Background
Methods
Study design
Measures
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the maturity of adoption (concerning how much Lean management is diffused within hospital units, the timing since it has been implemented by the hospital and Lean self-reported maturity);
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the implementation approach (concerning the methodologies, principles and techniques used, the people involved and the operations mechanisms), identifying both strategic and operational activities and tools; and
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the Lean performance, investigated through 15 self-reported achievements grouped in four main areas [14]: patients, employed and affiliated staff, costs and service provision.
Dimensions | Variables |
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Adoption maturity | • Number of years doing Lean • Lean Maturity Assessment • Number of units doing Lean |
Strategic implementation approach | • Approach for Lean adoption • Lean leadership commitment index • Central improvement team • External consultant |
Operational implementation approach | • Daily management system index • Index support by HR, IT and Finance units • Reward and Recognition • Lean team composition and leadership • Main tools used • Education and training index • Staff Involvement index |
Performance | • Self-reported index • Self-reported impact on patients (Improved patient satisfaction scores, Reduced medical errors, Reduced one or more types of hospital-acquired infections, Reduced hospital readmissions within 30 days of discharge, Reduced risk adjusted 30-day mortality, Reduced ambulatory care sensitive admissions) • Self-reported impact on employed and affiliated staff (Improved employee engagement in their work, Reduced employee turnover) • Self-reported impacts on costs (Reduced expenditures in two or more departments, eliminated waste in two or more processes or departments, Reduced average length of stay) • Self-reported impacts on service provision (Increased throughput in the emergency department, Increased throughput in the operating rooms, Increased throughput in the cardiac care unit, Increased throughput in med/surg nursing units) |
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The leadership commitment index was built with the following eight-items: how clear leaders communicate the reason(s) for implementing Lean, the expected outcomes, employee’s time and resources investment in Lean, successful projects with teachings about Lean, use of benchmarks to assess progress, leaders’ provision of needed resources, team champions/sponsors identification, and the recourse to a patient-centered care. The choice was from “strongly disagree” to “strongly agree” for each item. Agree and strongly agree answers were put together and one point to each of the eight items was given (range 0 to 8). The Cronbach alpha reliability coefficient was 0.70 for Italy and 0.81 for US.
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The daily management system (DMS) index consisted of nine-items with the aim of investigating whether or not managers were involved in few activities or used Lean tools (i.e., daily huddles, “gemba” walks, visual management, analysis tools such as scatter plots, A3 thinking, teaching Lean methods/tools, standard work, value stream mapping, and Plan-Do- Study-Act (PDSA) cycles). Points were collected for each “YES” of the items with a range from 0 to 9. Cronbach’s alpha reliability coefficient was 0.73 for Italy and 0.75 for US.
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The HR, IT and Finance indexes were measured by three composite indexes. HR index included five items - if HR: helps with Lean goals, has the role of advisor for managers, provides managers the data and analysis needed, works with leaders in redefining job roles and responsibilities or if working with Lean is considered in the recruitment process. The Cronbach’s reliability coefficient was for Italy 0.82 and 0.74 for the US. The finance index included three items - if the finance department: helps with Lean goals, contributes providing managers the data and analysis needed, has the role of advisor for managers. The Cronbach’s alpha reliability coefficient was 0.6 for Italy and 0.66 for the US. The IT function included six items - if the IT department: helps with Lean goals, has the role of advisor for managers, provides managers the data and analysis needed, the hospital has ready access to integrated data of clinical and operational processes, managers have very timely and accurate data. The Cronbach’s alpha for Italy was 0.78 and 0.80 for the US. For each item, the response categories were “strongly disagree”, “disagree”, “neither agree nor disagree”, “agree”, and “strongly agree”. The index was built with the number of responses “agree” or “strongly agree”.
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The education and training index aimed at measuring the degree of Lean education and training of the hospital’s staff (i.e., managers, nurses, and physicians) with training in scientific approaches to problem solving choosing between the following percentage ranges: 0% (categories of 0), 1–24% (category 1), 25–49% (category 2), 50–74% (category 3), and 75–100% (category 4). The averaged across the three groups—managers, nurses, and physicians— was conducted and an average score from 0 to 4 was built. The Cronbach’s alpha reliability coefficient was 0.88 for Italy and 0.82 for US.
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The staff involvement index aimed at measuring the involvement of managers, doctors, and nurses in the use of tools and activities for Lean implementation: establishing goals for Lean improvement; using value stream mapping/mapping of value flow, fishbone diagrams, A3 Reports, fast improvement events (Rapid Improvement Events - RIE) or related tools and approaches; coaching activities; attending daily huddles; establishing processes that help sustain improvements. Each “YES” was given 1 point. The scale ranges from 0 to 5.
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The self-reported performance index was built assigning 1 point to each “YES” response to the 15 performance improvement areas that could be primarily attributed to Lean implementation. The scale ranges from 0 to 15. The Cronbach’s alpha reliability coefficient was 0.84 for Italy and 0.89 for the US.
Data analysis
Results
The sample
US | Italy | |||||||
---|---|---|---|---|---|---|---|---|
Non-respondents (N = 672) | Respondents (N = 282) | Non-respondents (N = 107) | Respondents (N = 91) | |||||
N | % | N | % | N | % | N | % | |
Public hospitals | 672 | 70 | 282 | 30 | 107 | 54 | 91 | 46 |
Bed Size | (N = 672) | (N = 282) | (N = 101) | (N = 89) | ||||
Small | 504 | 75 | 190 | 67.4 | 34 | 33.6 | 24 | 27 |
Medium | 128 | 19.1 | 58 | 20.6 | 61 | 60.5 | 54 | 61 |
Large | 40 | 6 | 34 | 12.1 | 6 | 5.9 | 11 | 12 |
Mean | 106 | 131 | 738 | 873 |
Lean diffusion and adoption
US | Italy | |||||||
---|---|---|---|---|---|---|---|---|
N | % | Mean | SD | N | % | Mean | SD | |
Current Performance Improvement Approach | ||||||||
282 | 97 | |||||||
Benchmarking for Best Practices | 131 | 46 | 44 | 45 | ||||
Lean | 149 | 53 | 35 | 36 | ||||
The Model for Improvement | 54 | 19 | NA | NA | ||||
High Reliability Organization (HRO) | 81 | 29 | 69 | 71 | ||||
Value-based Healthcare | NA | NA | 9 | 9 | ||||
FOCUS-PDCA | 88 | 31 | 4 | 4 | ||||
Six Sigma without Lean | 18 | 6 | 1 | 1 | ||||
Currently doing any Lean? | 282 | 97 | ||||||
Yes | 149 | 53 | 35 | 36 | ||||
No | 133 | 47 | 62 | 64 | ||||
MATURITY ADOPTION | ||||||||
Number of years doing Lean | 143 | 4.6 | 3.56 | 35 | 4 | 3.57 | ||
Lean self- reported maturity | 144 | 34 | ||||||
Still in the new start-up stage | 32 | 22 | 10 | 29 | ||||
Beyond start-up, but challenged moving forward | 49 | 34 | 4 | 12 | ||||
Expanding to other units and getting traction | 55 | 38 | 16 | 47 | ||||
Mature transformational performance improvement | 8 | 6 | 4 | 12 | ||||
Number of units doing Lean | 138 | 11.9 | 7.69 | 35 | 6 | 3.87 |
Strategic implementation approach
US | Italy | |||||||
---|---|---|---|---|---|---|---|---|
N | % | Mean | SD | N | % | Mean | SD | |
Approach at the beginning of Lean implementation | 142 | 34 | ||||||
Some elements hospital-wide | 52 | 37 | 3 | 9 | ||||
Some elements in a small number of departments | 52 | 37 | 22 | 65 | ||||
Some elements in a single department | 13 | 9 | 9 | 26 | ||||
Comprehensive DMS hospital-wide | 11 | 8 | 0 | 0 | ||||
Comprehensive DMS in a small number of departments | 9 | 6 | 0 | 0 | ||||
Comprehensive DMS in a single department | 5 | 4 | 0 | 0 | ||||
Initiated Lean with a model cell | 143 | 35 | ||||||
Yes | 84 | 59 | 24 | 69 | ||||
No | 59 | 41 | 11 | 31 | ||||
Have a True North vision | 139 | 35 | ||||||
Yes | 68 | 49 | 19 | 54 | ||||
No | 71 | 51 | 16 | 46 | ||||
Overall Lean leadership commitment index (range: 0–8) | 139 | 4.7 | 2.48 | 35 | 4.6 | 2.18 | ||
Have a central improvement team | 139 | 35 | ||||||
Yes | 87 | 63 | 20 | 57 | ||||
No | 52 | 37 | 15 | 43 | ||||
Ever used an outside consultant | 138 | 35 | ||||||
Yes | 100 | 72 | 2 | 6 | ||||
No | 38 | 28 | 33 | 94 |
Operational implementation approach
US | Italy | |||||||
---|---|---|---|---|---|---|---|---|
N | % | Mean | SD | N | % | Mean | SD | |
Daily management system index (range: 0–9) | 135 | 4.8 | 2.53 | 35 | 2.4 | 1.55 | ||
HR index (range: 0–5) | 129 | 2.3 | 1.82 | 35 | 2.3 | 1.85 | ||
IT index (range: 0–6) | 129 | 2.7 | 2.05 | 35 | 3.8 | 1.97 | ||
Finance index (range: 0–3) | 130 | 2.0 | 1.07 | 35 | 1.8 | 1.11 | ||
Lean team multi-professionalism | 68 | 14 | ||||||
Information Technology | 32 | 47 | 7 | 50 | ||||
Human Resources | 16 | 24 | 4 | 29 | ||||
Finance | 20 | 29 | 3 | 21 | ||||
Staff involvement index (range: 0–6) | 76 | 3.9 | 1.34 | 35 | 1.04 | 1.41 | ||
Education and training index (range: 0–4) | 128 | 1.79 | 0.89 | 35 | 1.7 | 0.93 | ||
Reward and Recognition | 293 | 23 | ||||||
Departments | 103 | 35 | 4 | 17 | ||||
External Organizations | 84 | 29 | 6 | 26 | ||||
Hospital | 106 | 36 | 13 | 57 | ||||
Number of tools reported as high or very high use (range: 0–14) | 130 | 4.3 | 3.6 | 35 | 3.3 | 3.3 |
Tools and Methods | US (1) | Italy (2) | t-test difference | ||
---|---|---|---|---|---|
N | Mean [SD] | N | Mean [SD] | (1)–(2) | |
5 s: redesign of physical workspace | 129 | 3.977 [1.320] | 35 | 4.143 [1.115] | −0.166 |
A3 thinking | 129 | 3.341 [1.355] | 35 | 3.114 [1.255] | 0.227 |
Analysis tools such as scatter plots, Pareto charts | 129 | 3.705 [1.208] | 35 | 3.800 [1.256] | −0.095 |
Daily huddles | 129 | 4.628 [1.409] | 35 | 4.171 [1.014] | 0.456 |
Just-in-time process or inventory management | 129 | 3.891 [1.427] | 35 | 2.743 [1.221] | 1.149*** |
Kaizen improvement events | 129 | 3.318 [1.566] | 35 | 2.143 [1.264] | 1.175*** |
Mistake-proofing | 129 | 3.318 [1.256] | 35 | 2.886 [1.367] | 0.432 |
Redesign for continuous flow [pull system, etc.] | 130 | 3.469 [1.325] | 35 | 3.571 [1.290] | −0.102 |
PDSA | 129 | 4.388 [1.239] | 35 | 4.171 [1.014] | 0.216 |
Six Sigma DMAIC methodology | 130 | 3.115 [1.622] | 35 | 2.971 [1.382] | 0.144 |
Standard work | 130 | 3.923 [1.198] | 35 | 4.086 [1.040] | −0.163 |
Training in process improvement tools for employees | 129 | 3.310 [1.535] | 35 | 2.714 [1.467] | 0.596* |
Value stream process mapping | 130 | 3.477 [1.342] | 35 | 3.629 [1.215] | −0.152 |
Visual management such as huddle boards | 128 | 4.070 [1.421] | 35 | 3.743 [1.245] | 0.327 |
Lean outcomes
Variable | US (1) | Italy (2) | t-test difference | ||
---|---|---|---|---|---|
N | Mean [SD] | N | Mean [SD] | (1)–(2) | |
Self-reported performance index (range: 0–15) | 127 | 7.1 [3.7] | 35 | 8.6 [3.8] | |
PATIENT | |||||
Improved patient satisfaction scores | 110 | 0.727 [0.447] | 31 | 0.968 [0.180] | −0.240** |
Reduced medical errors | 104 | 0.702 [0.460] | 25 | 0.880 [0.332] | −0.178 |
Reduced one or more types of hosp-acquired infections | 100 | 0.640 [0.482] | 20 | 0.700 [0.470] | −0.060 |
Reduced hospital re-admissions within 30 days of discharge | 103 | 0.524 [0.502] | 22 | 0.773 [0.429] | −0.248* |
Reduced risk adjusted 30-day mortality | 83 | 0.253 [0.437] | 16 | 0.688 [0.479] | −0.434*** |
Reduced ambulatory care sensitive admissions | 68 | 0.279 [0.452] | 17 | 0.529 [0.514] | −0.250 |
EMPLOYED AND AFFILIATED STAFF | |||||
Improved employee engagement in their work | 114 | 0.816 [0.389] | 32 | 0.938 [0.246] | −0.122 |
Reduced employee turnover | 84 | 0.310 [0.465] | 14 | 0.500 [0.519] | −0.190 |
COSTS | |||||
Reduced expenditures in two or more departments | 112 | 0.795 [0.406] | 24 | 0.792 [0.415] | 0.003 |
Eliminated waste in two or more processes or depts | 121 | 0.926 [0.263] | 33 | 0.970 [0.174] | −0.044 |
Reduced average length of stay | 102 | 0.461 [0.501] | 30 | 0.800 [0.407] | −0.339*** |
SERVICE PROVISION | |||||
Increased throughput in the emergency department | 114 | 0.737 [0.442] | 28 | 0.679 [0.476] | 0.058 |
Increased throughput in the operating rooms | 103 | 0.544 [0.501] | 30 | 0.900 [0.305] | −0.356*** |
Increased throughput in the cardiac care unit | 91 | 0.275 [0.449] | 23 | 0.696 [0.470] | −0.421*** |
Increased throughput in med/surg nursing units | 100 | 0.510 [0.502] | 27 | 0.815 [0.396] | −0.305** |