Critical success factors for the successful initiation of Lean in public hospitals in KwaZulu-Natal: a factor analysis and structural equation modelling study

The volatile environment for health care delivery in South Africa, due to its quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders with generally poor health outcomes, compels health care managers to adopt contemporary management approaches shown to be effective in resource-constrained environments [1‐3]. Lean thinking is a philosophy involving proven operations practices and techniques that improve the quality and efficiency of production and service delivery by enhancing operational flow and diminishing wasteful activity in an organisation [4]. However, the question of what critical success factors will predict the success of Lean initiation in public hospitals remains unanswered and receives little attention in the literature describing the South African health care context.

Lean thinking is one of several operations management techniques which have yet to be fully embraced in the South African health care arena [5‐7]. The primary focus of Lean is on reducing waste, synchronising flows, and managing variability in (process) flows [8]. Lean methodology comprises five fundamental tenets [9, 10]:

Lean classifies activities in a value stream into three categories: (1) value-added work; (2) type 1 non–value-added work, which is necessary but does not add value from the standpoint of the patient; and (3) type 2 non-value-added work (waste or muda) which does not add any value to the patient from any perspective and should therefore be eliminated [4].

Lean has been revolutionising manufacturing and service industries globally for many years and is endorsed as “creat[ing] a balance between quality and finance by developing the most efficient and effective method of providing value to the customer” [4]. Faull posits that the application of Lean to health care has begun in earnest, mainly in the United States of America, the United Kingdom, and Australia [11]. However, the current application of Lean in Southern African health care lacks coherence, despite its increasing prevalence in health institutions [5, 7, 12].

Substantial resource constraints in the face of increasing demands on the health care system are cited as important factors underlying mismanagement in public sectors such as health [13]. In order to sustainably recuperate the delivery of health care in the context of the current local challenges of limited resources and poor prospects for economic growth, efforts must be made to create an improved health care management based on a philosophy of “doing better with less” [3]. It is therefore imperative that a fundamental shift in management philosophy be established to create a platform that nurtures inspiration and encourages productivity through efficiency. In most health care managers’ service delivery mandates, what needs to be done may be known, but how it should be done remains alien to most managers. To recognise the “how”, the critical success factors for Lean initiation must be acknowledged and emphasised.

Critical success factors (CSFs) can be defined as “the limited number of areas in which results, if they are satisfactory, will ensure successful competitive performance for the organisation” [14]. It has been posited that research results show both successful and unsuccessful Lean implementation, indicating that CSFs for its initiation must be recognised [15]. Further observations reveal that empirical literature to “evidence how Lean implementation is operationalised in healthcare over and above a few isolated case studies that often describe a successful, but isolated project” is lacking [16].

International studies have shown that there are striking similarities in the systemic application of Lean in three settings, namely, the United States of America, Australia, and the United Kingdom [17‐19]. These similarities include starting from a crisis standpoint, leadership commitment, commitment to organisational change, the use of rapid improvement events or kaizen events, structured problem identification and solving skills, training of staff on Lean, and the rigorous application of Lean tools. Organisational readiness factors such as a clear understanding of the system view, patient perception, the application of information, and engaging employees are also cited as key variables for preparing for Lean implementation [20].

In the South African health sector, however, there is a paucity of research on CSFs for Lean initiation. Some researchers merely describe the challenges and barriers of Lean implementation in the South African health sector, for example, the variability of processes and patient flow, a lack of understanding of Lean, poor communication and leadership, difficulty in defining waste, and the challenge of defining value from the patient’s perspective [11, 21, 22]. Simply identifying the challenges of Lean, however, does not necessarily translate into identifying CSFs.

In an influential study involving a systematic review of 33 articles on PubMed, Web of Science, and Business Source Premier, four different change mechanisms were identified as positive results yielded through Lean. Outlined in all 33 articles, these change mechanisms were understanding processes, planning and organising for effectiveness and efficiency, increasing awareness and process reliability, and collaboration amongst staff to solve problems systematically [23].

From a seminal literature review of 177 research papers dating from 2000 to 2015—conducted across several elements of health care operations management, including service quality, service operations strategy, service scheduling, service performance, and frontline employees [24]—it is clear that more health care operations management research is required in developing and underdeveloped countries due to the unique challenges experienced in these nations in comparison to developed nations. The literature review revealed that a large proportion of empirical studies have been conducted only in developed nations [24], a lack of balance that needs to be rectified.

In the reviewed literature, apart from the elaborate descriptions of the challenges and success factors for Lean implementation, mainly in non-health care organisations, it is clear that there is a dearth of studies in the health care sector in South Africa. None of the reviewed literature reveals any proposals or recommendations for the identification or application of CSFs for Lean in health care in South African hospitals.

The research was centred on a positivist paradigm and took the form of an observational, descriptive study with quantitative methods. The primary aim of the study was to develop a Lean Success Predictor for Rapid Initiation Tool (Lean-SPRInT) for the implementation of Lean in public hospitals across KwaZulu-Natal, South Africa. Two of the study’s objectives, the results of which are described in this article, were to identify the key variables for the successful initiation of Lean and then to conduct factor analysis and SEM on these variables, thus leading to the identification of CSFs for Lean initiation.

Although they remain beyond the scope and content of this article, other objectives of the study included uncovering the knowledge and experience of Lean amongst senior health care managers in KwaZulu-Natal, South Africa, and utilising the identified CSFs to develop a Lean Success Predictor for Rapid Initiation Tool (Lean SPRInT) for the successful initiation of Lean.

From an extensive literature review, Vermaak ([25], p., 183) established that the independent variables considered as CSFs for Lean implementation in the manufacturing sector can be classified under 8 categories: mindset and attitude, leadership, ordinary employees, strategic driver, basic stability, Lean promotion office, tools and techniques, and integration [25]. With permission, the researcher (and authors of this article) utilised these categories and independent variables in the data collection tool, subjected them to Likert scale ratings by senior health care managers, and conducted factor analysis to identify the CSFs (dependent variables) which would be incorporated into the Lean SPRInT. This process is reflected in the conceptual framework (Fig. 1).

For various manufacturing organisations, it appears that clear organisational goals, values, and vision and the communication thereof; emphasis on leadership and commitment; and resource capabilities are acknowledged as common CSFs for Lean [38‐40]. A large number of studies in non-healthcare industries on the CSFs for Lean implementation describe several common CSFs (Table 9). However, only one of the three identified CSFs (CSF1: strategic leadership and organisational attitude) closely resembles some of those described in the majority of studies reviewed for non-healthcare industries (Table 9).

Management leadership and incorporation of Lean in the organisation as a strategic driver is paramount as a Lean CSF in research literature, and the findings of this study in the KZN public hospitals corroborate this CSF as instrumental also within the health care industry [47‐51]. The other two CSFs (integration of Lean elements, tools, and techniques and basic stability in operational processes) appear peculiar to several of the non-healthcare industries as enablers or Lean implementation success indicators, but this study shows that they are nevertheless identified as critical in KZN public hospitals.

CSF2 and CSF3 are fundamental to the 5 Lean principles (specify value, identify the value stream, create flow, allow pull, and pursue perfection) [9]. The application of these principles justifies these two CSFs as integral rudiments for successful Lean initiation in the healthcare industry. Hospitals are rarely based on a typical assembly line structure; they are person-orientated operations with various “patient processing” service nodes in which unique and multi-faceted events occur. This would emphasise the need for the integration of Lean elements, tools, and techniques, and the requirement of basic stability in some of the value stream processes in order for Lean to be applied. One may ask, what is Lean without its signature elements, tools, techniques, and processes of flow in the value stream?

More importantly, each of the three CSFs cannot be viewed in isolation, as they all have significance in different dimensions of capability within the organisation, characteristically represented by Andersen et al.’s [51] framework of Lean facilitators (Table 10).

This framework suggests that the Lean CSFs and the context, content, application, and outcome of Lean should be viewed in light of the organisation’s strategic, technical, structural, and cultural environment [51]. Within the context (of the current situation and organisation), all three CSFs should be applied in view of the cultural, technical, strategic, and structural dimensions. The content of Lean interventions must be adapted to local conditions, with a focus on value creation for the patient, the culture of the workforce, substantial localised training on Lean tools and techniques, and accurate and robust data [51]. The collaboration of multi-skilled and multidisciplinary teams in the hospital, together with administrative project management, practical support, management and physicians’ engagement at the frontline, and the empowerment of staff, facilitates Lean application. Finally, a supportive environment with effective communication, feedback to employees and patients, the adoption of a holistic quality improvement philosophy, and the establishment of a long-term continuous improvement plan in a system-wide, multifaceted approach upholds the outcomes’ domain of the framework [51].

The three CSFs are ultimately identified and analysed, originating from the perceptions of senior managers working in public hospitals in KZN. The statistical methods and SEM fit indices presented above provide a basis for verifying the resemblance of these identified factors to the actuality at the population level.

Applying EFA, CFA, and SEM, the study identified three critical success factors for the successful initiation of Lean in public hospitals in KwaZulu-Natal, South Africa. CSF1 (strategic leadership and organisational attitude), CSF2 (integration of Lean elements, tools, and techniques), and CSF3 (basic stability in operational processes) consist of key elements for managers to consider prior to the initiation of Lean.

Collaborative leadership and the embedding of Lean as a strategic driver is depicted in the literature as an important enabler of Lean in non-healthcare industries, and the study findings corroborate CSF1 as instrumental for Lean success also within the health care industry. The study uniquely identifies CSF2 and CSF3 as the other two critical success factors in KZN public hospitals, despite these being reflected in reviewed literature as having less importance in other studies. The application of the five Lean principles justifies these two CSFs as integral rudiments for successful Lean initiation in the healthcare industry.

Ultimately, each of the three CSFs cannot be viewed in isolation, as they all have significance in different dimensions of capability within the organisation. The use of these CSFs and the context, content, application, and outcome of Lean should be considered in view of the organisation’s strategic, technical, structural, and cultural environment. The three identified CSFs will form the basis for the development of the Lean Success Predictor for Rapid Initiation Tool (“Lean SPRInT”), which will be proposed as a Lean initiation and situational baseline assessment tool for public hospitals in KwaZulu-Natal, and also as universally applicable to South Africa at large.

The Lean SPRInT will be put forward as an initiation tool for managers to embark on the Lean transformation journey. Lean SPRInT uses sets of elements for the three CSFs for Lean implementation. Once rated by the user, these would yield a fuzzy logic output of graded Lean implementation readiness levels and processes that would guide managers to initiating Lean. The calculated Lean readiness levels, ranging from 1 to 3, for each of the CSF elements allows managers to gauge the deficiencies in their institution, which once improved, would predict greater success. In addition to the Lean SPRInT, Andersen et al.’s [51] framework suggests that Lean CSFs and the context, content, application, and outcome of Lean should be viewed in light of the organisation’s strategic, technical, structural, and cultural environment.

Finally and significantly, further research in the effectiveness of these CSFs for the introduction of Lean in South African hospitals will be beneficial to the Lean body of knowledge.