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CHAPTER 36

The Paradox of Lean in

Healthcare: Stable
Processes in a Reactive
Environment
Ander Paarup Nielsen1, Kasper Edwards2
1

Aalborg University, Denmark

Technical University of Denmark

ABSTRACT
The principles of lean are widely being adopted in the healthcare sector.
Interestingly the realized benefits appear not to warrant the interest from managers
and policy makers.
This paper presents an analysis of 3 Danish healthcare organizations which all
introduced lean initiatives. However, only a limited set of tools has been used and
the productivity gains are limited focusing on peripheral activities and not the core
medical activities.
This apparent problem with lean in health care is hypothesized to be caused by
1) the nature of healthcare work, 2) the rationality and notion of validity among
different groups of healthcare professionals and 3) different rationalities in lean and
professionals in healthcare.
Through analysis of three cases it is concluded that the nature of work is
significantly different from manufacturing primarily because of the reactive nature
of work. Finally, different rationalities are observed between different groups of
healthcare professionals leading to problems employing the lean tool-box.
Keywords: Lean management, healthcare, reactive work processes

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INTRODUCTION
The Danish healthcare system is a public healthcare system. Like its siblings in
Europe its always under pressure to deliver more and better healthcare services. In
recent years this pressure has been increasingly accentuated.
There are several approaches for the healthcare system to deliver more care the
most common is to add resources. However as scholars know, adding resources to a
dysfunctional system does not provide proportionally more capacity and waiting
times are not shortened. Another approach to becoming more efficient is better
performing technology, which is often used but equally often the results do not
match investment as the processes are not changed. Examples of CT-scanners being
bought with no staff to man them are all too frequent in the press.
Recently fast-track systems as found in the UK and package systems such as in
Vejle hospital, Denmark (Jakobsen, 2007) has surfaced as examples of organizing
principles yielding high quality and low waiting times. Diagnostic packages are
somewhat similar to fast-track systems with the noteworthy difference that all
patients are offered a package not just those suspected of a particular illness.
Vejle hospitals success lie in their ability to diagnose all referred patients within a
matter of days thus minimizing delay in treatment. As such the healthcare systems
are beginning to use different modes of operation to obtain better performance and
quality as in production the amount of rework must be reduced to a minimum.
In this paper we focus on the use of lean in healthcare and observe that the ideas
and principles from lean management are now widely being adopted within the
health care sector both in Denmark but also internationally. The interest in lean
from managers and policy makers, however, appear to contrast the realized benefits.
This paper presents an analysis of cases reported in literature and three Danish
healthcare cases, which show that organizations within health care most often only
implement a limited set of tools and methods from the lean tool-box, leading to
limited productivity gains.
We hypothesize that the poor results from lean is caused by 1) the nature of
healthcare work, 2) the rationality and notion of validity among different groups of
healthcare professionals and 3) different rationalities in lean and professionals in
healthcare.

LEAN IN HEALTHCARE
Lean has been around for many years in the form of the Toyota Production
System (TPS). But the concept and term surfaced as lean following a study of the
Japanese car industry that tried to explain its high level of success (Womack et al.,
1991; Liker, 2004). During the past decade we have seen lean being applied in other
sectors of the economy, e.g., service industries (George, 2003), and administration
(Tapping & Shuker, 2003). Lean is now being transferred to the healthcare sector.
The goals are the same as in industry i.e. to increase quality of the care given to

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patients as well as to increase efficiency. This section will highlight some of the
findings from a literature review concerning lean implementation within the
healthcare sector (Edwards, Nielsen & Jacobsen, 2010).
In the process of writing this paper a thorough literature review concerning the
application of lean in health care was carried out. Focus in the literature review has
been on papers reporting findings from concrete cases concerning lean
implementation in different types of health care organizations. Excluded from the
literature review were conceptual papers and papers discussing lean implementation
in very general terms, i.e. focusing on key success factors for the successful
implementation of lean for example (Spear, 2005). 17 papers concerning lean and
health care were identified and examined. The papers were classified using the
following two dimensions. The first dimension is concerned with the type of
activity (or activities) that is being improved using lean. Here is has been decided to
distinguish between core activities, i.e. treatment of and care for patients, and
support activities, i.e. laboratory analysis, administrative processes, and the
management of consumables. The second dimension is concerned with the
approach to lean in the organization. The levels within this dimension are inspired
by the prestigious Shingo Prize and the lean approach is thus split into three levels.
The first level is tool driven which is characterized by an ad hoc use of a limited
number of lean tools. The second level is system driven which is focused on a
systematic use of a number of lean tools and principles. The third level is principle
driven this approach is characterized by a widespread use of lean in the
organization and an attempt to integrate lean principles into the organizational
culture. This results in a matrix with 6 different lean implementation patterns in
health care. Table 1 below reports the classification of the different papers in the
literature review.
Type of activity
Core

Tool
driven

King et al, 2006

Kelly et al, 2007
Ben-Tovin et al, 2007
Fairbanks, 2007

Count: 4
Lean
approach
System
driven

None

Support

Khandelwal & Lunch, 1999

Bushell & Shelest, 2002
Panchak, 2003
Leslie et al, 2006
Towne, 2006
Anonymous, 2007
Ball & Rgnier, 2007

Count: 7

Tragardh & Lindberg, 2004

Lummus et al, 2006
Weber, 2006
Fillingham, 2007
Ng et al, 2010

Count: 5

None
Stuenkel & Faulkner, 2009
Principle
driven
Count: 1
Table1: Lean implementation in health care.

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The literature review illustrate that most of the lean activities within health care
are focused on support or peripheral activities in the different organizations. Four
papers have been classified as focusing on the core activities. However, all four
papers focused on improving the flow of patients through an emergency ward. In all
of these four cases the actual treatment procedures were not changed as a result.
Improving the flow and thus reducing the waiting time can be seen as an attempt to
improve a core activity directly focused on improving the care of patients by
lowering their waiting times. Only one of the 17 papers reports an approach which
can be characterized as principle driven lean and still the primary emphasis is on the
support activities (Stuenkel & Faulkner, 2009).
The majority of the lean projects that has been analyzed are focused on the
peripheral and support activities within the healthcare system such as reducing the
turnover time in an operating room, improving the logistics of consumables, or
improving the planning process within the wards. The administrative processes
have also been analyzed, but a significant difference exists between public and
private healthcare systems: billing. Public healthcare, unlike private providers, is
not concerned with the front-office process of billing the patient.
Most of the papers with a focus on elements of patient care deals with
implementing lean in organizational units where the patients undergo some kind of
clearly identifiable medical procedure. Such procedures have distinct mechanical
elements such as moving patients, drawing a blood sample and analyzing it,
performing an x-ray etc. There are no studies of nursing wards where the patients
are receiving care or treatment of patients with multiple, complex, and competing
diagnoses. The reviewed lean implementations within hospitals are focused on
activities and processes which to a large extent have the same characteristics as
activities and processes in industrial manufacturing.
Also emerging from the literature review is the fact that implementation of lean
is limited to the implementation of a small number of lean related tools, typically
tools for process redesign or value stream mapping. For example, only one of the
examined papers has an intentional focus on waste (Panchak 2003) a key issue in
the lean implementation processes and only one of the papers enters into a
discussion concerning the role of lean philosophy and mindset in the organization
(Stuenkel & Faulkner, 2009). Finally, many of the papers focus almost exclusively
on productivity improvements and only one paper directly addresses the effects of
lean implementation on patient or customer satisfaction.
Based on this literature review the paper will now go on by examining the three
different explanations for the poor results of lean implementation outlined in the
introduction of this paper. This analysis is based on 3 cases from Danish hospitals.

CASES
The empirical evidence is based on three different cases all from hospital wards.
In the sections below the key findings from these three different cases will be
presented briefly.

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Case 1 is a surgery ward at a major hospital just outside Copenhagen. The ward
has about 200 employees, is open around the clock and covers both acute and
elective patients. It has 10 operating rooms whereas 6 rooms are for orthopaedic
surgeries. The staffs were overburdened and often subject to overtime, which was a
major point of complaint. Due to absenteeism and non-attendance from patients, the
department was cancelling 6-7% of the planned surgeries. An analysis of the ward
showed:
Each of the 10 operating rooms showed more than 2 hours non productive
time a day
Lack of procedures surrounding surgery leading to idiosyncrasies
Every surgeon and anaesthesia doctor had formed their own routines
during operating procedures making cooperation difficult
Clear sense of a lack of planning
Rigid organizational structure
Informal leaders especially among surgeons, leading nurses and
anaesthesia doctors.
A lean programme was initiated to create more effective working procedures,
and ensure a total continuity of care to the benefit of both staff and patients. The
basic idea was to create operating rooms where surgeons do not have to leave the
sterile area. In a similar manner teams were formed so that in-operating room team
members did not have to leave the sterile area, thus relying on team members in the
non-sterile area. With the complete operating team present in the operating room
no-one is waiting and procedures can be completed without waiting.
This resulted in the establishment of two so-called Turbo rooms that only
performs elective surgery on less complicated patients. The turbo rooms do not
perform any education and is manned by the senior staff i.e. the most skilled
doctors and nurses. The turbo rooms have a fixed team structure which has allowed
a deeper analysis of cooperation during the actual operating procedure. The result
has been overwhelming. What was previously done in three operating rooms can
now be done in two and the teams are finished within their shift. This has a
significant effect on morale as the teams experience a sense of accomplishment
they make a difference. While the number of patients treated by the teams are 33%
higher the activity level is reportedly not higher, but the waiting times have been
eliminated and absenteeism has decreased by 33%. However, the turbo rooms
require more support staff which must be ready to act when needed.
Case 2 is a regional hospital and in general the hospital has very positive
experiences with lean and has achieved significant positive results within, i.e.,
laboratory analysis and other non core activities. However, lean has primarily been
implemented in support activities. The hospital now has an ambition to implement
lean as part of the patient process. One example of this is a lean project in an outpatient surgical unit which tried to capture the process from patient arrival to
discharge. The staff did a value stream mapping of all the activities the staff thought
was involved. In the early phase of the value stream mapping there was widespread

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agreement on content of the different activities as well as the prioritization of the
task. However, in the later phases of the project when the lean staff at the hospital
began to test the value stream in real life by making test runs through ward the
value stream maps did not match the real world.
The different groups involved in the process had very different interpretations
concerning the value stream and actual content of activities. Differences arose over
a number of issues, for example, over the necessary preparations for patients with
different diagnoses, what equipment should be ready, and which specialists should
be on call, where the patient should wait and how the patient should navigate.
Interestingly, these different perceptions generally emerged between professions,
i.e. doctors, nurses, secretaries etc.
Part of the explanation can be found in the different rationalities inherent in the
professional groups. This gives rise to (mis)interpretation of the activities
performed by the other professions. An internal lean consultant at the hospital
stated that doctors and nurses focus on different values and metrics. Nurses tend to
focus on the quality of the care they can offer whereas doctors focus on the success
rate of the treatments.
Case 3 is an oncology ward at a Danish university hospital. The ward is
primarily focused on out-patient treatment of cancer patients, i.e. chemo therapy or
radiation treatment. The lean activities of the cancer ward were part of a major lean
initiative at the hospital. The lean activities were supported by a central lean task
force and had significant top management support. The ward carried out a number
of lean activities with good and positive results.
An element in the lean project in case 3 was the development of a standard
operating procedure (SOP) concerning the booking of couches for chemo therapy
patients. Besides initial technical problems this element of the lean project created
resistance especially amongst the nurses who normally had the discretion to plan a
series of sessions for the patients and book couches accordingly. Some nurses saw
this new booking system as an attack on their professional judgement and
discretion. They therefore resisted this standardization and argued that lean would
limit their ability to provide the best possible treatment of and care of the patients.

CASE ANALYSIS AND DISCUSSION

The surgery ward (case 1) highlights the importance of stability and leveling for
implementing lean. Of the 10 possible rooms only 2 was converted into turbo
rooms. This was due to the mix of patients which only allowed the required stability
and leveling for two operating rooms. Interestingly, emergency departments are
well suited for lean despite the variation in patient mix. This observation is also
supported by the classification of lean papers in table 1. The reason for this must be
found in the nature of emergency departments where patients are treated with little
or no preparation and a goal of being able to process patients quickly in order to
either finalize the treatment and release the patient or to diagnose the patient in

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order to be able to transfer the patient to the relevant wards in the hospital. Unlike
emergency departments, elective surgery requires extensive preparation and
unforeseen switching of patients will ruin preparation and reduce productivity. All
down stream activities such as wake-up and mobilization of the patients will be
affected as they cannot be precisely planned. The ward receives all sorts of patients
including emergencies it is not possible to turn all operating rooms into turbo
rooms.
The out-patient surgical ward (case 2) illustrates another aspect in connection
with challenges of implementing lean in health care. Here is found that is it very
difficult to establish a true value stream due to different perceptions of the patient
process. A key prerequisite in lean is that there is a shared understanding of the
value the organization is providing to its customers. An example of this is found in
(Stuenkel & Faulkner, 2009) where it is stated administrators do not speak the
language of nurses. Another part of the explanation can be found in the professions
perception of the patient process as a series of discrete events. Each profession does
his job without consideration for the prior or next activity in the process. This
makes the value stream tool difficult to use as it result in what participants believe
to be the process and not the actual process.
The final case from the oncology ward (Case 3) illustrates that there is a
potential conflict between the development of standardized routines or SOPs
inherent in lean and the professional judgment of the doctors and nurses. The health
care professionals will claim standardization to be a significant problem as it limits
the scope of their professional judgment, to the detriment of care quality. The
implementation of lean in health care is not just limited by the different rationalities
between the professions, but also by the potential conflict between the logics of
standardization and need for individualized treatment and care.

THE CHALLENGES OF IMPLEMENTING LEAN IN HEALTH CARE

A challenge concerning the implementation of lean in the healthcare sector
deals with hypothesis 1: the nature of the work. In industrial production the tasks
are predictable, routine and they can thus be standardized. Many activities in a
hospital are not to the same extent as industry predictable and routine they are
reactive. Performing surgery on or caring for critically ill patients in a medical
ward will require non-standard and specifically orchestrated care. Even though
hospitals and doctors to a large extent uses standardized procedures there is always
a level of variability involved as patients are different and complications might
emerge during a procedure. It is therefore difficult to employ the same high level of
standardization known from industrial production. Furthermore, healthcare is a
service which means that it is difficult to apply methods from industrial production
directly. Services are for example characterized by high levels of user/customer
involvement, demand fluctuations and labor intensity (Miles, 2000). These
characteristics again imply that healthcare in some areas differs significantly from
industrial production.

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It can therefore be concluded that it is not possible to use lean methods and
principles in healthcare in general. There is a need to adapt the lean methods and
principles to the special characteristics within the healthcare sector. This leads to
the conclusion that lean is not the universal tool for hospital process improvement
and lean cannot be applied in every activity and process in a hospital. Furthermore,
in general leveling and stable processes are a prerequisite to using lean in
healthcare.
Hypothesis 2 and 3 which addresses the challenges of lean implementation and
the different rationalities involved. The findings from the cases confirms that core
medical work is more complex than industrial work not just of because reactive
nature of the work but also because it is difficult to establish a common perception
of the patient process. There is no single process but many and doctors and nurses
apply different criteria when analyzing the process. Furthermore, lean also put the
discretion and professional judgment of the employees in the healthcare sector
under pressure as a core element in lean is the standardization of work processes.
This development towards standardization will in some case create a strong barrier
against the implementation of lean in the core activities of health care
organizations.
Lean is implemented in isolated organizational units, only few tools are being
applied and the goal is to increase efficiency. Lean is implemented in those
activities and organizational units that share close resemblance to industrial
production. Implementation that makes changes to the core medical work and
organization remains to be seen. Finally, care should therefore be taken not to
implement lean in an un-reflected manner, where advocates of lean just attempt to
implement lean without taking the special characteristics of health into
consideration when planning the lean project. The findings in this paper calls for a
more transformative approach to lean, where the special characteristics of health
care organizations and the nature of their activities are taken into consideration.

CONCLUSION
Lean manufacturing is hailed as a universal solution to many a productivity and
quality problem. Lean has proven itself as a valuable methodology in production
and administration. In short Lean works! But lean only work in some hospital
settings. The prerequisites of leveling and stability must be observed if success is to
be achieved. Image diagnostics and planned surgery of select patients are examples
of successful lean implantations. However, we can also observe that lean in some
situations reaches its natural limit. The meaning of this is that lean is not a
universal solution which can be applied successfully in every activity in a hospital.
The reactive or responsive nature of many of the core activities in hospital limits
the application of lean. The objective of stable and predictable processes inherent in
lean cannot be met in many activities at a hospital. Furthermore, the standardization
inherent in lean also creates challenges for the implementation of lean as some
employees see the establishment of standardized processes as a threat to their

343
professional judgment. The different rationalities in the different staff groups in a
hospital also create barriers for the successful implementation of lean in the
healthcare sector. These different rationalities make it difficult to develop a
common understanding of value and high-quality care. The cases we report in this
paper illustrate these points.
Does lean live up to its promise in health care? The answer to this question is
mixed. Lean can be used to create significant productivity improvement in
healthcare organizations. However, there need to fit between the nature of the
activities being improved by lean and the basic assumptions within lean. In
activities where fit is non-existent care should be taken not to implement standard
lean, i.e. lean as it is practiced in industrial manufacturing. This paper therefore
calls for a more transformative approach to lean where the nature of work within in
healthcare and the potential clashes between different rationalities are taken into
account.
Is there a paradox in healthcare? Yes it is. Most healthcare work is reactive and
yet the processes are very stable. The stability is tied to the different roles e.g.
doctors, nurses etc. which revert to basic behaviors when having to react to an
unforeseen event. The nurse and the doctor know what to do in the event of cardiac
arrest. Although these processes are stable they are not part of a larger planned
process its reactive. While lean require stable processes, lean also require larger
processes that span a chain of activities. Healthcare is troubled by not having such
tight integrated chains of activities, which of course is why lean does not in general
apply to healthcare.

ACKNOWLEDGEMENTS
This paper has been written with funding from The Working Environment Research
Fund, Denmark. The authors wish to acknowledge the help and input from our
fellow researchers in the Lean without Stress project: From the Technical
University of Denmark, Ass. Prof. Neils Mller, Ass. Prof. Peter Jacobsen. From
Aalborg University, Professor John Johansen, PhD. Student Rikke V. Matthiesen,
Ass. Prof. Jacob S. Nielsen. From the National. From the National Research Centre
for the Working Environmen, Ass. Prof. Peter Hasle, Ass. Prof Jan H. Pejtersen and
Ass. Prof. Pia Bramming.

REFERENCES
Anonymous (2007). OR Department uses LEAN to cut unneeded inventory and saves
money. Healthcare Purchasing News, 31, 68-69.
Ball, M. & Rgnier, A. (2007). Lean as a learning system in a hospital ward. Leadership in
Health Services, 20, 33-41.
Ben-Tovim, D. I., Bassham, J. E., & Bolch, D. (2007). Lean thinking across a hospital:
redesigning care at the Flinders Medical Centre. Australian Health Review, 31, 10-15.
Bushell, S. & Shelest, B. (2002). Discovering lean thinking at Progressive Healthcare. The

344
Journal for Quality and Participation.Cincinnati, 25, 20-25.
Edwards, K., Nielsen, A.P. & Jacobsen, P. (2010), Implementing Lean in surgery - Lessons
and Implications, International Journal of Technology Management (forthcoming)
Fairbanks, C. B. (2007). Using Six Sigma and Lean Methodologies to Improve OR
Throughput. Association of Operating Room Nurses, AORN Journal, 86, 73-82.
Fillingham, D. (2007). Can lean save lives? Leadership in Health Services, 20, 231-241.
George, M. L. (2003). Lean Six Sigma for service: How to use Lean speed and Six Sigma
quality to improve services and transactions. New York: McGraw-Hill Education Europe.
Jakobsen, M. (1-12-2007). Vejle-modellen: Gavner det patienten? (in Danish). tt p krft
[4], 4-7. Krftens Bekmpelse.
Kelly, A., Bryant, M., Cox, L., & Jolley, D. (2007). Improving emergency department
efficiency by patient streaming to outcomes-based teams. Australian Health Review,
31, 16-21.
Khandelwal, V. K. & Lynch, T. (1999). Reengineering of the patient flow process at the
Western Sydney Area Health Service. Proceedings of the Hawaii International
Conference on System Sciences, 145.
King, D. L., Ben-Tovim, D. I., & Bassham, J. (2006). Redesigning emergency Department
Patient Flows: Application of Lean Thinking to Health Care. Emergency Medicine
Australasia, 18, 391-397.
Leslie, M., Hagood, C., Royer, A., Reece, C. P., & Maloney, S. (2006). Using lean methods
to improve OR turnover times. Association of Operating Room Nurses AORN Journal,
84, 849-855.
Liker, J. K. (2004). The Toyota Way. New York: McGraw-Hill.
Lummus, R. R., Vokurka, R. J., & Rodeghiero, B. (2006). Improving Quality through Value
Stream Mapping: A Case Study of a Physicians Clinic. Total Quality Management &
Business Excellence, 17, 1063-1975.
Miles, I. (2000). Services Innovation: Coming of Age in the Knowledge-Based Economy.
International Journal of Innovation Management, 4, 371.
Ng, D., Vail, G., Thomas, S. & Schmidt, N. (2010), Applying the lean principles of the
Toyota production system to reduce wait times in the emergency department, CJEM
Journal of the Canadian Association of Emergency Physicians, Jan 2010. 12:1; 50-57
Panchak, P. (2003). Lean health care? It works! Industry Week, 252, 34-40.
Spear, S. (2005). Fixing Health Care from the Inside, Today. Harvard Business Review, 83,
162.
Steunkel, K. & Faulkner, T. (2009). A community hospital's journey into Lean Six Sigma,
Frontiers of Health Services Management, 26:1, 5-13
Tapping, D. & Shuker, T. (2003). Value stream management for the lean office: Eight steps
to planning, mapping, and sustaining lean improvements in administrative areas. New
York: Productivity Press.
Towne, J. (2006). GOING 'LEAN' STREAMLINES PROCESSES, EMPOWERS STAFF
AND ENHANCES CARE. H&HN: Hospitals & Health Networks, 80, 34.
Tragardh, B. & Lindberg, K. (2004a). Curing a meager health care system by lean methodstranslating 'chains of care' in the Swedish health care sector. International Journal of
Health Planning and Management, 19, 383.
Weber, D. O. (2006). Toyota-style Management Drives Virginia Mason. Physician
Executive, 32, 12.
Womack, J. P., Jones, D. T., & Roos, D. (1991). The Machine That Changed the World : The
Story of Lean Production. (First HarperPerennial ed.) New York: HarperCollins.