A Framework To Assess Sustaining Continuous Improvement in Lean Healthcare

International Journal of Production Research
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A framework to assess sustaining continuous

improvement in lean healthcare
Daniel Barberato Henrique, Moacir Godinho Filho, Giuliano Marodin, Ana

Beatriz Lopes de Sousa Jabbour & Charbel Jose Chiappetta Jabbour
To cite this article: Daniel Barberato Henrique, Moacir Godinho Filho, Giuliano Marodin, Ana
Beatriz Lopes de Sousa Jabbour & Charbel Jose Chiappetta Jabbour (2021) A framework to
assess sustaining continuous improvement in lean healthcare, International Journal of Production
Research, 59:10, 2885-2904, DOI: 10.1080/00207543.2020.1743892
To link to this article: https://doi.org/10.1080/00207543.2020.1743892
Published online: 17 Apr 2020.
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International Journal of Production Research, 2021
Vol. 59, No. 10, 2885–2904, https://doi.org/10.1080/00207543.2020.1743892
A framework to assess sustaining continuous improvement in lean healthcare

Daniel Barberato Henriquea , Moacir Godinho Filhoa∗ , Giuliano Marodinb , Ana Beatriz Lopes de Sousa Jabbourc and
Charbel Jose Chiappetta Jabbourc
a Production
Engineering Department, Federal University of Sao Carlos, Rod. Washington Luis, Km 235 caixa postal 676, CEP
13565-905 São Carlos, SP, Brazil; b Darla Moore School of Business, Department of Management Science, University of South
Carolina, Columbia, SC, USA; c Montpellier Business School, Montpellier Research in Management, 2300 Avenue des Moulins, 34000
Montpellier, France
(Received 25 February 2019; accepted 5 March 2020)
Many hospitals have achieved high levels of lean performance only to lose it later on. This research develops a theoretical
understanding of how organisations can sustain lean in healthcare, through a practical and innovative framework to assess
the maturity level of lean in healthcare that can be used by both practitioners and academics. Through the analysis of the
literature, it was possible to compile 22 main critical success factors of lean sustainability in hospitals. A comparative case
study provides evidence to confirm these 22 theoretical propositions, and also to add other 3 new success factors to the
framework. The proposed framework allows hospitals to conduct a structured process of change, with all the foundation
needed to succeed and sustain the lean journey in the long-term. New insights are revealed by studying hospitals after
minimum 18 months of lean implementation and comparing the ones that have achieved a high level of lean sustainability
with those that did not. To the best of our knowledge, this article is the first to attempt to bring together the key factors that
influence hospitals to sustain lean improvements in the long term.
Keywords: Lean healthcare; lean hospital; lean sustainability; lean assessment; continuous improvement
1. Introduction
Although many companies in several industries have achieved significant benefits from the use of Lean, sustaining the
gains obtained from lean thinking adoption proved to be a difficult task and, eventually, improvements may go back to their
original state over time (Kaye and Anderson 1999; Bateman and David 2002). The failure rate of initiatives to implement
Lean programmes are high, and some authors estimate that around 66% to 90% of companies fail to sustain implemented
improvements (Bhasin 2011b; Saurin, Marodin, and Ribeiro 2011; Bhasin 2012a).
Lean in healthcare has been broadly reported in the literature (see for example Costa et al. 2017; Nabelsi and Gagnon
2016; Li, Papadopoulos, and Zhang 2016; Cardoen, Beliën, and Vanhoucke 2015; Hicks et al. 2015), however very little
is known about how to sustain lean implementation in the long term in this environment (Taylor, Taylor, and McSweeney
2013; Bhasin 2012a; Hines et al. 2011) despite that the success rate of implementation of lean in healthcare is very low
(Narayanamurthy et al. 2018). Because of the complexity of healthcare environments, which includes the need for bal-
ancing strategic priorities and care delivery excellence (Bichescu et al. 2018), the application of continuous improvement
approaches as lean thinking in this sector may face unique challenges in comparison with other industries. Some of these
major challenges are: (i) a surge on demand for healthcare due to an increase in life expectancy, and, therefore a growth of
the elderly population; (ii) the importance of patience quality care in the healthcare environment; (iii) the variety of profes-
sional backgrounds that are within a hospital facility; (iv) the high hierarchical power of physicians over other employees;
and (v) the belief that some management practices of other industries are not compatible with hospitals (Eriksson et al. 2016;
Radnor, Holweg, and Waring 2012).
Our research attempts to answer the following question: what are the main critical success factors that should be con-
sidered in a lean hospital implementation in order to be sustainable in the long term? To answer this question, we propose a
framework to assess the presence of critical success factors to sustain lean implementation in healthcare. Assessment tools
to measure the maturity of the adoption of lean tools are commonly used to help in sustaining the implementation of lean on
the manufacturing industry (Netland 2013). Many companies have created their own Production System in order to mimic
Toyota’s Production System, and these assessments are intended to evaluate the implementation of lean on different areas
*Corresponding author. Email: moacir@dep.ufscar.br

© 2020 Informa UK Limited, trading as Taylor & Francis Group
2886 D. B. Henrique et al.
or plants. For example, Netland and Ferdows (2016) present an example of assessments developed by Volvo Trucks that
disseminated globally within the company. In academic literature, there are also other examples of assessment methods.
Doolen and Hacker (2005) and Saurin, Marodin, and Ribeiro (2011) are some examples of frameworks to assess the use of
lean tools at the plant level and in manufacturing cells.
Although lean assessment methods are widely spread across manufacturing industries, they are not frequently used
in healthcare. Indeed, adapting these assessments to a complex environment such as healthcare is not an easy task. For
instance, a single hospital is made of several departments with very different contexts (D’Andreamatteo et al. 2015). Thus,
the objective of our research was to propose a practical and innovative framework to assess the maturity level of the
sustainability of lean in healthcare that can be used by both practitioners and academics.
According to Liker (2004), a lean production system is much more than manufacturing cells, just-in-time deliver-
ies, poka-yokes and pull production. For a long time, several companies were only focusing on Lean tools, neglecting
the other aspects of the Lean as a system. Lean tools are important, but their ultimate effectiveness depends on the
ability to develop an underlying culture to support continuous improvement (Holweg and Pil 2001). As such, rather
than setting a goal of a specific level of the use of a set of lean tools, as most lean assessment methods do, we
focus on acknowledging that lean is based on on-going continuous improvement process (De Treville and Antonakis
2006). Improvement has to be sustained for it to become the current state and the baseline to the following improve-
ment to reach an even higher performance level (Womack, Jones, and Roos 1990). This creates a never-ending cycle of
improvements and a need for sustaining those improvements in order to be able to reach the next improved state of any
process.
Thus, this study contributes to the literature by (i) organising concepts previously disconnected in the literature into a
framework aimed to sustain continuous improvements in lean initiatives in healthcare through a systemic literature review;
(ii) testing the feasibility of the framework in multiple case studies to assess the degree of generalisation and practical
contribution of the framework; and (iii) further refining the knowledge of factors that sustain lean initiatives through a
cross-case analysis. We offer an innovative perspective of assessment tools that will allow practitioners and researchers to
evaluate the maturity of the continuous improvement as the focus of keeping lean in healthcare, which has not been fully
considered in the past.
2. Research method
2.1. Overview
This research was divided into three sequential steps: (i) a literature review to develop a list of Lean Healthcare assessment
constructs and definitions; (ii) multiple case studies to validate and refine the framework based on empirical evidences; (iii)
cross-case analysis to illustrate the practical use of the proposed framework.
2.2. Literature review

As such, we performed a systematic literature review to identify the key factors for sustaining lean healthcare gains in
the long term. A literature review, according to Grant and Booth (2009), involves the process for identifying materials for
potential inclusion, selecting materials, synthesising them in textual, tabular or graphical form, and for making analysis of
their contribution or value. This revision searched for articles in three databases: Engineering Village, Web of Science and
PubMed. These databases were chosen because of their high relevance in terms of publications on the subject of this paper.
For the search criteria, we used a combination of the following terms: ‘Lean’ and ‘healthcare’ or ‘health care’ or ‘hospital’
and ‘sustainability’ or ‘process control’ or ‘key success factors’ or ‘lessons learned’ or ‘barriers’. We selected 238 papers
from 75 different journals. Then, we filtered only articles published in English and eliminated the publications out of the
subject. Redundancies were also eliminated, and the remaining 64 articles selected from 52 journals composed the final list
of papers reviewed, as illustrated by Figure 1.
From the concepts that emerged from the systematic literature review, it was possible to identify 22 critical success
factors for sustaining lean in healthcare. These CSFs can be classified according to 3 main topics that are essential to sustain
lean implementation in healthcare. These constructs were defined according to the classic lean references to better group and
consolidate all the critical success factors. The first construct, Tools, is composed of two-second order concepts, Auditing
Tools and Lean Sustainability Tools. The second construct, Method, is made by two second-order concepts, Continuous
Improved Method and Step by Step Guide. The third and last construct, People, is composed of two second-order concepts,
Employee Involvement and Agenda Availability and Priority. Later on, the critical success factors that constitute each
second-order concepts were defined, and they are presented in Section 4.
International Journal of Production Research 2887
Figure 1. Decision tree – development of the dataset.
2.3. Multiple case studies

2.3.1. Data collection
Multiple case studies were conducted following the inductive theory-building approach of Eisenhardt (1989). Since sus-
taining lean healthcare gains in the long term has not been well studied, the inductive case study approach helps generate
valuable insights. The qualitative data comes from six different hospitals in Brazil. Data collection involved multiple rounds
of interviews over a two years’ period. We conducted a longitudinal case study since it is the most appropriate method to use
when the research question focuses on designing and describing the outcomes of a proposed solution (Stuart et al. 2002).
This approach allows us to study the experiences of managers in a real-life context, and increases the practical relevance of
the findings (Yin 2013).
2.3.2. Cases selection

This study uses a purposive sampling strategy in order to control extraneous variation and to help to define the limits
for generalising the findings (Patton 1990). Multiple case studies were conducted to increase generalisation of the results
(Eisenhardt and Graebner 2007). We selected six hospital units that follow four criteria for case selection. First, they had
to begin their lean implementation at least 18 month ago, so they had some experience with sustaining the lean tools.
Second, we included in our sample hospital units with both positive and negative experiences with implementing lean.
The hospital units with positive experiences, i.e. were able to sustain most of the lean practices, were important because
we could verify if they actually were consistently working on all the CSFs, and to reveal new CSFs. The hospital units
with negative experiences, i.e. were not able to sustain the lean practices, were also important because we could validate if
they were indeed not following the CSFs. Third, we did not want to restrict the sample to hospitals that worked with the
same consulting company, so we selected cases that have hired different consulting companies to implement lean. Forth, we
included hospital units that had a range of different levels of implementation of lean practices, in order to verify if the CSFs
were the same in these different settings.
Table 1 summarises the case profiles. All the performance outcomes shown in Table 1 were attributed by the company
to their lean initiative.
2.3.3. Site visits

We designed the initial interview protocol based on the literature review. The interview protocols were designed based on
the organisation position of the interviewee. The initial interview protocol consisted of a series of open-ended questions
about existing lean practices from the literature and additional questions about the interviewee’s opinion on sustaining lean.
2888
Table 1. Summary of the six hospital units
Hospital Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
Hospital Privaty oncology clinic Philanthropic hospital Philanthropic hospital Private hospital unit, Philanthropic hospital Private hospital
characteristics with chemotherapy unit, essentially public unit, Oncology Care carries out procedures unit, Oncology Care unit, carries out
and drug infusion service (medium and of high complexity procedures of
applications high complexity) medim and high
complexity
Number of beds 0 273 166 187 76 88
Number of 320 1400 1300 1100 600 500
employees
Number of 2 (Nurse Director and 3 (CEO, Physician and 3 (CEO, Quality Manager, 4 (President, Nurse 3 (Clinical Director, 3 (Quality Manager,
informants and Quality Manager) Quality Manager) Administrative Manager, Quality Administrative Director Nurse Manager, IT
position Manager) Manager, Lean and General Manager) Manager)
Consultant)
Beginning of lean May-14 Sep-14 Jan-14 Feb-12 Mar-11 Mar-15
implementation
D. B. Henrique et al.
Hired a consulting No Yes Yes Yes Yes Yes
firm
Motivational Possibility to produce Dissemination of Search for financial The reasons for imple- The institution was in Excess of materials
factor for lean more with less effort the continuous equilibrium. Fixed menting Lean financial trouble and and medicines in the
implementation improvement culture revenue over the Healthcare in the needed help to leverage hospital. Constant
throughout the years due to the hospital were the operational gains. shortages, loans
Institution – a strong frozen SUS table opportunities to become with other hospitals,
desire for employees to and rising expenses more competitive and lack of control at
absorb the culture of (wage settlements, effective, considering points of use. This
combating waste and high dollar prices on that the company’s is what motivated
promoting continuous imported materials, business model is a hospital leaders to
improvement inflation of materials model of operational look for a solution in
and medicines) caused competitive advantage. lean.
a major financial
imbalance
Initial focus Information flow: Material flow: Stock Patient flow: Material flow: CME Patient flow: Material flow: Stock
Authorisation and reduction Chemotherapy Chemotherapy reduction
Scheduling
Main results • Patient rescheduling • Reduction of R$ • Reduction of 66% in • Reduction of R$ • Chemotherapy billing • Reduction of 42%
of the lean rate: 2015 (14%) – 800,000.00 in general medication delivery 1,150,000.00 per year increase + 35% in the stock of
implementation 2016 (8%) costs of the Institution delays in general costs materials and
medicines
(Continued).
Table 1. Continued.
Hospital Case 1 Case 2 Case 3 Case 4 Case 5 Case 6
• Mat / Med dispensation • Reduction of 50% in total • Reduction of 45% of • Reduction of 10% in the • Increased number
International Journal of Production Research

compliance rate: 2015 inventory (R$ 700,000.00) Lead Time delivery of average time spent in of patients seen on
(81%) – 2016 (98%) Anatomopathological the hospital chemotherapy + 28%
exams (from 11 days to 6
days)
• Authorisation fee in the • Increase of R$ 500.000,00 • Increase of 30% of the • Reduction of 40% in the • Reduction of waiting
expected period: 2014 in revenue storage capacity of Medical stock of materials and times for onset of
(85%) – 2016 (96%) Records in the Medical medicines chemotherapy – 84%
File
• Early drug handling rate: • Reduction of 60% in nursing • Increase of 20% in • 60% reduction in billing • Increase in radiotherapy
2014 (47%) – 2016 movement the turnover of the gloss levels billing + 23%
(70%) Chemotherapy sector
• Rate of bills delivered • Reduction of 53% (R$ • Reduction of hospital • Reduction of waiting
on time: 2014 (83%) – 650.000,00) of the global infection levels to near time for radiotherapy
2016 (97%) stock of drugs and zero treatment – 28%
antineoplastics
• Infusion room occupa- • Increase of the capacity
tion time: 2014 (2.3 h) of the Autoclaves in
– 2016 (1.7 h) the Central of Materials
sterilised in 65%
2889
We used the literature review as a starting point, and then investigate any additions, enhancements or deviations from the
literature which could contribute to sustaining lean performance in healthcare. It made possible to evaluate the differences
of sustaining lean in the six case studies. In addition to the interviews, during the visits, we were able to walk through the
hospitals, make observations, talk to other employees, and analyse documents related to lean projects. All visits occurred
between 2016 and 2017.
2.3.4. Interviews
The first round of interviews typically included three activities in parallel by the researchers: leading discussion, taking
notes, and asking additional questions. During the interviews, the researchers probed informants with questions and encour-
aged them to discuss additional managerial practices or concepts that might affect the sustainability of lean in their hospitals.
The interviews included people from the strategic level (CEO or director) and operational level (managers). It is important to
have multiple sources of evidences with different professional backgrounds because lean implantation in hospitals involves
a large range of professionals, such as management, doctors, nursing, IT staff, etc. A single source of evidence for inter-
views could limit the understanding of the CSFs and generate misperceptions about lean sustainability. Also, sustaining lean
demands the direct involvement of employees in all organisational levels, from top executives to ‘shop floor’ staff. Thus,
it is important to know what was senior management level role, and their perception of lean implementation. In addition,
everyone in the organisation has its role in the sustainability of lean. For instance, the nurses have the responsibility of
keeping the visual standards on the hospital floor, keeping things organised and clean, and the management team has the
responsibility of controlling that operational performance metrics reflect the organisation strategic KPIs. It was asked the
informants of each hospital to describe several factors that influence the sustainability of lean healthcare gains over time.
These questions included: ‘In your opinion, after the implementation of the lean programme, has the continuous improve-
ment culture become part of the company?’ In positive case, ‘cite the main aspects that influenced in bringing this new
culture to the company’. In negative case, ‘cite the main aspects that contribute to failure’ and ‘what the main barriers faced
during the pre-implementation, the implementation and post implementation phase’ and ‘any ups and downs’ and ‘what the
main critical factors that ensured the success of lean implementation and maintenance’.
All interviews lasted between one hour to one hour and a half, and specific questions were targeted to the informant’s
expertise. They were tape-recorded, transcribed, and assembled into manuscripts that contain details of each of the six
hospitals for the qualitative data analysis (Andriopoulos and Lewis 2009; Gioia and Thomas 1996; Miles and Huberman
1994). Additional archival data such as internal audit reports of lean performance ratings, value stream mappings, kaizen
events presentations and historical key performance indicators were also collected to help minimise bias (Langley 1999). In
the first round of interviews, a total of 18 interviews were completed in 2016.
2.3.5. Qualitative data analysis

The qualitative data analysis began with a within-cases analysis followed by a cross-cases analysis (Miles and Huberman
1994). The researchers familiarised themselves with over 100 pages of transcribed interviews and they had several meetings
after the interviews to compare and contrast hospital units. The qualitative analysis started with a within-cases analysis of
each hospital unit to understand how they did or did not sustain the lean implementations. The researchers read the inter-
views’ transcripts individually and filled out the framework for the CSFs in four columns. The first column was to check
for the presence or not of each CSF on the hospital unit. The second column was to include quotes from the interviews
with evidences of the presence or not of each CSFs. The third column was for the researchers to include sentences of the
interviews that would support the importance of that CSFs to the cases according to the interviewees. The forth column was
to insert statements that exemplify the impact of the existence or not of the CSFs. Case summary reports were prepared and
reviewed to improve validity (Yin 2003). Then, we conducted a cross-cases analysis of hospital units to compare units with
higher and lower levels of sustainability of lean. The cross-cases comparisons helped rule out hospital unit-specific char-
acteristics and extract common reasons. This resulted in validating the first-order concepts of sustaining lean in healthcare
found previously in the literature and originated new success factors. These analyses came from comments, interviews, pri-
mary observations and materials analysed. The relevant literature was incorporated at this stage to conceptually understand
the emerging concepts, which also provided an additional source of validation (Eisenhardt 1989).
We tabulated the data to show evidence of the importance and presence/absence of each factor as they appear on the
transcripts. For example, referring to the Audit tools, the quality manager at CASE 4 stated that:
If it were not for sustainability audits, especially at the very beginning of the project, we would certainly have returned to the state
before the improvements. People are accustomed to doing their jobs in one way and do not want to leave the comfort zone. The
application of audit checklists shortly after the changes that occurred during kaizen events were fundamental for everyone to follow
if the new standards were being applied. These routines went on for a long time, until the new process was really rooted in the
organization.
Also, regarding the auditing tools, the nurse director of CASE 1 stated that:
We have the process audit, which is carried out periodically through check list, generating a note for the sector responsible for the
process. In addition to the audits, we set up bonus programs for sectors with a higher compliance rate. It is important to say that
long before lean arrived at the hospital, we had already lost many improvements, and in my opinion these losses occurred precisely
because we had not properly monitored the new processes.
As a negative example, the general manager at CASE 5 (low) pointed out that
a big failure was not to devote too much time to post-implementation monitoring. When the consulting firm was still helping us, the
audit process worked well and the new processes were in order. With the exit of the consultancy, the audits ceased to happen and
much was lost. I think the big failure was not having invested in building a continuous improvement team internally, and having
become so reliant on consulting.
These statements were used to support the list of factors proposed by the literature and to improve their description in order
to better capture the nuances of the enhanced list of factors.
2.3.6. Framework enhancements based on case studies

Three new factors were included in the frameworks after the first round of interviews: (i) Value Stream Map; (ii) Focus
on Material Flow as a pilot; (iii) Active participation of the IT professional. These three factors were then included in the
framework for the second round of interviews. We circled back to the literature to provide a description of these three factors
and included them in the tabulated data table.
2.3.7. Additional interviews and data analysis

The second-round interviews focused on gathering additional data that would help verify or shape the new success factors
that emerged from the first round of interviews. These interviews also provided additional information about changes in
the hospital unit’s lean practices and performance. During the second-round interviews, the researchers gave interviewees
an overview of the concepts that emerged from the first round of qualitative analysis and solicited their feedback about the
emerging concepts.
For the evaluation of each of them, we focused on quantitative and qualitative indicators of sustaining performance over
time. Some quantitative examples are sustainability audit ratings, adherence to the routines implemented, data on the amount
of training on lean principles, number of persons involved, performance indicators evolution in the value streams worked
such as average time spent in beds, inventory levels, total treatment lead time, patient satisfaction and patient safety. These
indicators demonstrate quantitatively whether aspects of sustainability were maintained over time. There are two types of
indicators: (i) the sustainability of the indicators themselves, as the auditing rating and the number of trainings and (ii) the
control of impact in operational performance, such as the average time per patient in beds, inventory levels, total treatment
lead time, etc. Performance data from archival sources helped to verify the lean sustainability in the hospital units.
Multiple contacts with the informants over time also provided relevancy to the concepts and theory that emerged from
this study (Emden, Calantone, and Droge 2006; Madhavan and Grover 1998). The second round of interviews resulted in
another 18 interviews done in 2017. Then, we went back and forth between the concepts, second-round interview data, and
existing literature to better refine the new propositions (Eisenhardt 1989; Yin 2003). Additional literature was brought in at
this stage (see for example Nabelsi and Gagnon 2016; Li, Papadopoulos, and Zhang 2016; Cardoen, Beliën, and Vanhoucke
2015; Hicks et al. 2015). This iteration process resulted in the proposed framework that emerged from the comparative case
study and the existing literature.
2.4. Evaluation of the levels of the sustainability of the hospital studied using the proposed framework
The proposed framework has 25 critical success factors (CSF). For the evaluation of each one of the CSFs, we focused
on quantitative and qualitative evidences of lean sustainability over time. For instance, examples of quantitative evidences
are sustainability audit ratings, adherence to the routines implemented, data on the amount of training on lean principles,
number of employees involved, performance metrics variation such as average time spent in beds, inventory levels, total
treatment lead time, patient satisfaction and patient safety. Operational performance data from archival sources helped
verify the sustainability of lean. For example, CASE 1, CASE 2, CASE 4, CASE 5 and CASE 6 provided several years
of internal audit reports made by the quality. The archival data sources from these hospitals in some cases exceeded four
years. In the qualitative form, we evaluated issues such as people’s involvement, level of knowledge and application of lean
tools, people’s ability to apply a continuous improvement method and others. The qualitative evaluations refer to interviews
and visits. Then, we classified the hospitals into three levels of lean sustainability (High, medium and low), based on the
adherence of maintaining CSFs over time. The final evaluation took into account the following criteria:
• High level of sustainability: Hospitals that on average had more than 90% adherence in maintaining the CSF
initially adopted over time (after 18 months).
• Medium level of sustainability: Hospitals that on average had between 50% and 90% adherence in maintaining the
CSF initially adopted over time (after 18 months).
• Low level of sustainability: Hospitals that on average had less than 50% adherence in maintaining the CSF initially
adopted over time (after 18 months).
3. Results
3.1. Overview on lean sustainability
There are several authors that highlight the importance of sustaining lean in healthcare. For instance, a systematic and
critical review made by Brandao de Souza (2009) identified the need to focus on the sustainability of lean implementations
in hospitals. Poksinska, Swartling, and Drotz (2013) proposed that the lean healthcare research agenda should focus on two
main areas: long-term performance of the health care system and the influence of the work environment in implementations
of processes improvement. In another lean healthcare systematic review presented by Mazzocato et al. (2012), the authors
reinforce that the success of lean thinking in healthcare, however, no cases of failure were discussed, and no long-term
sustainability question was addressed. Recently, Costa and Godinho Filho (2016) claim that a gap in the lean healthcare
literature is to explore the barriers and lessons learned to sustain the process changes through a lean journey in healthcare.
For D’Andreamatteo et al. (2015), there is still a lot to know about how to implement and sustain lean over time. Several
studies in the literature report that there is a gap of more in-depth studies on how to sustain lean improvements in the long
term in hospitals (see Nabelsi and Gagnon 2016; Li, Papadopoulos, and Zhang 2016; Cardoen, Beliën, and Vanhoucke 2015;
Hicks et al. 2015). In the systematic literature review conducted by Henrique and Godinho Filho (2020), the authors found
that about 85% of the empirical papers published about lean, six sigma and lean six sigma in healthcare environments not
even mentioned any sustainability aspect of the improvements and none of them described how lean initiatives were after
24 months of the beginning of the programme.
3.2. Framework construct 1: lean tools

By definition, sustaining improvements in hospital environments requires the organisation to properly and efficiently apply
lean tools. Although Bhasin (2012b) found in his study that lean tools are not critical success factors in lean implementations,
several other authors support the importance of certain lean tools for long-term success and sustainability of improvements
(Pepper and Spedding 2010; Hines et al. 2011). To achieve a high level of lean healthcare sustainability, hospitals need
to invest in training whether on theoretical or on the job trainings, with the support of aa expert, or sensei, for example.
Specifically, for the improvements sustainability in hospital environments, lean tools are divided into two groups: (i) Audit
tools of the implemented new standards and (ii) Tools for the development of a continuous improvement system.
3.2.1. Lean audit tools

Lean systems aim to refine and improve existing products and processes. A crucial factor related to the maintenance of
the new lean procedures implemented in the formulation of a routine of audits of the new processes since there is a need
of constant monitoring of the new work standards to identify possible deviations (Sisson and Elshennawy 2015). Upton
(1996) describes the practice of auditing as ‘structures to prevent setbacks’. Araújo and Rentes (2006) agree that, in the
post-implementation phase, there should be a concern with the anchoring of the improvement through audits, in the form of
management by rounds. To do this, they suggest that a verification checklist should be implemented to formalise the audit
process. As a result, audits work as a way to prevent setbacks and maintain the quality of the work. According to Murphree
and Daigle (2011), hospitals with strong adherence to the application of audit check-lists after kaizen events are more likely
to support lean implementations.
Additionally, companies that develop incentive programmes and competition among areas for rewarding the best sus-
tainability notes tend to maintain the improvements implemented in the long term more efficiently. These competition
programmes and awards make employees see greater importance in control procedures consequently feel more motivated
to sustain the new procedures and continue to improve (Araújo and Rentes 2006).
3.2.2. Lean sustainability tools

Several authors, such as Guimarães and de Carvalho (2012), Toussaint and Berry (2013), Poksinska, Swartling, and Drotz
(2013), Fillingham (2007), Henrique et al. (2016), Sobek II and Jimmerson (2004), Murphree and Daigle (2011) cite some
lean tools, as work standardisation, A3 method, key performance indicators, kaizen events, visual management boards,
gemba walk, as sustain lean in healthcare.
Work standardisation, for example, is essential for organisational learning. The work standardisation gives the possibility
to identify if the work is being executed in the planned way or not. It is a fundamental tool for organisational learning since
it registers the best way to perform a certain task known up to that moment (Liker and Hoseus 2008; Shah and Ward 2007).
Also, the A3 method is used to tell the story of a given project on a single sheet (A3 size of paper), containing the objective,
the current situation with the problems, the projected situation, the action plan outlined and the monitoring indicators. In
the same way, according to Sobek II and Jimmerson (2004), companies that use the A3 method are able to communicate
better and simpler the process of change, being more likely to sustain lean improvements in the long term. Monitoring the
key performance indicators is fundamental to avoid setbacks and continues to seek to improve the performance over time,
contributing to the maintenance of the lean system implemented (Kaye and Anderson 1999; Garcia-Sabater and Marin-
Garcia 2011; Parry and Turner 2006). Companies that use the Kaizen Event as a tool to implement improvements gain
greater adherence from people in the control phase and have more chances to sustain lean improvements (Van Aken et al.
2010; Chen, Li, and Shady 2010). It is also interesting to note that the visual management of problems, indicators, and
improvements through boards is a critical success factor to maintain lean implementations. Visual management boards
are very important to communicate what problems are happening, planned improvements are going, and how the key
performance metrics. This tool exposes to everyone in the organisation important metrics on the evolution of the lean
journey and has an essential role to control what has been implemented, creating mechanisms to a continuous improvement
culture in the organisation (Toussaint and Berry 2013; Poksinska, Swartling, and Drotz 2013; Liker 2004). In the same way,
the practice of Gemba Walk, where all levels of the organisation go where things happen to see problems for themselves
and discuss solutions is also crucial to sustaining lean improvements (Glasgow, Scott-Caziewell, and Kaboli 2010; Brandao
de Souza and Pidd 2011; Toussaint and Berry 2013; Rahani and Al-Ashraf 2012).
3.3. Framework construct 2: lean methods

To achieve a high level of lean healthcare sustainability, hospitals should follow a well-structured method that uses scientific
way of thinking and solve problems, such as PDCA or DMAIC. Also, the hospital should clearly define sequence of steps to
implement lean, identify the key people involved, and manage the lean implementation as a complex organisational change
project. This includes definition of the right tools for each time, leadership standard routines and following the lessons
learned in the literature and in other experiences (Shah, Chandrasekaran, and Linderman 2008; Cottyn et al. 2011). Thus,
it becomes essential for hospital units to have these two characteristics: (i) continuous improvement method and (ii) step
by step guide, lessons and routines. In the end, a structured method of problem solving and leadership routines will guide
people to the expected lean culture (Mann 2005).
3.3.1. Continuous improvement method

The application of process improvement techniques has increased in popularity especially for healthcare, and to implement
these techniques, researchers, in general, apply some type of conducting methodology (DelliFraine, Langabeer, & Nembhard
2010). The most known methodologies are the Define, Measure, Analyse, Improve and Control (DMAIC) and the Plan Do
Check and Act (PDCA). DMAIC and PDCA are the continuous improvement methods most used by companies (Nicolay
et al. 2012; Assarlind, Gremyr, and Bäckman 2012). The PDCA and the DMAIC are very similar methods, with the same
objective: to structure a scientific process of reasoning to solve problems and to lead improvement projects (Nicolay et al.
2012). Nevertheless, in a systematic literature review about empirical studies in lean and six sigma in healthcare, Henrique
et al. (2016) showed that the majority (55.9%) of the works studied by them have not cited any continuous improvement
method to conduct their implementations. Marodin and Saurin (2015) used a case study to provide empirical evidences
about how tools and methods used to implement lean practices are important to achieve a higher level of use and sustain
those lean practices on the shop-floor.
In addition, it is also important to say that companies that constantly invest in training their employees in the continuous
improvement method and lean techniques have a greater chance of sustaining lean implementations (Lee 2007; Bhasin
2011a, 2011b, 2012a; Glasgow 2010; Brandao de Souza and Pidd 2011). Lack of training is also constantly pointed out as a
barrier to the implementation of lean in manufacturing environments (Netland 2016; Marodin and Saurin 2015).
3.3.2. Step by step guide, lessons and routines

In addition to the method itself, one of the things that seems to make a difference in the lean healthcare sustainability of
the studied hospitals is to have a template with the step by step to be followed within each of the phases of the method
before starting the implementation. Bhasin (2012b) determines common characteristics that can be differential to success
in lean implementation and reveal the fact that a well-structured method can drive people in the direction to create a lean
culture and in consequence to have success in a lean journey. Many other authors also indicated that a set of structured
steps within the methodology could be a decisive factor for the success of a lean implementation (Shah, Chandrasekaran,
and Linderman 2008; Liker and Hoseus 2008). Murphree and Daigle (2011) identify that having a well-defined routine of
follow-up in the post kaizen event is essential to control the newly established standards and avoid losing what has been
implemented. Glasgow (2010), Brandao de Souza and Pidd (2011) indicate that the process of communicating the initiatives
and the results achieved throughout the organisation is also a critical success factor for lean implementations in hospitals.
The same authors comment that the alignment of actions and results among employees increases the motivation and the
sense of ownership of the project, contributing to long-term success. Liker (2004) brings long-term thinking as one of the
principles of the Toyota production system. According to the author, any decision made at Toyota should be based on long-
term thinking, even in the detriment of short-term financial losses. Similarly, Drew, McCallum, and Roggenhoffer state
that the most successful lean initiatives are precisely those that not stop encouraging and investing in lean during the first
difficulties. In the same way, these same authors reinforce the importance of decisions taken in consensus by those involved
in the operation and not by unilateral top-down decisions. Liker and Hoseus (2008), Bhasin (2011a) and Bhasin (2012a)
further argue that lean initiatives should always be based on the company’s strategy, aligned with the established strategic
objectives. This makes improvement efforts impact on better results for the organisation and has a long-term continuity,
being also a strategic tool for improving global results. Finally, another critical success factor for the success of long-term
lean implementations identified in the literature is the project focus (Hines et al. 2011; Bhasin 2012a; Brandao de Souza
2009). For these authors, it is better to initiate a specific and realistic project at a time rather than initiating various global
efforts without proper control of the process improvement as a whole.
3.4. Framework construct 3: lean people

Process improvement tools and methods are important, but their ultimate effectiveness depends on the ability to develop the
underlying culture in support growth and continuous improvement. If people were not who understand the culture behind
this system, there would be no operational excellence and organisational performance at Toyota (Holweg and Pil 2001).
They manage the system, define the path, the use of tools, verify and solve problems, present questions and concepts to
other employees, manage projects and form the culture of support. It is also the people who support the philosophical aspect
of the system: it is the people who put the client first, check the issues to be solved, do the Gemba Walk, and think about
efficiency and operational excellence. Understand the lean thinking as more than a set of mechanistic tools and techniques
means considering the dimension’s motivation, empowerment and respect for people. Indeed, these elements are essential
for the long-term sustainability of any lean programme, independently of the sector (Hines, Holweg, and Rich 2004).
To achieve a high level of lean healthcare sustainability, hospitals should involve people at all stages of implementation.
For this, it is important to invest in training, in releasing people time to focus on lean, and in an unrestricted support from
the hospital’s top management.
3.4.1. Employee involvement

Many authors cite the full relevance of involving people to succeed in the lean journey in different segments, including
healthcare (Smalley 2005; Lee 2007; Ohno 1988; Bhasin 2011a, 2011b, 2012a; Tapping, Luyster, and Shuker 2002; Eriksson
et al. 2016; Godinho Filho et al. 2015). In healthcare, for example, many authors, such as Eriksson et al. (2016) and Godinho
Filho et al. (2015) believe that the participation of physicians in lean healthcare projects is a mandatory condition for the
success of the sustainability phase of lean improvements. In hospital settings, where the medical professional is the only
one with real autonomy in decision making, Vink, Imada, and Zink (2008) and Eriksson et al. (2016) also believe that the
effective participation of the Senior Executive in the day-to-day of the project becomes even more essential. The author
argues that this is because the sponsor is the only one who has a hierarchical position above the physicians. In the same way,
health professionals, such as nurses and pharmacists, are the real system operators and who make the operation happen. Their
participation in the project and their conviction about the importance of lean are key success factors for the sustainability of
lean improvements (Brandao de Souza 2009).
3.4.2. Agenda availability and priority

According to Smalley (2005), to develop a sustainable lean transformation, companies need to develop employees. Many
companies have set up a special group known as ‘lean change agents’ in charge of lean production. The same author agrees
that it is necessary to have such dedicated resources in order to start a programme and keep up the momentum. The formation
of an internal lean team focused on making improvements, and responsible for replicating their knowledge through the
organisation is a mandatory condition of success for expansion and sustainability of the lean programme (Ben-Tovim et al.
2007).
The literature also suggests the need to initiate a specific and realistic project at a time rather than initiating various
global efforts without proper control of the process improvement as a whole (Hines et al. 2011; Bhasin 2011a, 2012a).
This sense of priority has a lot to do with the availability of time for hospital professionals to devote themselves to the
lean efforts in which they are involved. The focus of the leadership, with availability to give the necessary attention to the
project corroborates on a large scale for the success of the lean sustainability (Eriksson et al. 2016; Liker and Hoseus 2008).
According to Lee (2007), the engagement and training of the organisation’s employees are absolutely vital to the successful
implementation of the most diverse concepts of operations management.
3.5. Refining the framework

The first new factor included in the framework that emerged from the case studies was related to the use of Value Stream
Mapping (VSM) to sustain the implementation, not only at the initial deployment step. VSM is largely used to improve
operations in healthcare (see Henrique et al. 2016; Tortorella et al. 2017), but it is not mentioned as a critical factor to sustain
continuous improvement. However, it proved to be a decisive tool to achieve long term sustainability in the hospitals studied.
The importance of the VSM specifically to control and sustain the lean implementations appeared in multiple interviews.
For example, according to the president at CASE 4:
For me, the lean tool that made the most difference during the entire process was value stream mapping (VSM). The VSM was
important in the waste identification phase, in the future state construction phase, and especially in the sustainability phase, since
whenever we had a problem, we used the value stream analysis to identify the best way of solving it.
In the same way, the quality manager of CASE 1 suggested that:
What caught my attention in the methodology we used was to perform both current and future value stream mapping in a Workshop
format, involving all key people. This mapping process brought an ownership feeling to those involved, and, in my opinion, it was
what made the most difference for us to succeed in sustaining.
The second new factor that emerged from the case studies was to focus on ‘support’ flows as a pilot. It was verified
through the results of each studied case and in the comparison between the cases that hospital units which started their
lean initiatives through ‘support’ flows were more likely to sustain the improvements in the long term. There are three
major workflows in hospitals: (i) patient flow; (ii) information flow, and; (iii) materials flow (Henrique et al. 2016). In the
cases studied, it is possible to see lean implementations in these three different flows. Lean implementations that involve
patient flow are related to bed management, operating room optimisation, emergency room improvements, etc. Lean in the
materials flow refers usually to stock reduction, sterilisation and distribution of surgical instruments and dispensing of drugs
in the Pharmacy, etc. Lean implementations that involve the information flow are usually related to authorisation, billing,
information technology, and purchasing, etc.
The cases studied demonstrated that hospitals which started the lean project by areas focused on improving flows with
less interface with the physicians achieved better results in the long term. Starting lean initiatives through flows with less
medical interface does not mean not involving them, but engaging them in a more subtle way, showing the results and
breaking the initial resistances. As an example of the evidences collected on the interviews, the President of CASE 4
commented as follows:
We purposely started by the sterilized materials flow, since the medical staff did not believe in lean and were resistant. This strategy
worked very well, since we achieved expressive results that even impacted the life of the physician, such as eliminating the delays of
sterilized surgical instruments for performing surgeries and reducing the level of hospital infection in clean surgeries to zero. These
results caught the attention of the clinical staff, and some physicians asked me to start doing lean in the patient flow as soon as
possible, with necessary improvements in the operating room, in bed management, and in the emergency room.
Additionally, the Clinical Director of CASE 5 pointed out:
We found resistance from the physicians when we started the project by the chemotherapeutic patient flow. Since the patients were
often in a critical condition, the clinical staff did not want us to change any procedure, even the administrative ones. This posture
influenced the other professionals involved, such as nurses and pharmacists, since the physician has hierarchical power over them.
The third new factor that emerged from the case studies was the active participation of the information technology (IT)
professionals on the lean implementation. Several authors (e.g. Eriksson et al. 2016; Vink, Imada, and Zink 2008; Langabeer
et al. 2009; McGrath et al. 2008; Godinho Filho et al. 2015) cite the importance of engaging senior management, physicians,
nurses, pharmacists, and other health professionals as essential to increasing the chances of success in lean implementations
in hospitals. However, although it did not appear in the literature review, the IT professional demonstrated to have important
and differentiated skills to assist in the implementation and sustainability of lean healthcare.
As an example of how the importance of IT professional effect Lean sustainability, the President of CASE 4 commented
that:
Among the members of our lean team, a professional who caught my attention was the IT professional. Despite being a professional
outside the health area, his integration into the team provided a much broader systemic vision, and greater ease of searching for
data and information. I see that his participation was even more important in the sustainability phase, because all the changes that
occurred in the system were mapped and easily managed.
Hospitals CASE 1 and CASE 6 also had active participation of IT professionals in their lean implementations. The clinical
director of CASE 1 after being specifically questioned about the role of the IT professional in the hospital, emphasised: ‘It
is not enough to have just the medical care vision. We need to involve professionals who have a vision from outside and
the IT professional was essential for this.’ The CASE 6 quality manager told us: ‘Nowadays everything in the hospital is
computerized. All processes are also digital. How could we make process improvements without the active participation of
an IT professional?’
3.6. Framework
Figure 1 presents the practical framework that emerged from the above analysis. All the first-order concepts consolidated
during the literature review were analysed and showed to be differential factors among the hospitals that achieved long-term
lean sustainability over those which did not. In addition to the 22 critical success factors from the theoretical assessment, 3
new success factors were originated through the analysis of the cases and these were organised within the 3 main constructs
already emerged from the literature: People, Methods, and Tools.
3.7. Case analysis

Cases studies were performed in six hospital units, each unit is in a different hospital. Table 2 shows the respective
sustainability level of the six hospital units, with a ‘V’ for every CSF that was present on the Case and with a ‘X’ otherwise.
CASE 1 had a high value on the assessment, with 92% of the CSF that was being used on the first visit (23), and all 25
were identified at the second visit. That represents 100% level of sustainability of the CSFs over time, and the expansion to
cover new CSFs. CASE 4 was the second case in terms of use of CSF, with 92% (23) on the first visit and 96% (24) after
18 months. In CASE 4, all the CSFs were maintained and one was added. As such, we classified CASE 1 and 4 as a high
level of sustainability of lean healthcare.
CASE 2 and CASE 6 were considered a medium level of sustainability. For CASE 2, the initial assessment had 56%
(14 CSFs) of sustainability and the second 48% (12 CSFs), and for CASE 6 the results were 72% and 68%, respectively.
Both cases show efforts to implement and sustain lean, but they also show a slight decrease in the use of the CSFs. The
sustainability score was 71% for CASE 2, and 78% for CASE 6.
CASE 3 and CASE 5 were both considered to have a low level of sustaining. CASE 5 score the least in sustainability,
because it had 44% of the CSF on the first visit, and only 8% on the second visit, with a final sustainability score of 18%.
CASE 3 had a sustainability score of 30%, as they were using 40% of the CSFs at the first visit, and 12% on the second
visit.
It is interesting to note that despite the different sustainability levels achieved, all hospitals initially achieved significant
results in their key performance indicators. The problem is that when facing the first difficulties and obstacles, hospi-
tals CASE 3 and CASE 5 lost what was implemented. These hospitals generally did not involve key people during the
implementation process, did not use the lean control tools, and did not follow a structured approach during their lean
journey.
Hospitals CASE 2 and CASE 6 also failed to stabilise what was implemented with great success. These hospitals have
difficulty in prioritising lean initiatives within the organisation and investing in training and empowering their employees.
It has been observed that these hospitals, despite many advances, still fail to build a culture of continuous improvement and
people’s confidence to get out of their routines and get involved in the improvement process.
Lean Healthcare assessment framework.

Figure 2.
2898
Table 2. Cross-cases comparisons across three main theoretical themes and sustainability aspects.
D. B. Henrique et al.
Hospitals CASE 1 and CASE 4, in turn, consistently invested in training people, creating a continuous improvement
culture and dedicating time and resources for lean implementation. Both implementations were oriented through a structured
method of driving change.
4. Discussions and conclusions

4.1. Contributions to theory
This article proposes a framework to assess the sustainability of continuous improvement implementation of Lean in health-
care. Through a literature review and multiple longitudinal case studies, we developed and validated 22 main critical factors
of lean sustainability in hospitals. This study contributes to the literature by organising concepts previously disconnected in
a theoretical framework assessment to sustain lean initiatives in the healthcare sector, testing these concepts in the practice
and complementing it with new propositions. The comparative case analysis provided additional evidences of the impor-
tance of those the CSFs and the existence of three new CSFs. We offer an evolutionary dynamic perspective of sustaining
lean in healthcare, which has not been fully considered in the past.
To the best of our knowledge, this paper is the first to attempt to bring together the key factors that influence hospitals to
sustain lean improvements in the long term. Another interesting contribution to theory is to provide evidence that although
some lean practices are very well known, they are still difficult to implement and that hospitals are struggling to implement
some basics lean concepts. Indeed, many researchers assert that the literature in lean healthcare is specifically built on
positive cases (see Holden 2011; Mazzocato et al. 2012). Dickson et al. (2009) claim that a few cases in the literature
demonstrated impacts other than positive. These authors also agree that it would be important to learn from unsuccessful
initiatives and, generally, to apply a more critical view to evaluate Lean in healthcare.
4.2. Propositions
Three CSFs emerged from the case studies. The first one, the use of Value Stream Mapping shows that the tool is not only
important for the implementation of lean, as advocated by the literature (Henrique et al. 2016; Tortorella et al. 2017), but
also to sustain lean in the long run. When comparing hospital units, it is possible to conclude that hospital units that have
continued to use VSM for discussions and continuous improvement specifically in the Control phase were the most success-
ful in long-term sustainability (CASE 1 and CASE 4). In the other hand, hospitals with lower or medium sustainability did
not use VSM at all, or had some maps drawn by the consulting company at the beginning of the implementation, without the
involvement of the key people. As such, employees from that hospital unit did not had the opportunity to learn how to use
VSM and to adapt the tool to their needs. Adaptation of lean tools is essential in the implementation and sustainability of
those tools (Boscari, Danese, and Romano 2016). In addition, VSM can be used as a communication tool, in order to reduce
the fear and anxiety about the changes that will happen during the implementation process (Marodin and Saurin 2015). As
such, our first proposition can be described as follow:
Proposition 1: It is important for hospital units to map the current state of their processes and design improved future
state for those processes, such as using the Value Stream Map tool, in a regular bases (e.g. once a year) order to keep
improving their operations and to sustaining lean.
The second CSF that emerged from the case studies was that the focus of the pilot implementation of lean should be
on the material or information flow. We can assume that there are two reasons for the importance of this factor. First,
information flow and material are not as critical and important to the hospital as the patient flow. As lean in healthcare is a
very new topic in Brazil, very few people are familiar with the concepts of lean, and in a hospital environment people are
very concern about making everything possible to keep the quality of the services for the patients. First implementing on the
other flows, not patient flow, would reduce the fear of changing processes for all people involved. As results start to appear
and people get more familiar with lean, it will be easier to convince people to expand to the patient flow, which has more
potential gains to the hospitals (Brandao de Souza 2009). In fact, front line workers’ resistance to change is one of the most
importance barriers to implement lean (Marodin and Saurin 2015).
The second reason the importance of not starting with the patient flow is the fact that the improvements can be done with
minimum involvement of doctors. In healthcare environments, doctors have the highest ranks and the nurses and technician’s
role is to support the doctor’s activities. In that scenario, working with information and material flow reduces the impact and
involvement of the doctors at this beginning stage, which can be beneficial to help gain their support after some results are
already showing. It is possible to notice, from the data and evaluations, that hospitals that obtained the highest sustainability
index (CASE 1 and CASE 4) started with administrative flows (information and materials, respectively), while the worst
evaluated hospitals (CASE 3 and CASE 5) started their lean journeys through the patient flow. The second proposition
comes as follow.
Proposition 2: It is important for the sustainability of lean in healthcare that the pilot implementation of lean should
focus on the information or material flow.
The third CSF that came from the case studies was the inclusion of people from IT in the implementation process. Over
the last decade, information technology has increasingly been seen as a critical lever for improving the quality, safety and
efficiency of health systems (Chaudhry et al. 2006). Once processes by which new technologies in healthcare are adopted and
implemented between various relevant actors and networks, IT professionals can create a better interface with all players,
from physicians to analysts (Webster and Wyatt 2007). As such, it becomes important to improve the flow of materials and
information be using IT solutions.
In the case studies, the hospital units with higher scores on the sustainability assessment all involved heavily the IT
professional in all steps of the implementation. That allows them to develop the solutions to improve flow faster, and
also to achieve better sustainable use of those solutions. On the other hand, hospital units with low sustainability had
not involved IT in their implementation. If we compare to lean in manufacturing, maintenance plays an important role in
making sure that equipment is ready, reliable and that modifications are made to adapt the equipment to lean (poka-yokes,
etc). In administrative processes and services, IT professionals take this role, since they are the ones keeping the equipment
(computers and software) running, and responsible to customise software to insure the process is improved. As such, the
third proposition can be read as following.
Proposition 3: The involvement of people from Information Technology is important to sustain the implementation of
lean in healthcare.
4.3. Contributions to practice

The comparative case study of six different hospitals with different sizes and types of services resulted in a conceptual model
for sustaining lean in healthcare. The final assessment framework proposed has important implications for practitioners and
academics, bringing good opportunities for future research.
Regarding people, it was observed that hospital units with high sustainability invest since the beginning of the pro-
gramme to have a fully participative board in all phases of the project. Consequently, all health professionals are involved,
trained, and encouraged to learn and apply lean in their daily activities. Physicians have proven to be the most important
professionals to influence and make improvements sustainable. The formation of an internal lean team also proved to be
a differential factor in maintaining sustainability among the hospitals. It was also identified that the involvement of the IT
professional can be a differential factor to achieve success in lean sustainability.
Concerning the methods, it is possible to conclude that sustaining lean improvements in hospitals involves the appli-
cation of a structured method of conducting process change. The hospitals units with a higher level in maintaining lean
standards and with the greatest commitment to continue improving the processes were those that besides using the method
as a structuring tool for scientific problem resolution, used it as a methodology for conducting the project, with a detailed
step-by-step and lessons learned from other experiences. In addition to the propositions identified through the compilation
of previously disconnected success factors (theoretical framework), the comparison between the cases showed that in hos-
pitals where there is initial resistance from physicians, the initial focus of lean implementation should be the information or
material flow, instead of the patient flow.
About lean tools, it is possible to conclude that the correct application of lean tools at the right moments proved to be
decisive in the sustainability of lean in the hospitals studied. Lean audit tools, such as sustainability checklist, and audit
notes for standards maintenance, as well as visual management boards, kaizen events, and standardisation of activities were
key factors in maintaining lean in hospitals that have succeed to maintain a high standard of lean sustainability. Another
lean tool identified as a differential factor among the hospitals that applied it during the control phase was the value stream
map. VSM has proved to be essential both in the design phase and in the sustainability phase.
All the critical success factors raised in the literature were tested in the six hospitals to have a greater validity in their
application. The work contributes to hospitals that are planning to start their lean journey, in order to not neglect any critical
aspect for sustainability, and those who have already started their lean journey, but are struggling in the control phase.
4.4. Limitations and future research

This research presents some limitation that should be highlighted. Although we used multiple case studies as research
method to increase generalisation of our results, six hospital units are not enough sample size to allow quantitative theory
testing using statistical methods. We acknowledge that the sample was large enough to refine the proposed theoretical
model, and future studies using large sample sizes could be conducted in order to test the impact of those CSFs on the
implementation of other lean practices, or performance metrics (e.g. patience safety, productivity and cost performance), or
other contingent factors (e.g. hospital size, nationality, ownership).
Another limitation is the fact that our research focused only on hospitals in Brazil. As emphasised by the literature,
geographical, national and cultural aspects of the organisation can influence lean implementation in manufacturing, and
may have the same impact on lean on healthcare. Although limiting the research to the same region can restraint the bias of
those aspects into our results, future studies could compare hospital units from other countries, in developed and developing
economies. For example, Brazil has a large public and universal health system that is funded by the federal government, and
the United States health system is mostly supported by on private health insurance companies. Thus, cross-case studies in
different countries, both in developing and developed countries, could generate more understanding about the role of these
contextual factors on implementing and sustaining lean initiatives on healthcare. Nevertheless, there were no evidences that
the proposed framework could not be applicable to different healthcare environments, but further testing would support a
higher degree of generalisation.
Another suggestion for future research would be exploring the possibility of a longitudinal study for a longer period
of time. As we stated before, longitudinal studies in lean are very rare, and companies have difficulties in sustaining lean
practice over time. A longer period of observation would allow the researches to better understand the impact of the CSFs
over time, how CSFs could have different levels of importance in different phases of the lean implementation, and the rela-
tionship between the CSFs and organisation context. An in-depth case study would also allow the researchers to investigate
how lean implementation was conducted in different hospital units at the same hospital, and compare if the CSFs were
similar or different, and the reasons behind those differences.
Finally, we recognise that the developed framework has the unit of analysis of a single hospital unit, which makes it sim-
pler and easier to apply even in hospitals that just started implementing lean. Thus, we recommend that future studies could
enhance our sustainability framework to encompass a multi-level analysis that could be used to evaluate the sustainability in
multiple units within a hospital, and healthcare institutions with multiple hospitals. Expanding the scope of the framework
for a hospital or multiple hospitals would allow the framework to incorporate CSFs that are related to the interactions of
hospital units, corporate level and the external environment.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This work was supported by the CNPQ.
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International Journal of Production Research

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/tprs20

A framework to assess sustaining continuous

Daniel Barberato Henrique, Moacir Godinho Filho, Giuliano Marodin, Ana

To link to this article: https://doi.org/10.1080/00207543.2020.1743892

Published online: 17 Apr 2020.

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A framework to assess sustaining continuous improvement in lean healthcare

*Corresponding author. Email: moacir@dep.ufscar.br

2.2. Literature review

Figure 1. Decision tree – development of the dataset.

2.3. Multiple case studies

2.3.2. Cases selection

2.3.3. Site visits

International Journal of Production Research

2.3.5. Qualitative data analysis

2.3.6. Framework enhancements based on case studies

2.3.7. Additional interviews and data analysis

3.2. Framework construct 1: lean tools

3.2.1. Lean audit tools

3.2.2. Lean sustainability tools

3.3. Framework construct 2: lean methods

3.3.1. Continuous improvement method

3.3.2. Step by step guide, lessons and routines

3.4. Framework construct 3: lean people

3.4.1. Employee involvement

3.4.2. Agenda availability and priority

3.5. Refining the framework

3.7. Case analysis

Lean Healthcare assessment framework.

4. Discussions and conclusions

4.3. Contributions to practice

4.4. Limitations and future research

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