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JHOM
35,5
628
Received 8 October 2020
Revised 28 March 2021
Accepted 17 April 2021
Journal of Health Organization and
Management
Vol. 35 No. 5, 2021
pp. 628-642
© Emerald Publishing Limited
1477-7266
DOI 10.1108/JHOM-08-2020-0347
Access to surgical care as an
efficiency issue: using lean
management in French and
Australian operating theatres
Zeyad Mahmoud
Australian Institute of Health Innovation, Macquarie University,
Sydney, Australia and
LEMNA, Universit
e de Nantes, Nantes, France
Nathalie Angel
e-Halgand
LEMNA, Universit
e de Nantes, Nantes, France and
University of New Caledonia, Noumea, New Caledonia, and
Kate Churruca, Louise A Ellis and Jeffrey Braithwaite
Australian Institute of Health Innovation, Macquarie University,
Sydney, Australia
Abstract
Purpose – Millions around the world still cannot access safe, timely and affordable surgery. Considering
access as a function of efficiency, this paper examines how the latter can be improved within the context of
operating theatres. Carried out in France and Australia, this study reveals different types of waste in operating
theatres and a series of successful tactics used to increase efficiency and eliminate wastefulness.
Design/methodology/approach – Data for this qualitative study were collected through 48 semi-structured
interviews with operating theatre staff in France (n 5 20) and Australia (n 5 28). Transcripts were coded using
a theory-driven thematic analysis to characterise sources of waste in operating theatres and the tactics used to
address them.
Findings – The study confirmed the prominence of seven types of waste in operating theatres commonly
found in industry and originally identified by Ohno, the initiator of lean: (1) underutilised operating rooms; (2)
premature or delayed arrival of patients, staff or equipment; (3) need for large onsite storage areas and
inventory costs; (4) unnecessary transportation of equipment; (5) needless staff movements; (6) over-processing
and (7) quality defects. The tactics used to address each of these types of waste included multiskilling staff,
levelling production and implementing just-in-time principles.
Originality/value – The tactics identified in this study have the potential of addressing the chronic and
structurally embedded problem of waste plaguing health systems’ operating theatres, and thus potentially
improve access to surgical care. In a global context of resource scarcity, it is increasingly necessary for
hospitals to optimise the ways in which surgery is delivered.
Keywords Lean, Waste, Operating theatres management, Surgery, Efficiency
Paper type Research paper
Competing Interests: The authors declare no conflicts of interest.
Funding: This work was supported by a Macquarie University Research Excellence Cotutelle
Scholarship (number: 2017734) awarded to the first author for his PhD carried out in collaboration with
the University of Nantes, France. The funder had no role in the design, analysis and drafting of the
manuscript.
Data Sharing Statement: No additional data available.
Authors’ Contributions: This research was carried out in the framework of the doctoral studies of the
first author under the supervision of the co-authors who provided conceptual assistance on the topic and
acted as arbitrators and advisors where necessary. The first author conducted data collection, analysis
and prepared drafts of the manuscript. All authors reviewed and agreed with the final submitted
version.
Introduction Lean
Worldwide, lack of access to surgical care is estimated to account for 30% of the global management in
burden of disease (Shrime et al., 2015). Millions of people are dying prematurely or living
with preventable disabilities as more than half of the world’s population have limited access
operating
to safe and affordable surgery (Alkire et al., 2015). While problems of surgical access are theatres
particularly critical in low- and middle-income economies, they remain a significant issue
for many high-income countries (OECD, 2019). For instance, despite offering universal
health coverage and significantly reducing most of the financial barriers associated with 629
access to care, many OECD countries are still struggling with congested waitlists for
elective surgical procedures (OECD, 2019). In Australia, average non-emergency surgical
waiting times have been increasing, and a growing number of patients have to wait at least
a year before being admitted for elective procedures (Australian Institute of Health and
Welfare, 2019).
In a complex system such as healthcare, problems of surgical access are ubiquitous and
multi-factorial. While significant investments in low- and middle-income countries are
required to build surgical infrastructure and develop a qualified workforce before reaching
the World Health Organisation’s aim of universal access to surgery, this is not necessarily the
case in wealthier nations with comparatively accomplished health systems (Adhanom
Ghebreyesus, 2017; Alkire et al., 2015). Instead, in these countries, wide-spread interest is
emerging in organizational approaches than can help optimise the use of existing resources
and make gains in efficiency (Locock, 2003). It is now accepted that 30% of the resources
dedicated to the provision and delivery of healthcare in most developed countries is wasted
(Braithwaite, 2018). In this paper, access to surgery is considered a function of efficiency, and
thus, the focus is on how the latter can be improved.
In response to this widespread problem of inefficiencies, and faced with significant
financial and budgetary pressures, hospitals have been increasingly applying various
principles of the lean manufacturing (LM) philosophy to optimise their care delivery
processes (Young and Mcclean, 2008). LM was pioneered in the Japanese automotive industry
in the 1930s and has since become the de facto waste elimination and process improvement
approach across many industrial sectors in the world (Womack et al., 2007). At the core of LM
is the belief that efficiency and value are derived from a radical and continuous elimination of
waste in organisational processes (Womack et al., 2007; Liker and Convis, 2005). Waste is seen
here as the antithesis of value, is associated with reduced flexibility and hinders the capacity
of organisations to address the demands of their customers effectively (Arunagiri and
Gnanavelbabu, 2016).
The use of LM techniques to improve the quality and efficiency of healthcare delivery is not
a recent trend. Studies and evaluation research have associated it with reduced waiting times,
fewer medical errors and improved patient pathways (Baines et al., 2006; Dickson et al., 2009;
Raab et al., 2006; Collar et al., 2012; Trakulsunti et al., 2020). However, despite an increasing
number of publications on the topic, there is a paucity of research on how LM could be used to
improve the efficiency of operating theatres (OTs). This empirical study addresses this gap by
adopting a holistic vantage point to identify sources of waste in OTs and examines how LM
has been used to eliminate them from the perspective of in situ stakeholders. Addressing
health unit managers, hospital executives and quality improvement staff, the article identifies
key sources of waste in OTs, as well a set of tactics that can be mobilised to eliminate them.

Review of the literature

Also referred to as the Toyota Production System (TPS), LM has been defined as a
“management practice based on the philosophy of continuously improving processes by
either increasing customer value or reducing non-value-adding activities (muda), process
JHOM variation (mura), and poor work conditions (muri)” (Radnor et al., 2012). With an emphasis on
35,5 eliminating waste (i.e., non-value adding tasks) to enable the flexible use of productive
resources, LM constituted a radical shift from mass-production methods which often
struggled to meet rapidly changing customer demands. Taiichi Ohno, the founding father of
Lean, identified seven forms of waste commonly found in productive entities: overproduction,
excess inventory, idle times, unnecessary motion, not-needed transportation, duplicated
processes and defects (Ohno, 2014).
630 After proving its effectiveness in the car manufacturing industry, LM rapidly became a
widespread managerial philosophy that was linked to a host of positive outcomes in service-
delivery organisations as well as governments and public institutions (Stone, 2012; Jasti and
Kodali, 2015; Bhamu and Sangwan, 2014; Hines et al., 2004). Such outcomes included improved
service quality, reduced operational costs and higher levels of productivity (Baines et al., 2006).
In healthcare, LM has been used in a variety of settings and to reach different aims.
Overall, three levels of LM implementation can be observed. At the macro-level, governments
and policy makers have been promoting the use of LM through policies and guidelines that
directly reference LM tools and highlight how they contribute to greater operational and
financial performance gains (Machado and Leitner, 2010). At the meso-level, the adoption of
LM has been observed throughout hospitals and medical centres that have transformed and
redesigned care processes with the aim of improving efficiencies, access and putting patients
first (Nelson-Peterson and Leppa, 2007). Finally, at the micro-level, LM tools and principles
have had a rapid uptake by quality improvement, medical and nursing staff seeking to
optimise care pathways for specific procedures or within individual departments (Kruskal
et al., 2012). Generally, although not always, LM has been associated with efficiency outcomes
including shorter wait times and length of stays, fewer medication errors and improved
patient satisfaction (Akmal et al., 2020). There are strong arguments and studies, too, against
LM, where it is seen as a tool for stripping away needed resources, reducing organisational
flexibility and resilience (Sheps and Cardiff, 2017).
Whilst the last decade has seen a proliferation of studies examining the use of LM in
healthcare, recent literature reviews continue to demonstrate that few researchers have
devoted their attention to how this productive philosophy transposes to OTs (Akmal et al.,
2020; Henrique and Godinho Filho, 2018). When examined, the literature on the use of LM in
OTs echoes several of the gaps in the broader LM in healthcare literature. First, in addition to
the paucity of research, many of the published studies have a high risk of systematic bias
which casts a significant doubt over the veracity of their findings as well as the effectiveness
and suitability of adopting LM principles in healthcare (Mccann et al., 2015; Henrique and
Godinho Filho, 2018). Second, most of the studies tend to adopt a piecemeal approach with an
emphasis on reporting. Few studies adopt a systems approach to examining the use of LM in
OTs (Akmal et al., 2020). Finally, very few studies compare the use of LM across hospitals and
between different countries (Akmal et al., 2020; Costa and Godinho, 2016; Mazzocato et al.,
2010). This article set out to address these gaps by examining how LM practices were adopted
in two OTs, one in France and the other in Australia. The study adopts a systems perspective
mapping the seven sources of waste identified by Ohno to the OT context and revealing
strategies used to address them.

Methods
Data collection for this research was carried out as part of a joint French and Australian
research project (Mahmoud, 2020). The consolidated criteria for reporting qualitative research
(COREQ) guidelines were used to ensure thorough reporting of the study methods and
findings (Tong et al., 2007). The research was underpinned by a critical realist ontology, a
relativist epistemology (Vincent and O’Mahoney, 2018), and conducted using recognised
qualitative methodological approaches. Although the studied OTs were based in two different Lean
countries, they shared numerous similarities, which thus enabled the undertaking of this management in
comparative study. First, at the macro-level, both the French and Australian health systems
are under considerable pressure to improve efficiency to maintain sustainability in the face of
operating
the demands of ageing and growing populations with higher prevalence of chronic diseases theatres
(Agence Technique de l’Information sur l’Hospitalisation, 2017; Australian Institute of Health
and Welfare, 2018; Guzzanti et al., 1996). Both countries also have established guidelines and
regulations with the aim of providing OT managers with standardised indicators to measure 631
efficiency and performance of OTs (NSW Agency for Clinical Innovation, 2014; ANAP, 2016).
At the meso-level, the studied hospitals exhibited multiple similarities including being
publicly funded with a considerable focus placed by executive managers on improving access,
reducing costs and improving performance through a systemic elimination of waste and the
optimisation of operational processes. Finally, at the micro-level, the studied OTs had a similar
number of operating rooms (ORs) and hosted elective as well as emergency surgery in all
clinical specialities.

Study settings
In France, data were collected at a metropolitan, publicly funded, tertiary hospital referred to
as Grand Lac Hospital (GLH), a pseudonym chosen to preserve its anonymity. GLH provided
both routine and highly specialised medical and surgical care. Recently renovated, the
hospital’s OT housed 22 ORs used to provide elective and urgent surgical care to patients. In
Australia, the research was conducted at a structurally similar institution referred to as
Ocean View Hospital (OVH). OVH was a major public establishment providing general and
specialised care in most surgical specialties. The hospital recently built an OT of 18 ORs to
perform both emergency and elective procedures. Fieldwork was conducted between October
2016 and January 2019 in the two countries.
Prior to the commencement of the study, neither of the hospitals specifically referenced the
use of LM as a process improvement methodology or a managerial philosophy. However, as
data collection progressed and when explicitly asked, managers at GLH and OVH
acknowledged that their practices and structures were heavily influenced by the LM
philosophy. A discussion with a key informant in France suggested that LM suffers from a
poor reputation in the health sector and is often only explicitly referenced when it leads to
significant improvements. This was a plausible explanation given the multiple media reports
which associated the industrial philosophy with poor outcomes for health professionals
(SNPI, 2016). This was also later confirmed during a consultation with an informant at the
Australian Healthcare & Hospital Association (AHHA), who indicated that hospitals in the
country may not particularly advertise their use of LM unless it has been proven as an
effective method that led to tangible improvements in clinical outcomes and financial
performance. This concealed stance towards the use of LM in hospitals except when
vouching for its success is also echoed in the existing literature which largely depicts a
positively skewed picture of LM as a revolutionary tool that will transform the way
healthcare is organised and delivered (Holden, 2011, D’Andreamatteo et al., 2015). The
research team was unable to ascertain the duration of LM implementation at the two
hospitals as this information was not known to the research participants.

Participant recruitment and research ethics

Participants of this study were OT nurses, managers and hospital executives. Staff from
different occupations were targeted to capture a diverse range of experiences. Participants
were purposively recruited to seek a purposeful representation of different professional roles.
In each hospital, recruitment of participants was continuous until data saturation was
JHOM reached (Morse, 2010). None of the approached participants withdrew or refused to
35,5 participate in the study, nor did they have a pre-established relationship with the researchers.
Participants were provided with an information sheet detailing the scope and purpose of the
study. The research was approved by relevant ethics committees.

Semi-structured interviews and thematic analysis

632 Semi-structured interviews were carried out in person by the first author, a doctoral
researcher who is bilingual in French and English, trained and experienced in qualitative data
collection methods. All interviews took place in a private setting at the participants’
workplace (e.g., private office or a meeting room) and were audiotaped. At GLH, interviews
were conducted in French and were transcribed verbatim by the first author. Interviews at
OVH were conducted in English and transcribed verbatim using an online transcription
platform (NVivo transcription), with integrity checking by the first author and review by
other team members. No field notes were made during the interviews nor were transcripts
returned to participants for comment or correction given the time-poor nature of their
schedules. No repeat interviews were conducted.
The interviews conducted for this research followed a semi-structured guide created by the
research team. This choice of design allowed participants to express themselves freely about
the important aspects of their work (Demers, 2003). The guide was informed by discussions
with hospital executives and a series of non-participant observations conducted by the main
researcher at each hospital site. The observations provided the research team with critical
information regarding the specific context and internal organisation of the studied OTs. The
interview guide included four open-ended questions allowing the interviews to be dynamic,
with the researcher adapting to the answers of the interviewee (Beaud, 1996). All participants
were asked to: (1) introduce themselves and their role in the OT; (2) describe tasks they would
typically undertake in a day of work; (3) identify positive and challenging aspects of their role
and current work organisation (participants were prompted to reflect on the organisation of
the OTs, discuss strategies used to overcome challenges as well as highlight key performance
indicators used to measure performance) and (4) portray a future state of the OT’s
organisation stating any aspects they would like to see change and why. Interviews conducted
with OT managers and hospital executives included additional questions about the OT
mission, vision and strategy. Interviews were also used to evaluate the plausibility of nascent
hypotheses. All interviews lasted between 45 and 120 minutes.

Analysis
Interview transcripts were coded by the first author using NVivo 12 (Bazeley and Jackson,
2013) following a six-step thematic analysis approach (Braun and Clarke, 2006) consisting of:
(1) data familiarisation; (2) code generation; (3) theme development; (4) review of theme; (5)
naming and definition of themes and (6) reporting. An initial engagement with the data was
carried out inductively to sculpt a research question (Braun et al., 2015). Subsequently, a
theory-driven coding approach was used, keeping the research question in mind, to inform
the generation, naming and clustering of themes (Terry et al., 2017). To ensure the quality of
the analysis, and consistent with a Big Q approach (Kidder and Fine, 1987), the broader
research team contributed through frequent discussions ensuring that the coding process
was rigorous, thorough and founded on an in-depth engagement with the empirical material.

Results
A total of 40 semi-structured interviews were conducted at both GLH and OVH. Twenty staff
members from GLH and 28 staff members from OVH participated in the interviews, with
participation from diverse professional backgrounds (Table 1).
Grand Lac Hospital (GLH) Ocean View Hospital (OVH)
Lean
Professional Number of Professional Number of management in
background Code participants background Code participants operating
Scrub scout nurse SSN 3 Scrub scout nurse SSN 8 theatres
Scheduling nurse SN 1 Floor manager FM 2
Anaesthetic nurse AN 4 Anaesthetic nurse AN 4
Nurse unit manager NUM 3 Nurse unit manager NUM 5 633
Auxiliary nurse AXN 4 OT manager OTM 1
OT manager OTM 1 Data manager DTM 1
Financial officer FO 1 Divisional manager DVM 3
Quality manager QAM 1 Material manager MM 1
Divisional manager DVM 2 Educator ED 2 Table 1.
Clinical nurse CNC 1 Overview of interviews
consultant conducted at GLH and
Total 20 28 OVH (N 5 48)

Tactics used by the hospitals to optimise the organisation of the OTs were coded into seven
different themes representing the different sources of waste identified by Ohno (Ohno, 2014):
overproduction, waiting, excess inventory, unnecessary transportation, needless motion,
over-processing and quality defects. Explanations and examples for each theme are outlined
below. Quoted extracts from the interviews have been edited to enhance readability without
modifying their semantic or latent meaning. When quotes are included, professional
background codes presented in Table 1 are referenced to identify participants.

Overproduction
Overproduction at both OTs manifested in the form of available ORs (i.e., fully staffed and
equipped) not being used to operate on patients. The prevalence of this type of waste was
monitored monthly and annually through a utilisation key performance indicator (KPI). Both
hospitals targeted a utilisation rate of at least 80% (85% at GLH and 80% at OVH), and each
used a master surgical schedule (MSS), a customised managerial device used to allocate OR
time to the different clinical specialties. Developed to align the availability of ORs to the
demand for operating time expressed by surgeons, the MSSs were built after an extensive
historical analysis of the surgical activity at each institution. OR time was allocated using a
modified block scheduling approach (Kharraja et al., 2006) in which pre-allocated time
intervals, if expected to be unused, can be quickly released and transferred between
specialties. At GLH, fluctuations in demand and changes in allocations were monitored by an
analyst who updated the MSS yearly. At OVH, the MSS was not as frequently updated
although participants indicated that there was a need to do so in order to ensure that
fluctuations in demand were properly managed.
At both hospitals, and in tandem with the MSSs, the development of a multi-skilled
nursing workforce helped ensure that the OTs’ production was smoothed and avoided the
waste generated by an unbalanced use of productive resources. Surgical specialties requiring
similar nursing and anaesthetic skills were grouped into modules in which nurses worked
across a variety of procedures regardless of their specialties. The modules were described as
essential to the reduction of set-up and changeover times that would otherwise be required if a
different nursing team performed each surgery. In addition, at GLH, durations of surgical
procedures were digitally recorded for every surgeon and procedure type and used to
determine the number of operations that could be conducted daily in the OT. Production
levelling at GLH and OVH ensured that human and material resources were used optimally
and continuously engaged in delivering surgical care to patients.
JHOM We [OT staff] are in an optimisation logic . . .. All ORs have to be equally filled and we have to operate
all patients on the list (SN-D, GLH, author’s translation)
35,5
Waiting
Both GLH and OVH used a continuous flow approach coupled with visual management tools
to eliminate unnecessary waiting times and avoid delays or cancellations. At GLH, patient
634 identification bracelets were barcode-equipped and regularly scanned throughout their
journey in the OT. Scan data were collated into comprehensive visual management software
used by scheduling nurses (SN). When problems appeared, these newly trained scheduling
nurse specialists took necessary measures to address them, thus avoiding workflow
interruptions. The progress of every OR was also displayed on large digital screens located
throughout the OT, which allowed staff to keep a watch over the state of the work being
conducted. The screens provided real-time feedback on performance and pace of work.
The visual monitoring software was also crucial in managing flow in the OT as it included
a digital Kanban system (Liker and Convis, 2005). Used in manufacturing to replenish
workstations with supplies, Kanban was used at GLH to trigger the transport of patients to
and from the OT. As surgeries progressed in the different ORs, SNs lodged electronic patient
transport requests to a centralised patient transfer unit. The unit subsequently dispatched
porters to collect patients and bring them to the OT. This system enabled the elimination of
idle times between surgeries that were often linked to delays in patient transport. It was also
described as being helpful in regulating the flow of outgoing and incoming patients thus
waving the need for a large waiting area in the OT.
At OVH, a floor manager (FM) carried out a similar role to that of the SNs at GLH. They
worked on orchestrating the pre-, peri- and post-operative logistics associated with the
delivery of surgical procedures. Daily, it was the FM’s responsibility to ensure that the
scheduled surgeries took place within the best conditions for patients and staff. They
anticipated, identified and implement solutions to address any logistical or organisational
issues that risked generating delays or interruptions to the flow of surgeries.
The FM used a paper-based Kanban along with their phone to liaise with clinical wards
and patient porters ensuring the smooth flow of OT activity. They allocated call times for
each patient factoring in aspects such as anaesthesia induction times and leaving enough
time for any unforeseen medical complications. Avoiding premature or delayed patient
transport ensured that OT time was not wasted and was described as a way of improving the
value of care delivered to patients (e.g., reduced patient stress associated with long waiting
times in OT holding area).
To assist with executing their tasks, the FM used a computer program to visually monitor
the progress of the work conducted in the different ORs. The software presented a single list
of patients scheduled for each OR and included data on the type of procedures and the names
of surgeons and staff. Unlike the software used at GLH, this program was not updated in real-
time and did not capture any live data. Instead, the FM collected progress data frequently
either by calling the different ORs or by requesting call backs from the nurses in the ORs.
My role is to ensure that patients are operated in a timely manner . . . and to minimise delays. If a
surgery is small and quick, then as soon as the patient is in the theatre, I call the next one. . ..
Cataracts for instance, I always make sure there is one patient in the theatre and another one on the
red line. So as soon as the patient is off the table, the anaesthetic nurse can come in, get the next one
and put them in the [anaesthetic] bay. (FM-B, OVH)

Excess inventory
To reduce the need for onsite storage and dedicate more space to ORs, both hospitals
implemented a just-in-time approach to their procurement operations. Supplies for
elective procedures were, in most cases, ordered and delivered just-in-time for surgeries to Lean
take place. management in
At GLH, scheduling a patient triggered a series of logistical operations destined to ensure
the availability of the equipment, prosthesis or implants needed for surgery to take place.
operating
These operations were handled by specialist medical devices nurses (MDNs), who were theatres
trained in supply chain management and optimisation. The MDNs also looked after single
use medical equipment, tracking inventory movements and ensuring the availability of
essential supplies. The specialist nurses also were responsible for establishing the 635
traceability of used equipment and implants by linking them to patients’ case files.
The just-in-time approach was also implemented to the management of the sterilisation
activity. To provide more space for ORs, GLH externalised all sterilisation facilities to an off-
site structure. A small, semi-mechanised, pre-disinfection area was maintained on-site, where
a specialised nurse prepared and packed equipment before sending them off to the external
facility via shuttles. The shuttles also returned the equipment to the OT once sterilised.
At OVH, a similar just-in-time approach was also implemented to the procurement and
sterilisation operations. Materials managers (MM) worked closely with clinical nurse unit
managers to make sure that the right equipment was in the right OR at the right time and in
the required quantities needed. An electronic stock management system was in place to
capture real-time data on equipment and medical device usage. The software automatically
generated purchasing orders if stock were below a pre-set limit. Using this just-in-time
approach meant that stocks were optimised to reduce the need for storage space as well as to
cut down the costs linked to bulk-buying equipment that may not be used.
Sterilisation at OVH was also located outside the OT but remained in the same building.
Used, sterilisable equipment was enclosed in insulated trollies that were wheeled out of the
OR by staff and placed in elevators that delivered them to the sterilisation unit located one
floor above. Being in the same building reduced the sterilisation and delivery turnaround
time, which meant that equipment could be used multiple time within the same day at
relatively short intervals.
The just-in-time management of inventory and the externalisation of the sterilisation units
was pointed to as being a significant vector of cost reduction as space inside the OTs is often
very limited and costly.
We have created new roles dedicated to managing procurement and sterilisation of equipment. They
look at the OT schedule to anticipate the need of equipment, place orders, verify and quality check
the deliveries, send to sterilisation if needed and check that everything meets the norms. Once the
equipment is in the OR, they make sure it’s linked to the patient to ensure traceability for quality
purposes. . .. We realised that this is a key role when it comes to optimising our inventory. We are
now placing orders in real time for a just-in-time delivery (DVM-U, GLH)

Unnecessary transportation
Both OTs incorporated architecture design elements intended to optimise the transport of
frequently used equipment. At GLH, storage areas located in proximity of every OR were
identifiable by a bright orange floor colour. These zones were reserved for the storage of
mobile equipment and devices commonly used during surgery (e.g., amplification devices,
scanners or laparoscopic stations). Other equipment was directly mounted to the ceiling or
walls inside ORs (surgical lights, cameras, screens and microscopes).
At OVH, a dual corridor design allowed a central storeroom to be easily accessed from every
OR. This design meant that sterile goods and regularly used equipment were never too far out
of reach and did not need to be transported for long distances before being used. Eliminating
unnecessary transport time was considered to have improved the efficiency and productivity of
staff who dedicated more time to performing surgeries and delivering care to patients.
JHOM Every OR has an area assigned to them where we keep their consumables as well as their prosthesis,
so it is easy for the staff to come out and use the stock (MM-S, OVH)
35,5
Needless motion
In addition to the architectural structure, jobs were defined to eliminate unnecessary staff
movements. Whereas in the past nurses at GLH conducted organisational and logistical tasks
636 such as replenishing storerooms or managing patient flow, these tasks were handed over to
specialist staff in the new OT. MDNs handled all logistics relating to equipment and
consumables, specialised sterilisation nurse looked over the disinfection process, and SNs
managed both outgoing and incoming flows of patients. Redefining the scope of jobs was
described as a crucial element that facilitated standardised work procedures.
Tasks at GLH were standardised through the pre-definition of cycle times, the sequence of
task execution and the level of inventory available on hand. The pre-defined cycle times were
introduced to support production levelling and continuous flow. Time estimates for the
completion of surgeries were provided during the booking process and default time intervals
were allocated to tasks such as administering anaesthesia, installing the patient or cleaning
the OR. Checklists were developed with the aim of insuring safety by reducing practice
variations that could lead to errors. Finally, stocks were closely managed as a way of
reducing variability when it came to task execution.
A similar approach to job definition and standardisation was in place at OVH, specialist
staff conducted most logistical and administrative tasks (stock management, patient flow
coordination, sterilisation, cleaning and patient booking), allowing medical and nursing staff
to focus on tasks requiring their core skills and competencies. This distribution of tasks was
described as responsible for a considerable reduction in unnecessary staff movement, freeing
up more time for patient care. In addition, the scheduling nurses at GLH closely monitored
patient transport to avoid unneeded patient movement saving time and human resources.
Here your job is much more focused on scrubbing and scouting and not on organising, ordering or
liaising with other staff. Previously a fair bit of my time was spent on coordinating things, which I do
not have to do at all here. (SSN-G, OVH)

Over-processing
Duplication, rework or unnecessary use of equipment are forms of over-processing that can
negatively affect the quality of care delivered to patients, create extra costs and reduce the
operational capacity of OTs. Participants described standardisation as a critical strategy for
eliminating this type of waste. At GLH, standardisation was achieved through the pre-
definition of cycle times and the order of tasks executed by staff as well as by monitoring and
limiting the level of available inventory. At OVH, checklists, policies, guidelines and
inventory control were used to standardise aspects of the nurses’ work. At both hospitals, an
increased functional rationalisation was pointed to as key to the elimination of duplicate work
that would result from overlapping roles and responsibilities.
Although checklists tell you what to do, they do not indicate how to do things and for that we have
procedures. Procedures are used to standardise how we do certain things across the OT. . .. They are
usually very detailed and are sometimes used for training and education. They can be accessed from
a web portal and are meant to be regularly updated. . . We have hundreds of procedures. (QAM-
A, GLH)

Defects
Defects in the form of errors or low-quality care can have fatal consequences when they occur
in OTs, and they are also sources of delays and inefficiencies. Considerable effort was
invested at both hospitals to reduce the likelihood of mistakes and create an environment in Lean
which all the conditions required to deliver efficient and safe care are met. At GLH, an management in
electronic error declaration system enabled staff to report errors, dysfunctions or any quality-
related concerns to a quality assurance manager. The manager followed up on the reports by
operating
conducting investigations before identifying and implementing solutions. At OVH, a similar theatres
system was in place. Quality assurance was described as the responsibility of all staff
members who collaborated with educators, clinical nurse specialists and consultants to
develop and implement a wide range of quality assurance and improvement programs. Both 637
OTs also used checklists to minimise the risk of common mistakes and errors occurring. They
also regularly monitored a standard set of quality assurance indicators used in OTs (e.g.
consumption of hydro-alcoholic gels, infection rates, re-admission rates).
We ask our staff to declare any incident that they believe needs attention. Incidents could be related
to patients, staff or processes. . .. Our quality assurance strategy is largely inspired by what is done
in the aeronautics industry. We have put in place a no-blame declaration culture in which the
emphasis is on preventing the reoccurrence of errors and incidents. We never look for culprits but
instead focus on organisations and processes that need to be improved. (DVM-U, GLH)

Discussion and practice implications

Access to timely, safe and affordable surgery remains an unreachable luxury to many
citizens of the world. While investments are needed to build and develop medical
infrastructures in many countries, their impact will remain limited if operational and
structural inefficiencies continue to plague the daily operations of health systems. Today,
even in the most developed economies one-third of health spending is wasted on non-value
adding activities. This paper used an organisational perspective to identify sources of waste
commonly found in OTs and examine how LM was be used to eliminate them. Advocates of
LM indicate that it may contribute to increased surgical capacity and facilitate access
(Valsangkar et al., 2017). Conducted at two public hospitals in France and Australia, we
uncovered the tactics implemented to address the negative impacts of overproduction, long
waiting times, excess inventory, unnecessary transportation, needless motion, over-
processing and quality defects (Table 2).
At both hospitals, specialised staff were employed to ensure that surgical activity was
levelled, resources were being optimally utilised, workflows were not interrupted and
materials and equipment were delivered just-in-time when and where needed. Nursing
staff were encouraged to develop and master a wide range of skills and to intervene on
different surgical procedures grouped into modules. Visual management tools (e.g. MSS
and computer software) provided accurate performance information helping managers
formulate corrective measures to avoid suboptimal situations. Tasks were standardised to
prevent practice variation, cut unnecessary acts and ensure the quality of care delivered to
patients. Architecturally, OTs were designed to optimise the transport of equipment.
Quality managers and educators developed work processes to help ensure that error-free
care is delivered to patients thereby avoiding costly delays, readmissions and
inefficiencies.
This research’s holistic stance allowed it to overcome a persistent limitation of previous
research that focuses on evaluating isolated LM practices used to optimise individual
processes (Mazzocato et al., 2010; Akmal et al., 2020). Instead of focussing on assessing the
outcomes of LM, the study provided a detailed description of how it came to be implemented
in the first place, looking at the different components of the surgical delivery process. In
addition, the in situ and qualitative nature of the study provided an empirical work-as-done
examination of LM rather than the work-as-imagined outlook that characterises the
predominately conceptual publications on the topic (Filser et al., 2017). To the best of our
JHOM Source of waste Manifestation in OT Tactics to address waste
35,5
Overproduction Available and staffed ORs not used for Production levelling using master surgical
surgery schedule (MSS) with a modified block
approach and increased predictability over
cycle times
Multi-skilled staff reduce changeover times
638 Business analysts monitor and update the
MSS
Waiting Premature or delayed arrival of patients, Use of continuous flow and visual
staff, or equipment to the ORs management techniques
Dedicated flow management personnel
Excess Need for onsite storage of medical devices Case-by-case purchase strategy
inventory and equipment. Avoidable costs of Just in time delivery of equipment
purchased but unused equipment Specialist supply chain management staff
Transportation Valuable time is spent on transporting Space configuration to facilitate access to
frequently used materials to and from ORs stored equipment
Motion Unnecessary staff movements Point of use storage and job redefinitions
Over- Using more than it is required to undertake Standardising actions through default
processing procedures cycle times, limited inventory, and
sequence of task execution
Table 2. Defects Wrong medication, wrong patients, Continuous improvement initiatives
Sources of waste incorrect procedure. Poor patient outcomes Errors reporting systems
in OTs and tactics Quality assurance managers and educators
to address them work hand in hand with staff

knowledge, this is the first study presenting a set of Lean-based interconnected tactics that
can be used to eliminate waste in OTs.
This research has implications for health unit managers, hospital executives and quality
improvement staff interested in LM. It provides an operationalisable framework of
interconnected tactics that can be used to tackle waste and attempt to improve the
efficiency of OTs. Whilst there is not a “one fits all” approach when it comes to LM
implementation, the tactics identified in this study might be tailored to fit individual contexts.
Hospitals embarking on their LM journey should engage with their clinical, nursing and
support staff to discuss how these tactics will affect existing work processes. Engaging staff
is particularly crucial given the large amount of evidence indicating that success of LM
interventions is highly dependent on taking into account both the technical and
sociotechnical dimensions of this managerial philosophy (D’Andreamatteo et al., 2015;
Bortolotti et al., 2015; Abdallah and Alkhaldi, 2019). Practitioners should also consider that
although the tactics presented in this article can help optimise processes in OTs, it is
nonetheless important to highlight that excessively leaning a system can reduce its capacity
to cope with unexpected events making it less resilient (Sheps and Cardiff, 2017). Paying
particular attention to how LM may impact resilience capabilities is key, especially in OTs
where teams are often operating in rapidly changing and sometimes unpredictable conditions
(Mahmoud et al., 2021; Saurin et al., 2017).
While the tactics presented here offer potential opportunities for increasing the capacity
of OTs by improving efficiency, they may not directly translate into improved access to
surgery. That is because efficiency is only part of a complex surgical access equation that
encompasses demand and offer related factors. Eliminating non-beneficial procedures
and ensuring that surgery is only recommended for conditions where there are no
other alternatives can help reduce costs and free up congested waiting lists. To that end,
the use of more patient centred approaches that include tools such as patient-reported
outcome measures (PROMs) or patient decision aids could be very beneficial (Mangla Lean
et al., 2018). management in
The study has strengths and limitations. As is the case with all qualitative research,
internal validity is concerned with examining the extent to which a research design captures
operating
the intended object of study (Wacheux, 1996). In this regard, and as discussed in the theatres
methodology section, the choice of a qualitative design was particularly suited to the
exploratory nature of this research which aimed to capture how LM interventions were used
in OTs. However, while this choice of design provided the research team with rich and 639
contextualised data, it also limits the applicability of the findings to other settings (i.e., its
external validity). This is inherent to qualitative case study enquiries which are more
concerned with discerning complex phenomena in a contextually embedded way. More so
than generalisation, the test here is credibility and to that extent, the use of a multiple case
study design significantly reinforces the analytical validity of the study and provides a
strong basis for theory-building (Yin, 2014).

Conclusion
The world is far from reaching the WHO’s vision of universal access to emergency and
essential surgical care in a safe, timely and affordable manner. Based on our empirical study
conducted in two OTs, a typology of commonly found wastes is now available along with a
set of tactics to reduce them. Improving the efficiency of OTs through the elimination of waste
has the potential of improving access to surgical care.

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Corresponding author
Zeyad Mahmoud can be contacted at: zeyad.mahmoud@mq.edu.au

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