Key Themes in the Lean Healthcare Literature

A synthesis of academic writings on lean in healthcare can be divided into five key themes:

  • 1. Secondary care (hospital) setting: The majority of papers reviewed refer to research that has been conducted in the acute (hospital) setting (e.g. Coffin 2013; Vats et al. 2012). The most popular areas include the emergency department (e.g. Dickson et al. 2009), surgery (e.g. Mandahawi et al. 2011) and the ward (e.g. Morrow et al. 2012). Few papers consider the patient journey beyond the initial care setting in which the research is undertaken. The need to extend the research across organisational boundaries is a challenging but necessary call for future research.
  • 2. Role of standardisation: Standardisation is an area of lean that has generated some debate in terms of whether it is appropriate for healthcare. Many healthcare professionals believe that standardisation and the delivery of healthcare are at odds, particularly as the needs of patients can be complex and therefore the care they need will vary considerably. However, it is important to make the distinction between standardisation of care and the standardisation of processes employed to deliver healthcare services. Understanding variability and variation is fundamental to the redesign of patient pathways and healthcare services generally.
  • 3. Tool focus rather than patient focus: Many of the studies (e.g. Radnor et al. 2012) describe the tools and techniques that have been employed within improvement programmes. Although it is important for the development of theory to understand how these are being adopted for use in healthcare, there is also a need to report the benefits to patients. Much of the commentary focuses on how these tools and techniques have been implemented and there is less evidence on what difference these have made in relation to improvement of services for patients and staff and the wider healthcare system.
  • 4. Sustainability is an issue that some papers allude to in relation to lean in healthcare. Specifically, Radnor et al. (2012) from their case analysis of four UK hospitals report lean to be on the “fringes” of service transformation. Whilst the organisations reported short-term gains the majority failed to deliver more widespread and sustained improvements. The main reason given for these sustainability problems was the tool-based implementation. A more recent case (Burgess et al. 2015) reports on the demise of a whole systems approach to improvement as a result of a financial and performance crisis.
  • 5. Professional and functional silos: One of the main barriers to lean healthcare is reported to stem from how healthcare organisations are structured and the fragmentation of care and professional practice (Brandao de Souza and Pidd 2011). A professional silo refers to the professional groupings, of which a typical hospital might have a hundred or more. A simple professional division can be made between medical (e.g. doctors, nurses, therapists etc.) and non-medical (managers, administrators, finance, HR, etc.) staff. Some professional silos can be further divided into sub-silos which also include distinctions for seniority (e.g. registrars, junior doctors). This complex structure of professional silos is likely to inhibit or compromise communication and levels of interaction (Brandao de Souza and Pidd 2011).

A functional silo may contain members of many different professional silos (e.g. surgery may include general surgery, orthopaedics, anaesthetists, etc.) or those departments that undertake specific tasks such as phlebotomy, imaging, pharmacy, etc. Functional silos often lead to care being fragmented with the performance of single silos being improved but overall patient care being diminished (Mann 2005).

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