How to Use Lean Thinking for the Optimization of Clinical Pathways: A Systematic Review and a Proposed Framework to Analyze Pathways on a System Level

The maturity of lean management in a large academic medical center in Finland: a qualitative study

BACKGROUND

Lean management (LM) provides hospitals with tools to respond to today's rapidly changing healthcare environment. However, evidence of its success is inconclusive. In some cases, well-executed LM supports effective, beneficial, and safe patient care; reduces costs; and increases patient and staff satisfaction. In other cases, however, the desired outcomes have not been achieved. Organizations must acknowledge the maturity level of LM to successfully implement it for continuous development. This study evaluates the maturity of Lean implementation using a structured interview with a framework based on the Lean Healthcare Implementation Self-Assessment Instrument (LHISI) and utilizes findings about Lean adoption to evaluate factors that support and hinder its implementation, with the aim of assisting leaders in maintaining and developing Lean in health care.

METHODS

The article describes a case study done at Helsinki University Hospital. A qualitative study was conducted in three sectors (A, B, and C) of the hospital. Fifteen healthcare leaders from the three sectors participated in a semistructured interview based on the dimensions of the LHISI. Qualitative content analyses were based on grounded theory.

RESULTS

We concluded that the five dimensions (leadership, commitment, standard work, communication, and daily management system) of LHISI provide a comprehensive framework for qualitatively evaluating Lean in the hospital. We found that the five dimensions are influenced by other explanatory factors. These explanatory factors, knowledge about Lean, available data, and environmental, psychological, and organizational factors all support and hinder leadership, communication, daily management, and commitment to Lean in the hospital. The results highlight differences in the Lean maturity levels in the hospital. We noticed that 9 of 15 leaders had a misunderstanding of Lean, and all 3 sectors showed a lack of staff commitment to Lean in their units.

CONCLUSION

To strengthen the organization-wide implementation of Lean, it is necessary to understand that LM is a comprehensive sociotechnical management system, for which it is not enough to mechanically implement Lean with tools and techniques alone. By focusing on and developing the five dimensions and explanatory factors, organizations can achieve a high maturity of Lean and reach their full potential. A good level of competency and commitment to Lean by the leaders and the staff alike are important for achieving goals, engaging the staff, and increasing the quality of patient care in the hospital. The long-term Lean development of a hospital organization can be followed and continuously maintained via easy-to-use maturity tools.

Medical silos, social identity, and duty of care: A call for health leaders to improve transitions of care

This article explores the concept of medical silos, particularly within hospital systems, and examines their deeper roots in social identity and the fiduciary duty of care of healthcare providers. While traditional perspectives focus on informational and communication barriers, this analysis highlights how professional identity and moral obligations contribute to the persistence of silos. Social identity theory reveals that strong in-group affiliations, formed during medical training and specialization, fosters collaboration within groups but also create divisions between them. Similarly, the fiduciary duty of care, central to ethical medical practice, may inadvertently reinforce silo boundaries in resource-limited environments. By emphasizing the role of centralized leadership, the article proposes that health system managers and leaders, with the broadest possible duty of care, must take action to dismantle these barriers. Recommendations include re-evaluating policies for patient transitions and fostering integrated care pathways to improve overall system flow, rather than simply balancing the agendas of stakeholders within their silos.

Designing an integrated care pathway for spondyloarthritis: A Lean Thinking approach

INTRODUCTION

Integrated care pathways (ICPs) are crucial for delivering individualised care. However, the development of ICPs is challenging and must be well designed to provide the expected benefits. Regarding this, healthcare organisations are increasingly adopting management systems based on Lean Thinking to improve their organisational processes by eliminating non-value-added steps. This study elucidates the process and evaluates the impact of applying Lean Thinking to redesign an ICP for patients with spondyloarthritis, a chronic inflammatory disease affecting young adults.

METHODS

A multidisciplinary team was assembled and trained in Lean Thinking. Patient's perspective was gathered through a focus group. Guided by an expert methodologist, the team constructed a value stream map of the entire care pathway and analysed each step. Five work streams were defined to increase value at each step, leading to targeted process improvements. Key process and outcome metrics were collected and compared in 2-month baseline and post-implementation audits.

RESULTS

A total of 118 patients were included in the baseline audit (September-October 2022), and 116 in the post-implementation audit (January-February 2023). Process redesign resulted in statistically significant improvements (p < 0.05), including a reduction in the mean number of hospital visits per patient over a 2-month period from 2.54 (SD = 0.93) to 1.84 (SD = 0.79), an increase in complementary exams scheduled on the same day (81.4% to 94.8%) and an increase in baseline disease and treatment education (from 22.2% to 84.2% and from 18.2% to 84.6%, respectively). Regarding standardisation of clinical practice, there were significant increases in collecting data for medical records on composite activity indices (76.3% to 95.7%), reporting of pharmacological treatment adherence (68.6% to 94%) and providing nonpharmacological recommendations (31.3% to 95.7%).

CONCLUSIONS

The application of Lean Thinking to redesign the spondyloarthritis ICP led to significant improvements in outpatient appointment scheduling, reduced patient hospital visits, improved interdepartmental coordination and standardised clinical practice.

Slack Is Needed to Solve the Shortage of Nurses

Healthcare systems are facing a shortage of nurses. This article identifies some of the major causes of this and the issues that need to be solved. We take a perspective derived from queuing theory: the patient-nurse relationship is characterized by a scarcity of time and resources, requiring comprehensive coordination at all levels. For coordination, we take an information-theoretic perspective. Using both perspectives, we analyze the nature of healthcare services and show that ensuring slack, meaning a less than exhaustive use of human resources, is a sine qua non to having a good, functioning healthcare system. We analyze what coordination efforts are needed to manage relatively simple office hours, wards, and home care. Next, we address the level of care where providers cannot themselves prevent the complexity of organization that possibly damages care tasks and job quality. A lack of job quality may result in nurses leaving the profession. Job quality, in this context, depends on the ability of nurses to coordinate their activities. This requires slack resources. The availability of slack that is efficient depends on a stable inflow and retention rate of nurses. The healthcare system as a whole should ensure that the required nurse workforce will be able to coordinate and execute their tasks. Above that, workforce policies need more stability.