Abstract
BackgroundLean is a quality improvement management system from the Toyota manufacturing industry. Since the early 2000’s, Lean has been used as an intervention for healthcare improvement. Lean is intended to reduce costs and improve customer value through continuous improvement. Despite its extensive use, the contextual factors and mechanisms that influence the sustainability of Lean in healthcare have not been well studied. Realist synthesis is one approach to “unpack” the causal explanations of how and why Lean is sustained or not in healthcare. We conducted a realist synthesis using the context (C) + mechanim (M) = outcome (O) heuristic, to further develop and refine an initial program theory with seven CMO hypotheses, on the sustainability of Lean efforts across pediatric healthcare.MethodsOur search strategy was multi-pronged, iterative, and purposeful in nature, consisting of database, gray literature, and contact with three healthcare organizations known for Lean implementation. We included primary research studies, published and unpublished case studies or reports, if they included Lean implementation with a pediatric focus and sustainability outcome. We used the Normalization Process Theory and the National Health Services Sustainability Model, an operational definition for Lean and a comprehensive definition for sustainability as guidance for data extraction and analysis. Our initial program theory with was refined using a blend of abductive and retroductive analytical processes.ResultsWe identified six published primary research studies, two published quality improvement case studies, and three unpublished quality improvement case reports. Five CMO hypotheses from our initial program theory were substantially supported after synthesis, “sense-making and value congruency,” “staff engagement and empowerment,” and the “ripple effect” or causal pathway between Lean implementation outcomes that served as facilitating or hindering contexts for sustainability. Overall, there was variation with the conceptualization and measurement of sustainability.ConclusionsThis study is the first to examine Lean sustainability in pediatric healthcare using realist methods. Future research should examine whether the predictors of implementation are the same or different to sustainability and evaluate the underlying mechanisms that influence the sustainability of Lean. There is also a need for research to develop and test conceptual models and frameworks on sustainability.Systematic review registrationPROSPERO-CRD42015032252.
Highlights
Lean is a quality improvement management system from the Toyota manufacturing industry
We developed our initial program theory on Lean sustainability in healthcare using a multifaceted approach: (1) iterative brainstorming sessions within the review team; (2) realist methodological expertise, a scoping search of literature on Lean, quality improvement (QI), and sustainability; (3) use of a Lean operational definition [18]; (4) use of substantive theory (Normalization Process Theory (NPT)) [30, 31] and a sustainability model (National Health Service (NHS) Institute for Innovation and Improvement Sustainability Model (SM)) [32, 33]; and (5) use of the NHS SM definition for sustainability [32], and a comprehensive definition of sustainability [34]
Results are organized by document characteristics, CMO contribution and methodological quality, sustainability outcomes, evidence in relation to initial CMO mapping and program theory, and the five CMO hypotheses from our initial program theory that were substantively supported by evidence on sense-making and value, staff engagement and empowerment, at the organizational, clinical leadership level and front-line healthcare provider level, and the “ripple-effect” from implantation to sustainability
Summary
Lean is a quality improvement management system from the Toyota manufacturing industry. Lean is intended to reduce costs and improve customer value through continuous improvement. The goal of Lean management systems is to reduce costs and increase value for customers through the creation of a continuous quality improvement (QI) culture [1, 2]. In 2018 Toyota ranked number nine on Forbes list of the world's most valuable brands [3]. Given these presumptive positive outcomes of Lean management, it has become an attractive option for healthcare systems faced with demands to improve quality, increase efficiency, and decrease expenditure [4]. Successful implementations of Lean in healthcare report waste reduction and increased efficiency [5,6,7,8]; while unsuccessful implementations have described Lean as inappropriate for healthcare and reported superficial adoption, system dysfunction, and disengaged staff [9,10,11]
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