Organisational readiness and Lean Thinking implementation: Findings from three emergency department case studies in New Zealand

Abstract

This paper describes and contrasts the implementation of Lean Thinking – a quality methodology that emphasises waste reduction and performing at higher levels of productivity with the same or less resources – into New Zealand’s healthcare system. As the field is relatively new, three literature-based exemplar cases were developed to provide an analysis framework to analyse the three New Zealand research sites, which had activities, teamwork, leadership and sustainability as its core themes. Each research site’s case was developed from primary data gathered through interviews, augmented by secondary data from project reports, District Health Board websites and media stories. The results highlight the benefits of a supportive quality-focussed organisational culture, executive management involvement and cross-functional teams as enablers. Further, work intensification and workplace resistance were also evident in varying levels within the sites. The study, while reiterating the problems of introducing quality methods from other domains into healthcare, presents the New Zealand context and reinforces that organisational preparedness as a significant factor which contributes to implementation success. This study goes beyond investigations of the use of Lean tools, changing improvement metrics and descriptive statistics to identify the contexts and variables which surround quality and process improvement implementations.

Keywords

healthcare Lean Thinking New Zealand organisational readiness process improvement quality implementation

Introduction

Lean Thinking is the generic label given to the Toyota Production System’s combination of management philosophy and activities¹ and it is being introduced into healthcare systems across the globe as a solution for the problems of quality and costs.^2–4 In 2008, the New Zealand government introduced Lean Thinking to its health system through a series of projects, which included emergency departments (EDs).

EDs have become topical for healthcare performance and quality improvement as they signal a hospital’s ability to respond to demand within the context of the worldwide phenomenon of ED overcrowding, which is due to reasons both within and outside of the organisation.⁵ Lean Thinking has been found to have positive impacts on both patient quality and safety in ED’s⁶ contributing to reductions in overcrowding by enhancing patient management and flows.⁷

This paper presents the experiences of three ED Lean Thinking implementations that took place in New Zealand hospitals from 2008 to 2010. Since 2008, New Zealand’s largely publically funded health care system, which delivers care to its population of 4.1 million people, has been directed to focus on frontline services, quality and service integration. Hospitals are operated by 20 democratically elected District Health Boards (DHB) to provide services to regional populations guided by a set of national performance targets. The recent changes also have resulted in the recentralisation of certain functions, including national oversight of information technology, workforce forecasting and system quality.⁸

The paper contributes to the literature, first, by adding another country’s experiences to the emerging Lean implementation literature, a country whose system has reputation for regular and wide ranging system change.⁸ Second, through cases developed from the extant literature that enable identification of key analytic themes, the study’s analysis extends the investigation beyond Lean tools, improvement metrics and descriptive data to include the contexts and factors that determine implementation success.⁹ Thus, academic insight is offered regarding the introduction of Lean tools and techniques in healthcare and provides further evidence of the importance of organisational readiness as a precursor for healthcare organisational innovation.¹⁰

Lean in healthcare

The term ‘Lean’ describes the manufacturing methods used by the Toyota Motor Corporation specifying value in terms of the customer and identifying elements to maximise that value through processes such as work streams and process flows.¹ Performance and quality improvement are achieved by activities or tools¹ such as Plan-Do Study-Act (PDSA) improvement cycles, the 5S visual work organisation method, A3 problem solving and value stream mapping; some of which may be used as part of structured or cyclical improvement events.¹¹ Although, as the tools were developed in the manufacturing environment, they may not be directly transferable to service industries.¹²

Lean provides a philosophy, a management system and a toolset for healthcare organisations to use to lessen error rates, improve quality care and reduce wait-times for patients.¹³ It is these processes which are credited with savings and cost reallocations.¹³ Improvements can be achieved by reevaluating patterns of demand and redesigning the processes and work spaces,¹⁴ which have been identified as viable alternatives to traditional hospital quality problem solving methods.⁷ However, despite the benefits, few healthcare institutions are undertaking systematic organisation wide Lean implementations⁴ with Lean many times being introduced as independent initiatives or as unconnected multiple projects.¹⁵

Introducing Lean to a healthcare environment requires a certain sensitivity to the interplay between the operational and professional domains in healthcare.¹⁶ Similarly, unlike value identification in manufacturing, healthcare customer value depends on who the customer is⁹ and the customer’s expectation of value is then dependant on their identity and position within the health system.¹⁷ As a result, Lean efforts in hospitals may not be directed towards organisational performance objectives, but more pragmatically to those outcomes with which most actors can align.¹⁷ It is therefore preferable that Lean is part of an organisation’s strategy leading to sustainable continuous improvement.¹⁸ Moreover, Lean should not be used as a cost elimination methodology,¹⁸ particularly if the organisation is seeking cost control rather than service innovation or improvement¹⁴ – for in times of financial constraint, it can be difficult for healthcare leaders to change their view of their workplace’s systems.¹⁹ Managers and staff implementing Lean should receive training not only to be able to undertake the new techniques but also to prevent a return to their past behaviours.²⁰

Lean healthcare is generally executed by teams operating in a participative environment and organised across administrative or functional boundaries.^21,22 The role and the style of a Lean team leader are required to be more functional than authoritarian utilising facilitation skills and creating a climate of encouragement^23,24 by mitigating power differentials between staff to ensure inclusion, encouraging innovation and sustaining new work routines.²² These attributes are more important since the ‘hero clinician’ is less relevant as patient pathways become the operational norm.^21,24

Top management and leadership,^25,18 as well as the engagement of the hospital’s senior doctors,²⁶ provide vital support to Lean initiatives. However, clinical engagement may be restricted to those who have been ‘converted to Lean’^27,p.1339 or to occupational groups whose work organising principles are similar to Lean approaches.^19,22 There are few reports that include the examination of Lean’s effects on the health workforce²³ or its contribution to the intensification of work as found in manufacturing.²⁸ Although O’Donnell²⁹ and Willis³⁰ found indications of work intensification in organisations following some Australian Lean healthcare implementations, Waring and Bishop²⁷ provide insight into the issues of social organising within a UK hospital.

Research context

As Lean Thinking has only recently been introduced into the New Zealand healthcare system, it is relevant to seek to understand how it is being implemented as New Zealand EDs. By uncovering the outcomes and by situating the implementation within the hospital’s contexts the factors for success can be determined.⁹

To provide an analysis theme and the framework for content analysis and to enable transferability of findings, three exemplar cases were composed from the literature. These exemplars, Virginia Mason Medical Centre, Seattle, USA, Royal Bolton Hospital, Bolton, UK and Flinders Hospital, Adelaide, Australia, were chosen due to their frequency of appearance and referral in the general Lean healthcare literature and having become known as ‘celebrated examples’.^9,p.364 The exemplar cases were analysed using content analysis, a research method that enables researchers to make valid inferences from text,³¹ resulting in a set of implementation indicators, which are summarised in Table 1. These indicators appear later in the results section, where they are used as the study’s analytic themes.

Table 1.

Lean implementation indicators identified from the three exemplar cases.

Activities undertaken	Leadership involvement	Team development	Sustainability
Similar Lean tools were used across the sites, including PDSA cycles, value stream mapping, 5S and standardisation of work and processes. Tools and measures were adjusted or amended to better calculate and monitor changes of hospital processes.	There was an identified problem and an agreed commitment to have it addressed by not using or continuing to use the tools and techniques that were failing to deliver. The requirement for new skills and knowledge coupled with new orientations for managers or supervisors was also alluded to. Visible affirmation by senior leadership was a case feature as with the acknowledgement that to improve work or processes is achieved by those who do the work and know it best. The changes were led from the top and once agreed upon were implemented.	Outside support and technical input assisted the initial stages of implementation. An internal team was tasked with facilitating and developing staff awareness and understanding assisting with training and dissemination. Teamwork and the involvement of all staff to redesign processes and provide insights into waste and improved flow that improves acceptance of Lean and change and optimises interpersonal and professional relationships. It is acknowledged that organisational change is not easy to achieve.	A key feature of the cases was the implementation to effect continuous improvement, by either setting a cycle or programming for the next unit on the patient journey to undertake Lean activities. Progressing Lean across the organisation to capture the patient journey end to end, with the units undertaking Lean activities as part of their daily work. The importance of a new culture, with all of the cases branding ‘their’ improvement methodology.

Research method

The case study is a methodology that lends itself to examining new phenomena,³² using quantitative and qualitative data to develop an answer to a given research question – particularly when a ‘how’ or ‘why’ question is being posed.³³ A weakness of the case study method is the difficulty to generalise the results into other cases or situations;³³ in particular, a situation that exists for healthcare quality,³ leading authors suggest more rigorous research to expand on the exploratory and descriptive nature of the Lean healthcare cases published so far.^2,3,23

For this study, three ED sites from three different DHBs were used. Table 2 provides outlines of the case study sites and the outcomes of their Lean activities. The study’s approach and instruments were tested at Site A to validate the analytic themes in terms of their relevance to New Zealand’s hospital system and to provide improved confidence for case replication.³³

Table 2.

Summary of case study organisations and Lean activities.

Hospital	Organisation type	Lean activities
Site A	A 388-bed hospital providing secondary and tertiary services. 21-bed ED ED volume 37,000 per annum with a 25–30% admission rate (11,100) Mainly urban population	X-ray pathway: Before: 0:44 h. After: 0:26 h. Fast Track low acuity stream: Before: 3:20 h. After: (November 2008) 2:16 h: (May 2010): 1:56 h. Reduced non-urgent ED attendances. Reduced Rework and checking Pharmaceutical savings. New procedures developed.
Site B	A 260-bed hospital providing secondary and tertiary services. 14-bed ED. ED volume 40,000 per annum with a 23% admission rate (9200). Mainly urban population.	Patient admission/transfer times. Before >1:00 h. After (average) <1:00 h. Coaching undertaken. Scorecard, Ward discharge times, New performance measures displayed openly.
Site C	A 200-bed regional hospital providing secondary services. 14-bed ED. Ed volume 28,000 with 30% admission rate (8400). Mix of rural urban population.	Admission times: Before up to 4:00–5:00 h: After reduced by 2:00 h. Reduced clutter in ambulance bay and Resuscitation room. Patient notes procedures – reduced errors and location Standard documentation Blood testing – reduced rework and errors.

ED: emergency department.

Secondary data were gathered from a range of sources and were used to triangulate aspects of the implementations, their foci and evidence of process improvement. Hospital statistics and population data were found in national health reports, DHB annual reports and from the respective DHB websites. Summary and periodic progress reports of the implementations provided details of the activities, timelines, outputs and efficiency measures. Internal memos and staff newsletters provided additional evidence surrounding implementation progress.

Primary data collection consisted of a series of semi-structured interviews that were conducted with respondents at each site. A total of 28 interviews were undertaken. Access was gained through a key site respondent, who assisted with scheduling respondent interviews, provided access to internal data and introduced the researcher to the respondents. Respondents were selected from the pool of staff involved with the Lean implementations to provide some symmetry of occupation and numbers across the sites. Respondents were provided with alpha numeric codes to ensure anonymity. Table 3 provides respondent data. No approached respondents refused to take part in the ethically approved research project. Respondents who were unable to attend the scheduled interviews were later contacted by telephone and interviewed using the same procedures used for the face to face interviews. All semi-structured interviews followed the same question script with follow-up or clarifying questions conducted either during or at the close of the interview. Notes and observations taken at the sites and throughout the research were used to assist the initial sorting and coding, to triangulate data and test for consistency.³⁴ Data were recorded on a digital recorder with the files being professionally transcribed verbatim. The research cases were then composed and verified by each site’s key informant before commencing the cross-case analysis.

Table 3.

Summary of respondents.

Role	Site
Role	A	B	C
Service manager	1	1	1
Quality manager	1	1	1
Clinician	2	0	2
Nurse	3	3	2
Allied health	1	0	0
House keeping	1	1	1
Clerical	1	0	1
Lean facilitator	2	1	1
Total respondents	12	7	9

The comparative examination of the case findings was undertaken by thematic analysis using codes. Codes allow the researcher to more easily see what is going on or to test or support ideas³² through categorical data arrangement, which facilitates comparison.³⁴ Computerised qualitative analysis software enables a more ordered approach to search for patterns using key words and phrases to identify similar experiences and phenomena or different responses to similar situations at the cross-case analysis stage.³⁵ Data coding began with the analytic themes derived from the exemplar implementation indicators to develop a tree node coding structure in the qualitative data analysis program NVivo. The case data were then cross-analysed using the four analytic themes using coding trees, where: (i) activities considered the actual work undertaken by counting results and reviewing the different tools used; (ii) leadership involvement referred to leader activities, localised champion behaviours and the range of differing experiences, which were reported; (iii) team development described the project’s processes, peoples responsibilities, changes to work and group behaviour and (iv) sustainability related to the ongoing organisational commitment, team attitude and the reported capacity of the ED and the organisation. Summary results for leadership, team development and sustainability are presented in Table 4, while the activity theme results are presented as part of Table 3.

Table 4.

Case theme results.

Hospital	Leadership involvement	Team development	Sustainability
Site A	Top leadership absent with confused quality leadership in the ED. ED participation active. No strategy or policy for Lean. Implemented as a project outside of normal chain of command. Little evidence of organisational and site ownership.	Clinical involvement with Dr’s and nurses. Analysis and process skill development. Fragmented communication within projects but inter team and across silo cooperation improved. Work intensified for some groups.	Little stickiness of skills evident. Little site preparedness for change. Good site comprehension of Lean benefits, but localised at site. Moderate clinical buy-in. Moderate staff resistance. Significant improvements within the ED but isolated from hospital as a whole
Site B	Top leadership present through active involvement. Clear and active ED leadership. Implemented within a continuous improvement culture over the organisation with evidence of organisational ownership.	Nurse-led change. Developed analysis and process skills. Coordinated communication and ocussed on organisation cooperation. Additional Lean tasks accommodated into existing work routines.	Moderate stickiness of skills evident site and organisational preparedness. Reasonable comprehension of Lean across the organisation. Evidence of clinical buy-in, with little resistance. Synchronised change across the organisation.
Site C	Top leadership not visible. Responsibility for Lean in organisation changed. Clear ED leadership but with limited participation. Implemented as a quality project supported by an organisational Lean strategy. Moderate organisational ownership.	Nurse-led change. Improved interpersonal and process skills. Inconsistent communication, but improved cooperation. Work intensification resisted by staff.	Little ED stickiness and preparation for change. Limited ED comprehension, with overall awareness of Lean across the organisation. Little clinical buy-in with moderate resistance to change. Limited ED changes and some integration with the wider hospital.

ED: emergency department.

Findings

The findings reveal that the sites had different implementation approaches that were influenced by a range of management, resource and readiness factors. There were significant commonalities found in terms of the tools and practices adopted. Reflections on the use of the problem solving and quality tools were positive, with staff commenting favourably on the results of their use e.g. ‘it has improved definitely… We’ve streamlined our documentation and the process of getting the patients up to the ward is a lot easier’ (Respondent C4). This is not too dissimilar to other reported Lean healthcare implementations, where flow, waste and patient journeys are targets for improvement projects and a similar range of effects are observed.⁶

However, key differences emerged between the cases with respect to the involvement of organisational leaders. Top leadership engagement was found lacking at Sites A and C, where the respondents identified the lack of engagement quite readily, e.g.

This is a huge opportunity for executive managers to come down and talk to some of the real experts, and no one ever did. They were actually offered coaching – customised to how they want it – and they didn’t take up that offer. (Respondent A5)

Site B’s leadership involvement was significantly different as it was coordinated through an oversight committee, which sought to promote organisational ownership by reframing the ED Lean work to take a wider hospital view and to be more about the quality of a patient’s journey. Site B also exhibited the devolution of authority to the primarily nurse led teams to ‘basically get on with it [and] produce outcomes’ (Respondent B6). Nevertheless, the integration of clinicians was variable across the sites, in part through the existing hierarchies or through the different engagement processes, e.g. ‘I’m not convinced that the medical input was as good as it could have been. I think if you want to drive a fundamental change then you really need to get the doctors on-board’ (Respondent C2).

While Site B seemed to have the most favourable team working, all of the sites experienced morale improvements. However, work intensification was reported by respondents and was dealt with differently by each organisation. At Site A the staff absorbed the additional workload into their own time, while at Site C, the staff prioritised tasks with what they considered to be patient-centred or care-oriented work to be completed first. Even though both of these sites had made contingencies for additional compensation or overtime hours, the organisation’s cultural cues undermined some of the staff’s confidence to enact these provisions, e.g.

[the manager would say] if we need to pay [for extra time] then we can, but the innuendo from higher up says I shouldn’t be paid for doing [these] things, it should be done on your own time, or done in the time when you’re working … that’s the subtleness from the organisation. (Respondent A10)

Similarly, across the EDs, the level of staff ownership for the changes was variable. Workplace resistance manifested itself as a reluctance to engage or a de-prioritisation of Lean work, particularly at Site C where the volatile staffing levels significantly affected the ED, e.g. ‘we only had 5 staff, we don’t have 9 or 10, you take 3 of those staff away and you’re at 50%, so it was very difficult to resource or to commit time to it’ (Respondent C1). The planning, preparedness and a quality culture of the organisation seemed to be able to minimise the effects of these staff issues. At Site B their quality culture helped to localise Lean e.g. ‘we have these basic principles of quality improvement, [we’ve] just renamed to be honest’ (Respondent B7). As the implementations progressed the realisation of change and its effects became more apparent. It was at this stage that the organisational immune systems manifested themselves, e.g.

It went along swimmingly for a while, until people realised that there was an expectation that they do things other than what they were currently doing: that it might need change on their behalf. I guess we weren’t well equipped to deal with the sorts of behaviours that came out, and we didn’t understand that there was real angst behind that, in terms of what people were feeling. (Respondent A2)

Implementation sustainability seemed to rely on an underpinning culture to support a longer term view. Site B’s existing continuous improvement culture provided a basis for staff to make a start. There, both the operations and quality functions cooperated to implement the project across the hospital. While at Site C, the existence of a strategy gave the implementation a context, even though its development trajectory was impeded by unstable staffing and facility construction. Site A, which implemented a project management approach, achieved the most in terms of activities, but their changes were isolated from the hospital’s wider patient journey and lacked synchronisation with other hospital processes. This problem was readily identified by respondents, e.g. ‘clearly [the project] has not gone to that next value stream [and] beyond’ (Respondent A6).

When each of the cases is compared with the exemplar indicators, it becomes apparent which sites performed the closest. Table 5 reveals that Site B with its strong leadership and teamwork indicators has a higher prospect for sustainable implementation, whereas Site A, which undertook the most activities, has little prospect of sustainable change given the lack of sustainability and team indicators.

Table 5.

Case results and implementation indicators.

Theme	Lean implementation indicators from exemplar cases	Site
Theme	Lean implementation indicators from exemplar cases	A	B	C
Activities	Similar Lean tools used	✓	✓	✓
Activities	Resetting performance measures	✓	✓	✓
Leadership	Insight that change was necessary	=	✓	✓
	Top leadership involvement	=	✓	=
	Affirmation process improvement is achieved by those who do the work and know it best.	✗	✓	✗
	New skills and knowledge for managers	=	✓	✓
Team development	Initial external support	✓	✓	✓
	An internal Lean team	✗	✓	✓
	Involvement of all staff to redesign processes.	✓	=	✓
	Teamwork that optimises interpersonal and professional relationships.	=	=	=
	Organisational change is not easy to achieve.	✓	✓	✓
Sustainability	Long term continuous improvement cycle	✗	✓	=
	Capture the patient journey end to end.	✗	✓	=
	Lean becomes part of the daily work.	✗	=	=
	The importance of a new culture and ‘their’ improvement methodology.	✗	=	=

✓

, evident; =, neutral; ✗, absent.

Discussion

The method which is used to implement Lean is significant for the success of an endeavour¹⁶ and this study highlights the apparent differences of implementation method in relation to the prospect of longer term outcomes. Site A’s project management approach, while successful for delivering Lean outputs and wait-time gains, was not connected to an organisational strategy and thus, not linked to overall organisational performance. The contrast between Sites A and B points to the conclusion that organisational preparedness and an existing quality improvement strategy provide the basis for an increased likelihood for implementation success. The importance of preparedness or readiness and organisational strategy has been acknowledged^6,18 and it is also prominent within the Lean implementation exemplars. There, the organisation’s leaders were committed to change and so they facilitated sets of enabling resources to achieve organisational transformation. This is similar to the environment found at Site B, while Site C’s adoption of Lean to be the organisation’s quality framework revealed its intention to prepare and hence provide for some progress. Resistance to change is a perennial problem with quality improvement, particularly when implementing Lean into healthcare.³⁶ Although resistance was acknowledged at the case sites, it was seen as secondary or a consequence rather than being accorded any prominence or attention in plans.³⁷

The cases show that implementing Lean into healthcare improves flow and reduces waste. But after the easiest and most obvious problems are addressed, sustaining gains maybe more difficult.¹² Bicheno¹² offers the solution of a phased or staged systematic implementation across the organisation, building on each successive project’s success, a process observed in the exemplar cases. This pattern is also observed in the UK by Burgess and Radnor,¹⁵ with some hospitals beginning to implement more system type adoptions of Lean. Similarly, setting improvement metrics such as wait-times at the exclusion of the other internal customers seems to solve little. For example, Site A’s patient-streaming projects did reduce the wait-times for non-admitted patients, but the lack of synchronisation with the wider hospital found admitted patient wait-times barely improving. Admission times were the principal improvement targets at the other two sites, as these sites possessed an organisational quality strategy or policy that focussed on improving patient flow. These strategies or policies provided the direction for staff to be able to recognise the fundamental Lean tenet – understanding who the customer is – and thereby enabling a focus on synchronised flow improvement.

Conclusion

This paper reviews the performance of three New Zealand hospital ED’s implementation of Lean Thinking. The three sites implemented Lean differently, with some leveraging their existing quality culture and team processes. The different outcomes obtained by the EDs were: Site A substantively improving their non-admission patient wait-times, but failing to synchronise these improvements with the hospital; Site B improving patient admission times through ward admission synchronisation and Site C achieving reduced admission wait-times, even though their project was hampered by unstable staffing.

Lean Thinking is a quality system that appears to be able to be successfully applied to hospitals to realise waste reduction and improved patient flows. As a set of principles and techniques, its implementation is influenced by the environment in which it operates. Key influencers found from this research were top leadership involvement and visibility, an overarching programme of improvement governed by a stated strategy or policy and the existence of some organisation capacity or team culture, all of which are components of organisational readiness. Readiness factors influenced other aspects of implementation. While a project management implementation methodology may make many gains initially, sustaining the gains relies on the project’s integration and identifying what is needed for any changes to become routinised. Those sites with a quality improvement strategy or policy achieved integration or routines, in some form. Furthermore, the possibility of work intensification has the potential to derail any gains made from Lean. Therefore, any unintended consequences that the introduction of Lean may bring through role and job changes should be considered by organisation leaders.

Implementing Lean into healthcare challenges traditional healthcare delivery structures and asks that new types of skills and continuous learning become the organisational norm. The preparedness or readiness of an organisation appears to make a difference to achieve this change, particularly when taking the patient journey paradigm as the core quality value. For without this engagement, in the words of one frustrated New Zealand clinician: ‘we’re just going to end up with a temporarily tidier ED’.

Footnotes

Acknowledgements

The author would like to acknowledge the thoughtful comments of reviewers and the journal editor which helped to finalise this work, along with Richard Greatbanks for his supervisory assistance and research resources and Robin Gauld for commenting on earlier drafts.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

None declared.

References

Womack

Jones

. Lean Thinking, New York: Simon & Schuster, 1996.

Brandão de Souza

. Trends and approaches in lean healthcare. Leadersh Health Serv (Bradf Engl) 2009; 22: 121–139.

Øvretveit

. Does improving quality save money? A review of evidence of which improvements to quality reduce costs to health service providers, London: The Health Foundation, 2009.

Cohen

Restuccia

Shwartz

. A survey of hospital quality improvement activities. Med Care Res Rev 2008; 65: 571–595.

Ardagh

. How to achieve New Zealand’s shorter stays in emergency departments health target. N Z Med J 2010; 123: 1–9.

Holden

. Lean Thinking in emergency departments: a critical review. Ann Emerg Med 2011; 57: 265–278.

King

Ben-Tovim

Bassham

. Redesigning emergency department patient flows: application of Lean Thinking to health care. Emerg Med Australas 2006; 18: 391–397.

Gauld

. New Zealand’s post-2008 health system reforms: toward re-centralization of organizational arrangements. Health Policy 2012; 106: 110–113.

Radnor

Holweg

Waring

. Lean in healthcare: the unfilled promise? Soc Sci Med 2012; 74: 364–371.

10.

Williams

. Organizational readiness for innovation in healthcare: some lessons from the recent literature. Health Serv Manage Res 2011; 24: 213–218.

11.

Radnor

. Implementing Lean in healthcare: making the link between the approach, readiness and sustainability. Int J Ind Eng Manage 2011; 2: 1–12.

12.

Bicheno

. The Lean tool box for service systems, Buckingham: PICSIE Books, 2008.

13.

Graban

. Lean hospitals: improving quality, patient safety, and employee satisfaction, New York: Productivity Press, 2008.

14.

Kollberg

Dahlgaard

Brehmer

. Measuring lean initiatives in health care services: issues and findings. Int J Prod Perform Manage 2007; 56: 7–24.

15.

Burgess

Radnor

. Evaluating lean in healthcare. Int J Health Care Qual Assur 2013; 26: 220–235.

16.

Boaden

Harvey

Moxham

. Quality improvement: theory and practice in healthcare, Coventry: NHS Institute for Innovation and Improvement, 2008.

17.

Young

McClean

. A critical look at Lean thinking in healthcare. Qual Saf Health Care 2008; 17: 382–396.

18.

Radnor

Walley

Stephens

. Evaluation of the Lean approach to business management and its use in the public sector, Edinburgh: Office of Chief Researcher, Scottish Executive, 2006.

19.

Hellström A, Lifvergren S and Quist J. Applying process management in healthcare–investigating implementation difficulties. In: Proceedings of the 16th annual international EurOMA conference, Göteborg, Sweden, 14–17 June 2009. Göteborg: Offox Press, 2009.

20.

Ballé

Regnier

. Lean as a learning system in a hospital ward. Leadersh Health Serv (Bradf Engl) 2007; 20: 33–41.

21.

Bamford

Griffin

. A case study into operational team-working within a UK hospital. Int J Oper Prod Manage 2008; 28: 215–237.

22.

Weeks

Keen

. Climate for innovation: problems in patient flow. Nurs Adm Q 2009; 33: 258–265.

23.

Joosten

Bongers

Janssen

. Application of lean thinking to health care: issues and observations. Int J Qual Health Care 2009; 21: 341–347.

24.

Gawande

. Health care needs a new kind of hero. Interview by Gardiner Morse. Harv Bus Rev 2010; 88: 60–61.

25.

Olivella

Cuatrecasas

Gavilan

. Work organisation practices for lean production. J Manuf Technol Manage 2008; 19: 798–811.

26.

Øvretveit

. Leading improvement. J Health Organ Manage 2005; 19: 413–430.

27.

Waring

Bishop

. Lean healthcare: rhetoric, ritual and resistance. Soc Sci Med 2010; 71: 1332–1340.

28.

Gee

Hull

Lankshear

. The new work order: behind the language of the new capitalism, St Leonards, NSW: Allen & Unwin Pty, 1996.

29.

O’Donnell

. Empowerment or enslavement?: lean production, immigrant women and service work in public hospitals. Labour Ind 1995; 6: 73–94.

30.

Willis E. The hidden traps in multi-tasking: the experience of work intensification for personal service attendants in the healthcare sector. In: Baird M, Cooper R, Westcott M (eds) Reworking work – AIRAANZ 05. Proceedings of the 19th conference of the association of industrial relations academics of Australia and New Zealand, Sydney, NSW, 9–11 February 2005. Sydney: Association of Industrial Relations Academics of Australia and New Zealand, 2005, pp. 565–572.

31.

Webber

. Basic content analysis, Thousand Oaks: Sage, 1990.

32.

Maxwell

Designing a qualitative study. In: Rog

Bickman

(eds). The handbook of applied social research methods, 2nd ed. Thousand Oaks: Sage, 2008, pp. 214–253.

33.

Yin

. Case study research: design and methods, 4th ed. Thousand Oaks: Sage, 2008.

34.

Miles

Huberman

. Qualitative data analysis: an expanded sourcebook, 2nd ed. Thousand Oaks: Sage, 1994.

35.

Bringer

Johnston

Brackenridge

. Using computer-assisted qualitative data analysis software to develop a grounded theory project. Field methods 2006; 18: 245–266.

36.

Brandão de Souza

Pidd

. Exploring the barriers to lean health care implementation. Public Money Manage 2011; 31: 159–166.

37.

Tsasis

Bruce-Barrett

. Organizational change through Lean thinking. Health Serv Manage Res 2008; 21: 192–198.