Lean healthcare: scale, scope and sustainability

Cory R.A. Hallam (University of Texas at San Antonio, San Antonio, Texas, USA)
Carolina Contreras (University of Texas at San Antonio, San Antonio, Texas, USA)

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Publication date: 13 August 2018

Abstract

Purpose

Lean healthcare is highlighted in the literature as an approach to quality improvement and operational efficiency. The purpose of this paper is to study how Lean healthcare has been implemented by analyzing empirical outcomes.

Design/methodology/approach

The authors used a literature review as the primary research method, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses process. Peer-reviewed journals were analyzed – searching for Lean healthcare implementation, tools used, wastes addressed, outcomes and sustainability.

Findings

Evidence suggests that Lean can improve healthcare operational effectiveness. However, empirical studies show implementation is still highly localized with small successes. Most transformations are focused on implementing one or two Lean tools that primarily target patient waiting times and there is minimal evidence about sustainability. Establishing clear definitions for healthcare-related Lean terminology may improve practice, especially episodic care and service quality.

Originality/value

This work provides a Lean healthcare case review. The research makes a significant contribution to Lean healthcare by increasing understanding (scale, scope and sustainability). From a theory building perspective, the authors suggest that barriers to adoption include a common healthcare-specific Lean terminology, and a need to expand implementation beyond small successes. This understanding will help identify key areas for further research in Lean healthcare management.

Keywords

Citation

Hallam, C. and Contreras, C. (2018), "Lean healthcare: scale, scope and sustainability", International Journal of Health Care Quality Assurance, Vol. 31 No. 7, pp. 684-696. https://doi.org/10.1108/IJHCQA-02-2017-0023

Download as .RIS

Publisher

:

Emerald Publishing Limited

Copyright © 2018, Emerald Publishing Limited


Introduction

Providing safe, reliable and affordable care while improving efficiency and performance remains a challenge in the healthcare sector (Brackett et al., 2013; Deblois and Lepanto, 2016). In developed countries, ageing population and growing healthcare cost are increasing pressures on already constrained budgets, while enhanced service quality is expected (McIntosh et al., 2014). Given these challenges, healthcare providers and policy makers advocate Lean to increase value, eliminate waste and reduce costs, as other industries have done (Cookson et al., 2011; D’Andreamatteo et al., 2015; Teich and Faddoul, 2013). Lean is a well-known manufacturing approach that focuses on creating value through quality products and services by reducing waste (Shah and Ward, 2003). Interest in Lean healthcare has been growing steadily since the early 2000s (Deblois and Lepanto, 2016; Brandao de Souza, 2009), with promises that Lean improves healthcare performance, eliminates inefficiencies and waste in workflow processes, improves patient scheduling and increases patient satisfaction (Al-Hyari et al., 2016; Nayar et al., 2016). As an emerging research field, Lean healthcare publications have risen recently (Costa and Godinho Filho, 2016; D’Andreamatteo et al., 2015). While there has been an increase in publications discussing Lean healthcare (Brandao de Souza, 2009; Costa and Godinho Filho, 2016; D’Andreamatteo et al., 2015; Moraros et al., 2016; Mazzocato et al., 2010), a gap exists in the literature, i.e., addressing Lean’s lasting effect on healthcare organizations. Hence, we review how Lean has been implemented within the healthcare sector and highlight 37 Lean healthcare case studies from 2006 to 2017.

Lean manufacturing

Derived from the Toyota Production System (TPS), Lean enhances manufacturing performance by delivering a quality product on time at the lowest cost (Ohno, 1988; Womack et al., 1990; Womack and Jones, 1996). Lean is a process-oriented approach, focused on improving systemic customer value-delivery, rather than optimizing performance. This goal can be attained by improving flow and eliminating waste, not often found in traditional production techniques (Bhuiyan and Baghel, 2005; Ohno, 1988; Womack et al., 1990; Womack and Jones, 1996). Lean philosophy acknowledges value added (VA) and non-value added (NVA) activities (Murman et al., 2002; Ohno, 1988). Value added activities transform a product or service for which customers are willing to pay, whereas NVA activities are those for which a customer would not be willing to pay. Therefore, Lean manufacturing philosophy is based on eliminating waste that adds no value to the product (Crema and Verbano, 2015).

Workflow improvements are accomplished by eliminating seven wastes (Ohno, 1988): waiting; defects; overproduction; transportation; inventory; unnecessary motion; and overburden. To succeed, Lean promulgates five management tenets that support waste reduction: value; value stream; flow; pull and perfection (Womack and Jones, 1996). These tenets establish Lean as an organizational behavior that transforms an enterprise. In this regard, Lean is recognized as a continuous improvement whose success is based on complex integrated socio-technical practices and a culture focused on organizational change (Hallam and Keating, 2014; Burgess and Radnor, 2013; Shah and Ward, 2007). Successful Lean transformation requires a strategy for adopting Lean tools/techniques and culture changes (Papadopoulos et al., 2011; Shah and Ward, 2007). Lean manufacturing tools are intended to enhance customer value and reduce waste (Gupta and Jain, 2013; Jasti and Kodali, 2014). From a metrics perspective, successful Lean transformation results in reduced lead-times, better operational efficiencies, improved quality and reduced inventory (Bhuiyan and Baghel, 2005; Netland et al., 2015; Yang et al., 2011). As a strategy developed for production performance, Lean manufacturing has expanded as a business practice and extended beyond manufacturing to service industries and product development operations with varying success (Akugizibwe and Clegg, 2014; Bhamu and Singh Sangwan, 2014; Hallam and Keating, 2014; Marodin and Saurin, 2012).

Since Lean is concerned with reducing waste throughout the whole value-creation system (i.e. value stream, business process, supply chain, etc.), it requires a corporate cultural change (Schein, 1999; Rouse, 2011). Successful Lean implementation faces several cultural challenges, including effective communication between and within different organizational levels, long-term commitment to maximize stability in a changing environment, systematic and continuous focus on the customer, ensuring that there is a change strategy reflecting the organization’s goals (Rouse, 2011; Womack and Jones, 1996). Through implementing strategically-oriented Lean culture and effective tools/techniques, manufacturers optimize the time from order to delivery, while eliminating waste and improving quality. The Lean manufacturing philosophy, already successfully adopted in many industries, appears to have the potential to significantly improve healthcare performance, but may have nuances that make this industry-specific transformation more difficult and thus poses a threat to sustainability.

Lean healthcare

Lean tools and techniques have been implemented in different service sectors (Cheng et al., 2015; Stone, 2012). Lean healthcare’s popularity has grown in the last decade, as evidenced in the growth in publications on the topic (Brandao de Souza, 2009; Cookson et al., 2011). Similarities between Lean production and Lean healthcare suggest a potential positive impact. According to White et al. (2013), Lean in healthcare appears to have been driven by the necessity to do more with less. Teich and Faddoul (2013) point out that Lean is applicable to healthcare because managerial processes are the basis for Lean implementation, which are alike for all process-centric industries. Cookson et al. (2011) suggest that Lean is applicable to healthcare because both healthcare and manufacturing involve multiple departments, long sequential complex processes with varying cycle times, queuing and resource sharing to produce a product or service.

Lean healthcare emerged in the Lean literature as an approach focused on efficiency and patient satisfaction (Brandao de Souza, 2009; Dahlgaard et al., 2011; White et al., 2013). Healthcare costs and quality are dependent on the processes for delivering care. In some cases, these processes may include steps that are unnecessary, inappropriate or can lead to mistakes (Nicholas, 2012). Therefore, healthcare waste can result in inconsistent care, unreliable treatment and constant interruptions. These inefficiencies drive higher operating costs, potential for errors, worker frustration, delays and duplication (Fillingham, 2007; Hussain et al., 2015; Jimmerson et al., 2005). To reduce systemic inefficiencies, seven wastes proposed by Ohno (1988) in the Lean philosophy have been extended and adapted (Cookson et al., 2011; Fillingham, 2007; Hussain et al., 2016; Radnor et al., 2012) to include: overproduction (e.g. recording the same information multiple times and ordering unnecessary investigations); waiting (for patients, theatre staff, results, prescriptions and medicines, and discharge); transportation (patients, specimens and materials), overburden (stresses, overworked staff); inventory (excess stock); motion (unnecessary staff movement looking for paperwork, supplies or people); and defects (readmission, repeated tests and medical errors).

Lean’s five tenets have also been adapted for healthcare and are identified as an effective approach to meet an ever-increasing demand for treatment (Costa et al., 2015; Fine et al., 2009; Hussain et al., 2016). Value can be examined using patients’ wants and needs, which may include providing the appropriate diagnostic testing or avoiding excessive or costly tests. Value stream means finding the activities that produce or add value to the patient’s episodic care. For patients, numerous steps and waiting time should be reduced throughout the value stream. Flow is related to efficiency within healthcare, for example, reducing interruptions or queue times between a patient walking in the door and being seen by a physician. Pull relates to providers’ ability to have downstream process steps signal upstream process steps. Finally, perfection may be defined as providing timely and outstanding care that result in the correct diagnosis and cost-effective therapy for patients.

Positive outcomes associated with Lean healthcare have been documented (Cheng et al., 2015; Costa et al., 2015; Grove et al., 2010; Simons et al., 2016; Sanders and Karr, 2015). Different studies show that Lean is being applied to improve patient care and clinical processes, improve safety, eliminate delays and reduce hospital stay, all while reducing costs (Al-Hyari et al., 2016; Costa and Godinho Filho, 2016; D’Andreamatteo et al., 2015; White et al., 2013). However, McIntosh et al. (2014) acknowledge differences between healthcare and manufacturing, arguing there is no evidence to support Lean being successfully adapted. Although Lean healthcare literature acknowledges performance improvements, there is limited empirical research assessing how Lean has been implemented, its specific tools, what wastes have been reduced, what quality improvements have been systemically achieved and how transformation is sustained.

Research methodology

To understand how Lean healthcare has been implemented, we used a literature review as a research method, which helped identify, synthesize and evaluate existing publications (Onwuegbuzie et al., 2012). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses process (Deblois and Lepanto, 2016). We identified Lean implementation within medical institutions, Lean practices, wastes addressed, outcomes and sustainability. Multiple databases were searched, including Emerald Insight, Google Scholar, Science Direct, IEEE, Springer, Taylor and Francis and Wiley Online by using the following keywords: Lean manufacturing; Healthcare; Lean healthcare; Lean and hospitals; and/or Lean implementation. Combined keywords were also used to narrow the search, which only included English-language, peer-reviewed articles, excluding editorials, book chapters, reviews, comments and conference proceedings that can suffer less rigorous review processes. We reviewed references in the articles that we considered relevant to our study and identified relevant articles missed by the search. We found 215 articles and an additional 52 relevant titles from the reference review, totaling 267 Lean healthcare articles. A detailed review excluded 121 articles that did not contain empirical evidence, 28 that were general topic reviews and five that were purely theoretical. Of the remaining 113 articles that appeared to have empirical data, 76 did not mention specific lean tools nor did they provide Lean healthcare transformation outcomes, which resulted in 37 relevant peer-reviewed journal articles published between 2006 and 2017 that met our search criteria. These data enabled us to fill a gap by quantifying Lean healthcare implementations from local process improvements to enterprise-wide transformations. We further quantify the scope by analyzing Lean tool types and frequency, and the wastes addressed. Finally, we identify and quantify reported outcome measures used in these studies, highlight multi-stakeholder team roles and summarize outcome sustainability.

Descriptive analysis

Scale

The literature shows that implementing Lean in small projects creates best practice (Brandao de Souza, 2009; Radnor et al., 2012; Radnor, 2011) small successes (Murman et al., 2002), but does not ensure a broad positive effect on overall value creation for the enterprise. Lean transformation might end up failing to reach expected enterprise-level outcomes such as reducing total episodic care cost or readmission rates when implemented in isolation (Ben-Tovim et al., 2008; Costa and Godinho Filho, 2016; Fillingham, 2007). For 37 empirical works included in our study, Table I lists the implementation areas, ranging from clinic scheduling process to an operating room (OR) or hospital department. In Table I, we quantify these areas, which we categorized as a process (i.e. scheduling), a room (i.e. OR), a department (i.e. pharmacy) or the enterprise (i.e. entire hospital or system). Nearly two-thirds of the studies, we reviewed discussed Lean implementation at department level. The remainder were either conducted at room or process levels. No evidence was found for enterprise-wide implementation. Data suggest good examples upon which others can draw, but empirical data for healthcare systems in which Lean has been successfully implemented or patient value stream improved are lacking (Mazzocato et al., 2012).

Scope

Lean healthcare implementation was measured by looking at Lean tools and wastes. In total, 15 tools were identified in the articles (ranked in Table II). Nearly two-thirds of Lean healthcare implementations used value stream mapping (VSM). According to Ben-Tovim et al. (2008), Chiarini (2013), Naik et al. (2012) and Nicholas (2012), VSM is viable in the healthcare sectors because it improves patient flow and enhances process redesign. These articles also discuss the need for both current state and future state value stream maps (Lummus et al., 2006; Ng et al., 2010; Yousri et al., 2011). We found that 35 percent of the studies used Kaizen events and 5S techniques. Articles reporting Kaizen events highlight the need for a continuous improvement culture in healthcare (Mazzocato et al., 2012; Radnor, 2011; Papadopoulos et al., 2011; Dickson et al., 2009). The top five tools included DMAIC (24.3 percent) and standardized work (13.5 percent). Surprisingly, the Five Why’s method was only identified once. However, its use may have been present in Kaizen events and the DMAIC process, without having been explicitly named. Kanban, workload balancing, run chart, etc., relative in frequency, prevalent in the Lean manufacturing literature, reinforces our belief that the healthcare industry is in its infancy in adopting and exploiting Lean.

Detecting inefficiencies and improving processes using Lean tools results in reducing Ohno’s seven wastes (Fillingham, 2007; Ng et al., 2010; Simon and Canacari, 2012). Previous literature reviews have not directly addressed Lean healthcare waste but implicate waste removal on different healthcare performance parameters (Costa and Godinho Filho, 2016; D’Andreamatteo et al., 2015; Mazzocato et al., 2010). In our study, Table III summarizes the reported reductions in Ohno’s seven wastes. We found that most Lean healthcare implementation targets waiting (89.2 percent). According to Ng et al. (2010), quality and productivity in the healthcare sector, which are considered outcome measures, are improved when waiting is reduced between steps. King et al. (2006) report how Lean was applied in the emergency department at Flinders Medical Center to reduce waiting times and stays. Cima et al. (2011) showed how Lean improved operation room efficiency by reducing average turnover time. Less than a quarter of all studies (21.6 percent) discussed reduced defects, such as mortality rates (Yousri et al., 2011; Rutman et al., 2015). The remaining wastes were identified in less than 15 percent of the articles, including transportation (13.5 percent), inventory (13.5 percent), overproduction (13.5 percent), motion (10.8 percent) and overburden (5.4 percent). We observed that no single study explicitly addressed all seven wastes. In general, the literature suggests that reducing Lean wastes, specifically waiting and defects, may help boost healthcare performance (Bhat et al., 2016; Chan et al., 2014; Ng et al., 2010). Consequently, when managers reduce wastes throughout a Lean healthcare system, they may create a workflow where resources can be used to perform more productive tasks other than expending time searching for information, transporting patients, correcting medical errors and solving service problems (Lummus et al., 2006; Martin et al., 2013; Rutman et al., 2015; Tortorella et al., 2017).

Sustainability

Table IV tracks three elements associated with sustainable Lean healthcare. First, we list the outcome (or performance) measures identified in the articles. Next, we identify if long-term sustainability is mentioned. Finally, we look for multi-stakeholder involvement in the process, a key element in successful Lean transformation (Papadopoulos and Merali, 2008; Joosten et al., 2009; Hayes et al., 2010). In total, 32 outcome measures were identified. The top five were reduced: waiting times (32.4 percent), stay (24.3 percent), cost (18.9 percent) and improved: quality (16.2 percent) and patient satisfaction (16.2 percent). The remaining outcomes were mentioned in less than 15 percent but are provided in frequency order (Table IV). These were not entirely exclusive outcome measures, and could be grouped by time, cost and quality. From a sustainability perspective, only five articles (13.5 percent) specifically mention sustainability. Leslie et al. (2006) found that documenting standard work and a continued communications plan were necessary to ensure that changes stayed in place. Melanson et al. (2009) considered that efforts were sustained ten months after implementation. Cima et al. (2011) suggested that their process changes were sustained following the improved outcomes (financial and staff satisfaction). Naik et al. (2012) identified sustainability as a challenge and suggested four lessons to improve sustainability: clear communication and in-servicing (training) on new processes; implementing new processes at off-peak hours with process owners and executives present; representation from all Lean teams as each shift has different conditions; and developing clinical and mid-level management champions necessary for sustaining the change.

Bhat and Jnanesh (2014) implemented control plans that relied on documented standards and processes, along with clear training plans as staff turnover required continuous re-education. Their system integrated standard procedures displayed near the workplace and after run-charts tracked key performance indicators. About a third of the articles reviewed (35.1 percent) mentioned stakeholder involvement. Multidisciplinary teams and concurrent involvement by all departments were judged crucial in Lean transformation (Mazzocato et al., 2012; Nicholas, 2012; Rutman et al., 2015). According to Martin et al. (2013), staff involvement and collaboration between teams improves productivity and efficiency. Similarly, Naik et al. (2012) highlight that executive commitment and stakeholder support, and a vision statement based on departmental values are key tactics necessary to make Lean healthcare successful. Staff involvement and team creation are necessary tactics when planning and implementing Lean healthcare (Ng et al., 2010; Melanson et al., 2009; Dickson et al., 2009; Ben-Tovim et al., 2008; Fillingham, 2007).

Discussion

A successful Lean program follows the TPS approach to improve the working environment in ways that add value for customers (Seddon and Caulkin, 2007). Lean implementation requires systems thinking, a theory based on seeing wholes and where changing one system may affect others (McIntosh et al., 2014; Nicholas, 2012; Senge, 2006). Dahlgaard et al. (2011) state that like others, healthcare providers started to implement Lean without understanding the cultural and structural preconditions that Lean requires. In some cases, these transformations focused on implementing a tool, thus failing to embrace Lean’s systemic approach (White et al., 2013). Case studies suggest that Lean’s adoption in healthcare can positively affect performance in specific activities and practices. Yet, despite interest in Lean healthcare, empirical case study publication rate is low. Lean implementation in most cases does not affect the whole organization but is limited to small projects or activities. This issue was previously highlighted by Burgess and Radnor (2013), who affirmed that Lean healthcare tends to be implemented in isolation rather than system wide. Similarly, Costa and Godinho Filho (2016) reinforced this viewpoint, presenting articles that state how the approach to implementing Lean in healthcare is not affecting the entire system. Jasti and Kodali (2014) note that Lean in the manufacturing sector suffered from the same limitations early in its adoption. D’Andreamatteo et al. (2015) point out that Lean healthcare is still in its infancy and there are overlooked issues that require attention to make Lean more palatable in the healthcare sector and to be acknowledged system wide, including healthcare-specific terminology. McIntosh et al. (2014) state Lean healthcare challenges lie not in theory, but in application. Reflecting on Spear and Bowen (1999), we can look at their empirically derived Lean rules to drive the transformation.

Rule 1: all work shall be highly specified as to content, sequence, timing and outcome.

Rule 2: every customer-supplier connection must be direct and there must be an unambiguous yes-or-no way to send requests and receive responses.

Rule 3: the pathway for every product and service must be simple and direct.

Rule 4: any improvement must be made in accordance with the scientific method, under a teacher’s guidance and at the lowest possible level in the organization.

Mazzocato et al. (2012) and Jimmerson et al. (2005) adapted these four theoretical principles to Lean healthcare, with some improvements. Although Lean principles highlight the theoretical context to help Lean healthcare succeed, they do not account for broader organizational issues that might explain why Lean improvements are not achieved or sustained. In our opinion, problems reside in knowledge asymmetry that exists between different units (hospital, clinic, practice, department, etc.). In an organization, decisions are made by actors based on surrounding environment, contextual factors and decision maker knowledge and constraints. Missing systemic knowledge results in bounded rational decisions that can be sub-optimal from a systems perspective (Simon, 2000). In this light, we propose that bounded rationality may be an underlying failure mechanism related to Lean healthcare. The practical response to this failure mechanism creates multidisciplinary Lean implementation teams, which by default bring together different stakeholders associated with the process and expand the process addressed.

Bounded rationality states that actors have incomplete information and are more likely to make decisions using heuristics (Simon, 1991), or at best, locally optimize a problem using information that falls within their management and authority (Radner, 1996). In Lean transformation, bounded rationality may interfere with process optimization when stakeholders in the value stream act without understanding the broader system they are affecting. For example, localized cost measurement, and a cost reduction mindset may result in employee incentives that drive the choice for ordering the cheapest catheters. This minimizes (i.e. optimizes) the local expense function. However, in this example, the low-cost catheter may significantly increase biofilm infection risks, which result in more readmissions and higher systemic costs. Thus, the overall episodic care cost could increase dramatically. Lean healthcare transformation looks at overall infection rates and readmission as the outcome metrics to optimize, then use Lean tools, such as the five Why’s (Collar et al., 2012), to understand the root cause (i.e. catheter-induced bladder infection). This information would be used to eliminate problem causes, shifting to a slightly more expensive anti-biofilm catheter, in turn causing a minor increase in localized cost for catheters but dramatically reducing overall systemic costs with reduced infections and readmission rates.

Although Lean healthcare drivers are different from those in the manufacturing industry, evidence shows that TPS underlying tenets could apply to the healthcare sector, which may require establishing more healthcare-centric Lean terminology for value, wastes and overall episodic care quality. Payment systems around the globe also confound this problem, from fully nationalized systems, to private pay or co-pay systems, resulting in bounded rationality problems that limit systemic optimization. Developing clear Lean healthcare transformation roadmaps for each system may be required and may also suggest the need for modifying policies to encourage transformation. Furthermore, agreeing outcome metrics will be critical (Porter, 2010). These are rich research questions with significant practical implications that we feel need to be addressed in future work.

Conclusion

We show that empirical Lean healthcare research has increased during the last decade. Case studies that assessed Lean healthcare implementation are highly optimistic in their findings, pointing out that Lean manufacturing practices have a positive contribution to improving performance parameters such as hospital stay and waiting time. Reported quality and cost improvements remain more elusive. Our work highlights that current case studies report tools or practices that have worked for healthcare providers during a Lean implementation, but few have addressed sustainability. First, we find that Lean implementation is gaining acceptance in healthcare, notably through localized department or process improvements and not through large-scale enterprise transformations. Second, we find that practitioners are implementing different Lean tools, ranging from VSM to organizing the work area (5S’s). Third, the primary Lean waste addressed has been waiting time. Finally, very little evidence exists that demonstrates Lean healthcare sustainability. Creating a clear terminology for Lean healthcare may help improve this process by converting manufacturing-centric language into healthcare-centric language. Our future research seeks to better comprehend how performance in healthcare can be enhanced through Lean and derive practical Lean healthcare management practices that improve overall quality, efficiency and reduce cost. We also intend to expand our theoretical work by exploring healthcare bundled payment systems as one incentive structure that may deal with the bounded rationality problem.

Lean healthcare implementation – scale

Healthcare Area Articles %
Department 23 62.2
Room 8 21.6
Process 6 16.2
Enterprise 0 0

Lean tools in Lean healthcare

Tools %
VSM 64.9
Kaizen 35.1
5S’s 35.1
DMAIC 24.3
Standardized work 13.5
Gemba 10.8
PDCA 8.1
5 Why’s 2.7
Kanban 2.7
Process mapping 2.7
A3 Report 2.7
SMED 2.7
Spaghetti map 2.7
Workload balancing 2.7
Run chart 2.7

Notes: VSM – (value stream mapping); SMED – (single-minute exchange of dies); DMAIC – (define, measure, analyze, improve and control); PDCA – (Plan-Do-Check-Act)

Lean wastes in Lean healthcare

Waste Articles %
Waiting 33 89.2
Defects 8 21.6
Overproduction 5 13.5
Transport 5 13.5
Inventory 5 13.5
Motion 4 10.8
Overburden 2 5.4

Lean healthcare outcome measures

Outcome %
Waiting time 32.4
Hospital stay 24.3
Costs 18.9
Quality 16.2
Patient satisfaction 16.2
Profitability 10.8
Turnover time 10.8
Turnaround time 10.8
Patient safety 8.1
Lead time 8.1
Flow 8.1
Efficiency 5.4
Staff satisfaction 5.4
Cycle time 5.4
Materials delivery 5.4
Patient throughout 5.4
Medical waste 2.7
Mortality 2.7
Staff overtime 2.7
Storage 2.7
Readmissions 2.7
Employees overtime 2.7
Preparation time 2.7
Time to care 2.7
Admission time 2.7
Process time 2.7
Search and set-up time for materials 2.7
Blood result time 2.7
Processing time 2.7
Setup time 2.7
Colonoscopy time 2.7
Productivity 2.7
Sustainability 13.5
Stakeholders involvement 35.1

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Corresponding author

Cory R.A. Hallam can be contacted at: cory.hallam@utsa.edu