre-post controlled study implemented 5S in 10 health centers in Senegal and analyzed its

impact on client (patient and caretaker) satisfaction. A 5S ‘pretest’ was first conducted at a trial facility

to establish a reference health center as well as test and validate 5S training instruments. Then pre-5S

implementation data was collected at 4 facilities selected for implementation and 4 control facilities.

From September – December 2012, this data was gathered in the form of questionnaires given to clients

with 10 five-point Likert items to measure client satisfaction. From May – June 2013, data was collected

again at all 8 facilities post-5S implementation and an impact assessment was conducted. After the

second data collection, 5S intervention was also conducted at the 4 control facilities and 1 non-study

facility.

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In regression analysis, 5S implementation was associated with a significant increase in client

satisfaction scores. At baseline, the mean overall client satisfaction score was 4.01 (SD = 0.51) in

control facilities and 3.98 (SD = 0.59) in intervention facilities. At follow-up, satisfaction increased to

4.07 (SD = 0.51) in the control facilities and 4.20 (SD = 0.59) in the intervention facilities. The authors

concluded that 5S has potential to improve satisfaction in resource-poor health facilities, although it

does not directly address resource problems.

Khlie, K., Serrou, D., & Abouabdellah, A. (2016). The impact of Lean-logistics and the information system on

the information flow management within the healthcare supply chain. Intelligent Systems: Theories and

Applications (SITA), 2016 11th International Conference, 1-5. doi:10.1109/SITA.2016.7772315

This case study focused on the impact of lean on information management performance and cost

within a 10-hospital system in Morocco. The case study consisted of 1) identification of waste, 2)

evaluation of waste, and 3) performance measurement. To identify waste, interviews were conducted

with various healthcare professionals (e.g., pharmacists, managers, physicians) in several departments.

These interviews led to identification of problems in 3 main categories: organizational problems, lack of

a sufficient relevant information system (e.g., inaccurate or lacking information), and lack of sufficient

tools to track performance (e.g., in HR utilization rates). Focusing on the last two categories, the

researchers implemented a healthcare information system (HIS) and developed a dashboard to measure

the impact.

A working group was formed with 4 coordinators, 3 industrial engineering researchers, 4

organizational science experts, and pharmacists. The team collected 6 months of historical data on waste

identified by lean, and logistic costs associated with the lack of an HIS. Examples of waste were

expiration costs, stock shortage costs, and HR underutilization. To evaluate the data on waste, the

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researchers compared the 6 months of data before HIS implementation to 6 months of data after HIS

implementation. Lastly, in regards to performance measurement, the researchers used a balanced

scorecard to develop a dashboard evaluating expiration costs, stock shortage costs, and HR

underutilization costs before and after implementation of lean HIS. The authors found that on all 3

measures of costs (expiration, stock shortage, HR underutilization), costs were lower after HIS

implementation. They concluded that integrating HIS infrastructure is one of the most important

dimensions of improving information management, and that lean implementation within the HIS

reduced costs for the hospital system.

Ortiga, B., Salazar, A., Jovell, A., Escarrabill, J., Marca, G., & Corbella, X. (2012). Standardizing admission

and discharge processes to improve patient flow: A cross sectional study. BMC Health Services

Research, 12(1). doi:10.1186/1472-6963-12-180

Researchers at a university-affiliated Spanish hospital implemented and evaluated lean

methodologies in order to standardize admission and discharge processes. An interdisciplinary team of

physicians, administrators, and patients was assembled to identify bottlenecks and brainstorm

improvements. The team suggested the following interventions: 1) promoting admission on day of

surgery, 2) promoting discharge planning 24 hours in advance, and 3) implementing a centralized bed-

management team. Researchers compared 27,784 patients who were discharged prior to the intervention

(between January and December 2007) to 28,577 patients who were discharged after the intervention

(between January and December 2009).

Primary outcome measures were median length of stay, proportion of patients admitted on same

day as surgery, number of cancellations, proportion of day surgery, number of morning admissions

delayed due to capacity, and median number of patient outliers. Proportion of same day surgery patients

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increased significantly from 64.87% to 86.01% (p < 0.05). Pre-surgery length of stay and scheduled

patient length of stay reduced significantly from 0.58 to .26 days and 4.85 to 4.54 days, respectively (p <

0.05). Percentage of inpatient outliers decreased from 9.71% to 7.30% (p < 0.05). The median number of

emergency patients waiting for an in-hospital bed at 8:00 am decreased from 5 patients per day to 3

patients per day (p < 0.01). The proportion of patients that underwent discharge planning increased from

43.05% to 86.01% (p < 0.01). Number of cancellations due to capacity issues decreased from 216 to 42,

though no significance level was calculated. The percentage of emergency visits that were ultimately

admitted to the hospital increased slightly, but not significantly, from 10.46% to 10.49%. Finally, risk-

adjusted mortality rate diminished from 1.02 to 0.89, though no significance levels were reported.

Platke, M. & Andrabi, I. (2012). Focusing on White Space to Improve Patient Throughput. Healthcare Financial

Management. 66(8), 102-106, 108.

This case study describes a lean-Six Sigma intervention at a medical center located in a mid-

sized US city. In the wake of rising uncompensated care, regulatory requirements, and declining

payments, the medical center designed a program aimed at improving length of stay (LOS), nurse and

support staff labor, quality of care, and supply chain costs. The medical center set a goal of reducing

their LOS from 5.2 to 3.5 days.

Lean-Six Sigma consultants, executives, and frontline managers met to assess their current state

and design a future state around care process goals. A patient’s hospital stay was broken down into 8

distinct milestones, and the group discussed ways to decrease the amount of time to move from one

milestone to the next. These processes were implemented alongside the deployment of a new logistics

information system. It provided real time data on anticipated discharge, anticipated admission, available

beds, and clean beds. Its predictive modeling capabilities allowed for nurse managers to better assign

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resources. Automatic targeting of patients who exceeded expected LOS allowed nursing staff to redirect

their efforts appropriately.

Within two years of implementation between January 2009 and December 2010, the medical

center reported $70 million in cost reduction and a decrease in LOS from 5.4 to 4.6 days. Eighty five

percent of reported savings originated from increased productivity of non-nursing staff, reduction in

overtime, reduction in nursing hour variation, and other expense initiatives. In this same period, the

hospital doubled its operating margin, experienced a 41% reduction in nurse turnover, and realized a

71% reduction in preventable harm. In describing lessons learned, they discussed the importance of

setting specific goals for frontline staff, collecting actionable data, communicating frequent data reports,

preparing for success, and maintaining consistency in work.

Portioli-Staudacher, A. (2008). Lean Healthcare: An Experience in Italy. Lean Business Systems and Beyond,

257, 485-492. doi:10.1007/978-0-387-77249-3_50

The results of a Lean implementation at an Italian hospital were presented, stemming from a

need to cut cost and reduce inventory. A large reduction in inventory was achieved, and broken

processes leading to excessive inventories were identified to remove the problem’s root causes. Finally,

hospital staff was taught to think differently about materials management activities: rather than by

batching (e.g. ordering 3 weeks’ worth of a medicine at once), better and faster results were achieved by

standardizing activities and managing orders and activities throughout the week (e.g. ordering medicines

every day to replace those consumed).

Sampalli, T., Desy, M., Dhir, M. et al. (2015). Improving wait times to care for individuals with multi-

morbidities and complex conditions using value stream mapping. International Journal of Health Policy

and Management, 4(7), 459–466. doi:10.15171/ijhpm.2015.76

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Over an 18-month time period, healthcare staff applied a patient-centric approach that included

Lean methodology of Value Stream Mapping (VSM) to improve wait times to care. The evaluation

framework was grounded in the needs and perspectives of patients and individuals waiting to receive

care. Patient-centric views were obtained through surveys such as Patient Assessment of Chronic Illness

Care (PACIC) and process engineering-based questions. In addition, Lean VSM was added to identify

non-value added processes contributing to wait times. From this process, the care team successfully

reduced wait times to 2 months in 2014 with no wait times for care anticipated in 2015. Increased

patient engagement and satisfaction were also noted. In addition, successful transformations and

implementation resulted in resource efficiencies without cost increases. The authors stated that patients

showed significant improvements in functional health after intervention.

White M., Wells J. S., & Butterworth T. (2014). The impact of a large-scale quality improvement programme

on work engagement: Preliminary results from a national cross-sectional-survey of the 'Productive

Ward'. International Journal of Nursing Studies, 51(12), 1634-1643. doi:10.1016/j.ijnurstu.2014.05.002

This paper examined the impact of a large-scale Lean Quality Improvement program, the

‘Productive Ward’, on work engagement of involved nurses and ward teams in the UK. Using the

Utrecht Work Engagement Scale (UWES), the authors surveyed, measured, and analyzed work

engagement in a representative test group of hospital-based ward teams who had recently commenced

the latest phase of the national ‘Productive Ward’ initiative in Ireland and compared them to a control

group of similar size and matched (as far as is possible) on variables such as ward size, employment

grade and clinical specialty area. 338 individual datasets were recorded, n = 180 (53.6%) from the

Productive Ward group, and n = 158 (46.4%) from the control group; the overall response rate was 67%,

and did not differ significantly between the Productive Ward and control groups.

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The work engagement mean score (±standard deviation) in the Productive group was

4.33(±0.88), and 4.07(±1.06) in the control group, representing a modest but statistically significant

between-group difference (p = 0.013, independent samples t-test). Similarly modest differences were

observed in all three dimensions of the work engagement construct. Employment grade and the clinical

specialty area were also significantly related to the work engagement score (p < 0.001, general linear

model) and (for the most part), to its components, with both clerical and nurse manager grades, and the

elderly specialist areas, exhibiting substantially higher scores. The authors concluded that their findings

demonstrate how Lean QI activities appear to positively impact work engagement of ward-based teams.

Other

Kimsey, D. B. (2010). Lean methodology in health care. AORN J, 92(1), 53-60. doi:10.1016/j.aorn.2010.01.015

A rapid improvement team at Lehigh Valley Health Network, Allentown, Pennsylvania,

implemented a plan, do, check, act cycle to determine problems in the central sterile processing

department, test solutions, and document improved processes. By using A3 thinking, a consensus

building process that graphically depicts the current state, the target state, and the gaps between the two,

the team worked to improve efficiency and safety, and to decrease costs. Gap analysis was conducted to

examine the initial and future state of the staff’s tool sterilization cycle.

By eliminating jack jams and increasing drying temperature to the expected level, staff increased

capacity by 30%. Additionally, after repairing and calibrating tools, staff members were able to

eliminate the flash cycle portion of the sterilization cycle, saving 10 hours of work per day. The sterile

processing team and senior leaders found that non-preventive maintenance calls decreased from 6 per

month to 2. The cost of non-preventive maintenance decreased from $12,000 per month to $3,600 per

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month. The average use of the equipment increased from 60% to 90%, and the use of a responsibility

plan for routine inspection and maintenance of equipment increased from 0% to 90%. The end result

was cancellation of a unit upgrade because it was no longer needed.

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Primary research articles identifying components, methods, barriers, and

facilitators for implementing Lean in healthcare organizations

Cardiology

McConnell, K. J., Chang, A. M., Maddox, T. M., Wholey, D. R., & Lindrooth, R. C. (2014). An Exploration of

Management Practices in Hospitals. Healthcare, 2(2), 121-129. doi:10.1016/j.hjdsi.2013.12.014

US Researchers from Oregon Health and Science University, University of Colorado, and

University of Minnesota conducted a national hospital survey to test the association between reported

lean practices and hospital characteristics, processes of care, readmission, and patient mortality. 597

hospitals with at least 25 annual Acute Myocardial Infarction (AMI) discharges were surveyed. The

survey assessed four distinct management dimensions in cardiac units: standardizing care/lean

operations, performance and monitoring, target setting, and employee incentives. Each management

dimension features between three and six open ended questions on the survey, and responses are used to

determine a score for each dimension. The authors provide a detailed description of the practices that

were assessed to assign a score to each dimension.

Surveys with cardiac care nurse managers were conducted over the phone and were scored on a

scale of 1 to 5 by two independent researchers. The averages for each dimension were converted to z-

scores, and were then averaged to create an average management score. Average management score was

then regressed against HHI, net income, region, distance to nearest accredited MBA program, AMI

discharge volume, teaching status, system membership, and open heart surgery capability.

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Higher management scores were associated with a more competitive market (p < .005,

Coefficient = -2.82, 95% CI {-.552, -.011}), net income (p < .005, Coefficient = .0457, 95% CI {.001,

.091}), and status as a teaching hospital (p < .005, Coefficient = .149, 95% CI {.0168, .281}), and

proximity to an MBA program (p < .01, Coefficient = -.066, 95% CI {-.133, .0001}). The authors note,

however, that the magnitude of these associations are relatively small. In describing survey responses to

standardizing care/lean operations questions, the authors note best practices of utilizing streamlined and

integrative pathways of care, similar to what is produced in Value Stream Mapping. They theorized that

more associations were not found because the sample of hospitals included many with relatively high

volume, and because they focused on cardiac units that may undergo more management scrutiny.

McConnell, K. J., Lindrooth, R. C., Wholey, D. R., Maddox, T. M., & Bloom, N. (2013). Management

Practices and the Quality of Care in Cardiac Units. JAMA Internal Medicine,173(8), 684.

doi:10.1001/jamainternmed.2013.3577

US Researchers from Oregon Health and Sciences University conducted a survey of 597 hospital

cardiac care units to assess the variation of management practices, as well as test the association of these

practices to care processes, mortality, and readmission. The survey tool grouped 18 management

practices into 4 distinct dimensions: standardizing care/lean operations, performance monitoring, setting

targets, and incentivizing employees/managers. Nurse managers at each unit were asked open ended

questions regarding these 18 management practices, and each was scored on a scale of 1 to 5 with higher

scores indicating better performance. Management scores were converted to z scores and then averaged

to create an overall mean management score. This score was then regressed against interview

characteristics (interviewee job, location, duration, etc.) to mitigate bias, and create an adjusted mean

management score that was used as the primary exposure.

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Multivariate analysis was used to assess the relationship between management score and

outcomes. Overall management score was associated with lower 30 day risk adjusted mortality (p = .01).

Specifically, units in the 75th percentile of management scores had .17% lower mortality than those in

the 25th percentile. Regarding processes of care, hospitals with higher management scores performed

better on all process of care measures (p < .05), including measures of mortality, aspirin use on arrival

and discharge, percutaneous coronary intervention within 90 minutes of arrival, other targeted

medication use, and smoking cessation counseling.No significant association was found between

management score and 30-day risk adjusted readmissions.

Identified limitations of the study included difficulty in controlling for spillover effects from

unrelated initiatives on other hospital floors, as well as the use of only one respondent for each hospital.

Surveyed hospitals also differed slightly from non respondents, with surveyed hospitals more likely to

be located in rural areas, as well as having smaller but statistically significant lower mortality rates

compared to non respondents.

Ulhassan, W., Sandahl, C., Westerlund, H., Henriksson, P., Bennermo, M., von Thiele Schwarz, U., & Thor, J.

(2013). Antecedents and characteristics of Lean thinking implementation in a Swedish Hospital: a case

study. Quality Management in Health Care, 22(1), 48–61. doi:10.1097/QMH.0b013e31827dec5a

This case study investigated a cardiology department’s experience from initial adoption to

adaptation of Lean thinking. It sought to determine how the department - which had a long history of

quality improvement - decided to introduce Lean, and how Lean impacted employees’ work. The

authors used semi-structured interviews, non-participant observations, and document studies to gather

this information. They then conducted content analysis of the data, finding that the department’s

previous improvement efforts may have facilitated the introduction of Lean thinking. This history was

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not as important in predicting the sustained usage of Lean over time. Additionally, individual differences

in staff members’ perceived need for change led to varying degrees of Lean adoption. For successful

Lean implementation, the authors found work re-design and teamwork beneficial to improving patient

care. Similarly, problem solving was deemed helpful in maintaining staff engagement and thus sustained

improvements.

Community Health Clinics (CHCs) & Rural Facilities

Carter, P. M., Desmond, J. S., Akanbobnaab, C., Oteng, R. A., Rominski, S. D., Barsan, W. G., Cunningham, R.

M. (2012). Optimizing Clinical Operations as part of a Global Emergency Medicine Initiative in

Kumasi, Ghana: Application of Lean Manufacturing Principals to Low Resource Health Systems.

Academic Emergency Medicine, 19(3), 338–347. doi:10.1111/j.1553-2712.2012.01311.x

This study aimed to describe the application of Lean to improve clinical operations at Komfo

Anokye Teaching Hospital in Ghana, while identifying key lessons learned to aid future global

improvement initiatives. A 3-week Lean improvement program focused on the admissions process at the

hospital was completed by a 14-person team in six stages: problem definition, scope of project planning,

value stream mapping, root cause analysis, future state planning, and implementation planning.

Additionally, 8 lessons learned from the initiative were identified: 1) the Lean process aided in building

a partnership with Ghanaian colleagues; 2) obtaining and maintaining senior institutional support was

necessary and challenging; 3) addressing power differences among the team to obtain feedback from all

team members was critical to successful Lean analysis; 4) choosing a manageable initial project was

critical to influence long-term Lean use in a new environment; 5) data intensive Lean tools could be

adapted and were effective in a less-resourced health system; 6) several Lean tools focused on team

problem-solving techniques worked well in a low-resource system without modification; 7) using Lean

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highlighted that important changes do not require an influx of resources; 8) despite different levels of

resources, root causes of system inefficiencies were often similar across healthcare systems, but require

unique solutions appropriate to the clinical setting.

Emergency Department (ED)

Johnson, J. E., Smith, A. L., & Mastro, K. A. (2012). From Toyota to the Bedside: Nurses Can Lead the Lean

Way in Healthcare Reform. Nursing Administration Quarterly, 36(3), 234-242.

doi:10.1097/naq.0b013e318258c3d5

Nursing staff completed 2 case studies of lean interventions at a US university hospital in a small

town. The first was an intervention in the Operating Room (OR) that focused on improving efficiency

through scheduling and inventory management. Five rapid design teams were created to address 5 core

components of OR workflow: schedules, materials, case art, turnover, and central supply processing.

The teams conducted kaizen working sessions, where they assessed current and future states and

designed process flows and value streams. These teams reorganized supplies and renovated the OR

central facility. The authors reported reduced costs in purchasing, repair, and inventory. Usage of flash

sterilization (faster, but considered less desirable, than conventional sterilization) rates decreased and

OR suite turnaround time improved. A combination of decreased overtime and increased capacity

allowed for increased OR revenues.

The second case study was based in the Emergency Room (ER), with a focus on improving

inventory management, admission and patient flow, staffing levels, and length of stay. Teams mapped

the patient cycle from admission to discharge, assigning value at each phase. An environmental scan of

inventory was conducted to assess distance from equipment and point of use. A two year demand

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analysis was conducted to create a new staffing schedule. Throughout this pilot period, length of stay

data was collected from each patient and compared to control data, finding an average 47 minute

reduction in length of stay.

In assessing lessons learned from these case studies, the authors described the importance of

leadership from all levels of hospital organization, consistent communication, and a systems approach to

change making. They also discussed the difficulty in addressing change, particularly in achieving buy-in

from employees. Overall, authors argued that nurses are the ideal workforce to use lean to achieve

change in healthcare settings, and they should be given the proper tools for success.

Naik, T., Duroseau, Y., Zehtabchi, S., Rinnert, S., Payne, R., McKenzie, M., & Legome, E. (2012). A structured

approach to transforming a large Public Hospital Emergency Department via Lean methodologies.

Journal for Healthcare Quality, 34(2), 86–97. doi:10.1111/j.1945-1474.2011.00181.x

The authors outlined a systemic method to apply Lean principles across the entire emergency

department (ED) patient experience to transform a high volume ED in 1 hospital. They then compared

ED performance metrics before and after Lean implementation, finding that median and IQR results

showed improvement on several metrics after implementation. The hospital partnered with a Lean

consulting firm, established an executive Lean steering committee that ranked True North metrics for

the hospital’s improvement vision, and then determined major value streams based on their contribution

to True North metrics. The ED was identified as a key value driver and selected as 1 of 4 service lines

for initial Lean intervention. At the emergency department level, an ED Lean steering committee was

created and trained in a 2-day Lean introduction program. The committee consisted of departmental

leadership and other key stakeholders, such as representatives from finance and hospital operations.

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The steering committee participated in a 3-day value stream analysis to map out implementation

over the first year. Rapid Improvement Events (RIEs) were held monthly, and enlisted an 8 – 12

member team of front-line staff (e.g. MDs, RNs, support staff) with varying degrees of relationship to

the process of focus, providing diverse perspectives. A facilitator experienced in Lean principles guided

the team, and a member with intimate knowledge of the process (often a director/manager) was assigned

as ‘process owner,’ with oversight of implementation/sustainment. A new standard workflow and

responsibilities were then immediately shared with front-line staff following RIEs. Visible executive

commitment at all levels was noted as critical to successful Lean transformation.

Intensive Care Unit (ICU)

Bastian N. D., Munoz D., & Ventura M. (2016). A Mixed-Methods Research Framework for Healthcare

Process Improvement. Journal of Pediatric Nursing, 31(1), 39-51. doi:10.1016/j.pedn.2015.09.003

This paper applied a mixed-methods research framework incorporating lean thinking to a

pediatric intensive care unit (PICU) at Penn State Hershey Children’s Hospital. The researchers sought

to identify if this methodology could lead to better healthcare process improvement implementation

when assessing the current state of workflow in the PICU. The framework consisted of three phases: 1)

stakeholder analysis, 2a) staff survey, 2b) time-motion study, and 3) process improvement. In phase 1 of

the case study, researchers held two separate meetings: one with two physicians and the other with two

nurses in the PICU. This allowed the PICU stakeholders to walk through various workflow elements

they did not previously consider important. After interviews, the researchers observed nurses’ and

physicians’ activities in the PICU as part of an observational study, to examine issues previously

identified in the interviews as well as identify other causes of inefficiency.

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In phase 2a, the researchers conducted a survey of physicians and nurses in the PICU focused on

workflow efficiency and clinician satisfaction issues. This survey allowed the researchers to identify

perceived critical to quality elements for measuring work performance, including satisfaction of

patients’ families, patient safety, efficient use of resources and time, and job satisfaction.

Phase 2b was a time-motion study during which clinicians collected data on time spent on daily

workflow activities. This time-motion study assessed the appropriateness and time decomposition of

workflow processes, while further identifying critical workflow activities.

Phase 3, process improvement, used the main findings from phase 2b to address four main

categories impacting clinical efficiency and satisfaction: communication, layout, procedures/standards,

and health information technology. Fishbone diagrams were used for both root cause analysis (RCA)

and to generate recommendations for process improvement.

Overall, the study found that implementing the framework led to identification and

categorization of different workflow tasks and activities into both value-added and non-value added in

an effort to provide more valuable and higher quality patient care. The researchers emphasized that

involvement of healthcare stakeholders, namely nurses and physicians, was critical to fully

understanding PICU workflow and discovering root causes of inefficiencies.

Pharmacy

Al-Araidah, O., Momani, A., Khasawneh, M., & Momani, M. (2009). Lead-Time Reduction Utilizing Lean

Tools Applied to Healthcare: The Inpatient Pharmacy at a Local Hospital. Journal for Healthcare

Quality, 32(1), 59-66.

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The authors applied selected principles of Lean management to reduce time associated with drug

dispensing at an inpatient pharmacy at a local hospital. Thorough investigation of the drug dispensing

process revealed unnecessary complexities leading to delays in medication delivery. DMAIC (Define,

Measure, Analyze, Improve, Control) and 5S (Sort, Set-in-order, Shine, Standardize, Sustain) were used

to identify and reduce waste that increased the lead-time in healthcare operations at the pharmacy

understudy. The study’s results revealed potential savings of >45% in drug dispensing cycle time.

John, N., Snider, H., Edgerton, L., & Whalin, L. (2017). Incorporation of lean methodology into pharmacy

residency programs. American Journal of Health-System Pharmacy, 74(6), 438-444.

doi:10.2146/ajhp160131

Researchers describe the incorporation of lean methodologies into pharmacy residency training

programs at a Southern US teaching hospital. Authors describe how their training program have utilized

the four rules of lean to improve and ensure resident competency. Rule 1 states that all activities should

be highly specific and standardized. Standardization is essential in preventing duplication among the 4

distinct residency programs in the pharmacy department. Standard work was developed to create a

general orientation spanning all 4 programs, as well as training specific to the competencies of each

program. Residents apply 5S, a tool to standardize physical inventory, for their work in medication

management. Rule 2 states that direct connections must exist between customer and supplier to prevent

ambiguity. Resident Advisory Committee meetings changed in frequency from bi-annually to

bimonthly, with one monthly meeting focusing on program operations and another focusing on resident

progression. Every month residents were given a progression document detailing their strengths and

weaknesses. A chief resident role was created to act as a liaison between program staff and pharmacy

residents.

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Rule 3 states that product and services follow a simple predetermined path to limit interrupted

flow of resources. In the residency programs products are defined as the residents themselves and any

services they provide to the department and hospital. As a graduation requirement, residents must create

and offer 9 hours of continuing education to the department, but in 2012/2013 28.5% of residents were

required to repeat their CE due to failure of meeting objectives. To remedy this, standard work was

created detailing specific expectations of each step in the process, and why each step is important. in the

2013/2014 year of implementation, all residents passed their CE requirement on the first attempt, and

average attendance increased from 19 staff to 31.

Rule 4 states that improvement efforts follow a scientific process beginning at the lowest level in

the organization and under teacher guidance. Resident leadership saw an opportunity to meet an ASHP

requirement of continuous resident program improvement through lean methodology. Preceptors,

residents, and recent graduates formed groups to create fishbone diagrams to evaluate attrition rate and

potential barriers to success. Responses were divided into 2 categories (resident support and

communication within recent programs) and further assessed using an A3. Metrics were identified and

continually tracked to measure progress. Examples of countermeasures implemented include additional

organized social activities and the removal of evaluation responsibilities from resident advisors so they

may better serve as mentors to residents. The application of lean methodology in the pharmacy

residency program has allowed the program to systematically expand quality improvement initiatives,

resident leadership opportunities, and inter-program communication.

Primary & Preventive Care

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Grove, A. L., Meredith, J. O., Macintyre, M., Angelis, J,, & Neailey, K. (2010). Lean implementation in

primary care health visiting services in National Health Service UK. Quality and Safety in Health Care,

19(5), e43. doi:10.1136/qshc.2009.039719

Findings were presented on a 13-month Lean implementation in National Health Service (NHS)

primary care health visiting (HV) services from May 2008 to June 2009. A Lean Thinking project team

was established which included staff and management from a variety of roles related to the HV service,

without formalized roles or project champions. This team took part in 8 workshops throughout the

project to share ideas and learn from one another, and were assisted by Lean consultants. Stakeholder

and value stream mapping (VSM) was used to determine essential tasks in health visiting services and

links between relevant stakeholders. Through discussion with these stakeholders, waste processes were

identified and new process maps were produced. Quantitative data were provided through a 10-day

time-and-motion study of a selected number of staff. Analysis of VSM processes revealed that 67% of

67 identified processes were waste; the revised process map reduced this to 23 process steps. One

notable example of improved processes was a change to methods of contacting central administration.

Initially, administrative staff would wait for large quantities of documents to accumulate before

dispatching them in weekly batches to central administration; this led to extended waits for patient

appointments and increased stress to employees due to uneven workloads. To improve this process, the

Lean Thinking team introduced more document envelopes that could be dispatched daily, thus

eliminating uneven workloads from batching of documents and shortening the average wait for a new

appointment from 1 week to 2 days. The study concluded that a large amount of waste could be

eliminated through simplification and standardisation of day-to-day tasks, without the need for

expensive or time-consuming organisational changes. The authors noted that members of the Lean team

continue to make small improvements in their respective areas, but that changes in organizational

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culture and management practice will be required to provide a supportive environment for change.

Management support across the entire organization was also cited as necessary to sustain and introduce

future Lean initiatives.

Gray, C., Martinez, M., & Hung, D. (2014). PS1-29: Changing the Culture of Medicine: An Exploration of

Lean Healthcare in Primary Care. Clinical Medicine & Research, 12(1-2), 98–99.

doi:10.3121/cmr.2014.1250.ps1-29

This study qualitatively evaluated a Lean implementation at a large healthcare organization.

Researchers conducted observations of key implementation events and interviewed frontline leaders, as

well as physicians, nurses, and medical assistants who participated in the change effort. The data

produced from these qualitative methods were analyzed and coded using an inducted, grounded

approach. The paper highlighted five main changes that produced cultural conflict when this healthcare

organization implemented Lean. They were 1) adopting team care approaches, 2) democratization of the

workplace and the erosion of hierarchies, 3) reducing variation and standardizing work, 4) surveillance

of staff and employees, and 5) a perceived emphasis on profit over patient care. The authors concluded

that implementing new ways of delivering care in healthcare organizations is often met with many

challenges. Some of these challenges may be rooted in a conflict between new sets of cultural values and

those that have historically existed in the field of medicine. Reconciling these conflicts may be one of

the most difficult challenges healthcare organizations face as they try to implement wide- scale change.

Grove, A.L., Meredith, J.O., Macintyre, M. et al. (2010). ‘UK health visiting: challenges faced during lean

implementation’, Leadership in Health Services, 23 (3), pp. 204-218.

The paper presented challenges identified during a lean implementation in a health visiting

service within a large primary care trust in NHS UK. A triangulated approach to data collection was

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used to determine the root cause of challenges faced during lean implementation. The 3 methods were

selected for qualitative analysis were semi‐structured interviews, document analyses, and researcher

participant observation. From these methods, 6 key challenges were identified: 1) high process

variability, 2) a lack of understanding of lean, 3) poor communication and leadership, 4) target focused

implementation, 5) problems defining waste, and 6) difficulty in defining the customer and what the

customer values.

Hung D., Martinez M., Yakir M., & Gray C. (2015). ‘Implementing a Lean Management System in Primary

Care: Facilitators and Barriers From the Front Lines’, Quality Management in Healthcare Journal,

24(3), pp.103-108.

This case study was conducted to highlight key facilitators and barriers to implementing lean

among frontline primary care physicians (PCPs). It took place at a large California ambulatory care

delivery system serving 1 million patients. In-depth interviews were conducted with PCPs, staff, and

administrators to identify key factors affecting lean re-designs in primary care.

Aspects identified as critical when introducing lean were staff engagement and performance

management, sensitivity to the professional values and culture of medicine, and perceived adequacy of

organizational resources. Drivers of change were staff empowerment at all levels, visual display of

performance metrics, and a culture of innovation and collaboration. Identified barriers were physician

resistance to standardized work, difficulty transferring management responsibilities to non-physician

staff, and time and staffing required to participate in improvement efforts. The authors concluded that

understanding early facilitators and barriers can maximize lean’s potential to improve health care

delivery.

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Hung, D., Gray, C., Martinez, M., Schmittdiel, J., & Harrison, M. I. (2017). Acceptance of Lean redesigns in

primary care: A contextual analysis. Health Care Management Review, 42(3), 203-212.

doi:10.1097/HMR.0000000000000106

This study aimed to identify contextual factors that were most critical to implementing and

scaling Lean redesigns in all primary care clinics of a large ambulatory care system. The authors

conducted over 100 interviews and focus groups with frontline physicians, clinical staff, and operational

leaders. Data analysis was then conducted using a modified Consolidated Framework for

Implementation Research, called CFIR-PR. Several domains identified through CFIR-PR were vital to

acceptance of Lean redesigns. In the implementation process, acceptance was influenced by time and

intensity of exposure to changes, top-down versus bottom-up implementations, and degree of employee

engagement in developing new workflows. Important factors of the inner setting were the clinic’s

culture and style of leadership, and availability of information on Lean’s effectiveness. Lastly,

individual and team characteristics regarding changed work roles, and related issues of professional

identity, authority, and autonomy were important.

Surgery

van Rossum L., Aij, K. H., Simons, F. E., van der Eng, N., & ten Have, W. D. (2016). Lean healthcare from a

change management perspective: the role of leadership and workforce flexibility in an operating theatre.

Journal of Health Organization and Management, 30(3), 475-493. doi:10.1108/JHOM-06-2014-0090

This cross-sectional survey was conducted in the operating theatre (OT) of a Dutch University

Medical Centre to evaluate the influence of organizational factors on a hospital’s capacity for lean

change. Transformational leadership was expected to ensure top-down implementation of lean, while

researchers hypothesized that team leadership would also influence the necessary bottom-up

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commitment of employees. Further, it was expected that greater workforce flexibility would result in

increased lean implementation through adapting organizational elements and optimizing process flow.

The cross-sectional survey was conducted in the OT 18 months after lean implementation in the

department. Employees (n = 380) were asked to complete a 69-item survey that was distributed by e-

mail. After 2 weeks, a reminder to complete the survey was sent to those who had not responded/had

responded incompletely. The overall response rate was 27% (103/380 employees). The authors stated

that the respondents reflected the general OT ‘population’ as they were distributed evenly across

functions.

Linear regression analysis was conducted to test the hypotheses; it was found that all three

predictors together explain 53% of the difference in how lean healthcare implementation is perceived

(p<.0001). Each individual predictor also had a significant positive relationship to its respective

dependent variable. Workforce flexibility had the strongest relationship with lean implementation,

though the strength of the association was similar for all three predictors. The authors concluded that

transformational leadership, team leadership, and workforce flexibility were facilitators of lean

transformation in an operating theatre.

General

Aij, K. H., Simons, F. E., Widdershoven, G. A., & Visse, M. (2013). Experiences of leaders in the

implementation of Lean in a teaching hospital—barriers and facilitators in clinical practices: a

qualitative study. BMJ Open, 3(10), e003605. doi:10.1136/bmjopen-2013-003605

This study aimed to systematically investigate the experiences of leaders in the implementation

of Lean within a teaching hospital in the Netherlands. Authors conducted semi-structured, in-depth

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interviews of 31 medical, surgical and nursing professionals with an average of 19.2 years of

supervisory experience. All professionals were appointed to a Lean Training Program and were directly

involved in the implementation of Lean. Based on interview results, the researchers found that

leadership management support, a continuous learning environment, and cross-departmental cooperation

were seen as significant for successful Lean implementation. The results suggested that a Lean Training

Program contributed to positive outcomes in personal and professional skills that were evident during

the first 4 months after program completion.

Andersen, H., & Rovik, K. A. (2015). Lost in translation: a case-study of the travel of lean thinking in a

hospital. BMC Health Services Research, 15(1), 401-410. doi:10.1186/s12913-015-1081-z

The paper explore the ‘travel’ of Lean within a Norway hospital by assessing local actors’ Lean

perceptions through their images of factors for successful Lean intervention. These perceptions

described the characteristics of Lean in use. Perceptions were collected through focus group interviews

with three groups of stakeholders: managers, internal consultants and staff. A questionnaire was used to

reveal the factors’ relative importance. Identified important factors for Lean’s success matched the

literature, except that external expert change agents were not perceived to promote Lean. New factors

were also added. Two-thirds of the most important identified factors were novel, local ones. Among

these were a ‘problem’ rather than ‘method’ focus, a bottom-up approach, internal consultants,

credibility, realism, and patience. Local actors had different images of Lean depending on their

hierarchical level. The authors concluded that ideas of Lean were transformed more than once within the

hospital.

Ballé, M., & Régnier, A. (2007). Lean as a learning system in a hospital ward. Leadership in Health Services,

20(1), 33-41.

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Lean was applied in a hospital ward by nursing staff, who identified a number of complex

nursing issues, such as medication distribution errors, catheter infections, nosocomial infections,

bedsores. 5S was implemented in storage areas in order to move supplies out of ward corridors and keep

corridors clear for safety reasons. Nursing practices were also standardized, resulting in the rate of

incidents per patients being reduced by 45% over 2 years. The nursing manager additionally reported

that her greatest satisfaction from the Lean process was perceived noticeable improvement in nurse-

patient relationships.

Brandao de Souza, L., & Pidd, M. (2011). Exploring the barriers to Lean health care implementation. Public

Money & Management, 31(1), 59-66. doi:10.1080/09540962.2011.545548

This work analyzed implementation barriers in the UK National Health Service’s (NHS)

application of Lean healthcare principles. It concluded that with slight modifications for the healthcare

industry, Lean thinking can achieve good results. The authors conducted their analysis based on

interviews with directors, managers, and healthcare practitioners as well as their own experiences

implementing Lean at the NHS. The first major barrier identified was provider concerns that Lean treats

patients as uniform ‘parts’; clarification and evidence must be provided to show otherwise.

Additional identified barriers were professional and functional silos, organizational hierarchies,

and shifting managerial focus from temporary to permanent solutions. In addressing the former two

issues, non-hierarchical multidisciplinary teams must be established to ensure unbiased performance

improvement across departments. For the latter matter, managers may be trained to make decisions

using evidence-based analysis. To prevent the undesirable side effects of using performance measures to

quantify Lean’s impact, implementation teams should be involved in defining their own metrics, and

Lean terminology should be standardized to prevent miscommunication. Overall, it was found that

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provider empowerment and clear structure should be emphasized for Lean implementation to be

successful.

Burgess, N., & Radnor, Z. (2013). Evaluating Lean in healthcare. International Journal of Health Care Quality

Assurance, 26(3), 220-235.

The authors presented observations on Lean implementation in UK hospitals based on content

analyses of all annual reports and websites for said hospitals over two time periods. They found that

Lean implementation overall tends to be isolated to a few projects within organizations, and that across

hospitals there exists a spectrum of implementation levels ranging from tentative to systemic. Time-

series data noted an increase in Lean usage and system-wide Lean approaches over time. The paper

concludes that further analysis is needed to document the effects of organizational context on Lean

approaches used and the sustainability of said approaches.

Chiarini, A., & Baccarani, C. (2016). TQM and lean strategy deployment in Italian hospitals. Leadership in

Health Services, 29(4), 377-391.

This article analyzed the deployment path of lean-TQM implementation in Italian public

healthcare to assess benefits and pitfalls. 3 case studies were conducted in 3 large Italian hospitals with

500+ beds each. All 3 hospitals had embraced lean or TQM as part of their strategic objectives. The case

studies were based on interviews with 4 managers across the 3 hospitals, who were chosen because they

had managed several lean-TQM projects previously and were experienced with many different

organizational problems. The research team developed an interview guide with open-ended questions

that was used in a semi-structured interview format. Examples of questions were "what tools were used

[in lean implementation]?", "what did you think of these tools?", and "would you give me an example of

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what you think about it?" The authors then grouped interview responses based on patterns and repeated

elements.

The researchers found that there was a specific deployment path for TQM-lean implementation,

and that implementation was linked to increased patient satisfaction and organizational performance.

Some barriers that could affect TQM-lean effectiveness were problems with senior management

commitment, staff management, manufacturing culture, and tools adaptation.

Eiro, N. Y., & Torres-Junior, A. S. (2015). Comparative study: TQ and Lean Production ownership models in

health services. Revista Latino-Americana de Enfermagem, 23(5), 846–854. doi:10.1590/0104-

1169.0151.2605

Eiro and Torres-Junior compared the application of Total Quality (TQ) and Lean models in

healthcare through a descriptive case study in Brazil. TQ and Lean were compared at a large medical

diagnostic service and a medium-sized private hospital that had implemented Lean before. The study

found that Lean was better suited for people that work systemically and generate flow, leading to

increased adherence to standard work as well as continuous improvement and staff involvement in

problem-solving. The TQ model was found to be more widespread, and to involve more bureaucratic

procedures that were continuously audited and required more stable control.

Esain, A., Williams, S., & Massey, L. (2008). Combining Planned and Emergent Change in a Healthcare Lean

Transformation. Public Money & Management, 28(1), 21-26. doi:10.1111/j.1467-9302.2008.00614.x

A longitudinal study was employed to evaluate the implications of planned and emergent change

when deploying 5S Lean at a UK NHS Trust that employed approximately 13,000 staff serving a

population of around 600,000 at multiple locations. Formal interviews were conducted with 4 hospital

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personnel/managers who acted as Lean change agents, a questionnaire was employed that collected data

on successes and problems in implementation, and observations were recorded during meetings and

workshops. All of the change agents were supportive of 5S, but indicated there were limitations. They

thought the tool should not be seen as a vehicle for major change but, rather, as a starting point. It was

suggested that 5S is an integral part of wider strategic change management program.

Harrison, M. I., Paez, K., Carman, K.L., Stephens, J., Smeeding, L., Devers, K.J., & Garfinkel, S. (2016).

Effects of organizational context on Lean implementation in five hospital systems. Health Care

Management Review, 41(2), 127-144. doi:10.1097/HMR.0000000000000049

This case study consisted of semi-structured interviews at 5 healthcare organizations to evaluate

the effects of intra-organizational context on 12 lean rapid improvement projects at these organizations.

All of the projects sought to improve clinical care delivery. A framework of factors likely to affect lean

quality improvement (QI) was developed based on literature and utilized in developing interview

questions. Interviews were then transcribed and given qualitative codes. Available documents, data, and

observations were utilized as supplements to the interviews. Case studies were constructed for lean

implementation in each organization; these case studies and the 12 projects were compared across

organizations.

Based on data from the sources above, the researchers identified intra-organizational

characteristics affecting organization-wide lean projects, and also often shaping project outcomes.

Higher levels of these characteristics were associated with better project outcomes. The characteristics

were listed as follows: 1) CEO’s active support and commitment to lean, 2) prior organizational capacity

for QI initiatives, 3) alignments of lean initiatives with organizational mission, 4) dedication of

resources and experts to lean, 5) staff training before and during projects, 6) establishment of

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measurable and relevant project targets, 7) planning of project sequences that enhance staff capabilities

and commitment without overburdening them, and 8) ensuring communication between project

members and other affected staff. The authors concluded that their study underscores the importance of

ensuring that organizational infrastructure can support an improvement initiative.

Jorma, T., Tiirinki, H., Bloigu, R., & Turkki, L. (2016). LEAN thinking in Finnish healthcare. Leadership in

Health Services, 29(1), 9-36. doi:10.1108/LHS-08-2015-0021

This study used a mixed-methods survey approach to evaluate the use and associated outcomes

of lean in the Finnish public healthcare system. A 28-question survey with both qualitative and

quantitative questions was sent to Finnish public healthcare workers between February and June 2014,

and received a 44.4% response rate (110 out of 248). 79 respondents indicated that their organization

had at least one ongoing lean initiative focused on patient or care processes. 100% of respondents

ranked developing healthcare processes as either “very important” or “important.” Only 3 out of 110

respondents indicated that they did now know what lean meant and were subsequently excluded from

the rest of the survey.

In general, there was high awareness of lean methods; for example, among respondents who had

no ongoing lean initiatives focused on patient or care processes (n = 28), 84% reported that they had

considered launching a lean project in their organization. While there was high awareness of lean, the

authors found that lean was a new concept to Finnish healthcare and that it had not been implemented

deeply. Lean was mostly used as a development tool for financial savings and improved efficiency.

Implementations had not been systematic, data was lacking, and most lean initiatives documented were

started less than five years ago. However, respondents’ experiences with lean were encouraging, as

100% of those who had implemented lean initiatives defined them as successful.

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Kinder, T., & Burgoyne, T. (2013). Information Processing and the Challenges Facing Lean Healthcare.

Financial Accountability & Management, 29(3), 271-290. doi:10.1111/faam.12016

The authors suggested that the level of information required by Lean projects was beyond the

capacity of many NHS trusts, and used Galbraith’s information processing theory as a mode of

explanation for why many NHS Lean healthcare projects failed. They concluded that, if generalizable,

their findings challenge the premise that Lean can be used to deliver sustainable cost reduction while

improving quality of care. On a micro-level, the paper cited lack of clinician support and rejection of the

‘cuts’ ideology as reasons for failed Lean implementation. The paper focused on information processing

management as a mechanism to examine how the complexity and uncertainty of healthcare affected

Lean implementation.

It found that most Lean initiatives involved less than 20% of staff, and ‘rapid improvement

events’ (RIEs) rather than long-term systemic applications. Other studies were cited stating issues with

Lean implementation such as silos of Lean usage, lack of staff training and opportunities for

experimentation, and overly long time to complete projects. The authors looked at two Lean

implementation projects and conducted interviews with 3 project participants, 2 team leaders, and the

Deputy Chief Executive using a prepared survey. They deemed that Lean and all other change projects

are ‘information-hungry’. Lacking information processing systems make their sustained success

difficult. Inadequate information processing, low senior clinician engagement, and absence of

commitment-based HR were seen as difficulties for Lean RIEs.

Lee J. Y., McFadden K. L., & Gowen C. R. (2016). An exploratory analysis for Lean and Six Sigma

implementation in hospitals: Together is better? Health Care Management Review. Advance online

publication. doi:10.1097/HMR.0000000000000140

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This survey of U.S. hospitals sought to explore existing patterns of lean-Six Sigma

implementation and compare performance of the different patterns. Survey questions included

measurements developed from lean-Six Sigma healthcare research following a literature review. A

geographically stratified sample of 307 hospitals was selected from an online hospital database, and a

total of 215 responded to the survey (70%). The survey was completed by organizational managers most

likely to have acute knowledge of lean-Six Sigma: chief quality officers, patient safety directors, risk

management officials, and nursing directors.

Using factor analysis, the authors identified 2 clusters based on type of lean implementation: a

Moderate Six Sigma group (Cluster 1) and a lean-Six Sigma group (Cluster 2). Cluster 1 (n = 116)

represented hospitals that implemented Six Sigma at a moderate level but used little to no lean

implementation. The authors claimed that this might imply the use of project-based Six Sigma

approaches without using lean to manage internal processes on a daily basis for continuous

improvement. Cluster 2 (n = 99) represented hospitals that embraced both lean and Six Sigma activities

for continuous improvement. Hospitals in this cluster exhibited a much higher level of lean and Six

Sigma implementation, with lean’s holistic, whole-system view appearing to result in higher

performance in responsiveness capability and patient safety. The authors noted an interesting finding

from this study that no cluster was obtained for hospitals using only lean. This indicated that

implementing lean without Six Sigma was not a predominant implementation strategy in U.S. hospitals.

Based on the higher performance in Cluster 2, the authors found there was justification to use more lean

tools in combination with Six Sigma for better outcomes.

Radnor, Z., Holweg, M., & Waring, J. (2012). Lean in healthcare: The unfilled promise? Social Science &

Medicine, 74(3), 364-371. doi:10.1016/j.socscimed.2011.02.011

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This paper reported on 4 Lean implementation case studies in the UK National Health Service

(NHS). Similar to others, it found that implementation often involved Lean ‘tools’ such as rapid

improvement events (RIEs) that led to localized improvements. Contextual differences between Lean

healthcare and manufacturing were cited: first, patients’ status as both customers and commissioners of

care in the private sector, which impacts how customer value is defined; second, the healthcare

industry’s design as ‘capacity-led’, which limits the ability to influence demand and utilize freed-up

resources. If not addressed, these differences could severely limit Lean’s impact on healthcare. The

authors interviewed senior, middle management, and front-line NHS employees. They assessed

implementation on 4 dimensions: 1) Lean’s definition, 2) activities undertaken, 3) organizational

readiness, and 4) sustainability of process improvements. The study found that the definition of

‘customer’ and customer value was often variable and not clearly ascertained, leading to improvements

guessing at what customers wanted that were not necessarily aligned or even compatible across care

pathways. It also deemed that, similar to in manufacturing, there must be a shift from tool-based to

continuous improvement approaches for widespread, sustained productivity gains to be achieved.

Ulhassan, W., Ulrica von Thiele, S., Thor, J., & Westerlund, H. (2014). Interactions between lean management

and the psychosocial work environment in a hospital setting – a multi-method study. BMC Health

Services Research, 14, 480-491. doi:10.1186/1472-6963-14-480

This work aimed to ascertain the effects of Lean on the psychosocial work environment. As

such, psychosocial work environment was measured twice with the Copenhagen Psychosocial

Questionnaire (COPSOQ) employee survey during Lean implementations on May-June 2010 (T1)

(n = 129) and November-December 2011 (T2) (n = 131) at three hospital units (an Emergency

Department (ED), Ward-I and Ward-II). Information based on qualitative data analysis of the Lean

implementations and context from a previous paper was used to predict expected change patterns in the

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psychosocial work environment from T1 to T2 and subsequently compared with COPSOQ-data through

linear regression analysis. Between T1 and T2, qualitative information showed a well-organized and

steady Lean implementation on Ward-I with active employee participation, a partial Lean

implementation on Ward-II with employees not seeing a clear need for such an intervention, and

deterioration in already implemented Lean activities at ED, due to the declining interest of top

management.

Quantitative data analysis showed a significant relationship between the expected and actual

results regarding changes in the psychosocial work environment. Ward-I showed major improvements

especially related to job control and social support, ED showed a major decline with some exceptions

while Ward-II also showed improvements similar to Ward-I. The study’s results suggested that Lean

may have a positive impact on the psychosocial work environment when properly implemented, and that

deterioration of Lean work may correlate with deterioration of psychosocial work environment. The

authors also noted that employee involvement in Lean change processes may minimize any potential

harmful psychosocial effects from Lean intervention.

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Primary Research on Lean Tool Development, Testing, and Validation in

Healthcare

Intensive Care Unit (ICU)

Almoosa, K. F., Luther, K., Resar, R., & Patel, B. (2016). Applying the New Institute for Healthcare

Improvement Inpatient Waste Tool to Identify ‘Waste’ in the Intensive Care Unit. Journal for

Healthcare Quality, 38(5), e29-e38. doi:10.1097/JHQ.0000000000000040

The authors of this paper attempted to apply a new Institute for Healthcare Improvement (IHI)

tool to measure the prevalence of and reason for inappropriate use of intensive care unit (ICU) beds.

Unnecessary days (waste) in a 16-bed closed medical ICU (MICU) and a 10-bed semi-closed transplant

surgical ICU (TSICU) were identified by physicians over a 3-month period. Data was collected on 513

patients admitted to both ICUs for a total of 1,631 patient-days. This data demonstrated that 15% of

MICU days and 25.8% of TSICU days were unnecessary. Common causes of delays were transfer of

patients out of the ICU, end-of-life decision-making, and delays in procedures. However, determination

of waste varied widely among physicians, ranging from 4.5% to 27.7% in the MICU and 0% to 37.5% in

the TSICU. Therefore, although limited by variations in physician perceptions, the tool may be helpful

in identifying specific causes of delays in the ICU that could be the focus of improvement efforts. Based

on their findings, the authors also suggested that waste is likely common in the ICU and warrants further

attention.

Surgery

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Lasorsa, I., Liuzzi, G., Calabrese, R., & Accardo, A. (2015). An Innovative Method for Standardizing Lean

Management Approach in Hospitals. In 16th Nordic-Baltic Conference on Biomedical Engineering, 48,

67-70. Springer International Publishing.

This case study tested a new method for standardizing lean healthcare management in the

operating theatre (OT) of an Italian hospital; it specifically focused on improving the process of

providing surgical tools for operations. Preliminary, informal interviews were first conducted with

clinicians and nurses, and some selected to be part of the lean team based on their personal interest. This

team then set out to reduce seven forms of waste in the surgical tool value chain, as identified by Goal

Question Metric (GQM), a data measurement and metric identification tool originally used in computer

science. 15 questions and 17 metrics were defined to identify the root causes of waste in the process. A

value stream map (VSM) was designed that separated activities into stages: Stage 1 – preparation of

tools on the surgical cart in the OR, Stage 2 – utilization of surgical tools, Stage 3 – positioning of

instruments in the surgical cart for transport to the Central Sterile Supply Department (CSSD), and Stage

4 – transport to the Central Sterile Supply Department. Data was collected on all 4 of these stages.

Based on data collected, it was found that 71.2% of activities in Stage 1 of the surgical tool

process added value. In Stage 1 and Stage 3, percent of non-conformities to standard procedures was

47.8% and 75% of the process respectively. The team used these findings to create a future stream map,

which was simulated and potential economic savings calculated. The potential economic savings was

€229,421. The authors concluded that the teams’ proposal of improved inventory of surgical tools and

new classification of tools in containers could potentially increase the number of available surgical tools,

reduce the number of tools that need to be transported to the CSSD, and generate economic savings.

General

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Castle, A., & Harvey, R. (2009). Lean information management: the use of observational data in health care.

International Journal of Productivity and Performance Management, 58(3), 280-299. doi:

10.1108/17410400910938878

This paper compared traditional data collection methodologies in healthcare to observational

methods closely aligned with lean thinking. The authors conducted case studies on the use of

observational data in the UK National Health Service (NHS), and then used their evaluations to drive

general principals regarding the application of observational data in healthcare.

One such case study was conducted in the sterile services department of a general hospital,

which was perceived as responsible for delaying operations. The sterile services department felt that

these problems were the result of insufficient staffing to meet demand. The authors worked with this

department and the hospital’s surgery operating theatres over two months to examine processes and

improve workflow, using video to record the process of packing several different sets of instruments.

Analysis of video resulted in identification of waste (namely insufficient number of scanners/printers

and inefficient location of said printers), which led to the development of solutions to eliminate waste

(e.g., equipment purchase and workspace redesign). These solutions rendered the recruitment of 6 extra

staff members unnecessary.

Overall, the authors stated that the case studies resulted in fundamental changes in processes by

observing the current processes in a way that staff could relate to. They also found that having frontline

staff in charge of collecting data made the need for change and urgency of the situation more apparent.

In conclusion, the authors found that the observational data methodology was valid in a range of clinical

settings for examining a process to identify opportunities for improvement.

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Henrique, D. B., Rentes, A. F., Filho, M. G., & Esposto, K. F. (2016). A new value stream mapping approach

for healthcare environments. Production Planning & Control, 27(1), 24-48.

doi:10.1080/09537287.2015.1051159

This article presents a new lean value stream mapping (VSM) approach specifically geared

toward healthcare environments, as opposed to current healthcare VSM models that adapt

manufacturing-style VSM. The authors’ proposed VSM model analyzes activities in relation to their

effect on treatment time, with the intention of uniting the positive aspects of various mapping

methodologies found in healthcare literature. The novel VSM model was implemented in a Brazilian

hospital to observe its effect on processes and related patient lead times.

Results showed that the novel VSM model was able to identify some operational bottlenecks and

waste that the authors stated could not be identified by other mapping models studied; they determined

that these un-identified bottlenecks had a combined impact of 110 days, or 56%, of patients’ waiting

time. However, the researchers did not test these other mapping models against the novel VSM model

directly. The authors concluded that through this novel VSM model, all flows that impact patient lead

time can be shown on a single map, with clear visualization of patients’ actions and support activities.

Wallace, J., & Savitz, L. (2007). Estimating waste in frontline health care worker activities. Journal of

Evaluation in Clinical Practice, 14(1), 178-180.

As part of an AHRQ funded study intended to provide hospitals with estimates of waste,

researchers at Intermountain Healthcare and Abbot Associates examined waste estimates for hospital

frontline worker activity. Researchers used time-and-motion study design to observe staff activities for

72 hours at two tertiary referral centers and three community hospitals. The time-and-motion design

records data on the length and location of actors' different actions using a stopwatch or video recording.

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61 staff members were observed, with 69% classified as caregiver roles and 31% classified as technical.

43% of observed staff were nurses.

During 1-2 hour observation periods, observed group activity was classified into 1 of 6 classes.

These classes were operations, defects/errors, classifying activities, processing activities, motion, and

other. Classes were created using Toyota Production System, separating activities by value and non-

value adding activities. Frequency of interruption, location changes, and problems identified by staff

post-observation were documented in field notes. Statistically significant reliability estimates (intraclass

correlations) were computed by comparing the principal observer’s observation data with simultaneous,

independently collected observations from 8 different observers, resulting in intraclass correlations

between .67 and .88 (p < .054 to .007).

Operations, the class defined as having no waste, took up 41% of total observation time.

Activities considered 100% waste (defects/errors & other) comprised only 3% of observed time.

Clarifying, processing, motion, and other were assigned as low, medium, or high waste based on the

observed proportion of recoverable waste time: 20% indicated Low, 50% indicated Medium, and 80%

indicated High. Half of total documented waste was reported as part of the High range according to

these parameters. Researchers used base salary and fringe benefits to calculate a cost of waste per hour

ranging from $7.40 to $18.98. Interruptions and location changes occurred at average rates of 8 and 13

instances per hour, respectively, both with an SD of +/- 11 interruptions. The most common problems

reported by staff during post-observation interviews were supply/equipment related problems (36%),

missing information (22%), and redundant work (17%). The researchers concluded that their results

indicate a need for increased attention to operational quality.