Lean Healthcare in the institutional, professional, and patient perspective: an integrative review

Fernandes, Hellen Maria de Lima Graf; Jesus, Mariana Véo Nery de; Silva, Dirceu da; Guirardello, Edinêis de Brito

doi:10.1590/1983-1447.2020.20190340

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Integrative Review • Rev. Gaúcha Enferm. 41 • 2020 • https://doi.org/10.1590/1983-1447.2020.20190340 copy

Lean Healthcare in the institutional, professional, and patient perspective: an integrative review

Lean Healthcare en la perspectiva institucional, profesional y del paciente: una revisión integrativa

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To analyze the scientific evidences in the literature about the evaluation of Lean Healthcare after its implementation.

Method:

An integrative review conducted in the CINAHL, Scopus, WOS, and Embase databases, and in the PubMed portal, resulting in 18 articles published in English, Spanish and Portuguese, from 2008 to 2019.

Results:

The findings were categorized into results for the institution, professional, and patient. The predominant category was institutional, with cost analysis and increased productivity, followed by the professional, with job satisfaction and leadership, and finally the patient, with satisfaction, attitudes, and behaviors.

Conclusion:

This study reinforces the need to establish, for management, a systematic method of monitoring the results achieved in the Lean Healthcare implementation phase. Since the value in this method is defined by the patient, further research in this aspect may lead to new evidence.

Keywords
Total quality management; Quality improvement; Health management

1^st Author Year Place	Objective	Type of study Sample	Perspective	Main findings	Level of Evidence
Kaltenbrunner2020. Kaltenbrunner M, Mathiassen SE, Bengtsson L, Engström M. Lean maturity and quality in primary care. J Health Organ Manage. 2019;33(2):141-54. doi: https://doi.org/10.1108/JHOM-04-2018-0118 https://doi.org/10.1108/JHOM-04-2018-011... ⁾ 2019 Sweden	To describe Lean maturity in primary care and to determine the extent to which Lean maturity is associated with quality of care.	Descriptive, correlational, and mixed methods n=298 employees	Institutional Professional	Lean maturity varied between and within units. The highest level of maturity was found for “adhering to routines” and the lowest for “having a change agent in the unit”. Maturity was positively associated with satisfaction with care and adherence to the national guidelines to improve the quality of health care	VI
Fournier2121. Fournier PL, Jobin MH. Medical commitment to Lean: an inductive model development. Leadersh Health Serv. 2018;31(3):326-42. doi: https://doi.org/10.1108/LHS-02-2018-0015 https://doi.org/10.1108/LHS-02-2018-0015... ⁾ 2018 Canada	To study the factors that influence the involvement of physicians in Lean change initiatives in public health organizations	Inductive method n=18 physicians	Professional	Younger, less experienced physicians were more likely to commit to the Lean initiative, in addition to the previous level of training and positive experience with the method	VI
Gupta2222. Gupta SH, Kapil S, Sharma M. Improvement of laboratory turnaround time using lean methodology. Int J Health Care Qual Assur. 2018;31(4):295-308. doi: https://doi.org/10.1108/IJHCQA-08-2016-011 https://doi.org/10.1108/IJHCQA-08-2016-0... 2018 India	To discuss the implementation of the Lean methodology to reduce the response time of a clinical laboratory in a specialized hospital	Experimental method n=215 samples	Institutional	The results showed waste elimination, cost reduction, higher productivity and return on investments after the implementation of Lean	IV
Boronat2323. Boronat F, Budia A, Broseta E, Ruiz-Cerdá JL, Vivas-Consuelo D. Application of Lean Healthcare methodology in a urology department of a tertiary hospital as a tool for improving efficiency. Actas Urol Esp. 2018;42(1):42-8. doi: https://doi.org/10.1016/j.acuro.2017.03.009 https://doi.org/10.1016/j.acuro.2017.03.... ⁾ 2018 Spain	To describe the application of the Lean methodology as a method to continuously improve the efficiency of an urology department in a tertiary-level hospital	Cross-sectional study Not specified.	Institutional Professional	The Lean methodology can be effectively applied to improve efficiency, obtaining significant and continuous improvements in all its indicators, as well as professional satisfaction.	VI
Costa2424. Costa LBM, Godinho Filho M, Rentes AF, Bertani TM, Mardegan R. Lean healthcare in developing countries: evidence from Brazilian hospitals. Int J Health Plann Manage. 2017;32: E99-E120. doi: https://doi.org/10.1002/hpm.2331 https://doi.org/10.1002/hpm.2331 ... 2017 Brazil	To assess how five sectors of two Brazilian hospitals have implemented Lean health concepts in their operations	Case study n=Sectors A (CME and pharmacy) and B (chemotherapy, operating room, and radiotherapy)	Institutional	The results evidenced the improvement of the financial aspects, in the reduction of the delivery time, in the increase of the capacity, and in productivity	VI
Poksinska2525. Poksinska BB, Fialkowska-Filipek M, Engström J. Does Lean healthcare improve patient satisfaction? A mixed-method investigation into primary care. BMJ Qual Saf. 2017;26:95-103. doi: https://doi.org/10.1136/bmjqs-2015-004290 https://doi.org/10.1136/bmjqs-2015-00429... 2017 Sweden	To investigate how primary care centers define and improve patient value and satisfaction using Lean	Mixed method Case Study/Survey Qualitative phase: n=15 professionals Quantitative phase 23 control groups and 23 intervention groups	Patient	Did not show significant results in patient satisfaction	VI
Mutingi2626. Mutingi M, Isack HD, Musiyarira H, Mbohwa C. The impact of lean in medical laboratory industry: empirical studies in Namibia. In: World Congress on Engineering and Computer Science, WCECS 2017; Lecture Notes in Eng Comput Sci. 2017;II:965-9 2017 South Africa	To assess the impact of adopting Lean tools in the medical laboratory services in Namibia	Descriptive, cross-sectional study and mixed method n=72 laboratories	Institutional Professional Patient	The application of Lean tools had a positive impact, and management support plays an important role in success. The quality improvement had an impact in more than 85% of the laboratories. Lean tools have improved quality operational performance, reduced response times, improved employee motivation, and reduced costs	VI
Hassanain1111. Hassanain M, Zamakhshary M, Farhat G, Al-Badr A. Use of Lean methodology to improve operating room efficiency in hospitals across the Kingdom of Saudi Arabia. Int J Health Plann Manage. 2017 Apr;32(2):133-46. doi: https://doi.org/10.1002/hpm.2334 https://doi.org/10.1002/hpm.2334 ... 2017 Saudi Arabia	To assess whether an intervention using Lean principles in hospitals across Saudi Arabia would impact on the performance metrics in the operating room: use of the room, medical file opening for the first cases, turnover times, overrun cases, and weekly procedure volumes	Quasi-experimental design n=12 Hospitals	Institutional	Statistically significant improvements in the beginning of the first surgery time, room turnover times, and percentage of overrun cases. No significant statistical difference was detected in the use of the operating room or mean volumes of weekly procedures	VI
Van Rossum2727. Van Rossum L, Aij KH, Simons FE, der Eng NV, ten Have WD. Lean healthcare from a change management perspective: the role of leadership and workforce flexibility in an operating theatre. J Health Organ Manag. 2016;30(3):475-43. doi: https://doi.org/10.1108/JHOM-06-2014-0090 https://doi.org/10.1108/JHOM-06-2014-009... 2016 Netherlands	To enhance scientific knowledge about factors that close the implementation gap and make the transition from the “Lean toolbox” to a real transformation into Lean Healthcare in the operating room	Cross-sectional study n=103 participants	Institutional Professional	The correlation and regression analyses showed positive relationships between transformational leadership and team leadership styles and the implementation of Lean. The results also indicated a strong relationship between workforce flexibility and the implementation of Lean Healthcare	VI
Trzeciak2828. Trzeciak S, Mercincavage M, Angelini C, Cogliano W, Damuth E, Roberts BW, et al. Lean Six Sigma to reduce intensive care unit length of stay and costs in prolonged mechanical ventilation. J Healthc Qual. 2018 Jan/Feb;40(1):36-43. doi: https://doi.org/10.1097/JHQ.0000000000000075 https://doi.org/10.1097/JHQ.000000000000... 2016 USA	To test the hypothesis that a Lean Six Sigma approach to process improvement could reduce the length of hospital stay and the costs associated with caring for patients with prolonged mechanical ventilation	Cohort study n=259 patients (31 pre-intervention; 128 post-intervention)	Institutional	The intervention resulted in a 24% reduction in the hospital stay (29 days/22 days, p <0.001) and in a 27% reduction in the direct hospital cost per case (US$ 66,335/US$ 48,370, p <0.001)	IV
Eiro2929. Eiro NY, Torres-Junior AS. Comparative study: TQ and Lean Production ownership models in health services. Rev Latino-Am Enfermagem. 2015 Sept./Oct;23(5):846-54. doi: https://doi.org/10.1590/0104-1169.0151.2605 https://doi.org/10.1590/0104-1169.0151.2... 2015 Brazil	To compare the application of the Total Quality models used in health service processes, the cases of Lean Healthcare in the literature and of another institution that has already applied this model	Qualitative and descriptive, case study n=Two health institutions: A (private diagnostic medicine company); B (private cancer hospital)	Institutional	The Lean model was better systematically appropriated by the people who work and generate flow leading to greater adherence.	VI
Kane3030. Kane M, Chui K, Rimicci J, Callagy P, Hereford J, Shen S, et al. Lean Manufacturing improves emergency department throughput and patient satisfaction. J Nurs Adm. 2015;45(9):429-34. doi: https://doi.org/10.1097/NNA.0000000000000228 https://doi.org/10.1097/NNA.000000000000... 2015 USA	Not specified	Not specified Not specified	Institutional Patient	The implementation of Lean in the emergency department significantly reduced patient waiting times and length of stay, while improving satisfaction. This was achieved over a two-year period with a 7% growth in volume, without increasing the size or resources of the department.	*Not classified
Holden3131. Holden RJ, Eriksson A, Andreasson J, Williamsson A, Dellve L. Healthcare workers' perceptions of Lean: a context-sensitive, mixed methods study in three Swedish hospitals. Appl Ergon. 2015;47:181-92. doi: https://doi.org/10.1016/j.apergo.2014.09.008 https://doi.org/10.1016/j.apergo.2014.09... 2015 Sweden	To address how the perceptions of health care workers varied according to the contexts in three Swedish hospitals.	Mixed Method n=236 participants		The perceptions vary according to the hospital context, to the complexity of the sector, and to the professional role, with nurses being the category with a more favorable perception than physicians.	VI
Kanamori3232. Kanamori SH, Sow S, Castro MC, Matsuno R, Tsuru A, Jimba M. Implementation of 5S management method for lean healthcare at a health center in Senegal: a qualitative study of staff perception. Glob Health Action. 2015;8:27256. doi: https://doi.org/10.3402/gha.v8.27256 https://doi.org/10.3402/gha.v8.27256 ... 2015 Africa	To assess how the 5S management method creates changes in the workplace, process, and results of the health services, and how it can be applied in a low-resource setting, based on data from a pilot intervention of the 5S program implemented in a health system	Qualitative n=21 participants	Institutional Professional	The pilot intervention of the 5S management method generated changes in the quality of the services and in the attitude and behavior of the employees and patients in a health facility with few resources.	VI
Dávila3333. Dávila SP, González JT. Mejora de la eficiencia de un servicio de rehabilitación mediante metodología Lean Healthcare. Rev Calid Asist. 2015;30(4):162-5. doi: https://doi.org/10.1016/j.cali.2015.03.002 https://doi.org/10.1016/j.cali.2015.03.0... 2015 Spain	To evaluate cost reduction and increased time devoted to the patient, using the Lean Healthcare methodology.	Descriptive study n=Three rehabilitation health services	Institutional Professional	It was possible to standardize the processes and eliminate waste, reducing costs and increasing the value of the patient. The costs with stored materials decreased by 43%, the cost per patient treated by 19%, and the time dedicated to treating patients increased by 7%	VI
Drotz3434. Drotz E, Poksinska B. Lean in healthcare from employees’ perspectives. J Health Organ Manag. 2014;28(2):177-95. doi: https://doi.org/10.1108/JHOM-03-2013-0066 https://doi.org/10.1108/JHOM-03-2013-006... 2014 Sweden	To contribute to an understanding of the new roles, responsibilities, and job characteristics of employees in Lean Healthcare	Case study n=24 participants	Professional	The implementation of Lean had a great influence on the roles, responsibilities, and characteristics of the employees' work, the focus was shifted from the professionals to the process of improvement and teamwork	VI
Ponanake3535. Ponanake P, Limnararat S, Pithuncharurnlap M, Sangmanee W. Path analysis of the core competency of Thai private hospitals in the ASEAN economic community. Res J Bus Manag. 2014;8(3):157-72. doi: https://doi.org/10.3923/rjbm.2014.157.172 https://doi.org/10.3923/rjbm.2014.157.17... 2014 Thailand	To study the trajectory relationships between a Lean health system, the Six Sigma practice and the internal quality management of the core competence of Thai private hospitals as a health care center of the Association of Southeast Asian Nations	Quantitative n=312 participants	Institutional	The Lean health system and Six Sigma practices indirectly influence, through internal quality management, the core competence of a hospital to be a health care center. Six Sigma practices and internal quality management directly influence the same competence	VI
Wood3636. Wood D. A Prescription for Lean Healthcare. Healthc Q. 2014;17(2):24-8. doi: https://doi.org/10.12927/hcq.2014.23881 https://doi.org/10.12927/hcq.2014.23881 ... 2014 Canada	To examine three hospitals that have implemented Lean in the emergency department	Longitudinal study n=Three hospitals	Institutional Professional	They concluded that, although the presence of strong and persistent leadership can have favorable results in short-term performance, these improvements are not sustainable. To have a long-term impact, the professionals need to engage all the stakeholders in the health care system and create a culture that is continuously focused on improving the patient experience.	IV

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[1] Corresponding author:
Hellen Maria de Lima Graf Fernandes Email: hellenmlima@gmail.com