Lean management in health care: a review of reviews of socio-technical components for effective impact

Contextual factors and mechanisms in the implementation of Value Stream Mapping in breast cancer centres - A multiple case study

INTRODUCTION

Lean, especially Value Stream Mapping is increasingly used in hospitals to optimize processes. This method, which originated in the automotive industry, enables all staff involved in the process to make it more customer-friendly. Despite the widely reported success of Lean projects, they have failed in some cases. This study investigated the contextual factors and mechanisms that contribute to a successful implementation of Value Stream Mapping.

METHODS

Value Stream Mapping was applied to the discharge process in four breast cancer centers. A mixed-method approach was used in two steps. First, to verify the successful implementation, defined as time optimization, time measurement was conducted at three points in time and analyzed using an ANOVA. Second, an analysis of contextual factors was combined with a qualitative content analysis of mechanisms based on normalization process theory, using routine data, meeting protocols, field notes, and interview transcripts as data source.

RESULTS

At one of the four breast cancer centers, lead- and waiting time were significantly reduced; at the others, these reductions did not occur. Failure/success cannot be explained by the size of the hospital, the number of cases or staffing levels. The variable project team composition is evident, especially leadership involvement.

DISCUSSION

A comparative analysis was conducted to identify the factors that led to success. These factors were: participation of all leaders relevant to the process, in the case of the discharge process including medical and nursing leaders; dissemination of the changes from the project team to colleagues including its sense and possibility to discuss it; joint reflection of the implementation process in regular work team meetings.

CONCLUSIONS

These results confirm the important role of leadership in implementation projects. Leadership support enabled the mechanisms found. The used combination of theoretical approaches from management research and implementation science determined the interpretation and should be applied more often in implementation science.

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.

Managing inpatient bed setup: an action-research approach using lean technical practices and lean social practices

PURPOSE

This article aims to introduce a guide to improving hospital bed setup by combining lean technical practices (LTPs), such as kaizen and value stream mapping (VSM) and lean social practices (LSPs), such as employee empowerment.

DESIGN/METHODOLOGY/APPROACH

Action research approach was employed to analyze the process of reconfiguration of bed setup management in a Brazilian public hospital.

FINDINGS

The study introduces three contributions: (1) presents the use of VSM focused specifically on bed setup, while the current literature presents studies mainly focused on patient flow management, (2) combines the use of LSPs and LTPs in the context of bed management, expanding current studies that are focused either on mathematical models or on social and human aspects of work, (3) introduces a practical guide based on six steps that combine LSPs and LSPs to improve bed setup management.

RESEARCH LIMITATIONS/IMPLICATIONS

The research focused on the analysis of patient beds. Surgical beds, delivery, emergency care and intensive care unit (ICU) were not considered in this study. In addition, the process indicators analyzed after the implementation of the improvements did not contemplate the moment of the COVID-19 pandemic. Finally, this research focused on the implementation of the improvement in the context of only one Brazilian public hospital.

PRACTICAL IMPLICATIONS

The combined use of LSPs and LTPs can generate considerable gains in bed setup efficiency and consequently increase the capacity of a hospital to admit new patients, without the ampliation of the physical space and workforce.

SOCIAL IMPLICATIONS

The improvement of bed setup has an important social character, whereas it can generate important social benefits such as the improvement of the admission service to patients, reducing the waiting time, reducing hospitalization costs and improving the hospital capacity without additional physical resources. All these results are crucial for populations, their countries and regions.

ORIGINALITY/VALUE

While the current literature on bed management is more focused on formal models or pure human and social perspectives, this article brings these two perspectives together in a single, holistic framework. As a result, this article points out that the complex bed management problem can be efficiently solved by combining LSPs and LTPs to present theoretical and practical contributions to the important social problem of hospital bed management.

Lean adoption, implementation, and outcomes in public hospitals: benchmarking the US and Italy health systems

Background

Despite the growing interest in transformational performance improvement among nearly all countries, international benchmarking has rarely been used. Cross-comparative research could allow an appreciation of the extent of Lean’s use in healthcare and a better evaluation of possible cultural influences on Lean implementation. This study provides a comparative international benchmarking of Lean adoption, implementation, and outcomes of hospitals in the US and Italy.

Methods

The National Survey of Lean, developed in 2017 in the US and adapted in Italy in 2019 was used to compare the two healthcare systems along three dimensions: the maturity of adoption, the implementation approach, identifying both strategic and operational activities and tools, and the Lean performance, investigated through patients, employed, and affiliated staff, costs, and service provision areas. Descriptive statistics including T-tests were used to examine differences between the two countries on the study variables.

Results

Lean has been adopted less by Italian public hospitals (36%) than US public hospitals (53%). Each country averages 4 years of experience with Lean. Italian hospitals reported being at a higher maturity stage while the US implemented a more system-wide approach, developing Lean in more operational units. The daily management system, leadership commitment, education and training indexes were higher or the same in the US while in Italy, hospitals had a higher self-reported performance index.

Conclusion

This exploratory work is one of the first international benchmarking studies on Lean implementation in healthcare systems using a standardized survey with a common set of definitions and questions. The study identifies different forms of Lean implementation that can be adopted, both at strategic and operational levels, with related perceived outcomes. Despite the US public hospitals being more likely to report a higher number of units using Lean, a higher daily management system index and use of Lean tools, Italian hospitals report more achievements primarily due to Lean. Further research can build on these findings by examining the relationship between Lean adoption/implementation and independent, objective performance measures.