6th IFAC Conference on Management and Control of Production

and Logistics
The International Federation of Automatic Control
September 11-13, 2013. Fortaleza, Brazil

Lean principles in Healthcare: an overview of challenges and improvements

Gabriela S. Spagnol*. Li Li Min**,
David Newbold***
*Science Without Borders Student – CAPES. University of East London, London, E16 2RD, UK (Tel: +44 (0)20 8223 3000) and
Faculty of Medical Sciences, University of Campinas, São Paulo, SP 13083-887, Brazil (gabrielaspagnol21@hotmail.com)
**Faculty of Medical Sciences, University of Campinas (limin@fcm.unicamp.br)
*** University of East London ( e-mail: d.a.newbold@uel.ac.uk).

Abstract: The Institute of Medicine (IOM) estimates that, on average, hospitalized patients are subject to
at least one medication error per day. Patient safety and service quality systems have been developed in
order to establish barriers to medical errors. One method to reduce errors is continuous process
improvement through relentless waste reduction and its origin lies in the Japanese car industry. The Toyota
Production System (TPS) was capable of increasing reliability and reducing costs. Manufacturers and
academics went to Japan to learn the range of concepts later called as lean. The Lean approach, based on
Toyota’s concepts, relates to the complete elimination of waste (called ‘muda’), by focusing on
improvement and flow control techniques. A process or activity is considered value-added if it is aligned
to the customers’ interests, who are considered the firm’s final judges. In a healthcare service, the patient
seeks for cure or pain relief and that is what defines value in healthcare. Regarding the application of Lean
Thinking in healthcare, this article aims to analyze international studies on this field, discussing challenges
faced and success factors during its application, in order to guide future implementations in healthcare.
The studies were organized within the following topics: ‘Lean Healthcare implementation and the
Toyota’s Rules’; ‘Experience in hospitals worldwide’ and ‘Challenges in the implementation: overcoming
barriers’. Among the studies, many positive outcomes were registered, but a few have succeeded on
implementing lean principles in an organizational level. Therefore, this article concludes that to deliver
world-class healthcare in face of constrained resources and greater demand, a long-term vision and world-
class leadership should be developed to sustain the initiative and insert Lean in the DNA of healthcare
organizations. Keywords: lean principles, lean healthcare, service quality.

improvements, in which all employees actively participate’

1. INTRODUCTION
The Institute of Medicine (IOM) estimates that, on average,
hospitalized patients are subject to at least one medication
error per day (Radley et al, 2013). Medication errors are
expensive, harmful to patients and contradict the most basic
principle in health: ‘first, do no harm’ (Grout and Toussaint,
2009). Patient safety and service quality systems have been
developed in order to establish barriers to medical errors
(Kenagy et. al., 2007). One of these methods is characterized
by continuous process improvement through relentless waste
reduction, known as lean (Grout and Toussaint, 2009).
The origin of lean concepts lies in the Japanese car industry.
During the 1970’s in the United States of America, cars were
expected to require a lot of maintenance. The Toyota
Production System (TPS) changed that by providing
reliability on even less expensive models (Ohno, 1988).
Manufacturers and academics went to Japan to learn the
range of concepts later called as lean (Toussaint, Gerard and
Adams, 2010, p. 13). Lean reflects techniques and tools from
Total Quality Management (TQM) (Freytag and Arlbjørn,
2013; Dahlgaard and Dahlgaard-Park, 2006) and the early
work of Frederick W. Taylor’s The Principles of Scientific
Management (Taylor, 1911; Freytag and Arlbjørn, 2013).
From the TQM, lean has encompassed the company culture
of ‘increased customer satisfaction through continuous
(Andersson et.al., 2006, p.284).
Since its introduction and international recognition by the
book ‘The Machine That Changed The World’ (Womack et
al., 1990), lean has been applied in areas as service
companies (Swank, 2003; Piercy and Rich, 2009),
administrative processes (Atkinson, 2004), healthcare
(Kollberg et al., 2007; Brandao de Souza, 2009; LaGanga,
2011) and public administration (Pedersen and Huniche,
2011). Lean could be defined to include elements from
concepts such as just in time (TIP), TQM and business
process engineering (BPR); then, perhaps none of its
elements are actually new. However, it could be argued that it
is the combination of elements and tools that is new (Radnor
and Boaden, 2010). Regarding the application of Lean
Thinking in healthcare, this article aims to analyse
international studies on this field, discussing challenges faced
and success factor during its application, in order to guide
future implementations in healthcare.
2. METHODOLOGY
This paper consists of a narrative review of literature based
on the following databases: (a) Emerald and (b) Pubmed and
on hand-search. ‘Handsearching’ consists in a manual
examination of the entire contents of a journal issue to
identify all eligible reports of trials.

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Table 1 - The Seven Wastes results they were organized under the following topics: ‘Lean
Healthcare Implementation and the Toyota’s Rules’;
Ohno’s Seven Definition Healthcare example from
Wastes reviewed studies ‘Experience in hospitals worldwide’; ‘Challenges in the
implementation: overcoming barriers’.
Waste of time unnecessary In Canada, through the use of
queues and visual reminders and standard 3. DISCUSSION
waiting for process worksheets, quality
materials, improvement teams were able 3.1 Lean Healthcare Implementation and the Toyota’s Rules
resources and to achieve large reductions in
services, opposite physician reassessment waiting The first step towards waste reduction is to identify value-
to ‘just-in-time’ time. These improvements added steps in every process, accurately specifying those in
supply required minimal materials cost
and no additional staff the value stream map (Institute for Healthcare Improvement,
(Willoughby et. al., 2010). 2005). For instance, the customer would pay for the widget to
be assembled and painted blue, but not for the overproduction
Waste of wasteful patient In Virginia Mason Center, the
movement movement or distance travelled by people
and storage of widgets. The last is considered waste, which
misaligned to the reduced in 44% (Institute for have been described as seven types. In Table 1, these are
service demand: Healthcare Improvement, 2005) exemplified according to studies analysed.
too fast or too
slow These wastes can be recognized and eliminated using lean
Waste of holding high e.g. using beds to hold patients
principles and tools, as described in Table 2 and Figure 1
inventory levels of that could be discharged or over (Virtue and Chaussalet, 2013). Regarding that, several case
inventory which ordering material to compensate stories can be found on lean thinking initiatives in healthcare
could include for erratic supply. sector (McCulloch et. al., 2010; Holden, 2011; Kim et.al.,
patients
2007), which show positive impact on productivity, cost,
Waste of unnecessary e.g. reprocessing of exams quality, and timely delivery of services due to lean principles
processing processing because of reading errors, applied throughout the organization. Furthermore, in a
fulfilment of similar forms in healthcare service, the patient seeks for the cure or pain relief
different departments for the
same patient, reschedule of and that is what defines value in healthcare. The process to
missed appointments achieve this final goal is known as patient flow in healthcare.
It not only relates to physical goods like drugs,
Waste of defects in the Complaints about the assistance
making process and in and products provided that
pharmaceuticals, medical devices and health aids, but also to
defective services, don’t attend the customer’s all phases of their treatment from referral to full recovery
products expectations (lack of value for (Vries and Huijsman, 2011; Kenney, 2011).
the consumer)
Table 2 – Lean Principles
Waste in staff and material In Virginia Mason Center, there
transportation unnecessary was a reduction of 72% of Value Defined according to customer’s view and waste
movement product travelled distance after identification.
2 years of Lean implementation
(Institute for Healthcare Value 1) Product/service definition – from its concept, detailed
Improvement, 2005) planning and launch;
stream
Waste of just in case and/or unnecessary referrals, tests, map 2) Information management – from order taking, detailed
overproduction batch activity, hospitalisations, materials scheduling to delivery;
production must acquisition in excess.
be aligned to time 3) Physical transformation – from initial concept to product
and amount of delivery to consumer.
requested service
Flow This phase requires removal of large obstructions and
process reformulation, introducing new types of
In this article, handsearching included checking the reference organizations and technologies, eliminating interruption,
lists of journal articles, a technique called ‘snowballing’ detours, backflows or waiting.
(Higgins and Green, 2006). The term used to search was
‘lean healthcare’ and the number of articles found was: (a) Pull What the customer wants and when he wants it. The
customer is allowed to pull the service and it results in
417 and (b) 484. The inclusion criteria used was the presence prevention of waste, such as production of obsolete or
in the title of any reference to the implementation of lean or undesired goods, elaboration of unnecessary inventory
its tools in healthcare organisations, as the presence of ‘lean tracking system and overproduction.
manufacturing’, ‘lean production’, ‘lean thinking’, ‘Toyota Perfection Continuous and systematical root causes removal to achieve
Production’, ‘5S’, ‘Six Sigma’. Studies published before the ultimate goal of zero defects, minor time, steps and
2003 were excluded. Therefore, were selected: (a) 75 and (b) waste on customer services
25 studies from each database. Some articles were in both
databases, the final number of papers analysed was 37. The According to Womack and Jones (2003), lean application in
handsearch and snowball technique added 20 studies, healthcare focus on the patient and includes time and comfort
resulting in 57 studies analysed. A yearly growth in number as key performance measures of the system. Having multi-
of publications was observed, which points to an increasing skilled teams taking care of the patient and an active
presence of lean healthcare worldwide. Studies selected differ involvement of the patient in the process is emphasized.
in their research questions, design and results; to compare Quality improvements are driven by front line staff according

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to their perceptions of what needs to change (McCulloch et.
al., 2010; Joosten et. al., 2009) and what increases work
satisfaction by providing immediate feedback on efforts.
Thus, it represents a way to create new work rather than
simply destroying jobs in the name of efficiency (Womack
and Jones, 2003). The focus on zero defects, continuous
improvements and JiT (Just in Time) in healthcare makes
lean production especially applicable.
Fig. 1. ‘House of Quality’ for lean principles and tools. The
foundation of a lean implementation relies in the core principles:
eliminate waste, create flow and have respect for people, the agents
of change. Therefore, tools build the structure to achieve continuous
improvement, having the customer needs as the main goal.
In order to practice these principles, many tools are used, as
shown in Figure 1. Popular tools include Kaizen blitz, which
is sometimes referred to as rapid improvement event (RIE),
value stream mapping (VSM) and the six S’s (Sort,
Straighten, Shine, Standardise, Sustain, Safety – also referred
as 5S’s, as in Figure 1) are used to reorganize the working
place. RIE is a five-day workshop that aims at tracing
problems in the existing processes and suggests small and
quick changes (Fillingham, 2007; Snyder et. al., 2005). It
usually takes place in three phases, beginning with a
preparation period, followed by the event and a three to four-
week follow up period to implement the changes. VSM helps
in eliminating wasteful activities by the active participation
of all appropriate actors: those involved in the various steps
along the patient journey get together: firstly, to map out how
the process currently operates; and second, to identify waste
and delays and permit error visibility through daily audits
(McCulloch et.al., 2010; Papadopoulos, 2010). Furthermore,
Kollberg et. al. (2007) state that the map must analyse the
accessibility to healthcare services, interaction with the
healthcare organisation and patient participation. At last, the
flow map must be of visual access for the healthcare team
and include all steps of every process.
231
3.2 Experience in hospitals worldwide
According to reviewed articles, the pioneers in lean
healthcare in United States of America were Virginia Mason
in Seattle and Thedacare in Wisconsin (Institute for
Healthcare Improvement, 2005). For instance, in Virginia
Mason Medical Center, improvement results 2 years after
lean implementation (in 2002) registered a decrease in
expenditures (53% down in inventory), lead time (down
65%), people and product distance (decrease of 44% and
72%, respectively) and setup time (down 82%). This
achievements were based on six areas of focus: “Patient first”
as the driver for all process; the creation of an environment in
which people feel safe and free to engage in improvement –
including the adoption of a “no-layoff policy”;
implementation of a company-wide defect alert called “The
Patient Safety Alert System”; encouragement of innovation
and “trystorming” (beyond brainstorming, trystorming
involves quickly trying new ideas or models of new ideas);
creating a prosperous economic organization primarily by
eliminating waste; and accountable leadership (Kenney,
2011). Besides some different details, ThedaCare’s lean
history is similar to Virginia Mason’s. The organisation
centers its weekly meetings (called Event Week) in three
tenets: respect for people, teaching through experience and
focus on world-class performance, as well as in three goals:
improved staff morale, quality (reduction of defects) and
productivity. A new management culture is established;
managers become teachers and facilitators, rather than
directors setting rules (Toussaint et. al., 2010; Natarajan,
2006).
In United Kingdom, lean healthcare establishment in Bolton
Hospitals NHS Trust begins in 2005. Schenk (2006) argues
that lean represents a functional methodology and allows
well-planned and rapid improvement events. The author also
states that changes must involve the entire organisation in a
daily basis approach, using “Rapid Improvement Events”
(RIEs), 6S and the value stream map. These tools led to fewer
clinical incidents, fewer medication errors and higher staff
morale (Fillingham, 2007). Following these same principles,
NHS Trust in Scotland registered lean implementations
during the last few years. However, for many hospitals, it has
been stated that Lean is seen as a quick-win project; staff
training programs and implementation planning were
insufficient to embed Lean practices into the culture of NHS
Scotland (Antony and Kumar, 2012). In this study, five
barriers were identified to Lean implementation: culture and
resistance to change, lack of awareness, poor
training/coaching, availability of resources and time and lack
of leadership. Despite positive results when implemented,
lean initiatives remain department-restricted, such as in a
Dutch hospital, where lean principles and tools were used to
match supply with demand in an emergency department
(Rosmulder and Luitse, 2011). The next step, in both cases,
must be an entire organisation lean approach. Association
with universities, such as in a French case, provide resources
and support to accomplish a successful implementation, as
stated by Angelé-Halgand and S’Andreamatteo (2010).
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In Brazil, studies register lean initiatives in the healthcare
sector, such as in a hospital laundry (Cunha et. al, 2011), in
logistics activities of solid organs transplantation (Monteiro,
2011) and donation (Pestana et.al, 2013), in administration of
health care residues (Rodrigues et. al, 2008) and in the office
routine of health military organizations (Seraphim, 2010).
These studies show evidences that lean adapted to healthcare
in Brazil has improved clinical practice and management
processes, through an approximation between the medical
language and the process management language. Silberstein
(2006) highlights the synergy between evidence-based
medicine and lean thinking, permitting an integration of high
quality clinical practice and efficient process management.
Nevertheless, these studies refer to lean implementation in
offices or hospital departments. This is referred by Womack
and Jones (2003) as the first phase of a lean implementation.
Therefore, this paper suggests that the next step towards lean
healthcare in Brazil is to promote an entire change in the
organization culture, as the examples in USA and UK, to
permanently incorporate lean thinking.
3.3 Challenges in the implementation: overcoming barriers
This paper suggests a classification of barriers related to lean
implementation in three moments: (a) the first impression:
initial approach, (b) implementation process, and (c) lean
thinking maintenance. Regarding the first moment, most lean
projects are developed at departmental level (47%)
(Perdersen and Huniche, 2011), and even organisations which
administration is lean focused are still far from the ideal of
complete accordance with the principles. Attempts to
introduce lean thinking throughout the organisation are few,
for instance, in Denmark, only 16% of municipalities with
lean approaches have tried this goal (ibidem). A successful
tactic observed in the literature to implement lean (Snyder
and McDermott, 2009) was the support offered to a
department by a successful lean organisation, avoiding
common mistakes during early stages and permitting a higher
reliability on lean thinking due to staff having a successful
implementation as a model.
The Danish study also states that one great barrier to lean
implementation is the way it is negotiated with employees,
since the first moment (a) until the whole process is
developed (b). Among staff, it has been noted that not all
members have the same goals and values, what may result in
an incomplete adherence to lean principles (Storey et. al.,
2008). Two effective tactics used by hospitals to confront this
challenge were demonstrating results from elsewhere and
having senior-level leaders speak in terms of years of
commitment to Lean (Fine et. al., 2009). According to the
literature (Perdersen and Huniche, 2011), a good way to
involve people is to show quick visible results after lean
implementation, especially the ones that directly affect
employees’ satisfaction, such as reducing staff turnover or
workload. It must be clear to staff that lean ideals focus on
freeing resources to make what really matters, better; in
opposite to the wrong idea that lean management results in
staff reduction (Institute for Healthcare Improvement, 2005;
De Souza and Pidd, 2011, Fillingham, 2007, Hasle et. al.,
2012; Chalice, 2010).
232
Another difficulty described in studies (Brandao de Souza,
2009; Perdersen and Huniche, 2011; Papadopoulos, 2011)
was to gather all “decision makers” professionals in weekly
meetings, due to their full agenda. A simple issue like
meeting schedule is a potential barrier to an effective debate
and continuous development of lean thinking throughout
organisational structure. The involvement of professionals
from each department is crucial due to their reality
empowerment and specific knowledge about each department
process flow, important contributors during a value stream
map construction. Therefore, all employees must be educated
about the organisation’s strategy, understand their role and
personal goals, with its specific dates to accomplish. For that,
Chalice (2010) suggests the creation of a simple quality and
cost improvement manual and a ‘award/recognition/reward’
program to encourage employees’ involvement (Chalice,
2010).
During phase (c), organisation structure must prepare itself to
maintain the new management culture, and this implies time
investment and workload adaptation to new responsibilities.
A common mistake is to not devote necessary time for lean
activities, due to daily issues, leading to staff frustration in
face of poor results. At last, it is necessary to think lean as
something more than just a quick fix, the organisation has to
build internal competences in lean management and
implementation as part of the change process. Furthermore,
lean has been described in literature (Perdersen and Huniche,
2011) as vulnerable to key personnel changes. In order to
maintain the principles, lean change agents must remain on
leadership until lean thinking is successfully embedded in
organisation culture. As stated by Grove et al. (2010) , to
deliver world-class healthcare in face of constrained
resources and greater demand, hospitals need to develop a
long-term vision and world-class leadership to sustain the
initiative and insert Lean in the DNA of healthcare
organisations.
5. CONCLUSION AND RECOMMENDATIONS
Through this literature review, it has been observed an
increasing presence of lean principles and tools in healthcare
services, firstly in USA and UK and recently in other
countries, playing an important role in improvement and
service quality. According to Womack and Jones (2003), the
transition to lean requires a significant investment of time.
The current Toyota Production System has been in existence
since 1945; it has had many years of development to where it
is now. Therefore, the sense of urgency in healthcare services
improvement is recent compared to the world class
manufacturing organisations whose staff have long
understood the need for change and adapted in order to
remain competitive (Young and McClean, 2009; Langley et.
al., 2009). This recent focus on efficiency gains have led to a
number of partial implementations of lean as healthcare
managers have attempted to replicate success of others
without understanding underlying principles of lean.
However, a lot can be learnt from the early stages of Toyota
Production System implementation in the industry. This
knowledge can be used to prevent the same mistakes and
increase successful lean implementations in healthcare as the
ones cited in this research.
IFAC MCPL 2013
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According to articles reviewed, there are critical determinants
that need to be put in place before organisations can embark
on a lean transformation. These could be illustrated as a
house, such as in Figure 1. The foundation of a lean
implementation relies in the core principles: eliminate waste,
create flow and have respect for people, the agents of change.
Therefore, the tools build the structure to achieve continuous
improvement, having the customer needs as the main goal.
However, tools are easily seen and readily available, thus
they are often used for a quick fix. Unfortunately, a thorough
lean implementation requires all of the tasks from the
foundation of the house to the main aim at the roof. These
include the development of a shared vision and an action plan
(Hopp and Spearman, 2004). Lean implementation demands
changes in mindsets of health care professionals and
administrative staff, truly understanding that lean thinking is
not just about reducing waste, but enhancing efficiency,
having the patient at the centre of the care.
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