Lean thinking in healthcare – Findings from a systematic literature network and bibliometric analysis

Construction and validation of an instrument for evaluating Lean Healthcare in healthcare institutions

OBJECTIVE

To build and validate an instrument to evaluate Lean Healthcare in healthcare institutions.

METHOD

Methodological study conducted in three stages: 1) Instrument construction; 2) Content validity using the Delphi technique with 14 experts; and 3) Construct validation using Structural Equation Modeling with sample consisted of 113 professionals with experience in Lean Healthcare. Data collection carried out from October/2020 to January/2021 using a digital form. Data analysis performed with the SmartPLS2.0/M3 software.

RESULTS

Items were developed after an integrative review and divided into the dimensions Structure, Process and Outcome, according to Donabedian's theoretical framework. Content validation in two rounds of the Delphi technique. Final instrument, after model adjustment, containing 16 items with Cronbach's alpha of 0.77 in Structure, 0.71 in Process and 0.83 in Outcome.

CONCLUSION

The instrument presented evidence of validity and reliability, enabling its use in healthcare institutions to evaluate Lean Healthcare.

Exploring concepts and trends in informal caregiver burden: systematic review using citation network and content analysis

BACKGROUND

With the increase in the aging population, informal caregivers have become an essential pillar for the long-term care of older individuals. However, providing care can have a negative impact and increase the burden on caregivers, which is a cause for concern.

OBJECTIVE

This study aimed to comprehensively depict the concept of "informal caregiver burden" through bibliometric and content analyses.

METHODS

We searched the Web of Science (WoS) database to obtain bibliometric data and included only papers published between 2013 and 2022. We used content analysis to extract and identify the core concepts within the text systematically.

RESULTS

Altogether, 934 papers were included in the bibliometric analysis, from which we selected 19 highly impactful papers for content analysis. The results indicate that researchers have focused on exploring the factors that impact informal caregiver burden. Meanwhile, there has been a widespread discussion regarding the caregiver burden among those caring for recipients with specific illnesses, such as dementia, Alzheimer's disease, and cancer, as these illnesses can contribute to varying levels of burden on informal caregivers. In addition, questionnaires and interviews emerged as the predominant methods for data collection in the realm of informal caregiver research. Furthermore, we identified 26 distinct assessment tools specifically tailored for evaluating burden, such as caregiver strain index (CSI).

CONCLUSION

For future studies, we suggest considering the intersectionality of factors contributing to the burden on informal caregivers. This approach could enhance the well-being of both caregivers and older care recipients.

Unveiling the Impact of Lean Leadership on Continuous Improvement Maturity: A Scoping Review

Purpose

Lean Management (LM) is a process improvement approach with growing interest from healthcare organizations. Obtaining a culture of continuous improvement is a primary objective of LM, and a culture of continuous improvement indicates a mature LM approach, and here leadership plays a central role. However, a comprehensive overview of leadership activities influencing LM maturity is lacking. This study aims to identify leadership activities associated with continuous improvement and, thus, LM, maturity.

Methods

Following the PRISMA guidelines, a scoping literature review of peer-reviewed articles was conducted in twenty healthcare management journals. The search provided 466 articles published up until 2023. During the selection process, 23 studies were included in the review. The leadership activities related to continuous improvement maturity were identified using the grounded theory approach and data coding.

Results

The analysis highlighted a total of 58 leadership activities distributed across nine themes of LM leadership. Next, analysing leadership activities concerning the different maturity levels revealed three maturity stages: beginner, intermediate, and expert. Based on the findings, we propose a framework that guides suitable leadership activities at the various stages of LM maturity. The framework provides leaders in healthcare with a practical overview of actions to facilitate the growth of the LM approach, and the related propositions offer academics a theoretical basis for future studies.

Conclusion

This review presents the first comprehensive overview of LM leadership activities in relation to continuous improvement and LM maturity. To enhance LM maturity, leaders are encouraged to consider their leadership style, (clinical) stakeholder involvement, alignment with the organizational strategy, and their role in promoting employee autonomy.

What are barriers and facilitators in sustaining lean management in healthcare? A qualitative literature review

BACKGROUND

Lean management (LM) is a continuous improvement methodology originating from manufacturing and is widely adopted in healthcare to improve processes. LM shows promising results in healthcare and research on the topic is increasing. However, it can be difficult to sustain LM over time, and an overview of facilitators or barriers that influence the sustainment of LM in a healthcare context is unavailable.

METHODS

Prior to search, five inclusion and exclusion criteria were defined to establish suitability of identified articles for our research question. This study was based on 24 selected peer-reviewed studies that reported on the sustainment of LM in healthcare organisations, published in the last five years. Following the Preferred Reporting Items for Systemtic Reviews and Meta-Analyses (PRISMA) guidelines, all articles were scanned, retrieved for full-text and analysed thematically.

RESULTS

Following thematic analysis, we identified four overarching themes: Mobilising Employees, Guiding Change Efforts, Methods, and Local Context. Key facilitators for supporting LM are fostering an improvement culture and learning culture, providing professional development opportunities, assigning more responsibilities to employees in decision making processes and appointing change agents to act as local LM leaders. Key barriers for sustaining LM include overburdening employees with responsibilities, omitting staff involvement during LM implementation, lack of patient engagement, lack of resources to engage with LM, a lack of leadership commitment and follow-up on projects, and a lack of knowledge of LM among leaders.

CONCLUSION

Overall, studies emphasise the importance of actively involving and engaging the workforce to embed LM into organisational culture. Reflecting on the origins of LM, healthcare organisations can find inspiration in the virtue of respecting people in their journey to sustain and cultivate an improvement culture. LM provides potential to change healthcare for the better and could help healthcare organisations to cope with increasing external pressures.

Applying Lean Kaizen to Improve Timely Computed Tomography Scan Appointments for Oncology Patients in a Safety Net Hospital

PURPOSE

Timely radiographic studies are essential to oncology care. At our institution, a safety net hospital in a large metropolitan area, baseline assessment determined that the overwhelming majority of outpatient computed tomographic (CT) scans for oncology patients were overdue and not scheduled within 2 weeks of their first requested date.

METHODS

We conducted a series of structured, interdisciplinary meetings including staff from radiology, oncology, scheduling, and administration to critically review the scheduling process utilizing Lean Kaizen quality improvement methods. A new workflow was developed in which clinic staff scheduled CT scans before clinic discharge. Three months after our initial meeting, the new workflow was launched. We set a target of decreasing the percentage of overdue scans to below 20%.

RESULTS

At baseline, 87% (65 of 75) of CT scans awaiting scheduling were overdue. Data were gathered at 5 and 10 weeks after implementation of our workflow. The percentage of CT scans overdue for scheduling was 17% (9 of 53) at 5 weeks and 0.97% (1 of 103) at 10 weeks after implementation. Clinic visit durations were not affected.

CONCLUSION

The Lean Kaizen QI model was successful in decreasing the rate of oncology patients overdue for CT scan scheduling with minimal effects on clinic visit durations. This study demonstrated the importance of interdepartmental collaboration and continuous monitoring for improvement. Given the success of this project, this workflow will be expanded to other outpatient clinics within our institution.

Lean Perspectives in an Organizational Change in a Scientific Direction of an Italian Research Institute: Experience of the Cancer Institute of Bari

Lean management is a relatively new organizational vision transferred from the automotive industry to the healthcare and administrative sector based on analyzing a production process to emphasize value and reduce waste. This approach is particularly interesting in a historical moment of cuts and scarcity of economic resources and could represent a low-cost organizational solution in many production companies. In this work, we analyzed the presentation and the initial management of current ministerial research projects up to the approval by the Scientific Directorate of an Italian research institute. Furthermore, the initial mode in 2021 ("as is") and the potential mode ("to be") according to a Lean model are studied, according to the current barriers highlighted by the final users of the process and carrying out some perspective analyses with some reference indicators.

Measuring the current state-of-the-art in lean healthcare literature from the lenses of bibliometric indicators

Purpose

Lean healthcare (LHC) applies lean philosophy in the healthcare sector to promote a culture of continuous improvement through the elimination of non-value-added activities. Studies on the subject can be classified as conceptual (theoretical) or analytical (applied). Therefore, this research compares bibliometric indicators between conceptual and analytical articles on LHC.

Design/methodology/approach

For data collection, the PRISMA Protocol was employed, and 488 articles published from 2009 to 2021, indexed in the Scopus and WoS databases, were retrieved.

Findings

This study reveals how conceptual and analytical LHC studies are organized in terms of the most relevant journals, articles, institutions, countries, the total number of citations, collaboration networks (co-authorship, international collaboration network and institutional collaboration network) and main co-words.

Originality/value

Only four papers conducting bibliometric analysis on LHC studies were identified in the Scopus and Web of Science databases. In addition, none of these papers compared conceptual and analytical bibliometric indicators to reveal the evolution, organization and trends of each category. Therefore, this work is not only the first to make this comparison but also the first to analyze the collaboration between authors, institutions and countries in relation to studies on LHC. The analyses performed in this work allow one new possible understanding, by researchers and health professionals, of the literature behavior in this field of study.

An integrative perspective on interorganizational multilevel healthcare networks: a systematic literature review

BACKGROUND

Interorganizational networks in healthcare do not always attain their goals. Existing models outline the factors that could explain poor network performance: governance; structure; and the alignment of professional, organizational and network levels. However, these models are very generic and assume a functional approach. We investigate available empirical knowledge on how network structure and governance relate to each other and to network performance in a multilevel context, to get deeper insight, supported with empirics, of why networks (fail to) achieve their goals.

METHOD

A systematic literature review based on a search of Web of Science, Business Source Complete and PubMed was executed in May 2021 and repeated in January 2022. Full papers were included if they were written in English and reported empirical data in a healthcare interorganizational setting. Included papers were coded for the topics of governance, structure, performance and multilevel networks. Papers from the scientific fields of management, administration and healthcare were compared. Document citation and bibliographic coupling networks were visualized using Vosviewer, and network measures were calculated with UCINET.

RESULTS

Overall, 184 papers were included in the review, most of which were from healthcare journals. Research in healthcare journals is primarily interested in the quality of care, while research in management and administration journals tend to focus on efficiency and financial aspects. Cross-citation is limited across different fields. Networks with a brokered form of governance are the most prevalent. Network performance is mostly measured at the community level. Only a few studies employed a multilevel perspective, and interaction effects were not usually measured between levels.

CONCLUSIONS

Research on healthcare networks is fragmented across different scientific fields. The current review revealed a range of positive, negative and mixed effects and points to the need for more empirical research to identify the underlying reasons for these outcomes. Hardly any empirical research is available on the effects of different network structures and governance modes on healthcare network performance at different levels. We find a need for more empirical research to study healthcare networks at multiple levels while acknowledging hybrid governance models that may apply across different levels.

How to increase value and reduce waste in research: initial experiences of applying Lean thinking and visual management in research leadership

Waste in research has been well documented, but initiatives to reduce it are scarce. Here, we share our initial experiences of implementing Lean thinking and visual management into hospital research units in the Region of Southern Denmark. A Transformation Guiding Team (TGT) anchored in the top management was established with participation from leaders, researchers and patient representatives. The role of the TGT was to implement Lean methods, considering patients as primary end-users of the research results. This is in line with an explicit decision on setting patient values first in clinical settings at participating hospitals. The leaders of the research units were instructed in Lean thinking and Lean methods during a five-module course focusing on increasing value and reducing waste in research production. Initial experiences were that Lean tools could create a patient-centred vision that through visual management could identify waste in work processes. Concerns were lack of evidence for using Lean methods in research leadership and that the model itself could be a time consumer. Some lessons learnt were that adding Lean tools in research leadership should not just provide increased research productivity, but also improve other important key performance indicators such as quality of research and patient-relevant results. We intend to evaluate the value of the initiative by follow-up research and publish the outcome of key behavioural and key performance indicators.

Healthcare Supply Chain Reliability: The Case of Medical Air Transport

The principal task of national healthcare systems is to provide health services that are safe, accessible, high-quality and people-oriented. To ensure the continuity of healthcare, support activities related to patient transfer and logistics are necessary. Effective implementation of transport processes is a factor affecting the possibility of medical intervention, in terms of both planned and life-saving care. The reliability of the healthcare supply chain is a key factor in patient health. In our research, we have used the method of a single case study of a public regional hospital in Poland providing comprehensive medical services. The aim of the research is to identify the factors that affect the reliability of the healthcare supply chain in relation to the interhospital air transport of patients. Our qualitative research using process mapping reveals what factors affect the reliability of interhospital medical air transport. The analysis of 100 interhospital medical air transport cases has allowed us to create a general procedure related to the movement of patients between the facilities of the healthcare system in Poland. Our research shows that the key factor of reliability is the coherent and integrated cooperation of institutions involved in transport processes.

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

PURPOSE

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

DESIGN

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

SETTING AND PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

A practical framework for achieving value creation and capture in healthcare through process improvement

PURPOSE

The purpose of this study was to examine the concept of value in healthcare through a practical appraisal of the applicability of a conceptual framework, which is aimed at supporting the measurement and realisation of financial benefits from process improvement (PI) activities in a hospital setting.

DESIGN/METHODOLOGY/APPROACH

A single case study of a hospital system in Melbourne, Victoria, Australia, was used to assess the applicability of the framework. The study sought to verify the framework's intention, that PI methods could be used to address known wastes that contribute to the cost of providing healthcare. The case study examines the current approach taken by the hospital to measure and realise financial benefits from PI activities and compares these to the components of the Strategy to Balance Cost and Quality in Health Care framework to assess its applicability in practice.

FINDINGS

The case study revealed that the steps described in the framework were fundamentally in place albeit with some variation. Importantly, the case study identified an additional step that could be added into the framework to support hospitals to better define their portfolio of initiatives to deliver value. The case study also clarified three types of contributory elements that should be in place for the application of the framework to be successful.

PRACTICAL IMPLICATIONS

The Framework to Achieve Value in Healthcare is offered to hospitals as a model by which they can look to reduce expenditure through the removal of non-value adding activities. The modification to the conceptual framework has arisen from a single case study and would benefit from further testing by other hospitals in other policy settings (i.e. other countries).

ORIGINALITY/VALUE

This is the first paper to examine and enhance an existing framework to assist hospitals balance cost and quality through PI.

Externalities of Lean Implementation in Medical Laboratories. Process Optimization vs. Adaptation and Flexibility for the Future

Important in testing services in medical laboratories is the creation of a flexible balance between quality-response time and minimizing the cost of the service. Beyond the different Lean methods implemented so far in the medical sector, each company can adapt the model according to its needs, each company has its own specifics and organizational culture, and Lean implementation will have a unique approach. Therefore, this paper aims to identify the concerns of specialists and laboratory medical services sector initiatives in optimizing medical services by implementing the Lean Six Sigma method in its various variants: a comparative analysis of the implemented models, with emphasis on measuring externalities and delimiting trends in reforming/modernizing the method, a comprehensive approach to the impact of this method implementation, and an analysis of available databases in order to underline the deficit and information asymmetry. The results highlighted that in the case of clinical laboratories, the Lean Six Sigma method is conducive to a reduction of cases of diagnostic errors and saves time but also faces challenges and employees' resistance in implementation.

Improving performance of the hospitalization process by applying the principles of Lean Thinking

Purpose

The goal was to improve the quality of the hospitalization process and the management of patients, allowing the reduction of costs and the minimization of the preoperative Length of Hospital Stay (LOS).

Design/methodology/approach

The methodology used to improve the quality of the hospitalization process and patient management was Lean Thinking. Therefore, the Lean tools (Value stream map and Ishikawa diagram) were used to identify waste and inefficiencies, improving the process with the implementation of corrective actions. The data was collected through personal observations, patient interviews, brainstorming and from printed medical records of 151 patients undergoing oral cancer surgery in the period from 2006 to 2018.

Findings

The authors identified, through Value Stream Map, waste and inefficiencies during preoperative activities, consequently influencing preoperative LOS, considered the best performance indicator. The main causes were identified through the Ishikawa diagram, allowing reflection on possible solutions. The main corrective action was the introduction of the pre-hospitalization service. A comparative statistical analysis showed the significance of the solutions implemented. The average preoperative LOS decreased from 4.90 to 3.80 days (−22.40%) with a p-value of 0.001.

Originality/value

The methodology allowed to highlight the improvement of the patient hospitalization process with the introduction of the pre-hospitalization service. Therefore, by adopting the culture of continuous improvement, the flow of hospitalization was redrawn. The benefits of the solutions implemented are addressed to the patient in terms of lower LOS and greater service satisfaction and to the hospital for lower patient management costs and improved process quality. This article will be useful for those who need examples on how to apply Lean tools in healthcare.

Access to surgical care as an efficiency issue: using lean management in French and Australian operating theatres

PURPOSE

Millions around the world still cannot access safe, timely and affordable surgery. Considering access as a function of efficiency, this paper examines how the latter can be improved within the context of operating theatres. Carried out in France and Australia, this study reveals different types of waste in operating theatres and a series of successful tactics used to increase efficiency and eliminate wastefulness.

DESIGN/METHODOLOGY/APPROACH

Data for this qualitative study were collected through 48 semi-structured interviews with operating theatre staff in France (n = 20) and Australia (n = 28). Transcripts were coded using a theory-driven thematic analysis to characterise sources of waste in operating theatres and the tactics used to address them.

FINDINGS

The study confirmed the prominence of seven types of waste in operating theatres commonly found in industry and originally identified by Ohno, the initiator of lean: (1) underutilised operating rooms; (2) premature or delayed arrival of patients, staff or equipment; (3) need for large onsite storage areas and inventory costs; (4) unnecessary transportation of equipment; (5) needless staff movements; (6) over-processing and (7) quality defects. The tactics used to address each of these types of waste included multiskilling staff, levelling production and implementing just-in-time principles.

ORIGINALITY/VALUE

The tactics identified in this study have the potential of addressing the chronic and structurally embedded problem of waste plaguing health systems' operating theatres, and thus potentially improve access to surgical care. In a global context of resource scarcity, it is increasingly necessary for hospitals to optimise the ways in which surgery is delivered.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Why is Quality Improvement so Challenging? A Viable Systems Model Perspective to Understand the Frustrations of Healthcare Quality Improvement Managers

The challenges facing Quality Improvement Managers (QIMs) are often understood and addressed in isolation from wider healthcare organisation within which quality improvement initiatives are embedded. We draw on Stafford Beer's Viable System Model (VSM) to shed light on how the viability of quality improvement depends on the effective functioning of five critical quality improvement systems and the extent to which these systems are integrated within the healthcare organisation. These systems are System 1 (Operations), System 2 (Coordination), System 3 (Operational Control), System 4 (Development) and System 5 (Policy). Our analysis draws on interviews with 56 QIMs working in 15 of New Zealand's 20 District Health Boards. We use VSM to identify the sources of problems in QI implementation. These include changes in direction for QI initiatives; myopic behaviour resulting from fragmented systems of care; difficulties in managing and monitoring QI activities given variable staff engagement and inadequate resourcing; pressure for quick results rather developing QI capabilities; and a lack of strategic embeddedness. A viable QI system requires QI approaches that are (1) implemented at an organisation-wide level; (2) well-resourced and carefully monitored; (3) underpinned by a long-term vision; and (4) supported by QIMs with the necessary power and influence to integrate QI subsystem within the wider healthcare organisation.

The Role of Value Stream Mapping in Healthcare Services: A Scoping Review

Lean healthcare aims to manage and improve the processes in the healthcare sector by eliminating everything that adds no value by improving quality of services, ensuring patient safety and facilitating health professionals’ work to achieve a flexible and reliable organization. Value Stream Mapping (VSM) is considered the starting point of any lean implementation. Some papers report applications of VSM in healthcare services, but there has been less attention paid to their contribution on sustainability indicators. The purpose of this work is to analyze the role of VSM in this context. To do so, a scoping review of works from recent years (2015 to 2019) was done. The results show that most applications of VSM reported are in the tertiary level of care, and the United States of America (USA) is the country which leads most of the applications published. In relation with the development of VSM, a heterogeneity in the maps and the sustainability indicators is remarkable. Moreover, only operational and social sustainability indicators are commonly included. We can conclude that more standardization is required in the development of the VSM in the healthcare sector, also including the environmental indicators.

Value-based lean implementation in a surgical unit: the impact of the methodology

Purpose

This paper aims to present a method for strategic planning and implementation processes in health care based on lean management.

Design/methodology/approach

Within the framework of the action research methodology, the authors present the ten steps of a kaizen project, which enable lean transformation over a period of time. The study is underpinned by a literature review of enablers and barriers and an implementation case in a tertiary care hospital.

Findings

Key points and possible contingency issues are presented for each of the steps, and a successful lean tools intervention is illustrated by examples of improvement projects of the surgical process. Conclusions of the implementation establish a roadmap for improvement projects in hospital environments based on lean management, thus bridging the existing gap between the large number of theoretical projects (much of the projects described are not sustainable over time as the hospital sector is very particular) that have failed to be implemented, or been paused mid-term, and the self-sustaining projects developed by improvement teams in the hospital.

Originality/value

The study details knowledge gleaned from a three-year project entailing various stages: forming improvement teams; training health-care professionals in lean management; drawing up a process map to identify value stream mapping improvement opportunities; implanting projects and verifying the results obtained; and finally, laying the cornerstones, which would make the project self-sustaining and open to long-term continuous improvement.

Artificial intelligence in healthcare: opportunities and risk for future

OBJECTIVE

This study aimed to find out the opportunity of artificial intelligence (AI) and the risk in health service.

METHOD

A comprehensive literature search was collected from three databases (Web of Science, Google Scholar, and EBSCOhost) to identify articles studied Implementing AI in improving in health services. Two reviewers independently assessed the quality of studies using the Joanna Briggs Institute.

RESULTS

The application will improve diagnostics, prevention, and treatment of patients, increasing cost efficiency and equality and equality in health services. For the challenge, there is no AI adoption in public sector, patients' privacy, patient autonomy rights become problems in AI applications.

CONCLUSIONS

Implementation of AI is needed in the efficiency of health service management as well as making medical decisions. The challenge is facilitating early adoption and ongoing implementation in the health care system, and we consider some of the ethical problem lists faced by AI clinical application.

An Enhanced Kaizen Event in a Sterile Processing Department of a Rural Hospital: A Case Study

Operating Rooms (ORs) generate the largest revenues and losses in a hospital. Without the prompt supply of sterile surgical trays from the Sterile Processing Department (SPD), the OR would not be able to perform surgeries to its busy schedule. Nevertheless, little emphasis has been brought in the medical literature to research on surgical instrument processing in the medical literature. The present study was done applies an Enhanced Kaizen Event (EKE) in the SPD of a rural hospital to identify sources of waste and minimize non-value-added steps in the SPD processes. The EKE consisted of three successive Plan-Do-Check-Act (PDCA) cycles, which focused on improvements at the departmental level first, then at an area level, and finally at the station level. The EKE yielded an improved streamlined workflow and a new design for the SPD layout, one of its areas, and a workstation. This paper aims at building a methodology, including identified steps. Results exhibited a 35% reduction in travel distance by the staff, eliminating non-value-added processes, reducing errors in the sterilization process, and eliminating cross-contamination for sterilized materials.