Applying Lean to Healthcare Delivery Processes - a Case-based Research

D.T. Matt, G. Arcidiacono, E. Rauch


The purpose of this paper is to demonstrate that Lean principles and methodology should be applied on a regular basis to the entire process flow of healthcare delivery systems. With reference to an actual case-based research, this article demonstrates how patient flows can be successfully optimized if Lean is not limited to single processes/contexts only, and it is applied to achieve holistic process improvement of an entire system.
The complexity of healthcare delivery systems requires inclusive investigation from various points of view. This is why case-study-based research has been used to investigate dynamic, experiential and complex processes and areas, such as the ones featured by this article. The methodological basis for this research has been a twelve-step optimization approach outlined by the authors during a previous successful Lean programme. This same approach has been applied to optimize patient flows in the emergency departments of four different hospitals in Northern Italy. The research has involved teams composed of medical, nursing, technical and administrative staff.
The results outlined in the article suggest that inclusive application of Lean tools leads to effective process optimization and a better working environment, when in connection with a systematic and holistic optimization approach. Feedback from participants was obtained through a satisfaction survey and a project assessment; it reported enthusiastic project acceptance and good teamwork climate. Among the results of the research performed in the four hospitals, several measures have been effectively implemented to reduce the lead-time for patients from registration to discharge. At the same time, patient-staff ratio and quality of care have been either maintained or even improved. However, lack of a definite conclusive evaluation can be explained by the research project still being implemented.
The value of this paper lies in demonstrating how Lean contributes to achieve better process performance and high staff satisfaction, when implemented within the whole supply chain of a healthcare delivery system on a regular basis.


Healthcare; healthcare delivery process; Lean; emergency department; patient flow improvement

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J. P. Womack and D. T. Jones. Lean Thinking: Banish Waste and Create Wealth in your Corporation. London, UK: Simon and Schuster, 2003.

B. McIntosh, B. Sheppy and I. Cohen, "Illusion or delusion - Lean management in the health sector", International Journal of Health Care Quality Assurance, vol. 27, pp. 482-492, 2014.

A. Giorgetti, C. Cavallini, A. Ciappi, G. Arcidiacono, P. Citti, "A holistic model for the proactive reduction of non-conformities within new industrial technologies", International Journal of Mechanical Engineering and Robotics Research, vol. 6(4), pp. 313-317, 2017.

G. Arcidiacono, C. Calabrese, K. Yang, Leading Processes to Lead Companies: Lean Six Sigma: Kaizen Leader & Green Belt Handbook. Milan, Italy: Springer Verlag, 2012.

M. Godinho Filho, A. Boschi, A. Freitas Rentes, M. Thurer and T. M. Bertani, "Improving Hospital Performance by Use of Lean Techniques: An Action Research Project in Brazil", Quality Engineering, vol. 27, pp. 196-211, 2016.

P. Nayar, D. Ojha, A. Fetrick and A. T. Nguyen, "Applying Lean Six Sigma to improve medication management", International Journal of Health Care Quality Assurance, vol. 29, pp. 16-23, 2016.

J. De Mast, B. Kemper, R. J. M. M. Does, M. Mandjesb and Y. van der Bijlc, "Process Improvement in Healthcare: Overall Resource Efficiency" Quality and Reliability in Engineering International, vol. 27, pp. 1095-1106, 2011.

K. C. Van Leeuwen and R. J. M. M. Does, "Quality Quandaries: Lean Nursing", Quality Engineering, vol. 23, pp. 94-99, 2010.

T. Joosten, I. Bongers and R. Janssen, "Application of Lean thinking to health care: issues and observations", International Journal for Quality in Health Care, vol. 21, pp. 341-347, 2009.

J. P. Womack, D. T. Jones and D. Roos, D. The Machine That Changed the World: The Story of Lean Production - Toyota's Secret Weapon in the Global Car Wars That Is Now Revolutionizing World Industry. New York, USA: Free Press, 1990.

U. Dombrowski and S. Wesemann, "Übertragung der Prinzipien von Ganzheitlichen Produktionssystemen auf das Krankenhaus", Das Krankenhaus, vol. 103, pp. 693-697, 2011.

J. A. Farris, E. M. Van Aken, T. L. Doolen and J. Worley, "Learning from less successful Kaizen events: a case study", Engineering Management Journal, vol. 20, pp. 10-20, 2008.

W. J. Glover, J. A., Farris, E. M. Van Aken and T. L. Doolen, "Critical success factors for the sustainability of Kaizen event human resource outcomes: An empirical study", International Journal of Production Economics, vol. 132, pp. 197-213, 2011.

[U. Dombrowski and S. Wesemann, "Paradigmenwechsel in deutschen Krankenhäusern. Ganzheitliches Krankenhaussystem als Lösungsansatz", Das Krankenhaus, vol. 105, pp. 380-385 2013.

B. LariSemnani, R. Mohebbi Far, E. Shalipoor and M. Mohseni, "Using creative problem solving (TRIZ) in improving the quality of hospital services", Global Journal of Health Science, vol. 7, pp. 88-97, 2015.

G. Arcidiacono and L. Bucciarelli, "TRIZ: Engineering Methodologies to Improve the Process Reliability", Quality and Reliability Engineering International Journal, vol. 32, pp. 2537-2547, 2016.

G. Arcidiacono, A. Giorgetti and M. Pugliese, "Axiomatic Design to improve PRM airport assistance", in Proc. ICAD 2015, 9th International Conference on Axiomatic Design, 2015, pp. 106-111.

M. Baker, I. Taylor and A. Mitchell. Making Hospitals Work. Goodrich, UK: Lean Enterprise Academy Limited, 2009.

H. De Koning, J. P. S. Verver, J. Van Den Heuvel, S. Bisgaard and R. J. Does, "Lean Six Sigma in healthcare", Journal for Healthcare Quality, vol. 28, pp. 4-11, 2006.

O. Groene, D. Botje, R. Suñol, M. A. Lopez and C. Wagner, "A systematic review of instruments that assess the implementation of hospital quality management systems", International Journal for Quality in Health Care, vol. 25, pp. 525-541, 2013.

B. Kemper, J. de Mast and M. Mandjes, "Modeling process flow using diagrams", Quality and Reliability Engineering International, vol. 26, pp. 341-349, 2010.

B. Kemper and J. de Mast, "Measurement Plans for Process Flow Improvement in Services and Health Care", Quality Engineering, vol. 25, pp. 437-450, 2013.

S. Bhasin and P. G. Burcher, "Lean viewed as a philosophy", Journal of Manufacturing Technology Management, vol. 17, pp. 56-72, 2006.

M. Graban. Lean Hospitals. New York, USA: Taylor & Francis, 2009.

G. Arcidiacono, J. Wang and K. Yang, "Operating room

adjusted utilization study". International Journal of Lean Six Sigma, vol. 6, pp. 111-137, 2015.

D. T. Matt, V. M. Franzellin and E. Rauch, "Lean Hospital - Mit Motivation und Methode zum schlanken Krankenhausbetrieb", Das Krankenhaus, vol. 106, pp. 538-542, 2014.

D. T. Matt, M. Siller and M. Prantl, "Patientenorientierte und effiziente Notfallversorgung durch Lean Hospital in Südtiroler Krankenhäusern", Das Krankenhaus, vol. 107, pp. 555-561, 2015.

D. T. Matt, E. Rauch and V. M. Franzellin, "An Axiomatic Design based approach for the patient-value oriented design of a sustainable Lean Healthcare System", International Journal of Procurement Management, vol. 8, pp. 66-81, 2015.

X. Xie and M. A. Lawley, "Operations research in healthcare", International Journal of Production Research, vol. 53, pp. 7173-7176, 2015.

J. Li, C. T. Papadopoulos and L. Zhang, "Continuous improvement in manufacturing and service systems", International Journal of Production Research, vol. 54, pp. 6281-6284, 2016.

J. H. Sanders and T. Karr, "Improving ED specimen TAT using lean six sigma". International Journal of Health Care Quality Assurance, vol 28, pp. 428-440, 2015.

A. Abdelhadi, "Investigating emergency room service quality using lean manufacturing". International Journal of Health Care Quality Assurance, vol 28, pp. 510-519, 2015.

K. Al-Hyari, S. Abu Hammour, M. K S. Abu Zaid and M. Haffar, "The impact of Lean bundles on hospital performance: does size matter?". International Journal of Health Care Quality Assurance, vol 29, pp. 877-894, 2016.

P. Simons, H. Backes, J. Bergs, D. Emans, M. Johannesma, M. Jacobs, W. Marneffe and D. Vandijck, "The effects of a lean transition on process times, patients and employees". International Journal of Health Care Quality Assurance, vol. 30, pp. 103-118, 2017.

P. Hwang, D. Hwang and P. C. Hong, "Lean practices for quality results: a case illustration", International Journal of Health Care Quality Assurance, vol. 27, pp. 729-741, 2014.

B. Kollberg, J. J. Dahlgaard and P. O. Brehmer, "Measuring Lean initiatives in health care services: issues and findings", International Journal of Productivity and Performance Management, vol. 56, pp. 7-24, 2007.

L. Brandao de Souza, "Trends and approaches in Lean healthcare", Leadership in Health Services, vol. 22, pp. 121-139, 2009.

J. L. Dellifraine, J. R. Langabeer and I. M. Nembhard, "Assessing the evidence of Six Sigma and Lean in the health care industry", Quality Management in Health Care, vol. 19, pp. 211-225, 2010.

N. Burgess and Z. Radnor, "Evaluating Lean in healthcare". International Journal of Health Care Quality Assurance, vol. 26, pp. 220-235, 2013.

P. Dannapfel, B. Poksinska and K. Thomas, "Dissemination strategy for Lean thinking in health care". International Journal of Health Care Quality Assurance, vol 27, pp. 391-404, 2014.

S. Knapp, "Lean Six Sigma implementation and organizational culture". International Journal of Health Care Quality Assurance, vol 28, pp. 855-863, 2015.

M. Crema and C. Verbano, "Investigating the connections between health lean management and clinical risk management: insights from a systematic literature review". International Journal of Health Care Quality Assurance, vol 28, pp. 791-811, 2015.

S. Deblois and L. Lepanto "Lean and Six Sigma in acute care: a systematic review of reviews", International Journal of Health Care Quality Assurance, vol 29, pp. 192-208, 2016.

T. Katz-Navon, E. Naveh and Z. Stern, "The moderate success of quality of care improvement efforts: three observations on the situation", International Journal for Quality in Health Care, vol. 19, pp. 4-7, 2007.

M. Harrison, K. Henriksen and R. Hughes, "Improving the health care work environment: a sociotechnical systems approach", Joint Commission journal on quality and patient safety, vol. 33, pp. 3-6, 2007.

J. Moraros, M. Lemstra and C. Nwankwo, "Lean interventions in healthcare - do they actually work? A systematic literature review", International Journal for Quality in Health Care, vol. 28, pp. 150-165, 2016.

T. N. Goh, "Six Triumphs and Six Tragedies of Six Sigma", Quality Engineering, vol. 22, pp. 299-305, 2010.

N. V. K. Jasti and R. Kodali, "Lean production: literature review and trends", International Journal of Production Research, vol. 53, pp. 867-885, 2015.

A. Taylor, M. Taylor and A. McSweeney, "Towards greater understanding of success and survival of Lean systems", International Journal of Production Research, vol. 51, pp. 6607-6630, 2013.

G. Arcidiacono, N. Costantino and K. Yang, "The AMSE Lean Six Sigma Governance Model", International Journal of Lean Six Sigma, vol. 7, pp. 233-266, 2016.

G. C. Niemeijer, R. J. Does, J. de Mast, A. Trip and J. van den Heuvel, "Generic project definitions for improvement of health care delivery: a case-based approach", Quality Management in Health Care, vol. 20, pp. 152-164, 2011.

G. Arcidiacono, D.T. Matt, E. Rauch, "Axiomatic Design of a Framework for the Comprehensive Optimization of Patient Flows in Hospitals", Journal of HealthCare Engineering, vol. 2017, Article ID 2309265, 9 pp., 2017.

R. K. Yin. Case study research: Design and methods. Thousand Oaks, USA: Sage publications, 2013.

P. Mazzocato, R. J. Holden, M. Brommels, H. Aronsson, U. Bäckman, M. Elg and J. Thor, "How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden", BMC Health Services Research, vol. 12, pp. 28, 2012.

W. Ulhassan, C. Sandahl, H. Westerlund, P. Henriksson, M. Bennermo, U. von Thiele Schwarz and J. Thor, "Antecedents and characteristics of lean thinking implementation in a Swedish hospital: a case study", Quality Management in Healthcare, vol. 22, pp. 48-61, 2013.

S. L. Dong, M. J. Bullard, D. P. Meurer, S. Blitz, A. Ohinmaa, B. R. Holroyd and B. H. Rowe, "Reliability of computerized emergency triage", Academic Emergency Medicine, vol. 13, pp. 269-275, 2006.

K. Walshe, "Pseudoinnovation: the development and spread of healthcare quality improvement methodologies", International Journal for Quality in Health Care, vol. 21, pp. 153-159, 2009.

N. Scarpato, A. Pieroni, L. Di Nunzio, F. Fallucchi, "E-health-IoT Universe: A Review", International Journal on Advanced Science Engineering Information Technology, vol. 7, pp. 2328-2336, 2017.



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