Elsevier

Health Policy

Volume 119, Issue 9, September 2015, Pages 1197-1209
Health Policy

Review
Lean in healthcare: A comprehensive review

https://doi.org/10.1016/j.healthpol.2015.02.002Get rights and content

Highlights

  • We aim to provide a comprehensive review of Lean in healthcare.

  • Lean is an improvement approach increasingly applied in healthcare.

  • Notwithstanding the growing body of knowledge some issues remain underexplored.

  • Evaluation of more “system wide approach” in its implementation is needed.

Abstract

Background

Lean seems to be the next revolution for a better, improved, value-based healhcare. In the last 15 years Lean has been increasingly adapted and adopted in healthcare. Accordingly, Lean healthcare has been developing into a major strand of research since the early 2000s. The aim of this work is to present a comprehensive overview of the main issues highlighted by research on implementation of Lean in a complex contest such as the healthcare one.

Method

Comprehensive literature review was conducted in order to identify empirical and theoretical articles published up to September 2013. Thematic analysis was performed in order to extract and synthesis data.

Findings

243 articles were selected for analysis. Lean is best understood as a means to increase productivity. Hospital is the more explored setting, with emergency and surgery as the pioneer departments. USA appears to be the leading country for number of applications. The theoretical works have been focused mainly on barriers, challenges and success factors. Sustainability, framework for measurement and critical appraisal remain underestimated themes. Evaluations of “system wide approach” are still low in number.

Conclusion

Even though Lean results appear to be promising, findings so far do not allow to draw a final word on its positive impacts or challenges when introduced in the healthcare sector. Scholars are called to explore further the potentiality and the weaknesses of Lean, above all as for the magnitude of investments required and for the engagement of the whole organization it represents increasingly strategic choice, whilst health professionals, managers and policy makers could and should learn from research how to play a pivotal role for a more effective implementation of lean in different health contexts.

Introduction

The investigation of Lean healthcare has been developing into a major strand of research since the early 2000s (e.g., [1], [2], [3]), attracting many researchers worldwide. Accordingly, a growing number of books (e.g., [4], [5]), well-known and oft-quoted papers (e.g., [2], [3], [6]) and gray literature (e.g., [7], [8]) have been disseminated, highlighting different cases, topics, methodologies, countries, etc.

Organizations in the United States, such as the Institute for Healthcare Improvement, and the United Kingdom, such as the NHS Confederation and the Institution for Innovation and Improvement, advocated the use of Lean in 2005–2007, respectively, as Lean had proved itself useful in other sectors and began to show promising results in healthcare [7], [8], [9]. These organizations recognized the contribution of Lean in both maximizing value and eliminating waste [7] and suggested it as a possible answer to the need for change perceived in the sector [9].

One of the first papers published about Lean in healthcare, the study by Young et al. [2] addresses the use of industrial processes to improve patient care. Fundamentally, the authors describe three established industrial approaches, i.e., Lean thinking, the theory of constraints and Six Sigma, and explore how the concepts underlying each relate to healthcare. These authors conclude that the three methodologies have common features, as each emphasizes the concept of production as a complex interaction of individual activities, and each recognizes that for production to be efficient and effective, it is fundamental to identify weak links or bottlenecks and take appropriate remedial action. However, in order for them to work, all approaches would require strong leadership, the adoption of algorithmic methods to problem solving based on iterative improvement, and employee participation in all components of the system.

Widely cited is the study by Spear [3] published in the Harvard Business Review in 2005 in which the author discussed how health professionals could ensure that the quality of their service matched their knowledge and aspirations. Spear claims that learning how to improve the work one does while actually doing it can deliver extraordinary savings in lives and dollars. According to Spear, some hospitals are making enormous short-term improvements that are not based on legislation or market reconfiguration and with little or no capital investment. Instead of waiting for sweeping changes in market mechanisms, these institutions take an operations approach to patient care. Spear describes how doctors, nurses, technicians, and managers radically increase the effectiveness of patient care and dramatically lower its costs by applying the same capabilities in operations design and improvement as those that drive the famous Toyota Production System.

In 2006, Kim et al. [10] claimed that the readiness to act by hospitalists that use the new principles of Lean within hospitals can deliver high-quality and efficient care to patients. The authors also underlined the cultural and practical barriers to overcome to spread the use of Lean techniques. Among these barriers is the suspicion against management tools imported from a context other than healthcare, a misunderstanding of what Lean aims to achieve by cuts and layoffs, and the difficulty to act as a whole by units that are accustomed to functioning as autonomous “silos”.

The flourishing [11] of this new area of study has also prompted the publication of several literature reviews. For example, de Souza [12] sought to illuminate general emerging trends in and approaches to Lean healthcare and evaluate the research status quo by proposing a taxonomy primarily based on differentiating between theoretical papers and case studies. Poksinska [13] provided a portrait of how Lean has been implemented in healthcare, simultaneously presenting barriers, challenges and outcomes. Mazzocato et al. [14] produced a “realist review” that emphasizes the general mechanisms involved in the application of Lean. Conversely, Holden [15] crafted a critical review that deployed an analytical framework to focus on emergency care settings.

Other literature reviews evaluate Lean applications in specific settings or compare various process improvement approaches, analyzing the academic, the practitioner and the gray literature. Radnor et al. [16] highlighted some critical features of Lean in the public sector that remain sparsely investigated (i.e., how it works, its outcomes, barriers to change, and success factors for sustainability), highlighting that Lean principles were adapted for its application. Boaden et al. [17] demonstrated an increasing emphasis on Lean in healthcare, with Lean sometimes being integrated within the Six Sigma framework. The report also indicates that there are some difficulties in identifying guidelines for the implementation of Lean and in identifying additional studies with findings that are more comparative, independent, or critical.

Although all the precedents reviews offer important insights on the topic, they are based on narrow research questions (e.g. [18], [19]) and different inclusion criteria (e.g. [20], [21], [22], [23], [24], [25]). Some of them need to be updated (e.g. [12], [13]), as well. Consequently, the aim of the current paper is to present a comprehensive overview of Lean in healthcare as well as describing emerging important issues about its implementation. Accordingly, this work focuses on two main research questions: which is the diffusion of Lean in healthcare, so far? which are areas in need of further research?

The paper is organized as follows. The next section shows the methodological approach to the review; Section 3 synthesizes the principal themes drawn from the body of research reviewed; and Section 4 discusses the main issues to future research on Lean healthcare and challenges in its implementation.

Section snippets

Methods

A thematic analysis [26] was conducted to identify the main themes and concepts of the selected literature. The process followed the guidelines proposed by the Centre for Reviews and Dissemination [27], with some exceptions detailed in the following subparagraphs to take account of the variety of research approaches (quantitative or qualitative) and consequent methodologies as well as different traditions of research (social sciences and health sciences). The review protocol was designed around

Results

Following the method underlined in the previous section, 622 potentially relevant records were identified by searching in the databases. 40 papers were added subsequently after reading the full text of selected papers (e.g. reference lists of studies included). Next, by excluding some records, 306 articles were assessed for eligibility. Finally, by excluding some papers, 243 articles were included in the thematic analysis. Fig. 1 shows the selection process of the studies [28].

The findings were

Discussion

Drawing upon the themes underlined in the previous sections, this section highlights the main challenges and issues about Lean in healthcare, identifies possible future strands of research and notes the limitations of the current review.

First of all, it appears in literature to exist a lack of uniformity in the theoretical conceptualization of Lean. By reviewing the literature, it seems that everything may be Lean; on the contrary, a common definition should be established to distinguish what

Conclusion

Lean is an improvement approach increasingly applied in the healthcare field. Healthcare professionals and managers in many countries are experimenting with Lean tools and techniques to improve efficiency, clinical outcomes, satisfaction and safety for both staff and patients and ultimately to enhance financial performance and sustainability. In the USA, Lean experiences seemed to have significantly increased over time, and the UK government has primarily chosen Lean as a means to reform its

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