Introduction to Lean Management in Healthcare

Chapter 1

1.0 Introduction

This chapter gives an introduction to the study. It introduces the reader to background information regarding lean management in healthcare, thereby enabling a proper understanding of the research topic. Next, the chapter highlights the underlying research objectives and the problem that it seeks to solve. Likewise, this chapter will introduce the reader to the justification and significance of the study, before ultimately stating how the rest of the study will be organized.

1.1 Background of the Study

In the contemporary world, the practice of management is continuously under rapid change, and this affects both organizations and managers (Abdullah et al., 2008). In response to such changes, according to Aherne (2007), organizations tend to adopt decentralized systems of management while implementing various change tools to enhance performance and increase the efficiency of their operations. As some organizations attempt to keep up with competition while others struggle to adhere to set standards of services, some of them find Lean, a management tool that helps in enhancing their position in within the competitive environment by reducing cost and eliminating wasteful operations, helpful. Against this backdrop, several research studies have argued that a successful implementation of lean management could be of great benefit to organizations. For example, Appiotti & Bertels (2010) claims that that Lean management can enable organizations to achieve long term customer satisfaction. Existing literary materials indicate that the popularity of Lean tool has primarily emerged from the efficiency that it helps Japanese companies such as Toyota achieve (Balle & Reginier, 2007). Ideally, according to Barnas et al (2014), the concept of lean management was coined by top Toyota executives namely: Kiichiro Toyoda & Taiichi Ihno, when they attempted to identify various points of waste within the production system. But, today, the concept of lean management has evolved into a management tool useful in improving production processes across different industries (White, 2017). The increasing demand for quality services has contributed to high regard held by managers towards service operations, thus the adoption of any tool that would help improve the quality of services delivered within any industry (Chen et al., 2010). Therefore, according to De Souza (2009), managers have increasingly adopted Lean management especially with the aim of improving employee’s performance, and by effect, enhancing the quality of services provided by employees. Worryingly, despite the adoption of Lean, most organizations are still not able to deliver quality services. Notably, Lean has not received a broad implementation in the service industry, a phenomenon that Gapp et al. (2008) attributes to the mentality that Lean perfectly works in the manufacturing and production industries – in fact, the concept was first developed in the production industry. Balle & Reginier, (2007) also note that Lean management is primarily believed to be only beneficial for manufacturing organizations. Nevertheless, today, Lean management is applied across various industries, including the financial sector to improve efficiency in service delivery.

1.2 The concept of Lean Production

Lean production originated from the success that was achieved by Toyota Gapp et al. (2008), whereby it was implemented to reduce waste within the production system and use fewer production materials. Besides, according to Balle & Reginier (2007), lean production was mainly developed to minimize the use of resources by reducing the quantity of non-value added activities; and was thus implemented in various components if the production line, including shop floors and warehouses.

1.3 Lean thinking

De Souza (2009) defines lean thinking as the process of adopting efficient production services, which minimizes the amount of time and resource spent in the production process. It is achieved when organizational members develop thinking and listening culture, where workers are given the responsibility of developing process designs of delivering goods and services (Fillingham, 2007). Furthermore, Kotter (2007) argues that organizations develop lean thinking by informing employees of the benefits that could be achieved from its implementation. Besides, such organizations endeavour to monitor the flow of resources while minimizing waste.

1.4 Waste

In service or manufacturing context, waste entails any item or activity that does not add value to the system of production or to employees who deliver services (Grove et al., 2010). Besides, Grove et al. (2010) define waste as any item on which money or time is spent but does not add value to the customer. Typically, wastes occur in poorly managed operations or production processes within the organization.

1.5 Statement of the Problem

Regardless of the common knowledge that Lean management can be implemented in the service sector to cause various levels of improvement, there is a dearth of research and data materials that highlight the best practices of Lean management in the healthcare service industry that can give guide managers in this industry on how to implement the tool (Kastberg & Siverbo, 2017). Bedgood (2018) also confirmed that despite the proliferation of literature materials on the implementation of Lean management within the healthcare setting, such studies are either methodologically weak or lack a strong base of evidence regarding the effective implementation of the tool. To fill his research gap, the current study seeks to explore and understand the application of Lean management in the healthcare setting. In doing so, the researcher will be able to enhance the understanding of the implementation of Lean management style within the healthcare sector as well as the barriers that hospital managers might encounter while implementing the management style. Ultimately, after understanding the implementation of Lean, the researcher will identify and recommend effective techniques useful in the successful implementation of lean management in healthcare.

Research Aim

A study to explore the applicability and implementation of Lean management in healthcare setting

1.7 Research Objectives

i. To investigate the impact of lean management on the quality of healthcare

ii. To explore the tools and techniques useful in the effective implementation of lean management in healthcare

iii. To explore the challenges facing the implementation of lean management in healthcare

1.8 Research Questions

i. What is the impact of lean management on the quality of healthcare?

ii. What are the tools and techniques useful in the effective implementation of lean management in healthcare?

iii. What are the challenges facing the implementation of lean management in healthcare?

1.9 Justification of the study

This research will be of importance for several reasons. First, the past few decades have seen a growing interest in service delivery within the healthcare setting where hospitals are trying to improve the quality healthcare services they deliver to their patients across all departments (D’Andreamatteo et al, 2019). By exploring the application of lean management in hospitals, this study shall have developed relevant knowledge on tools and techniques that can help in improving the delivery of healthcare services. Secondly, concerns have been raised over the cost of healthcare and the burden borne by patients to acquire treatment, some of whom are not economically able to meet their healthcare needs (Patri & Suresh, 2018). By exploring lean management and how it can eliminate waste while improving value to patients, this study shall have contributed adequate knowledge on what hospitals can do to reduce the cost of healthcare services delivered to the public. Thirdly, according to Roemeling et al (2017), the vital role of efficiency in improving the quality of healthcare is unequivocal. Therefore, by studying Lean thinking, this study shall have contributed to a change in attitude and behaviour among healthcare managers as well as health workers on efficient delivery of healthcare services. Last but not list, this study will be able to fill the research gap that currently exists on the applicability and implementation of lean management in healthcare.

1.10 Scope of the Study

The study will explore secondary data on several hospitals that have implemented Lean management and compare them to identify the applicability and implementation of lean management. The researcher will endeavour to examine any relevant data that will help answer the research questions and achieve the research objectives. In doing so, a thorough exploration of secondary data (i.e., books, reports, and peer-reviewed journal articles) from across the globe will be evaluated in an attempt to draw evidence from a wide range of health settings. The study will focus more on answering the research questions rather than making generalizations on the findings.

1.11 The Study Structure

The study will draw evidence from different sources to familiarise with lean management and its applicability in the healthcare setting. The study will rely on online databases to retrieve data from peer-reviewed journal articles. Furthermore, the researcher will rely on reports and websites to support and validate data from academic literature. More importantly, the study will rely on publications from NHS giving guidelines on the use of lean management in healthcare. All in all, the process of reviewing literature will entail identifying various themes and comparing the findings of numerous academic research studies that could help in answering the research questions. The second chapter is the methodology section, where the researcher will highlight the tools and techniques used in achieving the research objectives. Here, the researcher will describe various elements of secondary research, including search strategy, keywords, data collection critical appraisal of secondary sources, data analysis, and ethical considerations. The third chapter will entail the results and discussion, whereby all the findings made by the researcher will be presented and analysed. Lastly, the researcher will conclude the study and give several recommendations for practice and future research.

Chapter 2

2.0 Literature Review

The main aim of this chapter is to highlight existing knowledge on lean implementation by evaluating empirical evidence, theoretical framework and a summary of relevant information that would help in understanding what is known about lean, what is not known, and how the research gaps can be filled. So, there will be a deeper evaluation of lean implementation and the aspects surrounding this implementation.

2.1 Historical background of lean

The concept of lean was coined in 1988 by Krafjick, who intended to acclimatise people to the idea of using fewer resources to achieve efficiency in production processes. According to Appiotti & Bertels (2010), Ktafjick’s main intention was to inform managers that they could use small space, make small investments, employ fewer employees and use fewer raw materials to develop the kind of products they would want to. Hence, Krafjick proposed that managers could eliminate any aspect of the production process that added no value onto the system and thus did not have any additional value to the customer. Similarly, according to Taleghani (2010), the main objective of lean system was to ensure that managers adopted management principles that focused on reducing waste. From the origin, managers practicing lean needed to adopt several management techniques and tools to successfully operate at a low waste. For instance, writings by Aherne (2007) indicate that to effectively manage multi-talented employees, managers had to develop effective leadership skills, develop teamwork among their employees, and adopt effective communication systems for purposes of performing trade-offs and prioritising the use of resources. A key inspiration to Kiichiro Toyoda in developing lean emanated from the theory of mass production invented by Henry Ford. But, as Appiotti & Bertels (2010) narrates, it was impossible for Toyota to adapt mass production due to the impact that World War II had had on Japan’s economy, whereby there was a low demand of mass produced goods. Consequently, Toyota developed the concept of Toyota Production System (Loughrin, 2010), whose emphasis was on building several models of vehicles by adopting a ‘just-in-time (JIT) production system characterised by low investment, low cost of production, and a shorter lead production time. As Slack et al (2007) & Aherne (2007) observe, TPS contributed to lower costs of production while enabling Toyota to maintain quality and develop several vehicle models that yielded customer satisfaction. Apparently, TPS marked the beginning of lean production system in production, and the concept was further improved to enhance its applicability while eliminating more cost of production (Kotter, 2007). Typically, upon improvement, Toyota’s lean concept encompassed five major themes namely: customer satisfaction, basic stability, JIT, standard work, and employee involvement (Cotte et al, 2008). The figure below illustrates the improved lean management concept created by Eiji Toyoda and Taiichi Ohno:

The improved lean concept began achieving popularity among various manufacturing company managers who adapted similar practices to run their organizations. For instance, a study by White (2017) revealed that lean began to be accepted in the service sector after most managers in that sector realised that it could help them achieve the level of success those in the manufacturing sector achieved. In order to justify the adoption of lean in the service sector, White (2017) argued that lean’s ability to eliminate waste within the production system and help managers achieve a faster delivery of customer demands was impressive to managers in the service sector. Interestingly, as developed by Eiji Toyoda and Taiichi Ohno, lean was to operate under five fundamental principles. According to Appiotti & Bertels (2010), these principles were meant to guide managers on how to achieve a continuous improvement of quality, and included: flow, perfection, pull, the value stream and value specification. In regards to value specification, the founders of lean proposed that managers needed to identify what could create value from the customer’s point of view. According to Slack et al (2007), this principle was developed based on the assumption that manufacturers only concentrated on convenience at the expense of considering what would bring value to the customer. Hence, Eiji Toyoda and Taiichi Ohno challenged managers to consider customer preferences while developing and producing products, thereby adopting lean principles in determining value (Cotte et al, 2008). The next principle, value stream, required managers to organize the entire production process, from raw materials to the final output, by considering the customer’s preference rather than concentrating on what the departments want (Kotter, 2007). Thirdly, the flow – emphasised on developing value flows that gave preference to culture, people and process, thereby reducing the eliminating activities that do not add value while fastening the implementation of those that added value (Abdullah et al., 2008). According to Appiotti & Bertels (2010), the fifth principle was the leverage pull, which required managers to focus on the customer demands, thereby eliminating excess production. Lastly, Lean required managers to focus on perfection through increased quality and meeting customer wants at low cost while selling at affordable prices (Kotter, 2007). Ultimately, it emerged that adhering to the principles require managers to maintain a continuous improvement of the production cycle without stopping.

Hence, the original five principles of lean production were applied in manufacturing, although they were also found to be applicable in the service industry. For instance, Taleghani (2010) observes that the five principles especially the value stream principle, i.e. identifying the processes within the value chain that creates value to the customer, could be explained as the ‘patient journey’ in healthcare. The following figure illustrates Slack et al (2007)’s conceptualization of the five principles within the context of healthcare:

2.2 The adoption of Lean in the service sector

Research by Appiotti & Bertels (2010) indicates that in most organizations, product design consumes 80% of the production cost, and this entails management activities such as human resources, research and development, finance; while interestingly, the cost of manufacturing consumes only 20%. Consequently, the cost of providing services becomes higher, a phenomenon that is compounded by increased competition – which may contribute to loss of customers (Slack et al, 2007) especially in the services sector. Hence, to maintain customers, managers in the service sector have integrated lean management systems into their organizations, thereby increasing profitability and reducing cost. According to Taleghani (2010) a fundamental action within lean management is that managers must identify where the value of the process lies, eliminate costs and create customer value. Thus, it clearly emerges that the concept can be applied in any type of organization, so long as the organization’s goal is to create value for the people they serve. In this regard, Slack et al (2007), comment that apart from manufacturing, lean was also developed for use in supply chain management, whereby organizations could use it to enhance their relationship with suppliers through effective information sharing, low cost and increased innovation. Research by Slack et al (2007) indicated that lean could easily be applicable in the service organizations with high interruption on task performance and limited in formation. Particularly, the researcher diagnosed that the high costs and slow process were experienced in service organizations due to a lack of focus on value added activities, contributing to poor quality services and customer dissatisfaction. As a result, a complexity emerges in the service delivery process that is characterised by delays and piles of work in progress. In fact, as Taleghani (2010) illustrates, a typical example of work in progress and delays include: unanswered mails and delayed delivery of orders. Research evidence shows the application of lean management in healthcare service. For instance, Taleghani (2010) indicate that health professionals can apply lean management by analysing how activities with the hospital setting are flowing, as well as by using various techniques to map processes and identify points of waste. Existing literature also show that people lean services involves giving a greater concentration on people compared to equipment. This insight can be inferred from the Roemeling et al (2017)’s proposition that there are several characteristics of lean services including aligning the organization’s objective with customer needs, implementing JIT, enhancing the knowledge and skills of employees through training, and empowering employees to enable them make a difference in the business.

The application of lean in service industry helps in improving the quality of services and consequently adding value to the customers through low cost and efficient production processes (Abdullah et al., 2008). But, Appiotti & Bertels (2010) argue that when applying lean in services, managers should conduct a proper analysis of the process activities to ensure that they involve minimum costs and complexities. Besides, Appiotti & Bertels (2010) insists that employees in service organizations that apply lean should be keen to identify any hidden elements of costs and wastes within the production process that may affect the organization’s production capacity or hinder colleagues from maximising their workplace potential. The importance of waste as a prominent concern for lean managers raises the question as to the different types of wastes that exist in the context of management. Besides, according to Slack et al (2007), waste emerges as a major concern for lean mangers because waste is a central element in the lean theory, and therefore poor knowledge about waste among employees would impede an effective implementation of lean. Against this backdrop, researchers have had a general consensus over seven main types of wastes that are experienced by most companies.

2.3 Types of Wastes

The first type of waste is over processing, which according to Slack et al (2007), implies that the organization could be using big inefficient machines that do not produce quality products. In such a situation, the organization should have a long-term focus on smaller and more efficient machines that can produce to optimum capacities and according to customer demands. However, from a service point of view, over processing implies incurring excess costs while trying to meet customers’ needs by adding more value to the service (Kotter, 2007). A good example is that in the healthcare sector, a practitioner may take too much samples than is required to perform of certain medical procedures. Another form of waste recorded in literature is transportation. According to Kotter (2007), transportation waste, from a service perspective, implies that the organization is spending much on moving information and materials rather than spending on activities that add value to the customers. Besides, Taleghani (2010) notes that transportation waste in the service industry may entail the occurrence of activities that increases customer waiting time or longer queues during service provision. For example, in healthcare this waste could emerge when the organization has centralised resources, thus samples have to be transported to fare distances. Slack et al (2007) also identifies a category of waste in the service industry called motion waste. Here, waste occurs when there is unnecessary movement of people within the service delivery premises, and this contributes to more resources and tie spent, especially when the movement is rampant among the employees. However, Taleghani (2010) points out that sometimes it might be hard to measure motion wastes in the service sector. A typical example in healthcare is when nurses have to move frequently in search of equipment placed a distance away from their area of operation. Another common form of waste in the service sector is inventory waste. According to Kotter (2007), inventory waste occurs when organizations uses more inventory than is required to meet the customer’s needs. Taleghani (2010) argues that inventory waste should be eliminated because they add on to the cost of delivering value to the customer. Furthermore, Kotter (2007) argues that it is always the inventory waste that contributes to overproduction. Inventory waste in healthcare may occur when a hospital stocks more drugs that are normally consumed. Waiting time has also been identified by scholars to be a form of waste both in the manufacturing and service industry. For instance, Taleghani (2010) argues that waiting time hinders flow in manufacturing by impeding the movement of materials in the production process. On the other hand, in regards to service, Taleghani (2010) contend that waiting is typically caused by a delay in one activity, which then contributes to a delay in another activity, thereby creating a cycle of process delay. But, Deloitte (2010) suggests that managers can use the value stream technique to evaluate the cause of process delay, or examine the waiting time of each service segment to identify what might be the main cause of delay. This form of waste is popular in the healthcare services, characterised by long queues of patients waiting to be served.

Defects are also forms of waste both in manufacturing and service industries. Particularly, in service industry, Taleghani (2010) argues that defects emerge when the organization fails to deliver services in according to customer specifications. Consequently, products deteriorate in quality or the organization might experience longer lead times. A typical example of defects in healthcare included hospital acquired infections as a result of poor adherence to hospital hygiene protocols. The penultimate form of waste identified by existing literature is overproduction. According to Slack et al (2007), overproduction implies producing excess service outputs than is the customers can consume. a typical example is when patients are admitted for hospital services but they have to wait till later to receive the services. The last form waste in the service industry is untapped talent. Taleghani (2010) explains that untapped talent occurs when the organization underutilizes the employee skills and knowledge. or failing to use the employees’ creativity in delivering quality services. Ideally, it happens when the organization fails to use employee skills that could create a difference in the quality of service delivered to customers (Kotter, 2007).

2.4 Implementation of Lean

Lean plays a vital role to the success of organization because it helps managers solve organizational problems through a deeper understanding, analysis and commitment to the problems at hand (Kotter, 2007). Consequently, as Taleghani (2010) observes, there is an increasing trend of organizations implementing lean to address the challenges they face with quality, costs, slow delivery, and longer queue times – especially in the service industry. However, remarks by White (2017) indicate that so success in implementing lean, managers must develop a commitment towards the course. External support has also been identified by Rubin & Babbie (2010) as an effective way of ensuring success in the implementation of lean. According to Slack et al (2007), organizations can seek external support for the implementation of lean, but they should not be highly b dependent on them because the implementation of lean takes long (White, 2017). Nonetheless, the implementation of lean is a long-term process and thus a commitment must be shown, especially with regards to waste reduction and identification of new cost cutting opportunities (Cotte et al, 2008). For example, Deloitte (2010) narrates that whereas Toyota begun to implement lean in the 1950s, there is still an on-going commitment by the organization to reduce waste. This reveals the vital nature of having a proper understanding of critical success factors of lean, challenges facing its implementation, and the tools that can be used in achieving its successful implementation.

2.5 Factors affecting the successful implementation of Lean

Several empirical research papers have identified various factors that must be considered by managers to achieve a successful implementation of lean. For instance, Frost (2007), Hanna (2007), Wickramasinghe et al (2014) and Loughrin (2010) agree that a successful implementation of lean depends on how the managers are committed to the course, how employees are involved into the process, the knowledge and skills held by employees on lean, and the manner in which employee are rewarded or recognized for their performance. Hence, employee education, managerial commitment, employee recognition and employee involvement can be summarised as key aspects in the implementation of lean. With regards to management commitment and support, Morrow & Main (2008) asserts that top managers have a role to play in ensuring a successful implementation of lean by initiating change (i.e. by implementing the concept of lean) and encouraging employees to embrace the change. Besides, according to Reichert (2008), managers have the responsibility of gathering all the necessary information from lower levels employees useful in the implementation of lean. More importantly, a critical success factor for lean implementation is communication. Thus, Frost (2007) insists that managers must be committed to enhance effective communication between employees as well as between managers and employees to enable a successful implementation of lean. Particularly, in manufacturing, effective communication is necessary to enable coordination between value streams White (2017), while in service, according to White (2017), communication assists in lesion. Fundamentally, effective communication is important in lean implementation because it enables an easier sharing of success stories as well as a constant delivery of feedback between managers and employees on the progress of lean implementation (Abdullah et al., 2008). However, Rubin & Babbie (2010) insist on a combination of management commitment and effective communication key enablers for successful implementation of lean. More importantly, according to Loughrin (2010), effective communication enables managers to maintain constant relationship with both suppliers and customers, whereby employees have clearly defined responsibilities for dealing with product or service delivery, as well as receiving complaints and concerns from the customers. In study conducted by Deloitte MCS (2010) involving 100 companies involved within the service sector, it was found that a belief among employees that lean will be successfully implemented; an organization-wide implementation of lean; as well as a development of a lean culture among all employees in the organization were found to be the critical success factors for the implementation of lean. Ideally, this study emphasised on developing a culture of trust among employees on the capabilities of lean to improve the service organization – in a similar ways as would be done in manufacturing. As a further emphasis on the culture of trust for lean, Loughrin (2010) asserts that managers can measure success of lean implementation in financial terms, and this will consequently make it easier for managers to demonstrate to the employees the benefits of lean in quality. Furthermore, research by White (2017) suggest that effective results can be achieved when managers link lean with strategic improvement by focusing on the organizational objective s, more success can be achieved. Hence, management support is a monumental success factor in the implementation of lean, and this support should especially be manifested in creating a lean culture among the employees. Rubin & Babbie (2010) have also made an important contribution to the literature on critical success factors for the implementation of lean. With a focus on financial services, the authors write that managers can achieve a successful implementation of lean if they focus on strategy, and if they insist on identifying customer needs and value demands. Furthermore, the authors insist that upon understanding the customers’ value needs, managers should simplify the process of delivering this value and have a proper understanding of the system before making any significant changes. However, literature by Cotte et al (2008) indicate that whereas managers in the financial sectors sometimes implement lean in a similar way that it is implemented in the manufacturing sector, it is wrong to take that approach because lean is more effective when it is of a greater strategic importance. The application of lean in areas where it has a strategic importance yield more effective results because it creates the opportunity to improve their core competencies, thereby gaining the necessary competitive advantage through process enhancement, which helps in cutting costs and building customer trust.

Literature by White (2017) proposes that managers have achieved much success in implementing lean by breaking down tasks into small processes that are easier to understand, which also acts as a motivation for employees. In a similar regard, Rexhepi & Shrestha (2011) also observes that managers who make small improvement changes in the process achieve more successful implementation of lean, giving an example of NHS UK, is an emergency doctor keeps on wasting time by looking for a prescription pad, time wastage can be eliminated by attaching the prescription pad on the desk. Observably, lean has also been made an organizational culture in NHS, facilitated by a lean support team whose main responsibility is to sensitize other members of the organization on lean (Cotte et al, 2008). This approach reveals an important aspect of lean, which is: the application of lean entails a radical change into the organization, and this requires the personal commitment of all employees. White (2017) also emphasize that employees’ commitment is vital to the process of lean implementation because when they are involved at the ground level, the play a monumental role in effecting change because they have more knowledge on the work flow processes. However, within the same context, Loughrin (2010) argues that whereas the implementation of lean occurs at the top level with the guidance top managers’ vision; its successful implementation requires the involvement of all levels of employees. Against this backdrop, it is useful to highlight the authors that have exceptionally highlighted the key success factors for successful implementation of lean, especially in the health. First, Abdullah and colleagues (2008) stated that in manufacturing, managers must be ready to develop employee involvement, train and develop their employees, and reward them for lean to be successfully implemented. Secondly, Furterer (2014) evaluated the process of implementing lean in the manufacturing sectors and found both communication and management involvement to be two important necessities for a successful implementation of lean. Thirdly, Delloitte (2010) highlighted the importance of linking lean to the strategic objectives, cultivating a culture of lean among employees, and implementing lean in all functions of the organization especially in service industry. Similarly, Appiotti & Bertels (2010) emphasise that to successfully implement lean in the manufacturing industry, managers need to understand customer preferences, identify key aspects of value to the customer, and master the process. All in all, these authors have a consensus on the idea that a successful implementation of lean requires managers to be fully committed and involved in all aspects of the implementation process – even though it may present several challenges.

2.6 Challenges of lean implementation

There is a bit of literature that has significantly explored some of the challenges that managers might encounter while trying to implement lean. For instance, White (2017) strongly insists that whereas managers have achieved significant success in implementing lean, they encounter several challenges in the process, one of them being the difficulty associated with persuading employees to change their focus towards eliminating waste and delivering customer value, because the process involves the implementation of new tools and techniques (Kotter, 2007). Furthermore, Rubin & Babbie (2010) point out that lean requires managers to break down tasks in small deliverable amounts that require JIT deliver, but suppliers may not be ready to cope with JIT. Also, according to Loughrin (2010), customer demand might not be in line with the managers’ forecast, and this may contribute to excess inventory and eventually waste. While most of the above-mentioned challenges are more related to the manufacturing industry, existing literature also highlight challenges that are specifically familiar with the service industry. Particularly, it emerges that the lack of standardized processes in the service industry, as opposed to the manufacturing industry, creates a big challenge in the implementation of lean. For instance, Rubin & Babbie (2010) say that as opposed to the manufacturing industry, it is difficult to identify various processes in the service industry within which lean can be applied. Besides, according to Loughrin (2010), some service organizations are so large in size that it may be difficult to identify waste and deal with them. Hence, as suggested by White (2017), such organization should keep an efficient system of documentation, so that managers can continuously keep track of the progress. Similar recommendations are given by George (2003), who suggested that mangers in the service sector should keep tract of the processes. A typical example given by Furterer (2014) is Bank of America, where there was no documentation of processes, and employees had to contact their colleagues with the highest experience if they needed anything. On the same note, Grove et al (2010), while discussing the difficulties of implementing lean in a hospital setting, acknowledges that healthcare service has a high level of process variability, and this affects manager’s ability to conduct value stream mapping for purposes of identifying waste and minimising cost. Similarly, according to Rubin & Babbie (2010), the variability of services delivered in healthcare means that a variety of professionals are involves, and thus not all of them would support lean. Furthermore, existing literature has also highlighted the several challenges associated to people and how people contribute to complexity of service delivery. For instance, because the implementation of lean involves every member of the organization, hierarchy barriers necessitate a strategic implementation of the changes (Sarkar, 2009). Similar remarks are made by Frost (2007) who says that hierarchy is a challenge to lean implementation because employees at the lower levels of the organization must be empowered because they are the ones handling the operations and have the ability to identify waste. Even White (2017) acknowledges that the implementation of lean in healthcare sector is challenging because managers have to empower and provide the relevant training to all the employees. Another problem that is associated with the complexity of service sector is that employees are unable to measure the specific duration required to complete certain tasks and thus they cannot keep track of the processes to identify areas of waste and opportunities for cost reduction (Kotter, 2007). According to Loughrin (2010), this happens because the structures of the tasks are solely determined by employees, and thus it becomes hard to define the processes involved. However, White (2017) remarks that when employees become aware of the freedom and empowerment that standardized processes can help them achieve, they become more reception to the change process involved in lean implementation. Nonetheless, existing literature also reveals the important role that mangers can play in a successful implementation of lean by managing employees’ behaviour. For instance, literature by Sarkar (2009) indicate that the actions and behaviours of employees may determine whether they make mistakes in the processes of not. This reveals the important need for constant communication between managers and lower level employees because without proper collaboration, it becomes difficult to develop the strategic action plans for implementing lean. These were the problems identified by Grove and colleagues (2010) when they evaluated the implementation of lean UK’s NHS. In similar observations, Aherne (2007) noted that the UK’s NHS was finding it difficult to implement lean due to inadequate government support.

Another challenge associated with the implementation of lean in service industry is that people interact differently and therefore they cannot be treated as machines (Rubin & Babbie, 2010). For example, whereas it by take a specific duration to set up a machine and start operating it, it may be difficult to determine a specific timeline within which employees can be called to begin offering certain services.

2.7 Tools and techniques for implementing lean

Existing literature identifies different tools and techniques used in the implantation of lean management most of them developed for application in the manufacturing sector, but can still be applied in the service sector. For instance, the five S’s model (i.e. set, sort, shine, sustain and standardize) has been identified by White (2017) as an effective tool for implementing lean. Notably, the model’s acronyms denotes the Japanese words of seiri, seiton, seiso, seiketsu, and shitsuke, which means organization, neatness, cleaning, standardization and discipline respectively (Cotte et al, 2008). Ideally, according to Frost (2007), the five S model’s main aim is to enable the creation of favourable environment which is characterised by reduced work load, minimum process errors, and providing education/training for employees, where employees have the ability to enhance the quality of their productivity. Furthermore, White (2017) acknowledge that managers can apply the 5S model to develop a positive attitude and behaviour towards lean while promoting the quality and safety of health services. The use of 5S tool in the implementation of lean is a simple affair. Basically, its main use is to help create a lean culture within the organization. The sorting component of 5S entails arranging all the components of the final product in the right order, then analysing them to determine whether they are useful or not. The useful ones are maintained while the less-useful ones are discarded (Chen et al., 2010). According to Frost (2007), the sort process should be performed on a regular basis, although the frequency with which sort is done depends on the organization. Set – means labelling everything so that they are easier to identify or find (Kotter, 2007). The reason behind set is: it puts everything in its place (i.e. a standardized position) and thus easier to access. On the other hand, shine denotes putting everything within the workplace environment clean (Cotte et al, 2008). While some organizations clean every day for five days so that the workplace looks tidy by the end of the week, others wait to tidy up in the weekend. Standardize denotes setting up a standard process which is known to every employee of the organization, so that employees follow that standard process to execute their duties (Cotte et al, 2008). Last but not least, according to Cotte et al (2008), sustain entails reviewing all the above items on a continuous basis to ensure that a continuous improvement is achieved by maintaining the set standards. In the context of health care, existing literature ha also captured examples of how the 5S tool can be used, For example, Manos et al (2006) illustrate how the 5S tool can be used in the pathologic department in a study whereby 5S was associated with a significant (40%) improvement of floor space usage, and a 17% increase in storage space, thereby contributing to an improvement in patient and employee satisfaction. In another study by Fillingham (2007), there was a demonstration of how the 5S assisted in improving the resuscitation room characterised with a reduction in clinical error and increased employee morale.

2.7.1 Kanban

Kanban is another tool used by some manager to implement lean. According to Loughrin (2010), it is a controlling device used in operations to control and release materials in operations. Ideally, it enables managers to know whether they should make more orders from the suppliers or stop receiving more orders (Slack and colleagues, 2007). More interestingly, the device, using visual signals, helps managers to stock products according to customer demands (Kotter, 2007). With these capabilities, managers are able to improve both product and service delivery. Typically, Kanban would be used by employees encountering problems with customers by signalling the manager to come and help. Besides, in a hospital setting, Kanban can be used to reduce the amount of medicine stock carried around the hospital. Interestingly, existing literature reveal that Kanban can also be used in health care setting. For instance, Frost (2007) observes that Kanban can be used by health practitioners to notify their collegues of of a completed session with the patient, or to call for another patient. Similarly, Rubin & Babbie (2010) argue that a major advantage of Kanban is that it assists practitioners to easily find various medicine, equipment, or supplies with minimum time wastage. The figure below illustrates how the Kanban tool can be used in a hospital context:

2.7.2 The Ishakawa Diagram

Also termed as the fishbone diagram, the Ishakawa diagram has largely been used by managers to implement lean. Ideally, according to Cotte et al (2008), the main use of this tool is to identify the main cause of a problem. Thus, this tool is of great importance for managers because it sometime becomes impossible to solve managerial problems without understanding their root cause. Furthermore, failure to fully understand the root cause of problems, and not solving these problems will lead to additional time and costs incurred by the organization (Sarkar, 2009). Taner et al (2007) identified the problem of repeated laboratory tests, which were attributable to reworks and delays of information from the physician. However, the use of fishbone diagram enabled the hospital to reduce the number of laboratory tests, thus eliminate the costs associated with these tests.

2.7.3 Value stream mapping

Grove et al (2010) define value stream mapping as an activity that involves evaluating all the actions in a process to identify and eliminate activities that do not create value to the process. Ideally, it is a tool that helps in identifying and understanding the organization’s process flow (Grove et al, 2010). When developing a product, time and resources and necessary, but it is likeliness that the time and resources might be wasted. To eliminate such wastes, managers use value stream mapping to identify the items within the process flow that are a waste. However, Rubin & Babbie (2010) observe that an effective value stream mapping can only be achieved when managers involve the employees who are responsible for those processes. Nonetheless, the vital role of value stream mapping can never be overemphasized, and it fundamentally entails involving employees in problem identification and development of solutions for the identified problems i.e. employees must participate in both problem identification and solution derivation (Sarkar, 2009). For instance, value stream mapping in the hospital setting involves an evaluation of activities involved in the whole process of healthcare service delivery from the time the patient is admitted for treatment to the time they are discharged. Fillingham (2007) gives an example of Boston Hospital where a team of doctors, nurses, managers and therapists was created and given the responsibility of mapping patients’ journey from admission to discharge. Interestingly, this team found that patients were receiving poor services due to the availability of various unnecessary activities that added no value to the patient. Besides, the team attributed the poor services to duplication of activities and errors committed by hospital staffs. According to Fillingham (2007), the Hospital spent nine months trying to rectify the situation and improving the quality of service delivery through various activities including process standardization, harnessing support from leaders, conveniently storing both equipment and information, establishing a 42% reduction in paperwork and 33% reduction in patient waiting time. Managers have also used process mapping as an effective tool for implementing lean. According to Frost (2007), process mapping shows the entire activities in the process that leads to the main output. It is typically similar to a road map, used to identify the key steps in the production process for the purpose of pinpointing and eliminating the bottlenecks (Sarkar, 2009). This tool is considered by Loughrin (2010) as the best for initiating continuous improvement in the organization. In the healthcare context, process mapping can be used for various activities. For instance, process mapping can be applied to reduce waiting time by identifying the steps within the service delivery chain that consumes the most time, and why the step consume much time (Sarkar, 2009). Secondly, Cotte et al (2008) observes that process mapping can help managers in the healthcare sector reduce the patient waiting time by distinguishing the steps that add value from those that do not add value, identifying the steps that are redundant, complex and have bottlenecks, as well as identifying the steps that cause more delays, require more storage duration, and those that involve unnecessary movement (Peterson et al, 2010).

2.7.4 Visual management

This tool is mostly used by manufacturers for the purpose of faster and effective communication. According to Rubin & Babbie (2010), its effectiveness has led to its popularity in the service sector, where it is used to provide vital information to customers through signs and lights. But visual management tools can be classified into two main categories: visual display and visual control. A typical example of visual control is the use of number tag dispenser which tells customers how long they will have to wait before being served (Peterson et al, 2010). When the waiting time elapses, the customer is visually informed that it is their turn to be served. On the other hand, visual display involves diagrams and charts meant to deliver certain information to employees or customers (Angelis et al, 2010).

2.7.5 The red tag

This technique is used to enhance communication among employees regarding equipment that do not work or that are not required (Angelis et al, 2010). However, Cotte et al (2008) writes that when using the red tag, employees need to agree on the equipment that they will give red tags, where the unnecessary equipment will be stored, and for how long will they be stored. Nonetheless, Frost (2007) remarks that the red tag is one of the most effective methods to eliminate the unnecessary objects in the workplace. Whereas the implementation of lean in a service sector is complicated, existing literature has highlighted several lean activities that can be adopted by managers to improve service delivery by reducing the waiting time, and improving patient pathways within various interactive value streams (De Souza, 2009). As will be highlighted below, a successful implementation of lean can create value to patients by improving quality of care. It is monumental that managers in the healthcare sector have proper understanding of lean by taking note of the changes it brings within the service value chain and the advantages associated with it. A typical example is that of Shoundice Hospital, where White (2017) illustrates how lean was implemented in the treatment of patients with Hernia. According to the authors, the implementation of lean begun at the patient admission process, which was fully automated and thus patients could register online. Besides, it is mentioned that the hospital operated in a way that patients were encouraged to do their own tasks such as shaving the body area meant for operation, mark where to operate, and immediately after operation, patients were encouraged to walk on their own, with the doctor’s help to the wheel chair. Whereas these were minor tasks, they played a vital role in fostering quick recovery and freed up doctors’ and nurses’ time for other tasks. Interestingly, according to White (2017), the Shoundice Hospital was recognised as one of the facilities for faster Hernia recovery compared to other facilities. In Australia, an example is given of Flinders Medical Centre, where lean management was applied in the emergency department. Before the implementation of lean, this hospital used to encounter problems with handling patients in the emergency department due to the complexities associated with the setting (Raxhepi & Shrestha, 2011). For example, the facility classified patients into five main categories using the triage system and patients from each category were to see the doctor within a certain timeframe. According to Wickramasinghe et al (2014), this system was associated with more time wastage and a risk of patient life in the emergency department. For, instance, internal statistics from the hospital indicated that in 2003 1000 patients waited for at least 8 hours to get treatment. To address this problem, managers at Flinders Medical Centre implemented lean by using value stream to create two separate departments – one dedicated for patients who could be treated immediately, and the other for patients who needed hospital admission. An evaluation of the changes revealed that the duration of patient waiting time had reduced by 25%. Besides, it emerged that the process had been simplified and staff were under less pressure.

Another good example of lean implementation within the healthcare context is the case of Virginia Mason Medical Centre. Here, various lean tools such as tact time, work standardization, value stream, load levelling and mistake-proofing were applied to improve quality of services (Black & Miller 2008). For instance, the hospital managers used load levelling to help in the flow of patients from one treatment process to another while developing appointment schedules. According to Black & Miller (2008) the application lf lead levelling resulted into a maximization of staff efficiency, a higher number of served patients due to better flow, and an increase in service timeline for each patient. The hospital’s oncology department also implemented lean by placing chare outside the treatment room to maximise the space within the room and reduce patient waiting time. An evaluation of results indicated that the hospital had reduced patient waiting time by 14% while the number of treated patients had increased by 57%. Also, the distance that the staff had to walk while providing services had reduced by 61%. Apparently, as is also observed by Berlanga & Husby (2016), a key advantage of lean that is experienced across the above mentioned organizations is a reduction of lead times, efficient processes of service delivery, a reduced use of inventory, a reduction in reworks, cost reduction and an improvement of knowledge management. The following section gives a broader exploration of literature highlighting the benefits that managers can achieve from lean management.

2.8 Advantages of lean management

Generally, existing literature document improved financial position, better quality services, process standardization and competitive advantage as some of the most eminent advantages of lean (Frost, 2007). On this note, Rubin & Babbie (2010) discussed that in process industries where managers face the problems of poor process flow and full work in progress (WIP), as well as a lack of a dedicated personnel responsible for order delivery within the supply chain, lean implementation can contribute to a decrease in supply chain and cycle time, a more accurate fulfilment of customer orders, and a reduction in inventory use. Furthermore, lean implementation can be associated with a reduction in functional barriers. For example, in a study by Lindenau-Stockfish (2011) among Australian manufacturing companies, it was found that an implementation of lean was associated flattened structures as well as other beneficial structural changes. Besides, the study revealed that lean implementation was associated with other changes such as reduced workforce, hiring of employees who could perform different tasks, increased employee empowerment and consequently a reduced autonomy. Some pieces of literature also indicate that lean implementation is associated with better employee competence, decreased timelines for completion of tasks, financial benefits, improved customer satisfaction and reduced employee frustration (White, 2017). Discussions by Hanna (2007) also reveal that lean implementation can contribute to better problem solving capabilities within the organization as well as process standardization. Similar remarks were made by Peterson and colleagues (2010) who insist that organizations that implement lean have better competitive advantage, are more reliable and tend to deliver quality goods or services. The benefits of lean implementation can better be argued from the perspective of financial services sector. For example, Graban (2016) highlight several examples of benefits harnessed from lean implementation by financial organizations that have particularly implemented lean to fasten the process of approving credit applications from customers. Being a complex process that involves may steps, the credit approval has been characterised by resource and time wastage until banks begun to implement lean (Graban, 2016). According to Frost (2007) the implementation of lean in banks’ loan approval system entails reducing and simplifying the customer loan application forms, and consequently reducing the number of days for loan approval. This has been associated with better customer satisfaction and quality of services.

Apart from the banks, literature has also documented a few benefits of lean implementation experienced in the healthcare context. For example, Cotte et al (2008) acknowledge that the use of various lean implementation tools to identify non-useful activities in the production process. In a study by Westwood et al (2007) it is highlighted that lean implementation can help managers achieve an improved patient flow, a faster delivery of treatment services, cost savings, reduce waste, as well as more reliable service delivery. As part of their concluding remarks, Westwood et al (2007) say that all these benefits have improved the hospitals’ ability to deliver more efficient and quality services. However, Westwood et al (2007) also comment that for sustainable results, the lean improvement should be done on a continuous basis. On the same note, Loughrin (2010) insists that employees should be exposed to continuous skill development on how to implement lean, giving an example of NHS UK, where continuous training program for senior managers was associated with better and sustainable lean implementation. According to Loughrin (2010), the training program was also associated with an improved willingness and desiccation among the employees to accept change in the organization.

2.8 Criticisms of Lean

Whereas lean implementation has been associated with various benefits to organizations that implement it, it is observable from existing literature that many authors have criticised it. For example Furterer (2014) noted that lean is more concerned with the process and does not give enough consideration to people. This critic is especially intriguing, considering the important role that employees play in the delivery of organizations’ missions (Peterson et al, 2010). Similar remarks are made by Cotte et al (2008) who say that whereas lean implementation can have a positive impact on organizational performance, the implementation may only have a significant impact if employees are motivated and empowered to contribute to the implementation process – this should even apply to the shop attendants responsible for the identification of waste. Apparently, companies may need to reduce excess workers to achieve a continuous improvement (Angelis et al, 2010). This element of lean implementation has received much criticism because employees are constantly under stress and anxiety in fear of losing their jobs, According to Rubin & Babbie (2010); this is in contrast to mass production where employees are not worried of losing their jobs whenever the organization is implementing continuous improvement. Chen et al (2010) also complain that companies that implement lean are more focused on short term benefits rather than long-term benefits. This is because such organizations are less likely to spend time and resources on innovation due to the fact that the returns may be hard to establish the benefits in monetary terms – hence, mangers might see innovative ideas as a waste of resources (Chen et al 2010). On the same context, Rubin & Babbie (2010) argue that when managers are not ready to invest on lean implementation, employees may also lack the morale to embrace innovation for improvement.

Chapter Three

3.0 Study Methodology

This section gives an overview of the research methods and techniques employed by the researcher in achieving the research objectives. The chapter presents both the theoretical and practical research methodologies and the justification for the adoption of such methods. With regards to theoretical methods, there will be an evaluation and justification of the research philosophy, research approach, and the research strategy implemented by the researcher in achieving the study objectives. On the other hand, a description of the practical research methodology will cover the study’s conceptual framework, data collection methods, data analysis, and the ethical considerations made by the researcher.

3.1 Research Philosophy

3.1.1 Research Epistemology

Bryman et al (2015) describes research philosophy as to how knowledge is developed and acquired within a particular field of study. Besides, according to Collis & Hussey (2013), research philosophy describes how the researcher has used their perception to make certain assumptions; and there are two significant categories of research philosophy namely ontological research philosophy and epistemological research philosophy. Epistemological research philosophy entails an evaluation of the kind of knowledge applicable in the social world, and these types of knowledge may include realism, interpretivism, and positivism (Coolican, 2017). Positivist researchers take a specific model to study a particular social reality, and us much more applied alongside a deductive approach whereby there are certain hypotheses to be tested (Forrester, 2010). Moreover, according to Gill et al. (2010), positivism is also associated with inductive approaches whereby data collection is the method used in gathering knowledge. The epistemological research philosophy can also be in the form of realism, which is observed by Krathwohl et al. (2005) to be associated with scientific practice. Ideally, realism supports positivism in the sense that it entails the data collection as a source of knowledge (Coolican, 2017). Nonetheless, Roberts (2010) writes that realism exists in two primary forms namely: critical realism and empirical realism, the latter referring to the use of appropriate methods to understand realism i.e. through what people may experience using their senses; while the former entails the understanding of the social world through people’s experience of sensation (Saunders et al., 2009). The last category of epistemology is interpretivism, which opposes the use of scientific models in the understanding of the social world (Coolican, 2017). Instead, interpretivists understand the social world through subjective human behaviours, and thus emphasize on the crucial role of people in achieving research objectives, considering that research is done by people and not objects (Apan et al., 2012). However, in the use of people to achieve research objectives, believers of this philosophy depend on their social roles. As Roberts (2010) observes, this philosophy is mostly adopted in business research due to the complex and unique nature of business situations. Against this backdrop, the current study took the interpretivst research philosophy, mainly because lean management is a business concept used in certain business situations that cannot be generalized (Given, 2008).

3.1.2 Research Ontology

A research study can also make specific ontological considerations that would assist in a comprehensive achievement of research objectives. According to Gisselle & Lotte (2018), ontological considerations entail the understanding of various social entities, whereby certain assumptions are made by the researcher to understand the world. Hence, there are two ontological considerations that a researcher can make namely: constructivism and objectivism. An objectivist researcher is one who considers structural aspects to determine similarities or differences between particular phenomena (Keegan, 2009). For instance, an objectivist believes that management in all organizations is similar due to a similarity in the management structures. On the other hand, constructivists believe that social entities are social constructions created by the beliefs and perceptions of social actors. Hence, constructivists sometimes use the interpretivist philosophy to understand social actors’ actions through an exploration of the subjective meaning of such actions. The current study adopts both the constructivism and objectivist research ontology, primarily because the study seeks to understand the implementation of lean by observing and interpreting meaning of activities taking place within the hospital setting.

3.2 Research Approach

A researcher can either adopt a deductive or inductive research approach when carrying out any scientific study. In a deductive approach, the researcher begins by deducing the study hypotheses, and then collects data to either reject or confirm the hypotheses (Leavy, 2014). Hence, inductive researchers use already existing theories to derive generalized answers to specific research questions. On the other hand, an inductive research approach entails the use of general information to derive a particular theory or hypothesis (Maxwel, 2013). The current study followed the inductive research approach. This process entailed data collection through observations to confirm or reject the theories of lean implementation in the hospital setting.

3.3 Research Strategy

Maxwel, (2013) argues that three main research strategies can be adopted by the researcher, namely: qualitative, quantitative, and mixed research strategies. Quantitative research strategy entails the use of statistical tools to confirm or reject the underlying research hypotheses by statistically collecting and analyzing data. Furthermore, Moule & Goodman (2009) observes that quantitative research strategy applies deductive research approach and focuses on positivism as its leading research philosophy. On the other hand, according to Newell & Burnard (2011), qualitative research strategy entails the use of words and subjective data to either reject or confirm the underlying research hypotheses, rather than using numerical or statistical methods. Hence, researchers who use this strategy are more inclined to the inductive research approach and apply interpretivism as their primary research philosophy (Padgett, 2008). In short, a qualitative research strategy involves finding answers to the research question by analyzing subjective human behaviour. It is a more flexible research strategy, especially with regards to the data collection procedure because the researcher can alter the data collection methodologies to suit the kind of information they may like to gather (Penelope et al., 2018). Based on the understanding of both qualitative and quantitative research strategy, the current study adopted the qualitative strategy based on several theoretical underpinnings. Having selected the qualitative research philosophy the researcher had various data collection methodologies to choose from, including interviewing, document analysis and participant observation. However, due to an inability to receive ethical consent from the university’s ethical committee, the researcher selected the participant observation as the main data collection strategy. So, the participant observation research strategy was selected because the researcher could go ahead to complete the study on time without seeking an ethical approval from the university’s ethical committee. There are abundant literature on the issue of ethics approval and when it is not necessary. For example, Maxwel (2013) argues that whereas human ethics approval is necessary for studies involving human subjects one may not need to seek approval for studies that involve negligible risks. Such studies, according to Penelope et al (2018) may include:

Studies that focus on training, education and practical experiences

Studies involving information that is freely and publicly available

Studies relying exclusively on publicly available information, performances, works, documents, or public archives

Purely observational research that do not involve any element of intervention

Quality assurance studies that do not require access to the collection of private information, sensitive information or health data

The researcher therefore considered the current study to have met two of the above-mentioned criteria in that, the study was purely observational and did not involve any element of intervention, and that it was a quality assurance study that sought to observe the quality of services (i.e. in terms of customer service flow) delivered in the hospital based on the use of lean management techniques.

3.3.1 Participant Observation

From time immemorial, participant observation has been use as a research strategy un both sociological and anthropological settings. However, the education sector has seen a recent rise in participant observation as part of qualitative research strategy, providing a better explanation to its meaning, advantages and limitation of use. According to Maxwel, (2013), participant observation is a description of behaviours, events through a comprehensive fieldwork research strategy. The participant observer uses active looking, note taking and sometimes informal interviewing to collect data for further interpretation (Penelope et al., 2018). Besides, according to Newell & Burnard (2011), participant observation enables the researcher to gather data through exposure and getting involved in the daily activities within of the environment from which data is collected. Apart from the logistical challenges and time constraints, there are many theoretical underpinnings of why participant observation was used in this particular study. First, according to Maxwel, (2013), observations provide an opportunity for the researcher to identify non-verbal expression of feelings from the target population and how they communicate with each other. Besides, Newell & Burnard (2011) postulate that observation technique is a good method of identifying how much time the target population spends on an activity. Therefore, because the study seeks to evaluate the quality of services delivered to patients in the hospital setting through the use of lean management technique, observations were the most appropriate, especially considering that one of the elements of interest to the research was the time taken before patients could receive health services in the hospital. Observations were also selected as the appropriate research strategy for this study because it would allow the researcher to observe the events that informants may not be willing to disclose in alternative data gathering strategies such as interviews thus making it easier to identify inaccuracies in alternative sources of information. But Newell & Burnard (2011) claim that a stronger validity can be achieved when observations are used alongside other sources such as document analysis. Hence, apart from the observations, the study relied on publicly available hospital documents such as service charter, to collect comprehensive information regarding lean implementation in the hospital.

3.4 Case Study Research Approach

Rubin & Babbie (2010) defines the case study research approach as one that involves the selection and use of a particular case to answer the research questions at hand. They present different settings through which a particular phenomenon can be analysed to derive conclusions about the event under investigation (Suzanne Franco, 2016). There are two types of case studies that a researcher can adapt to achieve research objectives i.e., multiple case studies or a single case study. The current study relied on a single case study, whereby the researcher identified The Sandwell and West Birmingham NHS Trust hospital and observed the tools they used and the challenges they faced in implementing lean. Thus, the purpose of case study in the current study relied on an inductive approach in answering the ‘why,’ ‘how’ and ‘what’ of the research questions (Bryman et al, 2015). In the process of selecting the case study, the researcher made five primary considerations namely: the underlying research questions, objectives of the study, the adopted data analysis technique, and the interpretation of the study findings (Coolican, 2017). Specifically, the case study methodology was selected because it was deemed useful in identifying the applicability of the existing theories, and thus encountering fewer challenges in the derivation of new approaches (Keegan, 2009). With a proper understanding of the theoretical principles for the application of case study approach, the researcher applied the qualitative research approach and employed a detailed analysis to explore the applicability of lean management in Sandwell and West Birmingham NHS Trust hospital.

3.5 The Conceptual Framework

The researcher developed a conceptual framework to ensure that the study could be conducted in a structured manner. The first aspect of the conceptual framework was the literature review section, which served two purposes, namely: understanding critical success factors for lean implementation and lean tools and their applicability in hospital settings. The second element of the conceptual framework entailed an empirical evaluation of the current practice and application of lean management, while the third step entailed the analysis and discussion of data from the study findings. The following section expounds on the conceptual framework:

3.6 Literature Review

The researcher reviewed secondary data sources (e.g., journal articles, periodicals, books, and dissertations) to identify the critical success factors for lean implementation, especially in hospital settings. Besides, a literature review was conducted to determine the specific lean tools used in the implementation of lean in service settings.

3.7 Understanding Lean Implementation Process and Practices

The researcher deemed it necessary to use empirical data in gaining a comprehensive understanding of the techniques and tools used in the current practice of lean management, and this was an essential step in answering the underlying research questions. This was partly the reason why observations were selected as data collection techniques.

3.8 Data Collection

The study relied on primary data to understand lean implementation in hospital settings. But first, Bryman et al (2015) the application of qualitative research method is characterized by several techniques such as questionnaires, interviews, document analysis, and observations. In the current study, the researcher applied a multiplicity of data collection techniques, which entails contacting the hospital management through email to seek permission for collecting data. Upon receiving the consent, the researcher visited the facility to conduct observations after arranging for the date, time, and location of observations through phone calls. While at Sandwell and West Birmingham NHS Trust hospital, made and recorded observations of customer service flow within the hospital’s outpatient section. The observation notebook was then transformed into an observation journal. The researcher’s main focus of observation was how fast the patients moved from one service area to the other. Therefore, the observation was conducted within the patient waiting area, where the researcher observed movements and interaction between patients and service providers. The written observation journal would then be used for narrative interpretations. However, the researcher also relied on both biographical and autobiographical documents, service delivery plans, rules, and picturing within the hospital that could give any information about the nature of the hospital’s service flow and the elements of len implementation in it.

3.9 Data Analysis

Qualitative data can be analysed in a variety of ways. However, Gisselle & Lotte (2018) argue that qualitative data analysis can be categorized in two main ways namely a structured approach that follows predetermined criteria or framework and a non-structured approach which allows the researcher the flexibility to interpret data according to their preference. In the current study, the researcher relied on a non-structured qualitative data analysis. The analysis process entailed a variety of activities that were geared towards sorting out the data into manageable bits. According to Collis & Hussey (2013), this process involves adoption of systematic order that ends up transforming the data for further analysis. For instance, the researcher first sorted the data into various categories depending on the underlying theoretical framework, a process that Newell & Burnard (2011) acknowledges as a way of providing the researcher with a workable structure. It should be noted however that during the data analysis process was conducted on a continuous basis through the observation process, and the final bit only entailed an analysis of the descriptive data that the researcher observed and recorded. The next activity involved the utilization of data, which entails selecting the most appropriate data, reducing data do a manageable size, rearranging the data and labelling them in a manner that would enable a more straightforward analysis for the achievement of research objectives (Coolican, 2017). Next, the researcher identified related categories of data by finding relationships and patterns between them, and rearranging them where necessary to end up with thematically organized sets of data – also termed as thematic analysis (Coolican, 2017). Finally, the researcher used the themes to develop propositions that could be tested, confirming, or rejecting the hypotheses and deriving a conclusion. While sorting the observational data into manageable bits, the researcher fundamentally relied on lean tools. Moreover, during the analysis, the researcher, rearranged, sorted, and structured the items within the observation journal before indulging in the final two stages of identifying the categories and relationship between the data.

3.10 Credibility

According to Collis & Hussey (2013), the credibility of any given researcher refers to the extent to which the study is socially reliable. Ideally, this reliability can be tested by evaluating how much the study findings are acceptable within the study setting. According to Newell & Burnard (2011), this process is called respondent validation and is part of an entire framework of internal validation. Fundamentally, internal validation is supposed to confirm whether there was an accurate interpretation of data and that the findings generated by the researcher match with the respondents’ perspectives. In the current study, the observations were validated through a comparison of the observations with documents gathered from the hospital.

3.11 Transferability

A significant characteristic of the current study is that it was focused only in one institutions, and therefore, the findings of the study may be limited to the local context within which the study is conducted. According to Gisselle & Lotte (2018), this characteristic explains why observations, as an element of qualitative study studies do not have the transferability aspect. However, the study findings and knowledge derived from these findings can be applied in other hospital or service contexts.

3.12 Dependability

The dependability of any given study relies on the extent to which the researcher kept study materials including the research problem formulation tools, data collection tools, recorded data and other essential tools safe (Coolican, 2017). Furthermore, some researchers adopt the auditing process as a technique for evaluating the study trustworthiness, whereas not a popular practice (Keegan, 2009). According to Roberts (2010), the audit process is conducted by peers to establish the trustworthiness of the research. In the current study, the researcher adopted the audit approach in ascertaining the study trustworthiness.

3.13 Confirmability

Collis & Hussey (2013) describe confirmability as the extent to which the researcher allows their values to influence the study outcome significantly. In the current study, the researcher adhered to the confirmability criteria by making various ethical considerations.

3.14 Ethical Considerations

Ethical considerations are an essential aspect of every research study, especially when the study involves human subjects (Coolican, 2017). Fundamentally, according to Gisselle & Lotte (2018), ethical considerations, in qualitative research, may take cover the areas such as informed consent, harm prevention, deception, and privacy invasion. To ensure that the study covered these ethical elements, the researcher sought permission from the hospital management through an email. Furthermore, because part of the study objectives was to understand the processes and workflow within the hospital, the researcher also sought permission to make a physical visit for purposes of observations. Commendably, the hospital management agreed to supply the researcher with any the documented information regarding the processes and workflows.

Chapter 4

4.0 Findings and discussions

This chapter presents the results of data collection (i.e. semi-structured interviews and observations) and a discussion of the result. It entails an analysis of data and discussion of the findings on lean implementation in Sandwell and West Birmingham NHS Trust hospital’s outpatient department. The chapter is presented in three main parts. The first part will give background information of Sandwell and West Birmingham NHS Hospital while the second section will discuss lean implementation, a discussion of the 5s and process mapping as tools of lean implementation used by Sandwell and West Birmingham NHS Trust hospital. Finally, section three will explore the challenges and advantages encountered by Sandwell and West Birmingham NHS Trust hospital in implementing lean within the outpatient department.

4.1 Lean management

4.1.1 The CSF and challenges facing Lean in Sandwell and West Birmingham NHS Hospital’s outpatient department

This section presents and evaluates results from the observations made on the challenges and CSFs of lean implementation. Herein, we also interpret and derive the implication of these findings to achieve the underlying research objectives. The first objective of the observation was to identify and note the critical success factors for lean implementation within the hospital setting. The researcher developed a table of preselected items and used them as a guide to the observation i.e. to know what to look for during the observation. The table below highlights the factors, how they were observed, and how they scored according to the researcher’s observation:

Noteworthy, these results have some considerable limitations due to observer bias. However, the data in these results are adequate for the development of valuable insight from the perspective of an observer. A possible implication of the above-responses is that implementing lean in the current state Sandwell and West Birmingham NHS Hospital may be marred by many challenges due to lack of proper investment. Nonetheless, it is encouraging that lean implementation may not require much investment, and thus the various tools highlighted within this study may be implemented anyway. So, implementing these tools may be an important move towards improving the processes within the department. Moreover, after solving the investment issues, Sandwell and West Birmingham NHS Hospital can adopt lean management to greater extent. Observation data provided a strong base of understanding the various challenges and critical success factors for lean implementation. Several unique challenges and critical success factors for lean implementation emerged from the case of Sandwell and West Birmingham NHS Hospital that would help in the implementation of various Lean management tools explored in this study. For instance, with regards to management support, it emerged that it would be impossible to achieve an effective implementation of lean without harnessing the top management’s support. This is because, in the case of Sandwell and West Birmingham NHS Hospital, the implementation of lean in the outpatient department might involve several processes that might take time to complete. To complete these processes, management support would be required. The management support can only be achieved when they accept change and understand the potential benefits of lean. The observations also revealed various challenges encountered by managers in the implementation of lean. For instance, a significant problem that emerged is resistance from employees. Based on the observations, it was possible to conclude that employees in the department had a low motivation attributable to poor working conditions. Whereas lean implementation would require the introduction of new items such as lean thinking, this would not be possible without employee support. Hence, encouraging change without addressing employee motivation would cause resistance to change. An evaluation of publicly available documents and government support reports also indicated a lack of government support as significant impediment to the implementation of lean. Sandwell and West Birmingham NHS Hospital receives its medicine from the government, and therefore improving the services processes without experiencing any shortage requires the government through the Ministry of Health to timely provide all the necessary stocks of medicine, leaving only the most expensive ones to be purchased at the patients’ cost. However, to introduce this change, a formal approval must be sought from the government. Besides, even the implementation of Lean in Sandwell and West Birmingham NHS Hospital will require government approval, and this may be a challenging affair.

4.1.2 The implementation of the 5s tool in Sandwell and West Birmingham NHS Hospital

Having explored the theoretical underpinnings of the 5s tool from the literature review, the researchers developed a set of interview questions that focused on identifying the current implementation of 5s in Sandwell and West Birmingham NHS Hospital ’s outpatient department.

4.1.2.1 Sort

With regards to ‘sort,’ which means separating the necessary activities from the unnecessary ones (Aherne, 2007), we observed that the outpatient department did not have a sitting secretary at that time to organize stuff within the service desk, leading to a disorganization of the service area with files and patient service documentations. Besides, we observed that the practitioners took longer than expected period to operate the computers and retrieve whatever information their intended to retrieve. Furthermore, based on the evidence from the publicly available hospital documents, it had taken a relatively longer duration before the hospital received new computers upon making a request. We also observed that the working areas were cluttered by unnecessary items such as non-functional computers, journals, and books. The lack of organization within the working space made the staff spend a lot of time looking for things.

4.1.2.2 Simplify

The researcher also found interesting insights with regards to ‘simplify,’ which questions whether the right procedure is followed to put important objects (e.g., patient lists or subscription pads) at the right place or not. For instance, we observed that all the patient records and files are stored in a physical archive, which made it difficult to retrieve. Even in the inpatient department, the files are stored in the hospital archives, and this makes it challenging to retrieve important information. Typically, the practitioners ask patients to mention their date of hospital admission to enable us easily trace their information. Ideally, this is because we lack a computer programmed database to store and manage patient information. Based on these observations, it is clear that Sandwell and West Birmingham NHS Hospital’s outpatient department has not implemented the ‘simplify’ tool within their operation areas. Whereas any patient information is an important aspect of their current and future treatment, it was evident that this information was not well organized and kept by Sandwell and West Birmingham NHS Hospital.

4.1.2.3 Sweep

Valuable insights also emerged with regards to ‘sweep,’ another element of the 5S which refers to evaluating whether the hospital operates in a clean environment – a phenomenon that entails gaining control of the working environment both physically and visually (Appiotti & Bertels 2010). Our observations revealed only one cleaner who sometimes may not clean everything. Besides, we observed that most practitioners only wear gloves when handling patients perceived to have infectious diseases, and not necessarily when handling all patients. Nonetheless, we observed a culture of regular hand washing. These observations indicate that the hospital staffs are aware of the necessity of adhering to cleanliness and hygiene protocols. However, there is still a need to maintain more cleanliness within the area.

4.1.2.4 Standardizing

Another element of the 5s is ‘standardizing,’ which is described by Balle & Regnier (2007) as the documentation of all agreements made in the previous steps. Ideally, according to Balle & Regnier (2007), this is a necessary process that ensures that any regular work is standardized for purposes of maintaining consistency within the operations. Barnas et al (2014) also argue that the standardization would mean following the best procedure regularly to enhance a smooth running of everything within the workplace – including patient admission and maintenance. The observations revealed interesting insights regarding ‘standardize.’ For example, we observed a note at the door of the waiting room that informs patients about the treatment process, when they were expected to wait in line, and average waiting time. These observations led to a conclusion that there is a standardization of some processes in the case study hospital (e.g., time taken to receive the treatment) by writing them on accessible notebooks. However, we assume that it is possible to standardize these processes further to create a faster provision of services.

4.1.2.5 Self-discipline

Another element of 5s that was of interest to the study was self-discipline, which entails following through the other four elements of the 5s. In this regard, we observed a complaint box within the patient waiting area for receiving complaints, and compliments. The following table summarizes the observations made by the researcher on the implementation of 5s:

4.1.2.6 Process Mapping

The researcher also was interested in observing process mapping as one of the lean implementation tools applicable in healthcare context. In doing so, the researcher observed the patient service delivery journey. But first, Berlanga & Husby (2016) argues that process mapping is a tool that enables managers to present the processes within an organization visually. Ideally, process mapping involves the identification of any visible waste within the organization and the establishment of a common language and objective among the staffs (Berlanga & Husby, 2016). To have a proper understanding of the process in Sandwell and West Birmingham NHS Hospital’s outpatient department, the initial step would involve mapping the process of the outpatient journey in each of the specialists units within that department based on the observation data gathered by the researcher. Mapping the current state of the patient journey would expose any wastes within the individual process and instil a culture of problem-solving among the staffs (Piercy & Rich, 2009). The following table indicates an observation of the process map with respective comments on the observations:

Primary care, PF1, is the first level of contact a patient makes whenever they have any kind of medical complaint. It is an essential healthcare service provided by general practitioners (GP) for patients from the community who pay affordable costs for the services (Taleghani, 2010). If the patient has a more complicated health condition, they are recommended for secondary healthcare, which is delivered by other regional hospitals such as Sandwell and West Birmingham NHS Hospital. However, if there is no local hospital within the area, patients are referred to the highest level healthcare facility in the region. In this case, whenever a patient is referred to Sandwell and West Birmingham NHS Hospital, they come with the refereeing physician’s information, the reason for referral and the diagnosis. At PF2, when the patient has been referred for secondary care, they are expected to receive the healthcare that they could not receive in the other hospitals in the region. They are referred for advanced care with medical specialists. PF3 requires the patients to make an effort by scheduling an appointment with the nurse. Whereas scheduling an appointment might take 1 to 3 hours, the researcher overheard a patient at the waiting room complaining that it took two months to get an appointment with a specialist. This indicates the possibility of delayed appointments. PF4 involves the patient arrival at the hospital after getting the appointment. Majority of them were observed to be arriving by public transport, while others come by private cars. The patients are mostly accompanied by someone else, especially when the patient is old-age. In PF5, the patient is required to hand over the referral form to the nurse, who is mostly on standby to maintain the patient queue. The patient data are usually recorded on the clinical protocol notes. Moreover, the referral forms are also handwritten, especially because the department lacks computer systems for recording patient data. Nonetheless, the nurse is responsible for receiving the patients at the specialist ambulance daily and makes patient appointments. According to the observations made by the researcher, an average of 15 to 20 patients sees the specialist daily. In PF6, the patient is expected to go to the waiting lounge, a crowded area where all the patients are expected queue as they wait to see the specialist. The waiting room is mostly crowded because the specialist departments are often adjacent to each other, and therefore, the waiting area comprises of patients waiting to see different specialists. Whereas the appointment date is usually accurate, the appointment time may be approximated depending on the time taken by the specialist to see the preceding patient, which means that the patient might have to wait for one or two more hours. At PF7, the patient is invited to see the specialist, a process which begins by the nurse calling out the patient’s name when their turn arrives. The single room is separated into two to accommodate the nurse and the specialist separately. This causes a lot of noise distractions in the room. For example, after visiting the specialist, the patient consults with the nurse to confirm the next appointment date. This consultation may create noise which distracts the specialist’s on-going consultation.

Chapter 5

5.0 Discussion

5.1 The 5S lean tool

Because the hospital’s outpatient department does not implement lean yet, the researcher encountered difficulty in evaluating the implementation of 5s within the hospital’s current process. However, attempts were made to assess whether or not the department took measures to improve its performance through various actions that could anyway be classified under the 5S lean tool. Based on the made observations, we opine that the hospital can use more realistic lean implementation tools to improve the quality of services within the outpatient department of Sandwell and West Birmingham NHS Hospital. Because the theory of lean management may be new to practitioners in this department, rapid implementation of the lean may not be feasible as it would bring too much change at ago, which may make the implementation less successful (Chen et al., 2010). The current study, therefore, proposes simple tools that can preliminarily be used to begin cultivating the culture of lean. With regards to Sort and Simplify, Crute et al. (2003) note that there is an enormous volume of technology to support various sectors even though this technology has mostly been underused. Moreover, 5s is one of the lean tools, though most hospital organization fail to utilize it well (Comm & Mathaisel, 2000). Nonetheless, sort and are some of the proposed elements of the 5s that can be implemented in the outpatient department – and the implementation can occur in the following ways:

5.1.1 The red Tagging

Existing literature reveals that red-tagging can help the outpatient department to sort out useful things from useless ones by removing cluttered items such as books, periodicals and stalled computers from the area of work. It entails putting red tags with a written description of whatever is being tagged. In doing so, the team can use different colours to sort out and describe different items using the right sign. All staffs should follow this standard within their working areas or even if they notice any disorganized items outside their department. For example, they can use green to indicate items that are useful but are in the wrong place or are not for use; while yellow can be used for stalled items such as equipment or computers. Alternatively, red can be used for items that are completely not in use and or those that should be discarded. Based on the observations made by the researcher, there was a poor management and organization of patient data. Hence, the department would benefit from an investment in computer and IT systems for filing patient documents, so that staffs can find it easier to retrieve and create patient reports. Moreover, the department would benefit from the automation of the entire patient registration process – from admission to discharge by storing the registration data in computers. The researcher’s observation also revealed that in the outpatient department, there are daily medicine supplies as well as prolonged supplies. The current study suggests the use of visual management equipment to manage these supplies for easier identification. For example, pictures can be placed on a medical mask for physicians to identify it when looking for it quickly. With regards to ‘Sweep,’ De Souza (2009) noted that most employees who are not familiar with the 5s assume that it is only useful in cleaning the workplace. However, 5s is also applicable in working environments whose processes do not involve too much waste. Nonetheless, Sweep is a tool used to ensure that the working area is clean and does not contain any cluster. If the department implements the suggested ‘Sort’ and ‘Simplify’ tools, they can easily have the workplace clean and organized – and maintain the cleanliness. This study also postulates that since the hospital staffs are already aware of the importance of maintaining hygiene, improving the hygiene standards would require the hiring of additional cleaners. Concerning standardization, De Souza (2009) argues that it can lead to massive cost savings and an increase in operational efficiency because staffs will follow the same procedure, thereby eliminating unnecessary confusion. This is especially important considering an observation by the researcher that even in the outpatient department, some processes require standardization.

Two important tools can be used to standardized processes in Sandwell and West Birmingham NHS Hospital, namely the use of visual management and labelling. With regards to the latter, according to Fillingham (2007), patients will be required to take a coupon at the reception area and wait for their turn to receive service. It is only when their turn reaches that the patient will be allowed to proceed for service. Ideally, the use of visual management enables the delivery of service on a first come first served basis – making it clear for everyone and allowing the nurse or physician to organize themselves (Hines et al., 2004). On the other hand, standardizing the process using labels entails labelling various designated areas or items for easier identification. For example, nurses or physicians in the department should separately label trays containing essential documents such as patient referral forms which should be separated from other documents that may require urgent processing. The labelling can also be supplemented with color-coding for easier sign identification. Holweg (2007) argues that self-discipline is an essential aspect in lean implementation, for it ensures that the processes are followed and that there is a culture of lean thinking within the workplace. However, to cultivate self-discipline among the staffs, they should have a clear understanding that for any problem to be solved, staffs need first to identify the problem, figure out what is required to solve the problem, and then select the appropriate tools for solving the problem (D’Andreamatteo et al 2019). The study makes the following suggestions to ensure that the hospital’s outpatient department follows the 5s: First, there needs to be staff education and empowerment towards process improvement. As indicated in the reviewed literature, employee involvement is a critical success factor in the implementation of lean (Black & Miller, 2008). However, to effectively involve the staffs, they need to be sensitized on the importance of lean implementation and provide them with the necessary tools as a form of empowering them towards a successful implementation of lean (D’Andreamatteo et al 2019). The current study suggests that with the sensitization and empowerment, staffs can develop self-discipline as a necessity for successful implementation of the 4s.

Another strategy that can be used to teach self-discipline among the department staff is the inclusion of Lean as part of the criteria for staff performance evaluation. The current study suggests that including Lean as a criterion for performance evaluation will ensure that staffs are continually working hard to maintain self-discipline with the knowledge that their performance will ultimately be judged based on how disciplined they are. The outpatient department would also benefit from asking the patients to give feedback on the quality of service after receiving treatment. According to D’Andreamatteo et al (2019), feedback would not only assist in understanding the patient experience of the department but also in improving the quality of services delivered to them. Lastly, the department can instil self-discipline is the creation of a lean audit team comprising of a few employees whose primary responsibility is to the staffs follow Lean, and that no item of Lean is ignored. The following table highlights the proposed 5s implementation process for Sandwell and West Birmingham NHS Hospital’s outpatient department:

5.2 Process Mapping

Having observed and collected useful data on Sandwell and West Birmingham NHS Hospital’s process mapping, it is essential to note that it may be challenging to develop an effective process mapping due to lack of standardization – which makes most organizations stuck (D’Andreamatteo et al 2019). The observations also reveal that the patients are taken through various processes from admission to discharge, which do not add value. Consequently, there is a need to develop a future state of the map that would help streamline the processes within the department. This can take the example given by Black & Miller (2008), who proposes that bringing services closer to the patients may help reduce the distance covered by patients to receive treatment. However, Bicheno (2004) argues that only someone with significant experience with Lean can develop an effective future state map. According to Peterson et al. (2010), a future state map indicates the expected achievements after adding value to the process with special consideration of customer feedback. Hence, it is crucial for Sandwell and West Birmingham NHS Hospital to adopt a ‘patient-first’ policy as a priority to deliver high-quality healthcare services (Black & Miller, 2008). Moreover, to develop an effective future state map, it is crucial to building on the current state map, thereby enabling the development of a culture of continuous improvement as part of Lean management (Fillingham, 2007). The observations revealed two wastes in four main areas, namely process flow 3 where patients had to contact the nurse to book an appointment; process flow 6 where the patient had to wait for their session; process flow 7 where the patient undergoes an examination with the specialist, and process flow 9 where the nurse schedules a new appointment for the patient. Developing a future state map would mean eliminating all the wastes associated with these process flows. Hence, the following section highlights the researcher’s suggestion of how the future state map can be improved. With regards to process flow 3, the patient can get an appointment with the specialist at the stage when they go for primary health care instead of waiting to secure the appointment at secondary health care. This can easily be achieved by developing an online patient appointment system that enables the nurse to check the specialist’s availability easily. When this is implemented, patients will know the date of appointment early enough so that they only visit the specialist clinic at the right timing. Furthermore, this will save the patient’s time, thereby increasing their satisfaction levels. Besides, this will eliminate the nurses’ responsibility to schedule an appointment and thus will no longer have to write the schedule on the clinical protocol. Ultimately, the system improvement will provide an opportunity for simpler processes, easing the jobs of nurses at each level of care and enabling easier tracking of patient records. Another point of improvement is sending the referral form that contains patient diagnosis and history via mail, so that the patient is not asked the same question that was asked at the primary care clinic when they visit the secondary care clinic – thereby eliminating this portion of the process. The study observations also revealed a high demand for outpatient services in Sandwell and West Birmingham NHS Hospital, whereby patients could wait for one to two months before receiving an appointment. Ideally, developing an autonomous clinic out of Sandwell and West Birmingham NHS Hospital’s outpatient department would reduce the patient waiting time and satisfy their needs by freeing up more waiting space. However, according to Black & Miller (2008), identifying the activities that cause waste to improve the processes requires managers to understand how the processes affect each other. For example, in Sandwell and West Birmingham NHS Hospital, an introduction of an electronic appointment scheduling database would eliminate the need for patients to book appointments at the hospital. Furthermore, the electronic database would reduce nurses’ burden of scheduling appointments and free up the waiting area space occupied by patients while seeking appointments. Ultimately, patients will be more satisfied with a reduction in waiting time.

Another area of interest in the process flow 7 was where the patient meets the specialist for a consultation. According to the observations, patients meet specialists in a room that hosts both the nurse and the specialist, thereby creating distraction whenever there is noise within the room. This study suggests that the nurse’s reception should be situated outside the consultation room in the waiting area, and the reception can adopt a Lean framework of a wheeled desk, which can be moved to create space. Moreover, the study suggests the adoption of first come first served criteria in the queue, together with a token system to maintain the line. While it may not be possible to initiate all these improvements, they are likely to increase the efficiency with which the outpatient department operates and subsequently contribute to patient satisfaction. The idea is to eliminate all elements of waste, including longer patient waiting time while delivering full care to the patient from admission to discharge. That said, the study has identified the existing wastes in West Birmingham NHS Hospital’s process map and suggested an effective process map that can be adopted by the hospital in the future to improve patient experience in the outpatient department. In Sandwell and West Birmingham NHS Hospital’s outpatient department, observation results revealed the patient’s waiting time, non-value added activities, and task duplication created within the process map. Whereas the study could not quantify the potential benefits of implementing lean in monetary terms, there were a few benefits that could directly be identified through observation. For example, reducing the patient waiting time could increase patient satisfaction because the suggested process map would reduce between one to three hours of patient waiting time. Moreover, the long hours and tedious processes experienced by nurses when reviewing patient documents and finding their illness histories will be eliminated or reduced by introducing an electronic database system. The system would eliminate some processes and relieve the nurses to focus on other activities that can improve the patient experience.

Lean implementation could also help in stress or distraction reduction. By developing a token queuing system, the outpatient department will be more organized, reducing noise, distraction, and stress for the nurses working in the waiting area. Furthermore, the suggested improvements will also reduce the patient to stay in the hospital, thereby creating more efficiency within the hospital.

Chapter 6

6.0 Conclusion & Recommendations

This is the final chapter of the study. It will highlight the study conclusion and recommendations based on the study findings. The entire chapter will be delivered in two main sections, namely conclusion and recommendation. The conclusion section will summarise the entire study and recap the underlying research question. The second section will give recommendations for the improvement of Sandwell and West Birmingham NHS Hospital, limitations of the study and finally recommendations for future research.

6.1 Conclusion

Organizations that have adopted lean management operate with systems that have minimum waste, thereby having smoothly running value added activities. Whereas it is possible to implement lean both in service and manufacturing settings, evidence explored by this study indicates that it has had less adoption in service settings. Hence, there is a need for managers in service settings such as healthcare to embrace lean so as to achieve better results. This study noticed a paucity of up to date literature on lean implementation in healthcare, even though several articles and credible materials for lean implementation in healthcare were found. Nonetheless, the paucity of literary sources on healthcare lean implementation justified the use UK NHS reports and websites as sources of evidence. Nonetheless, it is commendable that NHS UK has made significant contribution to lean implementation in UK’s healthcare sector by highlighting the its benefits and sharing the knowledge within the wider healthcare sector. The current study concludes that it is not difficult to implement lean service settings such as healthcare. However, it is important to note that lean implementation in service settings may have unique challenges compared to manufacturing settings because it deals with people. That said, it is possible to extrapolate that one of the reasons why lean implementation seems to be easier in the manufacturing sector compared to service sector is because there is more evidence of its success, and that lean in manufacturing has attracted more body of research. The main aim of the current study was to explore lean implementation in the healthcare. This entailed an exploration of the lean tools, key success factors for the implementation of lean, and the challenges, and benefits experienced by hospital managers when implementing lean in the healthcare sector. Hence, the study explored various theoretical underpinnings of lean implementation, especially in hospital service setting. Using both secondary and primary data, the study generally explored six aspects of lean implementation, including the critical success factors for lean challenges of lean implementation, lean tools and the criticism of lean. In an attempt to answer the research question, the study relied on a case study approach, which targeted the Sandwell and West Birmingham NHS Hospital’s outpatient department. Primary data was collected through observations and thematically analysed based on two major leant tools namely the 5s and process mapping. The study then recommended the tools and techniques for lean application in the hospital setting after exploring the current state of Sandwell and West Birmingham NHS Hospital’s outpatient operations. Some of the recommended tools were the 5s, process mapping, visual management and red tagging, and were believed could improve the service delivery process in the hospital’s outpatient department. However the study acknowledges that not all the tools can immediately applied (due to the financial implications), and therefore a few of the tools (e.g. visual management and red tagging) could be applied in the near future.

With regards to how lean management is implemented in the healthcare sector, the key success factors for lean implementation, its challenges and benefits, the study concludes that hospital managers have to choose the most appropriate lean tools and techniques that suite the needs of their organizations. The study has explored several lean tools and techniques considered to be effective including value stream mapping, Kanban, process mapping and red tagging. Choosing the most appropriate lean tool is easier when managers compare the application of lean tools in theory and in practice to identify the most applicable ones. Nonetheless, based on the observations made by the researcher on Sandwell and West Birmingham NHS Hospital, it is crucial for the hospital management to implement some of the recommended lean tools in their outpatient department. These recommendations are especially important because some of the critical success factors and challenge of lean implementation observed at Sandwell and West Birmingham NHS Hospital agree with those explored in the literature review. For instance, some of the most significant findings at the Sandwell and West Birmingham NHS Hospital that were also explored in the literature review include top management involvement, and availability of no-value added activities within the service delivery chain. Ultimately, the study has identified some benefits that Sandwell and West Birmingham NHS Hospital is likely to gain after implementing the recommended lean tools. The study has also highlighted the possibility of successfully implementing lean in Sandwell and West Birmingham NHS Hospital in future. However, we have also acknowledged that this implementation is likely to encounter some challenges across the service sector. Conversely, some of the possible benefits for lean implementation in Sandwell and West Birmingham NHS Hospital include reduced workload and employee stress levels, reduced waiting time and increased patient satisfaction. More importantly, the study has explored lean implementation in the healthcare sector in a manner that provides answers to some of the challenges that may be encounters by Sandwell and West Birmingham NHS Hospital when implementing lean in their outpatient department. By exploring the possible lean implementation challenges to be encountered by Sandwell and West Birmingham NHS Hospital, this study demonstrates a realistic approach to lean implementation. Overall, the study reveals the need for lean implementation in the UK’s health sector, covering not only the major hospitals but also private clinics and nursing homes. We speculate that lean may not be common in the healthcare sector because most healthcare managers are not familiar with the terms. Even in hospitals that have adopted lean, some employees may not be aware of the lean terms. However, the study holds that lean implementation is not different from other management models and theories, even though it has a broader scope of implementation and more possibility of successful implementation.

6.2 Recommendations

Based in the observations interview responses and explored literature, the following recommendations are proposed to Sandwell and West Birmingham NHS Hospital for purposes of improving service delivery through lean. The study speculates that these improvements will enable a practical lean implementation in Sandwell and West Birmingham NHS Hospital to enhance the quality of service delivery. The hospital needs to develop a sense of necessity among both the top management and other staffs on the urgent need for lean implementation. This is achievable by identifying and sharing the necessary improvements within the service delivery process and highlighting the benefits of implementing lean by focusing on value adding activities as well as waste elimination. The hospital should establish a lean thinking culture among its staffs through continuous training on various lean tools and strategies. Training employees on lean implementation would enhance employee involvement and promote lean thinking. The hospital should give more attention to patient feedback, address their needs and follow-up on their satisfaction levels. This can be achieved by developing a commitment among the staffs towards a ‘patient-first’ culture. The hospital should motivate its employees. A successful lean implementation requires motivated employees because when employees are motivated, they are able to be more creative and improve their performance. Normally, employee motivation is achieved through incentives. Therefore, Sandwell and West Birmingham NHS Hospital can develop various incentive programs such as monthly or yearly awards in tokens or certificates. The hospital can also consider giving the patients a change to commend their caregivers through ‘thank you’ notes for purposes of appreciating and motivating the staffs. Sandwell and West Birmingham NHS Hospital should also create an enabling environment for the implementation of lean tools. For instance, investing in an automated queuing system would help in implementing visual management at the waiting area. Moreover, implementing process mapping would help the hospital develop an effective service delivery process. Particularly, process mapping would entail identifying all the activities involved in the patient journey, standardizing and simplifying them to improve patient experience. However, while implementing these tools, Sandwell and West Birmingham NHS Hospital should conduct a continuous review of the processes to eliminate the wastes that could be jeopardizing the improvement process. Sandwell and West Birmingham NHS Hospital should also ensure that all the defects and machine breakdowns are immediately reported. This can be done by adopting the red tagging system to make the right identification and record the exact breakdown time of the equipment. The study also recommends more investment in computer systems and database to enhance the operation and delivery of services to patients. The database would help to keep track of the patients’ information and to effectively schedule appointments. However, before introducing the computer system and database, Sandwell and West Birmingham NHS Hospital should consider training the staffs on how to use the computer systems. By introducing the database computer system, Sandwell and West Birmingham NHS Hospital will emerge with simplified procedures that enhance customer satisfaction.

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