Production Planning & Control

The Management of Operations

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Lean healthcare: review, classification and analysis

of literature

Luana Bonome Message Costa & Moacir Godinho Filho

To cite this article: Luana Bonome Message Costa & Moacir Godinho Filho (2016): Lean
healthcare: review, classification and analysis of literature, Production Planning & Control, DOI:
10.1080/09537287.2016.1143131

To link to this article: http://dx.doi.org/10.1080/09537287.2016.1143131

Published online: 18 Feb 2016.

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 Production Planning & Control, 2016
http://dx.doi.org/10.1080/09537287.2016.1143131

Lean healthcare: review, classification and analysis of literature

Luana Bonome Message Costa and Moacir Godinho Filho
Department of Industrial Engineering, Federal University of São Carlos, São Carlos, Brazil

ABSTRACT ARTICLE HISTORY

This study presents a literature review of 107 papers on lean healthcare to evaluate its evolution by Received 16 June 2015
updating previous literature reviews and to propose a classification and analysis of the papers reviewed. Accepted 6 January 2016
The literature classification was performed based on six parameters: research method, country, healthcare KEYWORDS
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area, implementation, lean tools and methods and results. From the analysis performed, this paper Lean healthcare; lean
presents a quantitative analysis of the state of the art concerning lean healthcare and indicates current manufacturing; literature
research trends, based on the stage of evolution of the area, that may guide further studies on the subject. review
An example is lean healthcare expansion to other countries, such as Brazil and the Netherlands. Another
aspect is the application of lean healthcare in hospital as a whole, not limited to a specific setting. Finally, a
few studies detail the lean implementation process and use infrequently applied tools, present the barriers
and main critical factors found in the lean implementation.

1. Introduction Moreover, hospitals are facing an increasing number of external

The term ‘lean’ was first coined by Womack, Jones, and Roos
(1990) to describe the Toyota Production System and the
steps to continually improve the efficiency and effectiveness
of a system through elimination of waste. Womack and Jones
(1996) observed that to meet customer needs, an organisation
must first identify what its customers perceive as value. From
this information, the organisation can work to eliminate pro-
cess steps that do not add value, create continuous flow in the
remaining steps, implement pull systems where the flow is not
possible and work continuously in search of perfection.
Lean thinking has been extensively and rigorously studied
(Lyons et al., 2013). According to Bortolotti, Boscari, and Danese
(2015), lean is a management approach to process improvement
based on a complex system of interrelated socio-technical prac-
tices. Manufacturing is one of the corporate strategies to bring
the organisation to the forefront of business excellence (Wong,
Ignatius, and Soh, 2014). Lean manufacturing practices are being
increasingly adopted by companies to improve their competitive-
ness through increased flexibility, lower costs and improvement
in product quality (Tan et al., 2013). According to Panwar et al.
(2015), lean is beneficial for any sector provided that it is care-
fully adapted in the environment according to the process, supply
chain, market characteristics and other contingency factors.
In the healthcare area, according to Souza (2009), no one
knows for sure when the lean philosophy first appeared, but the
first publications are dated from 2002. In today’s world, the ‘neces-
sity’ of using lean techniques in healthcare is very clear in terms
of quality, patient safety, cost, waiting time and staff satisfaction.
pressures and challenges (Graban, 2012).
The systematic waste elimination is a major focus of the lean
philosophy, and according to Toussaint and Gerard (2010), the
seven waste categories of the Toyota Production System can be
adapted to healthcare: waiting (for an appointment), motion
(searching for drugs), transportation (transferring patients to new
rooms), overproduction (unnecessary treatment), defect (inspect-
ing work already done for errors), overprocessing (unnecessary
forms) and inventory (overstocked or understocked drugs), as well
as including an eighth category, talent (failure to train emergency
technicians and doctors in new diagnostic techniques).
Lean is a methodology that enables hospitals to improve
patient care quality, support employees and doctors, eliminate
barriers and focus on providing care. Lean also helps overcome
barriers between disconnected departments, allowing different
departments to work better together to benefit patients (Graban,
2012). Furthermore, lean requires cultural change, abandoning
the traditional hierarchical ‘top-down’ management (Collar et
al., 2012). Within this context, two literature reviews were found,
bringing together the main papers concerning lean healthcare by
the year 2008. Mazzocato et al. (2010) identified in the reviewed
papers the context in which lean was applied (healthcare area)
and evaluated the lean tools and methods used and the results
obtained. Souza (2009) classified the reviewed papers accord-
ing to the research method (case study and theoretical) and the
countries where the studies were undertaken.
Because lean healthcare is a relatively new subject, with the
first publications in 2002, the aim of this work is to verify whether
there has been an evolution of the theme over the last five years,

CONTACT  Moacir Godinho Filho  moacir@dep.ufscar.br

© 2016 Taylor & Francis
 2    L. B. MESSAGE COSTA AND M. GODINHO FILHO

highlighting the similarities and differences found, thus contrib- research findings. Therefore, this study addressed all parame-
uting to the growth of literature on the subject and identifying ters considered in the Souza (2009) and Mazzocato et al. (2010)
opportunities for future research that may help professionals in reviews in one study. These parameters are defined below:
the implementation and maintenance of the lean philosophy
(1) Research method: the main research method was
in healthcare. Therefore, the present study aims to update the
extracted from each study. In this review, the following
revisions of Mazzocato et al. (2010) and Souza (2009) to propose
methods were found:
a literature classification and analyse the literature reviewed.
Theoretical-conceptual (TC): studies that use scientific
To achieve these objectives, this study is structured as follows:
methodology based on the theory, such as conceptual dis-
Section 2 describes the research method used; Section 3 presents
cussions and literature reviews (Berto and Nakano, 2000);
the literature review and classification; Section 4 shows findings
Action research (AR): a type of social research with an empir-
and discussion; and Section 5 offers the concluding remarks of
ical basis that is designed and built in close association with
the study and suggestions for future research.
an action or resolution of a collective problem, in which
researchers and representative participants of the situation
2.  Research method or problem are involved in a cooperative and participatory
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way (Thiollent, 1998);

This study is classified as theoretical–conceptual and presents
Case study (CS): according to Meredith (1998), a CS typically
a literature review of 107 articles on lean healthcare, aiming to
uses multiple methods and tools for data collection from a
update the revision of Mazzocato et al. (2010) and Souza (2009),
number of entities by a direct observer(s) in a single, natu-
and also proposes a literature classification and analysis. The
ral setting that considers temporal and contextual aspects
literature review identifies and organises the relevant concepts
of the contemporary phenomenon under study but lacks
in the literature and aims to summarise the main points of the
experimental controls or manipulations;
study field (Rowley and Slack, 2004).
Survey (S): involves collecting information from individuals
The literature review process was divided into three main
(through questionnaires, phone calls, personal interviews,
stages: planning, conducting and reporting/dissemination, as
etc.) about themselves or about the social units to which
suggested by Tranfield, Denyer, and Smart (2003). In the plan-
they belong and aims to provide a numerical description;
ning stage was defining the research question: How lean health-
therefore, it is a quantitative procedure (Creswell, 1994;
care has evolved in the recent years compared to the evolution
Rossi, Wright, and Anderson, 1983);
presented by Mazzocato et al. (2010) and Souza (2009)? In this
Ethnography (E): generally involves the participation of the
stage, it was also defined the criteria for inclusion and exclusion
researcher, openly or secretly, in the daily lives of people for
of studies in the review: journals in English, excluding editorials,
an extended time period, watching what happens, listening
comments and congress articles.
to what is said and/or asking questions through formal and
In the conducting stage, it was identified the keywords, search
informal interviews, collecting documents and artefacts.
terms and the databases used. The literature review was con-
Indeed, this can include collecting any data available that
ducted in the databases Engineering Village, Web of Knowledge,
could bring some important point to address emerging
Scopus and Google Scholar, using the terms ‘lean health’, ‘lean
research topics (Hammersley and Atkisnon, 2007).
healthcare’ and ‘lean hospital’, from March 2008 until November
(2) Country: the country where the research was done to
2014, and also added articles from the snowball approach. In the
observe where the lean methodology in healthcare is
final stage, schematic classification and analysis were performed.
more widespread. The countries and their respective
The literature classification assists in the analysis of the revised
codes were Germany (DEU), Saudi Arabia (SAL), Australia
content.
(AUS), Austria (AUT), Belgium (BEL), Brazil (BRA), Canada
In this study, a classification system based on an adaptation
(CAN), Denmark (DNK), Spain (ESP), United States (USA),
of the five steps proposed by Godinho Filho and Saes (2013) was
France (FRA), Ghana (GHA), Netherlands (NLD), India
used:
(IND), Ireland (IRL), Israel (ISR), Italy (ITA), Malaysia (MYS),
• Step 1: review the subject studied; Norway (NOR), Oman (OMN), Portugal (PRT), United
• Step  
2: propose a classification method with defined Kingdom (UK), Taiwan (TWN) and Sweden (SWE);
parameters to classify and encode the papers reviewed; (3) Healthcare area: to the areas defined by Mazzocato et al.
• Step 3: classify the studies using the proposed method; (2010), new areas were added. The areas studied were
• Step 4: structure the classification from the healthcare area Operating Room, Emergency Department, Hospital,
studied; Mental Health Centre, Pharmacy, Ophthalmology,
• Step 5: perform analysis and propose suggestions for Health Visiting Service, Radiology, Nursing Department,
future research. Pathology, Anaesthesia, Sterile Services Department,
Audiology, Cardiology, Laboratory, Hospital Laundry,
The papers were classified according to six parameters:
Physiology, Information Department, Ambulatory,
research method and country, also analysed by Souza (2009),
Pediatrics, Orthopedics, Oncology and general for stud-
healthcare area, lean tools and methods, and the results, also
ies that do not specify the studied area;
analysed by Mazzocato et al. (2010). Whether the lean implemen-
(4) Implementation: this criterion aimed to verify whether
tation was performed in the reviewed studies was also verified.
the lean tools and methods were implemented in the
A spreadsheet was created which formed the database of the
revised article (yes) or not (no);
 Production Planning & Control   3

Table 1. Lean tools and methods classification and their respective codes.

Classification Lean tools and methods Codes

Assessment 5 Whys F1
A3 F3
Ishikawa diagram F5
Process mapping F18
Value stream mapping F19
Gemba walking F28
Improvement 5S’s F2
Team approach to problem solving F4
Spaghetti diagram F5
Workload balancing F6
Continuous flow F7
Andon F8
Rapid process improvements events/Kaizen event F11
Jidoka F16
Pull system/Kanban F17
One-piece-flow F21
Mistake-proofing (Poka-yoke) F24
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Process redesign F25

Production leveling (Heijunka) F26
Physical work setting redesign F27
Standardised work F22
Monitoring Visual management F13
Assessment/Improvement/Monitoring DMAIC (Define-Measure-Analyse-Improve-Control) F10
PDCA (Plan-Do-Check-Action) F23

(5) Lean tools and methods: 24 lean tools and methods
were identified in the reviewed articles, thus demon-
strating that the lean tools can be widely used in the
healthcare area. The lean tools and methods are clas-
sified according to its purpose by Radnor, Holweg, and
Waring (2012) in assessment, improvement and moni-
toring. Assessment tools are used to review the perfor-
mance of existing organisational processes in terms of
their waste, flow or capacity to add value, such as formal
process/value stream mapping exercises. Improvement
tools are used to support and improve processes.
Monitoring tools are used to measure the processes
and any improvement made. Table 1 contains the tools
classified and the codes used;
(6) Results: the outcomes were listed and organised to
highlight which improvement points were most often
found after the implementation of lean tools and meth-
ods. According to Anvari, Zulkifli, and Yusuff (2013) cost,
time, defects and value are the key components to
measure leanness. Therefore, the results were classified
in these four categories. The results classified accord-
ing to lean metrics are presented in Table 2 with their
respective codes.
3.  Literature review and classification
The papers obtained through the literature review were classi-
fied, and they are presented in Appendix 1.
This section presents the main points regarding the revised
papers. The section was organised into categories according
healthcare operations mentioned by Guo and Hariharan (2012).
In the first category are those that share characteristics with their
manufacturing counterparts (e.g. finance and accounting, mar-
keting, human resources and information technology), named
support activities. In the second category are those that are sim-
ilar to manufacturing operations in their repetitive nature (e.g.
laboratory, radiology and pharmacy), named ancillary services.
The third category is the group of clinical and therapeutic opera-
tions. The forth category (hospital) includes the papers that do not
mention a unique area, but common processes to the hospital as
a whole. And the fifth category is represented by the papers that
do not specify the studied area, named general studies.
3.1.  Category 1: support activities
The support activity found in this review was Information
Department. Two studies were conducted in this setting
(Bhat, Gijo, and Jnanesh, 2014; Bhat and Jnanesh, 2013),
both undertaken in India. These studies used lean integrated
within the Six Sigma. According to Snee (2010) Lean Six Sigma
works better than previous approaches because it integrates
the human and process aspects; has clear focus on getting
bottom-line results; and is a method that sequences and
links improvement tools into an overall approach. To Chen
and Lyu (2009) it is considered a powerful business strategy
for employing a well-structured continuous improvement
methodology. Several studies in other healthcare areas used
Lean integrated with Six Sigma (Chiarini, 2012; Cima et al.,
2011; Langabeer et al., 2009; Laureani, Brady, and Antony,
2013; Leeuwen and Does, 2010; Schoonhoven et al., 2011,
Stonemetz et al., 2011; Wijma et al., 2009, and among oth-
ers). Other approaches combined with lean also can be found
to improve the implementation process in other health-
care areas and obtain better results, as showed by Habidin
et al. (2014) with supply chain innovation, and Aronsson,
Abrahamsson, and Spens (2011) with Agile strategy.
Although Information Department is a support activity, the
results obtained with Lean Six Sigma implementation in the two
papers found in this research impacted not only the registration
process but also brought benefits to patients such as reduction
in waiting time of the patients in the system, and reduction in
queue length.
 4    L. B. MESSAGE COSTA AND M. GODINHO FILHO

Table 2. Results and their respective codes.

Lean metric Results Codes

Cost Costs reduction R4
Financial performance improvement R5
Productivity enhancements R10
Utilised area reduction R12
Teamwork improvement R14
Average staff overtime reduction R16
Medical waste reduction R17
Absenteeism reduction R18
Reduction in no-show rate R21
Elimination/Reduction of wastes R23
Inventory reduction R24
Time Waiting time reduction R1
Length of stay reduction R2
Time reduction in the appointment scheduling R6
Turnaround time reduction (i.e. exams) R20
Cycle time reduction R27
Reduction in room turnover time R29
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Reduction in the time looking for supplies R31

Defects Rework reduction R11
Medical error reduction R13
Mortality reduction R15
Value Service capacity increase R3
Improved patient satisfaction R7
Improved staff satisfaction R8
Motion minimisation R9
Increased in the number of medications doses dispensed R19
Reduction in hospital visit R22
Infection reduction R25
Reduction in the number of patients who leave the hospital without being seen R26
Reduced readmission rate R30

3.2.  Category 2: ancillary services non-repetitive activities to remain individualised. This approach
can take advantage of standardisation, while garnering the sup-
Among the articles reviewed categorised as ancillary services,
port of clinical staff.
seven were performed in hospital pharmacy, two in radiology,
Although the existence of this barrier, the present review could
four in pathology, one in anaesthesia, two in sterile services
show that standardisation of work has been used in this area,
department, two in laboratory, one in hospital laundry and two
being the second most used tool, behind only the value stream
in ambulatory.
mapping. The most frequent results obtained with the imple-
Guo and Hariharan (2012) affirm that these group (manufac-
mentation in this area are related to the time category (waiting
turing-like operations) offer great potential for standardisation,
time reduction and length of stay reduction), followed by cost
this was confirmed in this study. Standardised work and value
(financial performance improvement and costs reduction) and
stream mapping were the most utilised lean tool, and the results
value (service capacity increase). Only two papers (Ker et al., 2014;
were positive for almost all the cases. Only Kim et al. (2009) in
Yusof, Khodambashi, and Mokhtar, 2012) showed improvement
ambulatory showed unsatisfactory results, and the project was
in defects results.
finalised because of the team’s discouragement with the slow
progress, cross-departmental barriers and time constraints.
3.4.  Category 4: hospital
3.3.  Category 3: clinical and therapeutic operations Twenty-three studies were performed in the hospital category.
To Machado and Leitner (2010) it is important to treat the hos-
In this category, most of the papers were performed in
pital as one unity with a number of dependent processes. These
Emergency Department, which presented 18 studies, and
authors affirm that lean transformation in one process can also
in Operating Room, which presented 13 studies. The other
influence other processes, but not necessarily in a good man-
healthcare areas presented four to one study: Mental Health
ner. Improvement of one process can easily shift problems to
Centre (4), Ophthalmology (3), Nursing Department (3), Health
another connected process.
Visiting Service (2), Audiology (1), Cardiology (2), Physiology (1),
Ben-Tovim et al. (2008) paper is an example of study that
Pediatrics (1), Orthopedics (1) and Oncology (1).
expands the lean implementation across the hospital and got pos-
In the clinical and therapeutic operations, the resistance to
itive results. The initial focus was improving the flow of patients
changes can be stronger because according to Guo and Hariharan
through the emergency department, but the program quickly
(2012) physicians dislike the way process improvement seeks to
spread to involve the redesign of managing medical and surgical
standardise care. One of the fundamental tenets of clinical med-
patients throughout the hospital, and to improve major support
icine is to treat every patient as an individual, so a more practi-
services. The hospital has seen a substantial growth in demand
cal tactic for clinical work is to standardise repetitive activities,
for care. Smith et al. (2012) also expanded lean implementation
such as information and communication, whereas allowing
after the success of the first project and obtained positive results.

Figure 1. Percentage of studies per healthcare categories.
In this category, only 5 studies did not implement the lean
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tools and methods; the other 18 studies used a total of 18 dif-
ferent tools, and the most used were value stream mapping,
Ishikawa diagram and DMAIC. The most frequent results were
related to cost (financial performance improvement and cost
reduction), time (length of stay and waiting time reduction) and
value (increased service capacity).
3.5.  Category 5: general
Studies classified as general are those that do not specify the
healthcare area studied. Only two studies presented lean tools
and methods implementation (Drotz and Poksinska, 2014;
Wojtys et al., 2009). In both studies, the tools used were value
stream mapping and standardised work. The other studies did
not exhibit the lean tools and methods implementation. Some
of these studies presented facilitators, barriers or challenges in
lean process implementation (Al-Balushi et al. (2014); Andersen,
Rovik, and Ingebrigtsen (2014); Joosten, Bongers, and Janssen
(2009); Kim, Spahlinger, and Billi (2009); Schattenkirk (2012);
Steed (2012)). Other papers presented basic concepts of lean
healthcare or presented a framework to assess or describe
the lean application in healthcare (Dahlgaard, Pettersen, and
Dahlgaard-Park, 2011; Koeijer, Paauwe, and Huijsman, 2014;
Platchek and Kim, 2012; Reijula and Tommelein, 2012; Toussaint
and Berry, 2013). Some studies aimed to evaluate the pro-
cess and/or the degree of lean implementation in healthcare
(Glasgow, Scott-Caziewell, and Kaboli, 2010; Machado and
Leitner, 2010; Poksinska, 2010). Some studies also indicated
literature bias on lean healthcare, mainly related to the fact
that there are few published studies that show failure cases
(Dellifraine, Langabeer, and Nembhard, 2010; Shirazi and
Pintelon, 2012). Some studies presented the state of the art of
lean healthcare implementation with respect to cultural lenses,
such as the study of Guimarães and Carvalho (2012).
4.  Findings and discussion
This study found, in accordance with the results of Mazzocato
et al. (2010) that most papers have limited applications of lean
philosophy to specific processes within a unit or department.
However, unlike the results of Mazzocato et al. (2010), this
study found a reasonable number of papers (23) that studied
the application of lean healthcare in the hospital as a whole
(Figure 1). Despite this increase, the percentage is still low. Some
Production Planning & Control   5
studies support this affirmation, such as the paper of Burgess
and Radnor (2013) which the authors affirm that lean healthcare
implementation tends to be isolated rather than system-wide,
and Rich and Piercy (2013) that also suggest that most of studies
on improvement in healthcare focus on distinct features of the
system rather than the system as a whole.
The low number of articles that apply lean in the organisation
as a whole does not occur only in the healthcare is also observed
in the manufacturing. Jasti and Kodali (2015) in their lean produc-
tion literature review observed that many researchers are apply-
ing lean principles in manufacturing field instead of applying
across all activities of an organisation. Figure 1 also shows a high
amount of studies in clinical and therapeutic operations com-
pared with ancillary and support categories, even though these
two latter categories are more similar to manufacturing. It is dif-
ficult to understand why this occurs because of the lack of infor-
mation about why a specific area is chosen to study. To Joosten,
Bongers, and Janssen (2009) incidents and quality problems are a
prime cause why healthcare leaders are calling to redesign health-
care delivery. To Dahlgaard, Pettersen, and Dahlgaard-Park (2011)
some current problems and challenges in healthcare are errors
in administration of injected medication and infections. From
these affirmations, a possible explanation for the greatest choice
of clinical and therapeutic operations healthcare area emerges:
the problems cited can impact more directly this area.
Regarding the lean tools and methods implemented in this
review, the four most commonly used tools (value stream map-
ping, standardised work, rapid improvement events/Kaizen event
and process mapping) are among the six tools and methods most
frequently cited in the review of Mazzocato et al. (2010). Other
lean tools and methods were also used, some of which were only
identified in one paper, such as Jidoka and Production Leveling
(Heijunka).
In a recent literature review about lean in process industry,
Panwar et al. (2015) also found that value stream mapping
and standardised work are being used extensively. Machado
and Leitner (2010) affirm that in literature it is possible to find
several case studies of standardisation in different kinds of
processes showing the universality of this tool. Henrique et
al. (2016) affirm that value stream mapping models used in
lean healthcare implementations are simple adaptations of
the original model, which was initially directed towards man-
ufacturing and may not always represent important support
activities for the patient flow that directly impact treatment
time. Therefore, the authors proposed a new model that con-
templates information, material and patient flow involved in
the transformation of a sick patient into a healthy patient, also
present a time line and problems identification.
The present review also found a relatively large number (24)
of different lean tools and methods used in healthcare area. To
Machado and Leitner (2010) a number of lean tools gives the
opportunity to meet occurring problems adequately by choosing
the best fitting one. However, the implementation of some of
the tools is still limited, suggesting a lack of knowledge in some
settings of different existing tools and methods or even difficulty
in their implementation or adaptation to healthcare. In the clinical
and therapeutic operations despite avoid defects such as medical
errors be crucial to this area, only one study used mistake-proof-
ing tools.
 6    L. B. MESSAGE COSTA AND M. GODINHO FILHO
To Anvari, Zulkifli, and Arghish (2014), and Anvari et
al. (2014) lean tools selection is currently one of the main
challenges faced by managers in manufacturing because
lean tools selection is the most important process deter-
mining the success or failure of lean manufacturing sys-
tems; without implementing proper techniques, leanness
cannot be evaluated. According to Pavnaskar, Gershenson,
and Jambekar (2003), the main reasons for lean fails are
associated with the use of a wrong tool to solve a problem,
use of a single tool to solve all the problems, and use of all
the tools on each problem.
Figure 2 shows the frequency of use of lean tools and methods
according their function (assessment, improvement, monitoring
and all) in each healthcare category. It is possible to visualise that
monitoring tools are few used in all of them, being an important
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point to be observed because it can be related to lean imple-
mentation sustainability. Machado and Leitner (2010) affirmed
that lean transformation never ends; there will always be pro-
cesses that can be improved and waste that can be eliminated.
To Barnas (2011) the lack of a lean management system is the
leading cause of the failure to sustain lean process improvement
and productivity gains.
The main results obtained after lean implementation also
remained the same as the results found in Mazzocato et al. (2010).
The most frequent results obtained were waiting time reduction,
costs reduction, length of stay reduction and capacity increase.
Another aspect in which this review resembles the Mazzocato et
al. (2010) review is that the lean implementation results are always
positive. Few studies cover working on problems and difficulties
in lean healthcare implementation. The same is valid for lean pro-
duction and lean service. Marodin and Saurin (2013) in their liter-
ature review about lean production also pointed lack of studies
reporting failed implementations of lean production, and a lack
of in-depth knowledge on why companies fail or succeed in their
lean efforts. In Suárez-Barraza, Smith, and Dahlgaard-Park (2012)
lean service review the authors affirm the many of the articles
reviewed only show a positive face and practically none of them
indicate or refer to possible inhibitors to their efforts to improve.
Figure 2. Percentage of lean tools and methods per healthcare area.
In Figure 3, the four key components to measure leanness,
according to Anvari, Zulkifli, and Yusuff (2013), are related to the
healthcare areas. The cost, time and value components were used
often, however the defect component was not. A possible rea-
son for this is a concern in measure or reveals the result, such as
medical error. According to Guo and Hariharan (2012) healthcare
providers fear reporting medical errors and are reluctant to par-
ticipate in process improvement that intentionally finds fault in
a process.
The results found in this study regarding the different research
methods of the revised paper (Figure 4) differ from that found by
Souza (2009). His study found more theoretical cases (specula-
tive), namely, studies that show the use of lean healthcare without
presenting concrete evidence that this philosophy may (or may
not) work. The majority of these studies attempt to translate some
lean principles in the healthcare environment and speculate on
its potential uses, indicating the need for specific studies from a
practical point of view that was observed in this review. Therefore,
literature has evolved to show the practical application of lean
healthcare tools. In the recent lean production literature review
of Jasti and Kodali (2015) an increase in empirical studies was
found. The same authors affirm that although empirical research
is increasing at a faster rate, it requires more aggressive and focus
light in the dark spots of lean principles to get better benefits to
the organisations.
Regarding the number of countries that publish papers con-
cerning lean healthcare, the results are similar to those obtained
by Souza (2009). The two countries that have the most studies
are still the USA and the UK. This study observed the emergence
of a third country, the Netherlands, that stood out in publica-
tions number compared to other countries. Apart from these
three countries another 21 papers were published healthcare
as showed in Figure 5, however the number of publication per
country is still low, 16 countries published between only 2 and
1 paper. Marodin and Saurin (2013) also found more published
studies from USA and the UK, accounted for almost half of the
studies reviewed. According to Jasti and Kodali (2015), in spite of
the increasing globalisation of research interests and researchers

themselves, still researchers from UK and USA are more aggres-
sive over others in lean principles’ research. Panizzolo et al. (2012)
affirm that lean manufacturing approach has proven to be suc-
cessful as an operations model in developed economies, however
in India, the country of the research, similar to other developing
countries, the process is slow, largely because of the anxiety in
changing the mindset of people, lack of awareness and train-
ing about the lean concepts and cost and time involved in lean
implementation.
5. Conclusion
This study aims to verify the evolution of lean healthcare, com-
pared to evolution presented by Mazzocato et al. (2010) and
Souza (2009), highlighting the main differences with respect
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to previous reviews and others related resources about lean
healthcare. This paper contributes to a better analysis of how
lean philosophy implementation and adaptation is occurring in
healthcare, gathering in one study the parameters of research
method, country, healthcare area, lean tools and methods and
results, as analysed by the two previous reviews, and includes a
Figure 3. Percentage of results per healthcare area.
Figure 4. Percentage of papers per research method.
Production Planning & Control   7
parameter (implementation) that examines whether the studies
reviewed include cases of lean practice implementation or not.
The results indicate that some aspects related to lean practices
in healthcare remained similar to the reviews of Mazzocato et
al. (2010) and Souza (2009). The USA and UK are still the coun-
tries that publish the most studies on the subject. There is still a
high heterogeneity in the healthcare areas where lean practices
have been implemented, however the majority of this area is cat-
egorised as clinical and therapeutic operations. The lean tools
and methods (value stream mapping, standardised work, rapid
improvement events/Kaizen event and process mapping) and the
results (reduced waiting times, reduced cost, reduced length of
stay and increased capacity) most often found are also similar
to those of previous reviews. In addition, the lean philosophy
implementation in healthcare continues to be performed in a
superficial way, by implementing simple techniques of notori-
ous knowledge in the manufacturing area. However, other tech-
niques that require a higher degree of knowledge and maturity
of healthcare institution are infrequently used such as Jidoka and
Production Leveling (Heijunka). Related to the results there are
few studies that focus on problems and opportunities that impact
 8    L. B. MESSAGE COSTA AND M. GODINHO FILHO
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Figure 5. Number of papers per country.
results associated with defects, the most of them are associated
with time, cost and value.
Nevertheless, other aspects were different, which indicates an
evolution in research in the area. An example is the lean health-
care expansion to other countries, such as the Netherlands.
In Brazil, only two studies were found, which indicates a huge
opportunity for future research. Another aspect of this evolution
is the existence of current studies that exhibit the lean healthcare
application in the hospital as a whole, not limited to a specific
area, which was not found in previous reviews on the subject.
Some interesting topics that have been recently studied in
this context include studies that present facilitators, barriers or
difficulties in lean implementation process; present lean health-
care basic concepts or present frameworks to assess or describe
the use of lean in healthcare; evaluate the process and/or imple-
mentation degree of lean in healthcare; present literature bias on
lean healthcare, which is primarily related to the fact that there
are few published studies that show failure cases, and present
the benefits of its integration with other approaches, such as Six
Sigma, Supply Chain Innovation, Agile strategy and others. These
points represent recent and interesting topics for current research
in the area.
From the analysis of the reviews and also of this update, most
studies do not mention some information from the lean health-
care implementation process that could help future studies in
facilitating and speeding up lean healthcare implementation pro-
cess, such as motivational factor for implementation, the imple-
mentation period, the form (consultancy or internal), the team
(hospital and consultants), the project continuity/sustainability,
the problems faced/improvement opportunities found, the tools
used, the barriers faced, the critical factors for successful imple-
mentation and the results obtained in each case.
This information could help in developing models/roadmaps
for healthcare such as developed in manufacturing. To Anvari et
al. (2011) managers and practitioners need to learn how to get
started, where to start and how to proceed, in addition to know-
ing the available tools.
Therefore, for future studies the authors should present this
information in their papers, for future literature reviews be able
of grouping these data and developing a specific model for
healthcare.
Acknowledgement
This work was supported by CAPES and CNPQ.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Luana Bonome Message Costa has received her BS in Food
Engineering from São Paulo State University (Brazil), speciali-
sation course in Industrial Engineering from University of São
Paulo (Brazil), MS in Industrial Engineering from Federal
University of São Carlos (Brazil) and she is PhD student in
Industrial Engineering from the Federal University of São
Carlos (Brazil). Her areas of interest are: production planning
and control, lean healthcare and lean manufacturing.
Moacir Godinho Filho is a professor in the
Department of Industrial Engineering, Federal
University of São Carlos (Brazil). He received his BS
from Federal University of São Carlos, MBA from
Fundação Getúlio Vargas (Brazil), MS and PhD from
Federal University of São Carlos. Godinho Filho was
a visiting scholar at Department of Industrial and
Systems Engineering, University of Wisconsin at
Madison (USA) and also at Edward P. Fitts
Department of Industrial and Systems Engineering, North Carolina
State University (USA). Godinho Filho has about 60 papers published
in journals with selective review process. His areas of interest are: pro-
duction planning and control, lead time reduction, lean manufactur-
ing, logistics and supply chain management.
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 12    L. B. MESSAGE COSTA AND M. GODINHO FILHO

Appendix 1. Paper classification table

Research Coun- Imple

Paper Healthcare area method try mentation Tools Results
Mazzocato et al. (2012) Emergency Department CS SWE Yes F4; F13; F22; F27 R6; R10
Dickson et al.(2009b) Emergency Department AR USA Yes F11; F18; F19; F27; F22 R2; R7
Grove et al. (2010a) Health Visiting Service CS UK Yes F2; F19 Do not show
results
Grove et al. (2010b) Health Visiting Service AR UK Yes F4; F19; F22 R6
Joosten, Bongers, and General TC NLD No Do not apply tools Do not show
Janssen (2009) results
Ben-Tovim et al. (2008) Hospital AR AUS Yes F2; F6; F18; F22; F23; R1; R2; R3; R13
F25
Al-Araidah et al. (2010) Pharmacy AR USA Yes F1; F2; F10; F22; F27 R27
LaGanga (2011) Mental Health Center AR USA Yes F4; F11; F18; F25 R3; R21
Burgess and Radnor (2013) Hospital TC UK No Do not apply tools Do not show
results
Papadopoulos (2011) Pathology CS UK Yes F4; F11; F13; F18; F22; R9; R11; R12
F27
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Yousri et al. (2011) Emergency Department AR UK Yes F19 R15

Martin, Hogg, and Mackay Radiology CS UK Yes F19; F27 R1; R2; R8; R9
(2013)
Atkinson and Mukaeto- Mental Health Center AR UK Yes F6; F11; F17; F23 R1; R2
va-Ladinska (2012)
Vegting et al. (2012) Hospital AR NLD Yes F13; F22 R4
Yusof, Khodambashi, and Anaesthesia CS MYS Yes F3; F19 Do not show
Mokhtar (2012) results
Chadha, Singh, and Kalra Emergency Department AR IND Yes F2; F7; F19; F21; F22 R2; R3; R4
(2012)
Cima et al. (2011) Operating Room AR USA Yes F10; F19; F25 R13; R1; R5; R16;
R3; R14
Radnor, Holweg, and War- Hospital CS UK Yes F2; F11; F18; F25 R1; R12; R14
ing (2012)
Stonemetz et al. (2011) Operating Room AR USA Yes F10; F11; F18 R4; R17
Waring and Bishop (2010) Operating Room E UK Yes F18 Do not show
results
Van Vliet et al. (2011) Ophthalmology CS UK,U- Yes F18 R4; R22
SA,
NLD
Dahlgaard, Pettersen, and General TC SWE No Do not apply tools Do not show
Dahlgaard-Park (2011) results
Castle and Harvey (2009) Sterile Services Department; Ophthalmology; AR UK Yes F19; F27; F28 R1; R9
Operating Room; Emergency Department; Pharmacy
Langabeer et al. (2009) Hospital S USA No Do not apply tools Do not show
results
Guimarães and Carvalho General TC USA No Do not apply tools Do not show
(2012) results
Guimarães, Carvalho, and Hospital CS PRT Yes F18; F27 R4
Maia (2013)
Bucourt et al. (2011) Radiology AR DEU Yes F18; F19 R23
Souza and Pidd (2011) Nursing Department; Audiology AR UK Yes F2; F4; F11; F13; F24; R1; R2; R3; R7; R8
F25
Edwards, Nielsen, and Operating Room CS DNK Yes F4; F22 R1; R3; R10; R18
Jacobsen (2012)
Grout and Toussaint (2010) Hospital AR USA Yes F11; F13; F16; F22; R1; R4; R7
F24; F25
Leeuwen and Does (2010) Operating Room AR NLD Yes F10; F11; F13; F4; F18; R2; R5
F25
Schoonhoven et al. (2011) Cardiology AR NLD Yes F4; F10; F19; F22 R5; R6
Selau et al. (2009) Operating Room CS BRA Yes F18 Do not show
results
Dickson et al. (2009a) Emergency Department CS USA Yes F4; F11; F13; F18; F19; R2
F25; F27
Wijma et al. (2009) Nursing Department AR NLD Yes F10 Do not show
results
Rico and Jagwani (2013) Pharmacy CS ESP Yes F11; F19; F22 R1; R10; R13
Isaac-Renton et al. (2012) Laboratory AR CAN Yes F2; F4; F8; F11; F19; R1; R3
F27; F22
Papadopoulos (2012) Pathology CS UK Yes F11; F13; F22; F25 R9; R11; R20
Nicholas (2012) Emergency Department CS USA Yes F2; F5; F11; F19; F22; R5; R23
F27
Naik et al. (2011) Emergency Department AR USA Yes F3; F11; F13; F17; F18; R5; R10
F19; F22
Cunha, Campos, and Rifara- Hospital laundry CS BRA Yes F19; F22; F27 R2; R24
chi (2011)
Chiarini (2013) Emergency Department CS ITA Yes F5; F19; F25; F27 R1; R2; R4; R9
 Production Planning & Control   13

Appendix 1. (Continued).

Research Coun- Imple

Paper Healthcare area method try mentation Tools Results
Kimsey (2010) Sterile Services Department AR USA Yes F3; F7; F11; F13; F22; R3; R4; R27
F23; F25; F27; F28
Kim, Spahlinger, and Billi General TC USA Yes Do not apply tools Do not show
(2009) results
L’hommedieu and Kappeler Pharmacy CS USA Yes F19 R4; R19; R23
(2010)
Hintzen et al. (2009) Pharmacy CS USA Yes F2; F13; F19; F22; F27 R4; R23
Ulhassan et al. (2013) Cardiology CS SWE Yes F2; F4; F13; F19; F21; R2
F27
Curatolo et al. (2014) Hospital TC FRA No Do not apply tools Do not show
results
Poksinska (2010) General TC SWE No Do not apply tools Do not show
results
Johnson, Smith, and Mastro Operating RoomEmergency Department AR USA Yes F2; F11; F19; F17; F22; R2; R3; R4; R5;
(2012) F25; F27 R16
Carvalho, Ramos, and Emergency Department CS e S PRT No Do not apply tools Do not show
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Paixão (2014) results

Toussaint and Berry (2013) General TC USA No Do not apply tools Do not show
results
Chiarini (2012) Pharmacy AR ITA Yes F1; F10; F9; F19; R2; R4; R9; R23
Laureani, Brady, and Antony Hospital CS IRL Yes F2; F6; F9; F10; F18; R2
(2013) F19; F24
Shirazi and Pintelon (2012) General TC BEL No Do not apply tools Do not show
results
Schattenkirk (2012) General TC CAN No Do not apply tools Do not show
results
Carboneau et al. (2010) Hospital AR USA Yes F9; F10; F19 R4; R25
Schoonhoven, Lubbers, and Hospital AR NLD Yes F10; F18 R4
Does (2013)
Dellifraine, Langabeer, and General TC USA No Do not apply tools Do not show
Nembhard (2010) results
Andersen, Rovik, and Inge- General TC NOR No Do not apply tools Do not show
brigtsen (2014) results
Aij et al. (2013) Operating Room; Mental Health Center CS NLD No Do not apply tools Do not show
results
Al-Balushi et al. (2014) General TC OMN; No Do not apply tools Do not show
AUT results
Drotz and Poksinska (2014) GeneralPhysiology CS SWE Yes F2; F4; F13; F19; F22. Do not show
results
Bhat and Jnanesh (2013) Information Department CS IND Yes F2; F9; F10; F17; F18; R20
F22; F28
Bhat, Gijo, and Jnanesh Information Department CS IND Yes F9; F10; F18; F19; F22; R1; R27
(2014) F24; F28
Gijo and Antony (2013) Ambulatory CS IND Yes F9; F10; F18; F22; F28 R1
Yeh et al. (2011) Hospital CS TWN Yes F9; F10; F18; F19; F22 R2; R4; R27
Mazur, Mccreery, and Roth- Hospital CS USA No Do not apply tools Do not show
enberg (2012) results
Smith et al. (2012) Hospital CS USA Yes F2; F11; F23; F19; F28 R3; R5; R6; R8
Simon and Canacari (2012) Hospital AR ISR Yes F9; F19; F11; F21; F22; R29
F28
Tejedor-Panchon et al. Emergency Department CS ESP Yes F19; F25 R1; R25
(2014)
Cankovic et al. (2009) Pathology AR USA Yes F2; F13; F21; F25 R20
Reijula and Tommelein General TC USA No Do not apply tools Do not show
(2012) results
Deans and Wade (2011) Pediatrics AR CAN Yes F2; F11; F19 R1
Fine et al. (2009) Hospital CS CAN No Do not apply tools Do not show
results
Gayed et al. (2013) Operating Room AR USA Yes F13; F19; F21; F22 R2
Carter et al. (2012) Emergency Department AR GHA Yes F9; F11; F19; F28 Do not show
results
Kullar et al. (2010) Ophthalmo-logy AR UK Yes F4; F18 R1
Fache and Faulkner (2009) Hospital AR USA Yes F10 R5
Hayward (2012) Mental Health Center TC UK No Do not apply tools Do not show
results
Pocha (2010) Emergency Department AR USA Yes F10 R5
Al-Owad, Karim, and Ma Emergency Department AR SAU Yes F3; F10; F19 Do not show
(2014) results
Kim et al. (2009) Orthopedics; Oncology; Nursing Department; AR USA Yes F2; F19; F22; F25 R6; R20
Ambulatory.
Johnson, Patterson, and Hospital AR USA Yes F3; F4; F23; F28 R30
O’connell (2013)
Platchek and Kim (2012) General TC USA No Do not apply tools Do not show
results
Bhat and Jnanesh (2014) Ambulatory CS IND Yes F2; F9; F10; F17; F18; R1; R27
F22; F27; F28
 14    L. B. MESSAGE COSTA AND M. GODINHO FILHO

Appendix 1. (Continued).

Research Coun- Imple

Paper Healthcare area method try mentation Tools Results
Steed (2012) General CS USA No Do not apply tools Do not show
results
Eller (2009) Emergency Department AR USA Yes F2; F13; F19; F22; R1; R25
Barnas (2011) Hospital AR USA Yes F2; F3; F8; F9; F11; F13; R10
F19; F22; F23; F28
Black (2009) Hospital AR USA Yes F9; F10 Do not show
results
Ng et al. (2010) Emergency Department AR CAN Yes F11; F13 F19; F22; F27 R1; R7; R26
Wojtys et al. (2009) General AR USA Yes F19; F22 R7; R8
Melanson et al. (2009) Laboratory AR USA Yes F4; F11; F18; F22; F23 R1; R7
Snyder and Mcdermott Hospital AR USA Yes F13; F19; F27 R3; R4; R31
(2009)
Waldhausen et al. (2010) Operating Room AR USA Yes F2; F6; F11; F18; F22; R1; R8; R10
F25
Casey, Brinton, and Gonza- Ambulatory AR USA Yes F11; F19; F26 R1; R4; R7
lez (2009)
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Heitmiller et al. (2010) Hospital AR USA Yes F4; F9; F10; F13 R5; R23
Machado and Leitner (2010) General TC PRT No Do not apply tools Do not show
results
Lunardini et al. (2014) Operating Room AR USA Yes F4; F18 R4
Ker et al. (2014) Pharmacy CS USA Yes Do not apply tools R1; R4
Stanton et al. (2014) Emergency Department CS AUS Yes F10; F13; F25 R3
Glasgow, Scott-Caziewell, General TC USA No Do not apply tools Do not show
and Kaboli (2010) results
Koeijer, Paauwe, and Huijs- General TC NLD No Do not apply tools Do not show
man (2014) results
Chiarini and Bracci (2013) General CS ITA No Do not apply tools Do not show
results
Papadopoulos, Radnor, and Pathology CS UK Yes F20; F11; F13 Do not show
Merali (2011) results
Collar et al. (2012) Operating Room AR USA Yes F1; F25 R3; R5; R8
Aronsson, Abrahamsson, Hospital CS SWE Yes F19 Do not show
and Spens (2011) results