Appendices Contents Appendix 1 Literature review on Lean 2 …€¦ · 8 College of Nursing,...

Appendices

Contents

Appendix 1 Literature review on Lean ........................................................................................ 2

Appendix 2 Theory Maps .......................................................................................................... 86

Appendix 3 Interview guide for staff and patients ................................................................. 102

Appendix 4 Patient Safety CMOCs .......................................................................................... 106

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Appendix 1:

Literature review on Lean in

Healthcare

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Lean Management in health care: Definitions, concepts, methodology and effects reported (A Literature review).

Adegboyega K Lawal1, Thomas Rotter1, Leigh Kinsman2, Liz Harrison3, Cathy Jeffery4, Rachel Flynn5, Nazmi Sari6, Mareike Kutz7, Donna Goodridge8.

1 College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada. 2 School of Rural Health, Monash University, Bendigo, Australia. 3 School of Physical Therapy, College of Medicine, University of Saskatchewan. 4 College of Nursing, University of Saskatchewan, Saskatoon, Canada. 5 Faculty of Nursing, University of Alberta, Edmonton, AB, Canada. 6 Department of Economics, University of Saskatchewan, Saskatoon, SK, Canada. 7 Faculty of economy, University of Applied Science, Osnabrueck, Germany. 8 College of Nursing, University of Saskatchewan, Saskatoon, Canada. Background

Lean thinking can be thought of as the identification and elimination of waste in any activity performed within a facility (Campbell 2009). Based on the Toyota model, it focuses on how efficiently resources are being used and “what value is being added for the customer” in every process (Campbell 2009). The healthcare industry has reported some success in applying Lean principles in the United States, United Kingdom, Australia and now Canada (Fine 2009). Despite indications that aspects of Lean have been widely implemented in healthcare, Burgess et al regard its implementation to be pragmatic, patchy, fragmented (Burgess 2013) and limited in accounting for the complex interactions that take place in hospitals or other healthcare organizations (Fine 2009). Research on the application and wide-scale implementation of lean principles in healthcare is also limited (Mazzocato 2012) and the primary studies reported lack explicitly stated concepts, research designs, appropriate analysis, and outcome measures (Mazzocato 2012). The majority of studies also reported on successful lean interventions, whereas little has been documented about its failed attempts or barriers to its implementation in healthcare (Mazzocato 2012). It is therefore imperative to conduct a comprehensive literature review to examine the effects of lean implementation in healthcare, especially the potential effects on professional practice and healthcare outcomes in various settings.

Objectives

The primary review question is:

What are the effects of Lean Management in health care on professional practice, patient and healthcare outcomes?

The secondary review questions are as follows:

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(i) What can we learn from the existing evidence on Lean to better understand the various definitions and concepts used to describe lean, the methodology(s) applied in evaluating the impact, and the effects reported?

(ii) What are the differences in the implementation of Lean across various health care systems and settings and can we explain how those differences might lead to different outcomes?

Methods

Criteria for considering studies for this review

Types of studies

Articles were categorized based on three types of studies as suggested by a previously published literature review on Lean Management in hospitals (Brackett 2013). The three article types include those that: (1) discuss the application of Lean principles and are based only on the experience or general knowledge of the authors, (2) are based on actual case studies or research related to the application of Lean principles, and (3) are literature reviews and simulation studies related to Lean processes. Final inclusion criteria for the primary studies to be included for analysis were based on empirical evidence of the research related to the application of Lean principles (category 2).

Study designs considered for the review included randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analysis (ITS) based on Effective Practice and Organization of Care (EPOC) methodological design and quality criteria (Bero 2009). We also considered cohort or panel (longitudinal) studies, case-control studies, and relevant non-comparative publications such as case reports. A case report is a document that provides details about how a study was conducted and its subsequent findings. A panel study is a longitudinal study in which variables are measured on the same units over time, while an interrupted time series design involves a sequence of values of a particular measure taken at regularly spaced intervals over time (Wagner 2002).

Types of participants

There were three groups of participants considered relevant for this review:

1.) Health care providers: All health care providers directly involved with the implementation of Lean process in all healthcare settings e.g. physicians, nurses, health administrators, and other health care staff.

2.) Lean consultants and experts: Individuals with Lean implementation expertise.

3.) Patients: Patients involved in the application of Lean principles.

Types of interventions

Types of Lean interventions reported

Definition

Lean is a multi-faceted, patient-centred approach to managing and improving quality and efficiency. The approach was originally derived from the Toyota car company production line system: a continuous process improvement system comprising of structured inventory

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management, waste reduction and quality improvement techniques (Black 2008). Lean utilizes a continuous learning cycle that is driven by the “true” experts in the processes of health care, being the patients/families, health care providers and support staff (De Souza 2009). The majority of Lean investigations published in the international literature refer to the Toyota Management System as applied to healthcare (Mazzocato 2012; Hummer 2009; Belter 2012; Casey 2009; Ford 2012; Naik 2012; Waldhausen 2011; McDermott 2013). In particular, the Virginia Mason Medical Center’s application of Lean became the catalyst for Lean healthcare in other health systems, particularly in the United States and the United Kingdom (Wood 2012; Blackmore 2013). Other authors refer to: Thedacare Improvement System; a tailored fit improvement system at the Thedacare Centre for Healthcare Value in the United States (Barnas 2011), Lean Management system or simply Lean principles/Lean philosophy (Van Vliet 2011; Atkinson 2012; Vegting 2012; Smith 2012).

Lean application in Saskatchewan

As this review is part of a research project examining a provincial wide implementation of Lean in health care settings, we have also defined its application In Saskatchewan. In Saskatchewan, the Toyota Lean Management system is used in combination with a strategic management and policy deployment system, called Hoshin Kanri (Cowley 1997), usually presented with daily visual management tools. Daily visual management is an approach where staff members take the time each day to evaluate their progress using the key elements of daily huddles on visibility walls.

Types of Implementation strategy reported

Varying terms and Japanese terminology are also used to describe the Lean implementation strategies and activities. The most frequently reported Lean implementation activities are ‘Lean basics’ workshops, also described as ‘Kaizen basics’ workshops. A ‘Kaizen or Lean basics’ session is a one-day workshop, introducing Lean tools and techniques (McDermott 2013; Wood 2012; Blackmore 2013; Barnas 2011; Van Vliet 2011; Atkinson 2012 Vegting 2012; Smith 2012; Cowley 1997; Ulhassan 2013). Other activities reported in the literature to implement Lean in healthcare are 5S events to reorganize the workplace, rapid process improvement workshops (RPIW) also known as rapid improvement events, and value stream mapping (VSM) to improve current and future care processes (Mazzocato 2012; Hummer 2009; Belter 2012; Esain 2008).

5S stands for ‘Sort, Sweep, Simplify, Standardize, Sustain/Self-Discipline’ and it represents a set of concepts that help organizations ensure a clean and organized work place (JBA 2014). An RPIW is a week-long event also reported as a three day Lean event where teams of patients and their families, staff and clinicians focus on one problem, identify the root cause, create solutions and to implement the solution in the workplace (JBA 2014). A value stream map in health care is a visual tool to understand the flow of patients, supplies, or information through the journey of a patient and it maps all processes required to deliver a health care service (JBA 2014).

Kanban is a visual signaling system when new parts, supplies or services are needed, in the quantity needed, and at the time they are needed. A Kanban signal is usually presented in form of a card, indicating the need to reorder supplies (JBA 2014). The aim of a mistake-proofing

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project is to develop a device or procedure to avoid such an error in the future (e.g. specific hose coupling in anaesthesia, forcing functions in order entry, preventing falls, and mislabelilng of blood samples) (JBA 2014).

Types of outcome measures

Objectively measured outcomes reflecting the purpose of the thirty primary studies were divided into three categories: Patient outcomes, Professional outcomes and Health system outcomes. Patient outcomes include: a range of potential types of measurements collected via self-administered questionnaires and completed by the patient themselves or via interviews, while professional outcomes encompass measures that affect the practice of the professionals involved in the Lean implementation process.

Patient outcomes reported include: mortality, complications, patient satisfaction, patient safety and quality metric indicators, out of hospital rates and re-admission rates. Professional outcomes include: employee satisfaction, care provider productivity, number of steps saved, nursing time spent with patients and staff overtime. Health system measures are usually performance indicators that are used to evaluate, communicate and monitor the extent to which various aspect of the health system meet their objectives (Smith 2006). System improvements encompass referral rates, length of stay, re-admission rates, dispensing time, surgical error rates, turn-around time, admission rates, staff over time, turnover time, wait times, cycle time, number of steps saved, medication filling rates, triage time, patient journey time, time to see a physician, total processing time, number of safety reports, collection time, disposition time, medication round time and nursing shift time. See Table 2 for a detailed description of the types of outcomes reported by the thirty included studies.

Search methods for identification of studies

To develop our search strategy, we initially ran the Medline search strategy [Appendix 1] based on a Cochrane review on the broad concept of continuous quality improvement (Brennan 2009). However, this strategy was not focused on LEAN. Since LEAN is not represented in controlled vocabularies of biomedical databases, an information scientist developed a keyword search strategy [Appendix 2]. This focused search strategy was translated into the other databases using the appropriate controlled vocabulary as applicable. We did not apply language restrictions.

The following databases were searched:

· Medline (OVID)

· Embase (OVID)

· HealthStar (OVID)

· Web of Science (Science, Social Sciences, and Arts & Humanites Citations Indexes and Conference Proceedings)

· Health Technology Assessment (HTA), Cochrane Library

· Economics Evaluation (EED) databases, Cochrane Library

· EconLit,

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· PAIS (Public Affairs Information Service) International,

· Proquest Dissertations & Theses,

· Proquest Political Science,

· Canadian Research Index.

Other search methods included:

· Websites of organizations (grey literature searching) concerned with quality in health care such as AHRQ (Agency for Healthcare Research & Quality), and ASQ.org. Sites searched will be reported in the review.

· Contacting the authors of relevant studies or reviews to clarify reported published information or to seek unpublished results/data (as needed).

· Contacting researchers with expertise relevant to our topic (as needed).

· Conducting cited reference searches (in citation indexes) for studies included in this review.

Data collection and analysis

Screening

Two review authors independently screened all titles and abstracts (MFHK and MK) to assess which studies met the inclusion criteria. All titles and abstracts were pooled and duplicates deleted. Full text copies of potentially relevant papers were retrieved and unresolved disagreements on inclusion were referred to a third review author (TR).

Selection of studies

Data extraction and management

Data management

Data included the number of retrieved references, full text papers and included and excluded articles (Figure 1); managed with Endnote and RevMan. Full text articles were categorized based on three types of studies as suggested by a previously published literature review on Lean Management in hospitals (Brackett 2013). The three article types include those that: (1) discuss the application of Lean principles and are based only on the experience or general knowledge of the authors, (2) are based on actual case studies or research related to the application of Lean principles, and (3) are literature reviews and simulation studies related to Lean processes. Articles that reported on application of Lean methodologies and principles with empirical evidence after full text assessment were included for the final review (group 2). The data was then transferred into RevMan. The excluded group 1(Lean reports) for this literature review will be retained, assessed and analyzed in a subsequent systematic review on Lean. The systematic review on Lean will also include a rigorous risk of bias assessment of all group one and group two studies and will be published in Fall 2014.

Data abstraction

Pairs of two review authors (TR and LA, RF and MK, LH and NS, LK and CJ) independently extracted data. We used a standardized word data extraction sheet and transferred the primary

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study data into an Excel spreadsheet according to the double data entry method. We referred unresolved disagreements on data abstraction to a third review author (TR and LA). When necessary, we sought additional information from the authors of the primary studies.

Data presentation

The results of studies were presented in tabular form (Appendix 3). The studies were grouped according to the settings where they were conducted and an assessment of the effects of the studies, based upon empirical and statistical rigor was reported. The major outcome reported by the primary authors of the thirty included studies is presented below (Table 1), along side the direction of the effect of reported from application of various implementation of Lean tools and methodology.

Dealing with missing data

SD and P values

If a primary study did not provide information about the standard deviation, we used the approximate or direct algebraic link between the stated confidence intervals, or P values, and the standard deviation to calculate the inverse transformation to the individual or pooled standard deviation (Higgins 2008)

Main results

Description of studies

See figure 1 (trial flow) and table of characteristics of included studies. Thirty studies met the inclusion criteria of this review and were actual case studies or research related to the application of Lean principles (Brackett 2013).

Twenty nine of the included studies were pre-post comparisons (Atkinson 2012; Barnas 2011; Beard 2010; Blackmore 2013; Chiodo 2012; Cima 2011; Collar 2012; Fischman 2010; Ford 2012; Grove 2010; Harmelink 2008; Hummer 2009; King 2006; McDermott 2013; Melanson 2009; Michael 2013; Morrison 2011; Murrell 2011; Naik 2012; Ng 2010; O'Neill 2011; Piggott 2011; Smith 2011; Smith 2012; Smith 2012a; Ulhassan 2013; Waldhausen 2011; Yerian 2012; Yousri 2011). Out of the thirty studies one was an Interrupted time series (Cankovic 2009).

The purposes of the included studies were focused on different sections of the health care system. Out of the 30 studies, 22 (73%) were focused on system improvement (Beard 2010; Blackmore 2013; Cima 2011; Collar 2012; Fischman 2010; Ford 2012; Grove 2010; Harmelink 2008; Hummer 2009; McDermott 2013; Melanson 2009; Murrell 2011; Naik 2012; Ng 2010; O'Neill 2011; Piggott 2011; Smith 2011; Smith 2012; Smith 2012a; Waldhausen 2011; Yerian 2012 and Yousri 2011). Two out of the included studies focused on leadership, adoption and sustainability (Barnas 2011 and Ulhassan 2013), One (3%) focused on testing staffing models (Morrison 2011) and four out of the 30 studies focused on process redesign (Atkinson 2012). Finally, 1 study (3%) focused on the application of lean in transition of care (Chiodo 2012). See Table 1 for the characteristics of included studies.

The Lean management systems reported from the primary studies included the Toyota management system, Virgina mason production system, Thedacare improvement system, Lean principles / philosophies, Henry Ford production system and other management systems. Other

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management systems referred to studies that did not make a reference to any Lean management system but reported the application of lean concepts and methodology in their quality improvement initiative. Nine studies out of thirty reported the application of Toyota management system (Grove 2010; McDermott 2013; Melanson 2009; Michael 2013; Morrison 2011; Murrell 2011; Ng 2010; Piggott 2011; Waldhausen 2011). Of the included studies, 4 (13%) reported using lean principles or philosophies (Beard 2010; Harmelink 2008; King 2006; O'Neill 2011), two (6%) reported using the Virgina mason production system (Atkinson 2012; Blackmore 2013), 1 (3%) reported using other lean management systems (Ulhassan 2013). One study reported using Henry Ford Production system (Cankovic 2009), and one study referred to a Thedacare improvement system (Barnas 2011). 12 (40%) studies did not make reference to any management system (Chiodo 2012; Cima 2011; Collar 2012; Fischman 2010; Ford 2012; Smith 2012; Hummer 2009; Naik 2012; Smith 2011; Smith 2012a; Yerian 2012; Yousri 2011).

Out of the thirty included studies, only one reported the use of a theoretical background "Holdens theory" in the application of Lean concepts in leadership, adoption and sustainability of improvement initiatives (Ulhassan 2013).

Twenty of the included studies were conducted in the United States (Barnas 2011; Blackmore 2013; Chiodo 2012; Cima 2011; Collar 2012; Fischman 2010; Ford 2012; Harmelink 2008; Hummer 2009; Melanson 2009; Michael 2013; Morrison 2011; Murrell 2011; Naik 2012; Piggott 2011; Smith 2011; Smith 2012; Smith 2012a; Waldhausen 2011; Yerian 2012), 5 (16%) studies in the United Kingdom (Atkinson 2012; Beard 2010; Cankovic 2009 Grove 2010; Yousri 2011), 2 (6%) in Australia (King 2006; O'Neill 2011;), 1 each in Sweeden (Ulhassan 2013) Canada (Ng 2010) and Ireland (McDermott 2013).

Implementation activities

Some studies reported the use of only one type of implementation activity, while others reported the combinations of different types of implementation activities in executing the lean initiatives. In terms of one type of implementation activity, 1 (3%) study reported the use of RPIW (Barnas 2011), 2 (6%) reported Lean basics workshop (Hummer 2009; Smith 2012a), 10 (33%) reported using VSM alone (Beard 2010; Cima 2011; Collar 2012; Fischman 2010; Ford 2012; Grove 2010; Harmelink 2008; King 2006; Smith 2011; Yousri 2011). 1(3%) study reported the use of 5s and VSM (Morrison 2011; O'Neill 2011), two out of the thirty included studies reported the use of RPIW and 5s (Naik 2012; Yerian 2012), 2 (6%) also reported using VSM and LBW (Ulhassan 2013; Michael 2013). 5 (16%) studies utilized RPIW and VSM (Atkinson 2012; Melanson 2009; Murrell 2011; Ng 2010; Smith 2012), 3 (10%) studies used RPIW, 5s, LBW (Cankovic 2009; Waldhausen 2011), 1 (3%) reported the use of RPIW, 5s, VSM (McDermott 2013), 2 (6%) reported the use of RPIW, VSM, LBW (Chiodo 2012; Piggott 2011). One out of the thirty included studies reported using RPIW, 5s, VSM, and LBW (Blackmore 2013)

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Setting

The settings of the studies were extracted and recorded into one of 10 categories representing various areas of the health care system. Majority of the settings reported from the thirty included studies were conducted in hospital environments (out-patient, in-patient, emergency department, pharmacy units, psychiatric wards, laboratory, operating rooms and radiology units). While home care was the only non-hospital setting reported, others reported the application of lean principles in more than one setting. Out of the thirty included studies, 6 (20%) were conducted in emergency departments of a hospital (King 2006; Murrell 2011; Naik 2012; Ng 2010; Piggott 2011; Ulhassan 2013), 6 (20%) in hospital laboratories (Cankovic 2009; Melanson 2009; Michael 2013; Morrison 2011; Smith 2012a; Yerian 2012), 5 (16%) in out-patient department (Fischman 2010; Grove 2010; McDermott 2013; Smith 2011; Waldhausen 2011), 4 (13%) were conducted in an in-patient hospital ward comprising of stroke, surgical, rehabilitation and medical wards (Chiodo 2012; Ford 2012; O'Neill 2011; Yousri 2011), 3 (10%) in operating rooms (Blackmore 2013; Cima 2011; Collar 2012), 2 (6%) in pharmacy department (Beard 2010; Hummer 2009) and 1 (3%) in the radiology unit (Harmelink 2008). Out of the thirty included studies, one (3%) reported the application of lean principles in a dual setting comprising a community mental health centre and in-patient psychiatric ward (Atkinson 2012). One study out of the included thirty reported the application of lean methodology in an in-patient, outpatient and emergency department (Barnas 2011). Finally, one study (3%) reported the application of lean principles in a home care setting (Smith 2012).

Purpose

Table 1 Overview of the purpose reported by the 30 included primary studies

Study ID Year Duration Country Setting Implementation activities

Study design

Purpose 1: System improvements (73%)

Beard 2010 2010 NA UK OS VSM P/P

Blackmore 2013 2013 37 months

USA HC RPIW, 5s, VSM, LBW P/P

Cima 2011 2011 24 months

USA HC VSM P/P

Collar 2012 2006 18 months

USA HC VSM P/P

Fischman 2010 2010 3 months USA OS VSM P/P

Ford 2012 2012 36 months

USA HC VSM P/P

Grove 2010 2012 13 months

UK PC VSM P/P

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Harmelink 2008 2008 NA USA OS VSM P/P

Hummer 2009 2009 NA USA OS LBW P/P

McDermott 2013 2012 NA IRELAND HC RPIW, 5s, VSM P/P

Melanson 2009 2009 12 months

USA AC RPIW, VSM P/P

Murrell 2011 2011 12 months

USA ED RPIW, VSM P/P

Naik 2012 2012 30 months

USA ED RPIW, 5s P/P

Ng 2010 2010 24 months

CANADA ED RPIW, VSM P/P

O'Neill 2011 2011 NA AUSTRALIA OS 5s, VSM P/P

Piggott 2011 2011 22 months

USA ED RPIW, VSM, LBW P/P

Smith 2011 2011 6 months USA OS VSM P/P

Smith 2012 2012 28 months

USA HC RPIW, VSM P/P

Smith 2012a 2012 24 months

USA HC LBW P/P

Waldhausen 2011

2011 NA USA HC RPIW, 5s, LBW P/P

Yerian 2012 2012 NA USA HC RPIW, 5s P/P

Yousri 2011 2011 24 months

UK HC VSM P/P

Purpose 2: Process redesign (13%)

Atkinson 2012 2012 3 months UK HC RPIW, VSM P/P

Cankovic 2009 2009 48 months

UK OS RPIW, 5s, LBW ITS

King 2006 2006 24 months

AUSTRALIA ED VSM P/P

Michael 2013 2013 NA USA OS VSM, LBW P/P

Purpose 3: Sustainability, Adoption, Leadership (6%)

Barnas 2011 2011 36 months

USA HC RPIW P/P

Ulhassan 2013 2013 36 months

SWEEDEN ED VSM, LBW P/P

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Purpose 4: Care Transitions (3%)

Chiodo 2012 2012 23 months USA HC RPIW, VSM, LBW P/P

Purpose 5: Staffing model (3%)

Morrison 2011 2011 9 months USA OS 5s, VSM P/P

Legend: NA= not available; OS = other sections of the hospital e.g. Lab; HC = hospital care; ED = emergency department; PC = primary care; AC = acute care; LP = lean principles/philosophies; TMS = toyota management system; HFPS = henry ford production system; TIS = thedacare improvement system; VMPS = virginia mason production; duration = the data collection period.

Description of the Outcomes

Table 2: Summaries of the type of outcomes reported

System performance outcomes

Description Setting Studies N (%)

Admission time Time taken to move patients from acute care to the inpatient rehabilitation setting

IP Chiodo 2012 1 (3)

Collection time Time taken to collect all morning samples in a phlebotomy department

LA Morrison 2011 1 (3)

Dispensing time

Time taken to fill in-patient prescriptions at a hospital based pharmacy

PH Beard 2010 1 (3)

Disposition time

Time from first registration to time of disposition order placement

ED Naik 2012 1 (3)

Exam room time

Time which a provider was with a patient OP Waldhausen 2011

Number of patient visit

Number of hospital visit by patients per month

ED; OP Naik 2012; Smith 2011

2 (6)

Discharge rate Proportion of patients discharged from ED after 4hours

ED Ulhassan 2013

1 (3)

Length of stay Duration of a single episode of hospitalization

IP and DU; IP, ED, ED

Atkinson 2012; Ford 2012; Murrell 2011; Ng 2010; Ulhassan 2013

5 (16)

Medication renewal rate

Time taken to renew prescriptions in the pharmacy department

PH Hummer 2009 1 (3)

Medication round time

Length of medication round in the hospital IP O'Neill 2011

1 (3)

Number of Total number of safety reports filed for LA Morrison 2011 1

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safety reports delays in a phlebotomy laboratory (3)

Out of hospital rates

Patients remaining out of hospital IP Atkinson 2012

1 (3)

Patient journey time

Time from registration at clinic reception to the recorded time the patient physically left the department

OP McDermott 2013

1 (3)

Referral rates Number of people referred with dementia to liaison psychiatry

IP Atkinson 2012

1 (3)

Sterilization Error rate

Number of errors occurring during a surgical sterilization process over time

HC Blackmore 2013; Michael 2013

2 (6)

Scheduling time

Time taken by staffs to determine daily schedule for in-patients

LA Smith 2012

1 (3)

Near miss event rate

Number of unplanned event that did not result in injury, illness, or damage – but had the potential to do so over time

LA Smith 2012a

1 (3)

Time to see physician

Time from registration to the recorded time of physician encounter (i.e., door to doctor time)

OP McDermott 2013

1 (3)

Total processing time

Time taken to process all samples at the laboratory in a shift

LA Michael 2013

1 (3)

Time to triage Time taken for patient to get triaged ED; ED; ED

King 2006; Naik 2012; Piggott 2011

3 (10)

Turnaround time

The interval in minutes between surgical dressing end and surgical incision for the subsequent patient, i.e. time during which no surgery is taking place

LA; OR Cankovic 2009; Collar 2012

2 (6)

Turnover time

The interval in minutes between patient departure from the OR, and the arrival of the subsequent patient in the OR, i.e. time during which no patient is in the OR

OR; OR Cima 2011; Collar 2012

2 (6)

Wait time

Time between triage by the MA and the beginning of the patient’s encounter with the resident physician

OP; RD; ED; LA; ED

Fischman 2010; Harmelink 2008; King 2006; Melanson 2009; Ng 2010

5 (16)

Professional Outcomes

Employee satisfaction

Degree of satisfaction among staffs OR; RD Blackmore 2013; Harmelink 2008

2 (6)

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Login to Provider time

Time from first registration to provider assignment

ED Naik 2012; 1 (3)

Provider productivity

Number of patients seen per hour ED; OP Naik 2012; Waldhausen 2011

2 (6)

Number of steps saved

Number of wasteful steps removed from a care process

OP; LA Grove 2010; Yerian 2012

2 (6)

Nursing time with patients

Nursing time spent with the patient in a shift

OP, IP McDermott 2013; O'Neill 2011

2 (6)

Staff overtime The number of late shift and overtime obligation (minutes/specialty/month)

OR Cima 2011

1 (3)

Patient outcomes

NCR picker scores

Family experience survey scores OP Waldhausen 2011

Patient satisfaction

Degree of satisfaction by patients from service received, measured by NCR picker survey

RD; LA Barnas 2011; Harmelink 2008; Melanson 2009

2 (6)

Performance metrics

Safety/quality measures: medication errors IP; OP; ED

Barnas 2011

Out of hospital rates

Patients remaining out of hospital IP Atkinson 2012

1 (3)

Mortality rate Number of deaths during a time period IP; OP; ED; IP

Barnas 2011; Yousri 2011

2 (6)

Re-admission rates

Number of patients re-admitted to the hospital after discharge

IP Atkinson 2012

1 (3)

Legend: IP= in-patient units; OP = out-patient units; OR = operating room; ED = emergency department; LA = laboratory; PH = pharmacy; DU = mental Dubes;

Table 3: Studies that reported positive effects from Lean implementation

See Appendix 3a and 3b for a detailed list of all outcomes reported

Study ID Outcome Effect reported after Lean implementation

Statistical significance

Atkinson 2012

Number of patients referred Increase in the number of referred patients by 13

No

Atkinson 2012

Time to see referred subjects (days)

4 day reduction in time to see referred patients

No

Atkinson Readmission rate (%) 19% reduction in readmission rate No

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2012

Atkinson 2012

length of stay (days) Reduction in the length of stay by 4.8 days

No

Atkinson 2012

Out of hospital rate (%) 18% increase in the out of hospital rate

No

Barnas 2011

Time to restore cardiac vessel blood flow (min)

55 min reduction in the time to restore cardiac vessel blood flow.

No

Barnas 2011

Improvement in performance measures in AMC in-patient cardiac (%)

4% improvement in performance measures in AMC in-patient cardiac

No

Barnas 2011

Improvement in performance measures in TCMC neuro/surgical (%)

4% Improvement in performance measures in TCMC neuro/surgical

No

Barnas 2011

Improvement in performance measures in radiation oncology (%)

5% Improvement in performance measures in radiation oncology

No

Barnas 2011

Improvement in performance measures in AMC medical/surgical (%)

11% Improvement in performance measures in AMC medical/surgical

No

Barnas 2011

Improvement in first-call bed access for AMC in-patient cardiac

9% Improvement in first-call bed access for AMC in-patient cardiac

No

Barnas 2011

Improvement in falls for TCMC neuro/surgical (%)

35% Improvement in falls for TCMC neuro/surgical

No

Barnas 2011

Improvement of 14 safety/quality drivers (%)

88% Improvement of 14 safety/quality drivers

No

Barnas 2011

Improvement in people engagement drivers (%)

83% Improvement in people engagement drivers

No

Barnas 2011

Improvement in 23 of the financial stewardship drivers (%)

48% Improvement in 23 of the financial stewardship drivers

No

Barnas 2011

Reduction in Length of stay (%)

16.4% Reduction in Length of stay No

Barnas 2011

Improvement in customer satisfaction drivers (%)

85% Improvement in customer satisfaction drivers

No

Beard 2010 Dispensing time (min) Reduction in the median dispensing time by 161 mins

No

Blackmore Sterilization error rate (%) 2% reduction in the error rate of Yes

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2013 sterile surgical equipment

Cankovic 2009

Turn around time (days) Reduction in turn around time by 1.7 days

No

Cankovic 2009

Number of properly collected and shipped blood samples (%)

37% increase in the number of properly collected and shipped blood samples

No

Chiodo 2012 Discharge time (mins) 270 mins reduction in discharge time

No

Chiodo 2012 Admission time (mins) 218 mins reduction in admission time

No

Cima 2011

On-time starts in thoracic surgery (%)

30% increase in the on-time starts in thoracic surgery

No

Cima 2011

On-time starts in gynaecologic surgery (%)

28% increase n the on-time starts in gynaecologic surgery

No

Cima 2011

On-time starts in general/colorectal surgery (%)

32% increase in general/colorectal surgery

No

Cima 2011

Operations past 5pm in gynaecologic surgery

6% decrease in operations past 5pm in gynaecologic surgery

No

Cima 2011

Operations past 5pm in general/colorectal surgery

6% decrease in operations past 5pm in general/colorectal surgery

No

Cima 2011

Average turnover time for thoracic surgery (min)

10% reduction in the average turnover time for thoracic surgery

No

Cima 2011

Average turnover time for gynaecologic surgery (min)

15% reduction in the average turnover time for gynaecologic surgery

No

Cima 2011

Average turnover time for general/colorectal surgery (min)

11% reduction in the average turnover time for general/colorectal surgery

No

Cima 2011

Average staff overtime for thoracic surgery (min/specialty/mo)

3% reduction in the average turnover time for thoracic surgery

No

Cima 2011

Average staff overtime for gynaecologic surgery (min/specialty/mo)

19% reduction in the average turnover time for gynaecologic surgery

No

Cima 2011

Average staff overtime for general/colorectal surgery (min/specialty/mo)

46% reduction in the average turnover time for general/colorectal surgery

No

Cima 2011 Operating rooms 0.75% increase in the number of No

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saved/d/specialty for thoracic surgery

operating rooms saved/d/specialty for thoracic surgery

Cima 2011

operating rooms saved/d/specialty for gynaecologic surgery

0.55% increase in the number of operating rooms saved/d/specialty for gynaecologic surgery

No

Cima 2011

Operating rooms saved/d/specialty for general/Colorectal surgery

0.4% increase in the number of operating rooms saved/d/specialty for general/Colorectal surgery

No

Cima 2011

Change in operating margin/OR/d for thoracic surgery (%)

0.25% increase in the operating margin/OR/d for thoracic surgery

No

Cima 2011

Change in operating margin/OR/d for Gynecologic surgery (%)

0.16% increase in the operating margin/OR/d for Gynecologic surgery

No

Cima 2011

Change in operating margin/OR/d for General/Colorectal surgery (%)

0.51% increase in the operating margin/OR/d for General/Colorectal surgery

No

Collar 2012 OR turn around time (min) 20.2 mins reduction in the OR turn around time

Yes

Collar 2012 OR turn over time (min) 9.4 mins reduction in the OR turn over time

Yes

Collar 2012 Educational survey score 21 mins reduction in the door to needle time

No

Grove 2010 Number of steps saved 44 steps eliminated from the work process

No

Harmelink 2008

Patient examination wait time (min)

2.9 mins reduction in the mean patient examination wait time

No

Harmelink 2008

Employee satisfaction scores 1.14 increase in the mean satisfaction employee scores

No

Harmelink 2008

Patient satisfaction on radiology staff for comfort scores (%)

7.5% increase in patient satisfaction on radiology staff for comfort scores

No

Harmelink 2008

Radiology care providers collaboration scores (%)

7.3% increase in radiology care providers collaboration scores

No

Harmelink 2008

Radiology concern for privacy scores (%)

1% reduction in radiology concern for privacy scores

No

18

Harmelink 2008

Radiology response to concerns and complaints (%)

3.5% increase in radiology response to concerns and complaints

No

Harmelink 2008

Friendliness of radiology staff (%)

4% increase in the friendliness of radiology staff

No

Hummer 2009

Number of unfilled request Reduction in the number of unfilled request by 42

No

King 2006

Number of patients who waited 8 hrs. before seen by the physician

1.4% reduction in the number of patients who waited 8 hrs. before seen by the physician

Yes

King 2006

Number of cases seen within 4 hrs. or less

5% increase in the number of cases seen within 4 hrs. or less

No

King 2006 Total time spent in ED (hr) 0.8hr reduction in the total time spent in ED

Yes

King 2006

Time spent in ED if discharged (hr)

1.3 hr reduction in the time spent in ED if discharged

Yes

King 2006

Number of patients not waiting after triage

2.3% reduction in the number of patients not waiting after triage

No

McDermott 2013

Total patient journey time (min)

60 mins reduction in the total patient journey time

Yes

McDermott 2013

Time to see a physician (min) 22.88 mins reduction in time to see a physician

Yes

McDermott 2013

Time spent with the physician (min)

3.34 mins reduction in time spent with the physician

Yes

McDermott 2013

Time spent with the nurse (min)

1.4 mins increase in the time spent with the nurse

Yes

Melanson 2009

Patient satisfaction (%) 30% increase in the level of patient satisfaction

No

Melanson 2009

Wait time (min) 10mins reduction in wait time No

Michael 2013 Total processing time(days) 1 day reduction in the total processing time

No

Michael 2013 Number of errors Reduction in the mean number of errors by 3

No

Michael 2013

Number of labelling errors missed

Reduction in the mean number of labelling error missed by 5

No

Morrison 2011

Collection time (min) 17 mins reduction in time used for collection of samples

No

19

Morrison 2011

Number of safety reports Reduction in the number of safety reports by 8.4

No

Murrell 2011 Length of stay (hr) 50 mins reduction in the length of stay

No

Murrell 2011

Leaving the ED without been seen by the doctor LWBS (%)

3% reduction in the number of patients leaving the ED without been seen by the doctor LWBS

No

Murrell 2011

ED arrival to physician start time (min)

20.3 mins reduction in ED arrival to physician start time

No

Murrell 2011

Proportion of patients arriving by ambulance (%)

0.4% reduction in the proportion of patients arriving by ambulance

No

Murrell 2011 Hospital admission rate (%) 1.3% reduction in hospital admission rate

No

Naik 2012

Number of patient visit per month

Increase in the number of patient visit by 794.5

Yes

Naik 2012 Disposition time (hr) 0.6hr decrease in the disposition time

Yes

Naik 2012 Time to triage (hr) 0.3hr decrease in the time to triage

Yes

Naik 2012 Login to Provider time (hr) 50 mins reduction in the log in to provider time

Yes

Ng 2010 Length of stay (days) 8hrs reduction in the mean length of stay

No

Ng 2010 Wait time (min) 22 mins reduction in the wait time No

Ng 2010 Patient satisfaction (%) 2.2% increase in the patient satisfaction scores

No

O'Neill 2011

Nursing time spent on patient care (hr)

2 hr increase in the nursing time spent on patient care

No

O'Neill 2011

Time spent communicating information across 3 shifts (hr)

7.3 hr reduction in time spent communicating information across 3 shifts

No

O'Neill 2011 Medication round time (min) 56 mins reduction in medication round time

No

Piggott 2011

proportion of cases with 12-Lead ECGs completed within 10 mins of patient triage

37.4% increase in the proportion of cases with 12-Lead ECGs completed within 10 mins of patient triage

Yes

Piggott 2011 Proportion of cases with 12.2% increase in the number of Yes

20

physician assessment within 60 mins

patients assessed within 60 mins

Smith 2011

proportion of patient visit completed within < 60mins

22% increase in the proportion of patient visit completed within < 60mins

No

Smith 2011

Length of patient visit time (min)

10 mins reduction in length of patient visit time

No

Smith 2012 Scheduling time (min) 40 mins reduction in scheduling time

No

Smith 2012a

Process dependent near miss event rate

3.7 reduction in the process dependent near miss event rate

No

Smith 2012a Total near miss event rate 3.7 reduction in the mean total near miss event rate

Yes

Ulhassan 2013

Discharge rate (%) 9% increase in the number of patients discharged

No

Ulhassan 2013

Length of stay (min) 26 mins reduction in the mean length of stay

No

Waldhausen 2011

Provider patient time (%) 29% increase in the provider patient time

No

Waldhausen 2011

NRC Picker Problem Scores (%) 5.1 % decrease in the NRC Picker Problem Scores

No

Waldhausen 2011

Exam room time (min) 7 mins reduction in the exam room time

No

Waldhausen 2011

Number of patient in a 4hr clinic

Increase in the number of patient in a 4hr clinic by 2

No

Yerian 2012 Number of steps saved 28% reduction in the number of steps saved from the work process

No

Yousri 2011 Overall mortality rate (%) 9.3% reduction in the mean overall mortality rate

Yes

Yousri 2011 30-day mortality rate (%) 5 % reduction in the 30-day mortality rate

Yes

Yousri 2011 Admission rate 2.7% reduction in the mean admission rate

Yes

Yousri 2011 Lenght of stay (days) 2 day reduction in the mean length of stay

Yes

Yousri 2011

Door to theatre time within 24 hr

7% increase in the number of patient with door to theatre time within 24 hr

Yes

21

Yousri 2011

Number of patients delayed by more than 48hr

2.3% reduction in the number of patients delayed by more than 48hr

Yes

Legend: + = positive effect; * = statistical significant result

Table 4: Studies that reported negative effects from Lean implementation


Study ID Outcome Description Statistical significance

Collar 2012

Educational survey score Decrease in the mean educational survey score of staffs by 1

No

King 2006 No of deaths in the ED 0.01% increase in the number of deaths in the ED

No

Ford 2012 Door to complete blood count time (min)

2 mins increase in the door to complete blood count time

No

Michael 2013

Total number of labelling errors received

Increase in the mean number of labelling error received by 1

No

Cima 2011

Operations past 5pm in thoracic surgery

2% increase in operations past 5pm in thoracic surgery

No

Legend: - = negative effect; # = not statistically significant

Table5: Studies that reported null effects from Lean implementation


Study ID Outcome Description Statistical significance

Smith 2012a

Operator dependent near-miss event rate

Decrease in the mean educational survey score of staffs by 1

No

Legend: ± = no effect; # = not statistically significant

Statistics

Table 6: Summary of the type of statistics reported

Type Studies N (%)

Confidence intervals

King 2006; Murrell 2011; Ng 2010 3 (10)

22

Percentages Barnas 2011; Cankovic 2009; Cima 2011; Collar 2012; Fischman 2010; Grove 2010; Harmelink 2008; McDermott 2013; Michael 2013; Morrison 2011; Ng 2010; O'Neill 2011; Piggott 2011; Waldhausen 2011

14 (46%)

Median Atkinson 2012; Beard 2010; Ford 2012; King 2006; McDermott 2013; Melanson 2009; Michael 2013; Morrison 2011; Murrell 2011; Naik 2012; Ng 2010; Smith 2011; Smith 2012; Smith 2012a; Waldhausen 2011; Yousri 2011

16 (53)

Mean Blackmore 2013; Cankovic 2009; Chiodo 2012; Collar 2012; Fischman 2010; Grove 2010; Harmelink 2008; Hummer 2009; Melanson 2009; Morrison 2011; Murrell 2011; O'Neill 2011; Piggott 2011; Ulhassan 2013; Waldhausen 2011; Yerian 2012; Yousri 2011

17 (56)

Standard deviation

Beard 2010; Collar 2012; McDermott 2013; Yerian 2012 4 (13)

Interquartile range

Ford 2012; Melanson 2009; Morrison 2011; Murrell 2011; Naik 2012 5 (16)

P value Cima 2011; Collar 2012; Fischman 2010; Ford 2012; King 2006; McDermott 2013; Melanson 2009; Murrell 2011; Naik 2012; Ng 2010; Piggott 2011; Waldhausen 2011; Yerian 2012; Yousri 2011

14 (46)

Legend:

P value = probability value

Study setting

Table 7: Summaries of the settings for the included primary studies

Setting

Laboratory (20%)

Study ID Participants Analysis Outcomes reported Study designs

Cankovic 2009

HCP mean, percentages Turnaround time ITS

Melanson 2009

HCP, LC mean, median, p-value, interquartile range

wait time, patient satisfaction P/P

Michael 2013 HCP, LC median, percentage Total processing time, error rate

P/P

Morrison 2011

HCP, LC median, inter-quartile range, mean, percentage

number of safety report, collection time

P/P

Smith 2012a NA median Near miss event rate P/P

23

Yerian 2012 HCP mean, standard deviation, percentage

number of steps saved P/P

Legend: LA = Laboratories; HCP = health care professionals; LC = lean consultants; PT = patients; P/P = pre-post; ITS = interrupted time series Setting Emergency department (20%)

King 2006 HCP median, confidence interval, p-value

Wait time, Triage time P/P

Murrell 2011 HCP median, p-value, confidence interval, mean, Interquartile range

length of stay, physician start time

P/P

Naik 2012 HCP median, p-value, interquartile range, percentage

patients visit, disposition time, triage time, provider time, provider productivity

P/P

Ng 2010 HCP mean, median, confidence interval, p-value, percentages

wait time, length of stay, patient satisfaction

P/P

Piggott 2011 PT mean, p-value, percentage

Time to triage, time to physician assessment

P/P

Ulhassan 2013

HCP, LC mean Length of stay, patient discharge rate

P/P

Legend: ED = emergency department; HCP = health care professionals; LC = lean consultants; PT = patients; P/P = pre-post; Setting Out-patient department (16%)

Fischman 2010

HCP mean, p-value, percentages

Wait times P/P

Grove 2010 HCP, LC mean, percentage Number of steps saved P/P

McDermott 2013

HCP median, standard deviation, p-value, percentage

Patient journey time, time to see physician, time spent with nurse, time spent with physician

P/P

Smith 2011 HCP median Duration of patient visit P/P

Waldhausen HCP, LC mean, percentage, face to face provider time, P/P

24

2011 median, p-value problem scores, room time, number of patients

Legend: OP = out-patient department; HCP = health care professionals; LC = lean consultants; PT = patients; P/P = pre-post Setting In-patient department (16%)

Chiodo 2012 HCP, LC mean Admission time P/P

Ford 2012 HCP, LC median, interquartile range, p-value

Length of stay, cycle time P/P

O'Neill 2011 HCP mean, percentage Nurse shift time, medication round time

P/P

Yousri 2011 PT mean, median, p-value mortality rate, door to theatre time

P/P

Legend: IP = In-patient department (; HCP = health care professionals; LC = lean consultants; PT = patients; P/P = pre-post Setting Operating room (10%)

Blackmore 2013

HCP mean Surgical error rate P/P

Cima 2011 HCP percentage, p-value Average staff overtime, Average turnover, Change in operating margin

P/P

Collar 2012 HCP, LC mean, standard deviation, p-value, percentage

OR turnover time, OR turnaround time

P/P

Legend: OR = Operating room (; HCP = health care professionals; LC = lean consultants; P/P = pre-post Setting Pharmacy (10%)

Beard 2010 HCP median, standard deviation

Dispensing time P/P

Hummer 2009

HCP median Medication filling rate P/P

Legend:

25

PH = Pharmacy department (; HCP = health care professionals; LC = lean consultants; P/P = pre-post Setting Radiology (10%)

Harmelink 2008

HCP Percentage, Mean Patient satisfaction, Wait times, Employee satisfaction

P/P

Legend: RD= Radiology; P/P = pre-post Setting Home care (10%)

Smith 2012 HCP median Scheduling time P/P

Legend: HC= home care; HCP = health care professionals; P/P = pre-post Setting In-patient and Dubes (3%)

Atkinson 2012

HCP median Referral rates, Length of stay, readmission rates, out of hospital rates

P/P

Legend: PH = Pharmacy department (; HCP = health care professionals; LC = lean consultants; P/P = pre-post Setting In-patient, Out-patient and emergency department (3%)

Barnas 2011 HCP, LC Percentage Performance measures indicators

P/P

Legend:

IP = in patient department; ED = emergency department; OP = outpatient department (; HCP = health care professionals; LC = lean consultants; P/P = pre-post

Effects of Lean

A thorough review of the thirty included studies reveals the enormity in the variation about the implementation of Lean methodology and principles that has been reported in the literature. This may also influence the different effects reported by the authors in various settings where these studies are conducted. Impacts have been categorized according to positive, negative or null effects. The majority of the Lean interventions in healthcare management were conducted in different sections of the hospital with a small number conducted outside a hospital

26

environment (table 7). Furthermore, majority of the positive impacts of Lean implementation in healthcare management with empirical rigor reported were around improvement of health systems (table 2), even though a small proportion of these results were statistically significant (table 3). Out of the 103 positive outcomes reported from the thirty included studies, 91 (88%) from 26 studies were about positive health systems improvement (Atkinson 2012; Barnas 2011; Beard 2010; Blackmore 2013; Cankovic 2009; Chiodo 2012; Cima 2011; Collar 2012; Harmelink 2008; Hummer 2009; King 2006; McDermott 2013; Melanson 2009; Michael 2013; Morrison 2011; Murrell 2011; Naik 2012; Ng 2010; O'Neill 2011; Piggott 2011; Smith 2011; Smith 2012; Smith 2012a; Ulhassan 2013; Waldhausen 2011; Yousri 2011), 9 (9%) from 6 studies were on positive patient outcomes (Atkinson 2012; Barnas 2011; Harmelink 2008; Melanson 2009; Ng 2010; Yousri 2011 ) and 3 from 3 studies (3%) about positive professional outcomes (Grove 2010; Harmelink 2008; Yousri 2011). Although 5 studies reported 5 (5%) negative outcomes after the application of Lean for system improvement purposes, none of the results were statistically significant (Cima 2011; Collar 2012; Ford 2012; King 2006; Michael 2013 ) and only 1 (1%) study reported a null effect after Lean implementation in the hospital laboratory (Smith 2012a). In terms of statistical significance of the effects reported, only 23 (22%) out of 103 outcomes, reported statistical significant positive results. No statistical significance was reported for negative and null effects of Lean implementation from the thirty included studies (table 3; 4; 5).

Subgroup analysis

Setting

Studies were grouped based on the various settings where Lean was implemented and the analysis of the sub-groupings were based on the similarities of the type of statistics reported and study design. Majority of the studies reported on positive findings while some reported on the negative or null effects from the implementation of Lean in these settings. Only 4 out of the 10 settings were comparable (LA; ED; OP; OR). In the laboratory, 2 (33%) out of 6 studies (Michael 2013; Morrison 2011) reported positive effects from Lean implementation by a reduction in total number of processing time, number of errors, number of labelling error missed, collection time and number of safety reports respectively. A non significant increase in the total number of labelling errors after Lean implementation was also reported by (Morrison 2011). four out of six studies conducted in emergency department settings all reported positive effects on systems improvement measures, patient and professional outcomes (King 2006; Murrell 2011; Naik 2012; Ng 2010; Piggott 2011; Ulhassan 2013), (King 2006) also reported a 0.001% increase in the number of deaths in emergency department after Lean implementation. In the Out-patient department, 3 (60%) out of 5 studies reported improvement in systems measures (Fischman 2010; Grove 2010; Waldhausen 2011). Finally, two out of three studies conducted in operating rooms reported a reduction in staff overtime, surgical error rate, turnover and turn around time (Cima 2011; Chiodo 2012).

27

Country

Twenty out of the thirty included studies were conducted in the United States (66%), 5 (16%) in United Kingdom and 1 (3%) each in Australia, Canada, Ireland and Sweden. 4 (20%) studies conducted in the United states reported negative findings after Lean implementation around patient satisfaction and system improvement measures (Collar 2012;Cima 2011 Ford 2012; Michael 2013). The only study conducted in Australia reported a negative finding of a non-significant increase in the number of deaths in the emergency department after Lean implementation. All four studies conducted in the United Kingdom reported positive effects after Lean implementation in various settings around and similar findings were reported from studies conducted in Australia, Canada and Ireland. This finding agrees with the literature on the pioneer and broad scale implementation of Lean tools in healthcare systems with the advent of Virginia Mason Hospital and Medical centre in the USA.

Year of study

The year of publication of the thirty included studies ranges from 2006 to 2013 with majority around 2011 and 2012. 9 (30%) studies each were published in 2011 and 2012, 3 (10%) each in 2009, 2010 and 2013, 2 (6%) in 2006 and 1 (3%) in 2008. Eight of the nine studies conducted in 2011 focused on systems improvement (Cima 2011; Morrison 2011; Murrell 2011; O'Neill 2011; Piggott 2011; Smith 2011; Waldhausen 2011; Yousri 2011 ) and one on sustainability, adoption, leadership (Barnas 2011). 7 (23%) studies in 2012 focused on systems improvement (Ford 2012; Grove 2010; McDermott 2013; Naik 2012; Smith 2012; Smith 2012a; Yerian 2012) and 1 (3%) each on process redesign and transition of care respectively (Atkinson 2012 and Chiodo 2012). Two out of the three studies published in 2009 focused on systems improvement (Hummer 2009) and 1 (3%) on process redesign (Cankovic 2009). 1 (3%) study each in 2013 focused on systems improvement, process redesign and sustainability, adoption, leadership respectively (Blackmore 2013; Michael 2013; Ulhassan 2013), while all three studies published in 2010 focused on systems improvement (Beard 2010; Fischman 2010; Ng 2010). 1 (3%) study each in 2006, focused on systems improvement and process redesign (Collar 2012; King 2006) and the only study conducted in 2008 focused on systems improvement (Harmelink 2008).

Discussion

The results from the review shows that majority of empirical Lean investigations were conducted in hospital settings (Atkinson 2012; Barnas 2011; Beard 2010; Blackmore 2013; Cankovic 2009; Chiodo 2012; Cima 2011; Collar 2012; Fischman 2010; Ford 2012; Grove 2010; Harmelink 2008; Hummer 2009; King 2006; McDermott 2013; Melanson 2009; Michael 2013; Morrison 2011; Murrell 2011; Naik 2012; Ng 2010; O'Neill 2011; Piggott 2011; Smith 2011; Smith 2012a; Ulhassan 2013; Waldhausen 2011; Yerian 2012; Yousri 2011) (emergency departments, laboratories, out-patient departments, in-patient wards, and operating rooms, etc.), but the documentation of Lean implementation activities are limited, particular for large-scale implementation in healthcare. The primary studies often lack explicitly stated concepts, research design, appropriate analysis, and incomplete outcomes reported. The main purpose of Lean investigations was on system improvement and the majority of primary studies reported on health system improvement (Atkinson 2012; Beard 2010; Blackmore 2013; Cankovic 2009; Chiodo 2012; Cima 2011; Collar 2012; Fischman 2010; Ford 2012; Harmelink 2008; Hummer

28

2009; King 2006; McDermott 2013; Melanson 2009; Michael 2013; Morrison 2011; Murrell 2011; O'Neill 2011; Piggott 2011; Smith 2011; Smith 2012; Smith 2012a; Ulhassan 2013; Waldhausen 2011). Professional outcomes and patient outcomes were less commonly examined and there were few reported decrements in patient care or failures to achieve improvements (Cima 2011; Grove 2010; Harmelink 2008; McDermott 2013; Naik 2012; O'Neill 2011; Waldhausen 2011; Yerian 2012). Future research into evaluation of the implementation of Lean in healthcare settings must focus on patient outcomes. There is a potential for publication bias in the literature about Lean management in healthcare due to the low number of publications reporting on negative and null effects of Lean implementation in healthcare management. There is also a need for appropriate description of participants involved, variables measures and concise methodology of the Lean implementation processes that were lacking in majority of the studies.

Summary of main results

Quality of the evidence

The proportion of studies screened and sufficiently well designed, conducted and reported to be included for final analysis was very small. Of the 499 search-hits, only 30 studies met the inclusion criteria based on a previous literature review of Lean management in health care (Brackett 2013). The majority of the studies excluded from this literature review lacked empirical evidence and/or were simulation studies where scientific technology was used to gain insights into natural systems. Majority of the included studies used pre-post comparison design at one single time point which makes it challenging and misleading to draw meaningful conclusions due to lack of control and inherent high level of bias. Poor reporting played a significant role in hampering the assessment of the studies and better reporting of study methods could have improved the sample size of the included studies for further analysis.

While experimental methods such as randomized trials are recommended, they may be inapplicable in most cases and beyond the feasibility of many clinicians and researchers. Applying the principles and methodology of EPOC study design and quality criteria, which advocates for the use of time series analysis in the evaluation of complex interventions can help yield meaningful results with the use of minimal resources.

Authors' conclusions

Implications for practice

This review has established that appropriate implementation of Lean tools and principles in health care management may be associated with improved efficiency in systems improvement, patient outcomes and professional practice. The results should be interpreted with caution taking into account the various settings in which these studies are conducted. Likewise, there is a need to have evaluation set up prior to implementation and to ensure that the relevant measures/outcomes are examined during the research process.

29

Implications for research

Quality of Lean studies

Studies reporting the effects of Lean intervention in healthcare management should incorporate EPOC standards into their study design and methodology to maximize the quality of the evidence underpinning this model that is now been utilized widely in the area of healthcare.

Comparability of the evidence

Due to poor reporting, statistical pooling of studies was not applicable and the comparability of the studies was neither feasible in order to meaningfully detect a significant effects from similar health care settings. Considering the currently available evidence, there is also insufficient knowledge about the sustainability of the positive effects of Lean implementation in Healthcare management. Future research should ensure appropriate description of the study design, analysis and complete reporting of the outcomes so as to improve the empirical rigor of their conclusions.

Acknowledgements

We would like to thank Michelle Fiander, the Trial search coordinator from the Cochrane Effective Practice and Organisation of Care (EPOC) group in Ottawa for her contribution to the design of the search strategies we will use for the review.

Characteristics of studies

Characteristics of included studies

Atkinson 2012

Methods Study design: pre - post comparison Analysis: median

Participants Liaison nurse Ward doctors Nurse Support staff

Interventions Lean conceptualization: Virginia mason production system Lean tools: value stream mapping, Rapid process improvement workshops (RPIW) Duration: 3 months

Outcomes Referral rates, Length of stay, readmission rates, out of hospital rates

Notes

Risk of bias table

Bias Authors' judgement

Support for judgement

Random sequence generation (selection bias) Unclear risk

30

Allocation concealment (selection bias) Unclear risk

Blinding of participants and personnel (performance bias)

Unclear risk

Blinding of outcome assessment (detection bias) Unclear risk

Incomplete outcome data (attrition bias) Unclear risk

Selective reporting (reporting bias) Unclear risk

Other bias Unclear risk

Barnas 2011

Methods Study design: pre-post comparison Analysis: percentages

Participants Managers of targeted clinical units Lean experts, Senior leaders, Sensei consultant, trained staff facilitators

Interventions Lean conceptualization: other lean management system (Thedacare Improvement System) Lean tools: Rapid process improvement workshop Duration: 36 months

Outcomes Performance measures indicators

Notes

Risk of bias table






Unclear risk





Beard 2010

Methods Study design: pre-post comparison Analysis: median, standard deviation

31

Participants Pharmacists chief pharmacists

Interventions Lean conceptualization: Lean principles Lean tools: Value stream mapping Duration: NA

Outcomes Dispensing time

Notes

Risk of bias table






Unclear risk





Blackmore 2013

Methods Study design: pre-post comparison Analysis: mean

Participants OR staff Sterile processing staff

Interventions Lean conceptualization: Virginia mason production system Lean tools: Rapid process improvement workshop, Value stream mapping, Lean basics workshop, 5s Duration: 37 months

Outcomes Surgical error rate

Notes

Risk of bias table





32


Unclear risk





Cankovic 2009

Methods Study design: Interrupted time series Analysis: mean, percentages

Participants Pathologist Laboratory workers Histologist

Interventions Lean conceptualization: Henry ford production system Lean tools: Rapid process improvement workshop, Lean basics workshop, 5s Duration: 48 months

Outcomes Turnaround time

Notes

Risk of bias table






Unclear risk





Chiodo 2012


Participants Rehabilitation physician staff Resident physicians Project owner

33

Lean coach Rehabilitation unit clerk Rehabilitation nursing Nursing Rehabilitation unit admissions coordinator Physical therapist

Interventions Lean conceptualization: NA Lean tools: Rapid process improvement workshop, Lean basics workshop, Value stream mapping Duration: 23 months

Outcomes Admission time

Notes

Risk of bias table






Unclear risk





Cima 2011

Methods Study design: pre-post comparison Analysis: percentages, p-value

Participants Surgeons Anesthesiologists Certified registered nurse anaesthetist RNs Other allied health workers Administrators, system/procedure experts Financial analysts Information technology programmers

Interventions Lean conceptualization: NA Lean tools: Value stream mapping Duration: 24 months

34

Outcomes Average staff overtime, Average turnover, Change in operating margin

Notes

Risk of bias table






Unclear risk





Collar 2012

Methods Study design: pre-post comparison Analysis: mean, standard deviation, p-value, percentages

Participants Healthcare providers Management team Lean experts Scrub nurses circulating nurses Anesthesiologists Perioperative technicians Surgeons Administrators Engineers Schedulers

Interventions Lean conceptualization: NA Lean tools: Value stream mapping Duration:18 months

Outcomes OR turnover time, OR turnaround time

Notes

Risk of bias table



35




Unclear risk





Fischman 2010

Methods Study design: pre-post comparison Analysis: mean, p-value, percentages

Participants Patients Internal medicine faculty and residents clinic nurses Clinic ancillary staff (medical assistants) Administration


Outcomes Wait times

Notes

Risk of bias table






Unclear risk





Ford 2012

Methods Study design: pre-post comparison

36

Analysis: median, interquartile range, p-value

Participants Lean engineer ED and neurology physicians ED nurses patient care and radiology technicians ED pharmacist Leadership team Social worker


Outcomes Length of stay, cycle time

Notes

Risk of bias table






Unclear risk





Grove 2010

Methods Study design: pre-post comparison Analysis: mean, percentages

Participants 8 clinical staffs 2 managerial staffs 3 administrative staffs Lean consultants

Interventions Lean conceptualization: Toyota Management System Lean tools: Value stream mapping Duration: 13 months

Outcomes Number of steps saved

Notes

Risk of bias table

37






Unclear risk





Harmelink 2008


Participants NA

Interventions Lean conceptualization: Lean Principles Lean tools: Value stream mapping Duration: NA

Outcomes Patient satisfaction, Wait times, Employee satisfaction

Notes

Risk of bias table






Unclear risk





Hummer 2009

Methods Study design: pre-post comparison Analysis: median

38

Participants 4 licensed independent providers 1 pharmacist, the pharmacy technician Nurse manager 4 engineers IT support personnel

Interventions Lean conceptualization: Lean Principles Lean tools: Lean basics workshops Duration: NA

Outcomes Medication filling rate

Notes

Risk of bias table






Unclear risk





King 2006

Methods Study design: pre-post comparison Analysis: median, confidence interval, p-value

Participants Physicians Nurses Other health professionals Clerical staff Patient care assistants

Interventions Lean conceptualization: Lean Principles Lean tools: Value stream mapping Duration: 24 months

Outcomes Wait time, Triage time

Notes

Risk of bias table

39






Unclear risk





McDermott 2013

Methods Study design: pre-post comparison Analysis: median, standard deviation, p-value, percentages

Participants Endocrinologists Non-consultant hospital doctor Clinical nurse practitioner in diabetes, Two hospital employees.

Interventions Lean conceptualization: Toyota management system Lean tools: Rapid process improvement workshop, 5s, Value stream mapping Duration: 24 months

Outcomes Patient journey time, time to see physician, time spent with nurse, time spent with physician

Notes

Risk of bias table






Unclear risk




40


Melanson 2009

Methods Study design: pre-post comparison Analysis: mean, median, p-value, interquartile range

Participants Phlebotomists Chemistry medical technologist Lab technician Lean consultants Management

Interventions Lean conceptualization: Toyota Management Production System Lean tools: Rapid process improvement workshop, Value stream mapping Duration: 12 months

Outcomes wait time, patient satisfaction

Notes

Risk of bias table






Unclear risk





Michael 2013

Methods Study design: pre-post comparison Analysis: median, percentages

Participants Health care providers Management team Lean experts Cytotechnologist Laboratory supervisor Medical director Lean coach

41

Interventions Lean conceptualization: Toyota Management Production System Lean tools: Lean basics workshop, Value stream mapping Duration: NA

Outcomes Total processing time, error rate

Notes

Risk of bias table






Unclear risk





Morrison 2011

Methods Study design: pre-post comparison Analysis: median, inter-quartile range, mean, percentage

Participants Phlebotomist Lean experts

Interventions Lean conceptualization: Toyota Management Production System Lean tools: 5s, value stream mapping Duration: 9 months

Outcomes number of safety report, collection time

Notes

Risk of bias table






Unclear risk


42




Murrell 2011

Methods study design: pre-post comparison Analysis: median, p-value, confidence interval, mean, Interquartile range

Participants ED nurses ED technicians Physicians department leaders

Interventions Lean conceptualization: Toyota Management Production System Lean tools: rapid process improvement workshop, value stream mapping Duration: 12 months

Outcomes length of stay, physician start time

Notes

Risk of bias table






Unclear risk





Naik 2012

Methods Study design: pre-post comparison Analysis: median, p-value, interquartile range, percentage

Participants Doctors Nurses Support staff

Interventions Lean conceptualization: NA

43

Lean tools: Rapid process improvement workshop, 5s Duration: 30 months

Outcomes patients visit, disposition time, triage time, provider time, provider productivity

Notes

Risk of bias table






Unclear risk





Ng 2010

Methods Study design: pre-post comparison Analysis: mean, median, confidence interval, p-value, percentages

Participants Emergency physicians Nurses Nurse practitioners porters, clerks, cleaning staff Administrators, Representatives from diagnostic imaging, laboratory, respiratory therapy, home care and information services

Interventions Lean conceptualization: Toyota Management Production System Lean tools: rapid process improvement workshop, value stream mapping Duration: 24 months

Outcomes wait time, length of stay, patient satisfaction

Notes

Risk of bias table



44




Unclear risk





O'Neill 2011


Participants Nurses

Interventions Lean conceptualization: Lean principles Lean tools: 5s, Value stream mapping Duration: NA

Outcomes Nurse shift time, medication round time

Notes

Risk of bias table






Unclear risk





Piggott 2011

Methods Study design: pre-post comparison Analysis: mean, p-value, percentages

Participants 170 ACS (acute coronary syndrome) patients in Lean group 229 ACS (acute coronary syndrome) controls

Interventions Lean conceptualization: Toyota management system

45

Lean tools: Rapid process improvement workshop, Lean basics workshop, Value stream mapping Duration: 22 months

Outcomes Time to triage, time to physician assessment

Notes

Risk of bias table






Unclear risk





Smith 2011


Participants Health care providers Physician Laboratory supervisor Respiratory therapist Nutritionist Nurse social worker Pharmacist Admin staff management team


Outcomes Duration of patient visit

Notes

Risk of bias table



46




Unclear risk





Smith 2012


Participants Nursing staff Nursing team leaders The billing coordinator Patient intake staff

Interventions Lean conceptualization: NA Lean tools: Rapid process improvement workshop, value stream mapping Duration: 28 months

Outcomes Scheduling time

Notes

Risk of bias table






Unclear risk





Smith 2012a

Methods Study design: pre-post comparison

47

Analysis: median

Participants Laboratory leadership Frontline staff

Interventions Lean conceptualization: NA Lean tools: Lean basics workshop Duration: 24 months

Outcomes Near miss event rate

Notes

Risk of bias table






Unclear risk





Ulhassan 2013


Participants Cardiologist Managers Nurses Lean coaches Physicians

Interventions Lean conceptualization: Other lean management system Theoretical background: Holden's theory Lean tools: Lean basics workshop, value stream mapping Duration: 36 months

Outcomes Length of stay, patient discharge rate

Notes

Risk of bias table

Bias Authors' Support for

48

judgement judgement




Unclear risk





Waldhausen 2011

Methods Study design: pre-post comparison Analysis: mean, percentage, median, p-value

Participants Physicians Nurses Hospital staffs and administrators Lean team

Interventions Lean conceptualization: Toyota Management Production System Lean tools: Rapid process improvement workshop, 5s, Lean Basic Workshop

Outcomes face to face provider time, problem scores, room time, number of patients,

Notes

Risk of bias table






Unclear risk





Yerian 2012

49

Methods study design: Pre- post comparison Analysis: mean, standard deviation, percentages

Participants 55 medical technologist, 12 laboratory or managers

Interventions Lean conceptualization: NA Lean tools: Rapid process improvement workshop, 5s Duration: NA

Outcomes number of steps saved

Notes

Risk of bias table






Unclear risk





Yousri 2011

Methods study design: Pre- post Analysis: mean, median, p-value

Participants Patients


Outcomes mortality rate, door to theatre time

Notes

Risk of bias table





50


Unclear risk





Footnotes

Characteristics of excluded studies

Allen 2009

Reason for exclusion

Biffl 2011


Brackett 2013


Burstrom 2012


Casey 2009


DelliFraine 2010


Esain 2008


Hassell 2010


Ieraci 2008


Kelly 2007


L'Hommedieu 2011

51


Mazzocato 2012


McClean 2008


Raab 2008


Raab 2008a


Raghavan 2010


Ryan 2013


Siddique 2012


van Lent 2009


van Vliet 2010


Van Vliet 2011


Vats 2011


Vats 2012


Vegting 2012


52

Footnotes

Characteristics of studies awaiting classification

Footnotes

Characteristics of ongoing studies

Footnotes

Summary of findings tables

Additional tables

References to studies

Included studies

Atkinson 2012

Atkinson P, Mukaetova-Ladinska E B. Nurse-led liaison mental health service for older adults: service development using lean thinking methodology. Journal of Psychosomatic Research 2012;72:328-31.

Barnas 2011

Barnas K. ThedaCare's business performance system: sustaining continuous daily improvement through hospital management in a lean environment. Joint Commission Journal on Quality & Patient Safety 2011;37:387-99.

Beard 2010

Beard J, Wood D. Application of Lean principles can reduce inpatient prescription dispensing times. Pharmaceutical Journal 2010;284:369-71.

Blackmore 2013

Applying lean methods to improve quality and safety in surgical sterile instrument processing. 39:99-105.

Cankovic 2009

Cankovic M, Varney R C, Whiteley L, Brown R, D'Angelo R, Chitale D, et al. The Henry Ford Production System: LEAN Process Redesign Improves Service in the Molecular Diagnostic Laboratory A Paper from the 2008 William Beaumont Hospital Symposium on Molecular Pathology. Journal of Molecular Diagnostics 2009;11:390-9.

Chiodo 2012

Chiodo A, Wilke R, Bakshi R, Craig A, Duwe D, Hurvitz E. Using Lean principles to manage throughput on an inpatient rehabilitation unit. American Journal of Physical Medicine & Rehabilitation 2012;91:977-83.

Cima 2011

Cima R R, Brown M J, Hebl J R, Moore R, Rogers J C, Kollengode A, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. Journal of the American College of Surgeons 2011;213:83-92.

53

Collar 2012

Collar R M, Shuman A G, Feiner S, McGonegal A K, Heidel N, Duck M, et al. Lean management in academic surgery. Journal of the American College of Surgeons 2012;214:928-36.

Fischman 2010

Fischman D. Applying Lean Six Sigma methodologies to improve efficiency, timeliness of care, and quality of care in an internal medicine residency clinic. Quality Management in Health Care 2010;19:201-10.

Ford 2012

Ford A L, Williams J A, Spencer M, McCammon C, Khoury N, Sampson T R, et al. Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis. Stroke 3395;43:3395-8.

Grove 2010

Grove A L, Meredith J O, Macintyre M, Angelis J, Neailey K. Lean implementation in primary care health visiting services in National Health Service UK. Quality & Safety in Health Care 2010;19.

Harmelink 2008

Harmelink S. Performance improvement using methodology: case study. Radiology Management 2008;30:62-5.

Hummer 2009

Hummer J, Daccarett C. Improvement in prescription renewal handling by application of the Lean process. Nursing Economics 2009;27:197-201.

King 2006

King D L, Ben-Tovim D I, Bassham J. Redesigning emergency department patient flows: application of Lean Thinking to health care. Emergency Medicine Australasia 2006;18:391-7.

McDermott 2013

McDermott A M, Kidd P, Gately M, Casey R, Burke H, O'Donnell P, et al. Restructuring of the Diabetes Day Centre: a pilot lean project in a tertiary referral centre in the West of Ireland. BMJ Quality & Safety 2013;22:681-8.

Melanson 2009

Melanson S E, Goonan E M, Lobo M M, Baum J M, Paredes J D, Santos K S, et al. Applying Lean/Toyota production system principles to improve phlebotomy patient satisfaction and workflow. American Journal of Clinical Pathology 2009;132:914-9.

Michael 2013

Michael C W, Naik K, McVicker M. Value stream mapping of the pap test processing procedure: a lean approach to improve quality and efficiency. American Journal of Clinical Pathology 2013;139:574-83.

Morrison 2011

54

Morrison A P, Tanasijevic M J, Torrence-Hill J N, Goonan E M, Gustafson M L, Melanson S E. A strategy for optimizing staffing to improve the timeliness of inpatient phlebotomy collections. Archives of Pathology & Laboratory Medicine 1576;135:1576-80.

Murrell 2011

Murrell K L, Offerman S R, Kauffman M B. Applying lean: implementation of a rapid triage and treatment system. The Western Journal of Emergency Medicine 2011;12:184-91.

Naik 2012

Naik T, Duroseau Y, Zehtabchi S, Rinnert S, Payne R, McKenzie M, et al. A structured approach to transforming a large public hospital emergency department via lean methodologies. Journal for Healthcare Quality 2012;34:86-97.

Ng 2010

Ng D, Vail G, Thomas S, Schmidt N. Applying the Lean principles of the Toyota Production System to reduce wait times in the emergency department. CJEM Canadian Journal of Emergency Medical Care 2010;12:50-7.

O'Neill 2011

O'Neill S, Jones T, Bennett D, Lewis M. Nursing works: the application of lean thinking to nursing processes. Journal of Nursing Administration 2011;41:546-52.

Piggott 2011

Piggott Z, Weldon E, Strome T, Chochinov A. Application of Lean principles to improve early cardiac care in the emergency department. CJEM Canadian Journal of Emergency Medical Care 2011;13:325-32.

Smith 2011

Smith C, Wood S, Beauvais B. Thinking lean: implementing DMAIC methods to improve efficiency within a cystic fibrosis clinic. Journal for Healthcare Quality 2011;33:37-46.

Smith 2012

Smith G, Poteat-Godwin A, Harrison L M, Randolph G D. Applying Lean principles and Kaizen rapid improvement events in public health practice. Journal of Public Health Management & Practice 2012;18:52-4.

Smith 2012a

Smith M L, Wilkerson T, Grzybicki D M, Raab S S. The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency. American Journal of Clinical Pathology 2012;138:367-73.

Ulhassan 2013

Ulhassan W, Sandahl C, Westerlund H, Henriksson P, Bennermo M, von Thiele Schwarz U, et al. Antecedents and characteristics of lean thinking implementation in a Swedish hospital: a case study. Quality Management in Health Care 2013;22:48-61.

Waldhausen 2011

55

Waldhausen J H, Avansino J R, Libby A, Sawin R S. Application of lean methods improves surgical clinic experience. Journal of Pediatric Surgery 1420;45:1420-5.

Yerian 2012

Yerian L M, Seestadt J A, Gomez E R, Marchant K K. A collaborative approach to lean laboratory workstation design reduces wasted technologist travel. American Journal of Clinical Pathology 2012;138:273-80.

Yousri 2011

Yousri T A, Khan Z, Chakrabarti D, Fernandes R, Wahab K. Lean thinking: can it improve the outcome of fracture neck of femur patients in a district general hospital? Injury 1234;42:1234-7.

Excluded studies

Allen 2009

Allen M, Wigglesworth M J. Innovation leading the way: application of lean manufacturing to sample management. Journal of Biomolecular Screening 2009;14:515-22.

Biffl 2011

Biffl W L, Beno M, Goodman P, Bahia A, Sabel A, Snow K, et al. "Leaning" the process of venous thromboembolism prophylaxis. Joint Commission Journal on Quality & Patient Safety 2011;37:99-109.

Brackett 2013

Brackett T, Comer L, Whichello R. Do lean practices lead to more time at the bedside? Journal for Healthcare Quality 2013;35:7-14.

Burstrom 2012

Burstrom L, Nordberg M, Ornung G, Castren M, Wiklund T, Engstrom M L, et al. Physician-led team triage based on lean principles may be superior for efficiency and quality? A comparison of three emergency departments with different triage models. Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine 2012;20.

Casey 2009

Casey J T, Brinton T S, Gonzalez C M. Utilization of lean management principles in the ambulatory clinic setting. [Review] [35 refs]. Nature Clinical Practice Urology 2009;6:146-53.

DelliFraine 2010

DelliFraine J L, Langabeer J R 2nd, Nembhard I M. Assessing the evidence of Six Sigma and Lean in the health care industry. Quality Management in Health Care 2010;19:211-25.

Esain 2008

Esain A, Williams S, Massey L. Combining planned and emergent change in a healthcare Lean transformation. Public Money & Management 2008;28:21-6.

Hassell 2010

56

Hassell L A, Glass C F, Yip C, Eneff P A. The combined positive impact of Lean methodology and Ventana Symphony autostainer on histology lab workflow. BMC Clinical Pathology 2010;10.

Ieraci 2008

Ieraci S, Digiusto E, Sonntag P, Dann L, Fox D. Streaming by case complexity: evaluation of a model for emergency department Fast Track. Emergency Medicine Australasia 2008;20:241-9.

Kelly 2007

Kelly A M, Bryant M, Cox L, Jolley D. Improving emergency department efficiency by patient streaming to outcomes-based teams. Australian Health Review 2007;31:16-21.

L'Hommedieu 2011

L'Hommedieu T, Kappeler K. Lean methodology in i.v. medication processes in a children's hospital.[Erratum appears in Am J Health Syst Pharm. 2011 Jan 15;68(2):100]. American Journal of Health System Pharmacy 2115;67:2115-8.

Mazzocato 2012

Mazzocato P, Holden R J, Brommels M, Aronsson H, Backman U, Elg M, et al. How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden. BMC Health Services Research 2012;12.

McClean 2008

McClean S, Young T, Bustard D, Millard P, Barton M. Discovery of Value Streams for Lean Healthcare. 2008 4Th International Ieee Conference Intelligent Systems, Vols 1 and 2 2008;127-33.

Raab 2008

Raab S S, Andrew-Jaja C, Grzybicki D M, Vrbin C M, Chesin C M, Fisch J M, et al. Dissemination of Lean methods to improve Pap testing quality and patient safety. Journal of Lower Genital Tract Disease 2008;12:103-10.

Raab 2008a

Raab, S. S., Grzybicki, D. M., Condel, J. L., et al. Effect of Lean method implementation in the histopathology section of an anatomical pathology laboratory.

Raghavan 2010

Raghavan V A, Venkatadri V, Kesavakumaran V, Wang S Y, Khasawneh M, Srihari K. Reengineering the Cardiac Catheterization Lab Processes: A Lean Approach. Journal of Healthcare Engineering 2010;1:45-65.

Ryan 2013

Ryan A, Hunter K, Cunningham K, Williams J, O'Shea H, Rooney P, et al. STEPS: lean thinking, theory of constraints and identifying bottlenecks in an emergency department. Irish Medical Journal 2013;106:105-7.

Siddique 2012

57

Siddique K, Elsayed S E, Cheema R, Mirza S, Basu S. One-stop cholecystectomy clinic: an application of lean thinking--can it improve the outcomes? Journal of Perioperative Practice 2012;22:360-5.

van Lent 2009

van Lent W A, Goedbloed N, van Harten W H. Improving the efficiency of a chemotherapy day unit: applying a business approach to oncology. European Journal of Cancer 2009;45:800-6.

van Vliet 2010

van Vliet E J, Sermeus W, van Gaalen C M, Sol J C, Vissers J M. Efficacy and efficiency of a lean cataract pathway: a comparative study. Quality & Safety in Health Care 2010;19.

Van Vliet 2011

Van Vliet E J, Bredenhoff E, Sermeus W, Kop L M, Sol J C, Van Harten W H. Exploring the relation between process design and efficiency in high-volume cataract pathways from a lean thinking perspective. International Journal for Quality in Health Care 2011;23:83-93.

Vats 2011

Vats A, Goin K H, Fortenberry J D. Lean analysis of a pediatric intensive care unit physician group rounding process to identify inefficiencies and opportunities for improvement. Pediatric Critical Care Medicine 2011;12:415-21.

Vats 2012

Vats A, Goin K H, Villarreal M C, Yilmaz T, Fortenberry J D, Keskinocak P. The impact of a lean rounding process in a pediatric intensive care unit. Critical Care Medicine 2012;40:608-17.

Vegting 2012

Vegting I L, van Beneden M, Kramer M H, Thijs A, Kostense P J, Nanayakkara P W. How to save costs by reducing unnecessary testing: lean thinking in clinical practice. European Journal of Internal Medicine 2012;23:70-5.

Studies awaiting classification

Ongoing studies

Other references

Additional references

Atkinson 2012

Atkinson P, Mukaetova-Ladinska E B. Nurse-led liaison mental health service for older adults: service development using lean thinking methodology. Journal of Psychosomatic Research 2012;72:328-31.

Barnas 2011

Barnas K. ThedaCare's business performance system: sustaining continuous daily improvement through hospital management in a lean environment. Joint Commission Journal on Quality & Patient Safety 2011;37:387-99.

58

Belter 2012

Belter D, Halsey J, Severtson H, Fix A, Michelfelder L, Michalak K, et al. Evaluation of outpatient oncology services using lean methodology. Oncology Nursing Forum 2012;39:136-40.

Belter 2012a

Belter D, Halsey J, Severtson H, Fix A, Michelfelder L, Michalak K, et al. Evaluation of outpatient oncology services using lean methodology. Oncology Nursing Forum 2012;39:136-40.

Black 2008

Black John R, Miller David. The Toyota way to healthcare excellence: increase efficiency and improve quality with LEAN. Health Administration Press, 2008.

Black 2009

Black J. Transforming the patient care environment with Lean Six Sigma and realistic evaluation. J Healthc Qual 2009;31:29-35.

Brackett 2013

Brackett T, Comer L, Whichello R. Do lean practices lead to more time at the bedside? Journal for Healthcare Quality 2013;35:7-14.

Brennan 2009

Brennan S McKenzie Joanne E Whitty P Buchan H Green S. Continuous quality improvement: effects on professional practice and healthcare outcomes. 2009;In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2009.

Burgess 2013

Burgess N, Radnor Z. Evaluating Lean in healthcare. Int J Health Care Qual Assur 2013;26:220-35.

Campbell 2009

Campbell R J. Thinking lean in healthcare. J AHIMA 2009;80:40-3; quiz 45-6.

Casey 2009

Casey J T, Brinton T S, Gonzalez C M. Utilization of lean management principles in the ambulatory clinic setting. [Review] [35 refs]. Nature Clinical Practice Urology 2009;6:146-53.

Cowley 1997

Cowley M, E Domb. Beyond Strategic Vision: Effective Corporate Action with Hoshin Planning. 1997;New York.

De Souza 2009

De Souza Luciano Brandao. Trends and approaches in lean healthcare. Leadership in Health Services 2009;22:121-39.

Esain 2008

Esain A, Williams S, Massey L. Combining planned and emergent change in a healthcare Lean transformation. Public Money & Management 2008;28:21-6.

59

Fine 2009

Fine B A, Golden B, Hannam R, Morra D. Leading Lean: a Canadian healthcare leader's guide. Healthc Q 2009;12:32-41.

Ford 2012

Ford A L, Williams J A, Spencer M, McCammon C, Khoury N, Sampson T R, et al. Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis. Stroke 2012;43:3395-8.

Higgins 2008

Higgins JP, Deeks JJ. 2008.

Hummer 2009

Hummer J, Daccarett C. Improvement in prescription renewal handling by application of the Lean process. Nursing Economics 2009;27:197-201.

JBA 2014

JBA. John Black and Associates LLC. 25 Glossary. 2014;http://blog.hqc.sk.ca/wp-content/uploads/2013/2009/JBA-Lean-Glossary.pdf (Accessed Jan 23, 2014).

Mazzocato 2012

Mazzocato P, Holden R J, Brommels M, Aronsson H, Backman U, Elg M, et al. How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden. BMC Health Services Research 2012;12.

McDermott 2013

McDermott A M, Kidd P, Gately M, Casey R, Burke H, O'Donnell P, et al. Restructuring of the Diabetes Day Centre: a pilot lean project in a tertiary referral centre in the West of Ireland. BMJ Quality & Safety 2013;22:681-8.

Naik 2012

Naik T, Duroseau Y, Zehtabchi S, Rinnert S, Payne R, McKenzie M, et al. A structured approach to transforming a large public hospital emergency department via lean methodologies. Journal for Healthcare Quality 2012;34:86-97.

Selecting studies and collecting data

Selecting studies and collecting data. 151-85.

Smith 2006

Smith Peter C, Mossialos Elias, IrenePapanicolas. Performance measurement for health system improvement: experiences, challenges and prospects. 2006;Available from http://www.euro.who.int/__data/assets/pdf_file/0003/84360/E93697.pdf (accessed May 5, 2014).

Smith 2012

60

Smith G, Poteat-Godwin A, Harrison L M, Randolph G D. Applying Lean principles and Kaizen rapid improvement events in public health practice. Journal of Public Health Management & Practice 2012;18:52-4.

Ulhassan 2013

Ulhassan W, Sandahl C, Westerlund H, Henriksson P, Bennermo M, von Thiele Schwarz U, et al. Antecedents and characteristics of lean thinking implementation in a Swedish hospital: a case study. Quality Management in Health Care 2013;22:48-61.

Van Vliet 2011

Van Vliet E J, Bredenhoff E, Sermeus W, Kop L M, Sol J C, Van Harten W H. Exploring the relation between process design and efficiency in high-volume cataract pathways from a lean thinking perspective. International Journal for Quality in Health Care 2011;23:83-93.

Vegting 2012

Vegting I L, van Beneden M, Kramer M H, Thijs A, Kostense P J, Nanayakkara P W. How to save costs by reducing unnecessary testing: lean thinking in clinical practice. European Journal of Internal Medicine 2012;23:70-5.

Wagner 2002

Wagner AK, Soumerai SB, Zhang F, Ross‐Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. Journal of clinical pharmacy and therapeutics 2002;27:299-309.

Wagner 2002a

Wagner AK, Soumerai SB, Zhang F, Ross‐Degnan D. Segmented regression analysis of interrupted time series studies in medication use research. Journal of clinical pharmacy and therapeutics 2002;27:299-309.

Wood 2012

Wood D. Taking the pulse of lean healthcare. Healthcare quarterly (Toronto, Ont) 2012;15:27-33.

Other published versions of this review

Classification pending references

Data and analyses

Figures

Figure 1. Flow chart for number of hits (n=30)

61

Sources of support

Internal sources

No sources of support provided

External sources

No sources of support provided

62

Appendices

1 MEDLINE search strategy

A number of searches were conducted for this project.

Strategy A

In April 2013, the author team screened results of a sensitive search strategy written for a Cochrane systematic review: Brennan S, McKenzie JE, Whitty P, Buchan H, Green S, Bosch M. Continuous quality improvement: effects on professional practice and healthcare outcomes in primary care. Cochrane Database of Systematic Reviews 2009 , Issue 4 . Art. No.: CD003319. DOI: 10.1002/14651858.CD003319.pub2. Searches were run in Medline, EMBASE, CINAHL, and The Cochrane Library.

Strategy B: May 27, 2013

Conducted a focused Medline keyword search in title and abstract which retrieved 338 citations. The authors selected 194 of these citations as relevant; and 8 as potentially relevant.

Strategy C: July 2013

Conducted a title keyword search based on analysis of 194 relevant citations identified by May 2013 search. Databases: Medline, Embase, HealthStar, Web of Science (Science, Social Sciences, and Arts & Humanites Citations Indexes; and Conference Proceedings), HTA and EED sections of the Cochrane Library, EconLit, PAIS International, Proquest Dissertations & Theses, Proquest Political Science, and Canadian Research Index.

Strategy A:

Medline search strategy for CQI Cochrane Review. The strategy was translated for other databases.

1. continuous quality improvement.ti,ab.

2. process improvement.ti,ab.

3. or/1-2 [CQI Set 1]

4. *Total quality management/ [This MeSH included CQI]

5. (quality adj3 (COLLABORATIVE? or circle? or team? or group?)).ti.

6. (TQM or CQI).ti,ab.

7. (quality adj2 improv$).ti. or (quality adj improv$).ab.

8. ("model for improv$" or "model to improve").ti,ab.

9. (collaborative adj2 improvement?).ti,ab.

10. (quality adj2 (COLLABORATIVE? or circle? or team? or group?)).ti,ab.

11. (breakthrough adj2 (series or collaborative or project?)).ti,ab.

12. total quality.ti,ab.

13. continuous quality.ti,ab.

63

14. continuous improvement.ti,ab.

15. quality management.ti,ab.

16. (PDSA or PDCA or TQIS or "plan do study" or "plan do check").ti,ab.

17. ((shewhart or shewart or deming) adj3 (cycle or method$)).ti,ab.

18. (rapid cycle or six sigma).ti,ab.

19. (breakthrough adj3 (series or project or collaborative?)).ti,ab.

20. (lean adj (approach or care or enterpri?e or management or method? or methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).ab. or (lean and (approach or care or enterpri?e or management or method? or methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).ti.

21. toyota.ti,ab. not automobiles/

22. ("concept map$" or "process map$" or "value stream map$" or "fault tree analysis" or "failure mode and effects analysis").ti,ab.

23. (Primary Health Care/ or General Practice/ or Family Practice/) and Quality Assurance, Health Care/ and (Quality Assurance, Health Care/ or quality.ti.)

24. or/4-23 [CQI Set 2]

25. Total quality management/

26. (improve? or improvement? or improving).ti.

27. (initiative? or outcome or outcomes or patient? or practice or primary care or service or services or system or systems).ti.

28. (implement$ or intervention$ or model?).ti.

29. ((primary adj2 care) or (community or outcome or outcomes or collaborat$ or team or teams)).ti,hw. or (practice or practices).ti. or practice.hw.

30. (structure? or structural or organi?ational$).ti.

31. care project?.ti.

32. (delivery and (service or services)).ti.

33. ((primary care or primary health care or primary healthcare) and improv$ and (care or management)).ti.

34. (primary care and (improve or improving) and (practice or practices)).ti.

35. (service? and implement$).ti.

36. (quality assurance adj4 (practice or practices or scheme or project? or implement$ or intervention$ or care or outcome or practitioner? or physician? or program? or programme or programmes or service or services)).ab.

64

37. (quality assurance and (practice or practices or scheme or project? or implement$ or intervention$ or care or outcome or practitioner? or physician? or program? or programme or programmes or service or services)).ti.

38. (practice and (care or provider?) and (intervention$ or improv$ or project)).ti.

39. (practice and service).ti.

40. individual$ practice.ti.

41. ((practice or practices) and (care or provider? or physician? or doctor? or nurse or nurses) and (intervention$ or improv$ or implement$ or project? or program? or programme or programmes)).ti.

42. ((practice or practices) and (collaborat$ or interdisciplin$ or teambased or team? or mutlidisciplin$ or multi-disciplin$ or crossdisciplin$ or cross-disciplin$)).ti.

43. (25 and (or/26-30)) or (or/31,33-40) [CQI set 3]

44. (quality of health care or quality of care or quality of healthcare).ti,ab.

45. (intervention or implementation).ti.

46. 44 and 45 [CQI Set 4]

47. (improv$ and care).ti.

48. og.fs. [org & administration subheading]

49. 47 and 48 [CQI Set 5]

50. (randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti.

51. exp animals/ not humans.sh.

52. 50 not 51 [Cochrane RCT Filter 6.4.d Sens/Precision Maximizing]

53. intervention?.ti. or (intervention? adj6 (clinician? or collaborat$ or community or complex or DESIGN$ or doctor? or educational or family doctor? or family physician? or family practitioner? or financial or GP or general practice? or hospital? or impact? or improv$ or individuali?e? or individuali?ing or interdisciplin$ or multicomponent or multi-component or multidisciplin$ or multi-disciplin$ or multifacet$ or multi-facet$ or multimodal$ or multi-modal$ or personali?e? or personali?ing or pharmacies or pharmacist? or pharmacy or physician? or practitioner? or prescrib$ or prescription? or primary care or professional$ or provider? or regulatory or regulatory or tailor$ or target$ or team$ or usual care)).ab.

54. (pre-intervention? or preintervention? or "pre intervention?" or post-intervention? or postintervention? or "post intervention?").ti,ab. [added 2.4]

55. (hospital$ or patient?).hw. and (study or studies or care or health$ or practitioner? or provider? or physician? or nurse? or nursing or doctor?).ti,hw.

56. demonstration project?.ti,ab.

57. (pre-post or "pre test$" or pretest$ or posttest$ or "post test$" or (pre adj5 post)).ti,ab.

65

58. (pre-workshop or post-workshop or (before adj3 workshop) or (after adj3 workshop)).ti,ab.

59. trial.ti. or ((study adj3 aim?) or "our study").ab.

60. (before adj10 (after or during)).ti,ab.

61. ("quasi-experiment$" or quasiexperiment$ or "quasi random$" or quasirandom$ or "quasi control$" or quasicontrol$ or ((quasi$ or experimental) adj3 (method$ or study or trial or design$))).ti,ab,hw.

62. ("time series" adj2 interrupt$).ti,ab,hw.

63. (time points adj3 (over or multiple or three or four or five or six or seven or eight or nine or ten or eleven or twelve or month$ or hour? or day? or "more than")).ab.

64. pilot.ti.

65. Pilot projects/

66. (clinical trial or controlled clinical trial or multicenter study).pt.

67. (multicentre or multicenter or multi-centre or multi-center).ti.

68. random$.ti,ab. or controlled.ti.

69. (control adj3 (area or cohort? or compare? or condition or design or group? or intervention? or participant? or study)).ab. not (controlled clinical trial or randomized controlled trial).pt.

70. evaluation studies as topic/ or prospective studies/ or retrospective studies/ [Added Jan 2013]

71. (utili?ation or programme or programmes).ti. [Added Jan 2013]

72. (during adj5 period).ti,ab. [Added Jan 2013]

73. ((strategy or strategies) adj2 (improv$ or education$)).ti,ab. [Added Jan 2013]

74. "comment on".cm. or review.pt. or (review not "peer review$").ti. or randomized controlled trial.pt. [Changed Jan 2013]

75. (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti.

76. exp animals/ not humans.sh.

77. (or/53-73) not (or/74-76) [EPOC Methods Filter 2.5-added Evaluation Studies line forward--Jan 2013 Medline]

78. ("research support american recovery and reinvestment act" or research support nih extramural or research support nih intramural or research support non us govt or research support us govt non phs or research support us govt phs).pt.

79. (service or services or community or care or intervention or implement$).ti. and (quality.ti,hw. not (*"quality of life"/ or "quality of life".ti.))

66

80. (bundle? or champion$ or (continuing adj2 education$) or educational or feedback or organi?ation$ or program? or programme or programmes or structured or target$ or training).ti.

81. or/79-80 [Intervention related keywords to focus results]

82. "quality of life".ti. or *Quality of Life/

83. ((or/24,43) not 82) and 52 [RCT: CQI Sets 2 or 3 AND RCT Filter]

84. (and/24,77,81) not (or/82-83) [EPOC-1: CQI Set 2 & EPOC Filter & Intervention Terms]

85. (and/46,78) not (or/82-84) [EPOC-2: CQI Set 4 & Research Support PubType]

86. (49 and (or/43,77-78)) not (or/82-85) [EPOC-3: CQI Set 5 improve care og-fs & (CQI Set 3 or EPOC Filter or Research PT)]

87. (and/43,77,81) not (or/82-86) [EPOC-4: CQI Set 3 & EPOC Filter & Intervention Terms]

88. 3 not (or/75-76) not (or/82-87) [KW: CQI Set 1--keyword results]

2 Strategy B

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1946 to Present>

(lean adj (approach or care or enterpri?e or management or method? or methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).ab. or (lean and (approach or care or enterpri?e or management or method? or methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).ti. (338)

Strategy C: July 2013

Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1946 to Present>

1 a list of PMIDs for studies already selected and screened by author team. Run here so that they could be excluded prior to exporting results (194 citations)

2 (lean and (approach or care or enterpri?e or management or method? or methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).ti. (285)

3 (lean and (process improvement? or performance improvement? or (quality adj2 (care or improv$ or manag$ or outcome? or continuous)) or practice based)).ti. (20)

4 (lean adj2 (approach or care or enterpri?e or management or method? or methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).ab. (400)

5 (lean adj2 (process improvement? or performance improvement? or (quality adj2 (care or improv$ or manag$ or outcome? or continuous)) or practice based)).ab. (27)

67

6 (rapid cycle adj3 (approach or approaches or change or collaborat$ or cross-disciplin$ or decision? or healthcare or "health care" or hospital? or impact or initiative? or innovat$ or interprofessional$ or interdisiciplin$ or inter-disciplin$ or management or method$ or optimal$ or organi?ation$ or program? or programme or programmes or process improvement? or project? or quality improvement? or team? or team-based)).ti,ab. (86)

7 or/2-6 [Set 1] (689)

8 exp animals/ not humans.sh. (4002693)

9 (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti. (1352098)

10 7 not (or/1,8-9 [Set 1] (380)

11 remove duplicates from 25 (352)

Embase <1974 to 2013 Week 29> OVID



3 (rat or rats or cow or cows or chicken? or horse or horses or mice or mouse or bovine or animal?).ti. (1523784)

4 (mass or tissue or adipose or cellular or genet$ or genom$).ti,ab,hw. (5554148)

5 1 not or/2-4 (109) EMBASE

Ovid Healthstar <1999 to June 2013>

Search Strategy:



3 (rat or rats or cow or cows or chicken? Or horse or horses or mice or mouse or bovine or animal?).ti. (28592)

4 (mass or tissue or adipose or cellular or genet$ or genom$).ti,ab,hw. (808756)

5 1 not or/2-4

EBM Reviews - Health Technology Assessment and EBM Reviews - NHS Economic Evaluation Database = 0

(lean adj3 (approach or care or enterpri?e or management or method? or methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).mp. or (lean and (approach or care or enterpri?e or management or method? or

68

methodology or model? or oncology or philosophy or practice or practices or principles or program$ or thinking)).ti.

Web of Science

Databases=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years

Search 1: Title=("rapid cycle" or "plan do study" or "plan do check" or (shewhart near/3 cycle) or (shewhart* near/3 method*) or (deming near/2 management) or (deming near/2 philosoph*) or (deming near/2 principle*) or (deming near/3 method*) or "breakthrough series" or "breakthrough collaborative*" or "breakthrough project") AND Topic=("health care" or "primary care" or healthcare or hospital or hospitals) AND Document Types=( ARTICLE OR MEETING ABSTRACT OR PROCEEDINGS PAPER )= 16

Search 2: Title=("rapid cycle" or "plan do study" or "plan do check" or (shewhart near/3 cycle) or (shewhart* near/3 method*) or (deming near/2 management) or (deming near/2 philosoph*) or (deming near/2 principle*) or (deming near/3 method*) or "breakthrough series" or "breakthrough collaborative*" or "breakthrough project") AND Topic=("health care" or "primary care" or healthcare or hospital or hospitals) AND Databases=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years = 19

Search 3: Title=("rapid cycle" or "plan do study" or "plan do check" or (shewhart near/3 cycle) or (shewhart* near/3 method*) or (deming near/2 management) or (deming near/2 philosoph*) or (deming near/2 principle*) or (deming near/3 method*) or "breakthrough series" or "breakthrough collaborative*" or "breakthrough project") AND Title=("health care" or "primary care" or healthcare or hospital or hospitals) = 4

Databases=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=All years

Search 4: TI=(lean) AND TI=(management OR system OR systems OR approach OR method* OR principle* OR model* OR thinking) AND TS=("health care" or "primary care" or healthcare or hospital or hospitals) = 59

Search 5: Title=(lean) AND Title=(management OR system OR systems OR approach OR method* OR principle* OR model* OR thinking) AND Title=("health care" or "primary care" or healthcare or hospital or hospitals) AND Document Types=(ARTICLE OR MEETING ABSTRACT OR PROCEEDINGS PAPER ) = 16

ProQUest Platform; multiple databases searched using the following strategy:

("lean system*" or "lean approach" or "lean management" or "lean method*" or "lean practice" or "lean principle*" or "lean model*" or "lean practices" or "lean thinking" or "concept map*" or "process map*" or "value stream map*" or "fault tree analysis" or "failure mode and effects analysis" or "rapid cycle" or "plan do study" or "plan do check" or (shewhart near/3 cycle) or (shewhart* near/3 method*) or (deming near/2 management) or (deming near/2 philosoph*) or (deming near/2 principle*) or (deming near/3 method*) or "breakthrough series" or "breakthrough collaborative*" or "breakthrough project" ) AND (“health care” or healthcare or medicine or medical or disease management or “hospital” or “hospitals” or “primary care” or managed care or medicaid or medicare)

69

Dissertations & Theses (searched in ti/ab) = 120

PAIS International = 30

ProQuest Political science collection = 6

Canadian Research Index = 1 potentially relevant of 10 (M. Fiander screened)

Grey Literature

Rewarding Provider Performance: Aligning Incentives in Medicare (Pathways to Quality health Care Series, 2007. The Nation Academy of Science Press. Report available online: http://www.nap.edu/catalog.php?record_id=11723

Suggested authors browse:

AHRQ Innovations Exchange. Articles & Guides: http://innovations.ahrq.gov/articles.aspx May be worth browsing if you have not done so. http://innovations.ahrq.gov/innovations_qualitytools.aspx ASQ Web site: http://asq.org/healthcaresixsigma/articles/ssfhc-form.html

3 Pre and Post Lean continuous outcomes

Apeendix3a: Continuous primary study results (pre-intervention) baseline measures

Study ID Outcome measure N- mean pre- lean

E- Mean pre- lean

E- Median pre-lean

SD- pre-lean

IQR- Pre-lean

% Pre-lean

95% CI- pre-lean

Setting: Laboratory

Cankovic 2009

Turn around time (days) NA 2.7 NA NA NA NA NA

Cankovic 2009


NA 50 NA NA NA NA NA

Melanson 2009

Wait time (min) NA 21 NA 3 NA NA NA

Melanson 2009

Patient satisfaction (%) NA NA NA NA NA 56 NA

Michael 2013

Total processing time (days) 1140 2 NA NA NA NA NA

Michael 2013

Number of errors (%) 384 29 NA NA NA NA NA

Michael 2013


20060 29 NA NA NA NA NA

Michael 2013

Number of labelling errors missed (%)

20060 5 NA NA NA NA NA

http://www.nap.edu/catalog.php?record_id=11723

http://innovations.ahrq.gov/articles.aspx

http://innovations.ahrq.gov/innovations_qualitytools.aspx

http://asq.org/healthcaresixsigma/articles/ssfhc-form.html

70

Morrison 2011

Collection time (min) NA 7:42 NA NA 6:27–8:48

NA NA

Morrison 2011

Number of safety reports NA 10.6 NA NA NA NA NA

Smith 2012a Process dependent near miss event rate

421 5.5 NA NA NA NA NA

Smith 2012a Operator dependent near-miss event rate


Smith 2012a Total near miss event rate 421 6.1 NA NA NA NA NA

Yerian 2012 Number of steps saved 664 9.4 NA 3.7 NA 38 NA

Setting: Emergency department

King 2006 Number of patients who waited 8 hrs. before seen by the physician

49075 NA NA NA NA 21 NA

King 2006

Number of cases seen within 4 hrs. or less


King 2006 Total time spent in ED (hr) 49075 5.8 NA 9.2 NA NA NA

King 2006

Time spent in ED if discharged

49075 3.7 NA 2.6 NA NA NA

King 2006

Number of patients not waiting after triage

49075 NA NA NA NA 5.5 NA

King 2006 No of deaths in ED 49075 NA NA NA NA 0.1 NA

Murrell 2011 Length of stay (hr) 30981 4.2 NA 3.9 NA 4.2-4.3

Murrell 2011 Leaving the ED without been seen by the doctor (LWBS)

30981 NA NA NA NA 4.5 3.1-5.5

Murrell 2011 ED arrival to physician start time (min)

30981 62.2 NA 58.59 NA NA 61.5-63.0

Murrell 2011 Proportion of patients arriving by ambulance (%)

30981 NA NA NA NA 12.8 12.3-13.3

Murrell 2011 Hospital admission rate (%) 30981 NA NA NA NA 12.9 12.7-13.1

Naik 2012 Number of patient visit per month

10866.5 NA NA NA NA NA NA

Naik 2012 Disposition time (hr) 10866.5 4.6 NA NA 4.5-4.9

NA NA

71

Naik 2012 Time to triage (hr) 10866.5 NA 0.6 NA 0.5-0.7

NA NA

Naik 2012 Login to Provider time (hr) 10866.5 NA NA NA 1.5-2.1

NA NA

Ng 2010 Length of stay (days) NA 3.3 NA NA NA NA NA

Ng 2010 Wait time (min) NA 111 NA NA NA NA NA

Ng 2010 Patient satisfaction (%) NA NA NA NA NA 79.8 NA

Piggott 2011 proportion of cases with 12-Lead ECGs completed within 10 mins of patient triage


Piggott 2011 Proportion of cases with physician assessment within 60 mins


Ulhassan 2013

Discharge rate (%) NA NA NA NA NA 74 NA

Ulhassan 2013

Length of stay (min) NA 155 NA NA NA NA NA

Setting: Out-patient

Fischman 2010

Wait time between start of triage and physician encounter (min)

47 NA 18 NA NA NA NA

Fischman 2010

Wait time between end of triage and physician encounter (min)


Fischman 2010

Time spent with physician (min)


Grove 2010 Number of steps 67 NA NA NA NA NA NA

McDermott 2013


NA 118 NA 38.02 NA 0.001 NA

McDermott 2013

Time to see a physician (min)

NA 61.26 NA 33.08 NA 0.005 NA

McDermott 2013


NA 26.22 NA 10.97 NA 0.006 NA

McDermott 2013


NA 12.82 NA 6.86 NA 0.481 NA

Smith 2011 proportion of patient visit completed within < 60mins

NA NA NA NA NA 19.3 NA

72

Smith 2011 Length of patient visit time (min)

171 84 81 NA NA NA NA

Waldhausen 2011

Provider patient time (%) NA NA NA NA NA 30 NA

Waldhausen 2011

NRC Picker Problem Scores (%)


Waldhausen 2011

Exam room time (min) NA NA 49 NA NA NA NA

Waldhausen 2011


10 NA NA NA NA NA NA

Setting: In-patient

Chiodo 2012 Discharge time (PM) NA 3:00 NA NA NA NA NA

Chiodo 2012 Admission time (PM) NA 5:00 NA NA NA NA NA

Ford 2012 Door to needle time (min) 219 NA 60 NA 46-73 NA NA

Ford 2012 Percentage of patient with DNT < 60min


Ford 2012 Onset to needle time (min) 219 NA 131 NA 105-165

NA NA

Ford 2012 Door to CT time (min) 219 NA 16 NA (10 - 22)

NA NA


219 NA 22 NA 16 - 29

NA NA

Ford 2012

Door to partial thromboplastin time (min)

219 NA 34 NA 29 - 42

NA NA

Ford 2012 Symptomatic ICH (%) 219 NA NA NA NA 3 NA

Ford 2012

Favorable discharge location


Ford 2012

90-day modified ranking score of 0 to 2 on telephone follow up (%)


Ford 2012 Length of stay (days) 219 NA 4 NA (3-7) NA NA

Ford 2012 Stroke mimic (%) 219 NA NA NA NA 6.8 NA

O'Neill 2011


NA 2.8 NA NA NA NA NA

O'Neill 2011



73

O'Neill 2011

Medication round time (min)


Yousri 2011 Overall mortality rate (%) 608 NA NA NA NA 20.7 NA

Yousri 2011 30-day mortality rate (%) 608 NA NA NA NA 11.7 NA

Yousri 2011 Admission rate (%) 608 NA NA NA NA 79.6 NA

Yousri 2011 Length of stay (days) 608 NA 14 NA NA NA NA

Yousri 2011

Door to theatre time within 24 hr


Yousri 2011

Number of patients delayed by more than 48hr


Setting: Operating Room

Blackmore 2013

Sterilization error rate (%) 4090 NA NA NA NA 3 NA

Cima 2011



Cima 2011



Cima 2011



Cima 2011



Cima 2011



Cima 2011

Operations past 5pm in general/colorectal surgery


Cima 2011



Cima 2011



Cima 2011



Cima 2011



Cima 2011 Average staff overtime for 1740 NA NA NA NA 106 NA

74

gynaecologic surgery (min/specialty/mo)

Cima 2011



Cima 2011

Operating rooms saved/d/specialty for thoracic surgery


Cima 2011



Cima 2011

Operating rooms saved/d/specialty for general/Colorectal surgery


Cima 2011



Cima 2011



Cima 2011



Collar 2012 OR turn around time (min) 55 89.5 NA NA NA NA NA

Collar 2012 OR turn over time (min) 55 38.4 NA NA NA NA NA

Collar 2012 Educational survey score 55 156 NA NA NA NA NA

Setting: Pharmacy

Beard 2010 Dispensing time (min) NA NA 188 7 NA NA NA

Hummer 2009

Number of unfilled request 74 NA NA NA NA NA NA

Setting: Radiology

Harmelink 2008



Harmelink 2008

Employee satisfaction scores


Harmelink 2008

Patient satisfaction on radiology staff for comfort


75

scores (%)

Harmelink 2008

Radiology care providers collaboration scores (%)


Harmelink 2008



Harmelink 2008



Harmelink 2008



Setting: Home care

Smith 2012 Scheduling time (min) NA 60 NA NA NA NA NA

Setting: In-patient and Dubes

Atkinson 2012

Number of patients referred

7 10 NA NA NA NA NA

Atkinson 2012


NA 5 NA NA NA NA NA

Atkinson 2012

Readmission rates (%) NA NA NA NA NA 35 NA

Atkinson 2012

length of stay (days) NA 15.5 NA NA NA NA NA

Atkinson 2012

Out of hospital rates (%) NA NA NA NA NA 46 NA

Setting: In-patient, Out-patient and Emergency department

Barnas 2011



Barnas 2011

Improvement in performance measures in AMC in-patient cardiac

NA NA NA NA NA NA NA

Barnas 2011

Improvement in performance measures in TCMC neuro/surgical


Barnas 2011

Improvement in performance measures in radiation oncology


Barnas 2011

Improvement in performance measures in AMC (medical/surgical)


76

Barnas 2011

Improvement in first-call bed access for AMC in-patient cardiac


Barnas 2011

Improvement in falls for TCMC (neuro/surgical)


Barnas 2011

Improvement of 14 safety/quality drivers


Barnas 2011

Improvement in people engagement drivers


Barnas 2011

Improvement in 23 of the financial stewardship drivers


Barnas 2011



Barnas 2011

Improvement in customer satisfaction drivers


Legend: N = sample size; E = estimated; SD = standard deviation; IQR = inter quartile range; % = percentage; CI = confidence interval

Appendix3b: Continuous primary study results post-intervention measures

Study ID Outcome measure

N- mean post-lean

E- Mean post-lean

E- Median Post-lean

SD- pre-lean

IQR- Post-lean

% Post-lean

95% CI- post-lean

P- value post-lean

Direction of effect

Setting: Laboratory

Cankovic 2009

Turn around time (days)

NA 1.5 NA NA NA NA NA NA +

Cankovic 2009


NA 85 NA NA NA NA NA NA +

Melanson 2009

Wait time (min) 500 11 NA 5 NA NA NA NA +

Melanson 2009

Patient satisfaction (%)

500 NA NA NA NA 86 NA NA +

Michael 2013

Total processing time (days)

1355 1 NA NA NA NA NA NA +

Michael Number of errors 391 23 NA NA NA NA NA NA +

77

2013 (%)

Michael 2013


20000

30 NA NA NA NA NA NA -

Michael 2013

Number of labelling errors missed (%)

20000

0 NA NA NA NA NA NA +

Morrison 2011

Collection time (min)

NA NA 7:25 6:20–8:26

NA NA NA +

Morrison 2011

Number of safety reports


Smith 2012a

Process dependent near miss event rate

266 1.8 NA NA NA NA 0.01 NA +

Smith 2012a

Operator dependent near-miss event rate

266 0.6 NA NA NA NA NA NA +

Smith 2012a

Total near miss event rate

266 2.4 NA NA NA NA 0.02 NA +

Yerian 2012 Number of steps saved

644 1.2 NA 1.5 NA 9 NA NA +

Setting: Emergency department

King 2006 Number of patients who waited 8 hrs. before seen by the physician

50337

NA NA NA NA 19.6 0.001 NA +

King 2006 Number of cases seen within 4 hrs. or less

50337

NA NA NA NA 53 NA NA +

King 2006 Total time spent in ED (hr)

50337

5 NA 4.7 NA NA 0.001 NA +

King 2006 Time spent in ED if discharged

50337

3.4 NA 2.4 NA NA 0.001 NA +

King 2006 Number of patients not waiting after triage

50337

NA NA NA NA 3.2 NA NA +

78

King 2006 No of deaths in ED 50337

NA NA NA NA 0.11 NA NA -

Murrell 2011

Length of stay (hr) 33926

3.6 NA 3.7 NA NA NA 3.6-3.7

+

Murrell 2011

Leaving the ED without been seen by the doctor (LWBS)

33926

NA NA NA NA 1.5 NA 0.6-1.8

+

Murrell 2011

ED arrival to physician start time (min)

33926

41.9 NA 30.9

NA NA NA 41.5-42.4

+

Murrell 2011

Proportion of patients arriving by ambulance (%)

33926

NA NA NA NA 12.4 NA 12.0-12.8

+

Murrell 2011

Hospital admission rate (%)

33926

NA NA NA NA 11.6 NA 11.2-12.0

+

Naik 2012 Number of patient visit per month

11661

NA NA NA NA NA 0.013 NA +

Naik 2012 Disposition time (hr)

11661

NA 4 NA 3.7-4.1

NA 0.001 NA +

Naik 2012 Time to triage (hr) 11661

NA 0.3 NA 0.2-0.3

NA 0.001 NA +

Naik 2012 Login to Provider time (hr)

11661

NA 1.6 NA 1.5-1.8

NA 0.001 NA +

Ng 2010 Length of stay (days)


Ng 2010 Wait time (min) NA 78 NA NA NA NA NA NA +

Ng 2010 Patient satisfaction (%)

NA NA NA NA NA 82 NA NA +

Piggott 2011

proportion of cases with 12-Lead ECGs completed within 10 mins of patient triage

399 NA NA NA NA 42.6 0.0001

NA +

Piggott 2011

Proportion of cases with physician assessment within

399 NA NA NA NA 47.3 0.0251

NA +

79

60 mins

Ulhassan 2013

Discharge rate (%) NA NA NA NA NA 83 NA NA +

Ulhassan 2013

Length of stay (min)


Setting: Out-patient

Fischman 2010

Wait time between start of triage and physician encounter (min)

47 NA 15 NA NA NA 0.062 NA +

Fischman 2010

Wait time between end of triage and physician encounter (min)

47 NA 10 NA NA NA 0.011 NA +

Fischman 2010

Time spent with physician (min)

47 NA 5 NA NA NA 0.002 NA +

Grove 2010 Number of steps 23 NA NA NA NA NA NA NA +

McDermott 2013


NA 58 NA 18.3

NA NA 0.001 NA +

McDermott 2013

Time to see a physician (min)

NA 38.38 NA 23.3

NA NA 0.005 NA +

McDermott 2013


NA 18.18 NA 9.33

NA NA 0.006 NA +

McDermott 2013


NA 14.22 NA 8 NA NA 0.481 NA +

Smith 2011 proportion of patient visit completed within < 60mins

NA NA NA NA NA 41.5 NA NA +

Smith 2011 Length of patient visit time (min)

176 74 71 NA NA NA NA NA +

Waldhausen 2011

Provider patient time (%)


Waldhausen 2011

NRC Picker Problem Scores (%)


80

Waldhausen 2011

Exam room time (min)

NA NA 42 NA NA NA NA NA +

Waldhausen 2011


12 NA NA NA NA NA NA NA +

Setting: In-patient

Chiodo 2012

Discharge time (PM)

NA 10:30 NA NA NA NA NA NA +

Chiodo 2012

Admission time (PM)

NA 1:22 NA NA NA NA NA NA +

Ford 2012 Door to needle time (min)

219 NA 39 NA 28-56

NA 0.0001

NA +

Ford 2012 Percentage of patient with DNT < 60min

219 NA 78 NA NA NA 0.0001

NA +

Ford 2012 Onset to needle time (min)

219 NA 111 NA 80-158

NA 0.016 NA +

Ford 2012 Door to CT time (min)

219 NA 1 NA 0-4 NA 0.0001

NA +


219 NA 24 NA 17-34

NA 0.13 NA -

Ford 2012 Door to partial thromboplastin time (min)

219 NA 40 NA NA NA 0.14 NA -

Ford 2012 Symptomatic ICH (%)

219 NA 3.4 NA NA NA 1 NA +

Ford 2012 Favorable discharge location

219 NA 83 NA NA NA 0.24 NA +

Ford 2012 90-day modified ranking score of 0 to 2 on telephone follow up (%)

219 NA 43 NA NA NA 0.34 NA -

Ford 2012 Length of stay (days)

219 NA 3 NA (2-6) NA 0.056 NA +

Ford 2012 Stroke mimic (%) 219 NA 11.5 NA NA NA 0.33 NA +

O'Neill 2011



81

O'Neill 2011



O'Neill 2011

Medication round time (min)


Yousri 2011 Overall mortality rate (%)

608 11.4 NA NA NA NA 0.002 NA +

Yousri 2011 30-day mortality rate (%)

608 6.7 NA NA NA NA 0.034 NA +

Yousri 2011 Admission rate (%) 608 76.9 NA NA NA NA 0.421 NA +

Yousri 2011 Length of stay (days)

608 NA 12 NA NA NA 0.178 NA +

Yousri 2011 Door to theatre time within 24 hr

608 47.8 NA NA NA NA 0.08 NA +

Yousri 2011 Number of patients delayed by more than 48hr

608 19.1 NA NA NA NA 0.481 NA +

Setting: Operating room

Blackmore 2013

Sterilization error rate (%)

4594 NA NA NA NA 1 0.0001

NA +

Cima 2011



Cima 2011



Cima 2011



Cima 2011



Cima 2011



Cima 2011

Operations past 5pm in


82

general/colorectal surgery

Cima 2011



Cima 2011



Cima 2011



Cima 2011



Cima 2011

Average staff overtime for gynaecologic surgery (min/specialty/mo)


Cima 2011



Cima 2011

Operating rooms saved/d/specialty for thoracic surgery

2430 NA NA NA NA 0.75 NA NA +

Cima 2011



Cima 2011

Operating rooms saved/d/specialty for


83

general/Colorectal surgery

Cima 2011



Cima 2011



Cima 2011



Collar 2012

OR turn around time (min)

144 69.3 NA NA NA NA 0.001 NA +

Collar 2012

OR turn over time (min)

NA 29 NA NA NA NA 0.001 NA +

Collar 2012

Educational survey score

NA 155 NA NA NA NA NA NA -

Setting: Pharmacy

Beard 2010

Dispensing time (min)

NA NA 27 7 NA NA NA NA +

Hummer 2009

Number of unfilled request


Setting: Radiology

Harmelink 2008



Harmelink 2008

Employee satisfaction scores


Harmelink 2008

Patient satisfaction on radiology staff for comfort scores (%)


Harmelink Radiology care NA NA NA NA NA 91 NA NA +

84

2008 providers collaboration scores (%)

Harmelink 2008



Harmelink 2008



Harmelink 2008



Setting: Home care

Smith 2012

Scheduling time (min)


Setting:In-patient and Dubes

Atkinson 2012

Number of patients referred


Atkinson 2012



Atkinson 2012

Readmission rates (%)


Atkinson 2012

length of stay (days)


Atkinson 2012

Out of hospital rates (%)


Setting: Setting: In-patient, Out-patient and Emergency department

Barnas 2011



Barnas 2011

Improvement in performance measures in AMC in-patient cardiac (%)


Barnas 2011

Improvement in performance measures in TCMC


85

neuro/surgical (%)

Barnas 2011

Improvement in performance measures in radiation oncology (%)


Barnas 2011

Improvement in performance measures in AMC medical/surgical (%)


Barnas 2011

Improvement in first-call bed access for AMC in-patient cardiac (%)


Barnas 2011

Improvement in falls for TCMC neuro/surgical (%)


Barnas 2011

Improvement of 14 safety/quality drivers (%)


Barnas 2011

Improvement in people engagement drivers (%)


Barnas 2011

Improvement in 23 of the financial stewardship drivers


Barnas 2011



Barnas 2011

Improvement in customer satisfaction drivers


Legend: N = sample size; E = estimated; SD = standard deviation; IQR = inter quartile range; % = percentage; CI = confidence interval;

86

Appendix 2:

Theory Maps

102

Appendix 3:

Interview guide for staff and

patients

103

Appendix 3: Interview Guide for the Second Round of Interviews

First Phase Evaluation of Saskatchewan’s Lean Health Care Transformation

Qualitative Questions – Staff

1. Thinking back over the last 2 years how have things changed for you in your work? How and

why do you think these changes have occurred?

2. Releasing Time to Care (RTC) was an intervention designed to improve patient outcomes and

staff satisfaction. Were you involved in any way with RTC? (If the person had been involved

with RTC, what was the involvement about?)

Question 3 for those who identified Lean in the Question 1 and Question 4 for those who do

not identify Lean as a cause of change

3. You mentioned Lean (OR regarding Lean), please describe your understanding of what Lean

is…

Which components of Lean have you been most involved in?

Which components do you believe will make the biggest difference in your work? Why?

Which components of Lean do you most value? Why?

Has Lean affected:

o patient care and outcomes? please describe (how and why);

o your relationships with patients and families? please describe (how and why);

o your relationships with your coworkers? please describe (how and why);

o your relationships with your leaders? please describe (how and why); and

o the way things are done around here? Decision-making? Accountability? please

describe (how and why)

Have you adapted or changed Lean implementation at all? If yes, how and why? If not,

why not?

Has Lean affected patient care and outcomes for Aboriginal patients (how and why)? (or

has Lean affected the quality of care for Aboriginal patients? (Please explain)

Any comments regarding the pace or scope or timing of Lean implementation? Why do

you feel this way?

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Anything worrying you about Lean implementation? Why do you feel this way?

Do you have all the resources or support you require? What is needed for this work to

be sustainable? Why?

b) In the past couple of years the health care system has introduced Lean. Are you aware of

Lean?

If YES, go to 3

If NO, could try a few prompts: have you participated in Kaizen Basics? Visual daily

management? 5S activities? Plan-do-study-act improvement cycles?

If they have been involved in any Lean activities, go through Question 3. If not,

discontinue the interview.

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First Phase Evaluation of Saskatchewan’s Lean Health Care Transformation

Qualitative Questions – Patients

1. Thinking back over the last 2 years how have things changed for you in your care? How and

why do you think these changes have occurred?

2. One Path for those who identify Lean initially (a) and second for those who do not (b)

a) You mentioned Lean (OR regarding Lean), please describe your understanding of what Lean

is…

Which components of Lean have you observed or been most involved in?

Which components do you believe will make the biggest difference in your care? Why?

Which components of Lean do you most value? Why?

Has Lean affected:

o patient care and outcomes? please describe (how and why);

o your relationships with other patients and families? please describe (how and

why);

o your relationships with your health care staff? please describe (how and why);

Any comments regarding the pace or scope or timing of Lean implementation? Why do

you feel this way?

Do you think Lean will improve patient care and outcomes for Aboriginal patients? (how

and why) …. Or Do you think Lean will improve the quality of care for Aboriginal

patients? Please explain

Anything worrying you about Lean implementation? Why do you feel this way?

b) In the past couple of years the health care system has introduced Lean. Are you aware of

Lean?

If YES, go to A

If NO, could try a few prompts: are you aware of Kaizen Basics? Visual daily

management? 5S activities? Plan-do-study-act improvement cycles?

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Appendix 4:

Patient Safety CMOCs

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Context-Mechanism-Outcome Chart

CONTEXT MECHANISM OUTCOME

SYSTEMIC CHANGE

Concurrent application of Hoshin Kanri and Lean

Consistency of goals, methods and language

Common directions across the province

Early stage of implementation

Priority afforded to training leaders

Differential access to training generates different levels of understanding of - and commitment to - Lean

Leaders have higher level of understanding of and commitment to Lean than most staff or patients.

Staff and patients levels of understanding of reflect direct experience in Lean tasks, more than training.

Implementation of multiple Lean tools concurrently or within very short timeframes

Changes to multiple aspects of a local system concurrently create a new system – the outcomes from each activity reinforce the others.

Increased sustainability of changes?

Significance of problems affecting the health system?

Scale of investment and senior leadership commitment?

Pressure on leaders to be accountable

Leadership accountability

Lack of communication of the overarching plan, how priorities are set, or how they are to be set

Uncertainty, insecurity regarding directions

Lack of confidence in self as leader / role as leader.

Centralisation of planning and decision-making (potentially as a result of Hoshin Kanri?)

Centralisation of decision-making Reduced authority at the local level. Sense of reduced accountability to the local community / reduced responsiveness to local needs

LEAN TRAINING

Kaizen Basics Common language

Basic understanding of intent

Ease of communication amongst those trained.

Resistance by those not yet

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engaged

Use of car industry and American health system examples within training

Scepticism regarding applicability to Canadian health system

Disengagement

Repetition in training across modules (within Leadership training; in Kaizen basics and tools modules)

Frustration and boredom

Perceived inefficiency in implementation of Lean itself – incongruent with objectives

Reduced engagement

Cynicism

LEADERSHIP

Intensive leadership training

North American tour

Common language

Deep understanding of tools

“The evidence of my own eyes”

Common leadership approaches

Leadership buy-in

Lean tools are practical Feels like a “common sense” approach.

Approaches seen as consistent with existing ways of seeing the world

Leadership engagement

Lean tools are highly structured

Confidence / trust in processes

Feedback loops: seeing success as a result of using tools generates re-use

Leaders are confident to implement.

Processes are implemented and gains made

Repeated use embeds tools and ways of thinking?

Inability (or perceived inability) to modify tools to suit local needs

Frustration / disengagement

Leadership buy-in and accountability

Leaders reduce or remove barriers to implementation

Staff feel supported

Lean tools are implemented

DATA AND MEASUREMENT

Emphasis on data and measurement

Congruent with physician expectations re evidence based care

Physician engagement

Data collection and analysis prior to use of Lean tools

Clarity about the nature of the problem

Data provides ‘authority’ (warrant) to act

Activities target real problems

Data walls Locally relevant data Sustained motivation

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Audits Feedback loops – evidence of impacts of changes

(particularly for leaders?)

Selection of locally relevant data – for patient safety and quality

Perceived relevance to own work Motivates the team, “Changes our work”

RESOURCES AND IMPLEMENTATION

Inadequate resources for KPO in larger regions to support northern regions

Uncertainty about direction / implementation strategy

Delayed implementation

Delays between training and implementation

Loss of memory/skill Reduced capacity to implement

Pressure of normal work prevents allocation of resources to addressing inefficiencies

Lean gives both permission and strategies to address causes of problems

Time is allocated to address underlying problems

Solutions are developed

Resources not available or allocated to support Lean work during the process of transition

Inadequate levels of KPO support

Inadequate support services support

Services struggle to implement Lean and maintain service provision

Managers/leaders overwhelmed

Delays in implementation

Inadequate support in relation to developing measures and data analysis

Inappropriate measures developed

Low perceived relevance of measures

Inability to assess outcomes

Reduced positive impact on staff engagement

No additional resources for the units that have to support all units undertaking Lean activities – e.g. IT, maintenance

Inefficiencies in Lean implementation

Increased workload for support unit staff

Frustrations for staff –> lack of engagement

Increased stress for support unit staff

Decreased quality of work from support unit staff

Reduced sustainability?

Support services tied up with major Lean initiatives

Support not available for smaller Lean projects/initiatives

Poor sequencing of Previous work discarded and Inefficiencies created in the

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Lean activities

Too many activities too fast

No translation of effective strategies from one unit to another

replaced / not maintained process

ENGAGEMENT AND DIFFUSION

Physicians – powerful occupation within system

Peer to peer diffusion of innovation

Increased engagement by other doctors

Increased effectiveness of RPIWs

?Wrong people (or not enough of the right people) involved in a change process

Exclusion / disempowerment Resentment/offended

(In this case – the individual rose above it. But others may not).

Rapid pace of change Overwhelming/challenging Change burnout

Changes not monitored / sustained

Local implementation ‘at ward level’

Perceived relevance Staff ‘buy-in’

PATIENT PARTICIPATION

Direct participation of patients in Lean processes

Changes staff perspectives: seeing from the patient perspective, ‘seeing with new eyes’, generates patient centred decision-making.

Understand the patient journey – not just own appointment – reduces silo mentality

Changes direction of activities

More patient centred care

Increased understanding of patient flow across the system

Changes language used in information resource

More comprehensible, patient-friendly information

Changes patient understanding of what’s involved for service providers in providing care

More tolerant of changes in health system

Explain to other patients

PATIENT SAFETY AND QUALITY OF CARE

Personal Care Coordinators introduced

Transfer of responsibility for coordination of care post-release from nurses to PCC

Time freed up for senior nurses

Patients released earlier leads to reduced in-hospital costs

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Clear accountability for post release care leads to improved coordination, which improves safety?

Time freed up for senior nurses – able to spend more time training and supporting other staff

Capacity building for other staff

Increased supervision leads to fewer mistakes?

Improved safety / quality of care

“Leaning the meds cart” – ‘don’t interrupt’ sign; Person doing meds is ‘not on code’

Reduced interruptions during medications

Reduced time taken for medications

Reduced errors

Ward clerk staffing levels reduced

Reduced support/staffing capacity “Telephones are not answered”

Poorer communications/ responsiveness with families or other parts of the system.

Reduced quality of care, coordination, patient/family satisfaction?

Provincial system for printing out list of medications prescribed or provided, on entry to hospital

Prompts check of medications behaviours

Medications checked and updated.

RPIW outcome: Reduction in wait time for psychiatry

Reduced opportunity for deterioration in mental health?

Improved patient safety – e.g. reduced harm to self or others?

Reduced wait time during admission

Reduced opportunity for cross-infection

Reduced negative health impacts

Leadership training

Safety focus within Lean tools

Heightened awareness Increased leadership attention to safety:

Within measurement; In interactions with staff; As a focus in change processes

Application of Lean tools to patient safety issues and safety culture

Quality improvement Reduction in errors and incidents (e.g. falls)

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Lean tools – including Stop the line

Increased accountability of all staff Prevent critical incidents

Increased safety of daily work

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