Journal of Health Organization and Management

Readiness factors for lean implementation in healthcare settings a literature review

S. Al-Balushi A.S. Sohal P.J. Singh A. Al Hajri Y.M. Al Farsi R. Al Abri
Article information:
To cite this document:
S. Al-Balushi A.S. Sohal P.J. Singh A. Al Hajri Y.M. Al Farsi R. Al Abri , (2014),"Readiness factors for
lean implementation in healthcare settings a literature review", Journal of Health Organization and
Management, Vol. 28 Iss 2 pp. 135 - 153
Permanent link to this document:
http://dx.doi.org/10.1108/JHOM-04-2013-0083
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

Downloaded on: 31 January 2016, At: 04:32 (PT)

References: this document contains references to 89 other documents.
To copy this document: permissions@emeraldinsight.com
The fulltext of this document has been downloaded 1430 times since 2014*
Users who downloaded this article also downloaded:
Erik Drotz, Bozena Poksinska, (2014),"Lean in healthcare from employees perspectives", Journal of Health
Organization and Management, Vol. 28 Iss 2 pp. 177-195 http://dx.doi.org/10.1108/JHOM-03-2013-0066
Nicola Burgess, Zoe Radnor, (2013),"Evaluating Lean in healthcare", International Journal of Health Care
Quality Assurance, Vol. 26 Iss 3 pp. 220-235 http://dx.doi.org/10.1108/09526861311311418
Luciano Brandao de Souza, (2009),"Trends and approaches in lean healthcare", Leadership in Health
Services, Vol. 22 Iss 2 pp. 121-139 http://dx.doi.org/10.1108/17511870910953788

Access to this document was granted through an Emerald subscription provided by emerald-srm:199044 []
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald for
Authors service information about how to choose which publication to write for and submission guidelines
are available for all. Please visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company
manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as
providing an extensive range of online products and additional customer resources and services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee
on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive
preservation.

*Related content and download information correct at time of download.

 The current issue and full text archive of this journal is available at
www.emeraldinsight.com/1477-7266.htm

Lean
Readiness factors for lean implementation in
implementation in healthcare healthcare settings
settings a literature review
S. Al-Balushi 135
College of Economics and Political Science, Sultan Qaboos University,
Muscat, Sultanate of Oman
A.S. Sohal
Department of Management, Monash University, Caulfield East, Australia
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

P.J. Singh
Department of Management and Marketing, University of Melbourne,
Melbourne, Australia
A. Al Hajri
College of Economics and Political Science, Sultan Qaboos University,
Muscat, Sultanate of Oman, and
Y.M. Al Farsi and R. Al Abri
Sultan Qaboos University, Muscat, Sultanate of Oman

Abstract
Purpose The purpose of this paper is to determine the readiness factors that are critical to the
application and success of lean operating principles in healthcare organizations through a review of
relevant literature.
Design/methodology/approach A comprehensive review of literature focussing on lean and lean
healthcare was conducted.
Findings Leadership, organizational culture, communication, training, measurement, and reward
systems are all commonly attributed readiness factors throughout general change management and
lean literature. However, directly related to the successful implementation of lean in healthcare is
that a setting is able to authorize a decentralized management style and undertake an end-to-end
process view. These can be particularly difficult initiatives for complex organizations such as
healthcare settings.
Research limitations/implications The readiness factors identified are based on a review of
the published literature. The external validity of the findings could be enhanced if tested using
an empirical study.
Practical implications The readiness factors identified will enable healthcare practitioners to be
better prepared as they begin their lean journeys. Sustainability of the lean initiative will be at stake if
these readiness factors are not addressed.
Originality/value To the best of the knowledge, this is the first paper that provides a consolidated
list of key lean readiness factors that can guide practice, as well as future theory and empirical
research.
Keywords Readiness factors, Healthcare operations, Lean principles
Paper type Literature review

Journal of Health Organization and

Introduction Management
Vol. 28 No. 2, 2014
Globally, healthcare organizations are contending with the pressures of aging pp. 135-153
r Emerald Group Publishing Limited
population, longer-term care for lifestyle diseases such as cancer and diabetes, and 1477-7266
reduced government spending on public services (World Health Organization, 2008; DOI 10.1108/JHOM-04-2013-0083
 JHOM Waring and Bishop, 2010). Public demand for increased quality coupled with the
28,2 pressure to do more with less has led healthcare organization management teams to
reevaluate their operations strategy (Balle and Regnier, 2007; Carpenter, 2011).
Healthcare settings such as hospitals these days operate under a barrage of
improvement programs as a result, often adding to the pressures of operations rather
than dealing with the problems in the existing systems (Fillingham, 2007).
136 Many quality management and process reengineering practices offering increased
efficiency that originated from the manufacturing industry have been developed
and applied with measureable success to the service sector (Radnor and Boaden, 2008).
Of these practices adapted to a service context, a 51 percent majority of the
publications focus on lean, marking this process engineering strategy as one of
the most discernible means through which healthcare reforms are achieved (Radnor
et al., 2012). As a result, awareness of lean applications in healthcare settings and
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

interest in success stories are increasing among professionals in the healthcare and
academic communities (Wysocki, 2004; Womack and Miller, 2005; Radnor and Boaden,
2008; Poksinska, 2010).
Despite developing recognition of leans new role as a process strategy for
guiding the running of healthcare settings and the possible benefits of applying lean
to healthcare, little documentation exists in the research literature in the form of a
consolidated methodology for applying lean within the context of healthcare (Bateman,
2005; Mazzocato et al., 2010). There are many practitioner based how-to books on
this subject (e.g. Graban, 2011; Graban and Swartz, 2012, 2013); however, they do not
necessarily present complete and tested methodologies that are applicable to
different contexts.
Due to the multiple contexts found in health services and the unique features
of lean tools and techniques, the study of readiness factors deserves more
attention. Evidence from recent literature within public sector organizations
indicate that the focus is more on the tools and techniques of lean and less on the
readiness which could lead to lack of sustainability in the long run and more
focus on short gains (Radnor, 2011). The aim of this paper is to contribute to the
strategic and organizational thinking on lean. This study aims to develop a clearer
idea of what foundational mechanisms are needed to launch a successful project on
lean in a healthcare setting. The work is expected to be relevant, accessible,
and useful to both practitioners and academics in order to provide a concise
itinerary of organizational requirements that will enable them to assess the readiness
to implement lean. These can form a framework within which future research
can aim to design, test, and articulate the best methodology for applying lean in
healthcare settings.
This paper does not strive to draw conclusions about the benefits of lean when
applied to healthcare but instead endeavors to provide analysis of the readiness
factors required for successful lean implementation. Reflecting on the readiness factors
derived from examination of the literature, a case can be made as to whether or not the
current situation in a particular environment is favorable toward piloting lean
improvement initiatives.
The remainder of this paper is organized as follows. The next section defines lean
and lean in healthcare. This is followed by a description of the method for our literature
review. The main section of the paper presents our findings in terms of the main lean
readiness factors in healthcare settings. The final section presents our conclusions and
suggestions for further research.
 The definition of lean and lean in healthcare Lean
Lean, also called Lean Thinking and the Toyota Production System is a process implementation in
reengineering philosophy composed of strategic guiding principles and a set of tools
at the operational level exemplified by the best practices of Toyota Corporation healthcare settings
(Sugimori et al., 1977; Ohno, 1988; Womack et al., 1990; Cho, 1995; Papadopoulos et al.,
2011). Womack et al. (1990) maintain that one cannot define lean as existing without
its principles first being readily understood. 137
Lean principles are derived from the premise that organizations are made up of a
series of activities that are bound to a theory of value (creating value and increasing
value) (Young and McClean, 2008; Joosten et al., 2009). Activities contribute to a
process, and this process in lean terminology is often called a value-stream (Womack
and Jones, 2003). Deriving value theory by basing all required activities within the
value-stream on what is valuable to the customer rather than on production or sales
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

goals is what first differentiated the lean principles of Toyota Corporation from the
principles of mass production (Sugimori et al., 1977; Cho, 1995; Holweg, 2007).
Lean, when adapted from manufacturing to the service sector, continues to
differentiate its principles from the traditional business sense of getting things done
the right way by focussing on doing the right thing(s) from the outset (Ben-Tovim
et al., 2007, 2008; DelliFraine et al., 2010). Doing the right things involves streamlining
and standardizing all activities undertaken to best practices and to be of value to the
customer (Dennis, 2006; Lodge and Bamford, 2008; Castle and Harvey, 2009). Any
activity within the value-stream that does not serve the purpose, needs, or preferences
of the customer is termed waste (Young and McClean, 2009). Since the origins of lean
lie in post-Second World War Japan, the Japanese term muda is often used
interchangeably in the literature with waste to describe an activity or factor should
be eliminated from the value-stream in order to derive the maximum value desired by
the focus of all operations, i.e. the customer (Cho, 1995; Andersson et al., 2006; Holweg,
2007; Waring and Bishop, 2010). For the purposes of this paper, the term waste will
be used throughout.
Lean is also defined as a system which requires less time, less human effort, less
cost, less space, with less injuries, and less mistakes, to create an organization that
accomplishes more and does these better (Womack et al., 1990; Womack and Miller,
2005; Waring and Bishop, 2010). Having thus defined lean from the literature and by
its professional connotations, it becomes necessary to negotiate the significance of
organizational readiness in terms of assessing the requirements that aid or ensure
successful implementation, especially those that are applicable to the context of
healthcare. Often called the Lean Healthcare Management System (Poksinska, 2010)
or more simply, lean health (Waring and Bishop, 2010), lean requires to be defined
further in order to be thorough about the extent to which the philosophy is being
applied in the context of healthcare.
It is now around ten years since lean saw some of its earliest applications in
healthcare settings (Weber, 2006; Nelson-Peterson and Leppa, 2007; Carpenter, 2011). It
can be argued that the application of lean in healthcare is a relatively young field for
study when compared to the half-century of lean practice at Toyota Corporation, and
the 30 years or so in manufacturing generally around the world ( Joosten et al., 2009;
Waring and Bishop, 2010). Despite this, it remains evident from the literature that the
lean philosophy in its entirety has yet to permeate all aspects of operations in complex
service organizations such as hospitals (Hines et al., 2004; Radnor and Boaden, 2008;
Radnor et al., 2009).
 JHOM The view that lean health literature appears to take is that rarely are healthcare
28,2 settings and their operations developed in a strategic manner (Ben-Tovim et al., 2008;
McGrath et al., 2008; Kim et al., 2009). Due to the manner of growth, most processes
exist with the needs of clinical staff such as doctors and nurses, or even the
external stakeholders financing the organization, as the basis for the way operations
are carried out (Kim et al., 2006). This is in place of a focus on the healthcare settings
138 patients and what is valuable to them (Kim et al., 2006; Fillingham, 2007).
Perhaps due to the complex structure of healthcare organizations and the relatively
short span of lean experience within these settings, the available literature iterates that
lean is looked upon more as a process improvement strategy. It is also seen as a set of
tools guided by the idea of eliminating waste based on what is defined as being
valuable rather than as a total system such as the Toyota Corporation or with other
similar integrated manufacturers ( Jimmerson et al., 2005; Endsley et al., 2006; Spear,
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

2006; Balle and Regnier, 2007; Ben-Tovim et al., 2007; Fillingham, 2007; Hines and
Lethbridge, 2008; Dickson et al., 2009a, b). Put another way, the lean health literature
describes lean as providing some standards for processes, creating flow, decreasing
interruptions, and potential for errors. Lean is perceived as a set of tools with
strategic guiding principles but not as a total system governing the whole of the
organization as might be informed by lean in its manufacturing context (Ahlstrom,
2004; Young et al., 2004).
In the following section, we discuss our research methodology and the process used
to arrive at readiness factors for lean in healthcare.

Methodology
Readiness factors are defined as any practice or characteristic that aids an
organizational transformation by eliminating or nullifying possible inhibitors
for success, or providing the knowledge and capabilities required to succeed in
establishing change (Armenakis et al., 1993; Clark et al., 1997; Rich and Bateman, 2003;
Abdolvand et al., 2008; Weiner, 2009).
We conducted a search of the peer-reviewed English language publications (up until
January 2012) pertaining to lean health, lean readiness, healthcare change management,
and process redesign in healthcare for the subject of readiness factors for lean applicable
to healthcare. Key words such as lean health, lean hospital, lean services, lean
process re-design were entered into the online databases ABI/Inform and EBSCO.
A systematic review of the references cited in the resultant articles was also undertaken.
Content was then scrutinized from three perspectives. First, readiness factors
for general change management were highlighted and described. Second, the lean
literature was examined to derive additional factors integral to readiness for
lean implementation. Third, all the articles were scrutinized to identify those that dealt
with the implementation of lean to the specific context of healthcare.
The research team then reviewed the included papers and arrived at a consensus on
the relevant readiness factors for lean in healthcare settings. Specifically, all the factors
that were referred to as readiness, enabler, inhibitor, or requirement within the
scrutinized studies were categorized as readiness factors. In order to arrive at mutually
exclusive categories, similar factors were classified under one category.

Results and discussion

Initial search results for articles on lean in general returned over 380 references. After
filtering these articles for content-specific according to the inclusion criteria described
 above, the number of articles reduced to 170 articles. This included some additional Lean
references identified through citation analysis, including books, workshop materials, implementation in
and conference papers.
Most studies on lean in healthcare utilize a case study approach. These studies healthcare settings
primarily focus on some aspects of readiness factors of lean in healthcare settings
whereas others review mainly the implementation process. For example, Elijz et al.
(2011) provides an assessment checklist to help managers or clinicians when 139
considering the adoption of innovations in health settings. This checklist was
developed by reviewing the diffusion of innovation literature in health services coupled
with a case study of lean implementation in a hospital setting. The checklist
categorizes readiness for lean implementation into individual, group, and
organizational factors. Mazzocato et al. (2010) uses a realist review design to survey
the literature with the objective of understanding how lean thinking has been put into
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

practice in healthcare. The design enabled them to classify data gathered into contexts,
interventions, mechanisms, and outcomes. The study did not directly address the
readiness issue, however. Building on the concepts of Hines (2011), Radnor (2010)
utilized a case study of a third-party logistics company to develop what she called the
house of lean for public services. This house has a foundation of organizational
readiness factors and the pillars of the house are the tools and techniques of lean.
Parts of the organizational readiness factors presented in the house were used later by
Radnor (2011) in a healthcare setting.
We propose to build on the readiness factors for the general service sector
provided by Radnor (2010) by providing a more complete list of the readiness factors
specific to health services. We do this by adding factors described by other authors.
We believe this is relevant due to Radnors (2010) own admission that her list is limited.
For example, she claims that standardized work (a tool of lean) may not be a viable
means toward improvement, for say, a third-party logistics company, but that the same
tool has been used to great success in the healthcare settings (Radnor, 2011).
Our classification process resulted in seven categories of readiness factors
which we believe are important for a successful launch of lean in healthcare.
These factors are:
(1) strong leadership teams support for lean;
(2) identifying lean with the strategic agenda of the healthcare setting;
(3) understanding what value and customer groups exist in healthcare;
(4) undertaking the end-to-end process view to identify and eliminate waste;
(5) personnel training and involvement in lean principles and methods;
(6) measurement and reward systems aligned to lean objectives; and
(7) matching demand and capacity levels to improve flow.

The specific articles in which each of the seven factors are discussed are shown in
Table I. As Table I shows, the articles were not only categorized under the seven broad
lean readiness factors, but more specifically under the sub-category criteria of:
readiness factors for general change management; readiness factors integral for lean
implementation; general change management pertaining to healthcare; and, specific
readiness factors for lean implementation in healthcare. In the following sub-sections,
each of these readiness factors are discussed in detail.

Table I.
in healthcare settings
on lean readiness factors
Classification of literature
Lean readiness factor
1. Strong leadership
teams support for lean
2. Identifying lean with
the strategic agenda of
the healthcare setting
3. Understanding what
value and customer
groups exist in
healthcare
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)
Readiness factors for
general change
management
Armenakis et al. (1993),
Bateman (2005), Lehman
et al. (2002)
Armenakis et al. (1993),
Bateman (2001), Cinite et al.
(2009), Dick et al. (2006),
Dutton (1986), Kaye and
Anderson (1999), Nag et al.
(2007), Washington and
Hacker (2005)
Dick et al. (2006)
Sub-classification criteria
Readiness factors integral
for lean implementation in
service or health
Ben-Tovim et al. (2007),
Carpenter (2011), Joosten
et al. (2009), Papadopoulos
et al. (2011), Radnor et al.
(2012), Waring and Bishop
(2010)
Butler et al. (1996), Hines
and Lethbridge (2008),
Radnor (2010), Radnor and
Boaden (2008)
Andersson et al. (2006),
Sugimori et al. (1977),
Womack et al. (1990)
28,2
140
JHOM
General change Specific readiness factors for
management pertaining to lean implementation in
healthcare healthcare
Butler et al. (1996) Ben-Tovim et al. (2008),
de Souza and Pidd (2011),
Fillingham (2007), Golden
(2006), Graban (2011), Radnor
(2011), Steed (2011)
Rich and Bateman (2003), Fillingham (2007), Golden
Vest and Gamm (2009), (2006), Steed (2011), Womack
Waring and Bishop (2010) et al. (1990)
Ferlie et al. (2010) Fillingham (2007), Golden
(2006), Hayes et al. (2010),
Papadopoulos et al. (2011),
Poksinska (2010), Radnor
(2011), Womack and Jones
(2003), Young and McClean
(2009)
(continued)
 Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

Sub-classification criteria
Readiness factors for Readiness factors integral General change Specific readiness factors for
general change for lean implementation in management pertaining to lean implementation in
Lean readiness factor management service or health healthcare healthcare

4. Undertaking the end-to- Andersson et al. (2006), de Souza (2009), Fillingham

end process view to Womack and Jones (2003), (2007), Joosten et al. (2009),
identify and eliminate Womack et al. (1990), Papadopoulos et al. (2011),
waste Wysocki (2004) Radnor (2011)
5. Personnel training and Armenakis et al. (1993), Cho (1995), Steed (2011) Butler et al. (1996) Ben-Tovim et al. (2007),
involvement in lean Bateman (2001), Cinite et al. Fillingham (2007), Radnor
principles and methods (2009) (2011)
6. Measurement and reward Ackroyd (1996), Alange and Cho (1995), Hines and Graber and Kilpatrick Fillingham (2007), Kollberg
systems aligned to lean Steiber (2009), Cinite et al. Lethbridge (2008), Radnor (2008), Gubb (2009), Hacker et al. (2006), Papadopoulos and
objectives (2009) (2010), Shah and Ward (1997), Papadopoulos et al. Merali (2008), Proudlove et al.
(2007), Sugimori et al. (1977) (2011), Taner et al. (2007) (2008), Rich and Bateman
(2003), Steed (2011)
7. Matching demand and Ahlstrom (2004), Cho (1995), Harrison and Kimani (2009), Balle and Regnier (2007), Cinite et al. (2009)
capacity levels to Holweg (2007), Sugimori Parnaby and Towill (2008) DelliFraine et al. (2010),
improve flow et al. (1977), Womack et al. Dickson et al. (2009a), Esain
(1990), Womack and Jones et al. (2008), Fillingham
(2003) (2007), Kim et al. (2009),
King et al. (2006), Kuo et al.
(2011), Lodge and Bamford
(2008), Poksinska
(2010), Radnor (2011),
Setijono et al. (2010),
Womack and Miller (2005)
141
implementation in
Lean

Table I.
healthcare settings
 JHOM 1. Strong leadership teams support for lean
28,2 The professional environment of healthcare is based on a hierarchy of professional
achievement, with healthcare setting executives above doctors and doctors out-ranking
nurses in a very controlled environment which hardly contributes to the culture of
flexibility and encouragement of individual initiatives required by a truly lean
organization ( Joosten et al., 2009; Waring and Bishop, 2010; de Souza and Pidd, 2011).
142 Lean requires the leadership team to play a significant role in changing the hierarchical
culture of the healthcare setting they administer to the extent of exhibiting support
for, commitment to, and a demonstrated understanding of the principles of lean
(Ben-Tovim et al., 2008; Steed, 2011; Radnor et al., 2012). The leadership teams role in
commitment and demonstration of understanding of lean will be discussed in the
context of other readiness factors below. Here, leadership is discussed in terms of
facilitating the necessary means to allow for implementation, and willingness to be
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

involved in issues that arise during the implementation phase in the healthcare context.
Senior managers are responsible for actualizing meaningful involvement of
employees in the change process and facilitating the necessary resources to allow
implementation (Armenakis et al., 1993; Ackroyd, 1996; Lehman et al., 2002;
Steed, 2011). In terms of resources required for lean implementation, time for employee
training, and involvement in lean activities must be provided (Butler et al., 1996;
Bateman, 2005; Ben-Tovim et al., 2007; Alange and Steiber, 2009). Likewise, executive
leadership teams strategic actions to associate lean with educational and quality
departments will aid in sustainable operation of the clinical, operational, and
administrative departments (Radnor, 2011).
Given special regards to the hierarchical structure of healthcare settings, top
management should be ready and willing to demonstrate their support for any lean
projects whenever issues arise (Ben-Tovim et al., 2007; Carpenter, 2011; Steed, 2011).
Case studies share findings that doctors and nurses have the most trouble accepting
the cultural changes required for lean as occasionally (a) person(s) of a lesser or
different educational or professional designation will make suggestions that change
the way a doctor or nurses work is carried out (Ben-Tovim et al., 2007; Fillingham,
2007; Carpenter, 2011; Papadopoulos et al., 2011). Examples of such demonstrated
support for the lean initiative usually include the healthcare setting executive
personally and visibly supporting the person properly implementing the lean changes
(Ben-Tovim et al., 2007; Fillingham, 2007; Carpenter, 2011). Having the healthcare
setting executive present when any issues over implementation arise supports the
aim of prompting necessary behaviors from all levels of the organizations personnel to
encourage and sustain successful change management (Steed, 2011).
On this account, leaderships ability to show interest in and enable the availability
of resources to ensure the progress of lean initiatives reinforces its position in the
healthcare setting. The main purpose of doing this is to engender the required
behaviors of all staff to affect the necessary cultural changes needed for lean (Golden,
2006; Fillingham, 2007; Steed, 2011). Flexibility and individual initiative cannot be
ascribed to a healthcare settings hierarchy without the visible and sustained support
of the senior executive (Rich and Bateman, 2003; Ben-Tovim et al., 2007; Fillingham,
2007; Steed, 2011).

2. Identifying lean with the strategic agenda of the healthcare setting

The definition of lean calls for an organizational shift that relates to elements of culture
change (Womack et al., 1990). This will invariably impact a healthcare settings overall
 strategic agenda (Vest and Gamm, 2009). Subsequently, the object of lean Lean
implementation to healthcare requires a logical adaption of lean to an existing implementation in
agenda, or revision of the healthcare settings current agenda (Rich and Bateman, 2003;
Waring and Bishop, 2010). The definition of strategic agenda in healthcare is not clear healthcare settings
and therefore requires clarification. Strategic agendas are defined by the agendas
components (Dutton, 1986; Butler et al., 1996; Nag et al., 2007). According to this
definition, the strategic agenda of a healthcare setting encompasses its mission 143
statement, coherent policies consistent with available resources, and all derived
business strategies (Butler et al., 1996). On this account, the following discussion
covers what purpose is served by identifying lean with the strategic agenda of a
healthcare setting and the importance of leadership assuming this role.
The purpose of providing identification with a healthcare settings strategic agenda
and the object of lean implementation is to facilitate the necessary willingness to
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

change, an aspect that the general change management literature cites to be the
number one contributing factor to a change management programs success or failure
(Washington and Hacker, 2005; Dick et al., 2006; Cinite et al., 2009). Organizational
change requires a reason (i.e. be it a healthcare settings mission of providing the best
patient service or administrative policies to manage rising costs) for the organization
to change and the reason to change must be linked to the manner of change (Kaye and
Anderson, 1999; Bateman, 2001; Rich and Bateman, 2003; Cinite et al., 2009).
Identifying lean with the overall strategic agenda of the healthcare setting provides
clarification, justification, requirement, and support for work undertaken by its staff
during lean implementation (Armenakis et al., 1993; Dick et al., 2006). This is important
so that employees understand the nature of their work, the purpose and benefits of
their work, and provides confirmation that all derived initiatives are required (Rich and
Bateman, 2003). Moreover, direction and support capabilities of the healthcare setting
serve to allay any reservations staff might have about the capabilities of the setting
to sustain change when its strategic agenda demonstrates long-term support
commitments and perhaps even reward for successful initiatives (Steed, 2011).
The importance of identifying lean with the healthcare settings strategic agenda
as a readiness factor emphasizes the importance of leadership. The leadership teams
ability to identify or align all required changes with the healthcare settings strategic
agenda is an important success attribute for lean implementation (Golden, 2006;
Fillingham, 2007; Steed, 2011). Likewise, case studies investigating key success factors
for lean implementation agree with the general change management literature on
having, at the executive level, a formally written business strategy to govern focus
and actions required for fulfilling lean objectives which is often noted as a contributing
factor of sustainability (Hines and Lethbridge, 2008; Radnor and Boaden, 2008; Radnor,
2010). Similarly, case studies which focus on organizational willingness to change
during lean implementation concluded that members of healthcare settings applying
lean were more willing to accept the reorganization or reallocation of roles and/or
processes when lean implementation was clearly communicated as a long-term policy
within the healthcare settings strategic agenda (Rich and Bateman, 2003).

3. Understanding what value and customer groups exist in healthcare

The ability to establish value is essential to lean (Andersson et al., 2006). Womack et al.
(1990) describes understanding the principle of value by the ability to correctly
determine the customer, and concludes this to be a requirement for applying lean.
Several customer groups exist in the healthcare setting; patients themselves and
 JHOM relatives of the patient, caregivers, commissioners, decision makers, education-providers
28,2 for doctors and nurses, and even government, taxpayers, and insurance companies are
all examples of the various customers that often end up vying for the maximum value
provided by any one healthcare settings available processes (Papadopoulos and
Merali, 2008; Young and McClean, 2009; Hayes et al., 2010; Poksinska, 2010). The
following discussion will first establish what purpose is served by defining value, and
144 then illustrate why defining value for work accurately is dependent upon determining
the customer group(s) in healthcare.
The importance of being able to correctly determine a healthcare settings customer
groups as a readiness factor is derived from the need to define value for work
accurately (Womack and Jones, 2003). Value for work needs to be communicated
accurately as managerial, administrative, and clinical staff, along with the patient
and their family, government, and a healthcare settings commercial constraints, all
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

unavoidably attribute their own meaning to the concept of value during any
reorganization of processes (Papadopoulos et al., 2011). A well-defined value for a given
customer group prevents conflicting needs and objectives and reduces resistance to
change (Womack and Jones, 2003; Young and McClean, 2009).
The concept of value does not exist in lean without precise understanding of whom
all the work that is undertaken serves (Sugimori et al., 1977; Womack et al., 1990;
Andersson et al., 2006). Lean requires a clear understanding of who the customer is
which benefits from or requires the work that is being done or offered. Value for work
cannot be attributed without understanding that social, political, and cognitive
dimensions shape the meaning and outcome of lean concepts (Papadopoulos et al.,
2011). The value that the lean initiative entails can serve to maintain temporary
solidarity between different departments and varying employee levels (Papadopoulos
et al., 2011). Hence, without knowledge of which groups exist across the healthcare
settings various interconnecting departments, the needs and objectives of all relevant
groups cannot be accurately assessed (Poksinska, 2010; Papadopoulos et al., 2011).
Attributing the wrong customer to an otherwise correct value in healthcare can
result in no group being satisfied with the changes and efforts made (Dick et al., 2006;
Golden, 2006).
The issue of assigning a value for work that serves the wrong customer group
is a major failing of lean initiatives in healthcare (Fillingham, 2007; Ferlie et al., 2010).
Findings from case studies have shown that healthcare workers involved in lean
initiatives have difficulty attributing the correct customer group to any given
improvement initiative (Radnor et al., 2011). All interviewees tended toward an initial
statement of the patient being the focus for deriving value for work undertaken but
later conceded that the actual customer group established was the clinicians
(Fillingham, 2007; Poksinska, 2010).

4. Undertaking the end-to-end process view to identify and eliminate waste

As discussed above, having a clearly defined concept of value is a prerequisite for
applying lean to healthcare (Womack et al., 1990). When conceptualizing value in terms
of customer-groups in the healthcare-setting, a complete end-to-end view of the
existing processes must be undertaken, and then maintained (Fillingham, 2007;
Papadopoulos et al., 2011; Radnor, 2011). The end-to-end process view is also
commonly defined as a complete patient pathway in healthcare literature on lean
(Fillingham, 2007). This definition denotes all steps and work that make up the patients
journey from being admitted to the healthcare setting, to being released from care.
 Due to multiple customer groups vying for the maximum value provided by any one Lean
healthcare settings available processes, these customer groups are not exclusive to the implementation in
category of patient and so this paper will use the term end-to-end process to denote
the process in its entirety for the relevant customer. healthcare settings
The purpose of undertaking an end-to-end process view is to uncover all forms
of waste and value that exist in order to avoid missing the real cause of problems
( Joosten et al., 2009; Papadopoulos et al., 2011). If lean is relegated to improvement 145
of a single activity or the development of one functional area (such as a single
hospital ward), lean improvements will be unable to deliver the maximum value
desired by the customer group because of the waste inherent in hidden activities
(de Souza, 2009).
Due to the complex nature of healthcare settings, processes, and functions overlap
with different sections of an organizational setting. It has been suggested that only the
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

patients themselves are usually aware of every function involved in the treatment
process (Fillingham, 2007). Undertaking an end-to-end process view requires full
understanding of all the activities and functional areas within a process as well as
uncovering value and waste inherent in them (Andersson et al., 2006; Fillingham, 2007;
Radnor, 2011).

5. Personnel training and involvement in lean principles and methods

Education and involvement of personnel in and of the lean principles and methods are
integral to its implementation (Cho, 1995; Steed, 2011). Encouraging and engendering
the activity of personnel through training, and acknowledging their insights and
successes throughout the informative and initial stages of the application of lean may
allay employees concerns of a lack of readiness within the organization for change
(Armenakis et al., 1993; Cinite et al., 2009). Training should be designed to allow for an
introduction to lean principles, and lean tools, allowing the staff to make use of the lean
tools while still having support available (Fillingham, 2007).
Sustainability is also linked to the engagement and training of employees (Bateman,
2001). Having a value-stream mapping board for documenting processes and changes
to value metrics illustrates progress and thus demonstrates to healthcare setting staff
that their efforts are worthy of continuance (Fillingham, 2007; Radnor, 2011).
Sustainability of lean is reliant on the extent of embedded cultural change and
training of personnel within an organization adopting lean (Radnor, 2011). Retraining
in the fundamentals, and tools and techniques of lean is considered essential when
employee turnover is an issue (Radnor et al., 2011). It has been ascribed in the literature
that association of lean with departments beyond the clinical, operational, and
administrative, such as educational and quality development, are arguably the best
methods for improving sustainability (Butler et al., 1996; Bateman, 2005; Ben-Tovim
et al., 2007). Retraining and feedback infers that the concept of lean has been
transferred from leadership and has become embedded in the culture of the healthcare
setting. Feedback on the retraining results has been found in some case studies, to help
improve sustainability of initial lean efforts (Bateman, 2005).
While sustainability and success are not the subject of this discourse on lean, part of
readiness through training is that additional retraining will be necessary in the future
and leadership should be committed with this knowledge from the outset of any lean
improvement initiative. It is here that training overlaps with lean being identified
with the strategic agenda of the healthcare setting and commitment from the
leadership team.
 JHOM 6. Measurement and reward systems aligned to lean objectives
28,2 Original proponents of lean agree with later literature on lean health that reward for
adherence to lean measures encourages continuous improvement (Sugimori et al., 1977;
Cho, 1995; Fillingham, 2007; Taner et al., 2007). Organizations having a reward system
in place that will credit the accomplishments of employees and recognize units or
individuals according to their effort and value them for the work that they do are often
146 cited in general change management literature to be more successful than
organizations lacking a significant reward system or draw to warrant employee
effort (Ackroyd, 1996; Graber and Kilpatrick, 2008; Alange and Steiber, 2009).
Examples of reward systems in healthcare can be as varied as training opportunities,
promotions, accordance of additional authority, financial incentive, and peer
recognition (Graber and Kilpatrick, 2008).
Cinite et al. (2009), in their overview of organizational readiness for change, found
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

that it is vital that the influence of any change to employees previous work be regarded
with care, due to the employees perceived value of their own work being in flux. For
a healthcare organization, applying lean to existing networks, and protocols might
mean redefining or changing existing job descriptions and redistributing roles within
the institution (Papadopoulos et al., 2011). Therefore, having a good reward system
can help staff adapt lean to their work environment (Papadopoulos and Merali, 2008;
Papadopoulos et al., 2011). A good reward system enables capabilities and sustainability
of improvements undertaken (Papadopoulos et al., 2011). Furthermore, celebrating
the successes reinforces commitment to change, and having a well-established reward
system provides incentive for employees (Graber and Kilpatrick, 2008). Having a
foundation for perpetuation of successful lean efforts, a communication strategy to
acknowledge progress and exhibit reward efforts and work for is an essential
contributor to this readiness factor.
However, it is not possible to actually realize progress in order to reward employees
without an accurate measurement system in place to monitor the actual pace and
progress within the healthcare setting (Fillingham, 2007; Gubb, 2009). Measurement
systems are absolutely necessary when it comes to formulating improved strategic
aims (Rich and Bateman, 2003; Hines and Lethbridge, 2008). Without being able
to see where one is, one is unable to see where one may move from there. This puts
healthcare settings with poor or non-existent measurement systems in a dangerous
position (Proudlove et al., 2008). Designing and implementing an effective
measurement system is an important readiness factor for successful lean
implementation in that it guides an analysis of the value-stream, establishes
accountability, and provides easy recognition of progress (Shah and Ward, 2007;
Hines and Lethbridge, 2008; Steed, 2011). However, for these gains to be achieved,
the type and manner of the measurement system has to be sound. Reports from
the UK and USA criticize the extra burden of too many measurement systems
for a healthcare settings staff to maintain (Hacker, 1997; Gubb, 2009). Some of the
issues reported are that no one responsible for the requirement of measurements is
making use of the information collected, and that healthcare setting staff are unable
to understand what such systems are supposed to be measuring, and how such
measurement can contribute to the improvement of the current strategy of their
given healthcare setting (Gubb, 2009). Case studies on lean in health show that
metrics were required to be recognizable, relevant, easy to implement and understand,
and had to be accurate (Kollberg et al., 2006; Hines and Lethbridge, 2008;
Radnor, 2010).
 7. Matching demand and capacity levels to improve flow Lean
Lean requires organizations to create a pull system in order to control flow (Sugimori implementation in
et al., 1977; Womack et al., 1990). A pull system is created by manipulation of the value
desired by the customer group; flow is the regulated and efficient movement of all healthcare settings
activities within the process toward meeting this value expectation (Cho, 1995;
Womack and Jones, 2003; Holweg, 2007).
In lean healthcare, pull is most commonly termed in the literature as demand 147
(Womack and Miller, 2005; Poksinska, 2010; Setijono et al., 2010). This redefinition of a
lean principle for the purposes of healthcare can be rationalized by stating that value in
healthcare is generally whatever service or work is required or demanded by the
customer group (King et al., 2006; Lodge and Bamford, 2008; Parnaby and Towill, 2008;
Kim et al., 2009; Kuo et al., 2011). Likewise flow is also commonly redefined for the
context of lean in healthcare as dependent upon capacity (Fillingham, 2007; Dickson
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

et al., 2009b; DelliFraine et al., 2010). The ability to line up activities or otherwise flow
them according to lean philosophy depends upon standardizing best practices
(Ahlstrom, 2004). One challenge healthcare workers suffer when attempting to link
activities by standardization is the inability to predict or control hospital and ward
capacity levels (Fillingham, 2007; Dickson et al., 2009a; DelliFraine et al., 2010). Capacity
is the ability or extent the healthcare setting is able to accommodate or decrease the
demand for any given value (Fillingham, 2007; Radnor, 2011).
In the context of healthcare, demand is always in flux and seldom can it be created
or controlled in a level manner, as patients needs and conditions vary in required
activities and urgency (Fillingham, 2007). What may be articulated perhaps would be
observances of measured health trends in a given organization into regional/
administrative context and yearly demand surges (Balle and Regnier, 2007). It is
necessary to match demand with capacity as this pertains to readiness for lean
application in having a method to measure and reassess demand, and to arrange
processes and the activities within them to facilitate maximum value (Esain et al., 2008;
Harrison and Kimani, 2009; Radnor, 2011).

Conclusions
Based on a review of articles relating to lean and lean in healthcare, this paper has
identified and discussed the readiness factors for implementing lean in healthcare.
Peer-reviewed, English language, publications up until January 2012 were assessed
pertaining to lean health, lean readiness, healthcare change management, and process
redesign in healthcare. The readiness factors for implementing lean in healthcare
discussed in the previous section are summarized as follows:
(1) Lean implementation requires a change in the culture of a healthcare setting
and the leadership team must exhibit support for, commitment to, and a
demonstrated understanding of the principles of lean. This will engender the
required behaviors of all staff so that the necessary changes can be initiated.
(2) Lean implementation must be communicated to healthcare setting staff as a
long-term policy within the healthcare settings strategic agenda. This will
enable clarification and justification for lean in healthcare and provide support
for work undertaken by healthcare setting staff.
(3) There is a need to establish the importance of all the different customer groups
across the healthcare setting and the value for each customer group must be
 JHOM defined and communicated appropriately. This will prevent conflicting needs
28,2 and objectives and reduce resistance to change.
(4) The complex nature of healthcare settings and the processes and activities
involved in treating patients, an end-to-end process view is necessary. This will
enable identifying all forms of waste and value that exists within the system.
(5) Encouragement and involvement of staff in lean activity is best achieved
148 through training. Furthermore, sustainability of the lean initiative has been
found to be linked to the engagement and training of employees and retraining
in the fundamentals and tools and techniques of lean is considered essential
when employee turnover is an issue.
(6) Having a satisfactory reward system and hence a good measurement system to
monitor progress is essential. Staff should be provided with incentives for their
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

effort and these need to be communicated properly across the healthcare setting.
(7) Since patient needs and conditions vary greatly for the various healthcare
processes and activities, it is essential that patient demand is matched with
capacity as accurately as possible to maximize value. Poor performance in this
respect will result in dissatisfied patients and staff.

Implications for practice and future research

The divergent definitions of lean found in the lean literature and literature specific
to the application of lean in healthcare explain why there is some dissonance as to
whether or not all of the readiness factors must be established before implementation
in order to apply lean successfully (Womack et al., 1990; Wysocki, 2004; de Souza, 2009;
Vest and Gamm, 2009). The results of this review have three important implications for
launching a successful lean project in a healthcare setting. First, the readiness factors
derived above can serve as a checklist for healthcare practitioners for assessing the
preparedness of their organization as they begin their lean journeys. Second, recent
experiences from the public sector show that sustainability of lean initiatives could
be at stake if these readiness factors are not addressed appropriately. Third,
understanding of the readiness factors identified above will enable a healthcare
organization to implement lean more effectively. This will generate the benefits that
are possible in the sense that the organization will be more efficient and effective in its
operations. Collectively, this will enable healthcare organizations to deal with the
pressure of being able to do more with less.
Research can be extended in several directions. First, despite the large body of
literature used to arrive at the list of readiness factors, empirically examining the
applicability of these findings over a large sample of healthcare organizations will
be fruitful in the sense that this list will be empirically validated. Second, while
acknowledging the importance of each readiness factor for a successful lean
implementation in healthcare settings, yet to be articulated is whether these factors
need to be in place before tools of lean are implemented, or should the tools be
implemented simultaneously with the readiness factors? Finally, it is not clear how the
seven readiness factors are related to each other. Does an organization need to be high
on some or all the factors to be successful with implementation of lean principles
and practices? These research questions require further study in order to demonstrate
the link between the list of the readiness factors we propose herein, and sustainability
of lean implementations in the healthcare setting.
 References Lean
Abdolvand, N., Albadvi, A. and Ferdowsi, Z. (2008), Assessing readiness for business process implementation in
reengineering, Business Process Management Journal, Vol. 14 No. 4, pp. 497-511.
healthcare settings
Ackroyd, S. (1996), Organization contra organizations: professions and organizational change in
the United Kingdom, Organization Studies, Vol. 17 No. 4, pp. 599-621.
Ahlstrom, P. (2004), Lean service operations: translating lean production principles to service
operations, International Journal of Services Technology and Management, Vol. 5 No. 5, 149
pp. 545-564.
Alange, S. and Steiber, A. (2009), The boards role in sustaining major organizational change: an
empirical analysis of three change programs, International Journal of Quality and Service
Sciences, Vol. 1 No. 3, pp. 280-293.
Andersson, R., Eriksson, H. and Torstensson, H. (2006), Similarities and differences between
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

TQM, six sigma and lean, The TQM Magazine, Vol. 18 No. 3, pp. 282-296.
Armenakis, A.A., Harris, S.G. and Mossholder, K.W. (1993), Creating readiness for
organizational change, Human Relations, Vol. 46 No. 6, pp. 681-703.
Balle, M. and Regnier, A. (2007), Lean as a learning system in a hospital ward, Leadership in
Health Services, Vol. 20 No. 1, pp. 33-41.
Bateman, N. (2001), Sustainability: A Guide to Process Improvement, Lean Enterprise Research
Centre, Cardiff University, Cardiff.
Bateman, N. (2005), Sustainability: the elusive element of process improvement, International
Journal of Operations & Production Management, Vol. 25 No. 3, pp. 261-276.
Ben-Tovim, D.I., Dougherty, M.L., OConnell, T.J. and McGrath, K.M. (2008), Patient journeys:
the process of clinical redesign, Medical Journal of Australia, Vol. 188 No. 6, pp. S14-S17.
Ben-Tovim, D.I., Bassham, J.E., Bolch, D., Martin, M.A., Dougherty, M. and Szwarcbord, M.
(2007), Lean thinking across a hospital: redesigning care at the flinders medical centre,
Australian Health Review, Vol. 31 No. 1, pp. 10-15.
Butler, T.W., Leong, G.K. and Everett, L.N. (1996), The operations management role in hospital
strategic planning, Journal of Operations Management, Vol. 14 No. 2, pp. 137-156.
Carpenter, D. (2011), Transforming health care, Hospitals & Health Networks, Vol. 85 No. 5,
pp. 46-50.
Castle, A. and Harvey, R. (2009), Lean information management: the use of observational data in
health care, International Journal of Productivity and Performance Management, Vol. 58
No. 3, pp. 280-299.
Cho, F. (1995), International investment: the Japan-US dimension, Japan and the World
Economy, Vol. 7 No. 3, pp. 361-368.
Cinite, I., Duxbury, L.E. and Higgins, C. (2009), Measurement of perceived organizational
readiness for change in the public sector, British Journal of Management, Vol. 20 No. 2,
pp. 265-277.
Clark, C.E., Cavanaugh, N.C., Brown, C.V. and Sambamurthy, V. (1997), Building change-
readiness capabilities in the IS organization: insights from the Bell Atlantic experience,
MIS Quarterly, Vol. 21 No. 4, pp. 425-455.
DelliFraine, J.L., Langabeer, J.R. and Nembhard, I.M. (2010), Assessing the evidence of six sigma
and lean in the health care industry, Quality Management in Healthcare, Vol. 19 No. 3,
pp. 211-225.
Dennis, P. (2006), Getting The Right Things Done: A Leaders Guide to Planning and Execution,
Lean Enterprises Inst Inc., One Cambridge Center, Cambridge, MA.
de Souza, L.B. (2009), Trends and approaches in lean healthcare, Leadership in Health Services,
Vol. 22 No. 2, pp. 121-139.
 JHOM de Souza, L.B. and Pidd, M. (2011), Exploring the barriers to lean health care implementation,
Public Money & Management, Vol. 31 No. 1, pp. 59-66.
28,2
Dick, R., Ullrich, J. and Tissington, P.A. (2006), Working under a black cloud: how to sustain
organizational identification after a merge, British Journal of Management, Vol. 17 No. 1,
pp. 69-79.
Dickson, E.W., Anguelov, Z., Vetterick, D., Eller, A. and Singh, S. (2009a), Use of lean in the
150 emergency department: a case series of 4 hospitals, Annals of Emergency Medicine,
Vol. 54 No. 4, pp. 504-510.
Dickson, E.W., Singh, S., Cheung, D.S., Wyatt, C.C. and Nugent, A.S. (2009b), Application of lean
manufacturing techniques in the emergency department, The Journal of Emergency
Medicine, Vol. 37 No. 2, pp. 177-182.
Dutton, J.E. (1986), Understanding strategic agenda building and its implications for managing
change, Scandinavian Journal of Management Studies, Vol. 3 No. 1, pp. 3-24.
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

Elijz, K.K., Hayes, K.K., Dadich, A.A., Fitzgerald, J.J., Sloan, T.T. and Kobilski, S.S. (2011),
Can that work for us? Analysing organisational, group, and individual factors for
successful health services innovation, Asia Pacific Journal of Health Management, Vol. 6
No. 2, pp. 29-38.
Endsley, S., Magill, M.K. and Godfrey, M.M. (2006), Creating a lean practice, Family Practice
Management, Vol. 13 No. 4, pp. 34-38.
Esain, A., Williams, S. and Massey, L. (2008), Combining planned and emergent change in a
healthcare lean transformation, Public Money and Management, Vol. 28 No. 1, pp. 21-26.
Ferlie, E., Fitzgerald, L., McGivern, G., Dopson, S. and Exworthy, M. (2010), Networks in Health
Care: A Comparative Study of Their Management, Impact and Performance (SDO Project
08/1518/102), Department of Management, Kings College London, London.
Fillingham, D. (2007), Can lean save lives?, Leadership in Health Services, Vol. 20 No. 4, pp. 231-241.
Golden, B. (2006), Transforming healthcare organizations, Healthcare Quarterly, Vol. 10,
Special Issue, pp. 10-19, available at: www.longwoods.com/publications/healthcare-quarterly/457
Graban, M. (2011), Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement,
2nd ed., CRC Press, Boca Raton, FL.
Graban, M. and Swartz, J.E. (2012), Healthcare Kaizen: Engaging Front-Line Staff in Sustainable
Continuous Improvements, CRC Press, Boca Raton, FL.
Graban, M. and Swartz, J.E. (2013), The Executive Guide to Healthcare Kaizen: Leadership for a
Continuously Learning and Improving Organization, CRC Press, Boca Raton, FL.
Graber, D.R. and Kilpatrick, A.O. (2008), Establishing values-based leadership and value
systems in healthcare organizations, Journal of Health and Human Services
Administration, Vol. 31 No. 2, pp. 179-197.
Gubb, J. (2009), Have targets done more harm than good in the English NHS? Yes, British
Medical Journal, Vol. 338 No. 3130, pp. 442-443.
Hacker, J.S. (1997), Market-driven health care: who wins, who loses in the transformation of
Americas largest service industry, Journal of Health Politics, Policy and Law, Vol. 22 No. 6,
pp. 1443-1448.
Harrison, M.I. and Kimani, J. (2009), Building capacity for a transformation initiative: system
redesign at Denver Health, Health Care Management Review, Vol. 34 No. 1, pp. 42-53.
Hayes, K., Reed, N. and Fitzgerald, J. (2010), Who are your lean health customers?: identifying
influential lean customers in health services: current practice and insights from
stakeholder analysis, Asia Pacific Journal of Health Management, Vol. 5 No. 1, pp. 53-61.
Hines, P. (2011), Staying Lean: Thriving, Not Just Surviving, 2nd ed., CRC Press/Productivity
Press, New York, NY.
 Hines, P. and Lethbridge, S. (2008), New development: creating a lean university, Public Money Lean
and Management, Vol. 28 No. 1, pp. 53-56.
implementation in
Hines, P., Holweg, M. and Rich, N. (2004), Learning to evolve: a review of contemporary lean
thinking, International Journal of Operations & Production Management, Vol. 24 No. 10, healthcare settings
pp. 994-1011.
Holweg, M. (2007), The genealogy of lean production, Journal of Operations Management,
Vol. 25 No. 2, pp. 420-437. 151
Jimmerson, C., Weber, D. and Sobek, D.K. (2005), Reducing waste and errors: piloting lean
principles at intermountain healthcare, Joint Commission Journal on Quality and Patient
Safety, Vol. 31 No. 5, pp. 249-257.
Joosten, T., Bongers, I. and Janssen, R. (2009), Application of lean thinking to health care:
issues and observations, International Journal for Quality in Health Care, Vol. 21 No. 5,
pp. 341-347.
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

Kaye, M. and Anderson, R. (1999), Continuous improvement: the ten essential criteria,
International Journal of Quality & Reliability Management, Vol. 16 No. 5, pp. 485-509.
Kim, C.S., Spahlinger, D.A. and Billi, J.E. (2009), Creating value in health care: the case for lean
thinking, Journal of Clinical Outcomes Management, Vol. 16 No. 12, pp. 557-562.
Kim, C.S., Spahlinger, D.A., Kin, J.M. and Billi, J.E. (2006), Lean health care: what can hospitals learn
from a worldclass automaker?, Journal of Hospital Medicine, Vol. 1 No. 3, pp. 191-199.
King, D.L., Ben-Tovim, D.I. and Bassham, J. (2006), Redesigning emergency department patient
flows: application of lean thinking to health care, Emergency Medicine Australasia, Vol. 18
No. 4, pp. 391-397.
Kollberg, B., Dahlgaard, J.J. and Brehmer, P.O. (2006), Measuring lean initiatives in health care
services: issues and findings, International Journal of Productivity and Performance
Management, Vol. 56 No. 1, pp. 7-24.
Kuo, A.M.-H., Borycki, E., Kushniruk, A. and Lee, T.-S. (2011), A healthcare lean six sigma
system for postanesthesia care unit workflow improvement, Quality Management in
Healthcare, Vol. 20 No. 1, pp. 4-14.
Lehman, W.E.K., Greener, J.M. and Simpson, D.D. (2002), Assessing organizational readiness for
change, Journal of Substance Abuse Treatment, Vol. 22 No. 4, pp. 197-209.
Lodge, A. and Bamford, D. (2008), New development: using lean techniques to reduce radiology
waiting times, Public Money and Management, Vol. 28 No. 1, pp. 49-52.
McGrath, K.M., Bennett, D.M., Ben-Tovim, D.I., Boyages, S.C., Lyons, N.J. and OConnell, T.J. (2008),
Implementing and sustaining transformational change in health care: lessons learnt about
clinical process redesign, Medical Journal of Australia, Vol. 188 No. 6, pp. 32-35.
Mazzocato, P., Savage, C., Brommels, M., Aronsson, H. and Thor, J. (2010), Lean thinking in
healthcare: a realist review of the literature, Quality and Safety in Health Care, Vol. 19
No. 5, pp. 376-382.
Nag, R., Hambrick, D.C. and Chen, M. (2007), What is strategic management, really? Inductive
derivation of a consensus definition of the field, Strategic Management Journal, Vol. 28
No. 9, pp. 935-955.
Nelson-Peterson, D.L. and Leppa, C.J. (2007), Creating an environment for caring using lean
principles of the Virginia Mason production system, Journal of Nursing Administration,
Vol. 37 No. 6, pp. 287-294.
Ohno, T. (1988), Toyota Production System: Beyond Large-Scale Production, Productivity Press,
Cambridge, MA.
Papadopoulos, T. and Merali, Y. (2008), Stakeholder network dynamics and emergent
trajectories of lean implementation projects: a study in the UK National Health Service,
Public Money and Management, Vol. 28 No. 1, pp. 41-48.
 JHOM Papadopoulos, T., Radnor, Z. and Merali, Y. (2011), The role of actor associations in
understanding the implementation of lean thinking in healthcare, International Journal
28,2 of Operations & Production Management, Vol. 31 No. 2, pp. 167-191.
Parnaby, J. and Towill, D.R. (2008), Seamless healthcare delivery systems, International Journal
of Health Care Quality Assurance, Vol. 21 No. 3, pp. 249-273.
Poksinska, B. (2010), The current state of lean implementation in health care: literature review,
152 Quality Management in Healthcare, Vol. 19 No. 4, pp. 319-329.
Proudlove, N., Moxham, C. and Boaden, R. (2008), Lessons for lean in healthcare from using six
sigma in the NHS, Public Money and Management, Vol. 28 No. 1, pp. 27-34.
Radnor, Z. (2010), Transferring lean into government, Journal of Manufacturing Technology
Management, Vol. 21 No. 3, pp. 411-428.
Radnor, Z. (2011), Implementing lean in health care: making the link between the approach,
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

readiness and sustainability, International Journal of Industrial Engineering and

Management, Vol. 2 No. 1, pp. 1-12.
Radnor, Z. and Boaden, R. (2008), Editorial: lean in public services-panacea or paradox?, Public
Money & Management, Vol. 28 No. 1, pp. 3-7.
Radnor, Z., Davies, R. and Burgess, N. (2009), How much lean are English hospitals
implementing?, National Health Executive, September/October, pp. 60-62, available at:
www.nationalhealthexecutive.com/Issues-Archive/2010
Radnor, Z., Holweg, M. and Waring, J. (2012), Lean in healthcare: the unfilled promise?, Social
Science & Medicine, Vol. 74 No. 3, pp. 364-371.
Radnor, Z., Burgess, N., Sohal, A.S. and ONeill, P. (2011), Lean in healthcare: veiws from the
executive, European Operations Management Association Conference, Cambridge, July 3-6.
Rich, N. and Bateman, N. (2003), Companies perceptions of inhibitors and enablers for process
improvement activities, International Journal of Operations & Production Management,
Vol. 23 No. 2, pp. 185-199.
Setijono, D., Naraghi, A.M. and Ravipati, U.P. (2010), Decision support system and the adoption
of lean in a Swedish emergency ward: balancing supply and demand towards improved
value stream, International Journal of Lean Six Sigma, Vol. 1 No. 3, pp. 234-248.
Shah, R. and Ward, P.T. (2007), Defining and developing measures of lean production, Journal
of Operations Management, Vol. 25 No. 4, pp. 785-805.
Spear, S.J. (2006), Fixing healthcare from the inside: teaching residents to heal broken delivery
processes as they heal sick patients, Academic Medicine, Vol. 81 No. 10, pp. S144-S149.
Steed, A.D. (2011), Exploration of the leadership attributes and methods found to be associated
with successful lean system deployments in acute care hospitals, unpublished EdD,
Olivet Nazarene University, Chicago, IL.
Sugimori, Y., Kusunoki, K., Cho, F. and Uchikawa, S. (1977), Toyota production system and
Kanban system: materialization of just-in-time and respect-for-human system,
International Journal of Production Research, Vol. 15 No. 6, pp. 553-564.
Taner, M.T., Sezen, B. and Antony, J. (2007), An overview of six sigma applications in healthcare
industry, International Journal of Health Care Quality Assurance, Vol. 20 No. 4,
pp. 329-340.
Vest, J.R. and Gamm, L.D. (2009), A critical review of the research literature on six sigma, lean
and studergroups hardwiring excellence in the United States: the need to demonstrate and
communicate the effectiveness of transformation strategies in healthcare, Implementation
Science, Vol. 4 No. 35, pp. 1-9.
Waring, J.J. and Bishop, S. (2010), Lean healthcare: rhetoric, ritual and resistance, Social Science
& Medicine, Vol. 71 No. 7, pp. 1332-1340.
 Washington, M. and Hacker, M. (2005), Why change fails: knowledge counts, Leadership & Lean
Organization Development Journal, Vol. 26 No. 5, pp. 400-411.
implementation in
Weber, D.O. (2006), Toyota-style management drives Virginia Mason, Physician Executive,
Vol. 32 No. 1, pp. 12-17. healthcare settings
Weiner, B.J. (2009), A theory of organizational readiness for change, Implementation Science,
Vol. 4 No. 1, pp. 67-75.
Womack, J.P. and Jones, D.T. (2003), Lean Thinking: Banish Waste and Create Wealth in Your 153
Corporation, 1st ed., Free Press, New York, NY.
Womack, J.P. and Miller, D. (2005), Going Lean in Health Care, Institute for Healthcare
Improvement, Cambridge, MA.
Womack, J.P., Jones, D.T. and Roos, D. (1990), The Machine That Changed the World, Rawson
Associates, New York, NY.
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

World Health Organization (2008), Primary Health Care- Now More Than Ever, WHO, Geneva.
Wysocki, B. (2004), To fix health care, hospitals take tips from factory floor, The Wall Street
Journal, pp. 1-5, available at: http://online.wsj.com/news/articles/SB108146068260878363
Young, T. and McClean, S. (2008), A critical look at lean thinking in healthcare, Quality and
Safety in Health Care, Vol. 17 No. 5, pp. 382-386.
Young, T. and McClean, S. (2009), Some challenges facing lean thinking in healthcare,
International Journal for Quality in Health Care, Vol. 21 No. 5, pp. 309-310.
Young, T., Brailsford, S., Connell, C., Davies, R., Harper, P. and Klein, J.H. (2004), Using industrial
processes to improve patient care, British Medical Journal, Vol. 328 No. 7432, pp. 162-164.

Corresponding author
Professor A.S. Sohal can be contacted at: Amrik.Sohal@monash.edu

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints
 This article has been cited by:

1. Tapani Jorma, Hanna Tiirinki, Risto Bloigu, Leena Turkki. 2016. LEAN thinking in Finnish healthcare.
Leadership in Health Services 29:1, 9-36. [Abstract] [Full Text] [PDF]
2. Pascale A.M. Simons, Jochen Bergs, Madelon Pijls-Johannesma, Huub Backes, Wim Marneffe,
Dominique Vandijck. 2016. Safer radiation therapy treatment resulting from an equipment transition: A
mixed-methods study. Practical Radiation Oncology 6, 19-25. [CrossRef]
3. Aurlie Gurin, Denis Lebel, Kevin Hall, Jean-Franois Bussires. 2015. Change management in
pharmacy: a simulation game and pharmacy leaders' rating of 35 barriers to change. International Journal
of Pharmacy Practice 23:10.1111/ijpp.2015.23.issue-6, 439-446. [CrossRef]
4. Virginia Bodolica, Martin Spraggon, Gabriela Tofan. 2015. A structuration framework for bridging the
macro-micro divide in health-care governance. Health Expectations n/a-n/a. [CrossRef]
5. Jean-Franois Bussires, Jennifer Corny. 2015. Perspective sur lenseignement de la gestion en pharmacie
Downloaded by New Mexico State University At 04:32 31 January 2016 (PT)

hospitalire. Pdagogie Mdicale 16, 143-157. [CrossRef]