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Lean implementations in hospitals tend to be lengthy or lack the desired results. In addressing the question, how can lean be implemented effectively in a hospital-wide setting, this paper aims to examine two opposing approaches.

The authors studied two Dutch university hospitals which engaged in different lean implementation approaches during the same four-year period: top-down vs bottom-up. Inductive qualitative analyses were made of 49 interviews; numerous documents; field notes; 13 frontline meeting observations; and objective hospital performance data. Longitudinally, the authors depict how the sequential events unfolded in both hospitals.

During the six implementation stages, the roles played by top, middle and frontline managers stood out. While the top managers of one hospital initiated the organization-wide implementation and then delegated it to others, the top managers of the other similar hospital merely tolerated the bottom-up lean activities. Eventually, only the hospital with the top-down approach achieved high organization-wide performance gains, but only in its fourth year after the top managers embraced lean in their own daily work practices and had started to co-create lean themselves. Then, the earlier developed lean infrastructure at the middle- and frontline ranks led to the desired hospital-wide lean implementation results.

Change-management insights, including basic tenets of social learning and goal-setting theory, are shown to advance the knowledge of effective lean implementation in hospitals. The authors found lean implementation “best-oiled” through role-modeling by top managers who use a phase-based process and engage in close cross-hierarchical or co-creative collaboration with middle and frontline managerial members.

The purpose of this paper is to extend the understanding of Six Sigma (SS) and the underlying dimensions of its critical success factors (CSF) via an analysis of the effects of top management support (TMS), implementation strategy (IS), and collaborative team (CT) on project performance (PP) in Mexican manufacturing companies.

Based on a SS literature review, a survey was conducted to capture practitioners’ viewpoints about CSFs for SS implementation and their impact on performance in manufacturing companies. A factor analysis and structural equation modeling were conducted in order to identify and analyze causal relationships.

The results suggest that CSFs grouped in the constructs TMS, IS, and CT have a positive impact on PP as measured by cost reduction, variation reduction, and quality improvement.

Although the empirical data collected supported the proposed model, results might differ among organizations in different countries. In addition, the study did not analyze a unique performance metric; instead, general PP dimensions were used.

Boosting the TMS, IS, and CT enhances positive PP of SS in manufacturing companies.

IS as a construct has not been studied exhaustively; this work contributes to a better understanding of it and its impact on PP. Additionally, studies of SS in Latin America are limited, so this study gives a complementary vision to practitioners and researchers about it.