Lean Supply Chain Management in Healthcare - Khorasani (2018)

International Journal of Lean Six Sigma
Lean supply chain management in healthcare: a systematic review and meta-

study
Sasan T. Khorasani, Jennifer Cross, Omid Maghazei,
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Supply chain
Lean supply chain management in management
healthcare: a systematic review
and meta-study
Sasan T. Khorasani
Department of Industrial Engineering,
Edward E. Whitacre Junior College of Engineering, Texas Tech University, Received 16 July 2018
Revised 20 September 2018
Lubbock, Texas, USA 31 December 2018
Accepted 21 January 2019
Jennifer Cross
Department of Industrial, Manufacturing and Systems Engineering,
Texas Tech University, Lubbock, Texas, USA, and

Omid Maghazei
Department of Management, Technology, and Economics,
Eidgenossische Technische Hochschule Zurich, Zurich, Switzerland
Abstract
Purpose – By applying a systematic literature review, this paper aims to identify the major healthcare
problem domains (i.e. target areas) for lean supply chain management (LSCM) and to provide a list of the most
common techniques for implementing LSCM in healthcare. Moreover, this study intends to investigate
various contingency factors that may have influenced the selection of LSCM target areas or the application of
LSCM techniques by healthcare organizations.
Design/methodology/approach – A systematic literature review was carried out following the method
presented by Tranfield et al. (2003). Thereby, 280 peer-reviewed journal articles, published between 1995 and
2018, were selected, profiled and reviewed. In total, 75 papers were also selected for a qualitative analysis,
known as meta-study, on the basis of high relevancy to the research objectives.
Findings – This work extracts, from previous research, a set of target areas for improving supply chain in
healthcare by applying lean approaches. The work also unifies the language of lean thinking and supply
chain in healthcare by defining metaphors in circumstances under which healthcare organizations pursue
similar objectives from their supply chain management and lean programs (Schmitt, 2005). This paper also
outlines a list of applications of lean for supply chain improvement in healthcare. Finally, a set of contingency
factors in the field of lean supply chain in healthcare is found via the published literature.
Practical implications – This paper provides insights for decision-makers in the healthcare industry
regarding the benefits of implementing LSCM, and it identifies contingency factors affecting the
implementation of LSCM principles for healthcare. Implementing LSCM can help healthcare organizations
improve the following domains: internal interaction between employees, supply chain cost management,
medication distribution systems, patient safety and instrument utilization.
Social implications – The research shows potential synthesis of LSCM with the healthcare industry’s
objectives, and, thus, the outcome of this research is likely to have positive influence on the quality and cost of
healthcare services. The objectives of the healthcare industry are cost reduction and providing better service
quality, and LSCM implementation could be an effective solution to help healthcare to achieve these objectives.
Originality/value – The prime value of this paper lies in conducting a systematic literature review using a
meta-study to identify the major factors of implementing LSCM in healthcare. Only a few other studies have
been published in the literature about LSCM in healthcare.
International Journal of Lean Six
Sigma
Keywords Lean, Supply chain management, Healthcare service, Systematic literature review © Emerald Publishing Limited
2040-4166
Paper type Literature review DOI 10.1108/IJLSS-07-2018-0069
IJLSS 1. Introduction
Lean supply chain management (LSCM) in healthcare is in an early phase of development;
therefore, a lack of academic research in the field has been recognized (Olsson and Aronsson,
2015). In recent years, improving the healthcare sector’s supply chain management (SCM)
system has become remarkably important, due in part to the fact that healthcare inventory
costs are continuously increasing. Thus, delivering quality of service without passing on the
cost burden to the patients is a critical issue for healthcare organizations. Current evidence
shows how amelioration of the supply chain system in healthcare is essential. For instance,
statistical data from 2011 suggests that healthcare costs exceeded 17 per cent of the US GDP
(Porter and Kaplan, 2011). The National Health Expenditure Data Highlights (US Centers for
Medicare and Medicaid Services annual report) also show that healthcare costs increased to
17.9 per cent of the US GDP in 2016 and are expected to rise to 19.7 per cent by 2026 (Cuckler
et al., 2018). Accordingly, minimizing inventory cost, reducing waste, maximizing supply
chain interaction, and creating value in SCM in healthcare are fundamental for reducing
healthcare costs in general (Nollet and Beaulieu, 2003). Furthermore, hospitals suffer from
long wait times caused by an imbalance between supply and the number of patients in the
system (Setijono et al., 2010; Khurma et al., 2008). Parnaby and Towill (2008) also express
that it will be beneficial to observe the healthcare delivery system from a supply chain
perspective because the balance between patient needs and supply (doctors, nurses, staff
members, medications, and medical devices) reduces non-added-value activities in hospitals.
Recent studies revealed that healthcare organizations must view SCM as an opportunity
to improve their system’s flow by eliminating non-added-value parameters.
Correspondingly, lean thinking is widely known as a powerful method for removing such
non-added-value elements from a system. Therefore, adapting lean concepts within supply
chain – LSCM – seems to be able to improve the abovementioned healthcare issues. LSCM is
a relatively new stream of research, which can be applied to healthcare (Jasti and Kodali,
2015). The general goal of applying LSCM to healthcare is, as mentioned above, removing
the waste derived from non-added-value activities including waiting, overproduction,
motion, transportation, excessive processing, inventory, and underutilization of staff
members, which are all costly and troublesome in healthcare (Khorasani et al., 2015). Thus, it
would appear that LSCM can solve many issues for healthcare organizations. Nonetheless,
relatively few studies have been conducted on LSCM in healthcare, and no systematic
literature reviews exist to synthesize knowledge across the studies that have been done.
Therefore, in our research, we explore major healthcare problem domains (i.e. target areas)
and effective LSCM tools. This study attempts to fill the knowledge gap in the following
directions.
First, although several literature review articles on supply chain or general
implementation of lean tools in healthcare have been published in recent years, few works of
any type have been conducted specifically on LSCM for healthcare. For instance, we found
that only 17 out of 280 papers considered in the primary phase of the study focused on lean
supply chain in healthcare. The most similar previous studies appear to be the conceptual
work carried out by Habidin et al. (2014), Machado Guimarães and Crespo de Carvalho
(2013), Wijewardana and Rupasinghe (2013) and de Vries et al. (2011), each of whom aim to
develop the theoretical foundations for lean supply chain implementation in healthcare
based on traditional narrative literature reviews and case studies.
Second, a systematic and structured literature review method is applied to address the
previous studies in the field of LSCM, lean healthcare systems and healthcare supply chain
(HSC). Some of these prior studies, such as Halldorsson et al. (2007) and Parente et al. (2008),
analyze different factors in SCM by using survey and meta-analysis methods (Schmidt and
Hunter, 2014). However, Flynn et al. (2010) argue that a lack of comprehensive reviews still Supply chain
prevents researchers from fully understanding the conception of supply chain. Systematic management
literature reviews using qualitative analysis are required to enhance the findings of previous
statistical healthcare studies (Berger et al., 2018). Based on the findings of the present study,
there appear to be no previous literature review papers (systematic or otherwise) focused on
LSCM exclusively in the healthcare management field. This lack motivated us to conduct a
systematic literature review in which meta-synthesis (Paterson and Canam, 2001) is used for
determining the set of LSCM target areas (which we defined as those healthcare problem
domains that can be improved by LSCM), their applications, and the major contingency
factors to implementing lean thinking in HSC. In addition, this literature review differed
from other recent systematic literature reviews in the fields of lean healthcare and operation
management, as it used the meta-study method presented by Paterson and Canam (2001)
along with the systematic literature review method presented by Tranfield et al. (2003). To
the authors’ knowledge, the combination of a systematic literature review and meta-study
has not yet been applied to SCM in any context. Based on the research objectives, we derived
the following three research questions:
RQ1. What are the major target areas for LSCM in healthcare?
RQ2. What are the tools/techniques most frequently used in implementing LSCM in
healthcare?
RQ3. What are the central contingency factors affecting the implementation of LSCM in
healthcare?
2. Theoretical background
According to Goldsby et al. (2006), LSCM aims to provide a flow of goods, services and
technology from suppliers to customers without waste. As companies are under pressure to
reduce lead time and cost, and increase the service quality level, the integration of lean
principles and SCM has emerged as a new, effective approach to assist companies in
improving their service quality, achieving faster order delivery, and increasing profits
through more effective cooperation with suppliers rather than bargaining with them over
lower prices (Frazzon et al., 2017; Manzouri and Rahman, 2013).
Evidence shows that HSC arguably needs significant improvements in efficiency and
effectiveness. One successful technique, which has been widely used, is lean. The term “lean
thinking” was presented by James Womack and Daniel Jones in their in-depth study of
Toyota’s improvement system (Womack and Jones, 1996). Lean thinking aims to organize
human activities to produce more added value and eliminate waste – waste being defined as
any activity that consumes resources without adding value. Besides being utilized in a wide
spectrum of industries, lean thinking has been practiced in healthcare for several years, and
has been mostly focused on reducing waste in hospitals. Table I shows example healthcare
wastes by category.
The main goal of HSC is to provide medicines and equipment on time (Burns et al., 2002).
In this context, several stakeholders are involved. Complying with their functions,
stakeholders in HSC are categorized into three main groups: producers (suppliers, such as
pharmaceutical companies), purchasers (such as pharmaceutical wholesalers) and provider
customers (such as hospitals) (Burns et al., 2002).The producers deliver products, whether
directly to the patient or through a distributor (Mathew et al., 2013). However, this value
chain process does not seem effective and efficient enough for healthcare organizations at
both operational and strategic levels (Schneller and Smeltzer, 2006). The main problem of
IJLSS Waste category Definition Healthcare example
Overproduction Producing greater, faster or sooner than Unnecessary test

required
Waiting Patients and information idle time Waiting for a page to be returned
Material Movement Unnecessary patient or material movement Restocking unused LP (Lumbar
Puncture) needle
Inappropriate Using costly equipment Reentering patient’s social history by the
processing nurse
Motion Any unnecessary staff movement Searching for a manual blood pressure
cuff
Inventory Information, market, or patients in queue Patients waiting in examination room
or in stock
Underutilization Underutilized human talent and ability Nurse changing diapers
Table I.
Wastes in healthcare Note: Adapted from Platchek and Kim (2012)
the current HSC is the lack of integration between different levels of the supply chain, which
prevents the supply chain from acting as a coherent system (Mathew et al., 2013). According
to Vitasek et al. (2005), LSCM is a set of organizations in different supply chain levels that
collaboratively work to decrease cost and eliminate waste in the system. Moreover,
Manzouri and Rahman (2013) reveal that LSCM applications can improve organizational
interaction at the operational level by increasing the speed of data interchange and
operational flexibility. Shamah (2013) and Kim (2015) highlight the LSCM roles at the
strategic level, which can assist firms in achieving long-term relationships with their
suppliers. As HSC requires improvements in both operational and strategic levels, as well as
increased integrity between different supply chain levels, implementing LSCM in healthcare
has high potential for process improvement. For instance, one area of improvement could be
the pharmaceutical supply chain. Pharmaceutical product delivery is one of the most critical
parts of SCM in healthcare, accounting for 25-30 per cent of hospitals’ operational costs
(Roark, 2005). Thus, controlling this process is an essential element for assuring that both
service and cost objectives are being fulfilled (Mathew, et al., 2013). Evidence shows that
applying LSCM in healthcare has the potential to increase the efficiency and effectiveness of
the pharmaceutical product delivery system and improve waste management (Nightingale,
2005). However, it is less clear how much progress healthcare organizations have made to
date in implementing LSCM and what factors are related to implementation success.
Therefore, the review of literature on this topic is valuable and potentially stimulates the
improvement of HSC (Khorasani et al., 2015).
3. Methodology
The method adopted for this research is a systematic literature review utilizing meta-study.
Literature reviews are a substantial principle in any research field (Cooper, 1988; Baker,
2000), allowing researchers to discover research gaps and investigate fruitful results (Fischl
et al., 2014). Systematic reviews are different from traditional narrative reviews in that they
use a replicable, scientific, and clear process; they use a detailed methodology that decreases
bias through in-depth literature searches of published and unpublished studies and by
preparing a series of verifications of the reviewers’ decisions, procedures and outcomes
(Cook et al., 1997). The method of systematic review and its related approach, meta-
synthesis, have been practiced over the past 10 years and now play an important role in
evidence-based practice. Evidence-based practice has a significant influence in several Supply chain
disciplines but has been most notably applied in medical science, where knowledge management
extraction from an often contradictory mass of evidence is a complex process (Brittberg
et al., 1994). As systematic review and meta-synthesis involve a set of techniques for
minimizing bias and error, they are widely used for identifying “high-quality” evidence
(Tranfield et al., 2003).
A key element of any literature review is the research synthesis process. “Research
synthesis” is a general expression aiming at “bringing together of a body of research on a
particular topic” (Ten Ham-Baloyi and Jordan, 2016, p. 123). The purpose of research
synthesis is usually to explain analyses and to achieve clear findings on the evidence of
various studies, applying it to make decisions about the efficacy of healthcare interventions
(Ten Ham-Baloyi and Jordan, 2016).
Most fields involve both quantitative and qualitative evidence, and healthcare is no
exception (Ring et al., 2011). Quantitative evidence can be synthesized through methods
such as meta-analysis (Schmidt and Hunter, 2014), which use statistical pooling of numerical
data to predict the impact of an intervention (Ring et al., 2011). However, in many systematic
reviews, including the one reported in this paper, the heterogeneity of research data
obstructs purely quantitative synthesis methods, such as meta-analysis.
The synthesis of qualitative evidence can be attained using other methods, such as
realist synthesis, meta-synthesis or meta-ethnography, which rely on interpretative and
inductive methods (Barnett-Page and Thomas, 2009). In most systematic literature reviews,
the heterogeneity of study data from different paradigms increases the accuracy of the
research outcome. Meta-ethnography is a method of meta-synthesis that proposes
“reciprocal translations” between similar issues in different fields. Meta-ethnography
provides a complementary method of grounded theory analysis for open coding and data
classifications by unifying the language of phenomena from different fields (Beck, 2001).
Qualitative synthesis methods are more about fact-finding and require deeper
understanding of the studied phenomena than quantitative methods (Paterson and Canam,
2001). One reason for this is that the research objectives are not always straightforward in
the title of primarily qualitative studies. Hence, finding and analyzing qualitative studies is
usually more complicated and difficult in comparison to quantitative studies (Ring et al.,
2011). For this reason, qualitative synthesis methods, such as Cochrane reviews (Higgins
and Green, 2008), consist of exhaustive protocols and processes, which are often referred to
as meta-study methods. The meta-study methodology consists of three steps introduced by
Paterson and Canam (2001): meta-data analysis, meta-method, and meta-theory. Meta-study
does not merely aim to raise questions about what is already known, but also to build
theoretical approaches that may extend what is currently possible. In most meta-study
research, it is be possible to predict the degree to which new theory can be synthesized from
existing literature until the products of meta-theory, meta-method and meta-data analysis
are individually and collectively interpreted.
Meta-theory focuses on identifying the main cognitive paradigms and schools of thought
that are indicated in both the theoretical frameworks and the revealed theory of selected
research. Meta-theory suggests systematic tools of realization, and evaluates the theory that
results from qualitative research (Paterson and Canam, 2001). The goal of meta-method is to
indicate how the interpretation and implementation of qualitative research methods have
intensified research findings and developing theory in a specific field of knowledge
(Paterson and Canam, 2001). Meta-data determines the findings of research by, for instance,
using meta-ethnography to unify the language of main findings across different studies. The
goal is to provide a comprehensive understanding of the text to achieve a reliable result.
IJLSS Each primary study is translated into metaphors that are then compared with the metaphors
of other studies to produce a new interpretation that covers all reports (Paterson and Canam,
2001).
The systematic literature review methodology presented by Tranfield et al. (2003) was
adopted for this study; the three major stages of this approach are as follows: planning the
literature review process, conducting the review, and reporting the results.
3.1 Planning the literature reviews process

For the first stage of the approach, a review protocol was developed by applying the
conceptualization of topic methodology presented by Vom Brocke et al. (2009). This
methodology consists of four phases:
(1) Database search selection should enable the researchers to access a broad number
of academic papers (Fischl et al., 2014).
(2) Keyword search combinations should be selected carefully. Proper keyword

selection eases the next steps of qualitative analysis.
(3) Journal search should aim to guarantee the quality of research; therefore, the
researchers should select the appropriate group of academic journals (Rowley and
Slack, 2004).
(4) Backward search is the process of reviewing promising cited papers in articles
retrieved through the keyword search, and forward search is the process of
reviewing notable papers that cited the retrieved articles (Vom Brocke et al., 2009)
(Figure 1).
Firstly, six leading databases (Scopus, Science Direct, Google Scholar, Emerald, Pubmed,
SpringerLink, and EBSCO) were used to search for articles related to LSCM in healthcare.
Search strings restricted to the title and abstract were: “lean supply chain AND healthcare
OR health care OR health service”, “supply chain in healthcare OR health care OR health
service, “lean AND healthcare OR health care OR health service” and “lean supply chain.”
The resulting search contained 852 documents. This study was limited to the peer-reviewed
academic journal articles published in English after 1995. Therefore, all non-peer-reviewed
journal articles and articles written in languages other than English were removed from the
article pool. To verify the quality of journals, their SJR score (2016) and H index were
investigated. For the majority of the journals, we were able to obtain the SJR score. In cases
when the SJR score was not found, we checked the quality of the journal through its website
and other creditable index databases, such as PubMed. Accordingly, 134 peer-reviewed
academic journals were included in this study. The journals were published in 16 countries
all over the world. The geographic distribution of journals is shown in Table II. The name of
each journal, number of selected publications from each journal and other related details are
illustrated in Appendix. Finally, papers with fewer than four citations were deleted from the
selection pool, except for very recent articles published after 2016. The initial paper selection
criteria are summarized in Table III.
In the next step, we began categorizing the articles into “relevant” and “non-relevant”
documents by reviewing the titles and abstracts. Then, backward and forward searches
followed to add remarkable cited documents to our paper pool. In total, 280 papers remained
in our primary selection pool (the first round of review) at the conclusion of this stage.
Figure 2 shows the numbers of articles in the first round of review. As can be seen, the
number of articles with the main scope of LSCM for healthcare is limited, and the majority of
them were published after 2010.
Supply chain
Identification of Search Strings: management
Selection of Database: “Lean supply chain AND healthcare OR
health care OR health service”, “supply
Scopus, ScienceDirect, Google Scholar, chain in healthcare OR health care OR
Emerald, SpringerLink, EBSCO health service, “, “lean AND healthcare OR
health care OR health “service” and “lean
supply chain”.
852 documents
Select articles after 1995

Literature Search on
LSCM for Healthcare
Including only academic journal papers

utilizing peer review
Keep all papers from 2017 and 2018, and the

papers with more than four citaons
Only English language arcles
Title and abstract review
Yes
Backward and Forward search: Relevant to
Archive
Exclude redundant articles and Research Scope?
irrelevant to the scope of research
280 Documents No
Figure 1.
Exclude Planning the
literature review
process
3.2 Conducting the review

This stage consisted of two main review phases. In the primary phase, different analyses,
including identification of studies, study quality assessment, data extraction and data
synthesis, were conducted. First, we coded each of the 280 articles to identify the most
relevant studies for data extraction and synthesis (Table IV). For the first part of the code,
the paper was classified into one of four overall categories: Lean healthcare (LH), Lean
supply chain (LS), Supply chain in healthcare (SH), Lean supply chain in healthcare (TO).
IJLSS No. Country of publisher No. journals No. papers
1 UK 61 169
2 USA 46 62
3 The Netherlands 12 33
4 Iran 2 2
5 Germany 2 2
6 Hong Kong 1 2
7 South Africa 1 1
8 Nigeria 1 1
9 Israel 1 1
10 Brazil 1 1
11 Chile 1 1
12 Australia 1 1
13 Japan 1 1
Table II. 14 Canada 1 1

Journals 15 Switzerland 1 1
geographical 16 Poland 1 1
distribution 17 Total 134 280
Must have Metrics
Academic Journal Papers Yes

Peer-reviewed Yes
Citation (except 2017-2018) >4
Year range 1995-2018
Table III. Articles language English
Initial paper selection Scope “supply chain in healthcare OR health care OR health service”, “lean
criteria healthcare OR health care OR health service” and “lean supply chain”
16
14
14
13
12
12
11 11
10 10
10
9
8 8 8 8 8 8
8
7 7 7
6
5 5 5 5 5 5 5
4 4 4 4 4 4 4
4
3 3 3 3
2 2 2 2 2 2 22
2
1 1 1 1 1 1 1 1 11 1 1
Figure 2.
0 00 0 0
Numbers of articles in 0
the first round of
review
Lean healthcare Supply chain healthcare LSCM LSCM for healthcare
The code assigned to each paper was based on the search strings. For example, if a paper Supply chain
was found from “lean supply chain AND healthcare OR health care OR health service”, the management
LS code was assigned to that paper. If a paper was found using multiple strings, the TO
code was assigned to that paper. As stated previously, lean thinking is a trending approach
in SCM (Nightingale, 2005); thus, the year of publication was of interest and was also
included in the code. Most of the 280 selected papers were published after 2000, while the
oldest one was published in 1995. Finally, the papers’ research objectives and findings were
reviewed. To increase the quality of this study, we created a shortlist of papers as a
secondary review pool. Then, the meta-study was conducted on the shortlist. Figure 3 shows
the steps of the meta-study method applied in this research. To select the articles for
secondary review (the meta-study stage), we defined 18 tags (Table V). Then, we explored
the degree to which each paper captured the defined tags. All papers were assigned at least
one tag, and no paper captured more than eight tags. Based on the number of assigned tags,
we classified papers as having low, medium, or high relevance. Based on the actual
distribution of the tags, as well as the tag content, it was assumed that highly relevant
papers should obtain at least 30 per cent of the defined tags. Therefore, papers with at least
six tags were assigned a high (H) relevancy code and selected for our secondary pool. In
total, 75 papers were selected for the secondary pool. These papers were then analyzed using
meta-study.
4. Reporting results
The first major group in the primary pool were the articles related to supply chain in
healthcare: 79 papers. 55 papers in this group used qualitative methods; 22 used quantitative
methodologies; and two – Bendavid et al. (2012) and Masoumi et al. (2012) – contained a
combination of qualitative and quantitative methods. One of the major themes noted for this
group of papers was that surveys and questionnaires were the most common methods of
data collection. Hamid Abu Bakar et al. (2009), Kumar et al. (2009), Burns and Lee (2008), Pan
and Pokharel (2007), Ketikidis et al. (2006), Breen and Crawford (2005) and Aptel and
Pourjalali (2001) used surveys and questionnaires in their works. Meanwhile, another set of
papers – Uthayakumar and Priyan (2013), Masoumi et al. (2012), Kelle et al. (2012), Miori
et al. (2011), Shah et al. (2011), Burns and Lee (2008), and Nicholson et al. (2004) – applied
mathematical models for analyzing their research cases. Different qualitative methods were
also been used by authors in this group. For example, Chakraborty et al. (2014) used a
conceptual framework developed for supply chain collaboration (SCC), while Böhme et al.
(2013) applied Quick Scan Audit Methodology. Overall, 20 per cent of the literature in this
group was identified as highly relevant to this study and was transferred to the secondary
pool.
In total, 117 articles in the primary pool of 280 papers were identified as featuring
applications of lean tools in healthcare (the second group). In total, 77 per cent of these
articles used qualitative research methods, and 23 per cent utilized quantitative
Code Number Rational 1st part LH, LS, SH, TO

Code Number Rational 2nd part The number of paper in each category
Code Number Rational 3rd part V (papers with qualitative research methodology), M (papers with
quantitative research methodology), C (papers with both quantitative
and qualitative methodology) Table IV.
Code Number Rational 4th part Publication year (last two digits) Coding protocol for
Code Number Rational 5th part H, M, L [Relevance (based on # of tags)] article
IJLSS
Meta-study on the papers selected for secondary review
Conduct meta-theory:
Idenficaon of the theories, authors, and the scope of journals
Conduct meta-method:
Idenficaon of research quesons and research gaps

Meta-data:
Metaphor are defined to unify the language of all papers
Idenficaon of target areas (LSCM problem domains)
Idenficaon of LSCM applicaon
Record the replicaon of each target areas in the meta-study shortlist
Idenficaon of target areas and applicaons
Figure 3. Idenficaon of conngency factors

Meta-study steps
methodologies. This paper set included 20 literature reviews – such as Honeycutt (2018),
Rotter et al. (2018), D’Andreamatteo et al. (2015), Sloan et al. (2014), McIntosh et al. (2014),
Guimarães and de Carvalho (2012), Papadopoulos et al. (2011), Holden (2011), Brandao de
Souza (2009), Joosten et al. (2009), Cooper and Mohabeersingh (2008) and Kollberg et al.
(2006). Eight of the systematic literature reviews were identified as highly relevant to our
research on the basis of the tagging system, which was explained in the previous section.
The remaining 97 articles used various research methodologies. The importance of using
simulation in lean healthcare is one of the major themes in these articles, Robinson et al.
(2012), Chiocca et al. (2012) and Khurma et al. (2008) deployed simulation tools for their lean
studies. Overall, about 25 per cent of the articles related to the applications of lean tools in
Relevancy measurement
Supply chain
mechanism management
Search strings Tags Low Medium High
Supply chain in healthcare *Supply chain *Lean* Healthcare 1 or 2 tags 3, 4, 5 tags 6, 7, 8 tags
*Inventory
*Waste management *Technology/tools/
techniques
Lean healthcare *Cost management
*Transportation/logistics*movement of
material*distribution channel
Lean supply chain *Improvement/quality improvement*
Adding value Table V.
Lean supply chain in *Human factor*safety* Wait/time Tags for measuring
Healthcare *Efficiency *Effectiveness *Performance relevance
healthcare wer identified as highly relevant, which is significant. The combination of

literature reviews and research papers, and the mixture of quantitative and qualitative
studies, enhanced our ability to achieve comprehensive knowledge extraction as an outcome
of this study.
The third group of papers in our primary pool was defined as lean supply chain. This
segment consisted of 67 articles, including work conducted by Shamah (2013), Portioli-
Staudacher (2012) and Jonsson et al. (2011). Five papers of this group were literature reviews:
De Steur et al. (2016), Jasti and Kodali (2015), Martínez-Jurado and Moyano-Fuentes (2014),
London and Kenley (2001) and Croom et al. (2000). Thirteen papers of this group were
identified as highly relevant works and were added to the secondary pool. Defining this
group was important, as we attempted to extract knowledge for linking supply chain and
lean concepts regardless of the research area. This group of papers enabled us to better
understand how researchers observed the effect of lean applications on supply chain in
fields other than healthcare.
In the fourth group of papers, we identified 17 works focused on LSCM for healthcare as
follows: Kuupiel et al. (2017), Adebanjo et al. (2016), Habidin et al. (2014), Machado et al.
(2014), Habidin et al. (2014), Machado Guimarães and Crespo de Carvalho (2013),
Wijewardana and Rupasinghe (2013), Bendavis and Boeck (2012), Chiocca et al. (2012),
Aronsson et al. (2011), Setijono et al. (2010), Rahimnia and Moghadasian (2010), Samuel et al.
(2010), Revere et al. (2010), Shah et al. (2008), Swinehart and Smith (2005), and Heinbuch
(1995). Overall, 15 papers in this group were considered highly relevant to our research
scope. It is worth noting that, as this group focuses specifically on LSCM, it would appear,
on face value, that all 17 papers would be highly relevant and should be archived in the
secondary pool. However, Habidin et al. (2014) and Rahimnia and Moghadasian (2010) were
not selected for secondary analysis as they captured less than six tags, and the scopes of
their studies were not well matched with the objective of our systematic review. For
instance, Habidin et al. (2014) focused on lean healthcare and the supply chain innovation
relationship, which is more structural equation modeling than is discussion of LSCM
implementation.
5. Findings
This section presents the findings related to each of the three main components of meta-
study – meta-data analysis, meta-method and meta-theory – as well as the overall findings.
IJLSS
Theory/school of Influential domains in
thought Description LSCM Frequency
Lean theory/ Lean means increasing the customer value by Service delivery and 21
principles eliminating the waste in the system and utilizing patient safety
fewer resources. The lean philosophy is one of
the operations management theories that can be
used to decrease internal/external healthcare
expenditure, increase the level of patient safety,
raise profits, reduce litigation and diminish the
dependence on Government and Insurance
(Correa et al., 2005)
Transaction cost The transaction cost approach was introduced Inter-organizational 4
economics by Richard Coase. This theory refers to the cost
of pricing goods or services in the market
instead of presenting the service or good with

fixed price (Coase, 1937).This leads to higher
flexibility and helps to implement lean supply
chain. Narayana et al. (2014) reported that
service quality level in pharmaceutical supply
chain could be improved by effective pricing
policies. Thus, using theoretical approaches
such as transaction-cost economics can result in
medication SCM expenditure reduction.
Following, Chen et al. (2013) revealed that
exchange of transaction information between
hospital and suppliers generates knowledge,
which allows hospital supply chain’s
performance to surpass the former systems
Six sigma The concept of six sigma application in Process improvement 3
healthcare, i.e. process control in healthcare by and service delivery
using statistical tools, is discussed by Chiarini
and Bracci (2013) and Koning et al. (2006).
Chiarini and Bracci (2013) endeavored to
compare six sigma capability with basic TQM
and lean tools in terms of waste removal in
Italian public healthcare. While, Koning et al.
(2006) explained how the combination of lean
and six sigma can improve healthcare service
quality. Both lean and six sigma have the same
goal - that is, eliminating waste in the system.
However, lean attempts to eliminate non-value
added elements from the system while six sigma
asserts that the waste is generated by variation
in the process. Thus, by controlling the variation
in the process, the waste will be reduced
JIT Just in time or Toyota production system (TPS) 3
is a methodology for reducing time flow which
enables suppliers to respond faster to the
customer. JIT is applied widely in healthcare
industry. Hospital management should train
purchasing agents to collaborate with suppliers
Table VI. to practice just in time (Kumar et al., 2008). The
Theories explored in integrity between suppliers and purchasing
the literature (continued)
Supply chain
Theory/school of Influential domains in management
agents results in agility of the supply chain and

reduction of inventory levels (Khorasani, 2014)
Sim-lean theory The sim-lean approach is a theoretical and Service delivery 2
empirical perspective that suggests combination
of discrete-event simulation and lean.
Simulation and lean have a similar objective–
optimization of service delivery processes.
Although simulation and lean can be
complementary methodologies, they have been
usually applied individually. The sim-lean
approach attempts to create a fusion between
simulation and lean to increase improvement in

the process (Robinson et al., 2012). Specifically,
Robinson et al. (2012) showed how discrete-
event simulation can be used to better fulfill
three roles of lean: education, implementation
and assessment
Dynamic The processes of efficient deployment of Process improvement 1
capabilities organizational resources are dynamic
capabilities (Winter, 2003). In fact, the theory of
dynamic capabilities explains how application
of six sigma and utilization of knowledge
management can engender sustainable
competitive advantage (Barney, 2002). The
Gowen et al. (2008) study’s outcome shows how
knowledge management can enhance hospital
competitive advantage on the basis of dynamic
capabilities theory
Cross boundary This concept focused on disposal of medication Waste management 1
green PSC waste through pharmaceutical processes. Xie
(XGPSC) et al. (2012) show the complication of recycling
cost in this context. Generally, identification of
disposal cost is not difficult but the retrieval cost
estimation is complex and intricate.
Furthermore, the key to saving waste through a
green PSC (pharmaceutical supply chain) is an
efficient customer management approach in
healthcare, where patients are educated to bring
back unwanted medication
Knowledge- According to the knowledge-based view theory, Relational and 1
based view knowledge generated in the system is one of the
main resources for healthcare organizations. As
Chen et al. (2013) stated, trust has a direct effect
on hospital-supplier relationships. Thus, the
high level of security and trust between
hospitals and suppliers can result in an effective
knowledge exchange, which supports
implementing lean supply chain and increases
the profit for hospitals
(continued) Table VI.
IJLSS
Theory/school of Influential domains in
Relational view The core of this concept is based upon Relational and inter- 1
interorganizational strategies, which are not organizational
created by any individual firm (Zajac and Olsen,
1993). Small firms can make their network and
“rent” from the following resources: 1.
Investment in specific assets; 2. Organization’s
knowledge; 3. Capabilities and technologies; and
4. Regulations. According to the relational view
of knowledge exchange, IT systems are defined
as antecedents of effective SCM, which can be
developed by interorganizational relationships
that prevent many errors and waste in the

supply chain network (Chen et al., 2013)
Outsourcing Guimarães and de Carvalho (2012) affirmed Relational 1
outsourcing as a lean practice. They explained
how the outsourcing decision as lean practice
can improve the supply chain in healthcare at
both strategic and operational levels
The theory of According to this theory, an increase in swift Relational 1
swift exchange of information and material within a
process results in higher productivity
(Schmenner, 2004). Portioli-Staudacher and
Tantardini (2012) concluded that lean tools
bring higher productivity in the system as the
nature of lean implementation increases
information exchange and speeds up the flow of
material
Normalization A theory to realize the multifaceted effects that Process improvement 1
process Theory make innovations such as the proposing Lean
(npt) “workable” in practice settings (Goodrige et al.,
2018)
Table VI. Total 40
5.1 Meta-theory findings

Table VI presents the meta-theory results, describing the types of theories that were
detected in the secondary pool. The study shows that 40 of the 75 papers in the secondary
pool used a theoretical perspective. In total, 12 theoretical perspectives and concepts that
support lean supply chain application in healthcare have been detected in the literature
review. The frequency column in Table VI displays, for each theory, how many papers used
that theory as the most dominant lens. As expected, lean principles emerged as the most
significant theory applied in the secondary pool, with 21 out of 75 papers explicitly
mentioning this term or applying the theory. However, it is interesting to note that none of
the other identified theories were applied by more than four papers. This indicates a
diversity of theoretical lenses being applied in the field and a current lack of consensus
regarding the dominant theories (with the exception of lean thinking).
Machado et al. (2014), Machado Guimarães and Crespo de Carvalho (2013), Wijewardana
and Rupasinghe (2013), Bendavid et al. (2012), Radnor et al. (2012), Portioli-Staudacher and
Tantardini (2012), Arlbjørn et al. (2011), Setijono et al. (2010), Kumar et al. (2009) and Cooper
and Mohabeersingh (2008) state that lean concepts are an effective way to reduce healthcare Supply chain
cost and improve service quality. Holden (2011) discusses the effect of lean thinking on management
employees. He states that lean affects patient care and employees by changing the
organization structure. LaGanga (2011) concludes that lean improves healthcare
organization as well; therefore, lean concepts can offer a significant improvement in
emergency departments. Joosten et al. (2009) reports that lean applications definitely
improve healthcare delivery. The theory of lean is also being developed by IT applications,
such as digital scanning technology, which result in productivity improvement and larger
profit (Ker et al., 2014). Papadopoulos et al. (2011) focus on lean theory with a sociotechnical
approach. They explain how lean can improve the functionality of healthcare facilities by
reducing human errors. Lean theory does not focus only on overall waste in the healthcare
environment, but it can improve the physical layout of healthcare facilities. For instance,
Farrokhi et al. (2013) discuss how implementing 5S (one of the lean tools) improves the
quality of operating rooms. Indeed, the literature clearly reveals that lean, as an operations
management theory, is significantly influential and effective in healthcare. In addition, the
vast majority of papers consider the lean way of thinking as a cognitive approach, which
can influence different aspects of healthcare services.
The theory analysis indicates that transaction cost economics (Chen et al., 2013), dynamic
capabilities (Winter, 2003), (Gowen et al., 2008), knowledge-based views (Cohen and
Levinthal, 1990) and relational views (Zajac and Olsen, 1993) have been used to realize how
knowledge generation should be managed within SCM to increase the level of healthcare
service quality. Moreover, an integrated supplier-buyer relationship has been identified as
another main scope of work conducted by Pinna et al. (2015) and Kumar et al. (2008). The
authors of these articles apply JIT (Just in Time) as a theory to explain how collaboration
between suppliers and hospitals can reduce the level of inventory and result in fast flows of
material. Inventory is an important factor in US hospital supply chain expenditures (Kumar
et al., 2008). The synergy created from relationship optimization improves pharmaceutical
flow optimization, allows healthcare to overcome weaknesses, and increases the quality of
patient care (Pinna et al., 2015). In general, the increased agility of pharmaceutical systems
significantly reduces waste in healthcare SCM (Khorasani et al., 2017). Chen et al. (2013) also
uses the knowledge-based view to discuss the role of trust in building strong supplier-
hospital relationships. This meta-theory study has revealed that optimization of knowledge
flow and an integrated system between supplier and hospital are the main areas of
investigation for authors who attempt to find rational responses to the question: “How can
knowledge exchange and integrity between a hospital and suppliers generate more profit?”
Another insight extracted from the meta-theory results is the relationship between the
background of the authors and the scope of the journals in which they have published their
papers (Table VII). Knowing the background of the authors, such as their fields of study and
professions, helps us to better understand their schools of thought and use of language. This
analysis reinforces the finding that lean supply chain in healthcare is a diverse field with a
variety of perspectives being applied. The analysis also shows that applying lean in
healthcare has been an emerging topic for both academics and practitioners; however, to
date, most authors (almost 75 per cent) have been from purely academic backgrounds. Most
researchers have been from management and business backgrounds (51 per cent total), but
medical science was the next largest discipline (23 per cent); four other disciplines were also
represented. In terms of the journals’ scopes, there were almost equal numbers of
publications in operations management and medical science (approximately 30 per cent
each), while SCM was the next largest area (21 per cent).
IJLSS
Table VII.
vs journal scope
Author field of study
Author’s Field of study Industrial Medical Decision Chemical
Scope of journal Business engineering Management science Economics science engineering Total
Operation Management 4 4 12 2 2 0 0 24
Medical Science 4 1 2 15 0 1 0 23
SCM 3 2 7 0 2 0 2 16
Business Economics 6 0 2 0 2 0 0 10
Information Management 0 2 0 0 0 0 0 2
Chemical Engineering 0 0 0 0 0 0 2 2
Total 17 9 21 17 6 1 4 77
5.2 Meta-method and meta-data findings Supply chain
We classified the core research questions of the selected papers. In the first class, about 37 management
per cent of the secondary pool articles contained research questions related to the influence
of lean in healthcare. These works included: Farrokhi et al. (2013), Chiarini and Bracci (2013),
Wijewardana and Rupasinghe (2013), Machado Guimarães and Crespo de Carvalho (2013),
Robinson et al. (2012), Radnor et al. (2012), Holden (2011), Aronsson et al. (2011), Setijono
et al. (2010), Joosten et al. (2009), Cooper and Mohabeersingh (2008) and Koning et al. (2006).
In the second class, the research questions about 16 per cent of articles consider the influence
of technology in healthcare. Ker et al. (2014), Bendavid et al. (2012), Papadopoulos et al.
(2011), Revere et al. (2010), Correa et al. (2007) and Correa (2005) present research questions
related to the role of technology and its impact on healthcare. In the third class, articles focus
mainly on emerging trends in pharmaceuticals logistics. Pinna et al. (2015), Narayana et al.
(2014) and Xie et al. (2012) propose research questions related to new information flow
design in the pharmaceutical supply chain. Other research questions proposed in the
literature are as follows:
RQ4. What are the main challenges encountered during lean implementation in HSC?
(Grove et al., 2010).
RQ5. Why has lean implementation been slower in healthcare in comparison to other
sectors? (de Souza and Pidd, 2011).
Meta-method and meta-data analysis explain how authors identify research gaps, and
furthermore, how they approach filling the gaps by using different applications. We also
aimed to find the target areas affected by lean tool applications in HSC. Therefore, we
unified the language used for different papers, which, as described above, has been provided
by authors with different backgrounds. For this reason, we applied meta-ethnography
(Paterson and Canam, 2001). Therefore, as Paterson and Canam (2001) suggested, we
defined metaphors to translate all the target areas and applications extracted from the
secondary pool to a standard language. As the metaphors must be representative of the role
of lean implementation in healthcare, they were defined based on lean tools and waste. Four
categories of metaphors for the types of improvement targeted by the lean interventions
were identified: Waste, Safety, Value chain, and Cost.
5.2.1 Metaphors for waste (muda). Muda is a waste term in lean thinking (Womack and
Jones, 1996), and we define waste metaphors as follows:
(1) Patient-based (waste patient service delivery improvement).This metaphor is
assigned whenever at least one of a paper’s main scopes is associated with
improving service quality to patients by implementing LSCM in healthcare. Holden
(2011) has determined that many aspects of lean’s impact on patients must be
further discovered. Robinson et al. (2012) has identified lean as serving a
complementary role in service quality for patients, while Correa et al. (2005) has
identified the effects of new technology on patient scheduling, and LaGanga (2011)
arues for strategic development through lean application.
(2) Staff-based (waste organizational improvement). This metaphor is assigned
whenever at least one of a paper’s main scopes is recognized as LSCM
implementation for improving the efficiency of staff interactions. In hospitals, this
improvement is derived from better internal communication between managers,
doctors, and nurses. Grove et al. (2010) has reported bad communication among
staff and inefficient leadership as aspects of poor lean comprehension in health
organizations, which cause additional waste. Chiarini and Bracci (2013) have also
IJLSS discussed operational uniformity development and its significant role in waste
reduction.
(3) Instrument-based (waste of time reduction related to instrument usage). Papers
focused on saving time by better organizing instrument layout in operating rooms
are assigned the instrument-based metaphor. For example, Farrokhi et al. (2013)
applied 5S to instrument organization in an operatimg room, which reduced the
average number of instruments per surgery by 70 per cent; moreover, setup time
diminished by approximately 40 per cent.
(4) Drug distribution process-based (waste drug distribution system improvement).
Papers focused on drug distribution system improvement were assigned this
metaphor. For example, Ker et al. (2014) has studied the effect of digital scanning in
a drug distribution case study, which decreased more than one third of the overall
cost and significantly increased order processing time. Bendavid et al. (2012) has
focused on the traceability of high value products, which can be improved by

radio-frequency identification (RFID), while Pinna et al. (2015) has revealed how
the dose unit system reduces waste cost. The pharmaceutical supply chain
function greatly impacts overall waste reduction in healthcare. Creating interfaces
in healthcare between the supply function and healthcare procurement is replacing
the traditional approach, which only focused on pharmaceutical producers and
their distribution channels (Narayana et al., 2014). Improving the pharmaceutical
supply chain significantly impacts the overall expenditures of healthcare
organizations. Healthcare analysts have been attempting to use lean concepts and
technology to improve medication ordering systems and procurement processes,
rather than focusing on creating added value in manufacturing processes only.
(5) Overall waste in healthcare (overall waste in healthcare). We assigned this
metaphor to papers focusing on overall waste management improvement using
LSCM. For instance, Machado Guimarães and Crespo de Carvalho (2013) and
Correa et al. (2007) have conducted studies on implementing lean applications in
healthcare, which can decrease overall waste.
5.2.2 Metaphors for safety (patient safety improvement). This metaphor was assigned to
papers attempting to implement LSCM in healthcare to reduce the risk of errors and adverse
effects to patients. According to Healthcare Purchasing News (2006), 70 per cent of
healthcare firms announced that using technology like RFID improved patient safety in
their organizations. For instance, RFID boosts communication between different
departments and patient placement (Revere et al., 2010). Correa et al. (2005) affirms that
patient safety is the first motivation for hospitals and pharmacies to implement RFID. This
argument shows the importance of patient safety for healthcare providers who allocate
budget to increase patient safety levels in their organizations. Healthcare companies are
aware that they must not sacrifice patient safety for expenditure reduction. Furthermore, Six
Sigma and IT applications have been used by healthcare companies to resolve patient safety
issues. Lloyd and Holsenback (2006) suggest that Six Sigma is applied by healthcare
companies to improve their organizational performance. Consequently, increased internal
organizational performance allows them to raise patient safety levels. Moreover, IT
applications can improve staff scheduling, which increases the availability of nurses for
patients. This improvement enables the nursing staff to pay more attention to each patient,
which, consequently, improves patient safety (Mullaney et al., 2005).
5.2.3 Metaphor for value chain (value chain). This metaphor was assigned to papers Supply chain
with a holistic view of the entire value chain and overall performance improvement. Shah management
et al. (2011) indicates that creating a value chain from innovation management and research
development is equally as essential as optimizing material distribution in the
pharmaceutical supply chain. Another example is Susarla and Karimi (2012), who apply a
mixed integrated linear programming (MILP) model for a multinational pharmaceutical
company. The outcome of their research shows that the integrated model, which can include
inventory control, material flow, manufacturing and procurement, supports rational
decisions for solving long-term, complex problems for SCM in healthcare.
5.2.4 Metaphor for cost (cost reduction). If the main scope of a paper was connected to
healthcare system cost, this metaphor was assigned to the research. Total expenditure for
healthcare services is the main scope of many articles. This might be the most important
variable researchers have been attempting to minimize in healthcare SCM, and it can be
directly linked to applying lean. Papadopoulos et al. (2011), Arlbjørn et al. (2011), Joosten
et al. (2009), and Kumar et al. (2009) illustrate lean’s impact on overall cost. Koning et al.
(2006) attempts to depict how a combination of Six Sigma and lean can boost healthcare cost
reduction. Heinbuch (1995) also emphasizes the role of technology employment in inventory
cost management.
Figure 4 shows the frequency of the target area metaphors that occurred more than once
in the data set. As shown in Figure 4, organizational improvement (staff-based waste)
emerged as the most significant target area for applying lean thinking in healthcare SCM
among selected papers, with 18 papers focusing on it. Cost reduction was second, with 17
papers, and patient delivery service improvement (patient-based waste) was third, with 14
papers. All other metaphors accounted for nine or fewer papers.
5.2.5 Metaphors for lean tools or techniques. Each lean tool or technique applied for
reducing both waste and the cost of SCM in healthcare was identified as a metaphor.
Figure 5 shows a total of ten different applications for improving HSC in the secondary pool.
Value stream mapping (VSM) was the most commonly used technique for reducing cost and
eliminating waste in the supply chain system in hospitals and clinics, with 24 papers
focusing on this topic. Kaizen (continuous improvement) methods, including using IT
applications (ITAPP), was the second most popular technique (14 papers), even though
Rank Target Area of Lean Implementaon

20 120%
18
18 17
100% 100%
16 96%
14 92%
88%
14
78% 80%
12
66%
10 9 60%
8 47% 7
40%
6
4 24% 3 3 3
20%
2
0 0%
Waste Cost Reducon Waste paent Waste drug Over waste in paent safety Waste of me value chain Figure 4.
organizaonal
improvement
service
delivery
distribuon
system
healthcare improvement reducon
related to
Pareto chart for
improvement improvement instrument frequency of lean
usage
Frequency Cumulave Pct 80%Marker
target areas
IJLSS 30 120%
Rank of LSCM tools

25 100% 100%
97%
92% 95%
89%
86%
82%
20 80%
68%
15 60%
51%
10 40%
32%
5 20%
Figure 5.
Pareto Chart for
0 0%
frequency of lean
VSM Kaizen Heijunka RFID 5s Simlean Takt me Poka Yoke Kanban 3p
applications Frequency Cumulave Pct 80%Marker
ITAPP is not associated with the “traditional” lean toolkit. Specific IT applications
discussed in the literature under the ITAPP category include “no carbon required” (Ker
et al., 2014), electronic health records (LaGanga, 2011), smart partial least squares (Smart
PLS) (Chen et al., 2013), electronic data interchange (Breen and Crawford, 2005), and digital
scanning (Ker et al., 2014). Heijunka (production leveling) facilitating JIT is the third most
popular application, with 12 papers in the literature. Interestingly, although also not part of
the “traditional” lean toolkit, RFID was the next most commonly applied lean tool, with 11
papers. Many recent papers have focused on RFID application to reduce the time of
healthcare service delivery, including papers presented by and Bendavid et al. (2012).
It is also worth noting here that, while investigating which lean tools are most commonly
applied together was outside the scope of this research, a combination of lean tools are often
applied in practice to holistically improve organizations. For instance, Kaizen can be
integrated with VSM in healthcare organizations as a powerful improvement plan. In this
case, VSM is used to identify the Kaizen opportunities in the current system, which may
include the application of additional lean tools (5S, Standard Work, etc.). Afterwards,
process-level Kaizen activities, often organized as a workshop or Kaizen event, will take
place to implement these opportunities. For example, Nicholas (2012) shows how integrating
Kaizen events, VSM, 5S, and Standard Work can reduce operational costs in the hospital
facility redesign process.
The overall insight provided by the meta-data analysis is shown as the connection
between each lean application and target area (Table VIII). Table VIII shows that the
application of VSM has had the most significant impact to date in the areas of waste
reduction (particularly organizational and patient service delivery) and cost reduction.
Kaizen is the second most common lean application for healthcare LSCM. To date, many
hospitals have applied Kaizen for improving information flow and reducing errors in
various contexts. Kaizen has been most frequently applied to address patient service
delivery waste. The findings of this study also demonstrate that implementations of Kaizen
applications in hospitals improve the medication distribution system, decrease healthcare
cost, create value change, and improve organizational waste. Thus, we can conclude that,
based on the existing research literature, the first suggestions for improving the SCM
Waste Waste
Target Waste Patient service Drug distribution Overall waste
area Cost organizational delivery improvement Patient safety improvement in Waste related to Value
Application reduction improvement improvement system improvement healthcare instrument usage chain Total
VSM 5 9 4 2 2 2 24
Kaizen 3 1 6 2 2 14
Heijunka 3 3 3 3 12
RFID 4 2 1 3 1 11
5S 1 1 1 3
Simulation 1 1 2
3P 1 1 2
Poka Yoke 2 2
Takt Time 2 2
Kanban 1 1 2
Total 17 18 14 9 3 7 3 3 74
area relationships
Application-target
Supply chain
Table VIII.
management
IJLSS system in healthcare by using a lean thinking approach could be setting up workshops for
creating optimized VSM and implementing Kaizen events. The literature also suggests that,
to date, RFID implementation efforts have shown it to be helpful for healthcare
organizations, principally in reducing their cost and improving patient safety.
5.3 Contingency factors

Contingency factors illustrate context variables or sources of variance that influence the
context of our study (Pero et al., 2015). The final step of the meta-study was identifying
contingency factors that could have influenced the selection of lean target areas or the
application of lean tools and techniques. We then grouped the identified contingency factors
into a total of 18 categories. Our analysis shows that supply chain characteristics, leadership
and top management characteristics and organization characteristics are the most important
types of contingency factors, with 15, 14, and 13 instances, respectively (Table IX).
To increase the reliability of this study’s outcomes, we also report the other contingency
factors that may influence the target areas and applications used for lean implementation in
HSC (Table X).
6. Implications and limitations

This paper addresses supply chain managers and decision-makers working in healthcare,
encouraging them to consider implementing lean tools as an important opportunity for
improvement. The study suggests that they pay attention, not only to implementing lean
tools in HSC, but also to considering what tools can result in optimum improvement for each
HSC problem domain.
Implementing lean tools in HSC is challenging. One common challenge is that healthcare
companies have different policies and workflows, which implies that implementing lean
tools in this sector is likely to be a variegated process. Thus, managers and decision-makers
should evaluate the detailed parameters and characteristics of their own organization’s
systems when they plan to apply a lean tool. Another challenge is accurately estimating the
cost of implementing lean tools in healthcare companies. One recommendation to HSC
managers is that they continuously track the cost of implementing lean tools in their
companies.
Based on this study’s findings, a set of target areas for implementing lean tools in HSC,
applications of lean tools, and main contingency factors have been identified. Yet, our
Category Specific contingency factors Count
Supply chain characteristics Complexity of HSC, involvement of the entire supply chain, cross- 15
sector collaboration, fear of stock out situation, collaboration with
suppliers, traceability, logistical ease, security of supply, inventory
holding costs, materials’ shelf-lives, delivery priority, supply chain
strategy, supply chain actors, operational and strategic capabilities,
supply chain configuration
Leadership and top Involvement of healthcare managers (5), management styles (4), 14
management characteristics leadership determination to lean programs (2), lack of communication
willingness of managers to change project management capabilities
Table IX. Organization characteristics Organizational structure (4), resistance to change (2), size of 13
The most dominant organization (2) organizational commitment, institutional issues, ,
contingency factor professional and functional silos, incentive mechanisms,
categories communication channels
Category Specific contingency factors Count
Supply chain
management
Stakeholders Multiple stakeholders (3), role of insurance companies (2) stakeholder’s 9
characteristics interest in lean programs, influence of powerful groups (e.g. unions),
conflict of interests, drug regulatory agencies
Human resources Staff characteristics (e.g. roles, capabilities, mindsets, and perceptions) 9
(5), Human resources involvement (2), poor understanding of the lean
philosophy, staff training
ICT Information and Communication Technology (ICT) (4), using limited 8
IT technology, manual processes, advanced software packages,
information sharing
Cost and funding-related Current structures related to funding (2), commissioning of services, 7
issues cost of implementation, international tax differentials, healthcare fiscal
intermediaries and payers, cost of care
Hospital characteristics Hospital management system, coordination of pharmacists and 7
nurses, clinical issues, hospital system membership, hospital

environmental uncertainty, coordination between hospital and staff,
hospital facilities
Cultural characteristics National culture (3), cultural difference between parients and hospital 5
staff, cultural difference among hospital staff
Government roles Dependence on government, political issues, local political decisions, 5
moving toward public vs private sector, regulations
Technical know-how Professional skills (2), lack of resources and know-how (2), lack of 5
flexibility of resources
Country or environment Country characteristics, industrialization of healthcare, environmental 5
characteristics impact, aging population, infrastructure
Regulations and standards Regulation of services (through government targets) (2), standards (2), 5
privacy and security issues
Lean process and priorities Lean process priority, value recognition, waste treatment, waste 4
disposal
Customer characteristics Multiple customers, consumer preferences, internal customer 4
satisfaction, customer satisfaction
Change-related issues Prior attempts of lean programs, lean change initiatives, resistance to 4
change, change agents Table X.
Trust Trust among partners and stakeholders (3) 3 Other contingency
Globalization Globalization trends 1 factors
research has some limitations. Readers and other researchers should consider these
limitations for future studies.
First, this study used the following six databases: Scopus, ScienceDirect, Google scholar,
Emerald, SpringerLink and EBSCO. Despite the fact that these six databases seem likely to
cover an adequate number of documents for this study, if more databases had been utilized,
it is possible that additional relevant papers could have been identified, further increasing
the study’s accuracy.
Second, the research methodology excluded papers with fewer than four citations (except
those published after 2016), as these papers were assumed to have lower relevancy to the
research. However, some papers with fewer than four citations were ultimately considered in
this study through the backward and forward search processes, and as mentioned above,
exceptions had already been made for more recent articles, which might be expected to have
fewer than four citations simply due to the short time since their publication. However,
despite these measures, it is possible that some articles with high relevancy, but fewer than
four citations, were excluded from the research.
IJLSS Finally, four main search strings were applied for the study’s search protocol: “lean
supply chain AND healthcare OR health care OR health service”, “supply chain in
healthcare OR health care OR health service, “lean AND healthcare OR health care OR
health service” and “lean supply chain”. An article was selected for the primary pool if any
of the sets of keywords were detected in the title of the paper or mentioned in its abstract.
Due to this method, it is possible that papers may have been missed that were relevant but
did not include any of the main search terms in their titles or abstracts.
7. Conclusions and agenda for future research

The objective of this work was to perform a comprehensive qualitative analysis of the
emerging topic of LSCM in healthcare by conducting a systematic literature review
following the method presented by Tranfield et al. (2003). Specifically, this research aimed to
create an in-depth understanding of major factors affecting lean thinking implementation in
healthcare SCM by discovering major target areas, common techniques, and contingency
factors for lean implementation in the HSC. The research outcome is expected to be helpful
for practitioners and researchers in healthcare and the supply chain.
In this study, 280 recent, peer-reviewed articles from credible scientific journals were
examined using a qualitative methodology called meta-study. To draw the final conclusions
from our research, we revisit each of our research questions.
The first research question was “What are the major target areas for LSCM in
healthcare?” Conducting this meta-study, we detected and classified these target areas; we
next translated them into a common language by defining metaphors (applying meta-
ethnography). The outcome emerges as a set of target areas for lean implementation in the
HSC. The frequency of each target area was then explored. Most articles in this review focus
on applying lean concepts for decreasing waste from organizational issues, reducing cost,
and minimizing waste in patient service delivery. The fourth and fifth target areas –
implementing LSCM for minimizing waste in the drug distribution system and improving
patient safety – seem to have not been covered sufficiently yet in existing literature.
Our second research question was “What are the tools/techniques most frequently used in
implementing LSCM in healthcare?” In our meta-study, the tools and techniques applied for
eliminating waste, decreasing healthcare SCM cost, and improving safety were identified and
ranked based on frequency of appearance in the literature. Some of the tools most frequently
applied are traditionally known as “lean tools,” such as VSM; yet some of the most commonly
applied tools, such as RFID, are not recognized as “traditional” lean tools. The strongest
connection demonstrated to date between application and target area appears between VSM and
lean thinking for organizational improvement, with nine papers claiming a positive relationship.
This indicates that VSM is a strong lean tool for improving HSC. Moreover, VSM has more links
to the target areas than any of the other tools. Specifically, the literature indicates that VSM has
been applied for improving six different target areas: cost reduction, waste organizational
improvement, waste patient service delivery improvement, waste drug distribution system
improvement, overall waste in healthcare, and waste related to instrument usage.
Finally, our third research question was: “What are the central contingency factors
affecting the implementation of LSCM in healthcare?” Our results imply that there are 18
categories of contingency factors influencing lean supply chain in healthcare. The
characteristics of the supply chain, leadership and top management roles, and
organizational characteristics appear to have the most significant effects on implementing
LSCM in healthcare.
Several areas for potential future research can be identified based on this study’s findings.
First, the research demonstrates that the drug distribution system is an important area for
LSCM. However, to date, an insufficient number of studies have been detected on this topic. Supply chain
Similarly, although improving patient safety in the HSC is also a key topic, there is a relative management
lack of research in this area as well, with only three papers detected in the study’s secondary
pool. Another area for future research is comparing costs versus the potential savings of lean
implementation in each HSC target area. Although the benefits of implementing lean in SCM
are often identified in existing literature, they are not always quantified, and costs are much
less often addressed. Finally, future researchers should also study the effects of using multiple
lean applications in each target area of lean implementation, as most of the studies only focus
on one, or a few, applications and often do not address the relationships between applications.
In addition, analyzing the effects of implementing more than one lean application on each
target area was out of the present study’s scope; consequently, the authors believe that
understanding the impact of multiple applications will be a substantial extension of this study.
References
Adebanjo, D., Laosirihongthong, T. and Samaranayake, P. (2016), “Prioritizing lean supply chain
management initiatives in healthcare service operations: a fuzzy AHP approach”, Production
Planning and Control, Vol. 27 No. 12, pp. 953-966.
Aptel, O. and Pourjalali, H. (2001), “Improving activities and decreasing costs of logistics in hospitals: a
comparison of US and French hospitals”, The International Journal of Accounting, Vol. 36 No. 1,
pp. 65-90.
Arlbjørn, J.S., Freytag, P.V. and Haas, H.D. (2011), “Service supply chain management: a survey of lean
application in the municipal sector”, International Journal of Physical Distribution and Logistics
Management, Vol. 41 No. 3, pp. 277-295.
Aronsson, H., Abrahamsson, M. and Spens, K. (2011), “Developing lean and agile health care supply
chains”, Supply Chain Management: An International Journal, Vol. 16 No. 3, pp. 176-183.
Baker, M.J. (2000), “Writing a literature review”, The Marketing Review, Vol. 1 No. 2, pp. 219-247.
Barnett-Page, E. and Thomas, J. (2009), “Methods for the synthesis of qualitative research: a critical
review”, BMC Medical Research Methodology, Vol. 9 No. 1, p. 1.
Beck, C.T. (2001), “Caring within nursing education: a metasynthesis”, Journal of Nursing Education,
Vol. 40 No. 3, pp. 101-109.
Bendavid, Y., Boeck, H. and Philippe, R. (2012), “RFID-enabled traceability system for consignment and
high value products: a case study in the healthcare sector”, Journal of Medical Systems, Vol. 36
No. 6, pp. 3473-3489.
Berger, S.L.T., Tortorella, G.L. and Rodriguez, C.M.T. (2018), “Lean supply chain management: a
systematic literature review of practices, barriers and contextual factors inherent to its
implementation”, Progress in Lean Manufacturing, pp. 39-68.
Böhme, T., Williams, S.J., Childerhouse, P., Deakins, E. and Towill, D. (2013), “Methodology challenges
associated with benchmarking healthcare supply chains”, Production Planning and Control,
Vol. 24 No. 10, pp. 1002-1014.
Brandao de Souza, L. (2009), “Trends and approaches in lean healthcare”, Leadership in Health Services,
Vol. 22 No. 2, pp. 121-139.
Breen, L. and Crawford, H. (2005), “Improving the pharmaceutical supply chain: assessing the reality of
e-quality through e-commerce application in hospital pharmacy”, International Journal of
Quality and Reliability Management, Vol. 22 No. 6, pp. 572-590.
Brittberg, M., Lindahl, A., Nilsson, A., Ohlsson, C., Isaksson, O. and Peterson, L. (1994), “Treatment of
deep cartilage defects in the knee with autologous chondrocyte transplantation”, New England
Journal of Medicine, Vol. 331 No. 14, pp. 889-895.
IJLSS Burns, L.R. and Lee, J.A. (2008), “Hospital purchasing alliances: utilization, services, and performance”,
Health Care Management Review, Vol. 33 No. 3, pp. 203-215.
Burns, L.R., DeGraaff, R.A., Danzon, P.M., Kimberly, J.R., Kissick, W.L. and Pauly, M.V. (2002), “The
Wharton school study of the health care value chain”, The Health Care Value Chain: producers,
Purchasers and Providers, pp. 3-26.
Chakraborty, S., Bhattacharya, S. and Dobrzykowski, D.D. (2014), “Impact of supply chain
collaboration on value co-creation and firm performance: a healthcare service sector
perspective”, Procedia Economics and Finance, Vol. 11, pp. 676-694.
Chen, D.Q., Preston, D.S. and Xia, W. (2013), “Enhancing hospital supply chain performance: a
relational view and empirical test”, Journal of Operations Management, Vol. 31 No. 6,
pp. 391-408.
Chiarini, A. and Bracci, E. (2013), “Implementing lean six sigma in healthcare: issues from Italy”, Public
Money and Management, Vol. 33 No. 5, pp. 361-368.
Chiocca, D., Guizzi, G., Murino, T., Revetria, R. and Romano, E. (2012), “A methodology for supporting
lean healthcare”, Modern Advances in Intelligent Systems and Tools, pp. 93-99.
Coase, R.H. (1937), “The nature of the firm”, Economica, Vol. 4 No. 16, pp. 386-405.
Cohen, W.M. and Levinthal, D.A. (1990), “Absorptive capacity: a new perspective on learning and
innovation”, Administrative Science Quarterly, Vol. 35 No. 1, pp. 128-152.
Cook, D.J., Mulrow, C.D. and Haynes, R.B. (1997), “Systematic reviews: synthesis of best evidence for
clinical decisions”, Annals of Internal Medicine, Vol. 126 No. 5, pp. 376-380.
Cooper, H.M. (1988), “Organizing knowledge syntheses: a taxonomy of literature reviews”, Knowledge
in Society, Vol. 1 No. 1, pp. 104-126.
Cooper, R.G. and Mohabeersingh, C. (2008), “Lean thinking in a healthcare system-innovative roles”,
Journal of Pre-Clinical and Clinical Research, Vol. 2 No. 2, pp. 110-117.
Correa, F.A., Gil, M.J. and Redin, L.B. (2005), “Benefits of connecting rfid and lean principles in health
care”, Journal of Business Economic, Vol. 7 No. 8, pp. 44-65.
Correa, F.A., Gil, M.J. and Redin, L.B. (2007), “RFID and health management: is it a good tool against
system inefficiencies?”, International Journal of Healthcare Technology and Management, Vol. 8
Nos 3/4, pp. 268-297.
Croom, S., Romano, P. and Giannakis, M. (2000), “Supply chain management: an analytical framework
for critical literature review”, European Journal of Purchasing and Supply Management, Vol. 6
No. 1, pp. 67-83.
Cuckler, G.A., Sisko, A.M., Poisal, J.A., Keehan, S.P., Smith, S.D., Madison, A.J., Wolfe, C.J. and
Hardesty, J.C. (2018), “National health expenditure projections, 2017–26: despite uncertainty,
fundamentals primarily drive spending growth”, Health Affairs, Vol. 37 No. 3, pp. 482-492.
D’Andreamatteo, A., Ianni, L., Lega, F. and Sargiacomo, M. (2015), “Lean in healthcare: a
comprehensive review”, Health Policy, Vol. 119 No. 9, pp. 1197-1209.
de Souza, L.B. and Pidd, M. (2011), “Exploring the barriers to lean health care implementation”, Vol. 31
No. 1, pp. 59-66.
De Steur, H., Wesana, J., Dora, M.K., Pearce, D. and Gellynck, X. (2016), “Applying value stream
mapping to reduce food losses and wastes in supply chains: a systematic review”, Waste
Management, (New York, N.Y.), Vol. 58, pp. 359-368.
de Vries, J., Huijsman, R., Aronsson, H., Abrahamsson, M. and Spens, K. (2011), “Developing lean and
agile health care supply chains”, Supply Chain Management: An International Journal, Vol. 16
No. 3, pp. 176-183.
Farrokhi, F.R., Gunther, M., Williams, B. and Blackmore, C.C. (2013), “Application of lean methodology
for improved quality and efficiency in operating room instrument availability”, Journal for
Healthcare Quality, pp. 1-10.
Fischl, M., Scherrer-Rathje, M. and Friedli, T. (2014), “Digging deeper into supply risk: a systematic Supply chain
literature review on price risks”, Supply Chain Management: An International Journal, Vol. 19
Nos 5/6, pp. 480-503.
management
Flynn, B.B., Huo, B. and Zhao, X. (2010), “The impact of supply chain integration on performance: a
contingency and configuration approach”, Journal of Operations Management, Vol. 28 No. 1, pp. 58-71.
Frazzon, E.M., Albrecht, A., Pires, M., Israel, E., Kück, M. and Freitag, M. (2017), “Hybrid approach for
the integrated scheduling of production and transport processes along supply chains”,
International Journal of Production Research, pp. 1-17.
Goldsby, T.J., Griffis, S.E. and Roath, A.S. (2006), “Modeling lean, agile, and leagile supply chain
strategies”, Journal of Business Logistics, Vol. 27 No. 1, pp. 57-80.
Gowen, C., III, Stock, G. and McFadden, K. (2008), “Simultaneous implementation of Six Sigma and
knowledge management in hospitals”, International Journal of Production Research, Vol. 46
No. 23, pp. 6781-6795.
Grove, A.L., Meredith, J.O., Macintyre, M., Angelis, J. and Neailey, K. (2010), “UK health visiting: challenges
faced during lean implementation”, Leadership in Health Services, Vol. 23 No. 3, pp. 204-218.
Guimarães, C.M. and de Carvalho, J.C. (2012), “Lean healthcare across cultures: state-of-the-art”,
American International Journal of Contemporary Research, Vol. 2 No. 6, pp. 187-206.
Habidin, N.F., Shazali, N.A., Ali, N., Khaidir, N.A. and Jamaludin, N.H. (2014), “Exploring lean
healthcare practice and supply chain innovation for Malaysian healthcare industry”,
International Journal of Business Excellence, Vol. 7 No. 3, pp. 394-410.
Halldorsson, Á., Stefánsson, G., Fabbe-Costes, N. and Jahre, N. (2007), “Supply chain integration
improves performance: the Emperor's new suit?”, International Journal of Physical Distribution
and Logistics Management, Vol. 37 No. 10, pp. 835-855.
Hamid Abu Bakar, A., Lukman Hakim, I., Choy Chong, S. and Lin, B. (2009), “Measuring supply chain
performance among public hospital laboratories”, International Journal of Productivity and
Performance Management, Vol. 59 No. 1, pp. 75-97.
Heinbuch, S.E. (1995), “A case of successful technology transfer to health care: total quality materials
management and just-in-time”, Journal of Management in Medicine, Vol. 9 No. 2, pp. 48-56.
Higgins, J.P. and Green, S. (2008), Cochrane Handbook for Systematic Reviews of Interventions, Wiley
Online Library.
Holden, R.J. (2011), “Lean thinking in emergency departments: a critical review”, Annals of Emergency
Medicine, Vol. 57 No. 3, pp. 265-278.
Honeycutt, R. (2018), Mechanisms of Pesticide Movement into Ground Water, CRC Press.
Jasti, N.V.K. and Kodali, R. (2015), “A critical review of lean supply chain management frameworks:
proposed framework”, Production Planning and Control, Vol. 26 No. 13, pp. 1051-1068.
Jonsson, P., Andersson, D., Stentoft Arlbjørn, J., Vagn Freytag, P. and de Haas, H. (2011), “Service
supply chain management: a survey of lean application in the municipal sector”, International
Journal of Physical Distribution and Logistics Management, Vol. 41 No. 3, pp. 277-295.
Joosten, T., Bongers, I. and Janssen, R. (2009), “Application of lean thinking to health care: issues and
observations”, International Journal for Quality in Health Care, Vol. 21 No. 5, pp. 341-347.
Kelle, P., Woosley, J. and Schneider, H. (2012), “Pharmaceutical supply chain specifics and inventory
solutions for a hospital case”, Operations Research for Health Care, Vol. 1 Nos 2/3, pp. 54-63.
Ker, J.I., Wang, Y., Hajli, M.N., Song, J. and Ker, C.W. (2014), “Deploying lean in healthcare: evaluating
information technology effectiveness in US hospital pharmacies”, International Journal of
Information Management, Vol. 34 No. 4, pp. 556-560.
Ketikidis, P.H., Lenny Koh, S., Gunasekaran, A., Danas, K., Roudsari, A. and Ketikidis, P.H. (2006), “The
applicability of a multi-attribute classification framework in the healthcare industry”, Journal of
Manufacturing Technology Management, Vol. 17 No. 6, pp. 772-785.
IJLSS Khorasani, S.T. (2014), “Design-Driven integrated-comprehensive model CDFS strategic relationships”,
ASME 2014 International Design Engineering Technical Conferences and Computers and
Information in Engineering Conference, American Society of Mechanical Engineers.
Khorasani, S.T., Maghazei, O. and Cross, J.A. (2015), “A structured review of lean supply chain
management in health care”, Proceedings of the International Annual Conference of the
American Society for Engineering Management., American Society for Engineering
Management (ASEM).
Khorasani, S.T., Cross, J., Feizi, R. and Islam, M.S. (2017), “Application of lean tools in medication
ordering systems for hospital”, in Coperich, K., Cudney, E. and Nembhard, H. (Eds), Proceedings
of the 2017 Industrial and Systems Engineering Conference.
Khurma, N., Bacioiu, G.M. and Pasek, Z.J. (2008), “Simulation-based verification of lean improvement
for emergency room process”, Proceedings of the 40th conference on winter simulation, Winter
Simulation Conference.
Kim, S.K. (2015), “Lean initiative practice for supplier developments in Philippines”, International
Journal of Lean Six Sigma, Vol. 6 No. 4, pp. 349-368.
Kollberg, B., Dahlgaard, J.J. and Brehmer, P.O. (2006), “Measuring lean initiatives in health care
services: issues and findings”, International Journal of Productivity and Performance
Koning, H., Verver, J.P., Heuvel, J., Bisgaard, S. and Does, R.J. (2006), “Lean six sigma in healthcare”,
Journal for Healthcare Quality, Vol. 28 No. 2, pp. 4-11.
Kumar, S., DeGroot, R.A. and Choe, D. (2008), “Rx for smart hospital purchasing decisions: the impact
of package design within US hospital supply chain”, International Journal of Physical
Distribution and Logistics Management, Vol. 38 No. 8, pp. 601-615.
Kumar, S., Swanson, E. and Tran, T. (2009), “RFID in the healthcare supply chain: usage and
application”, International Journal of Health Care Quality Assurance, Vol. 22 No. 1, pp. 67-81.
Kuupiel, D., Bawontuo, V. and Mashamba-Thompson, T.P. (2017), “Improving the accessibility and
efficiency of point of care diagnostics services in low and middle income countries”, Lean and
Agile Supply Chain Management Diagnostics, Vol. 7 No. 4, p. 58.
LaGanga, L.R. (2011), “Lean service operations: reflections and new directions for capacity expansion in
outpatient clinics”, Journal of Operations Management, Vol. 29 No. 5, pp. 422-433.
Lloyd, D.H, II. and Holsenback, J. (2006), “The use of Six Sigma in health care operations: application
and opportunity”, Academy of Health Care Management Journal, Vol. 2, p. 41.
London, K.A. and Kenley, R. (2001), “An industrial organization economic supply chain approach for
the construction industry: a review”, Construction Management and Economics, Vol. 19 No. 8,
pp. 777-788.
McIntosh, B., Sheppy, B. and Cohen, I. (2014), “Illusion or delusion–lean management in the health
sector”, International Journal of Health Care Quality Assurance, Vol. 27 No. 6, pp. 482-492.
Machado Guimarães, C. and Crespo de Carvalho, J. (2013), “Strategic outsourcing: a lean tool of
healthcare supply chain management”, Strategic Outsourcing: An International Journal, Vol. 6
No. 2, pp. 138-166.
Machado, C.M., Scavarda, A. and Vaccaro, G. (2014), “Lean healthcare supply chain management:
minimizing waste and costs”, Independent Journal of Management and Production, Vol. 5 No. 4,
pp. 1071-1088.
Manzouri, M. and Rahman, M.N.A. (2013), “Adaptation of theories of supply chain management to the
lean supply chain management”, International Journal of Logistics Systems and Management,
Vol. 14 No. 1, pp. 38-54.
Martínez-Jurado, P.J. and Moyano-Fuentes, J. (2014), “Lean management, supply chain management
and sustainability: a literature review”, Journal of Cleaner Production, Vol. 85, pp. 134-150.
Masoumi, A.H., Yu, M. and Nagurney, A. (2012), “A supply chain generalized network oligopoly model Supply chain
for pharmaceuticals under brand differentiation and perishability”, Transportation Research
Part E: Logistics and Transportation Review, Vol. 48 No. 4, pp. 762-780.
management
Mathew, J., John, J. and Kumar, S. (2013), “New trends in healthcare supply chain”, International Annual
Conference, Production and Operations Management Society, Denver, CO.
Miori, V.M., Miori, D.J. and Segulin, B.W. (2011), “Simulation to forecast the impact of electronic medical
records and inventory (patient) postponement in developing efficient heath care supply chains”,
Advances in Business and Management Forecasting, Vol. 8, pp. 129-151.
Mullaney, T.J., Weintraub, A. and Reinhardt, A. (2005), “The digital hospital”, Business Week, pp. 42-47.
Narayana, S.A., Pati, R.K. and Vrat, P. (2014), “Managerial research on the pharmaceutical supply
chain–a critical review and some insights for future directions”, Journal of Purchasing and
Supply Management, Vol. 20 No. 1, pp. 18-40.
Nicholas, J. (2012), “An integrated lean-methods approach to hospital facilities redesign”, Hospital
Topics, Vol. 90 No. 2, pp. 47-55.

Nicholson, L., Vakharia, A.J. and Erenguc, S.S. (2004), “Outsourcing inventory management decisions
in healthcare: models and application”, European Journal of Operational Research, Vol. 154
No. 1, pp. 271-290.
Nightingale, D. (2005), Lean Supply Chain Management Principles and Practices, MA Institute of
Technology, Cambridge, MA.
Nollet, J. and Beaulieu, M. (2003), “The development of group purchasing: an empirical study in the
healthcare sector”, Journal of Purchasing and Supply Management, Vol. 9 No. 1, pp. 3-10.
Olsson, O. and Aronsson, H. (2015), “Managing a variable acute patient flow–categorising the
strategies”, Supply Chain Management: An International Journal, Vol. 20 No. 2,
pp. 113-127.
Pan, Z.X. and Pokharel, S. (2007), “Logistics in hospitals: a case study of some Singapore hospitals”,
Leadership in Health Services, Vol. 20 No. 3, pp. 195-207.
Papadopoulos, T., Radnor, Z. and Merali, Y. (2011), “The role of actor associations in understanding the
implementation of lean thinking in healthcare”, International Journal of Operations and
Production Management, Vol. 31 No. 2, pp. 167-191.
Parente, D.H., Lee, P.D., Ishman, M.D. and Roth, A.V. (2008), “Marketing and supply chain
management: a collaborative research agenda”, Journal of Business and Industrial Marketing,
Vol. 23 No. 8, pp. 520-528.
Parnaby, J. and Towill, D.R. (2008), “Seamless healthcare delivery systems”, International Journal of
Health Care Quality Assurance, Vol. 21 No. 3, pp. 249-273.
Paterson, B.L. and Canam, C. (2001), “Meta-study of qualitative health research: a practical guide to
meta-analysis and meta-synthesis”, Sage.
Pero, M., Stößlein, M. and Cigolini, R. (2015), “Linking product modularity to supply chain integration
in the construction and shipbuilding industries”, International Journal of Production Economics,
Vol. 170, pp. 602-615.
Pinna, R., Carrus, P.P. and Marras, F. (2015), “The drug logistics process: an innovative experience”,
The TQM Journal, Vol. 27 No. 2, pp. 214-230.
Platchek, T. and Kim, C. (2012), “Lean health care for the hospitalist”, Hospital Medicine Clinics, Vol. 1
No. 1, pp. 148-160.
Porter, M. and Kaplan, R. (2011), “How to solve the cost crisis in health care”, Harvard Business Rev,
pp. 46-64.
Portioli-Staudacher, A. and Tantardini, M. (2012), “Investigating the main problems in implementing
lean in supply chains of service companies”, International Journal of Services and Operations
IJLSS Radnor, Z.J., Holweg, M. and Waring, J. (2012), “Lean in healthcare: the unfilled promise?”, Social
Science & medicine, Vol. 74 No. 3, pp. 364-371.
Rahimnia, F. and Moghadasian, M. (2010), “Supply chain leagility in professional services: how to
apply decoupling point concept in healthcare delivery system”, Supply Chain Management: An
International Journal, Vol. 15 No. 1, pp. 80-91. No
Revere, L., Black, K. and Zalila, F. (2010), “RFIDs can improve the patient care supply chain”, Hospital
Topics, Vol. 88 No. 1, pp. 26-31.
Ring, N.A. Ritchie, K.L. and Jepson, R. (2011), “A guide to synthesising qualitative research for
researchers undertaking health technology assessments and systematic reviews”
Roark, D.C. (2005), “Managing the healthcare supply chain”, Nursing Management, Vol. 36 No. 2, pp. 36-40.
Robinson, S., Radnor, Z.J., Burgess, N. and Worthington, C. (2012), “SimLean: utilising simulation in the
implementation of lean in healthcare”, European Journal of Operational Research, Vol. 219 No. 1,
pp. 188-197.
Rotter, T., Plishka, C., Lawal, A., Harrison, L., Sari, N., Goodridge, D., Flynn, R., Chan, J., Fiander, M.,
Poksinska, B. and Willoughby, K. (2018), “What is lean management in health care?
Development of an operational definition for a cochrane”, Evaluation and the Health Professions,
p. 0163278718756992.
Rowley, J. and Slack, F. (2004), “Conducting a literature review”, Management Research News, Vol. 27
No. 6, pp. 31-39.
Samuel, C., Gonapa, K., Chaudhary, P.K. and Mishra, A. (2010), “Supply chain dynamics in
healthcare services”, International Journal of Health Care Quality Assurance, Vol. 23
No. 7, pp. 631-642.
Schmidt, F.L. and Hunter, J.E. (2014), Methods of Meta-Analysis: Correcting Error and Bias in Research
Findings, Sage publications.
Schmitt, R. (2005), “Systematic metaphor analysis as a method of qualitative research”, The Qualitative
Report, Vol. 10 No. 2, pp. 358-394.
Schneller, E.S. and Smeltzer, L.R. (2006), Strategic Management of the Health Care Supply Chain, Jossey-Bass.
Setijono, D., Mohajeri Naraghi, A. and Pavan Ravipati, U. (2010), “Decision support system and the
adoption of lean in a Swedish emergency ward: balancing supply and demand towards
improved value stream”, International Journal of Lean Six Sigma, Vol. 1 No. 3, pp. 234-248.
Shah, N., Sousa, R.T., Liu, S. and Papageorgiou, L.G. (2011), “Global supply chain planning for
pharmaceuticals”, Chemical Engineering Research and Design, Vol. 89 No. 11, pp. 2396-2409.
Shamah, R.A. (2013), “Measuring and building lean thinking for value creation in supply chains”,
International Journal of Lean Six Sigma, Vol. 4 No. 1, pp. 17-35.
Sloan, A.F., Hayes, K.J., Radnor, Z., Robinson, S., Sohal, T.A., Al-Balushi, S., Sohal, A., Singh, P., Al
Hajri, A., Al Farsi, Y. and Al Abri, R. (2014), “Readiness factors for lean implementation in
healthcare settings–a literature review”, Journal of Health Organization and Management,
Vol. 28 No. 2, pp. 135-153.
Susarla, N. and Karimi, I.A. (2012), “Integrated supply chain planning for multinational pharmaceutical
enterprises”, Computers and Chemical Engineering, Vol. 42, pp. 168-177.
Swinehart, K.D. and Smith, A.E. (2005), “Internal supply chain performance measurement, a health care
continuous improvement implementation”, International Journal of Health Care Quality
Assurance, Vol. 18 No. 7, pp. 533-542.
Ten Ham-Baloyi, W. and Jordan, P. (2016), “Systematic review as a research method in post-graduate
nursing education”, Health sa Gesondheid, Vol. 21, pp. 120-128.
Tranfield, D., Denyer, D. and Smart, P. (2003), “Towards a methodology for developing evidence-
informed management knowledge by means of systematic review”, British Journal of
Uthayakumar, R. and Priyan, S. (2013), “Pharmaceutical supply chain and inventory management Supply chain
strategies: optimization for a pharmaceutical company and a hospital”, Operations Research for
Health Care, Vol. 2 No. 3, pp. 52-64. management
Vitasek, K.L., Manrodt, K.B. and Abbott, J. (2005), “What makes a lean supply chain?”, Supply Chain
Management Review, Vol. 9 No. 7, pp. 39-45. (Oct. 2005)
Vom Brocke, J., Simons, A., Niehaves, B., Riemer, K., Plattfaut, R. and Cleven, A. (2009),
“Reconstructing the giant: on the importance of rigour in documenting the literature search
process”, ECIS, Vol. 9, pp. 2206-2217.
Wijewardana, R.L. and Rupasinghe, T. (2013), “Applicability of lean healthcare in Sri Lanka healthcare
supply chains”, International Journal of Supply Management, Vol. 2 No. 4, pp. 42-49.
Winter, S.G. (2003), “Understanding dynamic capabilities”, Strategic Management Journal, Vol. 24
No. 10, pp. 991-995.
Womack, J.P. and Jones, D.T. (1996), Lean Thinking: Banish Waste and Create Wealth in Your
Organisation, Simon and Shuster, New York, NY, p. 397.

Xie, Y., Cucchiella, F., Koh, L. and Breen, L. (2012), “Greening community pharmaceutical supply chain
in UK: a cross boundary approach”, Supply Chain Management: An International Journal,
Vol. 17 No. 1, pp. 40-53.
Zajac, E.J. and Olsen, C.P. (1993), “From transaction cost to transactional value analysis: implications
for the study of interorganizational strategies”, Journal of Management Studies, Vol. 30 No. 1,
pp. 131-145.
Further reading
Lee, S.M., Lee, D. and Schniederjans, M.J. (2011), “Supply chain innovation and organizational
performance in the healthcare industry”, International Journal of Operations and Production
North, D.C. (1992), Transaction Costs, Institutions, and Economic Performance, ICS Press San
Francisco, CA.
Voss, C., Tsikriktsis, N. and Frohlich, M. (2002), “Case research in operations management”,
International Journal of Operations and Production Management, Vol. 22 No. 2, pp. 195-219.
IJLSS Appendix
No. of SJR score

No. Peer-reviewed iournal articles (2016) H index Country
1 Leadership in Health Services 15 0.33 15 UK

2 Supply Chain Management: An 14 1.86 84 UK
International Journal
3 International Journal of Health Care Quality 10 0.28 35 UK
Assurance
4 International Journal of Production 10 2.22 131 The
Economics Netherlands
5 International Journal of Operations and 9 2.19 104 UK
Production Management
6 International Journal of Lean Six Sigma 8 2.23 19 UK

7 International Journal of Physical 7 1.52 76 UK
Distribution and Logistics Management
8 Production Planning and Control 7 1.07 56 UK
9 The International Journal of Logistics 7 0.67 32 UK
Management
10 European Journal of Operational Research 6 2.51 200 The
Netherlands
11 Journal for Healthcare Quality 6 0.5 19 USA
12 Journal of Health Organization and 6 1.32 9 UK
Management
13 Public Money and Management 5 0.54 36 UK
14 BMC Health Services Research 4 1.04 75 UK
15 European Journal of Purchasing and Supply 4 1.92 67 The
Management Netherlands
16 International Journal for Quality in Health 4 1.37 77 UK
Care
17 International Journal of Production 4 1.46 101 UK
Research
18 Computers and Chemical Engineering 3 1.04 113 UK
19 International Journal of Productivity and 3 0.61 36 UK
Performance Management
20 International Journal of Services and 3 0.41 19 UK
Operations Management
21 Journal of Operations Management 3 4.6 149 The
Netherlands
22 Social Science and Medicine 3 1.74 195 USA
23 Strategic Outsourcing: An International 3 0.21 9 UK
Journal
24 Journal of Supply Chain Management 3 4.98 47 USA
25 BMJ Quality and Safety 2 N/A N/A UK
26 Decision Sciences 2 1.25 90 UK
27 Expert Systems with Applications 2 1.43 131 UK
28 Frontiers of Health Services Management 2 0.14 19 USA
29 Health Affairs 2 4.46 139 USA
30 Health Services Management Research 2 0.26 26 UK
31 Hospital Topics 2 0.15 18 USA
32 IEEE Transactions on Information 2 N/A N/A Hong Kong
Technology in Biomedicine
Table AI.
(continued)
Supply chain
No. of SJR score management
33 Integrated Manufacturing Systems 2 0.65 52 UK

34 International Journal of Business Excellence 2 0.31 13 UK
35 International Journal of Logistics Systems 2 0.43 21 UK
and Management
36 International Journal of Quality and 2 0.48 67 UK
Reliability Management
37 International Journal of Technology 2 0.45 45 UK
Management
38 Joint Commission Journal on Quality and 2 0.79 66 USA
Patient Safety
39 Journal of Cleaner Production 2 1.62 116 USA
40 Journal of Humanitarian Logistics and 2 0.58 13 UK

Supply Chain Management
41 Journal of Medical Systems 2 0.5 51 USA
42 Nursing Administration Quarterly 2 0.48 30 USA
43 Omega 2 3.67 102 UK
44 Operations Research for Health Care 2 0.79 13 UK
45 Procedia Computer Science 2 0.27 29 The
Netherlands
46 Procedia Economics and Finance 2 0.13 N/A The
Netherlands
47 The TQM Journal 2 0.36 52 UK
48 Acta Ophthalmologica 1 1.5 72 USA
49 Advances in Business and Management 1 0.12 3 UK
Forecasting
50 Advances in Health Care Management 1 0.48 11 UK
51 African Journal of Business Management 1 0.16 10 S. Africa
52 American International Journal of 1 N/A N/A USA
Contemporary Research
53 American Journal of Business 1 0.21 41 USA
54 American Journal of Health-System 1 0.62 81 USA
Pharmacy
55 American Journal of Medical Quality 1 0.59 45 USA
56 Anesthesia and Analgesia 1 1.46 173 USA
57 Annals of Diagnostic Pathology 1 0.65 46 UK
58 Annals of Emergency Medicine 1 1.6 130 USA
59 AORN Journal 1 0.22 36 USA
60 Applied Ergonomics 1 0.87 72 UK
61 BMJ Global Health 1 N/A N/A UK
62 BMJ Open 1 N/A N/A UK
63 Business Economics Series 1 N/A N/A UK
64 California Management Review 1 1.87 107 USA
65 Chemical Engineering Research and Design 1 0.81 73 UK
66 Computers and Operations Research 1 2.33 118 UK
67 Construction Management and Economics 1 0.89 67 UK
68 Diagnostics in Neuropsychiatry 1 0.13 0 The
Netherlands
69 Emergency Medicine Journal 1 0.64 63 UK
(continued) Table AI.
IJLSS
No. of SJR score
70 Engineering Management Journal 1 0.28 27 UK

71 Environmental Health Perspective 1 3.37 227 USA
72 European Journal of Radiology 1 1.13 94 The
Netherlands
73 Evaluation and the Health Professions 1 0.77 45 USA
74 Fujitsu Scientific and Technical Journal 1 0.21 20 Japan
75 Global Health Action 1 0.96 24 UK
76 Health Care Management Review 1 0.99 44 USA
77 Health Care Management Science 1 0.72 45 The
Netherlands
78 Health Policy 1 1.32 68 The
Netherlands
79 Healthcare Financial Management 1 0.13 16 USA
80 Healthcare Management Science 1 0.72 45 The
Netherlands
Table AI. 81 Healthcare Quarterly 1 0.15 28 Canada
Corresponding author
Sasan T. Khorasani can be contacted at: sasan.torabzadehkhorasani@ttu.edu
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International Journal of Lean Six Sigma

Lean supply chain management in healthcare: a systematic review and meta-

*Related content and download information correct at time of download.

Texas Tech University, Lubbock, Texas, USA, and

Overproduction Producing greater, faster or sooner than Unnecessary test

Wastes in healthcare Note: Adapted from Platchek and Kim (2012)

3.1 Planning the literature reviews process

(2) Keyword search combinations should be selected carefully. Proper keyword

Select articles after 1995

Including only academic journal papers

Keep all papers from 2017 and 2018, and the

Only English language arcles

Title and abstract review

3.2 Conducting the review

Table II. 14 Canada 1 1

Must have Metrics

Academic Journal Papers Yes

Code Number Rational 1st part LH, LS, SH, TO

Idenﬁcaon of the theories, authors, and the scope of journals

Idenﬁcaon of research quesons and research gaps

Metaphor are deﬁned to unify the language of all papers

Idenﬁcaon of target areas (LSCM problem domains)

Idenﬁcaon of LSCM applicaon

Record the replicaon of each target areas in the meta-study shortlist

Idenﬁcaon of target areas and applicaons

Figure 3. Idenﬁcaon of conngency factors

healthcare wer identiﬁed as highly relevant, which is signiﬁcant. The combination of

instead of presenting the service or good with

agents results in agility of the supply chain and

simulation and lean to increase improvement in

that prevent many errors and waste in the

5.1 Meta-theory ﬁndings

focused on the traceability of high value products, which can be improved by

Rank Target Area of Lean Implementaon

Rank of LSCM tools

5.3 Contingency factors

6. Implications and limitations

Category Specific contingency factors Count

nurses, clinical issues, hospital system membership, hospital

7. Conclusions and agenda for future research

Topics, Vol. 90 No. 2, pp. 47-55.

Organisation, Simon and Shuster, New York, NY, p. 397.

No. of SJR score

1 Leadership in Health Services 15 0.33 15 UK

6 International Journal of Lean Six Sigma 8 2.23 19 UK

33 Integrated Manufacturing Systems 2 0.65 52 UK

40 Journal of Humanitarian Logistics and 2 0.58 13 UK

70 Engineering Management Journal 1 0.28 27 UK

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