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

Hellen Maria de Lima Graf Fernandes Mariana Véo Nery de Jesus Dirceu da Silva Edinêis de Brito Guirardello About the authors

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

RESUMEN

Objetivo:

Analizar las evidencias científicas en la literatura sobre la evaluación de Lean Healthcare después de su implementación.

Método:

Revisión integradora realizada en las bases de datos CINAHL, Scopus, WOS, Embase y en el portal PubMed, con la obtención de 18 artículos publicados en inglés, español y portugués, de 2008 a 2019.

Resultados:

Los hallazgos se clasificaron en resultados para las categorías institucional, profesional y paciente. La categoría predominante fue la institucional, con análisis de costos y mayor productividad, seguida por la profesional, con satisfacción laboral y liderazgo y, finalmente, la del paciente, con satisfacción, actitudes y comportamientos.

Conclusión:

Este estudio refuerza la necesidad de establecer, para la administración, un método sistemático de monitoreo de los resultados logrados en la fase de implementación de Lean Healthcare. Dado que el valor en este método es definido por el paciente, la investigación adicional en este aspecto puede conducir a nuevas pruebas.

Palabras clave
Gestión de la calidad total; Mejoramiento de la calidad; Gestión en salud

RESUMO

Objetivo:

Analisar as evidências científicas na literatura sobre avaliação do Lean Healthcare após sua implantação.

Método:

Revisão integrativa realizada nas bases de dados CINAHL, Scopus, WOS, Embase e no portal PubMed, resultando 18 artigos publicados nos idiomas inglês, espanhol e português, no período de 2008 a 2019.

Resultados:

Os achados foram categorizados em resultados para a instituição, profissional e paciente. A categoria predominante foi a institucional, com análise de custo e aumento da produtividade, seguida do profissional, com satisfação no emprego e liderança, e por fim o paciente, com satisfação, atitudes e comportamentos.

Conclusão:

Este estudo reforça a necessidade em estabelecer, para a gestão, um método sistemático de acompanhamento dos resultados alcançados na fase de implantação do Lean Healthcare. Sendo o valor nesse método definido pelo paciente, novas pesquisas nesse aspecto poderão levar a novas evidências.

Palavras-chave
Gestão da qualidade total; Melhoria de qualidade; Gestão em saúde

INTRODUCTION

Lean is a management philosophy derived from the Toyota System, widely applied in the industry and adapted to the health area in order to reduce costs and optimize resources through a process review to generate value for the patient11. Radnor ZJ, Holweg M, Waring J. Lean in healthcare: the unfilled promise? Soc Sci Med. 2012;74(3):364-71. doi: https://doi.org/10.1016/j.socscimed.2011.02.011
https://doi.org/10.1016/j.socscimed.2011...
-22. Costa LBM, Godinho Filho M. Lean healthcare: review, classification and analysis of literature. Prod Plan Control. 2016;27(10):823-36. doi: https://doi.org/10.1080/09537287.2016.1143131
https://doi.org/10.1080/09537287.2016.11...
.

It is an integrated system of principles, practices, tools, and techniques focused on reducing waste, synchronizing workflows and managing its variability, which, when applied in the health area, is called Lean Healthcare33. D'Andreamatteo A, Ianni L, Lega F, Sargiacomo M. Lean in healthcare: a comprehensive review. Health Policy. 2015;119(9):1197-209 doi: https://doi.org/10.1016/j.healthpol.2015.02.002
https://doi.org/10.1016/j.healthpol.2015...
.

This methodology is not simply a manufacturing technique for reducing waste and costs, but a philosophy that is applied in any type of organization and depends on several factors to achieve satisfactory results. Health institutions are complex and with many processes that can be improved with the use of the tools proposed by Lean44. Womack JP. Going lean in healthcare. Cambridge: Institute for Healthcare Improvement; 2005. (Innovation Series).

Lean Healthcare is based on a five-stage process that, after adapting the principles of Lean55. Womack JP, Jones DT. Beyond Toyota: how to root out waste and pursue perfection. Harvard Bus Rev. 1996 [cited 2019 Aug 15];74(5):140-58. Available from: https://hbr.org/1996/09/how-to-root-out-waste-and-pursue-perfection
https://hbr.org/1996/09/how-to-root-out-...
, were presented as follows: i)defining the value of the clients to meet their needs, such as diagnostic tests and indicated therapy; ii)mapping the value, which includes defining activities from the beginning to the end of the process stages; iii)reviewing the value stream to identify waste and solve it, that is, adapting and being efficient in health care iv)pulling, defined by the ability to signal the pace of the activities for the following stages, with a view to avoiding stocks and; v)the quest for perfection, a stage that must drive the continuous improvement of Lean Healthcare with the care provided in a timely manner and with quality22. Costa LBM, Godinho Filho M. Lean healthcare: review, classification and analysis of literature. Prod Plan Control. 2016;27(10):823-36. doi: https://doi.org/10.1080/09537287.2016.1143131
https://doi.org/10.1080/09537287.2016.11...
,66. Hussain M, Malik M, Al Neyadi HS. AHP framework to assist lean deployment in Abu Dhabi public healthcare delivery system. Bus Process Manag J. 2016;22(3):546-65. doi: https://doi.org/10.1108/BPMJ-08-2014-0074
https://doi.org/10.1108/BPMJ-08-2014-007...
.

Several studies present the process of implementing Lean in different health settings: pharmacy77. Pazeti M, Calache L. Application of Lean Six Sigma Concepts to Medicine Dispensation of Public Health Centers. Advances in Human Factors and Ergonomics in Healthcare. 2017;482:119-27. doi: https://doi.org/10.1007/978-3-319-41652-6_12
https://doi.org/10.1007/978-3-319-41652-...
, gynecology and obstetrics service88. Fernández Aranda MI. Aplicación del método Lean Healthcare en un servicio de ginecología y obstetrícia. Metas Enferm. 2016 [citado 2019 jul 15];19(1):21-6. Disponíble en: https://www.enfermeria21.com/revistas/metas/articulo/80858/aplicacion-del-metodo-lean-healthcare-en-un-servicio-de-ginecologia-y-obstetricia/
https://www.enfermeria21.com/revistas/me...
, oncology99. Henrique DB, Rentes AR, Godinho Filho M, Esposto KF. A new value stream mapping approach for healthcare environments. Prod Plan Control. 2015;27(1):24-48. doi: https://doi.org/10.1080/09537287.2015.1051159
https://doi.org/10.1080/09537287.2015.10...
, radiotherapy1010. Al-Balushi MM, Al-Mandhari Z. Implementing Lean Management Techniques at a radiation oncology department. 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 ...
, operating rooms1111. 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 ...
, and enteral diet therapy in the medical surgical unit1212. Leite SC, Ferreira SF, Calixtro LG, Carvalho GM, Sarantopoulos A. Enteral diet therapy: use of the Lean Healthcare philosophy in process improvement. Rev Bras Enferm. 2019;72(Suppl 1):235-22. doi: https://doi.org/10.1590/0034-7167-2017-0746
https://doi.org/10.1590/0034-7167-2017-0...
.

It is worth highlighting some studies that used the principles of Lean and that brought benefits such as: improved workflow77. Pazeti M, Calache L. Application of Lean Six Sigma Concepts to Medicine Dispensation of Public Health Centers. Advances in Human Factors and Ergonomics in Healthcare. 2017;482:119-27. doi: https://doi.org/10.1007/978-3-319-41652-6_12
https://doi.org/10.1007/978-3-319-41652-...
-88. Fernández Aranda MI. Aplicación del método Lean Healthcare en un servicio de ginecología y obstetrícia. Metas Enferm. 2016 [citado 2019 jul 15];19(1):21-6. Disponíble en: https://www.enfermeria21.com/revistas/metas/articulo/80858/aplicacion-del-metodo-lean-healthcare-en-un-servicio-de-ginecologia-y-obstetricia/
https://www.enfermeria21.com/revistas/me...
,1212. Leite SC, Ferreira SF, Calixtro LG, Carvalho GM, Sarantopoulos A. Enteral diet therapy: use of the Lean Healthcare philosophy in process improvement. Rev Bras Enferm. 2019;72(Suppl 1):235-22. doi: https://doi.org/10.1590/0034-7167-2017-0746
https://doi.org/10.1590/0034-7167-2017-0...
; reduction of waste1010. Al-Balushi MM, Al-Mandhari Z. Implementing Lean Management Techniques at a radiation oncology department. 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 ...
,1212. Leite SC, Ferreira SF, Calixtro LG, Carvalho GM, Sarantopoulos A. Enteral diet therapy: use of the Lean Healthcare philosophy in process improvement. Rev Bras Enferm. 2019;72(Suppl 1):235-22. doi: https://doi.org/10.1590/0034-7167-2017-0746
https://doi.org/10.1590/0034-7167-2017-0...
; and increased patient and professional satisfaction1010. Al-Balushi MM, Al-Mandhari Z. Implementing Lean Management Techniques at a radiation oncology department. 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 ...
,1313. Zeferino EBB, Sarantopoulos A, Spagnol GS, Min LL, Freitas, MIP. Value Flow Map: application and results in the disinfection center. Rev Bras Enferm. 2019;72(1):140-6. doi: https://doi.org/10.1590/0034-7167-2018-0517
https://doi.org/10.1590/0034-7167-2018-0...
; in addition to improving the operating and financial results of the institutions1010. Al-Balushi MM, Al-Mandhari Z. Implementing Lean Management Techniques at a radiation oncology department. 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 ...
,1212. Leite SC, Ferreira SF, Calixtro LG, Carvalho GM, Sarantopoulos A. Enteral diet therapy: use of the Lean Healthcare philosophy in process improvement. Rev Bras Enferm. 2019;72(Suppl 1):235-22. doi: https://doi.org/10.1590/0034-7167-2017-0746
https://doi.org/10.1590/0034-7167-2017-0...
.

However, longitudinal studies to monitor the results of its long-term implementation and its consequences for institutions, teams and patients are still scarce. Systematic reviews point to the need to improve the quality of evidence, in addition to the use of clear terminology for Lean Healthcare, transforming the language of manufacturing into one centered on health care33. D'Andreamatteo A, Ianni L, Lega F, Sargiacomo M. Lean in healthcare: a comprehensive review. Health Policy. 2015;119(9):1197-209 doi: https://doi.org/10.1016/j.healthpol.2015.02.002
https://doi.org/10.1016/j.healthpol.2015...
,1414. Amaratunga T, Dobranowski J. Systematic review of the application of Lean and Six Sigma quality improvement methodologies in radiology. J Am Coll Radiol. 2016;13(9):1088-95.e7. doi: https://doi.org/10.1016/j.jacr.2016.02.033
https://doi.org/10.1016/j.jacr.2016.02.0...

15. Hallam CRA, Contreras C. Lean healthcare: scale, scope and sustainability. Int J Health Care Qual Assur. 2018 Aug;31(7):684-96. doi: https://doi.org/10.1108/IJHCQA-02-2017-0023
https://doi.org/10.1108/IJHCQA-02-2017-0...
-1616. Lawal AK, Rotter T, Kinsman L, Sari N, Harrison L, Jeffery C, et al. Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Syst Rev. 2014;3 103. doi: https://doi.org/10.1186/2046-4053-3-103
https://doi.org/10.1186/2046-4053-3-103 ...
.

Given the above and the relevance of the Lean philosophy for management in health institutions, and because it is a relatively new subject, with the first publications appearing in 2002, the objective of the study was to analyze the scientific evidence in the literature on the evaluation of Lean Healthcare after its implementation.

METHOD

An integrative review study based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA1717. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. PLoS Med. 2009 Jul 21;6(7):e1000100. doi: https://doi.org/10.1371/journal.pmed.1000100
https://doi.org/10.1371/journal.pmed.100...
guidelines and included in the identification stages of the problem; literature search; evaluation and selection; analysis and interpretation of data1818. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nur. 2005;52(5):543-53. doi: https://doi.org/10.1111/j.1365-2648.2005.03621.x
https://doi.org/10.1111/j.1365-2648.2005...
. Therefore, the following was established as the research question: What were the results after the implementation of Lean Healthcare in health institutions?

The inclusion criteria considered the studies published in the last ten years (2008-2019) that address the proposed theme, and the availability of the entire text for the reader, in addition to them being written in English, Portuguese or Spanish. Editorials, letters to the editor, review studies, theses, dissertations, and studies that did not answer the research question or that described only the implementation stage of Lean were excluded.

The search for studies was carried out between July and September 2019, in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science (WOS), and Embase databases, as well as the US National Library of Medicine (PubMed) portal.

Medical Subject Headings (MeSH) were selected to search in the electronic databases. Thus, the following MeSH terms were used in the search strategy: “Total Quality Management”, “Quality Improvement” and the keyword “Lean healthcare”, defined by the authors after previous reading of the theme. The Boolean operators AND and OR were used in the crossing of the MeSH term and the keyword to expand the search for scientific evidence.

The initial search in each database, using the intersections of the search terms, according to each controlled vocabulary (MesH, EMTREE, and CINAHL titles) and keyword, resulted in 126 documents, which went through new stages of selection, represented in the flowchart in Figure 1. The search and selection of studies were carried out simultaneously by two researchers and, in situations of divergence, consensus was sought with the participation of an auxiliary researcher.

Figure 1-
Flowchart prepared in accordance with the PRISMA recommendations for the process of identification, selection, and inclusion of articles.

To classify the level of evidence, seven levels were considered: level I - evidence from a systematic review or meta-analysis of all the relevant and randomized controlled trials or from guidelines based on systematic reviews of randomized controlled trials; level II - evidence obtained from at least one randomized, controlled and well-designed clinical trial; level III - evidence of a well-designed and controlled study, without randomization; level IV - evidence from cohort or case-control studies; level V - evidence of a systematic review of descriptive and qualitative studies; level VI - evidence derived from a single descriptive or qualitative study; and level VII - evidence from the opinion of authorities and/or experts/expert committee reports1919. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Searching for the evidence: strategies to help you conduct a successful search. Am J Nurs. 2010;110(1):41-7. doi: https://doi.org/10.1097/01.NAJ.0000372071.24134.7e
https://doi.org/10.1097/01.NAJ.000037207...
.

RESULTS

A total of 126 articles were identified in the databases: 20 in CINAHL, 26 in Embase, 26 in PubMed, 37 in Scopus, and 17 in WOS, in addition to four articles included manually, searched from the verification of the reference lists, totaling 130 documents.

The reference manager (EndNote) was used to organize the search results, remove duplications, and assist in the selection. A total of 81 repeated studies were excluded, resulting in 49 documents. Subsequently, the titles and abstracts were read, excluding those that did not meet the criteria. Then, after a thorough and detailed reading, another four studies were excluded, as they did not answer the research question, resulting in a final sample of 18 articles.

For the analysis of the selected articles, a spreadsheet was built by the authors in order to target the evaluation and validation of the included studies, containing the following information: First author, year, country, objective, type of study, place of implementation, sample, perspective of analysis of results, level of evidence and main findings (Chart 1).

The final sample presented 88.9% of international productions and 11.1% of national ones. As for the focus, 27.7% of the articles have a qualitative approach, 50.0% quantitative, and 22.3% mixed. Regarding the design, we found variety in the types of studies presented, highlighting three studies that used more robust designs: longitudinal, experimental, and cohort. Thus, regarding the levels of evidence, 77.7% were level VI and 16.6%, level IV1919. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Searching for the evidence: strategies to help you conduct a successful search. Am J Nurs. 2010;110(1):41-7. doi: https://doi.org/10.1097/01.NAJ.0000372071.24134.7e
https://doi.org/10.1097/01.NAJ.000037207...
. One study could not be classified regarding the level of evidence, as it did not specify the type of study carried out.

For the analysis of the findings, they were categorized into results from the perspective of the institution, the professional, and the patient.

Chart 1 -
Characterization of the studies in relation to the 1stauthor, year, country, objective, type of study, place of implementation, sample, perspective of analysis of the implementation, level of evidence, and main findings. Campinas, SP, Brazil, 2019.

DISCUSSION

The eighteen articles that met the inclusion criteria were published in English between 2014 and 2019, with the majority being in the last three years (55.5%). As for the location, they were carried out in European (38.9%), American (33.3%), Asian (16.7%) and African (11.1%) countries. It is worth mentioning that the two articles from Brazil were published by authors from the state of São Paulo.

The findings showed diversity regarding the contexts in which Lean was implemented. The hospital area was predominant, accounting for 50% of the studies, followed by primary care and by support and diagnostic health services, with 12.3% and 16.6%, respectively. Two studies2929. 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...
,3434. 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...
(11.1%) carried out their analyses in two concomitant scenarios: assistance, and support and diagnosis services.

The results are presented below, according to the proposed grouping, in the perspective of evaluation after the implementation of Lean Healthcare in the categories: institutional, professional and patients.

From the institutional perspective, the studies brought results related to the work environment3232. 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 ...
; waste reduction2222. 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...
,2626. 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:965-9,2929. 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...
; cost analysis2222. 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...
,2626. 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:965-9,2828. 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...
,3333. 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...
; increase in productivity1111. 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 ...
,2222. 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...
,2424. 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 ...
,2626. 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; financial return2222. 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...
,2424. 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 ...
; response time2424. 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 ...
,2626. 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, permanence2828. 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...
,3030. 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...
and waiting time of the patient3030. 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...
; improvement in the performance of institutional indicators2323. 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....
,3636. 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 ...
; increase in the installed capacity of the services2424. 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 ...
; improvement in quality of care2626. 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:965-9,3232. 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 ...
; optimization of the physical structure1111. 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 ...
; turnover time1111. 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 ...
, and impacts on transformational leadership2727. 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...
.

In addition, a study conducted in Brazil compared the application of the traditional model of Total Quality with a theoretical approach of Lean Healthcare cases and a practical situation of this philosophy. It was concluded that Lean was better systematically appropriate, considering that it kept the focus on the patient, through the use of interaction instruments. On the other hand, the application of Total Quality did not promote team participation and partially shifted the responsibility from the professionals to bureaucratic tasks, causing a loss of focus2929. 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...
. It is highlighted that Lean proposes participatory management with greater involvement of the workers in decision-making processes, dividing responsibility and sharing power2424. 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 ...
.

It is worth highlighting the study2020. 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...
) that proposed a new perspective of analysis, evaluating the maturity of institutional Lean. High maturity was considered when all the principles were adopted and by all the employees, their evaluation being relevant, since it contributes to the analysis and sustainability of the results achieved with the method3737. Antierens A, Beeckman D, Verhaeghe S, Myny D, Van Hecke A. How much of Toyota’s philosophy is embedded in health care at the organisational level? a review. J Nurs Manag. 2018 May;26(4):348-57. doi: https://doi.org/10.1111/jonm.12555
https://doi.org/10.1111/jonm.12555 ...
-3838. Hasle P, Nielsen AP, Edwards K. Application of lean manufacturing in hospitals - the need to consider maturity, complexity, and the value concept. Human Factors Ergon Manuf Serv Ind. 2016;26(4):430-42. doi: https://doi.org/10.1002/hfm.20668
https://doi.org/10.1002/hfm.20668 ...
. Therefore, when evaluating in the context of primary care, the author obtained a variation in maturity between and within the health units. The greatest maturity was found for the “adhering to routines” item and the lowest for the “having a change agent in the unit” item, that is, most of the teams were highly qualified in the development, updating, and monitoring of the routines; however, 81% of the teams indicated that the unit did not have this “change agent”. Maturity was also positively associated with care satisfaction and adherence to the national guidelines for improving quality of health care2020. 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...
.

Regarding the professional perspective, the studies presented findings related to job satisfaction2323. 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....
,2626. 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) and regarding the care provided2020. 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...
; medical adherence2121. 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...
to Lean; workforce flexibility2727. 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...
; leadership of the team2727. 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...
,3636. 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 ...
; attitudes3131. 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...
-3232. 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 ...
; behavior3131. 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...
; commitment3232. 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 ...
; time devoted to assistance3333. 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...
, and the change of roles and responsibilities with the implementation of Lean3434. 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...
.

One of the studies highlighted that medical adherence influences the results of Lean2121. 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...
, revealing that younger, less experienced physicians were more likely to be committed to the initiative; in addition, the training level and positive previous experience facilitated adherence to the method. Some factors of medical resistance were highlighted, such as longest professional experience, reorganization of the work process, and the threat in the power relationship2121. 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...
. As the challenge of adhering to Lean, the other health professionals face the different characteristics in the work process, autonomy in decision-making, and engagement of the team3434. 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...
.

The medical professional plays an important role for the culture of continuous improvement2121. 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...
; however, it is worth mentioning that the approach of the multidisciplinary team, together with the training of this philosophy, is fundamental for the achievement of results in the implementation and maintenance of Lean1313. Zeferino EBB, Sarantopoulos A, Spagnol GS, Min LL, Freitas, MIP. Value Flow Map: application and results in the disinfection center. Rev Bras Enferm. 2019;72(1):140-6. doi: https://doi.org/10.1590/0034-7167-2018-0517
https://doi.org/10.1590/0034-7167-2018-0...
,3939. Honda AC, Bernardo VZ, Gerolamo MC, Davis MM. How Lean Six Sigma principles improve hospital performance. Qual Manag J. 2018;25(2):70-82 doi: https://doi.org/10.1080/10686967.2018.1436349
https://doi.org/10.1080/10686967.2018.14...
-4040. Henrique DB, Godinho Filho M. A systematic literature review of empirical research in Lean and Six Sigma in healthcare. Total Qual Manag. 2020;31(4):429-49 doi: https://doi.org/10.1080/14783363.2018.1429259
https://doi.org/10.1080/14783363.2018.14...
) .

Team training, process management, continuous improvement, and delegation of responsibilities have shown to be the pillars of this methodology, but it is necessary to involve the management to increase the motivation of the professionals and to avoid the exhaustion inherent to health work2323. 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....
. Therefore, strong leadership and an engaged team are essential to build an organizational Lean culture3030. 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...
,4040. Henrique DB, Godinho Filho M. A systematic literature review of empirical research in Lean and Six Sigma in healthcare. Total Qual Manag. 2020;31(4):429-49 doi: https://doi.org/10.1080/14783363.2018.1429259
https://doi.org/10.1080/14783363.2018.14...
where problems are seen as an opportunity for improvement, with the customer as main focus4141. Romeu-Silva SN, Spagnol GS, Li LM . Lean Healthcare modelo de gestão para projeto piloto no Ambulatório de Neurologia/AVC. Rev Saberes Univers. 2016 [citado 2019 jul 15];1(2):3-13. Disponível em: https://econtents.bc.unicamp.br/inpec/index.php/saberes/article/view/6949/4344
https://econtents.bc.unicamp.br/inpec/in...
.

As for the patient category, the aspects addressed were the following: satisfaction2525. 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...
-2626. 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:965-9,3030. 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...
, attitudes, and behavior3232. 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 ...
. This perspective was the least evaluated in the selected sample (22.2%); however, it is important to consider the patient's needs in order to reduce costs and improve the care processes4242. Min LL, Sharon J. Lean thinking turns ‘time is brain’ into reality. Arq.Neuro-Psiquiatr. 2015;73(6):526-30. doi: https://doi.org/10.1590/0004-282X20150047
https://doi.org/10.1590/0004-282X2015004...
, which reflects positively on quality and safety22. Costa LBM, Godinho Filho M. Lean healthcare: review, classification and analysis of literature. Prod Plan Control. 2016;27(10):823-36. doi: https://doi.org/10.1080/09537287.2016.1143131
https://doi.org/10.1080/09537287.2016.11...
,66. Hussain M, Malik M, Al Neyadi HS. AHP framework to assist lean deployment in Abu Dhabi public healthcare delivery system. Bus Process Manag J. 2016;22(3):546-65. doi: https://doi.org/10.1108/BPMJ-08-2014-0074
https://doi.org/10.1108/BPMJ-08-2014-007...
.

CONCLUSION

This study contributes to the need to establish a systematic assessment of Lean Healthcare after its implementation. The findings indicated that the most used category was institutional, with cost analysis and increased productivity being the most frequent results; followed by the professional, with job satisfaction and leadership as the most evaluated aspects and; finally, in the context of the patients, which was discussed as regards their satisfaction, attitudes, and behaviors. It should be highlighted that, in Lean, the value is defined by the patient and that this aspect in the results is still little explored.

This study provided an in-depth and integrated review on the theme; however, some limitations must be considered, such as the difference in the evaluation time after implementation; the various scenarios evaluated that make it impossible to compare institutions, and the predominance of the level of evidence VI, which should be considered in prospective studies. Therefore, it reinforces the need to establish, for the management, a systematic method of monitoring the results achieved in the implementation phase of Lean Healthcare.

The importance of expanding and continuing investigations in this field is highlighted, with well-defined and robust methods, in order to better understand the success factors and barriers to their implementation, in addition to their long-term impact for the institution, the professional, and the patient, as well as the maturity of the philosophy.

Acknowledgment:

Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) - Brazil - Finance Code 88882.434708/2019-01.

REFERENCES

  • 1. Radnor ZJ, Holweg M, Waring J. Lean in healthcare: the unfilled promise? Soc Sci Med. 2012;74(3):364-71. doi: https://doi.org/10.1016/j.socscimed.2011.02.011
    » https://doi.org/10.1016/j.socscimed.2011.02.011
  • 2. Costa LBM, Godinho Filho M. Lean healthcare: review, classification and analysis of literature. Prod Plan Control. 2016;27(10):823-36. doi: https://doi.org/10.1080/09537287.2016.1143131
    » https://doi.org/10.1080/09537287.2016.1143131
  • 3. D'Andreamatteo A, Ianni L, Lega F, Sargiacomo M. Lean in healthcare: a comprehensive review. Health Policy. 2015;119(9):1197-209 doi: https://doi.org/10.1016/j.healthpol.2015.02.002
    » https://doi.org/10.1016/j.healthpol.2015.02.002
  • 4. Womack JP. Going lean in healthcare. Cambridge: Institute for Healthcare Improvement; 2005. (Innovation Series)
  • 5. Womack JP, Jones DT. Beyond Toyota: how to root out waste and pursue perfection. Harvard Bus Rev. 1996 [cited 2019 Aug 15];74(5):140-58. Available from: https://hbr.org/1996/09/how-to-root-out-waste-and-pursue-perfection
    » https://hbr.org/1996/09/how-to-root-out-waste-and-pursue-perfection
  • 6. Hussain M, Malik M, Al Neyadi HS. AHP framework to assist lean deployment in Abu Dhabi public healthcare delivery system. Bus Process Manag J. 2016;22(3):546-65. doi: https://doi.org/10.1108/BPMJ-08-2014-0074
    » https://doi.org/10.1108/BPMJ-08-2014-0074
  • 7. Pazeti M, Calache L. Application of Lean Six Sigma Concepts to Medicine Dispensation of Public Health Centers. Advances in Human Factors and Ergonomics in Healthcare. 2017;482:119-27. doi: https://doi.org/10.1007/978-3-319-41652-6_12
    » https://doi.org/10.1007/978-3-319-41652-6_12
  • 8. Fernández Aranda MI. Aplicación del método Lean Healthcare en un servicio de ginecología y obstetrícia. Metas Enferm. 2016 [citado 2019 jul 15];19(1):21-6. Disponíble en: https://www.enfermeria21.com/revistas/metas/articulo/80858/aplicacion-del-metodo-lean-healthcare-en-un-servicio-de-ginecologia-y-obstetricia/
    » https://www.enfermeria21.com/revistas/metas/articulo/80858/aplicacion-del-metodo-lean-healthcare-en-un-servicio-de-ginecologia-y-obstetricia/
  • 9. Henrique DB, Rentes AR, Godinho Filho M, Esposto KF. A new value stream mapping approach for healthcare environments. Prod Plan Control. 2015;27(1):24-48. doi: https://doi.org/10.1080/09537287.2015.1051159
    » https://doi.org/10.1080/09537287.2015.1051159
  • 10. Al-Balushi MM, Al-Mandhari Z. Implementing Lean Management Techniques at a radiation oncology department. 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
  • 11. 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
  • 12. Leite SC, Ferreira SF, Calixtro LG, Carvalho GM, Sarantopoulos A. Enteral diet therapy: use of the Lean Healthcare philosophy in process improvement. Rev Bras Enferm. 2019;72(Suppl 1):235-22. doi: https://doi.org/10.1590/0034-7167-2017-0746
    » https://doi.org/10.1590/0034-7167-2017-0746
  • 13. Zeferino EBB, Sarantopoulos A, Spagnol GS, Min LL, Freitas, MIP. Value Flow Map: application and results in the disinfection center. Rev Bras Enferm. 2019;72(1):140-6. doi: https://doi.org/10.1590/0034-7167-2018-0517
    » https://doi.org/10.1590/0034-7167-2018-0517
  • 14. Amaratunga T, Dobranowski J. Systematic review of the application of Lean and Six Sigma quality improvement methodologies in radiology. J Am Coll Radiol. 2016;13(9):1088-95.e7. doi: https://doi.org/10.1016/j.jacr.2016.02.033
    » https://doi.org/10.1016/j.jacr.2016.02.033
  • 15. Hallam CRA, Contreras C. Lean healthcare: scale, scope and sustainability. Int J Health Care Qual Assur. 2018 Aug;31(7):684-96. doi: https://doi.org/10.1108/IJHCQA-02-2017-0023
    » https://doi.org/10.1108/IJHCQA-02-2017-0023
  • 16. Lawal AK, Rotter T, Kinsman L, Sari N, Harrison L, Jeffery C, et al. Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Syst Rev. 2014;3 103. doi: https://doi.org/10.1186/2046-4053-3-103
    » https://doi.org/10.1186/2046-4053-3-103
  • 17. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. PLoS Med. 2009 Jul 21;6(7):e1000100. doi: https://doi.org/10.1371/journal.pmed.1000100
    » https://doi.org/10.1371/journal.pmed.1000100
  • 18. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nur. 2005;52(5):543-53. doi: https://doi.org/10.1111/j.1365-2648.2005.03621.x
    » https://doi.org/10.1111/j.1365-2648.2005.03621.x
  • 19. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Searching for the evidence: strategies to help you conduct a successful search. Am J Nurs. 2010;110(1):41-7. doi: https://doi.org/10.1097/01.NAJ.0000372071.24134.7e
    » https://doi.org/10.1097/01.NAJ.0000372071.24134.7e
  • 20. 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-04-2018-0118
  • 21. 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
  • 22. 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-08-2016-011
  • 23. 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.2017.03.009
  • 24. 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
  • 25. 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-2015-004290
  • 26. 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
  • 27. 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-06-2014-0090
  • 28. 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.0000000000000075
  • 29. 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/10.1590/0104-1169.0151.2605
  • 30. 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.0000000000000228
  • 31. 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.2014.09.008
  • 32. 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
  • 33. 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.2015.03.002
  • 34. 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-03-2013-0066
  • 35. 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.2014.157.172
  • 36. 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
  • 37. Antierens A, Beeckman D, Verhaeghe S, Myny D, Van Hecke A. How much of Toyota’s philosophy is embedded in health care at the organisational level? a review. J Nurs Manag. 2018 May;26(4):348-57. doi: https://doi.org/10.1111/jonm.12555
    » https://doi.org/10.1111/jonm.12555
  • 38. Hasle P, Nielsen AP, Edwards K. Application of lean manufacturing in hospitals - the need to consider maturity, complexity, and the value concept. Human Factors Ergon Manuf Serv Ind. 2016;26(4):430-42. doi: https://doi.org/10.1002/hfm.20668
    » https://doi.org/10.1002/hfm.20668
  • 39. Honda AC, Bernardo VZ, Gerolamo MC, Davis MM. How Lean Six Sigma principles improve hospital performance. Qual Manag J. 2018;25(2):70-82 doi: https://doi.org/10.1080/10686967.2018.1436349
    » https://doi.org/10.1080/10686967.2018.1436349
  • 40. Henrique DB, Godinho Filho M. A systematic literature review of empirical research in Lean and Six Sigma in healthcare. Total Qual Manag. 2020;31(4):429-49 doi: https://doi.org/10.1080/14783363.2018.1429259
    » https://doi.org/10.1080/14783363.2018.1429259
  • 41. Romeu-Silva SN, Spagnol GS, Li LM . Lean Healthcare modelo de gestão para projeto piloto no Ambulatório de Neurologia/AVC. Rev Saberes Univers. 2016 [citado 2019 jul 15];1(2):3-13. Disponível em: https://econtents.bc.unicamp.br/inpec/index.php/saberes/article/view/6949/4344
    » https://econtents.bc.unicamp.br/inpec/index.php/saberes/article/view/6949/4344
  • 42. Min LL, Sharon J. Lean thinking turns ‘time is brain’ into reality. Arq.Neuro-Psiquiatr. 2015;73(6):526-30. doi: https://doi.org/10.1590/0004-282X20150047
    » https://doi.org/10.1590/0004-282X20150047

Publication Dates

  • Publication in this collection
    12 Aug 2020
  • Date of issue
    2020

History

  • Received
    03 Oct 2019
  • Accepted
    28 Apr 2020
Universidade Federal do Rio Grande do Sul. Escola de Enfermagem Rua São Manoel, 963 -Campus da Saúde , 90.620-110 - Porto Alegre - RS - Brasil, Fone: (55 51) 3308-5242 / Fax: (55 51) 3308-5436 - Porto Alegre - RS - Brazil
E-mail: revista@enf.ufrgs.br