Description of the condition
Healthcare systems are facing growing challenges as our aging society is increasing the demand for care (Al-Balushi 2014; Leggat 2015; Poksinska 2010). Healthcare systems are required to meet this growing demand, while increasing accountability and improving the quality of care (DelliFraine 2010; Leggat 2015; McIntosh 2014). The challenge of meeting these demands is complicated by the fact that financial conditions among healthcare systems are not improving and in some cases are even worsening (Al-Balushi 2014; Poksinska 2010).
In response to this phenomenon, healthcare providers are striving to improve outcomes while simultaneously achieving greater efficiency (Baker 2001; Fine 2009; Kohn 2000; McIntosh 2014). To meet these goals, many organisations have turned to industrial improvement approaches (Kaplan 2014). One prominent improvement method is the Lean management system (Lean); it has been estimated that this system has been adopted in some form by 53% of US hospitals (ASQ 2009). Lean management promises enhanced quality, capacity, and safety, while containing costs (Curatolo 2014; Kaplan 2014).
Description of the intervention
Lean management, originally termed the Toyota Production System (TPS), was developed in the auto industry by Taiichi Ohno (Black 2008; Radnor 2012). The original aim was to ensure defect-free manufacturing, while minimising waste and addressing customer needs (Andersen 2014; Black 2008; Curatolo 2014; Reijula 2014). Since it was developed, Lean has been applied to various industries and is now conceptually described as “an integrated socio-technical system whose main objective is to eliminate waste by concurrently reducing or minimizing supplier, customer, and internal variability” (Shah 2007).
When Lean was adopted into health care, numerous components were emphasised, and common foci include development of a culture of continuous improvement, empowerment of employees, and reduction of waste, with focus on improving the value of services received by patients (Andersen 2014; Casey 2009; Curatolo 2014; DelliFraine 2010; Holden 2011; Mann 2010; Mazzocato 2010; Poksinska 2010; Printezis 2007). Concentrating on these values is expected to result in decreased costs, enhanced safety, and improved quality of care (Casey 2009; D’Andreamatteo 2015; Mann 2010; Mazzocato 2010; Poksinska 2010). To achieve these goals, Lean management systems use several common activities. Table 1 depicts frequently used activities.
|Value stream mapping (VSM)||Visual tool plotting all processes required to deliver a healthcare service. VSM facilitates enhanced understanding of the flow of patients, supplies, or information through a healthcare process (RQHR 2015).|
|Rapid process improvement workshop (RPIW)||Generally a week-long event during which teams of patients and their families, staff, and clinicians focus on a single problem, identify the root cause, create solutions, and implement sustainable changes (SHR 2015)|
|5S events||Stands for ‘Sort, Sweep, Simplify, Standardise, Sustain/Self-Discipline’; represents a set of concepts that ensure a clean and well-organised workplace (RQHR 2015)|
|A3 problem solving||Standardised method of addressing problems utilising an A3 report - a standardised form for planning and report writing. Content follows the plan-do-study-act (PDSA) cycle (A3 Thinking 2015).|
|Gemba walk||Japanese term that means ‘the workplace’. This term simply refers to the ‘work floor’ or unit where necessary patient care is provided (SHR 2015). Refers to the action of a manager or CEO spending time on the hospital floor and speaking to front-line staff who understand problems and shortcomings of the organisation (Black 2008)|
|'Stop the Line' techniques||Derived from manufacturing (specifically, the assembly line); term refers to the act of enabling all healthcare professionals to immediately stop the line (a process of care) when a defect or error is realised. This prevents errors from being passed on and makes causes of errors more salient (JBA 2014).|
|Levelled production||Refers to elimination of unnecessary variation (unevenness) in health care to avoid bottlenecks and backups, which can lead to patient wait times and wasted time for healthcare professionals (Black 2008). Requires rigorous study of organisational processes and scheduling of patients and clients according to actual or forecasted demand (Black 2008)|
|Daily visual management (DVM)||System aimed at improving communication and ensuring that information is available when needed. Achieved by displaying objectives, metrics, and progress transparently and using measures (e.g. staff injuries, patient falls) to manage change (RQHR 2015). Closely linked to the wider strategic management system or policy deployment system of an organisation (Black 2008)|
|Kanban||Just-In-Time inventory management system which utilizes visual indicators to limit excess inventory and trigger the acquisition or production of specified goods (Black 2008)|
|Standard work||Details the steps in a course of treatment or health care in a multi-disciplinary care plan. Prescribes a uniform way to achieve a desired service or patient outcome based on best available evidence. Serves as the basis for any kind of improvement (RQHR 2015)|
DVM: daily visual management.
PDSA: plan-do-study-act cycle.
RPIW: rapid process improvement workshop.
VSM: value stream mapping.
How the intervention might work
Various authors have proposed theories for how outcomes in health care could be improved through the application of Lean management systems. Spear has suggested that Lean should empower front-line employees, providing them with the tools necessary to make improvements, while simultaneously promoting a focus on the patient. This approach is intended to encourage staff to focus on caring for patients while simultaneously finding better ways to provide care (Spear 2005).
Similarly, Womack has proposed that Lean could be utilised in health care by focusing on ensuring value to the patient and including various measures of patient satisfaction such as comfort and wait times as key performance indicators (Womack 1996). In contrast, Young has recommended that Lean should be used to eliminate waste in the form of wait times, repeat visits, errors, and inappropriate procedures (Young 2004).
The current literature demonstrates that Young's theory provides the best description of how Lean has been utilized in healthcare to date. This is shown by work suggesting Lean organizations have done little to develop a better understanding of customer’s value (Radnor 2012). Instead, most interventions have focused on implementing changes that reduce waste by standardising processes to bring them in line with best practices (DelliFraine 2010; Holden 2011). Additional evidence suggests that Lean is most commonly implemented as a set of individual interventions that use Lean tools to make improvements within specific departments or wards (Poksinska 2010; Radnor 2012).
Why it is important to do this review
Although Lean has been widely applied in healthcare systems in Canada, the United States, and the United Kingdom, patients, front-line staff, healthcare managers, and policy makers lack evidence-based information regarding the effectiveness of Lean management approaches in health care (ASQ 2009; Burgess 2013; Fine 2009; Hamilton 2014; Kaplan 2014; Mazzocato 2012). This is due in part to the fact that although the body of literature on Lean management in health care is slowly growing, most publications are case studies that present only anecdotal evidence, providing weak empirical support (D’Andreamatteo 2015). Researchers attempting to synthesise data have noted significant gaps (Andersen 2014; DelliFraine 2010; Leggat 2015; McIntosh 2014). Studies report conflicting results regarding effects of Lean implementation in various health contexts (Leggat 2015; McIntosh 2014). Many studies have demonstrated various shortcomings such as failure to describe the implementation process and utilisation of suboptimal evaluation designs. This evidence gap, combined with the fact that costs of both implementation and failure are high, necessitates a thorough, high-quality evaluation of the management system (McIntosh 2014; Mann 2005; Mann 2009). This protocol outlines the research that must be conducted to address this need and advance our knowledge through a rigorous, systematic review of Lean management in health care with focus on its effects on healthcare systems, professional practice, and patient outcomes.