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IJQRM QUALITY PAPER

36,8
A systematic review of Lean in
healthcare: a global prospective
1370 Jiju Antony
School of Management and Languages, Heriot-Watt University, Edinburgh, UK
Received 17 December 2018
Revised 4 February 2019
Vijaya Sunder M.
Accepted 18 February 2019 Department of Management Studies, Indian Institute of Technology,
Madras, Chennai, India and
Business Process Excellence, The World Bank, Chennai, India
Raja Sreedharan
Department of Industrial Engineering, Anna University, Chennai, India
Ayon Chakraborty
Department of Operations Management and Quantitative Techniques,
Indian Institute of Management Tiruchirapalli, Trichy, India, and
Angappa Gunasekaran
California State University, Bakersfield, Bakersfield, California, USA

Abstract
Purpose – Fostered by a rapid spread beyond the manufacturing sector, Lean philosophy for continuous
improvement has been widely used in service organizations, primarily in the healthcare sector. However,
there is a limited research on the motivating factors, challenges and benefits of implementing Lean in
healthcare. Taking this as a valuable opportunity, the purpose of this paper is to present the key motivating
factors, limitations or challenges of Lean deployment, benefits of Lean in healthcare and key gaps in the
literature as an agenda for future research.
Design/methodology/approach – The authors used the secondary data from the literature (peer-reviewed
journal articles) published between 2000 and 2016 to understand the state of the art. The systematic review
identified 101 articles across 88 journals recognized by the Association of Business Schools ranking guide 2015.
Findings – The systematic review helped the authors to identify the evolution, current trends, research gaps
and an agenda for future research for Lean in healthcare. A bouquet of motivating factors, challenges/
limitations and benefits of Lean in healthcare are presented.
Practical implications – The implications of this work include directions for managers and healthcare
professionals in healthcare organizations to embark on a focused Lean journey aligned with the strategic
objectives. This work could serve as a valuable resource to both practitioners and researchers for learning,
investigating and rightly adapting the Lean in the healthcare sector.
Originality/value – This study is perhaps one of the comprehensive systematic literature reviews covering
an important agenda of Lean in Healthcare. All the text, figures and tables featured here are original work
carried by five authors in collaboration ( from three countries, namely, India, the USA and the UK).
Keywords Benefits, Lean, Healthcare, Systematic literature review, Research gaps
Paper type Literature review

1. Introduction
The importance and applicability of healthcare services have evolved as a significant
constituent of services sector in recent years. The increased competitiveness within the
healthcare sector with an urge to improve operational efficiencies has been a key driver for
International Journal of Quality &
Reliability Management healthcare firms to stay ahead in business (Ebrahimi and Sadeghi, 2013; Carter et al., 2012).
Vol. 36 No. 8, 2019
pp. 1370-1391
Furthermore, the increasing customer expectations for high-quality services demands
© Emerald Publishing Limited
0265-671X
continuous process improvement through quality practices (Koning et al., 2006). To meet this
DOI 10.1108/IJQRM-12-2018-0346 cause, a focused approach to reduce operational costs and increase process throughput is
required. An overview of the literature on continuous process improvement shows that there A systematic
is a significant amount of research available on various quality practices that were applied in review of Lean
the services sector. While examining the proportion of papers published among the services in healthcare
sub-sectors in the field of continuous process improvement, Sunder M et al. (2018), in their
review, ranked the healthcare sector as the number one. In other words, compared to any other
services sectors where continuous process improvement has been studied/applied in the past,
the healthcare sector has the higher number of papers in scholarly publications. However, this 1371
increasing trend in the body of knowledge is unorganized and deserves a structure, to enable
future theory development (Sunder M et al., 2018).
Erstwhile scholars have noted various quality practices adopted by healthcare organizations
such as total quality management (TQM), business process re-engineering, quality circles, etc.
(Hietschold et al., 2014; Sreedharan et al., 2019). Furthermore, contemporary thinkers indicate
various quality improvement initiatives implemented by various organizations such as Six
Sigma, Lean and Lean Six Sigma (Ebrahimi and Sadeghi, 2013; Allen and Davenport, 2009;
Sreedharan et al., 2017; Idris and Zairi, 2006; Antony, 2004; Suresh Chandar et al., 2001; Powell,
1995). Among these, Lean has been recognized as an effective and practical philosophy for the
systemic elimination of waste and the non-value-added activities that serves the above purpose
(Rees and Gauld, 2017; Sunder M, 2016b; Koning et al., 2006). This is because Lean entails the
examination of the process through customer centricity to eliminate waste and reduce process
inefficiencies. Furthermore, Lean is rapid and easy to understand by organizational resources
across all levels unlike a few other methods (such as Six Sigma) that are perceived as a statistics
rich and requires significant investment of time and niche skilled resources for deployment.
According to the Lean literature, it has a huge potential in healthcare services to improve
operational efficiency and effectiveness when rightly embedded as a part of organization
culture (Koning et al., 2006; George, 2003; Snee and Hoerl, 2003). Though it originated as a
philosophy, Lean has proved as a practice with several practical implications in
organizations (Furterer and Elshennawy, 2005).
Lean is interpreted in diverse ways by researchers. Some find it as an approach to redesign
business operations (Altria and Smith, 2009; Koning et al., 2006), whereas others feel it more as
strategic resource that helps business in achieving high quality, quick delivery and cost
reduction (Antony, 2004). This is strongly supported by Lubowe and Blitz (2008), who
suggested Lean as a strategy to foster a culture of innovation in organizations. The literature
also suggests the integration of Lean and Six Sigma. Koning et al. (2006) proposed a framework
for Lean and Six Sigma integration, and this resulted in increased application in the fields of
banking and finance (Pinho and Mendes, 2017; Sunder M, 2016a; Sunder M and Antony, 2015;
George, 2003) and healthcare (Kim et al., 2006; Koning et al., 2006; George, 2003). Antony (2004)
visualized the growth and importance of finance and healthcare sectors in coming years and,
thus, the need for quality improvement initiatives such as Lean and Six Sigma. Even recently,
Sunder M (2013a) endorsed this claim though a global study with 98 percent acceptance rate
from the respondents about Lean and Six Sigma as improvement initiatives in services such as
healthcare and finance, confirming a high interest on this topic. The literature also shows the
integration of Lean with TQM, total preventive maintenance (TPM), just in time ( JIT) and
human resources management (HRM) (Shah and Ward, 2003). However, all these studies that
examined line alongside Six Sigma, TQM, TPM, JIT, HRM and a few other socio-technical
practices agreed directly or indirectly that Lean is the fundamental basis for all these quality
management practices, and hence reinforcing its importance for research.
However, not all organizations have gained real benefits from Lean (and its
combinations, mentioned above) as a few abortive implementations have rendered it
ineffective (Maike et al., 2009). In addition, the scholarly literature is rather disconnected
with many gaps that need to be addressed (Pinho and Mendes, 2017; Gupta et al., 2016;
Laureani and Antony, 2012; Pepper and Spedding, 2010). A few of them include
IJQRM understanding the motivation factors that drive Lean deployment in firms, major challenges
36,8 and limitations, and benefits. Hence, this study intends to synthesize the Lean literature
within the scope of healthcare sector and further provide directions for future research.
This study is novel and different from the traditional literature reviews due to two primary
reasons. First, it is performed not merely to identify research gaps in the existing body of
knowledge but also aims to create a structure to various disconnected but relevant topics
1372 that are present in the existing literature. Second, this review examines the motivating
factors, challenges and benefits of Lean in the healthcare sector, and, apparently, one such
work was not found in the extant literature reviewed. Thus, this study is novel and adds
value to the body of knowledge.
Following this introduction, we present an overview of the literature on Lean in
healthcare to arrive at focused research questions. Section 3 features the three-step
methodology adapted in this paper. The classification of the reviewed literature and
subsequent analysis is featured in Section 4, followed by findings and appropriate
discussion in Section 5. The paper concludes with the identification of significant research
gaps as an agenda for the future research.

2. Theoretical background and research questions

2.1 An overview of Lean
With its origins from the manufacturing shops of Toyota production system, Lean has become
particularly essential in services and consequently gained popularity (Lander and Liker, 2007;
Womack et al., 2003). The primary focus of Lean philosophy has been to eliminate Muda
(process waste), Mura (unevenness in operations) and Muri (over-burden on resources).
According to the Lean literature, Muda exists in seven forms, including transportation,
inventory, motion, waiting, overproduction, over processing and defects (Gupta et al., 2016).
Lean principles are used to identify and further eliminate these wastes. The first principle is to
identify value from the customers’ perspective. Second is to understand the value stream to
identify value adding and non-value adding activities. Value stream mapping is performed for
this purpose in order to discriminate, measure and map the value-added steps from the
non-value-added activities. The third principle focuses to create and improve the process flow.
This helps in moving out from silos toward integrated work for achieving the intended value to
be delivered to the customer. Fourth, Lean encourages “pull” methods, where customers pull
products or services as and when they need them rather than pushing them to the customers as
per the producer’s schedule. “Just-in-time” ways of working uphold this concept. Finally, Lean
also works on the principle of continuous improvement toward achieving perfection in
operations and, thus, aims to build a culture of continuous improvement in firms. In practice, the
application of Lean thinking involves a wide range of tools and techniques (Womack et al., 2003).
These include value stream mapping, 5S, five-why analysis, kanban, visual management, waste
analysis, standard work, mistake proofing, spaghetti diagrams, etc., Furthermore, Lean thinking
is a part of leadership agenda in firms to shape and sustain the change process (Mann, 2009).

2.2 Lean in healthcare

Healthcare is one of the biggest beneficiaries of Lean implementation. Hadid and Afshin
Mansouri (2014) reviewed Lean implementation in the services sector and proposed a
theoretical model with key constructs and discussed their impact on overall organizational
performance. According to Radnor (2010), Lean is widely applied in both public and private
sector healthcare organizations. Furthermore, “Lean” in healthcare helps in removing
duplicate processes and unnecessary procedures by organizing the patient records, reduced
waiting for staff, and coordinating the discharge process for patients.
The original application of Lean in healthcare first appeared in 2000 in the UK followed
by 2002 in the USA and is further accepted globally today (Radnor et al., 2012).
 The Lean implementation in healthcare is varied in its approach and scope. Although A systematic
some firms implement it as an enterprise initiative, a few firms limit it to certain projects on review of Lean
need basis (Sunder M, 2016c). This limits appreciating the full benefits that Lean that could in healthcare
be leveraged in the healthcare sector (Radnor, 2010; Brandao de Souza, 2009). According to
Spear (2005) “[…] in healthcare, no organization has fully institutionalized to Toyota’s level
the ability to design work as experiments, improve work through experiments, share
the resulting knowledge through collaborative experimentation and develop people as 1373
experimentalists (pg. 91).” One of the most widely cited Lean implementation initiative is by
The NHS Institute for Innovation and Improvement in the UK. The initiative provided how
an approach such as 5S can bring breakthrough improvements in hospital settings such as
in wards, theaters, community services, etc.
One of the major deterrents of Lean initiative in healthcare is due to the complexity of the
health care system (across different practices globally). The healthcare system is bound by
various professional groups within and due to regulatory bodies externally. These are a few
reasons why quality initiatives take longer time to be successfully implemented in the
healthcare sector (McNulty and Ferlie, 2002). According to Weiner et al. (2004), there are
some quality management techniques that are not well aligned with the healthcare sector
and require administrative procedures. These act as constraints for healthcare professionals
to embrace quality. Inherent limitations of healthcare sector in embracing quality initiatives
are documented by Currie et al. (2008). Their study noted how the knowledge management
system could widely be used in various sectors but was difficult in healthcare because of
their “deeply embedded cultural norms and organizational customs.” Furthermore, the
variability and ambiguity of clinical practices restrict database improvement initiatives
(Radnor, 2010). Hence, “Lean” in healthcare is both challenging and exciting (Waring and
Bishop, 2010). Despite the rich scholarly literature of Lean in healthcare, the complexity of
the subject and diversity in the body of knowledge has rather led to disconnectedness.
Therefore, there is a need to study and synthesize the same. For this purpose, the following
research questions were framed:
RQ1. What are the driving factors that motivate healthcare firms to embark on the Lean
journey, as noted in the literature?
RQ2. What are the challenges/limitations in deploying Lean in the healthcare sector, as
noted in the literature?
RQ3. What are the benefits of deploying Lean in health care, as noted in the literature?
RQ4. What are the key gaps in the extant literature?

3. Methodology
A systematic literature review (SLR) method proposed by Tranfield et al. (2003) was chosen
for this study. SLR has been successfully applied in other reviews in the field of operations
management (Sunder M et al., 2018; Narayanamurthy and Gurumurthy, 2016). The SLR
method consists of three phases suggested from Tranfield et al. (2003). In the first step,
leading databases were investigated to gather relevant papers from January 2000 to
December 2016 from peer-reviewed journals recognized by the Association of Business
Schools. By excluding myriad articles, book reviews, prefaces and editorial notes, 101
relevant peer-reviewed journal articles (Aboelmaged, 2010) were considered for this study.
The second step featured the classification of these papers based on their research
methodology, type of industry, author profile, country of research and year of publication
(Sreedharan et al., 2018). Finally, as part of Step 3, these papers were analyzed to derive
meaningful implications.
IJQRM 3.1 Planning the review
36,8 To collect a suitable literature related to Lean in healthcare, the following steps were followed:
(1) Research articles published between January 2000 and December 2016 were
gathered from search engines and research databases such as ProQuest, Emerald
Insight, Web of Knowledge and Medline using the following keywords: Lean
assessment, Lean evaluation, Lean measurement, Lean quantification, degree of
1374 Leanness and Leanness. The usage of multiple keywords resulted in studies that
addressed assessment topic in specific and thereby added studies of high relevance
to the material collected.
(2) The initial search for this review yielded many articles related to Lean, many of
which did not pertain to this review topic of Lean assessment, evaluation,
measurement and quantification. To restrict the search to articles relevant to the
scope of this study, the following inclusion criteria were used:
• papers that are relevant to the healthcare sector;
• papers published in journals; and
• papers answering research questions related to Leanness, degree of Leanness,
Leanness assessment, Leanness evaluation, Leanness measurement and
Leanness quantification.
(3) Above listed inclusion criteria reduced the number of papers of interest from
hundreds to 101 articles. Focused papers relevant to the research questions were
included, and papers that broadly describe and discuss the Lean implementation
aspects such as listing the principles, practices and tools of Lean, roadmap for Lean
implementation, Lean deployment frameworks, etc., were excluded.

3.2 Conducting the review

3.2.1 Descriptive analysis. Data on publication outlet, year of publication, authorship,
keywords and geographic region of the study were collected and analyzed to understand the
trend evolving over years in this research domain.
3.2.2 Category analysis. It is an iterative process, with authors adding to the exhaustive
list of categories based on their relevance to the current study. Detailed analysis of the
papers was further performed within the structural attributes. For example, under the
“methodology” attribute, a sub-category “nature of the study” was identified to help in
classifying the articles based on whether it utilizes a single case study, multiple case study
or survey (Figure 1).

3.3 Reporting the results

On the basis of above-identified structural attributes, the collected papers were critically
evaluated and analyzed by all the researchers of this study. The summary of the results
obtained from the articles was collected in the review database. Relevant issues and trends
in the literature were identified and presented.

4. Classification and analysis

4.1 Descriptive analysis
A descriptive analysis was carried out on the articles collected following the methodology
discussed in the previous section.
4.1.1 Article distribution. It is evident from the distribution (refer Figure 2) that the topic
of Leanness assessment is at its nascent stage and the literature has grown in recent years.
 Establishing the research Questions A systematic
• To identify the different types of qualitative and quantitative methodologies review of Lean
adopted to assess the leanness in hospitals
• To evaluate the methodological perspectives used in the study of Lean in HCs
in healthcare
• To review the research issues addressed by lean in the hospitals and its evolution
over the years
• Transfield (2003) Review method was used Planning, Conducting, Reporting
1375
Planning: Defining the conceptual boundaries:
• Broadly defining Lean
• Defining the HCs and its variants
• Defining the HCs context based on Lean

Setting the inclusion criteria

Search limits: Keywords for search: Cover period

• ABS ranked
(3&4* journals) “Lean”, “Six Sigma”, January 2000–
• Primary and secondary “Lean Six Sigma”, “Health December 2016
subject areas Care Services”
• Electronic
databases

Conducting: Applying the exclusion criteria:

• Articles that primarily focused on Lean and its key components of training, learning
and development in HCs
• Articles that primarily focused on hospitals, but not the other service ventures like
Banking and ITES.

Full papers appraised = 101 articles

Reporting: Validating search results

Descriptive analysis Categorical analysis Key gaps in existing literature

Conclusion
• Reporting the Results
Figure 1.
• Scope for future research Research methodology
• Research Implications

Preston (2000) was the first to perform integration of Lean with healthcare that leads to
greener and 22 profitable service. But the technique got popularized after 2008. There has
been a considerable rise in the number of Lean in healthcare publications in academic
journals since 2008. Since then, 56 articles on Lean healthcare have been published, which
represent the growing importance of quality consciousness in the healthcare sector, whereas
only 22 articles were published from 2000 to 2010.
4.1.2 Authorship. Papers with four or more authors accounted for over 39 percent,
whereas papers with three and two authors accounted for 24 and 22 percent of the articles,
IJQRM 25 23

36,8 19
20

14
15
Total

1376 10 8 8
7
Linear (Total)
6 6

5 3
2 2
1 1 1
Figure 2.
Year-wise publication 0
2000 2001 2004 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

respectively (refer Table I). An indication of increased collaboration between academicians

and/or academicians and practitioners as about 85 percent of the articles having more than a
single author was another keynote finding. The positive slope in the year-wise publication
graph suggests a steep growth in the number of journals and nine articles published in a
particular year in the domain of Lean in healthcare. The trend chart features the time period
during which 85 percent of the publications were carried out. From this, it can be concluded
that majority of the articles belong to the 2010–2016 period and only 16 papers belong to the
2000–2009 period.
4.1.3 Country. Papers were also classified based on where the study had been conducted,
that is, the geographical location of the firms from which the data have been collected for
review as shown in Figure 3. The classification of papers based on country of research

Number of authors Article numbers (percentage)

1 15
2 22
Table I. 3 24
Author details 4 39

35
Total 29
30

25
20
20

15 13

10
6
4 3
5 2 2 2 2 2 2 3
1 1 1 1 1 1 1 1 1 2

0
Australia
Belgium
Brazil
Canada
Finland
GA
India
Iran
Italy
Japan
Malaysia
The Netherlands
Oman
Portugal
Saudi Arabia
Serbia
Singapore
Sweden
Taiwan
Turkey
UAE
UK
USA

Figure 3.
Country of research
(arranged
alphabetically)
suggests the location in which the data were collected and analysis was carried out. A systematic
The chart distributes 101 papers over 23 countries across continents. About 47 percent of review of Lean
the research was found to be conducted in the USA and the UK. Another 23 percent were in healthcare
found to be from Sweden, Italy and Brazil. Comparing the nature of the Lean healthcare
scenario of these countries with regard to developing economies like India could establish
direction for future research.
1377
4.2 Categorical analysis
After understanding the overview and trend of the review topics through descriptive
analysis, categorical analysis was performed with respect to the structural attributes.
Supporting citations for each of the specific cases of the attributes are provided.
4.2.1 Number of organizations involved. Articles were classified based on the number of
organizations studied and data collection methods adopted to test their methodology in
three different categories: single case study (one organization), multiple case study (W1
organization) and empirical study (data collected from potential respondents from different
organizations or survey questionnaire). Leanness assessment techniques in the
manufacturing sector have been predominantly adopting the single case study approach.
Leanness assessment literature in the healthcare sector lacks assessment techniques that
have been empirically generalized, thereby opening the scope for future research. About
30 percent of the papers were longitudinal studies, i.e., based on data from a single
organization taken over varying periods of time. Totally, 26 percent of the papers were
based on data from more than one organization. It was not possible to find the number of
organizations involved for about 44 percent of the papers (refer Figure 4). This is primarily
due to a large number of conceptual papers involving literature reviews and case studies.
4.2.2 Nature of business/industries. Only 72 studies reported the nature of business
performed by the organizations studied, as the remaining studies were either under the
category of conceptual study or the details of the organization were not explicitly stated in
the paper. Hence, those articles were coded as “not mentioned.” The papers selected can be
categorized into two broad categories, namely, conceptual and practical (includes empirical)
studies. Totally, 73 percent of the papers were in the category of practical study, whereas
the remaining 27 percent were conceptual studies. The papers that used models and
example data were classified into conceptual category where in the rest of the papers that
collected data through various means were categorized as practical.
4.2.3 Nature of the studies. Based on the type of data and the extent of empirical
and statistical analysis involved in a paper, they were classified into quantitative and

Single Multiple
30% 26%

Not clear
No Data 27%
17% Figure 4.
Number of
organizations
IJQRM qualitative categories. Quantitative studies were given in 51 percent of papers and only
36,8 49 percent were qualitative studies. Qualitative assessment studies have started
pickingup in the recent past, and in parallel, quantitative assessment studies have
increased. Scope exists for developing qualitative data-based assessment techniques as
most of the past studies were of quantitative nature. Categorizing based on organization
type, it was interesting to observe that qualitative assessment techniques in the service
1378 industry were more in number than the quantitative assessment techniques. More
qualitative assessment techniques can be developed to take forward the existing literature
on Leanness assessment in the HC as shown in Figure 5.
From the Figure 7, it can be seen that about 46 percent of studies were conducted
through surveys and interviews. Around 5 percent articles discussed about the publicly
available report, whereas the rest of the study were descriptive in nature. Data collection
methodology was found in 41 percent of the articles. The distribution of articles based on
the methodology adopted for data collection, indicates that 28 percent of the papers
presented a framework, ~15 percent papers used a survey instrument, one paper used fuzzy
logic, and two papers used indexing methods. Classifying the papers based on whether
benchmarking was adopted while assessing Lean transformation. Not many studies have
extended or adapted their assessment methods to make it capable of performing
benchmarking of Leanness attained. Only a very small percentage that is 11 percent of the
papers were found to use benchmarking. Majority of the papers were found to not use
benchmarking. Papers have developed a numerical index as a measure of Leanness of the
organization. About 83 percent of the papers were found to use no scales. Only 17 percent
used scales. Some common scales that were used include the Likert scale. By categorizing
the reviewed literature based on the number of participative organizations, it was
interesting to observe that Lean initiatives were implemented in cases when multiple
organizations are involved. This has helped healthcare services sector to evolve drastically
in last decade. But, Lean can evolve more rapidly in the healthcare sector when more and
more organizations individually start implementing the initiative.

5. Findings, discussions and implications

This section presents the key findings of the analysis and further discusses the directions
for future research. For the ease of readers, this section is presented into subsections,
namely, motivating factors, Lean practices adapted and challenges existing within the
assessment methodology. In addition, it also features gaps in the extant literature reviewed
proposing directions and an agenda for future research.

Conceptual, Questionnaire,
21% 19%

Not clear, Interviews,

28% 27%

Figure 5. Publicly
Nature of the study available
reports, 5%
5.1 Motivating factors A systematic
There are 11 different factors mentioned in various articles, identified in our study, that review of Lean
motivate healthcare services to apply Lean in their organizations, as shown in Table II. in healthcare
In most cases, the common driving reasons for deploying Lean are to provide better services to
patients, to improve the process and operational efficiency, to improve service quality, to
transform organizational culture, to standardize and streamline the process, to reduce delays
and operational time, to reduce staff and administrative inefficiencies, motivation to 1379
outperform others and gain competitive advantage, to eliminate waste, and to eliminate non
value adding tasks. Additionally, it is observed that the drivers that motivate organizations to
implement Lean also include increased customer satisfaction, cost reduction and improvement
in bottom-line. The full benefits of Lean implementation are not realized by majority of the
organizations in the extant literature as the implementation takes place in most cases in a
particular business unit rather than the whole of an organization. In a few cases, it was
narrowly focused on improving a few metrics and not across the enterprise. This shows that
there is a considerable gap in understanding the full benefits of Lean implementation. Thus,
we feel that there is a strong link between motivation and benefits realization in Lean since
weak motivation will lead to limited deployment that further leads to lower benefits. As
Albliwi et al. (2015) mentioned that one of the strong motivator for organizations to implement
Lean is by disseminating knowledge about its success stories from other organizations and
highlighting the realized benefits achieved by these organizations. Furthermore, this review
unearthed the reasons behind the implementation of Lean in healthcare services inspired by
two kinds of reasons: proactive (i.e. self-desire by the company) and reactive (responds to
customer requirements and threats whereby failure comply may result in adverse effects).
These reasons are presented in Figure 6 and ranked in order of their frequency.

To provide better services to Crema et al. (2016), Drohomeretski et al. (2013), Crema and Verbano
customers (2015a, b), Goodridge et al. (2015), LaGanga (2011), Kim et al. (2006)
To enhance patient satisfaction Chiu et al. (2016), Kovacevic et al. (2016), Costa and Godinho Filho
(2016), Miller and Chalapati (2015)
To outperform others and gain Dannapfel et al. (2014), Waring and Bishop (2010)
competitive advantage
To improve the process and Efe and Efe (2016), Ishijima et al. (2016), Matos et al. (2016), Costa and
operational efficiency Godinho Filho (2016), Abdelhadi and Shakoor (2014), Drotz and
Poksinska (2014), Radnor et al. (2012), Meredith et al. (2011)
To improve service quality D’Andreamatteo et al. (2015), Costa and Godinho Filho (2016),
Hussain et al. (2015), Ker et al. (2014), Boyer et al. (2012),
Vest and Gamm (2009)
To transform organizational culture Costa and Godinho Filho (2016), Eriksson et al. (2016), Moraros et al.
(2016), Jorma et al. (2016), Drotz and Poksinska (2014), Procter and
Radnor (2014), Chiarini (2013), Poksinska et al. (2013), Mazzocato et al.
(2010), Esain et al. (2008)
To standardize and streamline the Langstrand and Drotz (2016), Tay (2016), McIntosh et al. (2014),
process Burgess and Radnor (2013), Bamford et al. (2015), Cima et al. (2011),
Fillingham (2007)
To reduce delays and Costa and Godinho Filho (2016), Ishijima et al. (2016), Kovacevic et al.
operational time (2016), O'Reilly et al. (2016), Abdelhadi (2015), Dahlgaard et al. (2011),
Yeh et al. (2011)
To eliminate waste Kılıç et al. (2016), Daultani et al. (2015), Grove et al. (2010)
To eliminate non value adding tasks Kılıç et al. (2016), Al Balushi et al. (2013), Collar et al. (2012),
Waring and Bishop (2010) Table II.
To reduce staff and administrative Van Rossum et al. (2016), Costa and Godinho Filho (2016), Motivating factors for
inefficiencies Mazur et al. (2012), implementing Lean in
Radnor et al. (2012), Papadopoulos et al. (2011) healthcare services
IJQRM 5.2 Limitations/challenges
36,8 In the case of Lean deployment, organizational limitations become challenges for a successful
implementation. The literature highlights that there exists a significant number of limitations in
Lean implementation. Twelve fundamental limitations were addressed in the articles reviewed
here that are presented in Table III. Strategies to overcome or mitigate these limitations could be
a potential area for future research. According to Table III, the top 5 limitations of Lean in the
1380 healthcare services are Lean is new in the healthcare sector that makes it difficult to implement,
lack of empirical evidence to convince top management, lack of coordination between functions,
managerial resistance to change and employee resistance to change.

5.3 Benefits
An analysis of articles indicating Lean benefits in the healthcare services sector has resulted
in 12 benefits (refer Figure 7). Some of the most cited benefits in the literature include
improved operational efficiencies; reduced error rate, waste and operational losses; reduced
delay and improved cycle times; improved service quality; positive change in culture,
eliminated unnecessary or non-value-added steps in the process; improved satisfaction of
customers or patients; and reduced operational costs. The other benefits mentioned in the
literature are increased profits, outperformed competitors and reduced complaints.

20

15

10

Figure 6.
Reasons for 0
To improve To improve Quality To reduce To identify To reduce To reduce to improve To reduce
implementing Lean in process decision Improvement cost weakness waste/ delays and customer customer
healthcare services efficiency making operational improve cycle satisfaction complaints
losses time

No commonly followed criteria to assess the Dobrzykowski et al. (2016), Miller and Chalapati (2015)
project value
No commonly followed criteria to assess the Hussain et al. (2015), Radnor et al. (2012)
project complexity
Lean is new in healthcare services Ishijima et al. (2016), Jorma et al. (2016), Kılıç et al. (2016),
which make it difficult to implement Kovacevic et al. (2016), Robinson et al. (2012), Waring and
Bishop (2010)
Lack of empirical evidence D’Andreamatteo et al. (2015), Shazali et al. (2013), Al Balushi
et al. (2013), Grove et al. (2010)
Lack of plausible theory Costa and Godinho Filho (2016), Collar et al. (2012)
Few projects to generalize the result Chiu et al. (2016), Henrique et al. (2016), Mazzocato et al. (2010)
Broad set of tools make it difficult McIntosh et al. (2014)
to select the proper one
Lack of in-depth knowledge of Drotz and Poksinska (2014), Meredith et al. (2011)
tools and techniques
Long project duration reduces Daultani et al. (2015), Waring and Bishop (2010)
employee motivation
Table III. Lack of coordination between functions Chiu et al. (2016), Rawson et al. (2016), Cima et al. (2011),
Limitations in Villa (2010), Young and McClean (2009)
implementing Lean Managerial resistance to change Chiu et al. (2016), Eriksson et al. (2016), Kim et al. (2006)
in healthcare Employee resistance to change Papadopoulos et al. (2011), Esain et al. (2008)
5.4 Key gaps in the reviewed literature (an agenda for future research) A systematic
As the paper highlights key driving motivation factors, challenges/limitations and benefits review of Lean
of Lean in the healthcare sector, most of the reviewed literature showed significant gaps for in healthcare
future research. A few of them include:
• Lack of systemic Leanness at firm level: the reviewed literature lacks a fully
developed assessment methodology (and subsequent frameworks) that can capture
the systemic nature of Lean practice implementation at a hospital level. 1381
• Lack of systemic Leanness at hospital: leanness assessment at hospitals is found to
be at its nascence. Not many studies have attempted to assess how Lean
implementation in hospital impacts.
• Assessment for Lean implementation procedure: assessment techniques capable of
assessing the outcomes of Lean in healthcare were found to be generic with
a few perceptions (opinions and awareness on Lean), rather than customized to
firm-specific attributes. Future research on this could lead to studying impact of
Lean on strategic outcomes like organizational decision making, managerial
effectiveness, etc.
• Assessment methods based on simulation: assessment methods based on simulation
with realistic assumptions have a huge potential to deliver great insights for firms
implementing Lean in healthcare, as the past research lacks such usage. Simulation
experiments provide a field to test for different possibilities and help firms in making
an informed decision.
• Assessment for entire Lean journey: existing assessment techniques do not capture
the entire Lean journey of the firm. Most of them take a piece meal approach by
assessing for shorter time periods and draw interpretations. This provides an
opportunity for future researchers to conduct longitudinal studies over a period of
several years on firms.
• Leanness for organizational learning: there is a dearth of studies to investigate the
organizational patterns (routines) that Lean implementation could enable, which can
further emerge into organizational learning capabilities. These studies could have a
foundational theoretical underpinning according to resource-based view (Bromiley
and Rau, 2016) or dynamic capabilities view (Sunder M et al., 2019).
• Index/Metrics for measuring wastes: most of the existing indexes attempt to provide
a single numeric for the entire Leanness of the firm. Metric capturing the extent of
prevalence of individual seven wastes proposed in the Lean literature and a metric

12

10

0 Figure 7.
Improved Reduced Reduced Improved Positive Eliminated Improved Reduced Improved job Increased Out Reduced
operational error, waste delay and service change in unnecessary/ satisfaction cost satisfaction profits performed complaints
Benefits of Lean
efficiencies and improved quality culture non value of customers of employees competitors implementation in
operational the cycle adding steps
loss time in the
healthcare services
process
IJQRM that logically cumulates these seven metrics into a single metric capturing the total
36,8 amount wastes in the firm would be a worthwhile contribution.
• Behavioral aspects of Lean implementation: Cho et al. (2017) presented a framework
of behavioral quality management as an organizational strategic resource. A similar
assessment of behavioral aspects of Lean deployment in healthcare would help in
further understanding of the variance associated with the success or failure outcome
1382 of Lean implementation. None of the assessment techniques in the reviewed literature
have attempted to capture the behavioral aspects that play a key role in Lean
implementation, reinforcing this opportunity for future research.
• Development of benchmarks: the assessment technique that can develop the
benchmarking index or metric that indicates the maximum or optimal improvements
that a hospital can attain through Lean implementation could be a great value
addition to the body of knowledge.
• Financial viability of implementing Lean: most of the healthcare firms see huge
benefits while initially graduating to Lean from their traditional ways of working, but
sustenance of Lean methods usually drops after a few years (Sunder, 2013b). The
assessment technique capable of indicating a “threshold” point beyond which the
firm would earn decreasing returns on investment would be a very useful tool for
practitioners. This could also help in creating organizational controls to avoid or
prevent these undesired outcomes.

6. Conclusion
Lean has proved its caliber as a successful continuous improvement practice in both
manufacturing and services, and healthcare is not an exception. The increasing trend of
Lean application in healthcare demands for further research within the academic
community to strengthen the associated theory. Along with Lean implementations, impetus
to researchers and practitioners to develop various mechanisms and methodologies to
perform an assessment of the system to understand the effectiveness of implementing Lean
in hospitals has also increased. By reviewing the Lean literature, this study answered all the
four research questions raised at the beginning of this paper. First, the fundamental analysis
featured here classified the literature across variants, namely, year, country, organizations
and the methodological nature of studies. Second, to answer RQ1, various drivers and
motivational factors for Lean deployment in healthcare were presented.
Third, in response to RQ2, various challenges/limitations of Lean in scope of healthcare
sector are presented. Fourth, the key benefits noted by various scholars in the erstwhile
literature is compiled to see patterns that resulted in 12 key benefits of Lean in healthcare, as
a response to RQ3. Finally, for RQ4, key research gaps were presented as an agenda for
future research in this field.
We believe that this study would help healthcare professionals to onboard on their Lean
journeys by aligning their motivation drivers, realizing and estimating the desired outcomes
(benefits) and being cognizant of the challenges/limitations. This study could also serve as a
resource for researchers as it provides directions for future research.

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in healthcare
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About the authors

Jiju Antony is Professor of Quality Management in the School of Management
and Languages, Heriot-Watt University. He is a certified Lean Six Sigma Master
Black Belt and has been a leading practitioner and academic. He has trained more
than 1,000 delegates on Six Sigma and Lean related topics over the past 11 years.
Professor Antony has published over 250 journal and conference papers
and 6 books on Six Sigma and Quality Management/Engineering related
topics. He is a regular speaker at various international conferences on quality and
Six Sigma related topics.

Vijaya Sunder M. is Head of Business Process Excellence at the World Bank Group.
He is Lean Six Sigma Master Black Belt at Indian Statistical Institute, and ISO
9001:2015 Quality Lead Auditor. He has led and mentored various re-engineering
and management consulting programs that helped to improve the customer
experience, employee satisfaction, eliminate process defects, increase productivity
and reduce costs across service organizations. He has trained more than 1,500
people (as on July 2018) in Lean, Six Sigma, Agile, Robotics Process Automations
(RPA), strategy and leadership. Alongside corporate job, Vijaya Sunder practices teaching at various
business schools and conducts academic research that has been published in various reputed peer-
refereed journals. He is currently pursuing his PhD from the Indian Institute of Technology Madras.
Vijaya Sunder M. is the corresponding author and can be contacted at: [email protected]

Raja Sreedharan is Assistant Professor in the Department of Management Studies,

Amrita School of Business, Kochi campus. He has undertaken doctoral research at the
Department of Industrial Engineering, Anna University. He has garnered corporate
exposure working with Apollo Hospital as external auditor for 5S implementation. He
has attended international conferences and has published articles on Lean Six Sigma,
MCDM Approach, and SEM.

Ayon Chakraborty is currently working as Associate Professor in the Operations

Management and Quantitative Techniques area at IIM Tiruchirappalli. Prof.
Chakraborty has more than 11 years of experience in teaching business students and
executives at various institutes such as Queensland University of Technology, James
Cook University Australia (Singapore Campus). He has taught MBA courses on
service operations and innovation management, project management, quality
planning and management and quantitative techniques. Chakraborty has worked
closely with private and public-sector organizations in India, Singapore and with Suncorp, Infosys
Australia and Queensland government.
 Angappa Gunasekaran is Dean in the Charlton College of Business, University of A systematic
Massachusetts Dartmouth (USA). He received the PhD Degree in Industrial review of Lean
Engineering and Operations Research from the Indian Institute of Technology
(Bombay). He was the Chairperson of the Department of Decision and Information in healthcare
Sciences from 2006–2012. Dr Gunasekaran has held academic positions at Brunel
University (UK), Monash University (Australia), the University of Vaasa (Finland), the
University of Madras (India) and the University of Toronto, Laval University, and
Concordia University (Canada). He is teaching undergraduate and graduate courses in operations 1391
management and management science.

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