Lean methodology: contributions to improving work processes in health and nursing

ABSTRACT Objective: to investigate the contributions of applying the Lean methodology to improve work processes in health and nursing and its impact on associated financial aspects. Method: an integrative review, carried out in six databases, whose sample of ten (100.0%) studies was analyzed and summarized descriptively. Results: the outcomes obtained were stratified into: benefits/barriers to Lean Healthcare implementation; economic aspects involving Lean Healthcare implementation; and process improvements through Lean Healthcare implementation. The majority of studies (60.0%) were carried out in university hospitals, contexts that need to continually improve the quality of services provided, generally with scarce and limited resources, which support the viability of maintaining the teaching, research and extension tripod. Conclusion: three (30.0%) studies highlighted the financial aspects associated with Lean methodology application. The others only mentioned the possibility of financial gains through improving processes and reducing waste.


INTRODUCTION
Lean methodology consists of a fact-based and data-driven improvement philosophy that values preventing defects over detecting them, aiming at customer satisfaction through delivering the best quality at the lowest possible cost (1) .Of industrial origin, its principle has been applied in the health area, due to the similarity of the production processes of institutions that, despite the distinctions, they seek to plan and execute actions, in a determined time, with specific resources, at the lowest cost, to create value for a customer (2) .
Lean aimed to identify waste, eliminating what does not add value (NAV) to customers, in order to increase process efficiency and product quality.In lean processes, added value is obtained through flows that include the essential activities that the customer goes through, and during the execution of these activities, value is added.Thus, added value results from cycles of continuous improvements, which are sources of innovation (3) .
In the health area, this methodology is called Lean Healthcare, whose results include identifying and eliminating waste in production processes, with the main focus on adding quality and delivering to customers only what they consider to be value (services that respect and meet their preferences and needs), through an efficient and waste-free process (2)(3)(4) .
Lean Healthcare adds maturity to management, as it goes beyond departmental vision and creates a process-oriented culture that can encourage people's engagement to deliver benefits to the business or the institutional mission and vision.Therefore, management needs to be clear about the final results it wants to achieve, assigning those responsible for the sustainability of processes and measuring performance based on these (2) .
Lean Healthcare application, as it is based on formal instructions and standardization of the work environment, professional training and respect for people, is favorable for increasing quality of care and patient safety.It assumes that "front line" or production chain professionals are able to assess and contribute to what patients need to have their needs met, considering good clinical practices.In this way, the strategic level approaches the production chain and effectively manages the practice that will progressively impact strategic indicators (2) .
The main repercussions arising from the application of this methodology are associated with increased team productivity and efficiency, reduced patient waiting time for care, standardization of care processes and, consequently, reduced costs (2) .
Considering that the result of the production process is dependent on people's behavior, in addition to the focus on standardizing activities, which provide greater productivity, it is necessary to have in-depth knowledge of current work procedures, with a view to continuous improvements in the process.Another important element is the institutional administrative commitment to investing in and promoting a culture of continuous improvement, covering a set of principles and personal values that transform people's way of life, guiding them towards improvement-seeking behavior with investment in corporate education, competencybased management and indicators (3) .
It is noteworthy that Lean thinking underlies a management model that is a reference in terms of operational excellence and the achievement of quality care, through the improvement of processes, with the central aspects that patients value, such as better, safe, fast, qualified and resolute service (5) .
The achievements of implementing continuous improvement strategies are recognized around the world.Using such strategies, processes are improved and efficiency increases and, therefore, waste is reduced and savings can be passed on to consumers, resulting in improved quality.When customers receive quality products, companies are able to increase their revenue and, consequently, the economy grows (6) .
It is noteworthy that, in Brazil, resources allocated to the health sector are increasingly scarce and limited, and the commitment of leaders, regardless of the legal nature of the institutions (public, private or philanthropic), with the organizational management model, cost management and its repercussions on the viability of different work processes is essential to ensure the provision of safe, efficient, effective and financially sustainable health services (7) .
Furthermore, Lean requires a structural change, from top management to the production chain, not being a point of arrival in itself, but rather a path of continuous search for improvements and operational excellence (7) .In health service provision, this methodology is designed to create a culture that applies science to design, execute and continually improve the work provided, focusing on measurable value to patients.

OBJECTIVE
To investigate the contributions of applying the Lean methodology to improve work processes in health and nursing and its impact on associated financial aspects.

Ethical aspects
Due to the type of article (review), there is no need for approval from a Research Ethics Committee.

Study design, place, and data collection period
This integrative review, a method that provides the synthesis of knowledge and the incorporation of the applicability of results from significant studies in practice (8) , was conducted based on the guiding question: what are the contributions of applying Lean methodology to improve work processes in health and nursing and its impact on associated costs?
The PICO strategy was used, an acronym for Population, Intervention, Comparison and Outcomes (9) , using the letters and their equivalent terms: "P" -work processes in health and nursing; "I" -Lean methodology application; "C" -no intervention was established for comparison; and "O" -improvement of processes and associated financial aspects.
To ensure the rigor of this review, the following steps were taken (9) : objective establishment; inclusion and exclusion criteria establishment (sample selection); definition of information to be extracted from selected articles; analysis of results; presentation and discussion of results.To select the articles, databases and portals were used that allowed expanding the scope of research (10) . of

Lean methodology: contributions to improving work processes in health and nursing
Brancalion FNM, Souza LG, Berger S, Lima AFC.

Sample; inclusion and exclusion criteria
Articles published in Portuguese, English and Spanish, with free texts available, in full, in the selected databases, in the period between 2018 and 2022, which highlighted the contributions of applying Lean methodology in health/nursing work processes and their repercussions on financial aspects, were included.Articles available only in abstract format, published only in conference annals and with paid access were excluded.

Study protocol
Based on the guiding question, a search was carried out in the US National Library of Medicine (PubMed), Latin American and Caribbean Center for Health Sciences Information (LILACS), Scientific Electronic Library Online (SciELO), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Scopus, Virtual Health Library (VHL) and Engineering Village databases.
Controlled descriptors were delimited (MeSH and MeSH terms, CINAHL Headings, Engineering Village Headings and DeCS) as well as specific keywords for some databases and their derivatives.They were combined with the appropriate Boolean operators (OR and AND).The Boolean operator OR was used between descriptors from the same PICO group, and AND, to search between the PICO groups, being: de enfermagem" OR" nursing team" OR "grupo de enfermería" OR "administração de recursos humanos hospital" OR "personnel administration hospital" OR "administración de personal en hospitales" OR "descrição de cargo" OR "job description" OR "perfil laboral" OR "papel profissional" OR "professional role" OR rol profesional AND "gestão qualidade total" OR "total quality management" OR "gestión de la calidad total" OR "aquisição baseada em valor" OR "value-based purchasing" OR "compra basada em calidad" OR "fluxo de trabalho" OR workflow OR "flujo de trabajo" AND "custos hospitalares" OR "hospital costs" OR "costos de hospital" OR "análise de custos economia e organizações dos cuidados em saúde" OR "costs and cost analysis" OR "costos y análisis de costo" OR "determinação do valor econômico de organizações de saúde" OR "practice valuation and purchase" OR "valorización y adquisición práctica" OR "redução de custos, cost savings, ahorro de costo"; • Scopus (keyword): Nursing OR Nursing Team OR personnel management hospital OR Job description OR professional role AND Total quality management OR value based purchasing OR workflow AND Costs OR cost and cost analysis OR health care economics and organizations OR practice valuation and purchase; • SciELO (DeCS): enfermagem OR nursing OR enfermería OR "equipe de enfermagem" OR "nursing team" OR "grupo de enfermería" OR "administração de recursos humanos hospital" OR "personnel administration hospital" OR "administración de personal en hospitales" OR "descrição de cargo" OR "job description" OR "perfil laboral" OR "papel profissional" OR "professional role" OR rol profesional AND "gestão qualidade total" OR "total quality management" OR "gestión de la calidad total" OR "aquisição baseada em valor" OR "value-based purchasing" OR "compra basada em calidad" OR "fluxo de trabalho" OR workflow OR "flujo de trabajo" AND "custos hospitalares" OR "hospital costs" OR "costos de hospital" OR "análise de custos economia e organizações dos cuidados em saúde" OR "costs and cost analysis" OR "costos y análisis de costo" OR "determinação do valor econômico de organizações de saúde" OR "practice valuation and purchase" OR "valorización y adquisición práctica" OR "redução de custos" OR "cost savings" OR "ahorro de costo";

Analysis of results
Data originating from the sample of selected studies were analyzed and synthesized descriptively.
It was found that, although all articles in the sample relate Lean methodology application to the impact on financial aspects, through process improvement and waste reduction, not all of them effectively demonstrated the associated financial gains.Therefore, to provide greater visibility to the results obtained, they will be presented below in three charts: Chart 2 -Benefits/barriers to Lean Healthcare implementation (7,11,15) ; Chart 3 -Economic aspects involving Lean Healthcare implementation (12,14,16) ; and Chart 4 -Process improvements through Lean Healthcare implementation (13,(17)(18)(19) . of

Lean methodology: contributions to improving work processes in health and nursing
Brancalion FNM, Souza LG, Berger S, Lima AFC.

DISCUSSION
The analysis of the sample studies of this integrative review showed the use of Lean methodology in applied research (12)(13)(14)16,(18)(19) linked to university hospitals, places where the teaching, research and care tripod predominates. Interventns, that contribute to improving the efficiency, efficacy and effectiveness of the health services provided, which underlie the training of human resources and favor the conduct of health research using available, but not unlimited, resources, are needed.
It is noteworthy that SC is considered one of the most complex and costly units, as it requires high technology to make procedures viable, in a hospital organization.Professionals who work in this unit need to develop skills to improve management processes, with the perspective of increasing and rationalizing the financial resources required.
A study (20) carried out with nurses working in SC identified the essential competencies for nursing professionals in this area.One of the aspects highlighted was assertiveness in communication flow, including strategic meetings between the team to discuss, plan and assess work processes.With the aim of articulating administrative and clinical spheres, as well as strengthening the culture of cooperation and collaboration, this management model, admittedly, consists of a tool to qualify the care provided.
The findings of the aforementioned study (20) are corroborated by the study (11) , which demonstrated the importance of engagement and alignment of people's and the organization's values with Lean methodology's values, aiming to provide participatory management with greater involvement of workers in decisionmaking processes (15) , without losing sight of the strategic map and organizational goals.Citation Title Year Country Journal (11)   The sustainability of Lean in pediatric healthcare: a realist review 2018 United Kingdom Systematic reviews (12)   Process optimization in total knee arthoplasty procedures: Impact of sizespecific instrument sets on costs and revenue 2019 Germany Orthopade (13)   Endoscopic -A reduction in the total surgery time (from 287 minutes and 5 seconds to 255 minutes and 5 seconds) and a reduction in the total time used in the operating room (from 380 minutes and 8 seconds to 145 minutes and 3 seconds) were identified; -After statistical analysis, an average saving in surgical time of 33 minutes and 3 seconds and an average total saving in surgery time of 35 minutes in phase II were revealed.
-The strategy used in phase II requires only one endoscopic conduit collection kit to be used per operation, saving 8.0% of surgery-related costs per patient.
The strategy improves intraoperative workflow, reduces surgery time and cost, and advances the delivery of high-quality care to patients.From this perspective, Lean methodology adoption makes the use of strategic, tactical and operational indicators crucial, as it requires a clear definition of the objectives and goals to be achieved, with systematic and continuous measurements.Strategic map integration with this methodology enables a systemic view of the institution by identifying weaknesses and points that can be improved, seeking sustainability based on results indicators, with gains in the small, medium and long term (7) .
Results related to savings and earnings, predictors of Lean interventions, were only reported in three studies (12,14,16) .Two studies (12,14) , which had evidence of correlation with economic aspects, were carried out in SC, with variables linked to the general work process, but both present limitations regarding the techniques used by medical professionals, denoting a hypothetical barrier in action sustainability, since the results obtained were linked to people and not to processes.One of these studies (14) , despite demonstrating that Lean methodology application, as a change in the work process, generated financial burden, highlighted that it could be balanced when related to customer satisfaction.
Among the studies analyzed, there was no evidence of measuring the results of customer satisfaction, team satisfaction or engagement levels.Thus, a systematic review (21) , conducted in 2022, reflected on the need for studies with Lean methodology supported by digital technologies in health services, through computerized systems, such as automation, simulation, real-time location system, telemedicine, machine learning, among others.It indicated that, with the digital transformation experienced in recent years, there has been an exponential growth in data, and digital technologies are already being used to carry out descriptive, predictive and prescriptive analyzes.Machine learning has been used to predict resource needs, treatment outcomes, and readmission patterns.Medication dispensing can now be carried out through automated distribution, with surgical methods being carried out using robotics, ultraviolet disinfection systems carried out by robots to prevent infection, consisting of technological improvements that are gradually becoming part of the realities (21) .The analysis of the ten articles (7,(11)(12)(13)(14)(15)(16)(17)(18)(19) demonstrates that the interventions were related to mechanical actions in the work process, with no use of digital technologies being found.
It is worth emphasizing that the Lean philosophy does not dispense with scientifically based participatory management, which can bring intangible benefits to the quality of the work processes of healthcare teams.Quality science offers valuable paths for managing the hostility that inspections, awards and punishments can generate, and it is important that this topic integrates health team professional and manager training (22) .
Among the studies analyzed, three corresponded to review articles (11,15,17) , which assessed the Lean tools used in research (17) , the results after implementing Lean methodology (16) and its sustainability (11) .In this integrative review, it was found that the Lean methodology can bring benefits to organizations (7,15) , and is associated with process improvements, waste reduction, increased efficiency and productivity, improvement in service quality (13,(17)(18)(19) , contributing favorably to economic aspects (12,16) .
Three articles (11,15,17) presented outcomes that correlated the Lean methodology's success or failure to behavioral attitudes, whether of the team or leadership.Given this context, the lack of clarity regarding its implementation to overcome the barrier of local units and materialize, in a sustainable manner, as a management philosophy at all hierarchical levels becomes evident.In this regard, one of the challenges of adopting the Lean method is employees' resistance in relation to change strategies, demanding the breaking of institutional paradigms, through process changes, changing culture, working with systemic objectives, team engagement and continuous improvement (10) .Thus, this method can be implemented in a sustainable way aiming at the continuous improvement of work processes in health and nursing, with favorable repercussions on associated costs.

Study limitations
As a limitation of this study, only the use of free access articles is indicated, which may have had an impact on sample size.

Contributions to nursing, health or public policies
This study demonstrated that Lean methodology has been widely disseminated to identify value for end customers and eliminate losses.Its application, adapted to health services, has been the object of study in different realities.It involves mapping the value chain and disseminating philosophy at all hierarchical levels, bringing together senior management professionals (strategic level) and front-line professionals (operational level) working with patients.

CONCLUSIONS
In this integrative review, based on the analysis of ten articles, it was found that only three of them effectively investigated the financial aspects associated with Lean methodology application.
The others only mentioned the possibility of financial gains through process improvements and waste reduction.
For future studies, research related to direct labor cost reduction in different contexts of health service provision is suggested, through improvement implementation in work processes using Lean methodology.

FUNDING
This work was carried out with support from the Brazilian National Council for Scientific and Technological Development (CNPq -Conselho Nacional de Desenvolvimento Científico e Tecnológico).

CONTRIBUTIONS
Brancalion FNM, Lima AFC contributed to the conception or design of the study/research.Brancalion FNM, Souza LG, Berger S and Lima AFC contributed to the analysis and/or interpretation of data and final review with critical and intellectual participation in the manuscript.

Figure 1 -Chart 1 -
Figure 1 -Flowchart of the primary studies selection process adapted from the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), 2023

contributions to improving work processes in health and nursing
Brancalion FNM, SouzaLG, Berger S, Lima AFC.Distribution of articles highlighting benefits/barriers to Lean Healthcare implementation according to citation, objective, design, outcomes and conclusions/recommendations, 2023 Chart 3 -Distribution of articles highlighting economic aspects involving Lean Healthcare implementation according to citation, objective, design, outcomes and conclusions/recommendations,

2023 Economic aspects involving Lean Healthcare implementation
To be continued of Lean methodology:

contributions to improving work processes in health and nursing
Brancalion FNM, SouzaLG, Berger S, Lima AFC.

contributions to improving work processes in health and nursing
Brancalion FNM, SouzaLG, Berger S, Lima AFC.

contributions to improving work processes in health and nursing
Brancalion FNM, SouzaLG, Berger S, Lima AFC.

Process improvements through Lean Healthcare implementation
The main problems encountered were in relation to sterile kits that were expired and not removed from the storage area and the number of packages inconsistent with records; -There was the standardization of aseptic items that contributed to reducing lost packaging and reducing costs (from 1,190 to 70 yuan) caused by the loss of sterile packaging. -