A systematic review of Lean in healthcare: a global prospective

A framework for lean implementation in preoperative assessment: Evidence from a high complexity hospital in Italy

Purpose: A routine preoperative assessment is considered both ineffective and inefficient. Despite the widespread application of lean thinking in healthcare, there is little evidence of successful experiences in preoperative admissions in order to reduce "No value added" activities. A conceptual framework reporting the drivers (clinic, tools, innovation, organization, and governance) and impacts (patient, efficiency, sustainability, time, learning and growth) was developed. Methodology: Drawing on the experience of an Italian high complexity hospital, this paper analyzes the case study by reporting evidence on how to implement lean in preoperative assessment and how to evaluate the positive results obtained. Results: Applying lean principles, the identification of value improved the appropriateness of care by creating 40 personalized pathways; the value stream resulted in a reduction of "No Value Added Time" from 37% to 28%, chest X-rays from 41% to 14% and cardiac visits from 49% to 37%; the pursuit of continuous flow through innovation contributed to increase the use of digitalization; the new pull organization helped to reduce the average time spent per year by 1.5 h; the continuous improvement was ensured through the governance of results. Conclusion: The proposed framework should be used to improve the quality of care in preoperative admissions by adopting the lean drivers for successful implementation and reporting the impacts.

Toward a roadmap for sustainable lean adoption in hospitals: a Delphi study

BACKGROUND

The benefits of lean adoption in healthcare include improved process efficiency and quality of patient care. However, research indicates that lean implementation in healthcare, and specifically hospitals, is often not sustained. Furthermore, there is a need for maturity models that guide lean implementation, specifically in hospitals. This study develops a prescriptive maturity model named the Sustaining of Lean Adoption in Hospitals Roadmap (SOLAR) that acts as a practical guideline for the sustainable adoption of lean in hospitals.

METHODS

The SOLAR has three theoretical foundations, namely lean implementation success factors in hospitals, implementation science, and change management theory. A systematic literature review was conducted to determine the lean implementation success factors in hospitals as the first building block. Secondly, practices from implementation science were used to create the action items in the SOLAR. Ten change steps were elicited from change management theory as the third theoretical building block of the roadmap. We refined the roadmap through three Delphi rounds that verified its useability in hospitals.

RESULTS

The final SOLAR consists of four maturity phases (prepare, plan, experiment and learn, and sustain) and includes action items for each phase related to the hospital's strategy, resources, engaging of people, and culture. The action items and change management steps shown in the SOLAR are not intended as an exhaustive list but provide guidelines on aspects hospitals must consider when they aim to adopt lean sustainably.

CONCLUSIONS

The strong theoretical base of the SOLAR enables hospitals to safely experiment and learn which implementation methods are best suited to their unique environment. The SOLAR is, therefore, an actionable guideline that informs both academics and practitioners involved in lean adoption in hospitals. This roadmap can guide future retrospective longitudinal or action research.

Decoding the persistence of delayed hospital discharge: An in-depth scoping review and insights from two decades

OBJECTIVE

This article addresses the persistent challenge of Delayed Hospital Discharge (DHD) and aims to provide a comprehensive overview, synthesis, and actionable, sustainable plan based on the synthesis of the systematic review articles spanning the past 24 years. Our research aims to comprehensively examine DHD, identifying its primary causes and emphasizing the significance of effective communication and management in healthcare settings.

METHODS

We conducted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) method for synthesizing findings from 23 review papers published over the last two decades, encompassing over 700 studies. In addition, we employed a practical and comprehensive framework to tackle DHD. Rooted in Linderman's model, our approach focused on continuous process improvement (CPI), which highlights senior management commitment, technical/administrative support, and social/transitional care. Our proposed CPI method comprised several stages: planning, implementation, data analysis, and adaptation, all contributing to continuous improvement in healthcare delivery. This method provided valuable insights and recommendations for addressing DHD challenges.

FINDINGS

Our DHD analysis revealed crucial insights across multiple dimensions. Firstly, examining causes and interventions uncovered issues such as limited discharge destinations, signaling unsustainable solutions, and inefficient care coordination. The second aspect explored the patient and caregiver experience, emphasizing challenges linked to staff uncertainty and negative physical environments, with notable attention to the underexplored area of caregiver experience. The third theme explored organizational and individual factors, including cognitive impairment and socioeconomic influences. The findings emphasized the importance of incorporating patients' data, recognizing its complexity and current avoidance. Finally, the role of transitional and social care and financial strategies was scrutinized, emphasizing the need for multicomponent, context-specific interventions to address DHD effectively.

CONCLUSION

This study addresses gaps in the literature, challenges prevailing solutions, and offers practical pathways for reducing DHD, contributing significantly to healthcare quality and patient outcomes. The synthesis introduces the vital CPI stage, enhancing Linderman's work and providing a pragmatic framework to eradicate delayed discharge. Future efforts will address practitioner consultations to enhance perspectives and further enrich the study.

PATIENT OR PUBLIC CONTRIBUTION

Our scoping review synthesizes and analyzes existing systematic review articles and emphasizes offering practical, actionable solutions. While our approach does not directly engage patients, it strategically focuses on extracting insights from the literature to create a CPI framework. This unique aspect is intentionally designed to yield tangible benefits for patients, service users, caregivers, and the public. Our actionable recommendations aim to improve hospital discharge processes for better healthcare outcomes and experiences. This detailed analysis goes beyond theoretical considerations and provides a practical guide to improve healthcare practices and policies.

Adapting lean management to prevent healthcare-associated infections: a low-cost strategy involving Kamishibai cards to sustain bundles' compliance

Lean healthcare visual management has been successfully integrated into infection control programs, leading to lower healthcare-associated infection (HAI) rates and greater provider compliance with evidence-based prevention practices; however, its implementation during quality improvement (QI) initiatives in limited-resource settings has not yet been well exploited. We aimed to describe a low-cost strategy involving Kamishibai cards to sustain bundles' adherence to prevent HAIs in a middle-income country. This descriptive case study evaluated the implementation of a lean healthcare visual management tool-Kamishibai board (K-board)-during a nationwide QI collaborative preventing three critical HAIs in 189 adult and pediatric/neonatal intensive care units (ICUs) from September 2021 to January 2023. Considering a limited-resource setting, our team adapted a K-board using simple, cheap, and easy-to-handle materials for routine monitoring of QI procedures, including safety bundles' compliance. After test prototypes, the final K-board version was implemented. The chart materials and assembly cost BRL 80.00 (USD 15.48). Before launching, expert working group meetings were held to shape the contents, refine technical issues, and prepare the ICU teams for implementation. After starting, plan-do-study-act cycles were conducted according to the Breakthrough Series model. Participating ICU teams, including leaders and front-line health workers, performed bedside audits following a weekly chronogram. Two indicators were calculated: the percentage of ICUs in which K-boards were being implemented and whether bundles' compliance was addressed in the K-board. Audit data were recorded in 'SimpleQI'. After 17 months of this initiative, 177 (93.7%) participating ICUs had included this visual management tool in their daily care routines. When more than 94 (>50%) ICUs posted K-board data, the mean compliance for the bundles for each HAI was sustained above 85%. A lean healthcare visual management tool can be adapted to local settings, including healthcare facilities with limited resources. K-board seems to be a feasible method for auditing evidence-based practices in medical care, including safety bundles to simultaneously prevent three types of HAIs.

The integration of lean and human resource management practices as an enabler for lean deployment –a systematic literature review

Purpose

The current research aims to map and investigate how human resource management and lean practices can be integrated. This investigation will help identify the HRM aspects critical in the success of lean initiatives while exploring the research gaps in the existing literature. The review also aims to delineate the benefits and challenges of integrating lean with HRM systems to discuss further research and practice areas.

Design/methodology/approach

This study utilizes a systematic literature review method to identify and synthesize the existing literature. As part of the process, a protocol that provided a plan for the review was followed, including the research questions and the data to be extracted.

Findings

The study results indicate that aspects of HRM practice and policies such as training and development, teamwork, motivation, communication, leadership, are key enablers of lean initiative deployment and success. The benefits of the integration of human resources with lean can help in lean training and development, communication of lean initiatives and successes, allocating and hiring continuous improvement personnel, and supporting leadership in lean deployment. Challenges to integrating lean and HRM practices included lack of integration and collaboration between disciplines. Further exploration areas in successful lean deployment would be practical longitudinal case studies on lean deployments with human resource (HR) partnerships and involvement.

Practical implications

This review paper has crucial implications for practice relating to, integration of lean with HRM structures and tailoring HRM initiatives to ensure the success of lean deployment and reduce risks of failure.

Originality/value

The systematic literature review study conducted in this paper is the first of its kind to integrate and map the HRM concepts that can be integrated with Lean to deploy the initiative successfully. This mapping is critical for ensuring the success of lean methodologies within an organization and paves the way for future research. In addition, managers and organizations can find support and guidance from this study to focus on vital areas of partnership between their lean and HR programs.

A bibliometric analysis of IJQRM journal (2002–2022)

Purpose

The purpose of this study is to explore the trends in publications made to International Journal of Quality and Reliability Management (IJQRM) for time period ranging from 2002–2022. In this study authors performed bibliometric analysis on the publications extracted from Scopus database using citations, authors, keywords and bibliographic coupling methods. The analysis helped authors highlighting the achievements of the journal towards the development of field of “quality” and “reliability” management and explore future avenues to be researched upon in the domain.

Design/methodology/approach

In this paper outputs derived through VoS viewer and bibliographic data of Scopus were used to examine various tabular and pictorial aspects of the authors, sources, documents, countries and keywords analysis.

Findings

The analysis results revealed that International Journal of Quality and Reliability Management (IJQRM) has got incredible 33,344 citations since 2002 with average citation count per document at 22.69. Sohal A.S. from Monash University, Australia has topped the list of most influential authors in terms of citations per document (107.20 citations/doc) published with IJQRM. However, Antony J. with massive 39 publications in total with 2074 citations is the most prominent contributor for the journal. The author has gained 6% of the total journal citations. The contributions from India, United Kingdom (UK), United States of America (USA), Iran, Australia, Portugal, Brazil, Spain, Sweden, Malaysia and Saudi Arabia are more noteworthy.

Research limitations/implications

The study has implications for future researchers and journal editorial team to explore possibilities in tapping various uncovered and upcoming research areas related to the scope of journal. The findings of the study may prompt research initiatives linked to diverse fields in sync with changes happening across globe such as: Artificial Intelligence, Robotics, Data Science etc.

Originality/value

The study is an attempt to investigate the long standing heritage offered by IJQRM to the world of quality and reliability management. The authors tried to unearth some hidden facts about the IJQRM and attempted to showcase the past and explore future directions to the researchers and editorial team.

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.

The management of healthcare-related infections through lean methodology: systematic review and meta-analysis of observational studies

INTRODUCTION

Lean is largely applied to the health sector and on the healthcare-associated infections (HAI). However, a few results on the improvement of the outcome have been reported in literature. The purpose of this study is to analyze if the lean application can reduce the HAI rate.

METHODS

A comprehensive search was performed on PubMed/Medline, Scopus, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: "lean" and "infection". Inclusion criteria were: 1) research articles with quantitative data and relevant information on lean methodology and its impact on healthcare infections; 2) prospective studies. The risk of bias and the study quality was independently assessed by two researchers using the "The National Institutes of Health (NIH) quality assessment tool for before-after (Pre-Post) study with no control group". The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines has been used. 22 studies were included in the present meta-analysis.

RESULTS

Lean application demonstrated a significant protective role on healthcare-associated infections rate (RR 0.50; 95% C.I.: 0.38-0.66) with significant impact on central line-associated bloodstream infections (CLABSIs) (RR 0.47; 95% C.I.: 0.28-0.82).

CONCLUSIONS

Lean has a positive impact on the decreasing of HAIs and on the improvement of compliance and satisfaction of the staff.

A balanced approach involving hard and soft factors for internalizing Lean Management and Six Sigma in hospitals

Purpose

This study examines the theoretical and empirical relationships between LM&SS, human resource management (HRM), climate for LM&SS and outcomes (employee well-being and performance) in hospitals. As part of this research, the authors examine the interplay between “hard” and “soft” practices for LM&SS and “soft” HR practices.

Design/methodology/approach

A cross-sectional, multisite survey study covering all internal service units at all eight Dutch university hospitals was conducted (42 units, N = 218 supervisors, N = 1,668 employees), and multivariate multilevel regression analyses were performed.

Findings

A systems approach involving “soft” LM&SS practices that are specifically HR-related has a positive effect (β is 0.46) on a climate for LM&SS. A climate for LM&SS is not related to perceived performance or employee health. It is, however, positively related to employee happiness and trusting relationships (both βs are 0.33). We did not find that a climate for LM&SS had a mediating effect.

Research limitations/implications

This study shows that a balanced approach involving both “hard” and “soft” factors is crucial to achieving the desired breadth and depth of LM&SS adoption at the macro, meso, and micro levels. The authors found that a climate for LM&SS positively affects employee well-being in hospitals.

Practical implications

In their attempt to create mutual gains for both their organization and their employees, hospitals that adopt LM&SS should foster a climate for LM&SS by embracing a balanced approach consisting of both “hard” and “soft” practices, thereby internalizing LM&SS at the macro, meso, and micro levels.

Originality/value

This is one of the first studies to examine in-depth the impact of “hard” and “soft” LM&SS on both employee well-being (subdivided into different components) and performance in healthcare, as well as the role of “soft” HRM in this relationship. Linking LM&SS, HRM and outcomes to a climate for LM&SS is relatively a new approach and has led to a deeper understanding of the mechanisms underpinning the internalization of LM&SS in healthcare.

Improving operational performance of manufacturing SMEs: the interactive effect of technical and human lean practices

Purpose

Although understanding how different resources are interconnected within firms is important, there are few studies that have focused on this area. This study aims to explore the unique and interactive effects of technical lean practices (TLPs) and human lean practices (TLPs) on the operational performance (OP) of manufacturing SMEs in Yemen, a less developed country (LDC).

Design/methodology/approach

Depending on data collected from 318 manufacturing SMEs in Yemen, the relationships in the proposed model were tested using hierarchical regression analysis via PROCESS Macro V. 3.5 in SPSS.

Findings

The results show that both TLPs and HLPs have unique effects on OP of SMEs. More importantly, both TLPs and HLPs have synergistic effects on OP.

Practical implications

The study would be of interest to Lean practitioners, as the results of this study can be used in firms to put a focus on how TLPs and HLPs have to interact when it comes to the successful implementation of lean manufacturing (LM).

Originality/value

Although research interest in LM is increasing, the interactive effects of TLPs and HLPs remain to be understood. This study provides an initial empirical evidence for performance outcomes from the interaction between TLPs and HLPs of SMEs in LDCs such as Yemen. Most of the previous studies on lean practices have focused on SMEs in developed countries, which may not fully apply to LDCs such as Yemen. This is helpful for SMEs' managers in the context of LDCs to understand how TLPs can further improve OP when interacting with HLPs.

An integrated multi-criteria decision-making approach to optimize the number of leagile-sustainable suppliers in supply chains

Global supply chains are increasingly becoming complex by having numerous suppliers around the world. To manage this complexity, organizations must identify the optimum number of suppliers. There have been many examples in the literature that used different approaches to solve this problem. Despite the importance of this issue, less attention has been paid to it and managers of the companies do not know how, and based on which approach and criteria, they should determine the optimal number of suppliers which leads to lower cost and higher reliability of the production line. Therefore, in this study, a hybrid methodology is proposed to expose the process of this problem which helps managers to learn how they can determine the optimal number of suppliers. We address this gap by developing an integrated approach based on multi-criteria decision-making (MCDM) comprising best-worst method (BWM), simple additive weighting (SAW), and technique for order preference by similarity to ideal solution (TOPSIS), and simulation to determine the optimal number of suppliers. This study utilizes a comprehensive approach based on leagile and environmentally sustainable criteria to determine the optimal number of suppliers. To examine the efficiency of the proposed approach, an empirical case study is conducted in an Iranian oil company. The final results represent that the scenario with a 1-1-1 arrangement (one supplier for each type of equipment) is the best possible scenario to determine the optimal number of leagile-sustainable suppliers. To examine the reliability and robustness of the obtained results, a sensitivity analysis based on the three most important criteria is conducted. Finally, discussions on the findings as well as theoretical and managerial implications are presented.

The evolution and future of lean Six Sigma 4.0

Purpose

This purpose of this study is to provide an overview of the current state of research on Lean Six Sigma (LSS) and Industry 4.0 and the key aspects of the relationships between them. The research analyses LSS's evolution and discusses the future role of LSS 4.0 in an increasingly digitalized world. We present the benefits and motivations of integrating LSS and Industry 4.0 as well as the critical success factors and challenges within this emerging area of research.

Design/methodology/approach

A systematic literature review methodology was established to identify, select and evaluate published research.

Findings

There is a synergistic nature between LSS and Industry 4.0. Companies having a strong LSS culture can ease the transition to Industry 4.0 while Industry 4.0 technologies can provide superior performance for companies who are using LSS methodology.

Research limitations/implications

One limitation of this research was that as this area is a nascent area, the researchers were limited in their literature review and research. A more comprehensive longitudinal study would yield more data. There is an opportunity for further study and analysis.

Practical implications

This study reviews the evolution of LSS and its integration with Industry 4.0. Organisations can use this study to understand the benefits and motivating factors for integrating LSS and Industry 4.0, the Critical Success Factors and challenges to such integration.

Originality/value

This is the first systematic literature review on LSS 4.0 and can provide insight for practitioners, organisations and future research directions.

A critical review of implementing lean and simulation to improve resource utilization and patient experience in outpatient clinics

Purpose

The purpose of this paper is to explore and critically review the existing literature on applications of Lean Methodology (LM) and Discrete-Event Simulation (DES) to improve resource utilization and patient experience in outpatient clinics. In doing, it is aimed to identify how to implement LM in outpatient clinics and discuss the advantages of integrating both lean and simulation tools towards achieving the desired outpatient clinics outcomes.

Design/methodology/approach

A theoretical background of LM and DES to define a proper implementation approach is developed. The search strategy of available literature on LM and DES used to improve outpatient clinic operations is discussed. Bibliometric analysis to identify patterns in the literature including trends, associated frameworks, DES software used, and objective and solutions implemented are presented. Next, an analysis of the identified work offering critical insights to improve the implementation of LM and DES in outpatient clinics is presented.

Findings

Critical analysis of the literature on LM and DES reveals three main obstacles hindering the successful implementation of LM and DES. To address the obstacles, a framework that integrates DES with LM has been recommended and proposed. The paper provides an example of such a framework and identifies the role of LM and DES towards improving the performance of their implementation in outpatient clinics.

Originality/value

This study provides a critical review and analysis of the existing implementation of LM and DES. The current roadblocks hindering LM and DES from achieving their expected potential has been identified. In addition, this study demonstrates how LM with DES combined to achieve the desired outpatient clinic objectives.

Lean six sigma in the healthcare sector: A systematic literature review

Healthcare is a very important sector as our lives depend on it. During the novel corona virus pandemic, it was evident that our healthcare organizations still lack in terms of efficiency and productivity. Especially in the developing nations, the problems were much bigger. Lean Six Sigma (LSS) is a methodology which when implemented in an organization, helps to increase the process capability and the efficiency, by reducing the defects and wastes. The present study systematically reviews the research studies conducted on LSS in the healthcare sector. It was found that comparatively less studies are focused on improving the medical processes, most of the studies targeted the management processes. Moreover, lesser number of studies were being conducted for developing nations, but now it seems that the focus of research scholars has shifted towards the developing nations also. But it was observed that the studies in these nations were majorly empirical in nature, very few studies were conceptual or exploratory. There is a need for guiding healthcare professionals on creating a continuous improvement environment, which sustains the improvements achieved after LSS implementation.

A conceptual framework for a systemic understanding of barriers during lean implementation

Purpose

Multiple organisations which have attempted to implement lean production/manufacturing/thinking have failed to achieve significant benefits. Practitioners and researchers have identified the barriers that hinder successful implementation. This study first consolidates such lean implementation barriers that are common across all industry sectors. Further, a systemic understanding of lean barriers is attempted by determining causal relationships between barriers and their relative causal strength.

Design/methodology/approach

Barriers to lean implementation were first identified from extant literature and categorised into broad barrier groups. These barrier groups were classified into four categories as specified by Liker's 4P model of lean–philosophy, people and partnership, processes and problem-solving. Additionally, interrelations between barriers, both within and among these four categories were determined.

Findings

The barriers classified under philosophy were the most critical as it affects the barriers in other groups. Similarly, barriers such as lack of leadership and top management commitment, lack of resources, shortage of lean consultants and trainers, lack of systemic understanding of lean and the need for its implementation, lack of lean expertise and training were found to be the most critical causal barriers.

Research limitations/implications

Highly critical barriers in terms of causality should be addressed with high priority, as effective measures against them may eliminate or reduce the impact of other barriers.

Originality/value

This study addresses the confusion regarding the high number of lean barriers in extant literature by providing a systemic understanding of the same. By exploring the interrelations among barriers, the most important causal barriers and barrier types (4Ps) are identified, the knowledge of which could improve lean implementation success. This is a novel attempt in the domain of lean.

Managing the resource allocation for the COVID-19 pandemic in healthcare institutions: a pluralistic perspective

Purpose

As COVID-19 outbreak has created a global crisis, treating patients with minimum resources and traditional methods has become a hectic task. In this technological era, the rapid growth of coronavirus has affected the countries in lightspeed manner. Therefore, the present study proposes a model to analyse the resource allocation for the COVID-19 pandemic from a pluralistic perspective.

Design/methodology/approach

The present study has combined data analytics with the K-mean clustering and probability queueing theory (PQT) and analysed the evolution of COVID-19 all over the world from the data obtained from public repositories. By using K-mean clustering, partitioning of patients’ records along with their status of hospitalization can be mapped and clustered. After K-mean analysis, cluster functions are trained and modelled along with eigen vectors and eigen functions.

Findings

After successful iterative training, the model is programmed using R functions and given as input to Bayesian filter for predictive model analysis. Through the proposed model, disposal rate; PPE (personal protective equipment) utilization and recycle rate for different countries were calculated.

Research limitations/implications

Using probabilistic queueing theory and clustering, the study was able to predict the resource allocation for patients. Also, the study has tried to model the failure quotient ratio upon unsuccessful delivery rate in crisis condition.

Practical implications

The study has gathered epidemiological and clinical data from various government websites and research laboratories. Using these data, the study has identified the COVID-19 impact in various countries. Further, effective decision-making for resource allocation in pluralistic setting has being evaluated for the practitioner's reference.

Originality/value

Further, the proposed model is a two-stage approach for vulnerability mapping in a pandemic situation in a healthcare setting for resource allocation and utilization.

Analytics and Lean Health Care to Address Nurse Care Management Challenges for Inpatients in Emerging Economies

Purpose

Prescriptive and predictive analytics and artificial intelligence (AI) provide tools to analyze data with objectivity. In this paper, we provide an overview of how these techniques can improve nursing care, and we detail a quantitative model to afford managerial insights about care management in a Hospital in Colombia. Our main purpose is to provide tools to improve key performance indicators for the care management of inpatients which includes the nurse workload.

Methods

The optimal nurse‐to‐patient assignment problem is addressed using analytics, lean health care, and AI. Also, we propose a new mathematical model to optimize the nurse‐to‐patient assignment decisions considering several variables about the patient state such as the Barthel index, their risks, the complexity of the care, and the mental state.

Findings

Our results show that there are several processes inherent to compassionate nursing care that can be improved using technology. By using data analytics, we can also provide insights about the high variability of the care requirements and, by using models, find nurse‐to‐patient assignments that are nearly perfectly balanced.

Conclusions

We illustrated this improvement with a pilot test that makes the equitable distribution of nursing workload the functionality of this strategy. The findings can be useful in highly complex hospitals in Latin America.

Clinical Relevance

The proposed model presents an opportunity to make near perfectly balanced nurse‐to‐patient assignments according to the number of patients and their health conditions using technology.

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

PURPOSE

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

DESIGN/METHODOLOGY/APPROACH

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

FINDINGS

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

ORIGINALITY/VALUE

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

Lean implementation within healthcare: imaging as fertile ground

PURPOSE

The purpose of this paper is to understand the barriers and enablers to lean implementation as part of an imaging quality improvement programme from a socio-cultural perspective.

DESIGN/METHODOLOGY/APPROACH

An in-depth 33 month ethnographic study, using observation and qualitative interviews, examined the process of lean implementation as part of an improvement programme.

FINDINGS

Implementation of lean was more successful compared with other reports of lean in healthcare settings. Key enablers of lean were high levels of multidisciplinary staff involvement and engagement; the professional credibility of facilitators and clinicians as early adopters, all within a wider culture of relatively strong inter-professional relationships in the imaging department. These enablers combined with the more routinised and standardised nature of imaging pathways compared to some other acute specialties suggest that imaging is fertile ground for lean, linked to the manufacturing origins of lean.

PRACTICAL IMPLICATIONS

When introducing lean within healthcare settings, special attention needs to be paid to the specific healthcare context and the existing cultures of inter-professional relationships. Fostering an improvement culture and engagement with training, together with adequate financial resource, are a key to contributing to the level of acceptability of an improvement tool such as lean.

ORIGINALITY/VALUE

This ethnographic study, bringing together rich multi-source data, has provided a detailed insight into the cultural workings of the process of lean implementation within a complex healthcare system.

Exploring the use of operational excellence methodologies in the era of COVID-19: perspectives from leading academics and practitioners

Purpose

This paper aims to present the results of a study carried out by the authors in the form of research interviews on the topic: “Exploring the use of operational excellence methodologies in the era of COVID-19.”

Design/methodology/approach

A qualitative interview approach was utilized by interviewing a panel of leading academics and practitioners who are familiar with operation excellence methodologies.

Findings

Operational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.

Research limitations/implications

One limitation of this research was that most of the interviewees who participated in this study came from Europe, North America, South America and Asia, representing four continents. It would have been better to have different views from other continents such as Australia and Africa. Also, the interviews were short and at a high level. There is an opportunity for further study and analysis.

Practical implications

Operational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.

Originality/value

The paper provides an excellent resource for those people to get an insight into the value of the application of operations excellence methodologies in pandemic situations to aid healthcare process improvement and aid public and patient safety.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Technology-dependent pedagogical process redesign: leveraging lean methods

Purpose

This research compared the efficacy of process outcomes leveraging lean methods versus traditional pedagogy applied to dental education dependent on emerging technology. The pedagogical objective was to improve system efficiency without compromising traditional outcomes of effectiveness (quality).

Design/methodology/approach

The research team tested the efficacy of a lean A3 framework to identify, remove waste and redesign a technology-dependent simulation laboratory course (CAD/CAM/IR Restorative Dentistry). Students were also sensitized to time-in-chair to introduce a stronger patient focus. Baseline data collected from a control group were statistically compared to the research group's data after the course redesign. In addition, course time allocations were measured and then compared.

Findings

The results showed the interventions significantly reduced procedure cycle times without compromising quality. Additionally, the course was more efficiently conducted as measured by course time allocations.

Practical implications

This research demonstrated that the use of the A3 framework enhanced learning through process documentation, reengineering and systems optimization resolving issues of inefficiency associated with the CAD/CAM/IR pedagogy. This work is significant because it demonstrates the practice of using lean interventions to redesign and improve a technology-based healthcare course to maximize benefits.

Originality/value

This research is the first to examine how to leverage lean methods in a healthcare simulation laboratory, dependent on innovative technology, to educate and train future practitioners. This research applied statistical rigor in a controlled experiment to maximize its applicability and generalizability.

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.

A lean approach to healthcare management using multi criteria decision making

Recent challenges induced by the global pandemic COVID-19 have highlighted the critical importance of coping with a sudden surge in demand for front line healthcare services. Motivated by the success of lean implementation in manufacturing systems, this study attempts to apply the lean principles in healthcare delivery environments. The lean approach begins with the identification of seven types of wastes in any production or service system. This study attempts to identify and prioritize the present in hospitals. The study contributes to the existing body of knowledge in two ways. First, we identify the various sources contributing to the seven basic wastes in healthcare delivery. Second, we prioritize the seven types of wastes and the dimensions contributing to these wastes using a Multi-Criteria Decision Making (MCDM). This paper used the fuzzy analytical hierarchy process approach, which is a well-accepted tool in MCDM. The study was conducted at select hospitals located in and around Pune city in India. We find that waiting, transportation, motion, and defects are dominant in adopting lean practices among the seven wastes. The findings of this study may guide hospital management in strategic planning in adopting a lean healthcare process. To our knowledge, this is one of the first studies to extract, and prioritise lean wastes within the context of the healthcare sector.

Quality and lean practices synergies

Purpose

The purpose of this study is to investigate the relationship between investments in quality and lean practices, and their impact on factory fitness. Using concepts originating in the theory of swift even flow, this study asserts that manufacturers, in order to improve their production swiftness and evenness, must leverage the potential synergetic effects between quality and lean practices.

Design/methodology/approach

This research uses data from the Global Manufacturing Research Group (GMRG) survey project (with data collected from 922 manufacturing plants, across 18 countries). The constructs and measurement model were assessed using confirmatory factor analysis (CFA) and the hypotheses were tested using ordinary least square (OLS) models.

Findings

This study highlights that both investments in quality and lean practices have direct impact factory fitness. The results provide insights into the efficacy of the investments in manufacturing practices and their role in augmenting the operational performance. The investments in quality practices were found to enhance the efficacy of investments in lean practices, which in turn impact the factory fitness.

Practical implications

From a practical perspective, the study informs managers on how to leverage investment in quality practices to enhance the impact of lean practice on performance. The results provide empirical evidence to support management decision-making concerning the development of competences in quality and lean practices, which may create competitive advantage.

Originality/value

This study contributes to the quality and lean literature and provides empirical evidence of the synergetic effects between investments in quality and lean practices. The analysis offers a greater understanding of the mechanisms that can be used to maximise the impact of investments in lean practices, from a global perspective. The findings are important to the advancement of theory in operations management, as it integrates three research streams: quality practices, lean practices and swift even flow research.