The development of care programmes requires organizations to clearly define the interventions that are included in the treatment of a specified target population and to measure the effect of these interventions. Even though Care Programmes have not been developed as part of a lean implementation effort, they help organizations to take a systemic view on improving performance, something lean thinking promotes. Integrated Care Pathways are another example.
Their use in health care is widespread and developing them [ 34 ] has many similarities with the lean instrument value stream mapping [ 35 ]. Pathways can be used to optimize Care Programmes, the same way value stream mapping can be used to optimize value systems [ 32 ]. Even this limited and rather arbitrary set of instruments shows that most health care organizations are already using instruments that are in line with lean principles.
A limited number of lean interventions deliberately include sociotechnical aspects. While operational improvements are reported in detail, sociotechnical improvements are described in general terms.
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With some exceptions [ 18 ], most lean implementation efforts are aimed mainly at improving operational efficiency and only secondly take into account the sociotechnical effects of their interventions. Even in mainstream lean literature, attention to sociotechnical aspects is recent [ 12 ] and adjusting these insights to health care takes time.
At the same time, sociotechnical systems theory can provide a framework for those who want to improve health care delivery [ 22 ]. This requires a substantial shift of mind, especially at the managerial level. Successful sociotechnical improvement requires managers to realize their job is not to improve care processes.
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That is the role of the professionals actually working in care processes. A manager's role is to improve and develop his or her own workforce. A manager's most important task is to create an environment where interaction between team members leads to a level of performance that can not be achieved by individual team members alone [ 12 , 30 ]. Such an approach starts with collecting and using information on organizational climate, learning and problem solving skills within teams.
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Based on this information, teams themselves need to decide if and where improvements are needed. Repeated measurements can be used to evaluate progress. This way, measures of organizational climate and learning become ingrained in an organizational Plan-Do-Check-Act cycle. Eventually, a balanced lean approach may lead to a situation where fewer trade-offs need to be made. This requires measures that describe both operational and sociotechnical effects of an intervention and their outcomes.
This is only partially the case in current reports on lean in health care. At present, most papers seem to report operational improvements [ 16 , 17 , 36 ].jlhghfdg.co.vu/la-obsesin-de-max-slow-death-n-3.php
Why Lean Might Not Be the Best Solution to Healthcare Inefficiencies
Less frequently, papers report on better outcomes, like health adjusted mortality [ 3 ]. Some report, in general terms, about sociotechnical improvements [ 36 ]. None, however, has clearly reported on all these aspects together or on cumulative capabilities. In this paper, we discussed lean thinking as a management approach that focuses on operational aspects and the sociotechnical dynamics these improvement systems causes.
We discussed how one can start to apply these insights to health care. Such an overly positive conclusion fails to take into account the variety of issues surrounding the application of lean thinking to health care. One difficulty regards the sociotechnical dynamics that occur when implementing lean thinking. While reports on the importance of sociotechnical issues start to emerge, the multitude of questionnaires, outcome parameters and research designs used make it hard to draw general conclusions.
Research on sociotechnical dynamics in lean organizations, especially in health care, is virtually absent. Operational aspects of lean thinking and their link to performance have been looked at more thoroughly, but application to health care has been limited. The same goes for cumulative capabilities, where research in and out of health care is scarce. More attention is needed to verify these key propositions of lean thinking in health care.
While it is beyond the scope of this paper to discuss the methodological aspects of the evaluation of lean thinking, it is important to note that lean thinking is composed of a number of components, which act both independently and interdependently.
Research on such complex interventions requires special methods and research designs [ 37 ]. Currently, case study designs are the most frequently used. While this design can provide useful insights, it has serious limitations regarding generalizability and inter-subjectivity. Along with the other methodological issues surrounding the evaluation of lean thinking, which we mentioned in the introduction [ 7 ], it is safe to say that not only more research, but also higher quality research is needed.
Even if these problems are addressed and lean delivers on its promises, the challenges to increasing the role of lean thinking are daunting. They require no less than the redesign of the health care system as we now see it. Perseverance, high quality leadership, dedicated professionals and patience are surely needed. Scepticism and resistance will be high, success not guaranteed. Organizations may think twice before embracing on such a journey, or worse, superficially implement lean thinking, adding to existing resistance and making it more difficult to improve health care in the long term.
Overall, we support the possibilities lean thinking offers to improve health care. Lean is a hands-on improvement method, in line with suggestions made by leading authors on how to improve health care systems worldwide [ 38 ]. Funding to pay the Open Access publication charges for this article was provided by the Fund Open Access publishing from Tilburg University. National Center for Biotechnology Information , U. Int J Qual Health Care. Published online Aug Author information Article notes Copyright and License information Disclaimer.
Accepted Jul This article has been cited by other articles in PMC. Abstract Background Incidents and quality problems are a prime cause why health care leaders are calling to redesign health care delivery. Development, theory and application of lean thinking to health care Lean thinking evolved from a tool designed to improve operational shop-floor performance at an automotive manufacturer to a management approach with both operational and sociotechnical aspects.
Discussion We believe lean thinking has the potential to improve health care delivery. Keywords: lean thinking, lean production, quality, health care, organizational climate, business process redesign. Background In , the death of a year-old patient in a Dutch Mental Health care Institute led to a firestorm of protest. Development of lean thinking Originally, lean was developed as a production philosophy and quality system, with elements of both craft production and mass production. Decrease variability. Open in a separate window.
Applying Lean methodology to medical-surgical care.
Operational aspects of lean thinking On an operational level, standard organizing tools like value stream mapping and 5S are available to create value for an overview see reference [ 10 ]. Sociotechnical aspects of lean thinking Lean interventions have the potential to make jobs more simple and repetitive or turn them into jobs that require more thinking, planning and responsibility. Cumulative capabilities We have elaborated on the importance of both operational and sociotechnical aspects of lean thinking. Operational aspects of lean thinking in health care Most lean implementations start with the introduction of lean instruments, aimed at redesigning operational aspects of the care delivery process [ 2 , 3 , 15 , 16 ].
Lean thinking Health care Value adding time Diagnostic and care time Diagnostic time collecting and analysing clinical information active care time clinical interventions passive care time under observation, no interventions WT positive WT patients condition is likely to improve without interventions Non-value adding time waste Diagnostic and care time Superfluous time not needed diagnostics, observations or interventions administrative time WT passive WT no change in patients condition is expected negative WT patients condition is likely to deteriorate.
Sociotechnical aspects of lean thinking in health care A limited number of lean interventions deliberately include sociotechnical aspects. Cumulative capabilities in health care Eventually, a balanced lean approach may lead to a situation where fewer trade-offs need to be made. Conclusions In this paper, we discussed lean thinking as a management approach that focuses on operational aspects and the sociotechnical dynamics these improvement systems causes. References Locock L.
Healthcare redesign: meaning, origins and application. Qual Saf Health Care. Lean thinking across a hospital: redesigning care at the Flinders Medical Centre.
Standard Work for Lean Healthcare
Aust Health Rev. Leadership commitment also appeared to be an important factor in long-term sustainability of Lean [ 30 ]. In a systematic review of employee experience in Lean health, White et al. Five research teams emphasized the importance of changing the hierarchical structure often present in health-care organizations. Al-Balushi et al. In many health-care systems, administrators rank above doctors, doctors rank above nurses, and nurses rank above other staff. Health-care professionals often experience difficulty accepting suggestions from employees lower in the hierarchy.
In their review of five Lean transformation case studies, these authors found that nurses and doctors have the most difficulty with cultural and hierarchical change. In contrast, Lean thinking relies on the experience and knowledge of front-line workers and the equal involvement of all employees in creating high-value processes. Support, interest, and involvement from top management for Lean implementation are essential in overcoming resistance to change [ 30 , 33 — 35 ].
Leader self-development emerged as a central requirement for Lean transitions in health care, with 13 research teams identifying it as a core principle. To successfully lead Lean transitions, health-care leaders need to develop new skills and competencies in Lean [ 26 , 35 , 36 ]. Mutwiri et al. Leaders need to develop these personal capabilities and demonstrate character so that they may effectively manage others and address the dynamics of change.
Likewise, leaders need to have a deep understanding of Lean principles before beginning the Lean implementation process [ 35 ]. Of the skills and competencies identified, excellent communication skills were most frequently mentioned. In a Lean organization, leaders need to communicate with people at all organizational levels, including top managers, project team managers, clinicians, and other employees [ 37 ].
Aij et al. Leaders in their study who had a modest attitude and were able to express concerns and uncertainty established stronger relationships with employees, encouraging the same behaviors in employees. Leaders who showed modesty and vulnerability also helped to shape a culture of improvement that allowed concerns to be raised more easily. Taken together, six articles in this review show how health-care leaders must function as role models during Lean transitions. Executives and other managers can act as effective role models by showing commitment and support throughout an implementation process.
In 18 studies, employee training was identified as important or essential for successful Lean management transitions in health care.
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