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Lean Six Sigma (LSS) implementation follows a structured approach called define-measure-analyze-improve-control (DMAIC). Earlier research about its application in emergency healthcare services shows that it requires organizational transformation, which many healthcare setups find difficult. The Kotter change management model facilitates organizational transformation but has not been attempted in LSS settings till now. This study aims to integrate the LSS framework with the Kotter change management model to come up with an integrated framework that will facilitate LSS deployment in emergency health services.

Two-stage Delphi method was conducted by using a literature review. First, the success factors and barriers of LSS are investigated, especially from an emergency healthcare point of view. The features and benefits of Kotter's change management models are then reviewed. Subsequently, they are integrated to form a framework specific to LSS deployment in an emergency healthcare set-up. The elements of this framework are analyzed using expert opinion ratings. A new framework for LSS deployment in emergency healthcare has been developed, which can prevent failures due to challenges faced by organizations in overcoming resistance to changes.

The eight steps of the Kotter model such as establishing a sense of urgency, forming a powerful guiding coalition, creating a vision, communicating the vision, empowering others to act on the vision, planning for and creating short-term wins, consolidating improvements and producing still more change, institutionalizing new approaches are derived from the eight common errors that managers make while implementing change in the institution. The study integrated LSS principles and Kotter’s change management model to apply in emergency care units in order to reduce waste and raise the level of service quality provided by healthcare companies.

The present study could contribute knowledge to the literature by providing a framework to integrate lean management and Kotter's change management model for the emergency care unit of the healthcare organization. This framework guides decision-makers and organizations as proper strategies are required for applying lean management practices in any system.

The proposed framework is unique and no other study has prescribed any integrated framework for LSS implementation in emergency healthcare that overcomes resistance to change.

This study aims to explore the lean leadership factors influencing the effectiveness of lean healthcare performance at hospitals.

A total of 217 healthcare professionals’ responses were included for data analysis. The data were analyzed using the partial least square technique.

The findings revealed that improvement culture, gemba (hands-on approach), hoshin kanri (goal-oriented) and qualification are the crucial lean leadership factors that positively influence the effectiveness of lean healthcare performance at hospitals. The results indicated that the self-development of lean leaders has no significant impact on the effectiveness of lead healthcare performance.

The findings of this study could contribute to the healthcare institutions in Malaysia perceive the benefits of lean healthcare and show a positive intention of using lean leadership principles.

The purpose of this study is to reflect upon the ramifications of two decades of Lean Six Sigma implementations in Dutch healthcare institutions in the light of the current COVID-19 pandemic.

The authors provide an evaluation of the impact that Lean Six Sigma implementations have had on the ability of Dutch healthcare institutions to respond adequately to healthcare needs during the COVID-19 crisis.

Process improvement in healthcare has had a tendency to cut capacity and flexibility which are needed to deal with excessive demand shocks, such as during a pandemic. The main reason for this failure seems to be an overly strong focus on cost reduction instigated by Lean Six Sigma during stable times.

Besides the research method being an inferential procedure, the research focuses on the Netherlands and so the generalizability might be limited. However, using Lean Six Sigma to improve healthcare processes has found broad acceptance, so the implications may well carry over to other countries.

The authors call for a more comprehensive approach of process improvement within healthcare that takes flexibility and buffering in anticipation of excess variability and disruption into greater account. Therefore, this study provides a new perspective on how and to which aim Lean Six Sigma should be applied in healthcare.

An assessment is given of the impact of Lean Six Sigma implementations on the ability to respond to the COVID-19 crisis. This is done by identifying the focus points of improvement projects and considering the impact on the resilience of healthcare operations.

This work seeks to offer a greater understanding of Lean healthcare implementation challenges conceptually taking a situated cultural organizational change perspective.

A descriptive model of healthcare organizations’ Lean adoption trajectories is built using ripple and bridging modelization strategies from elements of three classic organizational change theories and knowledge from Lean, organizational culture, healthcare and operations management literature.

The “contingent Lean culture adoption” (CLCA) model suggests five theoretical trajectories the healthcare organizations may experience when conducting a Lean transformation. These trajectories evolve from a new concept of Lean cultural friction (LCF) which represents cultural friction that a healthcare organization encounters toward an ultimate Lean culture proficiency state through time. From high to low initial LCF, a healthcare organization may in its Lean proficiency course end up in three states: lower, similar or higher LCF situation.

The CLCA model demonstrates the potential to be developed into a framework and possibly a Lean cultural friction theory pending further qualitative and quantitative validation.

The CLCA model may help healthcare managers to use more appropriate cultural change strategies during their organization’s Lean journey.

This work enriches the concept of Lean cultural change which may apply not only to healthcare organizations but also to other ones. It suggests the existence of a healthcare organization Lean culture proficiency archetype and introduces the notion of Lean cultural friction.

The purpose of this paper is to determine the readiness factors that are critical to the application and success of lean operating principles in healthcare organizations through a review of relevant literature.

A comprehensive review of literature focussing on lean and lean healthcare was conducted.

Leadership, organizational culture, communication, training, measurement, and reward systems are all commonly attributed readiness factors throughout general change management and lean literature. However, directly related to the successful implementation of lean in healthcare is that a setting is able to authorize a decentralized management style and undertake an end-to-end process view. These can be particularly difficult initiatives for complex organizations such as healthcare settings.

The readiness factors identified are based on a review of the published literature. The external validity of the findings could be enhanced if tested using an empirical study.

The readiness factors identified will enable healthcare practitioners to be better prepared as they begin their lean journeys. Sustainability of the lean initiative will be at stake if these readiness factors are not addressed.

To the best of the knowledge, this is the first paper that provides a consolidated list of key lean readiness factors that can guide practice, as well as future theory and empirical research.

The purpose of this paper is to review and discuss the effects of the introduction of lean into healthcare workplaces, phenomena that have not been widely investigated.

The paper draws on discussions and findings from the literature. It seeks to bring the few geographically dispersed experiences and case studies together to draw some conclusions regarding lean’s negative effects.

Two recurring themes emerge. The first is there is little evidence of Lean’s impact on work and the people who perform it. The literature therefore suggests that we understand very little about how work conditions are changed and how Lean’s negative effects arise and may be managed in healthcare workplaces. A second observation is that Lean’s effects are ambiguous. For some Lean seems to intensify work, while for others it leads to improved job satisfaction and productivity. Given this variety, the paper suggests a research emphasis on Lean’s socio-cultural side and to derive more data on how work and its processes change, particularly in the context of healthcare team-working.

The paper concludes that without improved understanding of social contexts of Lean interventions its value for healthcare improvement may be limited. Future research should also include a focus on how the work is changed and whether high-performance work system practices may be used to offset Lean’s negative effects.

The purpose of this study is to document the experience and impact of implementing lean thinking (LT) in an Indian healthcare institution.

A detailed review of literature documenting the experience of implementing LT in healthcare institutions is carried out. Review revealed that there is a dearth of documentation on implementation of LT in Indian healthcare institutions. To address this gap, the experience of implementing LT in an Indian case hospital is documented by adopting a single case study research methodology.

Lean practices adopted by the Indian case hospital are documented. Performance measures before and after implementation of lean practices in the case hospital are compared. Based on this experience, a framework for implementing LT is proposed for healthcare institutions.

The current study documents the experience of an Indian case hospital, which is only at its initial stages of LT implementation. Future studies can be undertaken to assess the long-term impact of implementing LT in a healthcare institution. Similarly, the proposed framework for implementing LT can be validated by using the same in different healthcare institutions.

Review of lean principles, practices and performance measures discussed in the literature on implementing LT in healthcare institutions can act as a ready reckoner for practitioners. Framework proposed based on the experience of the case hospital is expected to guide healthcare practitioners in their lean journey.

This study is unique, as it documents the experience of implementing LT in an Indian healthcare institution and proposes a framework for implementing LT for future validation.

Lean healthcare is used in a growing number of hospitals to increase efficiency and quality of care. However, healthcare organizations encounter problems with the implementation of change initiatives due to an implementation gap: the gap between strategy and execution. From a change management perspective, the purpose of this paper is to increase scientific knowledge regarding factors that diminish the implementation gap and make the transition from the “toolbox lean” toward an actual transformation to lean healthcare.

A cross-sectional study was executed in an operating theatre of a Dutch University Medical Centre. Transformational leadership was expected to ensure the required top-down commitment, whereas team leadership creates the required active, bottom-up behavior of employees. Furthermore, professional and functional silos and a hierarchical structure were expected to impede the workforce flexibility in adapting organizational elements and optimize the entire process flow.

The correlation and regression analyses showed positive relations between the transformational leadership and team leadership styles and lean healthcare implementation. The results also indicated a strong relation between workforce flexibility and the implementation of lean healthcare.

With the use of a recently developed change management model, the Change Competence Model, the authors suggest leadership and workforce flexibility to be part of an organization’s change capacity as crucial success factor for a sustainable transformation to lean healthcare.

This paper proposes the adoption of Industry 4.0 (I4) technologies and lean techniques for improving operational performance in the healthcare sector.

The research adopted a systematic literature review and feedback of healthcare professionals to identify the inefficiencies in the current healthcare system. A questionnaire was used to get feedback from the patients and the hospital staff about the current practices and issues, and the expected impact of technology on existing practices. Data were analysed using descriptive statistics, correlation analysis and multiple regression analysis.

The results indicate that I4 technologies lead to the improvement of the operational performance, and the perceptions about I4 technologies are made through the pre-medical diagnosis. However, a weak correlation between lean practices and healthcare operational performance compared to that of I4 technologies and operational performance indicate that lean practices are not fully implemented in the Sri Lankan healthcare sector to their full potential.

This study is limited to two government hospitals, with insights from only the doctors and nurses in Sri Lanka. Furthermore, the study is limited to only selected aspects of I4 technologies (big data, cloud computing and IoT) and lean concepts (value stream mapping and 5S). Therefore, recommendations on the adoption of I4 technologies in the healthcare sector need to be made within the scope of the study investigation.

The implementation of I4 technologies needs careful consideration of process improvement as part of the overall plan for achieving the maximum benefits of technology adoption.

The findings of the research can be used as a benchmark/guide for other hospitals to explore the adoption of I4 technologies, and how process improvement from lean concepts could influence the overall operational performance.

Considering lean thinking inside and beyond the organisation's boundaries, in the extended supply chain, this paper aims to fill a literature gap clearly stating some outsourcing practices as lean practices and establishing a deployment evolution parallel between both practices.

A literature review was carried out collecting cases of lean deployment in healthcare, from both scientific and grey literature. Cases were classified according to lean deployment taxonomy in healthcare settings, showing some differences in lean journey stages in 15 countries.

There is an alignment between SCM thinking in healthcare and lean thinking that places a SCM decision as outsourcing as a lean practice serving not only strategic intent but solving operational efficiency. There is a match between different outsourcing drivers (transactional, strategic and transformational) and lean maturity levels. The main constraint to deployment of both lean and outsourcing practices are cultural differences.

Understanding lean and outsourcing different deployment maturity levels under the national cultural umbrella can open new perspectives to study lean sustainability factors and better outsourcing relationships in healthcare organisations.

This paper presents a merger between the state‐of‐the art of both lean and outsourcing practices in healthcare settings and suggests an outsourcing and lean evolving pathway.