THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

Int J Health Plann Mgmt (2015)

Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/hpm.2331

Lean healthcare in developing countries:

evidence from Brazilian hospitals
Luana Bonome Message Costa1, Moacir Godinho Filho1*,
Antonio Freitas Rentes2, Thiago Moreno Bertani2 and Ronaldo Mardegan2
1
Department of Industrial Engineering, Federal University of São Carlos, São Carlos, São
Paulo, Brazil
2
Department of Industrial Engineering, University of São Paulo (USP), São Carlos, São
Paulo, Brazil

ABSTRACT
The present study evaluates how five sectors of two Brazilian hospitals have implemented lean
healthcare concepts in their operations. The main characteristics of the implementation process
are analyzed in the present study: the motivational factor for implementation, implementation
time, form (consultancy or internal), team (hospital and consultants), lean implementation
continuity/sustainability, lean healthcare tools and methods implemented, problems/
improvement opportunities, lean healthcare barriers faced during the implementation process,
and critical factors that affected the implementation and the results obtained in each case. The
case studies indicate that reducing patient lead times and costs and making financial improve-
ments were the primary factors that motivated lean healthcare implementation in the hospitals
studied. Several tools and methods were used in the cases studied, especially value stream
mapping and DMAIC. The barriers found in both hospitals are primarily associated with the
human factor. Additionally, the results obtained after implementation were analyzed and
improvements in financial aspects, productivity and capacity, and lead time reduction of the
analyzed sectors were observed. Further, this study also exhibited four propositions elaborated
from the results obtained from the cases that highlighted barriers and challenges to lean
healthcare implementation in developing countries. Two of these barriers are hospital organi-
zational structure (and, consequently, how the senior management works with medical staff),
and outsourcing hospital activities. This study also concluded that the initialization and main-
tenance of lean healthcare implementation rely heavily on external support because lean
healthcare subject knowledge is not yet available in the healthcare organization, which repre-
sents a challenge. Copyright © 2015 John Wiley & Sons, Ltd.

KEY WORDS: lean healthcare; lean manufacturing; developing countries; case study

INTRODUCTION

As healthcare costs increase at a faster rate than the cost of other products or
services, healthcare providers, particularly hospitals, are under continuous pressure

*Correspondence to: M. G. Filho, Department of Industrial Engineering, Federal University of São Carlos,
São Carlos, São Paulo, Brazil. E-mail: moacir@dep.ufscar.br

Copyright © 2015 John Wiley & Sons, Ltd.

 L. B. MESSAGE ET AL.

to dramatically improve services and patient safety while reducing costs, waiting
times and errors. Most hospitals, however, are not making the necessary improve-
ments in cost, quality and safety (Aherne and Whelton 2010).
To solve or improve this scenario, hospitals in many countries are using strategies,
tools and techniques that are known and widespread in the manufacturing area, such
as the use of lean manufacturing tools and methods (Liker 2005). These tools and
methods are used merely to support lean project; however, the employees’ engage-
ment is of utmost importance to implementation (Leyer and Moormann 2014).
Lean is an improvement approach designed to increase productivity by eliminating
waste. According to Womack et al. (1990), lean thinking is a way to specify value,
align the actions that create value in the best sequence, and effectively perform these
activities without interruption upon request; in other words, to do more with less while
moving to offer customers exactly what they want. Many companies started a lean
project motivated by the example of the success of Toyota and other lean organiza-
tions around the world (Bortolotti et al. 2015). According to Tan et al. (2013) and
Wong et al. (2014), the organizations want to be lean to be competitive in the global
market; however, the degree of adoption of the lean practices could vary significantly
among industries, regions and countries, according to Lucato et al. (2014).
To Bhamu and Sangwan (2014), applications of lean are found in different orga-
nizations, from manufacturing to service sectors. Healthcare organizations represent
an important sector within services (Dobrzykowski et al. 2014) and is also con-
cerned about the benefits of lean implementation. The number of lean project in this
sector is growing, which is reinforced by reports found in the literature. The key
aspects that make lean more adaptable to healthcare settings than other improvement
strategies are staff empowerment and the concept of gradual and continuous
improvement that is intrinsic to lean theory (Souza 2009).
Despite being implemented in many countries around the world, few studies examine
developing countries (for example, Brazil) to show how lean principles are being imple-
mented in healthcare, as noted in the literature reviews of Souza (2009) and Mazzocato
et al. (2010). Studying the current state of healthcare management in countries that have
serious infrastructure problems is an important and recent topic in healthcare manage-
ment (for example, Hartwig et al. 2008; Drew et al. 2015; Ganle et al. 2015).
Within this context, this paper presents a descriptive/exploratory case study
(Meredith 1998) showing lean healthcare implementation in five sectors (Sterile
Services Department, Pharmacy, Chemotherapy, Operating Room and Radiother-
apy) of two Brazilian hospitals. The main characteristics of the implementation
process are analyzed in the present study: the motivational factor for implementa-
tion, implementation time, form (consultancy or internal), team (hospital and consul-
tants), lean implementation continuity/sustainability, lean healthcare tools and
methods implemented, problems/improvement opportunities, lean healthcare bar-
riers faced during the implementation process, and critical factors that affected the
implementation and the results obtained in each case.
This study also aims to present propositions through the analysis and comparison
of these case studies with the literature to present lean implementation particularities
in the healthcare sector, especially in developing countries (in this case, Brazil) and
suggest relevant topics for future research.

Copyright © 2015 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2015)
DOI: 10.1002/hpm
 LEAN HEALTHCARE IN DEVELOPING COUNTRIES

The remainder of the paper is structured as follows. The section on Lean

Healthcare presents a literature review of lean healthcare. The section on Research
Methodology shows the research methodology used in the study. The section on
Case Descriptions presents the case descriptions and the main findings. The section
on Propositions shows the propositions formulated. The section on Conclusions
presents the conclusions of the study.

LEAN HEALTHCARE

According to Souza (2009), it is not known exactly when lean philosophy first
appeared in the healthcare sector; however, the earliest publications are dated
2002. In today’s world, the "need" to use lean techniques in the healthcare sector
is quite clear in terms of quality and patient safety, cost, waiting time and employee
satisfaction. Moreover, hospitals are facing an increasing number of external pres-
sures and challenges (Graban 2012).
To eliminate waste, that is, anything that does not add value inpatients’ eyes, it is
necessary to classify activities in any process as a value-added activity, non-value
added activities, but necessary, or non-value-added activities. Aherne and Whelton
(2010) present some examples from the healthcare sector:
• Value-added activities: diagnosis and treatment of an illness or injury;
• Non-value-added activities, but necessary: update to patient documentation that
does not directly affect the level of care a patient will receive, but is necessary
for a complete patient file;
• Non-value-added activities: waiting to be seen, waiting for a procedure or being
inspected several times.
Two literature reviews concerning lean healthcare were written at the end of the
last decade. Souza (2009) showed that the great majority of lean healthcare studies
were performed in developed countries (57% in the USA, 29% in the UK and 4%
in Australia). Concerning healthcare settings, Mazzocato et al. (2010) showed that
only 15% of studies were performed in three of the five areas studied in this paper
(Pharmacy, Operating Room and Radiotherapy). The other two areas (Sterile
Services Department and Chemotherapy) have not been previously studied. To
update these reviews, we performed a literature review across the databases of
Engineering Village, Web of Knowledge and Scopus using the terms “lean health”,
“lean healthcare” and "lean hospital" from 2008 (March) to 2014 (November),
focused specifically on the five healthcare settings examined in this paper; 21 papers
were found, as shown in Table 1.
Table 1 shows that only one study was undertaken in a developing country. The
content analysis of the previous papers follows.
Seven papers concerning Pharmacy were found, all showing a lean implementa-
tion approach. Nine different lean tools were used, three of which showed greater
use (value stream mapping, physical redesign and standardized work). The main im-
plementation results were cost reduction, elimination of waste and reduced waiting
times.

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Table 1. Recent papers about lean healthcare dealing with the five settings focused in this study

Healthcare settings Papers Countries

Pharmacy Al-Araidah et al. (2010) United States
Castle and Harvey (2009) United Kingdom
Rico and Jagwani (2013) Spain
L’Hommedieu and Kappeler (2010) United States
Hintzen et al. (2009) United States
Chiarini (2012) Italy
Ker et al. (2014) United States
Operating room Cima et al. (2011) United States
Stonemetz et al. (2011) United States
Waring and Bishop (2010) United Kingdom
Castle and Harvey (2009) United Kingdom
Edwards et al. (2012) Denmark
Leeuwen and Does (2010) The Netherlands
Selau et al. (2009) Brazil
Johnson, Smith and Mastro (2012) United States
Aij et al. (2013) The Netherlands
Gayed et al. (2013) United States
Waldhausen et al. (2010) United States
Collar et al. (2012) United States
Lunardini et al. (2014) United States
Radiotherapy Kim et al. (2009) United States
Sterile Services Department Castle and Harvey (2009) United Kingdom
Kimsey (2010) United States

Thirteen papers were found pertaining to the Operating Room, and only one paper
did not show the implementation of lean practices. Among the fifteen applied tools,
five were used more often: process mapping, redesign mapping, value stream
mapping, standardized work and Kaizen Event. The main implementation results
were reduced waiting times, increased capacity and better financial performance.
One paper concerning Radiotherapy was found. This paper presents a reduction in
the lead time from beginning patient treatment with bone and brain metastases. The
study showed that nearly all patients were seen and treated within a single day’s
visit, instead of 3 days as was previously required.
In the Sterile Services Department, the two papers found implemented lean tools. Ten
tools were used in these studies, but only physical redesign and gemba walking/meeting
were used in both papers; the other tools were used in only one paper (value stream
mapping, Kaizen Event, visual management, one piece flow, plan–do–check–act, pro-
cess redesign, A3 and continuous flow). Implementation of lean tools helped to increase
capacity and reduce waiting times, motion, costs and cycle time.
In the literature review, no paper was found that examined the chemotherapy sector.

RESEARCH METHODOLOGY

This paper follows a case study research approach. According to Stuart et al. (2002)
and Yin (2003), case study research is useful in several situations.

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In this study, case research was chosen mainly for the following reasons: when
theory exists but the environmental context is different; when understanding (why
and how questions) a phenomenon is important, especially in fields where the sub-
ject matter is complex; and when the focus is on a contemporary phenomenon within
some real-life context. The study is focused on the reality of the Brazilian healthcare
system and our intention is to understand a contemporary and important phenome-
non — the effects of lean implementation on the performance of hospitals.
According to Eisenhardt (1989) and Stuart et al. (2002), the methodology of case
study research must follow certain well-known steps. The steps followed in this
study are shown on Figure 1.
According to Eisenhardt (1989) recommendations, and also following some re-
cent studies such as Smaros (2007), this study was established without any particular
theory or hypothesis in mind to retain theoretical flexibility.
The first stage of the research process involves defining the research questions.
The research questions were defined after conducting an extensive review of aca-
demic and practitioner literature about lean practices related to healthcare systems.
The first research question is: How are Brazilian hospitals implementing lean
healthcare concepts in their operations? As observed in the literature review, there
are several studies concerning lean healthcare implementations across the world
(Table 1), but in Brazil, there is just one such study (Selau et al. 2009). Therefore,
this study aims to investigate the background of these implementations in Brazil.
The second research question is: What are the quantitative and qualitative results
that Brazilian hospitals are obtaining by implementing lean healthcare? Different
results pertaining to various countries were found in the literature review, decreased
waiting times and lengths of stay, cost reductions and increased capacity, among
others, but few results were found in Brazil, (inventory and lead time reduction) thus
indicating a gap this research can fill.
According to Eisenhardt (1989), investigators should formulate research questions
and some potentially important variables related to these questions. In our study, the
variables related to research question 1 are as follows: motivational factor for lean
implementation, implementation period, form (consultancy or internal), team
(hospital and consultant), project continuity/sustainability (continued, sustained
or interrupted), lean healthcare tools and methods implemented, problems/
improvement opportunities, barriers faced in implementing lean healthcare practices
and critical factors that affected the implementation. The variables related to research
question 2 are quantitative and qualitative benefits.
The second step is the case selection. According to the case study literature
(e.g., Eisenhardt 1989 and Meredith 1998, among others), the case selection is a
prerequisite for a rigorous case study.

Figure 1. The research steps followed in this paper

Copyright © 2015 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2015)
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To select these cases, we first conducted online research and interviewed two
experts on hospital management to discover hospitals that had implemented lean
healthcare. These hospitals were contacted and two of them accepted to participate
in the study. Hospital-Case A presented two sectors (Sterile Services Department
and Pharmacy) where lean practices were recently implemented, while Hospital-
Case B presented three sectors (Chemotherapy, Surgery and Radiotherapy). There-
fore, five sectors from two hospitals were selected for study, what characterizes this
study as a multiple case study.
The next research step is the development of a protocol. The protocol is more than
an instrument; it is a major tactic in increasing the reliability of case study research
(Yin 2003).
The core of the protocol is the set of questions to be used in interviews. It outlines
the subjects to be covered during an interview, states the questions to be asked and
indicates the specific data required. For the interviewer, the interview protocol serves
both as a prompt and a checklist to make sure that all topics have been covered. In
addition, it is often useful to send an outline of the protocol in advance so that the
interviewee(s) are properly prepared (Voss et al. 2002). The interview protocol
designed for this study is shown in Appendix A.
After the protocol development, the data collection is performed. A case study
typically uses multiple methods and tools for data collection, which include both
quantitative and qualitative approaches (Meredith 1998). Some of them are struc-
tured or semi-structured interviews, observations and archival sources (e.g., docu-
ments, historical records, organizational charts and production statistics) (Barrat
et al. 2011).
In this study, data were collected through semi-structured interviews, observations
in both hospitals, consultation of the information available on hospitals’ and consult-
ing companies’ websites, and the consultation of Silva’s (2013) and Bertani’s (2012)
academic work. Interviews were conducted with external members (consultants) and
internal members (hospital staff). During the interviews, the information was noted
in a summary form to generate a database. In addition, external members’ second
interviews and internal members’ interviews from both hospitals were recorded.

CASE DESCRIPTIONS

Hospital-Case A

The hospital identified as Hospital-Case A is composed of 140 internment beds and

30 intensive care beds, and the medical staff consists of more than 300 doctors of all
specialties. The hospital is certified by the National Accreditation Organization, a
non-governmental and non-profit entity that certifies healthcare services quality in
Brazil with a focus on patient safety. The hospital is certified at the full level (for
institutions that attend the safety criteria and provide integrated management, with
processes occurring fluidly and full communication between activities). In this case,
the healthcare settings studied were the sterile services department and pharmacy.

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Sterile services department. The sterile services department (SSD) is a healthcare

setting responsible for the cleaning and sterilization of non-disposable instruments
used during the surgical process. Proper material sterilization and its availability
before surgery are important to the hospital because it significantly increases the
chances of surgery being performed without generating infections to patients, as well
as without delays due to the unavailability of sterile surgical equipment.
In this sector, lean implementation occurred between April 2012 and September
2012, performed by a hospital internal team (quality manager (lean leader) with
1 day of dedication per week, and a quality analyst, a SSD coordinator, and a head
nurse in the operating room, with a dedication of two days per week). An external
consultant team was also involved (a solutions director, a solutions manager and
two consultant analysts) and acted as facilitators in the development and implemen-
tation of improvements. The second part of the implementation was performed from
October 2013 to March 2014 with the participation of the internal team alone.
The main factors that motivated lean implementation in this sector were the spon-
sor’s concern with increased hospital costs stemming partially from SSD because of
the sector’s challenges in handling overload work caused by uneven demand, which
caused a hand labor imbalance, extra hours, high use of more expensive sterilization
methods and delays in surgeries due to lack of material. These delays are also the
concern of physicians and were considered a motivational factor for implementation.
Another factor that motivated lean implementation was the intention to begin the
implementation in a sector that impacted medical staff work but involved little direct
interference in the sector as is the case in SSD. In the second phase of lean imple-
mentation, the motivational factor was to control oscillations in the hospital infection
rate.
The DMAIC methodology was used to structure the implementation process. This
methodology was defined by Pyzdek and Keller (2010) as a five-phase improvement
cycle (define, measure, analyze, improve, control) from the Six Sigma approach. A
current Value Stream Map was created to detect problems and opportunities for
improvement with the following findings:

• Uneven workloads caused by the high number of surgeries in the morning and the
high concentration of some surgery types on specific days of the week;
• High sterilization costs in short-cycle machines due to the lack of autoclave capac-
ity and because some items must be sterilized in an autoclave;
• Inappropriate standard organization in the sector;
• Difficulty in daily communication due to difficulties viewing the daily schedule;
• Peak loads during washing and in the thermal disinfector, especially in the
mornings;
• High motion of the staff responsible for cleaning the instruments and searching for
dirty parts;
• Frequent stops by inspection staff to perform other activities such as answering
the phone and attending to people;
• Lack of standardization in the autoclave cooling times;
• Low availability of sterilizing machines due to the long setup time in the thermal
disinfector and autoclaves;

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• Overload during assembly and inspection due to large batches between the assem-
bly and inspection teams;
• Delays in surgery due to lack of materials from the SSD.
A Kaizen Event was conducted to solve these problems using some of the
lean healthcare tools. The 5S was used to define the specific locations of mate-
rials and tools and dirty and clean parts of each process and was also used to
dispose of expired materials, damaged utensils and unused items, in general.
Visual management (identification of all boxes with labels (color and code))
facilitated the packaging process and avoided material waste. A visual manage-
ment system was also designed in a Kanban board form to visualize the surgical
supermarket kits prepared at the end of the SSD flow. Workload balancing
dedicated one person to perform all support activities for the sector. This person
became responsible for answering the phone and attending people who came to
the SSD, besides assisting the implementation of external setup of autoclaves
and the thermal disinfector. Standardization work was performed to avoid waste,
such as excessive paper use in packaging and longer than necessary cooling
times in the autoclave, and employee activities were standardized to decrease
the chance of error. The single-minute exchange of dies tool was used to clas-
sify internal and external setup. A physical redesign, accomplished by adapting
the area layout, was used to make the flow continuous, decrease the batch sizes,
increase system agility and flexibility and increase productivity, among other
benefits.
In the second phase of lean implementation, the main problems and improvement
opportunities were reducing the infection rate and standardizing instruments. A
second Kaizen Event was performed to solve these problems; 5S and visual manage-
ment tools were used and a new layout redesign that adapted the work area to a
cellular layout was devised. Another tool used was the gemba walk/meeting, and
the hospital also purchased a new rapid-setup thermal disinfector.
The main barriers faced during this process was the implementation of new con-
cepts, which generated an adverse reaction due to their origins in manufacturing;
previous attempts to implement lean healthcare with low success; and leadership
with little training and involvement. In the second phase of implementation, the
barriers had been broken because of the success of the first phase. Despite the
obstacles, positive results were reported, such as:

• 64% increase in SSD capacity (sterilization machines’ capacity);

• 78% SSD cost reduction (with short-cycle sterilization machines), representing
annual savings of R$150 000.00;
• 94% reduction in delayed surgery due to lack of material;
• 1–1.5% to 0.21% reduction in infection rate in clean surgeries;
• Reduction of the setup time between autoclave cycles by 30 min;
• Reduction in autoclave cycle time by 30 min.

In this case, the critical factors for the successful implementation and achievement of
the listed results were associated with leadership and employee involvement in lean
implementation and top management support, which helped to break the barrier of

Copyright © 2015 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2015)
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 LEAN HEALTHCARE IN DEVELOPING COUNTRIES

employee resistance, a resistance stemming from the fact that the Brazilian healthcare
sector is not yet familiar with lean concepts, unlike its manufacturing sector.

Pharmacy. Pharmacy is the department in which storage, control, dispensing activ-

ities and the distribution of medicines for other hospital departments occur. Lean
implementation occurred from October 2012 to March 2013 with the assistance of
a consulting company (external team) consisting of a solution director, a solution
manager and an analyst consultant, and the participation and involvement of a
hospital internal team formed by a quality manager, a quality analyst, supply coordi-
nator and a logistics coordinator. The second part of the implementation began in
March 2013 and is still being finalized and is being performed exclusive by the
internal team. The motivation factor for lean implementation in this sector was to
reduce the stock financial value and improve stock quality.
Through value stream mapping and the DMAIC methodology, we found several
sector problems, such as:
• Stock replenishment failure;
• Absence of materials and medicines forming part of the standard supply to inpa-
tient units;
• High nursing employee movement because employees had to move to the central
pharmacy to take materials and medicines, thus consuming much of their work
time.
The support of lean tools and changes in the process made the realization of some
improvements in this sector possible. The first step was to implement an electronic
system in which the prescription and scheduling of drugs was performed simulta-
neously by the physician. Another important step was to use visual management
with hour by hour medication status per patient to improve medication application
planning and control by nurses, as well as to facilitate communication and reduce
the chance of errors. Another tool used was 5S, which facilitated the organization
and provision of drugs to inpatient units, thus shortening the amount of work for
employees to find what they needed. The work standardization established a route
allowing greater patient care flexibility. The layout modification improved the agility
of drugs and materials location. Another improvement was the use of electronic
records for materials consumption, which allowed automatic replacements of needed
material from the central pharmacy.
Lean implementation was also performed throughout the materials and drugs
chain, and the warehouse, central pharmacy and satellite pharmacies’ stocks were
resized according to historical demand to ensure a reliable availability of supplies
while maintaining low inventory levels.
In the second part of the implementation, a Kaizen Event was performed to
reduce stocks using a Kanban system to realize materials and drugs purchases.
Herewith all inventory that was previously stored in a rented facility was moved
to onsite storage.
The main barrier faced during the process was the implementation of new, unfa-
miliar concepts that were the subject of an adverse reaction by employees because
of the lean approach’s origins in manufacturing. Other barriers included little

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 L. B. MESSAGE ET AL.

training and leadership commitment and employee difficulties regarding the use of
technologies such as computers.
Despite the difficulties and barriers in this sector, a positive result was reported
with lean implementation, a balance inventory reduction (monthly average) of
R$2 000 000.00 to R$1 600 000.00.
The critical factors for the successful implementation were the positive results of
the initial implementation in the sterile services department, the involvement and
active participation of employees and leadership and top management support.

Hospital-Case B
Hospital-Case B is a philanthropic institution. It consists of an admissions ward
(77 beds), an intensive care unit (seven beds), four operating rooms, a diagnostic
center, and radiotherapy, chemotherapy, pharmacy and warehouse units, and employs
more than 100 physicians from different specialties. This hospital was the setting for
the chemotherapy, operating room and radiotherapy case studies.

Chemotherapy. Chemotherapy was the first sector of Hospital-Case B to implement

lean healthcare. This sector essentially comprises a satellite pharmacy, a chapel for
handling drugs and 24 seats for the application of chemotherapy drugs.
Chemotherapeutic hospital patient flows begin at the triage stage, in which a
doctor examines the treatment options for patients diagnosed with cancer. After
the triage stage, the patient who will be treated through chemotherapy is referred
to his or her first appointment with the oncologist. In this medical consultation, the
doctor examines the patient’s exams and checks to see whether it is necessary to
order other exams.
After patients undergo these exams, they return for further consultation with the
oncologist. In this consultation, the doctor will determine the type of chemotherapy
treatment, for example, the number of sessions, medications and dosages types. The
treatment determined by the doctor must be approved by the Secretary of Health. For
this, the hospital prepares a High Complexity Procedure Authorization (APAC) for
each patient, with an average duration of 3 months. After the APAC is approved,
the chemotherapy sessions are scheduled and the treatment is performed.
In this sector, lean implementation occurred between February 2011 and
December 2011; the implementation was carried out by a consulting company com-
posed of a solution director and manager, and an internal team consisting of a quality
coordinator and a project sponsor. When necessary, other internal employees from
specific areas were also involved in the project. After this period, the improvements
already made were only sustained.
The main factors that motivated the lean implementation was the desire to reduce
patient lead time, which was considered very long by senior management, and to
improve several financial aspects to allow financial leverage across the entire
hospital, not only in this sector.
DMAIC was used to structure the implementation process, and Value Stream
Mapping was used to identify problems and opportunities for improvement. The
problems/improvement opportunities were:

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• Long waiting time in the hospital triage due to low service triage capacity;
• Low ambulatory triage use due to outdating of places available by the hospital
through the Integrated Service Management (SIGA);
• Realization of ultrasonography exams in batches, which generates greater test
result lead times and increases the possibility of errors;
• Blood exams results sent in batches, which increases patient waiting time;
• Long waiting line to perform tomography exams due to the high exam volume and
ordering of unnecessary exams that further contribute to overload in this sector;
• Patients entrance unlevelling in chemotherapy caused by APAC’s (High Com-
plexity Procedures Authorization) submission rules, thereby causing an increase
inpatient waiting time;
• Uneven workloads caused by the fact that sector treatment is performed in order of
arrival and not by the scheduled appointment time, which impacts patient satisfaction.
Improvements were implemented through a Kaizen Event. The first improvement
project was realized by increasing the delivery of APACs for approval from weekly
to daily frequency. A sector process redesign was also realized to eliminate the need
for patients to return to the hospital to schedule their chemotherapy; instead, patients
could schedule their session date after the hospital’s APAC audit. Another improve-
ment project was performed on blood exams. The exams results are now sent as
individual analyses via web. In triage, the improvement project was to eliminate
the triage scheduled by the hospital. In chemotherapy, the main solutions adopted
were after consultation scheduling and production leveling with scheduling per-
formed taking into account the infusion time and the sector capacity. Tools were also
used to balance and standardize activities for the nursing and pharmacy sectors and
to promote continuous flow between the preparation and application of medicines.
Employee distrust was the main barrier to implementation and was largely the
result of the chemotherapy section being the first to go through a lean healthcare
implementation. Employees felt that the implementation process would leave them
more overloaded due to a theorized work increase.
To address the barriers and to achieve the proposed objectives, support from
senior management, employee involvement in areas related to the implementation
and employee training, which explained lean concepts that were unfamiliar to hospi-
tal employees, were critical to the success of the implementation. Ultimately, a
number of positive results were reported:
• 33% increase in monthly revenues (R$1 090 000.00 to R$1 450 000.00);
• 23% increase in the number of chemotherapy applications;
• 42% reduction in average patient lead time;
• 6% increase in the sector capacity (measured in hours available);
• 82% (38 for 7 days) reduction in average APAC information lead time;
• 93% (15 for 1 day) reduction in average information lead time (reduction in blood
exam analysis time in the laboratory);
• Increase in percentage of triage occupation from 49 to 98%;
• 24% increase in number of triages via SIGA in the first quarter of 2011 and 14%
increase in the first semester of 2011;
• 50% reduction in the number of patients waiting to begin chemotherapy.

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Operating room. The operating room sector comprises 4 operating rooms, 7 inten-
sive care unit beds and 77 inpatient beds. The implementation team was staffed by
external and internal members, much as in the chemotherapy team. Lean implemen-
tation occurred from April 2013 to July 2013. After this period, only those improve-
ments already obtained were maintained.
The motivating factors for this case were to reduce the patient lead time, as in
chemotherapy, and improve operating room utilization due to spare capacity.
Several lean tools and methods were used to achieve the proposed objectives.
DMAIC was used to structure the implementation process, and current Value Stream
Mapping was used to identify any problems or improvement opportunities. The
problems or improvements opportunities found were:
• Decentralized scheduling of surgeries because of a lack of central scheduling to
consolidate all relevant information in one place. Instead, surgeries were sched-
uled directly by doctors;
• Uneven operating room demand due to the lack of proper management for surgery
scheduling;
• Limited number of surgical and intensive care unit beds. The hospitalization
process was one of the major bottlenecks in the surgical patient flow, and surgery
cancellations were frequent due to lack of vacant beds in wards and the intensive
care unit.
To solve these problems, a central scheduling surgery was created such that
surgeries could be scheduled by a central authority with access to information such
as operating room occupation, resources and restrictions (surgical instruments, beds
vacancies, materials, drugs and the surgical center capacity), which means that a
production leveling was done. Another improvement was the consolidation of preop-
erative tests into a single day and the same-day consultation with the cardiologist and
anesthetist, which previously took required separate visits.
The main barrier to implementation, in this case, was the doctors’ preference for
scheduling their own surgeries. With support from senior management, employee
involvement and concept alignment obtained through trainings, however, it was
possible to achieve the proposed objectives. They were reported an increase in
monthly revenue from R$400 000.00 to R$575 000.00, an increase in the number
of monthly surgical admissions from 131 to 177 and an increase in the number of
monthly surgeries from 203 to 220.

Radiotherapy. Radiotherapy comprises three radiotherapy machines. One machine

can treat 120 people a day. Although the sector is considered highly productive, it
is one of the cancer treatment bottlenecks.
The main motivating factor behind the lean implementation was reducing patient
lead times. As in the other two sectors in Hospital-Case B, the implementation team
was composed of internal and external groups.
The project began in February 2014 and ended in March 2014, utilizing the lean
tools value stream mapping, spaghetti diagram and DMAIC, which enabled the
identification of the main problems and opportunities for improvement:

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 LEAN HEALTHCARE IN DEVELOPING COUNTRIES

• High number of patients in the sector. Radiotherapy personnel attended 320

patients per day on average, requiring that the sector resources be highly effective
and well designed;
• Many scheduling fittings, causing delays in daily radiation applications and long
waiting line;
• Difficulty in planning and control due to the challenges of managing a schedule
marked by high attendance and high patient turnover;
• Difficulty in managing patient discharges.
To solve these problems, the first improvement project reduced the time between
the conclusion of one radiology application and the beginning of the next by elimi-
nating activities that did not add value while the machine was not operating (cobalt
machine setup time reduction), generating productivity gains. Another important
improvement was achieved through standardization activities, technician workload
leveling and redistribution, with the main objective of eliminating bureaucratic activ-
ities. Therefore, there was an increase in the time that professionals had available for
patient care. The scheduling system was also restructured to facilitate machine occu-
pancy planning based on the application duration for each patient and reducing the
amount of fittings by synchronizing the consultation time with the doctor and the
application time. Moreover, the new schedule facilitated patient discharge control.
In this project, the main barrier faced was the conflict of interest caused by the fact
that the sector is outsourced. In spite of this, the senior management supported for
lean implementation and employee involvement in this sector, which was facilitated
through training, as occurred in the two other sectors examined in Hospital-Case B.
In the radiotherapy project, the results were not measured, but an estimate was
made that pointed to an increase in monthly revenues from R$980 000.00 to
R$1 200 000.00, and an increase in monthly productivity from 26 000 to 29 500
application field.

Inter-cases analyses
The motivational factors for lean implementation are diverse, but they are often
directly or indirectly associated with waste elimination as proposed in the Toyota
Production System. In the healthcare arena, the main motivations are associated with
improvements in service and patient safety and the reduction of costs, waiting times
and errors (Aherne and Whelton 2010; Graban 2012). In the cases studied in this
work, the two main motivational factors are among the factors cited in the literature:
patient lead times reduction and financial improvements (costs decrease).
Lean implementations showed different durations in each case. A few lean tools
and methods were used repeatedly, particularly Value Stream Mapping and the
DMAIC methodology from Six Sigma approach, which were used in all cases.
Radnor et al. (2012) classify lean healthcare activities into three groups: assess-
ment, improvement and performance monitoring activities, all of which are present
in the five cases studies. This suggests a structured lean tools implementation by
the team members.
During the implementation of lean concepts and tools, several barriers emerged.
According to Kim et al. (2007), this occurs in any new initiative, and here, when

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DOI: 10.1002/hpm
 L. B. MESSAGE ET AL.

individuals learned that lean thinking originated in the automotive industry, they
usually argued that people are not vehicles and that each person requires special
attention and individualized, personalized treatment, which creates an even greater
barrier in the lean healthcare implementation process.
In the cases studied, the barriers faced were primarily associated with human
factors, including employee distrust, medical interests, conflicts of interest, the
frustration of previous attempts, adverse reactions due to lean healthcare’s origins
in the manufacturing sector and leadership with little training or involvement; other
barriers included the lack of knowledge about new lean concepts and technological
barriers such as employee computer use. These results corroborate the results found
in several papers, such as Aij et al. (2013), Bhat and Jnanesh (2013), Bhat et al.
(2014) and Bhat and Jnanesh (2014), among others.
In the five cases studied, three critical factors stood out across cases: concept
alignment through training, support from senior management and leadership and em-
ployee involvement. Senior management support was also presented by Liker (2005)
as a critical factor and a prerequisite for change; the author highlighted that senior
management should understand the Toyota Production System and leverage it to
become a "lean learning organization." Edwards et al. (2012) showed that high
employee involvement was the key factor to lean implementations success. Selau
et al. (2009) also highlighted the importance of all employees being involved in
the search for process improvements as a vital factor in successful lean
implementations. Some authors also presented employee training as a critical factor.
According to Bhat et al. (2014), awareness and training related to lean implementa-
tion is an obligation before starting the study, not only for the project team but also
for those associated with the process; ignoring that will lead to obstacles during
different phases.
It is also observed that the critical factors mentioned are directly associated with
the principal barriers, which shows that it was possible to overcome them and engage
people in the process and thus obtain positive results from the implementation of
lean healthcare.
The results of lean healthcare implementation can be divided into four groups:
those related to financial improvements, capacity improvements, lead time improve-
ments and others. Financial improvements were reported in the Sterile Services
Department, which showed a 78% reduction in costs and in Pharmacy, where a cost
reduction related to the reduction of outstanding stocks was obtained (monthly
average of R$2 000 000.00 to R$1 600 000.00). All sectors in Hospital-Case B also
showed improved financial performance: Chemotherapy obtained a 33% increase
in revenues, and Operating Room showed an increase in revenues from R
$400 000.00 to R$575 000.00. Some extant studies, including Collar et al. (2012),
Cima et al. (2011), Stonemetz et al. (2011) and Leeuwen and Does (2010), have also
shown significant results pertaining to financial improvements.
Capacity results were reported in the Sterile Services Department, where there was
a 64% capacity increase; and in Chemotherapy, with a 6% capacity increase. Papers
by Cima et al. (2011) LaGanga (2011), Souza and Pidd (2011) and Chadha et al.
(2012) also showed improvements in capacity. The productivity results, which were
found in the Hospital-Case B sectors, were also positive: In that hospital, there was

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 LEAN HEALTHCARE IN DEVELOPING COUNTRIES

an increase in the number of applications per month (1656 to 2029) in Chemotherapy;

in the number of surgical admissions per month from 131 to 177 and in the number of
surgeries per month (203 to 220) in the Operating Room; and an estimated increase
from 26 000 to 29 500 per month in the application field in Radiotherapy. Martin
et al. (2013) also found positive productivity gains in their study of an orthopedic
radiology department in the UK.
Positive lead time results were reported for Chemotherapy, where there was a 42%
reduction in waiting times related to patients, an 82% reduction in APAC approval
time and a 93% reduction in blood analysis time. The Sterile Services Department
also showed reductions in changeover times between autoclaves cycles (88%) and
autoclave cycle times (25%). Kimsey (2010) also found positive results for reducing
the sterilization cycle time from 27 to 20 min.
In terms of other results, the infection rate in the Sterile Services Department decreased
from 1–1.15% to 0.21%, and the seating load time was reduced by 47% in Chemother-
apy. Occupation of the SIGA triage increased from 49 to 98%; the number of patients in
the SIGA triage increased 24% in the first quarter of 2011 and 14% in the first semester of
2011; and the number of patients waiting for Chemotherapy at the beginning of turn was
reduced by 50%. No similar results were found in the literature review.
The results found in the five studied sectors are directly related to the main moti-
vating implementation factors. This is highly positive because the implementation
success is a critical factor in encouraging maintenance and the search for perfection
in environments where lean techniques have been implemented and is also an incen-
tive for new implementations.

PROPOSITIONS

Four propositions were formulated from the data obtained from the analyses of the
five sectors studied:
Proposition 1: Hospital organizational structures and the top management’s relation-
ship with the medical staff are implicit barriers to the lean healthcare implementation
process.
After analyzing interviews data from internal members of lean implementations
concerning the barriers and critical factors to implementation success, it was noted
that the hospital organizational structure influences the way the lean implementation
process is performed. During an interview with an internal member at Hospital-Case
A, the member affirmed that "the doctor is not hospital hired staff […] you cannot fire
a doctor […] you cannot disqualify a doctor […] the doctor you have to win, doing
the business be good for them, then they support you […] you have to reduce their
time, reduce their stress […]." According to an internal member from Hospital-Case
B, "In the nursing and administrative sector 95% of staff are motivated, the medical
part is more difficult, I think 50-60% support the cause […] they say: Why I will
waste time in making meeting, do training? […] What I will gain from it? […] ."
The interviewee indirectly affirms that the necessary gains are mainly related to finan-
cial aspects for doctors so that they commit to the implementation. In both hospitals
studied, doctors are service providers and not hired employees of the hospitals.

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 L. B. MESSAGE ET AL.

In the literature, organizational structure is also presented as a barrier to lean

healthcare implementation; however, the way in which top management works with
medical staff and healthcare professionals’ contracts are rarely addressed.
Healthcare organizations, in general, are characterized as complex institutions.
This complexity derives from their ambiguous objectives, the qualitative nature of
their activities, the use of multiple and complex technologies, shared power and
plurality of professionals involved in the activities. In these organizations, there
can be significant disputes between highly qualified professionals, with great auton-
omy in their work, and that are not subordinated to senior management (Meyer
Junior et al. 2012). For these authors, the strategic management of complex systems
such as hospitals requires greater attention than usual by strategy implementation
process managers.
Some authors showed the effects of organizational/hierarchical structures, as well
as aspects of the clinical staff barriers to implementing the lean approach. For exam-
ple, Stanton et al. (2014) presented organizational policy as one of the greatest
barriers in the implementation of lean healthcare and highlighted that the nature of
the work, the way that work is performed and the resources available are influenced
by a set of "sponsors." This context creates a special challenge for introducing inno-
vations. The authors concluded that the professional status and relative autonomy of
clinical staff indicate a different experience and vision of lean healthcare compared
with workers in manufacturing. Another salient point is that in manufacturing, the
work team involves multi-skilled employees performing a variety of jobs that are rel-
atively low skill, compartmentalized and standardized, whereas healthcare workers
are highly skilled and have a high degree of autonomy.
Poksinska (2010) highlighted healthcare structure as one of the main barriers to
the implementation of lean healthcare. The author argued that this structure is still
very hierarchical, with doctors being the dominant decision makers. The healthcare
arena consists of many individual departments, further increasing the challenge of
improving the system as a whole.
Souza and Pidd (2010) showed hierarchical and management functions as a
barrier to lean implementation. Doctors have more power than other professional
groups, but it does not seem prudent to assume that the best manager for a depart-
ment is the senior doctor, unless that doctor has an aptitude for management and
has been properly trained. Lean team members must be from different professional
groups and operate outside the hierarchy.
Drotz and Poksinska (2014) noted that healthcare leaders are usually skilled in
their own fields; however, they are not experts in managing people and they usually
have limited knowledge about how to motivate, train and involve employees.
Healthcare leaders often work in clinical areas and only manage healthcare facilities
part-time. They often have limited opportunities and interest in acting as facilitators
and trainers for healthcare professionals. In this case, professional knowledge is also
a barrier.
Although the literature presents the organizational structure as a barrier, its rela-
tionship to healthcare professionals’ working contracts and how top management in-
teracts with these professionals is not presented; this is an important point that arose
during the course of this paper and should therefore be considered.

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 LEAN HEALTHCARE IN DEVELOPING COUNTRIES

Proposition 2: Outsourcing a hospital sector can be an important barrier to lean

healthcare implementation.
In this work, the Radiotherapy sector of Hospital-Case B is a third party sector, admin-
istered by a doctor with high "power" over this sector. The conflict of interest between the
hospital’s top management and the service provider was the main barrier to lean imple-
mentation process in the sector, and the project has progressed slowly for this reason.
Some studies such as that by Souza et al. (2011) showed outsourcing as an initia-
tive used by hospitals to reduce costs and professionalize and improve the manage-
ment of these sectors, as an option for innovative and competitive positioning with
respect to costs and quality of services provided.
In cases where sector administration is mixed manner, for example, shared between
a hospital and a third party member, as in Radiotherapy, the fact that there is more
than one sponsor for lean implementation and that these sponsors have the same level
of "power" with different interests renders lean implementation more difficult.
Proposition 3: The initialization of lean healthcare projects in Brazilian hospitals still
requires the support of specialized consultants, as knowledge of this concept is still
not widespread in Brazilian institutions.
The five sectors of the two hospitals studied were assisted in the implementation
of lean healthcare by external consultants. This is associated with the fact that there
were no hospital employees with the required level of knowledge of lean concepts.
Few studies on the subject have been published in Brazil. This situation differs from
that found in developed countries, where a stream of literature concentrates on lean
healthcare. The larger number of publications promotes the further spread of the lean
approach to healthcare in those countries, which facilitates the implementation of
some lean initiatives by internal hospital members exclusively (external support is
mentioned in 44% of the papers reviewed in this study), which still seems far from
the reality of developing countries, such as Brazil.
Proposition 4: Lean implementation continuity/sustainability is a challenge for the
healthcare sectors of developing countries
Machado and Leitner (2010) affirmed that lean transformation never ends; there
will always be processes that can be improved and waste that can be eliminated. Fine
et al. (2009) affirmed that as with any initiative for change, lean initiatives are a chal-
lenge to be sustained. Thus, lean implementations must first be treated as a long-term
commitment. Second, the cultural penetration of lean concepts should be the main
initial objective, and lean principles should be taught to those who will practice them.
Third, lean principles should be a natural part of everyday life, not an isolated initia-
tive. Finally, the results should be demonstrated and transmitted. For Naik et al.
(2011), some lessons are important to support implementations, namely, the develop-
ment of clinical and middle manager "champions" as a key element for a successful,
sustained lean intervention. To Barnas (2011), the lack of a lean management system
is the main factor in sustaining lean process improvements and productivity gains.
Most of the elements cited by these authors represent a significant challenge for
developing countries, as they require that the hospital staff be conversant not only
in lean healthcare tools but also in the main concepts behind their benefits. This
requires time and resources. In this study, after completing the first initiatives in
Hospital-Case A, the hospital continued its implementation with new improvement

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 L. B. MESSAGE ET AL.

projects in the sectors studied as well as other sectors (Operating Room and Emer-
gency Center). Hospital-Case B, however, only maintained the improvements al-
ready made in existing projects. The continuity observed in Hospital-Case A is
probably because this hospital has invested in hiring experienced staff with expertise
in lean healthcare. Hospital-Case B, on the other hand, which made no such invest-
ment, had restricted the possibility of continuous improvement.

CONCLUSIONS
This study aimed to evaluate how five sectors of two Brazilian hospitals have imple-
mented lean healthcare concepts in its operations, assessing the motivational factor
for implementation, the implementation 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 implementation and the results obtained in each case.
The case studies showed that reducing patient lead times and costs and improve-
ments in financial aspects were the main factors that motivated lean healthcare
implementations in the hospitals studied. A number of tools and methods were used
in both hospitals, particularly Value Stream Mapping and DMAIC. The barriers to
implementation in both hospitals are primarily associated with the human factor,
for example, employee distrust, physicians’ interest, conflicts of interest, frustrations
with previous attempts, adverse reactions to the lean approach because of its origins
in the manufacturing sector, leadership with little training and involvement, igno-
rance of new concepts and technological barriers. The results, reported after imple-
mentation, were also analyzed and improvements in financial aspects, reduced lead
time, and improved productivity and capacity in the analyzed sectors were observed.
In addition, this paper also presented four propositions that were elaborated from
the results of the case studies, which highlighted the challenges to lean healthcare
implementation in developing countries. Two of these barriers are hospital organiza-
tional structure (and, consequently, how the senior management works with medical
staff) and hospital outsourcing. This study also concluded that both the initialization
and maintenance of lean healthcare implementation rely heavily on external support,
as lean healthcare knowledge is not yet available in healthcare organizations,
representing a challenge for these organizations.
Future research should evaluate these propositions to better understand the partic-
ularities of the healthcare sector and thus create strategies to overcome barriers and
minimize the challenges related to these and other possible particularities.

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Int J Health Plann Mgmt (2015)
DOI: 10.1002/hpm
 LEAN HEALTHCARE IN DEVELOPING COUNTRIES

APPENDIX A - Case Study Protocol

1. An overview of the case study project
This case study project describes the procedures necessary to conduct a case study to increase
the research reliability.
The information sources provided to the researcher in the interviews will be kept confidential.
The people and the corporate names of the interviewed companies will not be released. After
study finalization, a copy will be provided to each hospital researched.
1.1 Case study objectives
The case study purpose is to investigate how five sectors of two Brazilian hospitals have
implemented lean healthcare concepts within their operations. The study will assess the
motivational factor for implementation, the implementation period, the form (consultancy or
internal), the team (hospital and consultants), the project continuity/sustainability, the
problems or improvement opportunities found, the tools used, the barriers faced, the critical
factors for successful implementation and the results obtained in each case.
The study also aims to elaborate propositions through case studies and literature analyses to
present important lean implementation particularities in the healthcare sector, especially in
Brazil, and suggest relevant topics for future research.
1.2 Research Questions
The research questions were defined after conducting a literature review about lean techniques
related to healthcare systems. The first research question is: how are Brazilian hospitals
implementing lean healthcare concepts in their operations? The second research question is:
what are the quantitative and qualitative results obtained by Brazilian hospitals from
implementing lean healthcare?
To answer the research questions, the following variables were defined:
• Motivational factor for implementation;
• Implementation period;
• Form (consultancy or internal);
• Team (hospital and consultant);
• Project continuity/sustainability (continued, sustained or interrupted);
• Lean healthcare tools implemented;
• Problems or improvement opportunities;
• Barriers to lean healthcare implementation;
• Critical factors that affected the implementation;
• Quantitative and qualitative benefits.
2. Field procedure
The field procedure in this study presents the data collection plan, the preparation to realize the
visits and the interviewed members.
2.1. Data collection plan
To perform the data collection, external and internal members of lean healthcare
implementation process in the two selected hospitals will be interviewed. The interviews will
be scheduled by phone or email. A date for the interview will be proposed, but the interviewee
will determine the best date according to his or her availability.
Data collection will be conducted through semi-structured interviews, observations in the
hospitals, and consulting the information available on hospitals and consulting company
websites, as well as in academic studies developed in the two hospitals.
During the interviews, information in previously prepared and printed tables will be noted in a
summary form to generate a database. In addition to the notes, interviews will be recorded for
future reference.
After each interview, an interview summary should be drafted. This summary should contain
the respondent employee’s position, interview duration, other important points, and completed
printed tables.

(Continues)

Copyright © 2015 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2015)
DOI: 10.1002/hpm
 L. B. MESSAGE ET AL.

APPENDIX A. (Continued)
2.2 Preparation to realize the visits
An email with a general study description will be sent to interviewees, providing the
interviewees with some context regarding the research subject. Available information on the
hospitals and consulting firm websites and in academic work realized in the hospitals will be
collected prior to the interview to obtain important information that can later be discussed in
the interviews. It will also elaborate printed tables with the research variables to facilitate
note-taking during the interview.
The material to be taken into the field of research is: interview protocol, plus copies of this
protocol for interviewees, printed tables for data collection, recorder, and notepad.
2.3. Interviewed members
The interviews will be conducted with the internal members of the two hospitals and with
external members (consulting firm) that participated in the lean implementation in the five
studied sectors.
3. Case study questions
The following interview protocol was developed for this study:
1. What are the main particularities that characterize the hospital studied? Describe each of
these characteristics (for example: beds, doctors, and specialties numbers, classification with
regard to hospital size, among others).
For each sector:
2. Describe the same characteristics (beds, doctors, and specialties numbers, among others).
3. What were the main motivations for implementing the lean healthcare philosophy in the
sectors?
4. Was the lean implementation performed by a consultancy or internally?
5. What was the period of implementation?
6. Was there continuity/sustainability of the program?
7. Who were the members of the team (internal and/or external)?
8. What were the main tools and methods used in lean healthcare implementation?
9. What were the main barriers faced during implementation?
10. What were the main critical factors that ensured the success of lean implementation?
11. What were the main results obtained (quantitative and/or qualitative)?
12. Is there any other information you want to add that was not addressed in this interview?
4. Guide for the case report
The present study report will be structured from the notes made and the consultation of audio
recorded during the interviews, being conducted as quickly as possible. The results will be
presented in a descriptive way in a textual format for each of the five cases and will be
discussed and compared with the literature on the subject.

Copyright © 2015 John Wiley & Sons, Ltd. Int J Health Plann Mgmt (2015)
DOI: 10.1002/hpm