Leadership in Health Services

Emerald Article: Trends and approaches in lean healthcare Luciano Brandao de Souza

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To cite this document: Luciano Brandao de Souza, (2009),"Trends and approaches in lean healthcare", Leadership in Health Services, Vol. 22 Iss: 2 pp. 121 - 139 Permanent link to this document: http://dx.doi.org/10.1108/17511870910953788 Downloaded on: 29-03-2012 References: This document contains references to 111 other documents To copy this document: permissions@emeraldinsight.com This document has been downloaded 4402 times.

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Trends and approaches in lean healthcare

Luciano Brandao de Souza
Department of Management Science, Lancaster University Management School, Lancaster, UK
Abstract
Purpose The aim of this paper is to provide a review of the existing literature on lean healthcare. It seeks to describe how this concept has being applied and to assess how trends and methods of approach in lean healthcare have evolved over the years. Design/methodology/approach The paper surveys the applications of lean healthcare in the current literature and classies over 90 works according to a taxonomy suggested. Findings Though there seems to exist an agreement about the potential of lean healthcare, it remains a challenge for academics and practitioners to evaluate lean healthcare under a more critical perspective. Practical implications This work is helpful not only for healthcare practitioners and for researchers in private and public organisations, but also for journal editors and reviewers because it offers ready access to an up to date comprehensive review. Originality/value Since lean started being applied in healthcare, no effort to provide a complete resource surveying the existing literature has been done. Keywords Lean production, Health services, Production scheduling, Just in time, Patients Paper type Literature review

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Introduction Interest in the application of lean thinking in healthcare has grown signicantly in the last few years. This paper discusses how the concept of lean healthcare has evolved and proposes a taxonomy in order to assess the current state of development of the eld. This assessment is based on a systematic survey of the existing literature. This paper also presents a critical review of the works surveyed and classies them according to trends and approaches in different countries. So far, no effort to provide a resource surveying the existing literature has been made. For this reason, the focus of this article is not to detail lean principles and concepts, but rather to offer ready access to an up to date comprehensive review of works that can benet researchers, healthcare professionals and policy makers. lean thinking is a well-researched theme and a wide range of publications about it is available (see Womack and Jones (1996) and Liker (2004) for example). Methodology A number of search and metasearch engines were used to nd relevant published works on this survey. This paper consists in a systematic review (as in Westby et al., 2008) to identify the available literature about the subject and search criteria included expressions like lean healthcare, lean hospital, lean health, lean medical to cite only a few. Over 90 sources were found. A careful cross-reference search encompassing all the references cited in each work was also made. That is, if a work is not mentioned

Leadership in Health Services Vol. 22 No. 2, 2009 pp. 121-139 q Emerald Group Publishing Limited 1751-1879 DOI 10.1108/17511870910953788

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here it means that it neither could be found in any of the major electronic search engines nor was referenced in any of the works surveyed. In spite of this effort, some works may be missing. This however, does not invalidate the contribution towards the taxonomy proposed or the intention of providing a synthesis of the lean healthcare literature. Over 90 publications were found in ten countries from 2002 onward referring to the use of lean in healthcare. A yearly growth in the number of publications was observed, which points to an increasing presence of lean healthcare worldwide. A historical perspective of lean healthcare Lean is an improvement approach that consists in eliminating waste (steps that do not add value to the customer/patient, e.g. interruptions, delays, mistakes. . .) to improve the ow of patients, information or goods. Although lean concepts were initially developed to improve car production, a study showed that the lean principles could be applied to virtually any manufacturing system (Womack and Jones, 1996). Nowadays, lean principles are known around the world and applications reach well beyond the production of goods to service and healthcare delivery. Lean healthcare seems to be an effective way of improving healthcare organisations and the growing number of implementations and reports found in the literature reinforce this view. Apparently, key aspects that make lean more adaptable to healthcare settings than other improvement strategies are staff empowerment and the concept of gradual and continuous improvement intrinsic to lean theory. It is believed that lean healthcare is gaining acceptance not because it is a new movement or a management fashion but because it does lead to sustainable results as showed in this literature review. The precise date of the rst application of lean in healthcare is uncertain. Heinbuch (1995) offers an initial consideration about the use of lean concepts, in the particular case of just-in-time[1]. His work was an exercise to transfer manufacturing technology in order to reduce physical inventory in hospitals. Similar early publications regarding the use of manufacturing approaches in healthcare can be found in Jacobs and Pelfrey (1995) and Whitson (1997): none of them branded as lean. The literature reviewed shows that speculation about the potential use of lean in healthcare rst appears in a work published by the NHS Modernisation Agency (2001). The Modernisation Agency has been established in 2001 to coordinate improvement efforts in the NHS and has replaced the NHS Institute for Improvement and Innovation (III). Despite the fragmented beginning of lean initiatives in the UK, the III now attempts to condense the best practices in operation in this eld as lean recently assumed a pivotal role in remodelling the NHS in order to alleviate nancial pressure. A further publication by the same agency (NHS Modernisation Agency, 2002) and a research developed by Allway and Corbett (2002) emphasise the speculation but do not provide concrete evidence. Early reports about lean thinking specically on the improvement of patient ow include Bushell and Shelest (2002), who describe a pilot implementation of lean in a mid-sized hospital in the USA. Similarly, Feinstein et al. (2002) reports good results in clinical and non-clinical areas also in the USA. These works increased the speculation about the subject, by claiming that good results were achieved, though still not presenting explicit evidence. Figure 1 illustrates the evolution of lean healthcare from a historical perspective. Despite not bringing accurate dates (due to the vagueness around the rst application

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Figure 1. The appearance of lean healthcare

in each eld), the illustration highlights a ten-year delay in the appearance of lean healthcare, when compared to other industries that provide service. In addition, it seems that healthcare delivery is still far from achieving the level of excellence of lean applications in manufacturing, such as in Toyotas automobile production, as Berwick et al. (2005) suggests. More recently, several books have been published suggesting implementation guidelines for lean in healthcare, however not all of them base their claims on solid grounds. Chalice (2005) for instance, suggests 38 and subsequently 46 steps for improvement in which little detail or structure is provided (Chalice, 2007). In a similar manner, Vonderheide-Liem and Pate (2004) covers six sigma, lean thinking and balanced scorecard in a single volume. These books lack a deep discussion about the translation of lean tools into healthcare. Other publications, such as Zidel (2006), The Joint Commission on Accreditation of Healthcare Organizations (2006) and Smith et al. (2008) introduce the theme to healthcare practitioners and present a number of helpful examples. Taxonomy for lean healthcare literature Approximately six years after the initial trials of lean in healthcare, its use has increased considerably leading to the publication of many case studies, analysis and discussions. These publications can be placed into two categories: theoretical and case studies. The rst one refers to works that do not present a description of a real implementation, and the latter to practice-based discussions. Figure 2 illustrates this proposed taxonomy. The subcategories suggested and the criteria used to delineate these subcategories are detailed in subsequent sections. It is recognised that some reports can encompass a theoretical contribution (e.g. suggesting a new approach) and present a case study to validate its framework. Similarly, a report can contain two distinctive cases studies, which involve patient ow and manufacturing-like approaches. In order to avoid controversy, such works are only mentioned in the most relevant category. Proling theoretical publications Theoretical works about lean healthcare provide discussions, which have been classied as either methodological or speculative.

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Figure 2. Taxonomy of lean healthcare literature

Speculative Some publications are restricted to advertise the use of lean healthcare without presenting concrete evidence that it can (or cannot) work. Most of them attempt to translate some lean principles into the healthcare environment and speculate about its potential use. For this reason and with absolutely no intention of downplaying such works they are classied here as speculative. Methodological Existing methodological works provide a more productive contribution to lean healthcare. Examples include suggesting a new approach for implementation (e.g. Sobek and Jimmerson (2006)), describing the integration between key players in the healthcare context over a long-term lean implementation (e.g. Balle and Regnier (2007) suggesting further development of lean healthcare concepts (e.g. Spear (2005)) or discussing barriers for implementation (e.g. Brandao de Souza and Pidd, 2008a). Proling case studies in lean healthcare Case studies bringing an application of lean healthcare can be hosted in a wide range of hospital departments, areas and sub-areas, or often in a horizontal value stream across some of them. Brandao de Souza and Pidd (2008b) provide an initial attempt to classify the case studies in lean healthcare subdividing them into two categories: manufacturing-like and patient ow. In this survey, two other categories were identied and included to complete the taxonomy organisational, and managerial and support. Manufacturing-like case studies These case studies refer to departments within a hospital (or healthcare organisation) that typically deal with the physical ow of materials. Examples include pharmacy, radiology, pathology and laundry. In spite of being located in a hospital, these departments operate in most the same way as a manufacturing plant does. It is important to emphasise that crucial ethical issues inherent to healthcare provision may apply, but characteristically the effort to apply lean in such departments does not differ much from the way lean applications are conducted in manufacturing.

Managerial and support case studies Managerial and support services are found in areas of the hospital that deal mainly with the ow of information within the organisation. Examples are nance, medical secretaries, IT and all other managerial departments and divisions. Similarly, to what happens in manufacturing-like case studies, lean implementation in managerial and support areas can be carried out systematically in the same way as in service provision, although some specicities of healthcare provision may apply (Womack and Jones (2005a)). Patient ow case studies Patient ow case studies comprise the core implementations in lean healthcare. They attempt to improve the way patients are owing within the hospital (or system) by streamlining the patient pathway. Because many ethical concerns apply to patient ow case studies, it is important to highlight that it does not consist in mere exercises of cost reduction, length of stay (LOS) or waiting list reductions. In these case studies, it is mandatory to ensure that quality of care and patient safety are not compromised and that good staff morale for healthcare providers is established. Organisational case studies These emphasise the importance of designing a strategic and cultural plan from an organisational perspective in order to successfully implement lean healthcare. The process of becoming lean usually starts with a trial implementation, followed by a long-term structured approach conducted by the senior management. Organisational case studies thus focus on the strategic level rather than the operational one. Literature on lean healthcare Methodological works Many countries share an increasing concern that healthcare costs have exploded but with no evidence of, an equivalent improvement in healthcare. Even with increases in healthcare spending, it seems there is a need to improved healthcare delivery and lean methods may be one way to achieve this. Other methods are total quality management (Shewhart, 1980), systems thinking, systems dynamics (Forrester, 1989), theory of constraints (Goldratt, 1990; Goldratt and Cox, 1992), reengineering (Champy, 1995; Hammer and Champy, 1993) and discrete event simulation (Young, 2005). In the theoretical category there are three reports that distinctively discuss the potential of lean healthcare and simultaneously provide a comprehensive insight on how Lean, as a manufacturing approach, can be translated into healthcare (Miller, 2005; Spear, 2005; Jones and Mitchell, 2006). The rst report was edited by Diane Miller and based on presentations by James P. Womack, Arthur P. Byrne, Orest J. Fiume, Gary S. Kaplan and John Toussaint, during The Institute for Healthcare Improvement Calls to Action Series in January and February 2005. This report addresses key similarities between manufacturing and healthcare, describes how some of the tools can be translated from manufacturing into healthcare and presents two organisational case studies. The second one comprises two case studies (one manufacturing-like and the other patient ow related). Spear (2005) promotes healthcare adoption of lean techniques, whilst analysing some specicities of the health sector that delayed the use of lean.

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In the third report, Jones and Mitchell reect on the benets of lean and analyse the main challenges to implement lean in the British National Health Service (NHS). Three cases are acknowledged: (1) Bolton Hospitals NHS Trust; (2) Wirral University Teaching Hospital NHS Foundation Trust; and (3) Flinders Medical Centre, in Australia. In a similar vein, Jones and Filochowski (2006) reinterprets the ve principles of lean (value, value stream, ow, pull and perfection as in Womack and Jones (1996)) while encouraging other NHS Trusts[2] in the UK to pursue the lean journey. Without focusing specically on lean, Silvester et al. (2004) discusses four hypotheses related to the formation of waiting lists (queues) in the NHS scope. The formulated hypotheses are considered to be improvement inhibitors in the public health sector. The way in which Silvester et al. elucidate such myths within the NHS is relevant because it allows the authors to propose a conclusion that matches the lean view on performance improvement. They argue that it is possible to eradicate queues in the NHS without using the failed approach of continually adding capacity. Working in collaboration Jimmerson, Ghosh and Sobek make other relevant contributions. Sobek and Jimmerson (2004) suggest an adaptation of Toyotas A3 report system to concisely incorporate problem-solving efforts into healthcare practice. Their approach then evolves to a more operational one, which is described and tested in Sobek and Jimmerson (2006). Based on a pilot project, Jimmerson et al. (2005) highlights three key factors for the success of lean implementation. These are staff involvement, organisational momentum and senior management support. Spear and Bowen (1999) proposes four rules to guiding design, operation and improvement of connected activities in the Toyota Production System. Ghosh and Sobek (2006, 2008) and Ghosh (2006) rene and test these four rules in healthcare, providing answers to some health cares systemic issues. While most of these authors, including Aluka and Chalice (2007), address key issues for successful lean implementation, Brandao de Souza and Pidd (2008a) takes a different approach by classifying and suggesting solutions to overcome barriers for lean healthcare implementation. They analyse the existing literature as well as three case studies in the NHS. Still within the NHS, Esain et al. (2008) assesses the impact of 5S[3] (single tool approach) changes in a Trust whereas Papadopoulos and Merali (2008) analyses the formation of networks around lean healthcare key players. Finally, Swedish researchers discuss how performance measurement can inuence the understanding of lean initiatives. These authors explore the need for new performance indicators and suggest a framework to address this issue (Kollberg et al., 2007). Speculative works The rst speculative review reecting on the use of just-in-time in healthcare was published by Whitson (1997). Despite not providing much evidence, Whitson claims signicant improvement based in manufacturing techniques. As a growing market, the eld of lean healthcare has experienced an increased demand for specic literature adapting the lean theory to the healthcare environment. On the one hand, this literature is expected to address the subject with an appropriate

level of depth and without distortions or compromises to lean principles and ethical issues. Furthermore, as some of this literature is aimed at practitioners rather than scholars, it sometimes becomes a bit over-simplied. It is recognised that there must be a literature for both, scholars and practitioners, since the over-simplication or lack of detail/content observed in practitioners literature may lead to misunderstanding about the subject. For instance, most of the reports surveyed are restricted to translating the lean tools (or some of them) from manufacturing to healthcare in order to stimulate its use. Others focus simply on advertising lean healthcare or alternatively the organisation which is applying it (Feinstein et al., 2002; Sirio et al., 2003; Panchak, 2003; Long, 2003; Scotchmer, 2007; Vonderheide-Liem and Pate, 2004; Berwick et al., 2005; Caldwell, 2005, 2006; Jones, 2006; Lazarus and Andell, 2006; McVay and Cooke, 2006; Aheme, 2007; Chalice, 2005, 2007; Printezis and Gopalakrishnan, 2007; Varkey et al., 2007; Password and Prole, 2007; Weinstock, 2008; Newbold, 2008; Rajput, 2008). Other works speculate on combined approaches and pilot projects. Correa et al. (2005) describes lean healthcare along with a specic technological solution to trace patients within a hospital. In a different context, Silberstein (2006) reviews lean concepts and describes some of the early results of pilot implementations in Brazil. Allway and Corbett (2002) use hospitals to exemplify the potential of lean and linked it to the development of new performance indicators for healthcare. Likewise, Walley (2003) discusses the lessons learned from manufacturing in redesigning an emergency department. In a similar vein, Young et al. (2004) and Young (2005) argue that in spite of some obvious improvements in waiting time reductions, separating patient pathways in interactive value streams is more complex in healthcare than in manufacturing. Finally, Castro et al. (2008) also speculates that manufacturing approaches, including lean, can bring good results if well managed. Manufacturing-like case studies Early efforts to reduce internal stocks of material (mainly stationery) using just-in-time were reported by Heinbuch (1995). This is an example of a manufacturing-like case study. Although only addressing the use of one of the lean concepts, Heinbuch achieved good results in cost reduction by using standard methods of inventory control. His exercise does not exemplify a complete lean application, but provides evidence that good results can be achieved by adapting manufacturing techniques. Manos et al. (2006) brings another example of what can be achieved by the use of a single lean tool. He describes how the use of 5S in a storeroom shared by clinical labs (pathology department) led to a 40 per cent reduction in oor space utilisation, 17 per cent increase in storage space and nally to increased staff morale. It is believed that single tool implementation are likely to be less effective and it is advocated that whenever possible lean should be implemented fully and not in pieces (Womack and Jones, 1996). Condel et al. (2004) presents another case study in pathology. This work used a more consistent lean approach demonstrating the potential gains in the reduction of medical errors. This application included the use of 5S, value stream mapping, poka-yoke devices and visual control, among others. Subsequently, the same case study was published to provide evidence of the reduction of medical error in a particular laboratorial test (Raab et al., 2006). Persoon et al. (2006) describes the process to reduce

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lead-time in laboratorial tests and the effort to sustain it for nearly one year. Similarly, Sunyog (2004) highlights the cost reductions achieved in a chain of laboratories in Florida. Sobek and Jimmerson (2003) presents the results obtained in a pharmacy department by using a structured lean approach. Although not clarifying how the results were achieved, Sobek and Jimmerson report the staff involvement to drive the changes and achieve a 40 per cent decrease in missing medication. In another paper, that comprises the results of the above intervention, Jimmerson et al. (2005) reports reductions in backlog and inventory in the same pharmacy department. In another pharmacy case study, Esimai (2005) presents over 50 per cent reduction in medication errors, increased capacity, labour cost reduction and emphasises achievements in increasing staff morale. In addition, other works in pharmacies describe similar achievements (Spear, 2005; Zidel, 2006; Herasuta, 2007; Portioli-Staudacher, 2008). Lodge and Bamford (2008) reports on how lean healthcare was used to enhance a radiology department in the NHS. In summary, results include increased staff morale and reduced time for diagnosis, which impacts on anticipating the beginning of treatment. Similarly, a couple of other papers describe applications of lean (or lean six sigma) in radiology concluding that lean results in competitive advantage from money savings achieved by new workow and processes (Bahensky et al., 2005; Workman-Germann and Haag, 2007; Viau and Southern, 2007). More recently, Brandao de Souza and Pidd (2008b) presents a pilot project to launch lean thinking in a NHS Trust. The paper describes the implementation of manufacturing-like lean techniques in three hospital departments related to the ow of patient records. Managerial and support To some extent, Brandao de Souza and Pidd (2008b) can also be considered a managerial and support case study, as medical secretary ofces were streamlined as part of the lean implementation. Likewise, Jimmerson et al. (2005) and Stolle and Parrott (2007) report on how lean healthcare was used to eliminate paperwork and reduce costs. In similar papers, de Koning et al. (2006) and van den Heuvel (2006) describe gains obtained in hiring personnel, managing operating times and maintenance using the combined approach of lean and six sigma. Massey and Williams (2005) reports the evaluation of a single tool implementation in the Training and Development department in a NHS Trust. The tool used is named CANDO (cLean up, arranging, neatness, discipline and ongoing improvement); however, it differs little from the 5S technique conceived by the Toyota Production System (TPS). Another managerial and support case study is found in Towne (2006). It encompasses the use of lean to improve supply ordering, distribution and payment processes in a US hospital. Patient ow. Although providing little evidence, Bushell and Shelest (2002) suggests relevant results such as increased staff morale and the elimination of unnecessary steps (over processing) leading to reduced LOS in a patient-related case study. Laursen et al. (2003) describes elementary solutions to simplify patient

pathway and reduce lead-time for the pre-operative phase of coronary bypass patients in the Danish healthcare system. In 2004, the treatment of depression was analysed from a lean perspective in the USA, however it was not detailed what tools and principles were used nor the results achieved (Trangle, 2004). In the UK, Rogers et al. (2004) reports, again with little evidence and detail, the successful use of lean techniques to streamline emergency ows and reduce journey times in cancer care. Describing a large-scale project in the Swedish healthcare sector, Tragardh and Lindberg (2004) discuss a case study to improve patient ow in a disrupted elderly care service. The work also describes a lean implementation to increase capacity to cope with a 30 per cent to 40 per cent increase in demand in children care, due to new governmental policy. Brandao de Souza and Archibald (2008) also address a case study in elderly care in the Blackpool, Fylde and Wyre NHS Foundation Trust. In this work, a 50 per cent reduction in LOS was achieved in two wards. An innovative approach combining lean healthcare and computer simulation to reduce waiting lists in an audiology department at the same Trust can be found in Brandao de Souza et al. (2008). In this case study, a one-week kaizen blitz led to the implementation of new, more consistent schedule for clinics and better-organised consulting room and storage areas. These low cost changes led to a 25 per cent increase in capacity and persuaded funders to nance extra short-term capacity. In Australia, Kelly et al. (2007) describes how lean was used to map, analyse and redesign processes in an emergency department, achieving increased touch time and staff morale. No tangible results are presented though. Another emergency department was redesigned as part of a larger organisational approach at Flinders Medical Centre in Australia. Results for this case study include increased throughput and signicant reduction in LOS achieved through improved patient ow (King et al., 2006). In the UK, Lee and Silvester (2004) details a case study in another emergency department that is previously outlined in Silvester et al. (2004). These works show that a lot can be achieved just by reducing variation in demand and capacity. In addition, Woodward et al. (2007) provides a brief account of how an emergency department in the USA was redesigned using the concepts of ow and pull in order to improve quality of care and reduce LOS. In a paper that also addresses methodological issues, Spear (2005) advocates the use of lean healthcare by presenting an application that improved the ow of patients in a hospital ward. Similarly, Balle and Regnier (2007) suggests that proactive training, staff empowerment and the appropriate implementation of 5S to standardise nurses practices can lead to improvements in the quality of care. These authors also hold the view that future use of lean in healthcare will increase steadily in the next few years. In a US hospital, Kim et al. (2007) reports an increase from 43 per cent to 95 per cent in the number of patients with cancer treated in a single day, and states that this was achieved by knocking down steps in the patient pathway. Likewise, Hansen (2006) uses a similar approach to obtain a 30 per cent reduction in the number of cases of urinary tract infection. Finally, Furman (2005) proposes an unusual and relevant use of lean principles in healthcare as part of the Virginia Mason Production System (VMPS) from Virginia Mason Medical Center, in Seattle. This case study describes the implementation of a patient safety alert system, which means using jidoka and source inspection to ag and

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correct medical errors before they occur. Results point out that since the work began no patients experienced a ventilator-acquired pneumonia, which means the achievement of zero defects. Organisational In terms of organisational case studies, McCray et al. (2007) present the Pittsburgh Health System. Apparently, a single tool (5S) approach was used and for this reason, although good results are described, it is misleading to classify the strategic plan presented as lean in its full conception. In the USA, two strategic plans acquired both national and international prestige and are clearly ahead in overall results achieved by a structured lean healthcare approach. The rst one is the ThedaCare Improvement System (TIS) from ThedaCare Inc. in Wisconsin, which reports gains around U$10 million a year through cost savings and increased productivity (Miller, 2005). The second plan, also mentioned by Spear (2005), is the VMPS, which sent employees to Japan to learn how the TPS works (Miller, 2005). As noted before, Furman (2005) describes the Patient Safety Alert System at the operational level, whereas Nelson-Peterson and Leppa (2007) describes how the VMPS was used to increase time for nurses to care for their patients and impact on both staff and patients satisfaction. Other articles also mention the VMPS as an organisational approach to improve quality of care and staff satisfaction (Weber, 2006; Kaplan and Patterson, 2008). The equivalent to the US experiences in the UK is the Bolton Improving Care System (BICS), from Bolton Hospitals NHS Trust. The Trusts CEO, David Fillingham, investigates initial results obtained in over two years of practice and reects on the experience of launching such a system in the public sector (Fillingham, 2007, 2008). His work gives a relevant account of the lean journey in Bolton, in which manufacturing-like, patient ow and managerial and support case studies are discussed. Another organisational case study in the UK is called The Blackpool Way, which is a strategic and cultural approach based on lean healthcare in the Blackpool, Fylde and Wyre NHS Foundation Trust (Brandao de Souza and Archibald, 2008). In a programme called Redesigning Care, at the Flinders Medical Centre in Australia, a strategic plan for improvement has also been developed and is achieving good results, which include cost savings, reduced LOS and increased patient throughput (Ben-Tovim, 2007; Ben-Tovim et al., 2007). Results The existing literature evidences that most of the lean healthcare applications have occurred in the USA (57 per cent of the works surveyed), reecting the fact that lean healthcare is becoming a successful approach for improvement in the private sector. The eld is also growing in a fast pace in the UK public sector (29 per cent), it starts to appear more consistently in Australia (4 per cent) and in the international scenario (another 9 per cent). Figure 3 presents the increasing pattern in the number of publications from 2002 to 2008 (up to August), which indicates that works on the subject are growing signicantly. A sharp increase in the number of works in the UK

130

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Figure 3. Number of publications per year (from each country)

in 2008 can also be noted in Figure 3, which conrms the increasing recent interest in lean healthcare in the public sector. Figure 4 shows that a relatively small number of applications in managerial and support settings have been published. It also illustrates that a much higher number of speculative works has been produced in comparison with the other categories. This suggests the need for more concrete analysis to evidence the potential of lean healthcare. The survey also indicated that many case studies are branded as lean without the appropriate level of integrity. These applications are typically very nave but are called lean because they use one or two lean principles, this seems to be a problem related to the grey area around the denition of lean. In the public sector context, Radnor and Walley (2008), suggests that branding an improvement process as lean is perhaps less important than achieving initial results that can motivate and engage the staff. This reinforces the need for more concrete rather than speculative works on lean healthcare.

Figure 4. Number of publications per taxonomic category (from each country)

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Conclusions Lean healthcare is still in an early stage of development if compared to the same process in the auto industry. It is very hard to compare lean in the auto industry with lean in healthcare since the chronological developments are so large. However, it is certain that lean healthcare is learning with some of the mistakes made in the auto industry, as this issue is amply discussed in Brandao de Souza and Pidd (2008a). A natural step towards lean development that remains to be addressed is the cross-organisational interaction between different companies in a supply chain. The UK supermarket Tesco is an example outside the auto industry of such phenomenon. lean was implemented in Tesco not only internally, but the whole supply chain was rethought to better serve the customer and considerable nancial gains were achieved as a result (see Powell, 1991; Womack et al., 1990; Womack and Jones, 1996, 2005b, 2005a). Case studies found in the literature focus on the intra-organisational structure, both in strategic and operational aspects. In the NHS context, for example, this means the full integration of hospitals within the same area, Trusts in the same region, Primary Care Trusts, suppliers and other providers, all with the common purpose of providing better care. Proudlove et al. (2008) states that in hospitals there is still a lot of undergrowth to clear and that a deeper appreciation of lean may be necessary when referring to the lack of more complex lean implementations. This is probably because of the excess of simple actions that need to be taken before dealing with more complex cross-organisational integration. In an attempt to illustrate these future lean healthcare implementations Figure 5 proposes the envisioned taxonomy for lean healthcare, integrating the foreseen cross-organisational applications. No report describing the use of lean healthcare crossing organisational boundaries was found in the existing literature. Nevertheless, recent attempts were developed in The Blackpool Way to reduce the backlog in an audiology department (Brandao de Souza and Pidd, 2008b, Brandao de Souza et al., 2008). The integration described in these works does not hold a high level of cross-organisational complexity, but at least points to the right direction due to the partnership established to solve patients problems Womack and Jones (2005b). Three levels are identied to evaluate the outcomes of lean healthcare implementation: micro, meso and macro. Discussing these outcomes may be an important issue in evaluating lean efcacy in healthcare as a whole. At the operational (micro) level outcomes are represented by the manufacturing-like, managerial and support and patient ow case studies (e.g. reduced inventory, waiting times, length of

Figure 5. Envisaged Future Taxonomy for Lean Healthcare Literature

stay). At the strategic (meso) level, these improvements tend to focus on the nancial health of the organisation and potential outcomes to be evaluated are nancial gains and staff morale and involvement. Finally, at the macro level, outcomes of national initiatives such as the NHS, in the UK scenario, are still to be evaluated. In conclusion, lean healthcare has been a much-debated theme and implementations seem to outnumber the currently available literature. The survey shows that there seems to be a consensus about the potential of lean healthcare and it is surprising that no work rmly criticizing the use of lean healthcare was found in the literature. For this reason, it remains a challenge for academics and practitioners to evaluate lean healthcare under a more critical perspective and decide if it is just a management fashion or a valuable improvement philosophy.
Notes 1. Just-in-time is one of the tools used in lean practice that aims at reducing buffers between steps. In healthcare, it can be seen as reducing internal queues of patients to smooth a process. It can be better researched in Liker (2004). 2. A NHS Trust is a governmental body responsible for a number of hospitals and care providers in a determined region. 3. 5S is a lean tool that provides a structured technique that results in a well-organised workplace complete with visual controls and order. It consists in ensuring that an environment has a place for everything and everything is in its place, when you need it. References Aheme, J. (2007), Think lean, Nursing Management, Vol. 13, pp. 13-15. Allway, M. and Corbett, S. (2002), Shifting to lean service: stealing a page from manufacturers playbooks, Journal of Organizational Excellence, Vol. 21 No. 2, pp. 45-54. Aluka, G. and Chalice, R. (2007), Creating lean healthcare, in Chalice, R. (Ed.), Improving Healthcare Quality Using Toyota lean Production Methods: 46 Steps for Improvement, Quality Press, Milwaukee, WI, pp. 213-28. Bahensky, J.A., Roe, J. and Bolton, R. (2005), Lean sigma will it work for healthcare?, Journal of Healthcare Information Management, Vol. 19 No. 1, pp. 39-44. Balle, M. and Regnier, A. (2007), Lean as a learning system in a hospital ward, Leadership in Health Services, Vol. 20 No. 1, pp. 33-41. Ben-Tovim, D.I. (2007), Seeing the picture through lean thinking, British Medical Journal, Vol. 334, p. 169. Ben-Tovim, D.I., Bassham, J.E., Bolch, D., Martin, M.A., Dougherty, M. and Szwarcbord, M. (2007), Lean thinking across a hospital: redesigning care at the Flinders Medical Centre, Australian Health Review, Vol. 31 No. 1, pp. 10-15. Berwick, D., Kabcenell, A. and Nolan, T. (2005), No Toyota yet, but a start, Modern Healthcare, Vol. 35 No. 5, pp. 18-20. Brandao de Souza, L. and Archibald, A. (2008), The use of lean thinking to reduce LOS in elderly care, Proceedings of the Operational Research Applied to Health Services Conference, Toronto, ON, p. 61. Brandao de Souza, L. and Pidd, M. (2008a), Exploring the barriers for lean healthcare implementation, Public Money & Management.

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