Table Of ContentInternational Examples of
Lean in Healthcare
Typically entrenched and systemic, healthcare problems require the sort of comprehensive solutions
that can only be addressed by a change in culture and a shift in thinking. Organizations around
the world are using Lean to redesign care and improve processes in a way that achieves and sustains
meaningful results for patients, staff, physicians, and health systems. This book demonstrates how
honest appraisal, intelligent planning, and vigilant follow-up have led to dramatic improvements
in a variety of healthcare settings across the world. It teaches us how innovative organizations
can find sustainable solutions to seemingly intractable problems by following a path guided by
Lean Thinking. Lean methods may not solve every healthcare problem, but as these cases prove,
changing a culture rather than personnel results in more effective sustainable change.
This multi-authored book provides expert descriptions of Lean methods and their application
in healthcare, written by the people who developed and tested the methods in healthcare settings.
Each chapter brings together a description of the technique or approach, with examples of
application in practice from the author’s own practice. Authors use an engaging approach to their
narrative, with examples from their personal experience or engagement being described to illustrate
the practical application of theoretic approaches. In painting a picture of the environment in
which these tools and techniques have been applied, readers will understand the transferability to
their own workplace environment. This will be an opportunity to tell real stories of the application
of Lean in healthcare and give readers the opportunity to learn from people from across the world,
about subjects on which they are acknowledged topic experts, based on day-to-day Lean practice.
International Examples of
Lean in Healthcare
Case Studies of Best Practices
Elaine Mead, Cameron Stark, and Maimie Thompson
First published 2023
by Routledge
605 Third Avenue, New York, NY 10158
and by Routledge
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2023 selection and editorial matter, Elaine Mead, Cameron Stark, Maimie Thompson; individual chapters, the contributors
The right of Elaine Mead, Cameron Stark, and Maimie Thompson to be identified as the authors of the editorial material, and of the
authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents
Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval
system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and
explanation without intent to infringe.
ISBN: 9780367344696 (hbk)
ISBN: 9781032398464 (pbk)
ISBN: 9780429346958 (ebk)
DOI: 10.4324/9780429346958
Typeset in Garamond
by Deanta Global Publishing Services, Chennai, India
Contents Contents
Dedicated to the memory of our friend and colleague Murdina Campbell
1971–2022
Contents
Foreword ....................................................................................................................................ix
Acknowledgements ...................................................................................................................xi
Editors ....................................................................................................................................xiii
Contributors .............................................................................................................................xv
1 Using Lean in Healthcare .............................................................................................1
CAMERON STARK, ELAINE MEAD, AND MAIMIE THOMPSON
2 Applying 5S in Healthcare .........................................................................................15
MURDINA CAMPBELL
3 The Design and Use of Good Data in Clinical Processes ...........................................29
TODD L. ALLEN
4 Hospital Flow .............................................................................................................41
MARC ROUPPE VAN DER VOORT, ANNA ROOS VIJVERBERG,
AND FRITS VAN MERODE
5 Value Management .....................................................................................................59
KAY CORDINER, POONAM GUPTA, SALAH ARAFA, AND CAMERON STARK
6 Building a Model Value Stream for Older People Living with Frailty in Ireland ...........77
FIONA KEOGAN AND ANNE-MARIE KEOWN
7 Using Lean at Scale in Mental Health Service Provision ...........................................97
LOUISE ROIG AND JENS NORMAND
8 Organisation-Wide Implementation of Lean in Iceland ..........................................117
PÁLL MATTHÍASSON, BENEDIKT OLGEIRSSON, AND GUDRUN BJÖRG
SIGURBJÖRNSDOTTIR
9 Improving Learning Disabilities Services with Lean Design: A Case
Application of the 3P Method ..................................................................................131
IAIN SMITH AND STEVEN BARTLEY
10 Co-Producing an Organisation’s Quality Improvement Method: No Decision
about Me, without Me ..............................................................................................149
NATHAN CLIFFORD, SARAH CURTIS, AND KARL MARLOWE
11 Applying Kata in Healthcare ....................................................................................165
ANN HILL AND GRAHAM CANNING
vii
viii ◾ Contents
12 Executive Leadership in Sustaining Lean Transformation ......................................183
KIM BARNAS
13 Learning How to Apply Lean ...................................................................................207
ELAINE MEAD, CAMERON STARK, AND MAIMIE THOMPSON
Index .................................................................................................................................219
Foreword
I was talking to a group of surgeons recently, and they had issues with access to theatres, a backlog of
work after COVID-19, various problems with ineffective meetings, and a powerful sense that their
work could be more equitably and efficiently organised. A short exercise in thinking about improve-
ments generated a stream of good ideas ‒ as you might expect from a group of energised, effective,
and moderately competitive individuals ‒ and a clear set of priority actions for what might be done
next quickly emerged. Simultaneously, however, they were pessimistic about the possibilities of suc-
cess, doubtful if anything would change, and startlingly unwilling to commit to the first steps.
How could this be? How had they learned to be so negative? They worked for a highly effective
and externally validated organisation that had an excellent reputation with patients and profes-
sionals alike for the quality of their services. Experience, nonetheless, had taught the surgeons
that their ideas would be buried in interdepartmental disagreements and enervating discussions
about budgets and time and middle-management worries about unknowable, unforeseeable con-
sequences. As any bright and motivated people would, they could see many possibilities, but they
were also naturally conservative about any change that was not within the clinical research model.
They also doubted they had “permission” to try.
Yet the leaders of their organisation were publicly encouraging a continuous improvement
effort, supporting the wider and deeper learning of improvement science through Lean tools,
clearly wanting to support staff in their efforts to improve processes and thus improve both staff
and patient experience. They absolutely thought they had given everyone permission! What was
wrong? Why was there such a disconnect between intent and outcome?
Not long after this discussion, I was high up in the French Alps. I am an experienced alpin-
ist and together with my friend and guide Yves, we climbed up to our goal, high up on a remote
glacier, near the summit of Mont Blanc, Europe’s highest mountain. We were watching some
other climbers following in our tracks. My guide was not impressed. We were using very technical
equipment and techniques including very specialised touring skis and we had climbed the high
glacier roped together ‒ it was a notorious spot for hidden crevasses, accidents were likely, and
indeed climbers regularly died there or thereabouts. Our followers were attempting the route with-
out skis, and they were not roped together. We thought it likely they were heading for a famous
rock climb nearby. We had a brief discussion about the annual death toll on Mont Blanc. Often a
complex mixture of bad luck, rapid changes in weather, and inexperience led to tragic situations
and many near misses. More rarely the cause was foolhardiness ‒ itself usually just a lack of experi-
ence, combined with inadequate technique, dressed up in over-confidence.
Yves was strong on metaphor. “People," he said, nodding towards the other climbers, “need
to realise that Mont Blanc is like the ocean. Learning to swim in pool, sail dinghies on reservoir,
kayak on a gentle river, these things do not prepare you to cross the ocean.” He sighed and briefly
reflected with me on several mountain rescue callouts he had had to join over the years: in terrible
weather; in the dark; at bad times of the season. He didn’t mind helping ‒ indeed he felt a moral
ix
x ◾ F oreword
duty to help ‒ but he always wondered why, on so many occasions, people thought the ocean was
just a bigger version of the gentle waters they had come from and learned in, and thus, almost
inevitably, they had lacked the humility to see the real task they had given themselves.
This book is both a guide and a map, a description of the territory and its joys plus a helpful
sharing of experience.
After nearly 20 years of working on the implementation of Lean in healthcare, in organisations
I led and whilst trying to help others to cross the same ocean, climb the same mountain, there is
one thing I am certain of: we all need a guide by our sides. With us and beside us. However sure
we are, experienced we are, and enthusiastically we approach the task, we will need help.
In many texts and from many trainers, consultants, and other Lean leaders, what you first
get is a reductive account of Lean tools and promises of easy wins (not always sustained!). This
introduction may lead us to mistake the ocean for a balmy lido. Here, however, in this book, the
authors have brought together a full set of experiences to help develop a range of skills. Of course,
the technique is important and discipline with tools and methods must be learned. But, as a
counterpoint to the reductive (and indeed seductive) approach, here we learn about context and
leadership and timescale and performance demands ‒ and, of course, the patients ‒ all combining
to create a huge, complex challenge. Here the authors help us to see what they have learned and
where their experience can translate into general principles. And, crucially, help is outlined for
how to find the right guide, the right strategic partner.
So often, the attitudes and engagement (or otherwise) of the senior doctors is a massive reveal
in the progress that organisations are making by implementing Lean. Junior doctors may join
with the nurses, managers, other colleagues, and patients to make huge progress on individual
point and service line improvements, engineering great gains in time, mistake proofing, and other
process benefits that often feel transformational in a healthcare setting. This is climbing into the
scenic and sunny foothills, seeing the incredible views from a new perspective for the first time.
The local mountains can then be scaled by leaders who see that context, behaviour, and crucially
their visible leadership, all add to the creation of a culture where continuous improvement, driven
by Lean skills, can thrive. But the biggest mountains of all require even more effort, more time,
and more support. I am certain, from their own training and experience in clinical care, the senior
doctors know this huge challenge is there and prefer the safe ground of what they already know.
The view from the foothills may be sufficient for some Lean leaders, but for all staff, including the
senior doctors, to genuinely feel valued, engaged, trusted, respected, and happy ‒ and for every
patient consistently to receive timely, value-adding care ‒ this is the mountain we want to be on,
the real ocean we long to venture into. The surgeons I spoke to were not without ideas, enthusiasm,
and knowledge. Their managers hoped to engage their effort but so far had yet to penetrate their
protective cloak of realistic cynicism. They are making progress, nonetheless. They understand
their goal and they know there is climbing still to be done.
Faced with obvious difficulties and hidden traps and dangers created by a change in the
weather, we can all become guides; we can all coach each other and learn together. Partly this is
a new leadership ethos to learn with curiosity and humility ‒ and partly this progress is possible
because others have already learned and stand ready at our side.
Here, the authors set out to share their learning, stand with us, beside us, and guide us from
the gentle shallows into the great and fabulous ocean.
Dr Stephen Singleton
Cumbria, UK
July 2022
