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In the scientific literature, many studies describe the application of lean methodology in the hospital setting. Most of the articles focus on the results rather than on the approach adopted to introduce the lean methodology. In the absence of a clear view of the context and the introduction strategy, the first steps of the implementation process can take on an empirical, trial and error profile. Such implementation is time-consuming and resource-intensive and affects the adoption of the model at the organizational level. This research aims to outline the role contextual factors and introduction strategy play in supporting the operators introducing lean methodology in a hospital setting.
The methodology is revealed in a case study of an important hospital in Southern Italy, where lean has been successfully introduced through a pilot project in the pathway of cancer patients. The originality of the research is seen in the detailed description of the contextual elements and the introduction strategy.
The results show significant process improvements and highlight the spontaneous dissemination of the culture of change in the organization and the streamlined adoption at the micro level.
The case study shows the importance of the lean introduction strategy and contextual factors for successful lean implementation. Furthermore, it shows how both factors influence each other, underlining the dynamism of the organizational system.
The online version contains supplementary material available at 10.1186/s12913-021-06885-4.
Keywords: Lean implementation, Contextual factors, Introduction strategy, MUSIQ, Case studyOver the last decade, healthcare has been called upon to respond to the increasing pressures arising from changes in demand – due to epidemiological changes and the demand for quality and safety – and increased costs due to the introduction of new technologies [1, 2]. These major challenges are exacerbated by the shrinking resources available in health systems and, for most countries, by the principle of universal access to patient care. In order to meet the patients’ needs, a hospital must utilize a number of scarce resources at the right time: beds, technological equipment, staff with appropriate clinical skills, medical devices, diagnostic reports, etc. [1, 2].
One of the most relevant issues for the management of a healthcare provider is the management of patient flows in order to purchase, make available, and use these scarce resources at the right time and in the right way, and to ensure the best possible care [3–5]. In this scenario, hospitals need to focus on the patient pathways in order to ensure fast, safe, and high-quality service [3, 6–8]. The search for solutions to these challenges has extended beyond the boundaries of healthcare practices to study organizational methods and paradigms that have been successfully implemented in other sectors [3, 5]. Among these, lean thinking has proven to be one of the most effective solutions for improving operational performance and process efficiency and for reducing waste [5, 9]. Lean is a process-based methodology focused on improving processes to achieve a customer ideal state and the elimination of waste [10]. Waste is defined as the results of unnecessary or wrong tasks, actions or process steps that do not directly benefit the patient. The taxonomy of waste is: overproduction, defects, waiting, transportation, inventory, motion, extra-processing and unused talent [3–5]. In addition, lean addresses other key service issues such as continuous improvement and employee empowerment, whether healthcare professionals or managers [1, 11, 12]. Lean healthcare is defined as a strategic approach to increasing the reliability and stability of healthcare processes [7, 13, 14].
The first documented cases of lean applications in a hospital setting (HS) date back to the late 1990s. These aimed at improving patient care processes, interdepartmental interaction, and employee satisfaction [1, 2]. The Virginia Mason Medical Center is one of the first and most emblematic examples of a successful migration of lean methodology from the manufacturing sector to healthcare. The hospital, based on the principles of the Toyota Production System, created the Virginia Mason Production System, a holistic management model in continuous evolution that not only had a strong impact on the quality of the services provided and on the reduction of lead time, but it also led to a decrease in operating costs [14, 15]. Over time, many hospitals have followed in the footsteps of the Virginia Mason Medical Center [8, 16, 17]. The lean paradigm crossed the US border and spread to other countries such as Canada and England [5, 12]. It was not until the early 2000 that the model was introduced in European hospitals [12, 16].
The implementation of the lean paradigm in HS environments has increasingly attracted the attention of researchers and professionals. The interest in lean in HSs was fostered by the idea that the paradigm was particularly suitable for hospitals because its concepts are intuitive, compelling, and, therefore, easy for medical staff to use [18, 19]. However, over time, alongside the evidence of successful implementation of lean in HSs, much of the research has shown failures in adopting the paradigm [5, 20, 21]. Moreover, a literature review showed that most of the cases were characterized by a partial implementation of lean methodologies and concerned single processes in the value chain or restricted technical applications [20, 22]. Even today, few hospitals apply lean principles at a systemic level [23, 24].
The failure of lean implementation is a hot topic. Many authors who have focused their studies on social and managerial issues have highlighted the existence of factors that either enable or hinder the implementation of lean. These factors are mostly related to the context and the implementation strategies [5, 16, 25–27]. Lean implementation is not self-evident, and the process of transforming an organization into a lean organization requires a long-term strategic vision, a commitment by management, and a culture of change in the entire organization [5, 16, 26]. Contextual factors influence successful implementation and introduction strategy; lean adoption, in turn, changes contextual factors. A lean transformation must be planned and managed; it is not a quick solution, but a strategic plan in constant evolution [5, 28, 29]. From this point of view, the introduction phase plays a fundamental role in implementation because it facilitates the dissemination of the lean principle in hospitals and enables the contextual elements that support change. Although most researchers have recognized the role of the introduction step, the impact of this phase on contextual factors has been poorly reported on in the literature [5, 12, 20]. Most of the articles have focused more on the benefits of this phase than on how to manage it.
In light of this, it is necessary to examine how hospitals introduce lean into their clinical pathways in order to explain the success of the lean implementation. Starting with an in-depth analysis of the contextual factors discussed in the literature, the document helps to clarify what drives success in lean implementation within the hospital. The research has therefore undertaken a critical study of the introduction of lean in the case study of the haematology ward at a university hospital in the south of Italy. The objective is to highlight: (a) the role of contextual factors for successful lean introduction and implementation in a hospital ward; (b) how the pilot project has improved the pathway of a cancer patient undergoing chemotherapy infusion; and, (c) how the success of the pilot project modified the contextual factors, facilitating the spread of lean within the organization.
The study has the merit of detailing all the lean introduction phases. The analysis period is about 2 years. The lean introduction started in May 2018 and lasted 7 months. The pilot project results refer to the follow-up period of December 2018 to May 2020, while the dissemination results refer to the period from December 2019 to May 2020.
The paper is structured as follows: In the following section, the theoretical background is provided. Section 3 describes the research methods, while Section 4 presents the results of the pilot project. Finally, Section 5 presents the conclusion, highlights some limitations of this study, and proposes some directions for further research.
Most authors point out that the introduction phase is a crucial moment in lean implementation [10, 12, 16]. This phase reduces distrust of the method and organizational resistance to change. It shows the benefits of lean and assesses the organization’s ability to undertake continuous improvement. Many case studies report the success of lean in HSs by describing the use of lean instruments [8, 30, 31]. They offer the practitioners some methodological support, but not in a structured way since they do not provide a clear implementation roadmap [5, 32, 33]. Some authors have tried to fill this gap in the literature by offering guidelines for implementation. Augusto and Tortorella [33] suggests carrying out a feasibility study focused on the desired performance before implementing continuous improvement activities. The author suggests defining the techniques, roles, and results related to the improvement path. Curatolo et al. [5] argue that the improvement procedure has to take into account six core operational activities of business process improvement and five support activities. The six core operational activities are: selecting projects, understanding process flows, measuring process performance, process analysis, process improvement, and implementing of lean solutions. The five support activities are: monitoring, managing change, organizing a project team, establishing top management support, and understanding the environment. These studies, while offering further guidance on the process of introducing lean into a hospital, do not describe either the organizational context in which the method is being implemented or the strategies for its implementation [5, 12, 25]. The introduction of lean into a HS is not an easy task; there are many organizational issues to be addressed. Among these, the analysis of the context and the definition of the implementation strategy are the ones with the greatest impact on the success of the introduction [16, 26, 34].
The contextual elements are the special organizational characteristics that must be considered to understand how a set of interventions may play out [35, 36]. They interact and influence the intervention and its effectiveness [34, 36]. Two of the most cited contextual element are the drive to improve processes and the level of maturity [5, 10]. The drive for improvement is represented by the exogenous and endogenous needs that act as triggers for the introduction of improvement methodologies [25, 26, 35, 37]. The level of maturity refers to knowledge and experience in process improvement initiatives. It includes knowledge of methodologies and tools, experience gained, confidence, trust, and dissemination within the organization. Where the maturity is low, there is a risk of lean introduction failure in both the processes and the organization as a whole [5, 16, 38]. As long as the organization does not reach a fair level of maturity, the rate of change tends to be slow and sometimes frustrating. However, as the degree of maturity increases, lean implementation becomes a “day-to-day job” rather than a series of projects that take place at discreet moments [10, 21, 39]. Hasle et al. [39] highlighted that a high level of maturity allows for the implementation of principle-driven lean. Contextual elements include organizational and technological barriers such as resistance to change, lack of motivation, skepticism, and a lack of time and resources that inhibits the introduction and the implementation process [4, 8, 21, 40]. The lean introduction process in HS is also complicated by the organizational context and the double line of clinical and management authority in hospitals [41, 42].
With regard to internal contextual factors, many authors explored the readiness and sustainability factors influencing the adoption of lean. Readiness factors are those elements that improve the chances of lean implementation success; they provide the necessary skills and knowledge to enable organizational change [23, 43–45]. The readiness and sustainability factors include any practices or characteristics that allow organizational transformation by reducing or nullifying potential inhibitors of success. High commitment and strong leadership of managers and physicians, continuous training, value flow orientation, and the hospital’s involvement in continuous improvement are just some of the most discussed topics [5, 10, 16, 43]. Other examples include understanding employees needs, identifying the organization’s strategic objectives, project management, and teamwork [5, 12, 16, 46].
From the study of the contextual elements described so far, some authors have developed models to assess the impact of context on the implementation of organizational improvement activities. Kaplan et al. [36] put forth the Model for Understanding Success in Quality (MUSIQ). The authors identified 25 key contextual factors at different organizational levels that influence the success of quality improvement efforts. They defined five domains: the microsystem, the quality improvement team, quality improvement support and capacity, organization, and the external environment. Kaplan et al. [36] suggest that an organization that disregards contextual factors is doomed to fail in implementing an improvement program; an organization that adopts a context-appropriate implementation strategy can change the outcome by triggering implementation enablers. Previous studies of lean adoption in HSs suggest that the fit between the approach taken and the circumstances will influence the chances of success [3, 12, 34].
There are two strategies for introducing lean in a HS, and they are characterized by the implementation level. The level of implementation refers to either micro or meso implementation. Brandao de Souza [16] defined meso-level implementation as the condition under which lean is spread throughout the organization and is implemented at the strategic level, while micro-level implementation is where lean is implemented at a single process level in discrete moments. Meso-level implementation is crucial for long-term success because a lack of integration in a lean system can lead to the achievement of local rather than global objectives and can also affect the sustainability of the paradigm [23, 26, 47]. However, organizations that want to implement lean at the strategic level often do not recognize the need for a long-term implementation program and introduce lean as a “big-bang initiative”. This leads in many cases to a failure to introduce the method [16, 47]. Many researchers suggest introducing the lean approach through a pilot project run by a specially formed lean team [12, 16, 48, 49]. The pilot project should be challenging, involve a process relevant to the organization, and require the use of a systemic approach. In particular, it should not be limited to the application of “pockets of good practice” or lean tools, but should include the systemic adoption of improvement programs such as the Plan-Do-Check-Act (PDCA) cycle [21, 48]. Brandao de Souza [16] asserts that the first initiative should be tested on a relevant patient pathway. The lean team should be composed of clinical and non-clinical staff actively involved in the patient pathway. A pilot project that meets these conditions is a useful tool for increasing the maturity of the method within the organization [21, 39]. It can increase the confidence of the team and staff in the lean approach and can promote the learning of lean methodologies and techniques [21, 39]. Moreover, the pilot project activates the contextual elements, enabling the introduction of the model [10, 12]. The successes of the pilot initiative must be celebrated and communicated within the organization [10]. When the first initiative leads to visible and easily quantifiable results, the method has a greater chance of spreading throughout the organization [10, 12, 16]. In light of these considerations, the lean implementation requires that the contextual elements and the introduction strategy be assessed at the same time. In addition, it would seem fair to assume that as contextual factors influence the introduction strategy, the results of the implementation strategy will influence the contextual factors.
In Fig. 1 , we propose an adaptation of the MUSIQ model [36] that shows the impact that the lean implementation strategy has on the contextual elements.