Total Quality Management & Business Excellence

ISSN: 1478-3363 (Print) 1478-3371 (Online) Journal homepage: https://www.tandfonline.com/loi/ctqm20

Simulation modelling and lean management in

healthcare: first evidences and research agenda

Maria Crema & Chiara Verbano

To cite this article: Maria Crema & Chiara Verbano (2019): Simulation modelling and lean
management in healthcare: first evidences and research agenda, Total Quality Management &
Business Excellence, DOI: 10.1080/14783363.2019.1572504

To link to this article: https://doi.org/10.1080/14783363.2019.1572504

Published online: 29 Jan 2019.

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Total Quality Management, 2019
https://doi.org/10.1080/14783363.2019.1572504

REVIEW

Simulation modelling and lean management in healthcare: first

evidences and research agenda
Maria Crema and Chiara Verbano *

Department of Management and Engineering, University of Padova, Vicenza, Italy

There is a growth in the literature on simulation in healthcare that has been flourishing in
the last few years, since it allows predicting the consequences of different alternative
scenarios without the risks and the costs of real experiments. However, no literature
reviews can be found on how and in which cases simulation modelling can support
the adoption of Health Lean Management (HLM), in order to maximise the value for
patients, reducing wastes. Therefore, this research aims to supply a comprehensive
view of the state of the art about the combined application of HLM and simulation,
gaining benefits in health service delivery. Through a systematic literature review, a
database of papers has been analysed, considering the context of the application, lean
tools and practices, simulation models and software, and results obtained, in addition
to descriptive characteristics. The projects analysed in the papers regard mostly
emergency settings, outpatient care, surgery and medical laboratory, with the aim of
improving the patient flow and achieving mainly efficiency and patient safety. The
paper discusses which simulation models and software have been adopted to support
the implementation of HLM tools and practices, in relation to the specific
performance improvements achieved, triggering managerial implications and future
research directions.
Keywords: health lean management; simulation modelling; performance
improvements; systematic literature review

Introduction
In the last decade, the healthcare system has been facing several challenges worldwide.
First, government spending review struggle to deal with rising healthcare costs because
of the economic crisis; on the other hand, the growing demand for high-quality care requires
performance improvements in terms of both clinical efficacy and patient safety (OECD,
2015). Therefore, the imperative is to optimise the use of resources, improving health
service efficiency. According to this, the World Health Organization (2010) reports that
up to 40% of health available funds are wasted, highlighting the need of a wise deployment
of resources, instead of simply cutting the delivery of care services.
Due to these conflicting key issues, the development of new managerial approaches,
models and tools are undoubtedly required in order to identify new efficient ways to
provide care, meeting customer expectations.
Lean Management (LM) is a managerial approach which has been widely used in man-
ufacturing companies for decades, but its principles are relatively new in the health care
sector. However, it has been demonstrated that LM tools are effective to facilitate and
support changes in the delivery of health care (Womack, Byrne, Fiume, Kaplan, &

*Corresponding author. Email: chiara.verbano@unipd.it

© 2019 Informa UK Limited, trading as Taylor & Francis Group

2 M. Crema and C. Verbano

Toussaint, 2005). The focus of LM is the value of any process from the customer’s point of
view; this should be pursued by identifying and reducing wastes and non-value-added
activities. A valuable support to LM can be provided by simulation modelling, which
has a much longer history in healthcare, starting from the 1970s (Robinson, Radnor,
Burgess, & Worthington, 2012). The aim of simulation modelling is the improvement of
process and service delivery using a computerised environment, in order to support
decision-making in several ways, like testing different scenarios, gaining immediate feed-
back about proposed changes and promoting communication without compromising patient
safety (Forsberg, Aronsson, Keller, & Lindblad, 2011). Only a little attention has been paid
so far to the potentialities that the combination of LM and simulation modelling can
provide. Through a systematic literature review, this research aims to supply a comprehen-
sive view of the state of the art about the combined application of Health Lean Management
(HLM) and simulation, gaining incremental benefits in health service delivery.
The rest of the paper is organised as follows: Section 2 illustrates the theoretical back-
ground and the motivation for the research, in Section 3 the objectives and the adopted
methodology are defined, Section 4 reports the results of the descriptive and content analy-
sis and, finally, Sections 5 and 6 set out the discussion of results and conclusion,
respectively.

Theoretical background
The recent diffusion of HLM among healthcare settings is due to the possibility ‘to do more
with less,’ so that it meets the requirements of the government spending review faced by
most healthcare systems. This would guarantee at the same time a growing level of
quality of care, safety and volume of services provided (Kim, Spahliner, & Billi, 2009).
HLM is indeed defined as a managerial approach aimed at improving the flow of care
processes, through the identification and further elimination of wastes, with the final intent
to increase the value for the customer from a patient-centred point of view, in a continuous
improvement perspective (Womack & Jones, 1996). A key concept in HLM is the optim-
isation of the value flow, analysing the sequence of activities, often invisible and not expli-
citly recognised by the organisation managers, which must run without interruption to
create value. Whenever resources are used for activities that do not add value from the cus-
tomer’s point of view, a waste of one of the following types is recognised: overproduction,
waiting, transport, loss of process, inventory, movements, and errors/defects (Radnor,
Holweg, & Waring, 2012).
Therefore, the HLM guiding principles suggest the following steps to maximise the
value: identification of the customer value, mapping the value flow, identifying and
solving the wastes, aligning the value flow with the customer demand and pursuing perfec-
tion (Womack & Jones, 1996; Radnor et al., 2012).
To this extent, a set of tools and practices can be adopted, deriving from the manufac-
turing industry (Table 1).
In addition to these tools, simulation modelling can be used to support decision-making
in operations management problems, regarding design, planning and control, and process
improvement (van Sambeek, Cornelissen, Bakker, & Krabbendam, 2010). The develop-
ment of the Lean methodology applied to health service is relatively recent (Souza,
2009) while the simulation models have been used in the health sector since the early
1960s (Benneyan, 1997). These models consolidated and improved over the years have
become valuable tools for serving as a more innovative managerial approach.
 Total Quality Management & Business Excellence 3

Table 1. Classification of lean tools by purposes. Source: adapted from (Costa & Godinho Filho,
2016).
Assessment Improvement Monitoring
5 Whys 5S’s Visual
A3 Team approach to problem solving management
Ishikawa diagram Spaghetti diagram
Process mapping Workload balancing
Value stream Continuous flow
mapping Andon
Gemba walking Rapid process improvements events/Kaizen
event
Jidoka
Pull system/Kanban
One-piece-flow
Mistake-proofing (Poka-yoke)
Process redesign
Production levelling (Heijunka)
Physical work setting redesign
Standardised work
DMAIC (Define-Measure-Analyse-Improve-Control)
PDCA (Plan-Do-Check-Action)

Pegden, Sadowski, and Shannon (1995) define the simulation as a process of designing
a real system model, on which experiments are subsequently carried out in order to under-
stand its behaviour and/or evaluate different strategies to improve its functioning. Through
simulation modelling, decision-makers are able to understand a system’s behaviour before
changing the real system, and therefore avoid the risks and the costs of a real experiment
(van Sambeek et al., 2010).
The various simulation models (Table 3), underlying simulation software, can be classi-
fied considering:

. the nature of the variables describing the status of the process: stochastic models, if at
least one input variable changes randomly and is probabilistic and, therefore, also the
output is like that, or deterministic models in the other cases;
. the change of the variables over time: static models are not based on time; however,
variables samples are often repeated over time and used to estimate statistically the
state of the process at a certain point. To the contrary, dynamic models show the
whole process evolution over time. Among the dynamic models, it is possible to
find out discrete or continuous models, depending on how the system variables
change over time. Discrete models use variables that change at a discrete set of
points in time, while in continuous models, the variables change continuously. In
other words, ‘discrete models are defined by state variables, while continuous
models are constructed by defining equations for a set of state variables’ (Banks,
1998, p. 43).

Discrete Event Simulation (DES) is a discrete model that allows modelling discontinu-
ous systems using variables that record discrete and abrupt changes at variable times (Con-
nelly & Bair, 2004; Stahl et al., 2004). In this way, it is possible to define process activity as
a network of interdependent, discrete events (Stahl et al., 2004). In a health care context, the
4 M. Crema and C. Verbano

actual events considered in DES regard entities that can be patients, staff, but also orders,
raw materials, laboratory and imaging studies, and associated resources (Connelly & Bair,
2004; Banks, 1998). According to Stahl et al. (2004), with DES, you can capture and opti-
mise waiting time, flow time, resource competition and allocation, the interdependency of
the events. The same scholars state that, with DES, you can define the probability of events;
moreover, patients can enter into the system at intervals chosen randomly and the processes
can take time – which is also chosen randomly. Those stochastic draws come usually from
distributions derived from literature or from empirical evidences.
While in DES the components of a system and their interactions are reported, in system
dynamics (SD) the structure, dynamics, and behaviour of complex systems are represented
(Banks, 1998; Forsberg et al., 2011). As reported by Forsberg et al. (2011), system
dynamics are adopted in many health settings. Monte Carlo simulation and Markov
model are stochastic models, but the first one is static, while the second one is dynamic,
and it is defined by discrete variables.
In addition to these models, Agent-Based Simulation (ABS), called also Agent-Based
Modelling (ABM) must be mentioned: it represents a system as a set of autonomous entities
called agents which have the ability to make decisions. In the health context, ABS is useful
for modelling individual behaviours and coping with complex problems (Abar, Theodoro-
poulos, Lemarinier, & O’Hare, 2017). The specialised agents used in the ABM have soph-
isticated intellectual capabilities (e.g. of reasoning, learning and planning); thus, it permits
incorporation of the resource knowledge in the simulation model (Abar et al., 2017). Indi-
vidual behaviours are stochastic in nature, characterised by memory, learning, adaptation,
and ‘if-then’ rules. Finally, hybrid models have also been created.
The main advantages offered by these tools to support decision-making in HLM pro-
jects are (Pegden et al., 1995; Harrell, Ghosh, & Bowden, 2000; Robinson, 1994):

. they provide a realistic representation of reality, capturing the interdependencies of

the system;
. they offer a risk-free environment;
. they are less expensive and time-consuming than an experiment on a real system;
. they provide information about multiple performance measures;
. they generate results that are easy to understand and communicate;
. they are proposed as experiential training; and
. they increase the motivation of participants in improving clinical processes and facil-
itating group work.

Due to the potential variety of benefits, the literature has been growing on simulation in
healthcare and has been flourishing in the last few years. Along with this, Salleh, Thokala,
Brennan, Hughes, and Booth (2017) recently performed a review of systematic literature
reviews on simulation modelling in healthcare, analysing 37 articles on that theme.
Many of them were devoted to specific types of simulation modelling techniques (such
as Discrete Event simulation or System Dynamics), to specific fields of application (e.g.
emergency departments), and for different application purposes (healthcare operations
and system design, medical decision-making applications, infectious disease modelling
or miscellaneous studies). According to that systematic literature review, DES is the
most adopted in healthcare, but Monte-Carlo simulation and SD models are also commonly
used. On the other hand, ABM is used quite rarely.
Pitt, Monks, Crowe, and Vasilakis (2016) examined systems modelling and simulation
(from soft to hard methods) and their potential areas of applications in healthcare, but
 Total Quality Management & Business Excellence 5

without a specific focus on HLM. van Sambeek et al. (2010) reviewed different kinds of
decision-support models (descriptive, analytical and computer simulation models) for pro-
cesses design and control, concluding that ‘descriptive models are most appropriate when
the model has to be generic, and qualitative and computer simulation models are most
appropriate when situations are complex with a high degree of variability, and when the
results must be specific and quantitative’ (van Sambeek et al., 2010, p. 17).
A few studies have investigated the opportunities to combine simulation and HLM. For
instance, Robinson et al. (2012) define a new approach called ‘SimLean’, which combined
simulation and HLM. Simulation, in this case, can play three different roles: (1) educate the
key principle of HLM; (2) facilitate the process mapping, and (3) evaluate the to-be pro-
cesses defined in an HLM project.
However, no literature review has been found focused on how and in which cases simu-
lation modelling can support the adoption of HLM. Using simulation modelling, decision-
makers could predict the consequences of different alternative solutions identified to reduce
the wastes and maximise the value, through the adoption of the lean methodology. In this
way, they are able to understand a system’s behaviour before changing the real system and
avoid the risks and the costs of a real experiment.
Therefore, the purpose of this research is to give a contribution to fill this gap of studies
favouring the diffusion of HLM for the improvement of healthcare management and
performance.

Objectives and methodology

As mentioned in the previous section, this research aims at identifying the possibilities and
the advantages of combining LM and simulation models in an integrated methodology,
benefiting from the strengths of both of them. Two research questions (RQs) have been
defined from that general aim and they are:

RQ1: What has been studied in reference to the adoption of the simulation modelling to
support Health Lean Management?
RQ2: What performance improvements can be obtained using HLM tools and
approaches supported by simulation models and software?

Answering those research questions, insights regarding the opportunities to apply the
HLM tools and approaches with the simulation models and software, inside different
healthcare settings, will be provided to healthcare managers and suggestions for further
research activities will be grasped.

Research methodology
In order to answer the defined research questions and achieve the research objective of the
paper, a systematic literature review was carried out. The research protocol adopted (Figure
1) has been developed based on current handbooks and references to conduct a systematic
literature review and PRISMA guidelines (Brereton, Kitchenham, Budgen, Turner, &
Khalil, 2007; Kitchenham, 2004; Tranfield, Denyer, & Smart, 2003; Moher, Liberati, Tet-
zlaff, & Altman, 2009).
It includes the following elements:

(1) Need of a review

6 M. Crema and C. Verbano

Figure 1. The research protocol.

(2) Research questions

(3) Research strategy: database, keywords and searching fields
(4) Selection criteria: language, type of publication, content
(5) Quality assessment: quality indexes (WOS Impact factor, Scimago Journal Ranking)
(6) Data extraction and analysis including:

.database construction
.descriptive analysis: variable identification (year of publication, authors, journal,
quality index of the journal, first autho’s country of work) and analysis (fre-
quency analysis)
. content analysis: variable identification (research methodology, field of appli-
cation, type of process considered, objectives, results, lean tools, simulation
models, simulation software) and analysis (single variable and multiple variables
frequency analysis).
The ‘need of a review’ and the research questions have been defined in the previous
sections, while the other analyses have been reported in the following.

Research strategy and paper selection criteria

The selected academic databases were: Medline, Web of Science Core Collection, Scopus,
PubMed and Business Source Premiere.
Web of Science (ISI) includes all the journals with impact factor, useful for journal
quality assessment. Medline collects biomedical literature from around the world;
PubMed is another well-known database of journals regarding medicine, nursing, dentistry,
veterinary medicine, health organisation and preclinical sciences and it allows accessing
databases of National Centre for Biotechnology Information (NCBI). Scopus is one of
the largest abstract and citation databases, including papers of scientific journals, confer-
ence proceeding papers and book chapters. It collects research output regarding science,
medicine, arts and humanities social sciences, and technology. For completeness,
EBSCO (Business Source Premier) has also been considered, in order to not exclude
papers published in journals regarding disciplines of management and business.
The keywords used for the searching were ‘Lean Health’ and ‘Simulation’. Once the
paper searching was performed with those keywords, they were revised, in order to
obtain a larger number of relevant articles. Among the different available wildcard charac-
ters, an asterisk was used at the end of every keyword (see Table 2). At the end of the
searching process, performed in November 2015, there were 397 selected papers.
To narrow down the database and be sure of the relevance of the papers to be analysed, a
selection process was performed with the following filters: exclusion of duplications among
 Total Quality Management & Business Excellence 7

Table 2. The searching strategy and the selection criteria adopted in the systematic literature review.
Searching and selecting the paper
Keywords Database Searching field Results
Lean* Health* AND Medline Topic add mesh 39
simulation* Web of science core collection Topic 40
Scopus Article title, abstract, 132
keywords
Pubmed Text word 40
Business source premiere – All text 146
EBSCO
Total results 397
Selection criteria Results
1. Exclusion of duplications 307
1. Exclusion of paper not in English language 304
1. Inclusion of papers of scientific journals (exclusion of papers without references, paper 155
of periodicals, conference proceedings papers, company reports, book chapters,
editorials of less than 3 pages)
1. Abstract and full paper reading: exclusion of papers not focused on Healthcare lean 30
management and simulation

Baril et al. (2016); Bhat and Gijo (2014); Chang et al. (2013); Chen and Collins (2012); Chiocca,
Guizzi, Murino, Revetria, and Romano (2012); Doǧan and Unutulmaz (2016); Eitel, Rudkin,
Malvehy, Killeen, and Pines (2010); Faulkner (2013); Hayes et al. (2015); Isaac-Renton et al.
(2012); Leaven (2015); Lo et al. (2015); Marodin and Saurin (2013); Marshall-Ponting, Kobbacy,
Sapountzis, and Kagioglou (2013); Pati, Harvey Jr, and Thurston (2012); Raghavan et al. (2010);
Ravn and Petersen (2007); Richardson et al. (2014); Riley et al. (2012); Robinson et al. (2012);
Robinson et al. (2014); Romano et al. (2014); Rosales and Rao (2014); Saghafian, Hopp, Van
Oyen, Desmond, and Kronick (2014); Savino et al. (2014); Setijono et al. (2010); Sharma et al.
(2007); Swick et al. (2012); Yang et al. (2015); Young (2005)

the results of the queries and of the selected databases, exclusion of papers not in the
English language and not published in scientific journals, such as, for instance, conference
proceeding papers, books, company reports, as detailed in Table 2. After further reading,
the abstract and the full-text, papers not focused on HLM and simulation were excluded.
This final selection was performed independently by two researchers, which after that com-
pared and discussed their decisions until they agree on the final paper selection. Of the 125
excluded papers, 2 papers were pertinent but without scientific references and the others
were not pertinent. For example, one paper regards healthy air in the windy city, others
regard toxicological aspects of seafood consumption, efficiency and quality of modern
pork production, condition-based maintenance programme approach. Papers dealing with
only one of the two topics, for instance only lean supply chain or six sigma, were also
excluded. The obtained database contained 30 papers.

Quality assessment, data extraction and content analysis

To assess the quality of the selected papers, the related journals were ranked based on their
classification on the Scimago Journal Ranking (SJR) and on the Journals Citations Report
Impact Factor (JCR IF). The quality indexes permit certification of the high relevance of the
selected papers; according to that, most of the articles stand between the first and the second
quartile (41% and 36%, respectively), assuring the high quality of the database.
 8
M. Crema and C. Verbano
Table 3. The performance improvements obtained through simulation modelling.
Performance improvement obtained
Support to
decision-
Simulation Staff making Clinical Process Staff Competence
model Software Efficiency Safety Motivation Making Efficacy Communication Flexibility Sustainability Coordination Improvement
ABM Synphony 2
Dynamics
Powersim
Total 2
DES Arena 6 1 2 1 1 1
Simul8 2 1 2 2 1 1 1 1
ExtendSim Process 1
Modelling
Environment
Siemens 1 1 1 1
Tecnomatix
Sigma 1
n.a. 2 1 1 1
Total 12 4 5 4 1 2 2 2 1 1
Markov Cyclostationary 1 1 1
decision model
process Total 1 1 1
model
System Layout IQ 1 1 1
dynamics n.a. 3
Total 4 1 1
Total 19 6 5 4 3 2 2 2 1 1
 Total Quality Management & Business Excellence 9

According to the aim of the review, for every paper of the database, descriptive data,
like author, year of publication, country, and the journal’s name were recorded. Moreover,
research methodology, field of application and object of the processes analysed in the
papers were gathered.
Following Romano, Guizzi, and Chiocca (2014), several flows can be the object of a
simulation modelling in a hospital and they can regard: patients, clinical staff, drugs, infor-
mation, equipment, and flows of a department considering any kind of stocks to be reduced.
Process flow-technical engineering can be performed adopting simulation modelling. For
that reason, the object of the processes analysed in the selected papers was recorded.
Through content analysis, other features were investigated, like the results of the pro-
jects analysed in the papers, the HLM tools and approaches, simulation models and soft-
ware. For classifying the performance improvements, the dimensions adopted in the
literature for quality enhancement were considered (Arah, 2006; Mosadeghrad, 2012). At
the end of the analysis, a matrix with performance improvements obtained by adopting
the HLM tools and approaches and a matrix with HLM tools and approaches and simulation
models and software were created in order to answer the second research question.

Results
Results of descriptive analysis
Through the descriptive analysis, a lot of information was collected. Looking at the time
distribution of the papers (from 2005 to 2015) in Figure 2, it is possible to note a low pub-
lication rate for the first six-year period, while in the second phase, the number of articles
greatly increased. The rapid rise of the latter leads to forecasting of a growth in interest for
the next few years as well. In particular, the most fruitful countries for the analysed topic are
the US, the UK and Italy, with 51%, 14% and 10% of the publications, respectively. Papers
were published mainly in Scopus: it contains 83% of the selected papers (25 of 30). The five
scientific journals that dedicate great space to the research subject and which, therefore,
should be taken into consideration, are the following: Journal of Nursing Administration,
European Journal of Operational Research, International Journal of Procurement

Figure 2. Time and geographical distribution of the papers, main journals and authors.
10 M. Crema and C. Verbano

Management, Journal of Medical Systems, Total Quality Management and Business Excel-
lence. Even if the combined application of Health Lean Management and Simulation Mod-
elling is a relatively new topic, Robinson, Burgess, Chiocca and Guizzi published each two
articles on that topic, becoming the most highly referenced researchers (Figure 2).
Regarding the adopted methodology (Figure 3), a lot of papers present single or mul-
tiple case studies (40%); the remaining manuscripts are classified as simulations or concep-
tual papers (25% both) and literature reviews (10%). A preliminary content analysis has
shown that the fields of application in which this methodology has been more frequently
deployed are emergency, outpatient care, surgery and laboratory settings. Even if patients
are the main focus of the most analysed processes, information flow, material flow and flow
of clinical staff are also studied – though to a lesser extent.
Analysing the HLM tools and approaches and the results obtained, value stream
mapping (VSM), value and waste identification, Kaizen events and 5S were mainly
adopted – obtaining results in terms of improvement of efficiency, patient safety,
decision-making support, staff motivation and coordination, clinical effectiveness and com-
munication. The most applied simulation model is Discrete Event Simulation (DES)
through software like: SIMUL8, Arena, Siemens Technomatix, ExtendSim Process Model-
ling Environment. Another appreciated model is System Dynamics, but only one of its cor-
respondent software (Layout IQ software) has been mentioned. It should be stated that
almost 30% (9 out of 30) of the articles do not point out the simulation model nor the simu-
lation software adopted.

Results of content analysis

In order to answer the RQ2, the performance improvements obtained in the papers using
HLM tools and approaches and simulation modelling have been analysed. As reported in
Figure 4, the quality dimensions considered in the papers regard enhancement of efficiency,
safety, staff motivation, clinical efficacy, staff coordination, communication, competence
increase, process flexibility and sustainability. The projects analysed were adopted also
to increase the compliance with guidelines defined by the healthcare institute (e.g. Institute
for Healthcare Improvement) and in order to support the process of decision-making in
healthcare. Adopting the DES model, efficiency improvements are mainly obtained
through the use of ARENA or SIMUL8 (Table 3). System dynamics also permit the
achievement of efficiency results; however, DES seems more complete, reaching different

Figure 3. Research methodology, field of application and object of the projects analysed in the
selected papers.
 Total Quality Management & Business Excellence 11

Figure 4. HLM tools and approaches, simulation models and software in the selected papers.

kinds of performance simultaneously. In particular, in the selected database, the adoption of

SIMUL8 in the analysed projects leads to an improvement in all the reported quality dimen-
sions, except clinical efficacy and process flexibility (see Table 3).
As it is possible to note in Table 4, the most adopted HLM tool (VSM) also permits
the achievement of efficiency improvement, but it allows obtaining other different types
of performance improvements as well. There are other HLM tools and practices that
permit the achievement of multiple performance improvements, such as value and
waste identification, Kaizen, Gemba, A3, 5 Whys – with whom more than four different
quality dimensions have been improved in the analysed papers. However, projects adopt-
ing VSM can achieve improvements in terms of efficiency, safety, clinical efficacy, staff
coordination and communication, process flexibility, process uniformity, compliance,
staff motivation, competence improvement, sustainability, and support to the process
of decision-making.
Looking at Table 5, VSM is supported mostly by DES (in 9 papers) – in particular using
ARENA and Simul8. DES are adopted in combination with the VSM, Spaghetti chart,
value and waste identification and management, Kaizen, Gemba, 5S, Andon, Kanban,
Supermarket, pull strategy, heijunka, and following the HLM approaches of continuous
improvement and Lean Six Sigma.
ABM, particularly developing optimisation models in Synphony Dynamic Powersim,
supports the adoption of VSM, value and waste identification and management, kanban,
supermarket and pull strategy. With the ExtendSim Process Modelling Environment
VSM, Kaizen, gemba and Andon can be combined.
Finally, analysing the papers, it emerges that most of the described projects are realised
through rapid implementations, adopting frequently just one HLM tool and focusing on
short-term outcomes instead of long-term ones. The involvement of all healthcare pro-
fessions during the improvement events is mentioned in almost every article; on the
Table 4. Performance improvements obtained adopting HLM tools and approaches.

Performance improvement obtained

Support %
to paper
HLM tools and Staff Clinical Process decision- Staff Process Competence on
approaches Efficiency Motivation Efficacy Safety Communication Flexibility making Sustainability Coordination Uniformity Compliance improvement total

VSM 17 3 3 3 2 2 1 3 2 1 1 2 60
Value/Waste 6 2 1 2 1 23
identification
Kaizen 4 2 1 1 1 2 1 17
5S 3 1 1 13
Pull Strategy 3 10
Supermarket 2 7
Continuous 2 1 1 7
improvement
Kanban 2 7
Gemba 2 1 1 1 1 1 1 7
Spaghetti Chart 1 3
Lean Six Sigma 1 3
Heijunka 1 3
Andon 1 3
A3 1 1 1 1 1 1 3
5 whys 1 1 1 1 1 1 3
Total 46 9 7 6 6 5 5 5 4 4 4 3 –
Table 5. Simulation modelling and software supporting HLM tools and approaches.

HLM tools and practices

Lean
Simulation Value/ Waste Pull Continuous Spaghetti 5- Six
model Software VSM identification Kaizen Gemba 5 S strategy Kanban Supermarket improvement chart Whys A3 Andon Heijunka Sigma

ABM Synphony 1 1 1 1 1
Dynamics
Powersim
Total 1 1 1 1 1
DES Arena 4 2 1 1 2 1 1 1
ExtendSim Process 1 1 1 1
Modeling
Environment
Siemens 2
Tecnomatix
Sigma 1
Simul8 2 1
System Dynamics 2
n.a. 2 1 1 1 1 1
Total 9 6 4 2 3 2 1 1 1 1 1 1
Markov Cyclostationary 1
decision model
process Total 1
model
System Layout IQ software 1
dynamics n.a. 3 1
Total 3 2
N.A. n.a. 4 1 1 1 1 1 1 1
Total 18 10 5 3 3 3 2 2 2 1 1 1 1 1 1
14 M. Crema and C. Verbano

other hand, an interest in patient involvement is highlighted just in one article (Chang, Jen,
& Dahlgaard-Park, 2013).

Discussion and future direction

In order to answer the first RQ, a database of 30 papers was created. Despite the scant lit-
erature available, through the descriptive analysis of the database, it emerges that the
number of papers dealing with simulation modelling and its combination with HLM
tools and practices is increasing. The positive trend demonstrates that the use of simulation
modelling to support the implementation of lean management is an innovative but emerging
topic. There are scholars that can be considered experts in this topic. Most of the papers
come from the USA. The projects analysed in the papers regard mostly emergency settings
and they aim at improving the patient flow, achieving mainly efficiency and patient safety
improvements.
In the analysed literature, VSM is mostly adopted in combination with a simulation
model. VSM seems to be the basis for analysing the process and for determining which
other HLM tools or practices should be added (according to the specific performance
improvement you want to achieve). DES mainly supports the adoption of VSM in
healthcare.
As emphasised in the literature (Jacobson, Hall, & Swisher, 2013), DES is particularly
well-suited to tackle problems in healthcare systems. As reported by Jacobson et al. (2013),
in the studies about DES, several inputs, regarding, for instance, patient scheduling, patient
flow schemes, facility and staff resources, are integrated, in order to obtain mainly effi-
ciency improvement. An example would include enhancement in patient throughput and
waiting times, staff and facility utilisation.
The same results can also be obtained by adopting VSM and other HLM tools and prac-
tices without simulation modelling. However, DES can create the virtual setting that sup-
ports the development of VSM, allowing simulation of different VSMs, in order to
identify and eliminate wastes and improve the process performance.
These results contribute to answer the second RQ, demonstrating that, in the papers,
efficiency improvements are mainly achieved. Moreover, with DES, and still using
VSM, identifying value and waste and realising Kaizen events, staff motivation can
also be increased. Looking at Tables 3 and 4, it is possible to state that safety and clini-
cal efficacy can also be achieved by adopting simulation modelling and HLM. As it is
generally noted, simulation modelling supports the process of decision-making; more-
over, the results just mentioned are expected and achieved by implementing HLM pro-
jects, and they feed the diffusion and the sustainability of these new methodologies also
in other settings (Radnor et al., 2012; Costa & Godinho Filho, 2016; Crema & Verbano,
2016).
Surely, the implementation of simulation modelling, such as DES, is not straightfor-
ward in healthcare (Eldabi, Paul, & Young, 2007; Robinson et al., 2012). In particular,
scholars underline the difficulty of involving several stakeholders in DES realisation and
managing their diverse conflicts of interest (Brailsford, Bolt, Connell, Klein, & Patel,
2009; Robinson et al., 2012). To this extent, the results achievable with HLM tools and
practices can favour the successful implementation of simulation modelling in healthcare.
On the other hand, as emphasised in the literature (Pitt et al., 2016), simulation modelling,
such as discrete event simulation and agent-based simulation, facilitate process visualisa-
tion, supporting HLM tools and practices in understanding the situation and the potential
organisational and managerial solutions that decision-makers have to select and implement.
 Total Quality Management & Business Excellence 15

DES is usually adopted because it required fewer assumptions to capture details of the
care system (Pitt et al., 2016). However, some scholars state that there is a risk: simulation
modelling can produce in output results too optimistic respect to the actual settings, since it
is not always able to catch all the complex elements existing in the real process (Setijono,
Mohajeri Naraghi, & Pavan Ravipati, 2010; Swick, Doulaveris, Bagnall, & Womack, 2012;
Robinson, Worthington, Burgess, & Radnor, 2014) and cannot always represent all the
possible scenarios (Sharma, Abel, Al-Hussein, Lennerts, & Pfründer, 2007), and it
hardly can consider all the aspects that define the variability linked with actual human be-
haviour (Baril, Gascon, Miller, & Côté, 2016).
In addition, some authors underline the issues of the reliability and the completeness
of the data used for simulation (Lo, Rutman, Migita, & Woodward, 2015; Chang et al.,
2013; Savino, Mazza, & Marchetti, 2014) and the limited generalisability of the emerged
evidences when the research regards only a case study (Bhat & Gijo, 2014). Other
authors think that simplifying the process that is the object of the project is a winning
element (Robinson et al., 2014). To the contrary, other scholars claim the need to
model the process in a detailed way from the beginning of the project realisation in
order to accelerate the implementation of the defined solutions, avoiding too much iter-
ation (Baril et al., 2016).
Therefore, research to test the realised simulation models in different settings and pro-
cesses, through multiple case studies are requested in many of the papers considered in the
current literature review (Hayes, Eljiz, Dadich, Fitzgerald, & Sloan, 2015; Robinson et al.,
2012; Robinson et al., 2014; Yang, Wang, Li, & Su, 2015; Bhat & Gijo, 2014; Riley,
Smalley, Pulkrabek, Clay, & McCullough, 2012). Other studies highlight the need to con-
tinuously applying the models and invest in assuring the sustainability of the projects and
promoting it (Faulkner, 2013; Baril et al., 2016). This aspect is required also for the adop-
tion of HLM tools and practices, which should be supported by a participative culture. In
many of the projects analysed in the current literature review, HLM tools and practices are
still applied as a set of tools, while it should be a managerial methodology developed
through a whole-system strategic plan (Radnor & Walley, 2008).
Considering all the evidences emerged from this discussion, a research agenda comes
out and it can be summarised in the following main points addressing the future potential
academic and managerial research in this research field:

. to apply the models developed to support HLM tools and practices in other countries
and in other healthcare settings, in order to validate the obtained results and test if
other tools, practices and models are requested in the case the pursued performance
and/ or the settings change;
. to develop HLM projects supported by simulation modelling that regard also other
flows to be optimised, besides the patient one (e.g. information, material flows);
. to investigate whether it is possible to combine other HLM tools and practices with
other simulation models; for example, there are recent studies in which different
simulation models are combined and they could be considered, if they are useful
and applicable, in an HLM project;
. to define and test simulation models that include also sociotechnical aspects to
support the implementation of an HLM project (for example, starting from the new
ABMs that are developing through scholars);
. to conduct research and practical application regarding the organisational aspects of
developing HLM projects supported by simulation modelling; in particular, not only
hospital staff should be involved in the project team, but also the patient, or persons
16 M. Crema and C. Verbano

who represent its interests, is fundamental since patient centrality is essential for the
quality of health care;
. to conduct research in order to define the criteria useful to select and adopt a simu-
lation model or a simulation software for an HLM project;
. to define and adopt measurement systems that allow measuring indicators regarding
not only efficiency but also other dimensions of healthcare quality;
. to compare different HLM projects supported by diverse simulation models, like, for
example, conducting multiple case studies, in order to understand how they can be
successfully developed in different healthcare settings; this could lead to the devel-
opment of useful guidelines about organisational and managerial aspects, describing
the process to be followed to implement HLM projects supported by simulation
modelling.

Conclusion
With the aim at identifying the possibilities and the advantages of combining HLM and
simulation models in an integrated methodology, the state of the art regarding the simu-
lation models and software adopted to support the implementation of HLM tools and prac-
tices emerged, triggering new directions for future academic studies and managerial
implications. One of the main limitations of this research regards the number of papers
included in the analysis. It is an emerging topic; thus, in addition to the academic literature,
many managerial reports could be issued, and academic research can be in the process of
being conducted. Moreover, in some papers, the simulation model and/or the adopted soft-
ware were not reported.
Notwithstanding, this systematic review not only confirms the need and the opportunity
to conduct research about the integration of HLM tools and practices and simulation mod-
elling, but it can be valuable and supportive also for healthcare managers who are going to
exploit this combined approach, looking at the simulation models that have been applied
with HLM tools and practices and the performance achieved. Thanks to the development
of HLM projects supported by simulation modelling, indications about the potential
results, achievable by implementing a solution instead of another, can be grasped. To
this extent, healthcare managers can find valuable support in making decisions in healthcare
settings that are complex, challenging and require high performance in multiple dimensions
that define healthcare quality.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by the Università degli Studi di Padova under [grant number
PANI_SID17_01].

ORCID
Maria Crema http://orcid.org/0000-0002-4660-3910
Chiara Verbano http://orcid.org/0000-0002-2300-7235
 Total Quality Management & Business Excellence 17

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