1.

Title and Complete Article Information

Title : A case-based methodology for lean implementation in hospital operations
Author : Tatyana Karla Oliveira Régis, Luciano Costa Santos and Cláudia Fabiana
Gohr
School :Universidade Federal da Paraíba, João Pessoa, Brazil

2. Background
Purpose – Although there are general methodologies for lean implementation in
manufacturing companies, a specific methodology for the implementation of lean
healthcare in hospitals has not been addressed by the literature. Addressing this gap,
the purpose of this paper is to develop a practice-driven methodology for
implementing lean in hospital operations. Design/methodology/approach – Three case
studies were conducted to collect evidence on the lean implementation process in
Brazilian hospitals. From empirical evidence and literature, the implementation
methodology was proposed and submitted to critical assessment by experts from the
field. Findings – The process of lean implementation was very similar in all cases,
triggered by strategic planning and operationalized by continuous improvement
projects. On the other hand, in all cases, the lean implementation teams had to deal
with employees’ resistance. These findings were valuable inputs to the development
of the implementation methodology. After refinement, it was proposed a feasible,
useful and user-friendly methodology. Research limitations/implications – The
proposed methodology was raised from the practice through case study research.
However, the proposed methodology was not fully applied, and the associated
performance measures were not elaborated in this paper. Therefore, more case studies
and applications will be necessary to generalize the findings. Practical implications –
The methodology provides practical guidelines that support lean implementation in
hospital operations. Although it demands adaptations for each specific hospital
setting, this initial step may encourage hospital managers to start the lean journey.
Originality/value – This study addressed the gap in the literature regarding the lack of
methodologies for implementing lean healthcare in hospital operations. The
methodology synthesizes the knowledge, principles and tools of lean thinking that can
be applied in hospital operations.

3. Concept
Lean management is primarily based on the elimination of waste, assisting the process of
value creation for all stakeholders (Liker, 2004). The main processes of an organization
are those that create the desired value for the customer (Kollberg et al., 2007). In
hospitals, the main processes are those responsible for the diagnosis, treatment and
convalescence of the patient. The other processes are supporters of the essential services
(Kollberg et al., 2007; Aronsson et al., 2011). By applying lean, organizations can
eliminate waste such as overproduction, waiting, transport processing, unnecessary
inventory, unnecessary displacement and defects (Liker, 2004). Such types of waste are
also present in hospital operations. For example, duplicate work (overproduction),
transport of patients and materials (transport), duplication of information (processing),
wrong prescription (defects), patients lines (waiting), unnecessary staff movement
looking for documents (displacement) and materials not being used in storage areas
(inventory) (Hussain and Malik, 2016). Beyond waste elimination, Schonberger (2018)
argues that quick response should be the primary mission of lean healthcare to achieve
higher patient-centered performance. According to the author, an effective lean program
is built on specific lean practices or tools, such as quick setup and kanban. In the literature
review for this research, we found a number of lean tools that have been applied to
healthcare (Table I). According to Table I, value stream mapping (VSM) and kaizen are
the most frequent tools in the literature about lean healthcare, while kanban and Single
Minute Exchange of Die (SMED or quick setup) are less frequent. Most publications
shown in Table I focus on lean implementation in front-office processes (e.g. surgery and
emergency), albeit evidence of it has been identified in back-office processes as well (e.g.
laboratories and pharmacies). According to the current literature, emergency and surgical
procedures have been the main targets when it comes to lean implementation.

4. Study Result, Discussion and Analysis

Lean implementation begins with strategic planning since top management considers
lean as a strategic goal of the hospital. From this point, the improvement projects are
generated and the lean culture begins to develop. Step 2.1 – linking lean
implementation to strategic planning. The lean staff, consultants and members of
improvement teams should participate in the development of strategic planning and
define the link between lean actions and strategic objectives. Such activity increases
commitment to lean culture implementation and ensures financial support for the
improvement program. Even though the strategy link in lean implementation is highly
recommended in the literature (Barnabè et al., 2019; Matthias and Brown, 2016), it
has not been as formalized as this methodology proposes. Step 2.2 – implementation
of lean tools through a pilot project. The implementation of the pilot project will
follow a continuous improvement approach. Hospitals 1 and 2 used DMAIC for lean
implementation, and Hospital 3 used the PDCA improvement framework in a similar
operation. Due to the simplicity and degree of diffusion in healthcare, it was decided
to use in the proposed methodology the PDCA improvement cycle, which consists of
the following steps: (1) Plan. Objectives, deadlines and targets should be clearly
defined at the initial phase of the project and should be related to strategic objectives.
The result of this stage is the pilot project plan. The scope, the responsible team, the
deadlines, the budget, the objectives and the control measures are part of this plan. (2)
Do. This step begins with the process description, followed by the application of
VSM. Waste and potential improvement actions are identified from VSM. Next, a
future state for the process is designed, which will direct the actions for the
application of lean tools. For this purpose, it is important to run kaizen events, which
stimulate the formation of teams to implement focused improvements. (3) Check. The
results obtained by the application of lean tools should be compared with the
objectives of the pilot project, identifying the deviations and the possibilities of
adjustments. (4) Act. From the deviations identified, it is possible to modify or
 establish new objectives, deadlines and budgets. At this stage, lessons learned and
new improvement projects are also documented. The PDCA improvement cycle is an
adequate structure to keep lean healthcare as part of the daily routine. Through
PDCA, different lean tools may be adopted, according to the needs of each process.
Thus, in the proposed methodology, lean tools are not applied as isolated initiatives,
but as building blocks of a deliberated systemic improvement. Step 2.3 – development
of lean culture. The sustainability of improvements is achieved through the control of
performance indicators, audits, standardization and the development of process
owners, who are responsible for maintaining and reviewing the work. The lean staff
should identify employees with potential to be a leader, one who will be responsible
for leading the implementation together with the lean staff, being a multiplier of the
improvement culture. Lean leaders will be responsible for tracking performance
through visual control devices. They should review problems and ideas together with
the employees involved in the process on a weekly basis, and then generating new
projects. Lean leaders should be able to conduct the execution of the project without
the direct support of the lean staff. Continuous improvement occurs in cycles, that is,
when a future situation is implemented, it becomes the current situation, and then it is
analyzed and improved. 670 JHOM 33,6 The development of a lean culture is an
endless step in the proposed methodology since it is renewed with the execution of
improvement projects. Improvement projects are conducted as the pilot project,
according to the PDCA logic. The results of these projects, in turn, update the needs
for improvement and the future guidelines for new cycles of strategic planning. When
this cycle of improvement is embedded in the organizational routine, it may change
the way that workers think and behave. Therefore, continuous improvement and lean
culture are mutually supportive concepts in the proposed methodology.

5. Study Variables
Hospital 1
Hospital 1 began lean implementation in 2011 by hiring a consulting firm, which
remained working with the organization for three years. In this case, the lean
implementation was triggered by strategic planning as one of the priorities of the
organization. Initially, the consultants and the quality coordinator held awareness-
raising and training meetings with the staff for three months. The training was
theoretical and practical, and the practice occurred through improvement projects. As
can be seen in Figure 1, the implementation process began with the application of the
Define-Measure-Analyze-Improve-Control (DMAIC) framework, which provided a
structured procedure for conducting the improvement process. The patient flows in
chemotherapy and radiotherapy were the priorities of improvement. In the
chemotherapy process, the improvement project had as goals to improve care, reduce
the lead time of new patients, reduce the patient waiting time, increase the capacity of
the process, organize the sector and improve the financial situation. In radiotherapy,
the project aimed to reduce the time patients waited in line until the application of
radiotherapy. 662 JHOM 33,6 Through the application of VSM, the sources of waste
were identified to verify which lean tools would be implemented in the different
processes (Table III). Then, the top management sought to make efforts to develop a
culture of continuous improvement, although there was some employee resistance at
the beginning. From this, lean implementation has been expanded to the other sectors
of the hospital. Hospital 2 Motivated by the need to improve hospital processes,
senior management decided to implement lean in 2013. To this end, a consulting firm
was hired for six months. Human resources training - Awareness-raising meetings -
Theoretical and practical training Hospital processes - Trial - Authorization for
complex procedures - Reception - Control of medical records - Laboratories -
Pharmacy - Chemotherapy Hospital processes - Oncological consultation - Evaluation
by radiotherapist - Planning of radiotherapy - Radiotherapy scheduling - Application
of radiotherapy Implementation of lean tools: Kaizen and VSM Implementation of
lean tools: 5S, heijunka, standardization, visual control, multifunctional workers, zero
defect program, visual control Implementation of lean in the patient flow of
chemotherapy Implementation of lean in the patient flow of radiotherapy
Implementation of lean tools: Kaizen and VSM Implementation of lean tools: 5S,
standardization, visual control, SMED, zero defect program Trigger factors:
Improving services and increasing profitability Consulting
Hospital 2
Motivated by the need to improve hospital processes, senior management decided to
implement lean in 2013. To this end, a consulting firm was hired for six
monthsInitially, several awareness-raising meetings were held with managers in all
areas of the hospital. Subsequently, employee training for the preparation and
execution of lean projects was planned whenever necessary. Figure 2 shows the
sequence of the lean implementation process in Hospital 2. Since the very beginning,
lean implementation was linked to strategic planning. The hospital goals were
delivering health services with excellence, reducing internal costs, increasing
operational efficiency and becoming more competitive. The implementation process
was highly supported by top management in spite of the employee resistance,
especially nurses. The flow of the patient submitted to elective surgery by video was
the scope of the first improvement project because it is a process with a high volume
of work. For a previous diagnosis, the processes were mapped using SIPOC structure
(suppliers, inputs, processes, outputs and customers) and a “voice of the customer”
survey. Then, lean tools were implemented in different sectors of the hospital. Table
IV shows the lean tools implemented in Hospital 2. Hospital 3 Between 2006 and
2007, Hospital 3 began a certification process by National Accreditation
Organization. As a result, it found that its processes were confusing, generating a lot
of waste. Thus, lean thinking was considered as an alternative to improve processes,
increasing quality and efficiency. Thus, it established a partnership with a consulting
firm. At the same time, the director of the hospital began to attend events to meet
people and learn about this improvement approach. In 2008, the organization began
the lean implementation process using the Plan-Do-Check-Act (PDCA) improvement
framework, as part of its strategic planning. The goals were to improve the quality of
patient care, streamline processes and eliminate waste. Like Hospitals 1 and 2, the
staff faced a great employee resistance. However, top management support was
 essential for the implementation, and employee resilience decreased with an extensive
training program. Aiming to increase service capacity, the first process addressed for
improvement was the outpatient clinics. After the implementation in the outpatient
clinics, the lean system was disseminated throughout the organization. To start, the
first lean tools to be adopted were kaizen and VSM. Figure 3 shows the
implementation sequence in Hospital 3, and Table V presents the implemented tools.
In Hospital 3, kaizen improvement groups are formed to solve a specific problem, and
the result is formalized through an A3 report (a visual tool describing solutions for
problems). Through VSM, the processes are mapped and, from the actual state of a
given process, appropriate lean tools are identified. Hospital 3 is notable for its wide
adoption of visual control tools. They are adopted in all of its processes, in which
safety alerts, ideas for improvements, control of performance indicators, traceability
of records, billing control, preventive maintenance, control of reception activities and
various process controls arranged in the workplace are inserted.
6. Study Contribution
Case studies complemented the literature review in answering RQ1. From empirical
evidence, we found that the process of lean implementation was very similar in all
cases. In all cases studied, the implementation was related to strategic planning and
was operationalized using continuous improvement frameworks, such as PDCA and
DMAIC. All of them had a highnvolvement with the senior management, hired a
consulting company, and started with a troublesome process in which they sought to
reduce waste and increase efficiency. It was possible to verify that lean was
implemented through improvement projects. Although projects had a goal and an
expected result, the focus of top management was to disseminate lean systemically
and promote a culture of continuous improvement. Improvement projects began with
the implementation of kaizen and VSM to solve problems identified in the processes.
The VSM tool allowed identifying waste so that later interventions were made
through the simultaneous implementation of other tools. Trigger factors: Improve
processes by reducing lead time, costs and documentation volume Partnership with
LIB (Lean Institute Brazil) Executive director training Insertion of lean in strategic
planning and application of the PDCA framework Human resources training
(theoretical and practical training) Pilot project carried out in outpatient clinics
through the application of lean kaizen and VSM tools Development of projects
covering the entire hospital care chain Hospital processes - Reception - Medical
record center - Supplies - Billing - Outpatient clinics - Pharmacy - Laboratories -
Emergency - Chemotherapy - Radiotherapy - Maintenance - Laundry Implementation
of lean tools: 5S, standardization, visual control, multifunctional workers, zero defect
program Hiring of the LIB consulting for 6 months due to the acquisition of 3
radiotherapy units Training of flow coordinators Figure 3. Implementation process in
Hospital 3 Process Tools Results Reception VSM, kaizen, visual control, 5S,
standardized work, TQC, multifunctional teams Reduction of 30% of waste Medical
record center VSM, kaizen, visual control, 5S, standardized work, TQC Reduction of
90% of waste Supplies Reduction of 70% of inventory Billing VSM, kaizen, visual
control, 5S, standardized work, TQC, multifunctional teams Real-time billing
 Outpatient clinics VSM, kaizen, visual control, 5S, standardized work, TQC Increase
of 170% in the service capacity for consultations Pharmacy * Laboratories *
Emergency * Chemotherapy * Radiotherapy VSM, kaizen, visual control, 5S,
standardized work, TQC, SMED Reduction of waiting time for radiotherapy from
2:30 to 1:00 h. Increased utilization of radiotherapy machines from 44% to 70%
Maintenance Visual control, 5S, standardized work, TQC * Laundry 5S * Note:
*Results not yet evaluated Table V. Lean tools implemented in Hospital 3 666 JHOM
33,6 All hospitals began gradually by drafting a pilot project before the full
dissemination of the program. Even so, hospitals faced employee resistance, which
decreased through intensive training and a daily follow-up of managers.
7. Conclusion
This study began with two research questions unanswered by the lean healthcare
literature. The first one concerns how lean thinking has been implemented in hospital
operations. To answer this question, we reviewed the literature on it and thoroughly
studied the implementation process in three hospitals. The second research question
goes even further by highlighting the need to assist in the implementation process. For
that, we proposed a methodology for implementation of lean healthcare in hospitals in
two main phases: preparation and application. This methodology was developed from
empirical evidence collected from case studies, considering the theoretical
underpinnings available in the current literature on lean healthcare. After the
assessment of the initial methodology, the suggestions made by experts were
incorporated into the final methodology. This paper has some theoretical and
managerial implications. The development of the methodology represents a
theoretical contribution because it synthesizes the knowledge, principles and tools of
lean thinking that can be applied in hospital operations. Another contribution is that it
emphasizes that the lean implementation process is a strategic decision with systemic
implications. Even though strategic orientation has been emphasized in the literature,
it is not so usual in the current implementation models. The strategic orientation
supports the systemic nature of the proposed methodology. When lean healthcare
assumes a strategic role in the organization, the different subsystems are in
cooperation to achieve the strategic goals of the system. Rather than focusing on
specific tools, the organization pursues strategic goals, and lean tools are chosen
according to the system needs. Furthermore, the proposed methodology provides
practical guidelines in the form of a roadmap that supports lean implementation in
hospital operations. Nonetheless, albeit developed under a specific context, it is a
flexible roadmap, which is adaptable to different types of hospital, regardless of the
country. Although it demands adaptations for each specific hospital setting, this initial
step may encourage hospital managers to start the lean journey. Regardless of the
contributions, it is important to consider the limitations of our study. Future research
should address such limitations to increase the understanding of the lean
implementation process. The first limitation concerns the generalizability of the
results provided by case studies. Although case studies allow in-depth insights, they
are associated with the context of the study. Further research should verify to what
extent our findings could be generalized regarding the implementation process in
hospitals. Second, the interviews were limited to quality coordinators and managers.
Thus, adding different perspectives from employees and stakeholders would enrich
the previous findings from the same case studies. Third, even if derived from real
cases, the proposed methodology was not fully applied in hospital operations after its
final design. Therefore, future research will be needed to investigate the limitations of
the methodology by applying it to different hospital operations and thereby finding
out its contextual implications. Fourth, 671 Lean implementation in hospital
operations although the methodology recommends the design of performance
measures to evaluate the implementation progress (step “development of the lean
culture” – Phase 2), this is a context-dependent task. Thus, by applying the
methodology to hospital operations, it will be necessary to design the lean
performance measurement system, and it may represent another research opportunity
derived from this paper.