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"The Largest Lean Transformation in the World": The Implementation and Evaluation of Lean in Saskatchewan Healthcare



The Saskatchewan Ministry of Health has committed to a multi-million dollar investment toward the implementation of Lean methodology across the province's healthcare system. Originating as a production line discipline (the Toyota Production System), Lean has evolved to encompass process improvements including inventory management, waste reduction and quality improvement techniques. With an initial focus on leadership, strategic alignment, training and the creation of a supportive infrastructure (Lean promotion offices), the goal in Saskatchewan is a whole health system transformation that produces "better health, better value, better care, and better teams." Given the scope and scale of the initiative and the commitment of resources, it is vital that a comprehensive, longitudinal evaluation plan be implemented to support ongoing decision-making and program design. The nature of the initiative also offers a unique opportunity to contribute to health quality improvement science by advancing our understanding of the implementation and evaluation of complex, large-scale healthcare interventions. The purpose of this article is to summarize the background to Lean in Saskatchewan and the proposed evaluation methods.
Healthcare Quarterly Vol.17 No.2 2014 29
The Saskatchewan Ministry of Health has committed to a
multi-million dollar investment toward the implementa-
tion of Lean methodology across the province’s healthcare
system. Originating as a production line discipline (the
Toyota Production System), Lean has evolved to encompass
process improvements including inventory management,
waste reduction and quality improvement techniques. With
an initial focus on leadership, strategic alignment, training
and the creation of a supportive infrastructure (Lean promo-
tion offices), the goal in Saskatchewan is a whole health
system transformation that produces “better health, better
value, better care, and better teams.”
Given the scope and scale of the initiative and the
commitment of resources, it is vital that a comprehensive,
longitudinal evaluation plan be implemented to support
ongoing decision-making and program design. The nature of
the initiative also offers a unique opportunity to contribute
to health quality improvement science by advancing our
understanding of the implementation and evaluation of
complex, large-scale healthcare interventions. The purpose
of this article is to summarize the background to Lean in
Saskatchewan and the proposed evaluation methods.
Saskatchewan is a geographically large province (651,036 km2)
in central Canada with a population of just over 1,000,000
people. Across the province, there are 13 defined health
regions overseeing 40,000 employees in a system composed of
hospitals, community health centres, ambulance and emergency
services, supportive care, home care, mental health and rehabili-
tation. With a substantial proportion of the population and
many providers living and working in geographically isolated
settings, with 15% of the population older than 65 years and
15% of the population identified as Aboriginal, the province
faces many complex issues in healthcare delivery (Government
of Saskatchewan 2014). The Saskatchewan government found
through a variety of reviews, reports and patient experience
surveys that its health system was not fully addressing the needs
of the province’s citizens. As a result, the government committed
to a system-wide transformation based on the Lean method-
ology. This transformation has been referred to in the media as
“probably the largest lean transformation in the world” (French
2014, February 5).
Lean was originally derived from the Toyota car company
production line system. This continuous process improve-
ment system is composed of structured quality improvement
techniques, inventory management and waste reduction
(Marchildon 2013). The quality and cost efficiency improve-
ments identified through this system are seen as potentially
transferrable to other industries, including healthcare. For
example, Lean has been implemented in the Virginia Mason
Health System in the United States to improve processes of
patient flow, supply and procurement and payment in hospitals
(Marchildon 2013). The overarching approach used in Lean is
to create a continuous learning cycle that is driven by the “true”
experts in the processes of healthcare (i.e., patients/families, care
providers and support staff), with coaching and sponsorship
“The Largest Lean Transformation in
the World”: The Implementation and
Evaluation of Lean in Saskatchewan
Leigh Kinsman, Thomas Rotter, Katherine Stevenson, Brenna Bath, Donna Goodridge, Liz Harrison, Roy Dobson, Nazmi Sari,
Cathy Jeffery, Carrie Bourassa and Gill Westhorp
30 Healthcare Quarterly Vol.17 No.2 2014
“The Largest Lean Transformation in the World”: The Implementation and Evaluation of Lean in Saskatchewan Healthcare Leigh Kinsman et al.
from their managers and leaders (de Souza 2009). It provides
a multi-faceted, patient-centred approach to managing and
improving healthcare.
Lean is being introduced into the Saskatchewan healthcare
system in stages. The initial phase centred on a project called
“The Productive Ward: Releasing Time to Care,” a nurse-led
quality improvement approach for hospital wards that was devel-
oped by the National Health Service in the United Kingdom
(National Health Service 2014). This process improvement
initiative was implemented in all medical and surgical wards
across the province and used Lean principles to increase the
engagement of front-line nurses in improving quality of care
and reducing waste.
More recently, the Ministry of Health has established Lean
offices (also known as Continuous Improvement or Kaizen
Promotion Offices [KPOs]) in five health regions and provin-
cial health system organizations (e.g., the Saskatchewan Cancer
Agency and Saskatchewan Health Quality Council) and aims to
train and certify over 800 Lean leaders by 2016 to lead quality
improvement work (Saskatchewan Ministry of Health 2012).
The exact cost of the implementation of Lean is unknown, but
it is clear that this is an unprecedented investment in health
system improvement in Saskatchewan. The Saskatchewan
Health Quality Council has the overarching provincial roles of
standardization and coordination of Lean training, events and
planning across the province. As part of the Lean reform, all
large initiatives (e.g., major construction works) are required to
use the highly structured Lean design principles.
The Saskatchewan government has made publicly available
a range of ambitious targets to be achieved as a result of system
transformation using Lean methods. The following state-
ments reflect three of these targets (Saskatchewan Ministry of
Health 2013):
• “By2017,therewillbea50%improvementinthenumber
of people who say, ‘I can access my Primary Health Care
team for care on my day of choice; page 7.’”
• “ByMarch31,2017,nopatientwillwaitforemergency
room care (patients seeking non-emergency care in the
emergency room will have access to a more appropriate
care setting); page 10.”
• “ByMarch31,2017,establishacultureofsafetyresulting
in zero defects to patients and staff; page 6.”
The public investment and magnitude of this immense health
system transformation make comprehensive evaluation essen-
tial; the situation also provides an unprecedented opportunity
to add substantial knowledge to the evidence base regarding
large-scale health system transformation. Primarily, the purpose
of the evaluation of Saskatchewans Lean implementation is to
generate knowledge that will inform ongoing decision-making
regarding Lean in Saskatchewan. Just as importantly, the evalua-
tion creates a unique opportunity to understand how the princi-
ples from the Lean Management System, originally designed
as an industrial model, can be used to reduce healthcare costs,
maximize efficiency, improve the patient experience, decrease
wait times, improve care and enhance teamwork. The evalua-
tion will move beyond an understanding whether Lean “works
to provide a more nuanced picture of when, how and for
whom the Lean implementation in Saskatchewan is successful.
The underlying processes of change and how differences in
contexts influence system change and patient outcomes will be
essential to understanding the transferability of Lean to other
healthcare settings.
Systematic Review
We have undertaken a systematic review of the evidence
regarding the use and impact of Lean in healthcare. Previous
Lean investigations have reflected the challenges researchers
confronted in the evaluation of complex, real-world, large-scale
health services interventions. We have identified a lack of appro-
priate theoretical concepts, problems with the methodological
quality and limitations in outcome measures and analysis
that inhibit the generalizability of study findings, despite the
majority of studies reporting successful outcomes with Lean
(Holden 2011; Mazzocato et al. 2012). It is therefore impera-
tive to synthesize review findings to inform our research design
and optimize our contribution to the body of knowledge
regarding large-scale, complex health services interventions. We
have registered the systematic review on Lean in PROSPERO
(CRD42014008853) and submitted a review protocol to BMC
Systematic Reviews.
Methodological Development and Baseline Data
The evaluation framework and methodology for a multi-year
longitudinal evaluation was developed following these steps:
• Extensivestakeholderengagement(workshopsand
• KeyinformantinterviewswithregionalKPOleaders
• Asystematicliteraturereview
• Leanimplementationmapping(i.e.,theextentofthe
implementation of Lean across four selected health regions)
• In-depthinterviewswith29healthservicesmanagers,clini-
cians, administrative staff and patients who have partici-
pated in Lean initiatives
• Explorationofexistingpatientoutcomedatabases
• Consultationwithinternationalmethodologicalexperts
Healthcare Quarterly Vol.17 No.2 2014 31
Leigh Kinsman et al. “The Largest Lean Transformation in the World”: The Implementation and Evaluation of Lean in Saskatchewan Healthcare
To guide and link processes and results, an interim Logic
Model has been developed (Figure 1). The Logic Model incor-
porates contexts, inputs (i.e., funding, infrastructure, human
resources etc.), activities (Lean activities, including strategies),
outputs relating to health system processes and behaviour
change, and outcomes that align with the provincial Lean goals
(“better health, better value, better care, and better teams”).
The Logic Model is supported by a series of more detailed
“theory diagrams” that map out how processes of change are
expected to work. Selected theories will be tested and refined
over the course of the evaluation.
Using the Logic Model and theory diagrams as a founda-
tion, we will incorporate a variety of approaches and methods
to undertake our evaluation, including realistic evaluation
(RE), quantitative methods, economic analysis and qualitative
Realist Evaluation
As the overall approach, RE is particularly helpful for large-scale
evaluations as it moves beyond evaluating whether something
works to understanding what works for whom in what circum-
stances and why, and provides valuable contextual evidence for
translation of a policy or program into other settings (Pawson
and Tilley 1997). There are four concepts explored through
RE: context, mechanism, outcome (or outcome pattern)
and context-mechanism-outcome configuration, or CMOC.
Mechanism refers to underlying processes of change that
generate particular outcomes. Context refers to features of the
organization, staffing, geography and culture that affect whether
and how interventions work, and describe for whom and in
what circumstances they will work. For the evaluation of Lean
in Saskatchewan, this approach will be used to elucidate what
Lean achieves in different contexts and to understand how and
why this is the case.
Quantitative Methods
We will use an interrupted times series design examining indica-
tors of patient outcomes, quality of care and costs in the form
of a multiple-baseline approach. This research design represents
a robust method of measuring the effect of an intervention as
Interim Lean evaluation Logic Model*
3P = production, preparation, process; 5S = sort, streamline, shine, standardize, sustain; KPO = Kaizen Promotion Office; RPIW = Rapid Process Improvement Workshop.
*As of November 2013.
Context: Saskatchewan Health System and Population
Lean implementation
Lean impact
Kaizen basics workshops, protocols, policies
Resources, costs, time etc.
Number workshops, including 3P, 5S, RPIWs. Proportion of staff attending,
workshop evaluations, practice changes
Teamwork, professional practice, measurements of patient safety and
quality of care, staff and patient satisfaction, work loss reduction
Efficiency, cost, time, access, hospitalisation rates, length of stay
Chronic disease rates, population “wellness”, risk factors
Intervention activities
Description of province, regions and health system
Immediate Better teams
Better care
Intermediate Better value
Long term Better health
Inputs Policy, KPOs, infrastructure,
human resources
Implementation and
maintenance of Lean
System and behaviour changes
32 Healthcare Quarterly Vol.17 No.2 2014
a trend over time. It is a useful design when recruitment of
a control cohort is impractical, for example, due to changes
in hospital policy or, as in this case, where an intervention is
staggered, resulting in different stages of implementation across
the province. It is also amenable to Saskatchewan’s approach of
collecting and displaying indicators over time using run charts
or statistical process control methods. The final list of outcomes
includes the number and focus (service lines) of the different
interventions used to implement Lean; adverse events; health
services utilization (e.g., readmissions, lengths of stay); measures
of workplace efficiency (e.g., amount of waste); staff time
(e.g., sick leave); and wait times (e.g., wait times in the
emergency department, wait times to surgery).
Economic Analysis
We will track the total incremental cost of Saskatchewans Lean
healthcare implementation in two stages. The costing in stage 1
will include all costs and resources across all settings associated
with the implementation, including the total training cost of the
health professionals and administrators. The costing for stage 2
will assess the incremental cost of the operation of the imple-
mentation. A cost-benefit analysis will incorporate measures
such as the utilization of healthcare services (i.e., lengths of
stay in hospitals, readmission rate, emergency care visit, physi-
cian services and prescription drug use), waste reduction
(i.e., materials and inventories) and patterns in work loss (i.e.,
sick leaves).
Qualitative Methods
Qualitative methods guided by realist principles will consist of
interviews and focus groups. The emphasis in qualitative data
collection will be on collecting detailed information about
contexts and about decision-making processes that generate
specific outcomes in particular places.
The Saskatchewan health system transformation using Lean
methodologies is an ambitious and resource-intensive under-
taking that has the potential to substantially redesign the
Saskatchewan health system. It is imperative that such a huge
public investment be rigorously evaluated to inform ongoing
policy development. The comprehensive research design
described in this article (including Realist methods) will provide
invaluable evidence regarding the impact of Lean and the
contexts that influence its impact.
de Souza, L. 2009. “Trends and Approaches in Lean Healthcare
Leadership.” Leadership in Healthcare 22(2): 121–39.
French, J. 2014, February 5. “Lean Machine.” Star Phoenix.
Government of Saskatchewan. 2014. About Saskatchewan. Regina,
SK: Author. Retrieved April 24, 2014. <
Holden, R.J. 2011. “Lean Thinking in Emergency Departments:
A Critical Review.” Annals of Emergency Medicine 57(3): 265–78.
Marchildon, G. 2013. “Implementing Lean Health Reforms in
Saskatchewan.” Health Reform Observer 1(1). DOI: http://dx.doi.
Mazzocato, P., R.J. Holden, M. Brommels, H. Aronsson, U. Backman,
M. Elg et al. 2012. “How Does Lean Work in Emergency Care? A Case
Study of a Lean-Inspired Intervention at the Astrid Lindgren Children’s
hospital, Stockholm, Sweden.” BMC Health Services Research 12: 28.
National Health Service. 2014. The Productive Ward: Releasing Time to
Care. Coventry, United Kingdom: NHS Institute for Innovation and
Improvement. Retrieved April 24, 2014. <
Pawson, R. and N. Tilley. 1997. Realistic Evaluation. London: Sage.
Saskatchewan Ministry of Health. 2012. Contract Agreement. Regina,
SK: Author. Retrieved April 24, 2014. <
Saskatchewan Ministry of Health. 2013. Ministry of Health Plan for
2013–2014. Regina, SK: Author.
About the Authors
Leigh Kinsman, RN, BHSc, MHSc, PhD is a member of the
School of Rural Health, Monash University, in Victoria, Australia.
Thomas Rotter, Dipl. Kfm., BA health economics, MPH, PhD,
PhD is a member of the College of Pharmacy and Nutrition,
University of Saskatchewan, in Saskatoon, Saskatchewan. He can
be contacted by e-mail at
Katherine Stevenson, BA , BScPT, MSc, is a member of the
School of Physical Therapy, College of Medicine, University of
Brenna Bath, BScPT, MSc, PhD is a member of the School
of Physical Therapy, College of Medicine, University of
Donna Goodridge, RN, PhD is a member of the College of
Nursing, University of Saskatchewan.
Liz Harrison, DipPT, BPT, MSc, PhD is a member of the
School of Physical Therapy, College of Medicine, University of
Roy Dobson, BScPharm, MBA, PhD is a member of the College
of Pharmacy and Nutrition, University of Saskatchewan.
Nazmi Sari, PhD, is a member of the Department of Economics,
University of Saskatchewan.
Cathy Jeffery, BA, MN, PhD candidate, is a member of the
College of Nursing, University of Saskatchewan.
Carrie Bourassa, PhD, is a member of the Department of
Indigenous Education, Health and Social Work, First Nations
University of Canada, in Regina, Saskatchewan.
Gill Westhorp, PhD, is a member of Community Matters, in
Unley, South Australia.
“The Largest Lean Transformation in the World”: The Implementation and Evaluation of Lean in Saskatchewan Healthcare Leigh Kinsman et al.
... Examples of efforts to alternate views on Laboratory checking out consists of Choosing Wisely, which objectives to facilitate conversations among sufferers and physicians round deciding on most effective care this is important and warding off harm [4] . On an extra administrative level, Lean method has been implemented to healthcare with the goal to lessen waste, enhance highsatisfactory and create a supportive community thru control techniques [13] . As the accessibility of laboratory effects and fitness associated facts thru on line portals is growing, conversations approximately the that means and person context of check effects and consequences on remedy are getting an increasing number of essential [14] . ...
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... Flynn et al. (2019) [77] completed a realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on the outcome of sustainability of what was meant to be a whole system Lean intervention in a pediatric healthcare setting (CMOs). This intervention was noted as being the 'largest Lean transformation in the world' [78]. While Flynn et al.'s evaluation focused on the outcome of sustainability, the framework could still be used to assess whether the hospital intervention reported here did have an impact at a systems level. ...
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Healthcare systems internationally are working under increasing demand to use finite resources with greater efficiency. The drive for efficiency utilises process improvement methodologies such as Lean Six Sigma. This study outlines a pilot Lean Six Sigma intervention designed to release nursing time to care within a peri-operative environment; this was achieved by collaborating with stakeholders to redesign the process for laparoscopic hernia surgical case preparation (set up) material. Across 128 laparoscopic hernia surgical cases, the pilot resulted in a 55% decrease in overall nursing time spent in gathering and preparing materials for laparoscopic hernia surgical cases, with a corresponding reduction in packaging waste. The major impact of releasing nursing time to care within busy Operating Room environments enabled nurses to focus on continuing to deliver high-quality care to their patients and reduce pressure expressed by the Operating Room nurses. The results have led to an ongoing review of other surgical procedures preparation to further release nursing time and will be of interest to perioperative teams internationally.
... Calgary Zone participants reported that this approach initially yielded significant improvements in ED flow, but effects deteriorated after two to three years because such pressure could not be maintained indefinitely (Kreindler et al. 2020). The most common regional strategy has centred on encouraging local players to develop their own initiatives, whether through Lean or ad hoc methods (Kinsman et al. 2014;Kreindler 2018). As noted, such an approach succeeded in the two geographies of AHS South Zone, but other regions' attempts (which have, of course, varied widely in content and context) have not shown similar results. ...
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... Plusieurs pays de l'OCDE ont récemment entrepris des réformes des systèmes de santé appuyées par la mise en oeuvre nationale d'outils de gestion de la performance. Certains exemples des plus documentés incluent notamment : la réforme Lean Santé (méthodologie d'optimisation des services, des processus, des coûts et de l'expérience-usager) du système de santé en Saskatchewan de 2008 (Kinsman et al., 2014;, et ses efforts d'implantation à grande échelle au Québec Houle et al., 2015;Jobin & Lagacé, 2014) et au Royaume-Uni ; l'implantation nationale de High Performance Work Systems (systèmes de gestion de la performance axés sur la gestion des ressources humaines) dans le système de santé Australien à travers la réforme de 2009 (Dickinson et al., 2011;; la mise en oeuvre nationale de Comptes de résultats analytiques (outils financiers) dans le cadre de la réforme des hôpitaux publics (2009)(2010) en France Costin, 2010); l'implantation des Accountable Care Organizations (modèles et outils de prestations des services de santé axés sur la performance des professionnels de la santé), en appui à la réforme du Affordable Care Act (2010) aux États-Unis McClellan et al., 2010); la mise en oeuvre des Sustainability and transformation plans (outils de gestion de la performance axés sur l'intégration et la continuité des services) dans le système de santé britannique (NHS), en appui à la grande transformation de 2014-2019 (Five Year Forward View) , et plus récemment; l'implantation nationale et mandatée de salles de pilotage (outils de gestion intégrée de la performance), dans le cadre de la réforme du système de santé québécois (2015) Macpherson et al., 2018). Alors que les outils émergent dans le paysage des politiques de santé, l'expérience jusqu'à maintenant témoigne d'effets mitigés, voire décalés, des cibles de performance attendues par les réformes pilotées au moyen d'outils ). ...
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Problématique. Une nouvelle vague de réformes des systèmes de santé axées sur l’implantation nationale d’outils de gestion de la performance, s’est récemment développée dans les pays de l’OCDE. Le but étant de renforcer l’imputabilité des individus et des organisations envers les objectifs stratégiques de performance, et de maximiser la création de valeur à l’endroit de l’expérience-patient, de l’efficience des services, de l’état de santé populationnelle, et du mieux-être des intervenants (Quadruple Aim). Or, la littérature à ce jour soutient une difficulté généralisée à significativement améliorer la performance et la qualité des systèmes au moyen d’outils. Plusieurs auteurs soutiennent le besoin d’étudier le processus d’appropriation des outils, pour mieux comprendre le cheminement concomitant des outils, des individus, et des systèmes vers une meilleure performance. Objectif. Comprendre le processus d’appropriation des salles de pilotage (outils de gestion intégrée de la performance) mandatées en contexte de réforme du système de santé (Québec, Canada), et les effets qui en découlent sur le plan managérial et organisationnel. Cadre théorique. Cette étude s’appuie sur un cadre théorique multidimensionnel agrégé à partir des théories de la sociomatérialité, des théories institutionnelles et des work-studies, pour théoriser l’appropriation des outils de gestion en santé comme une forme de travail sociomatériel légitime. Méthodologie. Cette recherche a été réalisée au moyen d’une étude de cas ethnographique organisationnelle qualitative multi-sites (N=9 sites), dans deux directions régionales tactiques (N=2) imbriquées dans deux Centres intégrés (universitaires) de santé et de services sociaux, et mobilisant simultanément diverses stratégies de collecte (revue documentaire (N=143); observations ciblées non-participantes (N=179,5 heures); entrevues individuelles semi-dirigées (N=34)), et d’analyse processuelle narrative multi-niveaux des données. Résultats. 1) L’appropriation des salles de pilotage comme processus, se déploie en trois types (cognitive, structurelle, technique), et sur trois phases temporelles (implantation, test, adaptation). L’appropriation est notamment influencée par les capacités d’amélioration continue des acteurs, les arrangements de gouvernance clinique, et le leadership distribué. 2) L’appropriation comme travail sociomatériel, permet de reformuler le travail de gestion de la performance, de perturber le travail d’imputabilité, et d’effectuer la gestion intégrée de la performance centrée sur la valeur. Conclusion. Cette étude montre comment l’appropriation des outils de gestion en santé créer une nouvelle opportunité de dialogue entre la gouvernance, le leadership, et la pertinence clinique et managériale, en contexte de gestion intégrée. Abstract: Research problem. Various OECD countries have recently implemented performance management tools to support health system reforms. Performance management tools are increasingly used to bring about significant change in health care, by aligning provider behaviour with system goals, and increasing healthcare organization accountability for meeting national performance targets and improving experience of care (Quadruple Aim). While they are ever more common in the health policy landscape, previous work shows that large-scale implementation of management tools tends to produce unexpected effects and off-target performance results. The appropriation of performance management tools has recently become a key research avenue to better understand the shared journey of tools, people and systems towards better performance. Objective. Understand the appropriation process of control rooms (integrated performance management tools) mandated in the context of health system reform (Quebec, Canada), and the resulting managerial and organizational effects. Theoretical framework. This study is based on a multidimensional theoretical framework aggregated from sociomateriality, institutional theories and work-studies, to theorize the appropriation of management tools in healthcare as a form of legitimate sociomaterial work. Methodology. We conducted a qualitative multi-sites (N=9 sites) organizational ethnographic case study (N=2 cases), to explore the experience of organizational actors with the appropriation of control rooms in two regional directorates embedded in two different Integrated (academic) health and social services centres (CISSS/CIUSSS), and multi-level narrative process analysis of triangulated qualitative data collected through document review (N=143), non-participatory observations (179.5 hours), and individual semi-structured interviews (N=34). Results. 1) Appropriation of control rooms as a process, unfolds into three appropriation paths (cognitive, structural, technical), over three appropriation phases (implementing, testing, adapting). Appropriation is namely influenced by the large-scale transformative mechanisms of continuous improvement capacities, clinical governance, and distributed leadership. 2) Appropriating control rooms as legitimate sociomaterial work, sequentially allows to reformulating performance management work, disrupting accountability work, and effecting value-based integrated performance management. Conclusion. This study demonstrates how the appropriation of management tools in health care may create a new dialogue between governance, leadership, and clinical and managerial relevance, in the context of value-based integrated performance management.
... Examples of efforts to change perspectives on laboratory testing include Choosing Wisely, which aims to facilitate conversations between patients and physicians around choosing only care that is necessary and avoiding harm [4]. On a more administrative level, Lean methodology has been applied to healthcare with the objective to reduce waste, improve quality and create a supportive network through management strategies [13]. ...
... Another multi-million-dollar investment attempt using comprehensive lean approach was started in 2010 by the Saskatchewan Ministry of Health in Canada [63]. The goal was the transformation of the entire healthcare system to produce better health, better care, better teams and better value [64]. The Saskatchewan government claimed to accomplish saving of 125 million Canadian dollars through adopting lean [65,66]. ...
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Abstract Purpose: This paper aims to provide a historical overview of how lean thinking has transferred and spread from Toyota manufacturing to the healthcare sector. It aims to explain the origin of lean: how it is defined, the main tools, concepts, and principles behind it, provide some lean healthcare examples, and explore the differences between the manufacturing and healthcare systems. Design/methodology/approach: The article reviews current literature for lean application in healthcare from five databases. More than 60 articles and books were considered according to a taxonomy suggested. Findings: Lean originated from Toyota in the 1940s due to the need to increase production efficiency, specifically by reducing waste. Since then, lean has expanded to other industries and organisations, gradually advancing to services and, since the beginning of the twenty-first century, have also been used in the healthcare sector. While the philosophy was introduced to the world by Toyota, the term ‘lean’ was only introduced by Jon Krafcik in the late 1980s. Lean initially lacked an agreed-upon definition within the literature; any agreement reached was on the potential of lean thinking in the healthcare sector. Several lean tools and techniques were used by different organisations, mostly to reduce or eliminate waste. Some of the leading examples of lean healthcare include the United States of America’s (USA) Virginia Mason Medical Centre, Theda Care in Wisconsin (USA), Bolton Hospital in England, and the Saskatchewan health care system in Canada. Even with the encouraging success stories from adopting lean as a management approach, several challenges still remain. The healthcare sector differs greatly from the motor industry as hospitals are not factories, so the transition between the two is not straight forward. Originality/Practical implications: This literature review is helpful for journal editors and reviewers, researchers in healthcare organisations and healthcare practitioners as it offers a comprehensive, historical overview of how lean thinking has transformed and spread from Toyota manufacturers to the healthcare sector. Keywords: Lean; Toyota production system; Just in Time; Health services; Hospital; Patients
This article considers the complexities of how policy moves across jurisdictional and sectoral boundaries by examining how Lean Management was introduced into Saskatchewan’s healthcare system. In 2012, the government of Saskatchewan retained a management consulting firm to “transform” the province’s healthcare system using Lean Management. Over subsequent months and years, the consulting firm and provincial government worked to reconstitute the province’s healthcare system, which became the focal point of public debate in the province. This article explores the complexities of how Lean Management arrived in Saskatchewan, how it was translated to address “waste” in the province, and how resistance to its deployment shaped its mobilization in future settings. Cet article réfléchit aux complexités liées à la manière dont les politiques franchissent les frontières juridictionnelles et sectorielles en examinant comment la gestion allégée (Lean Management) a été introduite dans le système de soins de santé de la Saskatchewan. En 2012, le gouvernement de la Saskatchewan a engagé les services d'une société de conseil en gestion pour « transformer » le système de santé de la province à l'aide du Lean Management. Au cours des mois et des années consécutifs, la société d'experts‐conseils et le gouvernement provincial ont travaillé pour réformer le système de santé de la province, ce qui est devenu le centre d’attention du débat public dans la province. Cet article étudie la manière complexe dont le Lean Management est arrivé en Saskatchewan, comment il a abordé la lutte contre le « gaspillage » dans la province et comment la résistance à son déploiement a façonné sa mobilisation dans les contextes futurs.
Currently, in the healthcare of the Republic of Kazakhstan and many other countries, ISO standards are mandatory, and also in some countries the Lean Production System is used. In the Republic of Kazakhstan, the Ministry of Health issued guidelines for the implementation of lean technologies in healthcare organizations in 2017. However, the introduction of Lean technologies is not yet mandatory and has not become widespread in medical organizations in our country. In this regard, information on Lean technologies, experience of their application and effectiveness in healthcare organizations is useful for our medical managers and workers. Goal. Analysis of literature data on ISO and Lean quality management systems, their comparison, experience of application in healthcare organizations and efficiency. Material and methods. For this analysis, we searched for information on the issue with a depth of up to 20 years. Search for publications on the topic of the review was carried out in the databases of PubMed / MEDLINE, PMC, EMBASE, Web of Since, as well as a broad search through the browsers and The search criteria were combinations of terms: quality management system, healthcare, and lean production. Results and discussion. The description of the main features of the quality management systems ISO and Lean, as well as their comparison have been made. Information on the use of these systems in healthcare organizations is given. Currently, the Lean manufacturing system has been implemented in all healthcare organizations in the province of Saskatchewan (Canada), and a large-scale implementation has begun in the Russian Federation. Many medical organizations are implementing Lean system on their own initiative. Most publications have positive feedback on the Lean application. However, there are also several critical articles that the published positive reports lack a strong evidence base. In addition, it is impossible to compare the reports of different organizations due to the lack of a unified system for evaluating the effectiveness of Lean. Conclusion. The Lean manufacturing system is increasingly being used in healthcare organizations. Mostly positive results of Lean application are reported. However, the issue of its effectiveness in healthcare requires further research, since most of the reports cannot be considered as hard evidence. Keywords: quality management system, quality of care, lean management, customer satisfaction
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Saskatchewan has gone further than any other Canadian province in implementing health system process improvements using Lean, a production line discipline that originated with the automobile industry. The goal of the Lean reform is to reduce waste and improve quality and overall health system performance by long-term changes in behaviour. Lean enjoys a privileged position on the provincial government’s agenda because of the policy’s championing by the Deputy Minister of Health and the policy’s fit with the government’s patient-centred care agenda. The implementation of reform depends on a major investment of time in the training and Lean-certification of key leaders and managers in the provincial health system. The Saskatchewan Union of Nurses, the union representing the single largest group of health workers in the province, has agreed to co-operate with the provincial government in implementing Lean-type reforms. Thus far, the government has had limited independent evaluation of Lean while internal evaluations claim some successes.
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There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department. We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses. Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration. Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).
Purpose The aim of this paper is to provide a review of the existing literature on lean healthcare. It seeks to describe how this concept has being applied and to assess how trends and methods of approach in lean healthcare have evolved over the years. Design/methodology/approach The paper surveys the applications of lean healthcare in the current literature and classifies over 90 works according to a taxonomy suggested. Findings Though there seems to exist an agreement about the potential of lean healthcare, it remains a challenge for academics and practitioners to evaluate lean healthcare under a more critical perspective. Practical implications This work is helpful not only for healthcare practitioners and for researchers in private and public organisations, but also for journal editors and reviewers because it offers ready access to an up to date comprehensive review. Originality/value Since lean started being applied in healthcare, no effort to provide a complete resource surveying the existing literature has been done.
Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking. This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space. Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change. Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.
PhD is a member of the School of Physical Therapy
  • Liz Harrison
  • Dippt
  • Msc Bpt
Liz Harrison, DipPT, BPT, MSc, PhD is a member of the School of Physical Therapy, College of Medicine, University of Saskatchewan.
PhD is a member of the College of Pharmacy and Nutrition
  • Thomas Rotter
  • Dipl Kfm
  • Ba Health Economics
  • Phd Mph
Thomas Rotter, Dipl. Kfm., BA health economics, MPH, PhD, PhD is a member of the College of Pharmacy and Nutrition, University of Saskatchewan, in Saskatoon, Saskatchewan. He can be contacted by e-mail at
Ministry of Health Plan for 2013–2014. Regina, SK: Author. About the Authors
  • Saskatchewan Ministry
  • Health
Saskatchewan Ministry of Health. 2013. Ministry of Health Plan for 2013–2014. Regina, SK: Author. About the Authors Leigh Kinsman, RN, BHSc, MHSc, PhD is a member of the School of Rural Health, Monash University, in Victoria, Australia.