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The purpose of the proposed research is to explore the impact of lean on the operational performance of healthcare systems. Data will be collected using both primary and secondary research. Primary data will be received using semi-structured interviews with hospital personnel to gather their views on the characteristics and challenges of lean implementation. The secondary data will be collected from annual records of lean and non-lean hospitals, after which their operational performance measures will be compared to determine the impact of lean philosophy on their functioning. The metrics of operational performance that will be assessed include the time that patients spend receiving care, the number of patients, which the hospital handles, the number of incidents and medical errors, the waiting times, overtime hours, inventory costs.

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Hospitals are currently facing immense pressure to continually improve their services and operation (Agus & Shukri, 2012). There is an increasing demand for healthcare services; however, the funding of hospitals is constantly declining. Moreover, healthcare systems are facing the challenge of being cost-effective, efficient, thorough, accessible, and affordable (Akbulut-Bailey, Motwani, & Smedley, 2012). This poses the need for healthcare organizations to search for novel and more efficient methods of offering care. One of such methods that hold the promise for increasing the operational efficiency of healthcare organizations is lean production. In the business world, various organizations have adopted the concept of lean. Some authors proposed the potential applicability of lean in the services sector and, by extension, the healthcare industry (Alsmadi, Almani, & Jerisat, 2012; Čiarnienė & Vienažindienė, 2012). Still, there are conflicting beliefs concerning the suitability of lean production principles with respect to enhancing the operational performance of healthcare systems. To this end, there is the need to explore whether lean can be beneficial to hospitals, especially with respect to improving their operational performance (Antony, Krishan, Cullen, & Kumar, 2012). After establishing the value of lean thinking in healthcare settings, it is also crucial to explore the challenges that hospitals face when attempting to implement a lean strategy.

Literature Review

Lean in Healthcare

With the increment in concerns regarding the performance of healthcare systems, the concept of lean thinking is increasingly being adopted in hospitals in order to enhance the quality of care and reduce operational costs (Arfmann & Barbe, 2014; Čiarnienė & Vienažindienė, 2012). Although lean thinking has its origins in manufacturing, its adoption in service sectors has resulted in considerable improvements. The popularity of lean as a process improvement tool has lead to the increase in the academic interest to this topic as well as the appearance of considerable number of publications in journals and conferences.

The processes in hospitals are usually optimized for nurses, physicians, and other personnel with little emphasis being placed on patients (Aronsson, Abrahamsson, & Spens, 2011). The outcome is that patients can spend hours in hospitals while only a small fraction of this time is value-adding. In addition, healthcare operations are characterized by the inconsistency in the delivery of care, unending interruptions, and undependable access to processes and resources, what subsequently augments the inefficiencies, the waiting times, the likelihood of medical errors, and frustration among personnel (Ballard & Tommelein, 2012).

As mentioned earlier, lean in healthcare focuses solely on ways of managing and improving processes. In practice, healthcare organizations consider patients as their main customers and a crucial factor that should be taken into account when designing the processes associated with the delivery of care. Many authors agree on the importance of deriving value from the point of view of patients (Suárez-Barraza, Smith, & Dahlgaard-Park, 2012; Wijewardana & Rupasinghe, 2013; Talib, Rahman, & Azam, 2011). Thus, for healthcare processes to be improved, it is imperative to have a precise understanding of the customer’s view as well as the value that is added.

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The second important consideration in healthcare process improvement outlined by a number of authors relates to the importance of learning to see the processes as they are being undertaken with all the shortcomings and problems (Simon & Canacari, 2012; Shazali, Habidin, Ali, Khaidir, & Jamaludin, 2013). It poses the need to group diverse patients having different conditions into categories having similar value streams and determine various patient flows throughout the healthcare system. One of the commonly utilized lean tools in healthcare settings is the patient flow/journey/pathway, which refers to the series of various processes found in the patient journey (Hasle, Bojesen, Langaa Jensen, & Bramming, 2012; Gowen, McFadden, & Settaluri, 2012). The emphasis is on following the route that a patient uses in the healthcare system right from the demand stage to the point, at which the treatment is finished, based on his/her experiences. The third aspect of process improvement in healthcare settings mentioned in the literature relates to the specification of the manner, in which work is to be performed, as well as the elimination of various forms of waste including interruptions, workarounds, and poor procedures among others.

The most commonly cited lean approaches used in healthcare settings include continuous flow and reduction of waste (Burgess & Radnor, 2013). Continuous flow is the most commonly utilized lean approach in healthcare settings. Continuous flow in healthcare organizations requires the patient to flow between staff and healthcare units in the absence of interruptions and delays (Cudney & Elrod, 2011; de Souza & Pidd, 2011; Bortolotti & Romano, 2012; Clark, Silvester, & Knowles, 2013; Corbett, 2011). Achieving it poses the need for personnel to have the understanding of the process, recognize bottlenecks and waste, and be able to determine the root causes contributing to the identified problems (Cheng & Chang, 2012). Continuous flow also entails the elimination of barriers that hinder cooperation between various working units.

Impacts of Implementing Lean in Healthcare

In the literature, two broad categories of the outcomes associated with lean thinking exist. They include health outcomes and process outcomes, both of which are discussed in the subsequent sections.

Health outcomes

The outcomes related to healthcare system performance can be measured and often presented as improvement rates. One of the healthcare performance impacts of lean was explored by Kaplan (2013) and Moraros, Lemstra, and Nwankwo (2016) who focused on exploring lean in the Canadian healthcare system. Their findings reported that the adoption of lean did not result in any significant improvements with respect to patient satisfaction or health outcomes. Other studies have also explored the impact of lean on health outcomes and reported contradictory results when compared to those reported by Moraros et al. (2016). For instance, Jha, Joynt, Orav, and Epstein (2012) examined the effect of lean on the healthcare system in the United States using the retrospective cohort design with 6 million participants and reported that the adoption of lean was able to reduce the 30-day mortality rate by 0.08 percentage points (p. 1614). In another study by Toussaint (2009) investigating the effect of lean production philosophy at Thedacare of Wisconsin, it was reported that lean resulted in the improvement of staff productivity by 12 percent, the decrease in the length of patient stay by 22 percent, and a drop in the mortality rate by 40 percent (p. 1348). Another health outcome research associated with the implementation of lean in the United States healthcare system, particularly in the emergency ward, was conducted by McCulloch et al. (2010) who employed the interrupted time series. The researcher focused on examining how lean thinking can be used to lessen the risk of healthcare-associated harm and discovered that implementing of lean thinking in emergency settings significantly lowers the risk of adverse events. Ellingson et al. (2011) reported similar findings using a pre-test post-design and found out that lean philosophy helps to lower the incidence of hospital-related infections. An observation from the literature is the overwhelming support that the implementation of lean helps to improve the health outcomes for patients.

Process outcomes

Besides the impact of lean on health outcomes, studies have also focused on examining how lean philosophy affects process outcomes. Various measures of process outcomes have been used in the literature including overall time that patients spend receiving care, the patient throughput (the number of patients that a hospital can handle), the number of medical errors and incidents, the waiting times, employee overtime hours, inventory costs, and the travel time or walking distance for staff and patients. In this respect, studies have indicated that the implementation of lean can result in significant reductions in the amount of time that patients spend receiving care (Arfmann & Barbe, 2014; Hasle et al., 2012). Furthermore, empirical evidence to indicate that the implementation of lean in hospitals can significantly enhance their patient throughput exists (Aronsson et al., 2011; Burgess & Radnor, 2013; Jha et al., 2012). Other impacts that have been documented in the literature associated with the implementation of lean in healthcare settings. They include: a reduction in the number of incidents and errors (Aronsson et al., 2011); a reduction in the patient waiting times (Hasle et al., 2012); improvements in patient satisfaction (Agus & Shukri, 2012; Shazali et al., 2013); an increase in personnel satisfaction (Simon & Canacari, 2012); a reduction in the overtime hours (de Souza & Pidd, 2011); and a decrease in the costs of inventory (Gowen et al., 2012).

Other aspects of process outcomes associated with lean philosophy that have been evaluated empirically include the length of stay at the emergency department and the physician wait time, number of patients leaving the hospital without being seen, the emergency wait time, movements of the door at the operating room, improvements in work engagement and teamwork, reductions in the patient journey time, and improvements in workflow and efficiency. For instance, Simons, Aij, Widdershoven, and Visse (2014) investigated the adoption of lean on the number of door movements during surgery using the pre-test post-test design and reported a 78 percent reduction of door movements – from about 15-20 times/hour to about 4 times/hour (p. 5). In sum, it can be seen that the adoption of lean has beneficial outcomes with respect to process improvements.

The gap in the Literature

There is scanty evidence regarding the application of lean production philosophy in healthcare processes in the existing literature. Various authors are in agreement that in healthcare processes lean is usually viewed as a collection of techniques and tools that can be used to enhance processes (Simon & Canacari, 2012; Čiarnienė & Vienažindienė, 2012). Lean in healthcare places considerable attention to the simplification of processes through the understanding the process aspects that are value-adding and elimination of waste. The present healthcare system comprises of operations that are fragmented and need a change with respect to how the organization of patient care delivery flow. Although empirical evidence illustrates that lean can help improve health and process outcomes, there is a shred of the doubt since certain studies have not shown significant improvements following the implementation of lean. Hence, there is the need to conduct additional research to ascertain the true value of lean in healthcare.

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Methodology

Research Variables, Research Questions

The independent variable in this research is the application of lean by healthcare facilities whereas the dependent variable is the operational performance of hospitals. In addition, this study sought to explore hospitals, which are implementing lean, and the challenges that hospitals encounter in their quest to become lean. Based on these variables, the following are the research questions.

Qualitative questions:

1. What are the characteristics of lean hospitals?

2. What challenges do the hospitals face when implementing lean?

Quantitative questions:

1. What is the difference in operational performance between lean and non-lean hospitals?

Hypothesis: Lean hospitals will have higher operational performance characteristics when compared to non-lean hospitals?

Research Design

For the proposed research, the mixed methods design will be used. In the mixed methods design, the researcher collects and analyzes both qualitative and quantitative data. Creswell (2011) describes the mixed methods design as the most appropriate one to provide a better understanding of the research problem than when either qualitative or quantitative designs are used alone. The qualitative aspect of the proposed research will concentrate on exploring how healthcare facilities are implementing lean management principles and outline the challenges that they face. The utilization of the mixed methods will be helpful in facilitating both in-breadth and in-depth of the phenomenon being investigated – the application of lean in healthcare operations. Moreover, the mixed methods design facilitates triangulation through the exploration of the problem using various perspectives and techniques (Cozby & Bates, 2012; Daymon & Holloway, 2010).

The particular qualitative design that will be utilized in this research is the single case study design. The rationale underpinning the selection of the case study design for the qualitative part of the proposed research is that it facilitates the undertaking of the detailed investigation (Daymon & Holloway, 2010; Vogt, Gardner, & Lynne, 2012). The case study has been described as a viable tool for any research that seeks to answer “why” and “how” questions in order to perform a comprehensive study of the phenomenon of interest. In the proposed paper, the researcher is focusing on performing the in-depth exploration in order to have a better understanding of the phenomenon of lean application in healthcare instead of generalizing the study findings (Leedy & Ormrod, 2010). Therefore, the single case study design was the ideal approach for the qualitative aspect of the proposed study. The case study selected for the proposed research is a hospital in the state of Virginia that has officially adopted lean management principles in its operations. Before commencing with the data collection process, the researcher will seek the permission from the hospital administration to use the organization as the subject of the case study..

The quantitative aspect of the planned research will focus on examining the impact of lean principles on the operational performance of hospitals. The particular quantitative approach that will be utilized in the proposed research is the causal-comparative design, which seeks to discover a cause and effect relationship between variables (Johnson & Christensen, 2011; Leedy & Ormrod, 2010). The emphasis of the causal-comparative design is to look for the statistical relationship between variables with a particular accent on how circumstance affects the various groups. In the proposed research, the independent variable is the implementation of lean principles by healthcare facilities whereas the dependent variable is the operational performance of healthcare organizations. In this design, the sample will comprise of hospitals that have officially adopted lean principles in their operation and those that do not use them. The differences in the measures of operational performance between lean hospitals and non-lean hospitals will be used to determine the impact of the strategy on the healthcare facility functioning.

Method of Data Collection

The proposed research will utilize both secondary and primary data to answer the research questions. Secondary data refer to the data that has been collected and documented by other researchers. Secondary research will be first conducted through the literature search methodology in order to understand the measures of operational performance in healthcare settings (Cozby & Bates, 2012). The literature search will be conducted on a number of electronic databases and citation indices including Google Scholar, Pubgbet, Questia, SpringerLink, Emerald, and Ebscohost. The keywords that will be used in the literature search include such words as lean production, healthcare, hospital, health system, Thedacare, Virginia Mason, Toyota production system, Kaizen, HoshinKari, lean methodology, lean healthcare, lean principles, and subsidiarity. Identifying the measures of operational performance relevant in healthcare settings is to be followed by searching for the hospitals to be included in the sample, namelythose adopting lean management and those that do not implement lean methodologies. Their annual reports will be reviewed. Inthese reports, the researcher will look for the values measuring the operational performance of the facility, specifically the overall time that patients spend receiving care; the patient throughput (; the number of medical errors and incidents; the waiting times; employee overtime hours; inventory costs; and the travel time or walking distance for staff and patients.

After the completion of the secondary research, the next phase of the data collection will be conducting of the primary research. This phase will be conducted using semi-structured interviews with the individuals in administrative positions in the case hospital. The goal of the primary research will be to explore the aspects associated with the implementation of lean management at the organization as well as the challenges, which the hospital faces in the process of adopting the new approaches. The semi-structured interviews will be conducted using either telephone or video-link interviews in accordance with the preference of the respondents. In addition, the interview sessions will be recorded and transcribed later.

Sampling Plan

The sample for the primary research will comprise of the hospital personnel members working in administrative capacities. For the case study, a convenience sample of 15 members of personnel from the hospital will be interviewed. This sample size is sufficient to guarantee data saturation, which refers to the point, at which no new data emerges from the interviews. For the qualitative component of the research, the sample will comprise of hospitals categorized into lean and non-lean ones with each category comprising of 10 establishments. The operational performance metrics of these two groups will be compared in order to determine the impact of lean management.

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Data Analysis

Since the proposed research uses a mixed-method approach, both qualitative and quantitative data analysis techniques are required. For the qualitative component, data obtained from the semi-structured interviews will be analyzed using thematic content analysis, which is a technique that focuses on identifying dominant themes found in the data. After transcribing the information, an inductive approach will be used, which is characterized by adopting an open methos rather than using a predetermined framework (Creswell, 2011). After identifying the dominant themes in the data, relationships and patterns that exist between them will also be explored. When analyzing the data, the researcher will compare how the various participants responded to the questions in the interview protocol. A codebook will be used for the purposes of coding wherein participants will be identified using identifiers, after which their ideas and themes will be placed..

For the quantitative data analysis, a mix of both descriptive and inferential statistics will be employed. Descriptive statistics will be used to describe the hospitals included in the sample whereas the inferential statistics will be applied to characterize the relationships between the variables which are lean application and the operational performance of hospitals. The specific statistical technique that will be used is the independent samples t-test, which will be used to determine whether significant differences between lean and non-lean hospitals exist with respect to the measures of operational performance used in this research including the time that patients spend receiving care, the number of patients, which the hospital can handle, the number of incidents and medical errors, the waiting times, the number of overtime hours, inventory costs, and the walking distance/travel time for hospital personnel and patients.